Reintroduction of immunosuppressive medications in pediatric rheumatology patients with histoplasmosis: a case series
| Autor: | Shoghik Akoghlanian, Rachel A. Brown, Stacy P. Ardoin, Cagri Yildirim-Toruner, Fatima Barbar-Smiley, Monica I. Ardura |
|---|---|
| Jazyk: | angličtina |
| Rok vydání: | 2021 |
| Předmět: |
0301 basic medicine
Male medicine.medical_specialty corticosteroid abatacept Adolescent medicine.medical_treatment 030106 microbiology Case Report tumor necrosis factor alpha inhibitor Diseases of the musculoskeletal system Pediatrics Histoplasmosis RJ1-570 03 medical and health sciences chemistry.chemical_compound 0302 clinical medicine Tocilizumab Rheumatology Internal medicine Rheumatic Diseases Ustekinumab medicine Immunology and Allergy Humans 030212 general & internal medicine Child Leflunomide Retrospective Studies immunosuppression business.industry histoplasmosis Abatacept Immunosuppression Hydroxychloroquine medicine.disease DMARD chemistry RC925-935 Cushing’s syndrome Child Preschool Pediatrics Perinatology and Child Health Retreatment juvenile idiopathic arthritis Female business Immunosuppressive Agents medicine.drug |
| Zdroj: | Pediatric Rheumatology Online Journal, Vol 19, Iss 1, Pp 1-8 (2021) Pediatric Rheumatology Online Journal |
| ISSN: | 1546-0096 |
| Popis: | BackgroundChildren with rheumatic diseases (cRD) receiving immunosuppressive medications (IM) are at a higher risk for acquiring potentially lethal pathogens, includingHistoplasma capsulatum(histoplasmosis), a fungal infection that can lead to prolonged hospitalization, organ damage, and death. Withholding IM during serious infections is recommended yet poses risk of rheumatic disease flares. Conversely, reinitiating IM increases risk for infection recurrence. Tumor necrosis factor alpha inhibitor (TNFai) biologic therapy carries the highest risk for histoplasmosis infection after epidemiological exposure, so other IM are preferred during active histoplasmosis infection. There is limited guidance as to when and how IM can be reinitiated in cRD with histoplasmosis. This case series chronicles resumption of IM, including non-TNFai biologics, disease-modifying anti-rheumatic drugs (DMARDs), and corticosteroids, following histoplasmosis among cRD.Case presentationWe examine clinical characteristics and outcomes of 9 patients with disseminated or pulmonary histoplasmosis and underlying rheumatic disease [juvenile idiopathic arthritis (JIA), childhood-onset systemic lupus erythematosus (cSLE), and mixed connective tissue disease (MCTD)] after reintroduction of IM. All DMARDs and biologics were halted at histoplasmosis diagnosis, except hydroxychloroquine (HCQ), and patients began antifungals. Following IM discontinuation, all patients required systemic or intra-articular steroids during histoplasmosis treatment, with 4/9 showing Cushingoid features. Four patients began new IM regimens [2 abatacept (ABA), 1 HCQ, and 1 methotrexate (MTX)] while still positive for histoplasmosis, with 3/4 (ABA, MTX, HCQ) later clearing their histoplasmosis and 1 (ABA) showing decreasing antigenemia. Collectively, 8/9 patients initiated or continued DMARDs and/or non-TNFai biologic use (5 ABA, 1 tocilizumab, 1 ustekinumab, 3 MTX, 4 HCQ, 1 leflunomide). No fatalities, exacerbations, or recurrences of histoplasmosis occurred during follow-up (median 33 months).ConclusionsIn our cohort of cRD, histoplasmosis course following reintroduction of non-TNFai IM was favorable, but additional studies are needed to evaluate optimal IM management during acute histoplasmosis and recovery. In this case series, non-TNFai biologic, DMARD, and steroid treatments did not appear to cause histoplasmosis recurrence. Adverse events from corticosteroid use were common. Further research is needed to implement guidelines for optimal use of non-TNFai (like ABA), DMARDs, and corticosteroids in cRD following histoplasmosis presentation. |
| Databáze: | OpenAIRE |
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