When in a coma, some patients are able to maintain auditory connection to the world outside their unconscious space, hearing loved ones, medical staff or music playing softly. Caleb Fogal remembers nothing of the sort; the day before doctors placed him into a medically induced coma is lost to him entirely.
“I don’t even remember having difficulty breathing,” he said. “I don’t remember anything that followed for a good two weeks.”
Initially dismissed as a muscle tear, Fogal was unalarmed when a firm abscess appeared in his right elbow in September 2023. He had not encountered any major medical issues previously, then 21 years old and in his fourth year at Carleton University in Ottawa. He was healthy by all accounts. But when the lump began causing immense pain, he decided to seek medical help.
The diagnosis didn’t come easily. Fogal was prodded by doctors’ questioning as often as he provided samples for testing. It took 12 days of biopsies, culture tests and medical interrogation before the cause was identified: blastomycosis, a rare, naturally occurring and potentially fatal fungal infection.
Almost immediately, his condition worsened.
Caleb Fogal has fully recovered from a near-fatal blastomycosis infection. Reports of the rare disease are becoming more common in Ontario — and climate change might be driving the increase. Photo: Kamara Morozuk / The Narwhal
There is a large deficit of data surrounding blastomycosis, making it hard for experts to track and address. In Canada, researchers are still inquiring if the infection is endemic or hyperendemic — meaning it’s even more persistent — to certain areas of certain provinces. Currently, only Ontario and Manitoba consider the infection reportable, with public health authorities notified whenever a diagnosis is made.
“We haven’t properly mapped Ontario for blastomycosis, yet,” Emily Acheson, a spatial epidemiologist with the Public Health Agency of Canada, said. “We are largely depending on detecting cases, so if cases go understudied or they’re just not being reported, it’s really hard for us to gauge areas that are more high risk.”
In order to better understand the fungus proactively, Acheson said regular and more accurate soil testing would be needed on top of tracking cases in humans.
“Unfortunately, this particular fungus is very, very hard to detect in the environment using soil samples,” she said. “There are tests available in the soil that we can use, but it’s very hard to isolate and it can be very dodgy.”
In short: if we’re not looking for it, we’re unlikely to find it — and even when we are, the data is lacking. “It’s something that we really do need to study more actively and quantify,” she added. As blastomycosis is still a rare infection, it lacks the profile of a larger or more immediate issue that attracts resources — such as COVID-19.
Acheson specializes in disease ecology, the study of interactions between disease-causing pathogens and their environments. She has been working over the past few years to track the spread of this particular fungus and its potential subsequent infection.
Infectious fungi like blastomyces have historically been limited by cool climates, Acheson explained. “The barrier that’s been keeping these fungi out of Canada for so long — the fungi specifically that are making people sick … was really harsh winters,” she said. “It used to keep these fungi either down or even kill them.”
But with milder winters and spring seasons bringing more rain, that natural barrier is beginning to falter, Acheson said. As she put it, today’s environment is offering “Goldilocks conditions” for the fungus to not only survive, but thrive.
For an infection like blastomycosis, and a case like Fogal’s, time is of the essence: an early diagnosis is life-saving. In Canada, the rate of mortality is between zero and two per cent in treated patients, but 42 per cent if left untreated. Further, blastomycosis is often mischaracterized during the diagnostic process due to its rarity and presentation in humans mimicking that of more common infections.
As climate change appears to create better conditions for blastomycosis to flourish, the Canadian medical system needs a better understanding of this disease — before it becomes more widespread.
The fungi problem
Blastomycosis, also known as Gilchrist’s disease, is a highly rare infection caused by blastomyces fungi, found in forested areas and close to waterways, where moist soil hastens the decomposition of wood and leaves. The fungus is classified as dimorphic, meaning it exists as mold in the environment, but transforms into yeast when incubated in a host — human or an animal.
When soil harbouring the fungus is disturbed, such as by shoes or shovels, spores become airborne. If a person inhales those spores and becomes infected, blastomycosis can develop silently for weeks. Once inside the body, the infection can spread to the skin, bones, joints and other organs.
Emily Acheson, a public health epidemiologist, wants to improve techniques for detecting blastomyces fungi. “Unfortunately, this particular fungus is very, very hard to detect in the environment using soil samples,” Acheson said. For now, she doesn’t advise people worry too much about blastomycosis — it’s still extremely rare. Photo: Bailey Repp / The Narwhal
While there are many unknowns with blastomycosis, researchers have tracked infection rates and identified it as endemic to the Great Lakes and surrounding areas. That includes Manitoulin Island on Lake Huron, where Fogal’s family, who live in Sudbury, Ont., spend time each summer. Sheshegwaning First Nation on Manitoulin experienced an outbreak in 2017 that left six children and one adult hospitalized.
Fogal grew up visiting the Manitoulin acreage where his grandmother lives year-round, and exploring the island. After a year of studying abroad in Germany, where Fogal spent much of his free time hiking in the Bavarian Alps, Manitoulin’s unmaintained wooded trails had a strong draw. His medical team have since theorized that one of these summer hikes was likely the culprit for contraction.
Because the spores are microscopic, people won’t know they’ve been exposed until symptoms begin presenting. These can take anywhere from two weeks to several months to appear, and even then, only about half of those exposed will actually become sick.
It’s very difficult to avoid contracting the spores once contaminated soil is disturbed — but not everyone will get sick. “There’s no way that you can avoid getting these fungal pathogens,” Acheson said. “One person might contract it and the person right next to them might not.”
Acheson co-authored a report on the impacts of climate change on blastomycosis incidence in Canada in 2024, one year after Fogal’s hospitalization. It notes that in endemic areas across Canada, infection rates are typically between 0.4 and 1.3 cases per 100,000 people per year. Experts say rates of blastomycosis infection are likely much higher due to cases going unreported.
The coma
Fogal didn’t think much of it when the firm lump appeared on his right elbow. “I thought that I’d torn a muscle in my bicep,” he said over the phone from his family’s home in Sudbury.
Although first presentation of blastomycosis can range, one common early symptom may be skin lesions or ulcers. For Caleb, it started with a hematoma. “It was the second week back to school and he was at the gym,” Shari Fogal, Caleb’s mother, said. “He just thought it was a damaged muscle, but it kept getting bigger.”
Between work and university, Caleb was unable to schedule an appointment to have the abscess examined, unwittingly delaying the eventual diagnosis. By early October 2023, the lump had grown more inflamed and Caleb’s arm was in incredible pain. Even slight movements would leave him wincing.
“It was about the size of a golf ball by Thanksgiving weekend,” Shari said, “and then it ended up rupturing.”
At that point, unbeknownst to anyone, the fungal infection had begun to spread — first through Caleb’s skin and muscles, and then back to its entry point, his lungs. In mid-October, Fogal visited a clinic near his apartment in Ottawa as the mystery lump was not diminishing. He expected an ultrasound and straightforward diagnosis — but after reviewing his scan, the clinic staff sent him directly to the Ottawa Hospital General Campus emergency room with a doctor’s note to help bypass triage. Caleb didn’t know at the time what was causing the alarm and urgency.
“I was definitely a little scared,” Caleb said.
Blastomycosis is easily treated when identified early. But because it is so rare, it is sometimes mistaken for other diseases before a diagnosis is confirmed. Photos: Kamara Morozuk / The Narwhal
At the hospital, he was moved from room to room awaiting an explanation — but still expecting to be sent home. Instead, he was admitted, marking the start of two and a half months spent in hospital care. His first week at the Ottawa Hospital was focused on draining fluid from the ruptured hematoma through painful biopsies and injections into the joint; he still bears a large crescent-shaped scar on his elbow from this process.
“He was in a lot of pain,” Shari said. “I spent my nights trying to talk him through all of that pain and divert his attention elsewhere.”
Despite ongoing care, his symptoms worsened, and nobody knew why.
As is typical in cases of blastomycosis, he was initially mistakenly treated for bacterial pneumonia. When tests came back inconclusive, tuberculosis became the next suspect, forcing loved ones to temporarily quarantine away from him until it was ruled out.
Nearly two weeks after his admission, Fogal received a diagnosis. Shari had spoken earlier that day with her sister, a respiratory therapist and nurse, who suggested she raise the possibility of blastomycosis with his medical team.
“At the same time, the infectious control team came back into the room and said they’ve got a positive culture,” Shari said.
Doctors started Fogal on potent antifungal medication and began designing an outpatient treatment plan, as the infection can be treatable if correctly identified early. Within hours, everything changed.
“By that afternoon, he was having trouble breathing,” Shari said. “That was when all hell broke loose.”
“The crash team was there, the ICU team was there … the infectious disease team, and they were all looking at his X-rays, and his lungs which were all cloudy now, meaning the [infection] had spread,” she said. “Everything went from slogging along to racing a thousand miles a minute. His team of doctors had to tell me, ‘We’re not sugarcoating this, we’re not trying to dramatize the matter, we need you to be prepared that he might not come out of this alive.’ ”
Two days after his diagnosis, Fogal was moved to the ICU, intubated and placed in a medically induced coma.
Caleb Fogal spent more than two months at the Ottawa Hospital recovering from a blastomycosis infection. Photo: Getty Images
The climate changes
“There are about three to four million species of fungi. Of those, currently we have described about 150,000,” Jianping Xu, a biology professor studying the evolutionary genetics of fungi at McMaster University, said. He added that only around 300 of those have been associated with diseases in humans.
It stands to reason that there are many more disease-causing fungi that science has yet to describe, or the climate has yet to uncover.
When it comes to blastomyces, Xu said there are still many unknowns around what impact climate change is having. “With a warming climate, this fungus, just like any other fungi, their metabolism would be increased,” Xu said. “The rates of reproduction potentially could also be increased due to more conducive temperature.”
The combination of warmer temperatures and increased precipitation can accelerate fungal growth, especially in the soil. “Wet weather contributes to the proliferation of the fungus,” Amole Khadilkar, a senior health policy analyst with Indigenous Services Canada and co-author of the 2024 report with Acheson, told The Narwhal. Khadilkar warns that, while overly wet seasons produce more natural decomposition for blastomyces to thrive, drier summer days allow the fungus to spread. “Spores tend to be more airborne during abnormally dry days when the humidity and moisture is not bringing the spores to the ground,” he said.
The report notes the disease is more prevalent among Indigenous people in Ontario and Manitoba, potentially because of occupational or recreational exposure. Constance Lake First Nation, in northeastern Ontario, lost five community members to blastomycosis between November 2021 and January 2022, commencing a year-long state of emergency in the community. A coroner’s inquest into the five deaths was announced in July.
“There is definitely an increased risk among Indigenous communities and it’s not clear exactly why that could be,” Khadilkar said. “Could be a genetic predisposition that we’re not aware of, or there could be social determinants of health like access to medical care, socioeconomic status — factors like that.” He added that there are similar discrepancies among Native communities in the United States.
In 2022, the World Health Organization released the first-ever list of fungi representing the greatest threats to public health internationally. Blastomyces did not make the list.
Though still rare, blastomycosis infections are becoming harder to ignore. From January to December of 2019, Public Health Ontario documented 81 cases of blastomycosis. By 2023, that number had risen to 116 — and Caleb was one of them.
“It’s getting worse with climate change,” Acheson said. “It’s becoming more and more of a threat — and that’s why we’re starting to pay more attention to it.”
Both Acheson and Xu said there is cause for concern in the scale of fungal infections in general. But due to the scarce rate of blastomycosis in particular, Acheson didn’t advise an abundance of caution or worry — rather more effort on the part of the medical system to recognize and research the disease.
“It’s important that scientists and physicians increase their studies of it so that we can better map it, better predict where it’s gonna be and treat it better,” she said.
The fact is, blastomycosis is largely unavoidable in areas dense with spores — but infection is rare. Though some regional public health agencies recognize that preventative measures to avoid blastomycosis are not fully understood, Sudbury Public Health recommends face masks and proper footwear be worn when disrupting moist soil.
The recovery
Nearly two weeks after being put in a coma, Fogal’s lungs recovered to a point where he could be weaned off the anesthetics that kept him under, as well as the drugs used to medically paralyze him.
“When I first woke up, I was just a tangle of wires, tubes, needles and tape,” Caleb said. “There was nowhere I could look that didn’t have cables or tubing or something that was connected to me.”
He awoke still intubated, in a fog of sedatives and lingering memory loss, all of which prevented him from asking questions. From those early days, he was communicating through eye contact and hand gestures, asking his girlfriend for the time by rolling his wrist back and forth.
“Walking was difficult. I couldn’t get my brain to make my legs work,” he said. “It took almost a whole month before I could walk unaided again.”
Nearly two years after contracting a near-fatal case of blastomycosis, Caleb Fogal is able to look back at the incident with some lightheartedness: “I don’t really think about it much anymore.” Photo: Kamara Morozuk / The Narwhal
Originally, doctors expected him to remain hospitalized for another four months post-coma, but he was released after only 48 days. “I was hoping to fully be at home for Christmas, but that didn’t get to happen, unfortunately,” he said.
He was discharged in January, a full five months after that lump first appeared in his elbow.
Fogal remained on strong anti-fungal medication for a full year after emerging from the coma, prescribed double the regular dosage at first. Remarkably, he experienced no long-term medical complications from the infection. “It’s a big, kinda heavy, thing. But, I feel like I can just be lighthearted about it — I didn’t die,” he remarked.
Nearly two years later, the incident feels distant — reduced to fuzzy recollections and a few scars. “I don’t really think about it much anymore,” he said. “But I probably won’t go back to that hiking trail — at least for a little while.”
