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Clemente D, Cuadros EN, Lovillo MC, Hernández JC, Martín SG, Silveira LF, Cruz MJL, Tagarro A, Rueda RMA, López López A, Aritziturri MS, Calvo C. Position statement on infection screening, prophylaxis, and vaccination of pediatric patients with rheumatic diseases and immunosuppressive therapies, part 3: precautions in situations of surgery, fever, and opportunistic infections. Eur J Pediatr 2024; 183:915-927. [PMID: 38047962 PMCID: PMC10912362 DOI: 10.1007/s00431-023-05295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 12/05/2023]
Abstract
The objective of this study is to provide practical recommendations on the management of pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The recommendations specifically address the cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, invasive fungal disease). A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify publications on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The results were presented and discussed in a nominal group meeting, comprising a committee of 12 pediatric rheumatologists from the Infection Prevention and Treatment Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process; this was extended to members of the Spanish Society of Pediatric Rheumatology and Spanish Society of Pediatric Infectious Disease of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (totally disagree) to 10 (totally agree). Agreement was defined as a vote ≥ 7 by at least 70% of participants. The literature review included more than 400 articles. Overall, 63 recommendations (19 on surgery, fever, and opportunistic infections) were generated and voted by 59 pediatric rheumatologists and other pediatric specialists. Agreement was reached for all 63 recommendations. The recommendations on special situations cover management in cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, and invasive fungal disease). Conclusions: Hereby, we provided consensus and updated of recommendations about the management of special situations such as surgery, fever, and opportunistic in children with immune-mediated rheumatic diseases receiving immunosuppressive therapies. Several of the recommendations depend largely on clinical judgement and specific balance between risk and benefit for each individual and situation. To assess this risk, the clinician should have knowledge of the drugs, the patient's previous situation as well as the current infectious disease, in addition to experience. What is Known: • Infectious diseases and related complications are a major cause of morbidity and mortality in patients with immune-mediated rheumatic diseases. • Information on how to manage the treatment in situations of fever, opportunistic infections, and surgery in children is limited, and guidelines for action are often extrapolated from adults. What is New: • In the absence of strong evidence, a literature review and a Delphi survey were conducted to establish a series of expert recommendations that could support the clinical practice, providing a practical and simple day-to-day approach to be used by pediatric rheumatologists.
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Affiliation(s)
- Daniel Clemente
- Pediatric Rheumatology Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Esmeralda Núñez Cuadros
- Pediatric Rheumatology Unit, UGC Pediatría, Hospital Regional Universitario de Málaga, Instituto de investigación biomédica de Málaga (IBIMA), Málaga, Spain
| | - Marisol Camacho Lovillo
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío, Reumatología e Infectología pediátricas, Seville, Spain
| | - Joan Calzada Hernández
- Unitat de Reumatologia Pediàtrica, Servei de Pediatria, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Sara Guillén Martín
- Department of Pediatrics, Hospital Universitario de Getafe, CIBERINFEC ISCIII, Carretera de Toledo Km 12, 500, 28905, Getafe, Madrid, Spain.
| | - Laura Fernández Silveira
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología e Infectología pediátricas, Seville, Spain
| | | | - Alfredo Tagarro
- Pediatrics Department. Hospital Universitario Infanta Sofía, Instituto de Investigación 12 de Octubre (imas12), Universidad Europea, Madrid, Spain
| | | | - Agustín López López
- Department of Paediatrics, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Cristina Calvo
- Department of Pediatrics, Infectious and Tropical Diseases, Hospital Universitario La Paz, La Paz Research Institute (IdiPaz), Translational Research Network of Pediatric Infectious Diseases (RITIP), CIBERINFEC ISCIII, Madrid, Spain
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2
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Lima LDM, Aurilio RB, Fonseca AR, Parente AAAI, Sant’Anna MDFBP, Sant’Anna CC. Tuberculosis in children and adolescents with rheumatic diseases using biologic agents: an integrative review. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2023; 42:e2022084. [PMID: 37436237 PMCID: PMC10332438 DOI: 10.1590/1984-0462/2024/42/2022084] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 02/05/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE To conduct a bibliographic review on tuberculosis (TB) disease in children and adolescents with rheumatic diseases, being managed with biologic therapy. DATA SOURCE An integrative review with a search in the U.S. National Library of Medicine and the National Institutes of Health (PubMed) using the following descriptors and Boolean operators: (["tuberculosis"] AND (["children"] OR ["adolescent"]) AND ["rheumatic diseases"] AND (["tumor necrosis factor-alpha"] OR ["etanercept"] OR ["adalimumab"] OR ["infliximab"] OR ["biological drugs"] OR ["rituximab"] OR ["belimumab"] OR ["tocilizumab"] OR ["canakinumab"] OR ["golimumab"] OR ["secukinumab"] OR ["ustekinumab"] OR ["tofacitinib"] OR ["baricitinib"] OR ["anakinra"] OR ["rilonacept"] OR ["abatacept"]), between January 2010 and October 2021. DATA SYNTHESIS Thirty-seven articles were included, with the total number of 36,198 patients. There were 81 cases of latent tuberculosis infection (LTBI), 80 cases of pulmonary tuberculosis (PTB), and four of extrapulmonary tuberculosis (EPTB). The main rheumatic disease was juvenile idiopathic arthritis. Among LTBI cases, most were diagnosed at screening and none progressed to TB disease during follow-up. Of the TB cases using biologics, most used tumor necrosis factor-alpha inhibitors (anti-TNFα) drugs. There was only one death. CONCLUSIONS The study revealed a low rate of active TB in pediatric patients using biologic therapy. Screening for LTBI before initiating biologics should be done in all patients, and treatment, in cases of positive screening, plays a critical role in preventing progression to TB disease.
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Affiliation(s)
- Lenita de Melo Lima
- Instituto de Puericultura e Pediatria Martagão Gesteira, Rio de Janeiro, RJ, Brazil
| | | | - Adriana Rodrigues Fonseca
- Instituto de Puericultura e Pediatria Martagão Gesteira, Rio de Janeiro, RJ, Brazil
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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3
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Ribeiro MP, Duarte-Neto AN, Dolhnikoff M, Lindoso L, Lourenço B, Marques HH, Pereira MFB, Cristofani LM, Odone-Filho V, Campos LMA, Sallum AME, Carneiro-Sampaio M, Delgado AF, Carvalho WB, Mauad T, Silva CA. Major discrepancy between clinical diagnosis of death and anatomopathological findings in adolescents with chronic diseases during 18-years. Clinics (Sao Paulo) 2023; 78:100184. [PMID: 36972631 PMCID: PMC10091384 DOI: 10.1016/j.clinsp.2023.100184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 01/22/2023] [Accepted: 03/02/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVES To evaluate the inconsistency between clinical diagnosis of death and autopsy findings in adolescents with chronic diseases. METHODS A cross-sectional study including a sample of adolescents' autopsies who died in a pediatric and adolescent tertiary hospital over 18 consecutive years. During this period, there were n = 2912 deaths, and n = 581/2912(20%) occurred in adolescents. Of these, n = 85/581(15%) underwent autopsies and were analyzed. Further results were divided into two groups: Goldman classes I or II (high disagreement between main clinical diagnosis of death and anatomopathological findings, n = 26) and Goldman classes III, IV or V (low or no disagreement between these two parameters, n = 59). RESULTS Median age at death (13.5 [10‒19] vs. 13 [10‒19] years, p = 0.495) and disease duration (22 [0‒164] vs. 20 [0‒200] months, p = 0.931), and frequencies for males (58% vs. 44%, p = 0.247) were similar between class I/II vs. class III/IV/V. The frequency of pneumonia (73% vs. 48%, p = 0.029), pulmonary abscess (12% vs. 0%, p = 0.026), as well as isolation of yeast (27% vs. 5%, p = 0.008), and virus (15% vs. 2%, p = 0.029) identified in the autopsy, were significantly higher in adolescents with Goldman class I/II compared to those with Goldman class III/IV/V. In contrast, cerebral edema was significantly lower in adolescents of the first group (4% vs. 25%, p = 0.018). CONCLUSION This study showed that 30% of the adolescents with chronic diseases had major discrepancies between clinical diagnosis of death and autopsy findings. Pneumonia, pulmonary abscess, as well as isolation of yeast and virus were more frequently identified at autopsy findings in the groups with major discrepancies.
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Affiliation(s)
- Maira P Ribeiro
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Amaro N Duarte-Neto
- Patology Department, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Marisa Dolhnikoff
- Patology Department, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Livia Lindoso
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Benito Lourenço
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Heloisa H Marques
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Maria F B Pereira
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Lilian M Cristofani
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Vicente Odone-Filho
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Lucia M A Campos
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Adriana M E Sallum
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Magda Carneiro-Sampaio
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Artur F Delgado
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Werther B Carvalho
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Thais Mauad
- Patology Department, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Clovis A Silva
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
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4
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Piotto D, Nicacio A, Neto A, Mourão AF, Oliveira-Ramos F, Campanilho-Marques R, Guedes M, Cabral M, Santos MJ, Fonseca JE, Canhão H, Aikawa N, Oliveira SKF, Ferriani VPL, Pileggi GCS, Magalhães CS, Silva CA, Terreri MT. Spotlight on latent tuberculosis infection screening for juvenile idiopathic arthritis in two countries, comparing high and low risk patients. Adv Rheumatol 2022; 62:20. [DOI: 10.1186/s42358-022-00251-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 05/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Rheumatic diseases are associated with an increase in overall risks of tuberculosis (TB). The aim of this study was to evaluate the frequency of TB and the frequency of latent TB infection (LTBI), in clinical practice, for juvenile idiopathic arthritis (JIA) patients from high and low risk of TB incidence endemic countries.
Methods
This is an international, multicenter, cross-sectional, observational study of data collection from Brazil and Registry of Portugal at REUMA.PT. The inclusion criteria were patients with Juvenile Idiopathic Arthritis (JIA) with age ≤ 18 years who underwent screening for Mycobacterium tuberculosis infection [tuberculin skin test (TST) and/or interferon gamma release assay (IGRA)]. Chest X-rays and history of exposure to TB were also assessed.
Results
292 JIA patients were included; mean age 14.3 years, mean disease duration 7.5 years, 194 patients (66.4%) performed only TST, 14 (4.8%) only IGRA and 84 (28.8%) both. The frequency of LTBI (10.6%) and TB was similar between the two countries. The reasons for TB screening were different; in Brazil it was performed more often at JIA onset while in Portugal it was performed when starting Disease Modified Anti-Rheumatic Drugs (DMARD) treatment (p < 0.001). Isoniazid therapy was prescribed in 40 (13.7%) patients (31 with LTBI and 9 with epidemiologic risks and/or due to contact with sick people). Only three patients (1%) developed active TB.
Conclusion
We found nearly 10% of patients with LTBI, a small percentage of patients with treatment due to epidemiologic risks and only 1% with active TB. Distinct reasons and screening methods for LTBI were observed between the two countries.
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Noguera-Julian A, Calzada-Hernández J, Brinkmann F, Basu Roy R, Bilogortseva O, Buettcher M, Carvalho I, Chechenyeva V, Falcón L, Goetzinger F, Guerrero-Laleona C, Hoffmann P, Jelusic M, Niehues T, Ozere I, Shackley F, Suciliene E, Welch SB, Schölvinck EH, Ritz N, Tebruegge M. Tuberculosis Disease in Children and Adolescents on Therapy With Antitumor Necrosis Factor-ɑ Agents: A Collaborative, Multicenter Paediatric Tuberculosis Network European Trials Group (ptbnet) Study. Clin Infect Dis 2021; 71:2561-2569. [PMID: 31796965 DOI: 10.1093/cid/ciz1138] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 11/19/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In adults, anti-tumor necrosis factor-α (TNF-α) therapy is associated with progression of latent tuberculosis (TB) infection (LTBI) to TB disease, but pediatric data are limited. METHODS Retrospective multicenter study within the Paediatric Tuberculosis Network European Trials Group, capturing patients <18 years who developed TB disease during anti-TNF-α therapy. RESULTS Sixty-six tertiary healthcare institutions providing care for children with TB participated. Nineteen cases were identified: Crohn's disease (n = 8; 42%) and juvenile idiopathic arthritis (n = 6; 32%) were the commonest underlying conditions. Immune-based TB screening (tuberculin skin test and/or interferon-γ release assay) was performed in 15 patients before commencing anti-TNF-α therapy but only identified 1 LTBI case; 13 patients were already receiving immunosuppressants at the time of screening. The median interval between starting anti-TNF-α therapy and TB diagnosis was 13.1 (IQR, 7.1-20.3) months. All cases presented with severe disease, predominantly miliary TB (n = 14; 78%). One case was diagnosed postmortem. TB was microbiologically confirmed in 15 cases (79%). The median duration of anti-TB treatment was 50 (IQR, 46-66) weeks. Five of 15 (33%) cases who had completed TB treatment had long-term sequelae. CONCLUSIONS LTBI screening is frequently false-negative in this patient population, likely due to immunosuppressants impairing test performance. Therefore, patients with immune-mediated diseases should be screened for LTBI at the point of diagnosis, before commencing immunosuppressive medication. Children on anti-TNF-α therapy are prone to severe TB disease and significant long-term morbidity. Those observations underscore the need for robust LTBI screening programs in this high-risk patient population, even in low-TB-prevalence settings.
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Affiliation(s)
- Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Unitat d´Infeccions, Servei de Pediatria, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Barcelona, Spain.,Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain
| | - Joan Calzada-Hernández
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Unitat d´Infeccions, Servei de Pediatria, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Barcelona, Spain
| | - Folke Brinkmann
- Department of Pulmonology, University Children's Hospital, Ruhr University, Bochum, Germany
| | - Robindra Basu Roy
- Department of Paediatrics, Oxford University, Oxford, United Kingdom.,Children's Hospital, John Radcliffe Hospital, Oxford, United Kingdom
| | - Olga Bilogortseva
- Department of Child Phthisiology, National Institute of Phthisiology and Pulmonology, National Academy of Medical Sciences of Ukraine, Kiev, Ukraine
| | - Michael Buettcher
- Lucerne Children's Hospital, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Isabel Carvalho
- Department of Pediatrics, Vila Nova de Gaia Hospital Centre, Vila Nova de Gaia, Portugal
| | - Vira Chechenyeva
- Department of Child Phthisiology, National Institute of Phthisiology and Pulmonology, National Academy of Medical Sciences of Ukraine, Kiev, Ukraine.,Center of Infectious Diseases, "Clinic for Children With HIV/AIDS", National Specialized Children's Hospital (Okhmatdyt), Kiev, Ukraine
| | - Lola Falcón
- Department of Paediatric Infectious Diseases, Rheumatology and Immunodeficiency, Hospital Virgen del Rocío, Seville, Spain
| | - Florian Goetzinger
- Department of Pediatrics and Adolescent Medicine, Wilhelminenspital, Vienna, Austria
| | - Carmelo Guerrero-Laleona
- Infectious Diseases Unit, Pediatric Department, Miguel Servet University Hospital-University of Zaragoza, Zaragoza, Spain
| | - Peter Hoffmann
- Department of Internal Medicine, Gastroenterology, and Diabetology, Evang. Kliniken Essen-Mitte, Essen, Germany
| | - Marija Jelusic
- Department of Pediatrics, University of Zagreb, School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Tim Niehues
- Immunodeficiency and Rheumatology Center, Helios Klinikum Krefeld, Krefeld, Germany
| | - Iveta Ozere
- Department of Infectious Diseases and Dermatology, Riga Stradinš University, Riga, Latvia.,Center of Tuberculosis and Lung Diseases, Riga East University Hospital, Riga, Latvia
| | - Fiona Shackley
- Department of Paediatrics, Sheffield Children's National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Elena Suciliene
- Children Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Steven B Welch
- Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Elisabeth H Schölvinck
- University of Groningen, University Medical Center Groningen/Beatrix Children's Hospital, Groningen, the Netherlands
| | - Nicole Ritz
- Paediatric Infectious Diseases and Vaccinology Unit, University of Basel Children's Hospital, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland.,Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Marc Tebruegge
- Department of Paediatrics, University of Melbourne, Parkville, Australia.,Department of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.,Department of Infection, Immunity, and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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6
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Adiguzel Dundar H, Acari C, Turkucar S, Unsal E. Treatment of systemic JIA: When do we need a biologic? Real world data of a single center. Mod Rheumatol 2021; 31:684-690. [PMID: 32343644 DOI: 10.1080/14397595.2020.1761079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This paper aimed to present real-world data of treatment results of a single center in patients with systemic Juvenile Idiopathic arthritis (SJIA), in which methotrexate (MTX) along with glucocorticoids was preferred as the first-line treatment option. METHODS The medical records of 50 patients (58 episodes) with SJIA were evaluated. All patients with SJIA were hospitalized and were given high dose glucocorticoid treatment along with subcutaneous MTX. A biological agent was added in which disease activity control was not available with MTX. RESULTS Forty-one (70.6%) of 58 episodes were controlled by MTX, following discontinuation of steroids, while a biologic drug was needed in the remaining 17 (29.4%) episodes. The patients receiving MTX were divided into two groups: Group I (n = 36) (41 episodes) consisted of patients receiving MTX alone, and Group II (n = 14) (17 episodes) consisted of patients receiving MTX plus a biologic agent. Group I was dominated by the monocyclic course (56.1%), whereas group II was dominated by persistent course (70.6%). The initial erythrocyte sedimentation rate (82 vs 67 mm/h) and neutrophil/lymphocyte ratio (8.6 vs 4.1) were significantly elevated in the Group II (p = .003 and p = .007, respectively). NLR of 5.23 predicted the requirement for biological agents with a sensitivity of 66.7%, specificity 71.4%. Odds ratio for NLR ≥ 5.23 was 5.1 in Group II. CONCLUSION This study suggested that MTX was highly successful in cases with any SJIA episode, regardless of whether arthritis was present or not, even in cases presenting with MAS. A biologic drug is needed, if NLR is greater than 5.23.Key messagesHigh dose glucocorticoids with high dose SC methotrexate are the initial treatment option in systemic JIA.In glucocorticoid dependent patients, where methotrexate is ineffective, biologic therapy is mandatory.A neutrophil/lymphocyte ratio greater than 5.23 predicts the need for early biologic treatment.High dose S.C. MTX could be an option as an initial treatment in SJIA, especially biologics are not available.
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Affiliation(s)
- Hatice Adiguzel Dundar
- Division of Pediatric Rheumatolgy, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Ceyhun Acari
- Division of Pediatric Rheumatolgy, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Serkan Turkucar
- Division of Pediatric Rheumatolgy, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Erbil Unsal
- Division of Pediatric Rheumatolgy, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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7
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Klein A, Klotsche J, Hügle B, Minden K, Hospach A, Weller-Heinemann F, Schwarz T, Dressler F, Trauzeddel R, Hufnagel M, Foeldvari I, Borte M, Kuemmerle-Deschner J, Brunner J, Oommen PT, Föll D, Tenbrock K, Urban A, Horneff G. Long-term surveillance of biologic therapies in systemic-onset juvenile idiopathic arthritis: data from the German BIKER registry. Rheumatology (Oxford) 2021; 59:2287-2298. [PMID: 31846042 DOI: 10.1093/rheumatology/kez577] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/22/2019] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Using data from the German Biologics JIA Registry (BIKER), long-term safety of biologics for systemic-onset JIA with regard to adverse events of special interest was assessed. METHODS Safety assessments were based on adverse event reports after first dose through 90 days after last dose. Rates of adverse event, serious adverse event and 25 predefined adverse events of special interest were analysed. Incidence rates were compared for each biologic against all other biologics combined applying a mixed-effect Poisson model. RESULTS Of 260 systemic-onset JIA patients in this analysis, 151 patients received etanercept, 109 tocilizumab, 71 anakinra and 51 canakinumab. Patients with etanercept had higher clinical Juvenile Arthritis Disease Activity Score 10 scores, active joint counts and steroid use at therapy start. Serious adverse events were reported with higher frequency in patients receiving canakinumab [20/100 patient years (PY)] and tocilizumab (21/100 PY). Cytopenia and hepatic events occurred with a higher frequency with tocilizumab and canakinumab. Medically important infections were seen more often in patients with IL-6 or IL-1 inhibition. Macrophage activation syndrome occurred in all cohorts with a higher frequency in patients with canakinumab (3.2/100 PY) and tocilizumab (2.5/100 PY) vs anakinra (0.83/100 PY) and etanercept (0.5/100 PY). After adjustment only an elevated risk for infections in anakinra-treated patients remained significant. Three definite malignancies were reported in patients ever exposed to biologics. Two deaths occurred in patients treated with etanercept. CONCLUSION Surveillance of pharmacotherapy as provided by BIKER is an import approach especially for patients on long-term treatment. Overall, tolerance was acceptable. Differences between several biologics were noted and should be considered in daily patient care.
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Affiliation(s)
- Ariane Klein
- Centre for Paediatric Rheumatology, Department of Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin.,Department of Pediatrics, Medical Faculty, University of Cologne, Cologne
| | - Jens Klotsche
- German Rheumatism Research Centre Berlin, and Charité, University Medicine, Berlin
| | - Boris Hügle
- German Centre Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen
| | - Kirsten Minden
- German Rheumatism Research Centre Berlin, and Charité, University Medicine, Berlin
| | | | | | - Tobias Schwarz
- Department of Pediatric Rheumatology, St Josef Hospital, Sendenhorst
| | - Frank Dressler
- Pediatric Pneumology, Allergology, Neonatology, Immunology, Medizinische Hochschule Hannover, Hannover
| | | | - Markus Hufnagel
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Freiburg
| | - Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Hamburg
| | - Michael Borte
- Pediatric Immunology, Children's Hospital Sankt Georg, Leipzig
| | | | - Jürgen Brunner
- Department of Pediatrics I, Medical University, Innsbruck, Austria
| | - Prasad Thomas Oommen
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, University Children's Hospital, Heinrich-Heine-University, Düsseldorf
| | - Dirk Föll
- Department of Pediatrics, Rheumatology and Immunology, University Hospital, Münster
| | - Klaus Tenbrock
- Department of Pediatric and Adolescent Medicine, RWTH Aachen University, Aachen
| | - Andreas Urban
- Klinikum St Marien Klinik für Kinder und Jugendliche - Rheumatology/Pneumology, Amberg, Germany
| | - Gerd Horneff
- Centre for Paediatric Rheumatology, Department of Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin.,Department of Pediatrics, Medical Faculty, University of Cologne, Cologne
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Passone CGB, Grisi SJ, Farhat SC, Manna TD, Pastorino AC, Alveno RA, Miranda CVS, Waetge AR, Cordon MN, Odone-Filho V, Tannuri U, Carvalho WB, Carneiro-Sampaio M, Silva CA. COMPLEXITY OF PEDIATRIC CHRONIC DISEASE: CROSS-SECTIONAL STUDY WITH 16,237 PATIENTS FOLLOWED BY MULTIPLE MEDICAL SPECIALTIES. ACTA ACUST UNITED AC 2019; 38:e2018101. [PMID: 31778404 PMCID: PMC6909259 DOI: 10.1590/1984-0462/2020/38/2018101] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/30/2018] [Indexed: 12/15/2022]
Abstract
Objective: To assess demographic data and characteristics of children and adolescents with pediatric chronic diseases (PCD), according to the number of specialties/patient. Methods: We performed a cross-sectional study with 16,237 PCD patients at outpatient clinics in one year. Data were analyzed by an electronic data system, according to the number of physician appointments for PCD. This study assessed: demographic data, follow-up characteristics, types of medical specialty, diagnosis (International Statistical Classification of Diseases and Related Health Problems - ICD-10), number of day hospital clinic visits, and acute complications. Results: Patients followed by ≥3 specialties simultaneously showed a significantly higher duration of follow-up compared to those followed by ≤2 specialties [2.1 (0.4-16.4) vs. 1.4 (0.1-16.2) years; p<0.001] and a higher number of appointments in all specialties. The most prevalent medical areas in patients followed by ≥3 specialties were: Psychiatry (Odds Ratio - OR=8.0; confidence interval of 95% - 95%CI 6-10.7; p<0.001), Palliative/Pain Care (OR=7.4; 95%CI 5.7-9.7; p<0.001), Infectious Disease (OR=7.0; 95%CI 6.4-7.8; p<0.001) and Nutrology (OR=6.9; 95%CI 5.6-8.4; p<0.001). Logistic regressions demonstrated that PCD patients followed by ≥3 specialties were associated with high risk for: number of appointments/patient (OR=9.2; 95%CI 8.0-10.5; p<0.001), day hospital clinic visits (OR=4.8; 95%CI 3.8-5.9; p<0.001), emergency department visits (OR=3.2; 95%CI 2.9-3.5; p<0.001), hospitalizations (OR=3.0; 95%CI 2.7-3.3; p<0.001), intensive care admissions (OR=2.5; 95%CI 2.1-3.0; p<0.001), and deaths (OR=2.8; 95%CI 1.9-4.0; p<0.001). The diagnosis of asthma, obesity, chronic pain, and transplant was significantly higher in patients followed by ≥3 specialties. Conclusions: The present study showed that PCD patients who required simultaneous care from multiple medical specialties had complex and severe diseases, with specific diagnoses.
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Ferreira GRV, Tomioka RB, Queiroz LB, Kozu K, Aikawa NE, Sallum AME, Serafini P, Tacla M, Baracat EC, Pereira RMR, Bonfá E, Silva CA. Lower genital tract infections in young female juvenile idiopathic arthritis patients. Adv Rheumatol 2019; 59:50. [PMID: 31730499 DOI: 10.1186/s42358-019-0092-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate human papillomavirus (HPV), Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections in juvenile idiopathic arthritis (JIA) patients. METHODS After exclusion, 33 female adolescent and young JIA patients (ILAR criteria) and 28 healthy controls were selected for this study. Demographic data, gynecological, sexual function, cervical cytology and histological abnormalities were evaluated. JIA clinical/laboratorial parameters and treatment were also assessed. HPV-DNA, CT-DNA and NG-DNA testing in cervical specimens were performed by Hybrid Capture 2 assays. RESULTS The mean current age was similar in JIA patients and controls (23.3 ± 6.24 vs. 26.1 ± 6.03 years, p = 0.09). The frequencies of sexual intercourse (76% vs. 89%, p = 0.201) and abnormal cervical cytology (24% vs. 11%, p = 0.201) were similar in JIA compared to controls. The higher frequency of HPV infection in JIA patients than controls (30% vs. 11%, p = 0.155) did not reach statistical significance. CT (0% vs. 7%, p = 0.207) and NG infections (0% vs. 4%, p = 0.459) were also alike in both groups. Further evaluation of JIA patients with abnormal and normal cervical cytology showed that the former group had a higher frequency of HPV infection (87% vs. 12%, p = 0.0002) with a low frequency of HPV vaccination (0% vs. 8%, p = 1.0). No differences were evidenced between these two JIA groups regarding demographic data, sexual function and clinical/laboratorial parameters. The frequencies of methotrexate (p = 0.206) and biological agent use (p = 0.238) were similar in both JIA groups. CONCLUSIONS To our knowledge, this was the first study to assess lower genital infections in JIA patients allowing the identification of HPV as main cause of cervical dysplasia. Methotrexate and biological agents do not seem to increase risk of lower genital tract infections in JIA patients.
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Affiliation(s)
- Gabriela R V Ferreira
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Renato B Tomioka
- Discipline of Gynecology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.,Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Ligia B Queiroz
- Adolescent Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Katia Kozu
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Nadia E Aikawa
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil.,Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Adriana M E Sallum
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Paulo Serafini
- Discipline of Gynecology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Maricy Tacla
- Discipline of Gynecology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Edmund C Baracat
- Discipline of Gynecology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Rosa M R Pereira
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Eloisa Bonfá
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil. .,Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil.
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