Screen asthmatic kids before starting steroids
June 1, 2000 2 minutes read
Screen asthmatic kids before starting steroids
Recommendation applies even to inhalers
Despite a recent study that suggests otherwise,1 children about to start a course of corticosteroids — whether oral or systemic — should be screened routinely for TB infection, says pediatric TB expert Jeff Starke, associate professor of clinical pediatrics at Baylor University College of Medicine and chief of Pediatrics at Ben Taub Hospital, both in Houston.
In the study, researchers in Turkey followed 32 children who were tuberculin skin-test positive and who used inhaled budesonide for nine months. At the end of nine months, none of the children showed signs of having progressed to active disease, the report shows.
"Good for them," says Starke. "But if you’re asking me whether I’ve seen kids who’ve developed TB disease within months of having been started on corticosteroids, the answer is definitely yes."
The degree of risk varies according to whether the steroids are inhaled, as in the study, or systemic and whether they’re used on a short-term or long-term basis. Systemic and long-term use both equal greater risk; even so, it’s good policy to screen, even for short-term topical use, Starke says. "Whether the screening should consist of a skin test or just an oral history is an open question."
With pediatric asthma patients, there’s an especially compelling rationale for TB screening, says Starke. "If someone develops TB while you’re treating their asthma, it can be very tricky and confusing," he says. "That’s especially true in pediatrics, since children don’t produce sputum, and they don’t have [detectable] organisms. So there’s the danger of misdiagnosing the condition as bacterial pneumonia or a syndrome associated with asthma."
The same need for screening goes for patients in oncology and rheumatology as well. "Just this morning I saw a family where the mom had developed TB because she’d been started on corticosteroids for rheumatologic disease," Starke says. "Now all three of her kids are TB-infected."
Certainly, when long-term systemic corticosteroids are given, TB screening is an absolute must, he stresses. "I suspect only a small minority of children who get started on long-term steroids get TB testing as part of their evaluation. But it should be automatic. It should happen every time."
Reference
1. Bahceciler NN, Nuho Y, Guven A, et al. Inhaled corticosteroid therapy is safe in tuberculin-positive asthmatic children. Ped Infect Dis J 2000; 19:490.
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