From mushrooms to molds, fungal life on this planet is often overlooked - but has a big impact. In this series, we dive into fungal research across Duke, a growing area of strength for the university.
For people infected with TMVII , a newly emerging sexually transmitted fungal infection, symptoms can be painful, persistent, and disruptive.
Although identified three years ago, TMVII, or Trichophyton mentagrophytes genotype VII, is now being seen more frequently in the United States. Patients can develop lesions that are moist, inflamed, very red, and produce pus, according to Patricia Peterson , a postdoctoral associate in Duke University School of Medicine 's Heitman Lab , which focuses on human fungal infections. "They can be extremely uncomfortable," said Peterson.
Peterson is part of a Duke University team building a public-health response to a disease that is difficult to recognize, difficult to diagnose and under-reported.
TMVII belongs to a fungal family that causes common conditions such as ringworm and athlete's foot. However, researchers say this strain is different, appearing unusually adapted to genital skin.
Peterson's role is to study TMVII in the laboratory and help researchers better understand the organism. Other Duke collaborators include infectious disease physician-scientist Dr. Thuy Le and Duke Global Health Institute postdoctoral researcher Tom Carpino .
Le is contributing her expertise in fungal and infectious diseases. Carpino is focused on the public health response and building partnerships among researchers, healthcare providers, community organizations and public health agencies. Together, they have assembled a network that includes CDC scientists, state health departments and international collaborators.
Although roughly 100 confirmed cases have been documented in the United States by state health departments, Carpino believes there are likely more.
"The surveillance systems are poor. Diagnostics are poor. Education about this is poor," Carpino said. But, he added, "I'm optimistic we can work in partnership with our public health leaders to address these challenges."
Duke Takes on an Emerging Threat
Duke researchers became involved when Carpino brought TMVII to the attention of Dr. Chris Beyrer , director of the Duke Global Health Institute.
"The science is just beginning to emerge, and (Carpino) asked me if I thought it would be a good idea to get involved and take this on," Beyrer said. "And I said, absolutely. This is precisely the kind of thing that we should be doing."
The first U.S. case was reported in New York in 2024 . Since then, cases have been reported in at least nine other states, including Minnesota and Washington State .
Diagnosing TMVII is challenging because many clinicians are unaware of its existence. which can lead to misdiagnosis or inappropriate treatment that can worsen symptoms or cause further spread, says Le. Once diagnosed, it can be treated with antifungal pills, but it can take up to 12 weeks, and if treatment is stopped early, it can recur.
Confirming TMVII requires a skin scraping, a fungal culture, and often specialized genetic testing. Only a limited number of laboratories perform the advanced testing required to specifically identify TMVII. Duke is among them. Making diagnosis even more difficult is that the culture needs time to grow - as long as four weeks, according to Le.
For one patient who didn't want to be identified, symptoms began unexpectedly and lingered for more than a year before the correct diagnosis was made.
"I experienced some swelling. I thought it was because I swam in a lake and didn't have a proper swimsuit," he said. "And I was wearing it all day."
The patient and a pharmacist thought it was a yeast infection, and he was prescribed clotrimazole, an antifungal cream. That eased the symptoms, but it still did not go away completely. A physician assistant later gave him fluconazole tablets, but those didn't help either.
He eventually saw an LGBTQ-focused primary care provider who was familiar with TMVII and prescribed the proper medication, terbinafine.
"For me, it was like a miracle," he said. "It was like this thing I was stressed out about for over a year. Boom, I take the medicine and it's gone. I'm back to normal."
A Disease That's Easy to Miss
For Carpino, one of the most immediate challenges was awareness. He recognized that improving communication would be necessary to any public health response. Working with colleagues at Duke and the CDC, he helped develop educational materials for healthcare providers, public health partners and participants in Duke's HIV-related research studies, translating evolving scientific knowledge into practical information that communities could use.
That communication effort became one of the first visible outcomes of the collaboration.
"I wanted fact sheets and information, both for the people participating in our studies, but also for providers," Beyrer said. "Tom developed those, and we worked on them with the Centers for Disease Control."
Duke's outreach materials helped fill an early gap, providing clinicians and community organizations with guidance at a time when many healthcare providers had never heard of TMVII.
According to Le, one reason the infection may be underdiagnosed is that it often resembles more familiar skin conditions.
"Clinicians think this is like dermatitis and give steroids, and that's the wrong treatment, so they get worse and come back," Le said.
Patients may also be misdiagnosed with psoriasis or other inflammatory skin disorders before clinicians recognize the possibility of a fungal infection. That creates a cycle that Le and her colleagues are working to break. By helping frontline providers recognize the symptoms of TMVII, they hope to shorten the time between infection and treatment.
Connecting Research and Public Health
Peterson, a fifth-year postdoc, sees her role as communicating the science to epidemiologists and public health professionals. "The project is still in its infancy, so we're still figuring out how all of those collaborations will continue to develop," says Peterson.
Peterson is collecting TMVII samples and bringing them into the lab to study their characteristics and behavior. "This is new research that hasn't been done before," she said.
"TMVII represents exactly the kind of emerging infectious disease where early scientific investment can have an outsized impact."
R. Keith Reeves, director of the Duke CFAR Developmental Core
The project also provides Peterson with the opportunity to demonstrate her ability to secure funding. She recently secured a pilot grant from the Duke Center for AIDS Research , an award intended for new investigators who have not yet received major NIH funding as principal investigators.
"TMVII represents exactly the kind of emerging infectious disease where early scientific investment can have an outsized impact," said R. Keith Reeves, director of the Duke CFAR Developmental Core.
"While we are just beginning to understand TMVII biology, we know that people living with HIV are disproportionately affected by fungal diseases, making this a critical area of investigation for the Duke CFAR."
Searching for Answers
Many questions remain unanswered. Researchers still do not know exactly why TMVII evolved a preference for genital skin, how long it can persist on surfaces or whether antifungal resistance could emerge in the future.
Duke's team believes that answering those questions will require close collaboration among laboratory science, clinical medicine and public health.
"When you have an outbreak like this that's particularly affecting a community, I think you have a responsibility to really provide communities with information that they can act on to protect themselves," Beyrer said.
