Sinus aspergilloma in rheumatoid arthritis before or during tumor necrosis factor-alpha antagonist therapy

INTRODUCTION In 2008, the Food and Drugs Administration required manufacturers of TNFalpha antagonists to strengthen their warnings about the risk of serious fungal infections in patients with rheumatoid arthritis (RA). Sinus aspergilloma occurs occasionally in RA patients and can progress to invasive Aspergillus disease. The purpose of this study was to describe symptomatic sinus aspergilloma in RA patients treated with TNFalpha antagonists. METHODS Retrospective descriptive study of symptomatic cases of sinus aspergilloma in patients with RA followed in three French university hospitals. A systematic literature review was performed. RESULTS Among 550 RA patients treated with TNFalpha antagonists, six (1.1%) had symptomatic maxillary aspergilloma diagnosed by computed tomography before or during TNFalpha antagonist therapy. None had chronic neutropenia. Aspergilloma treatment was with surgery only in all six patients. In the literature, we found 20 reports of Aspergillus infection in patients with chronic inflammatory joint diseases (including 10 with RA). Only 5/20 patients were treated with TNFalpha antagonists (invasive lung aspergillosis, n = 3; intracranial aspergillosis, n = 1; and sphenoidal sinusitis, n = 1). CONCLUSIONS Otorhinolaryngological symptoms must be evaluated before starting or switching TNFalpha antagonists. Routine computed tomography of the sinuses before starting or switching TNFalpha antagonists may deserve consideration.