Tuberculosis Diagnosis and Prevention in Children on Biological Treatment: Clinical Challenges and Considerations.

Tuberculosis (TB) remains a major global health concern, especially for children with rheumatic diseases on biologic therapies. While these agents have improved disease management and quality of life, they also pose new challenges, mainly an increased risk of TB, particularly with tumor necrosis factor‑alpha (TNF‑α) inhibitors like infliximab, adalimumab, and etanercept. Since TNF‑α plays a crucial role in granuloma formation and controlling Mycobacterium TB, its inhibition can allow latent TB infection (LTBI) to develop into active disease. To reduce this risk, screening for LTBI before starting biologic therapy is highly recommended. However, accurately detecting LTBI in children-especially those who are immunosuppressed-remains challenging, as both the tuberculin skin test (TST) and interferon‑gamma release assays (IGRAs) have notable limitations in this context. Using both TST and IGRA together may improve case detection in selected pediatric populations. Preventive treatment for LTBI reduces the risk of developing active TB in patients receiving biologic therapies. Although non-anti-TNF therapies may offer a safer option in this regard, the evidence in pediatric patients is still limited. As the use of biologic and targeted therapies expands in children, further research is needed-especially on non-anti-TNF agents-to create internationally accepted guidelines and to optimize screening, diagnostics, and personalized prevention strategies.