Tuberculosis in children and adolescents with rheumatic diseases using biologic agents: an integrative review

Tuberculosis in children and adolescents using biological agents: a nationwide cohort study from Turkey

BACKGROUND

The use of biological agents in various diseases in children has been increasing and the risk of tuberculosis (TB) increases with them. We aimed to investigate the role of biological agents in children diagnosed with TB in a moderate level of TB country where TB screening is mandatory before and during biological agent treatment.

STUDY DESIGN AND METHODS

This was a retrospective cohort study. All patients who were 0-18 years old and diagnosed with TB-related ICD-10 in the national health database system between 2018 and 2023 were included in the study. The number of patients, demographic characteristics, treatments used by the patients, underlying diseases, and organ involvement of TB were recorded. Children using and not using biological agents were compared.

RESULTS

A total of 4351 children were diagnosed with TB, and 1.9% of them were treated with biological agents. The age of diagnosis was older (p = 0.001), and both pulmonary and extrapulmonary involvement was more frequent in children using biological agents (p = 0.001). Pulmonary involvement was more frequent in rheumatological diseases (p = 0.001), and naproxen usage was higher in children with pulmonary involvement (p = 0.014). Naproxen was found to increase the risk of pulmonary TB in children using biological agents (OR:3.824, p = 0.033).

CONCLUSIONS

The low frequency of TB may be due to effective TB screening before and during the therapy. The age of diagnosis was older, pulmonary and extrapulmonary TB involvement was more common in children using biological agents, which may be related to the immunosuppressive effects. Children using biological agents who are also using naproxen should be closely followed up in terms of pulmonary TB.

An update on the safety of biologic therapies for the treatment of polyarticular juvenile idiopathic arthritis

INTRODUCTION

An increasing number of patients with polyarticular course juvenile idiopathic arthritis are treated with biologics with great efficacy. Consequently, the importance regarding safety data in general as well as especially serious infections, incident autoimmune processes, or malignancies rises. In children, this is crucial concerning occurrences that manifest rarely and only after a prolonged latency period.

AREAS COVERED

This study aims to analyze safety under therapy with the five most commonly used biologicals for the treatment of juvenile idiopathic arthritis in Germany: abatacept, adalimumab, etanercept, golimumab, and tocilizumab, and a control cohort, who received methotrexate. For this, data from the Biologics in Pediatric Rheumatology (BiKeR) Registry were analyzed with a focus on potential adverse drug reactions like serious infections, autoimmune processes or malignancies.

EXPERT OPINION

Besides JIA category-specific differences, investigating side effects like severe infections and the development of additional autoimmune processes due to therapy is crucial. Future clinical randomized double-blinded studies are essential for direct drug comparisons, enabling optimal individualized therapy considering comorbidities and individual risks. Large patient data over a (life-)long period beyond childhood are particularly important, especially concerning the risk of malignancy after prolonged latency.

Osteoarticular tuberculosis: imaging findings in pediatric patients

Osteoarticular tuberculosis (TB) is an uncommon form of extrapulmonary TB that has the potential to damage joints and bones, generating long-term impairment. Mainly, the initial diagnosis of osteoarticular TB relies on clinical findings and imaging. When required, imaging can aim for less invasive tissue or fluid sampling for pathology, microbiology, and molecular biology analysis. Most TB diagnosis tests have variable and frequently poor sensitivities; however, bone biopsy samples have demonstrated a high percentage of culture positivity. Clinical and imaging findings of osteoarticular TB often mimic other processes, such as rheumatoid arthritis or chronic recurrent multifocal osteomyelitis. When the infection affects the growth plates, angular deformities and extremity length discrepancies can arise. Unfortunately, several osteoarticular TB cases are detected late due to the nonspecific nature of clinical symptoms and non-characteristic imaging findings. This article reviews the most common and atypical osteoarticular TB imaging presentations to increase awareness of osteoarticular TB.

Two Cases of Testicular Tuberculosis and Review of the Recent Literature

In this review, two cases of testicular tuberculosis (TB) are presented, and another 58 cases published in PubMed between January 1, 2012, and July 31, 2023, are reviewed. Testicular TB remains a disease mainly of the developing world, with one notable exception - the infections caused as a result of Bacillus Calmette-Guérin infusion immunotherapy for bladder cancer. Its clinical course is subacute; however, it might get disseminated and become life-threatening; therefore, prompt diagnosis is very important. The diagnosis can be quite challenging, and testicular tissue is the sample with the highest diagnostic yield, either for microbiological or histopathological diagnosis. On the other hand, its treatment follows the standard guidelines for TB treatment; however, the avoidance of an unnecessary orchiectomy is important.

Tuberculosis among children and adolescents with rheumatic diseases - case series

BACKGROUND

Rheumatic patients have a higher frequency of tuberculosis(TB) than the general population. This study aimed to describe children and adolescents with TB and rheumatic diseases(RD) who were being treated in a reference center.

METHODS

A series of TB cases were investigated in a reference center for childhood TB in Rio de Janeiro, Brazil, from 1995 to 2022.

RESULTS

Fifteen patients with underlying RD and TB were included with 8(53%) being female. The mean age at RD diagnosis was 7.10years (SD ± 0,57 years), and the mean age at TB diagnosis was 9.81 years(SD ± 0.88 years). A total of 9 cases of pulmonary TB(PTB) and 6 cases of extrapulmonary TB-pleural(2), joint/osteoarticular(1), cutaneous(1), ocular(1), and peritoneal(1)- were described. The RD observed in the 15 patients included juvenile idiopathic arthritis(9), juvenile systemic lupus erythematosus(3), juvenile dermatomyositis(1), polyarteritis nodosa(1), and pyoderma gangrenosum(1). Among the immunosuppressants/immunobiologics, methotrexate(8) was the most commonly used, followed by corticosteroids(6), etanercept(2), mycophenolate mofetil(1), cyclosporine A(1), adalimumab(1), and tocilizumab(1). The most common symptoms were fever and weight loss, and a predominance of PTB cases was noted. GeneXpert MTB/RIF® was performed in six patients and was detectable in two without rifampicin resistance; Xpert Ultra® was performed in five patients, and traces with indeterminate rifampicin resistance were detected in three. One female patient discontinued treatment, and another passed away.

CONCLUSIONS

The case series demonstrated the importance of suspecting and investigating TB in RD affected patients who are using immunosuppressants/ immunobiologics, particularly in countries with high rates of TB such as Brazil.