Psoriasis'te biyolojik tedavi öncesi latent tüberküloz enfeksiyonunun değerlendirilmesi: web tabanlı yorumlayıcı ile yeni bir tanı yaklaşımı

Yıl 2024, Cilt: 17 Sayı: 1, 131 - 141, 01.01.2024

Zuhal Metin , Kemal Özyurt , Mustafa Atasoy , Efşan Gürbüz Yontar , Ragıp Ertaş , Ozkan Gorgulu

https://doi.org/10.31362/patd.1393540

Öz

Amaç: Biyolojik ajanların, özellikle de anti-TNF-alfa tedavilerinin kullanımı artmış tüberküloz (TB) riski ile ilişkilidir. Bu nedenle, biyolojik tedavilerden önce latent tüberküloz enfeksiyonunun (LTBI) kapsamlı bir şekilde değerlendirilmesi gereklidir. Bu çalışmanın amacı, psöriazis hastalarında biyolojik tedavilere başlamadan önce LTBI riskini değerlendirmek için web tabanlı bir uygulama olan tüberkülin deri testi (TST) /interferon-γ salınım testi (IGRA) (OI-TST/IGRA) yorumlayıcısının faydasını değerlendirmektir.
Gereç ve yöntem: Biyolojik bir ajanla tedavi edilmeden önce göğüs hastalıkları uzmanı tarafından TB açısından değerlendirilen 116 psoriasis hastası retrospektif olarak OI-TST/IGRA (tstin3d.com) ile yeniden değerlendirildi. OI-TST/IGRA ile ortalama pozitif prediktif değer (PPV), ortalama yıllık aktif tüberküloz gelişme riski (ARDATB) ve ortalama kümülatif aktif tüberküloz riski (CRATB) değerleri hesaplandı ve önceki sonuçlarla karşılaştırıldı. Grup karşılaştırmaları Kruskal-Wallis ve Mann- Whitney U testleri kullanılarak yapılmıştır.
Bulgular: LTBI-pozitif grubun PPV'si, LTBI-negatif gruptan anlamlı olarak daha yüksekti. TST boyutu >15 mm olan grubun PPV ve ARDATB değerleri, TST boyutu 5-9 mm ve TST boyutu 10-15 mm olan gruplardan anlamlı olarak daha yüksekti. QuantiFERON-TB Gold In-tube test (QFT-GIT) pozitif grubun PPV, ARDATB ve CRATB değerleri QFT-GIT negatif gruptan anlamlı derecede yüksekti. Akciğer grafisi (CXR) pozitif grubun aynı değerleri CXR negatif gruptan anlamlı derecede yüksekti.
PPV, ARDATB ve CRATB değerleri TST, QFT-GIT ve CXR sonuçları ile pozitif korelasyon göstermiştir. Ayrıca, PPV önceki LTBI kararları ile pozitif korelasyon göstermiştir.
Sonuç: Birçok faktörün sorgulandığı ve PPV, ARDATB ve CRATB değerlerinin birlikte değerlendirildiği OI-TST/ IGRA, psoriasis hastalarında TB riskinin değerlendirilmesinde, yanlış tanı ve gereksiz profilaksinin önlenmesinde değerli bir araç olabilir.

Anahtar Kelimeler

Latent tuberculosis infection, psoriasis, biologic therapy

Etik Beyan

Çalışma Kayseri Eğitim ve Araştırma Hastanesi Etik Kurulu tarafından onaylanmıştır. (Tarih: 20.03.2019/ No: 2019/219)

Assessing latent tuberculosis infection prior to biologic therapy in psoriasis: a new diagnostic approach with an online interpreter

Öz

Purpose: The use of biological agents, particularly anti-TNF-alpha treatments, is associated with an elevated risk of tuberculosis (TB). Hence, a comprehensive assessment of latent tuberculosis infection (LTBI) before biologic therapies is imperative. The objective of this study was to evaluate the utility of an online tuberculin skin
test (TST)/ interferon-γ release assay (IGRA) interpreter (OI-TST/IGRA) in assessing the risk of LTBI prior to initiating biological therapies in psoriasis patients.
Materials and methods: 116 psoriasis patients who were previously evaluated for TB by a pulmonologist before being treated with a biologic agent were re-evaluated retrospectively with OI-TST/IGRA (tstin3d.com). Mean positive predictive value (PPV), mean annual risk of development of active tuberculosis (ARDATB), and mean cumulative risk of active tuberculosis (CRATB) values were calculated with OI-TST/IGRA and compared with previous results. Group comparisons were performed using Kruskal-Wallis and Mann-Whitney U tests.
Results: The PPV of the LTBI-positive group was significantly higher than the LTBI-negative group. The PPV and ARDATB values of the TST size of >15 mm group were significantly higher than the TST size of 5-9 mm and TST size of 10-15 mm groups. The PPV, ARDATB, and CRATB values of the QuantiFERON-TB Gold Intube test (QFT-GIT)-positive group were significantly higher than the QFT-GIT-negative group. And the same values of the chest X-ray (CXR)-positive group were significantly higher than the CXR-negative group. The PPV, ARDATB, and CRATB values were positively correlated with TST, QFT-GIT and CXR results. In addition, the PPV was positively correlated with previous LTBI decisions.
Conclusion: OI-TST/IGRA in which many factors are questioned and PPV, ARDATB, and CRATB values are evaluated together, may be a valuable tool for assessing the risk of active TB in psoriasis patients and preventing overdiagnosis and unnecessary prophylaxis.

Anahtar Kelimeler

Latent tuberculosis infection, psoriasis, biologic therapy

Etik Beyan

The study was approved by Ethics Committee of Kayseri City Education and Research Hospital (Date: 20.03.2019/ Number: 2019/219).

Kaynakça

• 1. Lande R, Botti E, Jandus C, et al. The antimicrobial peptide LL37 is a T-cell autoantigen in psoriasis. Nat Commun 2014;5:5621. https://doi.org/10.1038/ncomms6621
• 2. Raychaudhury SP. Recent advances in psoriasis: bench to bedside. Indian J Dermatol 2010;55:150. https://doi.org/10.4103/0019-5154.62749
• 3. Md Ms Duffin KC. Identifying and managing complications and comorbidities in patients with psoriasis. Semin Cutan Med Surg 2015;34:30-33. https://doi.org/10.12788/j.sder.2015.0135
• 4. Cataño J, Morales M. Isoniazid toxicity and TB development during biological therapy of patients with psoriasis in Colombia. J Dermatol Treat 2016;27:414-417. https://doi.org/10.3109/09546634.2016.1151857
• 5. Dilrukshi MDSA, Ratnayake CAP, Gnanathasan CA. Oral pyridoxine can substitute for intravenous pyridoxine in managing patients with severe poisoning with isoniazid and rifampicin fixed dose combination tablets: a case report. BMC Res Notes 2017;10:370. https://doi.org/10.1186/s13104-017-2678-6
• 6. Atikan BY, Cavusoglu C, Dortkardesler M, Sozeri B. Assessment of tuberculosis infection during treatment with biologic agents in a BCG-vaccinated pediatric population. Clin Rheumatol 2016;35:427-431. https://doi.org/10.1007/s10067-014-2842-5
• 7. Sellami M, Fazaa A, Cheikh M, et al. Screening for latent tuberculosis infection prior to biologic therapy in patients with chronic immune-mediated inflammatory diseases (IMID): Interferon-gamma release assay (IGRA) versus tuberculin skin test (TST). Egypt Rheumatol 2019;41:225-230. https://doi.org/10.1016/j.ejr.2018.11.003
• 8. Menzies D, Gardiner G, Farhat M, Greenaway C, Pai M. Thinking in three dimensions: a web-based algorithm to aid the interpretation of tuberculin skin test results. Int J Tuberc Lung Dis 2008;12:498-505.
• 9. Sürücüoğlu S, Türel Ermertcan A, Çetinarslan T, Özkütük N. The reliability of tuberculin skin test in the diagnosis of latent tuberculosis infection in psoriasis patients: a case‐control study. Dermatol Ther 2020;33:e13496. https://doi.org/10.1111/dth.13496
• 10. Zhou G, Luo Q, Luo S, et al. Interferon-γ release assays or tuberculin skin test for detection and management of latent tuberculosis infection: a systematic review and meta-analysis. Lancet Infect Dis 2020;20:1457-1469. https://doi.org/10.1016/S1473-3099(20)30276-0
• 11. The Online TST/IGRA Interpreter. https://www.tstin3d.com/en/calc.html. Accessed 12 May 2023
• 12. Scolarici M, Dekitani K, Chen L, Sokol Anderson M, Hoft DF, Chatterjee S. A scoring strategy for progression risk and rates of treatment completion in subjects with latent tuberculosis. PLoS One 2018;13:e0207582. https://doi.org/10.1371/journal.pone.0207582
• 13. Özyurt K, Avcı A, Ertaş R, et al. PSORTAKSIS: a new psoriasis patient registry system used in dermatology clinic of Kayseri health training and research center. Turk J Dermatol 2018;12:23-27. https://doi.org/10.4274/tdd.3418
• 14. Alper S, Atakan N, Gürer MA, Onsun N, Özarmağan G. Updated turkish guidelines for the management of psoriasis with biologic agents. Turkderm-Turk Arch Dermatol Venereol 2010;44:105-112.
• 15. Cohen JR, Swerdlik ME, Phillips SM. Psychological testing and assessment. 3th ed. London: Mayfield, 1996.
• 16. Cohen J. A coefficient of agreement for nominal scales. Educational and Psychological Measurement 1960;20:37-46. https://doi.org/10.1177/001316446002000104
• 17. Bassukas ID, Gaitanis G, Constantopoulos SH. Diagnosis of tuberculosis in patients with psoriasis: the need for a modified approach. Eur Respir J 2011;38:231-232. https://doi.org/10.1183/09031936.00016611
• 18. Lee EB, Amin M, Man J, Egeberg A, Wu JJ. Rates of latent tuberculosis infection in patients treated with TNF inhibitors for psoriasis: a retrospective chart review. J Dermatol Treat 2018;29:671-675. https://doi.org/10.1080/09546634.2018.1443198
• 19. Nast A, Smith C, Spuls PI, et al. EuroGuiDerm Guideline on the systemic treatment of Psoriasis vulgaris – Part 1: treatment and monitoring recommendations. J Eur Acad Dermatol Venereol 2020;34:2461-2498. https://doi.org/10.1111/jdv.16915
• 20. Menter A, Strober BE, Kaplan DH, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol 2019;80:1029-1072. https://doi.org/10.1016/j.jaad.2018.11.057
• 21. Elewski BE, Baddley JW, Deodhar AA, et al. Association of secukinumab treatment with tuberculosis reactivation in patients with psoriasis, psoriatic arthritis, or ankylosing spondylitis. JAMA Dermatol 2021;157:43-51. https://doi.org/10.1001/jamadermatol.2020.3257
• 22. Cho SI, Kang S, Kim YE, Lee JY, Jo SJ. Ustekinumab does not increase tuberculosis risk: results from a national database in South Korea. J Am Acad Dermatol 2020;82:1243-1245. https://doi.org/10.1016/j.jaad.2019.12.033
• 23. Rangaka MX, Wilkinson KA, Glynn JR, et al. Predictive value of interferon-γ release assays for incident active tuberculosis: a systematic review and meta-analysis. Lancet Infect Dis 2012;12:45-55. https://doi.org/10.1016/S1473-3099(11)70210-9
• 24. Pai M, Denkinger CM, Kik SV, et al. Gamma ınterferon release assays for detection of mycobacterium tuberculosis infection. Clin Microbiol Rev 2014;27:3-20. https://doi.org/10.1128/CMR.00034-13
• 25. Laffitte E, Janssens JP, Roux Lombard P, et al. Tuberculosis screening in patients with psoriasis before antitumour necrosis factor therapy: comparison of an interferon-gamma release assay vs. tuberculin skin test. Br J Dermatol 2009;161:797-800. https://doi.org/10.1111/j.1365-2133.2009.09331.x
• 26. Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res 2012;64:625-639. https://doi.org/10.1002/acr.21641
• 27. Huaman MA, Sterling TR. Treatment of latent tuberculosis ınfection—an update. Clin Chest Med 2019;40:839-848. https://doi.org/10.1016/j.ccm.2019.07.008
• 28. Puyat JH, Shulha HP, Balshaw R, et al. How well does TSTin3D predict risk of active tuberculosis in the canadian ımmigrant population? An external validation study. Clin Infect Dis 2021;73:3486-3495. https://doi.org/10.1093/cid/ciaa780
• 29. Megna M, Ferrillo M, Ruggiero A, Cinelli E, Gallo L, Fabbrocini G. QuantiFERON TB‐gold conversion rate among psoriasis patients under biologics: a 9‐year retrospective study. Int J Dermatol 2021;60:352-357. https://doi.org/10.1111/ijd.15217
• 30. Karataş Toğral A, Muştu Koryürek Ö, Şahin M, Bulut C, Yağci S, Ekşioğlu HM. Association of clinical properties and compatibility of the QuantiFERON-TB Gold In-Tube test with the tuberculin skin test in patients with psoriasis. Int J Dermatol 2016;55:629-633. https://doi.org/10.1111/ijd.12973
• 31. Akdogan N, Dogan S, Gulseren D, et al. Serial Quantiferon‐TB Gold test results in 279 patients with psoriasis receiving biologic therapy. Dermatol Ther 2021;34:e14699. https://doi.org/10.1111/dth.14699
• 32. Tsiouri G, Gaitanis G, Kiorpelidou D, et al. Tuberculin skin test overestimates tuberculosis hypersensitivity in adult patients with psoriasis. Dermatology 2009;219:119-125. https://doi.org/10.1159/000222431