[Show abstract][Hide abstract] ABSTRACT: Background There are case reports of severe disseminated varicella-zoster virus (VZV) infections in patients on methotrexate (MTX) or anti-TNF therapy. The severity of these infections can be significantly reduced in those vaccinated
Objectives The aims of this study were: to evaluate the safety and immunogenicity of a two dose protocol of varicella vaccine (VV) in susceptible patients with Juvenile Rheumatic Diseases (JRD) on MTX or anti-TNF therapy and to describe the vaccination efficacy over an observational 5-year follow-up period
Methods Fifty patients with JRD (1-18 years) and no history of varicella were vaccinated with VV, 32 of them received two doses. IgG anti-VZV antibody (VZV-IgG) titers were measured by ELISA before, 4-6 weeks after each dose of VV, one and five years thereafter. Patients were monitored prospectively during 8 weeks for adverse events related to the vaccine and over a 5-year observational period for exposure to or occurrence of varicella
Results All 50 patients were using MTX (mean dose 16 mg/m2/week, range 10 to 27); 23 were also receiving prednisone (range 5-20mg/day) and 5 were on anti-TNF therapy. Seroconversion rates were 50% after one dose of VV1 and 87% (28/32) for patients who received two doses (p<0,01). All 4/32 who did not reach protective titers after two VV doses were taking anti-TNF therapy (3/4 have systemic JIA). The vaccination neither induced overt varicella episodes or severe adverse events, nor underlying disease flare-ups after one or two doses. Twenty patients that received one dose of VV1 completed the five-year period of follow-up. Eleven of them were seronegative after one year: 2/11 developed varicella, six received a VV booster and all became seropositive. Only the 3/20 that refused the booster remained susceptible in the evaluation after 5 years. Among the 28 seroconverted patients that received two doses of VV, only 55% maintained protective VZV-IgG titers after one year, however none of them developed herpes zoster or chickenpox during the follow-up period of 1-3 years, including those with direct exposure to the wild virus in their environmental
Conclusions VV should be recommended for seronegative patients for whom immunosuppressive or biological therapy is planned and a protocol with 2 doses of VV should be considered to reach protective titers. If patients are on anti-TNF alpha therapy, additional boosters may be necessary.
Disclosure of Interest None Declared
Annals of the Rheumatic Diseases 01/2014; 71(Suppl 3):430-430. DOI:10.1136/annrheumdis-2012-eular.2800 · 10.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background In Brazil, there was a National immunization campaign against measles in 2011, using measles, mumps and rubella (MMR) vaccine in children aged 1-7 years.
Objectives The aim of this study was to document whether MMR vaccination aggravated the course of underlying disease in children with rheumatic diseases (RD) or presented risks in these patients when taking immunosuppressive drugs.
Methods In order to accomplish this, a prospective observational study was performed. All 68 patients in this age groupwho had confirmed diagnosis of a juvenile rheumatic diseaseand have been following at two pediatric rheumatology outpatient clinics in Brazil were eligible. They were invited by phone call or during their regular visits to participate in this study. Signed informed consents were obtained from their parents. The first interview was done 2 weeks post vaccination and subsequently the patients were seen monthlyfor 3 monthsin order to access the occurrence of flare-ups or aggravation of disease activity after vaccination and side effects such as clinically overt measles.
Results Twenty-eight/68 (41%) patients vaccinated with MMR were selected (for two of them the vaccine was their first dose and for 26 it was a booster). Twenty of them were male and the mean age was 4.5 years; 22 had Juvenile Idiopathic Arthritis (JIA), 4 with juvenile dermatomyositis and 2 scleroderma. At the time of vaccination 21/28 met no active disease criteria and 9/21 were in remission without medication. Regardless of disease activity, 19 patients were on medication, all of them using methotrexate (MTX); 5 were also receiving prednisone, and 2 were on anti-TNF agents too.
During the follow-up period of 3 months only one patient with active systemic JIA, for whom the MMR vaccine was the first dose, reported worsening of fever and skin rash 20 days after vaccination; and no worsening of clinical parameters, flare-ups or changes in doses of medications was observed in the patients for whom the MMR was a booster.No overt measles infections and no severe adverse reactions were observed, despite the fact that the patients were receiving immunosuppressive medication or biological agents.
Conclusions Conclusions: Most patients with RD can be vaccinated safely with MMR boosters. However, should be considered postponing the vaccination in patients with active disease, especially when the vaccine is the first dose.
Disclosure of Interest None Declared
Annals of the Rheumatic Diseases 01/2014; 71(Suppl 3):260-260. DOI:10.1136/annrheumdis-2012-eular.2274 · 10.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
To elaborate recommendations to the vaccination of patients with rheumatoid arthritis (RA) in Brazil.
Literature review and opinion of expert members of the Brazilian Society of Rheumatology Committee of Rheumatoid Arthritis and of an invited pediatric rheumatologist.
Results and conclusions:
The following 12 recommendations were established: 1) Before starting disease-modifying anti-rheumatic drugs, the vaccine card should be reviewed and updated; 2) Vaccines against seasonal influenza and against H1N1 are indicated annually for patients with RA; 3) The pneumococcal vaccine should be indicated for all patients with RA; 4) The vaccine against varicella should be indicated for patients with RA and a negative or dubious history for that disease; 5) The HPV vaccine should be considered for adolescent and young females with RA; 6) The meningococcal vaccine is indicated for patients with RA only in the presence of asplenia or complement deficiency; 7) Asplenic adults with RA should be immunized against Haemophilus influenzae type B; 8) An additional BCG vaccine is not indicated for patients diagnosed with RA; 9) Hepatitis B vaccine is indicated for patients with RA who are negative for antibodies against HBsAg; the combined hepatitis A and B vaccine should be considered; 10) Patients with RA and at high risk for tetanus, who received rituximab in the preceding 24 weeks, should undergo passive immunization with tetanus immunoglobulin in case of exposure; 11) The YF vaccine is contraindicated to patients with RA on immunosuppressive drugs; 12) The above described recommendations should be reviewed over the course of RA.
Revista Brasileira de Reumatologia 02/2013; 53(1):13-23. DOI:10.1590/S0482-50042013000100002 · 1.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To analyze available evidence on vaccinations in paediatric patients with rheumatic and autoinflammatory diseases. This evidence formed the basis of the recently constructed European League against Rheumatism (EULAR) recommendations for vaccination of these patients.
A systematic literature review in the MEDLINE and EMBASE databases was conducted using various terms for vaccinations, paediatric rheumatic and autoinflammatory diseases and immunosuppressive drugs. Only papers on paediatric patients (<18 years of age) were selected. A panel of 13 experts in the field graded methodological quality and extracted data using predefined criteria.
27 papers were available. No studies were found on autoinflammatory diseases. 14 studies considered live-attenuated vaccines. Evidence so far supports the safety and immunogenicity of non-live composite vaccines, although studies were underpowered to accurately assess safety. Live-attenuated vaccines did not cause disease flares or severe adverse events, not even in patients on methotrexate and low dose glucocorticosteroids. Seven patients on anti-TNFalpha therapy were described receiving the live-attenuated measles, mumps, rubella (n=5) or varicella (n=2) booster without severe adverse events.
Data on safety and efficacy of vaccinations in paediatric patients with rheumatic diseases is reassuring, but too limited to draw definite conclusions. More research is needed on the safety and efficacy of especially live-attenuated vaccines in patients with rheumatic and autoinflammatory diseases using high dose immunosuppressive drugs.
[Show abstract][Hide abstract] ABSTRACT: Evidence-based recommendations for vaccination of paediatric patients with rheumatic diseases (PaedRD) were developed by following the EULAR standardised procedures for guideline development. The EULAR task force consisted of (paediatric) rheumatologists/immunologists, one expert in vaccine evaluation, one expert in public health and infectious disease control, and one epidemiologist. A systematic literature review was conducted in MEDLINE, EMBASE, and abstracts of the EULAR and American College of Rheumatology meetings of 2008/9. The level of evidence and strength of recommendation were based on customary scoring systems. Delphi voting was applied to assess the level of agreement between task force members. 107 papers and eight abstracts were used. The majority of papers considered seasonal influenza (41) or pneumococcal (23) vaccination. 26 studies were performed specifically in paediatric patients, and the majority in adult rheumatoid arthritis and systemic lupus erythematosus patients. Fifteen recommendations were developed with an overall agreement of 91.7%. More research is needed on the safety and immunogenicity of (live-attenuated) vaccination in PaedRD, particularly in those using biologicals, and the effect of vaccination on prevention of infections.
Annals of the rheumatic diseases 08/2011; 70(10):1704-12. DOI:10.1136/ard.2011.150193 · 10.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evaluate clinical practice through assessment of vaccination card and recommendation of specific vaccines in pediatric patients with rheumatic diseases in use of different drugs and reveal the possible association between vaccination frequency and time of the clinical practice of pediatric rheumatologists in the state of São Paulo.
A questionnaire was sent to pediatric rheumatologists of the Departamento de Reumatologia da Sociedade de Pediatria de São Paulo. This instrument included questions about practice time on Pediatric Rheumatology, vaccination of patients with juvenile systemic lupus erythematosus (JSLE), juvenile idiopathic arthritis (JIA), juvenile dermatomyositis (JDM), and immunization according to the treatments used.
Vaccination card was seen by 100% of the professionals at the first visit and by 36% annually. Vaccines of live agents were not recommended for patients with JSLE, JIA, and JDM in 44%, 64%, and 48%, respectively. The professionals were divided into two groups: Group A (≤ 15 years of practice, n = 12) and B (≥ 16 years, n = 13). No statistical difference was observed in the use of live agent vaccine and vaccines with inactivated agents or protein components in the two treatment groups (P > 0.05). Moreover, the groups had similar opinion regarding severity of immunosuppression in patients with JSLE, JIA, and JDM (with or without activity) and treatment used (P > 0.05).
The frequency of immunization by pediatric rheumatologists in São Paulo is low, especially after the first visit, and not influenced by time of professional practice.
Revista Brasileira de Reumatologia 08/2010; 50(4):351-61. DOI:10.1590/S0482-50042010000400002 · 1.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the safety and immunogenicity of varicella vaccine (VV) in susceptible patients with juvenile rheumatic diseases receiving methotrexate and corticosteroids.
Twenty-five patients with juvenile rheumatic diseases (ages 2-19 years) and 18 healthy children and adolescents (ages 3-18 years) received a single dose of VV. All 25 patients were receiving methotrexate; 13 were also receiving prednisone and 5 were also receiving other disease-modifying antirheumatic drugs. None of the vaccinated patients or controls had a previous history of varicella. Anti-varicella-zoster virus IgG antibody (anti-VZV-IgG) titers were measured by enzyme-linked immunosorbent assay immediately before, 4-6 weeks after, and 1 year after vaccination. The patients were monitored prospectively for adverse reactions related to the vaccine, exposure, and occurrence of varicella. Disease activity was assessed 3 months before and 3 months after VV.
Twenty patients and all of the controls had negative preimmunization titers of VZV-IgG, and 5 patients had equivocal levels. Positive VZV-IgG titers were detected in 10 (50%) of 20 seronegative patients and 13 (72.2%) of 18 controls 4-6 weeks after VV (P = 0.2). One year after vaccination, 8 of 10 patients maintained positive VZV-IgG titers. No overt varicella episodes and no severe adverse reactions were observed during the followup period. No worsening of clinical parameters and no flares of juvenile rheumatic diseases or changes in doses of medications used were detected after vaccination. In fact, the number of active joints in patients with juvenile idiopathic arthritis was significantly lower after VV (P = 0.009).
VV appears to be safe in patients with juvenile rheumatic diseases receiving methotrexate, as long as continuous prospective vigilance for side effects is performed.
[Show abstract][Hide abstract] ABSTRACT: To assess the effect of measles, mumps and rubella (MMR) vaccination on disease activity in children with juvenile idiopathic arthritis (JIA).
A retrospective observational multicentre cohort study was performed in 314 patients with JIA, born between 1989 and 1996. Disease activity and medication use were compared during the period of 6 months before vaccination versus 6 months after vaccination. Disease activity was measured by joint counts, the Physician's global assessment scale and erythrocyte sedimentation rate. Next, we compared disease activity in patients vaccinated between 8 and 9 years of age with the activity in patients who had not been vaccinated at this time (who received MMR between the ages of 9 and 10 years).
No increase in disease activity or medication use was seen in the 6 months after MMR vaccination (n = 207), including in patients using methotrexate (n = 49). No overt measles infections were noted. When disease activity in vaccinated patients (n = 108) was compared with activity in those not yet vaccinated (n = 86), there were no significant differences.
The MMR booster vaccination does not seem to aggravate disease activity in JIA. This indicates that the most patients with JIA can be vaccinated safely with the MMR vaccine. A prospective study is recommended.
Annals of the Rheumatic Diseases 11/2007; 66(10):1384-7. DOI:10.1136/ard.2006.063586 · 10.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe a patient who had polyarteritis nodosa with central nervous system involvement mimicking infectious meningoencephalitis.
Pediatric intensive care unit of a university hospital. Patient: A 9-yr-old boy with prolonged fever, headache, decreased level of consciousness, neck stiffness, and papilledema.
Cerebrospinal fluid examination showed pleocytosis and a high protein level. After neurologic deterioration resulted from the initial treatment with antibiotic, the combination of clinical and laboratory findings with neuroradiologic features led to suspected systemic vasculitis. The patient was treated subsequently with corticosteroid, which resulted in great improvement. Biopsy of a skin lesion confirmed the diagnosis of polyarteritis nodosa.
Critical care physicians must recognize neurologic manifestation patterns of systemic vasculitides because appropriate diagnosis and therapy result in significantly improved morbidity and mortality.
Pediatric Critical Care Medicine 06/2004; 5(3):286-8. DOI:10.1097/01.PCC.0000124020.21574.2B · 2.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: The aim of this study was to describe the clinical manifestations and to assess the occurrence of atypical arthritis in ARF patients attending a Pediatric Rheumatology Clinic at the University Hospital of Ribeirão Preto. METHODS: We have studied retrospectively the records of 120 attacks of ARF in 109 children, 3-13 years old, who attended our clinic from January 1990 to December 1995. All children fulfilled the Jones criteria. RESULTS: 77% of the attacks involved arthritis, 62% carditis, 32% chorea, 2.5% subcutaneous nodules and 1.3% erythema marginatum. The number of involved joints was 1 in 3 episodes of ARF, 2-5 in 52, 6-10 in 30 and more than 10 in 5. Arthritis was considered atypical in 43 (47%) of the 92 ARF episodes with arthritis, based on the following criteria: involvement of unusual joints (cervical spine in 24 children, hip in 15, small joints of the hand in 12 or feet in 13); monarthritis (3); duration longer than 3 weeks (26); incomplete response to salicylates (18). Association of these atypical features were frequently present. For instance, considering the 24 episodes with cervical spine involvement, the duration of arthritis was longer than 3 weeks in 13 cases, 10 had insufficient response to salicylates and the hip joint was also involved in 7. Time to reach diagnosis was longer than 4 weeks in 59% of the patients presenting with atypical arthritis compared to 35% in the other patients (p=0.04). Different diagnosis were considered at the beginning of the disease in 40% of the 120 episodes and in 65% of the ones presenting with atypical arthritis (p=0.03). CONCLUSION: We conclude that atypical arthritis was present in a significant proportion of ARF episodes, adding an extra dilemma to the diagnosis of this intriguing disease.
Jornal de pediatria 01/2000; 76(1):49-54. DOI:10.2223/JPED.33 · 1.19 Impact Factor