Fungal infections commonly present with myriad symptoms that mimic other clinical entities, notable amongst which is tuberculosis. Besides histoplasmosis and chronic pulmonary aspergillosis, which can mimic TB, this review has identified several other fungal infections which also do. A total of 80 individual cases misdiagnosed as TB are highlighted: aspergillosis (n = 18, 22.5%), histoplasmosis (n = 16, 20%), blastomycosis (n = 14, 17.5%), cryptococcosis (n = 11, 13.8%), talaromycosis (n = 7, 8.8%), coccidioidomycosis (n = 5, 6.3%), mucormycosis (n = 4, 5%), sporotrichosis (n = 3, 3.8%), phaeohyphomycosis (n = 1, 1.3%) and chromoblastomycosis (n = 1, 1.3%). Case series from India and Pakistan reported over 100 cases of chronic and allergic bronchopulmonary aspergillosis had received anti-TB therapy before the correct diagnosis was made. Forty-five cases (56.3%) had favorable outcomes, and 25 (33.8%) died, outcome was unclear in the remainder. Seventeen (21.3%) cases were infected with human immunodeficiency virus (HIV). Diagnostic modalities were histopathology (n = 46, 57.5%), culture (n = 42, 52.5%), serology (n = 18, 22.5%), cytology (n = 2, 2.5%), gene sequencing (n = 5, 6.3%) and microscopy (n = 10, 12.5%) including Gram stain, India ink preparation, bone marrow smear and KOH mount. We conclude that the above fungal infections should always be considered or ruled out whenever a patient presents with symptoms suggestive of tuberculosis which is unconfirmed thereby reducing prolonged hospital stay and mortalities associated with a delayed or incorrect diagnosis of fungal infections.

Invasive fungal diseases (IFDs) are of huge concern in resource-limited settings, particularly in Africa, due to the unavailability of diagnostic armamentarium for IFDs, thus making definitive diagnosis challenging. IFDs have non-specific systemic manifestations overlapping with more frequent illnesses, such as tuberculosis, HIV, and HIV-related opportunistic infections and malignancies. Consequently, IFDs are often undiagnosed or misdiagnosed. We critically reviewed the available literature on IFDs in Africa to provide a better understanding of their epidemiology, disease burden to guide future research and interventions. Cryptococcosis is the most encountered IFD in Africa, accounting for most of the HIV-related deaths in sub-Saharan Africa. Invasive aspergillosis, though somewhat underdiagnosed and/or misdiagnosed as tuberculosis, is increasingly being reported with a similar predilection towards people living with HIV. More cases of histoplasmosis are also being reported with recent epidemiological studies, particularly from Western Africa, showing high prevalence rates amongst presumptive tuberculosis patients and patients living with HIV. The burden of pneumocystis pneumonia has reduced significantly probably due to increased uptake of anti-retroviral therapy among people living with HIV both in Africa, and globally. Mucormycosis, talaromycosis, emergomycosis, blastomycosis, and coccidiomycosis have also been reported but with very few studies from the literature. The emergence of resistance to most of the available antifungal drugs in Africa is yet of huge concern as reported in other regions. IFDs in Africa is much more common than it appears and contributes significantly to morbidity and mortality. Huge investment is needed to drive awareness and fungi related research especially in diagnostics and antifungal therapy.

Mucormycosis is a highly aggressive and life-threatening fungal disease caused by moulds belonging to the order Mucorales. 1,2 Although the disease is purportedly rare, 2 the causative fungi are ubiquitous in the environment and can be inhaled, ingested or acquired through contact with soil, decaying food and other organic matter. 2 The Mucorales are considered the third most common cause of invasive fungal infections in immunocompromised hosts after Candida and Aspergillus species and are associated with high morbidity and mortality. 3 They have a penchant for rapidly invading blood vessels leading to vascular thrombosis and tissue necrosis mostly in the immunocompromised, but also in immunocompetent hosts. 3 Infections which are initially localised progress swiftly to invasive rhino-orbitocerebral, pulmonary, gastrointestinal or soft tissue disease. 4 Isolated involvement of the brain, kidneys and other organs may also occur

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S9.1 Chronic Pulmonary Aspergillosis - where do we stand?, September 23, 2022, 4:45 PM - 6:15 PM Objectives Chronic pulmonary aspergillosis (CPA) is a known complication of post-TB treatment. It is a progressive disease characterized by progressive cavitation, fibrosis, and pleural thickening among others. Globally, an estimated 3 million people are affected. This study determined the burden of CPA amongst the post-TB and retreatment TB patients in two facilities in Lagos, Nigeria. Methods This was a prospective longitudinal study that was carried out at two TB clinics (LUTH and NIMR) in Lagos, Nigeria between February 2021 and March 2022. The study cohorts were patients that had been previously managed (2-4 years earlier) for TB, they were clinically classified as retreatment TB and post-TB patients. Patients were seen in clinics every 3 months and the following data were collected: Quality of life (WHO and SGRO questionnaires used), 5 mls of blood for Aspergillus IgG level (using Bordier; cut-off of 0.8 AU/ML), sputum for culture (those with productive cough), and chest X-ray. Infectious disease society of America (IDSA) case definition was used to determine cases of CPA. Results A total of 112 post-TB treatment patients were recruited, 60 (53.1%) were retreatment TB and 52 (46.0%) post-TB patients. The mean age was 41.14 years; with the majority between the ages of 21-30 years. The male/female ratio was 0.9/1. 98 (87.5%) were HIV negative, and only 40 patients had GeneXpert testing done. In all 32/40 were GeneXpert negative; of which 24/32 and 8/32 belonged to the retreatment, and post-TB groups respectively. Cough was the predominant symptom with 39 (34.8%) having productive cough. Hemoptysis occurred in 11 (9.8%), 10 in the retreatment group with 2 having frank hemoptysis. Chest imaging revealed that 27/112 of the studied cohort presented with multiple cavities, 4/112 had single cavities, 26/112 had cavities with surrounding opacities and 23/112 had upper lobe consolidation. A total of 17/112 of them had bilateral lung infiltrates and 13/112 had pleural thickening. Sputum culture yielded growth of Aspergillus spp, with A. flavus (n-11; 36.7%) being the predominant species followed by A. fumigatus (n-10; 33.3%), and A. niger (n-9; 30%). In all 38/112 (33.93%) patients had Aspergillus IgG titer above the cut-off level, while 6 symptomatic patients had borderline Aspergillus IgG levels. A total of 11/112 (9.82%) of the study cohorts with positive Aspergillus IgG levels were also culture positive; 8/68 of the Aspergillus IgG negative patients were culture positive and had abnormal chest imaging reported. A total of 38 (33.93%) were confirmed cases of CPA using IDSA criteria. Of the GeneXpert positive; 7/40 were retreatment TB; 16/32 of GeneXpert negative and 8/40 of GeneXpert positive met the criteria for CPA. Conclusion Our findings demonstrate that CPA is easily misdiagnosed as treatment failure TB or TB relapse. There is a need for further follow-up of post-TB patients for early identification of post-TB lung disease. It is also imperative to educate our clinicians to screen patients who have persistent symptoms and are GeneXpert negative for other post-TB lung diseases.

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Background: Most of the study reviews on Histoplasma capsulatum var duboisii (Hcd) infection have been limited to case reports from few African countries despite having cases reported outside Africa. We aimed at providing an update on the global epidemiology of histoplasmosis caused by Hcd, its diagnostic challenges and recommendations for improved diagnosis. Materials and methods:We conducted a retrospective review of case reports and case series on Hcd infection published "between 1 st January 1950 to 31 st December 2021" using PubMed, Google Scholar and African Journals Online. The following search terms: "African histoplasmosis" and "Histoplasma duboisii" AND/OR "diagnosis of African histoplasmosis" were used. Publications on histoplasmosis caused by H. capsulatum var. capsulatum (Hcc) were excluded. Data extracted from each case included: age, gender, disease type (single organ vs. disseminated disease), sites of infection, clinical features, HIV status, diagnostic tests, treatment, and patient outcome. Results: We identified 415 cases of Hcd infection reported globally (1950 -2021); 359 (86.5%) cases from Africa, while 56 (13.5%) were from other geographical regions. Hcd infection was misdiagnosed as other clinical entities including tuberculosis, malignancies, osteomyelitis, neurofibromatosis, and cystic lesions. Out of the 415 cases, diagnostic modality was specified in 307 (74%) cases, with histopathology (n=270, 87.9%) as the predominant diagnostic method followed by culture (n=59, 19.2%). Conclusion: Like classical histoplasmosis, the clinical presentation of Hcd infection mimics other diseases, hence a high index of suspicion by the attending clinician would be invaluable in making a prompt diagnosis and invariably improve clinical outcomes. In addition, there is a need to build capacity in molecular diagnostics and antigen assay specific for detecting Hcd infection as classical diagnostic methods have been proven to be inadequate.