title: Management of coccidioidomycosis in patients receiving biologic response modifiers or disease-modifying antirheumatic drugs.
abstract: OBJECTIVE
  Coccidioidomycosis (valley fever) is an endemic fungal infection of the American Southwest, an area with a large population of patients with rheumatic diseases. There are currently no guidelines for management of patients who develop coccidioidomycosis while under treatment with biologic response modifiers (BRMs) or disease-modifying antirheumatic drugs (DMARDs). We conducted a retrospective study of how both concurrent diseases were managed and the patient outcomes at 2 centers in Tucson, Arizona.
  
  
  METHODS
  A retrospective chart review identified patients who developed coccidioidomycosis during treatment with DMARDs or BRMs. Patients were seen at least once in a university-affiliated or Veterans Affairs outpatient rheumatology clinic in Tucson, Arizona, between 2007 and 2009.
  
  
  RESULTS
  Forty-four patients were identified. Rheumatologic treatment included a BRM alone (n = 11), a DMARD alone (n = 8), or combination therapy (n = 25). Manifestations of coccidioidomycosis included pulmonary infection (n = 29), disseminated disease (n = 9), and asymptomatic positive coccidioidal serologies (n = 6). After the diagnosis of coccidioidomycosis, 26 patients had BRMs and DMARDs stopped, 8 patients had BRMs stopped but DMARD therapy continued, and 10 patients had no change in their immunosuppressive therapy. Forty-one patients had antifungal therapy initiated for 1 month or longer. Followup data were available for 38 patients. BRM and/or DMARD therapy was continued or resumed in 33 patients, only 16 of whom continued concurrent antifungal therapy. None of the patients have had subsequent dissemination or complications of coccidioidomycosis.
  
  
  CONCLUSIONS
  Re-treating rheumatic disease patients with a BRM and/or a DMARD after coccidioidomycosis appears to be safe in some patients. We propose a management strategy based on coccidioidomycosis disease activity.
authors: University of California, Los Angeles, CA 90095-1685, USA. staroumian@gmail.com
authors: Sara
authors: S
authors: Taroumian
authors: Susan L
authors: SL
authors: Knowles
authors: Jeffrey R
authors: JR
authors: Lisse
authors: James
authors: J
authors: Yanes
authors: Neil M
authors: NM
authors: Ampel
authors: Austin
authors: A
authors: Vaz
authors: John N
authors: JN
authors: Galgiani
authors: Susan E
authors: SE
authors: Hoover
mesh_terms: D000305:Adrenal Cortex Hormones; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000935:Antifungal Agents / Q000627:therapeutic use; D018501:Antirheumatic Agents; D003047:Coccidioidomycosis / Q000150:complications / Q000276:immunology / Q000628:therapy*; D000075202:Contraindications; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016867:Immunocompromised Host; D007155:Immunologic Factors; D008875:Middle Aged; D012189:Retrospective Studies; D012216:Rheumatic Diseases / Q000150:complications* / Q000188:drug therapy / Q000276:immunology; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones; D000935:Antifungal Agents; D018501:Antirheumatic Agents; D007155:Immunologic Factors