Background/Purpose: Studies have shown an increased risk of coccidioidomycosis infection in immunosuppressed patients. However, relationship of coccidioidomycosis infections with different immunosuppressive medication is not well established. This study was aimed to examine the characteristics of symptomatic coccidioidomycosis infections in patients with rheumatic diseases on biologic infusions.

Methods: A retrospective study was conducted between 2013 and 2017 at two infusion centers affiliated with the University of Arizona. Patients with rheumatic diseases on biological infusions for the diagnosis of symptomatic coccidioidomycosis were identified. The data related to method of infection identification, subsequent management, and concurrent steroid.  

Results: Out of 548 patients, 21/548 (3.8%) had symptomatic coccidioidomycosis. Mean age was 54 years. 15/21 (71.4%) were female and 6 (28.6%) were male. 1/21 had disseminated disease, 17/21  had primary pulmonary disease, and 3/21 had unclear disease status. 6/21 (28.6%) patients were on rituximab therapy, 4/21 (19%) were on infliximab, 4/21 (19%) were on tocilizumab, 2/21 (9.5%) were on abatacept, 2/21 (9.5%) on golimumab 1/21 (4.8%) on canakinumab, and 1/21 (4.8%) on IVIG. Total of 15/21 (71.4%) patients used glucocorticoids with average dose being 14.5mg. 7/15 (46.7%) of patients were on chronic glucocorticoids treatment. 

10/21 (47.6%) were diagnosed with a positive qualitative immunodiffusion assay. 4/21 (19%) patients had a serum enzyme-linked immunosorbent assay with positive titers > 1:2. 4/21 (19%) patients had a positive complement fixation test. 3/21 (14.3%) patients were diagnosed with a positive fungal culture, 2/3 being from a respiratory source.

15/21 (71.4%) patients had an abnormal chest x-ray, with the most common finding being a nodule (6/15). 12/21 (57%) patients had an abnormal chest CT, with the most common finding being a nodule as well (6/12). 17/21 (80.9%) were started on antifungal therapy, with 16/17 (94%) being started on fluconazole. 9/21 (42.9%) patients had their biologic therapy stopped, with 3/9 (33.3%) eventually having their biologic therapy restarted. 12/21 patients continued their therapy without interruption.

Conclusion: This study showed that occurrence of symptomatic coccidioidomycosis infection was more prevalent in patients using concurrent glucocorticoids with biologics. Among biologics, rituximab had the highest rate of symptomatic infections. Qualitative immunodiffusion assay was commonly utilized test to diagnose coccidioidomycosis infection. The vast majority of patients were treated with fluconazole, but continued the antirheumatic therapy.

« Back to 2019 ACR/ARP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/symptomatic-coccidioidomycosis-infections-in-patients-on-biologic-therapies/