A The number of reported cases of valley fever in Arizona appears to be rising significantly. Recent preliminary statistics from the Arizona Department of Health Services (ADHS) show an increase of more than 20 percent in reported cases of valley fever in 2001 over 2000. The overall increase represents a rate of 43 cases per 100,000 population (compared to less than 41 cases per 100,000 in 1999). Maricopa County had the most reported cases followed by Pima County. Pinal County had the fewest cases. Central California and west Texas also are areas where valley fever is common. In Arizona, infections are more likely to occur from May through July and following the summer rainy season (October through December). In California, the disease peaks from June through November without the summer break.

According to the ADHS statistics, people age 60 and older were hardest hit with valley fever. Reported rates for this group (81.5 per 100,000) were almost twice as high as the 20- to 44-year old age group (42.6 cases per 100,000).

Those in occupations involving soil disturbance are at greater risk of contracting the disease. The fungus that causes valley fever — also called coccidioidomycosis, or "cocci" — is widespread in Southwestern desert soil. When the soil is disturbed and dust is raised, the microscopic spores may be inhaled with the dust, sometimes resulting in infection (valley fever is not contagious — it is not passed from person to person).

Valley fever is one of the most difficult illnesses to prevent, detect and treat. About 40 percent of those exposed to the spores become ill, and in about 60 percent of cases, the infection is so mild that individuals are unaware they are infected.

Symptoms begin seven to 21 days after inhaling the spores and typically involve fever, profuse sweating at night, chest pain, cough, loss of appetite, and generalized muscle and joint aches, particularly of the ankles and knees. There also may be a rash resembling measles or hives but it may also develop as tender red bumps on the shins or forearms. Signs and symptoms usually last for days to weeks.

Although complete recovery usually occurs, those afflicted may feel tired or have vague aches for up to a year. While it is not often fatal, occasionally valley fever develops into a severe, life-threatening disseminated form, which may involve skin, bones, the brain or other parts of the body. Meningitis is the most lethal form. Serious and disseminated cases require antifungal therapy.

Those susceptible to the most serious consequences of valley fever infection are people on chemotherapy, on immune suppression for organ transplantation or who have diseases that impair immunity, such as AIDS. People who move from the Southwest to other parts of the country subsequently may acquire a condition that suppresses immunity, which permits reactivation of infections acquired years earlier.

Individuals who develop long-lasting flu-like symptoms should contact their physician to determine if the problem is valley fever or some other illness. Winter visitors who develop these symptoms after returning home should tell their physician that they were in the Southwest, where valley fever is common.

The increasing number of valley fever cases support the need for additional research into the epidemiology, biology and treatment of valley fever - including development of a vaccine. For more information about valley fever, contact the UA Valley Fever Center for Excellence,

(520) 629-4777, or email vfever@arl.arizona.edu. The Center's website is http://www.arl.arizona.edu/vfce/.

—John N. Galgiani, MD, director, UA Valley Fever Center for Excellence (jointly sponsored by the University of Arizona and the Southern Arizona Veterans Affairs Health Care System); professor, medicine, UA College of Medicine; and program director for infectious diseases, Southern Arizona Veterans Affairs Health Care System, Tucson.

A Enbrel® (etanercept) and Remicade® (infliximab) are relatively new medications that are two of the most-used medications to treat rheumatoid arthritis. Enbrel® is approved by the Food and Drug Administration (FDA) for patients with moderate to severe active RA who have had an inadequate response to one or more anti-rheumatic medications. Since Enbrel® was introduced more than two years ago, demand has grown far beyond expectations, resulting in a national shortage. The Arizona Arthritis Center is studying Enbrel® to determine if once-a-week dosing works as well as twice a week.

Remicade® has been approved by the FDA for use with methotrexate for the treatment of moderate to severe RA in patients who have had an inadequate response to methotrexate alone. In February 2002, the FDA gave Remicade® the indication "improves physical function," the only RA medication that ever has received such an indication. Remicade® has dramatically changed the lives of many people.

The Arizona Arthritis Center was among the first to identify the target of these medications, tumor necrosis factor (TNF), in the late 1980s. TNF is an immune system protein involved in the joint inflammation and fatigue of RA. Both Enbrel® and Remicade® inhibit the action of TNF, thereby reducing common RA symptoms, including pain, swelling and fatigue, while limiting joint damage.

Enbrel® is the only TNF inhibitor that can be used without additional medication. Enbrel® is given by injection, normally twice a week, and can be administered by the patient at home.

Remicade® is given by intravenous injection under medical supervision, normally at two, and six weeks after the initial injection, then every eight weeks for the first year, then six infusions a year. The Arizona Arthritis Center has an active infusion clinic where more than 200 patients are receiving the medication on a regular basis. The Arizona Arthritis Center played an important role in the development of Remicade® and continues to study the medication.

For more information about treating your rheumatoid arthritis with Enbrel® or Remicade®, call the Arizona Arthritis Center at (520) 626-5026.

—David Yocum, MD, director, Arizona Arthritis Center, and professor, medicine, UA College of Medicine, Tucson

AHSC consists of the University of Arizona Colleges of Medicine, Nursing, Pharmacy, and Public Health, School of Health Professions, University Medical Center and The University Physicians.

Editors Note: ASK AHSC is published by the AHSC Office of Public Affairs. Reporters may quote from ASK AHSC; we request that credit be given. ASK AHSC is available on the Internet at www.ahsc.arizona.edu/opa/answers. To receive ASK AHSC via E-mail, call (520) 626-7301. Health questions should be sent to: ASK AHSC, AHSC Office of

Public Affairs, PO Box 245095, Tucson, AZ 85724-5095, or E-mail to: jspinell@u.arizona.edu. The information here is not intended to replace the advice of your physician. For referral to a UA physician, please call University Health Connection, (520) 694-8888.

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