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PReS-FINAL-2103: Real life management of VZV infection or reactivation in rheumatic children on biologics: the French experience
© Guillaume-Czitrom et al.; licensee BioMed Central Ltd. 2013
Published: 5 December 2013
Treatments of severe rheumatic conditions in children are increasingly based on biologics. The most common adverse events on all kind of biologics are mild infections in ENT, pulmonary and urinary systems. The number of cases of varicella-zoster-virus (VZV) manifestations while being on biologics is constantly growing. No consensus exists about what to do when facing this situation yet.
The aim of this work is to describe the French experience of VZV infection/reactivation management in children affected with chronic inflammatory rheumatisms and treated with available biologics in a real life setting.
French pediatric rheumatologists were asked through the web site of the Société Francophone des rhumatismes et maladies inflammatoires de l'enfant -SOFREMIP- by phone and/or e-mail to report their cases of VZV manifestations on biologics using a standardized and anonymized e-CRF.
21 cases of VZV infection/reactivation were reported in children less than 18 yrs, followed for rheumatic conditions treated with biotherapies. 19 had JIAs of which 9 had systemic JIAs, 1 had SLE, 1 had polyarthritis with immune deficiency. Biologics-associated treatments were NSAIDs in 5 cases, steroids in 9 cases, DMARDs in 14 (MTX in 12, MMF and HCQ in 1, AZA in 1). Biologics were anti-TNFs in 13 children (9 ETN, 4 ADA), anti-IL1 in 6 (4 CNK, 2 ANK), 1 had TCZ, and 1 RTX. A long delay was observed between the initiation of biologics and the VZV manifestations in the majority of patients, whatever the biologic. None of our cases was vaccinated against VZV. 12 children had varicella (7 with concurrent anti-TNF treatment, 4 with anti-IL1, 1 with RTX) and 9 patients had herpes zoster (6 with anti-TNFs, 2 with anti-IL1, 1 with TCZ). 2 patients had a complicated clinical picture of VZV infection/reactivation: 1 had an ophthalmic zoster and 1 had a systemic dissemination of VZV with severe hepatic involvement and pancytopenia. NSAIDs were stopped 4 times out of 5 continuous treatment, steroids were stopped in 1/9 patients, DMARDs were interrupted in 8/14, and biologics in 15/21 cases. 16/21 patients received a specific anti-herpetic drug despite a common non-complicated outcome, whereas 5 children were not treated in the same situation (3 on anti-TNFs, 2 on anti-IL1). All patients had favorable outcomes.
This study shows an overrepresentation of systemic JIAs among patients infected by or reactivating the VZV. This group of patients may be more immunosuppressed than others. In spite of the great heterogeneity of VZV management in France in children treated with biologics, the outcome was invariably good. This suggests 2 important points (i) VZV control may not need any of the cytokines/pathways targeted by the biologics we use, (ii) VZV management on biologics should be rationalized.
Disclosure of interest
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.