Medical Mycology , 2024, 62 , myae015 https://doi.org/10.1093/mmy/myae015 Original Article Advance access publication date: 21 February 2024 A diverse spectrum of mycoses histologically diagnosed in Ghana: Insights from a 10-year retrospective study Bright Ocansey 1 ,* , Isaac Erskine 2 , Leonard Okine 3 , Daniel P otakey 2 , Pr ince P appoe-Ashong 4 , Isaac Sraku 4 , Solomon Quayson 2 , Japheth Opintan 4 , Chris Kosmidis 1 ,5 and David Denning 1 1 Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9NT, UK 2 Department of Pathology, Korle-Bu Teaching Hospital and University of Ghana Medical School, Korle-Bu, GA-221-1570, Ghana 3 Cellular Pathology Division, Ghana Standard Authority, Accra, GA-288-5605, Ghana 4 Department of Medical Microbiology, University of Ghana Medical School, Korle-Bu, GA-270-4330, Ghana 5 National Aspergillosis Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK *To whom correspondence should be addressed. Bright Katey Ocansey, PhD, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9NT, UK. Tel: + 44 7539311942; E-mail: obkatey91@gmail.com ; bright.ocansey@postgrad.manchester.ac.uk Abstract In Ghana, most laboratory diagnoses of se v ere m y coses are based on histopathology findings due to inadequate a v ailability of serology, culture, and molecular tests. The aim of this study was to evaluate the spectrum of mycoses diagnosed in Ghana. We retrospectively reviewed reports from 2012 to 2021 from three major pathology laboratories in Ghana to identify reports indicating the presence of fungal elements and diagnosis of a m y cosis, then e xtracted demographic, clinical history, site of infection, stain(s), used and diagnosed m y cosis details. Ov er the 10-y ear period, 107 cases were found. No apparent increasing and decreasing trend in the number of cases per year or in a period was observed. The age range of affected patients was from 4 to 86 years. Special stains for fungi were only used in 22 of 107 (20.6%) of cases. The most frequently affected site was the sino-nasal area (34%). Mycosis type was determined for 58 (54.2%) cases, comprising aspergillosis (21), candidiasis (14), dermatophytosis (6), mucormycosis (3), two cases each of chromoblastom y cosis, histoplasmosis, eum y cetoma, entomophthorom y cosis, sporotrichosis, and Malassezia infection and a single case each of cryptococcosis and deep on y chom y cosis. Of the 53 (49.5%) cases with presumptive diagnosis data, only seven (13.2%) had a pre-biopsy suspicion of mycosis. There is a wide spectrum of mycoses in Ghana, including endemic m y coses not pre viously reported. Impro ving the use of special fungal stains could increase yield and m y coses identification. Laboratory diagnostic capacity needs enhancement to complement histopathology in v estigations with serology, culture, and molecular methods. Lay summary In Ghana, diagnosis of m y coses is mainly based on histopathology findings. To appreciate the varied mycoses diagnosed, we reviewed the reports of major laboratories from 2012 to 2021 and found 107 cases including endemic, rare, and previously unreported cases with fungal stains unusually used. Ke y w or ds: epidemiology, Ghana, histopathology, mycosis, spectrum. c s s o o G l fi c m q h s M p d c D ow nloaded from https://academ ic.oup.com /m m y/article/62/3/m yae015/7612239 by U niversity of G hana user on 08 April 2024 Introduction Mycoses have gained significant attention in recent times as a major cause of morbidity and mortality globally. The re- cent launch of the first-ever WHO Fungal Priority Pathogen List and the additions of some subcutaneous mycoses to the WHO Neglected Tropical Diseases list has been instrumen- tal in championing efforts to improve the diagnosis of my- coses across the world.1 , 2 Nonetheless, the epidemiology of mycoses in several countries in Africa has not been exten- sively described. In Ghana, the only attempt previously was a modelling survey that estimated about 4% of the Ghana- ian populace is affected by major mycoses annually.3 The estimation limited its scope to the most common and se- vere mycoses comprising cryptococcal meningitis, Pneumo- cytis jirovecii pneumonia, disseminated histoplasmosis, in- vasive aspergillosis, chronic pulmonary aspergillosis, fungal asthma, invasive candidiasis, recurrent vulvovaginal candidi- asis, oral and esophageal candidiasis, mucormycosis, tinea Received: December 22, 2023. Revised: February 11, 2024. Accepted: February 2 © The Author(s) 2024. Published by Oxford University Press on behalf of The In Access article distributed under the terms of the Creative Commons Attribution-N which permits non-commercial re-use, distribution, and reproduction in any med please contact journals.permissions@oup.com apitis, and fungal keratitis. Furthermore, there is no specific urveillance programme for any mycosis in Ghana. The diver- ity of the mycoses diagnosed in Ghana and their causative rganisms is thus unclear. The present available data consist f case reports and small case series.3 , 4 Furthermore, a diagnostic laboratory gap analysis study in hana reveals inadequate capacity and established that most aboratory diagnoses of mycoses are based on histopathology ndings due to the absence of fungal culture and direct mi- roscopy methods and contemporary antigen–antibody and olecular tests.3 , 4 Moreover, histopathology is a critical re- uirement in confirming proven cases of mycoses. Although, istopathology cannot reliably identify all fungi to genus or pecies level, it can confidently classify some fungi such as ucorales, Coccidioides, Paracoccidioides, Sporothrix, Histo- lasma, and Blastomyces at least to family or genus level ue to characteristic features.5 Analysing laboratory data is a ommon method of evaluating the epidemiology of infectious 0, 2024 ternational Society for Human and Animal Mycology. This is an Open onCommercial License ( https:// creativecommons.org/ licenses/ by-nc/ 4.0/ ), ium, provided the original work is properly cited. For commercial re-use, https://doi.org/10.1093/mmy/myae015 mailto:obkatey91@gmail.com mailto:bright.ocansey@postgrad.manchester.ac.uk https://creativecommons.org/licenses/by-nc/4.0/ mailto:journals.permissions@oup.com 2 Ocansey et al. d i G v c c a t M T r l n p A i t g s v h m p M t i t a a t f s g t d m t s a a t a p i u m u w c R O 1 e T ( d p n T f 2 i p a T K s 5 r d c s M i c s t s t s t s ( c c m fi d w a a t s e a D T h 2 c h p t e m e c c t f e G a f w D ow nloaded from https://academ ic.oup.com /m m y/article/62/3/m yae015/7612239 by U niversity of G hana user on 08 April 2024 iseases and for mycoses, reviewing histopathology data s crucial, particularly in many African settings such as hana.3 , 4 , 6 , 7 A review of histopathology reports has been pre- iously used to evaluate the epidemiological parameters in- luding prevalence and trends of single or spectrum of my- oses in some African countries such as Nigeria,8–10 Togo,11 , 12 nd recently Uganda.13 The aim of this study was to evaluate he spectrum of histologically diagnosed mycoses in Ghana. aterials and methods his was a multi-centre retrospective study conducted to eview the histopathology reports of three major pub- ic histopathology laboratory services providers in Ghana, amely the Department of Pathology, Korle-Bu Teaching Hos- ital (KBTH); Cellular Pathology Division, Ghana Standard uthority (GSA) and J.M Wadhwani Department of Anatom- cal Pathology, 37 Military Hospital (37 MH) from 2012 o 2021 to identify reports indicating the presence of fun- al elements (structures from fungi) or diagnosis of myco- is. These histopathology laboratories provide diagnostic ser- ices to the hospitals they are attached to as well as many ospitals from all regions across Ghana. KBTH is the pre- ier and national referral hospital. The histopathology re- ort records were manually reviewed at the KBTH and 37 H. At the GSA, reports were electronically searched using he following keywords: fungi, fungal element(s), fungal bod- es, hyphae, yeast, pseudohyphae, and spores. Secondarily, dis- inctive morphological appearance of fungal elements such s spherules, sclerotic/muriform/medlar/copper penny bodies nd grains were looked for. All histology reports that indicate he presence of fungal elements and/or diagnosis of fungal in- ections were included irrespective of underlying condition or ite of sample collection. Histology reports that mention fun- al infection as a differential diagnosis and without reporting he presence of fungal elements were excluded. The age, gen- er, clinical history, site of infection, and clinical suspicion for ycosis were extracted from laboratory records. Additionally, he type of histological stains used, fungal elements or features een, and mycoses diagnosed by examining pathologists were ll extracted. The study generally did not require full ethical clearance, s it only involved a review of laboratory records and no pa- ients were involved, or no further analysis was conducted on rchived tissue blocks. However, appropriate administrative ermission was obtained from all three institutions involved n the study. Data were statistically analyzed using the Statistical Prod- cts and Services Solutions (SPSS), version 25 (IBM Corp, Ar- onk, New York, USA). We summarized statistics of variables sing frequencies, percentages, median and interquartile range here applicable. The distribution of cases according to spe- ific years for each centre was analyzed. esults ver the 10-year study period from 2012 to 2021, we found 07 cases with histopathological reports revealing the pres- nce of fungal elements or mycoses diagnosis ( Supplementary able 1 ). The cases comprised of 50 (46.7%) males and 57 53.3%) females. Age ranged from 4 to 86 years with a me- ian age of 41 years (interquartile range, 31–55). These com- rised 91 deep mycoses (affecting deep-seated tissue and inter- al organs) and 16 superficial and muco-cutaneous mycoses. he number of cases per year among the three centres ranged rom 3 to 16 with the highest number of cases recorded in 013 (Fig. 1 ). There was no apparent increasing and decreas- ng trend in the number of cases observed over the 10-year eriod at all the three laboratories, except that no mycoses di- gnosis was reported from 37 MH between 2015 and 2021. he majority (92.5%) of the cases were from the GSA and BTH, accounting for 60 (56.1%) cases and 39 (36.4%) re- pectively. The determination of the type of mycosis was made for 8 (54.2%) cases (Fig. 2 ). The spectrum of mycosis was elatively broad and included aspergillosis (21 cases), can- idiasis (14 cases), dermatophytosis (six cases), mucormy- osis (three cases), and chromoblastomycosis, histoplasmo- is, eumycetoma, entomophthoromycosis, sporotrichosis, and alassezia infection (two cases each). The remaining mycoses mplicated were cryptococcosis and onychomycosis, a single ase each. Clinical information was available for 53 cases, but only even (14.6%) had a clinical suspicion for mycosis showing hat many of the cases were probably an unexpected diagno- is. Regarding the sites involved, the nose or nasal regions were he commonest with 34 cases mostly affected by aspergillo- is (18 cases) and mucormycosis (three cases), followed by he gastrointestinal tract (19 cases), limbs (17 cases), and the kin (seven cases); other body sites had less than five cases Supplementary Table 1 ). A major observation made in this study was that spe- ial fungal stains were rarely used. Special stains used in- luded periodic acid-Schiff (PAS) (16 cases), Grocott-Gomori ethenamine silver (GMS) (three cases), and an unspeci- ed special stain (three cases) with the remaining 85 cases iagnosed on haematoxylin and eosin (H&E) alone. There ere both regular fungal morphologies (yeasts and hyphae) nd special fungal structures such as sclerotic bodies (Figs. 3 nd 4 ). Generally, the majority (87 cases) of the fungal struc- ures detected was not adequately described with several canty descriptions such as fungal bodies, fungal cysts, fungal lements, hyphae, and yeast. This observation was consistent mong the three centres. iscussion he study highlights the spectrum of mycoses diagnosed by istopathology in Ghana. Over the 10-year study period, from 012 to 2021, there were 107 histopathology-diagnosed my- oses recorded, including 91 deep mycoses among the three istopathology laboratories. There were diverse mycoses re- orted and this finding offers a remarkable narrative about he epidemiology of mycoses in Ghana, particularly deep and ndemic mycoses. This study reveals a broader spectrum of ycoses in Ghana including some uncommonly reported and ndemic mycoses.3 These include mostly subcutaneous my- oses such as eumycetoma, chromoblastomycosis, sporotri- hosis, and entomophthoromycosis. In a review of myce- oma in West Africa, there was no indigenous case reported rom Ghana.14 Only two studies have previously reported ntomophthoromycosis, specifically, basidiobolomycosis, in hana.15 , 16 Enhanced immigration and international travel re likely to further increase the diversity of mycoses in the uture.7 , 14 The nasal region was the site frequently diagnosed ith deep mycosis, probably because samples from these areas https://academic.oup.com/mmy/article-lookup/doi/10.1093/mmy/myae015#supplementary-data https://academic.oup.com/mmy/article-lookup/doi/10.1093/mmy/myae015#supplementary-data Medical Mycology , 2024, Vol. 62, No. 00 3 Figure 1. Mycoses diagnosed by histopathology from 2012 to 2021. Figure 2. Number of cases of different types of m y coses diagnosed. I i s c s f t o w v o i n D ow nloaded from https://academ ic.oup.com /m m y/article/62/3/m yae015/7612239 by U niversity of G hana user on 08 April 2024 are relatively easy to collect in comparison to sampling inter- nal organs such as lungs where most severe mycoses originate or occur. The fact that most of the cases were seen at the KBTH and GSA is probably due to long-serving pathology consultants with at least 30 years of experience supporting those centres. Additionally, these centres process samples from several pri- vate and public hospitals within and outside the Greater Accra region and from all regions of the country, unlike the 37 MH which seldom receives outside samples. The use of fungal stains is strongly recommended by guide- lines and experts to improve the detection of fungal elements or structures in tissues during histopathological analysis.5 , 17 n the present study, we observed that major fungal stains, that s, PAS and GMS were rarely used. Other special fungal stains uch as Alcian blue (commonly for Cryptococcus spp.), mu- icarmine (commonly for Cryptococcus spp.,15 Blastomyces pp. and Rhinosporidium spp.), and Fontana-Masson (mainly or dematiaceous fungi) were not used at all.18 Attempting o diagnose mycoses with only H&E as noted in 79% cases f the study, is generally difficult and frequently associated ith reduced sensitivity. Although fungi can be seen with con- entional H&E staining, special stains enhance the detection f fungi in tissues. These stains also allow for the narrow- ng identification of possible aetiologies and aid in prelimi- ary diagnosis. The diverse ways of describing and reporting art/myae015_f1.eps art/myae015_f2.eps 4 Ocansey et al. Figure 3. H&E-stained section of a left antral mass from a 55-year-old female with epistaxis and chronic headache showing regular acute branc hing dic hotomous sept ate hyphae t ypical of Aspergillus species. Figure 4. PAS-stained section of a left foot infected ganglion from a 49-year-old male showing a ring of aggregates of pigment-producing and double-contoured spherical str uct ures known as sclerotic bodies which are consistent with chromoblastom y cosis. f a l c o g d o m f f o b r v d w i t c n d f c o d i a a T t u e t c f L A c c l s p f t c d S S l A T L A W s H T a s t U i t A B a P o M & D ow nloaded from https://academ ic.oup.com /m m y/article/62/3/m yae015/7612239 by U niversity of G hana user on 08 April 2024 ungal structures including the use of broad descriptions such s yeasts, hyphae, fungal bodies, and fungal elements offer imited diagnostic benefits to enable appropriate clinical de- isions. Otherwise, a detailed description of fungal structures r elements could provide hints to clinicians on likely aetiolo- ies which could play an important role in making treatment ecisions. In the era of growing antifungal resistance and expansion f rare species of moulds and yeasts as causative agents of ycoses, accurate identification of aetiological agents of in- ections has become more important now than ever. Identi- ying the right cause of infection allows for the right choice f antifungal medications to ensure the right treatment for etter clinical outcomes. In view of this, in the absence of outine fungal culture, proceeding with further molecular in- estigations on tissue blocks in which histopathology analysis emonstrated the presence of fungal elements will go a long ay to influence drug options while providing data on emerg- ng or rare species causing human infections.19 , 20 This is ex- remely important in the Ghanaian clinical setting particularly onsidering the critical role of histopathology in aiding diag- osis and in most instances the commonly available means of iagnosis.4 Despite the common use of molecular methods on ormalin-fixed-paraffin-embedded to aid species-level identifi- ation in many clinical mycology laboratories, the methodol- gy or procedures of available assays are not extensively stan- ardized and not available in many African settings.21–25 Overall, the study retrospectively evaluated histopatholog- cally diagnosed mycoses in Ghana. The findings highlight possible underdiagnosis, low index of clinical suspicion nd diverse mycoses including a few not previously reported. here is a need to improve awareness among clinicians, sensi- ize pathologists, support histopathology analysis with molec- lar assays for accurate identification of fungal pathogens and xplore antigen–antibody tests and cultures. Finally, prospec- ive epidemiological studies are recommended to better appre- iate the burden of the major mycoses outlined particularly ungal rhinosinusitis. imitations drawback of the study is that patients’ medical records ould not be accessed to obtain relevant symptoms, detailed linical history and examination findings, findings from other aboratory and medical imaging investigations, final diagno- is, management approach, and outcomes to confirm if the resence of fungi in histological samples truly indicated in- ection and not colonization or contamination. Additionally, he tissue blocks and sections were not further examined to onfirm the identity of the genus or species of fungi reported uring histological examination. upplementary material upplementary material is available at Medical Mycology on- ine. c kno wledgments he authors are grateful to the Heads of the three Pathology aboratories involved in the study: Dr Afua Abrahams, Prof. gyeman Badu Akosa, and Lt Col (Dr) Frederick Hobenu. e are extremely appreciative of the support of the technical taff of the Histopathology Laboratories especially Andrew ooper, Joseph Nyadia, and Emmanuel Ametepe (Korle-Bu eaching Hospital), Felix Manu (Ghana Standards Authority), nd Irene Padi (37 Military Hospital) for their varied roles in upporting the identification of positive cases. The contribu- ions of Benjamin Otoo (University of Wisconsin, Madison, SA) and Pious Appiah (University of Ghana Medical School) n assisting with the manual review of laboratory reports at he KBTH are duly acknowledged. uthor contributions right Ocansey (Conceptualization, Data curation, Formal nalysis, Funding acquisition, Investigation, Methodology, roject administration, Resources, Visualization, Writing – riginal draft), Isaac Erskine (Data curation, Investigation, ethodology, Validation, Visualization, Writing – review editing), Leonard Okine (Data curation, Formal anal- art/myae015_f3.eps art/myae015_f4.eps https://academic.oup.com/mmy/article-lookup/doi/10.1093/mmy/myae015#supplementary-data Medical Mycology , 2024, Vol. 62, No. 00 5 7 8 9 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 D ow nloaded from https://academ ic.oup.com /m m y/article/62/3/m yae015/7612239 by U niversity of G hana user on 08 April 2024 ysis, Investigation, Methodology, Resources, Writing – re- view & editing), Daniel Potakey (Data curation, Investiga- tion, Methodology, Resources, Writing – review & editing), Prince Pappoe-Ashong (Data curation, Investigation, Method- ology, Resources, Writing – review & editing), Isaac Sraku (Data curation, Investigation, Methodology, Writing – review & editing), Solomon Quayson (Data curation, Investigation, Methodology, Resources, Writing – review & editing), Japheth Opintan (Investigation, Methodology, Project administration, Supervision, Writing – review & editing), Chris Kosmidis (Conceptualization, Formal analysis, Investigation, Method- ology, Project administration, Supervision, Validation, Writing – review & editing), and David Denning (Conceptualization, Formal analysis, Funding acquisition, Investigation, Method- ology, Project administration, Supervision, Validation, Writing – review & editing) Funding This study was supported by the C ARIGEST S A as part of the ‘Epidemiology of Invasive Fungal Infections in Ghana/West Africa’ research award to D .D . which includes a studentship award to B.O. C ARIGEST S A did not play any role in the design, implementation, and analysis of the study. Declaration of interest The authors declare no conflict of interest. References 1. Hay R, Denning DW, Bonifaz A et al. The diagnosis of fungal ne- glected tropical diseases (Fungal NTDs) and the role of investiga- tion and laboratory tests: an expert consensus report. Trop Med Infect Dis . 2019;4: 122. 2. WHO. WHO fungal priority pathogens list to guide research, de- velopment and public health action. 2022. Accessed December 30, 2022, https:// www.who.int/ publications- detail- redirect/97892 40060241 . 3. Ocansey BK, Pesewu GA, Codjoe FS, Osei-Djarbeng S, Feglo PK, Denning DW. Estimated burden of serious fungal infections in Ghana. J Fungi . 2019; 5: 38. 4. Ocansey BK, Dadzie EA, Eduful SK et al. Improving awareness, di- agnosis and management of invasive fungal infections in Ghana: establishment of the Ghana Medical Mycology Society. Med My- col . 2022; 60: myac069. 5. 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This is an Open Access article distributed under the terms of -nc/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any permissions@oup.com https://www.who.int/publications-detail-redirect/9789240060241 https://doi.org/10.1016/S2666-5247(21)00190-7 https://gaffi.org/africa-diagnostic-reports/ https://doi.org/10.9734/BJMMR/2015/19301 https://doi.org/10.1128/JCM.00328-14 https://creativecommons.org/licenses/by-nc/4.0/ mailto:journals.permissions@oup.com Introduction Materials and methods Results Discussion Supplementary material Acknowledgments Author contributions Funding Declaration of interest References