Pleuropulmonary manifestations of rheumatoid arthritis are not uncommon. Moreover, medications frequently used to treat rheumatoid arthritis may result in complications. We report a case of coccidioimycosis pneumonia in a nonendemic area associated with the use of infliximab for treatment of rheumatoid arthritis.
A 50 year-old male presented with progressive dyspnea worsening over the past three weeks associated with a new productive cough. He described a persistent, mucopurulent cough despite 3 weeks treatment with different antibiotics. He denied hemoptysis, fever, night sweats, weight loss, recent travel or a history of tuberculosis. He carried a diagnosis of rheumatoid arthritis since the age of twenty having been treated with methotrexate, prednisone and indomethacin for 18 months and recently was initiated on infliximab. He resided in southeast Texas for twenty years but had briefly traveled to California as an adolescent. Physical examination revealed an afebrile gentleman with severe articular deformities. He demonstrated a rapid, shallow respiratory pattern and a resting room air oxygen saturation of 88%. The lung fields demonstrated basilar rhonchi. Chest radiograph demonstrated bilateral nodular opacities. A chest CT also revealed bilateral nodules with mediastinal lymphadenopathy. A bronchoscopy was performed and microscopic examination of tissue obtained from a subcarinal lymph node demonstrated granulomatous inflammation and intracellular spherules. Subsequently, fungal cultures from the bronchial secretions confirmed the organism as Coccidioides immitis. Unfortunately, he was released from the hospital prior to initiation of antifungal therapy. Attempts to contact him to initiate therapy were in vain and he arrived to his scheduled clinic appointment several weeks later with worsening dyspnea, cough and fevers. He was hospitalized, initiated on intravenous amphotericin and underwent a lumbar puncture that excluded extrapulmonary coccidioimycosis. His respiratory status deteriorated and he was placed on mechanical ventilation. He developed acute respiratory distress syndrome (ARDS) with multi-organ failure while being treated for coccidioidomycosis. After eight weeks later he was liberated from mechanical ventilation and released to a skilled nursing facility on anti-fungal treatment. He was released from the nursing facility four weeks later and currently resides at home without the use of oxygen.
We report a case of diffuse pulmonary coccidioidomycosis with ARDS in a patient treated with infliximab in a non-endemic area. Infliximab is used in the treatment of rheumatoid arthritis and Crohn’s disease. Post marketing data from 147,000 patients indicates that infliximab use is associated with an increased risk of bacterial, fungal and tuberculous infections. However, coccidioidomycosis was reported as a complication of therapy in only 2 cases. In endemic areas, coccidioidomycosis usually leads to a benign, self-limited upper respiratory tract infection and in an immunocompetent hosts disseminated is rare. However, in immunocompromised patients coccidioimycosis infection may lead to severe complications such as ARDS that carries a high mortality. Patients with rheumatoid arthritis presenting with respiratory ailments should lead to concerns about pleuropulmonary manifestations, infectious or medication-related complications. In the present case, this patient denied recent travel to endemic areas but stated having been extensively exposed to dust from crushed rocks imported from Arizona. Whether his illness was related to this dust exposure or reactivation remains unanswered.
Coccidioimycosis should be considered as potential pathogens in patients treated with infliximab.
M.O. Dweik, None.