Coccidiomycosis (Valley Fever) Occurring during Infliximab Therapy

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Coccidiomycosis (Valley Fever) Occurring during Infliximab Therapy

Category:  17 RA‹treatment

Laurie Bergstrom1, E Yocum1, Tesser2, Margaret 1,

Lisse1, Gluck2

1University of Arizona, Tucson, AZ;2Arizona Rheumatology Center, Phoenix, AZ

Presentation Number: 365

Poster Board Number: 365

Keywords: Rheumatoid Arthritis, Infliximab, Coccidiomycosis

Background: Coccidiomycosis is an endemic fungal infection, commonly seen in

the Southwestern United States. While the exact etiopathogenesis of the

disease in humans is unclear, the probability of infection increases with

duration of living in an endemic area (3% per year). Infection increases

during times of draught and high winds following periods of increased rain.

Immunosuppressed hosts and people of dark skin appear to have more

complications. Data from the last large review suggests death in these

populations can approach 50%. Between two practices (Tucson and Phoenix), we

have found 4 cases of Coccidiomycosis in the last 3 years occurring in

patients receiving infliximab therapy.

Methods: Cases of Coccidiomycosis were compiled between two practices in

Arizona regularly prescribing TNF antagonist therapy. Four cases were found.

The cases are summarized.

Cases: Four cases of Coccidiomycosis were found between the two practices.

All patients were female between the ages of 51 and 71 (mean 64). Three of

the four had a history of long-standing RA (20, 20 and 24 years) and had

received multiple immunosuppressive drugs. The fourth had had RA for only 3

years and received only MTX and low dose steroids. All four represented

reactivation of pre-existing Coccidiomycosis. One died as a complication of

an indwelling catheter for anti-fungal therapy (staphylococcal septicemia),

while the other 3 did well on fluconazole therapy alone. Coccidiomycosis

started after only two injections of infliximab in two patients, after 5

injections in the third and after 10 months in the fourth (patient who

died). None of the living patients have been placed back on infliximab.

Other cases of Coccidiomycosis are being collected (lack of data at present

time).

Conclusions: Coccidiomycosis is a severe fungal infection with serious

outcomes, especially if not diagnosed and treated early. Patients living in

or traveling to the Southwest should be evaluated with serologies and chest

x-ray before being placed on infliximab or other immunosuppressive therapy.