Management of asymptomatic coccidioidomycosis in patients with rheumatic diseases
- 24 Downloads
Coccidioidomycosis is an endemic fungal infection common in the southwestern United States. Some rheumatology clinics periodically screen patients with coccidioidal serology, resulting in the identification of patients who are serologically positive but without clinical symptoms. The management of such patients is unclear. A retrospective study was conducted between 2007 and 2015 at two arthritis centers in Tucson, Arizona. The asymptomatic patients were identified who were receiving disease-modifying antirheumatic agents and had a positive coccidioidal serology. Serological testing including IgM and IgG was performed by enzyme immunoassay (EIA), immunodiffusion (IDTP and IDCF), or complement fixation. Out of 71 patients who were identified with positive coccidioidal serologies, 19 were asymptomatic. 18/19 patients continued antirheumatic therapy, 13 without interruption. 13/19 patients received no antifungal treatment, including 10 who remained on antirheumatic treatment. The other six were started on fluconazole, ranging from 8 to 73 months (median 30.5 months). After a median follow-up of 43 months, no patient developed clinically active coccidioidomycosis. Overall, 14 had only a positive EIA serological test. These results suggest that continued antirheumatic therapy is safe in asymptomatic patients with positive coccidioidal serological tests and that routine implementation of antifungal treatment may not always be warranted. The findings also raise concern regarding the utility of routine serological testing of asymptomatic patients residing in the coccidioidal endemic area, mainly using the EIA test.
KeywordsBiologic drugs Coccidioidomycosis Antirheumatic agents Rheumatic diseases/drug therapy Coccidioidomycosis/therapy Coccidioidomycosis/immunology
Study concept and design: JB, JRL, DS, BB, and NMA; search and acquisition of data: JB, SK, and DS; analysis and interpretation of data: all the authors; drafting of the manuscript: JB, SK, DS, BB, and NMA; critical revision of the manuscript for important intellectual content: JRL, NMA, and DS; study supervision: NMA, DS, and JRL.
Compliance with ethical standards
Conflict of interest
Bilal J, Kollampare S, Bode B, Lisse J, Hoover SE, and Sudano D. Ampel NM declare that they have no conflict of interest related to this study.
Related abstract publications/poster presentations
Management of Asymptomatic Coccidioidomycosis in Patients with Rheumatic Disease. 2014 ACR/ARHP Annual Meeting. The related abstract publication is following: Sudano, Dominick, et al. “management of Asymptomatic Coccidioidomycosis in Patients with Rheumatic Disease.: 2205.” Arthritis & Rheumatology 66 (2014): S961.
Asymptomatic Coccidioidomycosis in Patients with Rheumatic Disease: 8 Years of Experience. 2016 ACR/ARHP Annual Meeting [Abstract Number: 1350]. The related abstract publication is following: Ajaz U, Lisse JR, Ampel NM, Sudano D. Asymptomatic Coccidioidomycosis in Patients with Rheumatic Disease: 8 Years of Experience [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). The Value of Routine Serological Screening for Coccidioidomycosis in Patients On Antirheumatic Therapy. 62nd Annual Cocci Study Group Meeting in Flagstaff, Arizona on April 13–14, 2018.
- 2.Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Geertsma F, Hoover SE, Johnson RH, Kusne S, Lisse J, MacDonald JD, Meyerson SL, Raksin PB, Siever J, Stevens DA, Sunenshine R, Theodore N (2016) 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis. Clin Infect Dis 63(6):e112–e146. https://doi.org/10.1093/cid/ciw360 CrossRefGoogle Scholar
- 3.Increase in reported coccidioidomycosis–United States, 1998–2011 (2013). MMWR Morbidity and mortality weekly report 62 (12):217-221Google Scholar
- 8.Bergstrom L, Yocum DE, Ampel NM, Villanueva I, Lisse J, Gluck O, Tesser J, Posever J, Miller M, Araujo J, Kageyama DM, Berry M, Karl L, Yung CM (2004) Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists. Arthritis Rheum 50(6):1959–1966. https://doi.org/10.1002/art.20454 CrossRefGoogle Scholar
- 10.Singh JA, Cameron C, Noorbaloochi S, Cullis T, Tucker M, Christensen R, Ghogomu ET, Coyle D, Clifford T, Tugwell P, Wells GA (2015) Risk of serious infection in biological treatment of patients with rheumatoid arthritis: a systematic review and meta-analysis. Lancet 386(9990):258–265. https://doi.org/10.1016/s0140-6736(14)61704-9 CrossRefGoogle Scholar
- 12.Taroumian S, Knowles SL, Lisse JR, Yanes J, Ampel NM, Vaz A, Galgiani JN, Hoover SE (2012) Management of coccidioidomycosis in patients receiving biologic response modifiers or disease-modifying antirheumatic drugs. Arthritis Care Res 64(12):1903–1909. https://doi.org/10.1002/acr.21784 CrossRefGoogle Scholar