Like any science fiction show worth its mettle, HBO hit The Last of Us has its roots in reality. Set in a post-apocalyptic world, a fungal infection called Cordyceps has wiped out much of humanity. It’s a little dystopian, to say the least. Can we dismiss the story as plain fantasy, or should we take heed of this ominous premonition?

Yes, it’s true, Cordyceps is a real-life fungus, and yes, it can induce zombie-like symptoms in its prey. The good news? You don’t need to start packing for the end of the world just yet. In reality Cordyceps only infects insects; it poses no real risk to humans.

Events depicted in The Last of Us use a healthy dose of artistic license, but they shine a light on the potential dangers of fungal infections and the importance of effective treatments. There are other fungal species around the world that can affect humans, sometimes with devastating outcomes.

Rare Disease Day is an opportunity to raise awareness of lesser-known diseases that affect people all around the world. Most have a genetic origin, but they can also be caused by types of infections, allergies, or cancers. So while Cordyceps is making headlines, we’re slightly shifting focus to a few other fungal infections you might not have heard of: invasive aspergillosis, mucormycosis, and coccidioidomycosis.

A disease is rare if it affects less than 1 in 2,000 people. With far fewer respective cases around the world annually, it’s surprising that the fungi causing these infections can be found pretty much everywhere. They’re in the ground we walk on, air we breathe, and food we eat.

The fungi are harmless to the vast majority of people. However, if their tiny seeds (called ‘spores’) enter the body of someone with a pre-existing condition or weakened immune system, they can cause infection. People with low immune defences (e.g., due to an autoimmune disease, leukaemia, or a serious lung disease), and those who are immunocompromised (e.g., after chemotherapy or after receiving an organ or stem cell transplant) are most at risk. When the spores penetrate bodily tissues, the infection is known as ‘invasive’.

Unfortunately, invasive fungal infections are becoming increasingly difficult to treat due to the rise of resistance, which is partly driven by overuse and/or inappropriate use of antifungal medicines. Climate change, international travel and trade, and a lack of drug candidates in the clinical pipeline are contributing factors, too.  

In an effort to galvanise the global response, last year the World Health Organization (WHO) developed the first-ever list of fungal pathogens posing the greatest threat to human health. Those in the highest-ranking group have critical public importance: Cryptococcus neoformans, Aspergillus fumigatus, Candida auris, and Candida albicans.

Despite growing concern and calls for action, fungal infections receive very little attention and resources. In the UK, there is currently no national consensus on best-practice strategy, and only 11% of acute NHS Trusts report having a dedicated programme to grapple with antifungal resistance. It’s a stark contrast to the 98% with equivalent arrangements in place for antibiotic resistance.  

Reassuringly, resistance to antifungal drugs is not yet as common as with antibiotics. To stop the spread, the best approach is following a set of principles known as ‘antifungal stewardship’. That means being a guardian of antifungal use and putting judicious measures in place.

Often, a first step for hospitals is establishing a multidisciplinary team of healthcare providers. Each member has a clear and defined role, working together, ensuring effectiveness, and bringing together expertise. It’s a powerful concept that can (and possibly, should) be applied to all collaborative professional relationships: information sharing across a group with different skills, to achieve a common goal.

At Langland, we live and breathe this philosophy. As a team, we value each other’s expertise and experience. We embrace different perspectives and cross-discipline thinking as part of our everyday, so we can create healthier futures together.  

Through united effort, we still have a chance to control rising antifungal resistance. The popularity of The Last of Us demonstrates that pop-culture shouldn’t be dismissed in this fight. In fact, if we are to protect ourselves and our communities, perhaps TV shows like this offer an opportunity for genuine, more obscure issues to enter the cultural zeitgeist. On Rare Disease Day, let’s spread awareness, not resistance.

Further reading

• Centers for Disease Control and Prevention. Fungal Diseases. Available from: https://www.cdc.gov/fungal/diseases/mucormycosis/risk-prevention.html. Accessed February 2023.
• GOV.UK Department of Health & Social Care. The UK Rare Diseases Framework. Available at: https://www.gov.uk/government/publications/uk-rare-diseases-framework/the-uk-rare-diseases-framework. Accessed February 2023.
• NHS England Antifungal Stewardship Implementation Pack. Available at: https://www.england.nhs.uk/wp-content/uploads/2019/03/PSS1-meds-optimisation-trigger-5-antifungal-stewardship-implementation-pack-v7.pdf. Accessed February 2023.
• World Health Organization. WHO fungal priority pathogens list to guide research, development and public health action. Available at: https://www.who.int/publications/i/item/9789240060241 Accessed February 2023.