**3. Knowledge gap**

The prevalence of histoplasmosis in Africa is unclear. Consequently, the disease's burden is underestimated. The largest rate of HIV infection, which increases the risk of histoplasmosis, is found in Africa [16]. Whereas the Western world has advanced technologies to diagnose histoplasmosis, it's not the same case in Africa. Thus, there is a general knowledge gap among health workers in Africa to diagnose histoplasmosis. Pulmonary histoplasmosis could be mostly misdiagnosed as pulmonary tuberculosis since it presents with similar clinical presentations. On the same note, histoplasmosis skin test surveys done in Africa indicated a 0–35% positive rate which proves there is an existing unknown burden of histoplasmosis [3]. As a result of clinical signs that are similar to TB, histoplasmosis is frequently mistaken as TB. Because histoplasmosis and tuberculosis (TB) present clinically similarly, some misdiagnoses may occur due to a lack of diagnostic resources. Both pulmonary TB and chronic pulmonary histoplasmosis have similar signs and symptoms, such as malaise, fever, lethargy, cough, and sputum production. However, sputum production, weight loss, and night sweats are less common in histoplasmosis patients than in TB. Chronic pulmonary histoplasmosis frequently progresses to pulmonary insufficiency at some point. Histoplasmosis rarely kills if untreated in immune-competent people, unlike TB in an advanced stage [1].

Studies comparing TB with histoplasmosis in the presence of HIV infection found that while the two diseases have many traits, with the majority of publications concentrating on disseminated Hcc infection, however, there are also important and substantial differences between the two diseases [11]. Disseminated histoplasmosis is common in the HIV/AIDS context, typically with lung involvement, but other clinical signs are more apparent, most prominently diarrhea and other gastrointestinal symptoms, skin lesions, and pancytopenia that vary by region. In 8–15% of cases, there has been evidence of coinfection with histoplasmosis. Reticulonodular lesions, many pulmonary nodules, hilar and mediastinal adenopathy, and advancing fibrosis are further characteristics.

Patients that are misdiagnosed with tuberculosis instead of histoplasmosis due to clinical similarities [17, 18] frequently receive presumptive anti-tuberculosis therapy, even when tuberculosis has not been diagnosed. The patients eventually pass away from what is most likely disseminated histoplasmosis (DH), and postmortem tissue samples may ultimately reveal the fungus infection [19]. Despite not being on the World Health Organization's official list, Hcd histoplasmosis is regarded as a neglected tropical illness. Since the first report in 1952, about only 400 Hcd cases have been documented;

nevertheless, due to the small number of case series, the epidemiologic and clinical traits as well as the best therapeutic therapy are still unknown [7]. As previously mentioned, there are few options for laboratory diagnosis in low-income countries, and 55% of cases may only be determined through direct inspection or histological study of clinical specimen(s). As a result, several diagnoses are in doubt [7].

According to studies, the frequency of Hcd infection is likely underestimated since cases are frequently ignored, particularly in developing countries with limited incomes. As a result of the disease's very pleiomorphic clinical presentation, it ought to be considered quite often. The prevalence of HIV coinfection (20% of patients) significantly alters this clinical picture. Most diagnoses are made through direct examination, which calls for specialized laboratory supplies and microscopist abilities that aren't usually available in Africa.

There is an urgent need for more precise and user-friendly diagnostic tools to confirm diagnoses and distinguish between Hcd and Hcc disorders, both of which are prevalent on the African continent. When seen under a direct microscope, Histoplasma var. duboisii typically stands out from Hcc due to the abundance of big yeasts it displays.
