From mushrooms to molds, fungal life on this planet is often overlooked - but has a big impact. In part two of this series, we meet a lung transplant patient whose life was turned upside down by a fungal infection, and the Duke doctor who treated him.
Dr. Ilan Schwartz spends his days treating infections most people will never hear about until one of them nearly kills someone they love. As an infectious disease specialist at Duke University, he works with patients whose immune systems are fragile and at high risk.
Over time, he has developed a clinical and research focus on fungal infections, particularly those caused by Histoplasma and Blastomyces, which originate in the lungs. Blastomycosis is a fungal infection caused by Blastomyces.
Blastomycosis, he explains, comes from the environment. People inhale spores found in soil, stirred up by something as ordinary as digging, gardening, or even a dog scratching in the dirt.
Once inside the lungs, the fungus can cause destruction and, in about a quarter of cases, spread to the skin, bones or brain. What makes it especially dangerous is that it can strike people who are previously healthy as well as those with weakened immune systems, Schwartz explains. One of his patients, Gerald Compton, became one of the most severe cases he has seen.
A former coal miner from Virginia, Gerald received a double lung transplant in February 2024. By late August the next year, his life seemed to be settling into a steady rhythm of recovery, until small, strange changes began to appear.
"He doesn't remember a lot leading back to how everything happened so quickly," his wife, Angie Compton, recalls. "I got home, and he said, 'Angie, I have a spot here on my chest, and I'm not sure what it's from.'"
Around the same time, Gerald began acting strangely. "He was getting disoriented," she says. "He would just say things out of the ordinary."
What made it so confusing was that everything else appeared normal - his blood pressure and oxygen levels were fine. But that soon changed. "By Sunday, he made it from the bed to the recliner, and he just felt terrible," Angie recalls.
A Rapid Freefall
When they arrived at Duke Hospital a few days later, Gerald was still able to walk into the clinic. But within hours, his condition deteriorated rapidly.
"They said it looked like pneumonia," Angie says. Overnight, it became far worse. "We weren't there probably thirty minutes until he was intubated and put on dialysis."
Gerald developed acute respiratory distress syndrome (ARDS), the most extreme version of pneumonia. "His lungs could no longer support his body," Schwartz said.
"His kidneys had shut down, and he couldn't breathe," Angie says. "It was really, really bad."
Biopsies confirmed what doctors suspected: Blastomycosis. Fortunately, Gerald had come to the right place.
"Blastomyces is an interesting fungus. It's part of a group of fungi we call dimorphic fungal pathogens, meaning they can grow in two different forms: mold or yeast. And we just happen to have two world experts on this group of pathogenic fungi here," said Joseph Heitman , chair of the Department of Molecular Genetics and Microbiology. Schwartz is one of them, he noted.
The Long Way Back
But with the help of Schwartz and aggressive treatment with three different antifungal medications, Gerald survived.
After 20 days in the ICU, he slowly improved. He began breathing on his own and eventually left the hospital. Today, Schwartz monitors him closely, along with a team of other Duke specialists. The Comptons often make the four-hour trip from Virginia to Durham for his care. Gerald will need antifungal medication for at least a year or possibly longer.
The treatment is lifesaving, but it comes with tradeoffs. The drugs have significant side effects and significant interactions with his transplant medication, Schwartz explains. Managing those risks requires careful monitoring and expertise.
His recovery, says Angie, is "really quite remarkable."
Gerald remembers little of the ordeal. What he does remember is the care. "That's the best treatment I've ever had in my life. Every nurse, every doctor, every one of them was super, super nice. I couldn't have asked for any better."
He's still rebuilding his strength. "I'm still weak," he says. "But other than that, I feel pretty good."
An Invisible Risk
What concerns both patients and doctors is how little most people understand about Blastomycosis, even among those who are most at risk.
"I suspect that the vast majority of people who are living in areas where the fungus resides in the soil are completely oblivious to the lurking threat," Schwartz says.
"I suspect that the vast majority of people who are living in areas where the fungus resides in the soil are completely oblivious to the lurking threat."
Ilan Schwartz, Duke Infectious Disease Specialist
Blastomyces is present in North Carolina, though less commonly than in states around the Great Lakes. Duke sees a few dozen cases each year, ranging from mild to fatal. Because symptoms can appear long after exposure, it's hard to know exactly where the fungus lives or who is most at risk.
"It really could be anybody," Schwartz says.
Looking back, Angie believes her husband's exposure came from mowing the lawn. "They said it comes from the ground," Gerald says. "I mowed two weeks before that. That's the only place I can think it could've come from."
Schwartz is careful to reassure patients about what can't be avoided. "You breathe it," Angie remembers him telling them. "You can't stay in a bubble. You still have to live."
Heitman noted that while Blastomyces historically has been found in the upper Midwest, "as the temperatures increase, the geographic range for these fungi is becoming broader," he says.
Why Fungal Research Matters
Fungal infections are especially difficult to treat because fungi share many cellular structures with humans.
Heitman notes an unmet medical need for new antifungal drugs, with the World Health Organization identifying 20 priority fungal pathogens that cause millions of deaths annually.
For decades, progress stalled, but that's changing. New antifungal classes are under development, including drugs that may be effective against the most severe infections.
Duke researchers are involved at every stage, from basic science to clinical trials. "At Duke, we have about a dozen people working on fungal pathogens. This is one of the world's major international centers for working on human fungal pathogens," Heitman says.
Still, funding remains a constant concern.
"I don't expect that you'll find many scientists who would state that the current funding climate is not something that concerns them," Schwartz says.
For Angie, the impact of that research is personal. She agreed to having Gerald's case shared for medical education. "We just hope something good can come from this for somebody else," she says.
Gerald's survival is a reminder that even the most ordinary places - backyards, fields - can hide deadly threats.
"It was very, very bad," Angie says. And yet, against the odds, he lived.
