Presentation and outcome of histoplasmosis in pediatric inflammatory bowel disease patients treated with antitumor necrosis factor alpha therapy: a case series.
BACKGROUND
Antitumor necrosis factor alpha (aTNF) therapies are commonly used in the treatment of pediatric inflammatory bowel disease (IBD). However, inhibition of the TNF-alpha pathway predisposes to serious infections, including histoplasmosis, which is the most common invasive fungal infection in individuals on aTNF therapy and carries a high mortality rate when associated with delayed diagnosis. Few data exist on the frequency, presentation, and appropriate treatment of pediatric patients with histoplasmosis on aTNF therapy.


METHODS
Following Institutional Review Board approval, cases were identified then reviewed with their primary gastroenterologist and infectious disease specialists.


RESULTS
Herein we describe histoplasmosis in five pediatric patients receiving aTNF therapy for IBD in an endemic area.


CONCLUSIONS
Histoplasmosis is an important complication of treatment with TNF-alpha neutralizing agents. Children with IBD treated with aTNF therapy who develop the infection may present with minimal pulmonary symptoms. While discontinuation of aTNF therapy is important initially, few data exist to determine when and how aTNF therapy can be reinstituted. Recognition of Histoplasma capsulatum is often delayed due to the overlap of symptoms with some of the extraintestinal manifestations of IBD and other more prevalent infectious complications.
Dotson
Jennifer L
JL
Nationwide Children's Hospital, Columbus, Ohio 43205, USA. Jenniferdotson@nationwidechildrens.org
Crandall
Wallace
W
Mousa
Hayat
H
Honegger
Jonathan R
JR
Denson
Lee
L
Samson
Charles
C
Cunningham
Dennis
D
Balint
Jane
J
Dienhart
Molly
M
Jaggi
Preeti
P
Carvalho
Ryan
R
D000068879:Adalimumab; D000293:Adolescent; D000328:Adult; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use*; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized; D000935:Antifungal Agents / Q000627:therapeutic use; D019353:Endemic Diseases; D005260:Female; D016469:Fungemia / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D006658:Histoplasma / Q000472:pathogenicity*; D006660:Histoplasmosis / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D006801:Humans; D015212:Inflammatory Bowel Diseases / Q000188:drug therapy* / Q000382:microbiology / Q000473:pathology; D000069285:Infliximab; D008172:Lung Diseases, Fungal / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D008297:Male; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D055815:Young Adult
D000893:Anti-Inflammatory Agents; D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D000935:Antifungal Agents; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab