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Enbrel and infections- Beware!

Folks,

I'm new here. I wanted to share some of my recent experience with you so you can maybe avoid or circumvent a problem.

I was diagnosed with RA about 8 years ago. I as fortunate enough to start on Enbrel right at its beginnings and experienced a great deal of relief. I lead a very busy life with pain mostly still just in my hands. It's pretty bad at times, but it is so much better than it was, I accept it.   

I have always been susceptible to sinus infections. I never stopped taking Enbrel when I got them, and I always seemed to get over them. I always took antibiotics when I got an infection.

Last November, I had a sinus infection. took antibiotics. Seemed to be better. Got on a plane and thought I was going to die.

Long story short- it's May. After five course of antibiotics since November, got a ct scan and my sinus were completely opacified. Took more, heavy duty antibiotics and they did nothing to clear it. Had sinus surgery- which is awful!   Still on antibiotics- also had to go on an antifungal as I had a fungal infection in my sinuses as well.

Folks- Enbrel looks to have decimated my immune system. This surgery really has been tough on me, my RA, my family.

Please- if you have recurring infections- watch the Enbrel. I am now awaiting my rheumatologists decision on what to take next. Just keep an eye on it.

Be well.

Hi Amy, 
 
Sorry about your infections.  Hope you find something that helps.
 
Pip
 
Amy...... Sorry that was your experience... I hate to hear of someone suffering like that.. I hope that you find something that works for you..
speedy healing to you.
 
wow.. Pip certainly jumped on this post.....
Do you think it happened because you didn't stop the Enbrel during the prior infections and antibiotic courses?oh.. how did I miss that point, wantto!! good job!
 
Your RD should have told you to stop it when on the Antibiotics....
Yeah,
 
She is chronic sinuses suffer. It seems that either her ear nose throat doctor or rheumatologist would have been ahead of this. Here is what I read about it but cannot find a good definition of immunocompetant. Anyone?
 

Sinusitis, Fungal

Author: Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University
Contributor Information and Disclosures

Updated: Apr 22, 2009

< =1.2 =text/> < =1.2 =text/ =ISO-8859-1 ="http://as.medscape.com/js.ng/transID=34709427&site=1&affiliate=2&ssp=14&artid=10070639&cg=ckb&pub=430&pubs=430&ct=0&pf=0&usp=0&st=0&occ=0&tid=0&pos=121">

Introduction

Fungal infections of the sinuses have recently been blamed for causing most cases of chronic rhinosinusitis. The evidence, though, is still controversial. Most fungal sinus infections are benign or noninvasive, except when they occur in individuals who are immunocompromised. Several reports are available that have shown invasive fungal infections in immunocompetent individuals.1,2,3

Distinguishing invasive disease from noninvasive disease is important because the treatment and prognosis are different for each. Noninvasive disease has 2 varieties of presentations, and invasive disease has 3 varieties of presentations. This article reviews all 5 varieties. For excellent patient education resources, see eMedicine's Headache Center. Also, visit eMedicine's patient education article, Sinus Infection.

Axial%20CT%20scan%20of%20sinuses%20shows%20a%20right%20fungal%20max...

Axial CT scan of sinuses shows a right fungal maxillary sinusitis with an expanding mass (possibly aspergillosis).

Axial%20CT%20scan%20of%20sinuses%20shows%20a%20right%20fungal%20max...

Axial CT scan of sinuses shows a right fungal maxillary sinusitis with an expanding mass (possibly aspergillosis).


History of the Procedure

Fungal infections of the paranasal sinuses are uncommon and usually occur in individuals who are immunocompromised. However, recently, the occurrence of fungal sinusitis has increased in the immunocompetent population.

The most common pathogens are from Aspergillus and Mucor species. Aspergillosis can cause noninvasive or invasive infections. Invasive infections are characterized by dark, thick, greasy material found in the sinuses. Invasive infections can cause tissue invasion and destruction of adjacent structures (eg, orbit, CNS). Noninvasive infections cause symptoms of sinusitis, and the sinus involved is opacified on radiographic studies. Routine cultures from the sinuses rarely demonstrate the fungus. However, the fungus is usually suspected upon reviewing the CT scan result and is detected on removal of the secretions from the sinus.

Problem

Fungal infections of the paranasal sinus can manifest as 2 distinct entities.

The more serious infection commonly occurs in patients with diabetes or in individuals who are immunocompromised and is characterized by its invasiveness, tissue destruction, and rapid onset. Early detection and treatment are vital for these infections because of the high mortality rate.

Noninvasive infections are chronic and are usually treated for extended periods as chronic sinusitis before the condition is recognized.

Etiology

Noninvasive fungal sinusitis

Two forms are described in this category: allergic fungal sinusitis and sinus mycetoma/ball.

Most commonly, Curvularia lunata, Aspergillus fumigatus, and Bipolaris and Drechslera species cause allergic fungal sinusitis.

A fumigatus and dematiaceous fungi most commonly cause sinus mycetoma.

Invasive fungal sinusitis

Invasive fungal sinusitis includes the acute fulminant type, which has a high mortality rate if not recognized early and treated aggressively, and the chronic and granulomatous types.

Saprophytic fungi of the order Mucorales, including Rhizopus, Rhizomucor, Absidia, Mucor, Cunninghamella, Mortierella, Saksenaea, and Apophysomyces species, cause acute invasive fungal sinusitis.

A fumigatus is the only fungus associated with chronic invasive fungal sinusitis.

Aspergillus flavus exclusively has been associated with granulomatous invasive fungal sinusitis.

Pathophysiology

Allergic fungal sinusitis

Allergic rhinitis is prevalent in this group and is considered to be the trigger mechanism behind allergic fungal sinusitis. Patients are immunocompetent and often have asthma, eosinophilia, and elevated total fungus-specific immunoglobulin E (IgE) concentrations.4

Surgery reveals greenish black or brown material (ie, allergic mucin), which has the consistency of peanut butter mixed with sand and glue. Allergic mucin and polyps may form a partially calcified expansile mass that obstructs sinus drainage. Growth of the mass may cause pressure-induced erosion of bone, rupture of sinus walls, and occasional leakage of the sinus contents into the orbit or brain.

Sinus mycetoma

This condition is usually unilateral and involves the maxillary sinus. Mucopurulent, cheesy, or claylike material is present at the time of surgery. Patients with sinusitis mycetoma are immunocompetent. Allergic conditions and fungus-specific IgE are less common.

Acute invasive fungal sinusitis

Acute invasive fungal sinusitis results from a rapid spread of fungi through vascular invasion into the orbit and CNS. It is common in patients with diabetes and in patients who are immunocompromised and has been reported in immunocompetent individuals. Typically, patients with acute invasive sinusitis are severely ill with fever, cough, nasal discharge, headache, and mental status changes. They usually require hospitalization.

Chronic invasive fungal sinusitis

Chronic invasive fungal sinusitis is a slowly progressive fungal infection with a low-grade invasive process and usually occurs in patients with diabetes.

Orbital apex syndrome, which is characterized by a decrease in vision and ocular immobility due to a mass in the superior portion of the orbit, is usually associated with this condition.

Granulomatous invasive fungal sinusitis

This condition has been reported almost exclusively in immunocompetent individuals from North Africa. Generally, proptosis is associated with granulomatous invasive fungal sinusitis.

Presentation

Allergic fungal sinusitis

Patients present with symptoms of chronic sinusitis, which may include facial pressure, headache, nasal stuffiness, discharge, and cough. The condition should be suspected in individuals with intractable sinusitis and nasal polyposis.

Some patients may present with proptosis or eye muscle entrapment. These patients usually have atopy and have had multiple surgeries by the time of diagnosis. CT scanning of the sinuses reveals opacification with concretions and/or calcifications.

Sinus mycetoma

Presentation of patients with sinus mycetoma is similar to that of patients with sinusitis. Examination may reveal polyposis with evidence of sinusitis, mainly on one side. The main report is blowing of gravel-like material from the nose. Usually, sinus mycetoma is found accidentally on CT scanning of the sinuses.

Acute invasive fungal sinusitis

Patients are usually hospitalized and are very sick with fever, cough, nasal discharge, headache, and mental status changes. A high index of suspicion for early diagnosis is critical, especially in individuals who are immunocompromised.

Signs and symptoms include dark ulcers on the septum, turbinates, or palate. In the late stages, signs and symptoms of cavernous sinus thrombosis are present.

Chronic invasive fungal sinusitis

Patients present with symptoms of long-standing sinusitis. Symptoms are usually not acute, and fever and mental status changes are absent.

Orbital apex syndrome, which is characterized by a decrease in vision and ocular immobility due to a mass in the superior portion of the orbit, is usually associated with this condition.

Nasal examination findings can be minimal. However, findings from the eye examination can be positive.

Granulomatous invasive fungal sinusitis

Patients present with symptoms of chronic sinusitis associated with proptosis. Examination of the nasal cavity can be nonrevealing. However, findings from the eye examination are usually impressive.

Indications

The treatment of choice for all types of fungal sinusitis is surgical (see Surgical therapy).

Relevant Anatomy

See Surgical therapy.

Contraindications

All forms of fungal sinusitis require surgical treatment. The only contraindications to surgical management relate to the general condition of the patient. Before surgery is recommended, risks and benefits of the surgical procedure should be weighed against the risks of general anesthesia.

More on Sinusitis, Fungal

Overview: Sinusitis, Fungal
Workup: Sinusitis, Fungal
Treatment: Sinusitis, Fungal
Follow-up: Sinusitis, Fungal
Multimedia: Sinusitis, Fungal
References
Further Reading
I was told to stop my Humira and Enbrel while on antibiotics for infections. I did but still had awful problems while on Humira with my sinuses. I have never felt so ill in all my life, the effects of it were worse than any RA pain I had been having.
Saying that many more have no problems so I think it is individual cases.
wow amy, I'm so sorry you've had such a rough time if it. I also have had sinus surgery and I can attest to it's awfulness. I hope things turn around for you soon!Amy, I hope you feel better soon.  We all need to be aware of our drug choices and the adverse reactions.  I too am surprised that you were not told to stop the Enbrel, though I have had other doctors not familiar with the biologics fail to mention stopping them.  My RD told me if I had an infection of any kind to stop at once and do not restart until I was free and clear. 

Amy, please be careful of any drug you take.   You should read everything you can so you will be aware of any side effects or drug interactions.  I am so sorry you had to learn this in such a rough way and I truly hope the path ahead is smoother for you. I'd like to be a little clearer on this subject.

Would I be correct in assuming that if I needed to take antibiotics for any infection, whether
internal or from the likes of an infected cut to the hand or what not, I should stop the Humira.


[QUOTE=Bodak]I'd like to be a little clearer on this subject.

Would I be correct in assuming that if I needed to take antibiotics for any infection, whether
internal or from the likes of an infected cut to the hand or what not, I should stop the Humira.


[/QUOTE]
 
My RD always told me if I had an infection, to stop using Humira.  I never had an infection while I was on Humira or Enbrel though........
Lynn492009-05-05 15:36:49Stephen, that is something you should ask your RD.  I am just reporting what my RD told me...  that may not be the same advice someone else would get.  I do know when I had a scratch to my leg while on Enbrel, and later on, another while on Humira, I developed cellulitis and had to stop the biologics.  I watch any breaks to the skin very carefully now. My doctor even insists I stop my MTX! Welcome Amy - sorry that you had issues with infections.  Hope you can get on something else quickly.  
 
I've been on Enbrel for almost two years now and only stopped once while on antibiotic and "knock on wood" no other problems since then.  I started using a netipot following my first sinus infection and that seems to help.
Has anyone who never got sinus infections previously get them now that they are on biologics? I never do. I was questioning my doctor last visit about has he seen any serious side effects in his patients using biologics. He said for the most part he's seen infections. I said yeah but not the fatal kind they warn you about right? He said well...mostly easily cleared up infections like sinus and cellulitis but I have had several patints that have had to be hospitilized for some serious kinds and they had a pretty tough time of it.
Good thought! However, I stopped Enbrel each time I had an infection and still got them and haven't been sick once since I stopped Enbrel.  I think there was a connection, but that is my opinion. 
Bodak, I would clarify with your RD.  I continued my MTX, but always stopped my Enbrel at my dr's direction. 
 
[QUOTE=wanttobeRAfree]Do you think it happened because you didn't stop the Enbrel during the prior infections and antibiotic courses?[/QUOTE]
 

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