Mythen in der Kinderrheumatologie – Stimmt es eigentlich, dass …? Eine Übersicht zu Infektionen

Zusammenfassung

Infektionen und Impfungen spielen in der Kinderrheumatologie in mehrfacher Hinsicht eine wichtige Rolle und sorgen sowohl bei Kinderärzten als auch bei Eltern regelmäßig für Verunsicherung. So wird gemeinhin davon ausgegangen, dass Patienten mit rheumatischen Erkrankungen, insbesondere unter antirheumatischer Medikation, eine erhöhte Anfälligkeit für Infektionen aufweisen. Daher kommt insbesondere Impfungen zur Prävention von Infektionen eine zentrale Rolle zu. Gleichzeitig würden die meisten Kinderrheumatologen aus Erfahrung wohl zustimmen, dass Infektionen oder Impfungen Schübe triggern können. Und dann kommt Infektionen nach der Hygienehypothese sogar möglicherweise eine präventive Funktion zu…? Einige der verbreiteten Annahmen werden im vorliegenden Artikel etwas genauer unter die Lupe genommen und auf ihre Evidenz hin überprüft.

Abstract

Infections and vaccinations play an important role in pediatric rheumatology in several ways and are a regular source of uncertainty for both pediatricians and parents. It is generally assumed that patients with rheumatic diseases, especially those taking anti-rheumatic medication, are more susceptible to infections. Vaccinations therefore play a key role in preventing infections. At the same time, most pediatric rheumatologists would agree from experience that infections or vaccinations can trigger flare-ups. And then, according to the hygiene hypothesis, infections may even have a preventive function… Some of the common assumptions are examined in more detail in this article and reviewed for evidence.

Schlüsselwörter

Infektionen - Impfungen - Kinderrheumatologie - rheumatische Erkrankungen

Keywords

infections - vaccinations - pediatric rheumatology - rheumatic diseases

Publikationsverlauf

Artikel online veröffentlicht:
04. Dezember 2025

• Literatur

• 1 Doran MF, Crowson CS, Pond GR. et al. Frequency of infection in patients with rheumatoid arthritis compared with controls: A population-based study. Arthritis Rheum 2002; 46: 2287-2293
• 2 Jung J-Y, Yoon D, Choi Y. et al. Associated clinical factors for serious infections in patients with systemic lupus erythematosus. Sci Rep 2019; 9 9704
• 3 Beukelman T, Xie F, Chen L. et al. Rates of hospitalized bacterial infection associated with juvenile idiopathic arthritis and its treatment. Arthritis Rheum 2012; 64: 2773-2780
• 4 Udaondo C, Núñez Cuadros E, Murias S. et al. Are infections in children with juvenile idiopathic arthritis more frequent than in healthy children? A prospective multicenter observational study. Front Pediatr 2022; 10: 917731
• 5 Salonen PH, Säilä H, Salonen JH. et al. Pneumonia in children with juvenile idiopathic arthritis in Finland 1999–2014: a nationwide retrospective register linkage study. Clin Exp Rheumatol 2018; 36: 502-507
• 6 Aeschlimann FA, Chong S-L, Lyons TW. Risk of Serious Infections Associated with Biologic Agents in Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analyses. J Pediatr 2019; 204: 162-171 e3
• 7 Becker I, Horneff G. Risk of Serious Infection in Juvenile Idiopathic Arthritis Patients Associated With Tumor Necrosis Factor Inhibitors and Disease Activity in the German Biologics in Pediatric Rheumatology Registry. Arthritis Care Res 2017; 69: 552-560
• 8 McLean-Tooke A, Aldridge C, Waugh S. et al. Methotrexate, rheumatoid arthritis and infection risk – what is the evidence?. Rheumatology 2009; 48: 867-871
• 9 Nimmrich S, Horneff G. Incidence of herpes zoster infections in juvenile idiopathic arthritis patients. Rheumatol Int 2015; 35: 465-470
• 10 Zhang N, Wilkinson S, Riaz M. et al. Does methotrexate increase the risk of varicella or herpes zoster infection in patients with rheumatoid arthritis? A systematic literature review. Clin Exp Rheumatol 2012; 30: 962-371
• 11 Wolfe F, Michaud K, Chakravarty EF. Rates and predictors of herpes zoster in patients with rheumatoid arthritis and non-inflammatory musculoskeletal disorders. Rheumatol Oxf Engl 2006; 45: 1370-1375
• 12 Perricone C, Ceccarelli F, Matteo S. et al. Porphyromonas gingivalis and rheumatoid arthritis. Curr Opin Rheumatol 2019; 31 517
• 13 Hanlon P, Avenell A, Aucott L, Vickers MA. Systematic review and meta-analysis of the sero-epidemiological association between Epstein-Barr virus and systemic lupus erythematosus. Arthritis Res Ther 2014; 16 R3
• 14 Rigante D, Bosco A, Esposito S. The Etiology of Juvenile Idiopathic Arthritis. Clin Rev Allergy Immunol 2015; 49: 253-261
• 15 Ercolini AM, Miller SD. The role of infections in autoimmune disease. Clin Exp Immunol 2009; 155: 1
• 16 Sharma V, Sharma A. Infectious mimics of rheumatoid arthritis. Best Pract Res Clin Rheumatol 2022; 36: 101736
• 17 Naddei R, Alfani R, Bove M. et al. Increased Relapse Rate During COVID-19 Lockdown in an Italian Cohort of Children With Juvenile Idiopathic Arthritis. Arthritis Care Res 2023; 75: 326-331
• 18 Conti G, Galletta F, Carucci NS. et al. Negative effect of lockdown on juvenile idiopathic arthritis patients. Clin Rheumatol 2021; 40: 3723-3727
• 19 Hügle B, Krumrey-Langkammerer M, Haas J-P. Infection with SARS-CoV-2 causes flares in patients with juvenile idiopathic arthritis in remission or inactive disease on medication. Pediatr Rheumatol 2021; 19 163
• 20 Sengler C, Eulert S, Minden K. et al. Clinical manifestations and outcome of SARS-CoV-2 infections in children and adolescents with rheumatic musculoskeletal diseases: data from the National Paediatric Rheumatology Database in Germany. RMD Open 2021; 7 e001687
• 21 Roux CH, Brocq O, Gerald F. et al. Impact of Home Confinement During the COVID-19 Pandemic on Medication Use and Disease Activity in Spondyloarthritis Patients. Arthritis Rheumatol Hoboken NJ 2020; 72: 1771-1772
• 22 Di Iorio M, Cook CE, Vanni KMM. et al. DMARD disruption, rheumatic disease flare, and prolonged COVID-19 symptom duration after acute COVID-19 among patients with rheumatic disease: A prospective study. Semin Arthritis Rheum 2022; 55: 152025
• 23 Hadiyen Fel, Tsang-A-Sjoe MWPP, Lissenberg-Witte BI. et al. Intercurrent infection as a risk factor for disease flares in patients with systemic lupus erythematosus. Lupus Sci Med 2024; 11: e001131
• 24 Torres-Ruiz J, Barrera-Vargas A, Ortiz-Hernández R. et al. Microbiological and immunological profile of patients with severe lupus flares related to bloodstream infections: a retrospective cohort study. Lupus 2018; 27: 312-318
• 25 Joo YB, Kim K-J, Park K-S, Park Y-J. Influenza infection as a trigger for systemic lupus erythematosus flares resulting in hospitalization. Sci Rep 2021; 11: 4630
• 26 Jansen MH, Rondaan C, Legger G. et al. Efficacy, Immunogenicity and Safety of Vaccination in Pediatric Patients With Autoimmune Inflammatory Rheumatic Diseases (pedAIIRD): A Systematic Literature Review for the 2021 Update of the EULAR/PRES Recommendations. Front Pediatr 2022; 10
• 27 Ohm M, van Straalen JW, Zijlstra M. et al. Meningococcal ACWY conjugate vaccine immunogenicity and safety in adolescents with juvenile idiopathic arthritis and inflammatory bowel disease: A prospective observational cohort study. Vaccine 2023; 41: 3782-3789
• 28 Jaeger VK, Hoffman HM, van der Poll T. et al. Safety of vaccinations in patients with cryopyrin-associated periodic syndromes: a prospective registry based study. Rheumatol Oxf Engl 2017; 56: 1484-1491
• 29 Heshin-Bekenstein M, Ziv A, Toplak N. et al. Safety and immunogenicity of BNT162b2 mRNA COVID-19 vaccine in adolescents with rheumatic diseases treated with immunomodulatory medications. Rheumatol Oxf Engl 2022; keac103
• 30 Akgün Ö, Çakmak F, Guliyeva V. et al. Humoral response and safety of BNT162b2 mRNA vaccine in children with rheumatic diseases. Rheumatol Oxf Engl 2022; keac140
• 31 Heshin-Bekenstein M, Ziv A, Toplak N. et al. Safety and Immunogenicity Following the Second and Third Doses of the BNT162b2 mRNA COVID-19 Vaccine in Adolescents with Juvenile-Onset Autoimmune Inflammatory Rheumatic Diseases: A Prospective Multicentre Study. Vaccines 2023; 11: 819
• 32 Lawson-Tovey S, Machado PM, Strangfeld A. et al. SARSCoV-2 vaccine safety in adolescents with inflammatory rheumatic and musculoskeletal diseases and adults with juvenile idiopathic arthritis: data from the EULAR COVAX physician-reported registry. RMD Open 2022; 8 e002322
• 33 Opoka-Winiarska V, Lipinska J, Michalak A. et al. Safety of the COVID-19 vaccination in children with juvenile idiopathic arthritis – A observational study from two pediatric rheumatology centres in Poland. Front Pediatr 2023; 11: 1103763
• 34 Farisogullari B, Lawson-Tovey S, Hyrich KL. et al. Factors associated with disease flare following SARS-CoV-2 vaccination in people with inflammatory rheumatic and musculoskeletal diseases: results from the physician-reported EULAR Coronavirus Vaccine (COVAX) Registry. Ann Rheum Dis 2024; 83: 1584-1595
• 35 Carlson D, Hernandez J, Bloom BJ. et al. Lack of Borrelia burgdorferi DNA in synovial samples from patients with antibiotic treatment-resistant Lyme arthritis. Arthritis Rheum 1999; 42: 2705-2709
• 36 Tory HO, Zurakowski D, Sundel RP. Outcomes of children treated for Lyme arthritis: results of a large pediatric cohort. J Rheumatol 2010; 37: 1049-1055
• 37 Bentas W, Karch H, Huppertz HI. Lyme arthritis in children and adolescents: outcome 12 months after initiation of antibiotic therapy. J Rheumatol 2000; 27: 2025-2030
• 38 Morbach H, Holl-Wieden A, Dirks J. et al. Lyme-Arthritis. Arthritis Rheuma 2022; 42: 185-192
• 39 Arvikar SL, Crowley JT, Sulka KB, Steere AC. Autoimmune Arthritides, Rheumatoid Arthritis, Psoriatic Arthritis, or Peripheral Spondyloarthropathy, Following Lyme Disease. Arthritis Rheumatol Hoboken NJ 2017; 69: 194
• 40 Steere AC, Angelis SM. Therapy for Lyme arthritis: strategies for the treatment of antibiotic-refractory arthritis. Arthritis Rheum 2006; 54: 3079-3086
• 41 Nimmrich S, Becker I, Horneff G. Intraarticular corticosteroids in refractory childhood Lyme arthritis. Rheumatol Int 2014; 34: 987-994
• 42 Lochhead RB, Strle K, Arvikar SL. et al. Lyme arthritis: linking infection, inflammation and autoimmunity. Nat Rev Rheumatol 2021; 17: 449
• 43 Lochhead RB, Arvikar SL, Aversa JM. et al. Robust interferon signature and suppressed tissue repair gene expression in synovial tissue from patients with post-infectious, Borrelia burgdorferi-induced Lyme arthritis. Cell Microbiol 2018; 21 e12954
• 44 Dirks J, Fischer J, Klaussner J. et al. Disease-specific T cell receptors maintain pathogenic T helper cell responses in postinfectious Lyme arthritis. J Clin Invest 2024; 134
• 45 Jutras BL, Lochhead RB, Kloos ZA. et al. Borrelia burgdorferi peptidoglycan is a persistent antigen in patients with Lyme arthritis. Proc Natl Acad Sci U S A 2019; 116: 13498-13507
• 46 Strle K, Jones KL, Drouin EE. et al. Borrelia burgdorferi RST1 (OspC Type A) Genotype Is Associated with Greater Inflammation and More Severe Lyme Disease. Am J Pathol 2011; 178: 2726
• 47 Steere AC, Dwyer E, Winchester R. Association of chronic Lyme arthritis with HLA-DR4 and HLA-DR2 alleles. N Engl J Med 1990; 323: 219-223
• 48 Strle K, Shin JJ, Glickstein LJ, Steere AC. A Toll-like Receptor 1 Polymorphism Is Associated with Heightened T-helper 1 Inflammatory Responses and Antibiotic-Refractory Lyme Arthritis. Arthritis Rheum 2012; 64: 1497
• 49 Sulka KB, Strle K, Crowley JT. et al. Correlation of Lyme Disease-Associated IgG4 Autoantibodies With Synovial Pathology in Antibiotic-Refractory Lyme Arthritis. Arthritis Rheumatol Hoboken NJ 2018; 70: 1835-1846
• 50 Nordal E, Zak M, Aalto K. et al. Ongoing disease activity and changing categories in a long-term nordic cohort study of juvenile idiopathic arthritis. Arthritis Rheum 2011; 63: 2809-2818
• 51 Steere AC, Angelis SM. Therapy for Lyme arthritis: strategies for the treatment of antibiotic-refractory arthritis. Arthritis Rheum 2006; 54: 3079-3086
• 52 Steere AC, Schoen RT, Taylor E. The clinical evolution of Lyme arthritis. Ann Intern Med 1987; 107: 725-731
• 53 Rose NR. The Adjuvant Effect in Infection and Autoimmunity. Clin Rev Allergy Immunol 2008; 34: 279-282
• 54 Scher JU, Littman DR, Abramson SB. Review: Microbiome in Inflammatory Arthritis and Human Rheumatic Diseases. Arthritis Rheumatol 2016; 68: 35-45
• 55 Bizjak M, Blazina Š, Zajc Avramovič M. et al. Vaccination coverage in children with rheumatic diseases. Clin Exp Rheumatol 2020; 38: 164-170
• 56 Morin M-P, Quach C, Fortin É, Chédeville G. Vaccination coverage in children with juvenile idiopathic arthritis followed at a paediatric tertiary care centre. Rheumatology 2012; 51: 2046-2050
• 57 Minden K, Niewerth M, Borte M. et al. Impfungen bei rheumatischen Erkrankungen des Kindes- und Jugendalters. Z Für Rheumatol 2007; 66: 111-120
• 58 Davies K. Immunization in rheumatic diseases of childhood: an audit of the clinical practice of British Paediatric Rheumatology Group members and a review of the evidence. Rheumatology 2002; 41: 937-941
• 59 Papailiou S, Markade A, Eleftheriou I. et al. A National Survey Across Primary Care Pediatricians Regarding Immunization Views and Practices in Children With Rheumatic Diseases. J Clin Rheumatol Pract Rep Rheum Musculoskelet Dis 2021; 27 e588–e590
• 60 Jansen MHA, Rondaan C, Legger GE. et al. EULAR/PRES recommendations for vaccination of paediatric patients with autoimmune inflammatory rheumatic diseases: update 2021. Ann Rheum Dis 2023; 82: 35-47
• 61 Aikawa NE, França ILA, Ribeiro AC. et al. Short and long-term immunogenicity and safety following the 23-valent polysaccharide pneumococcal vaccine in juvenile idiopathic arthritis patients under conventional DMARDs with or without anti-TNF therapy. Vaccine 2015; 33: 604-609
• 62 Çakmak F, Çakan M, Demir F. et al. Hepatitis B vaccination response of treatment-naive patients with juvenile idiopathic arthritis. Rheumatol Int 2022; 42: 1199-1205
• 63 Jensen L, Nielsen S, Christensen AE. et al. Response to influenza vaccination in immunocompromised children with rheumatic disease: a prospective cohort study. Pediatr Rheumatol Online J 2021; 19: 26
• 64 Keller M, Pittet LF, Zimmermann P. Immunogenicity and safety of routine vaccines in children and adolescents with rheumatic diseases on immunosuppressive treatment – a systematic review. Eur J Pediatr 2022; 181: 1329-1362
• 65 Blanchard-Rohner G. Vaccination in Children With Autoimmune Disorders and Treated With Various Immunosuppressive Regimens: A Comprehensive Review and Practical Guide. Front Immunol 2021; 12: 711637
• 66 Maritsi D, Vartzelis G, Soldatou A, Garoufi A, Spyridis N. Markedly decreased antibody titers against hepatitis B in previously immunised children presenting with juvenile idiopathic arthritis. Clin Exp Rheumatol 2013; 31: 969-973
• 67 Heijstek MW, Scherpenisse M, Groot N. et al. Immunogenicity and safety of the bivalent HPV vaccine in female patients with juvenile idiopathic arthritis: a prospective controlled observational cohort study. Ann Rheum Dis 2014; 73: 1500-1507
• 68 Cheent K, Nolan J, Shariq S. et al. Case Report: Fatal case of disseminated BCG infection in an infant born to a mother taking infliximab for Crohn’s Disease. J Crohns Colitis 2010; 4: 603-605
• 69 Whittembury A, Ramirez G, Hernández H. et al. Viscerotropic disease following yellow fever vaccination in Peru. Vaccine 2009; 27: 5974-5981
• 70 Wagner N, Assmus F, Arendt G. et al. Impfen bei Immundefizienz. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 2019; 62: 494-515
• 71 Borte S, Liebert UG, Borte M, Sack U. Efficacy of measles, mumps and rubella revaccination in children with juvenile idiopathic arthritis treated with methotrexate and etanercept. Rheumatology 2009; 48: 144-148
• 72 Heijstek MW, Pileggi GCS, Zonneveld-Huijssoon E. et al. Safety of measles, mumps and rubella vaccination in juvenile idiopathic arthritis. Ann Rheum Dis 2007; 66: 1384-1387
• 73 Heijstek MW, Kamphuis S, Armbrust W. et al. Effects of the live attenuated measles-mumps-rubella booster vaccination on disease activity in patients with juvenile idiopathic arthritis: a randomized trial. JAMA 2013; 309: 2449-2456
• 74 Heijstek MW, van Gageldonk PGM, Berbers GAM, Wulffraat NM. Differences in persistence of measles, mumps, rubella, diphtheria and tetanus antibodies between children with rheumatic disease and healthy controls: a retrospective cross-sectional study. Ann Rheum Dis 2012; 71: 948-954
• 75 Uziel Y, Moshe V, Onozo B. et al. Live attenuated MMR/V booster vaccines in children with rheumatic diseases on immunosuppressive therapy are safe: Multicenter, retrospective data collection. Vaccine 2020; 38: 2198-2201
• 76 Miyamoto M, Ono E, Barbosa C. et al. Vaccine antibodies and T- and B-cell interaction in juvenile systemic lupus erythematosus. Lupus 2011; 20: 736-744
• 77 Çakmak F, Akgün Ö, Demirkan FG. et al. Live-attenuated measles, mumps, and rubella booster vaccine in children diagnosed with rheumatic disease: A single-center study. Eur J Pediatr 2023; 182: 135-140
• 78 Horneff G, Burgos-Vargas R, Constantin T. et al. Efficacy and safety of open-label etanercept on extended oligoarticular juvenile idiopathic arthritis, enthesitis-related arthritis and psoriatic arthritis: part 1 (week 12) of the CLIPPER study. Ann Rheum Dis 2013; 73 1114
• 79 García-Doval I, Pérez-Zafrilla B, Descalzo MA. et al. Incidence and risk of hospitalisation due to shingles and chickenpox in patients with rheumatic diseases treated with TNF antagonists. Ann Rheum Dis 2010; 69: 1751-1755
• 80 Groot N, Pileggi G, Sandoval CB. et al. Varicella vaccination elicits a humoral and cellular response in children with rheumatic diseases using immune suppressive treatment. Vaccine 2017; 35: 2818-2822
• 81 Barbosa CMPL, Terreri MTRAA, Rosário PO. et al. Immune response and tolerability of varicella vaccine in children and adolescents with systemic lupus erythematosus previously exposed to varicella-zoster virus. Clin Exp Rheumatol 2012; 30: 791-798
• 82 Speth F, Hinze CH, Andel S. et al. Varicella-zoster-virus vaccination in immunosuppressed children with rheumatic diseases using a pre-vaccination check list. Pediatr Rheumatol Online J 2018; 16 15
• 83 Toplak N, Avčin T. Long-term safety and efficacy of varicella vaccination in children with juvenile idiopathic arthritis treated with biologic therapy. Vaccine 2015; 33: 4056-4059
• 84 Pileggi GSS, de Souza CBS, Ferriani VPL. Safety and immunogenicity of varicella vaccine in patients with juvenile rheumatic diseases receiving methotrexate and corticosteroids. Arthritis Care Res 2010; 62: 1034-1039