Endemic mycoses: geographical distribution is still a work in progress

Authors’ reply

We thank Spinello Antinori and colleagues for their interest in our Review.¹ Our primary objective was to provide evidence-based guidelines for the diagnosis and treatment of endemic mycoses. A comprehensive review of the epidemiology and geographical distribution of endemic mycoses was not the main objective of our paper. We, however, acknowledge that the maps provided were not an exhaustive effort to redraw the global distribution of endemic mycoses. Neither did they include all published case reports to date. We confirm that, on the talaromycosis map, the states of Assam and Sikkim, in addition to the state of Manipur in the north-eastern region of India, were included in the endemic region. Antinori and colleagues were correct in pointing out that Australia should not be the only continent with imported cases as indicated on the map. Imported talaromycosis cases have been reported in all continents of the world, with the exception of Antarctica.² Antinori and colleagues were also correct in pointing out, on the histoplasmosis map, that although cases are concentrated in the north and north-eastern regions of India, sporadic cases have been reported throughout India.³ Indeed, although histoplasmosis is hyper-endemic in parts of the USA and Latin America, histoplasmin skin-test surveys and sporadic autochthonous cases suggest that histoplasmosis occurs throughout much of the world.⁴ Until we have reliable diagnostic tests that can detect exposure to these endemic fungal pathogens, and until we have comprehensive population-based survey data of disease prevalence, the geographical distribution of endemic mycoses will continue to be a work in progress.