Coccidioides Serologic Screening Practices in Individuals With Rheumatic and Autoimmune Diseases.

OBJECTIVE: We aimed to estimate Coccidioides serologic screening rates before initiation of biologic disease-modifying antirheumatic drugs including tofacitinib (b/tsDMARDs), conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and/or noninhaled corticosteroids. METHODS: This retrospective cohort study used 2011 to 2016 US Medicare claims data and included beneficiaries with rheumatic or autoimmune disease residing in regions within Arizona, California, and Texas endemic for Coccidioides spp. with ≥1 prescription for a b/tsDMARD, csDMARD, and/or noninhaled corticosteroid. We estimated prior-year serologic screening incidence before initiating b/tsDMARDs, csDMARD, and/or noninhaled corticosteroid. RESULTS: During 2012 to 2016, 4,331 beneficiaries filled 64,049 prescriptions for b/tsDMARDs, csDMARDs, and noninhaled corticosteroids. Arizona's estimated screening rate was 20.1% (95% confidence interval [95% CI] 14.5-25.7) in the year before prescription initiation for b/tsDMARDs, 8.1% (95% CI 6.5-9.7) before csDMARDs, and 6.9% (95% CI: 5.6-8.2) before corticosteroids. Screening rates for b/tsDMARDs (2.8%, 95% CI 0.0-6.7), csDMARDs (1.0%, 95% CI 0.0-2.0), and corticosteroids (0.8%, 95% CI: 0.4-1.1) were negligible in California and undetected in Texas. Adjusted screening rate before prescription for b/tsDMARDs in Arizona increased from 14.5% (95% CI 7.5-21.5) in 2012 to 26.7% (95% CI 17.6-35.8) in 2016. Rheumatologists prescribing b/tsDMARDs in Arizona screened more than other providers (20.9% [95% CI 13.9-27.9] vs 12.9% [95% CI 5.9-20.0]). CONCLUSION: Coccidioides serologic screening rates among Medicare beneficiaries with rheumatic/autoimmune diseases on b/tsDMARDs, csDMARDs, and noninhaled corticosteroids was low in Coccidioides spp.-US endemic regions between 2012 and 2016. Alignment of screening recommendations and clinical practice is needed.

Acid Reflux: A Rare Adverse Effect of Duloxetine.

Duloxetine is a medication that belongs to the serotonin and norepinephrine reuptake inhibitor (SNRI) class of drugs and is commonly used to treat various conditions, such as depression, generalized anxiety disorder, neuropathic pain, fibromyalgia, and chronic musculoskeletal pain. While side effects, such as headaches, constipation, dry mouth, dizziness, and blurred vision, are commonly associated with duloxetine, we present a case of a 59-year-old woman who experienced a rare adverse event of acid reflux while taking a 30 mg dose of duloxetine for fibromyalgia. According to the available literature, this adverse event has been reported in only 1.38% of the population.

Management of asymptomatic coccidioidomycosis in patients with rheumatic diseases.

Coccidioidomycosis is an endemic fungal infection common in the southwestern United States. Some rheumatology clinics periodically screen patients with coccidioidal serology, resulting in the identification of patients who are serologically positive but without clinical symptoms. The management of such patients is unclear. A retrospective study was conducted between 2007 and 2015 at two arthritis centers in Tucson, Arizona. The asymptomatic patients were identified who were receiving disease-modifying antirheumatic agents and had a positive coccidioidal serology. Serological testing including IgM and IgG was performed by enzyme immunoassay (EIA), immunodiffusion (IDTP and IDCF), or complement fixation. Out of 71 patients who were identified with positive coccidioidal serologies, 19 were asymptomatic. 18/19 patients continued antirheumatic therapy, 13 without interruption. 13/19 patients received no antifungal treatment, including 10 who remained on antirheumatic treatment. The other six were started on fluconazole, ranging from 8 to 73 months (median 30.5 months). After a median follow-up of 43 months, no patient developed clinically active coccidioidomycosis. Overall, 14 had only a positive EIA serological test. These results suggest that continued antirheumatic therapy is safe in asymptomatic patients with positive coccidioidal serological tests and that routine implementation of antifungal treatment may not always be warranted. The findings also raise concern regarding the utility of routine serological testing of asymptomatic patients residing in the coccidioidal endemic area, mainly using the EIA test.

Spontaneous Resolution of Catheter-Induced Iatrogenic Vein Graft Dissection: First Case Report and Review of Literature.

An 86-year-old female patient with a history of bypass surgery was admitted for recurrent dyspnea and chest pain on exertion. She underwent coronary angiography showing high-grade saphenous vein graft stenosis supplying the right coronary. During an attempt to perform percutaneous intervention, saphenous vein graft to the right coronary artery was injured by the guide catheter resulting in dissection with thrombus formation but with normal distal blood flow. The procedure was abandoned since she had normal distal flow and also due to a fear of causing extension of the dissection with further manipulation. The patient was hemodynamically stable and free of chest pain after 30 minutes of observation. The patient was later discharged home on medical treatment. After 1 month, a repeat angiography showed patent saphenous vein graft to the right coronary artery with healed dissection. This is the first case report of spontaneous recovery of iatrogenic saphenous vein graft dissection. This case is followed by the review of literature.

Anomalous Origin of the Right Coronary Artery From the Left Anterior Descending Artery With Anomalous Course Between the Great Vessels: A Case for Conservative Management With Review of the Literature.

A single left coronary artery is a rare coronary anomaly. In such situations, the right coronary artery arises from the left anterior descending artery and traverses an unusual proximal course between the aorta and pulmonary trunk. There are only 10 such reported cases in the medical literature to date. After a detailed risk-to-benefit consideration, the decision was made for conservative management. In this report, we describe this rare case with a detailed review of the literature.

Presence of anomalous coronary seen on angiogram is not associated with increased risk of significant coronary artery disease.

It is unclear if anomalous coronary arteries are at higher risk for atherosclerosis. The link between anomalous coronary artery and early coronary artery disease has been suggested. The aim of this study is to determine whether the coronary artery anomaly predisposes to development of significant coronary disease. Using retrospective chart review, patients with documented anomalous coronary arteries recognized during coronary angiography between years 2000 to 2007 were analyzed. Prevalence of significant atherosclerotic coronary artery disease (defined as more than 50% luminal narrowing) was compared between normal and anomalous coronaries. A total of 147 patients with anomalous coronary arteries were found. Right coronary artery was the most common anomalous artery 128 of 148 (86.5%) in our dataset. There was no difference in the occurrence of atherosclerosis between anomalous and nonanomalous coronaries. Significant atherosclerosis was present in 59 of the 148 anomalous coronary arteries (37.8%), and 112 of the 293 nonanomalous coronary arteries (38.2%, p = 0.9). On the basis of our study, there is no evidence that anomalous coronary arteries predispose to significant coronary artery disease in comparison to normal coronary arteries.