Arthritis & Rheumatism, Volume 63,
November 2011 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Chicago, Illinois November 4-9, 2011.

Subsequent Therapy of Patients with Biologic Response Modifiers or Disease-Modifying Antirheumatic Drugs After Coccidioidomycosis.

Knowles1,  Susan, Taroumian1,  Sara, Lisse1,  Jeffrey R., Yanes1,  James, Ampel2,  Neil M., Gall3,  Eric P., Grau1,  Rafael G.

University of Arizona, Tucson, AZ
Southern AZ VA Medical Center, Tucson, AZ
Arizona Arthritis Center, Tucson, AZ
Catalina Pointe Arthritis and Rheumatology, Tucson, AZ
Valley Fever Center for Excellence, Tucson, AZ


Coccidioidomycosis (cocci, Valley fever) is a fungal infection endemic to the Southwestern United States, affecting approximately 150,000 people annually. While most are subclinical pulmonary infections, patients on biologic response modifiers (BRMs), including tumor necrosis factor (TNF) antagonists, are at higher risk of developing severe or disseminated disease. There are currently no guidelines regarding BRM or disease-modifying antirheumatic drug (DMARD) therapy or duration of antifungal therapy following cocci.


A retrospective chart review identified patients who developed cocci while on DMARDs or BRMs. Patients were seen at least once in a University-affiliated or Veterans Administration outpatient rheumatology clinic in Tucson, Arizona between 2007–2009. Charts were reviewed up to June 1, 2011. Review emphasized the mode of diagnosis, clinical manifestations, antifungal therapy and duration, and management of BRM/DMARDs after the diagnosis was made.


We identified 44 patients with cocci during treatment with a BRM and/or DMARD. Rheumatologic treatment was BRM alone (11), DMARD alone (8), or combination therapy (25). Cocci manifestations were asymptomatic positive serologies (6), pulmonary cocci (29), or disseminated disease (9). After the diagnosis of cocci, patients had no change in immunosuppressive therapy (10), all BRM and DMARDs stopped (26), or BRM stopped but DMARD therapy continued (8). All but 3 patients had antifungal therapy initiated for 3 months or longer.

Follow-up data were available for 38 patients. BRM and/or DMARD therapy was continued or resumed in 33 and none have had dissemination or complications from cocci. Sixteen also continued on antifungal therapy. Four patients were not treated with BRM/DMARD due to remission of their rheumatic disease; 1 patient was not treated with BRM/DMARD due to dissemination. The most common reasons for continuing antifungal therapy were persistent positive serologies and disseminated cocci. The most common reason for stopping antifungal therapy was negative cocci serology. Follow-up for patients who stopped antifungals or were never treated is 3 to 96 months (median 30 mos).


Treating with a BRM and/or DMARD after cocci infection appears to be safe in some patients based on our small series. Several patients with negative serologies and resolution of infection resumed BRM/DMARD without concomitant antifungal therapy. Some patients with disseminated disease or persistently positive serologies continued on antifungal therapy when a BRM/DMARD was restarted. Larger studies with longer follow up are indicated to further characterize the relationship between BRM/DMARD therapy and this endemic fungal infection.

To cite this abstract, please use the following information:
Knowles, Susan, Taroumian, Sara, Lisse, Jeffrey R., Yanes, James, Ampel, Neil M., Gall, Eric P., et al; Subsequent Therapy of Patients with Biologic Response Modifiers or Disease-Modifying Antirheumatic Drugs After Coccidioidomycosis. [abstract]. Arthritis Rheum 2011;63 Suppl 10 :2466

Abstract Supplement

Meeting Menu