Venturini et al.

BMC Infectious Diseases 2014, 14:652

http://www.biomedcentral.com/1471-2334/14/652

RESEARCH ARTICLE Open Access

Vitamin D and tuberculosis: a multicenter study in

children
Elisabetta Venturini1, Ludovica Facchini1, Nuria Martinez-Alier2, Vas Novelli3, Luisa Galli1, Maurizio de Martino1*
and Elena Chiappini1

Abstract
Background: The aim of this study is to evaluate vitamin D levels in children with latent and active TB compared
to healthy controls of the same age and ethnical background.
Methods: A multicenter observational study has been conducted in three tertiary care paediatric centres: Anna
Meyer Children's University Hospital, Florence, Italy; Evelina London Children's Hospital, London, United Kingdom
and Great Ormond Street Hospital, London, United Kingdom. Vitamin D was considered deficient if the serum level
was <25 nmol/L, insufficient between 25 and 50 nmol/L and sufficient for a level >50 nmol/L.
Results: The study population included 996 children screened for TB, which have been tested for vitamin D. Forty-four
children (4.4%) had active TB, 138 (13.9%) latent TB and 814 (81.7%) were controls. Our study confirmed a high prevalence
of hypovitaminosis D in the study population. A multivariate analysis confirmed an increased risk of hypovitaminosis D in
children with latent and active TB compared to controls [(P = 0.018; RR = 1.61; 95% CI: 1.086-2.388), (P < 0.0001; RR = 4.587;
95% CI:1.190-9.608)].
Conclusions: Hypovitaminosis D was significantly associated with TB infection in our study. Further studies are needed to
evaluate a possible role of vitamin D in the treatment and prevention of tuberculosis in children.
Keywords: Vitamin D, Tuberculosis, Children

Background Mechanisms through which vitamin D modulates the im-

In the pre-antibiotic era, cod liver oil and sunlight ex- mune system in the response to Mycobacterium tubercu-
posure were used to treat tuberculosis (TB) [1,2]. More losis infection are not completely understood, two possible
recently, increasing evidences from in vitro studies sug- mechanisms have emerged as the most likely. Vitamin D
gest that vitamin D enhances antimycobacterial immun- appears to reduce the viability of M. tuberculosis by enhan-
ity [3]. Several authors reported hypovitaminosis D in cing the fusion of the phagosome and lysosome in infected
TB patients [4-6], and serum level of vitamin D [25- macrophages [16]. In addition, vitamin D may enhance the
hydroxycholecalciferol) was found to be lower in TB pa- production of LL-37, an antimicrobial peptide of the cathe-
tients than in healthy controls [7-14]. A recent study licidin family [16-19]. Antimicrobial peptides, such as
conducted among adult TB contacts found that 94% of defensin and cathelicidin, are involved as a first line of de-
recruits were vitamin D insufficient and that a single, fences in the prevention of infections, including tubercu-
oral 2.5 mg dose of vitamin D significantly enhanced losis. The presence of vitamin D in neutrophils and
their anti-mycobacterial immunity in vitro [7]. Factors macrophages up-regulates in a dose-dependent manner the
such as low socioeconomic status, poor nutrition, trad- hCAP-18 gene that codes for LL-37, which suggests that
itional/cultural traits, and little exposure to sunlight may vitamin D induction of LL-37 may play a role in host de-
contribute to vitamin D deficiency [15]. fences against TB infection [3,16].
Vitamin D exerts its actions through vitamin D receptor
(VDR), a nuclear hormone receptor. Polymorphisms in
* Correspondence: [email protected]
1
Department of Health Sciences, University of Florence, Anna Meyer
the VDR gene, which may influence VDR activity and sub-
Children’s University Hospital, viale Pieraccini 24, I-50139 Florence, Italy sequent downstream vitamin D mediated effects, were
Full list of author information is available at the end of the article

© 2014 Venturini et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Venturini et al. BMC Infectious Diseases 2014, 14:652 Page 2 of 10
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therefore studied as potential candidates of risk markers Ethical issues

for various clinical outcomes [20,21]. This study was approved by the Ethical Committees of
Clinical trials [8,10,22-24] have been conducted to test the hospitals involved: Anna Meyer Children's University
whether vitamin D therapy improves TB outcomes, sug- Hospital, Florence, Italy; Evelina London Children's Hos-
gesting that vitamin D may be beneficial as an adjunctive pital, London, United Kingdom and Great Ormond
treatment to the traditional therapy in patients with TB; Street Hospital, London, United Kingdom.
however, additional trials in children need to be conducted
to clarify its role [25]. Case definitions
TB disease
Active TB diagnosis was assigned to any child with Myco-
Methods bacterium tuberculosis cultured or detected by microscopy
A multicenter study was conducted in three tertiary care
or molecular methods from sputum, gastric aspirate or
paediatric centres: Anna Meyer Children's University Hos-
other biologic samples. Active TB diagnosis was also
pital, Florence, Italy; Evelina London Children's Hospital,
assigned to any child with clinical and radiological evi-
London, United Kingdom and Great Ormond Street Hos-
dence of TB disease, and with either a history of exposure
pital, London, United Kingdom. The data regarding the
to an infectious case or a positive TST. In the absence of a
period of time between July 2008 and January 2013 were
recognized gold standard, latent tuberculosis diagnosis
collected retrospectively, whereas those between February
was assigned to any child with a positive TST and/or
and September 2013 prospectively. Written informed con-
IGRA and no clinical, bacteriological or radiographic evi-
sent for participation in the study was obtained from chil-
dence of active TB [26]. In the absence of those criteria
dren's parent or guardian. The aim of the study was to
children were included in the control group.
evaluate vitamin D levels in children with latent and active
tuberculosis, compared to healthy controls of the same age
and ethnical background. Secondary objective was to evalu- Hypovitaminosis D
ate potential differences between groups of patients (consid- Vitamin D level was evaluated testing for 25-OHD, which
ering age, race, enrolling centre, vitamin D supplementation, is considered its best indicator [27]. Following the European
latent or active tuberculosis). Society for Paediatric Gastroenterology, Hepatology and
Nutrition (ESPGHAN) definition, 25-OHD was considered
deficient in case of a serum vitamin D level less than
Study design 25 nmol/L, insufficient between 25 and 50 nmol/L and suf-
Children (aged <18 years) investigated for TB infection ficient for level above 50 nmol/L [28].
between July 2008 and September 2013, for whom vita-
min D was tested during the first visit, were eligible. Statistical analysis
The reasons for referral to the paediatric infectious dis- Continuous measurements analyzed were: age (years),
eases centres were clinical suspicious or confirmed TB weight (kilograms), height (centimetres), 25-OHD serum
disease, history of TB contact or immigrated/adopted level (nmol/L), calcium and phosphate levels (mmol/L).
child from a TB endemic country within the previous Median and interquartile range (IQR) were calculated for
2 years. Children with congenital or acquired immuno- those variables in the study groups. Categorical data were
deficiency were excluded. compared using the Chi-squared test (or Fisher's exact test,
For each child the following data were entered into when expected cell sizes were smaller than five). The
the study database: name, age, gender, ethnic group, fa- Wilcoxon-Mann–Whitney test was used for continuous
milial and personal history including risk factors for TB measurements to test relationships in unpaired analysis,
infection and for vitamin D deficiency, bacillus Camette- when assumed that the dependent variable was a not nor-
Guerin (BCG) vaccination and physical examination. mally distributed interval variable. Moreover, the risk factors
Data about tests performed were also included, in par- for vitamin D deficiency were evaluated using univariate
ticular vitamin D level (25-hydroxycholecalciferol, 25- and multivariate logistic regression. The variables included
OHD), tuberculin skin test (TST), interferon-γ release in the analysis were: TB infection status (active TB, latent
assay (IGRA), and if available calcium, phosphate, chest TB, and control), gender, age, ethnicity at risk for vitamin D
x-ray, chest computerised tomography, gastric aspirate deficiency, immigration, seasonality (categorized ad autumn-
or sputum (microscopy, culture and polymerase chain winter and spring-summer). For each factor the relative risk
reaction for M. tuberculosis) and anti-tubercular treat- (RR) and 95% confident intervals (95% CI) were evaluated.
ment. All results were recorded in the study database Statistical analysis was performed using the statistical soft-
following the international standards for the protection ware SPSS for Windows, version 12.0. P <0.05 was consid-
of privacy and personal information. ered statistically significant.
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Results All the variable analysed were statistically significant

Population also according to the US Endocrinology Society vitamin D
Nine hundred and ninety-six children were included in status classification (P < 0.0001) (29).
this study: 15 (1.5%) from Great Ormond Street Hospital, Calcium and phosphate levels (median and IQR) in the
London, UK; 63 (6.4%) from Evelina London Children’s different study groups are reported in Table 2.
Hospital, London, UK; and 918 (92.1%) from Anna Meyer In the study population 159 (16%) children were
Children's University Hospital, Florence, Italy. The study vitamin D deficient, 308 (30.9%) insufficient and 529
population characteristics are summarized in Table 1. (53.1%) sufficient.
The correlation between vitamin D status and other
factors (age, gender, seasonality, calcium and phosphate
TB status levels) has been reported in Table 3.
Forty-four (4.4%) children met the criteria for active TB. Vitamin D level was significantly lower if tested during
The most common condition was pulmonary TB (n = 24; Autumn-Winter compared to Spring-Summer (P < 0.0001)
54.5%). Extra-pulmonary TB was in order of frequency: (Figure 3).
lymphadenitis (n = 5; 11.4%), pleural-peritoneal (n = 4;
9.1%), skeletal (n = 4; 9.1%), ocular (n = 1; 2.3%), meningeal
(n = 1; 2.3%). Miliary TB was found in 5 patients (11.4%). Multivariate analysis
The median length of the treatment was 7 months (range A multivariate logistic regression analysis was used to
6–12). Quadruple therapy (isoniazid, rifampicin, etham- exclude possible confounding factors. This analysis con-
butol, pyrazinamide) was used in 36 children, in 4 of those firmed the risk of vitamin D deficiency to be statistically
in association with steroids. In other 8 cases different anti- correlated with TB infection (RR = 1.61; 95% CI:1.086-
TB treatment associations have been used, mostly because 2.388; P = 0.018;), and higher in active TB compared to
of resistant mycobacteria. latent TB and controls, ( RR = 4.587; 95% CI: 1.190-
One hundred and thirty-eight (13.9%) children met 9.608; P < 0.0001). In the multivariate analysis the re-
the criteria for latent TB. Double therapy (isoniazid and sults were adjusted for the different centres.
rifampicin) for 3 months was the commonest combin- There was no significant correlation between hypovitami-
ation used (91.3%, n = 126). The controls enrolled in the nosis D and gender (P = 0.113; RR = 0.799; 95% CI: 0.605-
study were 814 (81.7%). 1.055), ethnicity at risk of hypovitaminosis D (P = 0.688;
RR = 1.610; 95% CI: 0.715-1.747) and immigration
(P = 0.428; RR = 1.316; 95% CI: 0.668-2.590). On the con-
Vitamin D, calcium and phosphate levels in the study trary, a correlation between hypovitaminosis D and age
groups (P < 0.0001; RR = 1.147; 95% CI: 1.105-1.190) and be-
Vitamin D levels in the different study groups are reported tween vitamin D deficiency and seasonality (P < 0.0001;
in Table 2 and illustrated in Figure 1. About half (467; RR = 2.208; 95% CI: 2.132-3.698) was found.
46.9%) of the children tested, independently from the TB
status, resulted to have an insufficient or deficient vitamin
D level. Hypovitaminosis D was found respectively in 354 Vitamin D supplementation
(43.5%) of controls, 80 (58%) latent TB and 33 (75%) active In case of hypovitaminosis D, different vitamin D sup-
TB. The statistical analysis with the Mann–Whitney U test plementation protocols were used in the three centres,
showed that vitamin D level was significantly lower in case according with the most recent international guidelines
of latent and active TB compared to controls (p < 0.0001), [28-31]. At Anna Meyer Children's University Hospital,
with median level respectively of 45 nmol/L (IQR: 30– Florence, Italy, 1000 IU of colecalciferol were adminis-
62.5), 27.8 nmol/L (IQR: 19–50) and 52.5 nmol/L (IQR: tered daily for 8 weeks. At Evelina London Children’s
31.5-67.5). Hospital, London, UK, 3,000, 6,000, 10,000 or 20,000 IU
Vitamin D levels were significantly lower in latent TB of colecalciferol were used daily for 6 weeks depending
compared to controls (p = 0.002), in active TB compared on the severity of hypovitaminosis D. At Great Ormond
to controls (p < 0.0001) and in active TB compared to la- Street Hospital, London, UK 50,000 IU of ergocalciferol
tent TB (p = 0.001). were administered daily for 3 to 6 days.
Moreover, a deficient vitamin D level was found in Only one-third (133; 28.5%) of the patients with a low
higher percentage in the active TB group (n = 18; 40.9%) level of vitamin D received vitamin D supplementation.
compared to latent TB (n = 28; 20.3%) and controls Vitamin D supplementation was prescribed in 71 con-
(13.9%) (P < 0.0001). An insufficient level of vitamin D trols, 36 latent TB and 26 active TB, respectively 20%,
was more frequently found in the latent TB group (n = 45% and 79% of children with hypovitaminosis D in the
113; 37.7%, P < 0.0001) (Figure 2). 3 different groups.
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Table 1 Study population characteristics

Controls n = 814 Latent TB n = 138 Active TB n = 44 Total n = 996 P
Enrolling centre, n (%): <0.0001
- Evelina London Children’s 21 (2.6%) 25 (18.1%) 17 (38.6%) 63 (6.4%)
Hospital, London, UK
- Great Ormond Street 0 (0%) 0 (0%) 15 (34.1%) 15 (1.5%)
Hospital, London, UK
- Anna Meyer Children's University Hospital, Florence, Italy 793 (97.4%) 113 (81.9%) 12 (27.3 %) 918 (92.1%)
Age in years, median (IQR) 5.5 (3.1-8.1) 6.9 (4.3-10.8) 4.7 (3.0-11.6) 5.8 (3.1-8.5) <0.0001
Gender, n (%): <0.0001
- Male 496 (60.9%) 85 (61.6%) 15 (34.1%) 596 (59.4%)
- Female 310 (38.1 %) 52 (37.7%) 29 (65.9 %) 391 (39.6%)
- Not known 8 (1%) 1 (0.7%) 0 (0%) 9 (0.9%)
Country of origin*, n (%): <0.0001
- Asia 146 (17.9%) 19 (13.8%) 4 (9.1%) 169 (17%)
- Latin America 183 (22.5%) 24 (17.4%) 4 (9.1%) 211 (21.2%)
- Eastern Europe§ 269 (33%) 57 (41.3%) 5 (11.4%) 331 (33.2%)
- Western Europe 36 (4.4%) 7 (5.1%) 3 (6.8 %) 46 (4.6%)
- Nord Africa 16 (2%) 1 (0.7%) 2 (4.5%) 19 (1.9%)
- Sub-Saharan Africa 151 (18.6%) 29 (21%) 25 (56.8 %) 205 (20.6%)
- Other 8 (1%) 0 (0%) 0 (0%) 8 (0.8%)
- Not known 5 (0.6%) 1 (0.7%) 1 (2.3%) 7 (0.7%)
Ethnic group, n (%): <0.0001
- African 168 (20.7%) 30 (21.7%) 27 (61.4%) 225 (22.6%)
- Asiatic 146 (17.9%) 19 (13.8%) 4 (9.1%) 169 (17%)
- Caucasian 306 (37.6%) 64 (46.4%) 8 (18.2%) 378 (37.9%)
- Hispanic 183 (22.5%) 24 (17.4%) 4 (9.1%) 211 (21.2%)
- Other 6 (0.7%) 0 (0%) 0 (0%) 6 (0.6%)
- Not known 5 (0.6%) 1 (0.7%) 1 (2.2%) 7 (0.7%)
BCG, n (%): 0.109
- Yes 460 (56.5%) 89 (64.5%) 20 (45.5%) 569 (57.1%)
- No 244 (30.0%) 40 (29.0%) 19 (43.2%) 303 (30.4%)
- Not known 110 (13.5%) 9 (6.5%) 5 (11.4%) 124 (12.4%)
Risk factors for vitamin D 0.932
deficiency†, n (%):
- Yes 470 (57.7%) 74 (53.6%) 32 (72.7%) 576 (57.8%)
- No 344 (42.3%) 64 (46.4%) 12 (27.3%) 420 (42.2%)
Risk factors for TB <0.0001
infection, n (%):
- Tb contact 92 (11.4%) 31 (22.5%) 27 (21.2%) 150 (15.1%)
- Travel to/immigrated from 695 (85.3%) 104 (75.4%) 10 (22.8%) 809 (80.1%)
TB endemic country
- Not known 27 (3.3%) 3 (2.1%) 7 (15.9%) 37 (3.7%)
IGRA, n (%): <0.0001
- Positive 0 (0.0%) 45 (32.6%) 28 (63.6%) 73 (7.3%)
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Table 1 Study population characteristics (Continued)

- Negative 792 (97.3%) 71 (51.4%) 7 (15.9%) 870 (87.3%)
- Not known 22 (2.7%) 22 (15.9%) 9 (20.5%) 53 (5.3%)
TST, n (%): <0.0001
- Positive 0 (0.0%) 120 (87%) 32 (72.7%) 152 (15.3%)
- Negative 777 (95.5%) 10 (7.2%) 2 (4.5%) 789 (79.2%)
- Not known 37 (4.5%) 8 (5.8%) 10 (22.7%) 55 (55.2%)
*Whether the child’s family is originally from a TB endemic country, this has been indicated as country of origin, independently from the country of birth.
§Albania, Belarus, Bulgaria, Kosovo, Macedonia, Moldavia, Poland, Czech Republic, Romania, Russia, Serbia, Slovakia, Slovenia, Ukraine, Hungary.
†African, Asiatic and Hispanic ethnic group.

Discussion The correlation between low vitamin D and TB disease

The high prevalence of hypovitaminosis D in children is confirmed in our study on a large paediatric popula-
[32,33] is confirmed in our study, based on a large data tion including a matched control group. Hypovitamino-
set, reaching 47% of children tested, independently from sis D affected up to 75% children with active TB (P <
their TB status. 0.0001). Moreover, the active TB group exhibited the
The correlation between vitamin D deficiency and TB lowest level of vitamin D. Hypovitaminosis D was four
disease was previously demonstrated in adults [4-6,8-14], times more likely in children with active TB compared
although some authors do not agree with this hypothesis to healthy controls. This correlation was confirmed
[34-40]. No paediatric study with a matched control group using a multivariate logistic regression analysis, in order
is available in literature, and our study’s aim is to fill this to exclude possible confounding factors, and the results
gap. Three studies on a possible correlation between vita- were adjusted considering also the different enrolling
min D deficiency and TB in the paediatric population centre.
were previously published [41-43], including overall 442 About two-third of the study population ethnicity was
children. In the first study on refugee children, a vitamin at high risk for vitamin D deficiency (African, Asiatic
D level was significantly lower in 92 children with TB and Hispanic). It is well known that the major risk
infection compared to 236 healthy controls [41]. The main factors in these populations are dark skin, reduced ex-
limitations of this retrospective study were the omission posure to sunlight due to long clothing and vegetarian
of routine IGRA testing in the definition of TB status and diet [32]. The ethnical background at risk of hypovitami-
the missing data about BCG vaccination [41]. Hypovitami- nosis D were homogeneously distributed in the 3 study
nosis D prevalence in latent and active TB was 86% in a groups. Interestingly, in our study hypovitaminosis D oc-
retrospective study on 64 children [42]. The principal curred also in the Caucasian group, accounting for about
limitation of this study was the lack of an age and ethnic- one-third of the cases. Vitamin D was deficient in 32.7%
ally matched control group without a history of TB infec- of Caucasian children and insufficient in 37.3%. More-
tion or disease [42]. Finally, in a randomised study, done over, about 80% of children tested in the UK had hypovi-
on a small number of children (n = 24), vitamin D supple- taminosis D (respectively 43.6% was vitamin D deficient
mentation (colecalciferol 1000 UI daily for 8 weeks) was and 35.9% insufficient) compared to 44.1% of children
added to TB treatment, leading to clinical and radio- tested in Italy (respectively 13.6% was vitamin D defi-
logical improvement compared to the standard treat- cient and 30.5% insufficient). This difference could be
ment alone [43]. mainly explained by lower sun exposure in UK with

Table 2 Vitamin D, calcium and phosphate levels in the different study groups
Controls n = 814 Latent TB n = 138 Active TB n = 44 Total n = 996 P
Vitamin D level, n (%): 0.0001
- Deficient (<25 nmol/L) 113 (13.9%) 28 (20.3%) 18 (40.9%) 159 (16%)
- Insufficient (25–50 noml/L) 241 (29.6%) 52 (37.7%) 15 (34.1%) 308 (30.9%)
- Sufficient (>50 nmol/L) 460 (56.5%) 58 (42%) 11 (25%) 529 (53.1%)
Vitamin D level (nmol/L), median (IQR) 52.5 (31.5-67.5) 45 (30–62.5) 27.8 (19–50) 35 (24–54.5) 0.0001
Calcium (mmol/L), median (IQR) 2.38 (2.3-2.45) 2.38 (2.3-2.42) 2.35 (2.25-2.45) 2.4 (2.26-2.46) 0.709
Phosphate (mmol/L), median (IQR) 1.62 (1.49-1.71) 1.75 (1.32-1.78) 1.42 (1.23-1.6) 1.5 (1.28-1.61) 0.002
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Figure 1 Vitamin D levels (median and IQR) in the different study groups. About half (467; 46.9%) of the children tested, independently
from the TB status, resulted to have an insufficient or deficient vitamin D level. Hypovitaminosis D was found respectively in 354 (43.5%) of
controls, 80 (58%) latent TB and 33 (75%) active TB.

Figure 2 Vitamin D status defined by ESPGHAN according to TB status. A deficient vitamin D level was found in higher percentage in the
active TB group (n = 18; 40.9%) compared to latent TB (n = 28; 20.3%) and controls (13.9%) (P < 0.0001). An insufficient level of vitamin D was
more frequently found in the latent TB group (n = 113; 37.7%, P < 0.0001).
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Table 3 Characteristics of the population according to vitamin D status

Deficient n = 159 Insufficient n = 308 Sufficient n = 529 Total n = 996 P
TB status, n (%): <0.0001
- Controls 113 (71.1%) 241 (78.2%) 460 (87%) 814 (81.7%)
- Latent TB 28 (17.6%) 52 (16.9%) 58 (11%) 138 (13.9%)
- Active TB 18 (11.3%) 15 (4.9%) 11 (2%) 44 (4.4%)
Enrolling centre, n (%): <0.0001
- Evelina London Children’s 26 (16.4%) 23 (7.5%) 14 (2.6%) 63 (6.4%)
Hospital, London, UK
- Great Ormond Street 8 (5%) 5 (1.6%) 2 (0.4%) 15 (1.5%)
Hospital, London, UK
- Anna Meyer Children's University Hospital, Florence, Italy 125 (78.6%) 280 (90.9%) 513 (97%) 918 (92.1%)
Age, median (IQR) 6.5 (4.2-10.3) 6.6 (4–9.7) 4.8 (2.5-7.6) 5.8 (3.1-8.5) <0.0001
Gender, n (%): 0.106
- Male 85 (53.5%) 182 (59.1%) 329 (62.2%) 596 (59.8%)
- Female 74 (46.5%) 122 (39.6%) 195 (36.9%) 391 (39.3%)
- Not known 0 (0%) 4 (1.3%) 5 (0.9%) 9 (0.9%)
Country of origin*, n (%): <0.0001
- Asia 27 (17%) 44 (14.3%) 98 (18.5%) 169 (17%)
- Latin America 25 (15.7%) 74 (24%) 112 (21.2%) 211 (21.2%)
- Eastern Europe § 48 (30.2%) 95 (30.8%) 188 (35.5%) 331 (33.2%)
- Western Europe 4 (2.5%) 18 (5.8%) 24 (4.5%) 46 (4.6%)
- Nord Africa 7 (4.4%) 8 (2.6%) 4 (0.8%) 19 (1.9%)
- Sub-Saharan Africa 42 (26.4%) 65 (21.1%) 98 (18.5%) 205 (20.6%)
- Other 1 (0.6%) 3 (1%) 4 (0.8%) 8 (0.8%)
- Not known 5 (3.1%) 1 (0.3%) 1 (0.2%) 7 (0.7%)
Ethnic group, n (%): <0.0001
- African 50 (30.8%) 74 (24%) 101 (19.1%) 225 (22.6%)
- Asiatic 24 (15.1%) 43 (14%) 102 (19.3%) 169 (17%)
- Caucasian 52 (32.7%) 115 (37.3%) 211 (39.9%) 378 (37.9%)
- Hispanic 27 (17%) 73 (23.7%) 111 (21%) 211 (21.2%)
- Other 1 (1.2%) 2 (0.7%) 3 (0.5%) 6 (0.6%)
- Not known 5 (3.2%) 1 (0.3%) 1 (0.2%) 7 (0.7%)
Risk factors for vitamin D 0.932
deficiency†, n (%):
- Yes 93 (58.5%) 180 (58.4%) 303 (57.3%) 576 (57.8%)
- No 66 (41.5%) 128 (41.6%) 226 (42.7%) 420 (42.2%)
Season when blood test was <0.0001
done, n (%):
- Spring-Summer 58 (36.5%) 145 (47.1) 339 (64.1%) 542 (54.4%)
- Winter-Autumn 101 (63.5%) 163 (52.9) 190 (35.9%) 454 (45.6%)
Vitamin D level (nmol/L), median (IQR) 20 (15.5-22.5) 37.5 (32.5-42.5) 72.5 (57.5-87.5) 35 (24–54.5)
Calcium (mmol/L), median (IQR) 2.35 (2.28-2.42) 2.37 (2.3-2.43) 2.38 (2.33-2.48) 2.4 (2.26-2.46) 0.030
Phosphate (mmol/L), median (IQR) 1.5 (1.3-1.65) 1.59 (1.41-1.68) 1.65 (1.49-1.81) 1.5 (1.28-1.61) 0.001
*Whether the child’s family is originally from a TB endemic country, this has been indicated as country of origin, independently from the country of birth.
§Albania, Belarus, Bulgaria, Kosovo, Macedonia, Moldavia, Poland, Czech Republic, Romania, Russia, Serbia, Slovakia, Slovenia, Ukraine, Hungary.
†African, Asiatic and Hispanic ethnic group.
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Figure 3 Vitamin D level according to seasonality. Vitamin D level was significantly lower if tested during Autumn-Winter compared to
Spring-Summer (P < 0.0001).

respect to Italy and probably also by different diet within The major limitations of our study are: the lack of
the two countries. However, the high percentage of hypo- homogeneity between the study groups, as the majority of
vitaminosis in Italy despite good sun exposure, affecting controls were enrolled in the Italian centre. To minimize
about half of the children tested, should increase the the influence of this factor on our results a multivariate
awareness of this problem also in countries known to be analysis was performed, including the enrolling centre as a
at low risk for vitamin D deficiency. categorical variable. Moreover data regarding parathyroid
Hypovitaminosis D was statistically more frequent if hormone, alkaline phosphatase were lacking. In our study
tested during autumn and winter compared to spring the hypovitaminosis D definition used was in keeping with
and summer. This seasonality has been well described ESPGHAN guidelines [28], although we were aware about
and is mainly related to sun exposure [6,12,41,44]. different definitions. To avoid this bias we performed the
Surprisingly, only one-third of the patients with hypovi- analysis considering also vitamin D status classification by
taminosis D received vitamin D supplementation, with dif- the US Endocrine Society [29], and the results didn’t
ferent protocols depending on the prescribing centre. The change substantially.
protocols used in the three centres were in agreement
with the most recent international guidelines [28-31]. This Conclusions
data should alert the physicians about the need of vitamin Our large population study confirms an increasing inci-
D supplementation in children with hypovitaminosis, to dence of hypovitaminosis D in Europe, within native and
prevent rickets and its complications. However no clinical immigrated children, and the role played by vitamin D
sign of rickets was reported in our study population. The status in TB disease.
choice of vitamin D regimen in the paediatric population In our study hypovitaminosis D was significantly associ-
should take count of compliance, especially in young chil- ated with TB infection. Further studies are needed to
dren and in TB patients, which already receive a signifi- evaluate a possible role of vitamin D in the treatment and
cant amount of drugs. The need of clear guidelines for prevention of tuberculosis in children, especially novel
children with hypovitaminosis D in this setting should be randomized controlled trials to compare TB treatment
addressed, in order to unify the management of vitamin D outcomes in children receiving vitamin D supplementa-
supplementation in this group of patients. tion in addition to the standard therapy.
Venturini et al. BMC Infectious Diseases 2014, 14:652 Page 9 of 10
http://www.biomedcentral.com/1471-2334/14/652

Abbreviations 13. Gibney KB, MacGregor L, Leder K: Vitamin D deficiency is associated with
25-OHD: 25-Hydroxycholecalciferol; BCG: Bacillus Calmette-Guerin; tuberculosis and latent tuberculosis infection in immigrants from
CI: Confidence intervals; ESPGHAN: European Society for Paediatric sub-Saharan Africa. Clin Infect Dis 2008, 46:443–446.
Gastroenterology, Hepatology and Nutrition; IGRA: Interferon-γ release assay; 14. Friis H, Range N, Pedersen ML, Mølgaard C, Changalucha J, Krarup H,
IQR: Interquartile range; RR: Relative risk; TB: Tuberculosis; TST: Tuberculin skin Magnussen P, Søborg C, Andersen AB: Hypovitaminosis D is common
test; VDR: Vitamin D receptor. among pulmonary tuberculosis patients in Tanzania but is not explained
by the acute phase response. J Nutr 2008, 138:2474–2480.
Competing interests 15. Nnoaham KE, Clarke A: Low serum vitamin D levels and tuberculosis: a
The authors declare that they have no competing interests. systematic review and meta-analysis. Int J Epidemiol 2008, 37:113–119.
16. Chocano-Bedoya P, Ronnenberg AG: Vitamin D and tuberculosis. Nutr Rev
Authors’ contributions 2009, 67:289–293.
EV, EC have made substantial contributions to conception and design of the 17. Martineau AR, Wilkinson KA, Newton SM, Floto RA, Norman AW,
study; LF in the acquisition of data; MdM, LG, VN and NMA in the analysis Skolimowska K, Davidson RN, Sørensen OE, Kampmann B, Griffiths CJ,
and interpretation of data; EV, LG and EC have been involved in drafting the Wilkinson RJ: IFN-gamma- and TNF-independent vitamin D-inducible
manuscript; MdM and VN were involved in revising critically the paper for human suppression of mycobacteria: the role of cathelicidin LL-37.
the scientifical part. Each author participated sufficiently in the work to take J Immunol 2007, 178:7190–7198.
public responsibility for appropriate portions of the content. Each author 18. Ralph AP, Kelly PM, Anstey NM: L-arginine and vitamin D: novel adjunctive
gave a final approval of the version to be published. immunotherapies in tuberculosis. Trends Microbiol 2008, 16:336–344.
19. Campbell GR, Spector SA: Vitamin D inhibits human immunodeficiency
Author details virus type 1 and Mycobacterium tuberculosis infection in macrophages
1
Department of Health Sciences, University of Florence, Anna Meyer through the induction of autophagy. PLoS Pathog 2012, 8:1523–1525.
Children’s University Hospital, viale Pieraccini 24, I-50139 Florence, Italy. 20. Valdivielso JM, Fernandez E: Vitamin D receptor polymorphisms and
2
Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation diseases. Clin Chim Acta 2006, 371:1–12.
Trust, London, UK. 3Department of Infectious Diseases, Great Ormond Street 21. Gao L, Tao Y, Zhang L, Jin Q: Vitamin D receptor genetic polymorphisms
Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, and tuberculosis: update systematic review and meta-analysis. Int J
UK. Tuberc Lung Dis 2010, 14:15–23.
22. Martineau AR, Honecker FU, Wilkinson RJ, Griffiths CJ: Vitamin D in the
Received: 1 June 2014 Accepted: 21 November 2014 treatment of pulmonary tuberculosis. J Steroid Biochem Mol Biol 2007,
103:793–798.
23. Nursyam EW, Amin Z, Rumende CM: The effect of vitamin D as
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doi:10.1186/s12879-014-0652-7
Cite this article as: Venturini et al.: Vitamin D and tuberculosis: a
multicenter study in children. BMC Infectious Diseases 2014 14:652.

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