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Cited by 29Fungal Infections and StudiesAntifungal resistance and susceptibilityActinomycetales infections and treatment

Blastomycosis Surveillance in 5 States, United States, 1987–2018

Open access
Benedict, Kaitlin, Gibbons-Burgener, Suzanne, Kocharian, Anna, Ireland, Malia, Rothfeldt, Laura, Christophe, Natalie, Signs, Kimberly, Jackson, Brendan R.·2021·Emerging Infectious Diseases
DOI 10.3201/eid2704.204078PMC PMC8007286
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Abstract

In support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Emerging Infectious Diseases.Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.Medscape, LLC designates this Journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™.Physicians should claim only the credit commensurate with the extent of their participation in the activity.Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program.Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity.It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.All other clinicians completing this activity will be issued a certificate of participation.To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 75% minimum passing score and complete the evaluation at http://www.medscape.org/journal/eid;and (4) view/print certificate.For CME questions, see page 1255.

AI snapshot

Written from the paper’s full text.

TL;DR

Pooled blastomycosis surveillance from 5 US states during 1987–2018 identified 4,441 cases, with high hospitalization and death proportions and long diagnostic delays, suggesting underdetection. Wisconsin had the highest burden, while incidence declined in Arkansas and remained stable in Louisiana, Michigan, and Minnesota.

Key findings

  • Among 4,441 cases (Arkansas 348, Louisiana 296, Michigan 186, Minnesota 671, Wisconsin 2,904), 65% were male and median age was 46 years (range 0–97, IQR 31–59).
  • Among 2,912 patients with hospitalization data, 57% were hospitalized; median length of hospitalization was 7 days (range 1–379, IQR 4–15). Among 3,385 with mortality data, 8% died; the proportion who died increased from 9.9% to 12.4% during 2007–2017 (p=0.017), while hospitalization proportion did not change significantly (p=0.252).
  • Median time from symptom onset to diagnosis was 33 days (range 1–2,996; IQR 16–75; n=777). Most common symptoms were cough (79%), fever (61%), shortness of breath (55%), and weight loss (54%).
  • Arkansas incidence declined from 1.3 to 0.4 cases/100,000 during 1995–2017 (p<0.001); mean annual incidence was 0.2 in Louisiana, 0.2 in Michigan, and 0.6 in Minnesota. Wisconsin peaked at >3 cases/100,000 in 2006, 2010, and 2015, with highest county-level mean annual incidence in Menominee (42.1), Lincoln (28.4), and Vilas (26.5) counties.

Methods

  • Pooled deidentified surveillance data from Arkansas (Jan 1995–May 2018), Louisiana (Jan 1987–Oct 2018), Michigan (Jan 2007–Dec 2017), Minnesota (Jan 1999–Dec 2018), and Wisconsin (Jan 1990–Dec 2017); also used the Louisiana Hospital Inpatient Discharge Database for hospitalized patients during 1999–2014.
  • Included data elements collected by >3 states; event date was earliest associated date; all recorded positive blastomycosis laboratory tests were considered positive, and negative tests were not routinely available.
  • Calculated state- and county-level incidence using US Census Bureau population estimates; used χ2, Fisher exact, and t-tests, Cochran-Armitage tests for trends, and negative binomial regression, with p<0.05 considered significant.

Limitations

  • The paper states that pooling surveillance data based on different blastomycosis case definitions is fundamentally problematic; definitions changed over time, Arkansas had no formal case definition, Michigan had none until 2012, and Wisconsin changed its definition in September 2015.
  • The paper also states that combining data from different times and changing surveillance systems produced inconsistent denominators, and that race/ethnicity were often missing or unknown; environmental exposures, immunocompromised status, body site, occupation, illness duration, and treatment were not consistently available from every state.
  • Evident from the text: passive surveillance likely underdetects asymptomatic or milder cases; laboratory test data were consistently available from only Arkansas, Michigan, and Minnesota, and symptom data were available only from Michigan, Minnesota, and Wisconsin beginning in 2005.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.3201/eid2704.204078

Cites

21 of 21 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 27 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The proportion of blastomycosis patients who died increased from 9.9% to 12.4% during 2007-2017 (p = 0.017).

    “but the proportion of patients who died increased from 9.9% to 12.4% (p = 0.017).”
    Quote in the paperNot a substantial claim
  • Findingown data

    No clear seasonal patterns in blastomycosis cases by event month were observed.

    “We did not observe clear seasonal patterns by event month.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Mean annual blastomycosis incidence in several northern Wisconsin counties was >20 cases/100,000.

    “Consistent with previous reports, Wisconsin had the highest number of cases and incidence of the 5 states where blastomycosis is reportable, with mean annual incidence in several northern counties >20 cases/100,000 population.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Mean annual blastomycosis incidence in Minnesota was 0.6 cases/100,000.

    “Mean annual incidence was 0.2 cases/100,000 population in Louisiana, 0.2 cases/100,000 population in Michigan, and 0.6 cases/100,000 population in Minnesota.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Mean annual blastomycosis incidence in Michigan was 0.2 cases/100,000.

    “Mean annual incidence was 0.2 cases/100,000 population in Louisiana, 0.2 cases/100,000 population in Michigan, and 0.6 cases/100,000 population in Minnesota.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 13
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 7

  • May combine two claims.

    Findingown data

    Wisconsin had the highest number of cases and incidence of the 5 states where blastomycosis is reportable.

    “Consistent with previous reports, Wisconsin had the highest number of cases and incidence of the 5 states where blastomycosis is reportable, with mean annual incidence in several northern counties >20 cases/100,000 population.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Peaks in Wisconsin blastomycosis incidence corresponded to a known outbreak at a yard waste site in 2006, an outbreak likely associated with multiple sources in 2010, and an outbreak linked to recreational tubing on the Little Wolf River in 2015.

    “Peaks in incidence in Wisconsin corresponded to a known outbreak at a yard waste site in 2006 (20), an outbreak likely associated with multiple sources in 2010 (21), and an outbreak linked to recreational tubing on the Little Wolf River in 2015 (22).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [20] Pfister, 2011, Non-rural point source blastomycosis outbreak near a yard waste collection site., Clin Med Res source

      Not checked in the free run.

    • cites [21] Roy, 2013, A large community outbreak of blastomycosis in Wisconsin with geographic and ethnic clustering., Clin Infect Dis source

      Not checked in the free run.

    • cites [22] Koske SE, Kocharian A, Kazmierczak JJ, Gibbons-Burgener SN, Dieckman JL, Klos RF, Investigation of a large outbreak of blastomycosis caused by Blastomyces gilchristii among recreational river tubers, Wisconsin, 2015. Presented at: CSTE 2017 Annual Conference; Boise, Idaho, USA; June 4–8, 2017.

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    During 2007-2017, surveillance detected 2,111 blastomycosis cases across the five states, a mean of 192 cases per year.

    “During years for which data were available from all 5 states, 2007–2017, surveillance detected 2,111 cases, a mean of 192 cases per year.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Spodosols also occur widely in northern Michigan, where disease incidence was not elevated, and are less common in northern Minnesota, where incidence was higher.

    “However, spodosols also occur widely in northern Michigan, where disease incidence was not elevated, and are less common in northern Minnesota, where incidence was higher.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The average time of >1 month from symptom onset to diagnosis indicates delays in seeking healthcare, delays in diagnosis, or both.

    “The average time of >1 month from symptom onset to diagnosis indicates delays in seeking healthcare, delays in diagnosis, or both.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Most specimen types in the analysis were from bronchoalveolar lavage and lung and other tissue, which likely required biopsy.

    “Accordingly, most specimen types in our analysis were from bronchoalveolar lavage and lung and other tissue, which likely required biopsy.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The annual mean of <200 cases/year and hospitalization rate of 57% suggest that ≈110 patients are hospitalized each year from states where blastomycosis is reportable.

    “We found an annual mean of <200 cases/year; a hospitalization rate of 57% suggests that ≈110 patients are hospitalized each year from states where blastomycosis is reportable.”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Interpretationreasoning

    Blastomycosis is underdetected, even in states where it is reportable, and limited surveillance likely underdetects cases nationally.

    “The median time from symptom onset to diagnosis and the severity of illness suggest that surveillance underestimates the true number of cases.”
    • Also stated in: § Discussion · plain
      “Our results show that blastomycosis is underdetected, even in states where it is reportable”
    • Also stated in: § Discussion · hedged
      “Our findings indicate that blastomycosis likely is underdetected.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Blastomycosis is reportable in only five US states (Arkansas, Louisiana, Michigan, Minnesota, Wisconsin), so public health surveillance is limited.
    • Rests on an assumption: Physician awareness of blastomycosis is probably low in most parts of the United States.
    • Rests on an assumption: Acute blastomycosis illnesses can self-resolve before diagnosis.

  • May combine two claims.

    Interpretationown data

    Most blastomycosis cases occur sporadically, as outbreaks comprised <6% of cases overall.

    “However, outbreaks comprised <6% of cases overall, suggesting that most cases occur sporadically, which also is true for histoplasmosis and coccidioidomycosis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    More blastomycosis hospitalizations typically occur among men.

    “More blastomycosis hospitalizations typically occur among men (10,13), although a recent study found female sex was independently associated with death in blastomycosis patients with acute respiratory distress syndrome (14).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [10] Seitz, 2014, Incidence and trends of blastomycosis-associated hospitalizations in the United States., PLoS One source

      Not checked in the free run.

    • cites [13] Chu, 2006, Hospitalizations for endemic mycoses: a population-based national study., Clin Infect Dis source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Blastomycosis remains a rarely reported but severe disease in most areas where it is under public health surveillance.

    “In summary, blastomycosis remains a rarely reported but severe disease in most areas where it is under public health surveillance.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    Some states' surveillance systems underwent changes during the analysis period, resulting in inconsistent denominators in the pooled analysis.

    “Some states’ surveillance systems underwent changes during the analysis period; for example, data elements were added or removed, resulting in inconsistent denominators in the pooled analysis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Most blastomycosis cases are thought to occur in the midwestern, south-central, and southeastern states, in areas surrounding the Ohio and Mississippi River valleys, the Great Lakes, and the Saint Lawrence River.

    “In the United States, most blastomycosis cases are thought to occur in the midwestern, south-central, and southeastern states, in areas surrounding the Ohio and Mississippi River valleys, the Great Lakes, and the Saint Lawrence River.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [4] Benedict, 2015, Mycotic infections acquired outside areas of known endemicity, United States., Emerg Infect Dis source

      Not checked in the free run.

    • cites [5] McDonald, 2018, Notes from the field: blastomycosis cases occurring outside of regions with known endemicity—New York, 2007–2017., MMWR Morb Mortal Wkly Rep source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Study design and conductnone given

    Pooling surveillance data based on different blastomycosis case definitions is fundamentally problematic.

    “The limitations of our study include that pooling surveillance data based on different blastomycosis case definitions is fundamentally problematic; however, few other data sources would enable analyses of thousands of cases, which is helpful for studying this uncommon disease.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Combining data from different times in each state is an additional potential limitation.

    “Combining data from different times in each state is an additional potential limitation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    Wisconsin classified all blastomycosis cases as confirmed until September 2015, when their case definition changed to include confirmed and probable case classifications.

    “Wisconsin classified all cases as confirmed until September 2015, when their case definition changed to include confirmed and probable case classifications”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Another study found a decline in blastomycosis-associated deaths nationwide during 1990-2010.

    “Another study found a decline in blastomycosis-associated deaths nationwide during 1990–2010 (15); the reasons for the increase in deaths we observed during 2007–2017 are unclear but could reflect improvements in case follow-up, a decline in reporting of less severe cases, or other surveillance changes over time.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] Khuu, 2014, Blastomycosis mortality rates, United States, 1990-2010., Emerg Infect Dis source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductnone given

    Arkansas did not have a formal blastomycosis case definition, and Michigan did not have one until 2012.

    “Although blastomycosis was reportable in each state during the years included in this analysis, Arkansas did not have a formal case definition, and Michigan did not have one until 2012.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Blastomycosis often results in severe illness, even in previously healthy persons.

    “Blastomycosis often results in severe illness, even in previously healthy persons (9), but this observation might be influenced by underdetection of asymptomatic or milder, self-resolving disease.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] McBride JA, Sterkel AK, Matkovic E, Broman AT, Gibbons-Burgener SN, Gauthier GM. Clinical manifestations and outcomes in immunocompetent and immunocompromised patients with blastomycosis. Clin Infect Dis. 2020;ciaa276. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A recent study found female sex was independently associated with death in blastomycosis patients with acute respiratory distress syndrome.

    “More blastomycosis hospitalizations typically occur among men (10,13), although a recent study found female sex was independently associated with death in blastomycosis patients with acute respiratory distress syndrome (14).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Rush B, Lother S, Paunovic B, Mooney O, Kumar A. Outcomes with severe blastomycosis and respiratory failure in the United States. Clin Infect Dis. 2020;ciaa294. source

      Not checked in the free run.

20 of 20

  • The paper relies on this without support.

    Blastomycosis is reportable in only five US states (Arkansas, Louisiana, Michigan, Minnesota, Wisconsin), so public health surveillance is limited.

    “Public health surveillance for blastomycosis in the United States is limited because it is currently reportable in only 5 US states: Arkansas, Louisiana, Michigan, Minnesota, and Wisconsin.”

  • The paper relies on this without support.

    Physician awareness of blastomycosis is probably low in most parts of the United States.

    “because physician awareness of this generally uncommon disease probably is low in most parts of the United States”

  • The paper relies on this without support.

    Acute blastomycosis illnesses can self-resolve before diagnosis.

    “Because acute illnesses can self-resolve before diagnosis”

  • The paper relies on this without support.

    Blastomycosis is not nationally notifiable, so the Centers for Disease Control and Prevention does not routinely receive case reports from states where it is reportable.

    “Blastomycosis is not nationally notifiable, so the Centers for Disease Control and Prevention does not routinely receive case reports from states where it is reportable.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • In a survey of 4,441 blastomycosis cases in 5 US states from 1987 to 2018, 64% occurred in white persons, 17% in unknown race, 9% in black or African American persons, and 5% in Asian, Native Hawaiian, or other Pacific Islander persons.

    “In a survey reporting 4,441 blastomycosis cases in 5 US states from 1987 to 2018, 2,778 (64%) occurred in white persons, 740 (17%) in persons of unknown race, 406 (9%) in black or African American persons, and 193 (5%) in Asian, Native Hawaiian, or other Pacific Islander persons.”

    From Race and ethnicity: Risk factors for fungal infections? (2023) · cites this paper as [173]

  • Blastomycosis is endemic throughout much of the midwestern US, particularly along the Great Lakes and the Mississippi, Ohio, and Saint Lawrence River valleys.

    “It is endemic throughout much of the midwestern US [171,172], particularly along the Great Lakes and the Mississippi, Ohio, and Saint Lawrence River valleys [173,174].”

    From Race and ethnicity: Risk factors for fungal infections? (2023) · cites this paper as [173]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Female-sex hospitalization confidence interval differs between text and table

    Minor

    The text gives the lower bound of the 95% confidence interval as 1.06, whereas Table 3 gives it as 1.05.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Koske SE, Kocharian A, Kazmierczak JJ, Gibbons-Burgener SN, Dieckman JL, Klos RF, Investigation of a large outbreak of blastomycosis caused by Blastomyces gilchristii among recreational river tubers, Wisconsin, 2015. Presented at: CSTE 2017 Annual Conference; Boise, Idaho, USA; June 4–8, 2017.
  2. McCracken S, Signs K, Stobierski M. Evaluating blastomycosis disease reporting in Michigan’s disease surveillance system. Presented at: 2018 CSTE Annual Conference; West Palm Beach, Florida, USA; June 10–14, 2018.

Cited by

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Related

Authors
Benedict, K., Gibbons-Burgener, S., Kocharian, A., Ireland, M., Rothfeldt, L., Christophe, N., Signs, K., & Jackson, B. R.
Affiliations
Wisconsin Department of Health Services (US)
Corresponding author
Benedict, Kaitlin
ORCID
Venue
Emerging Infectious Diseases
Publisher
Centers for Disease Control and Prevention (CDC)
Published
2021-04
Volume
27
Issue
4
ISSN
  • 1080-6040 (ISSN-L)
  • 1080-6059
DOI
10.3201/eid2704.204078
PMC
PMC8007286
OpenAlex
W3135927290
Semantic Scholar
4933d8fca005463f05629ae5c272f668e64c2e03
Cited by
29
References
21
Citations by year
2026: 3 · 2025: 5 · 2024: 14 · 2023: 5 · 2022: 2
FWCI
3.78
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Emerging infectious diseases (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Medicine › Epidemiology › Fungal Infections and Studies
  • Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
  • Health Sciences › Medicine › Microbiology › Actinomycetales infections and treatment
Keywords
blastomycosis, disease surveillance, fungal infection, Blastomyces dermatitidis, United States
MeSH terms
Blastomycosis, Humans, United States, Wisconsin

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