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Clemente D, Cuadros EN, Lovillo MC, Hernández JC, Martín SG, Silveira LF, Cruz MJL, Tagarro A, Rueda RMA, López López A, Aritziturri MS, Calvo C. Position statement on infection screening, prophylaxis, and vaccination of pediatric patients with rheumatic diseases and immunosuppressive therapies, part 3: precautions in situations of surgery, fever, and opportunistic infections. Eur J Pediatr 2024; 183:915-927. [PMID: 38047962 PMCID: PMC10912362 DOI: 10.1007/s00431-023-05295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 12/05/2023]
Abstract
The objective of this study is to provide practical recommendations on the management of pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The recommendations specifically address the cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, invasive fungal disease). A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify publications on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The results were presented and discussed in a nominal group meeting, comprising a committee of 12 pediatric rheumatologists from the Infection Prevention and Treatment Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process; this was extended to members of the Spanish Society of Pediatric Rheumatology and Spanish Society of Pediatric Infectious Disease of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (totally disagree) to 10 (totally agree). Agreement was defined as a vote ≥ 7 by at least 70% of participants. The literature review included more than 400 articles. Overall, 63 recommendations (19 on surgery, fever, and opportunistic infections) were generated and voted by 59 pediatric rheumatologists and other pediatric specialists. Agreement was reached for all 63 recommendations. The recommendations on special situations cover management in cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, and invasive fungal disease). Conclusions: Hereby, we provided consensus and updated of recommendations about the management of special situations such as surgery, fever, and opportunistic in children with immune-mediated rheumatic diseases receiving immunosuppressive therapies. Several of the recommendations depend largely on clinical judgement and specific balance between risk and benefit for each individual and situation. To assess this risk, the clinician should have knowledge of the drugs, the patient's previous situation as well as the current infectious disease, in addition to experience. What is Known: • Infectious diseases and related complications are a major cause of morbidity and mortality in patients with immune-mediated rheumatic diseases. • Information on how to manage the treatment in situations of fever, opportunistic infections, and surgery in children is limited, and guidelines for action are often extrapolated from adults. What is New: • In the absence of strong evidence, a literature review and a Delphi survey were conducted to establish a series of expert recommendations that could support the clinical practice, providing a practical and simple day-to-day approach to be used by pediatric rheumatologists.
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Affiliation(s)
- Daniel Clemente
- Pediatric Rheumatology Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Esmeralda Núñez Cuadros
- Pediatric Rheumatology Unit, UGC Pediatría, Hospital Regional Universitario de Málaga, Instituto de investigación biomédica de Málaga (IBIMA), Málaga, Spain
| | - Marisol Camacho Lovillo
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío, Reumatología e Infectología pediátricas, Seville, Spain
| | - Joan Calzada Hernández
- Unitat de Reumatologia Pediàtrica, Servei de Pediatria, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Sara Guillén Martín
- Department of Pediatrics, Hospital Universitario de Getafe, CIBERINFEC ISCIII, Carretera de Toledo Km 12, 500, 28905, Getafe, Madrid, Spain.
| | - Laura Fernández Silveira
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología e Infectología pediátricas, Seville, Spain
| | | | - Alfredo Tagarro
- Pediatrics Department. Hospital Universitario Infanta Sofía, Instituto de Investigación 12 de Octubre (imas12), Universidad Europea, Madrid, Spain
| | | | - Agustín López López
- Department of Paediatrics, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Cristina Calvo
- Department of Pediatrics, Infectious and Tropical Diseases, Hospital Universitario La Paz, La Paz Research Institute (IdiPaz), Translational Research Network of Pediatric Infectious Diseases (RITIP), CIBERINFEC ISCIII, Madrid, Spain
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Corrêa RDS, Leal-Calvo T, Mafort TT, Santos AP, Leung J, Pinheiro RO, Rufino R, Moraes MO, Rodrigues LS. Reanalysis and validation of the transcriptional pleural fluid signature in pleural tuberculosis. Front Immunol 2024; 14:1256558. [PMID: 38288122 PMCID: PMC10822927 DOI: 10.3389/fimmu.2023.1256558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 12/18/2023] [Indexed: 01/31/2024] Open
Abstract
Introduction Pleural tuberculosis (PlTB), the most common site of extrapulmonary TB, is characterized by a paucibacillary nature and a compartmentalized inflammatory response in the pleural cavity, both of which make diagnosis and management extremely challenging. Although transcriptional signatures for pulmonary TB have already been described, data obtained by using this approach for extrapulmonary tuberculosis and, specifically, for pleural tuberculosis are scarce and heterogeneous. In the present study, a set of candidate genes previously described in pulmonary TB was evaluated to identify and validate a transcriptional signature in clinical samples from a Brazilian cohort of PlTB patients and those with other exudative causes of pleural effusion. Methods As a first step, target genes were selected by a random forest algorithm with recursive feature elimination (RFE) from public microarray datasets. Then, peripheral blood (PB) and pleural fluid (PF) samples from recruited patients presenting exudative pleural effusion were collected during the thoracentesis procedure. Transcriptional analysis of the selected top 10 genes was performed by quantitative RT-PCR (RT-qPCR). Results Reanalysis of the public datasets identified a set of candidate genes (CARD17, BHLHE40, FCGR1A, BATF2, STAT1, BTN3A1, ANKRD22, C1QB, GBP2, and SEPTIN4) that demonstrated a global accuracy of 89.5% in discriminating pulmonary TB cases from other respiratory diseases. Our validation cohort consisted of PlTB (n = 35) patients and non-TB (n = 34) ones. The gene expressions of CARD17, GBP2, and C1QB in PF at diagnosis were significantly different between the two (PlTB and non-TB) groups (p < 0.0001). It was observed that the gene expressions of CARD17 and GBP2 were higher in PlTB PF than in non-TB patients. C1QB showed the opposite behavior, being higher in the non-TB PF. After anti-TB therapy, however, GBP2 gene expression was significantly reduced in PlTB patients (p < 0.001). Finally, the accuracy of the three above-cited highlighted genes in the PF was analyzed, showing AUCs of 91%, 90%, and 85%, respectively. GBP2 was above 80% (sensitivity = 0.89/specificity = 0.81), and CARD17 showed significant specificity (Se = 0.69/Sp = 0.95) in its capacity to discriminate the groups. Conclusion CARD17, GBP2, and C1QB showed promise in discriminating PlTB from other causes of exudative pleural effusion by providing accurate diagnoses, thus accelerating the initiation of anti-TB therapy.
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Affiliation(s)
- Raquel da Silva Corrêa
- Laboratory of Immunopathology, Medical Sciences Faculty, Rio de Janeiro State University (FCM/UERJ), Rio de Janeiro, Brazil
| | - Thyago Leal-Calvo
- Laboratory of Leprosy, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (IOC/FIOCRUZ), Rio de Janeiro, Brazil
| | - Thiago Thomaz Mafort
- Department of Pulmonary Care, Pedro Ernesto University Hospital, Rio de Janeiro State University (HUPE/UERJ), Rio de Janeiro, Brazil
| | - Ana Paula Santos
- Department of Pulmonary Care, Pedro Ernesto University Hospital, Rio de Janeiro State University (HUPE/UERJ), Rio de Janeiro, Brazil
| | - Janaína Leung
- Department of Pulmonary Care, Pedro Ernesto University Hospital, Rio de Janeiro State University (HUPE/UERJ), Rio de Janeiro, Brazil
| | - Roberta Olmo Pinheiro
- Laboratory of Leprosy, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (IOC/FIOCRUZ), Rio de Janeiro, Brazil
| | - Rogério Rufino
- Department of Pulmonary Care, Pedro Ernesto University Hospital, Rio de Janeiro State University (HUPE/UERJ), Rio de Janeiro, Brazil
| | - Milton Ozório Moraes
- Laboratory of Leprosy, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (IOC/FIOCRUZ), Rio de Janeiro, Brazil
| | - Luciana Silva Rodrigues
- Laboratory of Immunopathology, Medical Sciences Faculty, Rio de Janeiro State University (FCM/UERJ), Rio de Janeiro, Brazil
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Lima LDM, Fonseca AR, Sant'Anna CC, Parente AAAI, Aurilio RB, Sant'Anna MDFBP. Tuberculosis among children and adolescents with rheumatic diseases - case series. Pediatr Rheumatol Online J 2023; 21:136. [PMID: 37950309 PMCID: PMC10636992 DOI: 10.1186/s12969-023-00918-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/22/2023] [Indexed: 11/12/2023] Open
Abstract
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.
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Affiliation(s)
- Lenita de Melo Lima
- Pediatric Pulmonology Unit, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro (UFRJ), Rua Bruno Lobo, 50 - Cidade Universitária, Rio de Janeiro, Brazil.
| | - Adriana Rodrigues Fonseca
- Pediatric Pulmonology Unit, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro (UFRJ), Rua Bruno Lobo, 50 - Cidade Universitária, Rio de Janeiro, Brazil
- Pediatric Rheumatology Unit, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro (UFRJ), Rua Bruno Lobo, 50 - Cidade Universitária, Rio de Janeiro, Brazil
| | - Clemax Couto Sant'Anna
- Pediatric Pulmonology Unit, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro (UFRJ), Rua Bruno Lobo, 50 - Cidade Universitária, Rio de Janeiro, Brazil
| | - Ana Alice Amaral Ibiapina Parente
- Pediatric Pulmonology Unit, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro (UFRJ), Rua Bruno Lobo, 50 - Cidade Universitária, Rio de Janeiro, Brazil
| | - Rafaela Baroni Aurilio
- Pediatric Pulmonology Unit, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro (UFRJ), Rua Bruno Lobo, 50 - Cidade Universitária, Rio de Janeiro, Brazil
| | - Maria de Fátima Bazhuni Pombo Sant'Anna
- Pediatric Pulmonology Unit, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro (UFRJ), Rua Bruno Lobo, 50 - Cidade Universitária, Rio de Janeiro, Brazil
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Lemos CX, Anton C, Machado FD, Bernardi RM, Freitas AA, Silva DR. Adjunctive corticosteroid therapy in patients with pulmonary tuberculosis. Rev Assoc Med Bras (1992) 2022; 68:1199-1203. [PMID: 36228251 PMCID: PMC9575022 DOI: 10.1590/1806-9282.20220196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/23/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES In tuberculosis treatment, corticosteroids are used as adjuvants, especially in meningeal/pericardial tuberculosis. In other forms of the disease, especially in severe tuberculosis requiring mechanical ventilation, its use is controversial. The aim of the present study is to assess whether the use of corticosteroids in the treatment of pulmonary tuberculosis patients in mechanical ventilation is associated with in-hospital mortality. METHODS This is a retrospective cohort study. Tuberculosis patients >18 years requiring mechanical ventilation, admitted to the emergency department or intensive care unit, were included. Data on corticosteroid use and mortality were collected. RESULTS In total, 467 patients were included in the analysis; 399 used corticosteroids and 68 were noncorticosteroid users. The mortality rate was higher among corticosteroid users (59.9%) than in noncorticosteroid users (41.2%) (p=0.010). The total dose of corticosteroid in prednisone equivalents was not different between survivors and nonsurvivors (median [interquartile range]: 80 mg [5-56.6 mg] vs. 80 mg [50-135 mg]; p=0.881). CONCLUSIONS Tuberculosis patients in mechanical ventilation who used corticosteroids had a higher mortality rate than those who did not use corticosteroids. The role of corticosteroids in pulmonary tuberculosis, especially in critically ill patients, remains unclear and needs further evaluation in prospective studies.
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Affiliation(s)
- Carolina Xavier Lemos
- Universidade Federal do Rio Grande do Sul, Graduate Program in Pulmonology Sciences – Porto Alegre (RS), Brazil
| | - Camila Anton
- Universidade Federal do Rio Grande do Sul, Graduate Program in Pulmonology Sciences – Porto Alegre (RS), Brazil
| | - Felipe Dominguez Machado
- Universidade Federal do Rio Grande do Sul, Graduate Program in Pulmonology Sciences – Porto Alegre (RS), Brazil
| | - Rafaela Manzoni Bernardi
- Universidade Federal do Rio Grande do Sul, Graduate Program in Pulmonology Sciences – Porto Alegre (RS), Brazil
| | - Alana Ambos Freitas
- Universidade Federal do Rio Grande do Sul, School of Medicine – Porto Alegre (RS), Brazil
| | - Denise Rossato Silva
- Universidade Federal do Rio Grande do Sul, Graduate Program in Pulmonology Sciences – Porto Alegre (RS), Brazil.,Universidade Federal do Rio Grande do Sul, School of Medicine – Porto Alegre (RS), Brazil.,Hospital de Clínicas de Porto Alegre, Department of Pulmonology – Porto Alegre (RS), Brazil.,Corresponding author:
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Dias VL, Storrer KM. Prevalence of latent tuberculosis infection among patients with interstitial lung disease requiring immunosuppression. J Bras Pneumol 2022; 48:e20210382. [PMID: 35352793 PMCID: PMC8963748 DOI: 10.36416/1806-3756/e20210382] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 01/22/2022] [Indexed: 12/12/2022] Open
Abstract
Objective To characterize the prevalence of latent tuberculosis infection (LTBI) in patients with interstitial lung diseases (ILDs) requiring immunosuppression. Only 5 to 10% of individuals infected with Mycobacterium tuberculosis develop tuberculosis, and certain groups of patients have an increased risk of illness, such as the immunocompromised. Patients with ILDs are frequently treated with immunosuppressants and, therefore, might have a higher risk of developing the disease. Methods Prospective study conducted at the ILD reference center of the Federal University of Paraná from January 2019 to December 2020. The screening of LTBI was performed with the use of the tuberculin skin test (TST). Results The sample consisted of 88 patients, of whom 64.8% were women, with a mean age of 61.4 years. The most frequent diagnoses were autoimmune rheumatic disease ILD (38.6%) and hypersensitivity pneumonitis (35.2%). The most common immunosuppressant in use at the time of the TST was prednisone, either in combination with mycophenolate (19.3%) or alone (17.1%). The majority of participants had fibrotic lung disease, characterized by a reticular interstitial pattern on chest computed tomography (79.5%) and moderate to severe functional impairment (mean FVC 69.2%). A prevalence of LTBI of 9.1% (CI 95%, 2.1%-15.1%) was found, with a TST median of 13. Conclusion Patients with ILD who are treated with immunosuppressants are not commonly screened for LTBI, despite being under a greater risk of progression to active disease. This study suggests the need for a more cautious approach to these patients.
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Silva DR, Mello FCDQ, Migliori GB. Tuberculosis Series 2021. J Bras Pneumol 2021; 47:e20210109. [PMID: 33950097 PMCID: PMC8332828 DOI: 10.36416/1806-3756/e20210109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Denise Rossato Silva
- . Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | - Fernanda Carvalho de Queiroz Mello
- . Instituto de Doenças do Tórax - IDT - Faculdade de Medicina, Universidade Federal do Rio de Janeiro - UFRJ- Rio de Janeiro (RJ), Brasil
| | - Giovanni Battista Migliori
- . Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri - IRCCS - Tradate, Italia.,. Blizard Institute, Queen Mary University of London, London, United Kingdom
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