Mycobacterial Disease in Immunocompromised Children in a High Endemic Area

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Excerpt

We read with interest the study published by Santiago-García et al1 that correlates immune disorders with extrapulmonary tuberculosis (EPTB). Tuberculosis is a major public health problem, especially in developing countries as Brazil, a high endemic area of the disease.2 Disseminated Mycobacterium bovis is also a concern, since vaccination with Bacillus Calmette Guérin is universally performed in the first year of life in Brazil, often before the diagnosis of immunodeficiency.3
A retrospective review of cases of mycobacterial disease in children ≤ 18 years of age with primary immunodeficiency or exposed to chronic immunosuppressive therapy managed in a tertiary hospital in São Paulo, Brazil from January 2009 to December 2016, was performed. HIV-positive patients were excluded.
During the study, 22 cases of mycobacterial disease in immunocompromised patients were identified. The median age at diagnosis was 8 years (9 months to 18 years). The main comorbidities were primary immunodeficiency (n = 8), rheumatologic diseases (n = 6), oncohematologic diseases (n = 4) and posttransplantion (n = 4). In all, 3 patients were diagnosed with nontuberculosis mycobacteria and were excluded from the following analysis. Among the 19 children with Mycobacterium tuberculosis, 5 were classified as confirmed tuberculosis (1 with EPTB) and 14 were classified as probable tuberculosis, using the same criteria as Santiago-García et al.1 Pulmonary tuberculosis (PTB) was diagnosed in 16 (84%) patients and EPTB in 3 patients. The sites of the EPTB cases were kidney (6 years old), abdominal (1 year old), and pericardium (16 years old), with the abdominal and pericardium cases associated with PTB. Tuberculin skin test was positive (≥ 5 mm) in 3 of 10 patients on whom it was performed. Only 1 of the EPTB children performed Tuberculin skin test, and the result was negative. Five patients had the source of infection identified, all in the PTB group. Evaluation of outcome revealed that 17 patients were cured and 2 had relapsing infection after initial successful treatment; 3 patients had moderate adverse reactions (2 hepatitis and 1 arthralgia). No drug resistance was identified in the confirmed cases. All 3 of the EPTB cases were cured, and none had complications related to treatment.
In a high prevalence area, different from the results of Santiago-García et al,1 we found a higher rate of PTB in the immunocompromised patients (16/19 patients in our study versus 17/25 immunocompromised non-HIV patients in Santiago-García et al1; P = 0.3). It is important to point out that, despite the immunodeficiency, most of our patients were cured and no deaths were reported. In the immunocompromised, a high level of suspicion for mycobacterial disease is needed because the presentation can be atypical and the diagnosis difficult to establish.4 Other mycobacteria than M. tuberculosis can cause disease in children with immune disorders as we report 2 with M. bovis and 1 with M. intracellullare.
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