Coccidioidomycosis in Rheumatology Patients

Abstract

Coccidioidomycosis is a potentially serious fungal infection contracted in endemic areas of the desert southwestern United States. Limited information exists about its incidence and clinical course in patients with rheumatic diseases, who may be at higher risk of symptomatic or disseminated coccidioidomycosis because of either the rheumatic disease itself or its treatment. We analyzed the incidence and risk factors for symptomatic and complicated coccidioidomycosis in our academic rheumatology practice in central Arizona. Between January 1, 2000, and June 30, 2006, coccidioidomycosis was diagnosed in 1.9% of the overall practice and in 3.1-3.6% of patients with rheumatoid arthritis (RA). The annual incidence was 1% in patients recently diagnosed with RA and 2% among patients with recently initiated infliximab treatment. Coccidioidomycosis was identified only in patients with inflammatory rheumatic diseases and extrathoracic dissemination occurred only to joints in two patients. Corticosteroids, immunosuppressive medications, and tumor necrosis factor inhibitors (TNFIs) appeared to be risk factors for symptomatic, but not disseminated coccidioidomycosis.

Pathogenesis of Coccidioidomycosis

“…In the first cohort, 11 of 985 (1 %) patients developed symptomatic coccidioidomycosis; the risk of symptomatic coccidioidomycosis in patients treated with infliximab, a monoclonal antibody TNF antagonist, was higher compared to those without infliximab (relative risk 5.23, 95 % confidence interval 1.54-17.71; p<0.01) [38]. In the second cohort, 16 of 854 (1.9 %) patients developed symptomatic coccidioidomycosis; among 121 infliximab patients, the incidence of coccidioidomycosis was 2 and 12 %, at 1 and 5 years, respectively [39]. The third study addressed management of patients who developed coccidioidomycosis while taking disease-modifying antirheumatic drugs (methotrexate, azathioprine, or leflunomide) and/or BRM.…”

Endemic Fungal Infections in Inflammatory Bowel Disease Associated with Anti-TNF Antibody Therapy

“…In a series of 29 cases of coccidioidomycosis, 27 (93%) were associated with IFX and 2 (7%) with etanercept, and all had concomitant use of corticosteroids or methotrexate. [126][127][128][129] In another series of 7 cases of coccidioidomycosis in patients with RA, 6 were taking infliximab and 1 was taking etanercept. 128 The incidence for infliximab was 5.58 per 100,000 and 0.88 per 100,000 for etanercept.…”

“…[126][127][128][129] In another series of 7 cases of coccidioidomycosis in patients with RA, 6 were taking infliximab and 1 was taking etanercept. 128 The incidence for infliximab was 5.58 per 100,000 and 0.88 per 100,000 for etanercept. 130 The rate of symptomatic infection in patients receiving TNF-a inhibitors is difficult to compare with the rate of disease in the general population because there is a great degree of geographic variability in the incidence of this infection.…”

Infectious pulmonary complications in patients treated with anti-TNF-α monoclonal antibodies and soluble TNF receptor

“…Obtaining a thorough history regarding prior residence in endemic areas is recommended before initiating TNF inhibitor therapy, and a chest radiograph is needed to screen for features indicating past respiratory infections [ 30,31 ]. Patients who receive biologic therapy and who travel to endemic or earthquake-active regions are potentially at high risk.…”