Pulmonary fungal infections in the age of biologics and climate change

PURPOSE OF REVIEW: This review examines the evolving epidemiology of invasive fungal infections, with emphasis in pulmonary presentations, in the context of climate change and the expanding immunomodulatory therapy use. RECENT FINDINGS: Fungal infections represent a growing global health threat, with epidemiological patterns increasingly extending beyond traditional immunocompromised populations. Climate-driven thermal adaptation and geographic range expansion of endemic fungi, particularly Coccidioides and Histoplasma species, are exposing immunologically naive populations to infection. The higher use of new biologic therapies (IFNγ inhibitors, immune checkpoint inhibitors, CAR-T cells) is growing cohorts of patients with selective immunosuppression/immunomodulation who exhibit distinct fungal infection susceptibility patterns compared to traditional immunocompromised populations. Additionally, severe respiratory viral pandemics have demonstrated that acute viral pneumonia - independent of underlying immunosuppression - constitutes a significant risk factor for secondary invasive fungal diseases, as evidenced by IAPA and CAPA outbreaks. These shifts are occurring in parallel to increasing azole resistance and rising Pneumocystis pneumonia incidence in non-HIV populations, collectively challenging surveillance strategies, diagnostic algorithms, and therapeutic approaches. SUMMARY: This review synthesizes current evidence on how climate-mediated geographic expansion, biologic-associated immunosuppression, and virus-associated fungal infections are redefining populations at risk for pulmonary fungal infections.