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Achini-Gutzwiller FR, Snowden JA, Corbacioglu S, Greco R. Haematopoietic stem cell transplantation for severe autoimmune diseases in children: A review of current literature, registry activity and future directions on behalf of the autoimmune diseases and paediatric diseases working parties of the European Society for Blood and Marrow Transplantation. Br J Haematol 2022; 198:24-45. [PMID: 37655707 DOI: 10.1111/bjh.18176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 11/27/2022]
Abstract
Although modern clinical management strategies have improved the outcome of paediatric patients with severe autoimmune and inflammatory diseases over recent decades, a proportion will experience ongoing or recurrent/relapsing disease activity despite multiple therapies often leading to irreversible organ damage, and compromised quality of life, growth/development and long-term survival. Autologous and allogeneic haematopoietic stem cell transplantation (HSCT) have been used successfully to induce disease control and often apparent cure of severe treatment-refractory autoimmune diseases (ADs) in children. However, transplant-related outcomes are disease-dependent and long-term outcome data are limited in respect to efficacy and safety. Moreover, balancing risks of HSCT against AD prognosis with continually evolving non-transplant options is challenging. This review appraises published literature on HSCT strategies and outcomes in individual paediatric ADs. We also provide a summary of the European Society for Blood and Marrow Transplantation (EBMT) Registry, where 343 HSCT procedures (176 autologous and 167 allogeneic) have been reported in 326 children (<18 years) for a range of AD indications. HSCT is a promising treatment modality, with potential long-term disease control or cure, but therapy-related morbidity and mortality need to be reduced. Further research is warranted to establish the position of HSCT in paediatric ADs via registries and prospective clinical studies to support evidence-based interspeciality guidelines and recommendations.
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Affiliation(s)
- Federica R Achini-Gutzwiller
- Division of Paediatric Stem Cell Transplantation and Haematology, Children's Research Centre (CRC), University Children's Hospital of Zurich, Zurich, Switzerland
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Selim Corbacioglu
- Department of Paediatric Oncology, Haematology and Stem Cell Transplantation, University Children's Hospital Regensburg, Regensburg, Germany
| | - Raffaella Greco
- Unit of Haematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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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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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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Bacillus Calmette-Guérin Cervical Lymphadenitis in a 6-Year-Old Boy on Infliximab for Inflammatory Bowel Disease. Pediatr Infect Dis J 2020; 39:e242-e244. [PMID: 32345827 DOI: 10.1097/inf.0000000000002712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We encountered a case of Bacillus Calmette-Guérin (BCG) cervical lymphadenitis in a patient undergoing infliximab after 6 years from BCG vaccination. Tumor necrosis factor-α inhibitors may be a risk for reactivation of BCG and serious infection even several years after vaccination.
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Salonen PH, Salonen JH, Säilä H, Helminen M, Linna M, Kauppi MJ. Decreasing trend in the incidence of serious pneumonias in Finnish children with juvenile idiopathic arthritis. Clin Rheumatol 2019; 39:853-860. [PMID: 31732822 DOI: 10.1007/s10067-019-04804-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Children with juvenile idiopathic arthritis (JIA) may be predisposed to serious pneumonia due to modern disease-modifying anti-rheumatic treatment. In this nationwide retrospective study with clinical data, we describe the pneumonia episodes among children with JIA. METHODS Patients under 18 years of age with JIA and pneumonia during 1998-2014 were identified in the National Hospital Discharge Register in Finland. Each individual patient record was reviewed, and detailed data on patients with JIA and pneumonia were retrieved, recorded, and analyzed. If the patient was hospitalized or received intravenous antibiotics, the pneumonia was considered serious. RESULTS There were 157 episodes of pneumonia among 140 children with JIA; 111 episodes (71%) were serious (80% in 1998-2006 and 66% in 2007-2014). The mean age of the patients was 9 years. Forty-eight percent had active JIA and 46% had comorbidities. Disease-modifying anti-rheumatic drugs (DMARD) were used at the time of 135 episodes (86%): methotrexate (MTX) by 62% and biologic DMARDs (bDMARD) by 30%. There was no significant difference in the use of bDMARDs, MTX and glucocorticoids between the patient groups with serious and non-serious pneumonia episodes. During six of the episodes, intensive care was needed. Two patients (1.3%) died, the remaining ones recovered fully. CONCLUSIONS Although the incidence of pneumonia and the use of immunosuppressive treatment among children with JIA increased from 1998 to 2014, the proportion of serious pneumonias in these patients decreased. There was no significant difference in the use of anti-rheumatic medication between patients with serious and non-serious pneumonia.Key Points• The incidence of serious pneumonias decreased from 1998 to 2014 among children with juvenile idiopathic arthritis (JIA).• There was no significant difference in the use of the disease-modifying anti-rheumatic medication between JIA patients with serious and non-serious pneumonias.• Active JIA, comorbidities, and combination medication were associated with nearly half of the pneumonias.
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Affiliation(s)
- Päivi H Salonen
- Faculty of Medicine and Life Science, Tampere University, Tampere, Finland. .,Päijät-Häme Joint Authority for Health and Wellbeing, Terveystie 4, 15870, Lahti, Hollola, Finland.
| | - Juha H Salonen
- Department of Infectious Diseases, Vaasa Central Hospital, Vaasa, Finland
| | - Hanna Säilä
- Orton Research Institute, Orton Foundation, Helsinki, Finland
| | - Mika Helminen
- Research, Development and Innovation Centre, Tampere University Hospital, Tampere, Finland.,Faculty of Social Sciences, Health Sciences, Tampere University, Tampere, Finland
| | | | - Markku J Kauppi
- Faculty of Medicine and Life Science, Tampere University, Tampere, Finland.,Department of Rheumatology, Päijät-Häme Central Hospital, Lahti, Finland
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Allogeneic hematopoietic stem cell transplantation for severe, refractory juvenile idiopathic arthritis. Blood Adv 2019; 2:777-786. [PMID: 29618462 DOI: 10.1182/bloodadvances.2017014449] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 02/21/2018] [Indexed: 12/13/2022] Open
Abstract
Patients with juvenile idiopathic arthritis (JIA) can experience a severe disease course, with progressive destructive polyarthritis refractory to conventional therapy with disease-modifying antirheumatic drugs including biologics, as well as life-threatening complications including macrophage activation syndrome (MAS). Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative immunomodulatory strategy for patients with such refractory disease. We treated 16 patients in 5 transplant centers between 2007 and 2016: 11 children with systemic JIA and 5 with rheumatoid factor-negative polyarticular JIA; all were either refractory to standard therapy, had developed secondary hemophagocytic lymphohistiocytosis/MAS poorly responsive to treatment, or had failed autologous HSCT. All children received reduced toxicity fludarabine-based conditioning regimens and serotherapy with alemtuzumab. Fourteen of 16 patients are alive with a median follow-up of 29 months (range, 2.8-96 months). All patients had hematological recovery. Three patients had grade II-IV acute graft-versus-host disease. The incidence of viral infections after HSCT was high, likely due to the use of alemtuzumab in already heavily immunosuppressed patients. All patients had significant improvement of arthritis, resolution of MAS, and improved quality of life early following allo-HSCT; most importantly, 11 children achieved complete drug-free remission at the last follow-up. Allo-HSCT using alemtuzumab and reduced toxicity conditioning is a promising therapeutic option for patients with JIA refractory to conventional therapy and/or complicated by MAS. Long-term follow-up is required to ascertain whether disease control following HSCT continues indefinitely.
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Abinun M, Lane JP, Wood M, Friswell M, Flood TJ, Foster HE. Infection-Related Death among Persons with Refractory Juvenile Idiopathic Arthritis. Emerg Infect Dis 2018; 22:1720-7. [PMID: 27648582 PMCID: PMC5038400 DOI: 10.3201/eid2210.151245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Bacterial sepsis led to multiorgan failure in persons receiving immunosuppressive and antiinflammatory drugs. Severe infections are emerging as major risk factors for death among children with juvenile idiopathic arthritis (JIA). In particular, children with refractory JIA treated with long-term, multiple, and often combined immunosuppressive and antiinflammatory agents, including the new biological disease-modifying antirheumatic drugs (DMARDs), are at increased risk for severe infections and death. We investigated 4 persons with JIA who died during 1994–2013, three of overwhelming central venous catheter–related bacterial sepsis caused by coagulase-negative Staphylococus or α-hemolytic Streptococcus infection and 1 of disseminated adenovirus and Epstein-Barr virus infection). All 4 had active JIA refractory to long-term therapy with multiple and combined conventional and biological DMARDs. Two died while receiving high-dose systemic corticosteroids, methotrexate, and after recent exposure to anti–tumor necrosis factor-α biological DMARDs, and 2 during hematopoietic stem cell transplantation procedure. Reporting all cases of severe infections and especially deaths in these children is of paramount importance for accurate surveillance.
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Davies HD. Infectious Complications With the Use of Biologic Response Modifiers in Infants and Children. Pediatrics 2016; 138:peds.2016-1209. [PMID: 27432853 DOI: 10.1542/peds.2016-1209] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Biologic response modifiers (BRMs) are substances that interact with and modify the host immune system. BRMs that dampen the immune system are used to treat conditions such as juvenile idiopathic arthritis, psoriatic arthritis, or inflammatory bowel disease and often in combination with other immunosuppressive agents, such as methotrexate and corticosteroids. Cytokines that are targeted include tumor necrosis factor α; interleukins (ILs) 6, 12, and 23; and the receptors for IL-1α (IL-1A) and IL-1β (IL-1B) as well as other molecules. Although the risk varies with the class of BRM, patients receiving immune-dampening BRMs generally are at increased risk of infection or reactivation with mycobacterial infections (Mycobacterium tuberculosis and nontuberculous mycobacteria), some viral (herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, hepatitis B) and fungal (histoplasmosis, coccidioidomycosis) infections, as well as other opportunistic infections. The use of BRMs warrants careful determination of infectious risk on the basis of history (including exposure, residence, and travel and immunization history) and selected baseline screening test results. Routine immunizations should be given at least 2 weeks (inactivated or subunit vaccines) or 4 weeks (live vaccines) before initiation of BRMs whenever feasible, and inactivated influenza vaccine should be given annually. Inactivated and subunit vaccines should be given when needed while taking BRMs, but live vaccines should be avoided unless under special circumstances in consultation with an infectious diseases specialist. If the patient develops a febrile or serious respiratory illness during BRM therapy, consideration should be given to stopping the BRM while actively searching for and treating possible infectious causes.
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Leuvenink R, Aeschlimann F, Baer W, Berthet G, Cannizzaro E, Hofer M, Kaiser D, Schroeder S, Heininger U, Woerner A. Clinical course and therapeutic approach to varicella zoster virus infection in children with rheumatic autoimmune diseases under immunosuppression. Pediatr Rheumatol Online J 2016; 14:34. [PMID: 27256096 PMCID: PMC4890263 DOI: 10.1186/s12969-016-0095-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/16/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To analyze the clinical presentation and complications of varicella zoster virus (VZV) infection in children with rheumatic diseases treated with immunosuppressive medication such as biological disease-modifying antirheumatic drugs (bDMARDs) and/or conventional disease-modifying antirheumatic drugs (cDMARDs), and to analyze the therapeutic approach to VZV infections with respect to the concomitant immunosuppressive treatment. METHODS Retrospective multicenter study using the Swiss Pediatric Rheumatology registry. Children with rheumatic diseases followed in a Swiss center for pediatric rheumatology and treated with cDMARD and/or bDMARD with a clinical diagnosis of varicella or herpes zoster between January 2004 and December 2013 were included. RESULTS Twenty-two patients were identified, of whom 20 were treated for juvenile idiopathic arthritis, 1 for a polyglandular autoimmune syndrome type III, and 1 for uveitis. Of these 22 patients, 16 had varicella and 6 had herpes zoster. Median age at VZV disease was 7.6 years (range 2 to 17 years), with 6.3 years (range 2 to 17 years) for those with varicella and 11.6 years (range 5 to 16 years) for those with herpes zoster. The median interval between start of immunosuppression and VZV disease was 14.1 months (range 1 to 63 months). Two patients had received varicella vaccine (1 dose each) prior to start of immunosuppression. Concomitant immunosuppressive therapy was methotrexate (MTX) monotherapy (n = 9) or bDMARD monotherapy (n = 2), or a combination of bDMARD with prednisone, MTX or Leflunomide (n = 11). Four patients experienced VZV related complications: cellulitis in 1 patient treated with MTX, and cellulitis, sepsis and cerebellitis in 3 patients treated with biological agents and MTX combination therapy. Six children were admitted to hospital (range of duration: 4 to 9 days) and 12 were treated with valaciclovir or aciclovir. CONCLUSION The clinical course of varicella and herpes zoster in children under immunosuppression is variable, with 4 (18 %) of 22 children showing a complicated course. Thorough assessment of VZV disease and vaccination history and correct VZV vaccination according to national guidelines at diagnosis of a rheumatic autoimmune disease is essential to minimize VZV complications during a later immunosuppressive treatment.
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Affiliation(s)
- Raphael Leuvenink
- University of Basel Medical School, Basel, Switzerland ,Pediatric Rheumatology, University of Basel Children’s Hospital, Spitalstrasse 33, CH – 4031 Basel, Switzerland
| | | | - Walter Baer
- Department of Pediatrics, Hospital of Chur, Chur, Switzerland
| | - Gerald Berthet
- Department of Pediatrics, Hospital of Aarau, Aarau, Switzerland
| | | | - Michael Hofer
- Unité romande de rhumatologie pédiatrique, CHUV, University of Lausanne and HUG, Geneva, Switzerland
| | - Daniela Kaiser
- Department of Pediatrics, Hospital of Lucerne, Lucerne, Switzerland
| | | | - Ulrich Heininger
- Pediatric Rheumatology, University of Basel Children’s Hospital, Spitalstrasse 33, CH – 4031 Basel, Switzerland
| | - Andreas Woerner
- Pediatric Rheumatology, University of Basel Children's Hospital, Spitalstrasse 33, CH - 4031, Basel, Switzerland.
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Tuberculosis in pediatric patients treated with anti-TNFα drugs: a cohort study. Pediatr Rheumatol Online J 2015; 13:54. [PMID: 26635208 PMCID: PMC4669612 DOI: 10.1186/s12969-015-0054-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 11/29/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Adult patients receiving anti-TNFα drugs are at increased risk of tuberculosis (TB), but studies in pediatric populations are limited, and the best strategy for latent tuberculosis infection (LTBI) screening in this population remains controversial. We describe the prevalence of LTBI prior to anti-TNFα therapy and the long-term follow-up after biological treatment initiation in a cohort of children and adolescents. METHODS Cohort observational study in children and adolescents receiving anti-TNFα agents in a tertiary-care pediatric hospital. LTBI was ruled out prior to the implementation of anti-TNFα drugs by tuberculin skin test (TST), and, from March 2012 on, QuantiFERON Gold-In Tube test (QTF-G). During anti-TNFα treatment, patients were evaluated every 6 months for TB with history and physical examination. TST/QTF-G were not repeated unless signs or symptoms consistent with TB arose or there was proven TB contact. RESULTS The final cohort consisted of 221 patients (56.1% female; 261 treatments), of whom 51.7%/30.0%/17.3% were treated with etanercept/adalimumab/infliximab, respectively, for a variety of rheumatic diseases (75.6%), inflammatory bowel disease (20.8%), and inflammatory eye diseases (3.6%). The median (IQR) age at diagnosis of the primary condition was 6.8 years (2.7-11.0) and the duration of the disease before implementing the anti-TNFα agent was 1.8 years (0.6-4.2). LTBI was diagnosed in 3 adolescent girls (prevalence rate: 1.4%; 95% CI: 0.4-4.2) affected with juvenile idiopathic arthritis: TST tested positive in only 1, while QTF-G was positive in all cases (including 2 patients already on etanercept). They all received antiTB chemoprophylaxis and were later (re)treated with etanercept for 24-29 months, without incidences. No incident cases of TB disease were observed during the follow-up period under anti-TNFα treatment of 641 patients-year, with a median (IQR) time per patient of 2.3 years (1.4-4.3). CONCLUSIONS In our study, the prevalence of LTBI (1.4%) was similar to that reported in population screening studies in Spain; no incident cases of TB disease were observed. In low-burden TB settings, initial screening for TB in children prior to anti-TNFα treatment should include both TST and an IGRA test, but systematic repetition of LTBI immunodiagnostic tests seems unnecessary in the absence of symptoms or known TB contact.
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