Mapping the Landscape of Endemic Mycoses in India: Insights From a Systematic Review of Reported Cases Spanning 6 Decades (1960–2025)

Background: Endemic mycoses are caused by fungi inhabiting specific ecological niches. These infections remain underreported due to diagnostic challenges and limited awareness. This study aims to provide a comprehensive synthesis of endemic mycoses in India, focusing on their distribution, clinical presentation, and outcomes. Method: A systematic literature search was conducted to identify Indian studies on proven endemic mycoses from 1960 to August 2025. Case reports, case series, and observational studies with laboratory-confirmed diagnosis of endemic mycoses were included, based on the European Organization for Research and Treatment of Cancer/Mycoses Study Group Education and Research Consortium (EORTC/MSGERC) criteria. Probable and possible cases were excluded. Demographic, clinical, diagnostic, treatment, and outcome data were extracted and analyzed using descriptive statistics. Results: A total of 230 studies comprising 893 patients were included. Histoplasmosis (399, 44.7%), sporotrichosis (386, 43.2%), and talaromycosis (87, 9.7%) were the most common infections. Cases were reported from 28 Indian states and union territories. Histoplasmosis was widely distributed, whereas sporotrichosis was concentrated in sub-Himalayan belt, and talaromycosis in north-eastern India. Reports increased sharply after 2000, peaking during 2011-2020. Histoplasmosis and talaromycosis predominantly affected males and caused disseminated disease, whereas sporotrichosis showed female predominance and manifested as cutaneous forms. Human immunodeficiency virus (HIV) infection was strongly associated with talaromycosis. Misdiagnosis as tuberculosis occurred in 7.6% of cases. Mortality was highest in histoplasmosis and coccidioidomycosis. In histoplasmosis, amphotericin B followed by itraconazole reduced mortality significantly. Conclusions: Endemic mycoses in India are increasingly recognized, with distinct epidemiological and clinical patterns. Persistent misdiagnosis and varied outcomes emphasize the need for improved diagnostics, clinician awareness, and optimized antifungal treatment strategies.