Abstract Objectives: To evaluate seroconverted asymptomatic COVID-19 in pediatric Autoimmune Rheumatic Diseases (ARDs) patients and to identify the risk factors related to contagion. Methods: A cross-sectional study was conducted in March 2021, before vaccination of children and adolescents in Brazil, including 77 pediatric ARDs patients, followed at a tertiary hospital and 45 healthy controls, all of them without a previous diagnosis of COVID-19. Data was obtained by a questionnaire with demographic data, symptoms compatible with COVID-19 over the previous year, and contact with people with confirmed COVID-19. Patient’s medical records were reviewed to access data regarding disease and current medications. A qualitative immunochromatographic SARS-CoV-2 test was performed on all participants. Results: Patients and controls were similar in terms of female gender (70.1% vs. 57.8%, p = 0.173), age (14 vs. 13 years, p = 0.269) and SARS-CoV-2 positive serology (22% vs. 15.5%, p = 0.481). 80.5% of rheumatic patients were in use of immunosuppressive drugs: 27.3% of them used corticosteroids (33.3% in high doses), and 7.8% on immunobiologicals. No statistical differences were found between positive (n = 17) and negative serology (n = 60) patients regarding demographic/socioeconomic data, contact with people with confirmed COVID-19, use and number of immunosuppressive drugs, use and dose of corticosteroids, use of hydroxychloroquine and immunobiological drugs (p > 0.05). Conclusions: Pediatric rheumatic disease patients were infected at the same rate as healthy ones. Neither the underlying pathology nor its immunosuppressive treatment seemed to interfere with contagion risk.

Resumo Introdução Um dos principais problemas no lúpus eritematoso sistêmico juvenil (LESJ) é a infecção, como a tuberculose (TB). É importante observar que pacientes com LES são suscetíveis à tuberculose pulmonar e extrapulmonar. No entanto, de acordo com o que se sabe, essa doença contagiosa é raramente relatada na população pediátrica com lúpus, particularmente a TB difusa ou miliar. De janeiro de 1983 a dezembro de 2011, 5.635 pacientes foram acompanhados na Unidade de Reumatologia Pediátrica; 285 deles (5%) preencheram os critérios de classificação para LES do American College of Rheumatology. Relatos de caso Quatro (1,4%) de nossos pacientes com LESJ tinham tuberculose disseminada e foram descritos neste estudo. Todos eram do sexo feminino, receberam a vacina BCG e não tinham história de contato domiciliar com a TB. A mediana da idade no momento do diagnóstico da TB e o período entre os diagnósticos de LES e tuberculose foram de 17 anos (variação de 14 a 20) e 5,5 anos (variação de dois a sete), respectivamente. Todas as pacientes desenvolveram tuberculose miliar durante o curso da doença. A mediana no SLE Disease Activity Index 2000 (SLEDAI-2K) foi de 4 (2 a 16) e as pacientes foram tratadas com agentes imunossupressores (glicocorticoides, azatioprina e/ou ciclofosfamida intravenosa). Duas delas apresentaram sepse e o diagnóstico de tuberculose só foi determinado na necropsia, com envolvimento especialmente dos pulmões, do sistema nervoso central e do abdome. A terapia antituberculose (isoniazida, rifampicina e pirazinamida) foi indicada nos outros dois casos de TB; porém, as pacientes foram a óbito. Discussão A TB miliar é uma infecção oportunista rara e grave na população pediátrica com lúpus. Este estudo reforça a importância de pesquisas de rotina para TB em pacientes com LESJ.

Abstract Introduction 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. Case reports 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. Discussion 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.

A tuberculose ainda é um problema grave de saúde pública, principalmente em países emergentes, como o Brasil. O acometimento do sistema nervoso central (SNC) pelo Mycobacterium tuberculosis é uma das formas da doença mais temidas na infância, devido à morbi-mortalidade alta que costuma causar. Este estudo teve como objetivo descrever aspectos epidemiológicos, clínicos e laboratoriais de 52 crianças com tuberculose do SNC em um hospital pediátrico terciário. A maioria dos pacientes apresentou idade baixa, estado nutricional precário, contato prévio com doentes, vacinação ausente ou tardia, comprometimento neurológico avançado, alterações quimiocitológicas de líquor compatíveis, assim como os achados de exames de imagem. A recuperação do agente no líquor e outros líquidos corpóreos por pesquisa direta ou cultura ocorreu em 40% dos pacientes. Apesar do perfil clínico-epidemiológico-laboratorial sugestivo e da viabilidade de acesso do paciente a serviço médico, na maioria dos casos o diagnostico foi tardio.

Tuberculosis still occupies a remarkable place as a worldwide health problem, chiefly in emerging countries, like Brazil. The central nervous system (CNS) involvement by Mycobacterium tuberculosis is one of the most feared features of disease, because of its high morbidity and mortality. This study aimed to describe some epidemiological, clinical and laboratorial aspects of 52 children in a tertiary pediatric hospital with CNS tuberculosis. At diagnosis, the majority of patients showed low age, compromised nutritional status, previous contact with bacillary individuals, delayed or absent immunization, advanced neurological signs and compatible abnormalities in cerebrospinal fluid (CSF) analysis and in radiological findings. The etiologic agent was identified by staining methods or CSF and other fluids culturing in 40% of patients. In most cases, despite of suggestive clinical, epidemiological and laboratorial picture and feasibility of patients access to health care centres, therapy was started lately.

Sequelas neurológicas não são raras após o tratamento da tuberculose do sistema nervoso central (SNC), que é longo, trabalhoso e sujeito a complicações. Vários fatores são implicados como determinantes de prognóstico. O objetivo deste estudo foi analisar o tratamento e a evolução de 52 crianças com tuberculose do SNC de um hospital pediátrico terciário. A maioria dos pacientes (41 ou 78,8%) utilizou corticosteróides associados ao esquema tríplice. A ocorrência de hidrocefalia foi comum (28 de 41 testados), porém apenas 8 (15,4%) necessitaram de derivação liquórica. Hiponatremia ocorreu em um terço dos casos testados. Hepatotoxicidade ao esquema tríplice aconteceu em 32 casos (61,5%), porém apenas 3 (9,4%) necessitaram de substituição destas drogas. Ocorreram 8 (15,4%) óbitos e 24 (46,1%) casos desenvolveram sequelas ao fim do tratamento. Houve tendência de pior prognóstico entre os pacientes que não usaram corticosteróides e os que apresentavam doença avançada ao diagnóstico.

Neurologic damage is usual after central nervous system (CSN) tuberculosis recovery. Treatment is long, difficult and prone to complications. Many factors are enrolled as prognostic determinants. This study aimed to describe the treatment and outcome of 52 children with CNS tuberculosis of a tertiary pediatric hospital. All of them received standard triple drug regimen, and 41 (78.8%) received corticosteroids as adjunctive therapy. Hydrocephalus was common (28 of 41 tested), but only 8 (15.4%) patients underwent ventricular shunt surgery. Hepatotoxicity to anti tuberculosis drugs occurred in 32 (61.5%) cases, but in only 3 (9.4%) drug substitution was necessary. There were 8 (15.4%) deaths and 24 (46.1%) cases developed neurologic damage after therapy. Patients who did not receive steroids during treatment and those with advanced neurological involvement at diagnosis showed a tendency to worse prognosis.

A poliomielite associada à vacina oral é definida como a forma paralítica da poliomielite anterior aguda decorrente da cepa vacinal. Uma vez que o comportamento da cepa vacinal é semelhante ao do vírus selvagem, epidemiologicamente podemos distinguir dois tipos de poliomielite associada à vacina, os casos em que o paciente foi vacinado e os casos em que o paciente teve contato com pessoas que receberam a vacina. Apresentamos o caso de um lactente não vacinado, que apresentou quadro de poliomielite anterior aguda associada à vacina oral, cujo irmão havia recebido a vacina Sabin 20 dias antes do início do quadro clínico. Na cultura de fezes do paciente foi isolado o poliovírus tipo 3, cepa vacinal, que apresentava mutação do nucleotídeo 472 (C<FONT FACE="Symbol">®</font>U) na região 5' não codificadora, a qual está significativamente relacionada com a maior virulência da cepa.

Poliomyelitis associated with live strain vaccine is defined as the paralytic form of the acute anterior poliomyelitis related to the vaccine strain. Since these strains behave similarly to the wild-type virus, we can differentiate, epidemiologically, two types of vaccine-associated poliomyelitis: cases in which the patient was vaccinated and cases in which the patient had had contact with vaccinated individuals. We herein present the case of an unvaccinated child, with a clinical picture of an acute anterior poliomyelitis associated with the live strain vaccine, whose brother received the Sabin vaccine 20 days before the onset of the symptoms. Vaccine strain of the type 3 poliovirus was isolated in fecal culture and a presented mutation in nucleotide 472 (C<FONT FACE="Symbol">®</font>U) in the 5' non-coding region, which is strongly related to the higher strain virulence.