Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.

Subsequent Therapy of Patients with Biologic Response Modifiers after a Diagnosis of Coccidiomycosis Infection.

Taroumian3,  Sara, Lisse5,  Jeffrey R., Gall5,  Eric P., Grau5,  Rafael G., Ampel2,  Neil M., Hoover4,  Susan E., Yanes4,  James

Tucson, AZ
Southern Arizona VA Health Care System, Tucson, AZ
The University of Arizona Department of Internal Medicine, Tucson, AZ
The University of Arizona Section of Infectious Diseases, Tucson, AZ
The University of Arizona Section of Rheumatology, Arizona Arthritis Center, Tucson, AZ


Coccidioides (cocci) are dimorphic fungi endemic to California, Arizona, New Mexico, Texas, Mexico, and Central and South America (1). Annually, approximately 100,000 people in the endemic areas of the United States are diagnosed (dx) with primary cocci (2). Chronic and disseminated disease may occur in up to 5% of patients (3); immunocompromised patients are very high risk.


A chart review of all patients seen at least once in a university-based outpatient rheumatology clinic in Tucson, AZ between 2007–2009 identified 298 patients who received biologic response modifiers (BRM), including anti-TNF drugs (TNF). Twenty four patients developed cocci during treatment with BRM. The review emphasized the mode of dx, clinical manifestations, antifungal treatments, the duration of treatment, and the course of action taken after the dx was made.


Twenty four patients developed cocci during treatment. Prior to cocci dx, 3/24 patients were taking only cytotoxic agents and 2/24 were on unclear immunosuppressive agents. The following table summarizes the medications at the time of dx in the remaining patients.

After the dx was made, all TNFs and DMARDs were held in 13/24 patients. 5/24 continued TNFs and/or DMARDs w/o any change in their regimen and 4/24 continued/started DMARDs but anti-TNFs were held. Two remaining patients had an unclear course of treatment after their cocci dx. Of the 13 patients in whom all TNFs and DMARDs were held, 11/13 wererestarted on either a DMARD alone or in combination with a TNF; 2 were not restarted. 17/24 patients had non-disseminated cocci. 4/17 were treated with Fluconazole (Fluc) until their cocci serol turned negative. 2/17 were lost to follow up. These patients continued to receive anti-TNFs w/o any cocci reactivation. 6/24 patients had severe cocci with dissemination to skin or joints. 5/6 patients will continue Fluc as long as they need to be treated w/ an immunosuppressive agent. Of all the patients reviewed in this study, 4/24 were found to have some evidence of cocci reactivation.


Despite clinicians' hesitation in treating a patient with BRM after dx of cocci, restarting BRM appears to be safe in some patients with non-disseminated disease. Patients with severe or disseminated disease who need to be treated with BRM most likely need to also continue treatment with an antifungal agent.

Medications at the Time of Cocci Diagnosis:

Biologic Response Modifier (BRM)BRM aloneCytotoxic agent (one or two in combo with BRM) (Methotrexate, Leflunomide, Azathioprine)
Infliximab (Inf)9/243/24
Etanercept (Etr)1/243/24
Adalimumab (Ada)0/243/24
Mode of Cocci DiagnosisPos serologies only (EIA)Pos serol plus CXR/CT chest findings w/o pulm symptomsDissemination to skin, joint or lungs with pulm symptoms
Number of Patients4/2413/246/24

To cite this abstract, please use the following information:
Taroumian, Sara, Lisse, Jeffrey R., Gall, Eric P., Grau, Rafael G., Ampel, Neil M., Hoover, Susan E., et al; Subsequent Therapy of Patients with Biologic Response Modifiers after a Diagnosis of Coccidiomycosis Infection. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :415
DOI: 10.1002/art.28184

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