Miliary tuberculosis: a severe opportunistic infection in juvenile systemic lupus erythematosus patients.
BACKGROUND
One of the main issues in juvenile systemic lupus erythematosus (JSLE) patients is infection, such as tuberculosis (TB). Of note, SLE patients are susceptible to pulmonary and extrapulmonary TB. However, to our knowledge, this contagious disease was rarely reported in pediatric lupus population, particularly diffuse or miliary TB. Therefore, from January 1983 to December 2011, 5,635 patients were followed-up at our Pediatric Rheumatology Unit and 285 (5%) of them met the American College of Rheumatology classification criteria for SLE.


METHODS
Four (1.4%) of our JSLE patients had disseminated TB and were described herein. All of them were female gender, received BCG vaccination and did not have a history of TB household contact. The median of current age at TB diagnosis and the period between JSLE and TB diagnosis were 17 years old (range 14-20) and 5.5 years (range 2-7), respectively. All patients developed miliary TB during the course of the disease. The median of SLE Disease Activity Index 2000 (SLEDAI-2K) was 4 (2-16) and the patients were treated with immunosuppressive agents (glucocorticoid, azathioprine and/or intravenous cyclophosphamide). Two of them presented sepsis and TB diagnosis was only established at autopsy, especially with lungs, central nervous system and abdominal involvements. Anti-TB therapy (isoniazid, rifampicin and pyrazinamide) was indicated in the other two TB cases, however they deceased.


CONCLUSIONS
Miliary TB is a rare and severe opportunist infection in pediatric lupus population. This study reinforces the importance of routine searches for TB in JSLE patients.
Pediatric Rheumatology Unit, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil.
Priscilla S
PS
Freire
Pediatric Rheumatology Unit, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil.
João D
JD
Montoni
Pediatric Rheumatology Unit, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil.
Aline S M
AS
Ribeiro
Pediatric Infectious Diseases Unit, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil.
Heloísa H
HH
Marques
Department of Pathology, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil.
Thais
T
Mauad
Pediatric Rheumatology Unit, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil; Division of Rheumatology, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil. Electronic address: clovis.silva@icr.usp.br.
Clovis A
CA
Silva
D000293:Adolescent; D001379:Azathioprine; D002648:Child; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects* / Q000627:therapeutic use*; D008180:Lupus Erythematosus, Systemic / Q000150:complications*; D008297:Male; D009894:Opportunistic Infections; D014391:Tuberculosis, Miliary / Q000453:epidemiology / Q000209:etiology*
D007166:Immunosuppressive Agents; D001379:Azathioprine
Children; Crianças; Immunosuppressive; Imunossupressor; Infection; Infecção; Lúpus eritematoso sistêmico; Systemic lupus erythematosus; Tuberculose; Tuberculosis