Histoplasmosis Complicating Tumor Necrosis Factor-α Blocker Therapy: A Retrospective Analysis of 98 Cases

被引:101
|
作者
Vergidis, Paschalis [1 ]
Avery, Robin K. [2 ]
Wheat, L. Joseph [3 ]
Dotson, Jennifer L. [4 ,5 ]
Assi, Maha A. [6 ]
Antoun, Smyrna A. [6 ]
Hamoud, Kassem A. [7 ]
Burdette, Steven D. [8 ]
Freifeld, Alison G. [9 ]
McKinsey, David S. [10 ]
Money, Mary E. [11 ]
Myint, Thein [12 ]
Andes, David R. [13 ]
Hoey, Cynthia A. [14 ]
Kaul, Daniel A. [15 ]
Dickter, Jana K. [16 ]
Liebers, David E. [17 ]
Miller, Rachel A. [18 ]
Muth, William E. [19 ]
Prakash, Vidhya [20 ]
Steiner, Frederick T. [21 ]
Walker, Randall C. [22 ]
Hage, Chadi A. [23 ]
机构
[1] Univ Pittsburgh, Sch Med, Div Infect Dis, Pittsburgh, PA 15260 USA
[2] Johns Hopkins Univ Hosp, Div Infect Dis, Baltimore, MD 21287 USA
[3] MiraVista Diagnost & Mirabella Technol, Indianapolis, IN USA
[4] Nationwide Childrens Hosp, Res Inst, Div Pediat Gastroenterol Hepatol & Nutr, Columbus, OH USA
[5] Nationwide Childrens Hosp, Res Inst, Ctr Innovat Pediat Practice, Columbus, OH USA
[6] Univ Kansas, Sch Med, Dept Internal Med, Wichita, KS 67214 USA
[7] Univ Kansas, Med Ctr, Div Infect Dis, Kansas City, KS USA
[8] Wright State Univ, Boonshoft Sch Med, Div Infect Dis, Dayton, OH 45435 USA
[9] Univ Nebraska Med Ctr, Div Infect Dis, Omaha, NE USA
[10] Infect Dis Associates Kansas City, Kansas City, MO USA
[11] Meritus Med Ctr, Dept Med, Hagerstown, MD USA
[12] Univ Kentucky, Div Infect Dis, Lexington, KY 40506 USA
[13] Univ Wisconsin, Dept Med & Med Microbiol & Immunol, Madison, WI 53706 USA
[14] Long Isl Infect Dis Associates, Huntington, NY USA
[15] Univ Michigan, Sch Med, Div Infect Dis, Ann Arbor, MI USA
[16] Kaiser Permanente, Div Infect Dis, Fontana, CA USA
[17] Ellis Hosp Schenectady, New York, NY USA
[18] Univ Iowa, Div Infect Dis, Iowa City, IA USA
[19] Samaritan Infect Dis, Corvallis, OR USA
[20] So Illinois Univ, Sch Med, Div Infect Dis, Springfield, IL USA
[21] Indiana Univ Hlth, Ball Mem Hosp, Muncie, IN USA
[22] Mayo Clin, Div Infect Dis, Rochester, MN USA
[23] Indiana Univ, Pulm Crit Care Med, Indianapolis, IN 46204 USA
基金
美国国家卫生研究院;
关键词
histoplasmosis; infliximab; adalimumab; etanercept; immune reconstitution syndrome; IMMUNE RECONSTITUTION SYNDROME; FACTOR ANTAGONISTS; FUNGAL-INFECTIONS; INFLIXIMAB; RISK; ETANERCEPT; INHIBITION; MECHANISMS;
D O I
10.1093/cid/civ299
中图分类号
R392 [医学免疫学]; Q939.91 [免疫学];
学科分类号
100102 ;
摘要
Background. Histoplasmosis may complicate tumor necrosis factor (TNF)-alpha blocker therapy. Published case series provide limited guidance on disease management. We sought to determine the need for long-term antifungal therapy and the safety of resuming TNF-alpha blocker therapy after successful treatment of histoplasmosis. Methods. We conducted a multicenter retrospective review of 98 patients diagnosed with histoplasmosis between January 2000 and June 2011. Multivariate logistic regression was used to evaluate risk factors for severe disease. Results. The most commonly used biologic agent was infliximab (67.3%). Concomitant corticosteroid use (odds ratio [OR], 3.94 [95% confidence interval {CI}, 1.06-14.60]) and higher urine Histoplasma antigen levels (OR, 1.14 [95% CI, 1.03-1.25]) were found to be independent predictors of severe disease. Forty-six (47.4%) patients were initially treated with an amphotericin B formulation for a median duration of 2 weeks. Azole treatment was given for a median of 12 months. TNF-alpha blocker therapy was initially discontinued in 95 of 98 (96.9%) patients and later resumed in 25 of 74 (33.8%) patients at a median of 12 months (range, 1-69 months). The recurrence rate was 3.2% at a median follow-up period of 32 months. Of the 3 patients with recurrence, 2 had restarted TNF-alpha blocker therapy, 1 of whom died. Mortality rate was 3.2%. Conclusions. In this study, disease outcomes were generally favorable. Discontinuation of antifungal treatment after clinical response and an appropriate duration of therapy, probably at least 12 months, appears safe if pharmacologic immunosuppression has been held. Resumption of TNF-alpha blocker therapy also appears safe, assuming that the initial antifungal therapy was administered for 12 months.
引用
收藏
页码:409 / 417
页数:9
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