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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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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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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: 15] [Impact Index Per Article: 5.0] [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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