The Food and Drug Administration ordered stronger warnings Thursday on four medications widely used to treat rheumatoid arthritis and other serious illnesses, saying they can raise the risk of possibly fatal fungal infections.

The drugs ¡ª Enbrel, Remicade, Humira and Cimzia ¡ª work by suppressing the immune system to keep it from attacking the body. For patients with rheumatoid arthritis, the treatment provides relief from swollen and painful joints, but it is ¡°a double-edged sword,¡± said Dr. Jeffrey Siegel of the drug agency. That is because the drugs also lower the body¡¯s defenses to infections.

Dr. Siegel, who heads the office that oversees arthritis drugs, said the agency became concerned after discovering that doctors seemed to be overlooking a kind of fungal infection called histoplasmosis. Of 240 cases reported to the agency in which patients taking one of the four drugs developed this infection, 45 died. That is about 20 percent.

The infection, which mimics the flu, is prevalent in the middle part of the country. It can have grave consequences if it is not caught and spreads from the respiratory system to other organs.

Dr. Siegel said the investigation began with a single case of a woman who was taking one of the drugs and later died of histoplasmosis. Delving into the case, doctors at the agency found that the woman had been sick with the fungal infection for a long time. Patients should call their doctors if they develop persistent fever, cough, shortness of breath or fatigue, which can be signs of the fungal infection.

Separately, the agency is investigating a possible link between the four medications and cancer in young patients. The agency said earlier this year that it had received 30 reports of cancers, mainly lymphomas, in patients who began taking the medications when they were 18 or younger. That investigation is expected to take the rest of the year.

Humira is sold by Abbott Laboratories; Cimzia by UCB; Enbrel by Amgen Inc. and Wyeth; and Remicade by Centocor, a unit of Johnson & Johnson and Schering-Plough Inc.

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