Background/Purpose: Coccidioidomycosis (valley fever) is an endemic fungal infection that typically causes a self-limited pulmonary illness in the Southwestern United States,. Immunosuppressed patients are at higher risk of more severe infection, and this includes patients with rheumatic disease on disease-modifying antirheumatic drugs (DMARD) or biologic response modifiers (BRM). At our institution, the routine practice is to screen patients for coccidioidomycosis before initiating BRM therapy, and then annually thereafter. Through this process, we have identified asymptomatic patients with positive serologies. This is concerning as it indicates a recent infection. A 2012 retrospective study proposed a protocol that suggested continuing antirheumatic therapy rather than stopping it in asymptomatic patients. Following this protocol has not resulted in the development of a more severe infection in asymptomatic patients.

Methods: A cohort study at two centers in Tucson, Arizona identified patients who developed coccidioidomycosis while on DMARD or BRM therapy. Several patients had asymptomatic illness as defined as a positive serology found on surveillance labs, not ordered in response to symptoms, and no concurrent signs or symptoms of active disease. Patients were seen at least once between 2007 and 2015. The study emphasized management of BRM/DMARD therapy, as well as antifungal therapy and duration.

Results: Seventy one patients with rheumatic disease were diagnosed with coccidioidomycosis, and 19 of them had positive serologies and no symptoms. Most (17/19) had rheumatoid arthritis, 1 had psoriatic arthritis, and 1 had dermatomyositis. Sixteen patients were identified during routine annual surveillance, and three were identified during pre-BRM therapy screening. Eight patients were on BRM alone, 9 on BRM with a DMARD, and 2 on a DMARD alone. Three patients were also on prednisone. Six patients stopped their antirheumatic therapy, while the rest continued without interuption. BRM therapy was restarted in 5 of these patients, most resuming therapy within 1 month of infection (range 0.5 – 12 mos). One did not resume therapy due to osteonecrosis of the jaw. Six patients received fluconazole, duration ranging from 8 to 73 months (median 30.5 mos). Ten patients neither reduced antirheumatic therapy, nor started antifungal treatment. The median follow up is 43 months, and no patients have developed symptomatic illness. Three patients have been lost to follow up, and one died from unrelated causes.

Conclusion: Positive coccidioidomycosis serologies in asymptomatic patients are concerning as they are indicative of a recent active infection. This cohort supports the management strategy of continuing DMARD and BRM therapy in patient with asymptomatic disease. It also suggests that in patients with persistently positive serologies, antifungal therapy should be considered. In the past 8 years there have been no complications in the asymptomatic cocci patients who continued BRM and DMARD. The management strategy implemented may be effective in guiding therapy.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/asymptomatic-coccidioidomycosis-in-patients-with-rheumatic-disease-8-years-of-experience/