Tuberculose em pacientes com doenças reumáticas imunomediadas em um centro pediátrico especializado no Rio de Janeiro

Abstract

Introduction: Patients with immune-mediated rheumatic diseases (IMRDs) are at risk for tuberculosis (TB). Considering the limited availability of studies on TB in children and adolescents with IMRDs, this research aims to assess the profile of these patients and provide valuable insights into the development of TB screening and treatment strategies. Objective: Describe children and adolescents with IMRDs and TB who were being treated in a tertiary university center in Rio de Janeiro, Brazil. Methodology: Descriptive, observational, and ambidirectional study evaluated from January 1, 1995, to December 31, 2022. The sample selection was convenience-based, and the diagnosis of pulmonary TB (PTB) was based on the scoring system of the Brazilian Ministry of Health (SS-MoH-Brazil) and/or suggestive radiographic findings of PTB, associated or not with smear microscopy, culture, and/or molecular rapid test for TB (MRT-TB) detected. The diagnosis of extrapulmonary TB (EPTB) was also based on clinical and/or radiographic findings suggestive of EPTB, associated with culture, TRM-TB, and/or histopathological findings compatible with TB. The diagnosis of IMRDs was established according to the classification criteria in force for each disease. Descriptive statistics were used for data analysis with mean and standard deviation (for normally distributed variables); absolute and percentage frequency, for categorical variables, and the statistical program used was the Statistical Package for the Social Sciences (SPSS) version 20.0 for Windows. Results: Fifteen patients with IMRDs and TB were included, with 8 (53%) being female. The mean age at IMRD diagnosis was 7.10 years (SD±0.57 years), and the mean age at TB diagnosis was 9.81 years (SD±0.88 years). There were 9 cases of PTB and 6 cases of EPTB - pleural(2), articular/osteoarticular(1), cutaneous(1), ophthalmic(1), and peritoneal(1). The IMRDs observed in these 15 patients included juvenile idiopathic arthritis (9), juvenile systemic lupus erythematosus (3), juvenile dermatomyositis (1), polyarteritis nodosa (1), and undifferentiated autoinflammatory syndrome (1). Among immunosuppressants/immunobiologics, methotrexate (8) was the most 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. According to the SS-MoH-Brazil, the diagnosis of PTB possible or very probable occurred in 7/8 patients. GeneXpertMTB/RIF® was performed in 6 patients, with no rifampicin resistance detected in 2 patients; XpertUltra® was performed in 5 patients, with 3 of them showing traces of rifampicin resistance undetermined. One patient was lost to followup, and one patient died. Conclusion: Juvenile idiopathic arthritis was the most prevalent IMRD, and the majority of patients were on non-biological immunosuppressive therapies. Fever and weight loss were the most frequent symptoms in PTB cases, although they are nonspecific findings and may suggest activity of some IMRDs or represent other infections. The application of SS-MoH-Brazil was important for the diagnosis of PTB in children, while MRT-TB played a significant role in identifying extrapulmonary forms of the disease. These findings highlight the complexity in the therapeutic approach to pediatric patients with IMRDs and TB, emphasizing the need to suspect and investigate TB in this group prior to the use of biological and immunossupressive therapy.