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Brehm TT, Reimann M, Köhler N, Lange C. (Re-)introduction of TNF antagonists and JAK inhibitors in patients with previous tuberculosis: a systematic review. Clin Microbiol Infect 2024; 30:989-998. [PMID: 38663653 DOI: 10.1016/j.cmi.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Tuberculosis (TB) is a common complication associated with treatment with tumour necrosis factor (TNF) antagonists and Janus kinase (JAK) inhibitors. However, there is uncertainty about the risk of TB relapse in patients with TB and comorbidities requiring treatment with these agents. OBJECTIVES To assess the risk of TB relapse in patients (re-)started on TNF antagonists or JAK inhibitors. METHODS Systematic review. DATA SOURCES PubMed and Cochrane Library databases until 11 December 2023. STUDY ELIGIBILITY CRITERIA Randomized control trials, prospective and retrospective cohort studies, case reports and case series. PARTICIPANTS Patients with current or previous TB who were (re-)started on TNF antagonists or JAK inhibitors. INTERVENTIONS (Re-)introduction of TNF antagonists and JAK inhibitors. ASSESSMENT OF RISK OF BIAS All studies meeting entry criteria were included regardless of quality. METHODS OF DATA SYNTHESIS Categorical data are presented as frequencies and percentages. For non-normally distributed aggregated data, we calculated the pooled weighted median with 95% CI. For individual patient data, the median and interquartile range (IQR) were calculated. RESULTS Of 5018 articles screened for eligibility, 67 publications reporting on 368 TB patients who (re-)initiated treatment with TNF antagonists for underlying diseases were included. The median age was 42.5 years (95% CI: 40.4-42.5) and the proportion of female patients was 36.6% (n = 74) of patients whose sex was reported. A total of 14 patients (3.8%, 95% CI: 2.1-6.3%) developed TB relapse after a median of 8.5 months (interquartile range, 6.8-14.8 months) following (re-)initiation of anti-TNF treatment. Furthermore, among 251 articles screened for eligibility, 11 reports on TB patients who were (re-)started on JAK inhibitors for underlying diseases were identified. The median age was 62 years (interquartile range, 48.5-68.5 years) and 45.5% (n = 5) were female. Only one patient (9.1%; 95% CI: 0.2-41.3%) had TB reactivation 10 months after starting treatment with ruxolitinib. In addition, 94 patients who were treated with TNF antagonists and two patients temporarily treated with JAK inhibitors for the prevention or treatment of paradoxical reactions were analysed. None of the publications reported microbiological failure or worsening of TB-related symptoms. CONCLUSIONS (Re-)initiation of TNF antagonists and JAK inhibitors may be relatively safe in patients with current or previous TB and the need for further treatment of underlying diseases.
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Affiliation(s)
- Thomas Theo Brehm
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany; Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.
| | - Maja Reimann
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany; Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
| | - Niklas Köhler
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany; Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany
| | - Christoph Lange
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany; Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; Baylor College of Medicine and Texas Children's Hospital, Global Tuberculosis Program, Houston, Texas, USA; Institute for Infection Research and Vaccine Development (IIRVD), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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2
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Rodríguez-Molino P, Tebruegge M, Noguera-Julian A, Neth O, Fidler K, Brinkmann F, Sainz T, Ivaskeviciene I, Ritz N, Brito MJ, Milheiro Silva T, Chechenieva V, Serdiuk M, Lancella L, Russo C, Soler-García A, Navarro ML, Krueger R, Feiterna-Sperling C, Starshinova A, Hiteva A, Hoffmann A, Kalibatas P, Lo Vecchio A, Scarano SM, Bustillo M, Blázquez Gamero D, Espiau M, Buonsenso D, Falcón L, Turnbull L, Colino E, Rueda S, Buxbaum C, Carazo B, Alvarez C, Dapena M, Piqueras A, Velizarova S, Ozere I, Götzinger F, Pareja M, Garrote Llanos MI, Soto B, Rodríguez Martín S, Korta JJ, Pérez-Gorricho B, Herranz M, Hernández-Bartolomé Á, Díaz-Almirón M, Kohns Vasconcelos M, Ferreras-Antolín L, Santiago-García B. Tuberculosis Disease in Immunocompromised Children and Adolescents: A Pediatric Tuberculosis Network European Trials Group Multicenter Case-control Study. Clin Infect Dis 2024; 79:215-222. [PMID: 38568992 DOI: 10.1093/cid/ciae158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND In high-resource settings, the survival of children with immunocompromise (IC) has increased and immunosuppressive therapies are increasingly being used. This study aimed to determine the clinical characteristics, performance of diagnostic tools, and outcome of IC children with tuberculosis (TB) in Europe. METHODS Multicenter, matched case-control study within the Pediatric Tuberculosis Network European Trials Group, capturing TB cases <18 years diagnosed 2000-2020. RESULTS A total of 417 TB cases were included, comprising 139 children who are IC (human immunodeficiency virus, inborn errors of immunity, drug-induced immunosuppression, and other immunocompromising conditions) and 278 non-IC children as controls. Nonrespiratory TB was more frequent among cases than controls (32.4% vs 21.2%; P = .013). Patients with IC had an increased likelihood of presenting with severe disease (57.6% vs 38.5%; P < .001; odds ratio [95% confidence interval], 2.073 [1.37-3.13]). Children with IC had higher rates of false-negative tuberculin skin test (31.9% vs 6.0%; P < .001) and QuantiFERON-TB Gold assay (30.0% vs 7.3%; P < .001) results at diagnosis. Overall, the microbiological confirmation rate was similar in IC and non-IC cases (58.3% vs 49.3%; P = .083). Although the mortality in children with IC was <1%, the rate of long-term sequelae was significantly higher than in non-IC cases (14.8% vs 6.1%; P = .004). CONCLUSIONS Children with IC and TB in Europe have increased rates of nonrespiratory TB, severe disease, and long-term sequelae. Immune-based TB tests have poor sensitivity in those children. Future research should focus on developing improved immunological TB tests that perform better in patients with IC, and determining the reasons for the increased risk of long-term sequelae, with the aim to design preventive management strategies.
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Affiliation(s)
- Paula Rodríguez-Molino
- General Pediatrics, Infectious and Tropical Diseases Department, Hospital La Paz, Madrid, Spain
- La Paz Research Institute (IdiPAZ), Madrid, Spain
- Faculty of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Marc Tebruegge
- Department of Paediatrics & National Reference Centre for Paediatric Tuberculosis, Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Department of Infection, Immunity & Inflammation, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Pediatric Infectious Diseases Department, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
- Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Olaf Neth
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, IBiS/Universidad de Sevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica (RITIP), Seville, Spain
| | - Katy Fidler
- Paediatric Infectious Diseases Department, Royal Alexandra Children's Hospital, Brighton, United Kingdom
| | - Folke Brinkmann
- Department of Pediatric Pneumology, Allergology and CF Center, University Children's Hospital Bochum, Bochum, Germany
| | - Talia Sainz
- General Pediatrics, Infectious and Tropical Diseases Department, Hospital La Paz, Madrid, Spain
- La Paz Research Institute (IdiPAZ), Madrid, Spain
- Faculty of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Inga Ivaskeviciene
- Clinic of Children's Diseases, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Nicole Ritz
- Department of Paediatrics & Paediatric Infectious Diseases, Children's Hospital of Central Switzerland, Lucerne, Switzerland
- Mycobacterial and Migrant Health Research, University Children's Hospital Basel and Department for Clinical Research University of Basel, Basel, Switzerland
| | - Maria Joao Brito
- Infectious diseases Unit, Pediatrics Department, Hospital Dona Estefânia, Centro Hospitalar e Universitário Lisboa Central, Lisboa, Portugal
| | - Tiago Milheiro Silva
- Infectious diseases Unit, Pediatrics Department, Hospital Dona Estefânia, Centro Hospitalar e Universitário Lisboa Central, Lisboa, Portugal
| | - Vira Chechenieva
- Department of Paediatrics & National Reference Centre for Paediatric Tuberculosis, Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
- Centre for Treatment Children with HIV/AIDS, National Specialised Children's Hospital "OKHMATDYT", Kyiv, Ukraine
- Pediatric TB Department, National institute of Phthisiology and Pulmonology named after F.G. Yanovsky NAMS of Ukraine, Kyiv, Ukraine
| | - Maryna Serdiuk
- Centre for Treatment Children with HIV/AIDS, National Specialised Children's Hospital "OKHMATDYT", Kyiv, Ukraine
| | - Laura Lancella
- Virology and Mycobacteria Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Cristina Russo
- Virology and Mycobacteria Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Aleix Soler-García
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Pediatric Infectious Diseases Department, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Maria Luisa Navarro
- Paediatric Infectious Diseases Department, Gregorio Marañón University Hospital, Madrid, Spain
- UDIMIFFA, Gregorio Marañón Research Health Institute (IiSGM), UCM, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Renate Krueger
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Cornelia Feiterna-Sperling
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Anna Starshinova
- St. Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Antonina Hiteva
- St. Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Anna Hoffmann
- Department of Pediatric Pneumology, Allergology and CF Center, University Children's Hospital Bochum, Bochum, Germany
| | - Paulius Kalibatas
- Clinic of Children's Diseases, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Andrea Lo Vecchio
- Pediatric Infectious Disease Unit, University Hospital Policlinico "Federico II", Naples, Italy
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Sara Maria Scarano
- Pediatric Infectious Disease Unit, University Hospital Policlinico "Federico II", Naples, Italy
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Matilde Bustillo
- Pediatrics Infectious Diseases Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Daniel Blázquez Gamero
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - María Espiau
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona (UAB), Barcelona, Catalonia, Spain
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lola Falcón
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, IBiS/Universidad de Sevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica (RITIP), Seville, Spain
| | - Louise Turnbull
- Department of Paediatrics, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Elena Colino
- Pediatric Infectious Diseases Unit, Complejo Hospitalario Insular Materno Infantil Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Santiago Rueda
- Department of Pediatrics, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Charlotte Buxbaum
- Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Begoña Carazo
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitario Regional de Málaga, Málaga, Spain
| | - Cristina Alvarez
- Pediatrics Department, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Marta Dapena
- Pediatric Infectious Diseases Unit, Hospital General de Castellón, Castellón, Spain
| | - Anabel Piqueras
- Pediatrics Department, Hospital Universitario La Fe, Valencia, Spain
| | - Svetlana Velizarova
- Children's Clinic, Department of Pulmonary Diseases, MHATLD "St Sofia", Medical University Sofia, Sofia, Bulgaria
| | - Iveta Ozere
- Department of Infectology, Centre of Tuberculosis and Lung Diseases of Riga Eastern Clinical University Hospital, Riga, Latvia
| | - Florian Götzinger
- Department of Paediatrics & National Reference Centre for Paediatric Tuberculosis, Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
| | - Marta Pareja
- Pediatrics Department, Albacete University Hospital, Albacete, Spain
| | | | - Beatriz Soto
- Pediatrics Department, Getafe University Hospital, Getafe, Spain
| | - Sonia Rodríguez Martín
- Pediatrics Department, Príncipe de Asturias University Hospital, Alcalá de Henares, Spain
- Medicine Department, Faculty of Medicine, University of Alcalá, Alcalá de Henares, Spain
| | - Jose Javier Korta
- Pediatrics Department, Donostia University Hospital, San Sebastián, Spain
| | - Beatriz Pérez-Gorricho
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Mercedes Herranz
- Pediatrics Department, Navarra University Hospital, Navarra, Spain
| | - Ángel Hernández-Bartolomé
- Paediatric Infectious Diseases Department, Gregorio Marañón University Hospital, Madrid, Spain
- UDIMIFFA, Gregorio Marañón Research Health Institute (IiSGM), UCM, Madrid, Spain
| | | | - Malte Kohns Vasconcelos
- Institute for Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Laura Ferreras-Antolín
- Paediatric Infectious Diseases and Immunodeficiencies Unit, St. George's University Hospital, NHS Foundation Trust, London, United Kingdom
| | - Begoña Santiago-García
- Paediatric Infectious Diseases Department, Gregorio Marañón University Hospital, Madrid, Spain
- UDIMIFFA, Gregorio Marañón Research Health Institute (IiSGM), UCM, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Minotti C, Costenaro P, Donà D, Zuliani M, Bosa L, Leon A, Perilongo G, Gaio P, Martini G, Cananzi M. Disseminated Mycobacterial Infection With Reactive Polyarthritis (Poncet's Disease) During Immune-suppressive Treatment Including Ustekinumab for Pediatric Crohn's Disease. Pediatr Infect Dis J 2024; 43:543-549. [PMID: 38377462 DOI: 10.1097/inf.0000000000004277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
BACKGROUND The incidence of pediatric inflammatory bowel disease is increasing. tumor necrosis factor alpha inhibitors medicines improved the prognosis of affected subjects. Nonetheless, a proportion of patients do not respond or lose response to treatment. Newer biologics, like ustekinumab, have been approved for adults. The pediatric off-label use of these drugs is increasing, despite limited safety evidence. We report a case of disseminated mycobacterial infection (MI) presenting with reactive polyarthritis (Poncet's disease, PD) in a girl with Crohn's disease receiving various immunosuppressants, including ustekinumab. CASE REPORT A 12-year-old girl with Crohn's disease was admitted for acute-onset migratory polyarthritis of large and small joints and opioid-resistant pain. She had recently received adalimumab and methotrexate and was currently under treatment with ustekinumab. She was vaccinated with Bacillus Calmette-Guérin and screened for tuberculosis before starting immunosuppressants. Interferon-gamma release assay, Mantoux test and chest computed tomography scan were negative. Disseminated MI with PD was diagnosed following positive cultures for Mycobacterium tuberculosis complex in blood and intestinal biopsies (with negative in synovial fluid and gastric aspirate). Whole-exome sequencing did not identify any genetic susceptibility to MI. Antituberculosis treatment eradicated MI. CONCLUSIONS Children with inflammatory bowel disease receiving combination immunosuppressive treatments including tumor necrosis factor alpha inhibitors and anti-IL-12/23 agents are at higher risk for MI. Disseminated MI should be considered and ruled out in these patients when presenting with pulmonary, extrapulmonary or unusual clinical manifestations, like PD. The collection of multiple specimens (including intestinal biopsies) for mycobacterial culture is recommended when mycobacterial disease is suspected.
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Affiliation(s)
- Chiara Minotti
- From the Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
- PhD Program in Clinical Research, Pediatric Research Center, University Children's Hospital Basel, Basel, Switzerland
| | - Paola Costenaro
- From the Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Daniele Donà
- From the Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Monica Zuliani
- Pediatric Radiology, Department for Integrated Diagnostic Services
| | - Luca Bosa
- Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padova
| | | | | | - Paola Gaio
- Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padova
| | - Giorgia Martini
- Pediatric Rheumatology, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Mara Cananzi
- Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padova
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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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5
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Buonsenso D, Seddon JA, Esposito S, Barcellini L. QuantiFERON-TB Gold Plus Performance in Children: A Narrative Review. Pediatr Infect Dis J 2023; 42:e158-e165. [PMID: 36795574 PMCID: PMC10097492 DOI: 10.1097/inf.0000000000003877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/17/2023]
Abstract
This review summarizes studies evaluating the performance of the QuantiFERON-TB Gold Plus (QFT-Plus) interferon-gamma release assay (IGRA) test for Mycobacterium tuberculosis ( Mtb ) infection in children. Literature searching was conducted using PubMed, MEDLINE and Embase (January 2017 to December 2021) and the terms "children" or "pediatric" and "IGRAs" or "QuantiFERON-TB Gold Plus." Selected studies (N = 14; 4646 subjects) enrolled children with Mtb infection, tuberculosis (TB) disease or healthy children with household TB contacts. Agreement between QFT-Plus and tuberculin skin test (TST) (kappa values) ranged from -0.201 (no agreement) to 0.83 (almost perfect agreement). Assay sensitivity of QFT-Plus (against reference standard of microbiologically confirmed TB disease) was 54.5%-87.3%, with no reported difference in children less than 5 versus greater than or equal to 5 years of age. In individuals less than or equal to 18 years of age, the rate of indeterminate results was 0%-33.3% (2.6% in children <2 years). IGRAs may overcome the limitations of TST in young, Bacillus Calmette-Guérin-vaccinated children.
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Affiliation(s)
- Danilo Buonsenso
- From the Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Global Health Research Institute, Università Cattolica del Sacro Cuore, Rome, Italy
| | - James A. Seddon
- Department of Infectious Disease, Imperial College London, London, United Kingdom
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Susanna Esposito
- Pietro Barilla Children’s Hospital, Pediatric Clinic, Department of Medicine and Surgery, University Hospital, University of Parma, Parma, Italy
| | - Lucia Barcellini
- Department of Paediatrics, Children Hospital V. Buzzi, University of Milan, Milan, Italy
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Tabatneck ME, He W, Lamb GS, Sun M, Goldmann D, Sabharwal V, Sandora TJ, Haberer JE, Campbell JI. Interferon Gamma Release Assay Results and Testing Trends Among Patients Younger Than 2 Years Old at Two US Health Centers. Pediatr Infect Dis J 2023; 42:189-194. [PMID: 36729979 PMCID: PMC10368003 DOI: 10.1097/inf.0000000000003794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Interferon-gamma release assays (IGRAs) are approved for children ≥2 years old to aid in diagnosis of Mycobacterium tuberculosis (TB) infection and disease. Tuberculin skin tests (TSTs) continue to be the recommended method for diagnosis of TB infection in children <2 years, in part due to limited data and concern for high rates of uninterpretable results. METHODS We performed a retrospective cohort study of IGRA use in patients <2 years old in 2 large Boston healthcare systems. The primary outcome was the proportion of valid versus invalid/indeterminate IGRA results. Secondary outcomes included concordance of IGRAs with paired TSTs and trends in IGRA usage over time. RESULTS A total of 321 IGRA results were analyzed; 308 tests (96%) were valid and 13 (4%) were invalid/indeterminate. Thirty-seven IGRAs were obtained in immunocompromised patients; the proportion of invalid/indeterminate results was significantly higher among immunocompromised (27%) compared with immunocompetent (1%) patients ( P < 0.001). Paired IGRAs and TSTs had a concordance rate of 64%, with most discordant results in bacille Calmette-Guérin-vaccinated patients. The proportion of total TB tests that were IGRAs increased over the study period (Pearson correlation coefficient 0.85, P < 0.001). CONCLUSIONS The high proportion of valid IGRA test results in patients <2 years of age in a low TB prevalence setting in combination with the known logistical and interpretation challenges associated with TSTs support the adoption of IGRAs for this age group in certain clinical scenarios. Interpretation of IGRAs, particularly in immunocompromised patients, should involve consideration of the broader clinical context.
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Affiliation(s)
- Mary E Tabatneck
- From the Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Wei He
- Center for Research Information Science and Computing, Massachusetts General Hospital, Boston, Massachusetts
| | - Gabriella S Lamb
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Mingwei Sun
- Center for Research Information Technology, Boston Children's Hospital, Boston, Massachusetts
| | - Don Goldmann
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Vishakha Sabharwal
- Division of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Thomas J Sandora
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffrey I Campbell
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
- Division of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
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7
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Calzada-Hernández J, Anton J, Martín de Carpi J, López-Montesinos B, Calvo I, Donat E, Núñez E, Blasco Alonso J, Mellado MJ, Baquero-Artigao F, Leis R, Vegas-Álvarez AM, Medrano San Ildefonso M, Pinedo-Gago MDC, Eizaguirre FJ, Tagarro A, Camacho-Lovillo M, Pérez-Gorricho B, Gavilán-Martín C, Guillén S, Sevilla-Pérez B, Peña-Quintana L, Mesa-Del-Castillo P, Fortuny C, Tebruegge M, Noguera-Julian A. Dual latent tuberculosis screening with tuberculin skin tests and QuantiFERON-TB assays before TNF-α inhibitor initiation in children in Spain. Eur J Pediatr 2023; 182:307-317. [PMID: 36335186 PMCID: PMC9829583 DOI: 10.1007/s00431-022-04640-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022]
Abstract
UNLABELLED Tumor-necrosis-factor-α inhibitors (anti-TNF-α) are associated with an increased risk of tuberculosis (TB) disease, primarily due to reactivation of latent TB infection (LTBI). We assessed the performance of parallel LTBI screening with tuberculin skin test (TST) and QuantiFERON-TB Gold In-Tube assays (QFT-GIT) before anti-TNF-α treatment in children with immune-mediated inflammatory disorders in a low TB-burden setting. We conducted a multicenter cohort study involving 17 pediatric tertiary centers in Spain. LTBI was defined as the presence of a positive TST and/or QFT-GIT result without clinical or radiological signs of TB disease. A total of 270 patients (median age:11.0 years) were included, mainly with rheumatological (55.9%) or inflammatory bowel disease (34.8%). Twelve patients (4.4%) were diagnosed with TB infection at screening (LTBI, n = 11; TB disease, n = 1). Concordance between TST and QFT-GIT results was moderate (TST+/QFT-GIT+, n = 4; TST-/QFT-GIT+, n = 3; TST+/QFT-GIT-, n = 5; kappa coefficient: 0.48, 95% CI: 0.36-0.60). Indeterminate QFT-GIT results occurred in 10 patients (3.7%) and were associated with young age and elevated C-reactive protein concentrations. Eleven of 12 patients with TB infection uneventfully completed standard LTBI or TB treatment. During a median follow-up period of 6.4 years, only 2 patients developed TB disease (incidence density: 130 (95% CI: 20-440) per 100,000 person-years), both probable de novo infections. CONCLUSION A substantial number of patients were diagnosed with LTBI during screening. The dual strategy identified more cases than either of the tests alone, and test agreement was only moderate. Our data show that in children in a low TB prevalence setting, a dual screening strategy with TST and IGRA before anti-TNF-α treatment is effective. WHAT IS KNOWN • The optimal screening strategy for latent tuberculosis in children with immune-mediated inflammatory disorders remains uncertain. • Children receiving anti-TNF-α drugs are at increased risk of developing severe tuberculosis disease. WHAT IS NEW • A dual screening strategy, using TST and an IGRA assay, identified more children with latent tuberculosis than either of the tests alone. • Identification and treatment of latent tuberculosis before initiation of anti-TNF-α therapy averted incident tuberculosis cases.
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Affiliation(s)
- Joan Calzada-Hernández
- grid.411160.30000 0001 0663 8628Pediatric Rheumatology Division, Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Jordi Anton
- grid.411160.30000 0001 0663 8628Pediatric Rheumatology Division, Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Barcelona, Spain ,grid.5841.80000 0004 1937 0247Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Javier Martín de Carpi
- grid.5841.80000 0004 1937 0247Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain ,grid.411160.30000 0001 0663 8628Servei de Gastroenterologia, Hepatologia I Nutrició Pediàtrica, Hospital Sant Joan de Déu - Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Berta López-Montesinos
- grid.84393.350000 0001 0360 9602Rheumatology Unit, Pediatrics Department, University Hospital La Fe, Valencia, Spain
| | - Inmaculada Calvo
- grid.84393.350000 0001 0360 9602Rheumatology Unit, Pediatrics Department, University Hospital La Fe, Valencia, Spain
| | - Ester Donat
- grid.84393.350000 0001 0360 9602Pediatric Gastroenterology and Hepatology Unit, Pediatrics Department, University Hospital La Fe, Valencia, Spain
| | - Esmeralda Núñez
- grid.411457.2UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Javier Blasco Alonso
- grid.411457.2UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - María José Mellado
- Servicio de Pediatria, Enfermedades Infecciosas Y Patología Tropical, Hospital La Paz, Madrid, Spain ,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,grid.512890.7Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Fernando Baquero-Artigao
- Servicio de Pediatria, Enfermedades Infecciosas Y Patología Tropical, Hospital La Paz, Madrid, Spain ,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,grid.512890.7Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Rosaura Leis
- grid.411048.80000 0000 8816 6945Unit of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatrics Department, University Clinical Hospital of Santiago (CHUS), Santiago de Compostela, Spain
| | - Ana María Vegas-Álvarez
- grid.411280.e0000 0001 1842 3755Gastroenterología Infantil, Hospital Universitario Río Hortega de Valladolid, Valladolid, Spain
| | - Marta Medrano San Ildefonso
- grid.411106.30000 0000 9854 2756Reumatología Pediátrica, Hospital Universitario Miguel Servet, Saragossa, Spain
| | | | - Francisco Javier Eizaguirre
- grid.414651.30000 0000 9920 5292Unidad de Gastroenterología Infantil, Hospital Universitario Donostia, San Sebastián, Spain
| | - Alfredo Tagarro
- Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,grid.119375.80000000121738416Paediatrics Department, Hospital Universitario Infanta Sofía; Paediatrics Research Group, Universidad Europea de Madrid, Madrid, Spain ,grid.144756.50000 0001 1945 5329Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain
| | - Marisol Camacho-Lovillo
- grid.411109.c0000 0000 9542 1158Servicio de Inmunología, Reumatología e Infectología Pediátrica, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Beatriz Pérez-Gorricho
- grid.411107.20000 0004 1767 5442Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - César Gavilán-Martín
- grid.411263.3Servicio de Pediatría, Hospital Universitario San Juan de Alicante, Alicante, Spain
| | - Sara Guillén
- grid.512890.7Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain ,grid.411244.60000 0000 9691 6072Department of Pediatrics, Hospital Universitario de Getafe, Madrid, Spain
| | - Belén Sevilla-Pérez
- grid.459499.cUnidad de Reumatología, Servicio de Pediatría del Hospital Universitario San Cecilio de Granada, Granada, Spain
| | - Luis Peña-Quintana
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Mother and Child Insular University Hospital,, Las Palmas, Spain ,grid.512890.7Centro de Investigación Biomédica en Red de Obesidad Y Nutrición (CIBEROBN), Madrid, Spain ,grid.4521.20000 0004 1769 9380University Institute for Research in Biomedical and Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Pablo Mesa-Del-Castillo
- grid.411372.20000 0001 0534 3000Department of Rheumatology, Hospital Clínico Universitario Virgen de La Arrixaca, Murcia, Spain
| | - Clàudia Fortuny
- grid.5841.80000 0004 1937 0247Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain ,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,grid.411160.30000 0001 0663 8628Malalties Infeccioses I Resposta Inflamatòria Sistèmica en Pediatria, Unitat d’Infeccions, Servei de Pediatria, Institut de Recerca Sant Joan de Déu, Barcelona, Spain ,grid.466571.70000 0004 1756 6246Centro de Investigación Biomédica en Red de Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
| | - Marc Tebruegge
- grid.83440.3b0000000121901201Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, UK ,grid.1008.90000 0001 2179 088XDepartment of Paediatrics, University of Melbourne, Parkville, VIC Australia ,Department of Paediatrics, Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
| | - Antoni Noguera-Julian
- Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain. .,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain. .,Malalties Infeccioses I Resposta Inflamatòria Sistèmica en Pediatria, Unitat d'Infeccions, Servei de Pediatria, Institut de Recerca Sant Joan de Déu, Barcelona, Spain. .,Centro de Investigación Biomédica en Red de Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain.
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8
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Kearsley-Fleet L, Klotsche J, van Straalen JW, Costello W, D’Angelo G, Giancane G, Horneff G, Klein A, Láday M, Lunt M, de Roock S, Ruperto N, Schoemaker C, Vijatov-Djuric G, Vojinovic J, Vougiouka O, Wulffraat NM, Hyrich KL, Minden K, Swart JF. Burden of comorbid conditions in children and young people with juvenile idiopathic arthritis: a collaborative analysis of 3 JIA registries. Rheumatology (Oxford) 2022; 61:2524-2534. [PMID: 34613385 PMCID: PMC9157174 DOI: 10.1093/rheumatology/keab641] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Burden of comorbidities are largely unknown in JIA. From 2000, national and international patient registries were established to monitor biologic treatment, disease activity and adverse events in patients with JIA. The aim of this analysis was to investigate in parallel, for the first time, three of the largest JIA registries in Europe/internationally-UK JIA Biologic Registers (BCRD/BSPAR-ETN), German biologic registers (BiKeR/JuMBO), multinational Pharmachild-to quantify the occurrence of selected comorbidities in patients with JIA. METHODS Information on which data the registers collect were compared. Patient characteristics and levels of comorbidity were presented, focussing on four key conditions: uveitis, MAS, varicella, and history of tuberculosis. Incidence rates of these on MTX/biologic therapy were determined. RESULTS 8066 patients were registered into the three JIA registers with similar history of the four comorbidities across the studies; however, varicella vaccination coverage was higher in Germany (56%) vs UK/Pharmachild (16%/13%). At final follow-up, prevalence of varicella infection was lower in Germany (15%) vs UK/Pharmachild (37%/50%). Prevalence of TB (0.1-1.8%) and uveitis (15-19%) was similar across all registers. The proportion of systemic-JIA patients who ever had MAS was lower in Germany (6%) vs UK (15%) and Pharmachild (17%). CONCLUSION This analysis is the first and largest to investigate the occurrence of four important comorbidities in three JIA registries in Europe and the role of anti-rheumatic drugs. Combined, these three registries represent one of the biggest collection of cases of JIA worldwide and offer a unique setting for future JIA outcome studies.
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Affiliation(s)
- Lianne Kearsley-Fleet
- Centre for Epidemiology Versus Arthritis, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Jens Klotsche
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Joeri W van Straalen
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Netherlands
| | - Wendy Costello
- iIrish Children’s Arthritis Network (iCAN), Bansha, Co Tipperary, Ireland
| | | | - Gabriella Giancane
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gerd Horneff
- Department of Pediatrics, Asklepios Kinderklinik Sankt Augustin, Sankt Augustin
- Department of Pediatric and Adolescent Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | - Ariane Klein
- Department of Pediatrics, Asklepios Kinderklinik Sankt Augustin, Sankt Augustin
- Department of Pediatric and Adolescent Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | - Matilda Láday
- Pediatric Clinical Department 1, Spitalul Clinic Judetean De Urgenta, Tîrgu-Mureș, Romania
| | - Mark Lunt
- Centre for Epidemiology Versus Arthritis, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Sytze de Roock
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Netherlands
| | - Nicolino Ruperto
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Casper Schoemaker
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Netherlands
- Dutch JIA Patient and Parent Organisation (Member of ENCA), Rijen, The Netherlands
| | - Gordana Vijatov-Djuric
- Faculty of Medicine, University of Novi Sad
- Department of Immunology, Allergology and Rheumatology, Institute for Child and Youth Health Care of Vojvodina, Novi Sad
| | - Jelena Vojinovic
- Faculty of Medicine, Department of Pediatric Immunology and Rheumatology, University of Nis, University Clinic Center
- Department of Pediatric Rheumatology, Clinical Center Nis, Clinic of Pediatrics, Nis, Serbia
| | - Olga Vougiouka
- ‘P a A Kyriakou’ Children’s Hospital, 2nd Paediatric Department, Athens University School of Medicine, Athens, Greece
| | - Nico M Wulffraat
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Netherlands
| | | | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- NIHR Manchester BRC, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Kirsten Minden
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
- Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Joost F Swart
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Netherlands
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9
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Dalgic N, Sahin A, Torun SH, Kaba O, Onal P, Yilmaz AT, Turel O, Yasar B, Kara M, Aygun D, Kilinc A, Oncel S, Duramaz BB, Urganci N, Somer A, Cokugras H, Arisoy ES. Active and Latent Tuberculosis in Children Treated with Anti-TNF-α: A Retrospective Multicenter Study. J PEDIAT INF DIS-GER 2022. [DOI: 10.1055/s-0042-1743195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Objective This study aimed to investigate the frequency of latent and active tuberculosis (TB) in pediatric patients receiving anti-tumor necrosis factor (TNF)-α therapy.
Methods Patients younger than 18 years with various inflammatory diseases and treated with anti-TNF-α agents in the past five years were included in the study. The patients' ages, follow-ups, medications received, clinical and laboratory findings, and treatments applied were recorded retrospectively.
Results Of the 160 patients included in the study, 78 (48.8%) were girls. The mean age was 139.54 ± 48.74 (30–226) months. Sixty (37.5%) patients had inflammatory eye disease, 55 (34.4%) had rheumatologic and autoimmune disease, and 45 (28.1%) had inflammatory bowel disease. As anti-TNF-α treatment, 67 (41.9%) patients received adalimumab, 50 (31.2%) received infliximab, and 43 (26.9%) received etanercept. As a result of TB screening performed prior to the treatment, 44 (25.4%) patients were started on isoniazid treatment with the diagnosis of latent TB. During follow-up, latent TB infection was detected in 16 (9.2%) patients and isoniazid treatment was started. The time to develop latent TB under anti-TNF-α treatment ranged from 3 to 28 months. During the treatment, active TB infection developed in two (1.2%) patients and anti-TB treatment was initiated.
Conclusion It is of vital importance to evaluate patients receiving, or planned to receive, anti-TNF-α treatment, for TB infection and to initiate appropriate treatments if latent or active TB infection is identified.
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Affiliation(s)
- Nazan Dalgic
- Division of Pediatric Infectious Diseases, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ayse Sahin
- Division of Pediatric Infectious Diseases, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Selda Hancerli Torun
- Department of Pediatric Infectious Disease, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ozge Kaba
- Department of Pediatric Infectious Disease, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Pinar Onal
- Department of Pediatric Pulmonology, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Ayse Tekin Yilmaz
- Section of Internal Medical Sciences, Division of Pediatric Infectious Diseases, Department of Pediatrics and Child Health, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Ozden Turel
- Department of Pediatric Infectious Diseases, Bezmialem Vakif University, Istanbul, Turkey
| | - Belma Yasar
- Division of Pediatric Infectious Diseases, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Manolya Kara
- Department of Pediatric Infectious Disease, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Deniz Aygun
- Department of Pediatric Pulmonology, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Ayse Kilinc
- Department of Pediatric Pulmonology, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Selim Oncel
- Section of Internal Medical Sciences, Division of Pediatric Infectious Diseases, Department of Pediatrics and Child Health, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Burcu Bursal Duramaz
- Department of Pediatric Infectious Diseases, Bezmialem Vakif University, Istanbul, Turkey
| | - Nafiye Urganci
- Division of Pediatric Infectious Diseases, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ayper Somer
- Department of Pediatric Infectious Disease, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Haluk Cokugras
- Department of Pediatric Pulmonology, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Emin Sami Arisoy
- Section of Internal Medical Sciences, Division of Pediatric Infectious Diseases, Department of Pediatrics and Child Health, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
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10
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Starke JR, Erkens C, Ritz N, Kitai I. Strengthening Tuberculosis Services for Children and Adolescents in Low Endemic Settings. Pathogens 2022; 11:pathogens11020158. [PMID: 35215101 PMCID: PMC8877840 DOI: 10.3390/pathogens11020158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/21/2022] [Accepted: 01/23/2022] [Indexed: 01/22/2023] Open
Abstract
In low tuberculosis-burden countries, children and adolescents with the highest incidence of tuberculosis (TB) infection or disease are usually those who have immigrated from high-burden countries. It is, therefore, essential that low-burden countries provide healthcare services to immigrant and refugee families, to assure that their children can receive proper testing, evaluation, and treatment for TB. Active case-finding through contact tracing is a critical element of TB prevention in children and in finding TB disease at an early, easily treated stage. Passive case-finding by evaluating an ill child is often delayed, as other, more common infections and conditions are suspected initially. While high-quality laboratory services to detect Mycobacterium tuberculosis are generally available, they are often underutilized in the diagnosis of childhood TB, further delaying diagnosis in some cases. Performing research on TB disease is difficult because of the low number of cases that are spread over many locales, but critical research on the evaluation and treatment of TB infection has been an important legacy of low-burden countries. The continued education of medical providers and the involvement of educational, professional, and non-governmental organizations is a key element of maintaining awareness of the presence of TB. This article provides the perspective from North America and Western Europe but is relevant to many low-endemic settings. TB in children and adolescents will persist in low-burden countries as long as it persists throughout the rest of the world, and these wealthy countries must increase their financial commitment to end TB everywhere.
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Affiliation(s)
- Jeffrey R. Starke
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-832-824-4330
| | - Connie Erkens
- KNCV Tuberculosis Foundation, 2516 AB The Hague, The Netherlands;
| | - Nicole Ritz
- Department of Paediatrics and Paediatric Infectious Diseases, Children’s Hospital, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland;
- Mycobacterial and Migrant Health Research Group, Department of Clinical Research, University of Basel Children’s Hospital, University of Basel, 4031 Basel, Switzerland
| | - Ian Kitai
- Department of Pediatrics, Division of Infectious Diseases, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada;
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11
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Martínez-Planas A, Baquero-Artigao F, Santiago B, Fortuny C, Méndez-Echevarría A, Del Rosal T, Bustillo-Alonso M, Gale I, Guerrero C, Blázquez-Gamero D, Canet A, Lillo M, Calavia O, Núñez Cuadros E, Falcón-Neyra L, Soriano-Arandes A, Van Ingen J, Tebruegge M, Noguera-Julian A. Interferon-Gamma Release Assays Differentiate between Mycobacterium avium Complex and Tuberculous Lymphadenitis in Children. J Pediatr 2021; 236:211-218.e2. [PMID: 33984332 DOI: 10.1016/j.jpeds.2021.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/24/2021] [Accepted: 05/04/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To assess the performance of interferon-gamma release assays (IGRAs) in the differential diagnosis between Mycobacterium avium complex (MAC) and tuberculosis (TB) in children affected with subacute/chronic submandibular/cervical lymphadenitis. STUDY DESIGN Multicenter observational study comparing children with microbiologically confirmed MAC lymphadenitis from the European NontuberculouS MycoBacterial Lymphadenitis in childrEn study with children with TB lymphadenitis from the Spanish Network for the Study of Pediatric TB database. RESULTS Overall, 78 patients with MAC and 34 with TB lymphadenitis were included. Among MAC cases, 44 out of 74 (59.5%) had positive tuberculin skin test (TST) results at the 5-mm cut-off, compared with 32 out of 33 (97%) TB cases (P < .001); at the 10-mm cut-off TST results were positive in 23 out of 74 (31.1%) vs 26 out of 31 (83.9%), respectively (P < .001). IGRA results were positive in only 1 out of 32 (3.1%) patients with MAC who had undergone IGRA testing, compared with 21 out of 23 (91.3%) TB cases (P < .001). Agreement between TST and IGRA results was poor in MAC (23.3%; κ = 0.017), but good in TB cases (95.6%; κ = 0.646). IGRAs had a specificity of 96.9% (95% CI 84.3%-99.8%), positive predictive value of 95.4% (95% CI 78.2%-99.8%), and negative predictive value of 93.9% (95% CI 80.4%-98.9%) for TB lymphadenitis. CONCLUSIONS In contrast to TST, IGRAs have high specificity, negative predictive value, and positive predictive value for TB lymphadenitis in children with subacute/chronic lymphadenopathy, and consequently can help to discriminate between TB and MAC disease. Therefore, IGRAs are useful tools in the diagnostic work-up of children with lymphadenopathy, particularly when culture and polymerase chain reaction results are negative.
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Affiliation(s)
- Aina Martínez-Planas
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Fernando Baquero-Artigao
- Pediatrics and Infectious Disease Unit, Hospital Universitario La Paz, Madrid, Spain; Fundación IdiPaz, Madrid, Spain; Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Begoña Santiago
- Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain; Department of Pediatric Infectious Diseases, University Hospital Gregorio Marañón and Gregorio Marañón Research Institute, Madrid, Spain
| | - Clàudia Fortuny
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Institut de Recerca Sant Joan de Déu, Barcelona, Spain; Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain; Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Pediatrics, University of Barcelona, Barcelona, Spain
| | - Ana Méndez-Echevarría
- Pediatrics and Infectious Disease Unit, Hospital Universitario La Paz, Madrid, Spain; Fundación IdiPaz, Madrid, Spain; Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Teresa Del Rosal
- Pediatrics and Infectious Disease Unit, Hospital Universitario La Paz, Madrid, Spain; Fundación IdiPaz, Madrid, Spain; Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | | | - Inés Gale
- Pediatrics Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Carmelo Guerrero
- Pediatrics Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Daniel Blázquez-Gamero
- Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain; Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain; Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Anna Canet
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Miguel Lillo
- Pediatrics Department, Hospital General Universitario de Albacete, Albacete, Spain
| | - Olga Calavia
- Pediatrics Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Esmeralda Núñez Cuadros
- Division of Pediatric Rheumatology, Hospital Regional Universitario Materno-Infantil de Málaga, Málaga, Spain
| | - Lola Falcón-Neyra
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Institute of Biomedicine, Seville, Spain
| | - Antoni Soriano-Arandes
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron Hospital Universitari, Barcelona, Spain; Infection in the Immunocompromissed Child Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Jakko Van Ingen
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marc Tebruegge
- 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 Pediatrics, The University of Melbourne, Parkville, Australia; Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Institut de Recerca Sant Joan de Déu, Barcelona, Spain; Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain; Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Pediatrics, University of Barcelona, Barcelona, Spain.
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12
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Emery JC, Richards AS, Dale KD, McQuaid CF, White RG, Denholm JT, Houben RMGJ. Self-clearance of Mycobacterium tuberculosis infection: implications for lifetime risk and population at-risk of tuberculosis disease. Proc Biol Sci 2021; 288:20201635. [PMID: 33467995 PMCID: PMC7893269 DOI: 10.1098/rspb.2020.1635] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/30/2020] [Indexed: 01/13/2023] Open
Abstract
Background: it is widely assumed that individuals with Mycobacterium tuberculosis (Mtb) infection remain at lifelong risk of tuberculosis (TB) disease. However, there is substantial evidence that self-clearance of Mtb infection can occur. We infer a curve of self-clearance by time since infection and explore its implications for TB epidemiology. Methods and findings: data for self-clearance were inferred using post-mortem and tuberculin-skin-test reversion studies. A cohort model allowing for self-clearance was fitted in a Bayesian framework before estimating the lifetime risk of TB disease and the population infected with Mtb in India, China and Japan in 2019. We estimated that 24.4% (17.8-32.6%, 95% uncertainty interval (UI)) of individuals self-clear within 10 years of infection, and 73.1% (64.6-81.7%) over a lifetime. The lifetime risk of TB disease was 17.0% (10.9-22.5%), compared to 12.6% (10.1-15.0%) assuming lifelong infection. The population at risk of TB disease in India, China and Japan was 35-80% (95% UI) smaller in the self-clearance scenario. Conclusions: the population with a viable Mtb infection may be markedly smaller than generally assumed, with such individuals at greater risk of TB disease. The ability to identify these individuals could dramatically improve the targeting of preventive programmes and inform TB vaccine development, bringing TB elimination within reach of feasibility.
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Affiliation(s)
- Jon C. Emery
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Alexandra S. Richards
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Katie D. Dale
- Victorian Tuberculosis Program, Melbourne Health, Melbourne, Victoria, Australia
- Department of Microbiology and Immunology, The University of Melbourne, Melbourne, Victoria, Australia
| | - C. Finn McQuaid
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Richard G. White
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Justin T. Denholm
- Victorian Tuberculosis Program, Melbourne Health, Melbourne, Victoria, Australia
| | - Rein M. G. J. Houben
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
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13
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Perret C, Le Corre N, Castro-Rodriguez JA. Emergent Pneumonia in Children. Front Pediatr 2021; 9:676296. [PMID: 34222146 PMCID: PMC8247473 DOI: 10.3389/fped.2021.676296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/21/2021] [Indexed: 12/11/2022] Open
Abstract
In recent decades there have been multiple pathogens, viruses and bacteria, which have emerged as causal agents of pneumonia affecting adults, albeit less frequently, to children. For the purposes of this article we have classified emerging pathogens as follows: True emerging, to pathogens identified for the very first time affecting human population (SARS-CoV-1, SARS-CoV-2, MERS-CoV, avian influenza, and hantavirus); Re-emerging, to known pathogens which circulation was controlled once, but they have reappeared (measles, tuberculosis, antimicrobial resistant bacteria such as CA-MRSA, Mycoplasma pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and new serotypes of post-vaccine pneumococcal); and finally, those that we have called old known with new presentations, including common pathogens that, in particular condition, have changed their form of presentation (rhinovirus, and non-SARS coronavirus). We will review for each of them their epidemiology, forms of presentation, therapy, and prognosis in children compared to the adult with the aim of being able to recognize them to establish appropriate therapy, prognostics, and effective control measures.
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Affiliation(s)
- Cecilia Perret
- Department of Pediatric Infectious Diseases and Immunology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicole Le Corre
- Department of Pediatric Infectious Diseases and Immunology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jose A Castro-Rodriguez
- Department of Pediatric Pulmonology and Cardiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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14
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Kilinc AA, Onal P, Oztosun B, Yildiz M, Adrovic A, Sahin S, Barut K, Cokugras H, Kasapcopur O. Determination of tuberculin skin test for isoniazid prophylaxis in BCG vaccinated children who are using anti-TNF agents for rheumatologic diseases. Pediatr Pulmonol 2020; 55:2689-2696. [PMID: 32776324 DOI: 10.1002/ppul.24963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/12/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The use of tumor necrosis factor inhibitors (anti-TNF) has a risk of activating latent tuberculosis infection (LTBI). This study was performed to investigate LTBI according to tuberculin skin test (TST) size and to determine the frequency of tuberculosis (TB) in bacillus Calmette-Guerin (BCG)-vaccinated children receiving anti-TNF treatment for rheumatological disease. MATERIALS AND METHODS The study consisted of 559 children. Information on demographics, anti-TNF agents, TST size, and isoniazid (INH) prophylaxis was recorded. Patients (n = 254) with TST size ≥5 mm were divided into three groups according to TST size and INH prophylaxis: group 1, TST size 5 to 9 mm and no INH prophylaxis; group 2, TST size 5 to 9 mm with INH prophylaxis; and group 3, TST size ≥10 mm with INH prophylaxis. RESULTS The 559 patients comprised 314 (56.3%) females and 245 (43.6%) males; they had a mean age of 13.1 ± 4.1 years. The mean TST size in all patients was 4.2 ± 4.7 mm. Group 1 consisted of 76 (29.9%) patients, group 2 consisted of 88 (34.6%) patients, and group 3 consisted of 90 (35.4%) patients. The mean TST sizes for the three groups were 6.8 ± 3.1 mm, 7.2 ± 3.2 mm, and 13.9 ± 2.8 mm, respectively. New TB was diagnosed in only two (0.35%) patients. Both of them were in group 3. CONCLUSIONS A TST size of ≥10 mm in BCG-vaccinated children receiving anti-TNF treatment may distinguish children at high risk for reactivation of LTBI.
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Affiliation(s)
- Ayse Ayzit Kilinc
- Department of Pediatric Pulmonology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Pinar Onal
- Department of Pediatric Infectious Diseases, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Berrak Oztosun
- Department of Pediatrics, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Mehmet Yildiz
- Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Haluk Cokugras
- Department of Pediatric Pulmonology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
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15
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Parigi S, Licari A, Manti S, Marseglia GL, Tosca MA, Miraglia Del Giudice M, Caffarelli C, Calvani M, Martelli A, Cardinale F, Cravidi C, Duse M, Chiappini E. Tuberculosis and TNF-α inhibitors in children: how to manage a fine balance. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020009. [PMID: 33004779 PMCID: PMC8023060 DOI: 10.23750/abm.v91i11-s.10311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/22/2020] [Indexed: 11/23/2022]
Abstract
Since the introduction of biologic response modifiers (BRMs) in the management of children affected by the immune-mediated inflammatory disease, these patients substantially improved their quality of life. BRMs are generally well tolerated and effective in most children and adolescents refractory to conventional immunosuppressive therapy. On the other hand, patients receiving BRMs, especially TNF-α inhibitors, display an increased risk of primary infections or reactivations, i.e. due to Mycobacterium tuberculosis. M. tuberculosis can cause severe disease with consequent short- and long-term morbidity in children on anti-TNF-α treatment. The present paper analyses the increased risk of reactivation of latent tuberculosis infection (LTBI) or de novo TB infection in children treated with TNF-α inhibitors, with the purpose to provide recommendations for screening strategies and safety monitoring of paediatric patients. Special attention is also given to the currently available TB screening tools (IGRAs and TST) and their utility in the diagnosis of LTBI before starting the biologic therapy and during the treatment. Finally, the paper analyses the suggested TB-preventing therapies to adopt in these children and the correct timing to overlap anti-TB and anti-TNF-a treatment.
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Affiliation(s)
- Sara Parigi
- Post-graduate School of Paediatrics, Anna Meyer Children's University Hospital, Department of Health Sciences, University of Florence, Florence, Italy.
| | - Amelia Licari
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Sara Manti
- UOC Broncopneumologia Pediatrica e Fibrosi Cistica, AOUP "Vittorio-Emanuele", San Marco Hospital, Università di Catania, Catania, Italy.
| | - Gian Luigi Marseglia
- Pediatric Clinic Department of Pediatrics, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy.
| | - Maria Angela Tosca
- Allergy Center, Department of Pediatrics, Istituto G. Gaslini, Genoa, Italy.
| | - Michele Miraglia Del Giudice
- Department of Woman, Child and of General and Specialized Surgery. University of Campania "Luigi Vanvitelli" Naples, Italy.
| | - Carlo Caffarelli
- Clinica Pediatrica, Dipartimento di Medicina e Chirurgia, Università di Parma, Italy.
| | - Mauro Calvani
- UOC di Pediatria. Azienda Ospedaliera S. Camillo Forlanini, Roma, Italy.
| | - Alberto Martelli
- Department of Pediatrics, G.Salvini Hospital, Garbagnate Milanese, Milan - Italy.
| | - Fabio Cardinale
- Department of Pediatrics and Emergency, Pediatric Allergy and Pulmunology Unit, Azienda Ospedaliera-Universitaria Consorziale-Policlinico, Ospedale Pediatrico Giovanni XXIII, Bari, Italy..
| | - Claudio Cravidi
- Agenzia Tutela della Salute, ATS (National Healthcare System), Pavia, Italy. .
| | - Marzia Duse
- Department of Pediatrics, Sapienza University, Rome, Italy.
| | - Elena Chiappini
- Division of Paediatric Infectious Disease, Anna Meyer Children's University Hospital, Department of Health Sciences, University of Florence, Florence, Italy..
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16
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Basu Roy R, Thee S, Blázquez-Gamero D, Falcón-Neyra L, Neth O, Noguera-Julian A, Lillo C, Galli L, Venturini E, Buonsenso D, Götzinger F, Martinez-Alier N, Velizarova S, Brinkmann F, Welch SB, Tsolia M, Santiago-Garcia B, Krüger R, Tebruegge M. Performance of immune-based and microbiological tests in children with tuberculosis meningitis in Europe: a multicentre Paediatric Tuberculosis Network European Trials Group (ptbnet) study. Eur Respir J 2020; 56:13993003.02004-2019. [PMID: 32299859 PMCID: PMC7330130 DOI: 10.1183/13993003.02004-2019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 03/09/2020] [Indexed: 01/31/2023]
Abstract
Introduction Tuberculous meningitis (TBM) is often diagnostically challenging. Only limited data exist on the performance of interferon-γ release assays (IGRA) and molecular assays in children with TBM in routine clinical practice, particularly in the European setting. Methods Multicentre, retrospective study involving 27 healthcare institutions providing care for children with tuberculosis (TB) in nine European countries. Results Of 118 children included, 54 (45.8%) had definite, 38 (32.2%) probable and 26 (22.0%) possible TBM; 39 (33.1%) had TBM grade 1, 68 (57.6%) grade 2 and 11 (9.3%) grade 3. Of 108 patients who underwent cranial imaging 90 (83.3%) had at least one abnormal finding consistent with TBM. At the 5-mm cut-off the tuberculin skin test had a sensitivity of 61.9% (95% CI 51.2–71.6%) and at the 10-mm cut-off 50.0% (95% CI 40.0–60.0%). The test sensitivities of QuantiFERON-TB and T-SPOT.TB assays were 71.7% (95% CI 58.4–82.1%) and 82.5% (95% CI 58.2–94.6%), respectively (p=0.53). Indeterminate results were common, occurring in 17.0% of QuantiFERON-TB assays performed. Cerebrospinal fluid (CSF) cultures were positive in 50.0% (95% CI 40.1–59.9%) of cases, and CSF PCR in 34.8% (95% CI 22.9–43.7%). In the subgroup of children who underwent tuberculin skin test, IGRA, CSF culture and CSF PCR simultaneously, 84.4% had at least one positive test result (95% CI 67.8%–93.6%). Conclusions Existing immunological and microbiological TB tests have suboptimal sensitivity in children with TBM, with each test producing false-negative results in a substantial proportion of patients. Combining immune-based tests with CSF culture and CSF PCR results in considerably higher positive diagnostic yields, and should therefore be standard clinical practice in high-resource settings. All existing immunological and microbiological TB tests have suboptimal sensitivity in children with TBM. Combining immune-based tests with CSF culture and PCR results in far higher positive diagnostic yields, and should therefore be standard practice.http://bit.ly/2TSAArl
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Affiliation(s)
- Robindra Basu Roy
- Clinical Research Dept, London School of Hygiene and Tropical Medicine, London, UK.,Joint first authors
| | - Stephanie Thee
- Dept of Pediatric Pneumology, Immunology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Joint first authors
| | - Daniel Blázquez-Gamero
- Paediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), RITIP, Madrid, Spain
| | - Lola Falcón-Neyra
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Institute of Biomedicine, Seville, Spain
| | - Olaf Neth
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Institute of Biomedicine, Seville, Spain
| | - Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en 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
| | - Cristina Lillo
- Paediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), RITIP, Madrid, Spain
| | - Luisa Galli
- Dept of Health Sciences, University of Florence, Florence, Italy.,Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Elisabetta Venturini
- Dept of Health Sciences, University of Florence, Florence, Italy.,Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Danilo Buonsenso
- Dept of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Florian Götzinger
- Dept of Paediatrics and Adolescent Medicine, Wilhelminenspital, Vienna, Austria
| | - Nuria Martinez-Alier
- Dept of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Svetlana Velizarova
- Dept of Pulmonary Diseases, Medical University, Hospital for Lung Diseases 'St. Sofia', Sofia, Bulgaria
| | - Folke Brinkmann
- Dept of Paediatric Pulmonology, Ruhr University Bochum, Bochum, Germany
| | - Steven B Welch
- Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Maria Tsolia
- Second Dept of Paediatrics, National and Kapodistrian University of Athens, School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - Begoña Santiago-Garcia
- Dept of Paediatric Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Renate Krüger
- Dept of Pediatric Pneumology, Immunology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marc Tebruegge
- Dept of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK .,Dept of Paediatrics, Royal Children's Hospital Melbourne, University of Melbourne, Melbourne, Australia.,Dept of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
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17
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Götzinger F, Santiago-García B, Noguera-Julián A, Lanaspa M, Lancella L, Calò Carducci FI, Gabrovska N, Velizarova S, Prunk P, Osterman V, Krivec U, Lo Vecchio A, Shingadia D, Soriano-Arandes A, Melendo S, Lanari M, Pierantoni L, Wagner N, L'Huillier AG, Heininger U, Ritz N, Bandi S, Krajcar N, Roglić S, Santos M, Christiaens C, Creuven M, Buonsenso D, Welch SB, Bogyi M, Brinkmann F, Tebruegge M. COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:653-661. [PMID: 32593339 PMCID: PMC7316447 DOI: 10.1016/s2352-4642(20)30177-2] [Citation(s) in RCA: 808] [Impact Index Per Article: 202.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 12/13/2022]
Abstract
Background To date, few data on paediatric COVID-19 have been published, and most reports originate from China. This study aimed to capture key data on children and adolescents with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection across Europe to inform physicians and health-care service planning during the ongoing pandemic. Methods This multicentre cohort study involved 82 participating health-care institutions across 25 European countries, using a well established research network—the Paediatric Tuberculosis Network European Trials Group (ptbnet)—that mainly comprises paediatric infectious diseases specialists and paediatric pulmonologists. We included all individuals aged 18 years or younger with confirmed SARS-CoV-2 infection, detected at any anatomical site by RT-PCR, between April 1 and April 24, 2020, during the initial peak of the European COVID-19 pandemic. We explored factors associated with need for intensive care unit (ICU) admission and initiation of drug treatment for COVID-19 using univariable analysis, and applied multivariable logistic regression with backwards stepwise analysis to further explore those factors significantly associated with ICU admission. Findings 582 individuals with PCR-confirmed SARS-CoV-2 infection were included, with a median age of 5·0 years (IQR 0·5–12·0) and a sex ratio of 1·15 males per female. 145 (25%) had pre-existing medical conditions. 363 (62%) individuals were admitted to hospital. 48 (8%) individuals required ICU admission, 25 (4%) mechanical ventilation (median duration 7 days, IQR 2–11, range 1–34), 19 (3%) inotropic support, and one (<1%) extracorporeal membrane oxygenation. Significant risk factors for requiring ICU admission in multivariable analyses were being younger than 1 month (odds ratio 5·06, 95% CI 1·72–14·87; p=0·0035), male sex (2·12, 1·06–4·21; p=0·033), pre-existing medical conditions (3·27, 1·67–6·42; p=0·0015), and presence of lower respiratory tract infection signs or symptoms at presentation (10·46, 5·16–21·23; p<0·0001). The most frequently used drug with antiviral activity was hydroxychloroquine (40 [7%] patients), followed by remdesivir (17 [3%] patients), lopinavir–ritonavir (six [1%] patients), and oseltamivir (three [1%] patients). Immunomodulatory medication used included corticosteroids (22 [4%] patients), intravenous immunoglobulin (seven [1%] patients), tocilizumab (four [1%] patients), anakinra (three [1%] patients), and siltuximab (one [<1%] patient). Four children died (case-fatality rate 0·69%, 95% CI 0·20–1·82); at study end, the remaining 578 were alive and only 25 (4%) were still symptomatic or requiring respiratory support. Interpretation COVID-19 is generally a mild disease in children, including infants. However, a small proportion develop severe disease requiring ICU admission and prolonged ventilation, although fatal outcome is overall rare. The data also reflect the current uncertainties regarding specific treatment options, highlighting that additional data on antiviral and immunomodulatory drugs are urgently needed. Funding ptbnet is supported by Deutsche Gesellschaft für Internationale Zusammenarbeit.
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Affiliation(s)
- Florian Götzinger
- Department of Paediatric and Adolescent Medicine, National Reference Centre for Childhood Tuberculosis, Wilhelminenspital, Vienna, Austria
| | - Begoña Santiago-García
- Department of Paediatric Infectious Diseases, University Hospital Gregorio Marañón and Gregorio Marañón Research Institute, Madrid, Spain; Red de Investigación Translacional en Infectología Pediátrica, Madrid, Spain
| | - Antoni Noguera-Julián
- 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; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain; Red de Investigación Translacional en Infectología Pediátrica, Madrid, Spain
| | - Miguel Lanaspa
- 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
| | - Laura Lancella
- Academic Department of Paediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Natalia Gabrovska
- Children's Clinic, Department of Pulmonary Diseases, MHATLD "St Sofia", Medical University Sofia, Sofia, Bulgaria
| | - Svetlana Velizarova
- Children's Clinic, Department of Pulmonary Diseases, MHATLD "St Sofia", Medical University Sofia, Sofia, Bulgaria
| | - Petra Prunk
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Veronika Osterman
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Uros Krivec
- Department of Paediatric Pulmonology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Andrea Lo Vecchio
- Section of Paediatrics, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Delane Shingadia
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital, London, UK; Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Antoni Soriano-Arandes
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Susana Melendo
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Marcello Lanari
- Medical and Surgical Science Department, S Orsola University Hospital, Bologna, Italy
| | - Luca Pierantoni
- Medical and Surgical Science Department, S Orsola University Hospital, Bologna, Italy
| | - Noémie Wagner
- Paediatric Infectious Diseases Unit, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Arnaud G L'Huillier
- Paediatric Infectious Diseases Unit, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Ulrich Heininger
- Department of Paediatric Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Basel, Switzerland
| | - Nicole Ritz
- Department of Paediatric Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Basel, Switzerland; Department of Paediatrics, Royal Children's Hospital Melbourne, University of Melbourne, Melbourne, Australia
| | - Srini Bandi
- Department of Paediatrics, Leicester Children's Hospital, Leicester, UK
| | - Nina Krajcar
- Department of Paediatric Infectious Diseases, University Hospital for Infectious Diseases, Zagreb, Croatia
| | - Srđan Roglić
- Department of Paediatric Infectious Diseases, University Hospital for Infectious Diseases, Zagreb, Croatia
| | - Mar Santos
- Department of Paediatric Infectious Diseases, University Hospital Gregorio Marañón and Gregorio Marañón Research Institute, Madrid, Spain; Red de Investigación Translacional en Infectología Pediátrica, Madrid, Spain
| | | | - Marine Creuven
- Department of Paediatric Infectious Diseases, CHC Montlegia, Liège, Belgium
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Steven B Welch
- Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Matthias Bogyi
- Department of Paediatric and Adolescent Medicine, National Reference Centre for Childhood Tuberculosis, Wilhelminenspital, Vienna, Austria
| | - Folke Brinkmann
- Department of Paediatric Pulmonology, Ruhr University Bochum, Bochum, Germany
| | - Marc Tebruegge
- Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, UK; Department of Paediatrics, Royal Children's Hospital Melbourne, University of Melbourne, Melbourne, Australia; Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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