Παιδιατρική | Τόμος 70 • Τεύχος 5 • Σεπτέμβριος - Οκτώβριος 2007

Paidiatriki 5 final

12-10-07

16:27

Page 1

¶·È‰È·ÙÚÈ΋ ¢ÈÌËÓÈ·›· ¤Î‰ÔÛË Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜

∆fiÌÔ˜ 70 ñ ∆‡¯Ô˜ 5 ñ ™Â٤̂ÚÈÔ˜ - √ÎÙÒ‚ÚÈÔ˜ 2007

¶Úfi‰ÚÔ˜ ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜

¶ÂÚȯfiÌÂÓ·

™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹

∞ƒ£ƒ√ ™À¡∆∞•∏™

¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ∫. ™ÙÂÊ·Ó›‰Ë˜

345 Classical and rare presentations of coeliac disease D. Branski, E. Lebenthal, E. Shteyer 347 §Ô›ÌˆÍË ·fi ÚÔÙ·˚fi. ¶fiÛÔ ÛÔ‚·Ú‹ ›ӷÈ; π.£. ∫·‚·ÏÈÒÙ˘

M¤ÏË ™. ∞Ó‰ÚÔÓ›ÎÔ˘ ¶. ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘ A. µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë °. µ·ÚÏ¿Ì˘ ª. °·Ï·Ó¿Î˘ §. £ˆÌ·˝‰Ô˘ ª. ∫·Ó¿ÚÈÔ˘ ∂. ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë A. K·ÙÙ¿Ì˘ ™. K›ÙÛÈÔ˘-∆˙¤ÏË ∞. ¶··‰ÔÔ‡ÏÔ˘ ¡. ¶··‰fiÔ˘ÏÔ˜ ∞. ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘ ª. ∆ÛÔÏÈ¿ ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ∞. µ·ÛÈÏÔÔ‡ÏÔ˘ EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘

∞¡∞™∫O¶∏™∂π™ 350 Diagnosis and management of obstructive uropathy in infants A. M. Becker, M. Baum 361 ¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘ °. ¶·Ú‰·Ïfi˜ 370 ÕÙ˘Ë-·ÙÂÏ‹˜ ÓfiÛÔ˜ Kawasaki: ¯ÚÂÈ·˙fiÌ·ÛÙ Ӥ· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·; °. °ÚËÁÔÚÈ¿‰Ô˘ 374 ™‡Á¯ÚÔÓ˜ ·fi„ÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi π. ¶·˘ÏÔÔ‡ÏÔ˘ 379 ∏ ‹È· Î·È Ì¤ÙÚÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ˆ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ ª. £·ÓÔÔ‡ÏÔ˘. °. ∆ÛfiÏ·˜ µƒ∞µ∂Àª∂¡∂™ ∂ƒ°∞™π∂™

EΉfiÙ˘ K. °ÚÈ‚¤·˜ ™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜ E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ¶ÈÂÚ›·˜ 1∞ 144 51 MÂÙ·ÌfiÚʈÛË TËÏ.: 210 87 78 810 Fax: 210 87 78 822 I‰ÈÔÎÙ‹Ù˘ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·© Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó· 115 28 TËÏ.: 210 7771 140 210 7771 663 Fax: 210 7758 354 e-mail: hps@ath.forthnet.gr EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹: 40 € EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜: 20 € ∫ˆ‰ÈÎfi˜ ¢È‡ı˘ÓÛ˘ ∂ÔÙ›·˜ ªª∂: 3889

ISSN 0377-2551

408 ¶·È‰È΋, Á˘Ó·ÈÎÔÏÔÁÈ΋ Î·È „˘¯ÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË ÂÓfi˜ ÎÔÚÈÙÛÈÔ‡ Ì ͤÓÔ ÛÒÌ· ÛÙÔÓ ÎfiÏÔ ∂. ¢ÂÏËÁÂÒÚÔÁÏÔ˘, ∞. ¢ÂÏË‚ÂÏÈÒÙÔ˘, µ. §¿ÁÁ·ÚË, ¶. ∆̷ۛÚ˘, π. ∆ÛÈ¿ÓÙ˘, °. ∫Ú·ÙÛ¿˜ 413 Rare manifestations of coeliac disease – Report of a case and review of the literature M. Ugras, D. Ertem, E. Pehlivanoglu

389 ªÂϤÙË ÙÔ˘ ÁÔÓȉȷÎÔ‡ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ +405g/c VEGF Î·È ÙˆÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û ·È‰È¿ Ì ÓfiÛÔ Kawasaki §. ºÈ‰¿ÓË, ∞. °È·ÓÓfiÔ˘ÏÔ˜, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜, °. ∆˙Ô˘‚ÂϤ΢, ∫. ∫·ÏÈÓ‰¤ÚË, ∞. ∫ÒÙÛ˘, π. ∫·‚·ÏÈÒÙ˘, º. ∞ı·Ó·ÛÈ¿‰Ô˘ ∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™ 395 ∂ȉËÌÈÔÏÔÁ›· ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Û ·È‰È¿ ÛÙËÓ ∂ÏÏ¿‰·: ªÂϤÙË Rotascore π. ∫·‚·ÏÈÒÙ˘, µ. ¶··Â˘·ÁÁ¤ÏÔ˘, ∂. ∫fiÎÎÔÚË, §. ª·ÓÙ·ÁÔ‡, °. ∆Ú›Ì˘, ∞. ∫ÔÓÙÔ‡, Ã. ª·ÛÈÔ‡ÚË, ¡. ¡ÈÎÔÏ·ÎÔÔ‡ÏÔ˘, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜, √Ì¿‰· ªÂϤÙ˘ ROTASCORE ∂¡¢π∞º∂ƒ√À™∂™ ¶∂ƒπ¶∆ø™∂π™ 402 º˘Ì·ÙÈ҉˘ ÛÔÓ‰˘Ï›ÙȘ (·ʈÛË Pott) Û ÓËȷ΋ ËÏÈΛ· ¢. Ã. ∫·Û›ÌÔ˜, ¢. §·˙ÔÔ‡ÏÔ˘, Õ. ∆Û·ÏΛ‰Ë˜, ¢. µÂÚ¤ÙÙ·˜, Ÿ. §ÂˆÓ›‰Ô˘, ∞. √ÈÎÔÓfiÌÔ˘, ¡. §·˙ÔÔ‡ÏÔ˘, ª. £ÂÔ‰ˆÚ›‰Ô˘, ∞. ÷Ù˙ËÌȯ·‹Ï

¶ƒ∞∫∆π∫√ £∂ª∞ 416 ∞ÛıÌ·ÙÈο ·È‰È¿ Î·È ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ º. ∫˘Ú‚·Û›Ï˘, ¡. ¶··‰fiÔ˘ÏÔ˜, π. ∆۷ӿη˜, º. ∫·Ó·ÎÔ‡‰Ë 420 ∂¶π™∆√§∏ ∞¶√ ∆∏ ™À¡∆∞•∏ ∫. ™ÙÂÊ·Ó›‰Ë˜ 421 ∫§π¡π∫√ ∫√Àπ∑ ∞. ∑¤ÏÏÔ˘ 422 ™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞ - ¡fiÛÔ˜ Kawasaki Î·È ‚Ï¿‚˜ ÛÙÂÊ·ÓÈ·›ˆÓ - ªËÓÈÁÁ›Ùȉ˜ Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ηٿÏÔÈ· - ∏ ·ÓÂÚ¯fiÌÂÓË Kingella kingae - ∆· ÂÌ‚fiÏÈ· οÓÔ˘Ó Î·Ïfi Î·È ÛÙÔ˘˜ ÁÔÓ›˜ - ∏ ÂÔ¯‹ ÌÂÙ¿ ÙÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ - ∂Ì‚fiÏÈÔ ·ÓÂÌ¢ÏÔÁÈ¿˜: ÌÈ· ‰fiÛË ‰ÂÓ ÊÙ¿ÓÂÈ - º˘Ì·Ù›ˆÛË: ÓÂfiÙÂÚ· ÛÙË ‰È¿ÁÓˆÛË - ÃÂψӛÙÛ˜ Î·È ™·ÏÌÔÓ¤ÏϘ - ¶·Ú¤· Ì ˙Ò· ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· - ∂ÎÊÔ‚ÈÛÌfi˜ ÛÙÔ Û¯ÔÏÂ›Ô Î·È ÌÂÙ¤ÂÈÙ·

„˘¯È΋ ˘Á›· - ∂ȉËÌ›· ÈÏ·Ú¿˜ Û ۯÔÏÂ›Ô ÛÙË °ÂÚÌ·Ó›·

∂. °·Ï·Ó¿Î˘ 424 ¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ πÛÙÔÛÂÏ›‰Â˜ ÁÈ· Ù· ÊıÈÓÔˆÚÈÓ¿ ÎÚ˘ÔÏÔÁ‹Ì·Ù· ¡. ¶··‰fiÔ˘ÏÔ˜

Paidiatriki 5 final

15-10-07

10:49

Page 3

Paediatriki Bimonthly Publication of the Greek Paediatric Society

Volume 70 ñ Number 5 ñ September-October 2007

President A. Constantopoulos

Contents

Editorial Board

EDITORIAL COMMENTARY

Editor-in-Chief C. Stefanidis Members S. Andronikou P. Augoustides-Savvopoulou A. Vazeou-Gerasimidi G. Varlamis M. Galanakis L. Thomaidou M. Kanariou ∂. Katsarou-Pectasides A. Kattamis S. Kitsiou-Tzeli ∞. Papadopoulou N. Papadopoulos A. Siamopoulou-Mavridou M. Tsolia Manuscript Editing Greek Editing A. Vasilopoulou English Editing S. Nakou

345 Classical and rare presentations of coeliac disease D. Branski, E. Lebenthal, E. Shteyer

402 Tuberculous spondylitis (Pott’s kyphosis) in a toddler D.H. Kasimos, D. Lazopoulou, A. Tsalkidis, D. Verettas, O. Leonidou, A. Oikonomou, N. Lazopoulou, M. Theodoridou, A. Hatzimihail

347 Rotavirus infection. How serious is it?

I.T. Kavaliotis

CASE REPORTS

REVIEW ARTICLES 350 Diagnosis and management of obstructive uropathy in infants A. M. Becker, M. Baum 361 Kawasaki disease: Clinical heterogeneity and strategic management G. Pardalos

408 Paediatric gynaecological and psychological evaluation of a girl with a foreign body in the vagina: a case report E. Deligeoroglou, A. Deliveliotou, V. Laggari, P. Tsimaris, I. Tsiantis, G. Creatsas 413 Rare manifestations of coeliac disease – Report of a case and review of the literature M. Ugras, D. Ertem, E. Pehlivanoglu

370 Atypical Kawasaki disease: criteria G. Grigoriadou

PRACTICAL ISSUE

374 Current concepts in prevention of rotavirus gastroenteritis I. D. Pavlopoulou

416 Influenza vaccination in children with asthma F. Kyrvassilis, N. Papadopoulos, I. Tsanakas, F. Kanakoudi

379 Mild-to-moderate hyperhomocysteinaemia as a risk factor for atherosclerosis and thromboembolic disease M. Thanopoulou, G. Tsolas

420 LETTER FROM THE EDITORS C. Stefanidis

Publisher K. Griveas

AWARD-WINNING ARTICLES

Publishing Coordinator

389 Study of VEGF 405VG C polymorphism and of relevant clinical and laboratory data in children with Kawasaki disease L. Fidani, A. Giannopoulos, A. Tragianidis, G. Tzouvelekis, K. Kalinderi, A. Kotsis, I. Kavaliotis, F. Athanassiadou

SCIENTIFIC PUBLICATIONS Ltd 1∞ Pierias St. GR - 144 51, Metamorfossi Tel.: +30 210 87 78 810 Fax: +30 210 87 78 822

ORIGINAL ARTICLES Owner Greek Paediatric Society© 92 Michalakopoulou str.

GR - 115 28, Athens Tel.: +30 210 7771 140 +30 210 7771 663 Fax: +30 210 7758 354 e-mail: hps@ath.forthnet.gr Annual Subscription All foreign countries: US $ 50

395 ROTASCORE Study: Epidemiological observational study of rotavirus acute gastroenteritis in children in Greece I. Kavaliotis, V. Papaevangelou, H. Kokori, L. Mantagou, G. Trimis, A. Kontou, C. Basiouri, N. Nikolakopoulou, A. Konstantopoulos, ROTASCORE Study Group

421 CLINICAL QUIZ A. Zellou 422 PAEDIATRIC NEWS IN BRIEF E. Galanakis 424 NEWS FROM THE INTERNET N. Papadopoulos

Paidiatriki 5 final

12-10-07

16:27

Page 5

™À¡∆∞∫∆π∫∏ E¶π∆ƒ√¶∏

EDITORIAL BOARD

¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘

Editor-in-Chief

∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜, ∞ı‹Ó·

Constantinos Stefanidis, Athens

∂ȉÈÎÔ› ™˘ÓÙ¿ÎÙ˜

Section Editors

™Ù¤ÏÏ· ∞Ó‰ÚfiÓÈÎÔ˘, ¡ÂÔÁÓÔÏÔÁ›·, πˆ¿ÓÓÈÓ·

Stella Andronikou, Neonatology, Ioannina

¶ÂÚÛÂÊfiÓË ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘, MÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, £ÂÛÛ·ÏÔÓ›ÎË

Persefoni Avgoustides-Savvopoulou, Metabolic Disorders, Thessaloniki

∞Ó‰ÚÈ·Ó‹ µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë, ∂Ó‰ÔÎÚÈÓÔÏÔÁ›·, ∞ı‹Ó·

Andriani Vazaiou-Gerasimidi, Endocrinology, Athens

°ÂÒÚÁÈÔ˜ µ·ÚÏ¿Ì˘, ∫·Ú‰ÈÔÏÔÁ›·, £ÂÛÛ·ÏÔÓ›ÎË

George Varlamis, Cardiology, Thessaloniki

∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘, ∏ıÈ΋ Î·È ¢ÂÔÓÙÔÏÔÁ›·, ∏Ú¿ÎÏÂÈÔ

Emmanouil Galanakis, Ethics and Deontology, Heraklion

§ˆÚ¤ÙÙ· £ˆÌ·˚‰Ô˘, ∞Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜, ∞ı‹Ó·

Loretta Thomaidou, Developmental Pediatrics, Athens

ª·Ú›· ∫·Ó¿ÚÈÔ˘, ∞ÓÔÛÔÏÔÁ›·, ∞ı‹Ó·

Maria Kanariou, Immunology, Athens

∂˘ÛÙ·ı›· ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë, ¡Â˘ÚÔÏÔÁ›·, ∞ı‹Ó·

Eustathia Katsarou-Pektasides, Neurology, Athens

∞ÓÙÒÓ˘ ∫·ÙÙ¿Ì˘, ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·, ∞ı‹Ó·

Antonis Kattamis, Haematology - √ncology, Athens

™ÔÊ›· ∫›ÙÛÈÔ˘-∆˙¤ÏË, °ÂÓÂÙÈ΋, ∞ı‹Ó·

Sophia Kitsiou-Tzeli, Genetics, Athens

∞ÏÂÍ¿Ó‰Ú· ¶··‰ÔÔ‡ÏÔ˘, °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ¢È·ÙÚÔÊ‹, ∞ı‹Ó·

Alexandra Papadopoulou, Gastroenterology - Nutrition, Athens

¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜, ∞ÏÏÂÚÁÈÔÏÔÁ›· ¶Ó¢ÌÔÓÔÏÔÁ›·, ∞ı‹Ó·

Nicos Papadopoulos, Allergology - Pneumonology, Athens

∞ÓÙÈÁfiÓË ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘, ƒÂ˘Ì·ÙÔÏÔÁ›·, πˆ¿ÓÓÈÓ·

Antigoni Siamopoulou-Mavridou, Rheumatology, Ioannina

ª·Ú›˙· ∆ÛÔÏÈ¿, §ÔÈ̈ÍÈÔÏÔÁ›·, ∞ı‹Ó·

Marisa Tsolia, Infectious Diseases, Athens

ª¤ÏË Ù˘ ¢ÈÂıÓÔ‡˜ ™˘ÓÙ·ÎÙÈ΋˜ ∂ÈÙÚÔ‹˜ ñ Members of the International Editorial Board Alexis Arzimanoglou, Paris, France

Peter Hoyer, Essen, Germany

Ellis D. Avner, Milwaukee, USA

Jan Janda, Prague, Czech Republic

Swati Bhave, New Delhi, India

Jan Kimpen, Ultrecht, Netherlands

Alberto Bissot, Panama, Panama

Craig B. Langman, Chicago, USA

David Branski, Jerusalem, Israel

John Manis, Boston, USA

Francesco Chiarelli, Chieti, Italy

Manuel Moya, Alicante, Spain

Chok-Wan Chan, Hong Kong, China

Hugh O'Brodovich, Toronto, Canada

Denis Daneman, Toronto, Canada

Ross Petty, Vancouver, Canada

Jochen Ehrich, Hannover, Germany

Willem Proesmans, Leuven, Belgium

Demetrius Ellis, Pittsburgh, USA

Jose Ramet, Antwerp, Belgium

Yoshikatsu Eto, Tokyo, Japan

Alan Sinaiko, Minneapolis, USA

Richard N. Fine, Stony Brook, USA

Nick J. Spencer, Coventry, UK

Margaret C. Fisher, Philadelphia, USA

Alfred Tenore, Udine, Italy

Raif Geha, Boston, USA

Alkis Togias, Bethesda, USA

Adenike Grange, Lagos, Nigeria

Eva Tsalikian, Iowa City, USA

Judith G. Hall, Vancouver, Canada

Catherine Weil-Olivier, Paris, France

Patricia Hamilton, London, UK

Max Zach, Graz, Austria

Enver Hasanoglu, Ankara, Turkey

Johannes Zschocke, Heidelberg, Germany

Christer Holmberg, Helsinki, Finland

v

Paidiatriki 5 final

12-10-07

16:28

Page 345

EDITORIAL COMMENTARY

∞ƒ£ƒ√ ™À¡∆∞•∏™

345

Classical and rare presentations of coeliac disease D. Branski, E. Lebenthal, E. Shteyer Coeliac disease (CD) is an autoimmune systemic disorder occurring in genetically susceptible subjects following exposure to gluten in the diet. It is a common disease, occurring in approximately 1% of the population of many geographical areas including Europe, USA, Northern Africa and the Middle East (1). The diagnosis of CD is based on the clinical presentation, the laboratory studies, mainly serological, the characteristic small bowel mucosal histopathology findings and the clinical response to a strict gluten-free diet (GFD). Although the small bowel biopsy is the “gold standard” for the ultimate diagnosis of CD, other disorders such as infections, infestations, food protein hypersensitivities, etc., may share the same histopathologic morphology of the small intestinal mucosa (1).

Classical presentations In recent decades the clinical presentation of CD has been changing, and the increased incidence of its diagnosis has become markedly apparent. In the past, most of the clinical features of CD presented early in life. The typical early presentations of CD included diarrhoea, steatorrhoea, malabsorption, failure to thrive and growth retardation. Some patients, mainly toddlers, manifested psychomotor delay, whereas adolescents showed delayed sexual development.

Anorexia, apathy and irritability were common.

Vomiting or constipation could be presenting symptoms; pseudo obstruction-like syndrome and intussusceptions were also, but less frequently, reported.

However, recently, the bulk of new cases of CD are no longer identified from the classical presentation, but instead, many new subjects are being diagnosed as suffering from CD through screening programmes, monosymptomatic presentation, extraintestinal manifestations, symptoms related to the outcome of malabsorption and “atypical forms”. A current study (2) on CD revealed that only 36% of patients presented with diarrhoea, while 26% were diagnosed by targeted screening, and 16% had non-specific recurrent abdominal pain. Furthermore, it is apparent that most children with CD remain undiagnosed.

Coeliac crisis, as presented in the paper of Ugras and colleagues in this volume (3), is nowadays a very rare occurrence during the clinical course of CD. It is a common final pathway of severe malabsorption, and consequently severe malnutrition of major nutrients including carbohydrates, proteins and lipids, electrolytes, minerals, trace elements and vitamins. Hence, the patient may suffer from a combination of several important nutritional deficiencies, the most striking of which are hypoglycaemia, hypokalaemia, hypocalcaemia and hypomagnesaemia. Ascites due to hypoalbuminaemia, related to protein losing enteropathy accompanied by protein malabsorption is very significant in coeliac crisis. This is a life threatening situation and immediate supportive treatment can be life saving.

In the past, CD patients were seldom observed with the very serious and ominous presentation of coeliac crisis. Very infrequently the admission of a patient with coeliac crisis constituted the presenting feature of CD. The main concern today is that even with the changing pattern of clinical presentation of CD a coeliac crisis can still happen. The second concern is how to explain the occurrence of coeliac crisis; is it due to secondary nutritional deficiencies or is it a primary occurrence?

At present, mass screening of the whole population is not recommended, the aim being to screen the population at risk of developing CD, such as first-degree relatives of patients with CD, subjects with autoimmune disorders, such as insulin dependent diabetes mellitus, thyroiditis and other endocrinopathies (4,5). As an increased incidence of non-Hodgkin lymphoma is observed in active CD patients, 42.7 times higher than that expected in the normal population, the screening of patients with non-Hodgkin lymphoma for CD should be considered (6).

Various autoimmune collagen diseases as well as several other disorders, mainly genetic syndromes, including Down syndrome (7), Turner syndrome and Beckwitt-Wiedemann syndrome, are associated with CD, and patients with these disorders should also be screened. Symptoms related to the outcome of malabsorption are not uncommon as presenting features of CD nowadays, such as iron deficiency anaemia or bone disorders, including osteoporosis.

Paediatric Gastroenterology Unit, Division of Paediatrics, Hebrew University, Hadassah Medical Centre, Jerusalem, Israel Correspondence: David Branski branski@hadassah.org.il Professor and Chairman Division of Paediatrics Hebrew University, Hadassah Medical Center Jerusalem, Israel

¶·È‰È·ÙÚÈ΋ 2007;70:345-346

Paidiatriki 5 final

12-10-07

16:28

Page 346

346

D. Branski et al.

Extraintestinal manifestations and “atypical forms” Growth retardation can be the only presenting symptom. Apart from endocrinopathies as mentioned earlier, endocrine abnormalities may occur in CD due to severe malabsorption. Secondary hypopituitarism, for example, probably caused by severe malnutrition, is found mainly in individuals with chronic disease on a gluten containing diet. Untreated female patients sometimes report hypomenorrhoea or amenorrhoea, or have recurrent abortions. Males may have hypogonadism, oligospermia and abnormal sperm motility and morphology. Mothers with active CD may have offspring of low birth weight in comparison to neonates born to mothers without CD (8).

Peripheral neuropathy, patchy demyelinization of the spinal cord, cerebellar atrophy and capillary proliferation have been reported in CD. A triad of intractable epilepsy, parieto-occipital calcifications and CD has been described. Recently coeliac ataxia has been reported, with demonstration of tissue transglutaminase activity in the brain tissues (9).

Chronic cryptogenic hepatitis and elevated liver transaminase levels are now recognized as isolated presenting symptoms of CD. Very rarely cardiac disorders and chronic lung diseases have been associated with CD. Monosymptomatic features, such as arthropathy and other associated disorders i.e., alopecia and enamel hypoplasia have been reported in CD. In addition, IgA deficiency is at least 3-6 times more common in people with CD than in the general population. Silent (asymptomatic) CD is being increasingly recognized, in which gastrointestinal symptoms are absent, but on small bowel biopsy, severe mucosal

Paediatriki 2007;70:345-346

damage consistent with CD is apparent. These patients are investigated during screening studies.

In conclusion, at present more patients are being diagnosed as suffering from CD through the screening of at-risk populations and from extraintestinal manifestations and atypical presentation. The awareness of the physician, as well as the public, is the key issue to diagnosis of the disease at an early stage and subsequent timely commencement of strict GFD for life in order to avoid future complications, mainly iron deficiency anaemia, osteoporosis, infertility and non-Hodgkin lymphoma.

References 1. Lebenthal E, Branski D. Childhood celiac disease-a reappraisal. J Pediatr 1981;98:681-690.

2. Ravikumara M, Tuthill DP, Jenkins HR. The changing clinical presentation of coeliac disease. Arch Dis Child 2006;91:969-971.

3. Ugras M, Ertem D, Pehlivanoglu E. Rare manifestations of coeliac disease - Report of a case and review of the literature. Paediatriki 2007;70:422-424.

4. Fasano A, Catassi C. Coeliac disease in children. Best Pract Res Clin Gastroenterol 2005;19:467-478.

5. Branski D, Fasano A, Troncone R. Latest developments in the pathogenesis and treatment of celiac disease. J Pediatr 2006;149:295-300.

6. Holmes GK, Prior P, Lane MR, Pope D, Allan RN. Malignancy in coeliac disease-effect of a gluten free diet. Gut 1989;30:333-338.

7. Amil-Dias J, Walker-Smith J.A. Down's syndrome and coeliac disease. J Pediatr Gastroenterol Nutr 1990;10:41-43.

8. Ludvigsson JF, Montgomery SM, Ekbom A. Celiac disease and risk of adverse fetal outcome: a population-based cohort study. Gastroenterology 2005;129:454-463.

9. Hadjivassiliou M, Mäki M, Sanders DS, Williamson CA, Grünewald RA, Woodroofe NM, et al. Autoantibody targeting of brain and intestinal transglutaminase in gluten ataxia. Neurology 2006;66:373-377.

Paidiatriki 5 final

12-10-07

16:28

Page 347

∞ƒ£ƒ√ ™À¡∆∞•∏™

EDITORIAL COMMENTARY

347

§Ô›ÌˆÍË ·fi ÚÔÙ·˚fi. ¶fiÛÔ ÛÔ‚·Ú‹ ›ӷÈ; π. £. ∫·‚·ÏÈÒÙ˘

¶ÂÚÈÙÒÛÂȘ ¡Ô.

∞ÏÏËÏÔÁÚ·Ê›·: π. £. ∫·‚·ÏÈÒÙ˘ kavagrc@netscape.net ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ∂ȉÈÎÒÓ ¶·ı‹ÛÂˆÓ £ÂÛÛ·ÏÔӛ΢, °Ú. §·ÌÚ¿ÎË 13, £ÂÛÛ·ÏÔÓ›ÎË

I

º

M

A

M

I I ª‹Ó˜

∞

™

√

¡

¢

∂ÈÎfiÓ· 1. ∂ԯȷ΋ ηٷÓÔÌ‹ ÚÔÙ·˚Ô‡. ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡∂¶£.

ÊÔÚ¿ ÙÔ˘Ï¿¯ÈÛÙÔÓ, ÂÓ›ÔÙ ÁÈ· >1 ÊÔÚ¿, ÂÓÒ 1:10 ·È‰È¿ ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ ¤ˆ˜ Î·È 5 ÓÔÛ‹ÛÂȘ. ¢ÈÂıÓÒ˜, 1:5 ·È‰È¿ ı· ÂÈÛÎÂÊı› ÁÈ·ÙÚfi ÏfiÁˆ Ïԛ̈͢ ·fi ÚÔÙ·˚fi, 1:50 ı· ÓÔÛËÏ¢ı› Î·È 1:285 ı· ηٷϋÍÂÈ. ∏ Ïԛ̈ÍË ·fi ÚÔÙ·˚fi ¤¯ÂÈ ›‰È· Û˘¯ÓfiÙËÙ· ‰ÈÂıÓÒ˜ ·ÏÏ¿ ‰È·ÊÔÚÂÙÈ΋ ¤Î‚·ÛË, Ì ÙÔ 80% ÙˆÓ ı·Ó¿ÙˆÓ Ó· ·Ú·ÙËÚÂ›Ù·È Û ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜. ™˘ÓÂÒ˜, ÙÔ ÚÔÛˆÂ›Ô Ù˘ Ïԛ̈͢ ·fi ÚÔÙ·˚fi Ì ‰È¿ÚÚÔÈ·-Â̤ÙÔ˘˜-·Ê˘‰¿ÙˆÛË-ηٷÏËÍ›·ı¿Ó·ÙÔ ÔÈΛÏÏÂÈ ·fi ¯ÒÚ· Û ¯ÒÚ· (4,5,6). ™ÙËÓ ÂÚÈÔ¯‹ Ì·˜, Ì ‚¿ÛË Ù· ÛÙÔȯ›· Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ Û ÌÂÁ¿ÏË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô (19842006) Ô˘ ·ÊÔÚÔ‡Ó 2264 ·ÛıÂÓ›˜ Ì ÔÍ›· ‰È¿ÚÚÔÈ· ·fi ÚÔÙ·˚fi (7), Î·È Ô˘ ÈÛÙ‡ԢÌ fiÙÈ Â›Ó·È ·ÓÙÈÚÔÛˆ¢ÙÈο fiÏ˘ Ù˘ ¯ÒÚ·˜, ÙÔ ÚÔÊ›Ï Ù˘ Ïԛ̈͢ ÂÚÈÁÚ¿ÊÂÙ·È ˆ˜ ÂÍ‹˜: ∏ ÂÙ‹ÛÈ· ηٷÓÔÌ‹ (∂ÈÎfiÓ· 2) ¤¯ÂÈ ‰È·Î˘Ì¿ÓÛÂȘ. øÛÙfiÛÔ, ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÈÂÙ›· ·Ú·ÙËÚÂ›Ù·È ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ Ïԛ̈͢ Û ÔÛÔÛÙfi 220% (∂ÈÎfiÓ· 3). ∏ ÔÍ›· ‰È¿ÚÚÔÈ· ‹Ù·Ó Û˘¯ÓfiÙÂÚË Û ·È‰È¿ 300 ¶ÂÚÈÙÒÛÂȘ ¡Ô.

250 200 150 100 50 0

4 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 20 06

∂Ó Û˘Ófiψ Ïԛ̈ÍË ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ô ÚÔÙ·˚fi˜ ·ÔÙÂÏ› Û‹ÌÂÚ· ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· ÔÍ›·˜ ‰È¿ÚÚÔÈ·˜ ÛÙ· ‚Ú¤ÊË. √ Èfi˜ ·ÔÙÂÏÂ›Ù·È ·fi ‰ÈÏfi η„›‰ÈÔ, ¤¯ÂÈ 20‰ÚÈ΋ Û˘ÌÌÂÙÚ›·, ÔÚÔÔÌ¿‰Â˜ (∞, µ, C, D, E, F, G), ÔÚÔÙ‡Ô˘˜ (P Î·È G) Î·È ‰ÔÌÈΤ˜ ÚˆÙ½Ó˜ (·ÚȘ Â›Ó·È ÔÈ VP7, VP4, VP6). √È 5 ·ÚÈÔÈ oÚfiÙ˘ÔÈ, G1, G2, G3, G4 Î·È G9, ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó >98% Ù˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi, Ô ÔÔ›Ô˜ ÌÂÙ·‰›‰ÂÙ·È Ì ÙËÓ ÂÓÙÂÚÔÛÙÔÌ·ÙÈ΋ Ô‰fi (¿ÙÔÌÔ-ÛÂ-¿ÙÔÌÔ), ÂÓÒ Â›Ó·È ‰˘Ó·Ù‹ Î·È Ë ·Ó·Ó¢ÛÙÈ΋ Ô‰fi˜ ÌÂÙ¿‰ÔÛ˘. °È· Ó· ·Ó·Ù˘¯ı› Ë Ïԛ̈ÍË, ··ÈÙÂ›Ù·È ÌÈÎÚ‹ ÏÔÈÌÔÁfiÓÔ˜ ‰fiÛË (10-100 pfu) ÙÔ˘ ÈÔ‡, Ô ÔÔ›Ô˜ ÂÈÔÏ¿˙ÂÈ Î˘Ú›ˆ˜ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜ (∂ÈÎfiÓ· 1) (3). √ Èfi˜ ÌÔχÓÂÈ Ô˘ÛÈ·ÛÙÈο fiÏ· Ù· ·È‰È¿ ÁÈ· 1

500 450 400 350 300 250 200 150 100 50 0

19 8

¶ÚfiÛÊ·Ù· ÚÔÛÎÔÌ›ÛÙËΠÁÈ· ÂÁÎÂÊ·Ï›Ùȉ· ÛÙËÓ ÎÏÈÓÈ΋ Ó‹ÈÔ Ì Â̤ÙÔ˘˜, ‰È¿ÚÚÔȘ Î·È ˘ÚÂÙfi ·fi 3Ë̤ÚÔ˘. ¶ÚÔÛÙ¤ıËΠ˘ÓËÏ›·, ÓˆıÚfiÙËÙ·, Û˘Á¯˘ÙÈÎÔ‰ÈÂÁÂÚÙÈ΋ ηٿÛÙ·ÛË, ÔÈÛıfiÙÔÓÔ˜, ÛÙÚ·‚ÈÛÌfi˜, ÙÚÈÛÌfi˜ Ô‰fiÓÙˆÓ, ¿Ù·ÎÙ˜ ÎÈÓ‹ÛÂȘ Î·È fi¯È ηϋ ÂÈÎÔÈÓˆÓ›· Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ. √ ·ÛıÂÓ‹˜ ·ÓÙÈÌÂÙˆ›ÛıËΠˆ˜ ÂÁÎÂÊ·Ï›Ùȉ· Ì ·ÈÙÈÔÏÔÁÈ΋ (ÁÈ· Èı·Ófi HSV) Î·È Û˘Ìو̷ÙÈ΋ ·ÁˆÁ‹. ∏ 1Ë ªRI ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ Î·È Ë 2Ë (ÌÂÙ¿ 15 Ë̤Ú˜) ¤‰ÂÈÍ ·Ú¯fiÌÂÓË ·ÙÚÔÊ›· ÂÁÎÂÊ·ÏÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ Î·È ‹ÈÔ Ô›‰ËÌ· ÊÏÔÈÔ‡ ËÌÈÛÊ·ÈÚ›ˆÓ. ∞fi ÙÔÓ ÂÊÈÎÙfi Û ̷˜ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, ÌÔÓ·‰ÈÎfi ‡ÚËÌ· ‹Ù·Ó ÎfiÚ·Ó· ıÂÙÈο ÁÈ· ÚÔÙ·˚fi. ∞Ó Î·È Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÈÔ‡ ÌfiÓÔ ÛÙ· ÎfiÚ·Ó· ‰ÂÓ Â›Ó·È Ë Î·Ï‡ÙÂÚË ·fi‰ÂÈÍË ÁÈ· ÙË Û¯¤ÛË ÙÔ˘ ÚÔÙ·˚Ô‡ Ì ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·È‰ÈÔ‡, ˆÛÙfiÛÔ ˘¿Ú¯Ô˘Ó ‰ËÌÔÛȇÛÂȘ Ô˘ ·Ô‰›‰Ô˘Ó ·Ó¿ÏÔÁ˜ ÂÈÎfiÓ˜ ÛÙÔÓ ÚÔÙ·˚fi Ì ÌfiÓË ÂͤٷÛË ÙË ıÂÙÈ΋ ‰ÔÎÈÌ·Û›· ÎÔÚ¿ÓˆÓ (1,2).

TËÓ ›‰È· ÂÚ›Ô˘ ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ‰Â¯ı‹Î·Ì ¤ÁÁÚ·ÊË ‰È·Ì·ÚÙ˘Ú›· ÁÔÓ¤· ÁÈ· ÌË Â˘ÚÂ‹ Û˘ÌÂÚÈÊÔÚ¿ ÂȉÈ΢Ô̤ÓÔ˘. ∆Ô ·È‰› ÙÔ˘ ‰È·Ì·ÚÙ˘ÚfiÌÂÓÔ˘ ÁÔÓ¤· ¤·Û¯Â ·fi Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi Èfi ÚÔÙ·˚fi. £· ÌÔÚÔ‡Û ‚¤‚·È· Ó· ¿Û¯ÂÈ ·fi ÔÙȉ‹ÔÙ ¿ÏÏÔ. ∆· ‰‡Ô ·Ú·¿Óˆ ÁÂÁÔÓfiÙ·, ·ÓÂÍ¿ÚÙËÙ· ÌÂٷ͇ ÙÔ˘˜, ·Ó·‰ÂÈÎÓ‡Ô˘Ó ÙȘ ‰‡Ô fi„ÂȘ Ù˘ Ïԛ̈͢ ·fi ÚÔÙ·˚fi: ÙËÓ ÂÓ Û˘Ófiψ Î·È ÙËÓ ÂÈ̤ÚÔ˘˜.

¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ∂ȉÈÎÒÓ ¶·ı‹ÛÂˆÓ £ÂÛÛ·ÏÔӛ΢

∂ÈÎfiÓ· 2. ∂Ù‹ÛÈ· ηٷÓÔÌ‹ Ù˘ ÔÍ›·˜ ‰È¿ÚÚÔÈ·˜ ·fi ÚÔÙ·˚fi. ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡∂¶£. ¶·È‰È·ÙÚÈ΋ 2007;70:347-349

Paidiatriki 5 final

12-10-07

16:28

Page 348

348

π. £. ∫·‚·ÏÈÒÙ˘

80 80

60 60 50 50 40 40 30 30 20 20

20

10 10

00 2005/2006

2006/2007

∂ÈÎfiÓ· 3. ™˘¯ÓfiÙËÙ· ÔÍ›·˜ ‰È¿ÚÚÔÈ·˜ ·fi ÚÔÙ·˚fi ÙËÓ ÂÚ›Ô‰Ô ¡Ô¤Ì‚ÚÈÔ˜ ¤ˆ˜ ∞Ú›ÏÈÔ˜ (2005-2006/2006-2007). ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡∂¶£.

ËÏÈΛ·˜ οو ÙˆÓ 2 ÂÙÒÓ Î·È ÂȉÈÎfiÙÂÚ· Û ·È‰È¿ 6 ÌËÓÒÓ ¤ˆ˜ 2 ÂÙÒÓ. √ ÚÔÙ·˚fi˜ ›¯Â ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË (p<0,01) ÌÂ: - ™ËÌ›· ·Ê˘‰¿ÙˆÛ˘ - ∞ÏÏ·Á‹ Û˘ÌÂÚÈÊÔÚ¿˜ (¢ÂÚÂıÈÛÙfiÙËÙ·, ÎfiˆÛË, Ï‹ı·ÚÁÔ˜) - ∞ÚÈıÌfi ‰È·ÚÚÔÈÒÓ / Ë̤ڷ - ∂̤ÙÔ˘˜ (·ÚÈıÌfi ·Ó¿ Ë̤ڷ Î·È ‰È¿ÚÎÂÈ·) - ⁄·ÚÍË ˘ÚÂÙÔ‡ ≥38ÔC ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ, 100 ·È‰È¿ ·ÚÔ˘Û›·Û·Ó ÂÈÏÔΤ˜ (¶›Ó·Î·˜ 1). √È ÂÈÏÔΤ˜ ‹Ù·Ó ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ÂÏ·ÊÚ¤˜. Œ¯Ô˘Ì ÏÔÈfiÓ ÌÈ· ÓfiÛÔ Ì ‹È· ÔÚ›·, ¯ˆÚ›˜ ıÓËÙfiÙËÙ·, ·ÏÏ¿ Û˘¯Ó‹ Î·È Ì ÔÛÔÛÙfi ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ Èı·ÓfiÓ ÍÂʇÁÔ˘Ó ÙÔ˘ ·˘ÛÙËÚÔ‡ ÔÚÈÛÌÔ‡, ·ÏÏ¿ ‰ÂÓ ·‡Ô˘Ó Ó· Â›Ó·È ÚÔ‚Ï‹Ì·Ù·.

∂È̤ÚÔ˘˜ Ïԛ̈ÍË ø˜ Ù¤ÙÔÈ· ÂÓÓÔԇ̠ÙËÓ Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ÛÙË ÓÔÛËÚfiÙËÙ· ηÙÂÍÔ¯‹Ó Î·È ÛÙ· ·Ú¿Ï¢ڷ ÚÔ‚Ï‹Ì·Ù· Ô˘ ÚÔηÏ›. ™ËÌ·ÓÙÈ΋ Â›Ó·È Î·È Ë ÔÈÎÔÓÔÌÈ΋ ÏÂ˘Ú¿ Ù˘ Ïԛ̈͢ (8,9). ∏ Â›ÙˆÛË ÏÔÈfiÓ Ù˘ Ïԛ̈͢ ‰È·ÎÚ›ÓÂÙ·È ÛÂ: ÕÌÂÛÔ È·ÙÚÈÎfi ÎfiÛÙÔ˜ - ™‡ÛÙËÌ· ÀÁ›·˜ - Ÿ¯È ÙfiÛÔ ÛÔ‚·Ú‹ ÓfiÛÔ˜ fiÛÔ ¿ÏϘ ÏÔÈÌÒÍÂȘ

¶›Ó·Î·˜ 1. ∂ÈÏÔΤ˜ ÔÍ›·˜ ‰È¿ÚÚÔÈ·˜ ·fi ÚÔÙ·˚fi Û ۇÓÔÏÔ 2264 ·ÛıÂÓÒÓ. ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡∂¶£ ™·ÛÌÔ› ¢˘Û·ÓÔ¯‹ ÛÙË Ï·ÎÙfi˙Ë ÀÔÓ·ÙÚÈ·ÈÌ›· ∞ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ∂ÁÎÂÊ·Ï›Ùȉ· ÕÛËÙË ÌËÓÈÁÁ›Ùȉ· √˘Ú·ÈÌÈÎfi ·ÈÌÔÏ˘ÙÈÎfi Û‡Ó‰ÚÔÌÔ £¿Ó·ÙÔ˜ Paediatriki 2007;70:347-349

100 89 51 10 11 3 2 1 1

ÕÌÂÛÔ ÌË È·ÙÚÈÎfi ÎfiÛÙÔ˜ - √ÈÎÔÁ¤ÓÂÈ· ·Û¯fiÓÙˆÓ - ORS ‰È·Ï‡Ì·Ù· - ¶¿Ó˜ - ªÂÙ·ÊÔÚÈο - ∆ÚÔÊ‹ ŒÌÌÂÛÔ ÎfiÛÙÔ˜ - √ÈÎÔÁÂÓÂÈ·Îfi˜ ÂÚ›Á˘ÚÔ˜ - ∫·ıÔÚ›˙ÂÙ·È ·fi ÙËÓ ÎÔÈÓˆÓÈ΋ ‰ÔÌ‹ οı ¯ÒÚ·˜ - ∞Ó Ë ÌËÙ¤Ú· ÂÚÁ¿˙ÂÙ·È, ÙÔ ÎfiÛÙÔ˜ ·˘Í¿ÓÂÈ Ôχ - ∞ÒÏÂÈ· ·Ú·ÁˆÁÈÎfiÙËÙ·˜ - ™ËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ¯·Ì¤ÓˆÓ ËÌÂÚÒÓ ·fi ÙËÓ ÂÚÁ·Û›· ÙˆÓ ÁÔÓ¤ˆÓ ªÂ›ˆÛË ‰È·ıÂÛ›ÌˆÓ ÎÏÈÓÒÓ - ÃÂÈÌÂÚÈÓ‹ ÓfiÛÔ˜ - ∂Ô¯‹ Ì ÌÂÁ¿ÏË Û˘¯ÓfiÙËÙ· ¿ÏÏˆÓ ÏÔÈÌÒÍÂˆÓ - ¶ÂÚÈÔÚÈÛÌfi˜ ÎÏÈÓÒÓ. ∏ Î¿Ï˘„Ë ÙˆÓ ÎÏÈÓÒÓ ·fi ·ÛıÂÓ›˜ Ì ÔÍ›· ‰È¿ÚÚÔÈ· ÂÌÔ‰›˙ÂÈ ÙË ‰È¿ıÂÛË ÙˆÓ ÎÏÈÓÒÓ Û ·ÛıÂÓ›˜ Ì ¿ÏÏ· ÓÔÛ‹Ì·Ù· ÂÔ¯‹˜.

- ∞˘Í¿ÓÂÈ Ô Û˘ÓˆÛÙÈÛÌfi˜ ·ÛıÂÓÒÓ Î·È Û˘ÓÔ‰ÒÓ Ì fiÏ· Ù· Â·ÎfiÏÔ˘ı¿ ÙÔ˘. ∏ ÛËÌ·Û›· Ù˘ ÙÂÏÂ˘Ù·›·˜ ·Ú·Ì¤ÙÚÔ˘ Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 4, fiÔ˘ ÏfiÁˆ Ù˘ Û˘Ó¯ԇ˜ ·‡ÍËÛ˘ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙˆÓ ÓÔÛËÏ¢ÔÌ¤ÓˆÓ ·ÛıÂÓÒÓ ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ (·Ó·Ê¤ÚÔÓÙ·È ÔÈ ¯ÂÈÌÂÚÈÓÔ› Ì‹Ó˜ fiÔ˘ Â›Ó·È ÈÔ Û˘¯Ófi˜ Ô ÚÔÙ·˚fi˜), Â›Ó·È ÂÌÊ·Ó‹˜ Ë ·Ó¿ÁÎË ÂÍÔÈÎÔÓfiÌËÛ˘ ÎÏÈÓÒÓ.

¡ÂfiÙÂÚ· ‰Â‰Ô̤ӷ ª¤¯ÚÈ Û‹ÌÂÚ· ÁÓˆÚ›˙·Ì fiÙÈ Ô ÚÔÙ·˚fi˜ ÚÔηÏ› ·ÓÙÈÁÔÓ·ÈÌ›·. ∆ÂÏÂ˘Ù·›·, ‰È·ÈÛÙÒıËΠfiÙÈ Û˘¯Ó‹ Â›Ó·È Î·È Ë È·ÈÌ›· Ô˘ Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ·ÓÙÈÁÔÓ·ÈÌ›· Î·È Â›Ó·È ·ÓÂÍ¿ÚÙËÙË Ù˘ ·ÚÔ˘Û›·˜ ‰È¿ÚÚÔÈ·˜. ∞˘Ùfi ÛËÌ·›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Â͈ÂÓÙÂÚÈÎÒÓ ÂÓÙÔ›ÛˆÓ. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, ‰ÂÓ ÁÓˆÚ›˙Ô˘ÌÂ

¶ÂÚÈÙÒÛÂȘ ¡Ô.

¶ÂÚÈÙÒÛÂȘ ¡Ô.

- ¶Ôχ ÈÔ Û˘¯Ó‹ - ÕÚ· ˘„ËÏfi ÎfiÛÙÔ˜ ÁÈ· Û˘ÛÙ‹Ì·Ù· ˘Á›·˜ - ¡ÔÛÔÎÔÌÂȷ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·. ÿÛˆ˜ Ë Î˘ÚÈfiÙÂÚË ·ÈÙ›· ÓÔÛÔÎÔÌÂÈ·ÎÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙ· ·È‰È¿ (1:5). ªÔÚ› Ó· ÂÈÌË·ÓÂÈ ÙË ÓÔÛËÏ›· ¤ˆ˜ Î·È 10 Ë̤Ú˜.

67

70 70

1000 900 800 700 600 500 400 300 200 100 0

2000

2001

2002

2003 2004 `EÙË

2005

2006

2007

∂ÈÎfiÓ· 4. ∂ÈÛ·ÁˆÁ¤˜ ÙÔ 1Ô ÙÂÙÚ¿ÌËÓÔ ÙÔ˘ ¤ÙÔ˘˜ ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡∂¶£ (2000-2007).

Paidiatriki 5 final

12-10-07

16:28

Page 349

349

§Ô›ÌˆÍË ·fi ÚÔÙ·˚fi

ÙËÓ Â›ÙˆÛË Ù˘ È·ÈÌ›·˜ ÛÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ Ïԛ̈͢ ‹ ÙËÓ ·ÎÚÈ‚‹ Û˘¯ÓfiÙËÙ· ÙˆÓ Â͈ÂÓÙÂÚÈÎÒÓ ÂΉËÏÒÛˆÓ. ∞˘Ùfi ‰ÂÓ ÌÂÈÒÓÂÈ, ‚¤‚·È·, ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ‰È·›ÛÙˆÛ˘ (10). ™Â Ôχ ÚfiÛÊ·ÙÔ ¿ÚıÚÔ (ª¿ÈÔ˜ 2007), ÔÈ Troncone R, Auricchio S (11) Û˘˙ËÙÔ‡Ó ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛË Ïԛ̈͢ ·fi ÚÔÙ·˚fi Î·È ÎÔÈÏÈÔο΢. ∆Ô ÂÓ ÏfiÁˆ ¿ÚıÚÔ Û‡ÓÙ·Í˘ ÛÙËÚ›¯ıËΠ۠‰‡Ô, Â›Û˘ ÚfiÛÊ·Ù˜, ÌÂϤÙ˜ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ Ô˘ ·Û¯ÔÏ‹ıËÎ·Ó Ì ÙÔ ı¤Ì·. ∏ ÚÒÙË (12) Â›Ó·È ÚÔÔÙÈ΋ ¤Ú¢ӷ Ù˘ Ê˘ÛÈ΋˜ ÈÛÙÔÚ›·˜ Î·È ÙˆÓ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ÂÎÏ˘ÙÈÎÒÓ ·ÈÙ›ˆÓ ÁÈ· ÙÔÓ ‰È·‚‹ÙË Î·È ÙËÓ ÎÔÈÏÈÔοÎË Û ÁÂÓÂÙÈÎÒ˜ ÚԉȷÙÂıÂÈ̤ӷ ¿ÙÔÌ·, fiÔ˘ ÔÈ Û˘ÁÁÚ·Ê›˜ ‚Ú‹Î·Ó fiÙÈ ÔÈ Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ ·fi ÚÔÙ·˚fi ÂÈʤÚÔ˘Ó ˘„ËÏfi ΛӉ˘ÓÔ ÁÈ· ÎÔÈÏÈÔοÎË. ∏ ‰Â‡ÙÂÚË (13) ·ÊÔÚ¿ ÙË ‰È¢ÎÚ›ÓËÛË ÙÔ˘ ÚfiÏÔ˘ ·ıÔÁfiÓˆÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ÚfiÎÏËÛË ·˘ÙÔ¿ÓÔÛ˘ ·¿ÓÙËÛ˘ ÛÙËÓ ÎÔÈÏÈÔοÎË Î·È ÙËÓ ¤Ú¢ӷ ÂÙȉ›ˆÓ ÛÙÔÓ ÔÚfi ·ÛıÂÓÒÓ Ì ÎÔÈÏÈÔοÎË Ô˘ ›¯·Ó ÔÌÔÏÔÁ›· Ì ·ÓÙÈÁfiÓ· ÙÔ˘ ÚÔÙ·˚Ô‡. √È ‰‡Ô ·˘Ù¤˜ ÌÂϤÙ˜ ¤ÊÂÚ·Ó ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÔÚÈṲ̂ӷ ÛËÌ›· ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÛË ˆ˜ ·˘ÙÔ¿ÓÔÛ˘ ÓfiÛÔ˘ Ù˘ ÎÔÈÏÈÔο΢, ÙË Û˘¯Ó‹ Û˘Ó‡·ÚÍ‹ Ù˘ Ì ¿ÏÏ· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·, ÙÔ˘˜ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó¿Ù˘ÍË Ù˘ ÓfiÛÔ˘ Î·È ÙÔÓ Èı·Ófi ÚfiÏÔ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙËÓ ·ıÔÁ¤ÓÂÛË. √ Ì˯·ÓÈÛÌfi˜ ·˘ÙÔ·ÓÔÛ›·˜ Â›Ó·È ÁÂÓÈο ¿ÁÓˆÛÙÔ˜. ∏ ÁÏÔ˘Ù¤ÓË Â›Ó·È Ô ÌÔÓ·‰ÈÎfi˜ ̤¯ÚÈ ÛÙÈÁÌ‹˜ Â͈ÁÂÓ‹˜ ÂÚÈ‚·ÏÏÔÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ˘ÂÈÛ¤Ú¯ÂÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ÓfiÛÔ˘. √È ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÚÔ‚¿ÏÏÔ˘Ó ˆ˜ Ô ‰Â‡ÙÂÚÔ˜ Â͈ÁÂÓ‹˜ ·Ú¿ÁÔÓÙ·˜. ∫·È Â‰Ò ÂÌϤÎÂÙ·È Ô ÚÔÙ·˚fi˜, ÏfiÁˆ Î·È Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ÏÔÈÌÒÍÂˆÓ Ô˘ ÚÔηÏ› ÛÙËÓ ÂÈΛӉ˘ÓË ÁÈ· ÎÔÈÏÈÔοÎË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ. ª¿ÏÈÛÙ·, Ë Û¯¤ÛË ÚÔÙ·˚Ô‡ Î·È ·Ó¿Ù˘Í˘ ·˘ÙÔ·ÓÔÛ›·˜ ˘ÔÏÔÁ›˙ÂÙ·È ˆ˜ 0 ÁÈ· ηıfiÏÔ˘ Ïԛ̈ÍË, 1,94 ÁÈ· 1 Ïԛ̈ÍË Î·È 3,76 ÁÈ· ¿Óˆ ·fi 2 ÏÔÈÌÒÍÂȘ. ∆Ô ÚÔÙÂÈÓfiÌÂÓÔ ÏÔÈfiÓ ÛÂÓ¿ÚÈÔ Â›Ó·È ÙÔ ÂÍ‹˜: ∏ ¯ÔÚ‹ÁËÛË ÁÏÔ˘Ù¤Ó˘ Û ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô, fiÔ˘ ˘¿Ú¯ÂÈ ÚÔ˚Ô‡Û· ÂÓÙÂÚÈ΋ Ïԛ̈ÍË, ‰È·Ù·Ú·¯‹ Ù˘ ‰È·‚·ÙfiÙËÙ·˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘, Î·È ·Ú·ÁˆÁ‹ ÈÓÙÂÚÊÂÚÔÓÒÓ, ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ÎÔÈÏÈÔο΢, ÙÔ˘Ï¿¯ÈÛÙÔÓ ÛÂ Û˘ÁÎÂÎÚÈ̤ÓË ÔÌ¿‰· ·ÛıÂÓÒÓ. ∞Ó Ù· ·Ú·¿Óˆ Â˘Ú‹Ì·Ù· Ù˘ È·ÈÌ›·˜ Î·È Ù˘ ÂÌÏÔ΋˜ ÙÔ˘ ÚÔÙ·˚Ô‡ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ÎÔÈÏÈÔο΢ ÂȂ‚·ÈˆıÔ‡Ó, ÙfiÙÂ, ÛÂ Û˘Ó‰˘·ÛÌfi Î·È Ì ÙȘ ¿ÏϘ ÂÈÙÒÛÂȘ Ù˘ Ïԛ̈͢ ·fi ÚÔÙ·˚fi (Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ·Ú·¿Óˆ), Ù›ıÂÙ·È ÙÔ ÂÚÒÙËÌ· ·Ó ı· Ú¤ÂÈ Ó· ‰Ô‡Ì ·fi ¿ÏÏË ϤÔÓ ÛÎÔÈ¿ ÙË Û˘ÓÔÏÈ΋ Ïԛ̈ÍË ·fi ÚÔÙ·˚fi Î·È ÙȘ Û˘Ó¤ÂȤ˜ Ù˘. °È· ÙË Ì›ˆÛË Ù˘ Û˘ÓÔÏÈ΋˜ Â›ÙˆÛ˘ Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· ÂÊ·ÚÌÔÛıÔ‡Ó 2 ̤ÙÚ·: 1. ∞˘ÛÙËÚ¿ ̤ÙÚ· ÂϤÁ¯Ô˘ ÏÔÈÌÒÍÂˆÓ ÛÙÔ ÓÔÛÔ-

ÎÔÌÂ›Ô Î·È ÛÙÔ˘˜ ‚ÚÂÊÔÓËÈ·ÎÔ‡˜ ÛÙ·ıÌÔ‡˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·˘ÛÙËÚ¿ ̤ÙÚ· ÚÔÛˆÈ΋˜ ˘ÁÈÂÈÓ‹˜. ∆¤ÙÔÈ· ̤ÙÚ· Ô˘‰¤ÔÙ ·¤‰ˆÛ·Ó, fiÔ˘ Î·È ·Ó ÂÊ·ÚÌfiÛıËηÓ.

2. ∂Ì‚ÔÏÈ·ÛÌfi˜ ηٿ ÙÔ˘ ÚÔÙ·˚Ô‡. ∏ ‡·ÚÍË Û‹ÌÂÚ· ÂÌ‚ÔÏ›ˆÓ ηٿ ÙÔ˘ ·ıÔÁfiÓÔ˘ ·˘ÙÔ‡ ÚÔ‚¿ÏÏÂÈ ˆ˜ Ë Î·Ï‡ÙÂÚË Ï‡ÛË, ‰ÈfiÙÈ ¤¯ÂÈ ‰ÈÙÙfi ÛÙfi¯Ô: ÙËÓ ›‰È· ÙË Ïԛ̈ÍË ·fi ÙÔ ·ıÔÁfiÓÔ Î·È ÙËÓ Èı·Ó‹ ÚÔʇϷÍË ·fi ÙËÓ ÎÔÈÏÈÔοÎË, ÂÊfiÛÔÓ ÙÂÎÌËÚȈı› Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ‰‡Ô ηٷÛÙ¿ÛˆÓ.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Lynch ª, Lee µ, Azimi P, Gentsch J, Glaser C, Gilliam S, et al. Rotavirus and central nervous system symptoms: cause or contaminant? Case reports and review. Clin Infect Dis 2001;33:932-938.

2. Minami K, Tamura A, Komori Y, Yanagawa T, Izumi G, Kioka N, et al. Acute encephalopathy and rhabdomyolysis following rotavirus gastroenteritis. J Paediatr Child Health 2007;43:90-91.

3. Santos N, Hoshino Y. Global distribution of rotavirus serotypes/genotypes and its implication for the development and implementation of an effective rotavirus vaccine. Rev Med Virol 2005;15:29-56.

4. Rivest P, Proulx M, Lonergan G, Lebel MH, Bédard L. Hospitalisations for gastroenteritis: the role of rotavirus.

Vaccine 2004;22:2013-2017.

5. Glass RI, Parashar UD, Bresee JS, Turcios R, Fischer TK, Widdowson MA, et al. Rotavirus vaccines: current prospects and future challenges. Lancet 2006;368:323-332.

6. Soriano-Gabarro M, Mrukowicz J, Vesikari T, Verstraeten T. Burden of rotavirus disease in European Union countries. Pediatr Infect Dis J 2006;25(1 Suppl):S7-S11.

7. Tsiatsiou O, Papagiannopoulos O, Sarantopoulou E, Alexandratos Ch, Karabaxoglou D, Kavaliotis J. Clinical and epidemiological data of children hospitalized with rotavirus acute gastroenteritis in Northern Greece (Period 1984-2005). 44th Annual Meeting of IDSA, 1215/10/2006, Toronto, Canada.

8. Gleizes O, Desselberger U, Tatochenko V, Rodrigo C, Salman N, Mezner Z, et al. Nosocomial rotavirus infection in European countries: a review of the epidemiology, severity and economic burden of hospital-acquired rotavirus disease. Pediatr Infect Dis J 2006;25(1 Suppl):S12-S21.

9. Rheingans RD, Heylen J, Giaquinto C. Economics of rotavirus gastroenteritis and vaccination in Europe: what makes sense? Pediatr Infect Dis J 2006;25(1 Suppl):S48-S55.

10. Blutt SE, Matson DO, Crawford SE, Staat MA, Azimi P, Bennett BL, et al. Rotavirus antigenemia in children is associated with viremia. PLoS Med 2007;4:e121.

11. Troncone R, Auricchio S. Rotavirus and celiac disease: clues to the pathogenesis and perspectives on prevention. J Pediatr Gastroenterol Nutr 2007;44:527-528.

12. Stene LC, Honeyman MC, Hoffenberg EJ, Haas JE, Sokol RJ, Emery L, et al. Rotavirus infection frequency and risk of celiac disease autoimmunity in early childhood: a longitudinal study. Am J Gastroenterol 2006;101:2333-2340.

13. Zanoni G, Navone R, Lunardi C, Tridente G, Bason C, Sivori S, et al. In celiac disease, a subset of autoantibodies against transglutaminase binds toll-like receptor 4 and induces activation of monocytes. PLoS Med 2006;3:e358. ¶·È‰È·ÙÚÈ΋ 2007;70:347-349

Paidiatriki 5 final

12-10-07

350

16:28

Page 350

REVIEW ARTICLE

∞¡∞™∫√¶∏™∏

Diagnosis and management of obstructive uropathy in infants Department of Pediatrics1 and Internal Medicine2 University of Texas Southwestern Medical Center at Dallas Dallas, Texas, 75390-9063 Correspondence: Amy M. Becker Amy.Becker@UTSouthwester n.edu Department of Pediatrics U.T. Southwestern Medical Center 5323 Harry Hines Blvd.

Dallas, Texas 75390-9063

A. M. Becker1, M. Baum1,2 Abstract: The institution of routine prenatal ultrasound has led to an increase in the diagnosis of antenatal hydronephrosis. Studies have shown that the greater the prenatal renal anterior posterior diameter, the greater the likelihood of significant postnatal renal obstruction. Postnatal evaluation should include a renal ultrasound and a voiding cystourethrogram. Common etiologies for prenatal hydronephrosis include vesicoureteral reflux, ureteropelvic junction obstruction, posterior urethral valves, prune belly syndrome, ureterovesical junction obstruction, and ureterocele. Multicystic dysplastic kidneys appear to be the consequence of early obstruction of the developing ureter. There is a significant probability of contralateral renal abnormalities in patients with unilateral dysplasia or renal agenesis thereby necessitating routine postnatal evaluation. Electrolyte abnormalities are common in bilateral obstructive uropathy and result from distal tubular damage. Hyperkalemic metabolic acidosis along with sodium and water wasting should be assessed and treated appropriately. In addition to distal tubular damage, total nephron number is decreased in patients with significant obstructive uropathy. In patients with severe bilateral obstruction, chronic renal failure may result from the reduced nephron endowment and progressive renal damage from obstruction and infections. Severe obstructive uropathy may lead to end stage renal disease, but patients with obstructive uropathy can successfully receive a kidney transplant.

Key words: Antenatal hydronephrosis, obstructive uropathy, vesicoureteral reflux, neonates.

List of abbreviations: APD anterior-posterior diameter UPJ ureteropelvic junction VUR vesicoureteral reflux PUV posterior urethral valves PBS prune belly syndrome UVJ ureterovesical junction MCDK multicystic dysplastic kidney VCUG voiding cystourethrogram DMSA dimercaptosuccinic acid PD peritoneal dialysis HD hemodialysis Introduction Obstructive uropathy is a broad term that describes kidney damage resulting from urinary obstruction at any level of the urinary system. In the past, obstructive uropathy presented with pain, urinary tract infection, poor urinary stream, failure to thrive, neonatal sepsis, or respiratory distress. More recently, urinary obstruction is identified during routine prenatal ultrasound screening. There are multiple etiologies leading to urinary obstruction including ureteropelvic junction (UPJ) obstruction, vesicoureteral reflux (VUR), posterior urethral valves (PUV), prune belly syndrome (PBS), ureterovesical Paediatriki 2007;70:350-360

(UVJ) obstruction, urethral atresia or stricture, duplicated collecting system with ureterocele, and multicystic dysplastic kidney (MCDK).

Detection and evaluation of hydronephrosis Routine second trimester ultrasound screening has led to an increase in the diagnosis of antenatal hydronephrosis with an incidence estimated between 0.5 and 1% (1,2). The Society for Fetal Urology (SFU) grade and the anteriorposterior diameter (APD) are the two criteria used for grading antenatal hydronephrosis. The APD is most frequently reported, and most studies use the APD in their analyses. Despite this, there is no agreed upon measurement for a normal fetal APD. Most studies delineate an APD greater than or equal to 5 mm as abnormal (3-5). The probability of significant renal pathology is correlated with the severity of the hydronephrosis (3). ∞ meta-analysis of 17 studies calculated the risk of postnatal pathology stratified by degree of APD dilatation (as measured in the second trimester) (6).

88.3% of infants with severe antenatal hydronephrosis (APD ≥10 mm) had detectable pathology. Rates in infants with moderate (APD

Paidiatriki 5 final

12-10-07

16:28

Page 351

351

Obstructive uropathy

Table 1. Etiologies of obstructive uropathy and potential associated findings Diagnosis Vesicoureteral Reflux

Physical Exam Findings

Physiologic Disturbances

± Palpable abdominal mass if associated with large, hydronephrotic kidney

None, unless bilateral or in a solitary kidney

UPJ Obstruction

± Palpable abdominal mass

None, unless bilateral or in a solitary kidney

Posterior Urethral Valves

± Palpable bladder, poor urinary stream

± Hyponatremia, hyperkalemic metabolic acidosis, volume depletion, uremia

Prune Belly Syndrome

Absent abdominal musculature, bilateral undescended testicles

± Hyponatremia, hyperkalemic metabolic acidosis, volume depletion, uremia

± Palpable abdominal mass

None, unless bilateral or in a solitary kidney

± Palpable abdominal mass if associated with large, hydronephrotic kidney

None, unless bilateral or in a solitary kidney

Multicystic Dysplastic Kidney Ureterocele

7-10 mm) and mild (APD ≤7 mm) hydronephrosis were 45.1% and 11.9%, respectively. The likelihood of UPJ obstruction increased with increasing APD, but there was no correlation of VUR with APD (6).

Initial evaluation of an infant with antenatal hydronephrosis should always begin with a physical examination (Table 1). UPJ obstruction and MCDK often present with a palpable abdominal mass.

Prune belly syndrome is associated with absent abdominal wall musculature and bilateral undescended testicles. Infants with PUV will often have a palpable bladder (5). Immediate postnatal evaluation with a renal ultrasound and voiding cystourethrogram (VCUG) should be performed in infants with prenatal severe bilateral hydronephrosis or severe unilateral hydronephrosis in a single functioning kidney (3,5).

Isolated antenatal hydronephrosis is defined as increased APD without identifiable urinary tract pathology (7). Systematic review of 25 studies on isolated antenatal hydronephrosis demonstrated spontaneous resolution of hydronephrosis and normal renal growth in infants with mild hydronephrosis (8). Meta-analysis of data from 7 of these studies showed improvement in 98% of infants with mild hydronephrosis (8). Transient and physiologic hydronephrosis represent the most common etiologies of isolated antenatal hydronephrosis. These may result from a large, unobstructed renal pelvis or an extrarenal pelvis (3). The dilatation may be exacerbated by the increased urine flow rate in the late gestation fetus, which is approximately 10 times higher, normalized for body weight, than the newborn (9).

Some studies recommend that antenatal APD of 5 mm or greater warrants postnatal evaluation (10-

13), and prophylactic antibiotics should be initiated to prevent urinary tract infections and continued until obstructive uropathy is ruled out.

The initial postnatal renal ultrasound should be delayed until after the first 24-48 hours of life as hydronephrosis may be missed due to the relative oliguria of infants immediately following birth (3,5). Routine postnatal screening with a VCUG for all infants with antenatal hydronephrosis is controversial. Some physicians recommend against routine VCUG in infants with two normal postnatal ultrasounds (14). Others suggest a VCUG be performed in all infants with prenatal detection of hydronephrosis, despite a normal postnatal ultrasound, as a significant proportion of these infants will have an abnormal VCUG (10-13). If VUR is detected, the current standard of care is to initiate prophylactic antibiotics. For infants with postnatal APD >10 mm and no evidence of VUR on VCUG, further evaluation with diuretic renography should be performed to detect UPJ obstruction (3,5,10) (Figure 1).

Etiologies of obstruction Vesicoureteral reflux Vesicoureteral reflux (VUR) occurs when urine flows upwards into the ureters during voiding. VUR is a common cause of antenatal hydronephrosis, occurring in up to 38% of infants (15), often despite a normal postnatal ultrasound (3). The International Reflux Study in Children classification system grades VUR from I to V. Grade I VUR is urinary reflux into a nondilated ureter, and grade II is reflux into the renal pelvis without dilatation.

Grade III VUR is reflux into a dilated ureter up to the renal pelvis with possible blunting of the calyceal ¶·È‰È·ÙÚÈ΋ 2007;70:350-360

Paidiatriki 5 final

12-10-07

16:28

Page 352

352

A.ÂŞ. Becker, M. Baum

Figure 1. Algorithm for systematic evaluation of antenatal hydronephrosis. APD = anterior-posterior diameter, US = ultrasound, VCUG = voiding cystourethrogram.

fornices. In grade IV VUR, the ureter is grossly dilated with moderate blunting of calyces, and grade V is characterized by massive ureteral dilatation and tortuosity with loss of the papillary impression (16) (Figure 2). VUR can lead to recurrent urinary tract infections (UTI) with parenchymal scarring resulting in hypertension and/or renal insufficiency

Figure 2. VCUG demonstrating bilateral grade V vesicoureteroreflux.

Note the markedly dilated, tortuous ureters and massive hydronephrosis with calyceal blunting.

Paediatriki 2007;70:350-360

(17). Spontaneous resolution of VUR occurs in 7890% of grades I-III reflux diagnosed after evaluation for antenatal hydronephrosis (18,19). Grades IV may spontaneously resolve, but Grade V rarely resolves and usually requires surgical intervention.

Infants with VUR of grade IV or higher should be referred to a pediatric urologist. The presence of renal scarring identifies infants at greatest risk for long term renal sequelae (20). It is important to be flexible in the investigation of the child with VUR. One should choose imaging techniques of the urinary tract with the goal of identifying children at risk of developing acquired renal scarring (20,21).

UPJ obstruction With an incidence of 1 in 1000 to 1500 newborns, UPJ obstruction is the most common cause of antenatal hydronephrosis (22,23). Bilateral obstruction is encountered in 20-25% of cases, and there is a male to female preponderance of 3:1 (3).

The etiology of UPJ obstruction is unknown, and many potential etiologies have been postulated including embryologic, anatomic, functional, histologic, and molecular factors (22). UPJ obstruction can result from intrinsic stenosis, insertion anomaly of the ureters, peripelvic fibrosis, peristaltic abnormalities, and blood vessels crossing the ureter (22). Renal ultrasound demonstrates dilatation of the renal pelvis with normal ureters and

Paidiatriki 5 final

12-10-07

16:28

Page 353

353

Obstructive uropathy

bilateral UPJ obstruction or unilateral UPJ obstruction with decreased differential function should be referred to a pediatric urologist.

Figure 3. In UPJ obstruction, renal ultrasound demonstrates significant hydronephrosis without ureteral dilatation.

bladder (Figure 3). Diuretic renography is necessary to confirm the diagnosis and also provides an estimation of differential renal function. The differential renal function is useful in management decisions. Although controversy exists concerning the indications for surgical intervention, most experts recommend a conservative approach of observation if the obstruction is unilateral and associated with a well functioning kidney (differential function >35%) (5). Patients with

Figure 4. In posterior urethral valves, VCUG demonstrates a marked change in the caliber of the urethra at the level of the valves.

Note the markedly dilated urethra above the site of obstruction. The arrow points to the site where the caliber change is seen.

Posterior urethral valves Occurring with an incidence of 1 in 5000 to 8000 live births, posterior urethral valves (PUV) are the most common cause of lower urinary tract obstruction in male infants. The “valves”, located in the posterior urethra, are actually a thin membrane of tissue causing obstruction of urinary flow out of the bladder (24). Detection of bilateral hydronephrosis and hydroureter with a distended, thick-walled bladder on prenatal ultrasound suggests a diagnosis of PUV. Antenatal detection of PUV prior to 24 weeks gestation carries a poorer prognosis; one study (with a mean follow-up of 4 years) reports a 50% chance of death or chronic renal failure in these patients (25).

Moderate or severe hydronephrosis (with APD >10 mm), increased echogenicity on ultrasound, and cystic changes within the kidneys suggesting renal dysplasia also portend a poor prognosis (26,27). In addition to classical prenatal ultrasound changes, evaluation of poor urinary stream, UTI, enlarged bladder, or failure to thrive may lead to the diagnosis of PUV. Infants may present with sepsis, respiratory distress, hyponatremia, and hyperkalemic metabolic acidosis (27,28). Older children presenting with bedwetting, UTI, dribbling, hematuria, urinary retention, or poor urinary stream may have PUV with milder obstruction (29).

An infant suspected of having PUV should have a thorough evaluation including renal ultrasound, VCUG, urinalysis, urine culture, and serum electrolytes, creatinine, and blood urea nitrogen.

Bladder wall thickening, hydronephrosis, and posterior urethral dilatation are commonly seen on renal ultrasound, and renal dysplasia may also be detected. The gold standard for diagnosing PUV is a fluoroscopic VCUG demonstrating a linear filling defect in the column of radiocontrast in a markedly dilated posterior urethra (27) (Figure 4). The VCUG will also detect VUR which is seen in 25-50% of patients with PUV (28). Prenatal diagnosis of PUV provides an opportunity to intervene prior to the infant developing sepsis or metabolic complications.

Despite this, the outcome of patients with PUV has not been significantly improved with prenatal diagnosis (30).

Initial treatment of an infant with PUV begins with stabilization of the infant including respiratory support, fluid resuscitation (if volume depletion is suspected), correction of electrolyte abnormalities, ¶·È‰È·ÙÚÈ΋ 2007;70:350-360

Paidiatriki 5 final

12-10-07

16:28

Page 354

354

A.ÂŞ. Becker, M. Baum

and initiation of antibiotics when clinically indicated (27,28). A urinary catheter should be inserted immediately to relieve the obstruction. Primary valve ablation with endoscopic incision of the PUV is the treatment of choice in a stabilized infant. Urinary diversion with a cutaneous vesicostomy may be necessary in infants whose urethras are too small for an 8F resectoscope (27). Persistent urethral dilatation after valve resection may also require urinary diversion (27-29,31). When possible, avoidance of urinary diversion is preferred. This helps to preserve bladder function and decreases the need for bladder augmentation later in life. Prophylactic antibiotics are indicated if concomitant VUR is present. Details of electrolyte and post-obstructive diuresis management are discussed later.

Prune belly syndrome Prune belly syndrome (PBS) has an incidence of 1 in 29,000 to 40,000 male births (32), and is believed to be the result of early urethral obstruction leading to massive bladder distention and possible urinary ascites (27). Subsequently, the abdominal wall musculature degenerates and testicular descent is prevented (27). The membrane causing urethral obstruction ruptures before birth, and the postnatal urethra may or may not be stenotic (32). Ultrasound examination demonstrates increased bladder wall thickness and dilated, tortuous ureters with thickened walls. Hydronephrosis and renal dysplasia may be evident, and a patent urachus can also be seen.

Multiple other anomalies are associated with PBS and include: gastrointestinal anomalies (malrotation, volvulus, gastroschisis, omphalocele, Hirschsprungâ&#x20AC;&#x2122;s, imperforate anus), pulmonary hypoplasia (secondary to oligohydramnios), cardiac anomalies (atrial septal defect, ventricular septal defect, tetralogy of Fallot),

Figure 5. Typical ultrasonographic appearance of a multicystic dysplastic kidney. Multiple cysts and no identifiable renal parenchyma are seen. The crosses mark the outer edges of the kidney.

Paediatriki 2007;70:350-360

and orthopedic problems (developmental dislocation of the hip, scoliosis, pectus excavatum, talipes equinovarus, torticollis) (27).

The initial evaluation of an infant suspected of having PBS should include a physical examination, renal ultrasound, VCUG, urinalysis, urine culture, and serum electrolytes, creatinine, and blood urea nitrogen. Because 85% of patients with PBS will have VUR, prophylactic antibiotics should be initiated immediately (33). Unfortunately, all patients with PBS will be sterile. Progressive azotemia or recurrent infections may be an indication for a vesicostomy.

Orchiopexy is required, and a few children may need abdominoplasty and appendicovesicostomy placement (27).

Multicystic dysplastic kidney Multicystic dysplastic kidney (MCDK) is the second most common cause for abdominal mass in a neonate with an incidence of 1 in 4300 live births (34).

Failed coordination of the branching ureteric bud and the developing metanephros is postulated to be involved in the pathogenesis of MCDK (35). Ureteric obstruction may initiate the process. PAX2, BCL2, IGF-II, and IGF binding protein have been implicated in the development of cysts in MCDK. Tubules with high rates of cellular proliferation express PAX2 (9), and multifocal microcystic tubular dilatation is seen in mice that over express PAX2 in the kidney (36).

Dysplastic kidney epithelial cells were shown to ectopically express BCL2, a protein that prevents apoptosis (9). Abnormal kidney tissue was shown to over express IGF-II with the epithelium of the cysts expressing IGF binding protein-3 (35).

Many different histopathological changes can be seen in MCDK. The kidney grossly appears as a grapelike cluster of non-communicating cysts. Normal renal architecture and function are completely lost (37,38).

Immature glomeruli, nests of metaplastic cartilage, primitive tubules surrounded by fibromuscular collars, and cysts derived from tubular and glomerular structures are seen on a microscopic level (35). Ultrasound appearance of MCDK includes non-communicating cysts, no identifiable renal parenchyma, and atretic proximal ureters (Figure 5). Classic ultrasound findings along with a non-functioning kidney on dimercaptosuccinic acid (DMSA) scan confirm the diagnosis of MCDK. Patients with MCDK have a 50% likelihood of a contralateral renal abnormality. The most commonly encountered abnormality is VUR, followed by UPJ obstruction (39). Since this represents a potential for renal damage in a solitary functioning kidney, postnatal evaluation should include a VCUG (and diuretic

Paidiatriki 5 final

12-10-07

16:28

Page 355

355

Obstructive uropathy

sports, however, may be safer than previously proposed.

Figure 6. Renal ultrasound showing hydroureteronephrosis characteristic of UVJ obstruction. The crosses mark the outer kidney edges, and the arrow points to the markedly dilated ureter.

renography when indicated) in all patients with an MCDK (39,40).

Complications of MCDK rarely include urinary tract infection, hypertension, and malignant transformation. Traditionally, nephrectomy of the MCDK was the preferred treatment to prevent these potential complications (40). Observational studies have demonstrated that the natural course of MCDK is typically benign with a decrease in size or complete involution over time (37,40-42). Because of the benign natural course, current recommendation for treatment of MCDK is observation with serial ultrasounds. Rarely, malignancies can arise in a MCDK. Renal cell carcinoma, Wilm’s tumor, and mesothelioma have been reported in patients with MCDK (40,43). Morphologic changes concerning for malignancy and refractory hypertension are indications for nephrectomy (41). Compensatory hypertrophy of the contralateral kidney occurs in response to the non-functioning MCDK (36,42). This compensatory hypertrophy puts the functioning kidney at increased risk for traumatic injury as it is no longer protected in its entirety by the posterior ribcage (44).

Many physicians recommend restricting participation in contact sports for patients with a solitary kidney.

This recommendation is controversial. Studies of large trauma registries have shown that bicycle riding, snow sports (sledding, skiing), and rollerblading are associated with the highest risk of renal injury (45,46).

In these analyses, team contact sports (excluding ice hockey) were not responsible for any high grade renal injury. The major limitation of both studies is that the number of patients with solitary kidneys is unknown (45,46). These studies highlight the importance of cautioning patients with a solitary kidney of the risks of recreational sporting activities; organized team

UVJ obstruction UVJ obstruction is more common on the left and is bilateral 25% of the time. It occurs 4 times as frequently in males. Ureteral dilatation (megaureter) and dilated renal pelvis are seen on ultrasound (Figure 6). An aperistaltic segment of the distal ureter, near the UVJ, leads to the UVJ obstruction.

Some urologists advocate conservative management (47,48). Surgical intervention involves excision of the distal ureteric segment, and tapering and reimplantation of the ureter (49).

Ureterocele Cystic dilatation of the intravesical ureter results in the formation of an ureterocele. With an incidence of 1 in 5000 infants, it is most often associated with a duplicated collecting system or ectopic ureteral insertion. It is bilateral in 20-50% of cases and 2.5-3 times more likely in females (50). On VCUG, ureterocele is seen as a round, smooth filling defect at the base of the bladder (Figure 7). A VCUG will also assess for concomitant VUR. Upper pole hydroureteronephrosis is most common in ureteroceles complicating a duplicated collecting system. Endoscopic incision of the ureterocele is the preferred treatment (51). Additionally, nuclear renography should be done to determine the function of the upper renal pole. Upper pole heminephro-ureterectomy may be indicated if the upper pole moiety is non-functioning.

Extrarenal manifestations of obstructive uropathy Since the kidneys produce 90% of the amniotic fluid after 20 weeks gestation, severe bilateral prenatal urinary obstruction often results in oligohydramnios (17). Normal lung and orthopedic/soft tissue development are dependent upon adequate amniotic fluid, and these systems are often compromised in prenatal urinary obstruction with oligohydramnios.

The respiratory complications range from mild to severe lung hypoplasia (17,28). Neonatal mortality commonly results from respiratory insufficiency in infants with severe urinary tract obstruction (29). The timing of the onset of urinary obstruction and resultant oligohydramnios has a significant impact on respiratory development and infant survival. Severe obstruction beginning after 24 weeks gestation affords a better prognosis due to improved pulmonary development (52). Talipes equinovarus and limb ¶·È‰È·ÙÚÈ΋ 2007;70:350-360

Paidiatriki 5 final

12-10-07

16:28

Page 356

356

A.ÂŞ. Becker, M. Baum

contractures are common orthopedic complications.

Severe oligohydramnios may lead to Potter sequence manifested by a typical facies with low-set ears, wideset eyes, and micrognathia along with orthopedic complications.

Fetal intervention Prevention of neonatal respiratory insufficiency (often leading to death) and progressive renal damage has led to studies in fetal intervention for obstructive uropathy. Open fetal surgery, percutaneous vesico-amniotic shunt placement, and fetoscopic surgery with laser ablation of posterior urethral valves have all been attempted (52,53).

Prenatal surgical intervention is reserved for male patients with severe bilateral hydronephrosis who develop oligohydramnios and have no evidence of renal damage. Normal fetal urine is hypotonic, and elevated urinary levels of sodium, chloride, and osmolality are suggestive of renal damage and possibly irreversible dysplasia. In order to remove the confounding variable of stagnant urine and establish a trend, serial measurements of urinary electrolytes at 48-72 hour intervals are commonly used for assessment of renal damage (54). Urinary values of sodium <100 meq/L, chloride <90 meq/L, and osmolality <210 mosm are associated with a more favorable prognosis (53,55). Some improvement in lung development has been reported with restoration of normal volumes of amniotic fluid, but fetal surgical intervention has not resulted in significant improvement in renal outcome (52). Fetal surgical intervention is associated with a fatality rate as high as 56%, and almost all surgical interventions result in premature labor (52,53). Multiple other complications exist including inadequate drainage or migration of the shunt, perforation of the fetal bowel or bladder, iatrogenic gastroschisis, hemorrhage, and chorioamnionitis. Currently, severe oligohydramnios without evidence of renal dysplasia is the only indication for fetal surgical intervention (52).

Management Electrolyte derangements and fluid balance abnormalities represent challenging problems in the management of infants with obstructive uropathy (Table 1). Decreased sodium absorption in the cortical collecting tubules, partially resulting from decreased Na+/K+- ATPase activity, leads to sodium wasting (23). Impairment of distal tubular potassium and hydrogen ion secretion results in a type IV renal tubular acidosis (RTA) and associated hyperkalemic metabolic acidosis (23). Potential etiologies of the Paediatriki 2007;70:350-360

â&#x2C6;&#x17E;

B

Figure 7. A. Bilateral ureteroceles are seen as round filling defects in the bladder on this VCUG. B. On renal ultrasound, the bilateral ureteroceles are also detected as thin membranes within the bladder. Arrows point to the ureteroceles.

type IV RTA include unresponsiveness of the damaged distal tubule to aldosterone (56), impaired turnover of the Na+/K+- ATPase, and loss of H+ATPase on the apical surface of intercalated cells (57,58). Down regulation of aquaporins and distortion of the medullary architecture may lead to nephrogenic diabetes insipidus. (23). As a result, infants with obstructive uropathy commonly require significant fluid administration to prevent dehydration.

Short stature and/or failure to thrive are often associated with obstructive uropathy and reduced renal function (26-29). In studies comparing surgical

Paidiatriki 5 final

12-10-07

16:28

Page 357

357

Obstructive uropathy

interventions for PUV, body growth was no different in children who underwent primary valve ablation compared to urinary diversion with temporary cutaneous vesicostomy. Unfortunately, growth was decreased in both groups compared to normal children (29,31).

Obstruction of the developing kidney results in a decrease in nephron endowment (59). Patients with obstructive uropathy rarely require renal replacement therapy as infants, and of those requiring dialysis, some may be able to transition off dialysis. Because of the decreased nephron endowment, children may need dialysis later in life.

The later decline in renal function commonly develops around the time of puberty when the body’s demands exceed the capacity of the remaining functioning nephrons. A combination of factors may contribute to the occurrence of end stage renal disease in late adolescence. These include persistent obstruction, renal dysplasia, hyperfiltration, recurrent infection, increasing muscle mass, and abnormal bladder function (60).

Classical sequelae of chronic renal failure are encountered in patients with severe obstructive uropathy. Electrolytes abnormalities including hyperkalemia and hyperphosphatemia require diet modification and dietary phosphate binders.

Because of the urinary concentrating defect associated with obstructive uropathy, patients typically do not experience problems with fluid overload as they continue to have large volumes of urine despite low glomerular filtration rates.

Hypertension may be caused by renal scars resulting in high renin production (56). Anemia of chronic renal failure requires treatment with human recombinant erythropoietin coupled with iron supplementation. Secondary hyperparathyroidism develops due to hyperphosphatemia and decreased production of 1,25-dihydroxyvitamin D, necessitating supplementation with exogenous 1,25dihydroxyvitamin D. Poor nutrition, uremia, and resistance to growth hormone contribute to poor body growth, and children often benefit from nutritional supplementation and recombinant growth hormone (61).

Options for renal replacement therapy in infants include peritoneal dialysis (PD) and hemodialysis (HD); however, PD is the preferred method. PD does not require maintenance of vascular access that is necessary for HD (62). PD uses the patient’s peritoneum as the dialysis membrane, and during PD dialysate is introduced into the peritoneal cavity through an indwelling

peritoneal catheter. Dextrose is used in the dialysate to create an osmotic gradient that drives the net removal of fluid. Clearance of solute is achieved through diffusion from the peritoneal capillaries into the dialysate. The most common complication of PD is infection. Repeated episodes of peritonitis result in damage to the peritoneal membrane and, with time, may render the membrane inadequate for dialysis (61).

Transplantation is a viable option for children with end stage renal disease resulting from obstructive uropathy, and 16.3% of pediatric patients presenting for renal transplantation have a diagnosis of obstructive uropathy (63). Historically, concerns for bladder dysfunction were a deterrent to transplantation in this population. In spite of this concern, numerous studies have shown transplantation to be successful. Severe bladder dysfunction may require bladder augmentation or reconstruction prior to transplant to ensure success (60,63). Aggressive management of dysfunctional voiding is also important for successful transplantation (63).

Animal models of obstruction Multiple animal models exist to investigate the pathogenesis and potential therapies for obstructive uropathy. The fetal sheep and the neonatal rat are the two most common models. The major benefit of fetal sheep is the ability to perform fetal surgery.

Ureteral ligation and contralateral nephrectomy performed early in sheep gestation results in severe hydronephrosis and dysplasia of the remaining kidney (64,65). Simple hydronephrosis results when ureteral ligation is carried out late in gestation (64).

Early decompression of surgically induced ureteral obstruction results in reversal of renal parenchymal damage. The previously obstructed kidney, however, has reduced postnatal function when compared to the contralateral kidney (66).

The neonatal rat is a useful model for prenatal obstructive uropathy because only 10% of its nephrons are present at birth. During the initial 10 postnatal days, nephron formation is completed. In contrast, human kidney nephron development is completed by 34-36 weeks gestation (23). This difference in development allows for obstruction of the neonatal rat kidney to approximate human kidney obstruction during midtrimester nephrogenesis. Studies in neonatal rats demonstrate a significant reduction in nephron number that correlates with the duration of obstruction (59).

Humoral and mechanical effects appear to play a ¶·È‰È·ÙÚÈ΋ 2007;70:350-360

Paidiatriki 5 final

12-10-07

16:28

Page 358

358

A.ÂŞ. Becker, M. Baum

role in the obstructed rat kidney model. Impaired growth and maturation lead to a decrease in renal mass and DNA, a reduced number of nephrons, and immature glomeruli, tubules, renal vasculature, and interstitium (59,67,68). As distal tubular epithelial cells undergo mechanical stretching, tubular cells are stimulated to undergo apoptosis. This process may be mediated in part by increased expression of TGFâ&#x20AC;&#x161;1 (69). EGF expression is reduced during obstruction, and exogenous administration of EGF results in an 80% decrease in apoptosis (70). The interstitium is infiltrated by macrophages which enhances the production of ceramide. Both the macrophages and ceramide induce apoptosis (71,72).

The renin-angiotensin system is activated during obstruction and mediates apoptosis via the AT2 receptor (23). Additionally, a reduction in renal blood flow and GFR is observed resulting from peritubular capillary compression and humoral effects (23,56).

Acknowledgements We would like to thank Dr. Jeane Joglar for her assistance in acquiring the renal images. M.B. is supported in part by DK065842 and DK41612.

References 1. Dudley JA, Haworth JM, McGraw ME, Frank JD, Tizard EJ. Clinical relevance and implications of antenatal hydronephrosis. Arch Dis Child Fetal Neonatal Ed 1997; 76:F31-F34.

2. Roth JA, Diamond DA. Prenatal hydronephrosis. Curr Opin Pediatr 2001;13:138-141.

3. Woodward M, Frank D. Postnatal management of antenatal hydronephrosis. BJU Int 2002;89:149-156.

4. Podevin G, Mandelbrot L, Vuillard E, Oury JF, Aigrain Y. Outcome of urological abnormalities prenatally diagnosed by ultrasound. Fetal Diagn Ther 1996;11:181-190.

5. Shokeir AA, Nijman RJ. Antenatal hydronephrosis: changing concepts in diagnosis and subsequent management.

BJU Int 2000;85:987-994.

6. Lee RS, Cendron M, Kinnamon DD, Nguyen HT. Antenatal hydronephrosis as a predictor of postnatal outcome: a meta-analysis. Pediatrics 2006;118:586-593.

7. Cheng AM, Phan V, Geary DF, Rosenblum ND. Outcome of isolated antenatal hydronephrosis. Arch Pediatr Adolesc Med 2004;158:38-40.

8. Sidhu G, Beyene J, Rosenblum ND. Outcome of isolated antenatal hydronephrosis: a systematic review and metaanalysis. Pediatr Nephrol 2006;21:218-224.

9. Winyard PJ, Risdon RA, Sams VR, Dressler GR, Woolf AS. The PAX2 transcription factor is expressed in cystic and hyperproliferative dysplastic epithelia in human kidney malformations. J Clin Invest 1996;98:451-459.

10. Jaswon MS, Dibble L, Puri S, Davis J, Young J, Dave R, et al. Prospective study of outcome in antenatally diagnosed renal pelvis dilatation. Arch Dis Child Fetal Neonatal Ed 1999;80:F135-F138.

Paediatriki 2007;70:350-360

11. Phan V, Traubici J, Hershenfield B, Stephens D, Rosenblum ND, Geary DF. Vesicoureteral reflux in infants with isolated antenatal hydronephrosis. Pediatr Nephrol 2003;18:1224-1228.

12. Alconcher L, Tombesi M. Mild antenatal hydronephrosis: management controversies. Pediatr Nephrol 2004;19:819820.

13. Tibballs JM, De Bruyn R. Primary vesicoureteric reflux-how useful is postnatal ultrasound? Arch Dis Child 1996;75:444-447.

14. Ismaili K, Avni FE, Hall M; Brussels Free University Perinatal Nephrology (BFUPN) Study Group. Results of systematic voiding cystourethrography in infants with antenatally diagnosed renal pelvis dilation. J Pediatr 2002;141:21-24.

15. Zerin JM, Ritchey ML, Chang AC. Incidental vesicoureteral reflux in neonates with antenatally detected hydronephrosis and other renal abnormalities. Radiology 1993;187:157-160.

16. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Mobius TE. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol 1985;15:105109.

17. Vanderheyden T, Kumar S, Fisk NM. Fetal renal impairment. Semin Neonatol 2003;8:279-289.

18. Ismaili K, Hall M, Piepsz A, Wissing KM, Collier F, Schulman C, et al. Primary vesicoureteral reflux detected in neonates with a history of fetal renal pelvis dilatation: a prospective clinical and imaging study. J Pediatr 2006;148:222-227.

19. Steele BT, Robitaille P, DeMaria J, Grignon A. Follow-up evaluation of prenatally recognized vesicoureteric reflux. J Pediatr 1989;115:95-96.

20. Stefanidis CJ, Siomou E. Imaging strategies for vesicoureteral reflux diagnosis. Pediatr Nephrol 2007;22:937947.

21. Proesmans W. Continuing medical education: introducing four papers on vesicoureteral reflux. Pediatr Nephrol 2007;22:785-787.

22. Williams B, Tareen B, Resnick MI. Pathophysiology and treatment of ureteropelvic junction obstruction. Curr Urol Rep 2007;8:111-117.

23. Chevalier RL. Perinatal obstructive nephropathy. Semin Perinatol 2004;28:124-131.

24. Imaji R, Moon DA, Dewan PA. Congenital posterior urethral membrane: variable morphological expression. J Urol 2001;165:1240-1242.

25. Hutton KA, Thomas DF, Arthur RJ, Irving HC, Smith SE. Prenatally detected posterior urethral valves: is gestational age at detection a predictor of outcome? J Urol 1994;152:698-701.

26. Lopez Pereira P, Espinosa L, Martinez Urrutina MJ, Lobato R, Navarro M, Jaureguizar E. Posterior urethral valves: prognostic factors. BJU Int 2003;91:687-690.

27. Strand WR. Initial management of complex pediatric disorders: prunebelly syndrome, posterior urethral valves. Urol Clin North Am 2004;31:399-415, vii.

28. Agarwal S. Urethral valves. BJU Int 1999;84:570-578.

29. Yohannes P, Hanna M. Current trends in the management of posterior urethral valves in the pediatric population.

Urology 2002;60:947-953.

Paidiatriki 5 final

12-10-07

16:28

Page 359

359

Obstructive uropathy

30. El-Ghoneimi A, Desgrippes A, Luton D, Macher MA, Guibourdenche J, Garel C, et al. Outcome of posterior urethral valves: to what extent is it improved by prenatal diagnosis?

J Urol 1999;162:849-853.

31. Narasimhan KL, Kaur B, Chowdhary SK, Bhalla AK. Does mode of treatment affect the outcome of neonatal posterior urethral valves? J Urol 2004;171:2423-2426.

32. Wheatley JM, Stephens FD, Hutson JM. Prune-belly syndrome: ongoing controversies regarding pathogenesis and management. Semin Pediatr Surg 1996;5:95-106.

33. Walker J, Prokurat AI, Irving IM. Prune belly syndrome associated with exomphalos and anorectal agenesis. J Pediatr Surg 1987;22:215-217.

34. Hartman GE, Shochat SJ. Abdominal mass lesions in the newborn: diagnosis and treatment. Clin Perinatol 1989;16:123-135.

35. Matsell DG, Bennett T, Goodyer P, Goodyer C, Han VK. The pathogenesis of multicystic dysplastic kidney disease: insights from the study of fetal kidneys. Lab Invest 1996;74:883-893.

36. Eccles MR. The role of PAX2 in normal and abnormal development of the urinary tract. Pediatr Nephrol 1998;12:712-720.

37. Feldenberg LR, Siegel NJ. Clinical course and outcome for children with multicystic dysplastic kidneys. Pediatr Nephrol 2000;14:1098-1101.

38. Sukthankar S, Watson AR. Unilateral multicystic dysplastic kidney disease: defining the natural history. Anglia Paediatric Nephrourology Group. Acta Paediatr 2000;89:811813.

39. Atiyeh B, Husmann D, Baum M. Contralateral renal abnormalities in multicystic-dysplastic kidney disease. J Pediatr 1992;121:65-67.

40. Okada T, Yoshida H, Matsunaga T, Kouchi K, Ohtsuka Y, Saitou T, et al. Multicystic dysplastic kidney detected by prenatal ultrasonography: natural history and conservative management. Pediatr Surg Int 2003;19:207-210.

41. Pérez LM, Naidu SI, Joseph DB. Outcome and cost analysis of operative versus nonoperative management of neonatal multicystic dysplastic kidneys. J Urol 1998;160:1207-1211.

42. Rabelo EA, Oliveira EA, Diniz JS, Silva JM, Filqueiras MT, Pezzuti IL, et al. Natural history of multicystic kidney conservatively managed: a prospective study. Pediatr Nephrol 2004;19:1102-1107.

43. Minevich E, Wacksman J, Phipps L, Lewis AG, Sheldon CA. The importance of accurate diagnosis and early close followup in patients with suspected multicystic dysplastic kidney. J Urol 1997;158:1301-1304.

44. Schmidlin FR, Iselin CE, Naimi A, Rohner S, Borst F, Farshad M, et al. The higher injury risk of abnormal kidneys in blunt renal trauma. Scand J Urol Nephrol 1998;32: 388-392.

45. Johnson B, Christensen C, Dirusso S, Choudhury M, Franco I. A need for reevaluation of sports participation recommendations for children with a solitary kidney. J Urol 2005;174:686-689.

46. Gerstenbluth RE, Spirnak JP, Elder JS. Sports participation and high grade renal injuries in children. J Urol 2002;168:2575-2578.

47. Oliveira EA, Diniz JS, Rabelo EA, Silva JM, Pereira AK, Filqueiras MT, et al. Primary megaureter detected by pre-

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

natal ultrasonography: conservative management and prolonged follow-up. Int Urol Nephrol 2000;32:13-18.

Keating MA, Escala J, Snyder HM 3rd, Heyman S, Duckett JW. Changing concepts in management of primary obstructive megaureter. J Urol 1989;142:636-640.

Shenoy MU, Rance CH. Is there a place for the insertion of a JJ stent as a temporizing procedure for symptomatic partial congenital vesico-ureteric junction obstruction in infancy? BJU Int 1999;84:524-525.

Pohl HG, Joyce GF, Wise M, Cilento BG Jr. Vesicoureteral reflux and ureteroceles. J Urol 2007;177:1659-1666.

Vergani P, Ceruti P, Locatelli A, Mariani E, Paterlini G, Zorloni C, et al. Accuracy of prenatal ultrasonographic diagnosis of duplex renal system. J Ultrasound Med 1999;18:463-467.

Coplen DE. Prenatal intervention for hydronephrosis. J Urol 1997;157:2270-2277.

Holmes N, Harrison MR, Baskin LS. Fetal surgery for posterior urethral valves: long-term postnatal outcomes. Pediatrics 2001;108:E7.

Johnson MP, Corsi P, Bradfield W, Hume RF, Smith C, Flake AW, et al. Sequential urinalysis improves evaluation of fetal renal function in obstructive uropathy. Am J Obstet Gynecol 1995;173:59-65.

Lipitz S, Ryan G, Samuell C, Haeusler MC, Robson SC, Dhillon HK, et al. Fetal urine analysis for the assessment of renal function in obstructive uropathy. Am J Obstet Gynecol 1993;168:174-179.

Roth KS, Koo HP, Spottswood SE, Chan JC. Obstructive uropathy: an important cause of chronic renal failure in children. Clin Pediatr (Phila) 2002;41:309-314.

Batlle DC, Arruda JA, Kurtzman NA. Hyperkalemic distal renal tubular acidosis associated with obstructive uropathy. N Engl J Med 1981;304:373-380.

Marra G, Goj V, Appiani AC, Dell Agnola CA, Tirelli SA, Tadini B, et al. Persistent tubular resistance to aldosterone in infants with congenital hydronephrosis corrected neonatally. J Pediatr 1987;110:868-872.

Chevalier RL, Thornhill BA, Chang AY, Cachat F, Lackey A. Recovery from release of ureteral obstruction in the rat: relationship to nephrogenesis. Kidney Int 2002;61:20332043.

Indudhara R, Joseph DB, Pérez LM, Diethelm AG. Renal transplantation in children with posterior urethral valves revisited: a 10-year followup. J Urol 1998;160:1201-1203.

Warady BA, Alexander SR, Watkins S, Kohaut E, Harmon WE. Optimal care of the pediatric end-stage renal disease patient on dialysis. Am J Kidney Dis 1999;33:567-583.

Andreoli SP. Acute renal failure in the newborn. Semin Perinatol 2004;28:112-123.

DeFoor W, Tackett L, Minevich E, McEnery P, Kitchens D, Reeves D, et al. Successful renal transplantation in children with posterior urethral valves. J Urol 2003;170:2402-2404.

Beck AD. The effect of intra-uterine urinary obstruction upon the development of the fetal kidney. J Urol 1971;105:784-789.

Glick PL, Harrison MR, Noall RA, Villa RL. Correction of congenital hydronephrosis in utero III. Early midtrimester ureteral obstruction produces renal dysplasia. J Pediatr Surg 1983;18:681-687.

Glick PL, Harrison MR, Adzick NS, Noall RA, Villa RL. Correction of congenital hydronephrosis in utero IV: in ¶·È‰È·ÙÚÈ΋ 2007;70:350-360

Paidiatriki 5 final

12-10-07

16:28

Page 360

360

A.ÂŞ. Becker, M. Baum

utero decompression prevents renal dysplasia. J Pediatr Surg 1984;19:649-657.

67. Chung KH, Chevalier RL. Arrested development of the neonatal kidney following chronic ureteral obstruction. J Urol 1996;155:1139-1144.

68. Chevalier RL, Kim A, Thornhill BA, Wolstenholme JT. Recovery following relief of unilateral ureteral obstruction in the neonatal rat. Kidney Int 1999;55:793-807.

69. Miyajima A, Chen J, Lawrence C, Ledbetter S, Soslow RA, Stern J, et al. Antibody to transforming growth factor-beta ameliorates tubular apoptosis in unilateral ureteral obstruction. Kidney Int 2000;58:2301-2313.

Paediatriki 2007;70:350-360

70. Chevalier RL, Goyal S, Wolstenholme JT, Thornhill BA. Obstructive nephropathy in the neonatal rat is attenuated by epidermal growth factor. Kidney Int 1998;54:38-47.

71. Lange-Sperandio B, Cachat F, Thornhill BA, Chevalier RL. Selectins mediate macrophage infiltration in obstructive nephropathy in newborn mice. Kidney Int 2002;61:516-524.

72. Malik RK, Thornhill BA, Chang AY, Kiley SC, Chevalier RL. Renal apoptosis parallels ceramide content after prolonged ureteral obstruction in the neonatal rat. Am J Physiol Renal Physiol 2001;281:F56-F61.

Paidiatriki 5 final

07-11-07

09:35

Page 361

∞¡∞™∫√¶∏™∏

REVIEW ARTICLE

361

¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘ °. ¶·Ú‰·Ïfi˜ ¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ Kawasaki (¡∫) Â›Ó·È ÌÈ· ÛÔ‚·Ú‹ ·ÁÁÂÈ›Ùȉ· ÙˆÓ Ì¤ÛÔ˘ ÌÂÁ¤ıÔ˘˜ ·ÚÙËÚÈÒÓ Ì ÚÔÙ›ÌËÛË ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜. ™‹ÌÂÚ·, ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Â›ÎÙËÙ˘ ηډÈÔ¿ıÂÈ·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜, ·Ú¿ ÙÔ fiÙÈ ÌÂÈÒıËΠÛËÌ·ÓÙÈο Ë Û˘¯ÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ıÂÚ·›·˜. ∏ ‰È¿ÁÓˆÛË Ù˘ ¡∫ ÛÙËÚ›˙ÂÙ·È Û ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ¤ˆ˜ ÙÒÚ· ‰ÂÓ ¤¯ÂÈ ‚ÚÂı› ·ıÔÁÓˆÌÔÓÈ΋ ÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË ÚÔÎÂÈ̤ÓÔ˘ Ó· ÙËÓ ÙÂÎÌËÚÈÒÛÂÈ. ŸÙ·Ó Ë ¤ÎÊÚ·ÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ ·˘ÙÒÓ Â›Ó·È Ï‹Ú˘, Ë ‰È¿ÁÓˆÛË Â›Ó·È Â‡ÎÔÏË. ™Â ·ÚÎÂÙÔ‡˜ fï˜ ·ÛıÂÓ›˜ ‰È·ÈÛÙÒÓÔÓÙ·È ÏÈÁfiÙÂÚ· ·fi Ù· ıÂÛÈÛı¤ÓÙ· ÎÚÈÙ‹ÚÈ· Î·È ·˘Ùfi ηıÈÛÙ¿ ÙË ‰È¿ÁÓˆÛË ‰˘Û¯ÂÚ‹. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ÔÈ Ôԛ˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ”·ÙÂÏ‹˜ ¡K”, Ë ‰È¿ÁÓˆÛË ·Ú·Ì¤ÓÂÈ ÂÈÙ·ÎÙÈ΋ ÁÈ·Ù› Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ·Ó¢ڢÛÌ¿ÙˆÓ Â›Ó·È ÂÍ›ÛÔ˘ ˘„ËÏfi˜ Ì ·˘ÙfiÓ Ù˘ Ù˘È΋˜ ÓfiÛÔ˘. ¶ÚfiÛÊ·Ù·, ·Ó·ÎÔÈÓÒıËÎ·Ó Ó¤Â˜ Û˘ÛÙ¿ÛÂȘ Ô˘ ‚ÔËıÔ‡Ó ÛÙË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¡∫. √È Û˘ÛÙ¿ÛÂȘ ·˘Ù¤˜ ÛÙÔ¯Â‡Ô˘Ó ÛÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ·È‰È¿ÙÚˆÓ ÛÙË ‰È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· Î·È ÛÙË ÛÙÚ·ÙËÁÈ΋ ıÂÚ·¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ô˘ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, ÒÛÙ ӷ ÚÔÏËÊı› Ô ·ÒÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘.

∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞ÚÈÛÙÔÙÂÏ›Ԣ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢, πÔÎÚ¿ÙÂÈÔ °¡ £ÂÛÛ·ÏÔӛ΢ AÏÏËÏÔÁÚ·Ê›·: °ÚËÁfiÚ˘ ¶·Ú‰·Ïfi˜ pargr@med.auth.gr §‡ÙÚ· 3 ∆.∫. 54 640, £ÂÛÛ·ÏÔÓ›ÎË

§¤ÍÂȘ ÎÏÂȉȿ: ∞ÙÂÏ‹˜ ÓfiÛÔ˜ Kawasaki, ·ÁÁÂÈ›Ùȉ·, ·Ó‡ڢÛÌ·, ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘, ·ÛÈÚ›ÓË.

Kawasaki disease: Clinical heterogeneity and strategic management G. Pardalos Abstract: Kawasaki disease (KD) is a severe form of vasculitis of the middle-sized arteries with a predilection for the coronary arteries. It is the leading cause of paediatric acquired heart disease in developed countries, despite the significant decline in the incidence of coronary artery complications following the introduction of effective treatment. The diagnosis of KD is based on clinical criteria, in the absence of a specific diagnostic assay. The complete expression of these criteria makes the diagnosis simple, but some children may present with “incomplete KD” that displays some of the features without meeting the classic criteria. Diagnosis of KD in these children is often difficult, and the incidence of coronary artery complications in patients with the incomplete disease spectrum is at least as high as in those with typical Kawasaki disease. Recently, new guidelines have been published to aid in the diagnosis and management of KD. The aim of these guidelines is to sensitize paediatricians to the diagnostic evaluation and strategic management of patients with KD, and thereby to prevent the further risk of myocardial infarction.

First Department of Paediatrics, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece Correspondence: Grigoris Pardalos pargr@med.auth.gr 3, Lytra St. 54 640, Thessaloniki, Greece

Key words: Incomplete Kawasaki disease, vasculitis, aneurysm, intravenous gamma globulin, aspirin.

™˘ÓÙÔÌÔÁڷʛ˜ ¡∫ À∫ ∏∫° IVIG

¡fiÛÔ˜ Kawasaki ÀÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ· ∏ÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· ∂Ó‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘

∏ ÓfiÛÔ˜ Kawasaki (¡∫) Â›Ó·È ÌÈ· ÛÔ‚·Ú‹ ·ÁÁÂÈ›Ùȉ· ÙˆÓ Ì¤ÛÔ˘ ÌÂÁ¤ıÔ˘˜ ·ÚÙËÚÈÒÓ ÌÂ Û˘¯Ó‹ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ. ∏ Û˘¯ÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ηٿ ÙËÓ ÂÚ›Ô‰Ô ÚÈÓ ÙËÓ ÂÊ·ÚÌÔÁ‹ ıÂÚ·›·˜ Ì Á-ÛÊ·ÈÚ›ÓË ¤Êı·Ó ÛÙÔ 20-40%, ÂÓÒ ÌÂÈÒıËΠ۠<5% ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ÂÊ·ÚÌÔÁ‹˜ Ù˘ ıÂÚ·¢ÙÈ΋˜ ·˘Ù‹˜ ·ÓÙÈÌÂÙÒÈÛ˘. ¶·ÚfiÏ· ·˘Ù¿,

Ë ¡∫ ·ÔÙÂÏ› Û‹ÌÂÚ· ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Â›ÎÙËÙ˘ ηډÈÔ¿ıÂÈ·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ (1,2). ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ Î˘Ì·›ÓÂÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÛÙȘ ‰È¿ÊÔÚ˜ ¯ÒÚ˜ (∂˘ÚÒË ~5, ∞ÌÂÚÈ΋ ~10, ¡. ∫ÔÚ¤· ~50 Î·È π·ˆÓ›· >100 ÂÚÈÙÒÛÂȘ /100.000 ÏËı˘ÛÌÔ‡), Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙ· ·ÁfiÚÈ· (1,31,7:1) Î·È ·ÔÙÂÏ› ÓfiÛÔ Ù˘ ‚ÚÂÊÔÓËȷ΋˜ ΢ڛˆ˜ ËÏÈΛ·˜ (85% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ≤ 5 ÂÙÒÓ) (1-4). ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Î·È Ë ·ıÔÁ¤ÓÂÈ¿ Ù˘ ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌË ‰È¢ÎÚÈÓÈÛÙ›. ¶Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ¤Ó· ¿ÁÓˆÛÙÔ Ì¤¯ÚÈ Û‹ÌÂÚ· ·ÓÙÈÁfiÓÔ ¶·È‰È·ÙÚÈ΋ 2007;70:361-369

Paidiatriki 5 final

12-10-07

16:28

Page 362

362

°. ¶·Ú‰·Ïfi˜

(Èı·ÓÒ˜ ÏÔÈÌÒ‰Ô˘˜ ·ÈÙÈÔÏÔÁ›·˜) ÚÔηÏ› ¤ÓÙÔÓË ‰È¤ÁÂÚÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ÔÔ›· ÂÎÊÚ¿˙ÂÙ·È Ì ÙȘ ÁÓˆÛÙ¤˜ ÊÏÂÁÌÔÓÒ‰ÂȘ Û˘ÛÙËÌ·ÙÈΤ˜ ·ÓÙȉڿÛÂȘ, Ì ΢ڛ·Ú¯Ô Û‡Ìو̷ ÙÔÓ ˘ÚÂÙfi. ŸÙ·Ó ÙÔ ·›ÙÈÔ ‰Ú· ¿Óˆ Û ¤Ó· ÁÂÓÂÙÈο ηıÔÚÈṲ̂ÓÔ ˘fiÛÙڈ̷, ÙÔ ÔÔ›Ô Ì¤¯ÚÈ Û‹ÌÂÚ· ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ, Ô‰ËÁ› Û ÌÈ· ˘¤ÚÌÂÙÚË Î·È ·Ú·ÙÂٷ̤ÓË ·ÓÔÛȷ΋ ·¿ÓÙËÛË ÂÓ·ÓÙ›ÔÓ ÙˆÓ Ì¤ÛÔ˘ ÌÂÁ¤ıÔ˘˜ ·ÚÙËÚÈÒÓ Ì ÈÔ ÛËÌ·ÓÙÈ΋ ÚÔÛ‚ÔÏ‹ ·˘Ù‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ. ∆ÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙˆÓ ‰ÈÂÚÁ·ÛÈÒÓ ·˘ÙÒÓ Â›Ó·È Ë Â›ÌÔÓË ÊÏÂÁÌÔÓ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ Î·È Ë ÚfiÎÏËÛË ·Ó¢ڢÛÌ¿ÙˆÓ (1,5,6). ∏ ‰È¿ÁÓˆÛË Ù˘ ¡∫ ÛÙËÚ›˙ÂÙ·È Û ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ·, ÁÈ·Ù› ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯ÂÈ ‚ÚÂı› ÌÈ· ·ıÔÁÓˆÌÔÓÈ΋ ÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË ÚÔÎÂÈ̤ÓÔ˘ Ó· ÙËÓ ÙÂÎÌËÚÈÒÛÂÈ. ŸÙ·Ó Ë ¤ÎÊÚ·ÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ ·˘ÙÒÓ Â›Ó·È Ï‹Ú˘, Ë ‰È¿ÁÓˆÛË Â›Ó·È Â‡ÎÔÏË. ™Â ·ÚÎÂÙÔ‡˜ fï˜ ·ÛıÂÓ›˜, Ë ÓfiÛÔ˜ ÂÎÊÚ¿˙ÂÙ·È Ì ÏÈÁfiÙÂÚ· ·fi Ù· ıÂÛÈÛı¤ÓÙ· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Î·È ·˘Ùfi ηıÈÛÙ¿ ÙË ‰È¿ÁÓˆÛË ‰˘Û¯ÂÚ‹. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ÔÈ Ôԛ˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ “·ÙÂÏ‹˜ ¡∫”, Ë ‰È¿ÁÓˆÛË ·Ú·Ì¤ÓÂÈ ÂÈÙ·ÎÙÈ΋, ÁÈ·Ù› Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ·Ó¢ڢÛÌ¿ÙˆÓ Â›Ó·È ÂÍ›ÛÔ˘ ˘„ËÏfi˜ Ì ·˘ÙfiÓ Ù˘ Ù˘È΋˜ ÓfiÛÔ˘ (7). ¶ÚfiÛÊ·Ù·, Ë ∞ÌÂÚÈηÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Âͤ‰ˆÛ Ӥ˜ Û˘ÛÙ¿ÛÂȘ Ô˘ ‚ÔËıÔ‡Ó ÛÙË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¡∫ (8). ™ÙÔ ¿ÚıÚÔ ·˘Ùfi, ı· ·Ó·Ù˘¯ıÔ‡Ó ÂÓ Û˘ÓÙÔÌ›· ÔÈ Û˘ÛÙ¿ÛÂȘ ·˘Ù¤˜ Ì ÛÙfi¯Ô ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ·È‰È¿ÙÚˆÓ ÛÙË ‰È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· Î·È ÙË ÛÙÚ·ÙËÁÈ΋ ıÂÚ·¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ô˘ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È fiÛÔÓ ·ÊÔÚ¿ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, ÒÛÙ ӷ ÚÔÏËÊı› Ô ·ÒÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘.

∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· ∏ ÎÏÈÓÈ΋ ÔÚ›· Ù˘ ¡∫, Û’ fiϘ ÙȘ ÌÔÚʤ˜ Ù˘, ·ÔÙÂÏÂ›Ù·È ·fi ÙÚÂȘ Ê¿ÛÂȘ: π. √Í›· Ê¿ÛË (‰È¿ÚÎÂÈ·˜ 1-2 ‚‰ÔÌ¿‰ˆÓ), fiÔ˘ ÂÈÎÚ·ÙÔ‡Ó Ù· ¤ÓÙÔÓ· ÊÏÂÁÌÔÓÒ‰Ë Ê·ÈÓfiÌÂÓ· Ì ΢ڛ·Ú¯Ô ÙÔÓ ˘ÚÂÙfi. ππ. ÀÔÍ›· Ê¿ÛË (‰È¿ÚÎÂÈ·˜ 2-4 ‚‰ÔÌ¿‰ˆÓ). ÀÔ¯ˆÚ› Ô ˘ÚÂÙfi˜ ·ÏÏ¿ ÂÈ̤ÓÔ˘Ó Ë Î·ÎÔ˘¯›· Î·È Ë ·ÓÔÚÂÍ›·. ÷ڷÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù· Ù˘ Ê¿Û˘ ·˘Ù‹˜ Â›Ó·È Ë ÂÚÈÔÓ‡¯È· ‰·ÎÙ˘ÏÈ΋ ·ÔϤÈÛË ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚˆÓ Î·È Ë ıÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË, ·ÔÙÂÏ› ‰Â ÙË Ê¿ÛË Î·Ù¿ ÙËÓ ÔÔ›· ÂÈÛ˘Ì‚·›ÓÂÈ Ë ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ Ì Â·ÎfiÏÔ˘ıÔ ÙË ‰È¿Ù·Û‹ ÙÔ˘˜ Î·È ÙË ‰ËÌÈÔ˘ÚÁ›· ·Ó¢ڢÛÌ¿ÙˆÓ. πππ. º¿ÛË ·Ó¿ÚÚˆÛ˘. ∞Ú¯›˙ÂÈ 6-8 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Ì ÙËÓ Ï‹ÚË ˘Ô¯ÒÚËÛË fiÏˆÓ ÙˆÓ Î‡ÚÈˆÓ ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙË ‰È·‰Èηۛ· Paediatriki 2007;70:361-369

˘ÔÛÙÚÔÊ‹˜ ‹ ÛÙ·ıÂÚÔÔ›ËÛ˘ ÙˆÓ ·Ó¢ڢÛÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ, Â¿Ó Ê˘ÛÈο ¤¯Ô˘Ó ÚÔ·„ÂÈ (1,2,5).

∆˘È΋ ÓfiÛÔ˜ Kawasaki ∆· ÎÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ Ù˘ Ù˘È΋˜ ¡∫ Â›Ó·È ÎÏÈÓÈο Î·È Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. √ ˘ÚÂÙfi˜ ·ÔÙÂÏ› ÙÔ Î˘Ú›·Ú¯Ô Û‡Ìو̷, Â›Ó·È ˘„ËÏfi˜ (>39,5ÔC), ·ÓıÂÎÙÈÎfi˜ ÛÙ· ·ÓÙÈ˘ÚÂÙÈο Î·È Û˘Óԉ‡ÂÙ·È ·fi ·ÓÔÚÂÍ›·, ηٷ‚ÔÏ‹ ‰˘Ó¿ÌˆÓ, ·ÓËÛ˘¯›·, ¢ÂÚÂıÈÛÙfiÙËÙ· Î·È ˘ÓËÏ›·. ∏ ̤ÛË ‰È¿ÚÎÂÈ¿ ÙÔ˘ ¯ˆÚ›˜ ıÂÚ·›· Â›Ó·È 11 Ë̤Ú˜, ·ÏÏ¿ ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È ÂÚÈÙÒÛÂȘ Ì ‰È¿ÚÎÂÈ· ÌÂÁ·Ï‡ÙÂÚË ·fi ¤Ó· Ì‹Ó·. ∏ ÂÈÂÊ˘Î›Ùȉ· Â›Ó·È ·ÌÊÔÙÂÚfiÏ¢ÚË, ÌË ˘Ò‰Ë˜ Î·È ·Û˘Ìو̷ÙÈ΋. ∆Ô ÁÂÁÔÓfi˜ ‰Â fiÙÈ ‰È·ÚΛ ÁÈ· ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, Ì›· ¤ˆ˜ ‰‡Ô Ë̤Ú˜, οÓÂÈ ÙËÓ ·Ó›¯ÓÂ˘Û‹ Ù˘ ‰‡ÛÎÔÏË. √È ·ÏÏÔÈÒÛÂȘ ·fi ÙÔÓ ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ· ÂÛÙÈ¿˙ÔÓÙ·È Î˘Ú›ˆ˜ ÛÙ· ÂÚ˘ıÚ¿ Ì ۯ¿ÛÂȘ ¯Â›ÏË Î·È ÙË ÌÔÚÔÂȉ‹ ÁÏÒÛÛ· (∂ÈÎfiÓ· 1). ™˘¯Ó¿, Û˘Ó˘¿Ú¯ÂÈ Î·È ‰È¿¯˘ÙË ÂÚ˘ıÚfiÙËÙ· ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ· ·ÏÏ¿ ¯ˆÚ›˜ ÂÛÙȷΤ˜ ·ÏÏÔÈÒÛÂȘ, ¤ÏÎË ‹ ÂȯڛÛÌ·Ù·. ™ËÌÂÈÒÓÔÓÙ·È Â›Û˘ ·ÏÏÔÈÒÛÂȘ ·fi Ù· ÂÚÈÊÂÚÈο ¿ÎÚ·. ∆Ô ÂÚ‡ıËÌ· Î·È ÙÔ Ô›‰ËÌ· ·Ï·ÌÒÓ (∂ÈÎfiÓ· 2) Î·È ÂÏÌ¿ÙˆÓ ·Ó‹ÎÔ˘Ó ÛÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÚÒÈÌ· Â˘Ú‹Ì·Ù· Ù˘ ÓfiÛÔ˘ Î·È ··ÓÙÔ‡Ó Ôχ Û˘¯ÓfiÙÂÚ· ÛÙ· ‚Ú¤ÊË. ∞ÓÙ›ıÂÙ·, Ë ÂÚÈÔÓ‡¯È· ‰·ÎÙ˘ÏÈ΋ ·ÔϤÈÛË (∂ÈÎfiÓ· 4) ·ÔÙÂÏ› ÙÔ ÌÔÓ·‰ÈÎfi ·fi Ù· ÎÏ·ÛÈο Â˘Ú‹Ì·Ù· Ô˘ ÂÌÊ·Ó›˙ÂÙ·È ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ Â‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. ∆Ô ÂÍ¿ÓıËÌ· ÂÌÊ·Ó›˙ÂÙ·È ÙȘ ÚÒÙ˜ ¤ÓÙ Ë̤Ú˜ Ù˘ ÓfiÛÔ˘, Â›Ó·È ÎËÏȉԂϷÙȉ҉˜ Û˘ÚÚ¤ÔÓ Î·È ÂÓÙÔ›˙ÂÙ·È ÈÔ ¤ÓÙÔÓ· ÛÙÔÓ ÎÔÚÌfi (∂ÈÎfiÓ· 3). ™·ÓÈfiÙÂÚ·, ÌÔÚ› Ó· ¿ÚÂÈ ÙË ÌÔÚÊ‹ ÙÔ˘ ÎÓȉˆÙÈÎÔ‡ ‹ ÙÔ˘ ÔÛÙÚ·ÎÈÒ‰Ô˘˜ Î·È Û¯Â‰fiÓ ÔÙ¤ ÙÔ˘ ÂÙ¯ÂÈÒ‰Ô˘˜ ‹ Ê˘Û·ÏÈ‰Ò‰Ô˘˜. ∆¤ÏÔ˜, Ë ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· Â›Ó·È ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ Ù˘ ÂÙÂÚfiÏ¢ÚË Î·È ˘ÔÏ›ÂÙ·È ÛÂ Û˘¯ÓfiÙËÙ· (25-50%) ÙˆÓ ÏÔÈÒÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ (>90%). √È ÏÂÌÊ·‰¤Ó˜ ¤¯Ô˘Ó ¶›Ó·Î·˜ 1. ∫ÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ Ù˘ Ù˘È΋˜ ÓfiÛÔ˘ Kawasaki ¶˘ÚÂÙfi˜ ≥5 Ë̤Ú˜ Î·È 4 ·fi Ù· ·ÎfiÏÔ˘ı· 5 Â˘Ú‹Ì·Ù·: 1. ∞ÌÊÔÙÂÚfiÏ¢ÚË ÂÈÂÊ˘Î›Ùȉ· (ÌË ˘Ò‰Ë˜) 2. ™ÙÔÌ·ÙÔÊ·Ú˘ÁÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ - ÂÚ‡ıËÌ· Î·È Û¯¿ÛË ¯ÂÈϤˆÓ - ÌÔÚÔÂȉ‹˜ ÁÏÒÛÛ· - ‰È¿¯˘ÙÔ ÛÙÔÌ·ÙÔÊ·Ú˘ÁÁÈÎfi ÂÚ‡ıËÌ· 3. ∞ÏÏÔÈÒÛÂȘ ·fi Ù· ÂÚÈÊÂÚÈο ¿ÎÚ· - ÂÚ‡ıËÌ· ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ - Ô›‰ËÌ· ¿ÎÚˆÓ ¯ÂÈÚÒÓ Î·È Ô‰ÈÒÓ - ·ÔϤÈÛË ‰·ÎÙ‡ÏˆÓ ¯ÂÈÚÒÓ Î·È Ô‰ÈÒÓ (ÌÂÙ¿ ÙËÓ ÔÍ›· Ê¿ÛË) 4. ∂Í¿ÓıËÌ· ÎËÏȉԂϷÙȉ҉˜ Û˘ÚÚ¤ÔÓ ‹ ÈÏ·ÚÔÂȉ¤˜, ÌË Ê˘Û·Ïȉ҉˜ 5. ∂ÙÂÚfiÏ¢ÚË ‰ÈfiÁΈÛË ÙÚ·¯ËÏÈÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ (≥1,5 cm)

Paidiatriki 5 final

12-10-07

16:28

Page 363

363

¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘

∂ÈÎfiÓ· 1. ∂Ú˘ıÚ¿ Ì ۯ¿ÛÂȘ ¯Â›ÏË Î·È ÌÔÚÔÂȉ‹˜ ÁÏÒÛÛ·. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ¿‰ÂÈ·˜ (23).

∂ÈÎfiÓ· 3. ∂Í¿ÓıËÌ· ÎËÏȉԂϷÙȉ҉˜ Û˘ÚÚ¤ÔÓ ÛÙÔÓ ÎÔÚÌfi. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ¿‰ÂÈ·˜ (23).

∂ÈÎfiÓ· 2. ∂Ú˘ıÚfiÙËÙ· Î·È Ô›‰ËÌ· ·Ï·ÌÒÓ. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ¿‰ÂÈ·˜ (23).

¶›Ó·Î·˜ 2. ÕÏϘ ÂΉËÏÒÛÂȘ Ù˘ ÓfiÛÔ˘ Kawasaki ·fi ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù· (ÂÎÙfi˜ ·fi Ù· ÎÏ·ÛÈο ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·) ∫·Ú‰È·ÁÁÂÈ·Îfi - ‚Ï¿‚˜ ÛÙÂÊ·ÓÈ·›ˆÓ (‰È¿Ù·ÛË, ·Ó¢ڇÛÌ·Ù·, Û·Ó›ˆ˜ ıÚfiÌ‚ˆÛË) - ·Ó¢ڇÛÌ·Ù· ÂÚÈÊÂÚÈÎÒÓ ·ÚÙËÚÈÒÓ - ‹È· ÂÚÈηډ›Ùȉ·, Ì˘Ôηډ›Ùȉ·, ·ÚÔ‰È΋ ·ÓÂ¿ÚÎÂÈ· ‚·Ï‚›‰ˆÓ ∫¡™ - ¢ÂÚÂıÈÛÙfiÙËÙ·, ¿ÛËÙË ÌËÓÈÁÁ›Ùȉ· °·ÛÙÚÂÓÙÂÚÈÎfi - ‰È¿ÚÚÔÈ·, Á·ÛÙÚÂÓÙÂÚÈΤ˜ ‰È·Ù·Ú·¯¤˜, Ë·Ù›Ùȉ·, Û·Ó›ˆ˜ ‡‰Úˆ·˜ ¯ÔÏˉfi¯Ô˘ ∞Ó·Ó¢ÛÙÈÎfi - ‚‹¯·˜, ÚÈÓ›Ùȉ·, Û·Ó›ˆ˜ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈΤ˜ ‰ÈËı‹ÛÂȘ ª˘ÔÛÎÂÏÂÙÈÎfi - ·ÚıÚ·ÏÁ›Â˜, ·ÚıÚ›Ùȉ·, Û·Ó›ˆ˜ Ì˘ÔÛ›Ùȉ· √˘ÚÔÔÈËÙÈÎfi - ¿ÛËÙË ˘Ô˘Ú›·, Û·Ó›ˆ˜ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ‹/Î·È ·ÈÌ·ÙÔ˘Ú›·

‰È¿ÌÂÙÚÔ ÌÂÁ·Ï‡ÙÂÚË ·fi 1,5 cm Î·È Â›Ó·È Û˘Ó‹ıˆ˜ ÔÌÔÈÔÁÂÓ›˜ ¯ˆÚ›˜ ÎÏ˘‰·ÛÌfi (1,2,8-10). ∏ ÓfiÛÔ˜, fï˜, ÂÎÊÚ¿˙ÂÙ·È Î·È Ì ÌÈ· ÏÂÈ¿‰· ¿ÏÏˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ·fi ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù· (¶›Ó·Î·˜ 2). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ηıÈÛÙ¿ ··Ú·›ÙËÙË ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ·fi ·ı‹ÛÂȘ Ì ·ÚfiÌÔÈ· ÎÏÈÓÈο Â˘Ú‹Ì·Ù·, fiˆ˜ Â›Ó·È ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (ÈÏ·Ú¿, ∂-µV Ïԛ̈ÍË, ∏∏V-6, ·‰ÂÓÔ˚Ô›, ÂÓÙÂÚÔ˚Ô› Î.¿), ÔÈ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ (‚·ÎÙËÚȷ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·, Ô˘ÚÔÏԛ̈ÍË, ÔÛÙÚ·ÎÈ¿, Û‡Ó‰ÚÔÌÔ ÛÙ·Ê˘ÏÔÎÔÎÎÈ΋˜ ·ÔÊÔÏȉˆÙÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, Û‡Ó‰ÚÔÌÔ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜), ÙÔ Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜, ÙÔ Û‡Ó‰ÚÔÌÔ Stevens-Johnson, Ë ˘ÂÚ¢·ÈÛıËÛ›· Û ʿÚ̷η, Ë Û˘ÛÙËÌ·ÙÈ΋ Ó·ÓÈ΋ ȉÈÔ·ı‹˜ ·ÚıÚ›Ùȉ· Î·È ¿ÏÏ· ÈÔ Û¿ÓÈ· ·›ÙÈ·. ÃÚÂÈ¿˙ÂÙ·È, ÏÔÈfiÓ, ȉȷ›ÙÂÚË ÚÔÛÔ¯‹ ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, ÔÈ· ‰ËÏ·‰‹ ÎÏÈÓÈο

∂ÈÎfiÓ· 4. ¶ÂÚÈÔÓ‡¯È· ‰·ÎÙ˘ÏÈ΋ ·ÔϤÈÛË. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ¿‰ÂÈ·˜ (23). ¶·È‰È·ÙÚÈ΋ 2007;70:361-369

Paidiatriki 5 final

07-11-07

09:36

Page 364

364

°. ¶·Ú‰·Ïfi˜

¶›Ó·Î·˜ 3. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ˘¤Ú Î·È ÂÓ·ÓÙ›ÔÓ ¡. Kawasaki ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο

À¤Ú ¡. Kawasaki

∫·Ù¿ ¡. Kawasaki

¶˘ÚÂÙfi˜

À„ËÏfi˜ (>39ÔC), Ô͇·È¯Ì· ·̷ٷ, ‰È·ÚΛ ≥ 5 Ë̤Ú˜ ªË ˘Ò‰Ë˜, ·ÌÊÔÙÂÚfiÏ¢ÚË ∂Ú˘ıÚ¿ Ì ۯ¿ÛÂȘ ¯Â›ÏË, ÌÔÚÔÂȉ‹˜ ÁÏÒÛÛ·, ‰È¿¯˘ÙË ÂÚ˘ıÚfiÙËÙ· ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ· ∂Ú‡ıËÌ· ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ, Ô›‰ËÌ· ¿ÎÚˆÓ ¯ÂÈÚÒÓ-Ô‰ÈÒÓ, ·ÔϤÈÛË ‰·ÎÙ‡ÏˆÓ ÌÂÙ¿ ÙËÓ 1Ë ‚‰ÔÌ¿‰· ∫ËÏȉԂϷÙȉ҉˜ Û˘ÚÚ¤ÔÓ, ÂÓÙfi˜ ÙˆÓ ÚÒÙˆÓ 5 ËÌÂÚÒÓ, ÌÔÈ¿˙ÂÈ Ì ÔÛÙÚ·ÎÈ҉˜ ‹ ÔχÌÔÚÊÔ, ÈÔ ¤ÓÙÔÓÔ ÂÚÈÚˆÎÙÈο-‰˘Ó·ÙfiÓ Î·È Ì ·ÔϤÈÛË ™˘Ó‹ıˆ˜ ÂÙÂÚfiÏ¢ÚË Î·È >1,5 cm ŒÓÙÔÓË Â˘ÂÚÂıÈÛÙfiÙËÙ·, ηډÈÔ·ÁÁÂȷΤ˜ ‰È·Ù·Ú·¯¤˜, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ‰È¿ÚÚÔÈ·, Ë·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹, ·ÚıÚ·ÏÁ›Â˜-·ÚıÚ›Ùȉ·, ¿ÛËÙË ÌËÓÈÁÁ›Ùȉ· ¿ÛËÙË ˘Ô˘Ú›·-Ô˘ÚËıÚ›Ùȉ·, ÈÚȉÔ΢ÎÏ›Ùȉ·

÷ÌËÏfi˜-̤ÙÚÈÔ˜ (<39ÔC), ˘Ô¯ˆÚ› Û ÏÈÁfiÙÂÚÔ ·fi 5 Ë̤Ú˜ ¶˘Ò‰Ë˜ ∂ͤڢıÚÔ˜ Ê¿Ú˘ÁÁ·˜ ÌfiÓÔ, fi¯È ÂÚ˘ıÚfiÙËÙ· ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ ∞ÔϤÈÛË ·Ï·ÌÒÓ-ÂÏÌ¿ÙˆÓ Û˘ÓÔÏÈο, fi¯È ÂȉÈο ÂÚÈÔÓ‡¯È· ‰·ÎÙ˘ÏÈ΋, ÛÙËÓ ·Ú¯‹ Ù˘ ÓfiÛÔ˘ ∂ÌÊ·Ó›˙ÂÙ·È ·ÚÁfiÙÂÚ· (> 5Ë Ì¤Ú· ÓfiÛÔ˘) Î·È ÌÂÙ¿ ÙËÓ ÙÒÛË ÙÔ˘ ˘ÚÂÙÔ‡

∂ÈÂÊ˘Î›Ùȉ· ∞ÏÏÔÈÒÛÂȘ ·fi ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ· ∞ÏÏÔÈÒÛÂȘ ·fi ÂÚÈÊÂÚÈο ¿ÎÚ· ∂Í¿ÓıËÌ·

∆Ú·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· ÕÏÏ· Â˘Ú‹Ì·Ù·

¯·Ú·ÎÙËÚÈÛÙÈο Â›Ó·È ÂÓ‰ÂÈÎÙÈο ÁÈ· ¡∫ Î·È ÔÈ· fi¯È (¶›Ó·Î·˜ 3). ∞·Ú·›ÙËÙË Â›Ó·È Â›Û˘ Î·È Ë Û˘Ó‰ÚÔÌ‹ ÙÔ˘ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÎÏÂÈÛÙÔ‡Ó ÔÈ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ (1,2,8-10).

∞ÙÂÏ‹˜ ÓfiÛÔ˜ Kawasaki ∏ ‰È¿ÁÓˆÛË Ù˘ ¡∫ Â›Ó·È Â‡ÎÔÏË fiÙ·Ó ÏËÚÔ‡ÓÙ·È Ù· Ù¤ÛÛÂÚ· ·fi Ù· ÚÔ·Ó·ÊÂÚı¤ÓÙ· ¤ÓÙ ÎÚÈ-

°ÂÓÈÎÂ˘Ì¤ÓË ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· ∫·Ï‹ ÁÂÓÈ΋ ηٿÛÙ·ÛË

Ù‹ÚÈ·, ·ÏÏ¿ ‰‡ÛÎÔÏË fiÙ·Ó ÏËÚÔ‡ÓÙ·È ÏÈÁfiÙÂÚ· (2 ‹ 3) (·ÙÂÏ‹˜ ¡. Kawasaki). ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ë ‰È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· ··ÈÙ›, ÂÎÙfi˜ ·fi ÙÔÓ ·ÔÎÏÂÈÛÌfi ÙˆÓ ¿ÏÏˆÓ ·ıÔÏÔÁÈÎÒÓ Î·Ù·ÛÙ¿ÛˆÓ, ÙË ‚Ô‹ıÂÈ· Î·È ÙÔ˘ ·Ú·ÎÏÈÓÈÎÔ‡ ÂϤÁ¯Ô˘ (7). ∏ ∞ÌÂÚÈηÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Ì ÙË Û‡ÌʈÓË ÁÓÒÌË Î·È Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ∞η‰ËÌ›·˜ ¶·È‰È·ÙÚÈ΋˜ Âͤ‰ˆÛÂ Û˘ÛÙ¿ÛÂȘ (guidelines) ÁÈ· ÙË ‰È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· Ô˘ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È Û ÂÚÈÙÒÛÂȘ “·ÙÂÏÔ‡˜ N. Kawasaki” (8).

¶˘ÚÂÙfi˜ ÁÈ· ≥5 ̤Ú˜ Î·È ≥2 ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· ¡∫ µ‹Ì· 1. ∫ÏÈÓÈ΋ ÂÎÙ›ÌËÛË ªË Û˘Ì‚·Ù‹ Ì ¡∫ Î·È ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ ∂·ÓÂÎÙ›ÌËÛË ¶ÏËÚÔ› Ù· ·ÚÈ· Î·È ≥3 Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” £ÂÚ·›· Î·È À∫

™˘Ì‚·Ù‹ Ì ¡∫ µ‹Ì· 2. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¶ÏËÚÔ› Ù· ·ÚÈ· Î·È <3 ¢ÂÓ ÏËÚÔ› Ù· ·ÚÈ· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” ÂÚÁ·ÛÙËÚȷο “ÎÚÈÙ‹ÚÈ·”

µ‹Ì· 3. ÀÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ (À∫) µ‹Ì· 4. ∫·ıËÌÂÚÈÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË £ÂÙÈÎfi £ÂÚ·›·

∞ÚÓËÙÈÎfi √ ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ ¡∞π

√Ãπ

√ ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ ÁÈ· ≥2 ̤Ú˜ ¡∞π

√Ãπ

∞ÔϤÈÛË ∂·Ó¿ÏË„Ë ªË Èı·Ó‹ ∂·ÓÂÎÙ›ÌËÛË À∫ ‰È¿ÁÓˆÛË ÎÏÈÓÈ΋ Î·È Â·ÓÂÎÙ›ÌËÛË ¡∫ ÂÚÁ·ÛÙËÚȷ΋ ¡∞π √Ãπ ∂·Ó¿ÏË„Ë ¢È·ÎÔ‹ À∫ ·Ú·ÎÔÏÔ‡ıËÛ˘ Â·ÓÂÎÙ›ÌËÛË ∂ÈÎfiÓ· 5. ∞ÏÁfiÚÈıÌÔ˜ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ ·ÙÂÏÔ‡˜ ÓfiÛÔ˘ Kawasaki.

Paediatriki 2007;70:361-369

Paidiatriki 5 final

13-11-07

16:18

Page 365

365

¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘

¶›Ó·Î·˜ 4. ∫‡ÚÈ· Î·È Û˘ÌÏËڈ̷ÙÈο ÂÚÁ·ÛÙËÚȷο “ÎÚÈÙ‹ÚÈ·” Ù˘ ·ÙÂÏÔ‡˜ ÓfiÛÔ˘ Kawasaki π. ∫‡ÚÈ· (2): - ∆∫∂: > 40 mm/h - CRP: > 3 mg/dL £ÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ·: ≥ 1 “ÎÚÈÙ‹ÚÈÔ” ππ. ™˘ÌÏËڈ̷ÙÈο (6): - §Â˘ÎÔ΢ÙÙ¿ÚˆÛË: > 15 x 103/ÌL - ∞Ó·ÈÌ›· (ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘) - £ÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË: > 450 x 103/ÌL, ÌÂÙ¿ ÙËÓ 7Ë Ì¤Ú· ÓfiÛÔ˘ - ÀÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›·: ≤ 3g/dL - ∞‡ÍËÛË ALT (SGPT) - ¶˘Ô˘Ú›·: > 10 ˘ÔÛÊ·›ÚÈ· ÎÔ £ÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ·: ≥ 3 “ÎÚÈÙ‹ÚÈ·”

∏ ‰È·‰Èηۛ· ·˘Ù‹, ÁÈ· ¢ÎÔÏ›·, ÛÙ·‰ÈÔÔÈÂ›Ù·È Û ٤ÛÛÂÚ· ‚‹Ì·Ù· (∂ÈÎfiÓ· 5). ¢È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· ·ÙÂÏÔ‡˜ ¡. Kawasaki µ‹Ì· 1. ∫ÏÈÓÈ΋ ÂÎÙ›ÌËÛË ∆Ô ÚˆÙ·Ú¯ÈÎfi Î·È Î‡ÚÈÔ ÂÚÒÙËÌ· Ô˘ Ù›ıÂÙ·È Â›Ó·È ·Ó Ë Û˘Ìو̷ÙÔÏÔÁ›· ÙÔ˘ ·ÛıÂÓÔ‡˜ ÏËÚÔ› Ù· ÎÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ Ù˘ “·ÙÂÏÔ‡˜ N. Kawasaki”, ‰ËÏ·‰‹ Â¿Ó ˘¿Ú¯ÂÈ ˘ÚÂÙfi˜ ≥5 Ë̤Ú˜ Î·È 2 ‹ 3 ·fi Ù· 5 ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ·. ∞Ó Ë ·¿ÓÙËÛË Â›Ó·È ıÂÙÈ΋, ÚÔ¯ˆÚԇ̠ÛÙÔ ‰Â‡ÙÂÚÔ ‚‹Ì·. ∞Ó fï˜ Ë ÛËÌÂÈÔÏÔÁ›· ‰ÂÓ Â›Ó·È Û˘Ì‚·Ù‹ ÂÓÒ Ô ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ, Ô ·ÛıÂÓ‹˜ Â·ÓÂÎÙÈÌ¿Ù·È. µ‹Ì· 2. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ·ÚÈ· Î·È Ù· Û˘ÌÏËڈ̷ÙÈο ÂÚÁ·ÛÙËÚȷο “ÎÚÈÙ‹ÚÈ·” (¶›Ó·Î·˜ 4) Î·È Ë ‰È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· ÂÍÂÏ›ÛÛÂÙ·È ·Ó·ÏfiÁˆ˜ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ. ŒÙÛÈ, fiÙ·Ó ÏËÚÔ‡ÓÙ·È Ù· ·ÚÈ· Î·È Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·”, ÙfiÙ ··ÈÙÂ›Ù·È Ë ¿ÌÂÛË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ·ÎÔÏÔ˘ı› Û ‰Â‡ÙÂÚÔ ¯ÚfiÓÔ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ (YK). ∞Ó fï˜ ÏËÚÔ‡ÓÙ·È ÌfiÓÔ Ù· ·ÚÈ· “ÎÚÈÙ‹ÚÈ·” Î·È ˘¿Ú¯Ô˘Ó <3 Û˘ÌÏËڈ̷ÙÈο, ÙfiÙ ÚÔ¯ˆÚԇ̠ÛÙÔ ÂfiÌÂÓÔ ‚‹Ì·. µ‹Ì· 3. ÀÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ ŸÙ·Ó ÙÔ À∫ Â›Ó·È ıÂÙÈÎfi ÁÈ· ‰È¿Ù·ÛË ‹ ·Ó‡ڢÛÌ· ÛÙÂÊ·ÓÈ·›ˆÓ, ÚÔ¯ˆÚԇ̠۠ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ∞Ó Â›Ó·È ·ÚÓËÙÈÎfi Î·È Ô ˘ÚÂÙfi˜ ¤¯ÂÈ ˘Ô¯ˆÚ‹ÛÂÈ, ÙfiÙÂ Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È Èı·Ó‹. ∞Ó fï˜ Ô ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ, ÙfiÙÂ Û˘ÓÈÛÙ¿Ù·È Â·Ó¿ÏË„Ë ÙÔ˘ À∫ Î·È Â·ÓÂÎÙ›ÌËÛË ÙÔ˘ ·ÚÚÒÛÙÔ˘, ÙfiÛÔ ÎÏÈÓÈ΋ fiÛÔ Î·È ÂÚÁ·ÛÙËÚȷ΋. ∆¤ÏÔ˜, ·Ó ‰ÂÓ ÏËÚÔ‡ÓÙ·È Ù· ·ÚÈ· ÂÚÁ·ÛÙËÚȷο ÎÚÈÙ‹ÚÈ· ÚÔ¯ˆÚԇ̠ÛÙÔ ÙÂÏÂ˘Ù·›Ô ‚‹Ì·. µ‹Ì· 4. ∫·ıËÌÂÚÈÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ŸÙ·Ó Ô ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ ÁÈ· >2 Ë̤Ú˜, ÙfiÙÂ Ô ·ÛıÂÓ‹˜ ˘Ô‚¿ÏÏÂÙ·È Û ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋

¶›Ó·Î·˜ 5. ∞Ú¯È΋ ıÂÚ·›· ¡. Kawasaki 1. ∂Ó‰ÔÊϤ‚È· ¤Á¯˘ÛË Á- ÛÊ·ÈÚ›Ó˘ (IVIG) Û ‰fiÛË 2 g/kg Û ̛· Û˘Ó¯‹ ¤Á¯˘ÛË 2. ∞ÛÈÚ›ÓË: - ¤Ó·ÚÍË Ì ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ·ÁˆÁ‹ (˘„ËÏ‹ ‰fiÛË) ∏¶∞, π·ˆÓ›·: 80-100mg/kg Û 4 ›Û˜ ‰fiÛÂȘ per os ‹ ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ: 30-50 mg/kg Û 3 ›Û˜ ‰fiÛÂȘ per os ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘: ·) ̤¯ÚÈ Î·È 2-3 ̤Ú˜ ÌÂÙ¿ ÙËÓ ÙÒÛË ˘ÚÂÙÔ‡ ‹/Î·È Ù˘ CRP ‹ ‚) ¤ˆ˜ Î·È ÙË 10Ë-14Ë Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ - ·ÎÔÏÔ˘ı› Ë ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ (¯·ÌËÏ‹ ‰fiÛË) 3-5 mg/kg ¿·Í ËÌÂÚËÛ›ˆ˜ ÁÈ· 6-8 ‚‰ÔÌ¿‰Â˜ Î·È ¤ˆ˜ fiÙÔ˘ Á›ÓÂÈ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜

Â·ÓÂÎÙ›ÌËÛË. ∏ ÙÒÛË, ˆÛÙfiÛÔ, ÙÔ˘ ˘ÚÂÙÔ‡, ‰ÂÓ ‰ÈηÈÔÏÔÁ› ÂÊËÛ˘¯·ÛÌfi. ∞·Ú·›ÙËÙË, ÂÓ ÚÔÎÂÈ̤ӈ, Â›Ó·È Ë Î·ıËÌÂÚÈÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· ÙÔ ÂӉ¯fiÌÂÓÔ ÂÌÊ¿ÓÈÛ˘ ÂÚÈÔÓ‡¯È·˜ ‰·ÎÙ˘ÏÈ΋˜ ·ÔϤÈÛ˘. ∂¿Ó ‰ÂÓ ˘¿Ú¯ÂÈ ·ÔϤÈÛË, ÙfiÙ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ·Ú·ÎÔÏÔ‡ıËÛË. ∞Ó fï˜ ‰È·ÈÛÙˆı› ·ÔϤÈÛË, ÚÔ¯ˆÚԇ̠··Ú·Èًو˜ Û À∫ ÒÛÙ ӷ ηıÔÚ›ÛÔ˘ÌÂ, ·Ó·ÏfiÁˆ˜ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ, ÙËÓ ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. π‰È·›ÙÂÚË ÚÔÛÔ¯‹ ··ÈÙÂ›Ù·È ÛÙ· ÌÈÎÚ¿ ‚Ú¤ÊË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ ¤ÍÈ ÌËÓÒÓ, ÁÈ·Ù› fiÛÔ ÈÔ ÌÈÎÚ‹ Â›Ó·È Ë ËÏÈΛ· ÙfiÛÔ ÈÔ ·ÙÂÏ‹˜ Â›Ó·È Ë ÎÏÈÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘, ·ÏÏ¿ Î·È ÙfiÛÔ ÈÔ ˘„ËÏfi˜ Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ·Ó¢ڢÛÌ¿ÙˆÓ. ŒÙÛÈ, Û ÌÈÎÚ¿ ‚Ú¤ÊË Ì ˘ÚÂÙfi >6 Ë̤Ú˜ Î·È Û˘ÓÔ‰fi ·‡ÍËÛË ∆∫∂ ‹/Î·È CRP, ·ÎfiÌË Î·È ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ó¤Ó· ·fi Ù· ‰È·ÁÓˆÛÙÈο ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘ (0/5), ··Ú·›ÙËÙÔ ıˆÚÂ›Ù·È ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ Ì ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ¤¯Ô˘Ó ·ÔÎÏÂÈÛÙ› ¿ÏÏ· ·ıÔÏÔÁÈο ·›ÙÈ· Î·È Î˘Ú›ˆ˜ ÔÈ ÏÔÈÌÒÍÂȘ (11). ŸÙ·Ó ·ÎÔÏÔ˘ıÂ›Ù·È Ë ‰È·ÁÓˆÛÙÈ΋ ·˘Ù‹ ‰È·‰Èηۛ·, ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ô Î›Ó‰˘ÓÔ˜ Ù˘ ÌË ‰È¿ÁÓˆÛ˘ ‹ Ù˘ ηı˘ÛÙ¤ÚËÛ˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ Î·È ·ÔʇÁÔÓÙ·È Ù· ‰È·ÁÓˆÛÙÈο ÛÊ¿ÏÌ·Ù·. ∆· ÈÔ Û˘¯Ó¿ ÛÊ¿ÏÌ·Ù· Ô˘ ‰È·ÈÛÙÒÓÔÓÙ·È Â›Ó·È: ·) Ë ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ˆ˜ ‚·ÎÙËÚȷ΋ Ì ÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ‚) Ë ˘Ô˘Ú›· Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ˆ˜ Ô˘ÚÔÏԛ̈ÍË Ì¤¯ÚÈ Ó· Á›ÓÂÈ ÁÓˆÛÙfi ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ηÏÏȤÚÁÂÈ·˜, Á) Ë Á·ÛÙÚÂÓÙÂÚÈ΋ ÛËÌÂÈÔÏÔÁ›· Ó· ıˆÚËı› ÔÍ›· ÎÔÈÏ›· Î·È Ó· ·ÓÙÈÌÂÙˆÈÛı› ·fi ·È‰Ô¯ÂÈÚÔ˘ÚÁÔ‡˜ Ì ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, fiÙ·Ó ·ÎÔÏÔ˘ı› Ë ¤Îı˘ÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜, ηıÒ˜ Î·È Ù· Â˘Ú‹Ì·Ù· ·fi ÙÔ ‰¤ÚÌ· Î·È ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜, Ë fiÏË ÛËÌÂÈÔÏÔÁ›· ÂÎÏ·Ì‚¿ÓÂÙ·È ÂÛÊ·Ï̤ӷ ˆ˜ ·ÓÂÈı‡ÌËÙË ·ÓÙ›‰Ú·ÛË ÛÙ· ·ÓÙÈ‚ÈÔÙÈο. ∆¤ÏÔ˜, ‰) Ô ˘ÚÂÙfi˜, ÙÔ ÂÍ¿ÓıËÌ· Î·È Ë ¶·È‰È·ÙÚÈ΋ 2007;70:361-369

Paidiatriki 5 final

12-10-07

16:28

Page 366

366

°. ¶·Ú‰·Ïfi˜

ÏÂÌÊÔ΢ÙÙ¿ÚˆÛË ÛÙÔ ∂¡À Ó· ÂÎÏ·Ì‚¿ÓÔÓÙ·È ÂÛÊ·Ï̤ӷ ˆ˜ ÈÔÁÂÓ‹˜ ¿ÛËÙË ÌËÓÈÁÁ›Ùȉ· Î·È fi¯È ˆ˜ Û˘ÓÔ‰¿ Â˘Ú‹Ì·Ù· Ù˘ ¡∫ (1,2,7-10).

£ÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ∏ ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¡∫ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ·Ú¯È΋ ıÂÚ·›· Î·È ÙË ÛÙÚ·ÙËÁÈ΋ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÓÙÈÌÂÙÒÈÛ˘. ∞Ú¯È΋ ıÂÚ·›· ∏ ·Ú¯È΋ ıÂÚ·›· Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘ (IVIG) Î·È ·ÛÈÚ›Ó˘ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ (¶›Ó·Î·˜ 5) Î·È ÂÊ·ÚÌfi˙ÂÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘. ∏ IVIG ¯ÔÚËÁÂ›Ù·È Û ‰fiÛË 2 g/kg ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ Û ̛· Û˘Ó¯‹ ¤Á¯˘ÛË ‰È¿ÚÎÂÈ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 10 ˆÚÒÓ. ∏ ıÂÚ·›· Ì ·ÛÈÚ›ÓË ÍÂÎÈÓ¿ ·) Ì ÙËÓ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ·ÁˆÁ‹ (˘„ËÏ‹ ‰ÔÛÔÏÔÁ›·) Î·È Û˘Ó¯›˙ÂÙ·È ‚) Ì ÙËÓ ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ (¯·ÌËÏ‹ ‰ÔÛÔÏÔÁ›·) (5,8-10). ·) ∞ÓÙÈÊÏÂÁÌÔÓ҉˘ ‰fiÛË ·ÛÈÚ›Ó˘. ∞ÎÔÏÔ˘ıÔ‡ÓÙ·È ‰‡Ô ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù·: ÛÙȘ ∏¶∞ Î·È ÙËÓ π·ˆÓ›· ·ÎÔÏÔ˘ıÂ›Ù·È ÙÔ Û¯‹Ì· ÙˆÓ 80-100 mg/kg/24ˆÚÔ Û 4 ›Û˜ ‰È·ÈÚÂ̤Ó˜ ‰fiÛÂȘ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜, ÂÓÒ ÛÙËÓ ∞ÁÁÏ›· Î·È ¿ÏϘ Â˘Úˆ·˚Τ˜ ΢ڛˆ˜ ¯ÒÚ˜ ·ÎÔÏÔ˘ıÂ›Ù·È ÙÔ Û¯‹Ì· ÙˆÓ 30-50 mg/kg/24ˆÚÔ Û 3 ›Û˜ ‰fiÛÂȘ. ∆Ô Î¿ı ۯ‹Ì· ͯˆÚÈÛÙ¿ ¤¯ÂÈ ÏÂÔÓÂÎÙ‹Ì·Ù· Î·È ÌÂÈÔÓÂÎÙ‹Ì·Ù· ·ÏÏ¿ ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Û‡ÁÎÚÈÛ˘ ÙˆÓ ‰‡Ô Û¯ËÌ¿ÙˆÓ Î·È ÙÔ Î¿ı ΤÓÙÚÔ ÂÊ·ÚÌfi˙ÂÈ ÙÔ ¤Ó· ‹ ÙÔ ¿ÏÏÔ ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÌÂÈÚ›· ÙÔ˘ (5,8-10). À¿Ú¯Ô˘Ó fï˜ Î·È ÌÂÚÈΤ˜ ÌÂϤÙ˜ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÔÈ Î›Ó‰˘ÓÔÈ ·fi ÙȘ ˘„ËϤ˜ ‰fiÛÂȘ ·ÛÈÚ›Ó˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔÈ ·fi Ù· ÔʤÏË Î·È ÚÔÙ›ÓÔ˘Ó ÙËÓ Î·Ù¿ÚÁËÛË Ù˘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜ Î·È ÙËÓ ·ÓÙÈηٿÛÙ·Û‹ Ù˘ Ì ÙËÓ ÂÍ ·Ú¯‹˜ ¯ÔÚ‹ÁËÛË Ù˘ ¯·ÌËÏ‹˜ ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋˜ ‰fiÛ˘ (12). ŸÌˆ˜, Û ̛· ÚfiÛÊ·ÙË ÌÂÙ··Ó¿Ï˘ÛË fiÏˆÓ ÙˆÓ ÂÚÁ·ÛÈÒÓ, ÔÈ Ôԛ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ÚfiÏÔ Ù˘ ·ÛÈÚ›Ó˘ ÛÙË ¡∫, ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ̤¯ÚÈ Û‹ÌÂÚ· ‰Â‰Ô̤ӷ Â›Ó·È ÂÏÏÈ‹ Î·È ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚ·ÈÙ¤Úˆ ¤Ú¢Ó˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÍ·¯ıÔ‡Ó ÔÚÈÛÙÈο Û˘ÌÂÚ¿ÛÌ·Ù·. ŒÙÛÈ, Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È ÔÈ ÈÛ¯‡Ô˘Û˜ Û˘ÛÙ¿ÛÂȘ Ù˘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ Î·È ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋˜ ·ÁˆÁ‹˜ Ì ·ÛÈÚ›ÓË (¶›Ó·Î·˜ 5) (13). ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Ù˘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ÙËÓ ÂÊ·ÚÌfi˙Ô˘Ó Ì¤¯ÚÈ Î·È 2-3 ̤Ú˜ ÌÂÙ¿ ÙËÓ ˘Ô¯ÒÚËÛË ÙÔ˘ ˘ÚÂÙÔ‡, ·ÏÏ¿ ˘¿Ú¯Ô˘Ó ·ÎfiÌË Î¤ÓÙÚ·, ΢ڛˆ˜ ÛÙËÓ π·ˆÓ›·, Ô˘ ÂÊ·ÚÌfi˙Ô˘Ó ÙÔ ·Ï·ÈfiÙÂÚÔ Û¯‹Ì· ¯ÔÚ‹ÁËÛ˘ ¤ˆ˜ Î·È 10-14 Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ (5,8-10). ‚) ∏ ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‰fiÛË Ù˘ ·ÛÈÚ›Ó˘ ·Ú¯›˙ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔ ¤Ú·˜ Ù˘ ·ÓÙÈPaediatriki 2007;70:361-369

ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜ Û ‰fiÛË 3-5 mg/kg/24ˆÚÔ ÂÊ¿·Í Î·È Û˘Ó¯›˙ÂÙ·È ÁÈ· 6-8 ‚‰ÔÌ¿‰Â˜ ̤¯ÚȘ fiÙÔ˘ Á›ÓÂÈ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ (5,8-10). ∏ ·Ú¯È΋ ıÂÚ·›· Ì Á-ÛÊ·ÈÚ›ÓË Î·È ·ÛÈÚ›ÓË Â›Ó·È Ë ÌfiÓË ÂӉ‰ÂÈÁ̤ÓË Ì¤¯ÚÈ Û‹ÌÂÚ· Î·È Â›Ó·È ÂÈÙ˘¯‹˜ Û >85% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (1,2,5,8-10). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ¤¯Ô˘Ó ·Ó·ÎÔÈÓˆı› ÌÂϤÙ˜ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ÂÍ ·Ú¯‹˜ ÚÔÛı‹ÎË ÎÔÚÙÈÎÔÂȉÒÓ (˘„ËϤ˜ ‰fiÛÂȘ ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘) ÛÙÔ ˆ˜ ¿Óˆ Û¯‹Ì· ÌÂÈÒÓÂÈ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÔͤˆÓ ÊÏÂÁÌÔÓˆ‰ÒÓ Ê·ÈÓÔ̤ӈÓ, ÙË Û˘¯ÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ Î·È ÙÔ ÔÛÔÛÙfi ·ÔÙ˘¯›·˜ Ù˘ ıÂÚ·›·˜ (14,15). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿, fï˜, ‰ÂÓ ÂȂ‚·ÈÒıËÎ·Ó ·fi ÌÈ· ÈÔ ÚfiÛÊ·ÙË ÌÂϤÙË, Ë ÔÔ›· ¤‰ÂÈÍ fiÙÈ ‰ÂÓ ˘‹Ú¯Â ηÌÈ¿ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÙÔ ÎÏ·ÛÈÎfi Û¯‹Ì· ‹ ·˘ÙÒÓ Ô˘ ‹Ú·Ó ÂÈϤÔÓ ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË (16). ÃÚÂÈ¿˙ÔÓÙ·È ÏÔÈfiÓ ÂÚÈÛÛfiÙÂÚ˜ ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ ÒÛÙ ӷ ÂÍ·¯ıÔ‡Ó ÈÔ ·ÎÚÈ‚‹ Û˘ÌÂÚ¿ÛÌ·Ù· (17). ÕÏϘ, ÌÈÎÚfiÙÂÚ˜ Û ¤ÎÙ·ÛË ÌÂϤÙ˜ Ô˘ Î·È ·˘Ù¤˜ ¯Ú‹˙Ô˘Ó ÂÚ·ÈÙ¤Úˆ ÂÓ‰Âϯԇ˜ ÌÂϤÙ˘, ›¯·Ó ·ÚfiÌÔÈ· ıÂÙÈο Â˘Ú‹Ì·Ù· fiÙ·Ó ÚÔÛ¤ıÂÛ·Ó ÂÍ ·Ú¯‹˜ ÛÙÔ ·Ú¯ÈÎfi Û¯‹Ì· ÙËÓ ÂÓÙÔÍ˘Ê˘ÏÏ›ÓË ‹ ÙËÓ Ô˘ÏÈÓ·ÛÙ·Ù›ÓË (Ë ÙÂÏÂ˘Ù·›· ÂÊ·ÚÌfi˙ÂÙ·È ÌfiÓÔ ÛÙËÓ π·ˆÓ›·) (8-9). ÃÚfiÓÔ˜ ÂÊ·ÚÌÔÁ‹˜ ·Ú¯È΋˜ ıÂÚ·›·˜ √ ¯ÚfiÓÔ˜ ÂÊ·ÚÌÔÁ‹˜ Ù˘ ·Ú¯È΋˜ ıÂÚ·›·˜ Ì IVIG Î·È ·ÛÈÚ›ÓË ·›˙ÂÈ ÛÔ˘‰·›Ô ÚfiÏÔ, ÁÈ·Ù› ‚Ú¤ıËΠfiÙÈ fiÛÔ ÓˆÚ›ÙÂÚ· ·Ú¯›˙ÂÈ Ë ·ÁˆÁ‹, ÙfiÛÔ ÌÈÎÚfiÙÂÚÔ˜ Â›Ó·È Ô Î›Ó‰˘ÓÔ˜ ÚfiÎÏËÛ˘ ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ (5,8-10,18-19). ŒÙÛÈ, Û ¤ÁηÈÚË ‰È¿ÁÓˆÛË (5Ë-10Ë Ì¤Ú· ÓfiÛÔ˘) ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ¿ÌÂÛ· Ô ·ÛıÂÓ‹˜. ™Â ÚÒÈÌË ‰È¿ÁÓˆÛË (<5Ë Ì¤Ú· ÓfiÛÔ˘), fiÏÔÈ Û˘ÌʈÓÔ‡Ó Ó· ·Ú¯›˙ÂÈ Ë ıÂÚ·›· ·fi ÙËÓ 4Ë Ì¤Ú· ÓfiÛÔ˘ Î·È ÚÈÓ Û˘ÌÏËÚˆı› ÙÔ ıÂÛÈÛı¤Ó ÎÚÈÙ‹ÚÈÔ Ù˘ 5˘ Ë̤ڷ˜ ˘ÚÂÙÔ‡, ÂÓÒ ˘¿Ú¯Ô˘Ó Î·È Î¤ÓÙÚ·, ΢ڛˆ˜ ÛÙËÓ π·ˆÓ›·, Ô˘ ÍÂÎÈÓÔ‡Ó ÙË ıÂÚ·›· Î·È ·fi ÙËÓ 3Ë Ì¤Ú· Ù˘ ÓfiÛÔ˘. ¶ÚÔ¸fiıÂÛË ÂÓ ÚÔÎÂÈ̤ӈ Â›Ó·È Ë ·ÚÔ˘Û›· ÙˆÓ 4/5 ÎÏÈÓÈÎÒÓ ÎÚÈÙËÚ›ˆÓ Î·È Ô ·ÔÎÏÂÈÛÌfi˜ ¿ÏÏˆÓ ·ıÔÏÔÁÈÎÒÓ ·ÈÙ›ˆÓ. ™Â ηı˘ÛÙÂÚË̤ÓË ‰È¿ÁÓˆÛË (>10Ë Ì¤Ú· ÓfiÛÔ˘), ·Ó Î·È ·˘Í¿ÓÂÙ·È ÛËÌ·ÓÙÈο Ô Î›Ó‰˘ÓÔ˜ ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÓÂÍ·Úًو˜ ıÂÚ·›·˜, Û˘ÓÈÛÙ¿Ù·È Ë ÂÊ·ÚÌÔÁ‹ Ù˘, ·Ó ÂÈ̤ÓÂÈ Ô ˘ÚÂÙfi˜ ‹/Î·È ˘¿Ú¯Ô˘Ó ·˘ÍË̤Ó˜ ÙÈ̤˜ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜ ‹/Î·È ·Ó ˘¿Ú¯Ô˘Ó ‚Ï¿‚˜ ÛÙ· ÛÙÂÊ·ÓÈ·›·. ∞Ó fï˜ Ë ÓfiÛÔ˜ Â›Ó·È Û Ï‹ÚË ‡ÊÂÛË Î·È ·ÏÒ˜ ηı˘ÛÙ¤ÚËÛÂ Ë ‰È¿ÁÓˆÛË Î·È ÙÂÎÌËÚÈÒıËΠ̠ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·ÔϤÈÛ˘, ÙfiÙÂ Ô ¿ÚÚˆÛÙÔ˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÌfiÓÔ Ì ¯ÔÚ‹ÁËÛË ÌÈÎÚ‹˜ ‰fiÛ˘ ·ÛÈÚ›Ó˘ ÁÈ· 6-8 ‚‰ÔÌ¿‰Â˜ (5,8-10). ∞¿ÓÙËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙËÓ ·Ú¯È΋ ıÂÚ·›· ∏ ·Ú¯È΋ ıÂÚ·›· Ì IVIG Î·È ·ÛÈÚ›ÓË Â›Ó·È ÂÈÙ˘¯‹˜ Û >85% ÙˆÓ ÂÚÈÙÒÛˆÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ

Paidiatriki 5 final

12-10-07

16:28

Page 367

367

¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘

ÌË ·¿ÓÙËÛ˘ ÛÙË ıÂÚ·›·, ·Ó ‰ËÏ·‰‹ ÂÈ̤ÓÂÈ Ô ˘ÚÂÙfi˜ ¤ˆ˜ Î·È 36 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÚÒÙË ‰fiÛË IVIG (10-15%), ‹ Û ÂÚÈÙÒÛÂȘ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘ (~1%), Ë ÂӉ‰ÂÈÁ̤ÓË ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È Ë ‰Â‡ÙÂÚË ¤Á¯˘ÛË ›‰È·˜ ‰fiÛ˘ IVIG Ì ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·. √ÚÈṲ̂ÓÔÈ ÂÊ·ÚÌfi˙Ô˘Ó ÛÙË Ê¿ÛË ·˘Ù‹ Î·È ÙËÓ ÚÔÛı‹ÎË ÎÔÚÙÈÎÔÂȉÒÓ, ȉȷ›ÙÂÚ· fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ‚Ï¿‚Ë ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ. ∞Ó fï˜ Ë ÓfiÛÔ˜ Â›Ó·È ·ÓıÂÎÙÈ΋ ·Ú¿ ÙË ‰Â‡ÙÂÚË ¤Á¯˘ÛË IVIG, ÙfiÙÂ Ë ÂӉ‰ÂÈÁ̤ÓË ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È Ë ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ (pulse) ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘, 30 mg/kg (̤ÁÈÛÙË ‰fiÛË 1 g) ÛÂ Û˘Ó¯‹ ¤Á¯˘ÛË ó-1 ÒÚ·˜ ÂÊ¿·Í Î·È ÁÈ· ÙÚÂȘ Û˘Ó¯›˜ ̤Ú˜ (5,8-10). ∆¤ÏÔ˜, Û ÂÚ›ÙˆÛË ·ÔÙ˘¯›·˜ Î·È ·˘Ù‹˜ Ù˘ ·ÁˆÁ‹˜ ÂÊ·ÚÌfi˙ÂÙ·È Ë ÚÔÛı‹ÎË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ, fiˆ˜ Ë Î˘ÎÏÔʈÛÊ·Ì›‰Ë, Ë Î˘ÎÏÔÛÔÚ›ÓË Î·È, ÙÂÏÂ˘Ù·›ˆ˜, ÔÈ ·ÓÙÈ-∆¡F ·Ú¿ÁÔÓÙ˜ Ì ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· (5,8-10,19-20). ™ÙÚ·ÙËÁÈ΋ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÓÙÈÌÂÙÒÈÛ˘ ∏ ÛÙÚ·ÙËÁÈ΋ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì ¡∫ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·ÚÔ˘Û›· Î·È ÙË ÛÔ‚·ÚfiÙËÙ· ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›·. ªÂ ‚¿ÛË ÙÔ ÎÚÈÙ‹ÚÈÔ ·˘Ùfi, Ë ∞ÌÂÚÈηÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Ì ÙË Û‡ÌʈÓË ÁÓÒÌË Î·È Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ∞η‰ËÌ›·˜ ¶·È‰È·ÙÚÈ΋˜ ηıfiÚÈÛ·Ó ¤ÓÙ “Â›‰· ÎÈÓ‰‡ÓÔ˘” ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, Âͤ‰ˆÛ·Ó ‰Â Û˘ÛÙ¿ÛÂȘ ÁÈ· ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜, ·Ó¿ÏÔÁ· Ì ÙÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ ÛÙÔ ÔÔ›Ô ·Ó‹ÎÔ˘Ó (8). √È Û˘ÛÙ¿ÛÂȘ ·˘Ù¤˜ ÂÛÙÈ¿˙ÔÓÙ·È, Û ÁÂÓÈΤ˜ ÁÚ·Ì̤˜, ÛÙËÓ ·Ó·ÁηÈfiÙËÙ· ‹ fi¯È ·) Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ì ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‹/Î·È ¿ÏÏË ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹, ‚) ÂÚÈÔÚÈÛÌÔ‡ ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Î·È Á) Û˘¯Ó‹˜ ‹ fi¯È ηډÈÔÏÔÁÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘. ∂ȉÈÎfiÙÂÚ·, ÔÈ Û˘ÛÙ¿ÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó Î¿ı ¤Ó· ·fi Ù· “Â›‰· ÎÈÓ‰‡ÓÔ˘” ¤¯Ô˘Ó ˆ˜ ÂÍ‹˜ (8,9,21,22): ∂›Â‰Ô ÎÈÓ‰‡ÓÔ˘ π. ∞Ô˘Û›· ‚Ï·‚ÒÓ ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›·. ™Ù· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ·˘Ù‹˜, Ë ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ ÂÊ·ÚÌfi˙ÂÙ·È Ì¤¯ÚÈ ÙËÓ 6Ë ¤ˆ˜ 8Ë Â‚‰ÔÌ¿‰· ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. ¢ÂÓ ··ÈÙÂ›Ù·È Î·ÌÈ¿ ÂÚ·ÈÙ¤Úˆ ıÂÚ·›·, Ô‡Ù ÂÚÈÔÚÈÛÌfi˜ Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È Û˘ÓÈÛÙ¿Ù·È Î·Ú‰ÈÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î¿ı 5 ¤ÙË. ™˘ÓÈÛٿٷÈ, Â›Û˘, Û fiÏ· Ù· ·È‰È¿ Ì ÈÛÙÔÚÈÎfi ¡∫ Ë ·ÔÊ˘Á‹ ·Ú·ÁfiÓÙˆÓ Ô˘ Úԉȷı¤ÙÔ˘Ó Û ·ıËÚÔÁ¤ÓÂÛË (·¯˘Û·ÚΛ·, οÓÈÛÌ·, Î.¿.) ÏfiÁˆ Èı·Ó‹˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘. ∂›Â‰Ô ÎÈÓ‰‡ÓÔ˘ ππ. ¶·ÚÔ‰ÈΤ˜ ‚Ï¿‚˜ ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›· Ô˘ ˘Ô¯ˆÚÔ‡Ó ÚÈÓ ÙËÓ 8Ë Â‚‰ÔÌ¿‰·. πÛ¯‡Ô˘Ó Ù· ›‰È· Ì ÙÔ ÚÔËÁÔ‡ÌÂÓÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ Ì ÌfiÓË ‰È·ÊÔÚ¿ ÙË Û˘¯ÓfiÙÂÚË Î·Ú‰ÈÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË, οı 3-5 ¯ÚfiÓÈ·.

∂›Â‰Ô ÎÈÓ‰‡ÓÔ˘ πππ. ªÈÎÚÔ‡ ‹ ÌÂÛ·›Ô˘ ÌÂÁ¤ıÔ˘˜ ·Ó¢ڇÛÌ·Ù· (3-6 mm) Û ·ÚÈ· ÛÙÂÊ·ÓÈ·›· ·ÚÙËÚ›·. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ¯·ÌËÏ‹˜ ‰fiÛ˘ ·ÛÈÚ›Ó˘ Â›Ó·È ··Ú·›ÙËÙË Ì¤¯ÚÈ ÙËÓ ˘ÔÛÙÚÔÊ‹ ÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ™ÙËÓ ÚÒÙË ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ·, ÌfiÓÔ ÂÙ‹ÛÈ· ηډÈÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ì ∏∫° Î·È À∫. ªÂÙ¿ ÙËÓ ÚÒÙË ‰ÂηÂÙ›·, ÂÚÈÔÚÈÛÌfi˜ ‹ fi¯È ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ηıÔÚ›˙ÂÙ·È Ì ‚¿ÛË ÙË ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘ Ì ·ÂÈÎÔÓÈÛÙÈ΋ ̤ıÔ‰Ô ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ Ì˘Ôηډ›Ô˘, Ë ÔÔ›· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Î¿ı ‰‡Ô ¯ÚfiÓÈ·. ∫·ı’ fiÏË, fï˜, ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜ Ì ·ÛÈÚ›ÓË Û˘ÓÈÛÙ¿Ù·È Ë ·ÔÊ˘Á‹ ·ıÏËÌ¿ÙˆÓ ˘„ËÏ‹˜ ¤ÓÙ·Û˘ Î·È ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ۈ̷ÙÈ΋˜ ÚfiÛÎÚÔ˘Û˘. ∂›Â‰Ô ÎÈÓ‰‡ÓÔ˘ πV. ŒÓ· ‹ ÂÚÈÛÛfiÙÂÚ· ÁÈÁ·ÓÙÈ·›· ·Ó¢ڇÛÌ·Ù· (>6mm) ‹ ÔÏÏ·Ï¿ ÌÈÎÚÔ‡-ÌÂÛ·›Ô˘ ÌÂÁ¤ıÔ˘˜ ·Ó¢ڇÛÌ·Ù· ÛÙËÓ ›‰È· ÛÙÂÊ·ÓÈ·›· ·ÚÙËÚ›·. ÃÔÚËÁÂ›Ù·È Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ Ì ·ÛÈÚ›ÓË Î·È Ù·˘Ùfi¯ÚÔÓ· ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ Ì ‚·ÚÊ·Ú›ÓË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ‹ Ë·Ú›ÓË ÌÈÎÚÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ ˘Ô‰ÔÚ›ˆ˜. ™ÙËÓ ÚÒÙË ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ·, ·ÏÏ¿ ÂÍ·ÌËÓÈ·›· ηډÈÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ì ∏∫° Î·È À∫. ∂›Û˘, Û˘ÓÈÛÙ¿Ù·È ÂÎÏÂÎÙÈ΋ ÛÙÂÊ·ÓÈÔÁÚ·Ê›· Ì ηډȷÎfi ηıÂÙËÚÈ·ÛÌfi ¤ÍÈ Ì‹Ó˜ Ì ¤Ó· ¯ÚfiÓÔ ÌÂÙ¿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘ Î·È Â·Ó¿ÏË„‹ Ù˘ fiÙ·Ó ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÈÛ¯·ÈÌ›·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘. ªÂÙ¿ ÙËÓ ÚÒÙË ‰ÂηÂÙ›·, Ë ‰Ú·ÛÙËÚÈfiÙËÙ· ηıÔÚ›˙ÂÙ·È Ì ‚¿ÛË ÙË ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘ Î·È ÈÛ¯‡ÂÈ, ÁÈ· fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜, Ë ·ÔÊ˘Á‹ ·ıÏËÌ¿ÙˆÓ ˘„ËÏ‹˜ ¤ÓÙ·Û˘ Î·È ÛˆÌ·ÙÈ΋˜ ÚfiÛÎÚÔ˘Û˘. ∂›Â‰Ô ÎÈÓ‰‡ÓÔ˘ V. £ÚfiÌ‚ˆÛË ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜. ∞ÎÔÏÔ˘ıÂ›Ù·È Ë ›‰È· Ù·ÎÙÈ΋ Ì ÙÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ IV. ∂ÈϤÔÓ, ÂÎÙÈÌ¿Ù·È Ë ·Ó¿ÁÎË ÚÔÛı‹Î˘ ‚·ÔÎÏÂÈÛÙÒÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÌÂȈı› Ë Î·Ù·Ó¿ÏˆÛË Ô͢ÁfiÓÔ˘ ·fi ÙÔ Ì˘ÔοډÈÔ. ∂›Û˘, ÂÈÛ‡‰ÂÙ·È Ô Î·Ú‰È·Îfi˜ ηıÂÙËÚÈ·ÛÌfi˜ fiÙ·Ó ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ıÚÔÌ‚ÔÏ˘ÙÈ΋˜ ·ÁˆÁ‹˜ ‹ ¿ÏÏ˘ ηډÈÔ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘ ÛÙ· ÛÙÂÊ·ÓÈ·›· (.¯. bypass).∆ËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÛÙÚ·ÙËÁÈ΋˜ ·˘Ù‹˜ ÙËÓ ·Ó·Ï·Ì‚¿ÓÔ˘Ó ÔÈ ·È‰ÔηډÈÔÏfiÁÔÈ. √ ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ ÙÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ ÙÔ˘ ·È‰ÈÔ‡ Ì ¡∫ Ô˘ ·Ú·ÎÔÏÔ˘ı›, Ó· Û˘ÓÂÚÁ¿˙ÂÙ·È ÛÙÂÓ¿ Ì ÙÔÓ ·È‰ÔηډÈÔÏfiÁÔ Î·È Ó· ÂϤÁ¯ÂÈ ·Ó Ô ·ÛıÂÓ‹˜ ÂÊ·ÚÌfi˙ÂÈ ÛˆÛÙ¿ ÙÔ ÚfiÁÚ·ÌÌ· Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜, ÙˆÓ ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Î·È Ù˘ Ù·ÎÙÈ΋˜ ηډÈÔÏÔÁÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘ (8,9,21,22). ∫‡ÚÈÔÈ ÚÔ‚ÏËÌ·ÙÈÛÌÔ› ÁÈ· ÙÔÓ ·È‰›·ÙÚÔ √È ÈÔ Û˘¯ÓÔ› ÚÔ‚ÏËÌ·ÙÈÛÌÔ› ÙˆÓ ·È‰È¿ÙÚˆÓ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Ó ·È‰È¿ Ì ¡∫ ÂÛÙÈ¿˙ÔÓÙ·È ·) ÛÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Reye ¶·È‰È·ÙÚÈ΋ 2007;70:361-369

Paidiatriki 5 final

12-10-07

16:28

Page 368

368

°. ¶·Ú‰·Ïfi˜

ÏfiÁˆ Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ Ï‹„˘ ·ÛÈÚ›Ó˘ Î·È ‚) ÛÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. ·) ∞ÛÈÚ›ÓË Î·È Û‡Ó‰ÚÔÌÔ Reye. ¢ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› ·Ó Ë ÌÈÎÚ‹ ‰fiÛË Ù˘ ·ÛÈÚ›Ó˘ ÌÔÚ› Ó· ÂÓÔ¯ÔÔÈËı› ÛÙËÓ ÚfiÎÏËÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘. ª¤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯ÂÈ ·Ó·ÊÂÚı› Ù¤ÙÔÈ· Û¯¤ÛË. ¶·ÚfiÏ· ·˘Ù¿ Û˘ÓÈÛÙ¿Ù·È Ô ÂÙ‹ÛÈÔ˜ ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ Î·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜. ∆Ô ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, fiˆ˜ Î·È Î¿ı ¿ÏÏÔ ÂÌ‚fiÏÈÔ Ì ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, Ú¤ÂÈ Ó· Á›ÓÂÙ·È 11 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Ù˘ Á-ÛÊ·ÈÚ›Ó˘. ∂È‚¿ÏÏÂÙ·È Â›Û˘ Ë ‰È·ÎÔ‹ Ù˘ ·ÛÈÚ›Ó˘ ÁÈ· 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Î·È Ë ·ÓÙÈηٿÛÙ·Û‹ Ù˘ Ì ¿ÏÏË ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ (8). ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi ı· Ú¤ÂÈ Ó· ÂÈÛËÌ·Óı› ˆ˜ Ë Û˘Á¯ÔÚ‹ÁËÛË È‚ÔÚÔ˘Ê¤Ó˘ Ì ·ÛÈÚ›ÓË Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È, ÁÈ·Ù› ‰È·ÈÛÙÒıËΠfiÙÈ Ë ÚÒÙË ·ÓÙ·ÁˆÓ›˙ÂÙ·È ÙËÓ ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‰Ú¿ÛË Ù˘ ‰Â‡ÙÂÚ˘. ™ÙËÓ ÂÚ›ÙˆÛË ÏÔÈfiÓ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ˘ÚÂÙÈÎÔ‡ ‹ ·Ó·ÏÁËÙÈÎÔ‡ ÛÙ· ·È‰È¿ Ì ¡∫, Ù· ÔÔ›· ·›ÚÓÔ˘Ó ÌÈÎÚ‹ ‰fiÛË ·ÛÈÚ›Ó˘, Ó· ÚÔÙÈÌ¿Ù·È Ë ·Ú·ÎÂÙ·ÌfiÏË (8). ‚) ∂Ì‚ÔÏÈ·ÛÌÔ› ·È‰ÈÒÓ Ì ¡∫. √È ÂÌ‚ÔÏÈ·ÛÌÔ› Ì ÂÌ‚fiÏÈ· ÂÚȤ¯ÔÓÙ· ÓÂÎÚÔ‡˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ ‹ ·Ó·ÙÔ͛Ә, ηıÒ˜ Î·È fiÛ· ·Ú·Û΢¿˙ÔÓÙ·È Ì ÙËÓ Ù¯ÓÈ΋ ÙÔ˘ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ DNA, Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È Î·ÓÔÓÈο Î·È ¿ÊÔ‚·, Û‡Ìʈӷ Ì ÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÙÔ˘ ·È‰ÈÔ‡, ¯ˆÚ›˜ ÂÚÈÔÚÈÛÌÔ‡˜. ºÚfiÓÈÌÔ fï˜ Â›Ó·È Ó· Á›ÓÔÓÙ·È 2 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘. ¶ÂÚÈÔÚÈÛÌfi˜ ˘¿Ú¯ÂÈ ÌfiÓÔ ÁÈ· Ù· ÂÌ‚fiÏÈ· Ì ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, ÁÈ·Ù› ÔÈ ˘„ËϤ˜ ‰fiÛÂȘ Ù˘ ÂÓ‰ÔÊϤ‚È·˜ Á-ÛÊ·ÈÚ›Ó˘ ÂÚȤ¯Ô˘Ó ÌÂÁ¿ÏË Û˘ÁΤÓÙÚˆÛË ÂȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÈÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ηٷÛÙ¤ÏÏÂÙ·È Ë ·ÓÙÈÁÔÓÈÎfiÙËÙ·, ¿Ú· Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·, ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ·˘ÙÒÓ. ™˘ÓÈÛÙ¿Ù·È ÏÔÈfiÓ, Û‡Ìʈӷ Ì ÙËÓ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜, ÔÈ ÂÌ‚ÔÏÈ·ÛÌÔ› ªªR Î·È ·ÓÂÌ¢ÏÔÁÈ¿˜ Ó· Á›ÓÔÓÙ·È 11 Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ¤Á¯˘ÛË Ù˘ πVIG. ™ÙȘ ÂÚÈÙÒÛÂȘ, ηٿ ÙȘ Ôԛ˜, ÏfiÁˆ ÂȉËÌ›·˜, ¯ÚÂÈ¿˙ÂÙ·È Ë ‰ÈÂÓ¤ÚÁÂÈ· ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÓˆÚ›ÙÂÚ·, ··ÈÙÂ›Ù·È Î·È ‰Â‡ÙÂÚË Â·Ó·ÏËÙÈ΋ ‰fiÛË ÛÙÔÓ ¯ÚfiÓÔ ·˘Ùfi (8).

™˘ÌÂÚ¿ÛÌ·Ù· ∏ ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ¡∫ ÚÔ¸Ôı¤ÙÂÈ ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË, ÁÈ·Ù› fiÛÔ ÈÔ Û‡ÓÙÔÌ· ÂÊ·ÚÌÔÛÙ› Ë ıÂÚ·›· Ì Á-ÛÊ·ÈÚ›ÓË Î·È ·ÛÈÚ›ÓË, ÙfiÛÔ ÌÈÎÚfiÙÂÚÔ˜ Â›Ó·È Ô Î›Ó‰˘ÓÔ˜ ÚfiÎÏËÛ˘ ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ªÂ ÙË ‚Ô‹ıÂÈ· Î·È ÙË ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙˆÓ Î‡ÚÈˆÓ Î·È Û˘ÌÏËڈ̷ÙÈÎÒÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ “ÎÚÈÙËÚ›ˆÓ”, ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ηډȿ˜ Î·È Ù˘ ηıËÌÂÚÈÓ‹˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÔ˘ ·ÚÚÒÛÙÔ˘, ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ô Î›Ó‰˘ÓÔ˜ Ù˘ ÌË ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ ‹ Ù˘ Ï·Óı·Ṳ̂Ó˘ Paediatriki 2007;70:361-369

‰È¿ÁÓˆÛ˘ οÔÈ·˜ ¿ÏÏ˘ ÓfiÛÔ˘, ·Ú¯›˙ÂÈ ¤ÁηÈÚ· Ë ıÂÚ·›· Î·È ·ÔÙÚ¤ÔÓÙ·È ÔÈ ·ÒÙÂÚ˜ ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜. ∏ ·Ú¯È΋ ıÂÚ·›· Ì IVIG Î·È ·ÛÈÚ›ÓË Â›Ó·È ÂÈÙ˘¯‹˜ Û ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 85% ÙˆÓ ÂÚÈÙÒÛˆÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ ÌË ·¿ÓÙËÛ˘ ÛÙË ıÂÚ·›·, ÔfiÙ ÂÈ̤ÓÂÈ Ô ˘ÚÂÙfi˜ ¤ˆ˜ Î·È 36 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÚÒÙË ‰fiÛË Ù˘ IVIG, Ë ÂӉ‰ÂÈÁ̤ÓË ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È Ë ‰Â‡ÙÂÚË ¤Á¯˘ÛË IVIG, Ì ÈηÓÔÔÈËÙÈο Û˘Ó‹ıˆ˜ ·ÔÙÂϤÛÌ·Ù·. ∞Ó fï˜ Ë ÓfiÛÔ˜ Â›Ó·È ·ÓıÂÎÙÈ΋ Î·È ÛÙË ‰Â‡ÙÂÚË ¤Á¯˘ÛË IVIG, ÙfiÙ ÂÓ‰¤¯ÂÙ·È Ó· ··ÈÙËı› Ë ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘ ηÈ, Û ÂÚ›ÙˆÛË ·ÔÙ˘¯›·˜ Î·È ·˘Ù‹˜ Ù˘ ·ÁˆÁ‹˜, Ë ÚÔÛı‹ÎË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (΢ÎÏÔʈÛÊ·Ì›‰Ë, ΢ÎÏÔÛÔÚ›ÓË, ·ÓÙÈ-TNF ·Ú¿ÁÔÓÙ˜ Î.¿.). ∏ ÛÙÚ·ÙËÁÈ΋ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì ¡∫ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·ÚÔ˘Û›· Î·È ÙÔÓ ‚·ıÌfi ÙˆÓ ‚Ï·‚ÒÓ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ (Â›‰· ÎÈÓ‰‡ÓÔ˘). ∞Ó·ÏfiÁˆ˜ ÏÔÈfiÓ ÙÔ˘ ÂÈ¤‰Ô˘ ÎÈÓ‰‡ÓÔ˘, ÛÙÔ ÔÔ›Ô ·Ó‹ÎÂÈ Ô ·ÛıÂÓ‹˜, ηıÔÚ›˙ÂÙ·È Î·È Ë ·Ó·ÁηÈfiÙËÙ· ‹ fi¯È Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ (·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‹/Î·È ¿ÏÏË ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹), ÂÚÈÔÚÈÛÌÔ‡ ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Î·È Û˘¯ÓfiÙËÙ·˜ ηډÈÔÏÔÁÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘. ∆ËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÛÙÚ·ÙËÁÈ΋˜ ·˘Ù‹˜ ÙËÓ ·Ó·Ï·Ì‚¿ÓÔ˘Ó ÔÈ ·È‰ÔηډÈÔÏfiÁÔÈ. √ ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ ÙÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ ÙÔ˘ ·È‰ÈÔ‡ Ì ¡∫ Ô˘ ·Ú·ÎÔÏÔ˘ı›, Ó· Û˘ÓÂÚÁ¿˙ÂÙ·È ÛÙÂÓ¿ Ì ÙÔÓ ·È‰ÔηډÈÔÏfiÁÔ Î·È Ó· ÂϤÁ¯ÂÈ ·Ó Ô ·ÛıÂÓ‹˜ ÂÊ·ÚÌfi˙ÂÈ ÛˆÛÙ¿ Î·È Ù·ÎÙÈο ÙÔ ÚfiÁÚ·ÌÌ· Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ıÂÚ·¢ÙÈ΋˜ ÙÔ˘ ·ÁˆÁ‹˜.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Burns JC, Glode MP. Kawasaki syndrome. Lancet 2004;364:533-544.

2. Falcini F. Kawasaki disease. Curr Opin Rheumatol 2006;18:33-38.

3. Huang GY, Ma XJ, Huang M, Chen SB, Huang MR, Gui YH, et al. Epidemiologic pictures of Kawasaki disease in Shanghai from 1998 through 2002. J Epidemiol 2006;16:9-14.

4. Yanagawa H, Nakamura Y, Yashiro M, Uehara R, Oki I, Kayaba K. Incidence of Kawasaki disease in Japan: the nationwide surveys of 1999-2002. Pediatr Int 2006;48:356-361.

5. Yeung RS. Pathogenesis and treatment of Kawasaki’s disease. Curr Opin Rheumatol 2005;17:617-623.

6. Wang CL, Wu YT, Lieu CA, Kuo HC, Yang KD. Kawasaki disease: infection, immunity and genetics. Pediatr Infect Dis J 2005;24:998-1004.

7. Baumer JH. Kawasaki disease: what to do with incomplete cases? Arch Dis Child Ed Pract 2005;90:102-104.

8. Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, et al. Diagnosis, treatment, and longterm management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Pediatrics 2004;114:1708-1733.

9. Royle J, Burgner D, Curtis N. The diagnosis and management of Kawasaki disease. J Paediatr Child Health 2005;41:87-93.

Paidiatriki 5 final

12-10-07

16:28

Page 369

369

¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘

10. Brogan PA, Bose A, Burgner D, Shingadia D, Tulloh R, Michie C, et al. Kawasaki disease: an evidence based approach to diagnosis, treatment, and proposals for future research. Arch Dis Child 2002;86:286-290.

11. Chang FY, Hwang B, Chen SJ, Lee PC, Meng L, Lu JH. Characteristics of Kawasaki disease in infants younger than six months of age. Pediatr Infect Dis J 2006;25:241-244.

12. Hsieh KS, Weng KP, Lin CC, Huang TC, Lee CL, Huang SM. Treatment of acute Kawasaki disease: aspirin’s role in the febrile stage revisited. Pediatrics 2004;114:e689-693.

13. Baumer JH, Love SJ, Gupta A, Haines LC, Maconochie I, Dua JS. Salicylate for the treatment of Kawasaki disease in children. Cochrane Database Syst Rev 2006;18:CD004175.

14. Inoue Y, Okada Y, Shinohara M, Kobayashi T, Kobayashi T, Tomomasa T, et al. A multicenter prospective randomized trial of corticosteroids in primary therapy for Kawasaki disease: clinical course and coronary artery outcome. J Pediatr 2006;149:336-341.

15. Burns JC. Revisiting steroids in the primary treatment of acute Kawasaki disease. J Pediatr 2006;149:291-292.

16. Newburger JW, Sleeper LA, McCrindle BW, Minich LL,

17.

18.

19.

20.

21.

22.

23.

Gersony W, Vetter VL, et al. Randomized trial of pulsed corticosteroid therapy for primary treatment of Kawasaki disease. N Engl J Med 2007;356:663-675.

Burns JC. The riddle of Kawasaki disease. N Engl J Med 2007;356:659-661.

Wilder MS, Palinkas LA, Kao AS, Bastian JF, Turner CL, Burns JC. Delayed diagnosis by physicians contributes to the development of coronary artery aneurysms in children with Kawasaki syndrome. Pediatr Infect Dis J 2007;26:256-260.

Yeung RS. Phenotype and coronary outcome in Kawasaki's disease. Lancet 2007;369:85-87.

Weiss JE, Eberhard BA, Chowdhury D, Gottlieb BS. Infliximab as a novel therapy for refractory Kawasaki disease. J Rheumatol 2004;31:808-810. ¶··‰fiÔ˘ÏÔ˜ °™. ¡fiÛÔ˜ Kawasaki Î·È ÔÈ ÂÈÙÒÛÂȘ Ù˘ ÛÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ·. ¶·È‰È·ÙÚÈ΋ 2001;64:420-423. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜ ¢, ¶··‰fiÔ˘ÏÔ˜ °. √‰ËÁ›Â˜ ÁÈ· ¿ÛÎËÛË Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ ÌÂ Û˘ÁÁÂÓ›˜ ‹ Â›ÎÙËÙ˜ ·ı‹ÛÂȘ ΢ÎÏÔÊÔÚÈÎÔ‡. ¶·È‰È·ÙÚÈ΋ 2006;69:468-477.

Cohen µ∞, Lehmann CU. DermAtlas, Johns Hopkins University; 2000-2007: http://dermatlas.med.jhmi.edu

Quiz 1. ¶fiÙ ÂÌÊ·Ó›˙ÂÙ·È ÙÔ ÂÍ¿ÓıËÌ· ÛÙË ÓfiÛÔ Kawasaki; ·. ∆Ș ÚÒÙ˜ ¤ÓÙ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡ ‚. ªÂÙ¿ ÙȘ ÚÒÙ˜ ¤ÓÙ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡ Á. ªÂÙ¿ ÙË ‰Â‡ÙÂÚË Â‚‰ÔÌ¿‰· Ù˘ ÓfiÛÔ˘ ‰. ¢ÂÓ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ¯ÚÔÓÈÎfi fiÚÈÔ ÂÌÊ¿ÓÈÛ˘ 2. ™Â ÂÚÈÙÒÛÂȘ ·ÙÂÏÔ‡˜ ¡. Kawasaki, fiÛ· ·fi Ù· ·ÚÈ· Î·È Û˘ÌÏËڈ̷ÙÈο ÂÚÁ·ÛÙËÚȷο “ÎÚÈÙ‹ÚÈ·” Ú¤ÂÈ Ó· ÏËÚÔ‡ÓÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ·Ú¯›ÛÂÈ ¤ÁηÈÚ· Ë ıÂÚ·›·; ·. ŒÓ· ·fi Ù· ·ÚÈ· Î·È 2 ·fi Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” ‚. ¢‡Ô ·fi Ù· ·ÚÈ· Î·È ¤Ó· ·fi Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” Á. ŒÓ· ·fi Ù· ·ÚÈ· Î·È ≥3 ·fi Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” ‰. ¢‡Ô ·fi Ù· ·ÚÈ· Î·È ≥2 ·fi Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” 3. ∏ ‰È¿ÚÎÂÈ· ıÂÚ·›·˜ Ì ¯·ÌËÏ‹, ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‰fiÛË ·ÛÈÚ›Ó˘ Û ·ÛıÂÓ›˜ Ì N. Kawasaki ¯ˆÚ›˜ ÚÔÛ‚ÔÏ‹ ÛÙÂÊ·ÓÈ·›ˆÓ ›ӷÈ: ·. ¢‡Ô ‚‰ÔÌ¿‰Â˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ‚. ∆ÚÂȘ ‚‰ÔÌ¿‰Â˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Á. ŒÍÈ Ì‹Ó˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ‰. ∆¤ÛÛÂÚȘ Ì ¤ÍÈ Â‚‰ÔÌ¿‰Â˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ 4. ¶fiÙ ÂӉ›ÎÓ˘Ù·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì MMR ÛÙ· ·È‰È¿ Ì ¡. Kawasaki, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘; ·. ¢ÂÓ ˘¿Ú¯ÂÈ Î·Ó¤Ó·˜ ÂÚÈÔÚÈÛÌfi˜ ‚. ¢‡Ô Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂÚ·›·˜ Á. ŒÓÙÂη Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂÚ·›·˜ ‰. ŒÍÈ Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ 5. ™Â ·È‰È¿ Ì ¡. Kawasaki Ô˘ Ú¤ÂÈ Â› ÛÂÈÚ¿ ÂÙÒÓ Ó· ·›ÚÓÔ˘Ó ¯·ÌËÏ‹ ‰fiÛË ·ÛÈÚ›Ó˘, Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜: ·. ∞ÓÙÂӉ›ÎÓ˘Ù·È ‚. ∂È‚¿ÏÏÂÙ·È ¯ˆÚ›˜ ηӤӷ ÂÚÈÔÚÈÛÌfi Á. ∂È‚¿ÏÏÂÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ ÓfiÛÔ˘, ·ÏÏ¿ Ì ÙËÓ ·Ú¿ÏÏËÏË ‰È·ÎÔ‹ Ù˘ ·ÛÈÚ›Ó˘ ÁÈ· 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ‰. ∂›Ó·È ˘Ô¯ÚˆÙÈÎfi˜, ·ÏÏ¿ 11 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘ Î·È Ì ÙËÓ ·Ú¿ÏÏËÏË ‰È·ÎÔ‹ Ù˘ ·ÛÈÚ›Ó˘ Î·È ·ÓÙÈηٿÛÙ·Û‹ Ù˘ Ì ¿ÏÏË ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ ÁÈ· 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ¶·È‰È·ÙÚÈ΋ 2007;70:361-369

Paidiatriki 5 final

12-10-07

370

16:28

Page 370

∞¡∞™∫√¶∏™∏

REVIEW ARTICLE

ÕÙ˘Ë-·ÙÂÏ‹˜ ÓfiÛÔ˜ Kawasaki: ¯ÚÂÈ·˙fiÌ·ÛÙ Ӥ· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·; ∫·Ú‰ÈÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ, “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” AÏÏËÏÔÁÚ·Ê›·: °ÂˆÚÁ›· °ÚËÁÔÚÈ¿‰Ô˘ grigeo9@yahoo.gr ∞Ó·ÙÔÏ‹˜ 87 ∆.∫. 155 62, ÃÔÏ·ÚÁfi˜

°. °ÚËÁÔÚÈ¿‰Ô˘ ¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ Kawasaki ·ÔÙÂÏ› ÙË Û˘ÓËı¤ÛÙÂÚË Â›ÎÙËÙË Î·Ú‰ÈÔ¿ıÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜.

20% ÙˆÓ ·ÛıÂÓÒÓ ı· ÂÌÊ·Ó›ÛÔ˘Ó ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÔÍ›·˜ ·ÁÁÂÈ›Ùȉ·˜. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Ù›ıÂÙ·È Ì ۷ʋ ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ·, ˆÛÙfiÛÔ Ë ÂÌÂÈÚ›· ¤¯ÂÈ ‰Â›ÍÂÈ fiÙÈ ‰ÂÓ Â›Ó·È Û¿ÓÈ· Ë ‰È·›ÛÙˆÛË ‚Ï·‚ÒÓ ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜, ¯ˆÚ›˜ Ó· ¤¯Ô˘Ó ÚÔËÁËı› fiÏ· Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘. √È ·È‰›·ÙÚÔÈ Â›Ó·È ·Ó·Áη›Ô Ó· ¯ÚËÛÈÌÔÔÈÔ‡Ó ÂÈÚfiÛıÂÙ· ‰È·ÁÓˆÛÙÈο ÛÙÔȯ›·, ÌË ÂȉÈο Ù˘ ÓfiÛÔ˘ ·ÏÏ¿ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ¤ÙÛÈ ÒÛÙ ӷ ÂÈÙ˘Á¯¿ÓÂÙ·È Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ıÂÚ·›·. ¶˘ÚÂÙfi˜ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 4 Ë̤Ú˜ Û ·È‰È¿ ¯ˆÚ›˜ Ù· ÎÏ·ÛÈο ÎÚÈÙ‹ÚÈ· ·ÔÙÂÏ› ˘„ËÏfi ‰Â›ÎÙË ˘Ô„›·˜ Ù˘ ÓfiÛÔ˘ Kawasaki. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ·ÔÙÂÏ› ÛÔ˘‰·›Ô ÂÚÁ·ÏÂ›Ô ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘. §¤ÍÂȘ ÎÏÂȉȿ: ÕÙ˘Ë ÓfiÛÔ˜ Kawasaki, ÛÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù·, ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·.

Atypical Kawasaki disease: criteria Cardiology Department, “P. & A. Kyriakou”, Athens, Greece Correspondence: Georgia Grigoriadou grigeo9@yahoo.gr 87, Anatolis St. 155 62, Cholargos, Athens, Greece

G. Grigoriadou Abstract: Kawasaki disease (KD) is the leading cause of acquired heart disease in children in several parts of the world. Of children with KD, 20% will develop coronary artery abnormalities as a result of intense vasculitis. Atypical (incomplete) KD occurs when children develop coronary aneurysms without having met the criteria for full case definition. Clinicians use several additional clues, which are not specific for the disease but which occur in a large number of patients with KD, so that they can initiate early treatment.

Paediatricians who are evaluating fever lasting more than 4 days in infants without classical forms of KD should have a “high index of suspicion” for the possibility of KD. Echocardiography is an important tool in the diagnosis of atypical KD.

Key words: Atypical Kawasaki disease, coronary aneurysm, diagnostic criteria.

∂ÈÛ·ÁˆÁ‹ ∏ ÓfiÛÔ˜ Kawasaki Â›Ó·È ÔÍ›· ·ÁÁÂÈ›Ùȉ·, Ë ÔÔ›· ÚÔÛ‚¿ÏÏÂÈ ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 5 ÂÙÒÓ Î·È ·ÔÙÂÏ› ÙË Û˘ÓËı¤ÛÙÂÚË Â›ÎÙËÙË Î·Ú‰ÈÔ¿ıÂÈ· ÛÙȘ ÚÔËÁ̤Ó˜ ¯ÒÚ˜ (1). ∏ ÛÔ‚·ÚfiÙÂÚË ÂÈÏÔ΋ Ù˘ ÓfiÛÔ˘ Kawasaki Â›Ó·È Ë ÚÔÛ‚ÔÏ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ, Ë ÔÔ›· ÂÌÊ·Ó›˙ÂÙ·È ÂÚ›Ô˘ ÛÙÔ 20% ÙˆÓ ÌË ıÂÚ·¢ı¤ÓÙˆÓ ·ÛıÂÓÒÓ. ∏ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÎÙ·Û›·, ÌÈÎÚÔ‡ Î·È ÌÂÛ·›Ô˘ ÌÂÁ¤ıÔ˘˜ ·Ó¢ڇÛÌ·Ù· (Ô˘ ˘Ô¯ˆÚÔ‡Ó ÂÓÙfi˜ 1-2 ÂÙÒÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘) Î·È ÁÈÁ·ÓÙÈ·›· ·Ó¢ڇÛÌ·Ù· Ô˘ ··ÈÙÔ‡Ó ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ Î·È ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ Ì˘Ôηډȷ΋˜ ÈÛ¯·ÈÌ›·˜ Î·È Ì˘ÔηډȷÎÔ‡ ÂÌÊÚ¿ÎÙÔ˘. ∏ ¤ÁηÈÚË ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘ ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ ÛÙÔ 3-8% Î·È ÌÂÈÒÓÂÈ ÙË ıÓËÛÈÌfiÙËÙ· ÛÙÔ 0,2% (2). ∏ ÓfiÛÔ˜ Â·ÓÂÌÊ·Ó›˙ÂÙ·È ÌÂ Û˘¯ÓfiÙËÙ· <4% Û˘Ó‹ıˆ˜ ÂÓÙfi˜ ‰‡Ô ÂÙÒÓ ·fi ÙËÓ ·Ú¯È΋ ÚÔÛ‚ÔÏ‹.

Paediatriki 2007;70:370-373

√È Ì·ÎÚÔÚfiıÂÛ̘ ÂÈÙÒÛÂȘ Ù˘ ÓfiÛÔ˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ¤˜, ·ÏÏ¿ ÎÏÈÓÈο ÛȈËÏ¿ ·Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ ÌÔÚ› Ó· ·Ó·ÁÓˆÚÈÛÙÔ‡Ó ÌÂÙ·ÁÂÓ¤ÛÙÂÚ· ÏfiÁˆ ·ÈÊÓ›‰ÈÔ˘ ηډȷÎÔ‡ ÂÂÈÛÔ‰›Ô˘ ‹ ı·Ó¿ÙÔ˘ (3).

ÕÙ˘Ô-·ÙÂϤ˜ Kawasaki: ÙÔ ‰›ÏËÌÌ· ÙÔ˘ ·È‰›·ÙÚÔ˘ ∫Ï·ÛÈο ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘ ·ÔÙÂÏÔ‡Ó ·ıÚÔÈÛÙÈο Ë ÂÈÌÔÓ‹ ÙÔ˘ ˘ÚÂÙÔ‡ ÁÈ· ÂÚÈÛÛfiÙÂÚ˜ ·fi 5 Ë̤Ú˜ Î·È Ô Û˘Ó‰˘·ÛÌfi˜ ÙÂÛÛ¿ÚˆÓ ·fi Ù· ·ÎfiÏÔ˘ı· ¤ÓÙÂ Â˘Ú‹Ì·Ù·: ·) ·ÌÊÔÙÂÚfiÏ¢ÚË ÂÈÂÊ˘Î›Ùȉ·, ‚) ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÏÏ·Á¤˜ ÛÙ· ¯Â›ÏË (ÂÚ‡ıËÌ·, ÍËÚfiÙËÙ·, ÚˆÁ̤˜, ·ÔϤÈÛË, ·ÈÌÔÚÚ·Á›·) Î·È ÙÔ ÛÙfiÌ· (‰È¿¯˘ÙÔ ÂÚ‡ıËÌ· ÛÙÔ ÛÙÔÌ·ÙÈÎfi ‚ÏÂÓÓÔÁfiÓÔ Î·È ÙÔÓ Ê¿Ú˘ÁÁ·), Á) ÁÂÓÈÎÂ˘Ì¤ÓÔ ÔχÌÔÚÊÔ ÂÍ¿ÓıËÌ·, ‰) ·ÌÊÔÙÂÚfiÏ¢ÚË ‰ÈfiÁΈÛË Î·È ·ÔϤÈÛË ÛÙ· ¯¤ÚÈ· Î·È Ù· fi‰È· Î·È Â) ÙÚ·¯ËÏÈ΋

Paidiatriki 5 final

12-10-07

16:28

Page 371

371

ÕÙ˘Ë ÓfiÛÔ˜ Kawasaki: ÎÚÈÙ‹ÚÈ·

ÏÂÌÊ·‰ÂÓ›Ùȉ· Ì ¤Ó·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ÏÂÌÊ·‰¤Ó· Ì ‰È¿ÌÂÙÚÔ ÌÂÁ·Ï‡ÙÂÚË ·fi 1,5 ÂηÙÔÛÙfi. ÕÙ˘Ë ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘ Kawasaki Û˘Ó·ÓÙ¿Ù·È ÛÙȘ ÂÚÈÙÒÛÂȘ, fiÔ˘ ·Ó·Ù‡ÛÛÔÓÙ·È ·Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ, ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· fiÏˆÓ ÙˆÓ ÎÚÈÙËÚ›ˆÓ (4). √ÚÈṲ̂ÓÔÈ ·ÛıÂÓ›˜ Ì ¿Ù˘Ë ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Èı·ÓfiÓ Ó· ·Ó·Ù‡ÍÔ˘Ó Ù· Ù˘Èο Â˘Ú‹Ì·Ù· ÛÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘. ∫¿ÔÈÔÈ ¿ÏÏÔÈ ‰ÂÓ ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Ù˘Èο Â˘Ú‹Ì·Ù· ÁÈ· Ì·ÎÚfi ‰È¿ÛÙËÌ·, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ‰È¿ÁÓˆÛË Î·È Ù¤ÏÔ˜, ÌÈÎÚfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ì ¿Ù˘· Â˘Ú‹Ì·Ù· ı· ‰È·Ê‡ÁÔ˘Ó ÙË ‰È¿ÁÓˆÛË, Ë ÔÔ›· Î·È ı· Á›ÓÂÈ ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ· ÏfiÁˆ ·ÈÊÓ›‰ÈÔ˘ ηډȷÎÔ‡ ÂÂÈÛÔ‰›Ô˘. √ ¯ÚfiÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Â›Ó·È Î·ıÔÚÈÛÙÈÎfi˜ ÁÈ· ÙËÓ ¤ÁηÈÚË ıÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ·Ó·ÁÓˆÚ›˙ÔÓÙ·È Û˘¯ÓfiÙÂÚ· ·ÛıÂÓ›˜ Ì ¿Ù˘˜ ÂΉËÏÒÛÂȘ. ¶ÔÛÔÛÙfi 28% ÙˆÓ ‚ÚÂÊÒÓ Î·È 7%-10% ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ·È‰ÈÒÓ Ì ÓfiÛÔ Kawasaki ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ¿Ù˘˜ ÂΉËÏÒÛÂȘ (5). ∏ ÓfiÛÔ˜ Kawasaki Â›Ó·È ·Û˘Ó‹ı˘ Û ‚Ú¤ÊË ËÏÈΛ·˜ <3 ÌËÓÒÓ (ÛÙËÓ π·ˆÓ›· ÙÔ ÔÛÔÛÙfi ·Ó¤Ú¯ÂÙ·È ÛÙÔ 1,6%, ÂÓÒ ÛÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ ÙÔ ÔÛÔÛÙfi Â›Ó·È <1%). ∆· ‚Ú¤ÊË, ΢ڛˆ˜ ·˘Ù¿ οو ÙˆÓ 6 ÌËÓÒÓ, ¤¯Ô˘Ó ‰˘ÛÌÂÓ¤ÛÙÂÚË ÚfiÁÓˆÛË ·fi Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ∏ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ ÛÙ· ·È‰È¿ Ì ¿Ù˘Ë ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘, Ê·›ÓÂÙ·È Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ‰È¿ÁÓˆÛ˘ Î·È ıÂÚ·›·˜. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Kawasaki, fiˆ˜ ·Ó·Ê¤ÚıËΠÚÔËÁÔ˘Ì¤Óˆ˜, ‚·Û›˙ÂÙ·È ÛÙ· ÎÏ·ÛÈο ÎÚÈÙ‹ÚÈ·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂȉÈΤ˜ ‰È·ÁÓˆÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Â›Ó·È ‰‡ÛÎÔÏË Ë ·Ó·ÁÓÒÚÈÛ‹ Ù˘ Û ¿Ù˘˜ ÂÚÈÙÒÛÂȘ.

ÕÙ˘Ô Kawasaki: Â›Ó·È ·Ó·Áη›· Ù· Ó¤· ÎÚÈÙ‹ÚÈ·; √ ¯ÂÈÚÈÛÌfi˜ ÙˆÓ ¿Ù˘ˆÓ ÂÚÈÙÒÛÂˆÓ Ù˘ ÓfiÛÔ˘ ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ ‰È¯ÔÁӈ̛·˜ ÌÂٷ͇ ÙˆÓ ·È‰È¿ÙÚˆÓ Î·È Ó¤Â˜ Ô‰ËÁ›Â˜ Â›Ó·È ·Ó·Áη›Â˜ ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË. ¢ÂÓ Â›Ó·È ·Û‡ÓËı˜, ·È‰È¿ Ô˘ ‰ÂÓ ÏËÚÔ‡Ó Ù· ÎÚÈÙ‹ÚÈ· Ó· ·Ó·Ù‡ÛÛÔ˘Ó ÛÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù·. Œ¯ÂÈ ‚ÚÂı› fiÙÈ ÂÚ›Ô˘ 30% ÙˆÓ ·ÛıÂÓÒÓ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ˘¿Ú¯ÂÈ ˘Ô„›· ÓfiÛÔ˘ Kawasaki Ï·Ì‚¿ÓÔ˘Ó Á-ÛÊ·ÈÚ›ÓË ÁÈ· ÙËÓ ÚfiÏË„Ë ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ, ÂÓÒ ÌÂÙ·ÁÂÓ¤ÛÙÂÚ· ·Ô‰ÂÈÎÓ‡ÂÙ·È fiÙÈ ÔÚÈṲ̂ÓÔÈ ·fi ·˘ÙÔ‡˜ ¿Û¯Ô˘Ó ·fi ¿ÏÏÔ ÓfiÛËÌ·. ∂›Ó·È ÂÔ̤ӈ˜ ·Ó·Áη›· Ë ¯ÚËÛÈÌÔÔ›ËÛË ÂÈÚfiÛıÂÙˆÓ ÛÙÔȯ›ˆÓ, Ù· ÔÔ›· ‰ÂÓ Â›Ó·È ÌÂÓ ÂȉÈο Ù˘ ÓfiÛÔ˘ Kawasaki, ·Ú·ÙËÚÔ‡ÓÙ·È fï˜ Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ Ì Kawasaki Î·È ÌÔÚÔ‡Ó Ó· ·˘Í‹ÛÔ˘Ó ÙËÓ ÈηÓfiÙËÙ· ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ (6). ∆· ÂÈÚfiÛıÂÙ· ‰È·ÁÓˆÛÙÈο ÛÙÔȯ›· ·ÊÔÚÔ‡Ó ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ, ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ‹ ÚÔÛ‚ÔÏ‹ ÔÚÁ¿ÓˆÓ. ¶·Ú·Ù›ıÂÙ·È Î·ÙˆÙ¤Úˆ ›Ó·Î·˜ Ì ٷ ÂÈÚfiÛıÂÙ· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· (¶›Ó·Î·˜ 1). ⁄‰Úˆ„ Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔ 10% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·È ÂΉËÏÒÓÂÙ·È Ì ¤ÓÙÔÓÔ fiÓÔ ÛÙÔ ‰ÂÍ› ¿Óˆ ÙÂÙ·ÚÙËÌfiÚÈÔ Ù˘ ÎÔÈÏ›·˜. ÕÛËÙË ÌËÓÈÁÁ›Ùȉ· Û˘Ì‚·›ÓÂÈ ÛÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ ·ÏÏ¿ Û˘Ó‹ıˆ˜ Â›Ó·È ÎÏÈÓÈο ÛȈËÏ‹. ∏ ·ÚıÚ›Ùȉ· ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔ 10%-20% Î·È ÚÔÛ‚¿ÏÏÂÈ ÌÈÎÚ¤˜ ·ÚıÚÒÛÂȘ ÙˆÓ ‰·ÎÙ‡ÏˆÓ ÛÙ· ¯¤ÚÈ· Î·È Ù· fi‰È·. ŸÙ·Ó ÚÔÛ‚¿ÏÏÂÈ ÌÂÁ¿Ï˜ ·ÚıÚÒÛÂȘ, ÌÈÌÂ›Ù·È ÛËÙÈ΋ ·ÚıÚ›Ùȉ·. ∏ ¢ÂÚÂıÈÛÙfiÙËÙ·, ÙÔ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, Ë ‰È¿ÚÚÔÈ·, Ô ÂÌÂÙfi˜ Î·È Ë ·ÚıÚ›Ùȉ· Â›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙȘ ¿Ù˘˜ ÂΉËÏÒÛÂȘ (7). ¢˘ÛÙ˘¯Ò˜, ‰ÂÓ ˘¿Ú¯Ô˘Ó ̤¯ÚÈ Û‹ÌÂÚ· ÌÂϤÙ˜ ·ÍÈÔÏfiÁËÛ˘ Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ·Í›·˜ ÙˆÓ ÂÈÚfiÛıÂÙˆÓ ·˘ÙÒÓ Â˘ÚËÌ¿ÙˆÓ.

¶›Ó·Î·˜ 1. ¶›Ó·Î·˜ ÂÈÚfiÛıÂÙˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÛÙÔȯ›ˆÓ Ù˘ ÓfiÛÔ˘ Kawasaki ∫ÏÈÓÈο Â˘Ú‹Ì·Ù·

∂ÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù·

∂˘Ú‹Ì·Ù· ·fi Ù· fiÚÁ·Ó·

∂˘ÂÚÂıÈÛÙfiÙËÙ·-¿ÛËÙË ÌËÓÈÁÁ›Ùȉ· ¶ÔÏ˘·ÚıÚ›Ùȉ· ∂Ú‡ıËÌ·/·ÔϤÈÛË ÙÔ˘ ÂÚÈÓ¤Ô˘, ∂Ú‡ıËÌ· ÛÙÔ ÛËÌÂ›Ô ¤ÓÂÛ˘ ÙÔ˘ BCG ∂Ï·Ùو̤Ó˜ ÂÚÈÊÂÚÈΤ˜ ÛʇÍÂȘ, ÈÛ¯·ÈÌ›· ¿ÎÚˆÓ, Á¿ÁÁÚ·ÈÓ· À¤ÚÙ·ÛË ∞‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ/ ÁÏÔ˘Ù·ÌÈÓÈ΋˜ ÙÚ·ÓÛÊÂÚ¿Û˘ ÕÛËÙË ˘Ô˘Ú›· ∞‡ÍËÛË ∆∫∂/ CRP ∞Ó·ÈÌ›· §Â˘ÎÔ΢ÙÙ¿ÚˆÛË £ÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË Ã·ÌËÏ¿ Â›‰· Na ÷ÌËÏ¿ Â›‰· ·Ï‚Ô˘Ì›Ó˘ ∞˘ÍË̤ӷ ÏÈ›‰È· Ï¿ÛÌ·ÙÔ˜ ∏ˆÛÈÓÔÊÈÏ›·/·‡ÍËÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙˆÓ IgE ⁄‰Úˆ„ Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜ ƒ·ÁÔÂȉ›ÙȘ ¶·È‰È·ÙÚÈ΋ 2007;70:370-373

Paidiatriki 5 final

12-10-07

16:28

Page 372

372

°. °ÚËÁÔÚÈ¿‰Ô˘

∫·Ú‰›Ùȉ· οÔÈÔ˘ ‚·ıÌÔ‡ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ Ù˘ ÓfiÛÔ˘ Kawasaki. ∆Ô ÂÚÈοډÈÔ, ÙÔ Ì˘ÔοډÈÔ Î·È ÙÔ ÂÓ‰ÔοډÈÔ ÌÔÚÔ‡Ó Ó· ÂËÚ·ÛÙÔ‡Ó. ¶ÂÚÈηډ›Ùȉ· ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔ 20%-40% ÙˆÓ ÂÚÈÙÒÛˆÓ. ºÏÂÁÌÔÓ‹ Ù˘ ÌÈÙÚÔÂȉԇ˜ ‹ ·ÔÚÙÈ΋˜ ‚·Ï‚›‰·˜ Ô‰ËÁ› Û ·ÓÂ¿ÚÎÂÈ· ÙˆÓ ‚·Ï‚›‰ˆÓ. ™˘ÌÊÔÚËÙÈ΋ ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· Û˘Ì‚·›ÓÂÈ ÛÙÔ 5% ÙˆÓ ÂÚÈÙÒÛˆÓ. ∞Ó¢ڇÛÌ·Ù· ı· ÂÌÊ·ÓÈÛÙÔ‡Ó ÛÙÔ 20%-25% ÙˆÓ ·ÛıÂÓÒÓ, Û˘Ó‹ıˆ˜ ÌÂٷ͇ 2˘ Î·È 4˘ ‚‰ÔÌ¿‰·˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Î·È Û·ÓÈfiÙÂÚ· ÓˆÚ›ÙÂÚ·, ÂÓÙfi˜ 7 ËÌÂÚÒÓ. ¶·Ú¿ÁÔÓÙ˜, ÔÈ ÔÔ›ÔÈ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ ·ÔÙÂÏÔ‡Ó ÙÔ Ê‡ÏÔ (Û˘¯ÓfiÙÂÚË ÛÙ· ·ÁfiÚÈ·), Ë ËÏÈΛ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ (οو ÙÔ˘ ¤ÙÔ˘˜), Ë ·Ú·ÌÔÓ‹ ÙÔ˘ ˘ÚÂÙÔ‡ ÁÈ· ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 16 ËÌÂÚÒÓ, Ë Î·Ú‰ÈÔÌÂÁ·Ï›·, Ë ·ÈÌÔÛÊ·ÈÚ›ÓË <·fi 10gr/dl, Ù· ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· >30.000/mm3, Ë ∆∫∂ >·fi 100 mm/hr, Ë ıÂÙÈ΋ CRP, Ë ÔÔ›· ·Ú·Ì¤ÓÂÈ ˘„ËÏ‹ ¿Óˆ ·fi 30 Ë̤Ú˜, Î·È ÔÈ ·ÚÚ˘ı̛˜. ™Â ·ÛıÂÓ›˜, fiÔ˘ ˘¿Ú¯ÂÈ ˘Ô„›· Ù˘ ÓfiÛÔ˘, ··ÈÙÂ›Ù·È Ë¯ÔηډÈÔÁÚ·ÊÈ΋ ÂÎÙ›ÌËÛË ÂÓÙfi˜ ÙˆÓ ÚÒÙˆÓ ÂÙ¿ ËÌÂÚÒÓ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ∆· ÛÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù· ·ÔÙÂÏÔ‡Ó ·ıÔÁÓˆÌÔÓÈÎfi ÛÙÔÈ¯Â›Ô Ù˘ ÓfiÛÔ˘. ∂› ÌË Â˘Ú¤Ûˆ˜ ıÂÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ· Ú¤ÂÈ Ó· Â·Ó·Ï·Ì‚¿ÓÂÙ·È Î·Ù¿ ÙËÓ 2Ë, 4Ë Î·È 8Ë Â‚‰ÔÌ¿‰·. ∏ ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘ Î·È ˘„ËÏ‹˜ ‰fiÛ˘ ·ÛÈÚ›Ó˘ ·ÔÙÂÏÔ‡Ó ÙË ıÂÚ·›· ÂÈÏÔÁ‹˜. ∂› ·ÔÙ˘¯›·˜ Ù˘ ·ÁˆÁ‹˜ (ÌË ÙÒÛ˘ ÙÔ˘ ˘ÚÂÙÔ‡ ‹ Â·ÓÂÌÊ¿ÓÈÛ‹˜ ÙÔ˘ ÌÂÙ¿ ·fi 48 ÒÚ˜) ··ÈÙÂ›Ù·È Ë ¯ÔÚ‹ÁËÛË 2˘ ‰fiÛ˘ Á-ÛÊ·ÈÚ›Ó˘. ∂› ·ÔÙ˘¯›·˜ Î·È Ù˘ 2˘ ‰fiÛ˘ Á-ÛÊ·ÈÚ›Ó˘, ÚÔÙÈÌ¿Ù·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙÔ Infliximamb (ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ ηٿ ÙÔ˘ TNF-·) ·fi ÙËÓ ÎÔÚÙÈ˙fiÓË, Ì Ôχ ηϿ ·ÔÙÂϤÛÌ·Ù·. ∏ ηډÈÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋˜ ·ÁˆÁ‹˜ ÂÍ·ÚÙÒÓÙ·È ·fi Ù· ηډÈÔÏÔÁÈο Â˘Ú‹Ì·Ù·. √È ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ıÂÚ·‡ÔÓÙ·È Ï‹Úˆ˜. ™ÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù· Ì ‰È¿ÌÂÙÚÔ <8mm Û˘Ó‹ıˆ˜ ·Ôηı›ÛÙ·ÓÙ·È ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜. ªÂÁ·Ï‡ÙÂÚ· ·Ó¢ڇÛÌ·Ù· Û¯ÂÙ›˙ÔÓÙ·È Ì ̷ÎÚÔ¯ÚfiÓȘ ÂÈÏÔΤ˜ Î·È ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ Î·Ú‰È·ÎÔ‡ ÂÂÈÛÔ‰›Ô˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ·˘ÍË̤Ó˘ ۈ̷ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ (·ÁÒÓˆÓ). ∏ American Heart Association ηıfiÚÈÛ ÙË ‰È·ÛÙڈ̿وÛË ÎÈÓ‰‡ÓÔ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì ÓfiÛÔ Kawasaki Î·È ÚfiÙÂÈÓ ·Ó¿ÏÔÁË ıÂÚ·›· Î·È ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ (8). √È ¿Ù˘˜ ÂΉËÏÒÛÂȘ Â›Ó·È Û˘¯ÓfiÙÂÚ˜ ÛÙ· ‚Ú¤ÊË. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Î˘Ú›ˆ˜ ÛÙ· ‚Ú¤ÊË Paediatriki 2007;70:370-373

ÂÚÈÏ·Ì‚¿ÓÂÈ ÈÔÁÂÓ›˜ Î·È ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ, Ê·Ú̷΢ÙÈ΋ ·ÓÙ›‰Ú·ÛË Î·È ÓÔÛ‹Ì·Ù· ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÔÓÙ·È ÂÚÈÙÒÛÂȘ ‚ÚÂÊÒÓ 2,5 Î·È 3 ÌËÓÒÓ Ì ¿Ù˘Ë ÓfiÛÔ Kawasaki (9,10). ™Â ‚Ú¤ÊÔ˜ 7 ‚‰ÔÌ¿‰ˆÓ Ì ÁÈÁ·ÓÙÈ·›· ·Ó¢ڇÛÌ·Ù·, Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË 2 ‰fiÛÂˆÓ Á-ÛÊ·ÈÚ›Ó˘ Î·È ÎÔÚÙÈ˙fiÓ˘ ‹Ù·Ó ·ÓÂ·Ú΋˜ Î·È ··ÈÙ‹ıËÎ·Ó 2 ‰fiÛÂȘ Infliximamb ÁÈ· ÙËÓ ˘Ô¯ÒÚËÛË ÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ (11). ¶·È‰› 2 ÂÙÒÓ Ì ¿Ù˘Ô Kawasaki Î·È ıÚÔÌ‚ÔÂÓ›· ·Ó¤Ù˘Í ÙÚ›· ÛÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù·. ∞Ó·ÊÔÚ¤˜ Û 30 ÂÚÈÙÒÛÂȘ Ì ÓfiÛÔ Kawasaki Î·È ıÚÔÌ‚ÔÂÓ›· Û˘ÁÎÏ›ÓÔ˘Ó ÛÙÔ fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ ÙÔ˘˜ Â›Ó·È Û˘¯ÓfiÙÂÚÔ˜ Û ÎÔÚ›ÙÛÈ· ÌÈÎÚ‹˜ ËÏÈΛ·˜ Î·È Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ Î·È Ì˘ÔηډȷÎÔ‡ ÂÌÊÚ¿ÎÙÔ˘. π‰È·›ÙÂÚ· ÂӉȷʤÚÔ˘Û· Â›Ó·È Ë ÂÚ›ÙˆÛË Ó¤·˜ Á˘Ó·›Î·˜ 20 ÂÙÒÓ Ô˘ ·ÚÔ˘Û›·ÛÂ Ì˘ÔηډȷÎfi ¤ÌÊÚ·ÎÙÔ ·fi ıÚfiÌ‚ˆÛË ÁÈÁ·ÓÙÈ·›Ô˘ ·Ó¢ڇÛÌ·ÙÔ˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜. ªÂÙ¿ ·fi ·ÔÎÏÂÈÛÌfi ·ÁÁÂȷ΋˜ ‹ Û˘ÛÙËÌ·ÙÈ΋˜ ÓfiÛÔ˘ ‰È·ÁÓÒÛıËΠ¿Ù˘Ë ÓfiÛÔ˜ Kawasaki (12). ¶·È‰È¿ (΢ڛˆ˜ ‚Ú¤ÊË) Ì ˘ÚÂÙfi ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 4 Ë̤Ú˜ Î·È Ì ÛÙÔȯ›· ÊÏÂÁÌÔÓ‹˜ ¯ˆÚ›˜ Û·Ê‹ ·ÈÙÈÔÏÔÁ›· Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È Ë¯ÔηډÈÔÁÚ·ÊÈο ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ÓfiÛÔ˘ Kawasaki (13). √ ˯ÔηډÈÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÔÙÂÏ› ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ∏ ‰˘ÛÎÔÏ›· ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ Î·È Û˘Ó·ÎfiÏÔ˘ı· Ù˘ ¤ÁηÈÚ˘ ıÂÚ·¢ÙÈ΋˜ ·ÁˆÁ‹˜ ÂÈ‚¿ÏÏÔ˘Ó ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ È·ÙÚÈÎÔ‡ ÎfiÛÌÔ˘ Î·È ÙËÓ ·ÍÈÔÔ›ËÛË fiÏˆÓ ÙˆÓ ÂÈÚfiÛıÂÙˆÓ ÛÙÔȯ›ˆÓ Ô˘ ı· ‚ÂÏÙÈÒÛÔ˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ÁÈ· ÁÚ‹ÁÔÚË Î·È ·ÛÊ·Ï‹ ‰È¿ÁÓˆÛË ÂÓfi˜ Â›ÎÙËÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Ì ̷ÎÚÔÚfiıÂÛ̘ ÂÈÙÒÛÂȘ, ÙˆÓ ÔÔ›ˆÓ ÙÔ ·ÎÚÈ‚¤˜ ̤ÁÂıÔ˜ ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi ̤¯ÚÈ Û‹ÌÂÚ· (14).

µÈ‚ÏÈÔÁÚ·Ê›· 1. Burns JC, Glode MP. Kawasaki syndrome. Lancet 2004;364:533-544.

2. Fulton DR, Newburger JW. Long-term cardiac sequelae of Kawasaki disease. Curr Rheumatol Rep 2000;2:324-329.

3. Kato H. Cardiovascular complication in Kawasaki disease: coronary artery lumen and long-term consequences.

Progress Pediatr Cardiol 2004;19:137-145.

4. Pfafferott C, Wirtzfeld A, Permanetter B. Atypical Kawasaki syndrome: how many symptoms have to be present?

Heart 1997;78:619-621.

5. Rowley AH. Incomplete (atypical) Kawasaki disease. Pediatr Infect Dis J 2002;21:563-565.

6. Burns JC, Pannaraj PS, Turner CL, Bastian JF. Kawasaki disease: do we need a new case definition? Pediatr Res 2002;53:163.

Paidiatriki 5 final

12-10-07

16:28

Page 373

373

ÕÙ˘Ë ÓfiÛÔ˜ Kawasaki: ÎÚÈÙ‹ÚÈ·

7. Uziel Y, Hashkes PJ, Kassem E, Gottesman G, Wolach B. “Unresolving pneumonia” as the main manifestation of atypical Kawasaki disease. Arch Dis Child 2003;88:940942.

8. Dajani AS, Taubert KA, Takahashi M, Bierman FZ, Freed MD, Ferrieri P, et al. Guidelines for long-term management of patients with Kawasaki disease. Report from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation 1994;89:916-922.

9. Dahifar H, Ghorbani A. Atypical Kawasaki disease in two infants younger than 6 mÔnths. JRMS 2005;10:239-243.

10. Genizi J, Miron D, Spiegel R, Fink D, Horowitz Y. Kawasaki disease in very young infants: high prevalence of atypical presentation and coronary arteritis. Clin Pediatr (Phila) 2003;24:263-267.

11. O’ Connor MJ, Saulsbury FT. Incomplete and atypical Kawasaki disease in a young infant: severe, recalcitrant disease responsive to infliximamb. Clin Pediatr (Phila) 2007;46:345-348.

12. Nofech-Mozes Y, Garty BZ. Thrombocytopenia in Kawasaki disease: a risk factor for the development of coronary artery aneurysms. Pediatr Hematol Oncol 2003;20:597-601.

13. Hsiao JY, Chen MR, Huang FY, Kao HA, Sung TC. Clinical analysis of Kawasaki disease in infants below 6 months of age. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi 1998;29: 318-323.

14. Brogan PA, Bose A, Burgner D, Shingadia D, Tulloh R, Michie C, et al. Kawasaki disease: an evidence based approach to diagnosis, treatment, and proposals for future research. Arch Dis Child 2002;86:286-290.

“∂ͤÁÂÚÛË” Tarja Tiihonen 13 ÂÙÒÓ, ºÈÓÏ·Ó‰›· ∆˘ÊÏfi ·È‰› “∆· Ù˘ÊÏ¿ ·È‰È¿ ˙ˆÁÚ·Ê›˙Ô˘Ó”, ÕÓÓ· §·Ô˘Ù¿ÚË °ÎÚÈÙ˙¿Ï·, ∞ı‹Ó·, 2006 “A rousing”

Tarja Tiihonen 13 years old, Finland Blind child “Blind children paint”, Anna LaoutariGritzala, Athens 2006 ¶·È‰È·ÙÚÈ΋ 2007;70:370-373

Paidiatriki 5 final

12-10-07

374

16:28

Page 374

∞¡∞™∫√¶∏™∏

REVIEW ARTICLE

™‡Á¯ÚÔÓ˜ ·fi„ÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ, ∆Ì‹Ì· ¡ÔÛËÏ¢ÙÈ΋˜

π. ¶·˘ÏÔÔ‡ÏÔ˘

AÏÏËÏÔÁÚ·Ê›·: πˆ¿ÓÓ· ¶·˘ÏÔÔ‡ÏÔ˘ idpavlop@yahoo.gr ºÂȉ›Ô˘ 25, ∆.∫.:155 62, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë: √ ÚÔÙ·˚fi˜ Â›Ó·È ÙÔ Û˘ÓËı¤ÛÙÂÚÔ ·›ÙÈÔ ‰È¿ÚÚÔÈ·˜ Î·È ·Ê˘‰¿ÙˆÛ˘ ÛÙ· ÌÈÎÚ¿ ·È‰È¿ Î·È ÚÔηÏ› ÛËÌ·ÓÙÈ΋ ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË ÛÙ· Û˘ÛÙ‹Ì·Ù· ˘Á›·˜ ÙˆÓ ·ÓÂÙ˘ÁÌ¤ÓˆÓ ¯ˆÚÒÓ ÂÍ·ÈÙ›·˜ ÙÔ˘ ˘„ËÏÔ‡ ÔÛÔÛÙÔ‡ ÓÔÛËÚfiÙËÙ·˜ Î·È Ù˘ Û˘¯Ó‹˜ ·Ó¿Á΢ ÁÈ· ÓÔÛËÏ›·. ∂Âȉ‹ Ë Ïԛ̈ÍË Â›Ó·È Û¯Â‰fiÓ ·Ó·fiÊ¢ÎÙË Î·È ÌÂÙ¿ ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ Ê·›ÓÂÙ·È Ó· ‰ËÌÈÔ˘ÚÁ› οÔÈÔ˘ ‚·ıÌÔ‡ ·ÓÔÛ›·, Â›Ó·È Â˘ÓfiËÙÔ fiÙÈ Ï‡ÛË ÛÙÔ Úfi‚ÏËÌ· ı· ÌÔÚÔ‡Û ӷ ÚÔÛʤÚÂÈ Ë ÚfiÏË„Ë Ù˘ ÛÔ‚·Ú‹˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Ì ÂÌ‚ÔÏÈ·ÛÌfi. ∏ ÚfiÛÊ·ÙË Î˘ÎÏÔÊÔÚ›· ‰‡Ô Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ ·fi ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜, Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ·fi ÙÔ ÛÙfiÌ· Î·È Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈο ¤Ó·ÓÙÈ Ù˘ ÛÔ‚·Ú‹˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi, ˘fiÛ¯ÂÙ·È Ó· ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ Î·È ÙˆÓ ÂÈÏÔÎÒÓ Ù˘. ∂ÈϤÔÓ, Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ·Ú·¿Óˆ ÂÌ‚ÔÏ›ˆÓ ÛÙȘ ÚÔηıÔÚÈṲ̂Ó˜ ËÏÈ˘ ‰ÂÓ ¤¯ÂÈ Û˘Ó‰˘·ÛÙ› Ì ÛÔ‚·Ú¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ, ȉ›ˆ˜ ÂÁÎÔÏ·ÛÌfi. ∞·Ú·›ÙËÙË Â›Ó·È Ë Û˘Ó¯‹˜ ÂÈÙ‹ÚËÛË, ÁÈ· Ó· ··ÓÙËıÔ‡Ó ÂÚˆÙ‹Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ ¤Ó·ÓÙÈ ÓÂÔÂÌÊ·ÓÈ˙fiÌÂÓˆÓ ÔÚÔÙ‡ˆÓ ÈÔ‡ Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ Û ¿ÏϘ ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜. ∂›Û˘, Ë Û˘ÏÏÔÁ‹ ÛÙÔȯ›ˆÓ ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ı· Û˘Ì‚¿ÏÂÈ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ Â›‰Ú·Û‹˜ ÙÔ˘ ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Î·È ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ Î·È ÛÙË ‰È¢ÎÚ›ÓËÛË Ù˘ Û¯¤Û˘ ÎfiÛÙÔ˘˜-ÔʤÏÔ˘˜. §¤ÍÂȘ ÎÏÂȉȿ: °·ÛÙÚÂÓÙÂÚ›Ùȉ·, ÚÔÙ·˚fi˜, ÂÌ‚fiÏÈ·.

Current concepts in prevention of rotavirus gastroenteritis Athens University, Faculty of Nursing, Athens, Greece

Correspondence: Ioanna D. Pavlopoulou idpavlop@yahoo.gr 25, Fidiou St. 155 62, Athens, Greece

I. D. Pavlopoulou Abstract: Rotavirus is the most common cause of diarrhoea and dehydration in young children, with a significant impact upon healthcare systems in developed countries, at both in- and outpatient levels. Since rotavirus infection is difficult to prevent, but provides some natural immunity after the first infection, prevention of severe gastroenteritis by vaccination could represent a solution to the burden of this illness.

Recent licensure of two new oral, live, attenuated vaccines that have proven efficacious against severe rotavirus gastroenteritis, offers a possibility of reducing the morbidity, mortality and economic burden of disease in nations able to afford the vaccines. Large scale efficacy and safety data have shown excellent efficacy of the above vaccines against severe rotavirus disease. In addition, their administration at the scheduled ages was not associated with serious adverse events, particularly intussusception. Ongoing surveillance is needed in order to answer questions regarding their coverage against new rotavirus serotypes and whether older children can also safely receive the vaccine. In addition, post-licensure data will be needed to assess the impact and cost-effectiveness of rotavirus vaccination.

Key words: Gastroenteritis, rotavirus, vaccines.

™˘ÓÙÔÌÔÁڷʛ˜ °ƒ:

Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi

∂ÈÛ·ÁˆÁ‹ ∏ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi (°ƒ) ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ Û ‚Ú¤ÊË Î·È ÌÈÎÚ¿ ·È‰È¿. ™ÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, Ô ÚÔÙ·˚fi˜ Â›Ó·È ˘‡ı˘ÓÔ˜ ÁÈ· 600.000 ı·Ó¿ÙÔ˘˜ ÂÙËÛ›ˆ˜, ÂÓÒ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ÙÔ Î‡ÚÈÔ Úfi‚ÏËÌ· ·ÔÙÂÏÔ‡Ó Ë ˘„ËÏ‹ ÓÔÛËÚfiÙËÙ· Ô˘ Ô‰ËÁ› Û ·˘ÍË̤ÓÔ Paediatriki 2007;70:374-378

·ÚÈıÌfi È·ÙÚÈÎÒÓ ÂÈÛΤ„ÂˆÓ Î·È ÂÈÛ·ÁˆÁÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È Ë ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ ˘Á›·˜ (1,2). ™‡Ìʈӷ Ì ÂÎÙÈÌ‹ÛÂȘ, fiÏ· Ù· ·È‰È¿ ı· ÌÔÏ˘ÓıÔ‡Ó ·Ô ÚÔÙ·˚fi ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ, Ë Û˘¯ÓfiÙËÙ· fï˜ ÚÔÛ‚ÔÏ‹˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Û ‚Ú¤ÊË 6 ¤ˆ˜ 24 ÌËÓÒÓ Ô˘ ÊÔÈÙÔ‡Ó Û ‚ÚÂÊÈÎÔ‡˜ ÛÙ·ıÌÔ‡˜ ‹ Û ÂΛӷ Ô˘ ÌÔχÓÔÓÙ·È ÂÓ‰ÔÓÔÛÔÎÔÌÂȷο, ÂÓÒ ÓÔÛËχÔÓÙ·È ÁÈ· ¿ÏÏË ·ÈÙ›· (3,4). ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÔÈ ÂÚÈÙÒÛÂȘ ÓÔÛËÏ›·˜ ÏfiÁˆ °ƒ ÛÙȘ

Paidiatriki 5 final

12-10-07

16:28

Page 375

375

¶ÚfiÏË„Ë Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi

∏¶∞ Â›Ó·È 58.000-70.000 οı ¯ÚfiÓÔ, ÂÓÒ ÛÙËÓ ∂˘ÚÒË Î·È ÙËÓ ∞˘ÛÙÚ·Ï›· ηٷÁÚ¿ÊÔÓÙ·È 87.000 Î·È 10.000 ÂÚÈÙÒÛÂȘ ·ÓÙ›ÛÙÔȯ· (5-7). §ÈÁfiÙÂÚÔ Â˘ÎÚÈÓ‹˜ Â›Ó·È Ë ·ÂÈÎfiÓÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÂÚ›ı·Ï„Ë, ηıÒ˜ Ù· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Ô˘ ˘¿Ú¯Ô˘Ó Â›Ó·È ·ÓÂ·Ú΋ (6). °ÂÁÔÓfi˜ ¿ÓÙˆ˜ Â›Ó·È fiÙÈ Ë Ú·ÁÌ·ÙÈ΋ Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ÎÔÈÓfiÙËÙ· ˘ÔÂÎÙÈÌ¿Ù·È, ·ÊÔ‡ ÔÏϤ˜ ÏÔÈÌÒÍÂȘ Â›Ó·È ‹Ș Î·È ·˘ÙÔ˚ÒÓÙ·È ¯ˆÚ›˜ Ó· ¯ÚÂÈ·ÛÙÔ‡Ó È·ÙÚÈ΋ ÊÚÔÓÙ›‰·. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ·Ó·ÁÓˆÚ›˙ÂÙ·È fiÙÈ fiÛÔ ‚·Ú‡ÙÂÚË Â›Ó·È Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û ̛· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, ÙfiÛÔ ·˘Í¿ÓÂÈ Ë Èı·ÓfiÙËÙ· ·˘Ù‹ Ó· ÔÊ›ÏÂÙ·È Û ÚÔÙ·˚fi (8). ¶ÂÚÈÔÚÈṲ̂ӷ ‰Â‰Ô̤ӷ ·ÂÈÎÔÓ›˙Ô˘Ó ÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÓÔÛËÏ›·˜ Û ÚfiˆÚ· ÓÂÔÁÓ¿ Ì °ƒ, ηıÒ˜ Î·È Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ ÌÂ Û˘ÁÁÂÓ›˜ ‹ Â›ÎÙËÙ˜ ·ÓÔÛÔ·ÓÂ¿ÚÎÂȘ Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ‹ Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ (9-11). ∏ Û˘¯ÓfiÙÂÚË ÂÈÏÔ΋ Ù˘ °ƒ Â›Ó·È Ë ·Ê˘‰¿ÙˆÛË, ηıÒ˜ Ù· ¿Û¯ÔÓÙ· ‚Ú¤ÊË Î·È Ó‹È· ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÔ˘Ó 10-20 ÎÂÓÒÛÂȘ ËÌÂÚËÛ›ˆ˜ Î·È Â̤ÙÔ˘˜ ‰È¿ÚÎÂÈ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ‹ ›Û˘ ÙˆÓ 24 ˆÚÒÓ. √ ΛӉ˘ÓÔ˜ ·Ê˘‰¿ÙˆÛ˘ ·˘Í¿ÓÂÈ fiÙ·Ó Ë ËÏÈΛ· ÚÔÛ‚ÔÏ‹˜ Â›Ó·È ÌÈÎÚfiÙÂÚË (2). ∆· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Î·È ÔÈ ÔÈÎÔÓÔÌÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ °ƒ ·ÁÎÔÛÌ›ˆ˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙȘ ȉÈfiÙËÙ˜ ÙÔ˘ ÚÔÙ·˚Ô‡ Î·È ÙËÓ ·Ô˘Û›· ·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ·ÓÙÈ˚΋˜ ıÂÚ·›·˜, Â›Ó·È ÔÈ Î‡ÚÈÔÈ ÏfiÁÔÈ Ô˘ Ô‰‹ÁËÛ·Ó ÛÙËÓ ·Ú·Û΢‹ ÂÌ‚ÔÏ›ˆÓ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘. ∏ ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ÂÈÎÂÓÙÚÒÓÂÈ ÛÙȘ ÚfiÛÊ·Ù˜ ÂÍÂÏ›ÍÂȘ ÛÙÔ ¯ÒÚÔ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ÚÔÙ·˚Ô‡.

ªÔÚÊÔÏÔÁ›· Î·È ·ÓÙÈÁÔÓÈΤ˜ ȉÈfiÙËÙ˜ ÙÔ˘ ÚÔÙ·˚Ô‡ √È ÚÔÙ·˚Ô› ÔÊ›ÏÔ˘Ó ÙÔ fiÓÔÌ¿ ÙÔ˘˜ ÛÙËÓ ÂÈÎfiÓ· Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÛÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ Ô˘ ÌÔÈ¿˙ÂÈ Ì “ÙÚÔ¯fi” (Ï·ÙÈÓÈÎfi˜ fiÚÔ˜, rota). AÓ‹ÎÔ˘Ó ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Reoviridae Î·È ·ÔÙÂÏÔ‡ÓÙ·È ·fi η„›‰ÈÔ Ì ‰‡Ô ÛÙÈ‚¿‰Â˜, ÔÈ Ôԛ˜ ÂÚÈÎÏÂ›Ô˘Ó 11 ÙÌ‹Ì·Ù· RNA Ì ‰ÈÏ‹ ¤ÏÈη. ∏ Â͈ÙÂÚÈ΋ ÛÙÈ‚¿‰· ÂÚȤ¯ÂÈ ‰‡Ô ‰ÔÌÈΤ˜ ÚˆÙ½Ó˜ ÙÔ˘ ÈÔ‡ (viral proteins, VP): ÙËÓ ÚˆÙ½ÓË VP4 (P-ÚˆÙ½ÓË, ÚÔÛÎÔÏÏË̤ÓË ÛÙËÓ ÚˆÙ¿ÛË) Î·È ÙË ÁÏ˘ÎÔÚˆÙ½ÓË VP7 (G-ÚˆÙ½ÓË). √È ÚˆÙ½Ó˜ ·˘Ù¤˜ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ ÚÔÙ·˚ÒÓ Û P Î·È G ÔÚÔÙ‡Ô˘˜ Î·È Ù·˘Ùfi¯ÚÔÓ· ¤¯Ô˘Ó ηıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ·Ó¿Ù˘ÍË ÂÌ‚ÔÏ›ˆÓ, ·ÔÙÂÏÒÓÙ·˜ ÛÙfi¯Ô˘˜ ÁÈ· Ù· ÂÍÔ˘‰ÂÙÂÚˆÙÈο ·ÓÙÈÛÒÌ·Ù· (12). ∏ ÂÛˆÙÂÚÈ΋ ÛÙÈ‚¿‰· ÂÚȤ¯ÂÈ ÙÔ Ì›˙ÔÓ ·ÓÙÈÁfiÓÔ ÙÔ˘ ÈÔ‡, ÙËÓ ÚˆÙ½ÓË VP6, Ì ‚¿ÛË ÙËÓ ÔÔ›· Á›ÓÂÙ·È Ë Ù·ÍÈÓfiÌËÛ‹ ÙÔ˘ Û ÔÌ¿‰Â˜ A-E (∂ÈÎfiÓ· 1). ∏ ÔÚÔÔÌ¿‰· ∞ Â›Ó·È ˘‡ı˘ÓË ÁÈ· ÙËÓ ÏÂÈÔÓfiÙËÙ·

11 ÙÌ‹Ì·Ù· RNA ‰ÈÏ‹˜ ¤ÏÈη˜ ¶ÚˆÙ½ÓË VP6 (Ì›˙ÔÓ ·ÓÙÈÁfiÓÔ ÙÔ˘ ÈÔ‡)

G - ÚˆÙ½ÓË (VP7) ∞ÓÔÛ›· P - ÚˆÙ½ÓË (VP4)

∂ÈÎfiÓ· 1: ¢ÔÌ‹ ÙÔ˘ ÚÔÙ·˚Ô‡.

ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂΉ‹ÏˆÛ˘ Ù˘ ÓfiÛÔ˘ ÛÙÔÓ ¿ÓıÚˆÔ. ∂ȉËÌÈΤ˜ ÂÍ¿ÚÛÂȘ °ƒ ·fi ÔÚÔÔÌ¿‰· µ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÛÙËÓ ∫›Ó·, ÂÓÒ Ë ÔÌ¿‰· C ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ·Û˘Ìو̷ÙÈΤ˜ ÏÔÈÌÒÍÂȘ (12,13). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÙÔ˘Ï¿¯ÈÛÙÔÓ 15 ÔÚfiÙ˘ÔÈ G Î·È 23 ÔÚfiÙ˘ÔÈ P, ÔÛÔÛÙfi 90-95% ÙˆÓ ÛÙÂϯÒÓ Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È Î¿ı ¯ÚfiÓÔ Û ·È‰È¿ Ì ÓfiÛÔ ·Ó‹ÎÂÈ ÛÙÔ˘˜ G1P[8], G2P[4], G3P[8], G4P[8] Î·È Û·ÓÈfiÙÂÚ· ÛÙÔÓ G9P[8] (12,13). ¡ÂÔÂÌÊ·ÓÈ˙fiÌÂÓÔÈ ÔÚfiÙ˘ÔÈ Â›Ó·È Ô G9 ÛÙȘ ∏¶∞, Û ¯ÒÚ˜ Ù˘ ∂˘ÚÒ˘ Î·È ÙËÓ π·ˆÓ›·, ÔÈ G5, G6, G8, G10 ΢ڛˆ˜ Û ¯ÒÚ˜ Ù˘ §·ÙÈÓÈ΋˜ ∞ÌÂÚÈ΋˜ Î·È Ô G12 ·Ú¯Èο ÛÙȘ ºÈÏÈ›Ó˜ Î·È ·ÚÁfiÙÂÚ· ÛÙËÓ ∫ÔÚ¤·, ÛÙȘ ∏¶∞ Î·È ÛÙËÓ ∂˘ÚÒË (13-16). ¢È·ÊÔÚÂÙÈο ÛÙÂϤ¯Ë ÙÔ˘ ÈÔ‡ ÌÔÚ› Ó· ÚÔÛ‚¿ÏÔ˘Ó Î·È ˙Ò·, fiˆ˜ ‚ÔÔÂȉ‹ Î·È Èı‹ÎÔ˘˜, Ë ÌÂÙ¿‰ÔÛË fï˜ ·fi ˙ÒÔ Û ¿ÓıÚˆÔ Â›Ó·È ·Û˘Ó‹ı˘. º˘ÛÈ΋ Û‡˙¢ÍË ˙ˆ˚ÎÒÓ Ì ·ÓıÚÒÂÈ· ÛÙÂϤ¯Ë ¤¯ÂÈ ·Ú·ÙËÚËı› Û ·ÓıÚÒÔ˘˜ Î·È ¤¯ÂÈ ·ÔÙÂϤÛÂÈ ·ÓÙÈΛÌÂÓÔ ¤Ú¢ӷ˜ ÁÈ· ·Ú·Û΢‹ ÂÌ‚ÔÏ›ˆÓ (13,17).

¡fiÛÔ˜ ·fi ÚÔÙ·˚fi Î·È ·ÓÔÛ›· √È ÚÔÙ·˚Ô› ÌÂÙ·‰›‰ÔÓÙ·È Ì ÙËÓ ÎÔÚ·ÓÔÛÙÔÌ·ÙÈ΋ Ô‰fi Ì ¿ÌÂÛË Â·Ê‹ ‹ ̤ۈ ·ÓÙÈÎÂÈ̤ӈÓ, ·ÏÏ¿ Èı·ÓfiÓ Î·È ·fi ÌÔÏ˘Ṳ̂ÓË ÙÚÔÊ‹ ‹ ÓÂÚfi ηıÒ˜ Î·È Ì ÛÙ·ÁÔÓ›‰È· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi (18,19). √ Èfi˜ Â›Ó·È ·ÓıÂÎÙÈÎfi˜ ÛÙ· Û˘Ó‹ıË Ì¤ÙÚ· ˘ÁÈÂÈÓ‹˜, fiˆ˜ ÙÔ χÛÈÌÔ ÙˆÓ ¯ÂÚÈÒÓ, ·ÏÏ¿ Î·È Û ·ÓÙÈÛËÙÈο Ô˘ ¤¯Ô˘Ó ˆ˜ ‚¿ÛË ÙË ¯ÏˆÚÂÍȉ›ÓË, ÂÓÒ ·‰Ú·ÓÔÔÈÂ›Ù·È ÌÂÙ¿ ·fi ¯Ú‹ÛË ·ÏÎÔÔÏÔ‡¯ˆÓ ‹ ¯ÏˆÚÈÔ‡¯ˆÓ ‰È·Ï˘Ì¿ÙˆÓ (20). √ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ‰Ú· ÚÔÛٷ٢ÙÈο ÌfiÓÔ ˆ˜ ÚÔ˜ ÙË ‚·Ú‡ÙËÙ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (21). ŒÓ·˜ ÂÈÚfiÛıÂÙÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ Û˘Ì‚¿ÏÏÂÈ ÛÙË ÌÂÙ·‰ÔÙÈÎfiÙËÙ· Â›Ó·È Ë ·Ô‚ÔÏ‹ ÙÔ˘ ·fi Ù· ÎfiÚ·Ó· Ï›ÁÔ ÚÈÓ Î·È Ì›· ‚‰ÔÌ¿‰· ÌÂÙ¿ ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ (22). ªÂÙ¿ ·fi ÂÒ·ÛË 1-3 ËÌÂÚÒÓ, Ë ÓfiÛÔ˜ ÍÂÎÈÓ¿ ·ÈÊÓ›‰È· Ì Â̤ÙÔ˘˜, ¶·È‰È·ÙÚÈ΋ 2007;70:374-378

Paidiatriki 5 final

15-10-07

11:29

Page 376

376

π. ¶·˘ÏÔÔ‡ÏÔ˘

ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÚÔÛÙ›ıÂÓÙ·È ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ, ÂÓÒ 25% ÙˆÓ ·ÛıÂÓÒÓ ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ Î·È ˘ÚÂÙfi. ∆· Û˘ÌÙÒÌ·Ù· ‰È·ÚÎÔ‡Ó Û˘Ó‹ıˆ˜ 3-7 Ë̤Ú˜, ÌÔÚ› Ó· Â›Ó·È ‹È· ‹ ÛÔ‚·Ú¿ Î·È Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ·Ê˘‰¿ÙˆÛË, ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È Î·Ù·ÏËÍ›· (12). ∏ Û˘Û¯¤ÙÈÛË Ù˘ ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘ Û ÚÔËÁËı›۷ Ïԛ̈ÍË ‹ ÓfiÛÔ, Ì ÙËÓ ÚÔÛÙ·Û›· ·fi Ó¤· ¤ÎıÂÛË ÛÙÔÓ ÚÔÙ·˚fi, ‰ÂÓ Â›Ó·È ·Ôχو˜ ηٷÓÔËÙ‹. ∏ ·Ó‡ÚÂÛË ·ÓÙÈÛˆÌ¿ÙˆÓ (IgG, IgA Î·È ÂÍÔ˘‰ÂÙÂÚˆÙÈÎÒÓ ·ÓÙÈۈ̿وÓ) ÛÙÔÓ ÔÚfi Î·È Û ÂÓÙÂÚÈΤ˜ ÂÎÎÚ›ÛÂȘ, ηıÒ˜ Î·È ·ÓÙÈÛˆÌ¿ÙˆÓ ÔÚÔ‡ ¤Ó·ÓÙÈ ÙˆÓ ÚˆÙÂ˚ÓÒÓ VP4 Î·È VP7, ¤¯ÂÈ Û˘Ó‰˘·ÛÙ› Û ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ Ì ÚÔÛÙ·Û›· ÂÓÒ Û ¿ÏϘ fi¯È (23,24). º·›ÓÂÙ·È ¿ÓÙˆ˜ fiÙÈ Ù· ·Ú·¿Óˆ ·ÓÙÈÛÒÌ·Ù· ÌÔÚ› Ó· ‰Ú¿ÛÔ˘Ó ÚÔÛٷ٢ÙÈο ÙfiÛÔ ¤Ó·ÓÙÈ ÙÔ˘ ›‰ÈÔ˘ fiÛÔ Î·È ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ·, ¤Ó·ÓÙÈ ¿ÏÏˆÓ ÔÚÔÙ‡ˆÓ ÙÔ˘ ÈÔ‡. ™˘Ó‹ıˆ˜, ÌÂÙ¿ ÙËÓ ÚÒÙË Ïԛ̈ÍË Ë ·ÓÔÛÔ·¿ÓÙËÛË ·ÊÔÚ¿ ÙÔ ›‰ÈÔ Û٤ϯԘ, ÂÓÒ Û ·ÎfiÏÔ˘ı˜ ÏÔÈÌÒÍÂȘ ·ÎfiÌ· Î·È Ì ÙÔÓ ›‰ÈÔ ÔÚfiÙ˘Ô, ‰ËÌÈÔ˘ÚÁÂ›Ù·È Â˘Ú‡ÙÂÚË, ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ÚÔÛÙ·Û›· (25). ∆¤ÏÔ˜, Ô ÚfiÏÔ˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ ·ÊÔÚ¿ ÙfiÛÔ ÙËÓ ·Ó¿ÚÚˆÛË ·fi ÙËÓ ÔÍ›· Ïԛ̈ÍË Î·È ÙË ‚Ú¿¯˘ÓÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·¤ÎÎÚÈÛ˘ ÙÔ˘ ÈÔ‡, fiÛÔ Î·È ÙËÓ ÚÔÛÙ·Û›· ·fi ÂfiÌÂÓ˜ ÏÔÈÌÒÍÂȘ (26).

¶ÚfiÏË„Ë-∂Ì‚fiÏÈ· ∏ ·Ó¿ÁÎË Ù˘ ¯Ú‹Û˘ ÂÌ‚ÔÏ›Ô˘ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ Ì ÛÎÔfi ÙËÓ ÚfiÏË„Ë Ù˘ °ƒ ÚԤ΢„ Ϸ̂¿ÓÔÓÙ·˜ ˘fi„Ë Ù· ·Ú·Î¿Ùˆ ‰Â‰Ô̤ӷ (12): 1. ∏ ÓÔÛËÚfiÙËÙ· ·Ô ÚÔÙ·˚fi ÌÂٷ͇ ·Ó·Ù˘ÛÛfiÌÂÓˆÓ Î·È ·ÓÂÙ˘ÁÌ¤ÓˆÓ ¯ˆÚÒÓ ‰ÂÓ ‰È·Ê¤ÚÂÈ, ÁÂÁÔÓfi˜ Ô˘ ·Ó·‰ÂÈÎÓ‡ÂÈ ÙËÓ ·‰˘Ó·Ì›· ÚfiÏ˄˘ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ̤ÙÚˆÓ ˘ÁÈÂÈÓ‹˜.

2. ∏ ¯Ú‹ÛË ÙˆÓ ‰È·Ï˘Ì¿ÙˆÓ ÂÓ˘‰¿ÙˆÛ˘ ·fi ÙÔ ÛÙfiÌ· Ì›ˆÛ ٷ ÔÛÔÛÙ¿ ÓÔÛËÏ›·˜ ÛÙȘ ∏¶∞ ÌfiÓÔ Î·Ù¿ 16%.

3. ∏ ·Ú¯È΋ Ïԛ̈ÍË Ê·›ÓÂÙ·È Ó· ÚÔÛٷهÂÈ ·fi ÂfiÌÂÓ· ÂÂÈÛfi‰È· ÛÔ‚·Ú‹˜ °ƒ. ¶·ÚfiÏ· ·˘Ù¿, ‹È· ‹ ·Û˘Ìو̷ÙÈ΋ Ïԛ̈ÍË ÌÔÚ› Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ.

4. ∫·Ù¿ Û˘Ó¤ÂÈ·, Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ÓˆÚ›˜ ÛÙË ˙ˆ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜, ÌÈÌÔ‡ÌÂÓÔ˜ ÙË Ê˘ÛÈ΋ Ïԛ̈ÍË, Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔÏ¿‚ÂÈ Ù· ÛÔ‚·Ú¿ ÂÂÈÛfi‰È· °ƒ Î·È ÙȘ ÂÈÏÔΤ˜ ÙÔ˘˜, ¯ˆÚ›˜ fï˜ Ó· Â›Ó·È Û ı¤ÛË Ó· ÚÔÛٷهÛÂÈ ·fi ‹È· ‹ ·Û˘Ìو̷ÙÈ΋ Ïԛ̈ÍË. ∆Ô ÚÒÙÔ ÂÌ‚fiÏÈÔ ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡ ÚfiÙ· Ô˘ ¤Ï·‚ ¿‰ÂÈ· ΢ÎÏÔÊÔÚ›·˜ ÙÔ 1998 ÛÙȘ ∏¶∞, ‹Ù·Ó ÙÔ ˙ˆÓ ÂÍ·ÛıÂÓË̤ÓÔ, ÙÂÙÚ·‰‡Ó·ÌÔ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ, Ì ÙËÓ ÔÓÔÌ·Û›· Rotashield, ÙÔ ÔÔ›Ô fï˜ Û‡ÓÙÔÌ· ·ÔÛ‡ÚıËΠÏfiÁˆ Ù˘ ¯ÚÔÓÈ΋˜ Û˘Û¯¤ÙÈÛ˘ Ì ÂÂÈÛfi‰È· ÂÁÎÔÏ·ÛÌÔ‡, 3-7 Ë̤Ú˜ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Ù˘ 1˘ ‰fiÛ˘ (27), ·ÏÏ¿ Î·È Ù˘ ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ ¿ÏÏˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ, fiˆ˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Î·È ·ÈÌ·ÙËÚÒÓ ÎÂÓÒÛÂˆÓ (28). ∏ ÂÎ Ó¤Ô˘ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·Ó¤‰ÂÈÍ ˆ˜ ·Ú¿ÁÔÓÙ· ÎÈÓPaediatriki 2007;70:374-378

‰‡ÓÔ˘ ÁÈ· ÂÁÎÔÏ·ÛÌfi ÙËÓ ËÏÈΛ· ≥90 ËÌÂÚÒÓ Î·Ù¿ ÙË ¯ÔÚ‹ÁËÛË Ù˘ 1˘ ‰fiÛ˘ (29). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È fiÙÈ Î·Ù¿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Ù˘ ¯Ú‹Û˘ ÙÔ˘ ·Ú·¿Óˆ ÂÌ‚ÔÏ›Ô˘ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÁÂÓÈÎfiÙÂÚË ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ (27,29). ∂ÈϤÔÓ, ‰ÂÓ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÙÔ˘ Ê˘ÛÈÎÔ‡ ÈÔ‡ Ì ÂÁÎÔÏ·ÛÌfi Î·È Ë ·ıÔÁ¤ÓÂÈ¿ ÙÔ˘ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË (30). ∞ÎÔÏÔ‡ıËÛÂ Ë ·Ú·Û΢‹, Ô ÂÎÙÂٷ̤ÓÔ˜ ¤ÏÂÁ¯Ô˜ Ì ÌÂϤÙ˜ Ê¿Ûˆ˜ πππ Î·È Ë ¿‰ÂÈ· ΢ÎÏÔÊÔÚ›·˜ ÙÔ 2006, ‰‡Ô Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ: ÙÔ˘ ÌÔÓÔ‰‡Ó·ÌÔ˘ Rotarix (GSK) Î·È ÙÔ˘ ÂÓÙ·‰‡Ó·ÌÔ˘ RotaTeq (Merck). ∆Ô Rotarix ÂÚȤ¯ÂÈ ˙ÒÓÙ· ÂÍ·ÛıÂÓË̤ÓÔ ·ÓıÚÒÂÈÔ Èfi (Û٤ϯԘ G1P1A[8]), ·Ú¤¯ÂÈ ÂÎÙfi˜ ÙÔ˘ G1 Î·È ÂÙÂÚÔÚÔÛÙ·Û›· ¤Ó·ÓÙÈ ÙˆÓ ÔÚÔÙ‡ˆÓ G3, G4, G9 Î·È Û‡Ìʈӷ Ì ÚfiÛÊ·Ù· ÛÙÔȯ›· Î·È ¤Ó·ÓÙÈ ÙÔ˘ G2P[4] (31,32), ÂÓÒ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ· Û 2 ‰fiÛÂȘ. ∆Ô RotaTeq Â›Ó·È ÂÓÙ·‰‡Ó·ÌÔ, ÂÍ·ÛıÂÓË̤ÓÔ, ÂÙÂÚÔÛ˘Ó‰˘·Ṳ̂ÓÔ ‚Ô›Ԣ/·ÓıÚˆ›Ԣ Ù‡Ô˘, ·Ú¤¯ÂÈ ÚÔÛÙ·Û›· ¤Ó·ÓÙÈ ÙˆÓ ÔÚÔÙ‡ˆÓ G1-4 Î·È G9 Î·È ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ· Û 3 ‰fiÛÂȘ. ∆· ÂÌ‚fiÏÈ· ·˘Ù¿ ¤¯Ô˘Ó ‰ÔÎÈÌ·Ûı› Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·È‰ÈÒÓ Â›Ó·È ·ÛÊ·Ï‹, ·ÓÔÛÔÁfiÓ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈο ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ÛÔ‚·ÚÒÓ ÂÂÈÛÔ‰›ˆÓ °ƒ Û ÔÛÔÛÙÔ 85-98%, ¯ˆÚ›˜ Ó· Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÛÔ‚·Ú¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ, ȉ›ˆ˜ ÂÁÎÔÏ·ÛÌfi, fiÙ·Ó ¯ÔÚËÁ‹ıËÎ·Ó ÛÙȘ ÚÔÙÂÈÓfiÌÂÓ˜ ËÏÈ˘ (31,33). ∆Ô ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·, ÔÈ ÂӉ›ÍÂȘ Î·È ·ÓÙÂӉ›ÍÂȘ ÙˆÓ ‰‡Ô ÂÌ‚ÔÏ›ˆÓ Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 1 Î·È 2 (12). ∆Ô Rotarix ¤¯ÂÈ ¿ÚÂÈ ¿‰ÂÈ· ΢ÎÏÔÊÔÚ›·˜ Û ÔÏϤ˜ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜, Û ¯ÒÚ˜ Ù˘ §·ÙÈÓÈ΋˜ ∞ÌÂÚÈ΋˜, ÙËÓ ∞˘ÛÙÚ·Ï›· Î·È ÌÂÚÈΤ˜ ¯ÒÚ˜ Ù˘ ∞Û›·˜, ÂÓÒ ÙÔ RotaTeq ¤¯ÂÈ ¿‰ÂÈ· ΢ÎÏÔÊÔÚ›·˜ ÛÙȘ ∏¶∞ (fiÔ˘ ¤¯ÂÈ ÂÓÙ·¯ı› Î·È ÛÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ), Û ¯ÒÚ˜ Ù˘ ∂˘ÚÒ˘ Î·È ÙËÓ ∞˘ÛÙÚ·Ï›·. ÕÌÂÛË Û‡ÁÎÚÈÛË ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÌ‚ÔÏ›ˆÓ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹, ‰ÈfiÙÈ ÔÈ ·ÓÙ›ÛÙÔȯ˜ ÌÂϤÙ˜ ‰ÂÓ ¤ÁÈÓ·Ó Û ›‰ÈÔ˘˜ ÏËı˘ÛÌÔ‡˜, Ô‡Ù ¯ÚËÛÈÌÔÔ›ËÛ·Ó Ù· ›‰È· ÙÂÏÈο ÎÚÈÙ‹ÚÈ· ·ÍÈÔÏfiÁËÛ˘. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙÔ ÎfiÛÙÔ˜ Û˘ÁÎÚÈÙÈο Ì ÙÔ ÚÔÛ‰ÔÎÒÌÂÓÔ fiÊÂÏÔ˜ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜, fiÔ˘ Ë ıÓËÙfiÙËÙ· ÂÍ·ÈÙ›·˜ °ƒ Â›Ó·È ¯·ÌËÏ‹ Î·È ÙÔ ÎfiÛÙÔ˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ˘„ËÏfi, Â›Ó·È ·Ó·Áη›· Ë Û˘ÏÏÔÁ‹ Î·È ·Ó¿Ï˘ÛË ÛÙÔȯ›ˆÓ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ÂȉËÌÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· Û˘Ó˘ÔÏÔÁÈÛıÔ‡Ó ÔÈ ¯·Ì¤Ó˜ ÂÚÁ·ÙÔÒÚ˜ ÙˆÓ ÁÔÓ¤ˆÓ, ÙÔ ÎfiÛÙÔ˜ Ù˘ ÓÔÛËÏ›·˜, ÙˆÓ È·ÙÚÈÎÒÓ ÂÈÛΤ„ÂˆÓ Î·È Ù˘ ÌË È·ÙÚÈ΋˜ ÊÚÔÓÙ›‰·˜ (ÂȉÈ΋ ‰È·ÙÚÔÊ‹, ¿Ó˜, ÂÓ˘‰·ÙÈο ‰È·Ï‡Ì·Ù·) (34). ∫·È Ù· ‰‡Ô ÂÌ‚fiÏÈ· ¤ÁÈÓ·Ó ‰È·ı¤ÛÈÌ· ÚfiÛÊ·Ù· Î·È ÛÙË ¯ÒÚ· Ì·˜, ¯ˆÚ›˜ fï˜ ·ÎfiÌ· Ó· ¯ÔÚËÁÔ‡ÓÙ·È ·fi Ù· ·ÛÊ·ÏÈÛÙÈο Ù·Ì›·. ∏ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ı· Ú¤ÂÈ Ó· Â›Ó·È Ù·˘Ùfi¯ÚÔÓË Ì ٷ ¿ÏÏ· ÂÌ‚fiÏÈ·, ¯ˆÚ›˜ Ó·

Paidiatriki 5 final

15-10-07

11:30

Page 377

377

¶ÚfiÏË„Ë Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi

ÂËÚ¿ÛÂÈ ÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ·˘Ù¿. ∆Ô ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·, ÔÈ ÂӉ›ÍÂȘ Î·È ·ÓÙÂӉ›ÍÂȘ ÙˆÓ ‰‡Ô ÂÌ‚ÔÏ›ˆÓ Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 1 Î·È 2 (12).

ªÂÏÏÔÓÙÈÎÔ› ÛÙfi¯ÔÈ ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÂÌ‚fiÏÈ· ¤Ó·ÓÙÈ ÙÔ˘ ÚÔÙ·˚Ô‡ ¤¯Ô˘Ó ÌÂÏÂÙËı› ÛÙÔÓ ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·È‰ÈÒÓ ÌÂÙ¿ ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜, ÂÚˆÙËÌ·ÙÈο ·Ú·Ì¤ÓÔ˘Ó Û¯ÂÙÈο Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ ÛÙËÓ ÚfiÏË„Ë ÓfiÛÔ˘ ·fi ÓÂÔÂÌÊ·ÓÈ˙fiÌÂÓÔ˘˜ ÔÚfiÙ˘Ô˘˜, ÙËÓ ·ÛÊ¿ÏÂÈ¿ ÙÔ˘˜ Â¿Ó ¯ÔÚËÁËıÔ‡Ó Û ‰È·ÊÔÚÂÙÈΤ˜ ·fi ÙȘ ÚÔÙÂÈÓfiÌÂÓ˜ ËÏÈ˘ ‹ Û ÏËı˘ÛÌÔ‡˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ ÚfiˆÚ· ‹ ·È‰È¿ Ì ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù· ‹ ·ÓÔÛÔηٷÛÙÔÏ‹. ∂˘ÓfiËÙË Â›Ó·È Ë ÚÔÙÂÚ·ÈfiÙËÙ· ÁÈ· ÙË ‰˘Ó·ÙfiÙËÙ· ·ÚÔ¯‹˜ ÙÔ˘˜ ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, fiÔ˘ Ë ıÓËÙfiÙËÙ· Â›Ó·È ÌÂÁ¿ÏË. ∫·È Ù· ‰‡Ô ÂÌ‚fiÏÈ· ¤ÁÈÓ·Ó ‰È·ı¤ÛÈÌ· ÚfiÛÊ·Ù· Î·È ÛÙË ¯ÒÚ· Ì·˜, ¯ˆÚ›˜ fï˜ ·ÎfiÌ· Ó· ¤¯ÂÈ ·Ó·ÏËÊı› Ë Î¿Ï˘„Ë Ù˘ ‰·¿Ó˘ ·fi Ù· ·ÛÊ·ÏÈÛÙÈο Ù·Ì›·. ™¯ÂÙÈο Ì ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘˜, ÌÂϤÙ˜ ÎfiÛÙÔ˘˜-ÔʤÏÔ˘˜ ÛÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ ·Ô˘ÛÈ¿˙Ô˘Ó. ∂›Ó·È ¢ÓfiËÙÔ fiÙÈ ·ÓÙ›ÛÙÔȯ˜ ÌÂϤÙ˜ ·fi ¿ÏϘ ¯ÒÚ˜ ‰ÂÓ ¤¯Ô˘Ó ·fiÏ˘ÙË ÂÊ·ÚÌÔÁ‹, ΢ڛˆ˜ ‰ÈfiÙÈ ÔÈ ‰·¿Ó˜ ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋˜ ÓÔÛËÏ›·˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ¿Ï˜ ‰È·ÊÔÚ¤˜ (34). ™ËÌ·ÓÙÈο ¿ÓÙˆ˜ Â›Ó·È Ù· ÂȉËÌÈÔÏÔÁÈο ÛÙÔȯ›· Ô˘ ÚԤ΢„·Ó ·fi ÚfiÛÊ·ÙË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË Û ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi Î·È ‰Â›¯ÓÔ˘Ó ÔÙÈ Ô ÚÔÙ·˚fi˜ ¢ı‡ÓÂÙ·È ÁÈ· ÙÔ ‹ÌÈÛ˘ ÂÚ›Ô˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Ô˘ ÓÔÛËχÔÓÙ·È ‹ ÂÈÛΤÙÔÓÙ·È Ù· ·È‰È·ÙÚÈο ÙÌ‹Ì·Ù· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ Ù˘ ¯ÒÚ·˜ (35). ™˘ÌÂÚ¿ÛÌ·Ù· ∏ ÂÊ·ÚÌÔÁ‹ ÙˆÓ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ ·fi ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ ¤Ó·ÓÙÈ ÙÔ˘ ÚÔÙ·˚Ô‡, Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ·fi ÙÔ ÛÙfiÌ·, Ê·›ÓÂÙ·È fiÙÈ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙË ÓÔÛËÚfiÙËÙ· Î·È ÙȘ ÂÈÏÔΤ˜ ÛÙ· ÌÈÎÚ¿ ·È‰È¿, ηıÒ˜ Î·È ÙËÓ ÂÈ‚¿Ú˘ÓÛË ÛÙ· Û˘ÛÙ‹Ì·Ù· ˘Á›·˜ ÙˆÓ ·ÓÂÙ˘ÁÌ¤ÓˆÓ ¯ˆÚÒÓ ÔÈ Ôԛ˜ ›¶›Ó·Î·˜ 1. ∂Ӊ›ÍÂȘ Î·È ÙÚfiÔ˜ ¯ÔÚ‹ÁËÛ˘ ÂÌ‚ÔÏ›Ô˘ ¤Ó·ÓÙÈ ÚÔÙ·˚Ô‡ ŸÏ· Ù· ‚Ú¤ÊË ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 6-12 ‚‰ÔÌ¿‰ˆÓ - RotaTeq: 2, 4, 6 ÌËÓÒÓ (3 ‰fiÛÂȘ) - ÔÏÔÎÏ‹ÚˆÛË Û¯‹Ì·ÙÔ˜ Û ËÏÈΛ· ≤32 ‚‰ÔÌ¿‰ˆÓ - Rotarix: 2, 4 ÌËÓÒÓ (2 ‰fiÛÂȘ) - ÔÏÔÎÏ‹ÚˆÛË Û¯‹Ì·ÙÔ˜ Û ËÏÈΛ· ≤24 ‚‰ÔÌ¿‰ˆÓ ∏ 1Ë ‰fiÛË ‰ÂÓ ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È Û ËÏÈΛ· >12 ‚‰ÔÌ¿‰ˆÓ ∂Ï¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· ‰fiÛÂˆÓ 4 ‚‰ÔÌ¿‰Â˜ Ÿ¯È ÂÌ‚ÔÏÈ·ÛÌfi˜ Û ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ ÚÔÙÂÈÓfiÌÂÓ˜ ËÏÈ˘ ªÔÚ› Ó· Û˘Á¯ÔÚËÁËı› Ì ¿ÏÏ· ÂÌ‚fiÏÈ·

¶›Ó·Î·˜ 2. ¢∂¡ ·ÔÙÂÏÔ‡Ó ·ÓÙÂӉ›ÍÂȘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ◊ÈÔ ÂÌ‡ÚÂÙÔ ÓfiÛËÌ· ¶ÚÔËÁËı›۷ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi ∫‡ËÛË ÛÙÔ ¿ÌÂÛÔ ÂÚÈ‚¿ÏÏÔÓ/ ıËÏ·ÛÌfi˜ ¶ÚÔˆÚfiÙËÙ· <37 ‚‰ÔÌ¿‰ˆÓ (ÂÊfiÛÔÓ ËÏÈΛ· 6 ‚‰ÔÌ¿‰ˆÓ, ÛÙ·ıÂÚ‹ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË) ÕÙÔÌÔ Ì ·ÓÔÛÔηٷÛÙÔÏ‹ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ (χÛÈÌÔ ¯ÂÚÈÒÓ) ™Â ¤ÌÂÙÔ, ‰ÂÓ Â·Ó·¯ÔÚËÁÂ›Ù·È Ë ‰fiÛË ™Â ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ ‹ ÚÔ˚fiÓÙˆÓ-ÌÂÛԉȿÛÙËÌ· 42 Ë̤Ú˜ A¡∆∂¡¢∂π•∂π™: ÈÛÙÔÚÈÎfi ÂÁÎÔÏ·ÛÌÔ‡, ·ÏÏÂÚÁÈ΋ ·ÓÙ›‰Ú·ÛË Û ÚÔËÁÔ‡ÌÂÓË ‰fiÛË, ·ÓÔÛÔηٷÛÙÔÏ‹, ¯ÚfiÓÈ· ÓfiÛÔ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡, ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·

Ó·È Û ı¤ÛË Ó· ·ÓÙ·ÂͤÏıÔ˘Ó ÛÙÔ ÎfiÛÙÔ˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘. ∂›Û˘, fiÙ·Ó Ù· Ó¤· ÂÌ‚fiÏÈ· ¯ÔÚËÁ‹ıËÎ·Ó Û ηıÔÚÈṲ̂ӷ ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù· Î·È ËÏÈ˘, ‰ÂÓ Û˘Ó‰˘¿ÛÙËÎ·Ó Ì ÛËÌ·ÓÙÈΤ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Î·È È‰È·›ÙÂÚ· ÂÁÎÔÏ·ÛÌfi. ¢È¢ÎÚ›ÓËÛË ¯ÚÂÈ¿˙ÂÙ·È Ë ‰˘Ó·ÙfiÙËÙ· ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ Û ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ ÚÔÙÂÈÓfiÌÂÓ˜ ËÏÈ˘ Ì ÙË Û˘Ó¯È˙fiÌÂÓË ÂÈÙ‹ÚËÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÁÎÔÏ·ÛÌÔ‡ ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜. ∂Í›ÛÔ˘ ÛËÌ·ÓÙÈ΋ Â›Ó·È Î·È Ë Û˘ÓÂÚÁ·Û›· ÁÈ· ÙËÓ ¿ÌÂÛË ‰È¿ıÂÛ‹ ÙÔ˘˜ ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, fiÔ˘ ÙÔ ÚÔÛ‰ÔÎÒÌÂÓÔ fiÊÂÏÔ˜ Û fiÙÈ ·ÊÔÚ¿ ÙË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· Â›Ó·È ÙÔ Ì¤ÁÈÛÙÔ.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis 2003;9:565-572.

2. Glass RI, Parashar UD, Bresee JS, Turcios R, Fischer TK, Widdowson MA, et al. Rotavirus vaccines: current prospects and future challenges. Lancet 2006;368:323-332.

3. Rodrigues A, Fisher TK, Valentiner-Branth P, Nielsen J, Steinsland H, Perch M, et al. Community cohort study of rotavirus and other enteropathogens: are routine vaccinations associated with sex-differential incidence rates? Vaccine 2006;24:4737-4746.

4. Floret D, Lina B, Pinchinat S, Billaut G, Aªt-Belghiti F, Largeron N, et al. Epidemiology and burden of rotavirus diarrhea in day care centers in Lyon, France. Eur J Pediatr 2006;165:905-906.

5. Soriano-Gabarro M, Mrukowicz J, Vesikari T, Verstraeten T. Burden of rotavirus disease in European Union countries. Pediatr Infect Dis J 2006;25:S7- S11.

6. Charles MD, Holman RC, Curns AT, Parashar UD, Glass RI, Bresee JS. Hospitalizations associated with rotavirus gastroenteritis in the United States, 1993-2002. Pediatr Infect Dis J 2006;25:489-493.

7. Galati JC, Harsley S, Richmond P, Carlin JB. The burden of rotavirus-related illness among young children on the Australian health care system. Austr N Z J Public Health 2006;30:416-421.

8. Orenstein EW, Fang ZY, Xu J, Liu C, Shen K, Qian Y, et al. ¶·È‰È·ÙÚÈ΋ 2007;70:374-378

Paidiatriki 5 final

12-10-07

16:28

Page 378

378

π. ¶·˘ÏÔÔ‡ÏÔ˘

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

The epidemiology and burden of rotavirus in China: a review of the literature from 1983 to 2005. Vaccine 2007;25:406-413.

Newman RD, Grupp-Phelan J, Shay DK, Davis RL. Perinatal risk factors for infant hospitalization with viral gastroenteritis. Pediatrics 1999;103:E3.

Saulsbury FT, Winkelstein JA, Yolken RH. Chronic rotavirus infection in immunodeficiency. J Pediatr 1980;97:61-65.

Liakopoulou E, Mutton K, Carrington D, Robinson S, Steward CG, Goulden NJ, et al. Rotavirus as a significant cause of prolonged diarrhoeal illness and morbidity following allogeneic bone marrow transplantation. Bone Marrow Transplant 2005;36:691-694.

Parashar UD, Alexander JP, Glass RI; Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC). Prevention of rotavirus gastroenteritis among infants and children. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-12):1-13.

Gentsch JR, Laird AR, Bielfelt B, Griffin DD, Banyai K, Ramachandran M, et al. Serotype diversity and reassortment between human and animal rotavirus strains: implications for rotavirus vaccine programs. J Infect Dis 2005;192(Suppl 1):S146-S159.

Santos N, Hoshino Y. Global distribution of rotavirus serotypes/genotypes and its implication for the development and implementation of an effective rotavirus vaccine. Rev Med Virol 2005;15:29-56.

Linhares AC, Verstraeten T, Wolleswinkel-van den Bosch J, Clemens R, Breuer T. Rotavirus serotype G9 is associated with more severe disease in Latin America. Clin Infect Dis 2006;43:312-314.

Rahman M, Matthijnssens J, Yang X, Delbeke T, Arijs I, Taniguchi K, et al. Evolutionary history and global spread of the emerging g12 human rotaviruses. J Virol 2007;81:23822390.

Glass RI, Bhan MK, Ray P, Bahl R, Parashar UD, Greenberg H, et al. Development of candidate rotavirus vaccines derived from neonatal strains in India. J Infect Dis 2005;192 (Suppl) 1:S30-35.

Butz AM, Fosarelli P, Dick J, Cusack T, Yolken R. Prevalence of rotavirus on high-risk fomites in day-care facilities. Pediatrics 1993;92:202-205.

Dennehy PH, Nelson SM, Crowley BA, Saracen CL. Detection of rotavirus RNA in hospital air samples by polymerase chain reaction (PCR). Pediatr Res 1998;43:143A. Ward RL, Bernstein DI, Knowlton DR, Sherwood JR, Young EC, Cusack TM, et al. Prevention of surface-to-human transmission of rotaviruses by treatment with disinfectant spray. J Clin Microbiol 1991;29:1991-1996.

Duffy LC, Riepenhoff-Talty M, Byers TE, La Scolea LJ, Zielezny MA, Dryja DM, et al. Modulation of rotavirus enteritis during breast- feeding. Implications on alterations in the intestinal bacterial flora. Am J Dis Child 1986;140:1164-1168.

Desselberger U, Gray J. Viruses associated with acute diar-

Paediatriki 2007;70:374-378

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

rheal disease. In: Zuckerman AJ, Banatvala JE, Pattison JR, Griffiths P, Schoub B, eds. Principles and practice of clinical virology. 5th ed. Chichester, UK: John Wiley& Sons; 2004. p. 249-270.

Franco MA, Angel J, Geeenberg HB. Immunity and correlates of protection for rotavirus vaccines. Vaccine 2006;24:2718-2731.

Ward RL, Bernstein DI. Lack of correlation between serum rotavirus antibody titers and protection following vaccination with reassortant RRV vaccines. US Rotavirus Vaccine Efficacy Group. Vaccine 1995;13:1226-1232.

Heaton PM, Goveia MG, Miller JM, Offit P, Clark HF. Development of a pentavalent rotavirus vaccine against prevalent serotypes of rotavirus gastroenteritis. J Infect Dis 2005;192(Suppl 1):S17-S21.

Jaimes MC, Feng N, Greenberg HB. Characterization of homologous and heterologous rotavirus-specific T-cell responses in infant and adult mice. J Virol 2005;79:4568-4579.

Bines J. Intussusception and rotavirus vaccines. Vaccine 2006;24:3772-3776.

Haber P, Chen RT, Zanardi LR, Mootrey GT, English R, Braun MM. An analysis of rotavirus vaccine reports to the vaccine adverse reporting system: more than intussusception alone? Pediatrics 2004;113:353-359.

Simonsen L, Viboud C, Elixhauser A, Taylor RJ, Kapikian AZ. More on RotaShield and intussusception: the role of age at the time of vaccination. J Infect Dis 2005;192(Suppl 1):S36-43.

Lynch M, Shieh WJ, Bresee JS, Tatti KM, Gentsch JR, Jones T, et al. Intussusception after administration of the rhesus tetravalent rotavirus vaccine (Rotashield): the search for a pathogenic mechanism. Pediatrics 2006;117:e827-832.

Ruiz-Palacios GM, Perez-Schael I, Velasquez FR, Abate H, Breuer T, Clemens SC, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med 2006;354:11-22.

Vesikari T, Karnoven A, Prymula R, Schuster V, Tejedor JC, Cohen R, et al. Human rotavirus vaccine Rotarix (RIX4414) is highly efficacious in Europe. In: 24th Annual Meeting of the European Society for Pediatric Infectious Diseases - ESPID; Basel, Switzerland; 3-5 May 2006: abstr. 457.

Vesikari T, Matson DO, Dennehy P, Van Damme P, Santosham M, Rodriguez Z, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med 2006;354:23-33.

Widdowson MA, Meltzer MI, Zhang X, Bresee JS, Parashar UD, Glass RI. Cost-effectiveness and potential impact of rotavirus vaccination in the United States. Pediatrics;119:684-697. ∫·‚·ÏÈÒÙ˘ π, ¶··Â˘·ÁÁ¤ÏÔ˘ µ, ª·ÓÙ·ÁÔ‡ §, ∫fiÎÎÔÚË ∂, ∆Ú›Ì˘ ° Î·È Û˘Ó. EȉËÌÈÔÏÔÁ›· ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Û ·È‰È¿ ÛÙËÓ ∂ÏÏ¿‰·: ªÂϤÙË Rotascore. ¶·È‰È·ÙÚÈ΋ 2007; 70(5):404-410.

Bhandari N, Sharma P, Glass RI, Ray P, Greenberg H, Taneja S, et al. Safety and immunogenicity of two live attenuated human rotavirus vaccine candidates, 116E and I321, in infants: results of a randomised controlled trial.

Vaccine 2006; 24(31-32): 5817-5823.

Paidiatriki 5 final

12-10-07

16:28

Page 379

∞¡∞™∫√¶∏™∏

REVIEW ARTICLE

379

∏ ‹È· Î·È Ì¤ÙÚÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ˆ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ ª.£·ÓÔÔ‡ÏÔ˘1, °. ∆ÛfiÏ·˜2 ¶ÂÚ›ÏË„Ë: ∏ ÔÌÔ΢ÛÙ½ÓË ·ÔÙÂÏ› ÂӉȿÌÂÛÔ ÚÔ˚fiÓ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ÌÂıÂÈÔÓ›Ó˘. ªÂϤÙ˜ ÙˆÓ ‰‡Ô ÙÂÏÂ˘Ù·›ˆÓ ‰ÂηÂÙÈÒÓ Û ÂÓ‹ÏÈΘ ηٷ‰ÂÈÎÓ‡Ô˘Ó ÙËÓ ‹È· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ˆ˜ ·ÓÂÍ¿ÚÙËÙÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚÒÈÌË ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ. ∆· Â›‰· ·›Ì·ÙÔ˜ Ù˘ ÔÏÈ΋˜ ÔÌÔ΢ÛÙ½Ó˘ (tHcy) ηıÔÚ›˙ÔÓÙ·È Î˘Ú›ˆ˜ ·fi ÙÔ Ê‡ÏÔ, ÙËÓ ËÏÈΛ·, Ù· Â›‰· Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ‚ÈÙ·ÌÈÓÒÓ µ6 Î·È µ12 ÛÙÔÓ ÔÚfi ηıÒ˜ Î·È ·fi ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ªÂÙ·ÏÏ¿ÍÂȘ ÙˆÓ ÂÓ˙‡ÌˆÓ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Î·È ·ÓÂ¿ÚÎÂÈ· ÙˆÓ ‚ÈÙ·ÌÈÓÒÓ µ6, µ12 Î·È Ê˘ÏÏÈÎÔ‡ ÔͤԘ Ô˘ ‰ÚÔ˘Ó ˆ˜ Û˘Ì·Ú¿ÁÔÓÙ˜ ÙˆÓ ÂÓ˙‡ÌˆÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ӷ Â›‰· ÔÌÔ΢ÛÙ½Ó˘. ∏ ÔÌÔ˙˘ÁˆÙ›· ÁÈ· ÙÔÓ ÔÏ˘ÌÔÚÊÈÛÌfi 677C-T ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÌÂı˘ÏÂÓÔÙÂÙÚ·¸‰ÚÔÊ˘ÏÏÈ΋ Ú‰ԢÎÙ¿ÛË (ª∆HFR) ·ÔÙÂÏ› ÙÔÓ ÈÔ Û˘¯Ófi ÁÂÓÂÙÈÎfi ·Ú¿ÁÔÓÙ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ Î·È Ë ‡·ÚÍ‹ Ù˘ ÚÔηÏ› ·‡ÍËÛË Ù˘ ÙÈÌ‹˜ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ηٿ ÂÚ›Ô˘ 2,5 Ìmol/l. ¶·Ú¿ÏÏËÏ·, ¤¯ÂÈ Á›ÓÂÈ ÁÓˆÛÙfi fiÙÈ Ë ·ıËڈ̷ÙÈ΋ ‰ÈÂÚÁ·Û›· ·Ú¯›˙ÂÈ Î·È ÂÍÂÏ›ÛÛÂÙ·È ‹‰Ë ·fi ÙËÓ ·È‰È΋ ËÏÈΛ·. ∆· Â›‰· ÛÙËÓ ·È‰È΋ ËÏÈΛ· ÙˆÓ ϤÔÓ ÛËÌ·ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚÒÈÌË ·ıËڈ̿وÛË, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ·˘Ù¿ ÙˆÓ ÏÈȉ›ˆÓ, ıˆÚÂ›Ù·È fiÙÈ ·ÔÙÂÏÔ‡Ó Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· Ù· ·ÓÙ›ÛÙÔȯ· Â›‰· ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹. ™ÙÔ ·ÚfiÓ ¿ÚıÚÔ Á›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÛÙË ÌÂÙ·‚ÔÏÈ΋ Ô‰fi Ù˘ ÔÌÔ΢ÛÙ½Ó˘, ÛÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó Ù· Â›‰¿ Ù˘ ÛÙÔ ·›Ì·, ÛÙ· ·›ÙÈ· Ù˘ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜, ÛÙË Û˘Û¯¤ÙÈÛ‹ Ù˘ Ì ÙËÓ ·ıËÚÔıÚÔÌ‚ˆÙÈ΋ ÓfiÛÔ, fiˆ˜ ·˘Ù‹ ÙÂÎÌËÚÈÒÓÂÙ·È ·fi ÌÂϤÙ˜ ÂÓËϛΈÓ, ηıÒ˜ Î·È ÛÙȘ ‰˘Ó·ÙfiÙËÙ˜ ıÂÚ·¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘. ∆¤ÏÔ˜, ÂÈÎÂÓÙÚÒÓÂÙ·È ÛÙ· ÓÂfiÙÂÚ· ÂÈÛÙËÌÔÓÈο ‰Â‰Ô̤ӷ ÁÈ· ÙÔ˘˜ Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ Î·È ÁÂÓÂÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Â›Û˘ Î·È ÙȘ Û˘Ó‹ıÂȘ ˙ˆ‹˜ Ô˘ ηıÔÚ›˙Ô˘Ó Ù· Â›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ÛÙ· ·È‰È¿.

1 °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ∞ÙÙÈÎfi ¡ÔÛÔÎÔÌÂ›Ô 2 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶·Ó. & ∞ÁÏ·˝·˜ ∫˘ÚÈ·ÎÔ‡” AÏÏËÏÔÁÚ·Ê›·: °ÂÒÚÁÈÔ˜ ∆ÛfiÏ·˜ geotsol@otenet.gr µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶·Ó. & ∞ÁÏ·˝·˜ ∫˘ÚÈ·ÎÔ‡”

§¤ÍÂȘ ÎÏÂȉȿ: √ÌÔ΢ÛÙ½ÓË, ·ıËڈ̿وÛË, ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜, ·È‰›.

Mild-tÔ-moderate hyperhomocysteinaemia as a risk factor for atherosclerosis and thromboembolic disease M. Thanopoulou1, G. Tsolas2 Abstract: Homocysteine is a metabolite of methionine. In the past two decades, there has been growing interest in mild to moderate degrees of hyperhomocysteinemia as an independent risk factor for atherosclerosis and thromboembolic disease. Total serum homocysteine (tHcy) levels may be associated with age, gender, with serum levels of folate and vitamin B6 and B12, and with renal function. Mutations in the enzymes involved in homocysteine metabolism and deficiencies of vitamins B6, B12 and folic acid (co-factors of these enzymes) are associated with hyperhomocysteinemia. Homozygosity for the methylenotetrahydrofolate reductase (MTHFR) 677C-T polymorphism is the most common genetic determinant, and individuals with the MTHFR 677TT genotype usually have tHcy levels approximately 2.5 Ìmol/l higher than the normal. It is well known that the atherosclerotic process begins and progresses during childhood and adolescence, and that some children display risk factors such as moderate to high levels of cholesterol, which may be predictive of adult levels. This article briefly summarizes the biochemical background of tHcy, the causes and diagnosis of hyperhomocysteinemia, and the role of high serum levels of homocysteine in atherosclerosis and thrombotic disease, through studies of adults, and its treatment. In addition, the article focuses on the physiologic, genetic and lifestyle determinants of homocysteine levels in children.

1 3rd Paediatric Department of the University of Athens, Attikon Hospital 2 2nd Paediatric Department of the University of Athens, “P. and A. Kyriakou” Children’s Hospital Correspondence: Georgios Tsolas geotsol@otenet.gr 2nd Paediatric Department of the University of Athens, “P. and A. Kyriakou” Children’s Hospital

Key words: Homocysteine, atherosclerosis, arterial and venous thrombosis, child.

∂ÈÛ·ÁˆÁ‹ √È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ·ıËڈ̿وÛ˘ Ê·›ÓÂÙ·È fiÙÈ ‰ÚÔ˘Ó ‹‰Ë ·fi ÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·. ∞ıËڈ̷ÙÈΤ˜

·ÏÏÔÈÒÛÂȘ ÛÙ· ÙÔȯÒÌ·Ù· ÙˆÓ ·ÁÁ›ˆÓ ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Û ÂÊ‹‚Ô˘˜ ·ÏÏ¿ Î·È Û ·È‰È¿ (13). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·‡ÍËÛË ÙÔ˘ ηÓ›ÛÌ·ÙÔ˜, Ù˘ ·¯˘Û·ÚΛ·˜, ¶·È‰È·ÙÚÈ΋ 2007;70:379-388

Paidiatriki 5 final

12-10-07

16:28

Page 380

380

ª.£·ÓÔÔ‡ÏÔ˘, °. ∆ÛfiÏ·˜

Ù˘ ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘, ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ù‡Ô˘ ππ Î·È ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, ηıÈÛÙÔ‡Ó ÂÈÙ·ÎÙÈ΋ ÙËÓ ·Ó¿Ù˘ÍË ÌÂıfi‰ˆÓ ÚˆÙÔÁÂÓÔ‡˜ ÚfiÏ˄˘ Û ·˘Ù‹ ÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· (4-5). ∏ ·Ó·˙‹ÙËÛË Ó¤ˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÂÚ¢ÓËÙÈÎfi ‰›Ô, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÂÚ›Ô˘ ÙÔ 25% ÙˆÓ ·ÛıÂÓÒÓ Ì ÚÒÈÌË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ó¤Ó·Ó ·fi ÙÔ˘˜ ÎÏ·ÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ (6). ∞Ó¿ÌÂÛ· ÛÙÔ˘˜ Ó¤Ô˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚÒÈÌË ·ıËڈ̿وÛË ÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë ÔÌÔ΢ÛÙ½ÓË, Ë ÔÔ›· ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛı› ˆ˜ ÛËÌ·ÓÙÈÎfi˜ ‚ÈÔ¯ËÌÈÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ Ù˘ ·ıËڈ̷ÙÈ΋˜ ‰ÈÂÚÁ·Û›·˜ Î·È ÙˆÓ ÂÈÏÔÎÒÓ Ù˘. ∏ ‹È· Î·È Ë Ì¤ÙÚÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ÌÔÚÔ‡Ó, ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛˆÓ, Ó· ·ÔηٷÛÙ·ıÔ‡Ó Â‡ÎÔÏ· Ì ·ÛÊ·Ï›˜ Î·È Û¯ÂÙÈο ÌÈÎÚÔ‡ ÎfiÛÙÔ˘˜ ıÂÚ·¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ, fiˆ˜ ÙÔ ‰È·ÙÚÔÊÈÎfi Û˘Ìϋڈ̷ Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ¿ÏÏˆÓ ‚ÈÙ·ÌÈÓÒÓ (713). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ÂÓ‰¤¯ÂÙ·È Ó· ÂËÚ¿ÛÂÈ ÙËÓ ÂȉËÌÈÔÏÔÁ›· Î·È Ê˘ÛÈ΋ ÈÛÙÔÚ›· Ù˘ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘, ÁÈ’ ·˘Ùfi Î·È ·ÔÙÂÏ› ÙÔ ·ÓÙÈΛÌÂÓÔ ÔÏÏÒÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÂͤÏÈÍË.

√ ÌÂÙ·‚ÔÏÈÛÌfi˜ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ∏ ÔÌÔ΢ÛÙ½ÓË (Hcy) ÚÔ¤Ú¯ÂÙ·È ·fi ÙË ÌÂÙ·‚ÔÏÈ΋ Ô‰fi ÙÔ˘ ··Ú·›ÙËÙÔ˘ ·ÌÈÓÔͤԘ ÌÂıÂÈÔÓ›ÓË. À¿Ú¯ÂÈ ÙfiÛÔ Û ÂχıÂÚË (›¯ÓË ~2%) fiÛÔ Î·È ÛÂ Û˘˙¢Á̤ÓË Ì ÚˆÙ½Ó˜ ÌÔÚÊ‹. ™ÙÔ Ï¿ÛÌ·, ÔÍÂȉÒÓÂÙ·È ÛÙ· ‰ÈÛÔ˘ÏÊ›‰È· ÔÌÔ΢ÛÙ½ÓË-ÔÌÔ΢ÛÙ½ÓË (ÔÌÔ΢ÛÙ›ÓË) Î·È ÔÌÔ΢ÛÙ½ÓË-΢ÛÙ½ÓË (ÌÈÎÙfi ‰ÈÛÔ˘ÏÊ›‰ÈÔ). ∏ ÂχıÂÚË Î·È Ë Û˘Ó‰Â‰Â̤ÓË Ì ÚˆÙ½ÓË ÔÌÔ΢ÛÙ½ÓË, ηıÒ˜ Î·È Ù· ‰ÈÛÔ˘ÏÊ›‰È¿ Ù˘,

·Ó·Ê¤ÚÔÓÙ·È ‰ÈÂıÓÒ˜ ˆ˜ ÔÏÈ΋ ÔÌÔ΢ÛÙ½ÓË (tHcy) ‹ ·ÏÒ˜ ÔÌÔ΢ÛÙ½ÓË (14). À¿Ú¯Ô˘Ó ‰‡Ô Ô‰Ô› Â·Ó·ÌÂı˘Ï›ˆÛ˘ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Û ÌÂıÂÈÔÓ›ÓË Î·È Ì›· Ô‰fi˜ ÌÂÙ·ÙÚÔ‹˜ Ù˘ Û ΢ÛÙ½ÓË (∂ÈÎfiÓ· 1). ™ÙÔ ÌÔÓÔ¿ÙÈ Ù˘ Â·Ó·ÌÂı˘Ï›ˆÛ˘ Ô˘ ηٷχÂÙ·È ·fi ÙË Û˘ÓıÂÙ¿ÛË Ù˘ ÌÂıÂÈÔÓ›Ó˘, Ë ‚ÈÙ·Ì›ÓË µ12 (ÎÔ‚·Ï·Ì›ÓË) ÏÂÈÙÔ˘ÚÁ› ˆ˜ Û˘Ó¤Ó˙˘ÌÔ Î·È Ë ÌÂı˘ÏÔÌ¿‰· ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ 5-ÌÂı˘ÏÔÙÂÙÚ·¸‰ÚÔÊ˘ÏÏÈÎfi Ô͇, ÙËÓ Î‡ÚÈ· ÌÔÚÊ‹ ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ ÛÙÔ Ï¿ÛÌ·, Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ 5,10 ÌÂı˘ÏÂÓÔÙÂÙÚ·¸‰ÚÔÊ˘ÏÏÈÎfi Ô͇ Ì ÙË ‰Ú¿ÛË Ù˘ Ú‰ԢÎÙ¿Û˘ ÙÔ˘ ÌÂı˘ÏÂÓÔÙÂÙÚ·¸‰ÚÔÊ˘ÏÏÈÎÔ‡ ÔͤԘ (MTHFR). ™ÙËÓ ÂÓ·ÏÏ·ÎÙÈ΋ Ô‰fi Â·Ó·ÌÂı˘Ï›ˆÛ˘, Ô˘ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Î˘Ú›ˆ˜ ÛÙÔ ‹·Ú, Ë ‚ÂÙ·˝ÓË Â›Ó·È Ô ‰ˆÚËÙ‹˜ Ù˘ ÌÂı˘ÏÔÌ¿‰·˜ Î·È Ë ·ÓÙ›‰Ú·ÛË Î·Ù·Ï‡ÂÙ·È ·fi ÙË ÌÂı˘ÏÔÙÚ·ÓÛÊÂÚ¿ÛË Ù˘ ‚ÂÙ·˝Ó˘-ÔÌÔ΢ÛÙ½Ó˘. ∏ ÔÌÔ΢ÛÙ½ÓË ÌÂÙ·ÙÚ¤ÂÙ·È ·fi ÙË ‚-Û˘ÓıÂÙ¿ÛË Ù˘ ΢ÛÙ·ıÂÈÔÓ›Ó˘ Û ΢ÛÙ·ıÂÈÔÓ›ÓË Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ÙË ‰Ú¿ÛË Ù˘ ΢ÛÙ·ıÂÈÔÓ¿Û˘ Û ΢ÛÙ½ÓË. ∏ ʈÛÊÔÚÈ΋ ˘ÚȉÔÍ¿ÏË, ·Ú¿ÁˆÁÔ Ù˘ ‚ÈÙ·Ì›Ó˘ µ6, ÏÂÈÙÔ˘ÚÁ› ˆ˜ Û˘Ó¤Ó˙˘ÌÔ Î·È ÛÙȘ ‰‡Ô ÂÓ˙˘ÌÈΤ˜ ·ÓÙȉڿÛÂȘ (14) (∂ÈÎfiÓ· 1). ∏ ‚ÈÙ·Ì›ÓË µ6 Â›Ó·È Â›Û˘ ··Ú·›ÙËÙË ÁÈ· ÙË ÌÂÙ·ÙÚÔ‹ Ù˘ ΢ÛÙ·ıÂÈÔÓ›Ó˘ Û ΢ÛÙ½ÓË Î·È ·-ÎÂÙÔ‚Ô˘Ù˘ÚÈÎfi Ô͇.

¶·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó Ù· Â›‰· ÔÌÔ΢ÛÙ½Ó˘ ·›Ì·ÙÔ˜ º˘ÛÈÔÏÔÁÈÎÔ› Î·È ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ Â›Û˘ ÔÈ Û˘Ó‹ıÂȘ ˙ˆ‹˜, Ê·›ÓÂÙ·È fiÙÈ ·›˙Ô˘Ó ÚfiÏÔ ÛÙË ‰È·ÌfiÚʈÛË ÙˆÓ ÂÈ¤‰ˆÓ ÔÌÔ΢ÛÙ½Ó˘ ÛÙÔ ·›Ì· ÙˆÓ ÂÓËÏ›ÎˆÓ ·ÏÏ¿ Î·È ÙˆÓ ·È‰ÈÒÓ (15). ∏ ÔÌÔ΢ÛÙ½ÓË ÌÔÚ› Ó· ÚÔÛ‰ÈÔÚÈÛı› ›Ù ÛÙÔÓ ÔÚfi

ª∂£∂π√¡π¡∏

º˘ÏÏÈÎfi Ô͇

∆ÂÙÚ·¸‰ÚÔÊ˘ÏÏÈÎfi ‹ THF Û˘ÓıÂÙ¿ÛË Ù˘ µ12 ÌÂıÂÈÔÓ›Ó˘ 5,10-ÌÂı˘ÏÂÓÔTHF 5-ÌÂı˘ÏÔTHF Ú‰ԢÎÙ¿ÛË ÙÔ˘ ÌÂı˘ÏÂÓÔTHF

S-·‰ÂÓÔÛ˘ÏÔÌÂıÂÈÔÓ›ÓË

‰ÈÌÂı˘ÏÔÁÏ˘Î›ÓË ÌÂı˘ÏÔÙÚ·ÓÛÊÂÚ¿ÛË Ù˘ ‚ÂÙ·˝Ó˘-ÔÌÔ΢ÛÙ½Ó˘ ‚ÂÙ·˝ÓË

√ª√∫À™∆∂´¡∏

‚-Û˘ÓıÂÙ¿ÛË Ù˘ ΢ÛÙ·ıÂÈÔÓ›Ó˘

S-·‰ÂÓÔÛ˘ÏÔÌÔ΢ÛÙ½ÓË

µ6

΢ÛÙ·ıÂÈÔÓ›ÓË Î˘ÛÙ·ıÂÈÔÓÈÓ¿ÛË

µ6

∫À™∆∂´¡∏ ∂ÈÎfiÓ· 1. ªÂÙ·‚ÔÏÈ΋ Ô‰fi˜ Ù˘ ÔÌÔ΢ÛÙ½Ó˘.

Paediatriki 2007;70:379-388

΢ÛÙÂ˚ÓÔÛÔ˘ÏÊÈÓÈÎfi

Paidiatriki 5 final

12-10-07

16:28

Page 381

381

ÀÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜

›Ù ÛÙÔ Ï¿ÛÌ·. ∆· ‰Â›ÁÌ·Ù· Ï¿ÛÌ·ÙÔ˜ ÚÔÙÈÌÒÓÙ·È ÁÈ·Ù› ÌÔÚÔ‡Ó Ó· Ê˘ÁÔÎÂÓÙÚËıÔ‡Ó ·Ì¤Ûˆ˜ ‹ Ó· ÙÔÔıÂÙËıÔ‡Ó Û ¿ÁÔ Î·È Ó· ‰È·ÙËÚËıÔ‡Ó ÁÈ· 6 ÒÚ˜. ªÂ ·˘Ùfi ÙÔÓ ÙÚfiÔ ·ÔʇÁÂÙ·È Ë ·ÂÏ¢ı¤ÚˆÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ·fi Ù· ÂÚ˘ıÚ¿ Î·È ÂÔ̤ӈ˜ Ë „¢‰‹˜ ·‡ÍËÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘. ∏ ηٷӿψÛË Á‡̷ÙÔ˜ ÏÔ‡ÛÈÔ˘ Û ÚˆÙ½ÓË ÌÔÚ› Ó· ·˘Í‹ÛÂÈ Ù· Â›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ̤¯ÚÈ Î·È 15% ÌÂÙ¿ ·fi ¿ÚÔ‰Ô 6-8 ˆÚÒÓ (14).

∂›‰· ÔÌÔ΢ÛÙ½Ó˘ Î·È ËÏÈΛ· ∆· Â›‰· Ù˘ tHcy ÛÙÔ ·›Ì· ·˘Í¿ÓÔÓÙ·È Ì ÙËÓ ËÏÈΛ·. ∏ ̤ÛË Û˘ÁΤÓÙÚˆÛË Â›Ó·È 4-8 Ìmol/l ÛÙ· ·È‰È¿ ËÏÈΛ·˜ <15 ÂÙÒÓ, Ô˘ ·ÓÙÈÛÙÔȯ› ÂÚ›Ô˘ ÛÙÔ 60% ÙˆÓ ÙÈÌÒÓ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (16). ∫¿ÔȘ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÂÏ·ÊÚÒ˜ ˘„ËÏfiÙÂÚË Û˘ÁΤÓÙÚˆÛË Ù˘ tHcy ÛÙ· ·ÁfiÚÈ· Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ·, ‰È·ÊÔÚ¿ Ë ÔÔ›· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ¤Î‰ËÏË Î·Ù¿ ÙËÓ ÂÊ˂›· Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ·fi ·˘Ù‹ (16-21). ∞ÎfiÌË, Â›Ó·È ¯·ÌËÏfiÙÂÚË ÛÙȘ Á˘Ó·›Î˜ ·Ó··Ú·ÁˆÁÈ΋˜ ËÏÈΛ·˜ ·fi fi,ÙÈ ÛÙÔ˘˜ ¿Ó‰Ú˜ Î·È ·˘Í¿ÓÂÙ·È ÌÂÙ¿ ÙËÓ ÂÌÌËÓfi·˘ÛË (22). ∂›‰· ÔÌÔ΢ÛÙ½Ó˘ Î·È ‚Èٷ̛Ә µ6, µ12 Î·È Ê˘ÏÏÈÎfi Ô͇ √È ÛËÌ·ÓÙÈÎfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó Ù· Â›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Â›Ó·È Ë Â¿ÚÎÂÈ· ‚ÈÙ·ÌÈÓÒÓ µ6, µ12 Î·È Ê˘ÏÏÈÎÔ‡ ÔͤԘ, ηıÒ˜ Î·È Ë Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (15). ∏ Â›‰Ú·ÛË ÙˆÓ ‚ÈÙ·ÌÈÓÒÓ ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ µ ÛÙ· Â›‰· ÔÌÔ΢ÛÙ½Ó˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù‹ Ô˘ ¤¯Â› ηٷÁÚ·Ê› ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (23). ™Â ·È‰È¿ ËÏÈΛ·˜ >24 ÌËÓÒÓ, Ë Û˘ÁΤÓÙÚˆÛË tHcy ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Û¯ÂÙ›˙ÂÙ·È Î˘Ú›ˆ˜ Ì ٷ Â›‰· ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ÏÈÁfiÙÂÚÔ Ì ·˘Ù¿ Ù˘ ÎÔ‚·Ï·Ì›Ó˘ (9,16). ∏ ‚ÈÙ·Ì›ÓË µ6 ›¯Â ÙËÓ ·ÛıÂÓ¤ÛÙÂÚË ‹ Î·È Î·Ì›· Â›‰Ú·ÛË (16-24). ∏ Û˘ÁΤÓÙÚˆÛË Ù˘ tHcy ‹Ù·Ó ¯·ÌËÏfiÙÂÚË ÛÙ· ¿ÙÔÌ· Ô˘ Ï¿Ì‚·Ó·Ó ÔÏ˘‚ÈÙ·ÌÈÓÔ‡¯· Û˘ÌÏËÚÒÌ·Ù· ‰È·ÙÚÔÊ‹˜ Û ۯ¤ÛË Ì ·˘Ù¿ Ô˘ ‰ÂÓ Ï¿Ì‚·Ó·Ó (7). ∂Ô̤ӈ˜, ‰ÂÓ ÌÔÚ› Ó· Á›ÓÂÈ ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ·ÛıÂÓÒÓ Ì ÎÏÈÓÈ΋ ˘Ô„›· ‰È·Ù·Ú·¯ÒÓ, ÔÈ Ôԛ˜ ÚÔηÏÔ‡Ó ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·Ó Ô ·ÛıÂÓ‹˜ Ï·Ì‚¿ÓÂÈ Û˘ÌÏËÚÒÌ·Ù· ‚ÈÙ·ÌÈÓÒÓ ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ µ. ∂›‰· ÔÌÔ΢ÛÙ½Ó˘ Î·È ·¯˘Û·ÚΛ· ∏ Û˘ÁΤÓÙÚˆÛË Ù˘ tHcy ÛÙ· ·È‰È¿ ·ÚÔ˘ÛÈ¿˙ÂÈ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ ÔÛfiÙËÙ· Ù˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ˘ ÁÏ˘Îfi˙˘. ™Ù· ·¯‡Û·Úη ·È‰È¿, Ë ÙÈÌ‹ Ù˘ tHcy ·ÚÔ˘ÛÈ¿˙ÂÈ ÈÛ¯˘Ú‹ Û˘Û¯¤ÙÈÛË Ì ÙÔÓ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜, ÙÔÓ ÏÈÒ‰Ë ÈÛÙfi Î·È Ù· Â›‰· ÈÓÛÔ˘Ï›Ó˘ (25). ∫·Ù·‰Â›¯ıËΠÂ›Û˘ Ë ‡·ÚÍË ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁ˘ Û¯¤Û˘ ·Ó¿ÌÂÛ·

ÛÙËÓ tHcy Î·È ÙË Û˘ÁΤÓÙÚˆÛË Ê˘ÏÏÈÎÔ‡ ÔͤԘ (26). √È ·Ú·ÙËÚ‹ÛÂȘ ·˘Ù¤˜ ˘Ô‰ÂÈÎÓ‡Ô˘Ó ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ Ô‰ËÁÔ‡Ó Û ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË tHcy ÛÙ· ·¯‡Û·Úη ·È‰È¿: ÚÒÙÔÓ, ÙËÓ ·ÓÂ·Ú΋ ÚfiÛÏË„Ë Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ‰Â‡ÙÂÚÔÓ, ÙÔÓ ˘ÂÚÈÓÛÔ˘ÏÈÓÈÛÌfi Ô˘ ÌÔÚ› Ó· ·ÓÙ·Ó·ÎÏ¿ ·ÓÔ¯‹ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË, ·ÊÔ‡ Ë ÈÓÛÔ˘Ï›ÓË ·fi ÌfiÓË Ù˘ ÌÂÈÒÓÂÈ ·ÓÙ› Ó· ·˘Í¿ÓÂÈ ÙË Û˘ÁΤÓÙÚˆÛË Ù˘ tHcy (27). ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·¯˘Û·ÚΛ·, fiˆ˜ Ë ·˘ÍË̤ÓË ‰È·ÛÙÔÏÈ΋ ›ÂÛË Î·È Ë Û˘ÁΤÓÙÚˆÛË Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÔÌÔ΢ÛÙ½ÓË ÛÙ· ·È‰È¿, ÛÙÔÈ¯Â›Ô ÙÔ ÔÔ›Ô ‰ÂÓ Â›Ó·È Û‡ÌʈÓÔ Ì ٷ ·ÓÙ›ÛÙÔȯ· Â˘Ú‹Ì·Ù· ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (16,26,28). ∂ӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë Û˘ÁΤÓÙÚˆÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ·˘Í‹ıËΠ·ÓÙ› Ó· ÂÏ·ÙÙˆı› Û ·¯‡Û·Úη ·È‰È¿, Ù· ÔÔ›· Û˘ÌÌÂÙ›¯·Ó Û ÚfiÁÚ·ÌÌ· Ì›ˆÛ˘ ÙÔ˘ ۈ̷ÙÈÎÔ‡ ÙÔ˘˜ ‚¿ÚÔ˘˜ (29). ∏ ·‡ÍËÛË ·˘Ù‹ ÂÓ‰¤¯ÂÙ·È Ó· Â›Ó·È ‰Â˘ÙÂÚÔÁÂÓ‹˜ ÏfiÁˆ Ù˘ ·ÂÏ¢ı¤ÚˆÛ˘ ÌÂıÂÈÔÓ›Ó˘ ·fi ÙÔÓ Î·Ù·‚ÔÏÈÛÌfi ÙˆÓ ÚˆÙÂ˚ÓÒÓ, ¯ˆÚ›˜ Ó· ÌÔÚ› Ó· ·ÁÓÔËı› Î·È Ë Èı·Ó‹ Û˘ÓÂÈÛÊÔÚ¿ Ù˘ ÌÂȈ̤Ó˘ ÚfiÛÏ˄˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ (29).

ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó Ù· Â›‰· ÔÌÔ΢ÛÙ½Ó˘ ÕÏÏÔÈ, ÏÈÁfiÙÂÚÔ Î·Ï¿ ÌÂÏÂÙË̤ÓÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó Ù· Â›‰· ÔÌÔ΢ÛÙ½Ó˘ Â›Ó·È ÙÔ Î¿ÓÈÛÌ·, Ë ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, Ë ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·, Ë ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË Î·È Ë Î·Ù·Ó¿ÏˆÛË Î·Ê¤ Î·È ÔÈÓÔÓ‡̷ÙÔ˜ (15). Ÿˆ˜ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ¤ÙÛÈ Î·È ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜, ÙÔ Î¿ÓÈÛÌ· Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ӷ Â›‰· tHcy, Ô˘ ÌÔÚ› ÂÓ Ì¤ÚÂÈ Ó· ·Ô‰Ôı› ÛÙËÓ ·ÓÂ·Ú΋ ÚfiÛÏË„Ë ‚ÈÙ·ÌÈÓÒÓ Î·È ÛÙËÓ Î·Î‹ ‰È·ÙÚÔÊ‹ ÙˆÓ Î·ÓÈÛÙÒÓ (9,16). √È Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ tHcy ÔÈΛÏÔ˘Ó ·Ó¿ÏÔÁ· Ì ÙËÓ ÂıÓÈÎfiÙËÙ· Î·È Â›Ó·È ˘„ËÏfiÙÂÚ˜ ÛÙ· Ì·‡Ú· ·È‰È¿ ·fi fi,ÙÈ ÛÙ· ÏÂ˘Î¿ (15). OÈ ¶·Ô˘ÙÛ¿Î˘ Î·È Û˘Ó. ¤‰ÂÈÍ·Ó fiÙÈ Ô ÔÌfi˙˘ÁÔ˜ ∆∆ ÁÔÓfiÙ˘Ô˜ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ӷ Â›‰· tHcy ÌfiÓÔ ÛÙ· ·È‰È¿ Ì ¯·ÌËÏ¿ Â›‰· Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È È‰›ˆ˜ ÛÙ· ¿ÚÚÂÓ· ¿ÙÔÌ· (30). ∞Ó¿ÏÔÁ˜ ·Ó·ÎÔÈÓÒÛÂȘ Û ÓÂÔÁ¤ÓÓËÙ· ·Ó·Ê¤ÚÔ˘Ó ÙË ÌË Â›‰Ú·ÛË ÙˆÓ ÔÏ˘ÌÔÚÊÈÛÌÒÓ MTHFR 677 C-T Î·È 1298A-C ÛÙ· Â›‰· Ù˘ tHcy Ï¿ÛÌ·ÙÔ˜ (31). ∞›ÙÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ ∞) ∂ÎÛÂÛËÌ·Ṳ̂ÓË ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· (√ÌÔ΢ÛÙÈÓÔ˘Ú›·) ∏ Û˘¯ÓfiÙÂÚË ·ÈÙ›· ÂÎÛÂÛËÌ·Ṳ̂Ó˘ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ (Â›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ÛÙÔ Ï¿ÛÌ· >100 Ìmol/L) Â›Ó·È Ë Ï‹Ú˘ ¤ÏÏÂÈ„Ë Ù˘ ‚-Û˘ÓıÂÙ¿Û˘ Ù˘ ΢ÛÙ·ıÂÈÔÓ›Ó˘ (CBS), Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ ¶·È‰È·ÙÚÈ΋ 2007;70:379-388

Paidiatriki 5 final

12-10-07

16:28

Page 382

382

ª.£·ÓÔÔ‡ÏÔ˘, °. ∆ÛfiÏ·˜

ÔÔ›·˜ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Â›Ó·È ÂÚ›Ô˘ 1/335.000 Ì ¢Ú›· ‰È·Î‡Ì·ÓÛË, ·fi 1/65.000 (πÚÏ·Ó‰›·) ¤ˆ˜ 1/900.000 (π·ˆÓ›·) (32). ∆· ¿Û¯ÔÓÙ· ¿ÙÔÌ· ·Ó·Ù‡ÛÛÔ˘Ó ÙÔ ÎÏ·ÛÈÎfi Û‡Ó‰ÚÔÌÔ Ù˘ ÔÌÔ΢ÛÙÈÓÔ˘Ú›·˜, ÙÔ ÔÔ›Ô ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¤ÎÙÔÔ˘˜ Ê·ÎÔ‡˜, ÛÎÂÏÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÚÒÈÌË ·ÁÁÂȷ΋ ÓfiÛÔ, ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· Î·È ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË (33). ¶ÂÚ›Ô˘ 5-10% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÌÔ΢ÛÙÈÓÔ˘Ú›·˜ ·Ô‰›‰ÔÓÙ·È Û ÎÏËÚÔÓÔÌÈ΋ ‰È·Ù·Ú·¯‹ Ù˘ Ô‰Ô‡ Ù˘ Â·Ó·ÌÂı˘Ï›ˆÛ˘ (34). ∏ Ï‹Ú˘ ¤ÏÏÂÈ„Ë Ù˘ ª∆∏FR (<10% ÙˆÓ ÙÈÌÒÓ ·Ó·ÊÔÚ¿˜ Ù˘ ÂÓ˙˘ÌÈ΋˜ ‰Ú·ÛÙÈÎfiÙËÙ·˜) ·ÔÙÂÏ› Û˘¯Ó‹ ÎÏËÚÔÓÔÌÔ‡ÌÂÓË ‰È·Ù·Ú·¯‹ Ù˘ Ô‰Ô‡ Â·Ó·ÌÂı˘Ï›ˆÛ˘ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi „˘¯ÔÎÈÓËÙÈ΋ ˘ÛÙ¤ÚËÛË, Û·ÛÌÔ‡˜, ÂÚÈÊÂÚÈ΋ Ó¢ÚÔ¿ıÂÈ·, ÚÒÈÌË ·ÁÁÂȷ΋ ÓfiÛÔ Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· (35,36). µ) ◊È·-̤ÙÚÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· √È ÌÔÚʤ˜ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ ‹È·˜ ‹ ̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ (Â›‰· Ó‹ÛÙÂÔ˜: 15-100 Ìmol/L) ·Ô‰›‰ÔÓÙ·È Û ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, Â›ÎÙËÙ˜ ηٷÛÙ¿ÛÂȘ ‹ Û˘¯ÓfiÙÂÚ· ÛÂ Û˘Ó‰˘·ÛÌfi ÙˆÓ ‰‡Ô. √È ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ Ô‰ËÁÔ‡Ó Û Ì›ˆÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙˆÓ ÂÓ˙‡ÌˆÓ ηٿ 50%, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ÂÙÂÚfi˙˘Á˘ ¤ÏÏÂȄ˘ ÙˆÓ CBS ‹ MTHFR Ì ·ıÚÔÈÛÙÈÎfi ÂÈÔÏ·ÛÌfi ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi 0,4%-1,5% Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ‹È· Î·È ÙË Ì¤ÙÚÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·. ÕÏÏË ÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì Ì›ˆÛË Ù˘ ÂÓ˙˘ÌÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ηٿ 50% ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ÌÈ·˜ ıÂÚÌÔ¢·›ÛıËÙ˘ ÌÂÙ¿ÏÏ·Í˘ Ù˘ MTHFR (37), Ë ÔÔ›· ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÓÙÈηٿÛÙ·ÛË Ù˘ ΢ÙÔÛ›Ó˘ ·fi ÙË ı˘Ì›ÓË ÛÙÔ ÓÔ˘ÎÏÂÔÙ›‰ÈÔ 677 ÙÔ˘ Έ‰ÈÎÔÔÈÔ‡ ÁÔÓȉ›Ô˘, ·ÓÙÈηıÈÛÙÒÓÙ·˜ ÛÙÔ ¤Ó˙˘ÌÔ ÙÔ Îˆ‰ÈÎfiÓÈÔ Ù˘ ·Ï·Ó›Ó˘ Ì ·˘Ùfi Ù˘ ‚·Ï›Ó˘. √ ÂÈÔÏ·ÛÌfi˜ Ù˘ ÔÌÔ˙˘ÁˆÙ›·˜ ÁÈ· ÙË ÌÂÙ¿ÏÏ·ÍË C677T Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 5% Î·È 20% ÛÙÔ˘˜ ∫·˘Î¿ÛÈÔ˘˜ (37). √È Ì¤ÙÚȘ ·˘Í‹ÛÂȘ ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ tHcy ‰ÂÓ ·Ó¢ڛÛÎÔÓÙ·È Û fiÏ· Ù· ¿ÙÔÌ· Ì ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ÚÔηÏÔ‡Ó ÂÏ¿ÙÙˆÛË Ù˘ ÂÓ˙˘ÌÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ηٿ 50%, ˘Ô‰ËÏÒÓÔÓÙ·˜ fiÙÈ Ë Ê·ÈÓÔÙ˘È΋ ÂΉ‹ÏˆÛ‹ ÙÔ˘˜ ÌÔÚ› Ó· ÂËÚ¿˙ÂÙ·È Î·È ·fi ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ Î·È Î˘Ú›ˆ˜ ·fi ÙËÓ ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ (38). ™Ù· ·›ÙÈ· Ù˘ Â›ÎÙËÙ˘ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ¤ÏÏÂÈ„Ë Ê˘ÏÏÈÎÔ‡ ÔͤԘ, ÎÔ‚·Ï·Ì›Ó˘ Î·È ˘ÚȉÔ͛Ӣ, ηıÒ˜ Î·È Ë ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· (39,40). º¿Ú̷η Ô˘ ·ÚÂÌ‚·›ÓÔ˘Ó ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Ì›·˜ ‹ ÂÚÈÛÛÔÙ¤ÚˆÓ ·fi ÙȘ ·Ú·¿Óˆ ‚Èٷ̛Ә, fiˆ˜ Ë ÌÂıÔÙÚÂÍ¿ÙË, Ù· ·ÓÙÈÛ·Û̈‰Èο, ÙÔ ·Ó·ÈÛıËÙÈÎfi nitrous oxide Î·È Ë ıÂÔÊ˘ÏÏ›ÓË, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ‹È· ˘ÂÚÔÌÔPaediatriki 2007;70:379-388

¶›Ó·Î·˜ 1. ∂ηÙÔÛÙÈ·›· ηٷÓÔÌ‹ Ù˘ ÔÏÈ΋˜ ÔÌÔ΢ÛÙ½Ó˘ (Ìmol/l) Û ·È‰È¿ ÂÏÏËÓÈ΋˜ ηٷÁˆÁ‹˜ Ì ‚¿ÛË ÙËÓ ËÏÈΛ· (46) ∂ηÙÔÛÙÈ·›· ηٷÓÔÌ‹ 25 50 75 85 95

6-9 ÂÙÒÓ (N=111)

10-12 ÂÙÒÓ (N=143)

13-15 ÂÙÒÓ (N=266)

5,6 6,4 7,3 7,6 10,0

6,3 7,2 8,3 8,6 10,6

7,2 8,3 9,9 10,4 14,4

΢ÛÙÂ˚Ó·ÈÌ›·. ∞ÓÙÈı¤Ùˆ˜, Ù· ÔÈÛÙÚÔÁfiÓ·, Ë Ù·ÌÔÍÈʤÓË, Ë ÂÓÈÎÈÏÏ·Ì›ÓË Î·È Ë ·ÎÂÙ˘ÏÔ΢ÛÙ½ÓË ÂÏ·ÙÙÒÓÔ˘Ó Ù· Â›‰· ÔÚÔ‡ Ù˘ tHcy (41-44).

¢È¿ÁÓˆÛË Ù˘ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ ø˜ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ÔÚ›˙ÂÙ·È Ë ·‡ÍËÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ¿Óˆ ·fi ÙËÓ ÙÈÌ‹ Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙËÓ 95Ë ÂηÙÔÛÙÈ·›· ı¤ÛË Ù˘ ηٷÓÔÌ‹˜ Ù˘ Û ˘ÁÈ‹ ¿ÙÔÌ· ·Ó·ÏfiÁÔ˘ ËÏÈΛ·˜ Î·È Ê‡ÏÔ˘, Ë ÔÔ›· ηıÔÚ›˙ÂÙ·È ÂÚ›Ô˘ ÛÙËÓ ÙÈÌ‹ ÙˆÓ 15Ìmol/l. √È “Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜” ÔÈΛÏÔ˘Ó Â˘Ú¤ˆ˜ ÛÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ÏËı˘ÛÌÔ‡˜, ·ÊÔ‡ ÂËÚ¿˙ÔÓÙ·È ·fi ÙȘ Û˘Ó‹ıÂȘ ‰È·‚›ˆÛ˘. ™Â ÏËı˘ÛÌÔ‡˜ Ì ÚfiÛıÂÙË Ï‹„Ë Ê˘ÏÏÈÎÔ‡ ÔͤԘ, ÙÔ ·ÓÒÙÂÚÔ Ê˘ÛÈÔÏÔÁÈÎfi fiÚÈÔ ÌÔÚ› Ó· ÔÚÈÛı› ÛÙ· 12 Ìmol/l (45). ™ÙÔÓ ÂÏÏËÓÈÎfi ·È‰ÈÎfi ÏËı˘ÛÌfi, Ë ÂηÙÔÛÙÈ·›· ηٷÓÔÌ‹ Ù˘ ÔÏÈ΋˜ ÔÌÔ΢ÛÙ½Ó˘ ÔÚÔ‡ ÌÂÏÂÙ‹ıËΠ·fi ÙÔ˘˜ ¶··Ó‰Ú¤Ô˘ ¢. Î·È Û˘Ó. (46) (¶›Ó·Î·˜ 1) Î·È ·fi ÙÔ˘˜ ¶·Ô˘ÙÛ¿ÎË Î·È Û˘Ó., Ô˘ ·Ó·Ê¤ÚÔ˘Ó ÙÈ̤˜ tHcy Ï¿ÛÌ·ÙÔ˜ 95˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ Ù˘ ٿ͈˜ ÙÔ˘ 11,5 Ìmol/l, fiÛÔÓ ·ÊÔÚ¿ 186 ÂÏÏËÓfiÔ˘Ï· ËÏÈΛ·˜ 11-12 ÂÙÒÓ (47). ∆· Â›‰· Ù˘ ÔÏÈ΋˜ ÔÌÔ΢ÛÙ½Ó˘ ÛÙÔÓ ÔÚfi ‹ ÛÙÔ Ï¿ÛÌ· ˘ÁÈÒÓ ·È‰ÈÒÓ Ì ‚¿ÛË ÙÔ Ê‡ÏÔ Î·È ÙËÓ ËÏÈΛ· ·fi ÌÂϤÙ˜ Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ÀÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· Î·È ·ıËÚÔıÚÔÌ‚ˆÙÈ΋ηډȷÁÁÂȷ΋ ÓfiÛÔ˜ ¶ÔÏϤ˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ·ÎfiÌË Î·È Ë ÌÈÎÚ‹ ·‡ÍËÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘ (49-61). ™Â ÌÂÙ·-·Ó¿Ï˘ÛË 27 ·Ó·‰ÚÔÌÈÎÒÓ ÌÂÏÂÙÒÓ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ Ô˘ ‰ËÌÔÛȇıËÎ·Ó ÚÈÓ ÙÔ 1994, ‰È·ÈÛÙÒıËΠfiÙÈ Ô Û˘ÓÔÏÈÎfi˜ Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (odds ratio) Û ¿ÙÔÌ· Ì ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ‹Ù·Ó 1,7 (95% C.I., 1,5-1,9) ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, 2,5 (2,0-3,0) ÁÈ· ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ Î·È 6,8 (2,9-15,8) ÁÈ· ÂÚÈÊÂÚÈ΋ ·ÚÙËÚȷ΋ ÓfiÛÔ (50). °È· οı ·‡ÍËÛË Ù˘ Ù¿Í˘ ÙˆÓ 5Ìmol/L Ù˘ Û˘ÁΤÓÙÚˆÛ˘ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ˘‹Ú¯Â ·‡ÍËÛË ÂÚ›Ô˘ ηٿ 40% ÙÔ˘ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ. ∏ Û¯¤ÛË Ù˘

Paidiatriki 5 final

12-10-07

16:28

Page 383

383

ÀÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜

¶›Ó·Î·˜ 2. ™˘ÁÎÂÓÙÚˆÙÈÎfi˜ ›Ó·Î·˜ ÙˆÓ Î˘ÚÈfiÙÂÚˆÓ ÌÂÏÂÙÒÓ ·Ó·ÊÔÚÈο Ì ٷ Â›‰· ÔÏÈ΋˜ ÔÌÔ΢ÛÙ½Ó˘ (tHcy) ÔÚÔ‡ ‹ Ï¿ÛÌ·ÙÔ˜ ˘ÁÈÒÓ ·È‰ÈÒÓ Ì ‚¿ÛË ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ (∞: ·ÁfiÚÈ·, ∫: ÎÔÚ›ÙÛÈ·) µÈ‚ÏÈÔÁÚ·ÊÈ΋ ·Ó·ÊÔÚ¿

ŒÙÔ˜

º‡ÏÔ

∏ÏÈΛ· (¤ÙË)

∞ÚÈıÌfi˜ ·È‰ÈÒÓ

tHcy (Ìmol/L)

Infante-Rivard et al (31) Tonstad et al (48) Delvin et al (39)

2002 1997 2000

<1 7-17 2-19

Rauh et al (21)

2001

A+K A+K A+K A ∫

438 155 127 120 137 62 108 138 142 60 60 105 59 31

5,1(4,9-5,2) 6,3 (3,3-33) 5,8 (2,6-24,3) 5,7+/-1,7 5,5+/-1,6 4,8 (2,2-8,1) 5,7 (2,7-10,6) 6,4 (3,5-11,8) 7,8 (3,9-14,3) 8,5+-2,8 9,3+-2,9 5,8 (3,3-8,3) 6,6 (4,7-10,3) 8,1 (4,7-11,3)

6-17

Bates et al (16)

2002

∞

4- 6 7-10 11-14 15-18

Reddy et al (19)

1997

A ∫

0,1-18

Vilaseca et al (20)

1997

A+K

0,6-10 11-15 16-18

˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ Ì ÙËÓ ·ÁÁÂȷ΋ ·ÔÊÚ·ÎÙÈ΋ ÓfiÛÔ ·Ú¤ÌÂÈÓ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Î·È ÌÂÙ¿ ÙÔÓ ¤ÏÂÁ¯Ô ÁÈ· ÙÔ˘˜ ÎÏ·ÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ fiˆ˜ Â›Ó·È ÙÔ Î¿ÓÈÛÌ·, Ë ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·, Ë ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË Î·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ ÂȂ‚·ÈÒÓÔÓÙ·˜ fiÙÈ Ë ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ·ÔÙÂÏ› ¤Ó·Ó ‰È·‚·ıÌÈ˙fiÌÂÓÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘, ·Ó¿ÏÔÁÔ Î·È ·ÓÂÍ¿ÚÙËÙÔ ÙˆÓ ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘. ªÈ· ÈÔ ÚfiÛÊ·ÙË ·Ó¿Ï˘ÛË Ù˘ ›‰È·˜ ÌÂϤÙ˘ ¤‰ÂÈÍ fiÙÈ ÂÈÚfiÛıÂÙÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Â›Ó·È ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ ÙˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ Î¿Ùˆ ·fi ÙË 10Ë ÂηÙÔÛÙÈ·›· ı¤ÛË Î·È Ù˘ ‚ÈÙ·Ì›Ó˘ µ6 οو ·fi ÙËÓ 20‹ ÂηÙÔÛÙÈ·›· ı¤ÛË (51). ¢‡Ô ÌÂϤÙ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË Û¯¤ÛË ·Ó¿ÌÂÛ· ÛÙËÓ ÔÌÔ΢ÛÙ½ÓË Î·È ÙÔ ¿¯Ô˜ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ηڈٛ‰·˜ Ô˘ ÚÔÛ‰ÈÔÚ›˙ÂÙ·È Ì ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô Û ¿ÙÔÌ· ÂχıÂÚ· ÎÏÈÓÈο ¤Î‰ËÏ˘ ·ıËڈ̿وÛ˘. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, Ë ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· Û¯ÂÙÈ˙fiÙ·Ó Ì ¯·ÌËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ˘ÚȉÔ͛Ӣ Î·È Ê˘ÏÏÈÎÔ‡ ÔͤԘ (52,53). ÕÏϘ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó ÙËÓ ‡·ÚÍË Û˘Û¯¤ÙÈÛ˘ ·Ó¿ÌÂÛ· ÛÙ· Â›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Î·È ÙËÓ ¤ÎÙ·ÛË Ù˘ ·ıËڈ̷ÙÈ΋˜ ‚Ï¿‚˘ ÛÙËÓ ·ÔÚÙ‹, ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›· Î·È ÛÙȘ ÂÚÈÊÂÚÈΤ˜ ·ÚÙËڛ˜ (54-56). ™ËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÚÔÔÙÈÎÒÓ ÌÂÏÂÙÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË Û¯¤ÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Ì ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ Û ¿ÙÔÌ· Ù· ÔÔ›· ‹Ù·Ó ˘ÁÈ‹ ÙË ÛÙÈÁÌ‹ Ù˘ ¤ÓÙ·Í‹˜ ÙÔ˘˜ ÛÙË ÌÂϤÙË, ¤‰ÂÈÍ·Ó fiÙÈ ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ·Ó¿ÌÂÛ· ÛÙ· Â›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Î·È ÛÙÔÓ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ı·Ó·ÙËÊfiÚÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÂÂÈÛÔ‰›Ô˘ (57-6). ∏ ÌÔÓ·‰È΋ ÚÔÔÙÈ΋ ÌÂϤÙË ·ÛıÂÓÒÓ Ì ÎÏÈÓÈο ¤Î‰ËÏË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ¤‰ÂÈÍ ÌÈ· ÈÛ¯˘Ú‹ Î·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û¯¤ÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ Ù˘ tHcy Î·È Ù˘ Û˘ÓÔÏÈ΋˜ ıÓËÛÈÌfiÙËÙ·˜, Ë ÔÔ›·

‹Ù·Ó ·ÓÂÍ¿ÚÙËÙË ·fi ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘. ∏ ·Ó¿Ï˘ÛË ÙˆÓ ˘ÔÔÌ¿‰ˆÓ ¤‰ÂÈÍ fiÙÈ Ë tHcy ·ÔÙÂÏÔ‡Û ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ı·Ó¿ÙÔ˘ ·ÓÂÍ·Úًو˜ ËÏÈΛ·˜, ʇÏÔ˘ Î·È ÏÔÈÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ (60). ∆· ÂÂÈÛfi‰È· ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ ÛÙ· ·È‰È¿ Â›Ó·È Û¿ÓÈ·, ÂÚ›Ô˘ 2/100.000 ÂÙËÛ›ˆ˜. ™ÙÔ 30% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÂÓ ·Ó¢ڛÛÎÂÙ·È ·ÈÙÈÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (62). √ÚÈṲ̂Ó˜ ·Ó·ÎÔÈÓÒÛÂȘ Ô˘ ‰ËÌÔÛȇıËÎ·Ó ÙËÓ ÙÂÏÂ˘Ù·›· ÂÓÙ·ÂÙ›· ·Ó·Ê¤ÚÔ˘Ó ÙËÓ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË tHcy ˆ˜ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ·ÁÁÂȷ΋˜ ÓfiÛÔ˘ Î·È ·ÁÁÂÈ·ÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ (∞∂∂) Î·È ÛÙ· ·È‰È¿ (62-64). ∏ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË tHcy ÛÙ· ·È‰È¿ ‹ Û ӤԢ˜ ÂÓ‹ÏÈΘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ‡·ÚÍË ıÂÙÈÎÔ‡ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÈÛÙÔÚÈÎÔ‡ ÁÈ· ÚÒÈÌË (<55 ÂÙÒÓ) ηډȷÁÁÂȷ΋ ÓfiÛÔ ÛÙÔ˘˜ ¿ÚÚÂÓ˜ Û˘ÁÁÂÓ›˜ ‹ ÁÔÓ›˜ Î·È ·ÓȯÓ‡ıËΠ۠·È‰È¿ Ì ÁÔÓ›˜ ‹ ·Ô‡‰Â˜ Ì ·ÔÊÚ·ÎÙÈ΋ ·ÚÙËÚȷ΋ ÓfiÛÔ (63,65-67). ™Ù· ·È‰È¿ Ì ÔÈÎÔÁÂÓ‹ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·, Ë tHcy ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË Û fiÛ· ›¯·Ó ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÚÒÈÌ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ (48,68). √È ·Ú·ÙËÚ‹ÛÂȘ ·˘Ù¤˜ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ Ô ÔÈÎÔÁÂÓ‹˜ ΛӉ˘ÓÔ˜ ÁÈ· ηډȷÁÁÂȷ΋ ÓfiÛÔ ÂÍËÁÂ›Ù·È ÌÂÚÈÎÒ˜ ·fi ÙËÓ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË tHcy. ¶Èı·ÓfiÙÂÚË Â›Ó·È Ë ÂΉԯ‹ Ù˘ Â›‰Ú·Û˘ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ Î·È ¿ÏÏˆÓ ÂÈ‚·Ú˘ÓÙÈÎÒÓ ÛÙÔȯ›ˆÓ Ù˘ ‰È·‚›ˆÛ˘ ÙfiÛÔ ÛÙÔÓ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ fiÛÔ Î·È ÛÙË Û˘ÁΤÓÙÚˆÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘. ∂ÈÚÔÛı¤Ùˆ˜, ÛÙ· ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌÈο ·È‰È¿ Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÚÒÈÌ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘, ··ÈÙÂ›Ù·È ÂÓÙÔÓfiÙÂÚË ÚÔÛ¿ıÂÈ· ÂϤÁ¯Ô˘ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Î·È ı· Ú¤ÂÈ Ó· Û˘˙ËÙÂ›Ù·È ÙÔ ÂӉ¯fiÌÂÓÔ Ì›ˆÛ˘ ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ tHcy Ì ÙË Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË ‚ÈÙ·ÌÈÓÒÓ (67). ¶·È‰È·ÙÚÈ΋ 2007;70:379-388

Paidiatriki 5 final

12-10-07

16:28

Page 384

384

ª.£·ÓÔÔ‡ÏÔ˘, °. ∆ÛfiÏ·˜

∏ Â›‰Ú·ÛË ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ MTHFR 677CT ÛÙ· Â›‰· tHcy Î·È Ê˘ÏÏÈÎÔ‡ ÔͤԘ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙÈ̤˜ ÔÌÔ΢ÛÙ½Ó˘ ˘„ËÏfiÙÂÚ˜ ηٿ 25% Î·È ¯·ÌËÏfiÙÂÚ˜ ÙÈ̤˜ Ê˘ÏÏÈÎÔ‡ ÔͤԘ ÛÙ· ÔÌfi˙˘Á· ∆∆ ¿ÙÔÌ· Û ۯ¤ÛË Ì ٷ CC ¿ÙÔÌ·, ‰È·ÈÛÙÒıËÎÂ Î·È Û 92 ·È‰È¿ Ì ÔÈÎÔÁÂÓ‹ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· ËÏÈΛ·˜ 611 ÂÙÒÓ (69-70). ∂ÈÚfiÛıÂÙ·, Û 108 ·È‰È¿ ËÏÈΛ·˜ 4-18 ÂÙÒÓ Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÚÒÈÌ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘, ·Ó¢ڤıËÛ·Ó 32 ·È‰È¿ Ì ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·fi Ù· ÔÔ›· 12 ‹Ù·Ó ÔÌÔ˙˘ÁÒÙ˜ ÁÈ· ÙÔÓ C677T ÔÏ˘ÌÔÚÊÈÛÌfi ÙÔ˘ MTHFR ÁÔÓȉ›Ô˘ Î·È 10 ÂÌÊ¿ÓÈ˙·Ó ·˘ÍË̤ӷ Â›‰· ÔÌÔ΢ÛÙ½Ó˘ (71). ∏ tHcy ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› ÙfiÛÔ Ì ÙËÓ ÂÌÊ¿ÓÈÛË ∞∂∂ (64,72,73), fiÛÔ Î·È Ì ÙËÓ ÂΉ‹ÏˆÛË ÊÏ‚È΋˜ ıÚfiÌ‚ˆÛ˘ (74) ÛÙ· ÓÂÔÁ¤ÓÓËÙ· Î·È ÛÙ· ·È‰È¿. §fiÁˆ Ù˘ Û·ÓÈfiÙËÙ·˜ ÙˆÓ Û˘Ì‚·Ì¿ÙˆÓ, ÔÈ ÏËı˘ÛÌÔ› Ô˘ ¤¯Ô˘Ó ÌÂÏÂÙËı› Â›Ó·È ÌÈÎÚÔ› (ÂÚ›¶·Ú·‰ÔÛÈ·ÎÔ› ·Ú¿ÁÔÓÙ˜ - ÀÂÚÏÈȉ·ÈÌ›· - ¶·¯˘Û·ÚΛ·/ ªÂȈ̤ÓË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· - ™·Î¯·Ú҉˘ ‰È·‚‹Ù˘ - ∫¿ÓÈÛÌ· - À¤ÚÙ·ÛË

Ô˘ 400 ÂÚÈÙÒÛÂȘ ̤¯ÚÈ Û‹ÌÂÚ·), ·ÏÏ¿ Ë Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ÙËÓ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Â›Ó·È ÂÍ·ÈÚÂÙÈο ÈÛ¯˘Ú‹, ·ÓÙÈÛÙÔȯÒÓÙ·˜ Û ۯÂÙÈÎfi ΛӉ˘ÓÔ >4 (73). ™Â ÌÂϤÙË Ô˘ ÂÚȤϷ‚ 118 ·È‰È¿, ÂΛӷ Ì ÔÌfi˙˘ÁÔ ÁÔÓfiÙ˘Ô MTHFR TT ›¯·Ó ·˘ÍË̤Ó˜ Û˘ÁÎÂÓÙÚÒÛÂȘ tHcy Î·È ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ÂÓfi˜ ÚÒÙÔ˘ Î·È ·ÎÔÏÔ‡ıˆ˜ Â·ÓÂÈÏËÌÌ¤ÓˆÓ ÂÂÈÛÔ‰›ˆÓ (75). √ÌÔ›ˆ˜, ÌÂϤÙË Ô˘ ·ÊÔÚÔ‡Û ÂÚÈÛÛfiÙÂÚ· ·fi 140 ·È‰È¿ ¤‰ÂÈÍ fiÙÈ ÔÈ ÁÔÓfiÙ˘ÔÈ TT Î·È CT Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ∞∂∂ (74). ∆¤ÏÔ˜, ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÔÌÔ΢ÛÙ½Ó˘ Ï¿ÛÌ·ÙÔ˜ ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Û ·È‰È¿ Ì ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ∞∂∂ Û ËÏÈΛ· <50 ÂÙÒÓ, ·ÏÏ¿ Î·È Û ÂÊ‹‚Ô˘˜ ÌÂ Û˘ÛÙÔÏÈ΋ ˘¤ÚÙ·ÛË (76). √È ·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› Ù˘ ·ıËڈ̷ÙÔÁfiÓÔ˘ ‰Ú¿Û˘ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ‰ÂÓ Â›Ó·È Ï‹Úˆ˜ ÍÂηı·ÚÈṲ̂ÓÔÈ. ¶Èı·ÓÔÏÔÁÂ›Ù·È ¿ÌÂÛË ‚Ï¿‚Ë

∂Ó‰ÔÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜ - °ÂÓÂÙÈ΋ ÚԉȿıÂÛË - ¶ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ - ∞˘ÍË̤ÓË Â˘·ÈÛıËÛ›·

¡ÂÔÂÌÊ·ÓÈ˙fiÌÂÓÔÈ ·Ú¿ÁÔÓÙ˜ - ™˘ÛÙËÌ·ÙÈ΋ Ïԛ̈ÍË/ ÊÏÂÁÌÔÓ‹ - ∫˘ÙÙ·ÚÔΛÓ˜ - CRP - √ÌÔ΢ÛÙ½ÓË

¢À™§∂π∆√Àƒ°π∞ ∞°°∂π∞∫√À ∂¡¢√£∏§π√À

∞˘ÍË̤ÓË ÚÔÛÎfiÏÏËÛË Ï¢ÎÔ΢ÙÙ¿ÚˆÓ

ªÂȈ̤ÓË ·Ú·ÁˆÁ‹/ ‚ÈԉȷıÂÛÈÌfiÙËÙ· ÙÔ˘ ÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘

∞˘ÍË̤ÓË ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË ÂÓ‰ÔıËÏ›Ô˘

™¯ËÌ·ÙÈÛÌfi˜ Î·È ÂͤÏÈÍË ·ıËڈ̷ÙÈ΋˜ ‚Ï¿‚˘ ∂ÓÂÚÁÔÔ›ËÛË/ ·fiÛ·ÛË ·ıËڈ̷ÙÈ΋˜ Ͽη˜ £ÚfiÌ‚ˆÛË/ ·ÁÁÂÈfiÛ·ÛÌÔ˜ ∂Ï·Ùو̤ÓË ·ÈÌ·ÙÈ΋ ÚÔ‹

∫∞ƒ¢π∞°°∂π∞∫∏ ¡√™√™ ∂ÈÎfiÓ· 2. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚÒÈÌË ·ıËڈ̿وÛË Î·È ‚Ï¿‚Ë ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ ÂÓ‰ÔıËÏ›Ô˘.

Paediatriki 2007;70:379-388

ÀÂÚÏ·Û›· ÙÔ˘ ¤Ûˆ ¯ÈÙÒÓ· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Î·È ‰È‹ıËÛË ÙˆÓ Ï›ˆÓ Ì˘ÈÎÒÓ ÈÓÒÓ ·fi ÊÏÂÁÌÔÓÒ‰Ë Î‡ÙÙ·Ú·

Paidiatriki 5 final

12-10-07

16:28

Page 385

385

ÀÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜

ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Ì ÙËÓ ·Ú·ÁˆÁ‹ ÂÓÂÚÁÒÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘ Ô˘ ÚÔηÏÔ‡Ó ÔÍÂȉˆÙÈ΋ ‚Ï¿‚Ë ÛÙ· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú·, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Ì›ˆÛË Ù˘ ·Ú·ÁˆÁ‹˜ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙÔ˘ ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ¡√. ∞˘Ùfi Ô‰ËÁ› Û ÌÂȈ̤ÓË ‰È·Ù·ÛÈÌfiÙËÙ· ÙˆÓ ·ÁÁ›ˆÓ, Û ¿ıÚÔÈÛË Î·È ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ, Û ÚÔÛÎfiÏÏËÛË ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ Î·È Û ۯËÌ·ÙÈÛÌfi ıÚfiÌ‚Ô˘, ηٷÛÙ¿ÛÂȘ ÔÈ Ôԛ˜ ÚÔ¿ÁÔ˘Ó ÙËÓ ·ıËڈ̷ÙÈ΋ ‰ÈÂÚÁ·Û›· (77-79) (∂ÈÎfiÓ· 2).

£ÂÚ·›· Ù˘ ‹È·˜ Î·È Ì¤ÙÚÈ·˜ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ √ ·ÚÈÔ˜ ıÂÚ·¢ÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ù˘ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ Â›Ó·È ÙÔ Ê˘ÏÏÈÎfi Ô͇, ÌfiÓÔ ÙÔ˘ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÎÔ‚·Ï·Ì›ÓË Î·È ÙË ‚ÈÙ·Ì›ÓË µ6 (7). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ÙÚÂȘ ·˘ÙÔ› ·Ú¿ÁÔÓÙ˜ Û˘¯Ó¿ Û˘Á¯ÔÚËÁÔ‡ÓÙ·È, Ê·›ÓÂÙ·È fiÙÈ ÙÔ Ê˘ÏÏÈÎfi Ô͇ Â›Ó·È ÙÔ ϤÔÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfi, ·ÊÔ‡ Ô‰ËÁ› Û ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ fiÙ·Ó ¯ÔÚËÁÂ›Ù·È ˆ˜ ÌÔÓÔıÂÚ·›· (8,9). ªÂÙ·-·Ó¿Ï˘ÛË ‰Ò‰Âη ÌÂÏÂÙÒÓ, ÔÈ Ôԛ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË Ì›ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Ì ÙËÓ ÚÔÛı‹ÎË Ê˘ÏÏÈÎÔ‡ ÔͤԘ ÛÙÔ ‰È·ÈÙÔÏfiÁÈÔ 1114 ·ÙfïÓ, ›Ù ÌfiÓÔ˘ ›Ù ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‚ÈÙ·Ì›ÓË µ6 ‹ ‚ÈÙ·Ì›ÓË µ12 ‹ Î·È ÙȘ ‰‡Ô ‚Èٷ̛Ә (10), ¤‰ÂÈÍ fiÙÈ Ë ·Ó·ÏÔÁÈ΋ Î·È ·fiÏ˘ÙË Ì›ˆÛË ÙˆÓ ÙÈÌÒÓ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Ô˘ ÚÔÎÏ‹ıËΠ·fi ÙË Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË Ê˘ÏÏÈÎÔ‡ ÔͤԘ ‹Ù·Ó ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚË fiÛÔ ˘„ËÏfiÙÂÚË ‹Ù·Ó Ë ÙÈÌ‹ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Î·È fiÛÔ ¯·ÌËÏfiÙÂÚ· Ù· Â›‰· Ê˘ÏÏÈÎÔ‡ ÔͤԘ ÛÙÔÓ ÔÚfi ÚÈÓ ÙË ıÂÚ·¢ÙÈ΋ ·Ú¤Ì‚·ÛË. ∏ ‚ÈÙ·Ì›ÓË µ12 Ô‰‹ÁËÛ Û ÂÈÚfiÛıÂÙË Ì¤ÛË ÂÏ¿ÙÙˆÛË Ù˘ ٿ͈˜ ÙÔ˘ 7% (3-10%), ÂÓÒ Ë ‚ÈÙ·Ì›ÓË µ6 ‰ÂÓ Â›¯Â ÛËÌ·ÓÙÈ΋ ÂÈÚfiÛıÂÙË ‰Ú¿ÛË (10). ¶·ÚfiÏ· ·˘Ù¿, Ë ‚ÈÙ·Ì›ÓË µ6 Ú¤ÂÈ Ó· Û˘Á¯ÔÚËÁÂ›Ù·È Ì ÙÔ Ê˘ÏÏÈÎfi Ô͇ Î·È ÙË ‚ÈÙ·Ì›ÓË µ12, ηıÒ˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÌÂÈÒÓÂÈ Ù· Â›‰· ÔÌÔ΢ÛÙ½Ó˘ ·›Ì·ÙÔ˜ ÌÂÙ¿ ·fi ÙË ÊfiÚÙÈÛË Ì ÌÂıÂÈÔÓ›ÓË (10). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ‚Èٷ̛Ә ÌÂÈÒÓÔ˘Ó Ù· Â›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ÛÙÔ ·›Ì·, ‰ÂÓ ÁÓˆÚ›˙Ô˘Ì ·ÎfiÌË ·Ó Ù·˘Ùfi¯ÚÔÓ· ÂÈÙ˘Á¯¿ÓÔ˘Ó Î·È Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂΉ‹ÏˆÛ˘ ·ÁÁÂȷ΋˜ ÓfiÛÔ˘. ªÂ ‚¿ÛË ÙË ‰È·‚·ıÌÈ˙fiÌÂÓË Â›‰Ú·ÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ÛÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘, ÌÈ· ÌÂÙ·-·Ó¿Ï˘ÛË ¤Ó‰Âη ÌÂÏÂÙÒÓ Ù˘ Â›‰Ú·Û˘ Ù˘ ·˘ÍË̤Ó˘ ÚfiÛÏ˄˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ ˘ÔÏfiÁÈÛ fiÙÈ 13.500 ¤ˆ˜ 50.000 ı¿Ó·ÙÔÈ ÂÙËÛ›ˆ˜ ·fi ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ı· ÌÔÚÔ‡Û·Ó Ó· ·ÔÊ¢¯ıÔ‡Ó ÛÙȘ ∏.¶.∞. Ì ÙÔÓ ÂÌÏÔ˘ÙÈÛÌfi ÙˆÓ ÙÚÔÊ›ÌˆÓ ÛÂ Ê˘ÏÏÈÎfi Ô͇ (11). ∏ Ï‹„Ë 100 g ‰ËÌËÙÚÈ·ÎÒÓ ËÌÂÚËÛ›ˆ˜ Ô˘ ·Ú¤¯Ô˘Ó 127 Ìg Ê˘ÏÏÈÎÔ‡ ÔͤԘ, ÔÛfiÙËÙ· Ë ÔÔ›· ·ÓÙÈÛÙÔȯ› ÂÚ›Ô˘ ÛÙ· Â›‰·

ÂÌÏÔ˘ÙÈÛÌÔ‡ ÌÂ Ê˘ÏÏÈÎfi Ô͇ Ô˘ Û˘ÓÈÛÙ¿ Ë ∂ÈÙÚÔ‹ ∆ÚÔÊ›ÌˆÓ Î·È º·ÚÌ¿ÎˆÓ ÙˆÓ ∏.¶.∞., F.D.A.Food and Drug Administration-(140 Ìg ÁÈ· οı 100 g ‰ËÌËÙÚÈ·ÎÒÓ), ÂÈÙ˘Á¯¿ÓÂÈ Ì›ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ tHcy ÌfiÓÔ Î·Ù¿ 3,7%, fiˆ˜ Ê¿ÓËΠ·fi Ì›· ÚfiÛÊ·ÙË ÌÂϤÙË, Ì›ˆÛË Èı·Ófiٷٷ ·ÓÂ·Ú΋ ÁÈ· ÙËÓ ·ÔÙÚÔ‹ ηډȷÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ (12). ™ÙË ÌÂϤÙË “Nurses’ Health Study”, Ô˘ ·ÊÔÚÔ‡Û ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· 14 ¤ÙË 80.082 Á˘Ó·ÈÎÒÓ, ÛÙËÓ ÔÔ›· ˘ÔÏÔÁ›ÛıËÎÂ Ë Û˘Ó‹ı˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓË ‰fiÛË Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ‚ÈÙ·Ì›Ó˘ µ6 ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô Î·È ÁÈ· ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ‰È·ÈÛÙÒıËΠfiÙÈ Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ·Ó¿ÌÂÛ· ÛÙ· ·ÎÚ·›· ÂÌÙËÌfiÚÈ· Ù˘ ËÌÂÚ‹ÛÈ·˜ ÚfiÛÏ˄˘ ‹Ù·Ó 0,69 (95% C.I. 0,53-0,87) fiÛÔÓ ·ÊÔÚ¿ ÙÔ Ê˘ÏÏÈÎfi Ô͇ (̤ÛË ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë 696 Ìg ¤Ó·ÓÙÈ 158 Ìg) Î·È 0,67 (95% C.I. 0,530,85) ÁÈ· ÙË ‚ÈÙ·Ì›ÓË µ6 (̤ÛË ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë 4,6 mg ¤Ó·ÓÙÈ 1,1 mg) (13). ™ÙËÓ ›‰È· ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ Ô Î›Ó‰˘ÓÔ˜ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ ÌÂÈÒıËΠ۠fiÛ˜ Á˘Ó·›Î˜ Ï¿Ì‚·Ó·Ó Û˘ÛÙËÌ·ÙÈο ÔÏ˘‚ÈÙ·ÌÈÓÔ‡¯· Û˘ÌÏËÚÒÌ·Ù· (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜: 0,76, 0,65-0,9) (13). ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ˘fiıÂÛË fiÙÈ Ë ÚfiÛÏË„Ë Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ‚ÈÙ·Ì›Ó˘ µ6 ÌÔÚ› Ó· ‰È·‰Ú·Ì·Ù›ÛÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ÔÙÚÔ‹ Ù˘ ÚÒÈÌ˘ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘. ∏ ̤¯ÚÈ Û‹ÌÂÚ· Û˘ÓÈÛÙÒÌÂÓË ıÂÚ·›· Ù˘ ‹È·˜ Î·È Ì¤ÙÚÈ·˜ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯ÔÚ‹ÁËÛË Ê˘ÏÏÈÎÔ‡ ÔͤԘ Û ‰fiÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ 0,5 mg ËÌÂÚËÛ›ˆ˜ Î·È ‚ÈÙ·ÌÈÓÒÓ µ6 Î·È µ12 Ì ÛÎÔfi ÙË ‰È·ÛÊ¿ÏÈÛË Ù˘ Ï‹ÚÔ˘˜ ·ÓÙ·fiÎÚÈÛ˘ ÛÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ÙËÓ ·ÔÙÚÔ‹ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂΉ‹ÏˆÛ˘ Ó¢ÚÔ¿ıÂÈ·˜ ÏfiÁˆ ¤ÏÏÂȄ˘ Ù˘ ÎÔ‚·Ï·Ì›Ó˘, ÂÈÎfiÓ· ÙËÓ ÔÔ›· Û˘ÁηχÙÂÈ Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ. √È ‰fiÛÂȘ ÙˆÓ ‚ÈÙ·ÌÈÓÒÓ µ6 Î·È µ12 Ô˘ ı· Ú¤ÂÈ Ó· Û˘Á¯ÔÚËÁÔ‡ÓÙ·È Ì ÙÔ Ê˘ÏÏÈÎfi Ô͇ ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌË Î·ıÔÚÈÛı› (80). ¢ÈÂÍ¿ÁÔÓÙ·È ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ Ì ÛÎÔfi ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ÂÈη˙fiÌÂÓ˘ ·ÓÙÈ·ıËڈ̷ÙÈ΋˜ Î·È ·ÓÙÈıÚÔÌ‚ˆÙÈ΋˜ ‰Ú¿Û˘ Ù˘ Û˘ÌÏËڈ̷ÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ‚ÈÙ·ÌÈÓÒÓ.

™˘Ì¤Ú·ÛÌ· ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÌÂÏÂÙÒÓ Î·Ù·‰ÂÈÎÓ‡ÂÈ fiÙÈ ·ÎfiÌË Î·È Ë ‹È· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·ÓÂÍ¿ÚÙËÙÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÚÒÈÌ˘ ·ıËڈ̿وÛ˘ ηıÒ˜ Î·È ·ÚÙËÚȷ΋˜ Î·È ÊÏ‚È΋˜ ıÚfiÌ‚ˆÛ˘ Û ÂÓ‹ÏÈΘ. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ηٷ‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË Ù˘ tHcy ·ÔÙÂÏ› ÈÛ¯˘Úfi ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÔÊÚ·ÎÙÈ΋ ·ÁÁÂȷ΋ ÓfiÛÔ Î·È ÛÙ· ·È‰È¿. ∞·ÈÙ›ٷÈ, ˆÛÙfiÛÔ, Ë ‰ÈÂÓ¤ÚÁÂÈ· Î·È ¿ÏÏˆÓ ÚÔÔÙÈÎÒÓ ÌÂÏÂÙÒÓ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÙÂÎÌËÚȈı› ÏËÚ¤ÛÙÂÚ· ¶·È‰È·ÙÚÈ΋ 2007;70:379-388

Paidiatriki 5 final

12-10-07

16:28

Page 386

386

ª.£·ÓÔÔ‡ÏÔ˘, °. ∆ÛfiÏ·˜

Ë ·Ú·¿Óˆ Û¯¤ÛË ·ÏÏ¿ Î·È Ó· ˘¿ÚÍÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ÚfiÏ˄˘ Ì ÙȘ ηٿÏÏËϘ ·ÚÂÌ‚¿ÛÂȘ Î·È ÚÔÛı‹Î˜ ÛÙÔ ‰È·ÈÙÔÏfiÁÈÔ.

17.

µÈ‚ÏÈÔÁÚ·Ê›· 1. McGill HC Jr, McMahan CA, Zieske AW, Sloop GD, Walcott JV, Troxclair DA, et al. Associations of coronary heart disease risk factors with the intermediate lesion of atherosclerosis in youth. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Arterioscler Thromb Vasc Biol 2000;20:1998-2004.

2. Berenson GS, Srinivasan SR, Bao W, Newman WP 3rd, Tracy RE, Wattingney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults: The Bogalusa Heart Study. N Engl J Med 1998;338:1650-1656.

3. Groner JA, Joshi M, Bauer JA. Pediatric precursors of adult cardiovascular disease: noninvasive assessment of early vascular changes in children and adolescents. Pediatrics 2006;118:1683-1691.

4. Gaziano JM. When should heart disease prevention begin?

New Engl J Med 1998;338:1690-1692.

5. Van Horn L, Greenland P. Prevention of coronary artery disease is a pediatric problem. JAMA 1997;278:1779-1780.

6. Hoeg JM. Evaluating coronary heart disease risk. JAMA 1997;277:1387-1390.

7. Brattstrom L. Vitamins as homocysteine-lowering agents.

J Nutr 1996;126:1276-1280.

8. Wiltshire EJ, Couper JJ. Improved folate status in children and adolescents during voluntary fortification of food with folate. J Paediatr Child Health 2004;40:44-47.

9. Ganji V, Kafai MR. Population references for plasma total homocysteine concentrations for U.S. children and adolescents in the post-folic acid fortification era. J Nutr 2005;135:2253-2256.

10. Homocysteine Lowering Trialists’ Collaboration. Lowering blood homocysteine with folic acid-based supplements: meta-analysis of randomised trials. BMJ 1998;316: 894-898.

11. Boushey CJ, Beresford SA, Omenn GS, Motulsky AG. A quantitative assessment of plasma homocysteine as a risk factor for vascular disease: probable benefits of increasing folic acid intakes. JAMA 1995;274:1049-1057.

12. Malinow MR, Duell PB, Hess DL, Anderson PH, Kruger WD, Phillipson BE, et al. Reduction of plasma homocyst(e)ine levels by breakfast cereal fortified with folic acid in patients with coronary heart disease. N Eng J Med 1998; 338:1009-1015.

13. Rimm EB, Willet WC, Hu FB, Sampson L, Colditz GA, Manson JE, et al. Folate and vitamin B6 from diet and supplements in relation to risk of coronary heart disease among women. JAMA 1998;279:359-364.

14. Fowler B. Disorders of homocysteine metabolism. J Inherit Metab Dis 1997;20:270-285.

15. Ueland PM. Determinants of plasma homocysteine. In: Robinson K, ed. Homocysteine and vascular disease.

Boston: Kluwer Academic Publishers; 2000:59-84.

16. Bates CJ, Mansoor MA, Gregory J, Pentiev K, Prentice A. Correlates of plasma homocysteine, cysteine and cysteinyl-glycine in respondents in the British National Diet and Nutrition Survey of young people aged 4-18 years, and Paediatriki 2007;70:379-388

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

a comparison with the survey of people aged 65 years and over. Br J Nutr 2002;87:71-79.

Minniti G, Cerone R, Piana A, Armani U, Lorini R. Plasma and serum total homocysteine concentrations in paediatric patients, evaluated by high-performance liquid chromatography with fluorescence. Clin Chem Lab Med 2000;38:675-676. van Beynum IM, den Heijer M, Thomas CM, Afman L, Oppenraav-van Emmerzaal D, Blom HJ. Total homocysteine and its predictors in Dutch children. Am J Clin Nutr 2005;81:1110-1116.

Reddy MN. Reference ranges for total homocysteine in children. Clin Chim Acta 1997;262:153-155.

Vilaseca MA, Moyano D, Ferrer I, Artuch R. Total homocysteine in pediatric patients. Clin Chem 1997;43:690-692.

Rauh M, Verwied S, Knerr I, Dörr HG, Sönnichsen A, Koletzko B. Homocysteine concentrations in a German cohort of 500 individuals: reference ranges and determinants of plasma levels in healthy children and their parents.

Amino Acids 2001;20:409-418.

Nygard O, Vollset SE, Refsum H, Stensvold I, Tverdal A, Nordrehaug JE, et al. Total plasma homocysteine and cardiovascular risk profile. The Hordaland Homocysteine Study. JAMA1995;274:1526-1533.

Ueland PM, Monsen AL. Hyperhomocysteinemia and Bvitamin deficiencies in infants and children. Clin Chem Lab Med 2003;41:1418-1426.

Giraud DW, Driskell JA, Setiawan B. Plasma homocysteine concentrations of Indonesian children with inadequate and adequate vitamin B-6 status. Nutr Res 2001;21:961-966.

Martos R, Valle M, Morales R, Canete R, Gavilan MI, Sãanchez-Margalet V. Hyperhomocysteinemia correlates with insulin resistance and low-grade systemic inflammation in obese prepubertal children. Metabolism 2006;55:72-77.

Gallistl S, Sudi K, Mangge H, Erwa W, Borkenstein M. Insulin is an independent correlate of plasma homocysteine levels in obese children and adolescents. Diabetes Care 2000;23:1348-1352.

Glowinska B, Urban M, Koput A, Galar M. New atherosclerosis risk factors in obese, hypertensive and diabetic children and adolescents. Atherosclerosis 2003;167:275-286.

Juonala M, Viikari JS, Laitinen T, Marniemi J, Helenius H, Rönnemaa T, et al. Interrelations between brachial endothelial function and carotid intima-media thickness in young adults: the cardiovascular risk in young Finns study.

Circulation 2004;110:2918-2923.

Gallistl S, Sudi KM, Erwa W, Aigner R, Borkenstein M. Determinants of homocysteine during weight reduction in obese children and adolescents. Metabolism 2001;50: 1220-1223.

Papoutsakis C, Yiannakouris N, Manios Y, Papaconstantinou E, Magkos F, Schulpis KM, et al.The effect of MTHFR(C677T) genotype on plasma homocysteine concentrations in healthy children is influenced by gender. Eur J Clin Nutr 2006;60:155-162.

Infante-Rivard C, Rivard GE, Yotov WV, Théôret Y. Perinatal reference intervals for plasma homocysteine and factors influencing its concentration. Clin Chem 2002;48: 1100-1102.

Orend aã c M , Zeman J, Stabler SP, Allen RH, Kraus JP, Bodamer O, et al. Homocystinuria due to cystathionine

Paidiatriki 5 final

12-10-07

16:28

Page 387

387

ÀÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

beta-synthase deficiency: novel biochemical findings and treatment efficacy. J Inherit Metab Dis 2003;26:761-773.

Mudd SH, Levy HL, Kraus JP. Disorders of transulfuration. In: Scriver CR, Beaudet AL, Sly WS, Valle D, Childs B, Kinzler KW, editors. The Metabolic and Molecular Bases of Inherited Disease. New York: McGraw-Hill 1995; pp 1279-1327.

Rozen R. Molecular genetics of methylenetetrahydrofolate reductase deficiency. J Inherit Metab Dis 1996;19:589-594.

Rook JL, Nugent DJ, Young G. Pediatric stroke and methylenetetrahydrofolate reductase polymorphisms: an examination of C677T and A1298C mutations. J Pediatr Hematol Oncol 2005;27:590-593.

Kosch A, Koch HG, Heinecke A, Kurnik K, Heller C, Nowak-Göttl U, et al. Increased fasting total homocysteine plasma levels as a risk factor for thromboembolism in children. Thromb Haemost 2004;91:308-314.

Prengler M, Sturt N, Krywawych S, Surtees R, Liesner R, Kirkham F. Homozygous thermolabile variant of methylenetetrahydrofolate reductase gene: a potential risk factor for hyperhomocysteinaemia, CVD, and stroke in childhood. Dev Med Child Neurol 2001;43:220-225.

Ma J, Stampfer MJ, Hennekens CH, Frosst P, Selhub J, Horsford J, et al. Methylenetetrahydrofolate reductase polymorphism, plasma folate, homocysteine, and risk of myocardial infarction in US physicians. Circulation 1996;94:2410-2416.

Delvin EE, Rozen R, Merouani A, Genest J Jr, Lambert M. Influence of methylenetetrahydrofolate reductase genotype, age, vitamin B-12, and folate status on plasma homocysteine in children. Am J Clin Nutr 2000;72:1469-1473.

Bostom AG, Culleton BF. Hyperhomocysteinemia in chronic renal disease. J Am Soc Nephrol 1999;10:891-900. van der Mooren MJ, Wouters MG, Blom HJ, Schellekens LA, Eskes TK, Rolland R. Hormone replacement therapy may reduce high serum homocysteine in postmenopausal women. Eur J Clin Invest 1994;24:733-736.

Cattaneo M, Baglietto L, Zighetti ML, Bettega D, Robertson C, Costa A, et al. Tamoxifen reduces plasma homocysteine levels in healthy women. Brit J Cancer 1998;77:2264-2266.

Kang SS, Wong PW, Glickman PB, MacLeod CM, Jaffe IA. Protein-bound homocyst(e)ine in patients with rheumatoid arthritis undergoing D- penicillamine treatment. J Clin Pharmacol 1986;26:712-715.

Wiklund O, Fager G, Andersson A, Lundstam U, Masson P, Hultberg B. N-acetylcysteine treatment lowers plasma homocysteine but not serum lipoprotein(a) levels. Atherosclerosis 1996;119:99-106.

Papandreou D, Mavromichalis I, Makedou A, Rousso J, Arvanitidou M. Total serum homocysteine, folate and vitamin B12 in a Greek school age population. Clin Nutr 2006;25:797-802.

Papandreou D, Mavromichalis I, Makedou A, Rousso J, Arvanitidou M. Reference range of total serum homocysteine level and dietary indexes in healthy Greek schoolchildren aged 6-15 years. Br J Nutr 2006;96:719-724.

Papoutsakis C, Yiannakouris N, Manios Y, Papaconstantinou E, Magkos F, Schulpis KH, et al. Plasma homocysteine concentrations in Greek children are influenced by an interaction between the methylenetetrahydrofolate reductase C677T genotype and folate status. J Nutr.

2005;135:383-388.

48. Tonstad S, Refsum H, Ueland PM. Association between plasma total homocysteine and parental history of cardiovascular disease in children with familial hypercholesterolemia. Circulation 1997;96:1803-1808.

49. Refsum H, Ueland PM, Nygard O, Vollset SE. Homocysteine and cardiovascular disease. Annu Rev Med 1998;49:31-62.

50. Boushey CJ, Beresford SA, Omenn GS, Motulsky AG. A quantitative assessment of plasma homocysteine as a risk factor for vascular disease. Probable benefits of increasing folic acid intakes. JAMA 1995;274:1049-1057.

51. Robinson K, Arheart K, Refsum H, Brattström L, Boers G, Ueland P, et al. Low circulating folate and vitamin B6 concentrations: risk factors for stroke, peripheral vascular disease, and coronary artery disease. European COMAC Group. Circulation 1998;97:437-443.

52. Juonala M, Viikari JS, Laitinen T, Marniemi J, Helenius H, Rönnemaa T, et al. Interrelations between brachial endothelial function and carotid intima-media thickness in young adults: the cardiovascular risk in young Finns study.

Circulation 2004;110:2918-2923.

53. Malinow MR, Nieto FJ, Szklo M, Chambless LE, Bond G. Carotid artery intimal-medial wall thickening and plasma homocyst(e)ine in asymptomatic adults. The Atherosclerosis Risk in Communities Study. Circulation 1993;87: 1107-1113.

54. Konecky N, Malinow MR, Tunick PA, Freedberg RS, Rosenzweig BP, Katz ES. Correlation between plasma homocyst(e)ine and aortic atherosclerosis. Am Heart J 1997;133:534-540.

55. Verhoef P, Kok FJ, Kruyssen DA, Schouten EG, Witteman JC, Grobbee DE, et al. Plasma total homocysteine, B vitamins, and risk of coronary atherosclerosis. Arterioscler Thromb Vasc Biol 1997;17:989-995.

56. van den Berg M, Stehouwer CD, Bierdrager E, Rauwerda JA. Plasma homocysteine and severity of atherosclerosis in young patients with lower-limb atherosclerotic disease.

Arterioscler Thromb Vasc Biol 1996;16:165-171.

57. Arnesen E, Refsum H, Bo/ naa KH, Ueland PM, Fo/ rde OH, Nordrehaug JE. Serum total homocysteine and coronary heart disease. Int J Epidemiol 1995;24:704-709.

58. Evans RW, Shaten BJ, Hempel JD, Cutler JA, Kuller LH. Homocyst(e)ine and risk of cardiovascular disease in the Multiple Risk Factor Intervention Trial. Arterioscler Thromb Vasc Biol 1997;17:1947-1953.

59. Wald NJ ,Watt HC, Law MR, Weir DG, McPartlin J, Scott JM. Homocysteine and ischemic heart disease: results of a prospective study with implications regarding prevention.

Arch Intern Med 1998;158:862-867.

60. Nygard O, Nordrehaug JE, Refsum H, Ueland PM, Farstad M, Vollset SE. Plasma homocysteine levels and mortality in patients with coronary artery disease. N Engl J Med 1997;337:230-236.

61. Folsom AR, Nieto FJ, McGovern PG, Tsai MY, Malinow MR, Eckfeldt JH, et al. Prospective study of coronary heart disease incidence in relation to fasting total homocysteine, related genetic polymorphisms, and B vitamins. The Atherosclerosis Risk In Communities (ARIC) study. Circulation 1998;98:204-210.

62. Kirkham FJ, Prengler M, Hewes DK, Ganesan V. Risk factors for arterial ischemic stroke in children. J Child Neurol 2000;15:299-307.

63. Kaplan ED. Association between homocyst(e)ine levels ¶·È‰È·ÙÚÈ΋ 2007;70:379-388

Paidiatriki 5 final

12-10-07

16:28

Page 388

388

ª.£·ÓÔÔ‡ÏÔ˘, °. ∆ÛfiÏ·˜

64.

65.

66.

67.

68.

69.

70.

71.

72.

and risk of vascular events. DrugsToday (Barc.) 2003;39: 175-192.

Kosch A, Koch HG, Heinecke A, Kurnik K, Heller C, Nowak-Göttl U, et al. Increased fasting total homocysteine plasma levels as a risk factor for thromboembolism in children. Thromb Haemost 2004;91:308-314.

Kark JD, Sinnreich R, Rosenberg IH, Jacques PF, Selhub J. Plasma homocysteine and parental myocardial infarction in young adults in Jerusalem. Circulation 2002;105:27252729.

Hyanek J, Stribrny J, Sebesta B, Klika M, Kramar J, Kozich V, et al. Diagnostic significance of mild hyperhomocysteinemia in a population of children with parents or grandparents who have peripheral or coronary artery disease. Cas Lek Cesk 1999;138:333-336.

Zhu W, Huang X, Li M, Neubauer H. Elevated plasma homocysteine in obese schoolchildren with early atherosclerosis. Eur J Pediatr 2006;165:326-331.

Laskowska-Klita T, Szymczak E, Radomyska B. Serum homocysteine and lipoprotein (a) concentrations in hypercholesterolemic and normocholesterolemic children. Clin Pediatr (Phila) 2001;40:149-154.

Ueland PM, Hustad S, Schneede J, Refsum H, Vollset SE. Biological and clinical implications of the MTHFR C677T polymorphism. Trends Pharmacol Sci 2001;22:195-201.

Tonstad S, Refsum H, Ose L, Ueland PM. The C677T mutation in the methylenetetrahydrofolate reductase gene predisposes to hyperhomocysteinemia in children with familial hypercholesterolemia treated with cholestyramine. J Pediatr 1998;132:365-368.

Szamosi ∆, Roth E, Szamosi T, Tomsits E, Tordai A, Szabo T. Hyperhomocysteinemia, enzyme polymorphism and thiobarbituric Acid reactive system in children with high coronary risk family history. J Am Coll Nutr 2004;23:386-390.

Nowak-Göttl U, Sträter R, Heinecke A, Junker R, Koch HG, Schuierer G, von Eckardstein A. Lipoprotein (a) and

Paediatriki 2007;70:379-388

73.

74.

75.

76.

77.

78.

79.

80.

genetic polymorphisms of clotting factor V, prothrombin, and methylenetetrahydrofolate reductase are risk factors of spontaneous ischemic stroke in childhood. Blood 1999;94:3678-3682.

Hogeveen M, Blom HJ, van Amerongen M, Boogmans B, van Beynum IM, van de Bor M. Hyperhomocysteinemia as risk factor for ischemic and hemorrhagic stroke in newborn infants. J Pediatr 2002;141:429-431.

Nowak-Gottl U, Duering C, Kempf-Bielack B, Strater R. Thromboembolic diseases in neonates and children.

Pathophysiol Haemost Thromb 2003 Sep-2004 Dec;33:269-274.

Prengler M, Sturt N, Krywawych S, Surtees R, Liesner R, Kirkham F. Homozygous thermolabile variant of the methylenetetrahydrofolate reductase gene: a potential risk factor for hyperhomocysteinaemia, CVD, and stroke in childhood. Dev Med Child Neurol 2001;43:220-225.

Gillum RF. Distribution of total serum homocysteine and its association with parental history and cardiovascular risk factors at ages 12-16 years: the Third National Health And Nutrition Examination Survey. Ann Epidemiol 2004;14:229-233.

Undas A, Brozek J, Szczeklik A. Homocysteine and thrombosis: from basic science to clinical evidence. Thromb Haemost 2005;94:907-915.

Cesari M, Rossi GP, Sticchi D, Pessina AC. Is homocysteine important as risk factor for coronary heart disease?

Nutr Metab Cardiovasc Dis 2005;15:140-147.

Clarke R. Commentary: an updated review of the published studies of homocysteine and cardiovascular disease.

Int J Epidemiol 2002;31:70-71.

Huemer M, Vonblon K, Födinger M, Krumpholz R, Hubmann M, Ulmer H, et al. Total homocysteine, folate,and cobalamin, and their relation to genetic polymorphisms, lifestyle and body mass index in healthy children and adolescents. Pediatr Res 2006;60:764-769.

Paidiatriki 5 final

12-10-07

16:28

µƒ∞µ∂Àª∂¡∏ ∂ƒ°∞™π∞

Page 389

AWARD-WINNING ARTICLE

389

ªÂϤÙË ÙÔ˘ ÁÔÓȉȷÎÔ‡ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ +405g/c VEFG Î·È ÙˆÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û ·È‰È¿ Ì ÓfiÛÔ Kawasaki §. ºÈ‰¿ÓË1, ∞. °È·ÓÓfiÔ˘ÏÔ˜1, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜1, °. ∆˙Ô˘‚ÂϤ΢1, ∫. ∫·ÏÈÓ‰¤ÚË2, ∞. ∫ÒÙÛ˘2, π. ∫·‚·ÏÈÒÙ˘3, º. ∞ı·Ó·ÛÈ¿‰Ô˘1 ¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ Kawasaki (¡∫) ·ÔÙÂÏ› ÔÍ›· Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈ›Ùȉ· Ù˘ ‚ÚÂÊÈ΋˜ Î·È ·È‰È΋˜ ËÏÈΛ·˜ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÚÂÙfi Î·È ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÏÏÔÈÒÛÂȘ ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ Î·È Û˘ÛÙËÌ¿ÙˆÓ. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ Ì·˜ ‹Ù·Ó Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È ÙÔ˘ ÁÔÓȉȷÎÔ‡ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ +405G/C ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ ÂÓ‰ÔıËÏÈ·ÎÔ‡ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (VEGF) Ì ÙË ¡∫ Û ·È‰È¿ ·fi ÙË µfiÚÂÈ· ∂ÏÏ¿‰·. ∏ ÌÂϤÙË Ì·˜ ‰ÈÂÓÂÚÁ‹ıËΠ·fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ 2004 ˆ˜ ÙÔÓ ¢ÂΤ̂ÚÈÔ 2006. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ‚·Û›ÛÙËΠÛÙ· ÎÚÈÙ‹ÚÈ· Ô˘ ¤¯Ô˘Ó ıÂÛÈÛÙ› ·fi ÙËÓ ∞ÌÂÚÈηÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›·. °È· οı ·ÛıÂÓ‹ ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙˆÓ ‰ËÌÔÁÚ·ÊÈÎÒÓ, ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘. ™Â 19 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ Ì·˜ ¤ÁÈÓ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ VEGF 405G C ÔÏ˘ÌÔÚÊÈÛÌÔ‡ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Û˘ÁÎÚ›ıËÎ·Ó Ì ٷ ·ÓÙ›ÛÙÔȯ· 55 ˘ÁÈÒÓ Ì·ÚÙ‡ÚˆÓ È‰›Ô˘ ʇÏÔ˘. ∞fi ÙÔ˘˜ 20 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘, 10 (50%) ÂÌÊ¿ÓÈ˙·Ó ÂΉËÏÒÛÂȘ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡Ìʈӷ Ì ٷ ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈο ÙÔ˘˜ Â˘Ú‹Ì·Ù·, ÂÎ ÙˆÓ ÔÔ›ˆÓ 8 (80%) ·ÁfiÚÈ· (p<0,05). ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ ˘ÚÂÙÔ‡ ÚÈÓ ÙËÓ ¯ÔÚ‹ÁËÛË ÎÔÈÓ‹˜ Á-ÛÊ·ÈÚ›Ó˘ Î·È Ë ¯·ÌËÏ‹ ÙÈÌ‹ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ηٿ ÙË ‰È¿ÁÓˆÛË ·ÔÙ¤ÏÂÛ·Ó ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ. TÔ ÔÛÔÛÙfi ÙˆÓ VEGF +405 CC ÔÌÔ˙˘ÁˆÙÒÓ ÂÌÊ·Ó›ÛÙËΠ·˘ÍË̤ÓÔ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, Û ۯ¤ÛË Ì ÙÔ˘˜ ÌË ¿Û¯ÔÓÙ˜, ·Ó Î·È Ë ‰È·ÊÔÚ¿ ‹Ù·Ó ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (26,3 ¤Ó·ÓÙÈ 14,5%, p =0,205). ∂ÈϤÔÓ, Û‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ηٷÁÚ¿ÊËΠ·˘ÍË̤ÓË ·ÚÔ˘Û›· ÙˆÓ ÊÔÚ¤ˆÓ ÙÔ˘ G ·ÏÏËÏÔÌfiÚÊÔ˘ ÛÙËÓ ˘ÔÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜. ¶ÚÔ·ÙÂÈ Û˘ÓÂÒ˜, fiÙÈ Ë Â¤ÎÙ·ÛË Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û ÌÂÁ·Ï‡ÙÂÚÔ ‰Â›ÁÌ· ·ÛıÂÓÒÓ ·Ó·Ì¤ÓÂÙ·È Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÂÍ·ÁˆÁ‹ ·ÛʷϤÛÙÂÚˆÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ÁÈ· ÙÔÓ ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi ÛÙÔ Ì¤ÏÏÔÓ.

1 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£, ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞ £ÂÛÛ·ÏÔÓ›ÎË 2 ∂ÚÁ·ÛÙ‹ÚÈÔ °ÂÓÂÙÈ΋˜µÈÔÏÔÁ›·˜ ∞.¶.£, £ÂÛÛ·ÏÔÓ›ÎË 3 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ∂ȉÈÎÒÓ ¶·ı‹ÛˆÓ, £ÂÛÛ·ÏÔÓ›ÎË AÏÏËÏÔÁÚ·Ê›·: º. ∞ı·Ó·ÛÈ¿‰Ô˘¶ÈÂÚÔÔ‡ÏÔ˘ atriagia@auth.gr, atragian@hotmail.com ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞ ™Ù. ∫˘ÚȷΛ‰Ë 1 ∆.∫. 54 636, £ÂÛÛ·ÏÔÓ›ÎË

§¤ÍÂȘ ÎÏÂȉȿ: ¡fiÛÔ˜ Kawasaki, ·ÁÁÂÈ·Îfi˜ ÂÓ‰ÔıËÏÈ·Îfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, ÔÏ˘ÌÔÚÊÈÛÌfi˜, ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜.

Study of VEGF 405G C polymorphism and of relevant clinical and laboratory data in children with Kawasaki disease L. Fidani1, A. Giannopoulos1, A. Tragianidis1, G. Tzouvelekis1, K. Kalinderi2, A. Kotsis2, I. Kavaliotis3, F. Athanassiadou1 Abstract: Kawasaki disease (KD) represents an acute systemic vasculitis of infancy and childhood, characterized by fever and signs of mucocutaneous inflammation in many systems and organs with predilection of cardiovascular system. Aim of our study was to correlate clinical and laboratory data and to analyze the genetic polymorphisms of vascular endothelial growth factor (VEGF) with the development of KD in children from Northern Greece. We conducted a 3-year prospective study from January 2004 to December 2006. Diagnosis of KD was based on the American Heart Association criteria for KD. For each patient demographic, clinical and laboratory data were registered. VEGF 405G C polymorphism was typed in 19 patients and results were compared with those of 55 healthy sex paired controls. Of the 20 patients with KD, 10 (50%) had coronary artery abnormalities (dilatations, aneurisms) in echocardiograms. Of 10 patients that developed coronary abnormalities 8 (80%) were boys (p<0.05).

Duration of fever before diagnosis and administration of intravenous gamma-globulin and low hemoglobin values at diagnosis were predictive risk factors for the development of coronary abnormalities.

A higher percentage of VEGF 405 CC homozygotes was found in patients with KD compared to the healthy controls. However, this difference was not found statistically significant (26.3 ¤Ó·ÓÙÈ 14.5%, p =0.205). Moreover, the presence of the G allele was pronounced in the subgroup of patients with cardiovascular complications. We deduce that the study of a larger number of patients with KD in the Greek population may give valid conclusions in the future.

1 2nd Paediatric Clinic of Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece 2 Laboratory of Biogenetics of Aristotle University of Thessaloniki, Thessaloniki, Greece 3 Paediatric Clinic of the Special Disease Hospital, Thessaloniki, Greece Correspondence: F. AthanassiadouPiperopoulou atriagia@auth.gr, atragian@hotmail.com AHEPA Hospital 1, St. Kyriakidis St. 54 636, Thessaloniki, Greece

Key words: Kawasaki disease, vascular endothelial growth factor, polymorphisms, cardiovascular complications.

∞’ ÈڤÌÂÈÔ Œ·ıÏÔ, 45Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, 25-27 ª·˝Ô˘ 2007, ÷ÏÎȉÈ΋. ¶·È‰È·ÙÚÈ΋ 2007;70:389-394

Paidiatriki 5 final

12-10-07

16:28

Page 390

390

§. ºÈ‰¿ÓË Î·È Û˘Ó.

∂ÈÛ·ÁˆÁ‹ ∏ ÓfiÛÔ˜ Kawasaki (¡∫) ·ÔÙÂÏ› ÌÈ· ÔÍ›·, ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈ›Ùȉ· ·ÁÓÒÛÙÔ˘ ̤¯ÚÈ Û‹ÌÂÚ· ·ÈÙÈÔÏÔÁ›·˜ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÚÂÙfi Î·È ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÏÏÔÈÒÛÂȘ ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ Î·È Û˘ÛÙËÌ¿ÙˆÓ Ì ΢ÚÈfiÙÂÚÔ ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi (1,2). ¶ÚÒÙÔ˜ Ô Tomisaku Kawasaki ‰ËÌÔÛ›Â˘Û ÙÔ 1967 ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· 50 Ӥ˜ ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ Ì ¡∫ (3). §fiÁˆ Ù˘ ·Ô˘Û›·˜ ÂȉÈ΋˜ ‰È·ÁÓˆÛÙÈ΋˜ ÂÚÁ·ÛÙËÚȷ΋˜ ÂͤٷÛ˘, Ë ‰È¿ÁÓˆÛË Ù˘ ¡∫ Ù›ıÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ˘ÚÂÙÔ‡ ‰È¿ÚÎÂÈ·˜ ≥5 ËÌÂÚÒÓ Î·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÂÛÛ¿ÚˆÓ ·fi Ù· ¤ÓÙ ÎÏÈÓÈο ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Ô˘ ¤¯Ô˘Ó ıÂÛÈÛÙ› ·fi ÙÔÓ Tomisaku Kawasaki Î·È ·Ó·ıˆÚËı› ·fi ÙȘ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ÔÌ¿‰Â˜ ÔÌÔʈӛ·˜ ÁÈ· ÙËÓ ¡∫ (1,2,4). √È Î·Ú‰È·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ Ù˘ ¡∫, Ì ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ÙȘ ÂÎٷۛ˜, ÙȘ ‰È·Ù¿ÛÂȘ Î·È Ù· ·Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ, ·ÔÙÂÏÔ‡Ó ·ıÔÁÓˆÌÔÓÈÎfi ‡ÚËÌ· ηٿ ÙË ‰È·‰ÚÔÌ‹ ÂÌ‡ÚÂÙ˘ ÓfiÛÔ˘ Ì ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ÂΛӷ Ù˘ ¡∫ (5-8). ∞Ó Î·È ¤¯ÂÈ ÂÎÙÂÓÒ˜ ÌÂÏÂÙËı› Ë Û˘Û¯¤ÙÈÛË Ù˘ ÓfiÛÔ˘ Ì ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜, ηıÒ˜ Â›Û˘ Î·È Ë ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË Ô˘ ÂÎχÂÙ·È, ÂÓÙÔ‡ÙÔȘ ‰ÂÓ ¤¯ÂÈ Ì¤¯ÚÈ Û‹ÌÂÚ· ηٷÛÙ› ‰˘Ó·Ùfi Ó· ‰È¢ÎÚÈÓÈÛÙ› Ô ÚfiÏÔ˜ ÙÔ˘˜ ÛÙËÓ ÂΉ‹ÏˆÛ‹ Ù˘ (9-12). ∂ÈϤÔÓ, Ë ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· Ì ÙËÓ ÔÔ›· ηٷÁÚ¿ÊÂÙ·È Ë ÓfiÛÔ˜ ÛÙË µÔÚÂÈÔ·Ó·ÙÔÏÈ΋ ∞Û›· Û˘ÓËÁÔÚ› ˘¤Ú Ù˘ ÁÂÓÂÙÈ΋˜ ÚԉȿıÂÛ˘ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ (13,14). ™‹ÌÂÚ·, Â›Ó·È Â˘Ú¤ˆ˜ ÁÓˆÛÙfi fiÙÈ Ô VEGF ÚÔ¿ÁÂÈ ÙËÓ ·ÁÁÂÈÔÁ¤ÓÂÛË Î·È Û˘ÌÌÂÙ¤¯ÂÈ ÛÙË Ú‡ıÌÈÛË Ù˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ·ÁÁ›ˆÓ (15). ªÂÙ·‚ÔϤ˜ ÛÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ VEGF ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› ÛÙÔ ·ÚÂÏıfiÓ Ì ηډȷÁÁÂȷο Î·È ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· (15). ∞˘ÍË̤ÓË ¤ÎÊÚ·Û‹ ÙÔ˘ ¤¯ÂÈ Î·Ù·ÁÚ·Ê› Û ·ÛıÂÓ›˜ Ì ¡∫ ÁÂÓÈÎfiÙÂÚ· Î·È Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÂΉ‹ÏˆÛË ·Ó¢ڢÛÌ¿ÙˆÓ ÂȉÈÎfiÙÂÚ·, ÂÓÒ ÂÈϤÔÓ, Ë ·Ó‡ÚÂÛË ˘„ËÏÒÓ Û˘ÁÎÂÓÙÚÒÛÂÒÓ ÙÔ˘ ÛÙÔÓ ÔÚfi ·ÛıÂÓÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË, ıˆÚÂ›Ù·È ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ (16-20). ŒÓ· ÔÛÔÛÙfi Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ‰È·Î‡Ì·ÓÛ˘ ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ VEGF ÛÙÔÓ ÔÚfi Û ¤Ó·Ó ÏËı˘ÛÌfi, ÔÊ›ÏÂÙ·È ÛÙËÓ ‡·ÚÍË ÁÂÓÂÙÈÎÒÓ ÔÏ˘ÌÔÚÊÈÛÌÒÓ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ‹ ÙË ‰ÔÌÈ΋ ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ŒÓ·˜ Ù¤ÙÔÈÔ˜ ÔÏ˘ÌÔÚÊÈÛÌfi˜ Â›Ó·È Ô VEGF 405G C: ÔÈ CC ÔÌÔ˙˘ÁÒÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙ· Â›‰· ÙÔ˘ VEGF ÛÙÔ Ï¿ÛÌ· Û ۯ¤ÛË Ì ÙÔ˘˜ GG ÔÌÔ˙˘ÁÒÙ˜ (19,21) Î·È ÂÔ̤ӈ˜ Ô ÂÓ ÏfiÁˆ ÔÏ˘ÌÔÚÊÈÛÌfi˜ ı· ÌÔÚÔ‡Û ӷ Û˘Û¯ÂÙÈÛÙ› Ì ÙË ¡∫ ‹/Î·È ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ. ™ÎÔfi˜ ÂÔ̤ӈ˜ Ù˘ ÚÔÔÙÈ΋˜ Ì·˜ ÌÂϤÙ˘ Paediatriki 2007;70:389-394

‹Ù·Ó Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Ì ÙËÓ ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Î·ıÒ˜ Â›Û˘, Î·È Ë ‰ÈÂÓ¤ÚÁÂÈ· Û˘Û¯ÂÙÈÛÌÔ‡ ÙÔ˘ VEGF 405G C ÔÏ˘ÌÔÚÊÈÛÌÔ‡ Ì ÙËÓ ¡∫ Û ·È‰È¿ ·fi ÙË µfiÚÂÈÔ ∂ÏÏ¿‰·.

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ÀÏÈÎfi Ù˘ ÌÂϤÙ˘ Ì·˜ ·ÔÙ¤ÏÂÛ·Ó 20 ·È‰È¿ Ì ¡∫, Ù· ÔÔ›· ÓÔÛËχÙËÎ·Ó ÛÙË µã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ∞.¶.£ Î·È ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ∂ȉÈÎÒÓ ¶·ı‹ÛÂˆÓ £ÂÛÛ·ÏÔӛ΢. °È· ÙË Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·È‰ÈÒÓ ÛÙË ÌÂϤÙË ÂÏ‹ÊıË ·fi ÙÔ˘˜ ÁÔÓ›˜ ÁÚ·Ù‹ Û˘ÁηٿıÂÛË. ∞fi Ù· 20 ·È‰È¿ Ù˘ ÌÂϤÙ˘, Ù· 12 (60%) ‹Ù·Ó ·ÁfiÚÈ· Î·È Ù· 8 (40%) ÎÔÚ›ÙÛÈ·. ∏ ̤ÛË ËÏÈΛ· ηٿ ÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 16,5 Î·È Ë ‰È¿ÌÂÛË 13 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ· (‡ÚÔ˜: 3-84 Ì‹Ó˜). ∂ÈϤÔÓ, ·fi ÙÔ˘˜ 20 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ Ì·˜ 12 (60%) ‹Ù·Ó ‚Ú¤ÊË. ø˜ ÔÌ¿‰· ÂϤÁ¯Ô˘ ÁÈ· ÙË ÌÂϤÙË ÙÔ˘ VEGF 405G C ÔÏ˘ÌÔÚÊÈÛÌÔ‡ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó 55 ˘ÁÈ›˜ Ì¿ÚÙ˘Ú˜ ›‰ÈÔ˘ ʇÏÔ˘. ¢ÈÂÓÂÚÁ‹ıËΠÚÔÔÙÈ΋ ÌÂϤÙË ‰È¿ÚÎÂÈ·˜ 3 ÂÙÒÓ (·fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ 2004 ˆ˜ ÙÔÓ ¢ÂΤ̂ÚÈÔ 2006). ∏ ‰È¿ÁÓˆÛË ‚·Û›ÛÙËΠÛÙ· ÎÚÈÙ‹ÚÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Ô˘ ¤¯Ô˘Ó ıÂÛÈÛÙ› ·fi ÙËÓ ∞ÌÂÚÈηÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›· (2). ™ÙȘ ÂÚÈÙÒÛÂȘ ÙˆÓ ·ÛıÂÓÒÓ, ÙˆÓ ÔÔ›ˆÓ ÔÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ‰ÂÓ ÏËÚÔ‡Û·Ó Ù· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·, ÂÓÒ Û˘Á¯ÚfiÓˆ˜ ›¯·Ó ·ÔÎÏÂÈÛÙ› ¿ÏϘ Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ, Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË ·ÙÂÏÔ‡˜ ¡∫, Û‡Ìʈӷ Ì ÙȘ ·Ó·ıˆÚË̤Ó˜ Ô‰ËÁ›Â˜ Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ∫·Ú‰ÈÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ (2). °È· οı ·ÛıÂÓ‹ ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙˆÓ ‰ËÌÔÁÚ·ÊÈÎÒÓ (ʇÏÔ, ËÏÈΛ·), ÎÏÈÓÈÎÒÓ (Ë̤Ú˜ ˘ÚÂÙÔ‡ ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜, Ù˘È΋/·ÙÂÏ‹˜ ¡∫) Î·È Î˘ÚÈfiÙÂÚˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ (∆∫∂, CRP, ·ÈÌÔÛÊ·ÈÚ›ÓË, ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·, ·ÈÌÔÂÙ¿ÏÈ·) ηٿ ÙË ‰È¿ÁÓˆÛË (ÂÎÙfi˜ ·fi ÙËÓ ÙÈÌ‹ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Ô˘ ηٷÁÚ¿ÊËÎ·Ó ÙË 10Ë Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘). ∂ÈϤÔÓ, fiÛÔÓ ·ÊÔÚ¿ Ù· ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· ÙˆÓ ·ÛıÂÓÒÓ Î·Ù·ÁÚ¿ÊËÎÂ Ë ·ÚÔ˘Û›· ‰È·Ù¿ÛˆÓ, ÂÎÙ·ÛÈÒÓ (ÌÈÎÚÔ‡ ‡ÚÔ˘˜ ‰È¿Ù·ÛË ÙÔ˘ ·ÁÁ›Ԣ) Î·È ·Ó¢ڢÛÌ¿ÙˆÓ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ, Ù· ÔÔ›· ‚¿ÛÂÈ ÙˆÓ ‰È·ÛÙ¿ÛÂÒÓ ÙÔ˘˜ ‰È·ÎÚ›ÓÔÓÙ·È Û ÌÈÎÚÔ‡ (‰È¿ÌÂÙÚÔ˜ <5mm), ÌÂÛ·›Ô˘ (‰È¿ÌÂÙÚÔ˜ 5-8mm) Î·È ÁÈÁ·ÓÙÈ·›Ô˘ ÌÂÁ¤ıÔ˘˜ (‰È¿ÌÂÙÚÔ˜ >8mm).

A. ∞ÔÌfiÓˆÛË DNA ·fi ÔÏÈÎfi ·›Ì· °È· ÙËÓ ·ÔÌfiÓˆÛË ÙÔ˘ ÁÔÓȉȈ̷ÙÈÎÔ‡ DNA ·fi ÔÏÈÎfi ·›Ì· ¯ÚËÛÈÌÔÔÈ‹ıËΠkit ÙÔ˘ ÂÌÔÚ›Ô˘ (“PUREGENEì DNA PURIFICATION SYSTEM”, Gentra Systems, Minneapolis, MN, USA).

B. °ÔÓÔÙ˘ÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ VEGF +405G/C 1. ∂Ó›Û¯˘ÛË ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÁÔÓȉ›Ô˘ VEGF Ì ÙËÓ ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË Ù˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR). °È· ÙËÓ ÂÓ›Û¯˘ÛË ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÁÔÓȉ›Ô˘ VEGF, ÙÔ ÔÔ›Ô ÂÚȤ¯ÂÈ ÙÔÓ ÔÏ˘ÌÔÚÊÈÛÌfi +405G/C, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÂȉÈÎÔ› ÔÏÈÁÔÓÔ˘ÎÏÂÔÙȉÈÎÔ› ÂÎÎÈÓËÙ¤˜: VEGF(F): 5’-ATTTATTTTTGCTTGCCATT-3’ VEGF(R): 5’-GTCTGTCTGTCTGTCCGTCA-3’ ∆Ô Ì›ÁÌ· Ù˘ οı ·ÓÙ›‰Ú·Û˘ ÂÚÈ›¯Â 20 mM Tris -HCl (pH 8,4), 50 mM KCl, 3 mM MgCl2, 0,1 mM ·fi οı ‰ÂÔ͢ÓÔ˘ÎÏÂÔÙ›‰ÈÔ (dATP, dGTP, dTTP, dCTP), 25 pmole ·fi οı ÂÎÎÈÓËÙ‹, 1 unit Taq DNA ÔÏ˘ÌÂÚ¿ÛË Î·È 100 - 200 ng DNA, Û ÙÂÏÈÎfi fiÁÎÔ 25 ÌL. √È Û˘Óı‹Î˜ Ù˘ PCR Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‹Ù·Ó: 5 ÏÂÙ¿ ÛÙÔ˘˜ 94oC, 15 ·ÎÏÔÈ ·fi 30’’ ÛÙÔ˘˜ 94oC/ 30’’

Paidiatriki 5 final

12-10-07

16:28

Page 391

391

°ÔÓȉȷÎfi˜ ÔÏ˘ÌÔÚÊÈÛÌfi˜ +405g/c VEFG Î·È ¡fiÛÔ˜ Kawasaki

ÛÙÔ˘˜ 61oC/ 45’’ ÛÙÔ˘˜ 72oC , 20 ·ÎÏÔÈ ·fi 30’’ ÛÙÔ˘˜ 94oC/ 30’’ ÛÙÔ˘˜ 55oC/ 45’’ ÛÙÔ˘˜ 72oC, Î·È 10 ÏÂÙ¿ ÛÙÔ˘˜ 72oC. ∆Ô ÙÌ‹Ì· ÙÔ˘ ÁÔÓȉ›Ô˘ VEGF Ô˘ ÂÓÈÛ¯‡ÂÙ·È Ì ·˘Ù¤˜ ÙȘ Û˘Óı‹Î˜ ¤¯ÂÈ Ì‹ÎÔ˜ 304 ˙‡ÁË ‚¿ÛÂˆÓ (bp).

2. ∂Ó˙˘ÌÈ΋ ˘‰ÚfiÏ˘ÛË ÙÔ˘ ÂÓÈÛ¯˘Ì¤ÓÔ˘ DNA Ì ÙËÓ ÂÓ‰ÔÓÔ˘ÎÏ¿ÛË ÂÚÈÔÚÈÛÌÔ‡ BsmF1.

10 ÌL ·fi οı ·ÓÙ›‰Ú·ÛË ÂÓ›Û¯˘Û˘ ÙÔ˘ DNA Ì PCR Âˆ¿ÛÙËÎ·Ó ÛÙÔ˘˜ 65oC, ÁÈ· 4 ÒÚ˜, Ì 5 units Ù˘ ÂÓ‰ÔÓÔ˘ÎÏ¿Û˘ ÂÚÈÔÚÈÛÌÔ‡ BsmF1, ·ÚÔ˘Û›· 50 mM Tris HCl (pH 8,0), 50 mM NaCl Î·È 10 mM MgCl2, Û ÙÂÏÈÎfi fiÁÎÔ 20 ÌL. 3. ∞Ó›¯Ó¢ÛË Î·È Ù·˘ÙÔÔ›ËÛË ÙˆÓ ÚÔ˚fiÓÙˆÓ Ù˘ ÂÓ˙˘ÌÈ΋˜ ˘‰ÚfiÏ˘Û˘ ÙÔ˘ ÂÓÈÛ¯˘Ì¤ÓÔ˘ DNA. ∏ ·Ó›¯Ó¢ÛË Î·È Ù·˘ÙÔÔ›ËÛË ÙˆÓ ÚÔ˚fiÓÙˆÓ Ù˘ ÂÓ˙˘ÌÈ΋˜ ˘‰ÚfiÏ˘Û˘ ÙÔ˘ ÂÓÈÛ¯˘Ì¤ÓÔ˘ DNA ¤ÁÈÓ Ì ËÏÂÎÙÚÔÊfiÚËÛË Û ËÎÙ‹ ·Á·Úfi˙˘ 2,5. ªÂÙ¿ ÙÔ ¤Ú·˜ Ù˘ ËÏÂÎÙÚÔÊfiÚËÛ˘, Ë ËÎÙ‹ ÙÔÔıÂÙ‹ıËΠÂ¿Óˆ Û ÙÚ¿Â˙· ÂÎÔÌ‹˜ ˘ÂÚÈÒ‰Ô˘˜ ·ÎÙÈÓÔ‚ÔÏ›·˜ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ˙ˆÓÒÓ ÙÔ˘ DNA. ∏ Ù·˘ÙÔÔ›ËÛË ÙˆÓ ÚÔ˚fiÓÙˆÓ Ù˘ ÂÓ˙˘ÌÈ΋˜ ˘‰ÚfiÏ˘Û˘ ÙÔ˘ DNA Ì ÙÔ BsmF1 ¤ÁÈÓ Ì ۇÁÎÚÈÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ˙ˆÓÒÓ ÙÔ˘ DNA Ì ÚfiÙ˘Ë Îϛ̷η ÙÂÌ·¯›ˆÓ DNA ÁÓˆÛÙÔ‡ ÌÂÁ¤ıÔ˘˜, Ù· ÔÔ›· ‰È·¯ˆÚ›ÛÙËÎ·Ó Î·Ù¿ ÙËÓ ËÏÂÎÙÚÔÊfiÚËÛË ·Ú¿ÏÏËÏ· ÚÔ˜ Ù· ˘fi ÌÂϤÙË ‰Â›ÁÌ·Ù·. ∏ ·Ó›¯Ó¢ÛË ÌÈ·˜ ÌfiÓÔ ˙ÒÓ˘ DNA ÌÂÁ¤ıÔ˘˜ 304 bp ˘Ô‰ËÏÒÓÂÈ ÔÌÔ˙˘ÁˆÙ›· ÙÔ˘ ·ÏÏËÏÔÌfiÚÊÔ˘ VEGF +405 G, ÙÚÈÒÓ ˙ˆÓÒÓ 304, 193 Î·È 111 bp, ÂÙÂÚÔ˙˘ÁˆÙ›· ÁÈ· Ù· ·ÏÏËÏfiÌÔÚÊ· VEGF +405 G Î·È VEGF +405 C, ÂÓÒ ‰‡Ô ˙ˆÓÒÓ 190 Î·È 130 bp ÔÌÔ˙˘ÁˆÙ›· ÁÈ· ÙÔ ·ÏÏËÏfiÌÔÚÊÔ VEGF +405 CC. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤ÁÈÓ Ì ÙÔ ÛÙ·ÙÈÛÙÈÎfi ÚfiÁÚ·ÌÌ· SPSS (version 11.0). ∏ ̤ıÔ‰Ô˜ Ù˘ ÛÙ·ÙÈÛÙÈ΋˜ ·Ó¿Ï˘Û˘ ÂÚÈÏ¿Ì‚·Ó ˘ÔÏÔÁÈÛÌfi ÁÈ· οı ÌÂÙ·‚ÏËÙ‹ Ù˘ ̤Û˘ ÙÈÌ‹˜ (mean), Ù˘ ‰È·Ì¤ÛÔ˘ ÙÈÌ‹˜ (median), Ù˘ ÛÙ·ıÂÚ‹˜ ·fiÎÏÈÛ˘ (standard deviation, SD) Î·È ÙÔ˘ ÛÙ·ıÂÚÔ‡ ÛÊ¿ÏÌ·ÙÔ˜ ÙÔ˘ ̤ÛÔ˘ fiÚÔ˘ (standard error of the mean, SEM). °È· ÙÔÓ ¤ÏÂÁ¯Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ÂÊ·ÚÌfiÛÙËÎ·Ó Ë ‰ÔÎÈÌ·Û›· Fisher (ÁÈ· ÙȘ ·Û˘Ó¯›˜ ÌÂÙ·‚ÏËÙ¤˜) Î·È Ë ‰ÔÎÈÌ·Û›· t-test ÁÈ· ·ÓÂÍ¿ÚÙËÙ· ‰Â›ÁÌ·Ù· (unpaired samples t-test) (ÁÈ· ÙȘ Û˘Ó¯›˜ ÌÂÙ·‚ÏËÙ¤˜). ø˜ fiÚÈÔ ÛÙ·ÙÈÛÙÈ΋˜ ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ıˆڋıËÎÂ Ë ÙÈÌ‹ p<0,05.

∞ÔÙÂϤÛÌ·Ù· ™‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· Ù˘ ¡∫ ·fi Ù· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ÚԤ΢„ fiÙÈ fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ ›¯·Ó ˘ÚÂÙfi ‰È¿ÚÎÂÈ·˜ ≥5 ËÌÂÚÒÓ (100%). ∞ÌÊÔÙÂÚfiÏ¢ÚË ÌË ˘Ò‰Ë˜ ÂÈÂÊ˘Î›Ùȉ· ηٷÁÚ¿ÊËΠ۠18 ·ÛıÂÓ›˜ (90%), ÛÙÔÌ·Ù›‰·/¯ÂÈÏ›Ùȉ· Û 16 (80%), Ô›‰ËÌ·/ÂÚ‡ıËÌ· ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ Ô˘ Û˘Óԉ‡ÙËΠ·fi ·ÔϤÈÛË Û 15 (75%),

ÔχÌÔÚÊÔ ÂÍ¿ÓıËÌ· Û 16 (80%) Î·È Ù¤ÏÔ˜, ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· Û 10 (50%). ø˜ ·ÙÂÏ‹˜ ‹ ¿Ù˘Ë ¯·Ú·ÎÙËÚ›ÛÙËÎÂ Ë ÓfiÛÔ˜ Û 8 ·ÛıÂÓ›˜ (40%). ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ Âԯȷ΋ ηٷÓÔÌ‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ¡∫, ÚԤ΢„ fiÙÈ 6 (30%) ÂΉ‹ÏˆÛ·Ó ÙË ÓfiÛÔ ÙËÓ ¿ÓÔÈÍË, 2 (10%) ÙÔ Î·ÏÔη›ÚÈ, 8 (40%) ÙÔ ÊıÈÓfiˆÚÔ Î·È Ù¤ÏÔ˜, 4 (20%) ÙÔ ¯ÂÈÌÒÓ·. ∏ ̤ÛË ÙÈÌ‹, Ë ‰È¿ÌÂÛÔ˜ Î·È Ë ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÌÂϤÙ˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∞fi ÙÔ˘˜ 20 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ Ì·˜, 10 (50%) ÂÌÊ¿ÓÈ˙·Ó ÂΉËÏÒÛÂȘ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi (‰È¿Ù·ÛË, ÂÎٷۛ˜, ·Ó¢ڇÛÌ·Ù· ÛÙÂÊ·ÓÈ·›ˆÓ) Û‡Ìʈӷ Ì ٷ ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈο ÙÔ˘˜ Â˘Ú‹Ì·Ù·. ∞fi ÙË Û˘Û¯¤ÙÈÛË ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÌÂϤÙ˘ ÚԤ΢„ fiÙÈ Ë Ì¤ÛË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ, Ù˘ CRP, Ù˘ ∆∫∂ Î·È ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ÌÂٷ͇ ·È‰ÈÒÓ ÌÂ Î·È ¯ˆÚ›˜ ‚Ï¿‚˜ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi ·ÓÙ›ÛÙÔȯ·. ∏ ̤ÛË ÙÈÌ‹ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ‹Ù·Ó 9,89 g/dl (±1,23) Î·È 10,74 g/dl (±0,9) ÁÈ· Ù· ·È‰È¿ ÌÂ Î·È ‰›¯ˆ˜ ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ·ÓÙ›ÛÙÔȯ· Î·È ·ÔÙ¤ÏÂÛ ÙË ÌfiÓË ÂÚÁ·ÛÙËÚȷ΋ ·Ú¿ÌÂÙÚÔ Ù˘ ÌÂϤÙ˘ Ì·˜ Ô˘ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο (p<0,05). ∆¤ÏÔ˜, Ë ‰È¿ÚÎÂÈ· ÙÔ˘ ˘ÚÂÙÔ‡ ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ÎÔÈÓ‹˜ Á-ÛÊ·ÈÚ›Ó˘ (9,9 Ë̤Ú˜ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ηډȷÁÁÂȷΤ˜ ‚Ï¿‚˜ ¤Ó·ÓÙÈ 6,4 Ë̤Ú˜ ÁÈ· ÂΛÓÔ˘˜ ¯ˆÚ›˜ ‚Ï¿‚˜) (p<0,05) ·ÔÙ¤ÏÂÛ ÙË ÌfiÓË ÎÏÈÓÈ΋ ·Ú¿ÌÂÙÚÔ Ô˘ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο. ∞fi ÙË ÌÂϤÙË ÙˆÓ ÔÈÔÙÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÌÂϤÙ˘ Ì·˜ ‰ÂÓ ÚԤ΢„ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ·fi ÙË Û˘Û¯¤ÙÈÛË Ù˘ ÓfiÛÔ˘ (Ù˘È΋/·ÙÂÏ‹˜) Î·È Ù˘ ËÏÈΛ·˜ ÙˆÓ ·ÛıÂÓÒÓ (‚Ú¤ÊË/Ó‹È·) Ì ÙËÓ ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ. ¢È¤ÊÂÚÂ, fï˜, Ë ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Û ۯ¤ÛË Ì ÙÔ Ê‡ÏÔ ÙˆÓ ·ÛıÂÓÒÓ. ™˘ÁÎÂÎÚÈ̤ӷ, ·fi ÙÔ˘˜ 10 ·ÛıÂÓ›˜ Ô˘ ÂΉ‹ÏˆÛ·Ó ηډȷÁÁÂȷΤ˜ ·ÓˆÌ·Ï›Â˜, 8 (80%) ‹Ù·Ó ·ÁfiÚÈ·, ‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p<0,05).

TÔ ÔÛÔÛÙfi ÙˆÓ VEGF +405 CC ÔÌÔ˙˘ÁˆÙÒÓ ÂÌÊ·Ó›ÛÙËΠ·˘ÍË̤ÓÔ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, Û ۯ¤ÛË Ì ÙÔ˘˜ ÌË ¿Û¯ÔÓÙ˜, ·Ó Î·È Ë ‰È·ÊÔÚ¿ ‹Ù·Ó ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÛÙÔ ‰Â›ÁÌ· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ (26,3% ¤Ó·ÓÙÈ 14,5%, p = 0,205) Î·È ÔÈ Î·Ù·ÓÔ̤˜ ÙˆÓ ÁÔÓÔÙ˘ÈÎÒÓ Û˘¯ÓÔÙ‹ÙˆÓ ÛÙÔ Û‡ÓÔÏfi

¶›Ó·Î·˜ 1. ª¤ÛË ÙÈÌ‹, ‰È¿ÌÂÛÔ˜ Î·È ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÌÂϤÙ˘ ¶·Ú¿ÌÂÙÚÔ˜ ∆∫∂ (mm 1Ë ÒÚ·) CRP (mg/dl) WBC (/mm3) Hb (g/dl) PLT (/mm3)

ª¤ÛË ÙÈÌ‹ (mean)

¢È¿ÌÂÛÔ˜ (median)

™Ù·ıÂÚ‹ ·fiÎÏÈÛË (standard deviation)

76 10,54 17130 10,3 732000

80 7,2 16000 10,4 669000

26,5 7,59 5940 1,1 233000

¶·È‰È·ÙÚÈ΋ 2007;70:389-394

Paidiatriki 5 final

12-10-07

16:28

Page 392

392

§. ºÈ‰¿ÓË Î·È Û˘Ó.

¶›Ó·Î·˜ 2. ∫·Ù·ÓÔÌ‹ ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ VEGF +405GC Û ·ÛıÂÓ›˜ Ì ¡∫ Î·È ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘

∞ÛıÂÓ›˜ Ì NK (n = 19) √Ì¿‰· ÂϤÁ¯Ô˘ (n = 55) ™Ù·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ·

GG

GC

GG+GC

CC

7 (36,8%) 18 (32,7%)

7 (36,8%) 29 (52,7%) P1 = 0,383

14 (73,7%) 47 (85,5%)

5 (26,3%) 8 (14,5%) P2 = 0,205

1 ™‡ÁÎÚÈÛË Ù˘ ηٷÓÔÌ‹˜ ÙˆÓ ÁÔÓÔÙ‡ˆÓ GG, GC, CC 2 ™‡ÁÎÚÈÛË Ù˘ ηٷÓÔÌ‹˜ ÙˆÓ ÊÔÚ¤ˆÓ ÙÔ˘ G ·ÏÏËÏÔÌfiÚÊÔ˘ Î·È ÙˆÓ CC ÔÌÔ˙˘ÁˆÙÒÓ (¢ÔÎÈÌ·Û›· Fisher ÚÔ˜ ÌÈ· ηÙ‡ı˘ÓÛË)

ÙÔ˘˜ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ·Ó¿ÌÂÛ· ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ (p = 0,383) (¶›Ó·Î·˜ 2, ∂ÈÎfiÓ· 1). √ ÏfiÁÔ˜ Ù˘ Èı·ÓfiÙËÙ·˜ ÂΉ‹ÏˆÛ˘ ¡∫ Û ¿ÙÔÌ· Ì ÁÔÓfiÙ˘Ô VEGF +405 CC ÚÔ˜ ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Èı·ÓfiÙËÙ· Û ¿ÙÔÌ· - ÊÔÚ›˜ ÙÔ˘ VEGF +405 G ·ÏÏËÏÔÌfiÚÊÔ˘ (odds ratio) ˘ÔÏÔÁ›ÛÙËΠ›ÛÔ˜ ÚÔ˜ 1,809 (95% CI = 0,674 - 4,860). ∂ÈϤÔÓ, Ë ˘ÔÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÌÊ¿ÓÈÛ·Ó Î·Ú‰È·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ‹Ù·Ó Û¯ÂÙÈο ÂÌÏÔ˘ÙÈṲ̂ÓË Û ÊÔÚ›˜ ÙÔ˘ VEGF +405 G ·ÏÏËÏÔÌfiÚÊÔ˘ (8/10 ¤Ó·ÓÙÈ 6/9), ·ÏÏ¿ Î·È Û’·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, Ë ‰È·ÊÔÚ¿ ‹Ù·Ó ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (ƒ = 0,444) (¶›Ó·Î·˜ 3). √ ÏfiÁÔ˜ ÙˆÓ Èı·ÓÔÙ‹ÙˆÓ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·Ó¢ڇÛÌ·ÙÔ˜ Û ·ÛıÂÓ‹ Ì ¡∫, Û ۯ¤ÛË Ì ÙË ÊÔÚ›· ÙÔ˘ VEGF +405 G ·ÏÏËÏÔÌfiÚÊÔ˘ ˘ÔÏÔÁ›ÛÙËΠ›ÛÔ˜ ÚÔ˜ 1,2 (95% CI = 0,688 - 2,093).

∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ %

™˘˙‹ÙËÛË ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ¡∫, Ë ÂÈÎÚ·Ù¤ÛÙÂÚË Û‹ÌÂÚ· ıˆڛ· ÂÓÔ¯ÔÔÈ› ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÛ‹ Ù˘ οÔÈÔÓ ÏÔÈÌÒ‰Ë ·Ú¿ÁÔÓÙ· (9-11). ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ÔÍ›· ÂÌ‡ÚÂÙË ÓfiÛÔ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ Âԯȷ΋, ËÏÈÎȷ΋ Î·È ÂȉËÌÈ΋ ηٷÓÔÌ‹ Ù¿ÛÛÔÓÙ·È ˘¤Ú Ù˘ ÏÔÈÌÒ‰Ô˘˜ ·ÈÙÈÔÏÔÁ›·˜, fï˜ ·Ú¿ ÙȘ ÚÔÛ¿ıÂȘ ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ 30 ¯ÚfiÓˆÓ ‰ÂÓ Î·Ù¤ÛÙË ‰˘ÛÙ˘¯Ò˜ ‰˘Ó·ÙfiÓ Ó· ·ÔÌÔÓˆı› ‹ Ó· Û˘Û¯ÂÙÈÛÙ› οÔÈÔ˜ ÏÔÈÌ҉˘ ·ÈÙÈÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ì ÙËÓ ¡∫. ™‡Ìʈӷ Ì ̛· ¿ÏÏË ıˆڛ· Ë ¡∫ Û˘Û¯ÂÙ›˙ÂÙ·È 100 90 80 70 60 50 40 30 20 10 0

GG+GC CC

¶›Ó·Î·˜ 3. ∫·Ù·ÓÔÌ‹ ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ VEGF +405GC Û ·ÛıÂÓ›˜ Ì ¡∫, Û ۯ¤ÛË Ì ÙË ·ÚÔ˘Û›· ‹ fi¯È ∫∂1 ∫∂

NK

ª¿ÚÙ˘Ú˜

∂ÈÎfiÓ· 1. °Ú·ÊÈ΋ ·Ú¿ÛÙ·ÛË Ù˘ ηٷÓÔÌ‹˜ ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ VEGF +405 GC ÛÙËÓ ÔÌ¿‰· ÌÂϤÙ˘ (¡∫) Î·È ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ (Ì¿ÚÙ˘Ú˜).

Paediatriki 2007;70:389-394

Ì ÙËÓ ÎÏËÚÔÓÔÌÈ΋ ÚԉȿıÂÛË, ·ÊÔ‡ fiˆ˜ Â›Ó·È ÁÓˆÛÙfi Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ˘„ËÏ‹ Û ∞ÛÈ¿Ù˜ Û˘ÁÎÚÈÙÈο Ì ¿ÙÔÌ· Ù˘ ∫·˘Î¿ÛÈ·˜ Ê˘Ï‹˜ (1,2,14). ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ Â›Ó·È ˘„ËÏfiÙÂÚË ÛÙËÓ µÔÚÂÈÔ·Ó·ÙÔÏÈ΋ ∞Û›·, ΢ڛˆ˜ ÛÙËÓ ∫ÔÚ¤· Î·È ÛÙËÓ π·ˆÓ›·. ∂Í¿ÏÏÔ˘, Ë ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· Ù˘ ¡∫ ÛÙËÓ π·ˆÓ›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ˘„ËÏ‹ Â›ÙˆÛ‹ Ù˘ Û π¿ˆÓ˜ 2˘ Î·È 3˘ ÁÂÓ¿˜ ÛÙȘ ∏¶∞ Û˘ÓËÁÔÚ› ˘¤Ú Ù˘ ÁÂÓÂÙÈ΋˜ ÚԉȿıÂÛ˘ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ (2,10). ∏ Û˘¯ÓfiÙËÙ· Ù˘ ¡∫, fiˆ˜ ÚÔ·ÙÂÈ ·fi ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, ·˘Í¿ÓÂÙ·È ·ÁÎÔÛÌ›ˆ˜. ™‡Ìʈӷ Ì ÛÙÔȯ›· È·ÒÓˆÓ ÂÚ¢ÓËÙÒÓ Î·Ù·ÁÚ¿ÊÔÓÙ·È ÂÚ›Ô˘ 5000-6000 Ӥ˜ ÂÚÈÙÒÛÂȘ ¡∫ ÂÙËÛ›ˆ˜ Î·È Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ·ÁÁ›˙ÂÈ ÙȘ 120150 Ӥ˜ ÂÚÈÙÒÛÂȘ/100.000 ·È‰È¿ Û ·ÓÙ›ıÂÛË Ì ÙȘ ∏¶∞, fiÔ˘ Ë ·ÓÙ›ÛÙÔÈ¯Ë Â›ÙˆÛË ·Ó¤Ú¯ÂÙ·È Û 5-15 Ӥ˜ ÂÚÈÙÒÛÂȘ/100.000 ·È‰È¿ (1,2,10). ∂ÈϤÔÓ, Ë ¡∫ Â›Ó·È 1,5 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚË ÛÙ· ·ÁfiÚÈ·, fiˆ˜ ÚÔ·ÙÂÈ Î·È ·fi Ù· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜, fiÔ˘ Ù· ·ÁfiÚÈ· ·ÔÙ¤ÏÂÛ·Ó ÙÔ 60% (22,23). ∞fi ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ·ÛıÂÓÒÓ Ì ¡∫ ÚÔ·ÙÂÈ fiÙÈ Ë Ì¤ÛË ËÏÈΛ· Â›Ó·È <2 ÂÙÒÓ Î·È ÔÈ Î·Ú‰È·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ Â›Ó·È Û˘¯ÓfiÙÂÚ˜ ÛÙ· ‚Ú¤ÊË, ·Ú·Ù‹ÚËÛË Ô˘ ‰ÂÓ ÂȂ‚·ÈÒıËΠ·fi Ù· Â˘Ú‹Ì·Ù¿ Ì·˜ (5,8,22,24). ∏ Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ Ù˘ ¡∫ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 2-3% Î·È Â›Ó·È ˘„ËÏfiÙÂÚË Û ·È‰È¿ ËÏÈΛ·˜ <3 ÂÙÒÓ Î·È Û ÂΛӷ Ì ‰È¿Ù·ÛË ‹ ÂÎÙ·Û›· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ÛÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ (1,25). ∂ÈϤÔÓ, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Û ·‰¤ÚÊÈ· Â›Ó·È 10 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ Û ۇÁÎÚÈÛË Ì ÙÔÓ ˘fiÏÔÈÔ ÏËı˘ÛÌfi, Û‡Ìʈӷ Ì ‰Â‰Ô̤ӷ ÌÂϤÙ˘ ÛÙËÓ π·ˆÓ›·, Î·È ÙÔ

¡·È Ÿ¯È ™Ù·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ·

GG+GC

CC

8 6

2 3 ƒ2=0,444

1 ∫·Ú‰È·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ (ÂÎٷۛ˜, ‰È·Ù¿ÛÂȘ, ·Ó¢ڇÛÌ·Ù· ÛÙÂÊ·ÓÈ·›ˆÓ) 2 ¢ÔÎÈÌ·Û›· Fisher ÚÔ˜ ÌÈ· ηÙ‡ı˘ÓÛË

Paidiatriki 5 final

12-10-07

16:28

Page 393

393

°ÔÓȉȷÎfi˜ ÔÏ˘ÌÔÚÊÈÛÌfi˜ +405g/c VEFG Î·È ¡fiÛÔ˜ Kawasaki

50% ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ ÂΉËÏÒÓÔ˘Ó ÙË ÓfiÛÔ ÂÓÙfi˜ 10 ËÌÂÚÒÓ (26). ∆¤ÏÔ˜, Ë ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ Û ‰›‰˘Ì· ·‰¤ÚÊÈ· Î·È Û ·È‰È¿, ÔÈ ÁÔÓ›˜ ÙˆÓ ÔÔ›ˆÓ ›¯·Ó ÓÔÛ‹ÛÂÈ ·fi ¡∫ ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·, ÂÓÈÛ¯‡ÂÈ ÙËÓ ˘fiıÂÛË Ù˘ ÁÂÓÂÙÈ΋˜ ÚԉȿıÂÛ˘ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛ‹ Ù˘ (27,28). ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ¤¯ÂÈ Á›ÓÂÈ ÌÂÁ¿ÏË ÚÔÛ¿ıÂÈ· ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Û ·È‰È¿ Ì ¡∫. ™‡Ìʈӷ Ì ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ÚÔ·ÙÂÈ fiÙÈ Ë Ï¢ÎÔ΢ÙÙ¿ÚˆÛË, Ô ¯·ÌËÏfi˜ ·ÚÈıÌfi˜ ·ÈÌÔÂÙ·Ï›ˆÓ, Ë ˘„ËÏ‹ ÙÈÌ‹ Ù˘ CRP, Ë ¯·ÌËÏ‹ ÙÈÌ‹ ÙÔ˘ ·ÈÌ·ÙÔÎÚ›ÙË, Ë ÌÈÎÚ‹ ËÏÈΛ· Î·È ÙÔ ¿ÚÚÂÓ Ê‡ÏÔ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ÛËÌ·ÓÙÈÎfiÙÂÚÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ·Ó¢ڢÛÌ¿ÙˆÓ (6). ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ ˘ÚÂÙÔ‡ ÚÈÓ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Î·È Ë ¯·ÌËÏ‹ ÙÈÌ‹ ÙÔ˘ Ó·ÙÚ›Ô˘ Î·È Ù˘ ·Ï‚Ô˘Ì›Ó˘ ÙÔ˘ ÔÚÔ‡ ·ÔÙÂÏÔ‡Ó ÂÈϤÔÓ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û‡Ìʈӷ Ì ¿ÏϘ ÌÂϤÙ˜ (29,30). ∞fi ÙË ÌÂϤÙË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ ‰È·ÈÛÙÒÛ·Ì fiÙÈ ÌfiÓÔ Ë ‰È¿ÚÎÂÈ· ÙÔ˘ ˘ÚÂÙÔ‡ ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ÎÔÈÓ‹˜ Á-ÛÊ·ÈÚ›Ó˘ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ ÌÂ Î·È ¯ˆÚ›˜ ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜, ·Ú·Ù‹ÚËÛË Ô˘ Û˘ÌʈÓ› Ì ÙȘ ·ÓÙ›ÛÙÔȯ˜ Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ (6,29,30). ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· ÚfiÛÊ·Ù˘ ÌÂϤÙ˘ ÙˆÓ Kim Î·È Û˘Ó. ÚԤ΢„ fiÙÈ Ë Ì¤ÛË ÙÈÌ‹ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È Ù˘ CRP ‹Ù·Ó ˘„ËÏfiÙÂÚË Î·È ‰È¤ÊÂÚ Û ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ‚·ıÌfi ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ (·ÛıÂÓ›˜ ÌÂ Î·È ¯ˆÚ›˜ ‚Ï¿‚˜ ·ÓÙ›ÛÙÔȯ·) (6). ∞fi ÙË ÌÂϤÙË Ì·˜ ηٷÁÚ¿ÊËΠÌfiÓÔ ˘„ËÏfiÙÂÚË Ì¤ÛË ÙÈÌ‹ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜, Ë ÔÔ›· ‰ÂÓ ‰È¤ÊÂÚ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙÔÓ ÁÔÓȉȷÎfi ÔÏ˘ÌÔÚÊÈÛÌfi VEGF +405 GÆC, ÛÙË ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ‰È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ÁÔÓÔÙ‡ˆÓ ·Ó¿ÌÂÛ· ÛÙËÓ ÔÌ¿‰· ÌÂϤÙ˘ Î·È ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘. ¶·ÚfiÏ· ·˘Ù¿, Ë ·˘ÍË̤ÓË ·Ó·ÏÔÁ›· ÙˆÓ CC ÔÌÔ˙˘ÁˆÙÒÓ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ¡∫ ı· ÌÔÚÔ‡Û ӷ Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ÌÈ·˜ Ù¿Û˘, Ô˘ fï˜ ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÁÁ›ÍÂÈ ÙË ÛÙ·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ· ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜. ™ÙÔ ›‰ÈÔ Úfi‚ÏËÌ·, ·˘Ùfi Ù˘ ·ÓÂ·ÚÎÔ‡˜ ÛÙ·ÙÈÛÙÈ΋˜ ÈÛ¯‡Ô˜, ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Î·È Ë ·‰˘Ó·Ì›· ·Ó›¯Ó¢Û˘ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋˜ Û˘Û¯¤ÙÈÛ˘ ÙÔ˘ VEGF +405 GÆC Ì ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË. ™’ ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË ‚¤‚·È·, Ë Û¯ÂÙÈο ·˘ÍË̤ÓË ·ÚÔ˘Û›· ÙˆÓ ÊÔÚ¤ˆÓ ÙÔ˘ G ·ÏÏËÏÔÌfiÚÊÔ˘ ÛÙËÓ ˘ÔÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ‚Ú›ÛÎÂÙ·È ÛÂ Û˘Ìʈ-

Ó›· Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘ Û ȷˆÓÈÎfi ÏËı˘ÛÌfi (31). ™‡Ìʈӷ Ì ·˘Ù‹ ÙËÓ ˘fiıÂÛË, Ô VEGF ÚÔηÏ› ‚Ï¿‚Ë ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ÌÈÎÚÔ·ÁÁÂȷ΋ ‰È·ÂÚ·ÙfiÙËÙ· ·ÊÂÓfi˜ Î·È ÚÔηÏÒÓÙ·˜ ÂÚÈ·ÁÁÂÈ·Îfi Ô›‰ËÌ· ·ÊÂÙ¤ÚÔ˘, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ÙÔȯˆÌ¿ÙˆÓ ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘ Ô˘ ‰Â˘ÙÂÚÔ·ıÒ˜ Û˘Ì‚¿ÏÏÂÈ ÛÙË ‰ËÌÈÔ˘ÚÁ›· ·Ó¢ڢÛÌ¿ÙˆÓ. ∂ÈϤÔÓ, Ô VEGF ÚÔ¿ÁÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi Î·È ÙË ÌÂÙ·Ó·ÛÙ¢ÙÈ΋ ÈηÓfiÙËÙ· ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÙÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ (NO) Û˘Ì‚¿ÏÏÔÓÙ·˜ ÛÙËÓ ·Ó·Î·Ù·Û΢‹ Î·È ÙË ‰È·Ù·Ú·¯‹ Ù˘ ÌÈÎÚÔ·Ú¯ÈÙÂÎÙÔÓÈ΋˜ ÙˆÓ ·ÁÁ›ˆÓ ÌÂÙ¿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘ (31). ∞fi Ù· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ÚÔ·ÙÂÈ Ë ·Ó¿ÁÎË ÁÈ· Â¤ÎÙ·ÛË Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û ÌÂÁ·Ï‡ÙÂÚÔ ‰Â›ÁÌ· ·ÛıÂÓÒÓ Ì ¡∫, ¤ÙÛÈ ÒÛÙ ӷ ÂÍ·¯ıÔ‡Ó ·ÛʷϤÛÙÂÚ· Û˘ÌÂÚ¿ÛÌ·Ù·, ÙfiÛÔ Û ۯ¤ÛË Ì ٷ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· fiÛÔ Î·È ·Ó·ÊÔÚÈο Ì ÙËÓ Â›‰Ú·ÛË ÙÔ˘ VEGF +405 GÆC ÔÏ˘ÌÔÚÊÈÛÌÔ‡ ÛÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ¡∫ ·ÊÂÓfi˜ Î·È Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ ·ÊÂÙ¤ÚÔ˘. ™˘ÌÂÚ·ÛÌ·ÙÈο, ηٷϋÁÔ˘Ì fiÙÈ Ë ‰ÈÂÚ‡ÓËÛË Ó¤ˆÓ ÁÂÓÂÙÈÎÒÓ Î·È ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ¡∫ ı· Û˘Ì‚¿ÏÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ ÚÒÈÌË ‰È¿ÁÓˆÛË Î·È ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ÂÚÈÔÚ›˙ÔÓÙ·˜ ÙÔÓ ·ÚÈıÌfi ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Japanese Circulation Society Joint Research Group.

Guidelines for diagnosis and management of cardiovascular sequelae in Kawasaki disease. Pediatr Int 2005;47:711732.

2. Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, et al. Diagnosis, treatment and longterm management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardioascular Disease in the Young, American Heart Association. Pediatrics 2004;114:1708-1733.

3. Kawasaki T. Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children. Arerugi 1967;16:178-222.

4. Freeman AF, Shulman ST. Kawasaki disease: summary of the American Heart Association guidelines. Am Fam Physician 2006;74:1141-1148.

5. Chuang CH, Hsiao MH, Chiu CH, Huang YC, Lin TY. Kawasaki disease in infants three months of age or younger. J Microbiol Immunol Infect 2006;39:387-391.

6. Kim T, Choi W, Woo CW, Choi B, Lee J, Lee K, et al. Predictive risk factors for coronary artery abnormalities in Kawasaki disease. Eur J Pediatr 2007;166:421-425.

7. Belay ED, Maddox RA, Holman RC, Curns AT, Ballah K, Schonberger LB. Kawasaki syndrome and risk factors for coronary artery abnormalities: United States, 1994-2003.

Pediatr Infect Dis J 2006;25:245-249. ¶·È‰È·ÙÚÈ΋ 2007;70:389-394

Paidiatriki 5 final

12-10-07

16:28

Page 394

394

§. ºÈ‰¿ÓË Î·È Û˘Ó.

8. Chang FY, Hwang B, Chen SJ, Lee PC, Meng CC, Lu JH. Characteristics of Kawasaki disease in infants younger than six months of age. Pediatr Infect Dis J 2006;25:241-244.

9. Benseler SM, McCrindle BW, Silverman ED, Tyrrell PN, Wong J, Yeung RS. Infections and Kawasaki disease: implications for coronary artery outcome. Pediatrics 2005;116:760-766.

10. Wang CL, Wu YT, Liu CA, Kuo HC, Yang KD. Kawasaki disease: infection, immunity and genetics. Pediatr Infect Dis J 2005;24:998-1004.

11. Yeung RS. Pathogenesis and treatment of Kawasaki's disease. Curr Opin Rheumatol 2005;17:617-623.

12. Burgner D, Harnden A. Kawasaki disease: what is the epidemiology telling us about the etiology? Int J Infect Dis 2005;9:185-194.

13. Park YW, Han JW, Park IS, Kim CH, Yun YS, Cha SH, et al. Epidemiologic picture of Kawasaki disease in Korea, 2000-2002. Pediatr Int 2005;47:382-387.

14. Yanagawa H, Nakamura Y, Yashiro M, Uehara R, Oki I, Kayaba K. Incidence of Kawasaki disease in Japan: the nationwide surveys of 1999-2002. Pediatr Int 2006;48:356-361.

15. Ferrara N. Molecular and biological properties of vascular endothelial growth factor. J Mol Med 1999;77:527-543.

16. Hamamichi Y, Ichida F, Yu X, Hirono KI, Uese KI, Hashimoto I, et al. Neutrophils and mononuclear cells express vascular endothelial growth factor in acute Kawasaki disease: its possible role in progression of coronary artery lesions. Pediatr Res 2001;49:74-80.

17. Maeno N, Takei S, Masuda K, Akaike H, Matsuo K, Kitajima I, et al. Increased serum levels of vascular endothelial growth factor in Kawasaki disease. Pediatr Res 1998;44:596-599.

18. Ohno T, Igarashi H, Inoue K, Akazawa K, Joho K, Hara T. Serum vascular endothelial growth factor: a new predictive indicator for the occurrence of coronary artery lesions in Kawasaki disease. Eur J Pediatr 2000;159:424-429.

19. Watson CJ, Webb NJ, Bottomley MJ, Brenchley PE. Identification of polymorphisms within the vascular endothelial growth factor (VEGF) gene: correlation with variation in VEGF protein production. Cytokine 2000;12:1232-1235.

20. Stevens A, Soden J, Brenchley PE. et al. Haplotype analysis of the polymorphic human vascular endothelial growth factor gene promoter. Cancer Res 2003;63:812-816.

Paediatriki 2007;70:389-394

21. Awata T, Inoue K, Kurihara S, Ohkubo T, Watanabe M, Inukai K. A common polymorphism in the 5’- untranslated region of the VEGF gene is associated with diabetic retinopathy in type 2 diabetes. Diabetes 2002;51:1635-1639.

22. Holman RC, Curns AT, Belay ED, Steiner CA, Schonberger LB. Kawasaki syndrome hospitalizations in the United States, 1997 and 2000. Pediatrics 2003;112:495-501.

23. Chang RK. The incidence of Kawasaki disease in the United States did not increase between 1988 and 1997. Pediatrics 2003;111:1124-1125.

24. Gandhi A, Wilson DG. Incomplete Kawasaki disease: not to be forgotten. Arch Dis Child 2006;91:276-277.

25. Yanagawa H, Nakamura Y, Yashiro M, Ojima T, Tanihara S, Oki I, et al. Results of the nationwide epidemiologic survey of Kawasaki disease in 1995 and 1996 in Japan. Pediatrics 1998;102:65.

26. Fujita Y, Nakamura Y, Sakata K, Hara N, Kobayashi M, Nagai M. Kawasaki disease in families. Pediatrics 1989;84: 666-669.

27. Newburger JW, Taubert KA, Shulman ST, Rowley AH, Gewitz MH, Takahashi M, et al. Summary and abstracts of the Seventh International Kawasaki Disease Symposium: December 4-7, 2001, Hakone, Japan. Pediatr Res 2003;53: 153-157.

28. Kaneko K, Obinata K, Katsumata K, Tawa T, Hosaka A, Yamashiro Y. Kawasaki disease in a father and daughter.

Acta Paediatr 1999;88:791-792.

29. Honkanen VE, McCrindle BW, Laxer RM, Feldman BM, Schneider R, Silvermann ED. Clinical relevance of the risk factors for coronary artery infiammation in Kawasaki disease. Pediatr Cardiol 2003;24:122-126.

30. Nakamura Y, Yashiro M, Uehara R, Watanabe M, Tajimi M, Oki I, et al. Use of laboratory data to identify risk factors of giant coronary aneurysms due to Kawasaki disease.

Pediatr Int 2004;46:33-38.

31. Kariyazono H, Ohno T, Khajoee V, Ihara K, Kusuhara K, Kinukawa N, et al. Association of vascular endothelial growth factor (VEGF) and VEGF receptor gene polymorphisms with coronary artery lesions of Kawasaki disease.

Pediatr Res 2004;56:953-959.

Paidiatriki 5 final

12-10-07

16:28

Page 395

∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

ORIGINAL ARTICLE

395

∂ȉËÌÈÔÏÔÁ›· ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Û ·È‰È¿ ÛÙËÓ ∂ÏÏ¿‰·: ªÂϤÙË ROTASCORE π. ∫·‚·ÏÈÒÙ˘1, µ. ¶··Â˘·ÁÁ¤ÏÔ˘2, ∂. ∫fiÎÎÔÚË3, §. ª·ÓÙ·ÁÔ‡4, °. ∆Ú›Ì˘5, ∞. ∫ÔÓÙÔ‡1, Ã. ª·ÛÈÔ‡ÚË3, ¡. ¡ÈÎÔÏ·ÎÔÔ‡ÏÔ˘4, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜2, √Ì¿‰· ªÂϤÙ˘ ROTASCORE* ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: √ ÚÔÙ·˚fi˜ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ Î·È ÛÔ‚·ÚfiÙÂÚÔ ·›ÙÈÔ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Û ·È‰È¿ ËÏÈΛ·˜ ˆ˜ 5 ÂÙÒÓ ·ÁÎÔÛÌ›ˆ˜. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ ·È‰ÈÒÓ Ì ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi (°ƒ) Î·È Ë Û‡ÁÎÚÈÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ Û ۯ¤ÛË Ì ÙË Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ¿ÏÏ· ·ıÔÁfiÓ· (°∞). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∏ ÌÂϤÙË Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙ· ∆Ì‹Ì·Ù· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ (∆∂¶) ÙÂÛÛ¿ÚˆÓ ÌÂÁ¿ÏˆÓ ÓÔÛÔÎÔÌ›ˆÓ Î·È Û 50 ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· ÌÂٷ͇ π·ÓÔ˘·Ú›Ô˘ Î·È ª·˝Ô˘ 2006. ªÂÏÂÙ‹ıËÎ·Ó ·È‰È¿ ËÏÈΛ·˜ ˆ˜ 5 ÂÙÒÓ Ì ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·. ∏ ·Ó›¯Ó¢ÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ÚÔÙ·˚Ô‡ ÛÙ· ÎfiÚ·Ó· ¤ÁÈÓ Ì ٷ¯Â›· ·ÓÔÛԯڈ̷ÙÔÁÚ·ÊÈ΋ ‰ÔÎÈÌ·Û›·. ∏ ‚·Ú‡ÙËÙ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ ·ÍÈÔÏÔÁ‹ıËΠ̠ÙËÓ Îϛ̷η Clark. ∞ÔÙÂϤÛÌ·Ù·: ¶ÂÚÈÂÏ‹ÊıËÛ·Ó 706 ·È‰È¿ (385 ·ÁfiÚÈ·, ‰È¿ÌÂÛË ËÏÈΛ· 20 Ì‹Ó˜), ·fi Ù· ÔÔ›· ÙÔ 38,6% ÂÈÛΤÊıËΠٷ ∆∂¶ Î·È ÙÔ 61,4% Ù· ȉȈÙÈο È·ÙÚ›·. °ƒ ÂÌÊ¿ÓÈÛ ÙÔ 29,1% ÙˆÓ ·ÛıÂÓÒÓ, ÙÔ 18,3% ÙˆÓ ·È‰ÈÒÓ ·fi Ù· ȉȈÙÈο È·ÙÚ›·, ÙÔ 45,7%, ÙˆÓ ·ÛıÂÓÒÓ ·fi Ù· ∆∂¶ Î·È ÙÔ 49,1% ÙˆÓ ÓÔÛËÏ¢ÔÌ¤ÓˆÓ ·È‰ÈÒÓ. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ °ƒ (71,7%) ÂÌÊ·Ó›ÛıËΠ۠·È‰È¿ ËÏÈΛ·˜ 0,53 ÂÙÒÓ. ¢È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜, ÛËÌ›· ·Ê˘‰¿ÙˆÛ˘, ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ˘ÚÂÙfi˜ ≥38ÔC, ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ Î·È ¤ÌÂÙÔÈ ·Ú·ÙËÚ‹ıËÎ·Ó Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÛÙËÓ ÔÌ¿‰· Ù˘ °ƒ (p<0,01), ηıÒ˜ Â›Û˘ Î·È ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ÓfiÛÔ˘ ̤ÙÚÈ·˜ ‹ ÛÔ‚·Ú‹˜ ‚·Ú‡ÙËÙ·˜ (p=0,013 Î·È p=0,021 ·ÓÙÈÛÙÔ›¯ˆ˜), ·Ó¿Á΢ ÁÈ· ÓÔÛËÏ›· (p=0,011) Î·È ·Ú¿Ù·Û˘ ¯ÚfiÓÔ˘ ÓÔÛËÏ›·˜ (p=0,039). ™˘ÌÂÚ¿ÛÌ·Ù·: √ ÚÔÙ·˚fi˜ ¢ı‡ÓÂÙ·È ÁÈ· ÙÔ ‹ÌÈÛ˘ ۯ‰fiÓ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Ô˘ ÂÈÛΤÙÔÓÙ·È Ù· ∆∂¶ ‹ ¯Ú‹˙Ô˘Ó ÓÔÛËÏ›·˜. ∏ ¯Ú‹ÛË Î·Ù¿ÏÏËÏÔ˘ ÂÌ‚ÔÏ›Ô˘ ı· ÌÔÚÔ‡Û ӷ Û˘Ì‚¿ÏÂÈ ÛÙËÓ ÚfiÏË„Ë ·˘Ù‹˜ Ù˘ Û˘¯Ó‹˜ Î·È ÔÏϤ˜ ÊÔÚ¤˜ ÛÔ‚·Ú‹˜ ÓfiÛÔ˘.

1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô §ÔÈ̈‰ÒÓ £ÂÛÛ·ÏÔӛ΢ 2 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡” 3 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, µÂÓÈ˙¤ÏÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ 4 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ, ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ƒ›Ô˘ 5 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: °ÈÒÚÁÔ˜ ∆Ú›Ì˘ gtrim@otenet.gr ∫ËÊÈÛ›·˜ 32 T.K. 115 26 ∞ÌÂÏfiÎËÔÈ, ∞ı‹Ó·

§¤ÍÂȘ ÎÏÂȉȿ: ∂ȉËÌÈÔÏÔÁ›·, Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, ÚÔÙ·˚fi˜, ·È‰È¿.

ROTASCORE study: Epidemiological observational study of rotavirus acute gastroenteritis in children in Greece I. ∫avaliotis1, V. Papaevangelou2, H. ∫okori3, L. Mantagou4, G. Trimis5, A. Kontou1, C. Basiouri3, N. Nikolakopoulou4, A. Konstantopoulos2, ROTASCORE Study Group* Abstract Background: Rotavirus is the most frequent and serious cause of acute gastroenteritis (AGE) in children aged up to 5 years worldwide. The aim of this study was to determine the proportion of Paediatric Rotavirus Gastroenteritis (PRG) and compare its burden to that of AGE due to other pathogens.

Methods: The study was conducted in four Hospital Emergency Units (HEU) and 50 private paediatric clinics between January and May 2006. Children aged up to 5 years with AGE were included. A rapid stool immunochromatographic test for rotavirus antigen detection was performed. The symptom severity score was evaluated using the Clark scale.

Results: The study included 706 children (385 boys) of median age 20 months; 38.6% of the patients visited HEU and 61.4% private clinics. Rotavirus antigen was identified in 29.1% of the patients, and specifically in 18.3% of the children who were examined in private clinics, 45.7% of those in HEU and 49.1% of hospitalised children. Most children with PRG (71.7%) were aged between 0.5 and 3 years.

Behavioural changes, signs of dehydration, weight loss, fever ≥38ÔC, diarrhoea and vomiting were all more prevalent in the PRG group (p<0.01). In addition, children with PRG presented higher rates of moderate or severe gastroenteritis (p=0.013 and p=0.021 respectively) and hospitalization (p=0.011), and had a longer hospitalization stay (p= 0.039).

Conclusions: PRG is responsible for nearly half of the cases of children aged up to 5 years with AGE attending HEU or requiring hospitalization. Appropriate vaccination could help prevent this common and often severe disease.

1 Paediatric Department, Hospital of Infectious Diseases of Thessaloniki 2 2nd Paediatric Department, Athens University School of Medicine, “Aglaia Kyriakou” Children’s Hospital, Athens 3 2nd Paediatric Department, Venizelio Hospital of Heraklion 4 Paediatric Department, University Hospital of Rio, Patras 5 1st Paediatric Department, Athens University School of Medicine, ”Agia Sophia” Children’s Hospital, Athens Correspondence: Georgios Trimis gtrim@otenet.gr 32, Kifissias Avenue 115 26, Ambelokipoi Athens, Greece

Key words: Epidemiology, gastroenteritis, rotavirus, children. ¶·È‰È·ÙÚÈ΋ 2007;70:395-401

Paidiatriki 5 final

12-10-07

16:28

Page 396

396

π. ∫·‚·ÏÈÒÙ˘ Î·È Û˘Ó.

™˘ÓÙÔÌÔÁڷʛ˜ ∆∂¶: ∆Ì‹Ì·Ù· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ °ƒ: √Í›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi °∞: √Í›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ¿ÏÏ· ·ıÔÁfiÓ·

∂ÈÛ·ÁˆÁ‹ √ ÚÔÙ·˚fi˜ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Û ·È‰È¿ ËÏÈΛ·˜ ≤5 ÂÙÒÓ (1). ∏ Û˘¯ÓfiÙËÙ· Ù˘ Ïԛ̈͢ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ‰È·ÊÔÚ¤˜ ·Ó¿ÏÔÁ· Ì ÙË ÁˆÁÚ·ÊÈ΋ ηٷÓÔÌ‹, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ÔÛÔÛÙfi ı·Ó¿ÙˆÓ ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ ÂÍ·ÈÙ›·˜ Û˘ÓıËÎÒÓ Î·Î‹˜ ‰È·ÙÚÔÊ‹˜ Î·È ·ÓÂ·ÚÎÔ‡˜ È·ÙÚÈ΋˜ ÊÚÔÓÙ›‰·˜ (2). ™ÙËÓ Ú¿ÍË ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ fiÏ· Ù· ·È‰È¿ ı· ÌÔÏ˘ÓıÔ‡Ó ·fi ÚÔÙ·˚fi ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì›· ÊÔÚ¿ ÛÙ· 23 ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜ Î·È Û˘¯ÓfiÙÂÚ· ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ (3-5). √È ÔÈÎÔÓÔÌÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi (°ƒ) Â›Ó·È ÛËÌ·ÓÙÈΤ˜, ÏfiÁˆ Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Î·È Ù˘ Â›‰Ú·Û‹˜ ÙÔ˘˜ ÛÙË ˙ˆ‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ™ÙËÓ ∂˘ÚÒË ‰ÂÓ ˘¿Ú¯Ô˘Ó Â·Ú΋ ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ Â›ÙˆÛË Ù˘ °ƒ. ∞˘Ùfi ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Û¿ÓÈ· Á›ÓÂÙ·È ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÚÔ˘Û›·˜ ÚÔÙ·˚Ô‡, ηıÒ˜ ·˘Ùfi ‰ÂÓ Û˘ÓÙÂÏ› Û ·ÏÏ·Á‹ ıÂÚ·›·˜ ‹ ÛÙË Ï‹„Ë ÂȉÈÎÒÓ ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ. ÕÏÏÔ˜ ÏfiÁÔ˜ Â›Ó·È fiÙÈ Ë °ƒ ‰ÂÓ ·Ó‹ÎÂÈ ÛÙ· ˘Ô¯ÚˆÙÈÎÒ˜ ‰ËÏÔ‡ÌÂÓ· ÓÔÛ‹Ì·Ù·. ∂ÈϤÔÓ, Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ °ƒ ·fi ÙËÓ ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· Ô˘ ÚÔηÏÂ›Ù·È ·fi ¿ÏÏ· ·ıÔÁfiÓ· (°∞) Â›Ó·È ÂÍ·ÈÚÂÙÈο ‰‡ÛÎÔÏË, ηıÒ˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó Û˘ÁÎÂÎÚÈ̤ӷ Î·È Û·Ê‹ ÎÏÈÓÈο ‹ ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· (6). º·›ÓÂÙ·È ÏÔÈfiÓ fiÙÈ Ë Â›ÙˆÛ‹ Ù˘ ÛÙËÓ ÎÔÈÓfiÙËÙ· ˘ÔÂÎÙÈÌ¿Ù·È. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙËÓ Âԯȷ΋ ηٷÓÔÌ‹ Ù˘ ÓfiÛÔ˘, ÌÂϤÙ˜ Û ¯ÒÚ˜ Ì ‡ÎÚ·ÙÔ Îϛ̷ ‰Â›¯ÓÔ˘Ó ¤Í·ÚÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ, ΢ڛˆ˜ ηٿ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜ (7). °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ë ÌÂϤÙË Ú·ÁÌ·ÙÔÔÈ‹ıËΠηٿ ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô. ∫‡ÚÈÔ˜ ÛÎÔfi˜ ‹Ù·Ó Ë ÂÚÈÁÚ·Ê‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛËÌ›ˆÓ ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ ≤5 ÂÙÒÓ Ì °ƒ Î·È Î·Ù¿ ‰Â‡ÙÂÚÔ ÏfiÁÔ, Ô Î·ıÔÚÈÛÌfi˜ ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ ·È‰ÈÒÓ Ì °ƒ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ì Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, Ë Û‡ÁÎÚÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛËÌ›ˆÓ ÙˆÓ ·È‰ÈÒÓ Ì ÚÔÙ·˚fi Û ۯ¤ÛË Ì ÙË °∞ ηÈ, Ù¤ÏÔ˜, Ë ·Ó›¯Ó¢ÛË Èı·ÓÒÓ ÚÔÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ °ƒ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™¯Â‰È·ÛÌfi˜ ÌÂϤÙ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ÔÏ˘ÎÂÓÙÚÈ΋, ÌË ·ÚÂÌ‚·ÙÈ΋, ÚÔÔÙÈ΋ ÌÂϤÙË ÂȉËÌÈÔÏÔÁÈ΋˜ ·Ú·Ù‹ÚËÛ˘, Ë ÔÔ›· ÂÁÎÚ›ıËΠ·fi ÙȘ ∂ÈÙÚÔ¤˜ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÓÔÛÔÎÔÌ›ˆÓ Î·È ·Ú¿ÏÏËÏ· ÁÓˆÛÙÔÔÈ‹ıËΠÛÙÔÓ ∂ıÓÈÎfi √ÚÁ·ÓÈÛÌfi º·Ú̿ΈÓ. ™ÙË ÌÂϤÙË ÂÚÈÂÏ‹ÊıËÛ·Ó Paediatriki 2007;70:395-401

·È‰È¿ ËÏÈΛ·˜ ¤ˆ˜ 5 ÂÙÒÓ Ô˘ ÂÍÂÙ¿ÛıËÎ·Ó ÛÙ· ∆Ì‹Ì·Ù· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ (∆∂¶) Î·È Û ηıÔÚÈṲ̂ӷ ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›·, ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 15/1 ¤ˆ˜ 15/5/2006, ÌÂ Û˘ÌÙÒÌ·Ù· ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜. ∏ ÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË Ù˘ °ƒ ÁÈÓfiÙ·Ó Ì ‰ÔÎÈÌ·Û›· ·Ó›¯Ó¢Û˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ÚÔÙ·˚Ô‡ ÛÙ· ÎfiÚ·Ó·. ∫ÚÈÙ‹ÚÈ· Û˘ÌÌÂÙÔ¯‹˜ Î·È ·ÔÎÏÂÈÛÌÔ‡ ∫ÚÈÙ‹ÚÈÔ Û˘ÌÌÂÙÔ¯‹˜ ‹Ù·Ó Ë Â›ÛÎÂ„Ë ·È‰ÈÔ‡ ÌÈÎÚfiÙÂÚÔ˘ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ Ì ÂÂÈÛfi‰ÈÔ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Û οÔÈÔ ·fi Ù· ∆∂¶ ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ÎÏÈÓÈÎÒÓ ‹ Ù· ηıÔÚÈṲ̂ӷ ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›·. √ ÔÚÈÛÌfi˜ ÙÔ˘ ÂÂÈÛÔ‰›Ô˘ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ÂÚÈÏ¿Ì‚·Ó ÙËÓ ‡·ÚÍË ÙÚÈÒÓ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ˘‰·ÚÒÓ ÎÂÓÒÛÂˆÓ Ì ‹ ¯ˆÚ›˜ ¤ÌÂÙÔ Û ‰È¿ÛÙËÌ· 24 ˆÚÒÓ. ∫ÚÈÙ‹ÚÈ· ·ÔÎÏÂÈÛÌÔ‡ ‹Ù·Ó Ë ·ÚÔ˘Û›· ¯ÚfiÓÈ·˜ ‰È¿ÚÚÔÈ·˜ (‰È¿ÚÎÂÈ· >7 ̤Ú˜), ÓÔÛËÌ¿ÙˆÓ ÌË Û˘Ì‚·ÙÒÓ Ì ÙÔÓ ÔÚÈÛÌfi Ù˘ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ (.¯. ÎÔÈÏÈÔοÎË, ÓfiÛÔ˜ ÙÔ˘ Hirschprung, Î.Ï.), Ë ÚÔۤϢÛË ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ È·ÙÚfi ÁÈ· ¿ÏÏÔÓ ÏfiÁÔ, Ë ÁÓˆÛÙ‹ ÙÚÔÊÈ΋ ‰ËÏËÙËÚ›·ÛË ‹ Ë È·ÙÚÔÁÂÓ‹˜ ‰È¿ÚÚÔÈ· (.¯. Ï‹„Ë ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ). ∂›Û˘, ·ÔÎÏ›ÛÙËÎ·Ó ·È‰È¿ Ì ·‰˘Ó·Ì›· ¯ÔÚ‹ÁËÛ˘ ‰Â›ÁÌ·ÙÔ˜ ÎÔÚ¿ÓˆÓ Î·È Ì ÁÔÓ›˜, ÔÈ ÔÔ›ÔÈ ‰ÂÓ ¤‰ˆÛ·Ó Û˘ÁηٿıÂÛË ÁÈ· Û˘ÌÌÂÙÔ¯‹ ÛÙË ÌÂϤÙË. ∂ÈÏÔÁ‹ ÙˆÓ Î¤ÓÙÚˆÓ Ù˘ ÌÂϤÙ˘ ∏ ‰ÈÂÍ·ÁˆÁ‹ Ù˘ ÌÂϤÙ˘ ¤ÁÈÓ ÛÙ· ∆∂¶ ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ÎÏÈÓÈÎÒÓ ÙÂÛÛ¿ÚˆÓ ÌÂÁ¿ÏˆÓ ÓÔÛÔÎÔÌ›ˆÓ (µã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡”, ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ §ÔÈ̈‰ÒÓ £ÂÛÛ·ÏÔӛ΢, µã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ µÂÓÈ˙¤ÏÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ∏Ú·ÎÏ›Ԣ Î·È ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ, ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ƒ›Ô˘) Î·È Û 50 ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· Û ‰È¿ÊÔÚ˜ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜. √ Û˘ÓÙÔÓÈÛÌfi˜ Î·È Ë Û˘ÏÏÔÁ‹ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ·Ó ·fi ÙË µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ. ∏ ÁˆÁÚ·ÊÈ΋ ηٷÓÔÌ‹ ÙˆÓ Î¤ÓÙÚˆÓ ‹Ù·Ó ¢Ú›·, ÒÛÙ ӷ ˘¿Ú¯ÂÈ ·Ó·ÏÔÁÈ΋ Ì ÙÔÓ ÏËı˘ÛÌfi ·ÓÙÈÚÔÛÒ¢ÛË fiÏˆÓ ÙˆÓ ÂÚÈÔ¯ÒÓ. ™˘ÏÏÔÁ‹ ‰Â‰ÔÌ¤ÓˆÓ ∏ Û˘ÏÏÔÁ‹ ‰Â‰ÔÌ¤ÓˆÓ ÂÚÈÏ¿Ì‚·Ó ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ÙÔ˘ ·ÛıÂÓ‹ (ʇÏÔ, ËÏÈΛ·), ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÓfiÛÔ˘ (Û˘ÌÙÒÌ·Ù·, Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ ·Ó¿ Ë̤ڷ Î·È ‰È¿ÚÎÂÈ·) Î·È ÙÔ˘ ÙÚfiÔ˘ ‰È·‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ (·ÚÈıÌfi˜ ·‰ÂÚÊÒÓ, ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÎÔ‡ ÛÙ·ıÌÔ‡, ıËÏ·ÛÌfi˜). ∏ ÛÔ‚·ÚfiÙËÙ· ÙÔ˘ οı ÂÚÈÛÙ·ÙÈÎÔ‡ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ‚·ıÌÔÏÔÁ‹ıËΠۇÌʈӷ Ì ÙËÓ Îϛ̷η ÙÔ˘ Clark, Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë ÙËÓ ·ÚÔ˘Û›·, ÙËÓ ¤ÓÙ·ÛË Î·È ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰È·ÊfiÚˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (8). ∏ ·Ó›¯Ó¢ÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÛÙ· ÎfiÚ·Ó· ÁÈÓfiÙ·Ó Ì ÙËÓ Ù·¯Â›· ·ÓÔÛԯڈ̷ÙÔÁÚ·ÊÈ΋ ‰ÔÎÈÌ·Û›· VIKIA (BioMerieux), ÂÓÒ ÙÔ ‰Â›ÁÌ· ÌÔÚÔ‡Û ӷ Ê˘Ï·¯ı› ÁÈ· 24-48 ÒÚ˜ Û ıÂÚÌÔÎÚ·Û›· „˘Á›Ԣ (2-8ÆC). ™ÙÔ Ù¤ÏÔ˜ Ù˘ ÂͤٷÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈÓfiÙ·Ó ·Ó¿ÁÓˆÛË ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ Ù˘ ‰ÔÎÈÌ·Û›·˜ ÎÔÚ¿ÓˆÓ, ¤ÙÛÈ ÒÛÙ o È·ÙÚfi˜ Ó· ÌËÓ ÂËÚ·ÛÙ› ÛÙËÓ ÂÈÏÔÁ‹ Ù˘ Û˘ÓÈÛÙÒÌÂÓ˘ ·ÁˆÁ‹˜. ™˘ÌÏËڈ̷ÙÈο ÛÙÔȯ›· ÁÈ· ÙË Û˘ÓÔÏÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘ Ï·Ì‚¿ÓÔÓÙ·Ó ÌÂÙ¿ ·fi ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›· Ì ÙÔ˘˜ ÁÔÓ›˜, 6-10 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÂÚÈÂÏ¿Ì‚·Ó ۇÁÎÚÈÛË ÙˆÓ ·È‰ÈÒÓ ÛÙ· ÔÔ›· ‰È·ÁÓÒÛıËΠ°ƒ Ì ٷ ·È‰È¿ ÛÙ· ÔÔ›·

Paidiatriki 5 final

12-10-07

16:28

Page 397

397

∂ȉËÌÈÔÏÔÁ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Û ·È‰È¿

‰È·ÁÓÒÛıËΠ°∞, ηıÒ˜ Î·È Û‡ÁÎÚÈÛÂȘ ÌÂٷ͇ ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ËÏÈÎÈ·ÎÒÓ ÔÌ¿‰ˆÓ Ì ÙË ¯Ú‹ÛË ÙÔ˘ t-test. °È· Ó· ÂÏÂÁ¯ı› Ë ÛËÌ·ÓÙÈÎfiÙËÙ· Ù˘ Â›‰Ú·Û˘ ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ·ÚÔ˘Û›· °ƒ, ηıÒ˜ Î·È Ë ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘, ÂÊ·ÚÌfiÛÙËÎÂ Ô ¤ÏÂÁ¯Ô˜ χ2. ∆¤ÏÔ˜, ˘ÔÏÔÁ›ÛÙËÎ·Ó ÔÈ Û¯ÂÙÈÎÔ› ΛӉ˘ÓÔÈ (odds ratios) Ù˘ ÂÌÊ¿ÓÈÛ˘ ÔÚÈÛÌ¤ÓˆÓ ÌÂÙ·‚ÏËÙÒÓ ÛÙ· ·È‰È¿ Ì °ƒ Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ì °∞. ∆Ô Â›Â‰Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ÔÚ›ÛÙËΠˆ˜ p<0,05. ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi Û‡ÛÙËÌ· SPSS (version 10.0, Chicago, USA).

ı› ·È‰› ıÂÙÈÎfi ÁÈ· ÚÔÙ·˚fi ·’ fi,ÙÈ ÛÙ· ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· (p<0,01). ™˘ÁÎÂÎÚÈ̤ӷ, °ƒ ÂÌÊ¿ÓÈÛ·Ó 125/273 ·ÛıÂÓ›˜ ·fi Ù· ∆∂¶ (45,7%, CI 95%: 40-51,7%) Î·È 77/420 ·ÛıÂÓ›˜ ·fi Ù· ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· (18,3%, CI 95%: 14,9-22,3%). ∏ Û˘¯ÓfiÙËÙ· Ù˘ °ƒ ·ÚÔ˘Û›·Û ‰È·Î˘Ì¿ÓÛÂȘ ·Ó¿ÏÔÁ· Ì ÙË ÁˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹, fï˜, ·Ú¤ÌÂÓ ÛÙ·ıÂÚ¿ ˘„ËÏfiÙÂÚË ÛÙ· ∆∂¶, fiˆ˜ Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ °ƒ ηٷÁÚ¿ÊËΠÛÙȘ ËÏÈ˘ 6 ÌËÓÒÓ - 3 ÂÙÒÓ (71%, ∂ÈÎfiÓ· 2). ∏ ‰È¿ÌÂÛË ËÏÈΛ· ÂÌÊ¿ÓÈÛ˘ Ù˘ °ƒ ‹Ù·Ó 17 Ì‹Ó˜ (̤ÛË ËÏÈΛ· 20±13 ÌËÓÒÓ) Î·È Ù˘ °∞ 22 Ì‹Ó˜ (̤ÛË ËÏÈΛ· 26±12 ÌËÓÒÓ), p=0,042. ∞Ó·Ï˘ÙÈÎfiÙÂÚ·, ÛÙ· ∆∂¶ Ë ‰È¿ÌÂÛË ËÏÈΛ· Ù˘ ÂÌÊ¿ÓÈÛ˘ °ƒ ‹Ù·Ó 15 Ì‹Ó˜ Î·È Ù˘ ÂÌÊ¿ÓÈÛ˘ °∞ 18 Ì‹Ó˜ (p>0,05), ÂÓÒ ÛÙ· ȉȈÙÈο È·ÙÚ›· ÔÈ ·ÓÙ›ÛÙÔȯ˜ ÙÈ̤˜ ‹Ù·Ó 19 Î·È 26 Ì‹Ó˜ (p=0,035). ∆¤ÏÔ˜, Ë Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ °ƒ ‹Ù·Ó ÛÙ·ıÂÚ‹ ηٿ ÙÔ˘˜ Ì‹Ó˜ π·ÓÔ˘¿ÚÈÔ ˆ˜ ∞Ú›ÏÈÔ (2831%), ÂÓÒ ÙÔÓ ª¿ÈÔ ‹Ù·Ó ¯·ÌËÏfiÙÂÚË (17,2%). ¢ÂÓ ÂÓÙÔ›ÛÙËÎ·Ó ·Ú¿ÁÔÓÙ˜ Ô˘ Ó· Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ °ƒ, ηıÒ˜ ‰ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙË ¯ÔÚ‹ÁËÛË ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·‰ÂÚÊÒÓ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÎÔ‡ ÛÙ·ıÌÔ‡. ¢È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ (ÓˆıÚfiÙËÙ·, ¢ÂÚÂıÈÛÙfiÙËÙ·, ÎfiˆÛË, ˘ÔÙÔÓ›·, Ï‹ı·ÚÁÔ˜), ·ÚÔ˘Û›· ÛËÌ›ˆÓ ·Ê˘‰¿ÙˆÛ˘ Î·È ·ÒÏÂÈ· ‚¿ÚÔ˘˜ ‹Ù·Ó ÔÈ ÂΉËÏÒÛÂȘ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó Û ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÛÙË °ƒ Û˘ÁÎÚÈÙÈο Ì ÙË °∞ (p<0,01,

∞ÔÙÂϤÛÌ·Ù· ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó Û˘ÓÔÏÈο 706 ·È‰È¿, (54,5% ·ÁfiÚÈ·), ÂÎ ÙˆÓ ÔÔ›ˆÓ ÛÙ· 6 ‰ÂÓ Î·Ù·ÁÚ¿ÊËΠÙÔ Ê‡ÏÔ. ∏ ‰È¿ÌÂÛË ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó 20 Ì‹Ó˜ (̤ÛË ËÏÈΛ· 24±12 Ì‹Ó˜), ÂÓÒ Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ (63,0%) ·Ó‹Î ÛÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· ÙˆÓ 6 ÌËÓÒÓ ˆ˜ 3 ÂÙÒÓ. ™ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ‰ÂÓ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó 9 ·ÛıÂÓ›˜, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ‰ÂÓ Â›¯·Ó Û˘ÌÏËÚˆı› Ù· ‰Â‰Ô̤ӷ Î·È 4 ·ÛıÂÓ›˜, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·Ó›¯Ó¢Û˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ·Ó·Ê¤ÚıËΠˆ˜ ·‰È¢ÎÚ›ÓÈÛÙÔ. ™˘ÓÂÒ˜, Ë ·Ó¿Ï˘ÛË ÂÚÈÏ¿Ì‚·Ó 693 ·ÛıÂÓ›˜ (98,2% ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜), ÂÎ ÙˆÓ ÔÔ›ˆÓ ÔÈ 273 (39%) ÂÈÛΤÊıËÎ·Ó Ù· ∆∂¶ Î·È ÔÈ 420 (61%) Ù· ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›·. ∞fi ÙÔ Û‡ÓÔÏÔ Ô˘ ÂÍÂÙ¿ÛıËΠ(¡=693), 202 ·È‰È¿ (29,1%, CI 95%: 25,9-32,6%) ‚Ú¤ıËÎ·Ó ıÂÙÈο ÁÈ· ÚÔÙ·˚fi. ™Ù· ·ÁfiÚÈ· ‰È·ÈÛÙÒıËΠ°ƒ Û ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·’ fi,ÙÈ ÛÙ· ÎÔÚ›ÙÛÈ· (p=0,038). ∂›Û˘, ÛÙ· ∆∂¶ ‹Ù·Ó Èı·ÓfiÙÂÚÔ Ó· ‚ÚÂ-

µÂÓÈ˙¤ÏÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ (¡=63)

56%

¡ÔÛÔÎÔÌÂ›Ô §ÔÈ̈‰ÒÓ £ÂÛÛ·ÏÔӛ΢ (¡=110)

45%

¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡ (¡=70)

41%

¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ƒ›Ô˘ (¡=30)

40%

π‰ÈˆÙÈο È·ÙÚ›· ∫Ú‹Ù˘ (¡=48)

23%

π‰ÈˆÙÈο È·ÙÚ›· πˆ·ÓÓ›ÓˆÓ (¡=28)

21%

π‰ÈˆÙÈο È·ÙÚ›· ∞ıËÓÒÓ (¡=205)

21%

π‰ÈˆÙÈο È·ÙÚ›· ¶¿ÙÚ·˜ (¡=34)

18%

π‰ÈˆÙÈο È·ÙÚ›· £ÂÛÛ·ÏÔӛ΢ (¡=68)

12%

π‰ÈˆÙÈο È·ÙÚ›· ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘(¡=20)

10%

π‰ÈˆÙÈο È·ÙÚ›· §¿ÚÈÛ·˜ (¡=17)

6% 0%

1000%

2000%

3000%

4000%

5000%

6000%

∂ÈÎfiÓ· 1. ™˘¯ÓfiÙËÙ· ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi (°ƒ) ·Ó¿ ÂÚÈÔ¯‹.

¶·È‰È·ÙÚÈ΋ 2007;70:395-401

Paidiatriki 5 final

12-10-07

16:28

Page 398

398

π. ∫·‚·ÏÈÒÙ˘ Î·È Û˘Ó.

3000%

30%

26%

2500%

2000%

1500%

15% 13%

1000% 9% 7% 500%

0% < 0,5

0,51 - 1

1,1 - 2

2,1 - 3

3,1 - 4

4,1 - 5

∏ÏÈΛ· (¤ÙË)

(N=202)

∂ÈÎfiÓ· 2. ¶ÔÛÔÛÙÈ·›· ηٷÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ Ì ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi (°ƒ) ·Ó¿ ËÏÈΛ·.

¶›Ó·Î·˜ 1). ∂ÈϤÔÓ, Ë ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ·fi ÚÔÙ·˚fi ·ÚÔ˘Û›·Û ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ ·ÚÔ˘Û›· ˘ÚÂÙÔ‡ ≥38ÔC, ÙËÓ ÂÌÊ¿ÓÈÛË Î·È ÙÔÓ ·ÚÈıÌfi ·Ó¿ Ë̤ڷ ‰È·ÚÚÔ˚ÎÒÓ ÎÂÓÒÛÂˆÓ Î·È Â̤وÓ, ηıÒ˜ Î·È ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÌ¤ÙˆÓ (p<0,01, ¶›Ó·Î·˜ 1).

34,6% ◊È· ª¤ÙÚÈ· ™Ô‚·Ú‹

58,9% °∞ (N=491) 40,1%

1,1% ◊È· ª¤ÙÚÈ· ™Ô‚·Ú‹ 58,8%

∂ÈÎfiÓ· 3. ™‡ÁÎÚÈÛË ‰ÂÈÎÙÒÓ ÛÔ‚·ÚfiÙËÙ·˜ ÌÂٷ͇ ·È‰ÈÒÓ Ì ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi (°ƒ) Î·È ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ¿ÏÏ· ·ıÔÁfiÓ· (°∞).* *µ·ıÌÔÏfiÁËÛË Ì ÙËÓ Îϛ̷η Clark Paediatriki 2007;70:395-401

¶›Ó·Î·˜ 1. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi (°ƒ) Î·È Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ¿ÏÏ· ·ıÔÁfiÓ· (°∞) ∫ÏÈÓÈ΋ ÂÈÎfiÓ·

°ƒ (N=202) 6,5%

™‡Ìʈӷ Ì ÙËÓ Îϛ̷η ÙÔ˘ Clark, Ë ÔÔ›· ‰È·¯ˆÚ›˙ÂÈ ÙË Á·ÛÙÚÂÓÙÂÚ›Ùȉ· Û ‹È·, ̤Û˘ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜, Ù· ·È‰È¿ Ì °ƒ ·ÚÔ˘Û›·Û·Ó Û˘¯ÓfiÙÂÚ·

∞Ê˘‰¿ÙˆÛË ∞ÒÏÂÈ· ‚¿ÚÔ˘˜ ¢È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ ∫fiˆÛË-Ï‹ı·ÚÁÔ˜ ¶˘ÚÂÙfi˜ ≥38oC ¢È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ ≥8 ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ/Ë̤ڷ ∫ÂÓÒÛÂȘ Ì ÚfiÛÌÈÍË ‚ϤÓÓ˘ ŒÌÂÙÔÈ ≥7 ¤ÌÂÙÔÈ/Ë̤ڷ ≥3 Ë̤Ú˜ Ì Â̤ÙÔ˘˜ ≥5 Ë̤Ú˜ Ì ‰È¿ÚÚÔÈ· ≥3 Ë̤Ú˜ Ì ˘ÚÂÙfi ™·ÛÌÔ› √Í›· ̤ÛË ˆÙ›Ùȉ· ™À¡√§√

°ƒ (n, % )

°∞ (n, %)

p

93 (46,0) 87 (43,1) 143 (70,7)

92 (18,7) 125 (25,5) 269 (54,7)

0,01 0,01 0,01

74 (36,6) 154 (76,2) 201 (99,5) 31 (15,4)

66 (13,4) 248 (50,5) 441 (89,8) 24 (4,9)

0,01 0,01 0,01 0,01

151 (74,7)

233 (47,4)

0,01

141 (69,8) 13 (6,5) 29 (14,4) 15 (7,4) 39 (19,3) 2 (0,9) 13 (6,5) 202

197 (40,1) 4 (0,8) 36 (7,3) 33 (6,7) 75 (15,3) 4 (0,8) 33 (6,7) 491

0,01 0,01 0,01 NS NS NS NS

°ƒ: √Í›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi °∞:√Í›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ¿ÏÏ· ·ıÔÁfiÓ· ¡S: ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi

Paidiatriki 5 final

12-10-07

16:28

Page 399

399

∂ȉËÌÈÔÏÔÁ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Û ·È‰È¿

̤Û˘ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜ ÓfiÛÔ, (65,4 ¤Ó·ÓÙÈ 41,2%, p<0,01, ∂ÈÎfiÓ· 3). ∏ ̤ÛË ÙÈÌ‹ ‚·ıÌÔÏfiÁËÛ˘ Ù˘ ‚·Ú‡ÙËÙ·˜ ηٿ Clark ÁÈ· Ù· ·È‰È¿ Ì °ƒ ‹Ù·Ó 11,1±5,1, ÂÓÒ ÁÈ· Ù· ·È‰È¿ Ì °∞ ‹Ù·Ó 9,2±4,9. ∆Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ Â‡ÚËÌ· ‹Ù·Ó fiÙÈ Ù· ·È‰È¿ Ì °ƒ ‹Ù·Ó Èı·ÓfiÙÂÚÔ Ó· ÂÈÛ·¯ıÔ‡Ó ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ¤Ó·ÓÙÈ ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤·Û¯·Ó ·fi °∞ (104/202, 51,5%, ¤Ó·ÓÙÈ 108/491, 22%, p=0,011). ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ÚԤ΢„ ·fi ÙËÓ ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÂÈÛ·ÁˆÁ‹˜ Ô˘ ›¯·Ó Ù· ·È‰È¿ Ì °ƒ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· ȉȈÙÈο È·ÙÚ›· (42,8 ¤Ó·ÓÙÈ 6%, p<0,01), ηıÒ˜, ÛÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· ∆∂¶, Ë Û˘¯ÓfiÙËÙ· ÂÈÛ·ÁˆÁÒÓ ‰ÂÓ ‰È¤ÊÂÚ ÌÂٷ͇ ·È‰ÈÒÓ Ì °ƒ Î·È ·È‰ÈÒÓ Ì °∞ (56,8 ¤Ó·ÓÙÈ 59%, p>0,05). ∆· ·È‰È¿ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· ∆∂¶, ·ÓÂÍ·Úًو˜ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ›¯·Ó ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ¿Û¯Ô˘Ó ·fi ̤Û˘ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· (76,4 ¤Ó·ÓÙÈ 24,2%, p<0,01). ™Ù· ·È‰È¿ ÙˆÓ È‰ÈˆÙÈÎÒÓ È·ÙÚ›ˆÓ Ì °ƒ Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ì °∞, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (odds ratio) ÁÈ· ÂÌÊ¿ÓÈÛË Ì¤Û˘ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ‹Ù·Ó ·˘ÍË̤ÓÔ˜ ηٿ 5,3 ÊÔÚ¤˜ (5,32, CI 95%: 1,65-14,8, p<0,01) Î·È ÁÈ· ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ·˘ÍË̤ÓÔ˜ ηٿ 7,1 ÊÔÚ¤˜ (7,12, CI 95%: 2,49-19,52, p<0,01). ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ÓÔÛËÏ›· ·ÓÂÍ·ÚÙ‹ÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜ (¡=212), Ù· 104 ·È‰È¿ (49,1%, CI 95%: 42,3-55,7%) ¤·Û¯·Ó ·fi °ƒ. ∂›Û˘, Ù· ·È‰È¿ Ì °ƒ ›¯·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚfiÓÔ ÓÔÛËÏ›·˜ (̤ÛË ‰È¿ÚÎÂÈ· 5,1±3,2 Ë̤Ú˜ ÁÈ· ÙËÓ °ƒ ¤Ó·ÓÙÈ 3,7±2,2 ËÌÂÚÒÓ ÁÈ· ÙËÓ °∞, p=0,039). √È ·Ó·ÊÂÚfiÌÂÓ˜ Ë̤Ú˜ ·Ô˘Û›·˜ ÁÔÓ¤ˆÓ ·fi ÙËÓ ÂÚÁ·Û›· ‹Ù·Ó ·ÚÎÂÙ¤˜ Û ÔÔÈ·Û‰‹ÔÙ ·ÈÙÈÔÏÔÁ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· (3,6±2,8 Ë̤Ú˜ ÁÈ· ÙÔ˘˜ ÁÔÓ›˜ ·È‰ÈÒÓ Ì °ƒ Î·È 3,4±3,2 Ë̤Ú˜ ÁÈ· ÙÔ˘˜ ÁÔÓ›˜ ·È‰ÈÒÓ Ì °∞). ∞ÎfiÌ·, Ù· ·È‰È¿ Ì °ƒ ‹Ù·Ó Èı·ÓfiÙÂÚÔ Ó· ¯ÚÂÈ·ÛÙÔ‡Ó ÎÏÈÓÈ΋ Â·ÓÂÎÙ›ÌËÛË, Û˘ÁÎÚÈÙÈο Ì ÙËÓ ¿ÏÏË ÔÌ¿‰· (73,8 ¤Ó·ÓÙÈ 46,4%, p=0,012). ™Ù· ·È‰È¿ Ì °ƒ Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ì °∞, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (odds ratio) ÁÈ· ·Ú¿Ù·ÛË Ù˘ ÓÔÛËÏ›·˜ ¤Ú·Ó ÙˆÓ 3 ËÌÂÚÒÓ ‹Ù·Ó ·˘ÍË̤ÓÔ˜ ηٿ 2,1 ÊÔÚ¤˜ (2,13, CI 95%: 1,29-4,6, p<0,01) Î·È ÁÈ· ÎÏÈÓÈ΋ Â·ÓÂÎÙ›ÌËÛË ·˘ÍË̤ÓÔ˜ ηٿ 1,6 ÊÔÚ¤˜ (1,59, CI 95%: 1,02-3,44, p=0,012). ∆¤ÏÔ˜, ·È‰È¿ ËÏÈΛ·˜ <2 ÂÙÒÓ Ì °ƒ ·ÚÔ˘Û›·˙·Ó ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ̤Û˘ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ (73,9 ¤Ó·ÓÙÈ 46,9%, p=0,019) Î·È ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÈÛ·ÁˆÁ‹˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Û˘ÁÎÚÈÙÈο Ì ٷ ·ÓÙ›ÛÙÔȯ· ·È‰È¿ ËÏÈΛ·˜ 2-5 ÂÙÒÓ (56,5 ¤Ó·ÓÙÈ 40,6%, p=0,0431).

™˘˙‹ÙËÛË ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ·ÔÙ‡ˆÛË Ù˘ ÂȉËÌÈÔÏÔÁ›·˜ Î·È ÙˆÓ ÂÈÙÒÛÂˆÓ Ù˘

Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi ÛÙË ¯ÒÚ· Ì·˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÌÔÚʈı› ÛÙÚ·ÙËÁÈ΋ ÚfiÏ˄˘ Ù˘ ÓfiÛÔ˘, Ì ÙËÓ Â˘Î·ÈÚ›· Ù˘ ÂÈΛÌÂÓ˘ ΢ÎÏÔÊÔÚ›·˜ ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÂÌ‚ÔÏ›ˆÓ. ∂ÈϤÔÓ, Ù· ·Ú·¿Óˆ Â˘Ú‹Ì·Ù· ÌÔÚ› Ó· ·ÔÙÂϤÛÔ˘Ó Ì›· ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÌÂÙ·‚ÔÏÒÓ ÛÙËÓ ÂȉËÌÈÔÏÔÁ›·, ÂÊfiÛÔÓ ÙÔ ÂÌ‚fiÏÈÔ ÙÔ˘ ÚÔÙ·˚Ô‡ ÂÓÙ·¯ı› ÛÙÔ ∂ıÓÈÎfi ÃÚÔÓԉȿÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ (9). ∆· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ·Ó·‰ÂÈÎÓ‡Ô˘Ó ÙË Û˘¯ÓfiÙËÙ· Î·È ÙËÓ ÎÏÈÓÈ΋ ÂÈ‚¿Ú˘ÓÛË Ô˘ ÚÔηÏ› Ë °ƒ Û ·È‰È¿ ËÏÈΛ·˜ ˆ˜ 5 ÂÙÒÓ ÛÙË ¯ÒÚ· Ì·˜ Î·È ÂȂ‚·ÈÒÓÔ˘Ó fiÙÈ Ë ÓfiÛÔ˜ Â›Ó·È Û˘¯Ó‹ ÛÙËÓ ∂ÏÏ¿‰·, ·ÊÔ‡ ۯ‰fiÓ ÛÙ· ÌÈÛ¿ ·È‰È¿ ËÏÈΛ·˜ <5 ÂÙÒÓ Ô˘ ÂÈÛΤÙÔÓÙ·È Ù· ∆∂¶ ‹ ÂÈÛ¿ÁÔÓÙ·È ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÏfiÁˆ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜, ˘‡ı˘ÓÔ ·ıÔÁfiÓÔ Â›Ó·È Ô ÚÔÙ·˚fi˜. ∏ °ƒ ÂÌÊ·Ó›˙ÂÈ ÌÂÁ·Ï‡ÙÂÚË ‚·Ú‡ÙËÙ· ·fi ÙË °∞, ÂÓÒ Ë ÛÔ‚·Ú‹ ÌÔÚÊ‹ Ù˘ ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ·È‰È¿ ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 2 ÂÙÒÓ. ¢ÂÓ ı· ‹Ù·Ó ˘ÂÚ‚ÔÏ‹ Ó· ÈÛ¯˘ÚÈÛÙԇ̠fiÙÈ Â›Ó·È Ì›· “·Ó·fiÊ¢ÎÙË” ÓfiÛÔ˜, ηıÒ˜ Ù· ÂӉ¯fiÌÂÓ· ÚÔÏËÙÈο ̤ÙÚ· (.¯. ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ÌË ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÎÔ‡ ÛÙ·ıÌÔ‡) ‰ÂÓ ÂËÚ¿˙Ô˘Ó ÙË Û˘¯ÓfiÙËÙ¿ Ù˘, Ô˘ ·Ú·Ì¤ÓÂÈ ÛÙ·ıÂÚ¿ ˘„ËÏ‹ Û fiÏË ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ·, ŒÙÛÈ, Ì·˙› Ì ÙȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ¤Í·ÚÛË ÙËÓ ›‰È· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô, ÚÔηÏ› Â›Û˘ ÛËÌ·ÓÙÈ΋ ÏÂÈÙÔ˘ÚÁÈ΋ Î·È ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË ÛÙÔ ™‡ÛÙËÌ· ÀÁ›·˜. ªÂ ‚¿ÛË ÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘, fiˆ˜ ÚÔ·ÙÂÈ ·fi ÙËÓ Îϛ̷η Clark, Ë °ƒ ÂÌÊ·Ó›˙ÂÈ ·˘ÍË̤ÓË ‚·Ú‡ÙËÙ· Û˘ÁÎÚÈÙÈο Ì ÙË °∞ Î·È ·ÔÙÂÏ› ηٿ Û˘Ó¤ÂÈ· ·›ÙÈÔ ÌÂÁ·Ï‡ÙÂÚ˘ Ù·Ï·ÈˆÚ›·˜ ÁÈ· Ù· ·È‰È¿ Ô˘ ¿Û¯Ô˘Ó Î·È ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜. ∞Ó·Ï˘ÙÈÎfiÙÂÚ·, ÛËÌ›· ÂÓ‰ÂÈÎÙÈο ÛÔ‚·Ú‹˜ ·Ê˘‰¿ÙˆÛ˘ (·ÒÏÂÈ· ‚¿ÚÔ˘˜, ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜), Ì›·˜ ηٿÛÙ·Û˘ Ô˘ ÌÔÚ› Ó· ·Ô‰Âȯı› ·ÂÈÏËÙÈ΋ ÁÈ· ÙË ˙ˆ‹, Â›Ó·È ÈÔ Û˘¯Ó¿ ÛÙË °ƒ. ∆Ô ›‰ÈÔ ÈÛ¯‡ÂÈ Î·È ÁÈ· ÙÔÓ Ì¤ÁÈÛÙÔ ·ÚÈıÌfi ÙˆÓ ˘ÔÏÔ›ˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ·Ó¿ Ë̤ڷ Î·È ÙË ‰È¿ÚÎÂÈ¿ ÙÔ˘˜. ∂›Û˘, Û ËÏÈΛ· ˆ˜ 2 ÂÙÒÓ, Ë ‚·Ú‡ÙËÙ· Ù˘ °ƒ Î·È ÙÔ ÔÛÔÛÙfi ÂÈÛ·ÁˆÁÒÓ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚ·. ™‡Ìʈӷ Î·È Ì ¿ÏϘ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Î·È Ì›· ÚfiÛÊ·ÙË ÛÙËÓ πÛ·Ó›·, Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ °ƒ ·ÊÔÚÔ‡Û ÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· ÌÂٷ͇ 6 ÌËÓÒÓ Î·È 3 ÂÙÒÓ (3,9). ™˘ÓÂÒ˜, ¤Ó· ÂÌ‚fiÏÈÔ, ÙÔ Û¯‹Ì· ÙÔ˘ ÔÔ›Ô˘ ı· ÔÏÔÎÏËÚÒÓÂÙ·È Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ Î·È ı· ·Ú¤¯ÂÈ ÚÔÛÙ·Û›· ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ¯ÚfiÓÈ·, ı· Â›Ó·È Î·Ù¿ÏÏËÏÔ ÁÈ· ÙÔÓ Ì·˙ÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ‚ÚÂÊÒÓ Î·È ÙËÓ ÚfiÏË„Ë Ù˘ Ïԛ̈͢ ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÏËı˘ÛÌÔ‡ Ô˘ ÎÈÓ‰˘Ó‡ÂÈ (10). ¶·È‰È·ÙÚÈ΋ 2007;70:395-401

Paidiatriki 5 final

12-10-07

16:28

Page 400

400

π. ∫·‚·ÏÈÒÙ˘ Î·È Û˘Ó.

∞fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ ÚÔ·ÙÂÈ fiÙÈ Ë °ƒ Â›Ó·È 2,5 ÊÔÚ¤˜ Èı·ÓfiÙÂÚÔ Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ·fi ÙË °∞. ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ÔÊ›ÏÂÙ·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÙˆÓ È‰ÈˆÙÈÎÒÓ È·ÙÚ›ˆÓ Ì °ƒ, ÙˆÓ ÔÔ›ˆÓ Ë ‰È¿ÌÂÛË ËÏÈΛ· ‹Ù·Ó ÌÈÎÚfiÙÂÚË ·fi ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ì °∞ (19 ¤Ó·ÓÙÈ 26 ÌËÓÒÓ), ÔÈ ÔÔ›ÔÈ ¯ÚÂÈ¿ÛıËÎ·Ó ÂÈÛ·ÁˆÁ‹ Û ÔÛÔÛÙfi 7 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ (42,8 ¤Ó·ÓÙÈ 6%). ∞ÓÙÈı¤Ùˆ˜, Ù· ·È‰È¿ ÙˆÓ ∆∂¶ ÂÌÊ¿ÓÈÛ·Ó Û˘¯ÓfiÙÂÚ· ̤Û˘ ‹ ÛÔ‚·Ú‹˜ ‚·Ú‡ÙËÙ·˜ ÓfiÛÔ Î·È ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÈÛ·ÁˆÁ‹˜ (57-59%), ·ÓÂÍ·Úًو˜ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ∆¤ÏÔ˜, Ù· ·È‰È¿ Ô˘ ÓfiÛËÛ·Ó ·fi °ƒ ÓÔÛËχıËÎ·Ó Î·Ù¿ ̤ÛÔÓ fiÚÔ 2 ·Ú·¿Óˆ Ë̤Ú˜, ÂÓÒ fiÛ· ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó Â͈ÓÔÛÔÎÔÌÂȷο ¯ÚÂÈ¿ÛıËÎ·Ó Û˘¯ÓfiÙÂÚ· ÎÏÈÓÈ΋ Â·ÓÂÎÙ›ÌËÛË. ŸÏ· Ù· ·Ú·¿Óˆ ‰Â‰Ô̤ӷ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓÔ ÎÔÈÓˆÓÈÎfi Î·È ÔÈÎÔÓÔÌÈÎfi ÎfiÛÙÔ˜ (11). ∏ °ƒ ¢ı‡ÓÂÙ·È ÁÈ· ÂÚÈÛÛfiÙÂÚ· ¿ÌÂÛ· ¤ÍÔ‰· ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ ·È‰ÈÒÓ ÏfiÁˆ Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ‚·Ú‡ÙËÙ·˜ Î·È ‰È¿ÚÎÂÈ·˜ Û˘Ìو̿وÓ, fiˆ˜ ÔÈ ¤ÌÂÙÔÈ Î·È ÔÈ ‰È¿ÚÚÔȘ (·ÁÔÚ¿ Á·Ï¿ÙˆÓ ÂχıÂÚˆÓ Ï·ÎÙfi˙˘, ηٷӿψÛË ÌÂÁ·Ï‡ÙÂÚÔ˘ ·ÚÈıÌÔ‡ ·ÓÒÓ, ÂÚÈÛÛfiÙÂÚ˜ È·ÙÚÈΤ˜ ÂÈÛΤ„ÂȘ Î·È ¤ÍÔ‰· ÌÂٷΛÓËÛ˘). ŸÌˆ˜ Î·È ÁÈ· ÙÔ ™‡ÛÙËÌ· ¢ËÌfiÛÈ·˜ ÀÁ›·˜ Ë °ƒ ÎÔÛÙ›˙ÂÈ ÂÚÈÛÛfiÙÂÚÔ (ÂÚÈÛÛfiÙÂÚ˜ ÂÈÛ·ÁˆÁ¤˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÂÚÈÛÛfiÙÂÚ˜ Ë̤Ú˜ ÓÔÛËÏ›·˜, ·Ó¿ÁÎË ıÂÚ·›·˜ Ì ·ÚÂÓÙÂÚÈÎÒ˜ ¯ÔÚËÁÔ‡ÌÂÓ· ‰È·Ï‡Ì·Ù·, ÂÚÈÛÛfiÙÂÚ˜ È·ÙÚÈΤ˜ ÂÈÛΤ„ÂȘ) (12,13). ∆¤ÏÔ˜, Ë Ì¤ÛË ·ÒÏÂÈ· ËÌÂÚÒÓ ÂÚÁ·Û›·˜ ÁÈ· ÙÔ˘˜ ÁÔÓ›˜ Â›Ó·È ÛËÌ·ÓÙÈ΋ (>3 Ë̤Ú˜). ∏ ÎÏÈÓÈ΋ ÂÈ‚¿Ú˘ÓÛË Ô˘ ÚÔηÏ› Ë °ƒ ÛÙËÓ ∂ÏÏ¿‰· Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù‹ Ô˘ ¤¯ÂÈ ·Ú·ÙËÚËı› Û ¿ÏϘ ¯ÒÚ˜. ∏ Ïԛ̈ÍË ·fi ÚÔÙ·˚fi ·Ó·Ê¤ÚÂÙ·È ˆ˜ ÙÔ Û˘¯ÓfiÙÂÚÔ Î·È ÛÔ‚·ÚfiÙÂÚÔ ·›ÙÈÔ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Û ·È‰È¿ ËÏÈΛ·˜ ̤¯ÚÈ 5 ÂÙÒÓ Û fiϘ ÙȘ ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ Ô˘ ¤¯Ô˘Ó ‰ÈÂÍ·¯ı› ÛÙËÓ ∂˘ÚÒË, ·ÏÏ¿ Î·È Û ÂıÓÈΤ˜ ÌÂϤÙ˜ ÛÙË °ÂÚÌ·Ó›·, ÛÙË ¢·Ó›· Î·È ÛÙËÓ πÛ·Ó›· (3-6,9,14). ∏ Û˘¯ÓfiÙËÙ· Ù˘ °ƒ, fiˆ˜ ÚÔ·ÙÂÈ ·fi ÙÔ ÔÛÔÛÙfi ·Ó‡ÚÂÛ˘ ·ÓÙÈÁfiÓÔ˘ ÚÔÙ·˚Ô‡ Û ·È‰È¿ ËÏÈΛ·˜ ̤¯ÚÈ 5 ÂÙÒÓ Ô˘ ÂÈÛΤÙÔÓÙ·È Ù· ∆∂¶ (45,7%) ‹ ÓÔÛËχÔÓÙ·È (49,1%) ÏfiÁˆ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜, Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù¿ ¿ÏÏˆÓ Â˘Úˆ·˚ÎÒÓ ÌÂÏÂÙÒÓ, fiÔ˘ Ù· ·ÓÙ›ÛÙÔȯ· ÔÛÔÛÙ¿ Î˘Ì·›ÓÔÓÙ·È ·fi 45-60%. ∏ ÌÔÓ·‰È΋ ÂÍ·›ÚÂÛË Â›Ó·È Ë Û˘¯ÓfiÙËÙ· Ù˘ °ƒ ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÊÚÔÓÙ›‰· (18%), ÙËÓ ÔÔ›· ÛÙË ¯ÒÚ· Ì·˜ Û ÌÂÁ¿ÏÔ ‚·ıÌfi ¤¯Ô˘Ó ·Ó·Ï¿‚ÂÈ ÔÈ È‰ÈÒÙ˜ ·È‰›·ÙÚÔÈ, fiÔ˘ ÙÔ ÔÛÔÛÙfi Â›Ó·È ¯·ÌËÏfiÙÂÚÔ ·fi ÙÔÓ Ì¤ÛÔ Â˘Úˆ·˚Îfi fiÚÔ Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 25 ˆ˜ 40% (3,4,14). ∞˘Ùfi ÔÊ›ÏÂÙ·È Èı·ÓfiÓ, fiˆ˜ Ê¿ÓËÎÂ Î·È Ì ÙË ‚·ıÌÔÏfiÁËÛË Clark, ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Ì ̤ÙÚÈ·˜ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, fiÔ˘ Ë °ƒ Â›Ó·È Û˘¯ÓfiÙÂÚË, ÚÔÛÎÔPaediatriki 2007;70:395-401

Ì›˙ÔÓÙ·È ·¢ı›·˜ ÛÙ· ∆∂¶ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ. µ¤‚·È·, Ë Û˘¯ÓfiÙËÙ· Ù˘ °ƒ, fiˆ˜ Î·È Ë Î·Ù·ÓÔÌ‹ ÙˆÓ ÔÚÔÙ‡ˆÓ ÙÔ˘ ÈÔ‡, Î˘Ì·›ÓÂÙ·È ·fi ÂÔ¯‹ Û ÂÔ¯‹ Î·È ·fi ÂÚÈÔ¯‹ Û ÂÚÈÔ¯‹, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ÂȉËÌÈÔÏÔÁÈ΋ ·Ú·Ù‹ÚËÛË Î·È Û ¿ÏϘ ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜, ȉ›ˆ˜ ¯ÂÈÌÂÚÈÓ¤˜, ÁÈ· Ó· ¤¯Ô˘Ì ·ÎÚÈ‚¤ÛÙÂÚË ÂÈÎfiÓ· Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘ ÛÙË ¯ÒÚ· Ì·˜ (5,15). ™ÙË ÌÂϤÙË ‰ÂÓ ‰ÈÂÚ¢ӋıËÎÂ Ë Û˘¯ÓfiÙËÙ· Î·È Ë ‚·Ú‡ÙËÙ· Ù˘ ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋˜ °ƒ, Ë ÔÔ›· ¢ı‡ÓÂÙ·È ÁÈ· ¿Óˆ ·fi ÙÔ ‹ÌÈÛ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Û ·È‰È¿ ËÏÈΛ·˜ ˆ˜ 5 ÂÙÒÓ (16). ÕÏÏ· ÂÚÈÛÙ·ÙÈο Ô˘ ‰ÂÓ Û˘Ó˘ÔÏÔÁ›ÛÙËÎ·Ó ‹Ù·Ó fiÛ· ¤Ï·‚·Ó ÙËÏÂʈÓÈΤ˜ Ô‰ËÁ›Â˜. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ Ë ÌÂϤÙË ‰ÂÓ ÂÚȤϷ‚ fiÏÔ˘˜ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜ ÌÔÚ› Ó· ˘ÔÙ›ÌËÛ ÙË Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘. ∂ӉȷʤÚÔÓ ı· ›¯Â Ó· ÚÔÛ‰ÈÔÚÈÛıÔ‡Ó Î·È ÔÈ ÔÚfiÙ˘ÔÈ ÙÔ˘ ÚÔÙ·˚Ô‡. µ¤‚·È·, ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Û ÔÏϤ˜ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ÁÈ· ÔÛÔÛÙ¿ ÌÂÁ·Ï‡ÙÂÚ· ÙÔ˘ 98% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Â˘ı‡ÓÔÓÙ·È 5 ÔÚfiÙ˘ÔÈ ÚÔÙ·˚Ô‡ (G1P[8], G2P[4], G3P[8], G4P[8] Î·È G9P[8]), ÔfiÙÂ Â›Ó·È ·Ó·ÌÂÓfiÌÂÓÔ Ë ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÔÚÔÙ‡ˆÓ ÙÔ˘ ÚÔÙ·˚Ô‡ Ó· Â›Ó·È ·ÚfiÌÔÈ· Î·È ÛÙË ¯ÒÚ· Ì·˜ (14). ∆· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ ·Ó·‰ÂÈÎÓ‡Ô˘Ó ÙË Û˘¯ÓfiÙËÙ· Î·È ÙË ‚·Ú‡ÙËÙ· Ù˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Î·È ÛÙË ¯ÒÚ· Ì·˜, Î·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÌÂϤÙ˜ ÎfiÛÙÔ˘˜-ÔʤÏÔ˘˜ ı· ‹Ù·Ó ‰˘Ó·ÙfiÓ Ó· ˘ÔÛÙËÚ›ÍÔ˘Ó ÙËÓ ÂÊ·ÚÌÔÁ‹ ÂÓfi˜ ·ÛÊ·ÏÔ‡˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘, ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ Î·È Ù˘ ÎÔÈÓˆÓÈ΋˜ Î·È ÔÈÎÔÓÔÌÈ΋˜ ÂÈ‚¿Ú˘ÓÛ˘ Ô˘ ÚÔηÏ›.

∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ÙÔ˘˜ ·Ú·Î¿Ùˆ ·È‰È¿ÙÚÔ˘˜, ̤ÏË Ù˘ √Ì¿‰·˜ ªÂϤÙ˘ ROTASCORE*, ÁÈ· ÙË ÛËÌ·ÓÙÈ΋ Û˘Ì‚ÔÏ‹ ÙÔ˘˜ ÛÙË ‰ÈÂÓ¤ÚÁÂÈ· Ù˘ ÂȉËÌÈÔÏÔÁÈ΋˜ ÌÂϤÙ˘ (ηٿ ·ÏÊ·‚ËÙÈ΋ ÛÂÈÚ¿): ∞ÁÁÂÏ¿ÎÔ˘ µ·ÛÈÏÈ΋, µ·ÛÈÏ¿ÎË-°·Ú˘Ê·Ï¿ÎË ∂ÈÚ‹ÓË, µÏ·¯¿ÎË °ÂˆÚÁ›·, µÚÂÙ¿ÎÔ˘ µÂÓÂÙ›·, °·Ù›‰Ë˜ ¡¤ÛÙÔÚ·˜, °ÂÚÔÁÈ¿ÓÓ˘ ÃÚ‹ÛÙÔ˜, °ÂˆÚÁ·ÎfiÔ˘ÏÔ˘ £Â·ÓÒ, °È·ÓӷΛ‰Ô˘-∫Ô˘ÊÔÁÈ¿ÓÓË ª·Ú›·, °È·ÓÓ·ÎfiÔ˘ÏÔ˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜, °È·ÓÓ·ÎfiÔ˘ÏÔ˜ ¶·Ó·ÁÈÒÙ˘, °È‰¿Ú˘ ¢‹ÌÔ˜, °ÚÈ‚¿ÎË ª·Ú›·, ¢Â‰Ô‡ÎÔ˘ •·Óı‹, ¢Ú¿ÎÔ˘ ∞Ó·ÛÙ·Û›·, ∑·ÚÁ¿Ó˘ ¢È·ÁfiÚ·˜, ∑˘ÁÔÁÈÒÚÁÔ˜ ∞ÛÙ¤ÚÈÔ˜, £ˆÌ·˝‰Ô˘ ∞Á·ı‹, ∫·ÂÙ·Ó¿Î˘ °ÈÒÚÁÔ˜, ∫·Ú·ÓÙÈÓfi˜ °ÈÒÚÁÔ˜, ∫·Ú‡‰Ë˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜, ∫Ï¿ÓıÔ˘˜ ¶fiÏ˘˜, ∫ÔÌÌ·Ù¿˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜, ∫Ô˘ÙÛfi˜ ¶·Ó·ÁÈÒÙ˘, ∫ˆÛÙfiÔ˘ÏÔ˜ ∂ÌÌ·ÓÔ˘‹Ï, §˘ÁÂÚÔ‡ª·Ó›Î· ¢¤ÛÔÈÓ·, §ÒÏ˘ £ÂÔ¯¿Ú˘, ª·ÓÙ¿-∫·ÏÔÌÂÓÔÔ‡ÏÔ˘ ÃÚÈÛÙ›Ó·, ª·ÓÙ·Áfi˜ ™Ù¤Ê·ÓÔ˜, ª¿ÓÙ˙ÈÔ˘ £ÂÔ‰ÒÚ·, ª·Ú·ÁÎÔ˘‰¿ÎË ∂ϤÓË, ªÂÏ¿˜ °ÚËÁfiÚÈÔ˜, ªÂÓ¤ÎÔ˜ ¶¤ÙÚÔ˜, ª¤Û˘ ™ˆÙ‹ÚÈÔ˜, ªÔ˘ÛÌԇ΢ πˆ¿ÓÓ˘, ¡ÈÎÔÏ¿Ô˘-ƒ·ÌÔÙ¿ ª·Ú›·, ¡ÈÎÔÏÔ˘‰¿Î˘ ¡ÈÎfiÏ·Ô˜, ¡ÈˆÙ¿Î˘ °ÈÒÚÁÔ˜, √ÏÔÔÈ¿‰Ô˘ ¶fiË, √ÚÊ·ÓÔ‡ ª·Ú›·, ¶·Ó¿ÁÔ˜ ∞ÓÙÒÓÈÔ˜, ¶·ÓÙÂÏ‹-ÃÚÈÛÙÔÔ‡ÏÔ˘ §›ÏÈ·Ó, ¶··‰ÔÔ‡ÏÔ˘ µËıϤÌ, ¶··Ó‰Ú¿‰Ë-ª¤Ê· ™ÔÊ›·, ¶··ÛÙ·Ì·Ù›Ô˘ µ·Û›ÏÂÈÔ˜, ¶·Ú›Û˘ ¶·Ó·ÁÈÒÙ˘, ¶·ÙÚÒÓË ∞ıËÓ¿,

Paidiatriki 5 final

12-10-07

16:28

Page 401

401

∂ȉËÌÈÔÏÔÁ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Û ·È‰È¿

¶ÂÚ‰ÈÎÔÁÈ¿ÓÓ˘ ªËÓ¿˜, ¶ËÚÔ˘Ó¿ÎË-¢·ÚÈ‚È·Ó¿ÎË ∂‡Ë, ¶ÈÙÛÈÏ›‰Ô˘ ∂ÈÚ‹ÓË, ¶Ïȿη˜ ¢ËÌ‹ÙÚÈÔ˜, ™È·Ê¿Î·˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜, ∆˙¿ÏÏ·˜ ¢ËÌ‹ÙÚÈÔ˜, ∆Ú›Îη °ÈԇϷ, º¿ÎÔ˜ ¶·Ó·ÁÈÒÙ˘, º·Ú¿¯ ∆˙ÒÚÙ˙, ÷ڛÙÔ˘ ∞ÓÙˆÓ›·, æ·ı¿-ª·˙Ì¿ÓË ª·Ú›·. ∂›Û˘ ¢¯·ÚÈÛÙԇ̠ÙȘ º·Ú̷΢ÙÈΤ˜ ∂Ù·ÈÚ›˜ µπ∞¡∂• Î·È Sanofi Pasteur MSD ÁÈ· ÙË ‰ˆÚÂ¿Ó ¯ÔÚ‹ÁËÛË ÙˆÓ kit ·Ó›¯Ó¢Û˘ ÙÔ˘ ÚÔÙ·˚Ô‡ ÛÙ· ÎfiÚ·Ó·.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis 2003;9:565-572.

2. Haffejee IE. The epidemiology of rotavirus infections: a global perspective. J Pediatr Gastroenterol Nutr 1995;20: 275-286.

3. The Pediatric ROTavirus European CommitTee (PROTECT). The paediatric burden of rotavirus disease in Europe. Epidemiol Infect 2006;134:908-916.

4. Soriano-Gabarro M, Mrukowicz J, Vesikari T, Verstraeten T. Burden of rotavirus disease in European Union countries. Pediatr Infect Dis J 2006;25:S7-S11.

5. Ehlken B, Laubereau B, Karmaus W, Petersen G, Rohwedder A, Forster J, RoMoD Study Group. Prospective population-based study on rotavirus disease in Germany. Acta Paediatr 2002; 91:769-775.

6. Fischer TK. Incidence of hospitalizations due to rotavirus gastroenteritis in Denmark. Acta Paediatr 2001;90:10731075.

7. Koopmans M, Brown D. Seasonality and diversity of group A rotaviruses in Europe. Acta Paediatr 1999;88 (Suppl): 14-19.

8. Clark HF, Bernstein DI, Dennehy PH, Offit P, Pichichero M, Treanor J, et al. Safety, efficacy and immunogenicity of a live, quadrivalent, human-bovine reassortant rotavirus vaccine in healthy infants. J Pediatr 2004;144:184-190.

9. Diez-Domingo J, Martin IO, Sanz AB, Lopez AG, Martinez CC, Boronat CP, et al. Rotavirus gastroenteritis among children under five years of age in Valencia, Spain. Pediatr Infect Dis J 2006;25:455-457.

10. Vesikari T, Matson DO, Dennehy P, Van Damme P, Santosham M, Rodriguez Z, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med 2006;354:23-33.

11. Berner R, Schumacher RF, Hameister S, Forster J. Occurrence and impact of community-acquired and nosocomial rotavirus infections-a hospital-based study over 10 y.

Acta Paediatr 1999;88 (Suppl):S48-S52.

12. Piednoir E, Bessaci K, Bureau-Chalot F, Sabouraud P, Brodard V, Andreoletti L, et al. Economic impact of healthcare-associated rotavirus infection in a paediatric hospital.

J Hosp Infect 2003;55:190-195.

13. Harrington M, Butler K, Cafferkey M. Rotavirus infection in hospitalised children: incidence and impact on healthcare resources. Ir J Med Sci 2003;172:33-36.

14. Giaquinto C, Gothefors L, Huet F, Hulbe C, Paricio Talayero J, Tomas Vila M et al. Burden of paediatric rotavirus gastroenteritis at hospital and primary care levels in seven European countries: Results from REVEAL study [∞bstract]. Presented at 24th Annual Meeting of ESPID, Basel, May 3-5, 2006.

15. Rosenfeldt V, Vesikari T, Pang XL, Zeng SQ, Tvede M, Paerregaard A. Viral etiology and incidence of acute gastroenteritis in young children attending day-care centers.

Pediatr Infect Dis J 2005;24:962-965.

16. Gleizes O, Desselberger U, Tatochenko V, Rodrigo C, Salman N, Mezner Z et al. Nosocomial rotavirus infection in European countries: a review of the epidemiology, severity and economic burden of hospital-acquired rotavirus disease. Pediatr Infect Dis J 2006;25:S12-S21.

¶·È‰È·ÙÚÈ΋ 2007;70:395-401

Paidiatriki 5 final

402

12-10-07

16:28

Page 402

∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏

1 ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ 2 √ÚıÔ‰È΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ 3 ∞ÎÙÈÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ 4 ∞’ √ÚıÔ‰È΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” 5 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”.

AÏÏËÏÔÁÚ·Ê›·: ∞ı·Ó¿ÛÈÔ˜ ÷Ù˙ËÌȯ·‹Ï, dimalexpoli@yahoo.com ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶ÂÚÈÊÂÚÈ·ÎÔ‡ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ ¢‹ÌËÙÚ·˜ 19, ∆.∫. 68 100, ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏË

CASE REPORT

º˘Ì·ÙÈ҉˘ ÛÔÓ‰˘Ï›ÙȘ (·ʈÛË Pott) Û ÓËȷ΋ ËÏÈΛ· ¢. Ã. ∫·Û›ÌÔ˜1, ¢. §·˙ÔÔ‡ÏÔ˘5, Õ. ∆Û·ÏΛ‰Ë˜1, ¢. µÂÚ¤ÙÙ·˜2, Ÿ. §ÂˆÓ›‰Ô˘4, ∞. √ÈÎÔÓfiÌÔ˘3, ¡. §·˙ÔÔ‡ÏÔ˘5, ª. £ÂÔ‰ˆÚ›‰Ô˘5, ∞. ÷Ù˙ËÌȯ·‹Ï1 ¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ ÙÔ˘ Pott ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ÌÔÚÊ‹ Ê˘Ì·Ù›ˆÛ˘ ÙˆÓ ÔÛÙÒÓ Î·È ÙˆÓ ·ÚıÚÒÛˆÓ. ∂ÓÙÔ›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙË ıˆÚ·ÎÈ΋ Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÛÙËÓ ÔÛÊ˘˚΋ Î·È ÙËÓ ·˘¯ÂÓÈ΋ ÌÔ›Ú· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘. ∂ΉËÏÒÓÂÙ·È Ì ÂÌÊ¿ÓÈÛË ‡‚Ô˘, fiÓÔ˘ Î·È Ó¢ÚÔÏÔÁÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·. √ ˘ÚÂÙfi˜ ‰ÂÓ ·ÔÙÂÏ› Û˘¯Ófi Û‡Ìو̷ Ù˘ ÓfiÛÔ˘. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ı‹ÏÂÔ˜, ËÏÈΛ·˜ 2 ¯ÚfiÓˆÓ, ·ıÈÁÁ·ÓÈ΋˜ ηٷÁˆÁ‹˜, Ô˘ ÓÔÛËχÙËΠÛÙËÓ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ ÁÈ· ‰ÈÂÚ‡ÓËÛË ‡‚Ô˘ ÛÙË ıˆÚ·ÎÈ΋ ÌÔ›Ú· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘. √ ‡‚Ô˜ ·ÚÔ˘ÛÈ¿ÛÙËΠ·ÈÊÓ›‰È· 10 Ë̤Ú˜ ÚÈÓ ·fi ÙËÓ ÚÔÛ¤ÏÂ˘Û‹ Ù˘ ÛÙÔ ¡ÔÛÔÎÔÌ›Ô, ¯ˆÚ›˜ Ó· ·Ó·Ê¤ÚÔÓÙ·È ¿ÏÏ· Û˘ÓÔ‰¿ Û˘ÌÙÒÌ·Ù·. ∏ ‰È¿ÁÓˆÛË ‚·Û›ÛÙËΠÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ÛÙËÓ ·ÎÙÈÓÔÏÔÁÈ΋ ·ÂÈÎfiÓÈÛË Ì ·/· ıÒڷη, ·ÍÔÓÈ΋ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Î·È ÛÙË ıÂÙÈ΋ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux. ™ÎÔfi˜ Ù˘ ·ÚÔ˘Û›·Û˘ Â›Ó·È Ó· ÙÔÓÈÛı› Ë Û¿ÓÈ· ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ Û ÌÈÎÚ‹ ËÏÈΛ· Ì ·Ô˘Û›· Ó¢ÚÔÏÔÁÈÎÒÓ ‹ ¿ÏÏˆÓ ÚÒÈÌˆÓ ·ıÔÏÔÁÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È Ë Î·Ï‹ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘ ÌÂÙ¿ ·fi ‰ÈÂÙ‹ ·ÓÙÈÊ˘Ì·ÙÈ΋ ıÂÚ·›·.

§¤ÍÂȘ ÎÏÂȉȿ: º˘Ì·Ù›ˆÛË ÔÛÙÒÓ, ÛÔÓ‰˘Ï›ÙȘ, ÊÏÂÁÌÔÓ‹ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, ·ʈÛË Pott.

Tuberculous spondylitis (Pott’s kyphosis) in a toddler 1 University Paediatric Clinic of the Hospital of Alexandroupolis 2 Orthopedic Clinic of the Hospital of Alexandroupolis 3 Radiology Department of the Hospital of Alexandroupolis 4 First Orthopedics Clinic of the “Aghia Sophia” Children’s Hospital 5 First Paediatric Clinic of the University of Athens, “Aghia Sophia” Children’s Hospital Correspondence: Athanassios Hatzimihail, dimalexpoli@yahoo.com Paediatric Clinic of Peripheral General Hospital of Alexandroupolis 19, Dimitra St. 68 100, Alexandroupolis, Greece

D.H. Kasimos1, D. Lazopoulou5, A. Tsalkidis1, D. Verettas2, O. Leonidou4, A. Oikonomou3, N. Lazopoulou5, M. Theodoridou5, A. Hatzimihail1 Abstract: Pott’s disease is the most common form of bone and joint tuberculosis. It is usually localized in the thoracic region and less commonly in the lumbar and the cervical regions of the spine. The presenting symptoms are a hump, pain and neurological findings. Fever is not a common symptom of Pott’s disease.

The case of a 2 year-old girl is described, who was hospitalized for a hump in the thoracic region of the spine that had appeared 10 days before admission, without neurological symptoms. The diagnosis was based on the clinical presentation, the findings on the chest X-ray, CT scan and MRI, and on the positive PPD tuberculin skin test. The favourable outcome after treatment is discussed.

Key words: Bone tuberculosis, Pott’s disease, spondylitis, spinal infection.

™˘ÓÙÔÌÔÁڷʛ˜ ·/· ∞ª™™ £ª™™ √ª™™ ∆∫∂ ™™ ∆∂¶ £9-£10 C/T MRI ¢.¢. Ê.Ù.

∞Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ∞˘¯ÂÓÈ΋ ÌÔ›Ú· ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ £ˆÚ·ÎÈ΋ ÌÔ›Ú· ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ √ÛÊ˘˚΋ ÌÔ›Ú· ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ∆·¯‡ÙËÙ· ηı›˙ËÛ˘ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ ™ÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ∆Ì‹Ì· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ 9Ô˜ Î·È 10Ô˜ ıˆÚ·ÎÈÎfi˜ ÛfiÓ‰˘ÏÔ˜ ∞ÍÔÓÈ΋ ∆ÔÌÔÁÚ·Ê›· ª·ÁÓËÙÈ΋ ∆ÔÌÔÁÚ·Ê›· ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË º˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜

∂ÈÛ·ÁˆÁ‹ ∏ Ê˘Ì·Ù›ˆÛË ·ÔÙÂÏ› ¤Ó· ·fi Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜ ÙÔ˘ Ï·Ó‹ÙË. ™‡Ìʈӷ Ì ÙËÓ ¶·ÁÎfiÛÌÈ· √ÚÁ¿ÓˆÛË ÀÁ›·˜ (¶.√.À.), ÙÔ 1/3 ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ Á˘ ¤¯ÂÈ ÌÔÏ˘Óı› ·fi ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Paediatriki 2007;70:402-407

Ù›ˆÛ˘ Î·È Î¿ı ¯ÚfiÓÔ ÓÔÛÔ‡Ó 8-10 ÂηÙÔÌ̇ÚÈ· ¿ÓıÚˆÔÈ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Â›Ó·È ÙÔ Û˘¯ÓfiÙÂÚÔ ÏÔÈÌ҉˜ ·›ÙÈÔ ı·Ó¿ÙÔ˘ Û ӤԢ˜ ÂÓ‹ÏÈΘ Î·È ˘‡ı˘ÓÔ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi 100.000 ı·Ó¿ÙÔ˘˜ ·È‰ÈÒÓ ·ÁÎÔÛÌ›ˆ˜ (1). ™ÙËÓ ∂ÏÏ¿‰·, Ë ÂÙ‹ÛÈ· ÓÔÛËÚfiÙËÙ· Â›Ó·È 51/100.000 ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ Î·È Ë ·È‰È΋ ÂÙ‹ÛÈ· ÓÔÛËÚfiÙËÙ· 11,6/100.000. ™ÙËÓ ÂÚÈʤÚÂÈ· Ù˘ £Ú¿Î˘, Ë ÂÙ‹ÛÈ· ÓÔÛËÚfiÙËÙ· Â›Ó·È 37,8/100.000. ¶·ÚfiÏÔ Ô˘ Û¯ÂÙÈο ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ÛÙË µ. ∂ÏÏ¿‰· ¤‰ÂÈ¯Ó·Ó Ì›· Ù¿ÛË Ì›ˆÛ˘ ÙÔ˘ Ê˘Ì·ÙÈÓÈÎÔ‡ ‰Â›ÎÙË ‰È·ÌfiÏ˘ÓÛ˘ (2), Ë ·ÏÏ·Á‹ Ù˘ Û‡ÛÙ·Û˘ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ÏfiÁˆ Ù˘ ÌÂÙ·Ó¿ÛÙ¢Û˘ ͷӷʤÚÓÂÈ ÙÔ Úfi‚ÏËÌ· ÛÙËÓ ÂÈÊ¿ÓÂÈ·. ª›· ·fi ÙȘ Û·ÓÈfiÙÂÚ˜ ÂÓÙÔ›ÛÂȘ Ù˘ ÓfiÛÔ˘ Â›Ó·È Ë ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË. ™ÎÂÏÂÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ Û˘Ì‚·Ù¤˜ ÌÂ Ê˘Ì·ÙÈÒ‰Ë ÛÔÓ‰˘Ï›Ùȉ· ¤¯Ô˘Ó ·Ó·ÁÓˆÚÈÛÙ› ÛÙËÓ ∞›Á˘ÙÔ Û ÌÔ‡ÌȘ

Paidiatriki 5 final

12-10-07

16:28

Page 403

403

º˘Ì·ÙÈ҉˘ ÛÔÓ‰˘Ï›ÙȘ

ËÏÈΛ·˜ 5000 ÂÙÒÓ Î·È Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Ù˘ ÓfiÛÔ˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Î·È ·fi ÙÔÓ πÔÎÚ¿ÙË. ∏ ÓfiÛÔ˜ ÂÚÈÁÚ¿ÊËΠˆ˜ ͯˆÚÈÛÙ‹ ÎÏÈÓÈ΋ ÔÓÙfiÙËÙ· ÙÔ 1779 ·fi ÙÔÓ Percival Pott, Î·È ¤ÎÙÔÙ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙË Ê˘Ì·Ù›ˆÛË Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘. ∏ ‚Ï¿‚Ë ÂÓÙÔ›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ £ª™™ Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÛÙË √ª™™ ‹ ∞ª™™. ∏ ÓfiÛÔ˜ ÂΉËÏÒÓÂÙ·È Ì ÂÌÊ¿ÓÈÛË ‡‚Ô˘, fiÓÔ˘, „ËÏ·ÊËÙ‹˜ Ì¿˙·˜ Î·È Ó¢ÚÔÏÔÁÈ΋ ÛËÌÂÈÔÏÔÁ›·. √ ˘ÚÂÙfi˜ ‰ÂÓ ·ÔÙÂÏ› Û˘¯Ófi Û‡Ìو̷ Ù˘ ÓfiÛÔ˘. ∏ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË ªantoux Â›Ó·È Û˘Ó‹ıˆ˜ ıÂÙÈ΋, ÂÓÒ Ë ∆∫∂ Â›Ó·È ˘„ËÏ‹ ÌfiÓÔ ÛÙÔ 35% ÙˆÓ ÂÚÈÙÒÛˆÓ. ∏ ·ÔÌfiÓˆÛË ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È ·fi ÙÔ˘˜ ÈÛÙÔ‡˜, Ù· Ù‡ÂÏ· Î·È ÙÔ Á·ÛÙÚÈÎfi ˘ÁÚfi (3). ™ÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, Ë ÓfiÛÔ˜ ÂÌÊ·Ó›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙ· ÌÂÁ¿Ï· ·È‰È¿ Î·È Û ӤԢ˜ ÂÊ‹‚Ô˘˜, ÂÓÒ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ Û ÂÓ‹ÏÈΘ. ™ÙËÓ ∂ÏÏ¿‰· ˘¿Ú¯Ô˘Ó Ï›Á˜ ·Ó·ÊÔÚ¤˜, ΢ڛˆ˜ ÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ‰ÂηÂٛ˜, Ì ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘ ÛÙË ™™.

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ £‹Ï˘ ËÏÈΛ·˜ 2 ÂÙÒÓ, ÌÔ˘ÛÔ˘ÏÌ¿Ó· ·ıÈÁÁ·ÓÈ΋˜ ηٷÁˆÁ‹˜, ÚÔÛÎÔÌ›ÛıËΠÛÙ· ∆∂¶ ÏfiÁˆ ·ÈÊÓ›‰È·˜

∞

ÂÌÊ¿ÓÈÛ˘ ÁˆÓÈÒ‰Ô˘˜ ‡‚Ô˘ ÛÙË £ª™™ ·fi 10Ë̤ÚÔ˘. ∂›Ó·È ÙÔ ÙÚ›ÙÔ ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi, ›¯Â ÔÌ·Ï‹ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË, ηϋ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÂχıÂÚÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi. ™ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠ‡‚Ô˜ ÛÙÔ ‡„Ô˜ ÙˆÓ £9-£10 Ù˘ ™™. ∞fi ÙËÓ ˘fiÏÔÈË ÂͤٷÛË ‰ÂÓ ˘‹Ú¯·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Î·È Ë Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË Î·Ù¤‰ÂÈÍÂ Ê˘ÛÈÔÏÔÁÈ΋ ·ÈÛıËÙÈÎfiÙËÙ·, ÎÈÓËÙÈÎfiÙËÙ· Î·È Ì˘˚΋ ÈÛ¯‡ ¿Ìʈ. ∏ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË ªantoux, ÌÂÙ¿ 48 ÒÚ˜, ‹Ù·Ó ıÂÙÈ΋ Ì ÙÔÈ΋ ‰È‹ıËÛË 16mm. √ ·ÈÌ·ÙÔÏÔÁÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ (ÁÂÓÈ΋ ·›Ì·ÙÔ˜- ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜) ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ∆∫∂ ‹Ù·Ó 75 mm/1h Î·È Ë CRP 3,72mg/L (Ê.Ù.<1). Hb 10,5gr%, Ht 33,2%. §Â˘Î¿ 13.400/ÌL (¶62% §30% ª6%). ∞ÈÌÔÂÙ¿ÏÈ· 460.000/ÌL, ۿί·ÚÔ 80mg/dL, Ô˘Ú›· 27mg/dL, ÎÚ·ÙÈÓ›ÓË 0,7mg/dL, Na 138 mEq/L, K 40mEq/L, SGOT 29U/L (Ê.Ù. 15-48U/L), SGPT 45U/L (Ê.Ù. 15-48U/L), ÔÏÈο Ï¢ÎÒÌ·Ù· 7,6 g/L, ·Ï‚Ô˘Ì›ÓË 4,5 g/L. ™ÙËÓ ÔÈÛıÔÚfiÛıÈ· ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη (∂ÈÎfiÓ· 1) ·Ú·ÙËÚ‹ıËΠÔÈÛıÔηډȷ΋ ÛΛ·ÛË Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ·ÒıËÛË ÙˆÓ ·Ú·ÛÔÓ‰˘ÏÈÎÒÓ

B

∂ÈÎfiÓ· 1. √ÈÛıÔÚfiÛıÈ· (·) ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη: ·ÒıËÛË ÙˆÓ ·Ú·ÛÔÓ‰˘ÏÈÎÒÓ ÁÚ·ÌÌÒÓ ·fi ÙË Ì¤ÛË ÁÚ·ÌÌ‹ ¿Ìʈ ÛÙË ÌÂÛfiÙËÙ· Ù˘ ıˆÚ·ÎÈ΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, ‰ÈfiÁΈÛË Ù˘ ‰ÂÍÈ¿˜ ·Ú·ÙÚ·¯Âȷ΋˜ ¯ÒÚ·˜ Î·È Ù˘ ‰ÂÍÈ¿˜ ‡Ï˘ Î·È ·Û·Ê‹˜ ‡ÎÓˆÛË ÛÙÔÓ Ì¤ÛÔ ÏÔ‚fi. ¶Ï¿ÁÈ· (‚) ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη: ™ÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ £10 ÛÔÓ‰‡ÏÔ˘. ¶·È‰È·ÙÚÈ΋ 2007;70:402-407

Paidiatriki 5 final

12-10-07

16:28

Page 404

404

¢. Ã. ∫·Û›ÌÔ˜ Î·È Û˘Ó.

ÁÚ·ÌÌÒÓ ÚÔ˜ Ù· ¤Íˆ, ‰ÈfiÁΈÛË Ù˘ ‰ÂÍÈ¿˜ ·Ú·ÙÚ·¯Âȷ΋˜ ¯ÒÚ·˜ Î·È Ù˘ ‰ÂÍÈ¿˜ ‡Ï˘ ÌÂ Û˘ÓÔ‰fi ‡ÎÓˆÛË ÛÙÔ ‰ÂÍÈfi ̤ÛÔ Ó¢ÌÔÓÈÎfi ‰›Ô. ∂ÈϤÔÓ, ÛÙËÓ Ï¿ÁÈ· ·ÎÙÈÓÔÁÚ·Ê›· ·ÂÈÎÔÓ›ÛÙËÎÂ Ë ÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ £10 ÛÔÓ‰‡ÏÔ˘. ∏ ηÏÏȤÚÁÂÈ· Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡ ‹Ù·Ó ·ÚÓËÙÈ΋ ÁÈ· ‚¿ÎÈÏÏÔ Koch. ™ÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ıÒڷη (∂ÈÎfiÓ· 2) ·Ó·‰Â›¯ıËÎ·Ó ÂÎÛÂÛËÌ·Ṳ̂ÓË ‰ÂÍÈ¿ ·Ú·ÙÚ·¯Âȷ΋ Î·È ‰ÂÍÈ¿ ˘Ï·›· ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· Ì ÔÏÏ·Ϥ˜ ·‰Ú¤˜ Â·Û‚ÂÛÙÒÛÂȘ Î·È ‡ÎÓˆÛË ÙÔ˘ ̤ÛÔ˘ ÏÔ‚Ô‡. ™ÙÔ Â›Â‰Ô ÙÔ˘ £10 ·Ú·ÙËÚ‹ıËΠ‰È¿‚ÚˆÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÛÔÓ‰‡ÏÔ˘ Î·È ÌÂÚÈο ÂηÙÔÛÙ¿ ¯·ÌËÏfiÙÂÚ· ·fi ·˘ÙfiÓ ÙÔÓ ÛfiÓ‰˘ÏÔ ÚÔÛÔÓ‰˘ÏÈ΋ Î·È ·Ú·ÛÔÓ‰˘ÏÈ΋ Ì¿˙· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ Ì ÛÙÈÎÙ¤˜ Â·Û‚ÂÛÙÒÛÂȘ (·fiÛÙËÌ· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ). ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Û ÂÁοÚÛÈÔ Î·È Ô‚ÂÏÈ·›Ô Â›Â‰Ô Ì ÂÈÎfiÓ˜ ∆1 Î·È ∆2 ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡ (∂ÈÎfiÓ· 3·) ·Ó¤‰ÂÈÍ ÙËÓ Î˘ÊˆÙÈ΋ ·Ú·ÌfiÚʈÛË Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÏfiÁˆ ÛÊËÓÔÂȉԇ˜ ·Ú·-

∂ÈÎfiÓ· 2. ∞ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ıÒڷη. ™ÙÔ Â›Â‰Ô ÙÔ˘ ̤ÛÔ˘ ÏÔ‚Ô‡ ·Ó·‰ÂÈÎÓ‡ÂÙ·È ‡ÎÓˆÛË ÙÔ˘ ̤ÛÔ˘ ÏÔ‚Ô‡ Ô˘ Û˘Ó¤¯ÂÙ·È Ì ÙË ‰ÂÍÈ¿ ‡ÏË Ì¤Û· ÛÙËÓ ÔÔ›· ·Ú·ÙËÚÔ‡ÓÙ·È Î·È ·‰Ú¤˜ ··Û‚ÂÛÙÒÛÂȘ.

Paediatriki 2007;70:402-407

ÌfiÚʈÛ˘ ÙÔ˘ £10 ÛÔÓ‰‡ÏÔ˘ Î·È ‹È· ·Û·ÊÔÔ›ËÛË ÙÔ˘ ˘ÂÚÎÂÈ̤ÓÔ˘ £9-£10 ÌÂÛÔÛÔÓ‰˘Ï›Ô˘ ‰›ÛÎÔ˘. ∞Ó·‰Â›¯ıËÎÂ, Â›Û˘, Û˘ÏÏÔÁ‹ ˘ÁÚÔ‡ (˘„ËÏ‹˜ ¤ÓÙ·Û˘ Û‹Ì· Û ·ÎÔÏÔ˘ı›Â˜ ∆2 Î·È ¯·ÌËÏ‹˜ ¤ÓÙ·Û˘ Û‹Ì· Û ∆1 ·ÎÔÏÔ˘ı›Â˜ ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡), Ë ÔÔ›· ÂÂÎÙÂÈÓfiÙ·Ó Î·È ÔÈÛı›ˆ˜ ÛÙÔÓ ÂÈÛÎÏËÚ›‰ÈÔ ¯ÒÚÔ, Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ·Ú·ÛÔÓ‰˘ÏÈ΋ Ì¿˙·-·fiÛÙËÌ· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ. ™ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ô ·Ù¤Ú·˜, ËÏÈΛ·˜ 31 ¯ÚfiÓˆÓ, ›¯Â ÂÓÂÚÁfi Ê˘Ì·Ù›ˆÛË ÙˆÓ Ó¢ÌfiÓˆÓ Ì ηÏÏȤÚÁÂÈ· Ù˘¤ÏˆÓ ıÂÙÈ΋ ÁÈ· ‚.Koch Î·È ÂÙ¤ıË Û ÙÚÈÏ‹ ·ÓÙÈÊ˘Ì·ÙÈ΋ ıÂÚ·›·. ∏ ÌËÙ¤Ú·, ËÏÈΛ·˜ 25 ¯ÚfiÓˆÓ, ‹Ù·Ó ·ÚÓËÙÈ΋ ÁÈ· Ïԛ̈ÍË ·fi Ê˘Ì·Ù›ˆÛË. ∆· ‰‡Ô ·‰¤ÏÊÈ· Ù˘ ·ÛıÂÓÔ‡˜ (ËÏÈΛ·˜ 6 Î·È 4 ¯ÚfiÓˆÓ) ›¯·Ó ıÂÙÈ΋ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux, ¯ˆÚ›˜ ·ÎÙÈÓÔÏÔÁÈο ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ¯ÔÚËÁ‹ıËΠÚÔÏËÙÈ΋ ·ÁˆÁ‹ Ì ÈÛÔÓÈ·˙›‰Ë ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 9 ÌËÓÒÓ. ∞fi Ù· ÎÏÈÓÈο Î·È ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙÔ ·È‰› Î·È ÛÂ Û˘Ó¿ÚÙËÛË Ì ÙËÓ ÂÓÂÚÁfi Ê˘Ì·Ù›ˆÛË ÙÔ˘ ·Ù¤Ú· ÂÙ¤ıË Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÙÔ˘ Pott. ∏ ·ÛıÂÓ‹˜ ·ÓÙÈÌÂÙˆ›ÛıËΠ̠ÙÚÈÏ‹ ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹ (ÚÈÊ·ÌÈΛÓË, ÈÛÔÓÈ·˙›‰Ë Î·È ˘Ú·˙ÈÓ·Ì›‰Ë) ÁÈ· 6 Ì‹Ó˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ‰ÈÏ‹ (ÚÈÊ·ÌÈΛÓË Î·È ÈÛÔÓÈ·˙›‰Ë) ÁÈ· 18 Ì‹Ó˜. ∂ÈϤÔÓ, ÙÔÔıÂÙ‹ıËΠÂȉÈÎfi˜ Ó¿ÚıËη˜ ÛÙ‹ÚÈ͢ Ù˘ ıˆÚ·ÎÈ΋˜ ÌÔ›Ú·˜ Ù˘ ™™. ∆Ô ·È‰› ·Ú·¤ÌÊıËΠÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “∞Á›· ™ÔÊ›·” ÛÙËÓ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÁÈ· ÂÈϤÔÓ Ó¢ÚÔ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙ›ÌËÛË, fiÔ˘ Û˘ÓÂÛÙ‹ıË Ë Û˘Ó¤¯ÈÛË Ù˘ Û˘ÓÙËÚËÙÈ΋˜ ıÂÚ·¢ÙÈ΋˜ ·ÁˆÁ‹˜. ∫·Ù¿ ÙÔÓ Ù·ÎÙÈÎfi Â·Ó¤ÏÂÁ¯Ô ·fi ÙËÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. √ Â·Ó¤ÏÂÁ¯Ô˜ Ì ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· 12 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ η٤‰ÂÈÍ ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ì ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ Ù˘ ·Ú·ÛÔÓ‰˘ÏÈ΋˜ Ì¿˙·˜ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, ÂÓÒ ·Ú¤ÌÂÈÓÂ Ë ÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ £10 ÛÔÓ‰‡ÏÔ˘ (∂ÈÎfiÓ· 3‚). ∏ ·Ú·ÌfiÚʈÛË Ù˘ ™™ Ì ۯËÌ·ÙÈÛÌfi ‡‚Ô˘ ·Ú¤ÌÂÈÓ ÛÙ·ıÂÚ‹ ¯ˆÚ›˜ ÂÚ·ÈÙ¤Úˆ Âȉ›ӈÛË Î·È ¯ˆÚ›˜ Ó¢ÚÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ ‹ ¿ÏϘ ÂÈÏÔΤ˜ (∂ÈÎfiÓ· 4). ∏ ‰È·ÎÔ‹ Ù˘ ·ÁˆÁ‹˜ Î·È Ë ·Ê·›ÚÂÛË ÙÔ˘ ÂȉÈÎÔ‡ Ó¿ÚıËη ¤ÁÈÓ ÌÂÙ¿ ·fi 2 ¯ÚfiÓÈ·, ÂÓÒ Ë ·ÛıÂÓ‹˜ Â›Ó·È Û Ôχ ηϋ ηٿÛÙ·ÛË Î·È Ì ÈηÓÔÔÈËÙÈ΋ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË.

™˘˙‹ÙËÛË ∏ Ê˘Ì·Ù›ˆÛË ·Ú·Ì¤ÓÂÈ ¤Ó· ÛÔ‚·Úfi Úfi‚ÏËÌ· ˘Á›·˜ ÁÈ· ÙËÓ ¯ÒÚ· Ì·˜, ȉȷ›ÙÂÚ· ÁÈ· ÏËı˘ÛÌȷΤ˜ ÔÌ¿‰Â˜ Ì ηΤ˜ Û˘Óı‹Î˜ ˘ÁÈÂÈÓ‹˜, fiˆ˜ ÔÈ ÔÈÎÔÓÔÌÈÎÔ› ÌÂÙ·Ó¿ÛÙ˜ Î·È ¿ÏϘ ÎÔÈÓˆÓÈΤ˜ ÔÌ¿‰Â˜ Ù˘ ¯ÒÚ·˜ Ì·˜ Ì ¯·ÌËÏfi ‚ÈÔÙÈÎfi Â›‰Ô.

Paidiatriki 5 final

12-10-07

16:28

Page 405

405

º˘Ì·ÙÈ҉˘ ÛÔÓ‰˘Ï›ÙȘ

∂ÈÎfiÓ· 3. ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ıˆÚ·ÎÔÔÛÊ˘˚΋˜ ÌÔ›Ú·˜ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ (™™) Û ԂÂÏÈ·›Ô Â›Â‰Ô Ì ÂÈÎfiÓ· ∆2 ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡. ¶·Ú·ÙËÚÂ›Ù·È ÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË Î·È Î·ı›˙ËÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ £10 ÛÔÓ‰‡ÏÔ˘ Ì ›ÂÛË Â› ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡ Î·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ ·ʈÛË Ù˘ ™™, ηıÒ˜ Î·È ·ÚÔ˘Û›· ·ÏÏÔ›ˆÛ˘ ˘„ËÏ‹˜ ¤ÓÙ·Û˘ ∆2 Û‹Ì·ÙÔ˜ ÚÔÛÔÓ‰˘ÏÈο („˘¯Úfi ·fiÛÙËÌ·) (·), Ë ÔÔ›· Û Â·Ó¤ÏÂÁ¯Ô 12 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ıÂÚ·›·˜ ÂÏ·ÙÙÒıËΠÛËÌ·ÓÙÈο Û ̤ÁÂıÔ˜ (‚).

∏ ÓfiÛÔ˜ ÙÔ˘ Pott ÚÔηÏÂ›Ù·È ·fi ÙËÓ ·ÈÌ·ÙÔÁÂÓ‹ ‰È·ÛÔÚ¿ ÙˆÓ Ì˘ÎÔ‚·ÎÙËÚȉ›ˆÓ Ù˘ Ê˘Ì·Ù›ˆÛ˘, ΢ڛˆ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÚˆÙÔ·ıÔ‡˜ Ïԛ̈͢. ™·ÓÈfiÙÂÚ·, ÌÔÚ› Ó· ÚÔÎÏËı› ÌÂÙ¿ ·fi Û˘ÁÁÂÓ‹ Ïԛ̈ÍË ‹ ÌÂÙ¿ ·fi Ï¢ڛÙȉ· Î·È ÏÂÌÊÔÁÂÓ‹ ‰È·ÛÔÚ¿. ™ÙË Ê˘Ì·ÙÈÒ‰Ë ÛÔÓ‰˘Ï›Ùȉ·, Û˘Ó‹ıˆ˜, Ë ‚Ï¿‚Ë ÍÂÎÈÓ¿ÂÈ ÛÙÔ ÚfiÛıÈÔ ÙÌ‹Ì· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÛÔÓ‰‡ÏÔ˘ ˘Ô¯ÔÓ‰Ú›ˆ˜ ÛÙËÓ ÂÈÊ˘Ûȷ΋ Ͽη, Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÂÂÎÙ›ÓÂÙ·È Î¿Ùˆ ·fi ÙÔÓ ÚfiÛıÈÔ ÂÈÌ‹ÎË Û‡Ó‰ÂÛÌÔ ÛÙ· Á‡Úˆ ̷Ϸο ÌfiÚÈ·, ‰È·‚ÚÒÓÔÓÙ·˜ ÙËÓ ÚfiÛıÈ· ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÛÔÓ‰‡ÏÔ˘. ∆Ë ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË ·ÎÔÏÔ˘ı› Ë ·Ó¿Ù˘ÍË ÎÔÎÎȈ̷ÙÒ‰Ô˘˜ ÈÛÙÔ‡, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰È¿‚ÚˆÛË Î·È Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ Ô˘ ·ÎÔÏÔ˘ı› ‚Ú·‰‡ÙÂÚË ÔÚ›· Û ۯ¤ÛË Ì ÙËÓ ˘ÔÁfiÓÔ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·, ÏfiÁˆ ÌË ·Ú·ÁˆÁ‹˜ ÚˆÙÂÔÏ˘ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ. ∏ ÊÏÂÁÌÔÓ‹ Û·ÓÈfiÙÂÚ· ÂÂÎÙ›ÓÂÙ·È Î·È ÛÙÔÓ ·Ú·Î›ÌÂÓÔ ÌÂÛÔÛÔÓ‰‡ÏÈÔ ‰›ÛÎÔ, ›Ù ‰È·Ì¤ÛÔ˘ ÙˆÓ ÂÈÌ‹ÎˆÓ Û˘Ó‰¤Û̈Ó, ›Ù ‰È·ÂÚÓÒÓÙ·˜ ÙËÓ ¯fiÓ‰ÚÈÓË ÂÈÊ˘Ûȷ΋ Ͽη. ¶ÈÔ Û¿ÓÈ·, Ë ‰È¿‚ÚˆÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÛÔÓ‰‡ÏÔ˘ ÚÔηÏ› Úfi-

ÙˆÛË Î·È ÂÈÓ¤ÌËÛË ÙÔ˘ ‰›ÛÎÔ˘. ∏ Ù·˘Ùfi¯ÚÔÓË Û˘ÌÌÂÙÔ¯‹ ÛÔÓ‰‡ÏÔ˘ Î·È ‰›ÛÎÔ˘ Â›Ó·È Û·ÓÈfiÙÂÚË ÛÙË Ê˘Ì·ÙÈÒ‰Ë ÛÔÓ‰˘Ï›Ùȉ· Û ۯ¤ÛË Ì ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜ ˘ÔÁÂÓ‹ ÛÔÓ‰˘Ï›Ùȉ·, Ô˘ Û˘Ó‹ıˆ˜ Â›Ó·È Î·È Ù·¯‡ÙÂÚ· ÂÍÂÏÈÛÛfiÌÂÓË. ™ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ô˘ Û˘ÓËÁÔÚÔ‡Ó ÂÚÈÛÛfiÙÂÚÔ ˘¤Ú Ê˘Ì·ÙÈÒ‰Ô˘˜ ÛÔÓ‰˘Ï›Ùȉ·˜, ÂÎÙfi˜ ·fi ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ‰›ÛÎÔ˘, Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë Â˘ÌÂÁ¤ı˘ Î·È Â·Û‚ÂÛو̤ÓË Ì¿˙· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ (fiˆ˜ Î·È ÛÙË ‰È΋ Ì·˜ ÂÚ›ÙˆÛË), Ë ·Ô˘Û›· ÛÎÏ‹Ú˘ÓÛ˘ ÙˆÓ ·ÚıÚÈÎÒÓ ÂÈÊ·ÓÂÈÒÓ Î·È Ë Û˘ÌÌÂÙÔ¯‹ ÔÏÏ·ÏÒÓ ÂÚÈÔ¯ÒÓ Ù˘ ™™. ∞fi ÙÔÓ ·ÎÙÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒÓÂÙ·È Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÛÔÓ‰˘ÏÈÎÒÓ ÛˆÌ¿ÙˆÓ Î·È ·Ú·ÌfiÚʈÛË Ù˘ ™™. ªÂ ÙËÓ C/∆ Ù˘ ™™ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ηıÔÚÈÛÙ› Ë ¤ÎÙ·ÛË Ù˘ ‚Ï¿‚˘. ∏ ‰È·›ÛÙˆÛË Â·Û‚ÂÛو̤Ó˘ ·Ú·ÛÔÓ‰˘ÏÈ΋˜ Ì¿˙·˜ ıˆÚÂ›Ù·È ·ıÔÁÓˆÌÔÓÈ΋ Ù˘ ÓfiÛÔ˘ Î·È ‚ÔËı¿ ÛÙË ¢.¢. ·fi ÙËÓ ˘ÔÁfiÓÔ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·. ∏ ªRI ηٷ‰ÂÈÎÓ‡ÂÈ ÙËÓ ›ÂÛË ÙˆÓ ÓÂ‡ÚˆÓ ·fi ÙÔ˘˜ ÈÛÙÔ‡˜ (4-7). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Á›ÓÂÙ·È Ì ‚¿ÛË ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ÙËÓ ·ÎÙÈÓÔÏÔÁÈ΋ ·ÂÈÎfiÓÈÛË Ì ·Ϥ˜ ¶·È‰È·ÙÚÈ΋ 2007;70:402-407

Paidiatriki 5 final

12-10-07

16:28

Page 406

406

¢. Ã. ∫·Û›ÌÔ˜ Î·È Û˘Ó.

∂ÈÎfiÓ· 4. ∆Ô ·È‰› ÌÂÙ¿ ‰‡Ô ÂÙÒÓ ·ÓÙÈÊ˘Ì·ÙÈ΋˜ ıÂÚ·›·˜, fiÔ˘ ·ÂÈÎÔÓ›˙ÂÙ·È ÂÚÈÔÚÈṲ̂ÓË ‚Ï¿‚Ë Ù˘ ™.™. (ÁˆÓÈ҉˘ ‡‚Ô˜ ÛÙÔ ‡„Ô˜ £9-£10).

·ÎÙÈÓÔÁڷʛ˜ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ™™, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ∏ ÂȂ‚·›ˆÛË Ù˘ ÌfiÏ˘ÓÛ˘ ·fi ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘ Á›ÓÂÙ·È Ì ÙËÓ ·ÔÌfiÓˆÛË ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ ‹ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ·˘ÙÔ‡ Ì PCR ‹ ÙËÓ ·Ó‡ÚÂÛË ÎÔÎÎÈˆÌ¿ÙˆÓ Û ÈÛÙÔÏÔÁÈο ·Ú·Û΢¿ÛÌ·Ù· Î·È Ì ÙË ıÂÙÈ΋ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË ªantoux. ∏ ıÂÚ·›· Ù˘ ÓfiÛÔ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Î·Ù¿ÏÏËÏË ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹. ÃÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ì ÚÈ˙ÈÎfi ¯ÂÈÚÔ˘ÚÁÈÎfi ηı·ÚÈÛÌfi ÙˆÓ ÓÂÎÚˆÌ¤ÓˆÓ ÈÛÙÒÓ Î·È ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ™™ Á›ÓÂÙ·È fiÙ·Ó ˘¿Ú¯ÂÈ Ó¢ÚÔÏÔÁÈÎfi ¤ÏÏÂÈÌÌ·, ·ÛÙ¿ıÂÈ· ‹ ·Ú·ÌfiÚʈÛË Ù˘ ™™ ‹ ηٷÛÙÚÔÊ‹ >50% ÙˆÓ ÛÔÓ‰˘ÏÈÎÒÓ ÛˆÌ¿ÙˆÓ (8-10). ∏ ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘ ÛÙË ™™ Â›Ó·È Û¿ÓÈ· ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Î·È È‰È·›ÙÂÚ· Û ·È‰È¿ ÓËȷ΋˜ ËÏÈΛ·˜, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜. ∏ ȉȷÈÙÂÚfiÙËÙ· Ù˘ ÂÚ›ÙˆÛ‹˜ Ì·˜ Â›Ó·È fiÙÈ Ë ÓfiÛÔ˜ ÂΉËÏÒıËΠ·ÈÊÓ›‰È· Ì ÂÌÊ¿ÓÈÛË ‡‚Ô˘ ¯ˆÚ›˜ ˘ÚÂÙfi Î·È ¯ˆÚ›˜ Ó¢ÚÔÏÔÁÈ΋ ÛËÌÂÈÔÏÔÁ›·. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ë Ì¤ÛË ‰È¿ÚÎÂÈ· Ù˘ Û˘Ìو̷ÙÔÏÔÁ›·˜ ÛÙË ÓfiÛÔ ÙÔ˘ Pott ΢Paediatriki 2007;70:402-407

Ì·›ÓÂÙ·È ·fi ‚‰ÔÌ¿‰Â˜ ¤ˆ˜ Î·È ¯ÚfiÓÈ·, ÚÈÓ ÙÂı› Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ (3,11), Î·È ÌÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ÂÈÏÔÎÒÓ ·˘Ù‹˜, fiˆ˜ ·Ú¿Ï˘ÛË, ·Ú·ÌfiÚʈÛË ‹ ÂÌÊ¿ÓÈÛË Û˘ÚÈÁÁÒ‰Ô˘˜ fiÚÔ˘ (12). ÿÛˆ˜ ·˘Ùfi Ó· ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ Ë ÓfiÛÔ˜ ÂÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ Û ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ Î·È Û ÏËı˘ÛÌÔ‡˜ Ì ¯·ÌËÏfi ‚ÈÔÙÈÎfi Â›‰Ô, fiÔ˘ ‰ÂÓ ‰›ÓÂÙ·È Ë ‰¤Ô˘Û· ÛËÌ·Û›· ÛÂ Û˘ÌÙÒÌ·Ù·, fiˆ˜ Ô fiÓÔ˜ ÛÙË Ú¿¯Ë ‹ ÛÙÔÓ ·˘¯¤Ó·. ∂Ӊ¯Ô̤ӈ˜, Ù¤ÙÔÈ· Û˘ÌÙÒÌ·Ù· Ó· ˘‹Ú¯·Ó Î·È ÛÙËÓ ·ÛıÂÓ‹ Ì·˜, ·ÏÏ¿ ‰ÂÓ ·ÍÈÔÏÔÁ‹ıËηÓ. ™ÙËÓ ·ÛıÂÓ‹ Ì·˜, Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ‚·Û›ÛıËΠÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ì ÙÔÓ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ıˆÚ·ÎÈÎfi ‡‚Ô, ÙË ıÂÙÈ΋ ªantoux Î·È Ù· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù·: ‡ÎÓˆÛË (¢∂) ̤ÛÔ˘ Ó¢ÌÔÓÈÎÔ‡ ‰›Ô˘, ‰ÈfiÁΈÛË ÏÂÌÊ·‰¤ÓˆÓ ÌÂÛÔıˆÚ·Î›Ô˘, ‰È¿‚ÚˆÛË ÛÔÓ‰˘ÏÈÎÒÓ ÛˆÌ¿ÙˆÓ (£10-£11) Ì ‰ËÌÈÔ˘ÚÁ›· ·Ú·ÛÔÓ‰˘ÏÈο ÊÏÂÁÌÔÓÒ‰Ô˘˜ Ì¿˙·˜, ·ıÔÁÓˆÌÔÓÈ΋˜ Ù˘ Ê˘Ì·ÙÈÒ‰Ô˘˜ ÛÔÓ‰˘Ï›Ùȉ·˜ Î·È ÙËÓ ·Ó‡ÚÂÛË Ê˘Ì·Ù›ˆÛ˘ ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡. √È ÂÈÏÔΤ˜ Ù˘ ÓfiÛÔ˘ Â›Ó·È ÔÛÙÈΤ˜ Î·È Ó¢ÚÔÏÔÁÈΤ˜ (9,10,13). ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È Ë Î·Ù¿ÏÏËÏË Ê·Ú̷΢ÙÈ΋ ıÂÚ·›· Î·È ÔÚıÔ‰È΋ ·ÓÙÈÌÂÙÒÈÛË Ì ÙÔÔı¤ÙËÛË Ó¿ÚıËη Û˘Ó¤‚·Ï ÙÂÏÈο ÛÙËÓ ÚfiÏË„Ë ÂÈÚfiÛıÂÙˆÓ ÔÛÙÈÎÒÓ ‚Ï·‚ÒÓ Î·È Ó¢ÚÔÏÔÁÈÎÒÓ ÂÈÏÔÎÒÓ Ì ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ™™ Î·È ¯ˆÚ›˜ ÙÂÏÈο ÙËÓ ÂÌÊ¿ÓÈÛË Î‡ÊˆÛ˘. ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜, Ë ËÁ‹ ÌfiÏ˘ÓÛ˘ ÂÓÙÔ›ÛÙËΠÛÙÔ ÔÈÎÂ›Ô ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡, ÛÙÔÓ ·Ù¤Ú· ÙÔ˘, Ô ÔÔ›Ô˜ ÛÙËÓ ·/· ıÒڷη ·ÚÔ˘Û›·˙ ÂÈÎfiÓ· ÛËÏ·›Ô˘. ∆· Û˘¯Ó¿ ÎÚÔ‡ÛÌ·Ù· Ù˘ ·È‰È΋˜ Ê˘Ì·Ù›ˆÛ˘ ·ÓÙ·Ó·ÎÏÔ‡Ó ÙËÓ ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ Ó· ÂϤÁÍÂÈ ÙË ÌÂÙ¿‰ÔÛ‹ Ù˘. ∏ ¿ÌÂÛË Î·È ÈηÓÔÔÈËÙÈ΋ ÂÍ·ÎÚ›‚ˆÛË Ù˘ ËÁ‹˜ ÌfiÏ˘ÓÛ˘, ȉȷ›ÙÂÚ· ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÂȉÈÎÒÓ ÎÔÈÓˆÓÈÎÒÓ ÔÌ¿‰ˆÓ Î·È Ë ÂÊ·ÚÌÔÁ‹ ·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ıÂÚ·›·˜ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔÓ Î·Ï‡ÙÂÚÔ ¤ÏÂÁ¯Ô Ù˘ ·È‰È΋˜ Ê˘Ì·Ù›ˆÛ˘. ∏ ÂÚÈÁÚ·Ê‹ ÙÔ˘ ÂÚÈÛÙ·ÙÈÎÔ‡ ·ÔÙÂÏ› ÚfiÎÏËÛË ÁÈ· ··ÓÙ‹ÛÂȘ Ô˘ ÂÎÎÚÂÌÔ‡Ó, ΢ڛˆ˜ Û ۯ¤ÛË Ì ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÙÔ˘ ·ÓÙÈÊ˘Ì·ÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ BCG. ∏ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Î·È Ì¿ÏÈÛÙ· Û ÌÈÎÚ‹ ËÏÈΛ· Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÂӉ‰ÂÈÁ̤ÓË ÁÈ· ÂÚÈÔ¯¤˜ Î·È ÏËı˘ÛÌÔ‡˜ Ì ·˘ÍË̤ÓÔ ÂÈÔÏ·ÛÌfi Ù˘ ÓfiÛÔ˘.

µÈ‚ÏÈÔÁÚ·Ê›·: 1. American Academy of Pediatrics. Report of the Committee on Infectious Diseases. Red Book 2006; 595-613, 27th Ed. 2. ÷˚‰ÔÔ‡ÏÔ˘ ∫, ∂ÌÔÚÈ¿‰Ô˘ ª, £¿ÓÔ˘-∫‡ÚÙÛÔ˘ ¶, ∆ÛÈÏÈÁÁ›ÚË, ª, µ·ÚÏ¿Ì˘ °, ∫·Ú·Ì¤Ú˘ ™. ¢Â›ÎÙ˘ Ì˘-

Paidiatriki 5 final

12-10-07

16:28

Page 407

407

º˘Ì·ÙÈ҉˘ ÛÔÓ‰˘Ï›ÙȘ

3.

4.

5.

6.

7.

8.

ÎÔ‚·ÎÙËÚȉȷ΋˜ ‰È·ÌfiÏ˘ÓÛ˘ Û ·È‰È¿ Ù˘ ∞ã¢ËÌÔÙÈÎÔ‡ ÛÙÔ ¡ÔÌfi £ÂÛÛ·ÏÔӛ΢ ÙË ‰ÂηÂÙ›· 1988-1997. ¶·È‰È·ÙÚÈ΋ µÔÚ. ∂ÏÏ¿‰Ô˜ 2001;13:55-59.

Crofton J, Horne N, Miller F. Tuberculosis in children. In: Crofton J, Horne N, Miller F, editors. Clinical Tuberculosis. 2nd ed. London: Macmillan; 1999. p. 29-86.

Resnick D, Kransdorf MJ. Osteomyelitis, septic arthritis and soft tissue infection: organisms. In: Resnick D, editor.

Bone and Joint imaging. 3rd ed. Philadelphia: Elsevier Saunders; 2005. p. 758-761.

Jung NY, Jee WH, Ha KY, Park CK, Byun JY. Discrimination of tuberculous spondylitis from pyogenic spondilitis on MRI. Am J Roentgenol 2004;182:1405-1410.

Ng AW, Chu WC, Ng BK, Li AM. Extensive paraspinal abscess complicating tuberculous spondylitis in an adolescent with Pott kyphosis. Clin Imaging 2005;25:359-361.

Chang MC, Wu HT, Lee CH, Chen TH. Tuberculous spondylitis and pyogenic spondylitis: comparative magnetic resonance imaging features. Spine 2006;31:782-788.

MRC Working Party on Tuberculosis of the spine. Fiveyear assessment of controlled trials of short-course

9.

10.

11.

12.

13.

chemotherapy regimens of 6, 9 or 18 months’ duration for spinal tuberculosis in patients ambulatory from the start or undergoing radical surgery. Int Orthop 1999;23:73-81.

Turgut M. Spinal tuberculosis (Pott’s disease): its clinical presentation, surgical management and outcome. A survey study of 694 patients. Neurosurg Rev 2001;24:8-13.

Alici E, Akçali O, Tatari H, Günal I. Effect of preoperative chemotherapy on the outcome of surgical treatment of vertebral tuberculosis: retrospective analysis of 434 cases.

Arch Orthop Trauma Surg 2001;121:65-66.

Rezai AR, Lee M, Cooper PR, Errico TJ, Koslow M. Modern management of spinal tuberculosis. Neurosurgery 1995;36:87-97; discussion 97-98.

Fitzerald D, Haars DW. Mycobacterium tuberculosis. In: Mandel GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia: Churchill Livingston; 2005.p: 2852-2908.

Moghtaderi A, Alavi-Naini R, Rahimi-Movaghar V. Tuberculous myelopathy: current aspects of neurologic sequels in the southeast of Iran. Acta Neurol Scand 2006;113:267-272.

™ˆÛÙ¤˜ ··ÓÙ‹ÛÂȘ ÙÔ˘ Quiz ÁÈ· ÙÔ ¿ÚıÚÔ “¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘” 1. ¶fiÙ ÂÌÊ·Ó›˙ÂÙ·È ÙÔ ÂÍ¿ÓıËÌ· ÛÙË ÓfiÛÔ Kawasaki; ·. ∆Ș ÚÒÙ˜ ¤ÓÙ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡ 2. ™Â ÂÚÈÙÒÛÂȘ ·ÙÂÏÔ‡˜ ¡. Kawasaki, fiÛ· ·fi Ù· ·ÚÈ· Î·È Û˘ÌÏËڈ̷ÙÈο ÂÚÁ·ÛÙËÚȷο “ÎÚÈÙ‹ÚÈ·” Ú¤ÂÈ Ó· ÏËÚÔ‡ÓÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ·Ú¯›ÛÂÈ ¤ÁηÈÚ· Ë ıÂÚ·›·; Á. ŒÓ· ·fi Ù· ·ÚÈ· Î·È ≥3 ·fi Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” 3. ∏ ‰È¿ÚÎÂÈ· ıÂÚ·›·˜ Ì ¯·ÌËÏ‹, ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‰fiÛË ·ÛÈÚ›Ó˘ Û ·ÛıÂÓ›˜ Ì N. Kawasaki ¯ˆÚ›˜ ÚÔÛ‚ÔÏ‹ ÛÙÂÊ·ÓÈ·›ˆÓ ›ӷÈ: ‰. ∆¤ÛÛÂÚȘ Ì ¤ÍÈ Â‚‰ÔÌ¿‰Â˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ 4. ¶fiÙ ÂӉ›ÎÓ˘Ù·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì MMR ÛÙ· ·È‰È¿ Ì ¡. Kawasaki, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘; Á. ŒÓÙÂη Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂÚ·›·˜ 5. ™Â ·È‰È¿ Ì ¡. Kawasaki Ô˘ Ú¤ÂÈ Â› ÛÂÈÚ¿ ÂÙÒÓ Ó· ·›ÚÓÔ˘Ó ¯·ÌËÏ‹ ‰fiÛË ·ÛÈÚ›Ó˘, Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜: ‰. ∂›Ó·È ˘Ô¯ÚˆÙÈÎfi˜, ·ÏÏ¿ 11 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘ Î·È Ì ÙËÓ ·Ú¿ÏÏËÏË ‰È·ÎÔ‹ Ù˘ ·ÛÈÚ›Ó˘ Î·È ·ÓÙÈηٿÛÙ·Û‹ Ù˘ Ì ¿ÏÏË ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ ÁÈ· 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi

¶·È‰È·ÙÚÈ΋ 2007;70:402-407

Paidiatriki 5 final

12-10-07

408

16:28

Page 408

∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏

CASE REPORT

¶·È‰È·ÙÚÈ΋, Á˘Ó·ÈÎÔÏÔÁÈ΋ Î·È „˘¯ÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË ÂÓfi˜ ÎÔÚÈÙÛÈÔ‡ Ì ͤÓÔ ÛÒÌ· ÛÙÔÓ ÎfiÏÔ 1 ∆Ì‹Ì· ¶·È‰È΋˜-∂ÊË‚È΋˜ °˘Ó·ÈÎÔÏÔÁ›·˜ Î·È ∂·ÓÔÚıˆÙÈ΋˜ ÃÂÈÚÔ˘ÚÁÈ΋˜, µ’ ª·È¢ÙÈ΋ Î·È °˘Ó·ÈÎÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ”∞ÚÂÙ·›ÂÈÔ” ¡ÔÛÔÎÔÌ›Ô, ∞ı‹Ó· 2 ¶·È‰Ô„˘¯È·ÙÚÈ΋ ∫ÏÈÓÈ΋ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: ∂˘ı‡ÌÈÔ˜ ¢ÂÏËÁÂÒÚÔÁÏÔ˘ edeligeo@aretaieio.uoa.gr ª·Ú·ıÒÓÔ˜ 48, ∆∫ 152 35, µÚÈÏÏ‹ÛÈ·

E. ¢ÂÏËÁÂÒÚÔÁÏÔ˘1, ∞. ¢ÂÏË‚ÂÏÈÒÙÔ˘1, µ. §¿ÁÁ·ÚË2, ¶. ∆̷ۛÚ˘1, π. ∆ÛÈ¿ÓÙ˘2, °. ∫Ú·ÙÛ¿˜1 ¶ÂÚ›ÏË„Ë: ∏ Èı·ÓfiÙËÙ· ‡·Ú͢ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ Î·Ù¿ ÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ·. ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È ÂÚ›ÙˆÛË ÂÓfi˜ ÂÓÙ¿¯ÚÔÓÔ˘ ÎÔÚÈÙÛÈÔ‡ Ô˘ ÚÔÛ‹Ïı ÁÈ· ·ÓÙÈÌÂÙÒÈÛË ÂÈ̤ÓÔ˘Û·˜ ‰‡ÛÔÛÌ˘ ηÊÂÔÂȉԇ˜ ÎÔÏÈ΋˜ ˘ÂÚ¤ÎÎÚÈÛ˘, Û˘ÓÔ‰Â˘Ì¤Ó˘ ·fi ÎÓËÛÌfi, ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ ‰‡Ô ¯ÚfiÓˆÓ. ∫·Ù¿ ÙËÓ ·ÌÊ›¯ÂÈÚË Á˘Ó·ÈÎÔÏÔÁÈ΋ ÂͤٷÛË ·fi ÙÔ ÔÚıfi ·ÔηχÊıËΠÌÈ· „ËÏ·ÊËÙ‹ Ì¿˙·, ·ÓÒ‰˘ÓË, ÛÎÏËÚ‹˜ Û‡ÛÙ·Û˘ Î·È ÔÌ·Ï‹˜ ˘Ê‹˜, ÛÙÂÚ¿ ÚÔÛÎÔÏÏË̤ÓË ÛÙÔÓ Ô›ÛıÈÔ ÎÔÏÈÎfi ıfiÏÔ. ∆Ô ‰È·ÎÔÈÏÈ·Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ·ÂÎ¿Ï˘„ ¤Ó· ÂÙÂÚÔÁÂÓ¤˜ ÌfiÚʈ̷ ÛÙÔ ¿Óˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÎfiÏÔ˘, ÂÓÒ Ì ÙËÓ ·ÓÈÔ‡Û· ÎÔÏÔÁÚ·Ê›· ηٷ‰Â›¯ıËΠÛÙËÓ ›‰È· ı¤ÛË ÛÎÈ·ÁÚ·ÊÈÎfi ¤ÏÏÂÈÌÌ·, ÂȂ‚·ÈÒÓÔÓÙ·˜ ÙË ‰È¿ÁÓˆÛË ÂÓ‰ÔÎÔÏÈÎÔ‡ ͤÓÔ˘ ÛÒÌ·ÙÔ˜. ∞ÎÔÏÔ‡ıËÛ ·Ê·›ÚÂÛË ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ‰È· ̤ۈ ÙÔ˘ ·ÚıÂÓÈÎÔ‡ ˘Ì¤Ó·. ∂ÚfiÎÂÈÙÔ ÁÈ· ¤Ó· ÏÂÙfi ‰Èψ̤ÓÔ ÎÔÌÌ¿ÙÈ ÛfiÁÁÔ˘. ∆Ô ·È‰› ·Ó¤ÊÂÚ fiÙÈ Â›¯Â ‚¿ÏÂÈ ÌfiÓÔ ÙÔ˘ ÙÔ Í¤ÓÔ ÛÒÌ· ÛÙÔÓ ÎfiÏÔ, ÙÔ ÔÔ›Ô ¤‚Á·Ï ·fi ÙÔ Á¤ÌÈÛÌ· ÌÈ·˜ ÎÔ‡ÎÏ·˜. ¢ÈÂÓÂÚÁ‹ıËΠ„˘¯ÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ·È‰ÈÔ‡, ̤ۈ Ù˘ ¯ÔÚ‹ÁËÛ˘ Ù˘ Îϛ̷η˜ “Child Behaviour Check List”(CBCL), Ë ÔÔ›· ¤‰ÂÈÍ ÙËÓ Èı·Ó‹ ‡·ÚÍË „˘¯ÔÏÔÁÈÎÒÓ ‰˘ÛÎÔÏÈÒÓ Ô˘ ÂËÚ¿˙Ô˘Ó ÙȘ ÎÔÈÓˆÓÈΤ˜ ‰ÂÍÈfiÙËÙ˜ Î·È ÙËÓ ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ· ÙÔ˘ ÎÔÚÈÙÛÈÔ‡, ηıÒ˜ Â›Û˘ Î·È ÙËÓ ÁÓˆÛÙÈ΋ ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·. °È· ÙËÓ ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË ÎÔÚÈÙÛÈÒÓ Ì ˘Ô„›· ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ Â›Ó·È ··Ú·›ÙËÙË Ë Û˘ÓÂÚÁ·Û›· ÔÏÏÒÓ ·È‰È·ÙÚÈÎÒÓ ˘ÔÂȉÈÎÔًوÓ. §¤ÍÂȘ ÎÏÂȉȿ: ∂Ó‰ÔÎÔÏÈÎfi ͤÓÔ ÛÒÌ·, ·È‰È΋ ËÏÈΛ·, ·È‰È·ÙÚÈ΋- Á˘Ó·ÈÎÔÏÔÁÈ΋- „˘¯ÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË.

Paediatric, gynaecological and psychological evaluation of a girl with a foreign body in the vagina: a case report 1 Division of PaediatricAdolescent Gynaecology and Reconstructive Surgery, 2nd Department of Obstetrics and Gynaecology, University of Athens Medical School, Aretaieion Hospital, Athens, Greece 2 Department of Child Psychiatry, University of Athens Medical School, Children’s Hospital “Aghia Sophia”, Athens, Greece Correspondence: Efthimios Deligeoroglou, edeligeo@aretaieio.uoa.gr 48, Marathonos St., 152 35, Vrilissia, Athens, Greece

E. Deligeoroglou1, A. Deliveliotou1, V. Laggari2, P. Tsimaris1, I. Tsiantis2, G. Creatsas1 Abstract: A five year-old girl was referred by a paediatrician for evaluation of persistent foul-smelling brown vaginal discharge with pruritus for over two years, not responding to antibiotic therapy. On bimanual abdomino-rectal examination, a solid mass was palpated, deeply embedded in the posterior vaginal fornix, without tenderness. Transabdominal ultrasound identified a heterogeneous mass securely fixed in the upper third of the vaginal wall. Vaginography revealed a filling defect in the upper part of the vagina, confirming the diagnosis of an intravaginal foreign body. The foreign body, partially visualized in the vaginal introitus, was grasped and removed by traction. It turned out to be a thin doubly wrapped piece of sponge. The girl recalled having herself inserted the material, which was derived from the stuffing of a doll. Psychological assessment of the girl included Ackenbach’s “Child Behaviour Check List” (CBCL), which indicated psychological disturbances relating to social competence, adaptiveness and cognitive functioning. The aim of this paper is to present the effective approach and successful management of a child with a retained intravaginal foreign body (in this case a piece of sponge) through the collaboration of different medical subspecialists.

Key words: Intravaginal foreign body, childhood, paediatric- gynaecological- psychological evaluation.

∂ÈÛ·ÁˆÁ‹ ∏ ˘ÔÙÚÔÈ¿˙Ô˘Û· ‹ ÂÈ̤ÓÔ˘Û· ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË Û ¤Ó· ÎÔÚ›ÙÛÈ ·È‰È΋˜ ËÏÈΛ·˜ ÌÔÚ› Ó· Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ÔÈÎ›ÏˆÓ ·ÈÙÈÒÓ, fiˆ˜ Ë ÚˆÙÔ·ı‹˜ ÌÈÎÚԂȷ΋ ÎÔÏ›Ùȉ·, Ë ‰ÂÚÌ·ÙÈ΋ ÓfiÛÔ˜ ÙÔ˘ ·È‰Ô›Ô˘, ηÎÔ‹ıÂȘ fiÁÎÔÈ ÙÔ˘ ÎfiÏÔ˘ ‹ ·ÎfiÌË Î·È ·ÔÙ¤ÏÂÛÌ· Èı·Ó‹˜ ÛÂÍÔ˘·ÏÈ΋˜ ηÎÔÔ›ËÛ˘ (1-3). ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ, ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ú¤ÂÈ Ó· Paediatriki 2007;70:408-412

Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ·. √ ÛÎÔfi˜ ÙÔ˘ ·ÚfiÓÙÔ˜ ¿ÚıÚÔ˘ Â›Ó·È Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ÌÈ· ÂӉȷʤÚÔ˘Û· ÂÚ›ÙˆÛË ÎÔÚÈÙÛÈÔ‡ Ì ÂÈ̤ÓÔ˘Û· ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË Û·Ó ·ÔÙ¤ÏÂÛÌ· ‡·Ú͢ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ, ηıÒ˜ Î·È ¤Ó·Ó ·ÏÁfiÚÈıÌÔ ÁÈ· ÙËÓ ÛˆÛÙ‹ ÚÔÛ¤ÁÁÈÛË Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋

Paidiatriki 5 final

12-10-07

16:28

Page 409

409

∫ÔÚ›ÙÛÈ Ì ÛÒÌ· ÛÙÔÓ ÎfiÏÔ

·ÓÙÈÌÂÙÒÈÛË ·ÚfiÌÔÈˆÓ ÂÚÈÙÒÛˆÓ, Ì ÙËÓ Ô˘ÛÈ·ÛÙÈ΋ Û˘ÓÂÚÁ·Û›· ÔÏÏÒÓ È·ÙÚÈÎÒÓ ÂȉÈÎÔًوÓ.

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ŒÓ· ÂÍ¿¯ÚÔÓÔ ÎÔÚ›ÙÛÈ ·Ï‚·ÓÈ΋˜ ηٷÁˆÁ‹˜, Û˘Óԉ¢fiÌÂÓÔ ·fi ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘, ·Ú·¤ÌÊıËΠÛÙÔ ∆Ì‹Ì· ¶·È‰È΋˜ Î·È ∂ÊË‚È΋˜ °˘Ó·ÈÎÔÏÔÁ›·˜ ÙÔ˘ “∞ÚÂÙ·›ÂÈÔ˘” ¡ÔÛÔÎÔÌ›Ԣ ·fi ·È‰›·ÙÚÔ ÁÈ· ·ÓÙÈÌÂÙÒÈÛË ÂÈ̤ÓÔ˘Û·˜ ‰‡ÛÔÛÌ˘ ηÊÂÔÂȉԇ˜ ÎÔÏÈ΋˜ ˘ÂÚ¤ÎÎÚÈÛ˘ Û˘Óԉ¢Ô̤Ó˘ ·fi ÎÓËÛÌfi, ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 2 ¯ÚfiÓˆÓ. ∂ÚfiÎÂÈÙÔ ÁÈ· ¤Ó· ÎÔÚ›ÙÛÈ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÁÈ· ÙËÓ ËÏÈΛ· Ù˘ ‡„Ô˜ Î·È ‚¿ÚÔ˜, Ì ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi Î·È ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi. ∆Ô ÎÔÚ›ÙÛÈ ÛÙÔ ·ÚÂÏıfiÓ Â›¯Â Ï¿‚ÂÈ Û˘ÓÔÏÈο 5 Û¯‹Ì·Ù· ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ÌÂÙ¿ ·fi ηÏÏȤÚÁÂÈ· ÎÔÏÈÎÔ‡ ˘ÁÚÔ‡, ¯ˆÚ›˜ fï˜ ˘Ô¯ÒÚËÛË ÙˆÓ ÎÏÈÓÈÎÒÓ Û˘Ìو̿وÓ. TfiÛÔ Ë ›‰È·, fiÛÔ Î·È Ë ÌËÙ¤Ú·, ·¤ÎÏÂÈÛ·Ó ÙËÓ Èı·ÓfiÙËÙ· ÛÂÍÔ˘·ÏÈ΋˜ ηÎÔÔ›ËÛ˘. ∫·Ù¿ ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË, ÙÔ ÎÔÚ›ÙÛÈ ‚Ú¤ıËΠӷ ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈο ¤Íˆ ÁÂÓÓËÙÈο fiÚÁ·Ó· ı‹ÏÂÔ˜ Ì ¤ÓÙÔÓË ÂÚ˘ıÚfiÙËÙ· Î·È ÍËÚfiÙËÙ· ÛÙ· ÌÂÁ¿Ï· ¯Â›ÏË ÙÔ˘ ·È‰Ô›Ô˘ Û˘Óԉ¢Ô̤ÓË ·fi ÔÏÏ·Ϥ˜ ÂΉÔÚ¤˜ Û fiÏË ÙËÓ ¤ÎÙ·ÛË ÙÔ˘ ÂÚÈÓ¤Ô˘. √ ·ÚıÂÓÈÎfi˜ ˘Ì¤Ó·˜ ‹Ù·Ó ¿ıÈÎÙÔ˜ Ì ηϿ Û¯ËÌ·ÙÈṲ̂ÓË ÎÂÓÙÚÈ΋ Ô‹. ∫·Ù¿ ÙËÓ ·ÌÊ›¯ÂÈÚË Á˘Ó·ÈÎÔÏÔÁÈ΋ ÂͤٷÛË ·fi ÙÔ ÔÚıfi ·ÔηχÊıËΠÌÈ· „ËÏ·ÊËÙ‹ Ì¿˙·, ·ÓÒ‰˘ÓË, ÛÎÏËÚ‹˜ Û‡ÛÙ·Û˘ Î·È ÔÌ·Ï‹˜ ˘Ê‹˜, ÛÙÂÚ¿ ÚÔÛÎÔÏÏË̤ÓË ÛÙÔÓ Ô›ÛıÈÔ ÎÔÏÈÎfi ıfiÏÔ. ™ÙË Û˘Ó¤¯ÂÈ· ÂÏ‹ÊıË ÎÔÏÈÎfi ˘ÁÚfi, ‰È·Ì¤ÛÔ˘ Ù˘ Ô‹˜ ÙÔ˘ ·ÚıÂÓÈÎÔ‡ ˘Ì¤Ó·, ÙÔ ÔÔ›Ô ÛÙ¿ÏıËΠÁÈ· ηÏÏȤÚÁÂÈ·. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ηÏÏȤÚÁÂÈ·˜ ·ÂÎ¿Ï˘„·Ó ÙËÓ ·ÚÔ˘Û›· Staphylococcus epidermidis Î·È Streptococcus faecallis. ™ÙË Ê¿ÛË ·˘Ù‹ ¤ÁÈÓ ¤ÎÏ˘ÛË ÙÔ˘ ÎfiÏÔ˘ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi, Ë ÔÔ›· fï˜ ‰ÂÓ ·oÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· οÔÈÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜. ∞fi ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Ô˘ ·ÎÔÏÔ‡ıËÛÂ, ÙÔ ‰È·ÎÔÈÏÈ·Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· η٤‰ÂÈÍ ÙËÓ ·ÚÔ˘Û›· ÂÓfi˜ ·ÓÔÌÔÈÔÁÂÓÔ‡˜ ˯ԉÔÌ‹˜ ÌÔÚÊÒÌ·ÙÔ˜, Û ÛÙÂÓ‹ Û˘Ó¿ÊÂÈ· Ì ÙÔ ¿Óˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÎfiÏÔ˘, Ì ‰È·ÛÙ¿ÛÂȘ 16 cm x 8 cm x16 cm, fiˆ˜ Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1. ∏ Ì‹ÙÚ· Î·È ÔÈ ˆÔı‹Î˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÌÂÁ¤ıÔ˘˜ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘, ÂÓÒ Ô ÙÚ¿¯ËÏÔ˜ Î·È ÙÔ ÙÔ›¯ˆÌ· ÙÔ˘ ¿Óˆ ÙÚÈÙËÌÔÚ›Ô˘ ÙÔ˘ ÎfiÏÔ˘ ·ÚÔ˘Û›·˙·Ó ¤ÓÙÔÓË ˘ÂÚ·ÈÌ›·. ™ÙËÓ ·ÓÈÔ‡Û· ÎÔÏÔÁÚ·Ê›· Ê¿ÓËΠ¤Ó· ¤ÏÏÂÈÌÌ· ÛÎÈ·ÁÚ¿ÊËÛ˘ ÛÙÔ ¿Óˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÎfiÏÔ˘ Ì ‰È·ÛÙ¿ÛÂȘ 2 cm Û Ï¿ÙÔ˜ Î·È 3 cm Û ̋ÎÔ˜, ÂȂ‚·ÈÒÓÔÓÙ·˜ ÙË ‰È¿ÁÓˆÛË ÂÓfi˜ ÂÓ‰ÔÎÔÏÈÎÔ‡ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ (∂ÈÎfiÓ· 2). ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI) ‰ÂÓ Î·Ù¤‰ÂÈÍ ÙËÓ ·ÚÔ˘Û›· ÂÌÊ·ÓÔ‡˜ ·ıÔÏÔÁ›·˜ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÎfiÏÔ˘. ™Â ÌÈ· ‰Â‡ÙÂÚË ·È‰ÔÁ˘Ó·ÈÎÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË

∂ÈÎfiÓ· 1. ∆Ô ‰È·ÎÔÈÏÈ·Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ¤‰ÂÈÍ ÙËÓ ·ÚÔ˘Û›· ÂÓfi˜ ·ÓÔÌÔÈÔÁÂÓÔ‡˜ ˯ԉÔÌ‹˜ ÌÔÚÊÒÌ·ÙÔ˜, ÛÙÔ ¿Óˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÎfiÏÔ˘.

ÙÔ˘ ÎÔÚÈÙÛÈÔ‡, ÌÂÙ¿ ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, ÙÔ Í¤ÓÔ ÛÒÌ· ‹Ù·Ó ÌÂÚÈÎÒ˜ ÂÌÊ·Ó¤˜ ›Ûˆ ·fi ÙÔÓ ·ÚıÂÓÈÎfi ˘Ì¤Ó·, Î·È Ì ÙË ‚Ô‹ıÂÈ· Ï·‚›‰·˜ Allis Û˘ÓÂÏ‹ÊıË Î·È ·Ê·ÈÚ¤ıËÎÂ. ∂ÚfiÎÂÈÙÔ ÁÈ· ¤Ó· ÏÂÙfi ‰Èψ̤ÓÔ ÎÔÌÌ¿ÙÈ ÛfiÁÁÔ˘, ÚÔÂÚ¯fiÌÂÓÔ ·fi ÙÔ ˘ÏÈÎfi Á¤ÌÈÛ˘ Ì›·˜ ÎÔ‡ÎÏ·˜ Ì ‰È·ÛÙ¿ÛÂȘ 2 cm. Â› 3 cm ηٿ ÙËÓ ÚÒÙË ÂÎÙ›ÌËÛË, ÙÔ ÔÔ›Ô fiÙ·Ó Í‰ÈÏÒıËΠ›¯Â ‰È·ÛÙ¿ÛÂȘ 5,5 cm Â› 3,5 cm (∂ÈÎfiÓ· 3). ŒÓ· ‰Â‡ÙÂÚÔ ‰È·ÎÔÈÏÈ·Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· η٤‰ÂÈÍ ÙËÓ ·Ô˘Û›· Èı·ÓÔ‡ ·Ú·Ì¤ÓÔÓÙÔ˜ ÙÌ‹Ì·ÙÔ˜ ‹ Î·È ¿ÏÏÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ. ™ÙÔ ÎÔÚ›ÙÛÈ Û˘ÓÂÛÙ‹ıË ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ Ì ·ÌÔÍ˘Î˘Ï›ÓË Î·È ÎÏ·‚Ô˘Ï·ÓÈÎfi Ô͇ ÁÈ· 10 ̤Ú˜. ¢‡Ô ‚‰ÔÌ¿‰Â˜ ·ÚÁfiÙÂÚ·, ÙfiÛÔ Ë ÌËÙ¤Ú· fiÛÔ Î·È ÙÔ ·È‰› ·Ó¤ÊÂÚ·Ó ‡ÊÂÛË Ù˘ ÎÔÏÈ΋˜ ˘ÂÚ¤ÎÎÚÈÛ˘ Î·È ÙÔ˘ ÎÓËÛÌÔ‡, ÂÓÒ Î·È Ë Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ÎÔÏÈÎÔ‡ ˘ÁÚÔ‡ ‹Ù·Ó ÛÙ›ڷ ÌÈÎÚÔ‚›ˆÓ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Û˘ÓÔÌÈÏ›·˜ Ì ÙÔ ·È‰›, ·˘Ùfi ·Ó¤ÊÂÚ fiÙÈ Â›¯Â ‚¿ÏÂÈ ÌfiÓÔ ÙÔ˘ ÙÔ Í¤ÓÔ ÛÒÌ· ÛÙÔÓ ÎfiÏÔ, ÙÔ ÔÔ›Ô ¤‚Á·Ï ·fi ÙÔ Á¤ÌÈÛÌ· ÌÈ¿˜ ÎÔ‡ÎÏ·˜. ∆Ô ÎÔÚ›ÙÛÈ ·ÈÙÈÔÏfiÁËÛ ̿ÏÈÛÙ· ·˘Ù‹ ÙË Û˘ÌÂÚÈÊÔÚ¿ ϤÁÔÓÙ·˜ ¶·È‰È·ÙÚÈ΋ 2007;70:408-412

Paidiatriki 5 final

12-10-07

16:28

Page 410

410

E. ¢ÂÏËÁÂÒÚÔÁÏÔ˘ Î·È Û˘Ó.

∂ÈÎfiÓ· 2. ∏ ·ÓÈÔ‡Û· ÎÔÏÔÁÚ·Ê›· ¤‰ÂÈÍ ¤Ó· ¤ÏÏÂÈÌÌ· ÛÎÈ·ÁÚ¿ÊËÛ˘ ÛÙÔ ¿Óˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÎfiÏÔ˘ Ì ‰È·ÛÙ¿ÛÂȘ 2ÂÎ Ã 3ÂÎ.

ˆ˜ ÙÔ ¤Î·ÓÂ Û·Ó ·ÓÙ›‰Ú·ÛË ÚÔ˜ ÙË ÌËÙ¤Ú· ÙÔ˘, Ë ÔÔ›· ÙÔ Â›¯Â ÙÈ̈ڋÛÂÈ, ÂÂȉ‹ ‰ÂÓ ÎÔÈÌfiÙ·Ó. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÙÔ ·È‰› Ì·˙› Ì ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘ ·Ú·¤ÌÊıËΠÁÈ· ÂÎÙ›ÌËÛË ÛÙËÓ ¶·È‰Ô„˘¯È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”.

∂ÈÎfiÓ· 3. ∆Ô Í¤ÓÔ ÛÒÌ· ‹Ù·Ó ¤Ó· ÏÂÙfi ‰Èψ̤ÓÔ ÎÔÌÌ¿ÙÈ ÛfiÁÁÔ˘, ÚÔÂÚ¯fiÌÂÓÔ ·fi ÙÔ ˘ÏÈÎfi Á¤ÌÈÛ˘ Ì›·˜ ÎÔ‡ÎÏ·˜.

Paediatriki 2007;70:408-412

∞ÔÙÂϤÛÌ·Ù· „˘¯ÔÌÂÙÚÈ΋˜ ÂÎÙ›ÌËÛ˘ ™ÎÔfi˜ Ù˘ ·Ú·ÔÌ‹˜ ‹Ù·Ó Ë ·Ó›¯Ó¢ÛË Èı·ÓÒÓ Û˘Ó·ÈÛıËÌ·ÙÈÎÒÓ Î·È Û˘ÌÂÚÈÊÔÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÓÙȉڷÛÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡, Ô˘ ÚÔοÏÂÛ ÙÔ Á˘Ó·ÈÎÔÏÔÁÈÎfi Úfi‚ÏËÌ·. ∆Ô ·È‰› ηٿ ÙËÓ ÂÚ›Ô‰Ô ‰ÈÂÓ¤ÚÁÂÈ·˜ Ù˘ ÂÎÙ›ÌËÛ˘ ‹Ù·Ó 6 ÂÙÒÓ Î·È 2 ÌËÓÒÓ. ™Ù· Ï·›ÛÈ· Ù˘ „˘¯ÔÏÔÁÈ΋˜ ÂÎÙ›ÌËÛ˘ ¯ÔÚËÁ‹ıËΠÛÙË ÌËÙ¤Ú· Ë ÂÏÏËÓÈ΋ ÛÙ¿ıÌÈÛË Ù˘ ∫ϛ̷η˜ “Child Behaviour Check List” (CBCL) ÙÔ˘ Ackenbach, Ë ÔÔ›· ·ÔÙÂÏ› ¤Ó· ¢ڤˆ˜ Î·È ‰ÈÂıÓÒ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ·˘ÙÔ·Ó·ÊÔÚ¿˜, ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÎÔÈÓˆÓÈ΋˜ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜-ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ·˜, ηıÒ˜ Î·È ÚÔ‚ÏËÌ¿ÙˆÓ Û˘ÌÂÚÈÊÔÚ¿˜ Û ·È‰È¿ ËÏÈΛ·˜ 6-12 ÂÙÒÓ, Û‡Ìʈӷ Ì ÙËÓ ·Ó·ÊÔÚ¿ ÙˆÓ ÁÔÓÈÒÓ (4,5). ∆· ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ˘ÔÎϛ̷Θ ÙÔ˘ CBCL ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. Ÿˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î·, ÔÈ ‚·ıÌÔÏÔÁ›Â˜ ÙÔ˘ ·È‰ÈÔ‡ ÛÙȘ ˘ÔÎϛ̷Θ “∫ÔÈÓˆÓÈ΋ §ÂÈÙÔ˘ÚÁÈÎfiÙËÙ·”, “∫ÔÈÓˆÓÈο ¶ÚÔ‚Ï‹Ì·Ù·” Î·È “¶ÚÔ‚Ï‹Ì·Ù· ¶ÚÔÛÔ¯‹˜” ‚Ú›ÛÎÔÓÙ·È Û ÎÏÈÓÈο ÛËÌ·ÓÙÈÎfi Â›Â‰Ô (2Ô Î·È 90fi ÂηÙÔÛÙËÌfiÚÈÔ ·ÓÙ›ÛÙÔȯ·), Û ۇÁÎÚÈÛË Ì ÙȘ ‚·ıÌÔÏÔÁ›Â˜ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ ›‰ÈÔ˘ ʇÏÔ˘ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ Ù˘ ÂÏÏËÓÈ΋˜ ÛÙ¿ıÌÈÛ˘ ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘. ™˘˙‹ÙËÛË ∏ ·Ó‡ÚÂÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Û˘Ì‚·›ÓÂÈ Û ÔÛÔÛÙfi 4% ÙˆÓ ÎÔÚÈÙÛÈÒÓ, ËÏÈΛ·˜ οو ÙˆÓ 13 ÂÙÒÓ, Ô˘ ÚÔÛ¤Ú¯ÔÓÙ·È ÛÙ· ¶›Ó·Î·˜ 1. ∆· ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ˘ÔÎϛ̷Θ ÙÔ˘ CBCL, Ô˘ ·ÊÔÚÔ‡Ó ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ·˜ ¶ÚÔ‚Ï‹Ì·Ù· ™˘ÌÂÚÈÊÔÚ¿˜

∞ÔÙÂϤÛÌ·Ù· CBCL

∞fiÛ˘ÚÛË ™ˆÌ·ÙÈο ∂Óԯϋ̷ٷ ÕÁ¯Ô˜/ ∫·Ù¿ıÏÈ„Ë ∫ÔÈÓˆÓÈο ¶ÚÔ‚Ï‹Ì·Ù· ¶ÚÔ‚Ï‹Ì·Ù· ™Î¤„˘ ¶ÚÔ‚Ï‹Ì·Ù· ¶ÚÔÛÔ¯‹˜ ∂͈ÙÂڛ΢ÛË ∂ÛˆÙÂڛ΢ÛË ¶·Ú·‚·ÙÈ΋ ™˘ÌÂÚÈÊÔÚ¿ ∂ÈıÂÙÈ΋ ™˘ÌÂÚÈÊÔÚ¿ ™‡ÓÔÏÔ ¶ÚÔ‚ÏËÌ¿ÙˆÓ ¶ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ· ¢Ú·ÛÙËÚÈfiÙËÙ˜ ∫ÔÈÓˆÓÈ΋ §ÂÈÙÔ˘ÚÁÈÎfiÙËÙ·

4 0 7 6* 1 8* 16 10 3 13 42 3 2**

* ÙÈ̤˜ ÛÙȘ ˘ÔÎϛ̷Θ Û ÎÏÈÓÈο ÛËÌ·ÓÙÈÎfi Â›Â‰Ô (>90Ô‡ ÂηÙÔÛÙËÌÔÚ›Ô˘ ‹ >90% ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ÛÙ¿ıÌÈÛ˘). ** ÙÈ̤˜ ÛÙȘ ˘ÔÎϛ̷Θ Û ÎÏÈÓÈο ÛËÌ·ÓÙÈÎfi Â›Â‰Ô (<2Ô˘ ÂηÙÔÛÙËÌÔÚ›Ô˘ ‹ <2% ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ÛÙ¿ıÌÈÛ˘).

Paidiatriki 5 final

12-10-07

16:28

Page 411

411

∫ÔÚ›ÙÛÈ Ì ÛÒÌ· ÛÙÔÓ ÎfiÏÔ

Â͈ÙÂÚÈο È·ÙÚ›· ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ Ô˘ÚÔÔÈËÙÈÎfi ‹ ÙÔ ÁÂÓÓËÙÈÎfi Û‡ÛÙËÌ· (6). ™Â Ì›· ¿ÏÏË ÌÂϤÙË, Ô Capraro η٤ÏËÍ fiÙÈ Ë Û˘¯ÓfiÙËÙ· ·Ó‡ÚÂÛ˘ ÂÓ‰ÔÎÔÏÈÎÔ‡ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ Û ÎÔÚ›ÙÛÈ· ÚÔÂÊË‚È΋˜ ËÏÈΛ·˜, Ì ·Ó·ÊÂÚfiÌÂÓË ÎÔÏÈ΋ ·ÈÌfiÚÚÔÈ·, ‹Ù·Ó 10% (7). √È Stricker Î·È Û˘Ó. (8) ·Ó¤ÊÂÚ·Ó fiÙÈ ÂÚ›Ô˘ ÛÙ· ÌÈÛ¿ (49%) ·fi Ù· ÎÔÚ›ÙÛÈ· Ô˘ ÙÂÏÈο ‚Ú¤ıËÎ·Ó Ó· ¤¯Ô˘Ó ͤÓÔ ÛÒÌ· ÛÙÔÓ ÎfiÏÔ, ÙÔ ÚÔÂÍ¿Ú¯ÔÓ Û‡Ìو̷ ‹Ù·Ó Ë ÎÔÏÈ΋ ·ÈÌfiÚÚÔÈ· ‹ Ë ·ÈÌ·ÙËÚ‹ ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË, ÂÓÒ ÛÙÔ 20 % ÙÔ Î‡ÚÈÔ Û‡Ìو̷ ‹Ù·Ó Ô ÎÔÈÏÈ·Îfi˜ fiÓÔ˜. °ÂÓÈο, Â›Ó·È Ôχ ‰‡ÛÎÔÏÔ ¤Ó· ÌÈÎÚfi ·È‰› Ó· ÂÚÈÁÚ¿„ÂÈ ÂÓԯϋÛÂȘ ·fi ÙÔ ·È‰Ô›Ô Î·È ÙÔÓ ÎfiÏÔ. ∆· Û˘Ó‹ıË Û˘ÌÙÒÌ·Ù·, ÁÈ· Ù· ÔÔ›· ·Ú·ÔÓÔ‡ÓÙ·È Ù· ·È‰È¿ ÛÙË ÌËÙ¤Ú· ÙÔ˘˜, Â›Ó·È Ë Ê·ÁÔ‡Ú·, Ô fiÓÔ˜, Î·È ÙÔ ·›ÛıËÌ· η‡ÛÔ˘. ∏ ˘ÔÙÚÔÈ¿˙Ô˘Û· ‹ ÂÈ̤ÓÔ˘Û· ‰‡ÛÔÛÌË ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË ‹ Ë ÎÔÏÈ΋ ·ÈÌfiÚÚÔÈ· ·Ó·Î·Ï‡ÙÂÙ·È Û˘ÓËı¤ÛÙÂÚ· ·fi ÙÔ˘˜ ÁÔÓ›˜, ÔÈ ÔÔ›ÔÈ ¤ÓÙÔÓ· ıÔÚ˘‚Ë̤ÓÔÈ ·¢ı‡ÓÔÓÙ·È ·Ì¤Ûˆ˜ ÛÙÔÓ ·È‰›·ÙÚÔ. ŒÓ·˜ ˘„ËÏfi˜ ‚·ıÌfi˜ ˘Ô„›·˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÁÈ· ÙËÓ Èı·ÓfiÙËÙ· ‡·Ú͢ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ, Â›Ó·È ··Ú·›ÙËÙÔ˜, ÒÛÙ ӷ ·Ú·¤Ì„ÂÈ ¤ÁηÈÚ· ÙÔ ÎÔÚ›ÙÛÈ Û ¤Ó· ÂÍÂȉÈÎÂ˘Ì¤ÓÔ Î¤ÓÙÚÔ ·È‰È΋˜ Î·È ÂÊË‚È΋˜ Á˘Ó·ÈÎÔÏÔÁ›·˜. √ ·È‰ÔÁ˘Ó·ÈÎÔÏfiÁÔ˜ ÔÊ›ÏÂÈ Ì ÙË ÛÂÈÚ¿ ÙÔ˘ Ó· οÓÂÈ ÌÈ· ÚÔÛÂÎÙÈ΋ Á˘Ó·ÈÎÔÏÔÁÈ΋ ÂͤٷÛË, Ë ÔÔ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÙË Ï‹„Ë ÎÔÏÈÎÒÓ Î·ÏÏÈÂÚÁÂÈÒÓ. ª›· ÚÒÙË ÚÔÛ¿ıÂÈ· ÁÈ· ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÂÓfi˜ Èı·ÓÔ‡ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÌÔÚ› Ó· Á›ÓÂÈ Ì ¤ÎÏ˘ÛË ÙÔ˘ ÎfiÏÔ˘ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi ‹ Ì Ȉ‰ÈÔ‡¯Ô. ∏ ÛÙÂÓ‹ Û˘ÓÂÚÁ·Û›· ÙÔ˘ ·È‰ÔÁ˘Ó·ÈÎÔÏfiÁÔ˘ Ì ¤Ó·Ó ·ÎÙÈÓÔÏfiÁÔ Ì ·ÓÙ›ÛÙÔÈ¯Ë ÂÌÂÈÚ›· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÎÔÚÈÙÛÈÒÓ ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜, Â›Ó·È ÂÍ·ÈÚÂÙÈο ÛËÌ·ÓÙÈ΋, ÒÛÙ ӷ ÂÈÙ¢¯ı› Ô Î·Ï‡ÙÂÚÔ˜ ‰˘Ó·Ùfi˜ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ·È‰ÈÔ‡ Ì ‰È·ÎÔÈÏÈ·Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ÎÔÏÔÁÚ·Ê›· Î·È MRI (9). ∆· ÂÚÈÛÛfiÙÂÚ· ͤӷ ÛÒÌ·Ù· ‰ÂÓ Â›Ó·È ·ÎÙÈÓÔÛÎÈÂÚ¿, ÔfiÙÂ Î·È ‰ÂÓ Ê·›ÓÔÓÙ·È ÛÙȘ ·Ϥ˜ ·ÎÙÈÓÔÁڷʛ˜. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ë MRI ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È Ë ÈÔ ·ÍÈfiÈÛÙË ÁÈ· ÙËÓ ·ÂÈÎfiÓÈÛË ÂÓfi˜ ÂÓ‰ÔÎÔÏÈÎÔ‡ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ (10). ŸÙ·Ó ÙÔ Í¤ÓÔ ÛÒÌ· Â›Ó·È ÔÚ·Ùfi ÛÙËÓ Â›ÛÔ‰Ô ÙÔ˘ ÎfiÏÔ˘, Ë Û‡ÏÏË„Ë Ì Ϸ‚›‰· Allis Â›Ó·È Â‡ÎÔÏË Î·È Ô‰ËÁ› ÛÙËÓ ·Ê·›ÚÂÛ‹ ÙÔ˘. ∂›ıÈÛÙ·È fï˜, Ù· ͤӷ ÛÒÌ·Ù· Ó· ÂÓÛÊËÓÒÓÔÓÙ·È ‚·ıÈ¿ ÛÙÔ ÎÔÏÈÎfi ÙÔ›¯ˆÌ·, ÔfiÙ ÁÈ· ÙÔÓ Ï‹ÚË ¤ÏÂÁ¯Ô ÙÔ˘ ÎfiÏÔ˘ ηı›ÛÙ·Ù·È ··Ú·›ÙËÙË Ë ÂÎÙ¤ÏÂÛË ·ÚıÂÓÔÛÎfiËÛ˘ Ì ¯ÔÚ‹ÁËÛË ·Ó·ÈÛıËÛ›·˜. ∏ ÔÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ Ù›ıÂÙ·È Ì ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜. ¶·Ú·Ì¤ÓÂÈ ˆÛÙfiÛÔ ·ÌÊÈÏÂÁfiÌÂÓË

ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Ë ·Í›· Ù˘ ÙÔÈ΋˜ ÂÊ·ÚÌÔÁ‹˜ ·ÏÔÈÊ‹˜ ÔÈÛÙÚÔÁfiÓˆÓ Î·È ÙˆÓ ÙÔÈÎÒÓ χÛÂˆÓ Ì ¯·ÌÔÌ‹ÏÈ ‹ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi ÌÂÙ¿ ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ (8). ∫¿ÓÔÓÙ·˜ ·Ó·‰ÚÔÌ‹ Û ·ÚÎÂÙ¿ ÌÂÌÔӈ̤ӷ ÂÚÈÛÙ·ÙÈο ÂÊ‹‚ˆÓ ·ÁÔÚÈÒÓ Ô˘ ›¯·Ó ÌfiÓ· ÙÔ˘˜ ÙÔÔıÂÙ‹ÛÂÈ Í¤Ó· ÛÒÌ·Ù· ÛÙÔ Ô˘ÚÔÁÂÓÓËÙÈÎfi ÙÔ˘˜ Û‡ÛÙËÌ·, Ô Kenney ·Ó·Ê¤ÚÂÈ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ÌÈ· Û˘ÌÂÚÈÊÔÚ¿ ‰ÈÂÚ‡ÓËÛ˘, Ì ¿ÁÓˆÛÙË Û˘¯ÓfiÙËÙ·, Ë ÔÔ›· fï˜ ÌÔÚ› Ó· Â·Ó·Ï·Ì‚¿ÓÂÙ·È Ì ·ÓÙÈΛÌÂÓ· ‰˘ÓËÙÈο ÂÈΛӉ˘Ó·, ÂÓÒ ÙÔ „˘¯È·ÙÚÈÎfi ÚÔÊ›Ï ÙÔ˘˜ Ê·ÓÂÚÒÓÂÈ ¿ÙÔÌ· Ì οÔÈ· „˘¯ÔÏÔÁÈ΋ ÚԉȿıÂÛË (11). √ Wise, ÂÍ¿ÏÏÔ˘, Û˘ÓÔ„›˙ÔÓÙ·˜ ÙËÓ ÂÌÂÈÚ›· ÙÔ˘ Û¯ÂÙÈο Ì ¿ÙÔÌ· Ì ͤӷ ÛÒÌ·Ù· ÛÙËÓ Ô˘Ú‹ıÚ· η٤ÏËÍ ˆ˜ Ë ‰˘Ó·ÌÈ΋ ηٷÓfiËÛË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ·˘Ù‹˜ Û˘Ì‚·‰›˙ÂÈ Ì ÙËÓ ·Ó¿Ù˘ÍË Ù˘ „˘¯·Ó·Ï˘ÙÈ΋˜ ıˆڛ·˜ (12). ∏ ·ÚÔ‡Û· ÂÚ›ÙˆÛË ·ÔÙÂÏ› ÙËÓ ÚÒÙË ·Ó·ÊÔÚ¿ ÛÙËÓ ‚È‚ÏÈÔÁÚ·Ê›·, ÛÙËÓ ÔÔ›· ¤ÁÈÓ „˘¯ÔÌÂÙÚÈ΋ ÂÎÙ›ÌËÛË ÂÓfi˜ ÎÔÚÈÙÛÈÔ‡ Ô˘ ‰È·ÁÓÒÛÙËΠ̠ÂÓ‰ÔÎÔÏÈÎfi ͤÓÔ ÛÒÌ·, ÙÔ ÔÔ›Ô Â›¯Â ÙÔÔıÂÙËı› ·fi ÙÔ ›‰ÈÔ. √ ÛÙfi¯Ô˜ Ù˘ ·Ú·ÔÌ‹˜ ÁÈ· „˘¯ÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ‹Ù·Ó Ë ·Ó›¯Ó¢ÛË Èı·ÓÒÓ Û˘Ó·ÈÛıËÌ·ÙÈÎÒÓ Î·È Û˘ÌÂÚÈÊÔÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ÛÙȘ Ôԛ˜ ı· ÌÔÚÔ‡Û ӷ ·Ô‰Ôı› Ë Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡, ηıÒ˜ ÂÓ ÙË ·Ô˘Û›· „˘¯Ô·ıÔÏÔÁÈÎÔ‡ Â˘Ú‹Ì·ÙÔ˜ ·˘Ù‹ ı· ÌÔÚÔ‡Û ӷ ·Ô‰Ôı› Û Ú¿ÍÂȘ ·˘ÙÔÂÚˆÙÈÛÌÔ‡ Î·È ÛˆÌ·ÙÈ΋˜ ÂÍÂÚ‡ÓËÛ˘ ÙÔ˘ ·È‰ÈÔ‡. ∏ Îϛ̷η “Child Behaviour Check List” (CBCL) ÙÔ˘ Ackenbach ¤¯ÂÈ Á›ÓÂÈ ·Ô‰ÂÎÙ‹ ·ÁÎÔÛÌ›ˆ˜ ÙfiÛÔ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË fiÛÔ Î·È ÛÙËÓ ¤Ú¢ӷ, ˆ˜ ¤Ó· ¯Ú‹ÛÈÌÔ „˘¯ÔÌÂÙÚÈÎfi ÂÚÁ·ÏÂ›Ô ÁÈ· ÙË ÛÊ·ÈÚÈ΋ ÂÎÙ›ÌËÛË Ù˘ ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ·˜ Î·È Ù˘ „˘¯Ô·ıÔÏÔÁ›·˜ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ (4). ∂ÈϤÔÓ, Ë ‡·ÚÍË ˘ÔÏÔÁÈÛÌ¤ÓˆÓ cut-off ÙÈÌÒÓ ‚¿ÛÂÈ ÙÔ˘ ÂÏÏËÓÈÎÔ‡ ‰Â›ÁÌ·ÙÔ˜ ÛÙ¿ıÌÈÛ˘ (5) ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ¯·Ú·ÎÙËÚÈÛÌÔ‡ Ù˘ ÂοÛÙÔÙ ‚·ıÌÔÏÔÁ›·˜ ˆ˜ ÎÏÈÓÈο ÛËÌ·ÓÙÈ΋˜ ‹ ÌË. ∆· ÎÏÈÓÈο ÛËÌ·ÓÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ˘ÔÎϛ̷Θ ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ CBCL ˘Ô‰ËÏÒÓÔ˘Ó ÙËÓ ‡·ÚÍË „˘¯ÔÏÔÁÈÎÒÓ ‰˘ÛÎÔÏÈÒÓ Ô˘ ÂËÚ¿˙Ô˘Ó Î˘Ú›ˆ˜ ÙȘ ÎÔÈÓˆÓÈΤ˜ ‰ÂÍÈfiÙËÙ˜ Î·È ÙËÓ ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ· ÙÔ˘ ÎÔÚÈÙÛÈÔ‡, ηıÒ˜ Â›Û˘ Î·È ÙËÓ ÁÓˆÛÙÈ΋ ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·. ∂ȉÈÎfiÙÂÚ·, Ë „˘¯ÔÌÂÙÚÈ΋ ÂÎÙ›ÌËÛË ¤‰ÂÈÍ fiÙÈ Ê·›ÓÂÙ·È Ó· ÚÔÂÍ¿Ú¯Ô˘Ó ÔÈ ‰˘ÛÎÔϛ˜ ÎÔÈÓˆÓÈ΋˜ ·ÏÏËÏÂ›‰Ú·Û˘ Î·È Ó· ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÂÏÏÈ‹˜ ÎÔÈÓˆÓÈÎÔÔ›ËÛË Î·È ÊÙˆ¯¤˜ Û¯¤ÛÂȘ ÌÂ Û˘ÓÔÌ‹ÏÈη ·È‰È¿, ÂÓÒ ÛÙÔ ÁÓˆÛÙÈÎfi Â›Â‰Ô ÂÓÙÔ›˙ÂÙ·È ·‰˘Ó·Ì›· Û˘ÁΤÓÙÚˆÛ˘, ÔÓÂÈÚÔfiÏËÛË Î·È ·ÚÔÚÌËÙÈÎfiÙËÙ·. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›ÙˆÛË, Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ ·Ú¤¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ¶·È‰È·ÙÚÈ΋ 2007;70:408-412

Paidiatriki 5 final

12-10-07

16:28

Page 412

412

E. ¢ÂÏËÁÂÒÚÔÁÏÔ˘ Î·È Û˘Ó.

ÏËÚÔÊÔڛ˜ Û ۯ¤ÛË Ì ÙËÓ „˘¯ÔÏÔÁÈ΋ Î·È ÎÔÈÓˆÓÈ΋ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·, ηıÒ˜ Î·È ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡. ÕÏψÛÙÂ, ·ÔÙÂÏ› Û˘Ó‹ıË Î·È ÂÈÛÙËÌÔÓÈο ·Ô‰ÂÎÙ‹ Ú·ÎÙÈ΋ Ë ÂÚÈÁÚ·Ê‹ ÙÔ˘ „˘¯ÔÏÔÁÈÎÔ‡ ÚÔÊ›Ï ·ÛıÂÓÒÓ, ̤ۈ Ù˘ ¯ÔÚ‹ÁËÛ˘ ÛÙ·ıÌÈÛÌ¤ÓˆÓ Î·È ¤ÁÎ˘ÚˆÓ „˘¯ÔÌÂÙÚÈÎÒÓ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ. µ¤‚·È·, ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ‰ÂÓ ·ÔÙÂÏ› ‰È·ÁÓˆÛÙÈÎfi ÂÚÁ·ÏÂ›Ô ÛÙÔ ÔÔ›Ô ı· ÌÔÚÔ‡Û ηÓ›˜ Ó· ‚·ÛÈÛÙ› ÁÈ· ÙË ‰È¿ÁÓˆÛË ÌÈ·˜ Û˘ÁÎÂÎÚÈ̤Ó˘ ÓÔÛÔÏÔÁÈ΋˜ ÔÓÙfiÙËÙ·˜ Î·È Û˘ÓÂÒ˜ ‰ÂÓ ÌÔÚ› Ó· ·ÓÙÈηٷÛÙ‹ÛÂÈ ÙËÓ ‰È·ÁÓˆÛÙÈ΋ ÎÏÈÓÈ΋ Û˘Ó¤ÓÙ¢ÍË Î·È ·ÍÈÔÏfiÁËÛË. ∂ÈϤÔÓ, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ „˘¯ÔÌÂÙÚÈ΋˜ ÂÎÙ›ÌËÛ˘ ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·Ùfi Ó· Â·ÏËı¢ÙÔ‡Ó Î·È Ó· Û˘ÓÂÎÙÈÌËıÔ‡Ó Ì ÎÏÈÓÈο ÛÙÔȯ›· ηıÒ˜ ‰ÂÓ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÂÚ·ÈÙ¤Úˆ „˘¯ÔÏÔÁÈ΋ ·ÍÈÔÏfiÁËÛË ÏfiÁˆ ¿ÚÓËÛ˘ ÙˆÓ ÁÔÓÈÒÓ - ·Ú¿ ÙȘ Û˘ÛÙ¿ÛÂȘ ÙˆÓ ÂȉÈÎÒÓ ÚÔ˜ ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ÙËÓ ·Ó¿ÁÎË ÂÚ·ÈÙ¤Úˆ ÎÏÈÓÈ΋˜ ‰ÈÂÚ‡ÓËÛ˘ ÙÔ˘ ·È‰ÈÔ‡ ηıÒ˜ Î·È Û˘Ì‚Ô˘Ï¢ÙÈ΋˜ ÚÔ˜ ÙÔ˘˜ ›‰ÈÔ˘˜. ∂Ô̤ӈ˜, Â›Ó·È Û·Ê¤˜ fiÙÈ ¤Ú·Ó Ù˘ ÎÏÈÓÈ΋˜ Î·È ÂÚ¢ÓËÙÈ΋˜ ¯ÚËÛÈÌfiÙËÙ·˜ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘, Î·È ·Ú¿ Ù· ·ÔÙÂϤÛÌ·Ù· Ô˘ Ì·˜ ·Ú¤¯ÂÈ ÁÈ· ÙÔ „˘¯ÔÏÔÁÈÎfi ÚÔÊ›Ï ·˘ÙÔ‡ ÙÔ˘ ÎÔÚÈÙÛÈÔ‡, Ë Î·Ù·ÓfiËÛË ÙˆÓ ÂÚÈÔÚÈÛÌÒÓ Î·È ÙˆÓ ÔÚ›ˆÓ ÛÙË ¯Ú‹ÛË ÙÔ˘ -fiˆ˜ ¿ÏψÛÙÂ Î·È fiÏˆÓ ÙˆÓ „˘¯ÔÌÂÙÚÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ- Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ·ÍÈÔÔ›ËÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙÔ˘ ηٿ ÙÔÓ ÔÚıfiÙÂÚÔ ÂÈÛÙËÌÔÓÈο Î·È ‰ÂÔÓÙÔÏÔÁÈο ÙÚfiÔ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÎÔÚÈÙÛÈÒÓ Ô˘ ÚÔÛ¤Ú¯ÔÓÙ·È Ì ÂÈ̤ÓÔ˘Û· ‰‡ÛÔÛÌË ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË, ı· Ú¤ÂÈ Ó· ‰ÈÂÚÂ˘Ó¿Ù·È Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ÂÓfi˜ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ. ªÈ· ηϿ ÔÚÁ·ÓˆÌ¤ÓË, ÛÊ·ÈÚÈ΋ Î·È ‰ÈÂÈÛÙËÌÔÓÈ΋ ÚÔÛ¤ÁÁÈÛË ··ÈÙ› ÚˆÙ·Ú¯Èο ÙËÓ Ô˘ÛÈ·ÛÙÈ΋ Û˘ÓÂÚÁ·Û›· ÙÔ˘ ·È‰È¿ÙÚÔ˘, Ô ÔÔ›Ô˜ ÚÒÙÔ˜ ‚ϤÂÈ ÙÔ ·È‰›, Ì ÙÔÓ Á˘Ó·ÈÎÔÏfiÁÔ, Ô ÔÔ›Ô˜ Ú¤ÂÈ Ó· Â›Ó·È ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˜ Û ÚÔ‚Ï‹Ì·Ù· Ù˘ ·È‰È΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜. °ÓˆÚ›˙ÔÓÙ·˜, ÂÍ¿ÏÏÔ˘, fiÙÈ Ë ÙÔÔı¤ÙËÛË ÂÓfi˜ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ ·fi ÙÔ ›‰ÈÔ ÙÔ ÎÔÚ›ÙÛÈ, ÌÔÚ› ‰˘ÓËÙÈο Ó· ·ÔÙÂÏ› ÚÒÈÌË ¤Ó‰ÂÈÍË „˘¯È΋˜ ‰È·Ù·Ú·¯‹˜ ‹ Û‡Ìو̷ ˘Ô‚fiÛÎÔ˘Û·˜ ‰È·Ù·Ú·¯‹˜ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜, Ë ·ÓÙÈÌÂÙÒÈÛË ‰ÂÓ ı· Ú¤ÂÈ Ó· ÂÚÈÔÚ›˙ÂÙ·È ÛÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ·fi ÙÔÓ ÎfiÏÔ. ∫·ıÔ-

Paediatriki 2007;70:408-412

ÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜, ÙfiÛÔ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË fiÛÔ Î·È ÁÈ· ÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Â·ÓÂÌÊ¿ÓÈÛ˘ Ù¤ÙÔÈÔ˘ ›‰Ô˘˜ ÂÚÈÛÙ·ÙÈÎÒÓ, ıˆÚÂ›Ù·È Ë Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ÂȉÈÎÔÙ‹ÙˆÓ Ô˘ ÂÌϤÎÔÓÙ·È Á‡Úˆ ·fi ı¤Ì·Ù· „˘¯È΋˜ ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ, ηıÒ˜ Î·È Ë ‰˘Ó·ÙfiÙËÙ· ‰È·Û‡Ó‰ÂÛ˘ ÙˆÓ ˘ËÚÂÛÈÒÓ, Ì ÛÎÔfi ÙËÓ ·Ú·ÔÌ‹ Û ˘ËÚÂۛ˜ „˘¯È΋˜ ˘Á›·˜ ·È‰ÈÒÓ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ „˘¯ÔÏÔÁÈ΋˜ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ·È‰ÈÔ‡.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Herman-Giddens ME. Vaginal foreign bodies and child sexual abuse. Arch Pediatr Adolesc Med. 1994;148(2):195-200.

2. Striegel AM, Myers JB, Sorensen MD, Furness PD, Koyle MA. Vaginal discharge and bleeding in girls younger than 6 years. J Urol.2006;176(6 Pt 1):2632-2635.

3. Cuadros J, Mazon A, Martinez R, Gonzalez P, Gil-Setas A, Flores U, Orden B, Gomez-Herruz P, Millan R; Spanish Study Group for Primary Care Infection. The aetiology of paediatric inflammatory vulvovaginitis. Eur J Pediatr. 2004; 163(2):105-107.

4. MacDonald VM, Tsiantis J, Achenbach TM, Motti-Stefanidi F, Richardson SC. Competencies and problems reported by parents of Greek and American children, ages 611. Eur Child Adolesc Psychiatry 1995;4(1):1-13.

5. Roussos A, Karantanos G, Richardson C, Hartman C, Karajiannis D, Kyprianos S, Lazaratou H, Mahaira O, Tassi M, Zoubou V. Achenbach's Child Behaviour Checklist and Teacher's Report Form in a normative sample of Greek children 6-12 years old. Eur Child Adolesc Psychiatry 1999; 8:165-172.

6. Paradise JE, Willis ED. Probability of vaginal foreign body in girls with genital complaints. Am J Obstet Gynecol 1985; 139:472.

7. Capraro VJ. Vulvovaginitis and other local lesions of the vulva. Clin Obstet Gynecol 1974;1:533.

8. Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatr Child Health. 2004;40(4):205-207.

9. Caspi B, Zalel Y, Katz Z, Appelman Z, Insler V. The role of sonography in the detection of vaginal foreign bodies in young girls: the bladder indentation sign. Pediatr Radiol.

1995;25 Suppl 1:S60-61.

10. Kihara M, Sato N, Kimura H, Kamiyama M, Sekiya S, Takano H. Magnetic resonance imaging in the evaluation of vaginal foreign bodies in a young girl. ArchGynecol Obstet 2001; 265(4):221-222.

11. Kenney RD. Adolescent males who insert genitourinary foreign bodies: is psychiatric referral required? Urology 1988;32:127.

12. Wise TN. Urethral manipulation: an unusual paraphilia. J Sex Marital Ther 1982;8:222.

Paidiatriki 5 final

12-10-07

16:28

Page 413

CASE REPORT

∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏

413

Rare manifestations of coeliac disease - Report of a case and review of the literature M. Ugras, D. Ertem, E. Pehlivanoglu Abstract: Coeliac disease (CD) is an immune-mediated enteropathy caused by the ingestion of gluten in genetically susceptible individuals. Classically, coeliac disease presents with anorexia, chronic diarrhoea, abdominal distension, muscle wasting and failure to thrive. However, atypical CD may present with iron deficiency anaemia resistant to therapy, leukopenia, thrombocytopenia, osteoporosis, arthritis, dental enamel defects, pubertal delay and recurrent abdominal pain. Coeliac crisis is a manifestation of the disease which was very frequent in the past. It is characterized by diarrhoea, electrolyte imbalance and metabolic acidosis. The case is reported here of a child presenting with coeliac crisis, with emphasis on the importance of this rare manifestation of CD. Key words: Coeliac disease, coeliac crisis, electrolyte imbalance, acidosis, child.

Introduction Coeliac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. The introduction of gluten into the diet leads to damage of the intestinal mucosa, which causes malabsorption. The classical presentation of CD is with anorexia, chronic or recurrent diarrhoea, abdominal distension, muscle wasting and failure to thrive. However, atypical CD has become a more common clinical presentation nowadays. It is manifested with iron deficiency anaemia resistant to therapy, prolonged prothrombin time (PT) and aPTT, osteoporosis, arthritis, dental enamel defects, pubertal delay, recurrent abdominal pain and hyperamilasaemia (1). The serological tests available for the diagnosis of CD include antigliadin antibodies and connective tissue antibodies: reticulin, endomysial and tissue transglutaminase antibodies (tTG). The current gold standard in coeliac serology remains the IgA endomysial antibody (EMA). Overall the sensitivity of the EMA and tTG is greater than 90% (2-4).

The laboratory findings of CD include thrombocytosis, thrombocytopenia, leukopenia, and prolonged PT and APTT (5).

Coeliac crisis is a manifestation of the disease which was frequent in past decades, but has now almost disappeared. A few cases of coeliac crisis are reported annually in the developing countries, and it should be kept in mind among the differential diagnoses of children having severe electrolyte imbalance, metabolic acidosis and a history of coeliac disease.

Marmara University, Department of Paediatric Gastroenterology, Hepatology and Nutrition, Istanbul, Turkey Correspondence: Meltem Ugras meltemkorkut@yahoo.com Marmara University, Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Tophanelioglu cad 13-15, Altunizade, Istanbul, Turkey

Case report A 13 year-old girl was admitted with carpopedal spasm, oedema and intermittent diarrhoea.

During the previous few months she had been weak, had lost 5 kg and had arthralgia. There was no consanguinity between her parents; her prenatal and postnatal history was unremarkable.

On physical examination her height and weight were below the 3rd percentile. She was pale and weak and had abdominal distension.

There was pitting oedema over her tibia and she also had digital clubbing. Her liver was 2 cm palpable below the right costal margin.

She was anaemic with a blood haemoglobin value of 8.1 g/dl, and on admission measurement of her serum electrolytes revealed hyponatraemia, hypokalaemia, hypocalcaemia and hypoproteinaemia (Na 127 meq/dl K 1.97 meq/dl, Ca 6.2 mg/dl, ionized calcium 0.6 mmol/L, albumin 1.5 g/dl) and acidosis (blood pH 7.24, HCO3 8.6). AST 46 IU/L, ALT 47 IU/L, PT 24.2 sec, INR 2.31. HBsAg, Anti HBs, HAV Ig G and M, Anti HCV were negative, and alpha-fetoprotein and alpha1-antitripsin levels were within the normal range. Abdominal ultrasonography showed an enlarged liver with normal parenchymal echogeneity, gall bladder, intrahepatic and extrahepatic biliary tract.

Since the arterial blood gas analysis revealed metabolic acidosis, intravenous fluid, electrolyte and bicarbonate supplements were started immediately. During her hospital stay, she developed hyperaemic, papular, pruritic skin lesions on the buttocks, legs and arms (Figure 1). ¶·È‰È·ÙÚÈ΋ 2007;70:413-415

Paidiatriki 5 final

12-10-07

16:28

Page 414

414

M. Ugras, D. Ertem, E. Pehlivanoglu

Figure 1. Papular lesions on the legs and arms.

The electrolyte imbalance and mild degree of acidosis persisted, and it was not possible to discontinue intravenous fluid and albumin infusion. An upper gastrointestinal endoscopy was performed and the characteristic pathological findings on the duodenal biopsies (Figure 2), and high levels of antiendomysium and antigliadin IgA and IgG, revealed that the patient had gluten sensitive enteropathy. The girlâ&#x20AC;&#x2122;s condition was considered to be â&#x20AC;&#x153;coeliac crisisâ&#x20AC;? and methyprednisolone at a dose of 2 mg/kg/day was started consequently, in addition to gluten free diet (GFD). On the 8th day of steroid treatment, her serum electrolyte and acid-base status became stable, the pruritic skin lesions regressed, and it was possible to stop intravenous fluid and electrolyte support within a few days.

Discussion CD is common in European countries, with a wide spectrum of gastrointestinal and systemic signs and symptoms. The definitive diagnosis depends on the histopathological examination of the distal duodenal mucosa. The differential diagnosis of total or partial villous atrophy includes food allergy, immunodeficiency states, Rotavirus enteritis, Giardia lamblia infestations, tropical sprue and post-enteritis syndrome.

The clinical presentation of CD in children is diverse. Classic CD is characterized by gastrointestinal manifestations starting between 6 and 24 months of age, after the introduction of gluten into the diet. Infants and young children typically present with impaired growth, chronic diarrhoea, abdominal distension, muscle wasting and hypotonia, poor appetite and unhappy behaviour. Within weeks to months of starting to ingest gluten, weight gain velocity decreases and finally weight loss can be observed. Despite a wide variation between countries, typical CD still represents a common presentation in the paediatric age group. Atypical presentation of CD usually tends to Paediatriki 2007;70:413-415

Figure 2. Histopathologic examination revealing villous atrophy, increased intraepithelial lymphocytes. (HEx200 magnification).

occur in older children, who present a picture of recurrent abdominal pain, nausea, vomiting, bloating, and constipation. Extra-intestinal manifestations such as short stature, pubertal delay, iron deficiency, dental enamel defects and abnormalities in liver function are common in atypical CD (1).

Dermatitis herpetiformis (DH) is a chronic papulovesicular skin disease frequently associated with asymptomatic gluten-sensitive enteropathy.

Dermatitis herpetiformis is at present regarded as a variant of CD rarely affecting the paediatric population. In general the treatment of DH consists of removal of gluten from the diet and use of pharmacological agents such as dapsone, dexamethasone and cyclophosphamide (6-9). There is strong evidence that DH is a skin manifestation of CD. Most patients with DH have concomitant intestinal mucosal changes of CD on duodenal biopsy, even in the absence of gastrointestinal symptoms. Both the rash and intestinal mucosal morphology improve on gluten free diet (9,10).

The association of osteoporosis and CD has been reported in several clinical and epidemiological studies, but no conclusive data on the pathogenesis of bone involvement in CD are available. Bone changes were originally thought to be secondary to intestinal malabsorption of calcium and vitamin D, but recently, other causes of bone metabolism impairment have been cited, including the interaction between cytokines and local/systemic factors influencing bone formation and reabsorption. Further, there is now substantial evidence supporting the concept that lifelong GFD is the only effective measure to restore bone metabolism to normal. In the paediatric population, prompt introduction of GFD can even lead to satisfactory recovery

Paidiatriki 5 final

12-10-07

16:28

Page 415

415

M. Ugras et al.

of the bone mass. It has been shown that in children and adolescents the bone mineral content, bone area and bone mineral density were significantly lower in CD subjects than in controls, and that GFD causes complete recovery of bone density and body mass composition. Conversely, adults affected by osteoporosis secondary to CD do not experience spontaneous recovery, and there are no conclusive data on the efficacy of standard therapies for osteoporosis in reducing the fracture risk. This evidence stresses the need for timely diagnosis as a preventive intervention to avoid CD complications (1,11-13).

Apart from the characteristic manifestations of the disease, CD can also present with unusual clinical features, which can lead to delayed diagnosis and treatment. A rare and life-threatening complication, usually affecting children under 2 years of age is the so called “coeliac crisis” (14). Clinically, this condition is characterized by severe diarrhoea, dehydration and electrolyte imbalance. Various precipitating factors have been identified for coeliac crisis, including severe malnutrition, infections, hypoproteinaemia, poor compliance to GFD, bacterial overgrowth in a setting of altered gastrointestinal motility and use of anticholinergic drugs (15).

Early reports of CD described several patients suffering from severe and life-threatening malabsorption. In 1952, Andersen and Di Saint Agnese described the course of CD in 58 children (16). Although the majority suffered from growth retardation and hypoproteinaemia, 35 of them had episodes of sudden dehydration and acidosis, a condition called coeliac crisis.

This kind of clinical presentation was confined to the children of under 2 years. There are some case reports of children presenting with coeliac crisis who were successfully treated with steroid and GFD (16).

In the middle of the 19th century, severe malabsorption due to coeliac crisis was the leading presentation of CD. Recently, advances in serological testing have made the diagnosis of CD easier, with the result that the consequences of severe malabsorption are now rarely seen.

In conclusion, CD is still a common diagnosis in current medical practice. Although the numbers of newly diagnosed CD patients are increasing, either because of the improved diagnostic techniques or the approach of the clinicians, fewer new coeliac crisis cases are being reported from the developing countries. However, this condition should be kept in mind

among children with severe electrolyte imbalance, metabolic acidosis, and severe malabsorption even in older children.

References 1. Fasano A, Catassi C. Celiac disease in children. Best Pract Res Clin Gastroenterol 2005;19:467-478.

2. NIH Consensus Development Conference on Celiac Disease [Statement]. 2004: Webpage: http://www.consensus.nih. gov/ cons/118/118cdc_intro. htm. [ Available from: http:// www.consensus.nih.gov/cons/118/118cdc_intro.htm] 3. Rossi TM, Kumar V, Lerner A, Heitlinger LA, Tucker N, Fisher J. Relationship of endomysial antibodies to jejunal mucosal pathology: specificity towards both symptomatic and asymptomatic celiacs. J Pediatr Gastroenterol Nutr 1988;7:858-863.

4. Chorzelski TP, Beutner EH, Sulej J, Tchorzewska H, Jablonska S, Kumar V, et al. IgA anti-endomysium antibody. A new immunological marker of dermatitis herpetiformis and coeliac disease. Br J Dermatol 1984;111:395-402.

5. Halfdanarson TR, Litzow MR, Murray JA. Hematologic manifestations of celiac disease. Blood. 2007;109:412-421.

6. Egan CA, Smith EP, Taylor TB, Meyer LJ, Samowitz WS, Zone JJ. Linear IgA bullous dermatosis responsive to a gluten-free diet. Am J Gastroenterol 2001;96:1927-1929.

7. Burks W. Skin manifestations of food allergy. Pediatrics 2003;111:1617-1624.

8. Sacchidanand S, Hiremath NC, Natraj HV, Revathi TN, Rani S, Pradeep, G, et al. Dexamethasone-cyclophosphamide pulse therapy for autoimmune-vesiculobullous disorders at Victoria hospital, Bangalore. Dermatol Online J 2003;9:2.

9. Andersson H, Mobacken H. Dietary treatment of dermatitis herpetiformis. Eur J Clin Nutr 1992;46:309-315.

10. Brow JR, Parker F, Weinstein WM, Rubin CE. The small intestinal mucosa in dermatitis herpetiformis. I. Severity and distribution of the small intestinal lesion and associated malabsorption. Gastroenterology 1971;60:355-361.

11. Mora S, Barera G, Beccio S, Menni L, Proverbio MC, Bianchi C, et al. A prospective, longitudinal study of the long-term effect of treatment on bone density in children with celiac disease. J Pediatr 2001;139:516-521.

12. Barera G, Mora S, Brambilla P, Ricotti A, Menni L, Beccio S, et al. Body composition in children with celiac disease and the effects of a gluten-free diet: a prospective casecontrol study. Am J Clin Nutr 2000;72:71-75.

13. Lunt H, Florkowski CM, Cook HB, Whitehead MR. Bone mineral density, type 1 diabetes, and celiac disease. Diabetes Care 2001;24:791-792.

14. Anderson M, Forbes D, Gracey M. Celiac disease. In: Gracey M, Burke V, editors. Pediatric Gastroenterology and Hepatology. 3rd ed. Boston: Blackwell Scientific Publications; 1993. p: 403-425.

15. Walia A, Thapa BR. Celiac crisis. Indian Pediatr 2005;42: 1169.

16. Andersen DH, Di Sant’ Agnese PA. Idiopathic celiac disease. I. Mode of onset and diagnosis. Pediatrics 1953;11: 207-222.

¶·È‰È·ÙÚÈ΋ 2007;70:413-415

Paidiatriki 5 final

12-10-07

416

16:28

Page 416

¶ƒ∞∫∆π∫√ £∂ª∞

PRACTICAL ISSUE

∞ÛıÌ·ÙÈο ·È‰È¿ Î·È ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 1 ¶·È‰ÔÓ¢ÌÔÓÔÏÔÁÈ΋ ªÔÓ¿‰·, °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£.

2 ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì·, µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ 3 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£.

AÏÏËÏÔÁÚ·Ê›·: ºÒÙÈÔ˜ ∫˘Ú‚·Û›Ï˘ ¶·È‰ÔÓ¢ÌÔÓÔÏÔÁÈ΋ ªÔÓ¿‰·, °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£., πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢,

º. ∫˘Ú‚·Û›Ï˘Å, ¡. ¶··‰fiÔ˘ÏÔ˜Ç, π. ∆۷ӿη˜Å, º. ∫·Ó·ÎÔ‡‰ËÑ ¶ÂÚ›ÏË„Ë: ∆Ô ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· ÛÙ· ·È‰È¿ ıˆÚÂ›Ù·È ˆ˜ ¤Ó·˜ ·fi ÙÔ˘˜ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ ÌÂÙ¿ ÓfiÛËÛË ·fi ÙÔÓ Èfi Ù˘ ÁÚ›˘. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ÚfiÛÊ·Ù· Û˘ÓÈÛÙ¿Ù·È Ô Î·ıÔÏÈÎfi˜ ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ. ∞fi ÙËÓ ·Ó·ÛÎfiËÛË Ù˘ Û‡Á¯ÚÔÓ˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ Û¯ÂÙÈο Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙ· ·ÛıÌ·ÙÈο ·È‰È¿, Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. ∆· ‰Â‰Ô̤ӷ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ Ù˘¯·ÈÔÔÈË̤ÓË, ÚÔÔÙÈ΋ ÌÂϤÙË Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ ÛÙ· ·ÛıÌ·ÙÈο ·È‰È¿, ‰Â›¯ÓÔ˘Ó fiÙÈ ‰ÂÓ ·Ú¤¯ÂÈ ÚÔÛÙ·Û›· ·fi ÙȘ ÂÍ¿ÚÛÂȘ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Î·ÙfiÈÓ ÈÒÛˆÓ, ÂÓÒ ·Ú¿ÏÏËÏ· ‰ÂÓ ˘¿Ú¯Ô˘Ó ÛÙÔȯ›· ·fi ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ Ô˘ Ó· ÂȂ‚·ÈÒÓÔ˘Ó fiÙÈ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÌÂÈÒıËÎ·Ó ÔÈ ÂÈÛ·ÁˆÁ¤˜ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÙÔ ¿ÛıÌ· ÛÙ· ·È‰È¿ ·ÚÔ˘ÛÈ¿˙ÂÈ Â˘Ú›· Ê·ÈÓÔÙ˘È΋ ¤ÎÊÚ·ÛË ·fi ÙËÓ ‹È· ˆ˜ ÙËÓ ‚·ÚÈ¿ ÌÔÚÊ‹ ÙÔ˘, Î·È fiÙÈ ÔÈ ÈÔ› Ô˘ ¢ı‡ÓÔÓÙ·È Î˘Ú›ˆ˜ ÁÈ· ÙȘ ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ ÛÙ· ·È‰È¿, Â›Ó·È ÔÈ ÚÈÓÔ˚Ô› Î·È Ô ·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜, Û˘ÌÂÚ·›ÓÔ˘Ì fiÙÈ ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· Ó· ·Ô‰Âȯı› Ë ·Ó·ÁηÈfiÙËÙ· ÙÔ˘ ηıÔÏÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ Ì ÙÔ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚fiÏÈÔ. §¤ÍÂȘ ÎÏÂȉȿ: ÕÛıÌ·, ·È‰È¿, ·ÓÙÈÁÚÈÈÎfi ÂÌ‚fiÏÈÔ, Èfi˜ ÁÚ›˘, ÚÈÓÔ˚Ô›.

Influenza vaccination in children with asthma 1 Unit of Paediatric Pneumonology, 3rd Paediatric Clinic, Aristotle University of Thessaloniki 2 Department of Allergology, 2nd Paediatric Clinic, University of Athens 3 1st Paediatric Clinic, Aristotle University of Thessaloniki Correspondence: Fotios Kirvassilis 47a, A. Ypsilantou St., 57013, Oraiokastro, Thessaloniki, Greece

F. KÈrvassilisÅ, N. PapadopoulosÇ, I. TsanakasÅ, F. KanakoudiÑ Abstract: Bronchial asthma is considered to be a risk factor for the occurrence of post influenza infection complications. For this reason influenza vaccination has recently been recommended for all children with asthma. However, review of the current literature on the application of influenza vaccination to children with asthma revealed conflicting results. Data from the randomized prospective study of its application in asthmatic children failed to demonstrate protection from post-viral bronchial asthma exacerbations. There are also no data from prospective studies to show that hospitalizations of children with asthma are reduced following influenza vaccination. Considering that bronchial asthma in children has a wide phenotypic occurrence ranging from mild to severe types, and that the rhinoviruses and respiratory syncytial virus are the viruses mainly responsible for asthma exacerbations in children it is concluded that more data is needed to confirm the necessity of influenza vaccination for all children with asthma.

Key words: Asthma, children, influenza vaccination, influenza virus, rhinoviruses.

∆Ô ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· ·ÔÙÂÏ› ÙËÓ ÈÔ Û˘¯Ó‹ ¯ÚfiÓÈ· ¿ıËÛË ÛÙ· ·È‰È¿ Î·È ıˆÚÂ›Ù·È ÂÈ‚·Ú˘ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ ÌÂÙ¿ ·fi ÓfiÛËÛË ·fi ÙÔÓ Èfi Ù˘ ÁÚ›˘ (1). ∆Ô Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ÂÍ¿ÚÛÂˆÓ ÛÙ· ·È‰È¿ Â›Ó·È Ë Ïԛ̈ÍË ·fi ÈÔ‡˜ (2-5). ∆ËÓ ÎÏÈÓÈ΋ ·˘Ù‹ ÂÌÂÈÚ›· ÂȂ‚·ÈÒÓÂÈ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÌÂÏÂÙÒÓ. √È Jartti Î·È Û˘Ó. ‚Ú‹Î·Ó fiÙÈ ÛÙÔ 88% 293 ·È‰ÈÒÓ Ô˘ ÓÔÛËχÙËÎ·Ó Ì Ô͇ ÂÎÓ¢ÛÙÈÎfi Û˘ÚÈÁÌfi Î·È ÌÂÏÂÙ‹ıËÎ·Ó ÚÔÔÙÈο, ·ÔÌÔÓÒıËΠÈfi˜ ˆ˜ ·›ÙÈÔ Ù˘ ¤Í·ÚÛ˘ (3). ™‡Ìʈӷ Ì ÌÂϤÙË ÙˆÓ Neuzil Î·È Û˘Ó. ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÔÈ ÂÈÛ·ÁˆÁ¤˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÏfiÁˆ ÁÚ›˘ Ô˘ ηٷÁÚ¿ÊËÎ·Ó Î·Ù¿ ÙËÓ ÂÈÎÔÛ·ÂÙ›· 1973-1993 Paediatriki 2007;70:416-419

‹Ù·Ó ÂÚ›Ô˘ ‰ÂηÏ¿ÛȘ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· (500-1000/100.000 ÏËı˘ÛÌÔ‡) Û˘ÁÎÚÈÙÈο Ì ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ ̤¯ÚÈ ÙËÓ ÂÊ˂›·. √ ·ÚÈıÌfi˜ ÙˆÓ ·Ú·¿Óˆ ÂÈÛ·ÁˆÁÒÓ ‰ÈÏ·ÛÈ¿˙ÂÙ·È Û ·È‰È¿ Ì ηډÈÔ·Ó·Ó¢ÛÙÈΤ˜ ·ı‹ÛÂȘ (4,5). ∆Ô Î¤ÓÙÚÔ ÂϤÁ¯Ô˘ ÏÔÈÌÒÍÂˆÓ ÙˆÓ ∏¶∞ ·Ó·Ê¤ÚÂÈ fiÙÈ Î·Ù¿ ÙËÓ ÂÚ›Ô‰Ô 1990-1999 ηٷÁÚ¿ÊËÎ·Ó 36.000 ı¿Ó·ÙÔÈ ·fi ÁÚ›Ë ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi 90% ·ÊÔÚÔ‡Û ¿ÙÔÌ· ËÏÈΛ·˜ >65 ÂÙÒÓ. √È ı¿Ó·ÙÔÈ ÔÊ›ÏÔÓÙ·Ó Î˘Ú›ˆ˜ Û Ó¢ÌÔÓ›·, ηډÈÔ·Ó·Ó¢ÛÙÈο ÓÔÛ‹Ì·Ù· Î·È ¿ÏϘ ¯ÚfiÓȘ ·ı‹ÛÂȘ (1,6). ∫·Ù·‰ÂÈÎÓ‡ÂÙ·È ÏÔÈfiÓ Ë ÌÂÁ¿ÏË ÛËÌ·Û›· οı ÚÔÛ¿ıÂÈ·˜ ÚfiÏ˄˘ Ù˘ ÁÚ›˘, ȉȷ›ÙÂÚ· Ì¿ÏÈÛÙ· Â¿Ó ·Ó·ÏÔÁÈÛÙ› ηÓ›˜ ÙÔÓ Î›Ó‰˘ÓÔ ÚfiÎÏËÛ˘

Paidiatriki 5 final

12-10-07

16:28

Page 417

417

∞ÛıÌ·ÙÈο ·È‰È¿ Î·È ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜

·Ó‰ËÌ›·˜ Ô˘ ÛÙÔ ·ÚÂÏıfiÓ ·ÔÙ¤ÏÂÛ ·ÈÙ›· ÔÏÏÒÓ ı·Ó¿ÙˆÓ (1). √ ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ¤¯ÂÈ Î·ıÈÂÚˆı› ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÏËı˘ÛÌȷΤ˜ ÔÌ¿‰Â˜ ÌÂٷ͇ ÙˆÓ Ôo›ˆÓ Û˘ÁηٷϤÁÔÓÙ·È fiÏ· Ù· ¿ÙÔÌ· ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 65 ÂÙÒÓ Î·È ·È‰È¿ Ì ¯ÚfiÓȘ ·ı‹ÛÂȘ ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Î·È ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ™ÙËÓ ÂÙ‹ÛÈ· ¤ÎıÂÛ‹ Ù˘ ÁÈ· ÙÔ 2003, Ë ™˘Ì‚Ô˘Ï¢ÙÈ΋ ∂ÈÙÚÔ‹ ÙˆÓ ∂Ì‚ÔÏÈ·ÛÌÒÓ ÙˆÓ ∏¶∞ (Advisory Committee on Immunization Practices) (1) Û˘ÓÈÛÙ¿ ÂÌ‚ÔÏÈ·ÛÌfi fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ ≥6 ÌËÓÒÓ Ì ¿ÛıÌ·, Ô‰ËÁ›· Ô˘ ·Ú·Ì¤ÓÂÈ ÛÙËÓ ÙÚÔÔÔ›ËÛË ÙˆÓ Ô‰ËÁÈÒÓ ·˘ÙÒÓ ÁÈ· ÙËÓ ÂÚ›Ô‰Ô 2004-2005 Î·È Ì¤¯ÚÈ Û‹ÌÂÚ· (6). ¶·Ú¿ ÙËÓ ÈÛ¯‡Ô˘Û· Û‡ÛÙ·ÛË ÁÈ· ÙÔÓ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ·È‰ÈÒÓ Ì ηډÈÔ·Ó·Ó¢ÛÙÈΤ˜ ·ı‹ÛÂȘ, ¤¯ÂÈ ‰ËÌÔÛÈ¢Ù› ÚfiÛÊ·Ù· fiÙÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ Ô˘ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È ·ÁÁ›˙ÂÈ ÌfiÓÔ ÙÔ 16% (7). ¶·Ú¿ÏÏËÏ·, ¿ÏÏË ÌÂϤÙË ·Ó·Ê¤ÚÂÈ fiÙÈ Ù· ·È‰È¿ Ì ¿ÛıÌ· Â›Ó·È ·˘Ù¿ Ì ÙÔ ¯·ÌËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ ˆ˜ ÚÔ˜ ÙÔ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚fiÏÈÔ Û ۇÁÎÚÈÛË Ì ÙȘ ˘fiÏÔÈ˜ ÔÌ¿‰Â˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (8). ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ Ô‰‹ÁËÛ·Ó Û ÌÈ· ÚÔÛ¿ıÂÈ· ηٷÁÚ·Ê‹˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ì ÛÎÔfi ÙËÓ ˘ÔÛÙ‹ÚÈÍË Ù˘ ÛÙÚ·ÙËÁÈ΋˜ ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙÔ˘˜ ÏËı˘ÛÌÔ‡˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (9-11). ™ÙËÓ ÚÔÛ¿ıÂÈ· ·˘Ù‹ ÂÓÙ¿ÛÛÔÓÙ·È Î·È Ù· Â˘Ú‹Ì·Ù· ÙˆÓ Quach Î·È Û˘Ó., ·fi ÌÂϤÙË 182 ·ÛıÂÓÒÓ Ô˘ ¯ÚÂÈ¿ÛÙËΠӷ ÓÔÛËÏ¢ÙÔ‡Ó ÏfiÁˆ ÁÚ›˘. ¢È·›ÛÙˆÛ·Ó fiÙÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÓÔÛËÏ›· ÏfiÁˆ ÁÚ›˘ ‹Ù·Ó ·) ËÏÈΛ· <12 ÌËÓÒÓ, ‚) ·Ê˘‰¿ÙˆÛË Î·È Á) ¯·ÌËÏfi˜ ÎÔÚÂÛÌfi˜ √2. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÙÔ 70% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÓÔÛËχÙËÎ·Ó ‰ÂÓ ·Ó‹Î·Ó Û ÏËı˘ÛÌÔ‡˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (11). ∂›Ó·È ‰Â ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ ÙÔ ÔÛÔÛÙfi ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·È‰ÈÒÓ Ì ̤ÙÚÈÔ-‚·Ú‡ ¿ÛıÌ· Êı¿ÓÂÈ ÙÔ 21-25% (1,7), ÂÓÒ ·˘Ùfi ÙˆÓ ·È‰ÈÒÓ Ì ΢ÛÙÈ΋ ›ÓˆÛË ÙÔ 79% (1). ∆Ô Ê·ÈÓfiÌÂÓÔ ÙÔ˘ ÌË Î·ıÔÏÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ÔÊ›ÏÂÙ·È Î¿ÔȘ ÊÔÚ¤˜ ÛÙËÓ ÂÈÊ˘Ï·ÎÙÈÎfiÙËÙ· ÔÚÈÛÌ¤ÓˆÓ ·ÛıÂÓÒÓ ˆ˜ ÚÔ˜ ÙÔÓ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi (12). ∂ÈϤÔÓ, Ê·›ÓÂÙ·È fiÙÈ Ô ÎÏÈÓÈÎfi˜ ÁÈ·ÙÚfi˜ Ô˘ ÚfiÎÂÈÙ·È Ó· ÂÌ‚ÔÏÈ¿ÛÂÈ ¤Ó· ·ÛıÌ·ÙÈÎfi ·È‰› Û˘Ó˘ÔÏÔÁ›˙ÂÈ fiÙÈ ÙÔ ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· ˆ˜ Ë ÈÔ Û˘¯Ó‹ ¯ÚfiÓÈ· ¿ıËÛË ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi, ·ÚÔ˘ÛÈ¿˙ÂÈ Â˘Ú›· Ê·ÈÓÔÙ˘È΋ ¤ÎÊÚ·ÛË. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ “·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ” ÂÌÊ·Ó›˙Ô˘Ó ‰È·Ï›ÔÓ ‹ ‹ÈÔ ¿ÛıÌ· Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÂÈÛfi‰È· ‚ÚÔÁ¯fiÛ·ÛÌÔ˘ ÌÂÙ¿ ·fi ÈÒÛÂȘ ÌÂÌÔӈ̤ÓÔ˘ ¯·Ú·ÎÙ‹Ú·, ¯ˆÚ›˜ Û˘ÌÙÒÌ·Ù· ÛÙÔ ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÂÍ¿ÚÛˆÓ. ∆· ÂÂÈÛfi‰È· ·˘Ù¿ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Â‡ÎÔÏ· Ì ıÂÚ·›· ÛÙÔ Û›ÙÈ, ¯ˆÚ›˜ ·Ó¿ÁÎË ÓÔÛËÏ›·˜ ÛÙÔ ÓÔÛÔ-

ÎÔÌ›Ô, ÁÂÁÔÓfi˜ Ô˘ ÌÂÈÒÓÂÈ ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ Î·È Î·Ù’ Â¤ÎÙ·ÛË, ÙËÓ ·Ó¿ÁÎË ÚfiÏ˄˘ Ù˘ ÁÚ›˘ Ì ÂÌ‚ÔÏÈ·ÛÌfi. ∏ ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ÏfiÁˆ ¿ÛıÌ·ÙÔ˜ Û ·È‰È·ÙÚÈΤ˜ ÎÏÈÓÈΤ˜ ÙÚÈÒÓ ÓÔÛÔÎÔÌ›ˆÓ Ù˘ µfiÚÂÈ·˜ ∂ÏÏ¿‰·˜ ηٿ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ‰È·ÈÛÙÒıËΠ̠ÚfiÛÊ·ÙË ÌÂϤÙË (13), Ô˘ Û˘Ì‚·‰›˙ÂÈ Ì ٷ ‰ÈÂıÓ‹ ‰Â‰Ô̤ӷ (14). ™ÙË Ì›ˆÛË ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ¤¯ÂÈ Û˘Ì‚¿ÏÂÈ ÛËÌ·ÓÙÈο Ë ¯Ú‹ÛË ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Û ¯·ÌËϤ˜ ‰fiÛÂȘ ÛÙ· ·È‰È¿ Ì ‹ÈÔ ¿ÛıÌ·, ·ÓÙÈÌÂÙÒÈÛË Ë ÔÔ›· ·Ú¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ηχÙÂÚ˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ Î·È Ì›ˆÛË ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·ÚÔ͢ÛÌÒÓ (15). ∆· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙ· ·È‰È¿ Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. ™Â ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÂÙ·È Ì›ˆÛË ÙˆÓ ÂÌ‡ÚÂÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÁÂÓÈο ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi (17) ηıÒ˜ Â›Û˘ Î·È Ì›ˆÛË ÙˆÓ ÂÌ‡ÚÂÙˆÓ ÂÂÈÛÔ‰›ˆÓ Î·È ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ÂÍ¿ÚÛÂˆÓ ÛÙ· ·ÛıÌ·ÙÈο ·È‰È¿, ÌÂÙ¿ ÙËÓ Î·ıȤڈÛË ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ (18,19). ¢ÂÓ ˘¿Ú¯Ô˘Ó ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ô˘ Ó· ÂȂ‚·ÈÒÓÔ˘Ó ÙË Ì›ˆÛË ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡, ÁÂÁÔÓfi˜ Ô˘ ‰È·ÈÛÙÒıËΠ۠ÌÂϤÙË Ô˘ ¤ÁÈÓ ÛÙË ™Ô˘Ë‰›· Û ¿ÙÔÌ· ËÏÈΛ·˜ ≥65 ÂÙÒÓ (16). °È· ÙÔ˘˜ ÏfiÁÔ˘˜ ·˘ÙÔ‡˜ ÔÏÏÔ› ÂÚ¢ÓËÙ¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÚÔÔÙÈΤ˜, ÂÏÂÁ¯fiÌÂÓ˜, Ù˘¯·ÈÔÔÈË̤Ó˜ Î·È Ì·ÎÚÔ¯ÚfiÓȘ ÌÂϤÙ˜ ÛÙ· ·ÛıÌ·ÙÈο ·È‰È¿, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂȂ‚·Èˆı› fiÙÈ Ô ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÚÔÏ·Ì‚¿ÓÂÈ ÙȘ Û¯ÂÙÈ˙fiÌÂÓ˜ Ì ÙË ÁÚ›Ë ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜, Î·È ÌÂÈÒÓÂÈ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÓÔÛÔÎÔÌÂÈ·ÎÒÓ ÂÈÛ·ÁˆÁÒÓ (20), ˘fi ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ÙÔ ÂÌ‚fiÏÈÔ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ˘‡ı˘Ó· ÁÈ· Ù· ÎÚÔ‡ÛÌ·Ù· Ù˘ ÁÚ›˘ ÛÙÂϤ¯Ë οı ÂÔ¯‹˜. ™˘ÛÙËÌ·ÙÈ΋ ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔı‹Î˘ Cohrane, ÁÈ· ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·ÙfiÌˆÓ Û˘ÌÂÚ·›ÓÂÈ fiÙÈ Ù· ¤ˆ˜ Û‹ÌÂÚ· ‰Â‰Ô̤ӷ ÁÈ· Ù· ÔʤÏË Î·È ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙ· ·ÛıÌ·ÙÈο ¿ÙÔÌ· Â›Ó·È ·ÓÂ·Ú΋ ÏfiÁˆ ¤ÏÏÂȄ˘ Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÚÔÔÙÈÎÒÓ ÌÂÏÂÙÒÓ (21). √È Ì¤¯ÚÈ Û‹ÌÂÚ· ÌÂϤÙ˜ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÛÙËÓ Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ÂÍ¿ÚÛÂˆÓ ·Ó·‰ÚÔÌÈο (18) ‹ ÙÔ˘ ÔÛÔÛÙÔ‡ ·ÓÙÈۈ̷ÙÈ΋˜ ·¿ÓÙËÛ˘ ÛÙÔÓ Èfi Ù˘ ÁÚ›˘ Û ·ÛıÌ·ÙÈÎfi ÏËı˘ÛÌfi (20). ¶ÚfiÛÊ·ÙË ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ô˘ ‰ÈÂÚ‡ÓËÛ ÙȘ ÂÈÛΤ„ÂȘ ÛÙÔ ÙÌ‹Ì· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Î·È ÙȘ ÂÈÛ·ÁˆÁ¤˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÌÂٷ͇ ‰‡Ô ÏËı˘ÛÌÒÓ 400 ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 1-19 ÂÙÒÓ, Ô˘ ¤Ï·‚·Ó ‹ fi¯È ÙÔ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚fiÏÈÔ, ¤‰ÂÈÍ fiÙÈ ÛÙ· ·È‰È¿ Ô˘ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ¶·È‰È·ÙÚÈ΋ 2007;70:416-419

Paidiatriki 5 final

12-10-07

16:28

Page 418

418

º. ∫˘Ú‚·Û›Ï˘ Î·È Û˘Ó.

ηٷÁÚ¿ÊËΠÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ÂÈÛΤ„ÂˆÓ ÛÙ· È·ÙÚ›· ¿ÛıÌ·ÙÔ˜ Î·È ÛÙ· ÙÌ‹Ì·Ù· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ (23). ∏ ÌÔÓ·‰È΋ Ù˘¯·ÈÔÔÈË̤ÓË ‰ÈÏ‹-Ù˘ÊÏ‹ ÂÏÂÁ¯fiÌÂÓË Ì ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ ÌÂϤÙË, ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ √ÏÏ·Ó‰›·, Î·È ‰ËÌÔÛȇÙËΠÙÔÓ ª¿ÚÙÈÔ ÙÔ˘ 2004 (24). ∞ÊÔÚ¿ ÛÙËÓ ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË ·‰Ú·ÓÔÔÈË̤ÓÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ Û 347 ·ÛıÌ·ÙÈο ·È‰È¿ Û ۇÁÎÚÈÛË Ì 349 ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ. ™ÙȘ ‰‡Ô ÔÌ¿‰Â˜ ÁÈÓfiÙ·Ó Î·ıËÌÂÚÈÓ‹ ηٷÁÚ·Ê‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ·fi ÙÔ ·ÓÒÙÂÚÔ Î·È Î·ÙÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi Î·È Ï‹„Ë Ê·Ú˘ÁÁÈÎÔ‡ ‰Â›ÁÌ·ÙÔ˜ ηٿ ÙȘ ÂÍ¿ÚÛÂȘ. ¢È·ÈÛÙÒıËΠfiÙÈ Ô ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ‰ÂÓ Î·Ù¤ÏËÍ Û ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡, Ù˘ ‚·Ú‡ÙËÙ·˜ ‹ Ù˘ ‰È¿ÚÎÂÈ·˜ ÙˆÓ ÂÍ¿ÚÛÂˆÓ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Ô˘ ÚÔÎÏ‹ıËÎ·Ó ·fi ÁÚ›Ë. π‰È·›ÙÂÚ· ·ÍÈfiÏÔÁ˜ ÚÔÛ¿ıÂȘ Á›ÓÔÓÙ·È Û‹ÌÂÚ· ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ, fiˆ˜ ÙÔ ÂÓ‰ÔÚÚÈÓÈο ¯ÔÚËÁÔ‡ÌÂÓÔ ÂÌ‚fiÏÈÔ Ì ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜. ∆Ô ÂÌ‚fiÏÈÔ ·˘Ùfi ÚÔ˜ ÙÔ ·ÚfiÓ ·ÓÙÂӉ›ÎÓ˘Ù·È ÛÙ· ·È‰È¿ Ì ¿ÛıÌ· ÏfiÁˆ Âȉ›ӈÛ˘ Ô˘ Èı·ÓfiÓ Ó· ÚÔηϤÛÂÈ ÛÙË ÓfiÛÔ. ¶·Ú¿ÏÏËÏ·, ¤¯ÂÈ ‰È·Ù˘ˆı› Ë ¿Ô„Ë fiÙÈ Ë ÙÔÈ΋ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ ÂӉ¯Ô̤ӈ˜ Ó· ÂÓÈÛ¯‡ÂÈ ÙËÓ ÙÔÈ΋ IgA ·ÓÔÛ›· Ë ÔÔ›· ·ÔÙÂÏ› ÙËÓ ¿Ì˘Ó· ÚÒÙ˘ ÁÚ·ÌÌ‹˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∞ӷ̤ÓÔÓÙ·È ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ·ÓÙÈΛÌÂÓÔ ¤Ú¢ӷ˜. ¶ÚÔÛ·ıÒÓÙ·˜ Ó· ÂÚÌËÓ‡ÛÔ˘Ì ٷ Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ ·Ú·¿Óˆ ÌÂÏÂÙÒÓ ·Í›˙ÂÈ Ó· ÂÈÛËÌ¿ÓÔ˘Ì fiÙÈ ·fi ÙȘ ÂȉËÌÈÔÏÔÁÈΤ˜ ηٷÁڷʤ˜ Û ·È‰È¿ Ì ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ ÔÈ Î˘Ú›ˆ˜ ¢ı˘ÓfiÌÂÓÔÈ ÈÔ› Â›Ó·È ·) ÁÈ· Ù· ‚Ú¤ÊË Ô RSV Û ÔÛÔÛÙfi 2070% Î·È ÔÈ ÚÈÓÔ˚Ô›-ÂÓÙÂÚÔ˚Ô› Û ÔÛÔÛÙfi 30-60%, ÂÓÒ ‚) ÁÈ· Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ÔÈ ÚÈÓÔ˚Ô›-ÂÓÙÂÚÔ˚Ô› ÛÙÔ 65% ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 1-2 ÂÙÒÓ Î·È ÛÙÔ 82% ÙˆÓ ·È‰ÈÒÓ ¿Óˆ ÙˆÓ 3 ÂÙÒÓ (3,25-27). º·›ÓÂÙ·È fiÙÈ ÔÈ ÚÈÓÔ˚Ô› ¤¯Ô˘Ó ÌÈ· ȉȷ›ÙÂÚË Û¯¤ÛË Ì ÙȘ ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ ÛÙ· ·È‰È¿ ·Ú·Ì¤ÓÔÓÙ·˜ ÛÙȘ ÚÈÓÈΤ˜ ÂÎÎÚ›ÛÂȘ ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (26), ÂÓÒ ·fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿ ˘¿Ú¯Ô˘Ó ‰Â‰Ô̤ӷ fiÙÈ ÂÎÙfi˜ ·fi ÙÔ ·ÓÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔηϤÛÔ˘Ó Î·È Ó¢ÌÔÓ›· Û ˘ÁÈ‹ ¿ÙÔÌ· (28,30,31). ¶ÚfiÛÊ·Ù· ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ë ·ÓÔÛȷ΋ ·¿ÓÙËÛË ÛÙÔÓ ÚÈÓÔ˚fi fi¯È ÌfiÓÔ ‰ÂÓ Â›Ó·È ·ÔÎÏÂÈÛÙÈο Ù‡Ô˘ 1 (Th1) ·ÏÏ¿ fiÙÈ Û ·ÙÔÈÎÔ‡˜ ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Â›Ó·È ÌÂȈ̤ÓË Û ۯ¤ÛË ÌÂ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ Ù·˘Ùfi¯ÚÔÓ· ··ÓÙ‹ÛÂȘ Th2 Ù‡Ô˘ (29,30). º·›ÓÂÙ·È ÏÔÈfiÓ fiÙÈ ÔÈ Û˘¯ÓfiÙÂÚ· ÂÓÔ¯ÔÔÈÔ‡ÌÂÓÔÈ ÁÈ· ÙȘ ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ Â›Ó·È ÔÈ ÚÈÓÔ˚Ô› ÔÈ ÔÔ›ÔÈ Ì ÙËÓ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ·ÛıÌ·ÙÈÎÔ‡ ·ÙfiÌÔ˘ ÎÈÓËÙÔÔÈÔ‡Ó Ì˯·ÓÈÛÌfi Paediatriki 2007;70:416-419

·ÓÔÛ›·˜ Ô˘ ÌÔÈ¿˙ÂÈ Ì ÙËÓ Ù‡Ô˘ 2 ·ÓÙ›‰Ú·ÛË, ÂÓÒ ÔÈ ÈÔ› Ù˘ ÁÚ›˘ Ôχ Û·ÓÈfiÙÂÚ· ·ÔÌÔÓÒÓÔÓÙ·È ·fi ÙȘ ÚÈÓÈΤ˜ ÂÎÎÚ›ÛÂȘ ·ÙfiÌˆÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ·ÛıÌ·ÙÈ΋ ¤Í·ÚÛË.

™˘ÌÂÚ¿ÛÌ·Ù· ·) §·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, ‰ÂÓ ˘¿Ú¯ÂÈ ·ÌÊÈ‚ÔÏ›· fiÙÈ Ô ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ Â›Ó·È ÂȂ‚ÏË̤ÓÔ˜ Û ·È‰È¿ Ì ‚·ÚȤ˜ ηډÈÔ¿ıÂȘ Î·È ¯ÚfiÓȘ Ó¢ÌÔÓÔ¿ıÂȘ, fiˆ˜ ‚·Ú‡ ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ·, ΢ÛÙÈ΋ ›ÓˆÛË, Û‡Ó‰ÚÔÌÔ ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ, ‚ÚÔÁ¯ÂÎٷۛ˜ Î.Ï., fiÔ˘ ˘¿Ú¯ÂÈ ÌË ·Ó·ÛÙÚ¤„ÈÌË Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È ÂÏÏÈ‹˜ ·Ó¿Ù˘ÍË Ù˘ ÙÔÈ΋˜ ·ÓÔÛ›·˜. ‚) À¿Ú¯Ô˘Ó ‰ËÌÔÛÈÂ˘Ì¤Ó· ÛÙÔȯ›· Ô˘ ÎÏÔÓ›˙Ô˘Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ˆ˜ ÚÔ˜ ÙË Ì›ˆÛË ÙˆÓ ÂÍ¿ÚÛÂˆÓ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ ÛÙ· ·È‰È¿, ηıÒ˜ ÔÈ Î·ÙÂÍÔ¯‹Ó ¢ı˘ÓfiÌÂÓÔÈ ÈÔ› ÁÈ· ÙȘ ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ Â›Ó·È Ô RSV Î·È ÔÈ ÚÈÓÔ˚Ô›. ŒÙÛÈ ıˆÚÂ›Ù·È ·ÌÊ›‚ÔÏË Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ηıÔÏÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·È‰ÈÒÓ Ì ‹ÈÔ ‹ ·ÎfiÌË Î·È Ì¤ÙÚÈÔ ¿ÛıÌ·, fiÔ˘ Ë ‚Ï¿‚Ë ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂÈıËÏ›Ô˘ Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌË. ¶ÚÔÔÙÈΤ˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Ì ٷÍÈÓfiÌËÛË ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ Û‡Ìʈӷ Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ı· ‰ÒÛÔ˘Ó ÔÚÈÛÙÈ΋ ·¿ÓÙËÛË ÛÙÔ ı¤Ì· ÙÔ˘ ηıÔÏÈÎÔ‡ ‹ ÂÈÏÂÎÙÈÎÔ‡ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. CDC. Prevention and control of illness: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza 2003/ 52 (RR08);1-36.

2. Johnston SL, Pattemore PK, Sanderson G, Smith S, Lampe F, Josephs L et al. Community study of the role of viral infections in exacerbations of asthma in 9-11 year old children. BMJ 1995;310:1225-1229.

3. Jartti T, Lehtinen P, Vuorinen T, Osterback R, van den Hoogen B, Osterhaus AD, Ruuskanen O. Respiratory picornaviruses and respiratory syncytial virus as causative agents of acute expiratory wheezing in children. Emerg Infect Dis 2004;10:1095-1101.

4. Neuzil KM, Mellen BG, Wright PF, Mitchel EF, Griffin MR. Effect of influenza on hospitalizations, outpatient visits, and courses of antibiotics in children. New Engl J Med 2000;342:225-231.

5. Neuzil KM, Wright PF, Mitchel EF, Griffin MR. Burden of influenza illness in children with asthma and other chronic medical conditions. J Pediatr 2000;137:856-864.

6. CDC. Prevention and control of illness: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza 2004/ 53 (No. RR-6).

7. Gnanasekaran SK, Finkelstein JA, Lozano P, Farber HJ,

Paidiatriki 5 final

12-10-07

16:28

Page 419

419

∞ÛıÌ·ÙÈο ·È‰È¿ Î·È ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

Chi FW, Lieu TA. Influenza vaccination among children with asthma in medicaid managed care. Ambul Pediatr 2006;6:1-7.

Esposito S, Marchisio P, Droghetti R, Lambertini L, Fealli N, Bosis S, et al. Influenza vaccination coverage among children with high-risk medical conditions. Vaccine 2006;24:5251-5255.

Gnanasekaran SK, Finkelstein JA, Hohman K, O’Brien M, Kruskal B, Lieu T. Parental perspectives on influenza vaccination among children with asthma. Public Health Rep 2006;121:181-188.

Daley M, Barrow J, Pearson K, Crane L, Gao D, Stevenson J, et al. Identification and recall of children with chronic medical conditions for influenza vaccination. Pediatrics 2004; 113:26-33.

Quach C, Piche-Walker L, Platt R, Moore D. Risk factors associated with severe influenza infections in childhood: Implication for vaccine strategy. Pediatrics 2003;112: e197-e201.

Fiebach NH, Viscoli CM. Patient acceptance of influenza vaccination. Am J Med 1991;91:393-400.

Hatziagorou E, Kirvasilis F, Valeri R, Hatzimichail A, Vanioti G, Tsanakas J. Paediatric hospitalizations for bronchiolitis, asthma and laryngitis in three hospitals in Northern Greece. Eur Respir J 2001;18:130S. D M Fleming, R Sunderland, K W Cross, A M Ross. Declining incidence of episodes of asthma: a study of trends in new episodes presenting to general practitioners in the period 1989-1998. Thorax 2000;55:657-661.

Blais L, Ernst P, Boibin J, et al. Inhaled corticosteroids and the prevention of readmission to hospital for asthma. Am J Respir Crit Care Med 1998; 158:126-132.

Belshe RB, Mendelman PM, et al. The efficacy of live attenuated, cold-adapted, trivalent, intranasal influenza virus vaccine in children. N Engl J Med 1998;338:14051412.

Kramarz P, Destefano F, Gargiullo PM, Chen RT, Lieu TA, Davis RL, et al. Does influenza vaccination prevent asthma exacerbations in children? J Pediatr 2001;138:306-310.

Smits AJ, Hak E, Stalman WA, van Essen GA, Hoes AW, Verheii TJ. Clinical effectiveness of conventional influenza vaccination in asthmatic children. Epidimiol Infect 2002;128(2):205-211.

19. Christenson B, Hedlund J, Lundbergh P, Ortqvist A. Additive preventive effect of influenza and pneumococcal vaccines in elderly persons. Eur Respir J 2004;23:363-368.

20. Neuzil KM. Influenza vaccine for children. Clin Infect Dis 2004;38:689-691.

21. Cates CJ, Jefferson TO, Bara AI, Rowe BH. Vaccines for preventing influenza in people with asthma. Cohrane Database Syst Rev 2004;(2):CD000364.

22. Ruben FL. Inactivated Influenza Virus Vaccines in Children. Clin Infec Dis 2004; 38:678-688.

23. Christy C, Aligne CA, Auinger P, Pulcino T, Weitzman M. Effectiveness of influenza vaccine for the prevention of asthma exacerbations. Arch Dis Child 2004;89:734-735.

24. Beuving HJ,Bernsen RMD, de Jongste JC, et al. Influenza vaccination in children with asthma.Randomized DoubleBlind Placebo-controlled Trial. Am J Respir Crit Care Med 2004;169:488-493.

25. Jartti T, Lehtinen P, Vuorinen T, Koskenvuo M, Ruuskanen O. Persistence of rhinovirus and enterovirus RNA after acute respiratory illness in children. J Med Virol.

2004;72:695-699.

26. van Benten I, Koopman L, Niesters B, Hop W, van Middelkoop B, de Waal L, et al. Predominance of rhinovirus in the nose of symptomatic and asymptomatic infants. Ped Allergy Immunol 2003;14:363-370.

27. Fleming DM, Pannell RS, Elliot AJ, Cross KW. Respiratory illness associated with influenza and respiratory syncytial virus infection. Arch Dis Child 2005; 90:741-746.

28. Papadopoulos NG. Do rhinoviruses cause pneumonia in children? Paediatr Respir Rev 2004;5 (Suppl A):S191S195.

29. Papadopoulos NG, Stanciou LA, Papi A, Holgate ST, Johnston SL. A defective type 1 response to rhinovirus in atopic asthma. Thorax 2002;57:328-332.

30. Papadopoulos NG, Papi A, Psarras S, Johnston SL Mechanisms of rhinovirus-induced asthma. Paediatr Respir Rev 2004;5:255-260.

31. Papadopoulos N, Bates PJ, Bardin PG, Papi A, Leir SH, Fraenkel DJ, et al. Rhinovirus infects the lower airways. J Infect Dis 2000:181:1875-1884.

¶·È‰È·ÙÚÈ΋ 2007;70:416-419

Paidiatriki 5 final

420

12-10-07

16:28

Page 420

∂¶π™∆√§∏ ∞¶√ ∆∏ ™À¡∆∞•∏

LETTER FROM THE EDITORS

¢ÈÏ‹ ÙÈÌËÙÈ΋ ‰È¿ÎÚÈÛË ÛÙÔ˘˜ ¤ÏÏËÓ˜ ·È‰›·ÙÚÔ˘˜ ∏ ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· (∂¶∂) ‰ÈÂÍ‹Á·Á ÛÙËÓ ∞ı‹Ó· ÙÔ 25Ô ¶·ÁÎfiÛÌÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ˘fi ÙËÓ ÚÔ‰ڛ· ÙÔ˘ ηıËÁËÙÔ‡ ∞Ó‰Ú¤· ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˘ ·fi 25-30 ∞˘ÁÔ‡ÛÙÔ˘, ÙÔ ÔÔ›Ô ÂÛÙ¤ÊıË ·fi ·fiÏ˘ÙË ÂÈÙ˘¯›· (ÔÚÁ·ÓˆÙÈο Î·È ÂÈÛÙËÌÔÓÈο). ∆Ô ·Ú·ÎÔÏÔ‡ıËÛ·Ó ÂÚ›Ô˘ 8.000 Û‡Ó‰ÚÔÈ ·fi 133 ¯ÒÚ˜. ™Ù· ÁÚ·Ê›· Ù˘ ∂¶∂ Êı¿ÓÔ˘Ó Î·ıËÌÂÚÈÓ¿ ‰Âο‰Â˜ ÂÈÛÙÔϤ˜ Î·È e-mails, ÛÙ· ÔÔ›· ÂÎÊÚ¿˙ÔÓÙ·È Ù· Û˘Á¯·ÚËÙ‹ÚÈ· ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ. ¶·Ú¿ÏÏËÏ·, Ë ÁÂÓÈ΋ Û˘Ó¤Ï¢ÛË Ù˘ ¶·ÓÂ˘Úˆ·˚΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜, ÛÙË Û˘Ó‰ڛ· Ù˘ 27 ∞˘ÁÔ‡ÛÙÔ˘, ÂͤÏÂÍ ·Ì„ËÊ› ÙÔÓ Î·ıËÁËÙ‹ Î. ∞Ó‰Ú¤· ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ ˆ˜ Úfi‰ÚÔ Ù˘ ¶·ÓÂ˘Úˆ·˚΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜. ŸÏ· ·˘Ù¿ ÂȂ‚·ÈÒÓÔ˘Ó ÙÔ ‡„Ô˜ Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂ÈÛÙ‹Ì˘ ÛÙÔÓ ‰ÈÂıÓ‹ ÔÚ›˙ÔÓÙ·. ™˘Á¯·›ÚÔ˘Ì ÙÔÓ Î·ıËÁËÙ‹ Î. ∞Ó‰Ú¤· ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ ÁÈ· ÙËÓ ÂÎÏÔÁ‹ ÙÔ˘ ÛÙË ı¤ÛË ·˘Ù‹ Î·È ÙÔ˘ ¢¯fiÌ·ÛÙ ÂÈÙ˘¯›· ÛÙÔ Ó¤Ô ÙÔ˘ ¤ÚÁÔ, ÁÈ· ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ Ù˘ ∂˘ÚÒ˘. °È· ÙË ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜ ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘

Paediatriki 2007;70:420-420

Paidiatriki 5 final

15-10-07

11:31

Page 421

∫§π¡π∫√ ∫√Àπ∑

421

¶·È‰ÔÁ·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎfi ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ “ªËÙ¤Ú·”

∞. ∑¤ÏÏÔ˘

∞ÁfiÚÈ ËÏÈΛ·˜ 11 ÂÙÒÓ ·Ú·¤ÌÊıËΠÏfiÁˆ ‰È·Ï›ÔÓÙÔ˜ ÎÔÈÏÈ·ÎÔ‡ ¿ÏÁÔ˘˜ ÛÙÔ ‰ÂÍÈfi ˘Ô¯fiÓ‰ÚÈÔ. ¢ÂÓ ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi ˘ÚÂÙÔ‡, ‰È¿ÚÚÔÈ·˜ ‹ Â̤وÓ. ™ÙË Ê˘ÛÈ΋ ÂͤٷÛË, ÙÔ ·È‰› ‹Ù·Ó ·¯‡Û·ÚÎÔ Ì ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ >95˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ Î·È Ì ̿˙· ÛÒÌ·ÙÔ˜ >95˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘. ∫·Ù¿ ÙËÓ „ËÏ¿ÊËÛË Ù˘ ÎÔÈÏÈ¿˜ ‰È·ÈÛÙÒıËΠ¢·ÈÛıËÛ›· ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ‰ÂÍÈÔ‡ ˘Ô¯fiÓ‰ÚÈÔ˘, Ì ·ÚÓËÙÈÎfi ˆÛÙfiÛÔ ÛËÌÂ›Ô Murphy. ™Â ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ·Ú·ÙËÚ‹ıËÎ·Ó ·˘ÍË̤ӷ Ë·ÙÈο ¤Ó˙˘Ì· ÛÙÔÓ ÔÚfi (SGPT= 120 IU/L, SGOT= 99 IU/L, GGT= 47 IU/L), Î·È ·˘ÍË̤ÓË ¯ÔÏËÛÙÂÚfiÏË Î·È ÙÚÈÁÏ˘ÎÂÚ›‰È· (ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË = 220 mg/dl, ÙÚÈÁÏ˘ÎÂÚ›‰È· = 334 mg/dl) ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ·Ì˘Ï¿ÛË ÔÚÔ‡ (·Ì˘Ï¿ÛË = 34 IU/L). √È ÁÂÓÈΤ˜ ÂÍÂÙ¿ÛÂȘ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ‹Ù·Ó ÂÓÙfi˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. ∏ ·1 ·ÓÙÈıÚ˘„›ÓË, ÛÂÚÔ˘ÏÔÏ·ÛÌ›ÓË, ¯·ÏÎfi˜ ÔÚÔ‡ Î·È Ë Û˘ÁΤÓÙÚˆÛË ¯·ÏÎÔ‡ ÛÂ Û˘ÏÏÔÁ‹ Ô‡ÚˆÓ 24ÒÚÔ˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∆Ô ·È‰› ˘Ô‚Ï‹ıËΠ۠˘ÂÚ˯Ô-

ÁÚ¿ÊËÌ· ‹·ÙÔ˜, ÙÔ ÔÔ›Ô ·¤ÎÏÂÈÛ ÙËÓ ‡·ÚÍË ¯ÔÏÔÏÈı›·Û˘, Î·È Û ‰È·‰ÂÚÌ·ÙÈ΋ ‚ÈÔ„›· ‹·ÙÔ˜, Ë ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Ù˘ ÔÔ›·˜ ·ÂÈÎÔÓ›˙ÂÙ·È ·Ú·Î¿Ùˆ.

AÏÏËÏÔÁÚ·Ê›·: ∞›ÁÏË ∑¤ÏÏÔ˘ azellos@jhmi.edu ¶·È‰ÔÁ·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎfi ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ “ªËÙ¤Ú·” §ÂˆÊ. ∫ËÊÈÛ›·˜ Î·È ∂Ú˘ıÚÔ‡ ™Ù·˘ÚÔ‡ 6, ∆.∫. 151 23, ª·ÚÔ‡ÛÈ, ∞ı‹Ó·

¶ÔÈ¿ Â›Ó·È Ë ‰È¿ÁÓˆÛË; 1. ÃÚfiÓÈ· Ë·Ù›Ùȉ· B ‹ C 2. ∞˘ÙÔ¿ÓÔÛË Ë·Ù›Ùȉ· 3. ¡fiÛÔ˜ Wilson 4. §È҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜

¶·È‰È·ÙÚÈ΋ 2007;70:421-421

Paidiatriki 5 final

12-10-07

16:29

Page 422

422

™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞

AÏÏËÏÔÁÚ·Ê›·: ∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘ egalanak@med.uoc.gr ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘

∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘

¡fiÛÔ˜ Kawasaki Î·È ‚Ï¿‚˜ ÛÙÂÊ·ÓÈ·›ˆÓ ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Kawasaki ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË, fiˆ˜ ·Ú·Ì¤ÓÂÈ ·Ó·¿ÓÙËÙÔ Î·È ÙÔ ÁÈ·Ù› Ù· ÛÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù· ‰ÂÓ ÂÌÊ·Ó›˙ÔÓÙ·È Û fiÏ· Ù· ·È‰È¿. ∆Ô ÃˆÚ¤ÌÂÈÔ ¤·ıÏÔ 2007 ‰fiıËΠ۠ÌÂϤÙË ·fi ÙË £ÂÛÛ·ÏÔÓ›ÎË (‰ËÌÔÛȇÂÙ·È ÛÙÔ ·ÚfiÓ Ù‡¯Ô˜ Ù˘ ¶·È‰È·ÙÚÈ΋˜) ÁÈ· ÙÔÓ ÔÏ˘ÌÔÚÊÈÛÌfi VEGF 405G/C ˆ˜ ÁÂÓÂÙÈÎfi ·Ú¿ÁÔÓÙ· ¢¿ıÂÈ·˜ ÛÙË ÓfiÛÔ Kawasaki. ªÂϤÙË ·fi ÙËÓ √ÏÏ·Ó‰›·, ˘fi ‰ËÌÔÛ›Â˘ÛË ÛÙÔ Clin Exp Immunol (ËÏÂÎÙÚÔÓÈ΋ ÚÔ‰ËÌÔÛ›Â˘ÛË 2 ∞˘Á 2007), Û˘Û¯ÂÙ›˙ÂÈ ÙÔ˘˜ ÔÏ˘ÌÔÚÊÈÛÌÔ‡˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙˆÓ ¯ËÌÂÈÔÎÈÓÒÓ CCR3-CCR2-CCR5 Ì ÙËÓ Â˘¿ıÂÈ· ÛÙË ÓfiÛÔ Kawasaki Î·È ÌÂϤÙË ·fi ÙËÓ π·ˆÓ›· ÛÙÔ Ù‡¯Ô˜ ∞˘ÁÔ‡ÛÙÔ˘ ÙÔ˘ J Pediatr (2007;151:155-160) ηٷϋÁÂÈ fiÙÈ ÔÈ ÔÏ˘ÌÔÚÊÈÛÌÔ› ÛÙÔ ÁÔÓ›‰ÈÔ ÙÔ˘ ÈÛÙÈÎÔ‡ ·Ó·ÛÙÔϤ· Ù˘ ÌÂÙ·ÏÏÔÚˆÙÂ˚Ó¿Û˘ 2 ·ÔÙÂÏÔ‡Ó ÚԉȷıÂÛÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ‚Ï·‚ÒÓ ÛÙ· ÛÙÂÊ·ÓÈ·›·. ªËÓÈÁÁ›Ùȉ˜ Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ηٿÏÔÈ· ∏ ·fi ·ÏÈ¿ ÁÓˆÛÙ‹ ÏËÚÔÊÔÚ›· fiÙÈ Ë ‚·ÎÙËÚȉȷ΋ ÌËÓÈÁÁ›Ùȉ· ÌÔÚ› Ó· ÚÔηϤÛÂÈ Ì·ÎÚÔ¯ÚfiÓÈ· ÚÔ‚Ï‹Ì·Ù· Ì¿ıËÛ˘ ÂȂ‚·ÈÒıËΠ̠ÚfiÛÊ·ÙË ‚ÚÂÙ·ÓÈ΋ ÌÂϤÙË (Arch Dis Child, ËÏÂÎÙÚÔÓÈ΋ ÚÔ‰ËÌÔÛ›Â˘ÛË ª·ÚÙ 2007) Û 461 Ó¤Ô˘˜ Ô˘ ›¯·Ó ÓÔÛ‹ÛÂÈ ˆ˜ ‚Ú¤ÊË ·fi ÌËÓÈÁÁ›Ùȉ· ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1980 Î·È 289 Ì¿ÚÙ˘Ú˜. ∏ ÔÌ¿‰· Ì ·Ó·ÌÓËÛÙÈÎfi ÌËÓÈÁÁ›Ùȉ·˜ ›¯Â ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ÊÔ›ÙËÛ˘ Û ÂȉÈο Û¯ÔÏ›· (8% ¤Ó·ÓÙÈ 0%) Î·È ·ÔÙ˘¯›·˜ ÛÙȘ ÂÍÂÙ¿ÛÂȘ ÂıÓÈÎÔ‡ ÂÈ¤‰Ô˘. ∫·Ù¿ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980 ‹Ù·Ó Û˘¯Ó‹ Ë ÌËÓÈÁÁ›Ùȉ· ·fi ·ÈÌfiÊÈÏÔ Ù˘ ÁÚ›˘ Ù‡Ô˘ b, ·ıÔÁfiÓÔ ÁÓˆÛÙfi ÁÈ· Ù· Ì·ÎÚÔ¯ÚfiÓÈ· ηٿÏÔÈ¿ ÙÔ˘, Î·È ÂӉ¯Ô̤ӈ˜ Ë ¤Î‚·ÛË ÙˆÓ ·È‰ÈÒÓ Ó· Â›Ó·È Î·Ï‡ÙÂÚË Û‹ÌÂÚ· Ô˘ Ô ·ÈÌfiÊÈÏÔ˜ Û·Ó›˙ÂÈ. ∞ÓÙ›ıÂÙ·, ÔÈ ÂΉfiÙ˜ ÙÔ˘ Pediatr Infect Dis J (ª¿ÈÔ˜ 2007; Newsletter) ·ÓËÛ˘¯Ô‡Ó Ì‹ˆ˜ Ë Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ÌËÓÈÁÁ›Ùȉ·˜ ÌÂÙ¿ Ù· ÂÈÙ˘¯Ë̤ӷ ÂÌ‚fiÏÈ· Ô‰ËÁ‹ÛÂÈ Û ¯·Ï¿ÚˆÛË Ù˘ Â·ÁÚ‡ÓËÛ˘, ηı˘ÛÙÂÚË̤ÓË ‰È¿ÁÓˆÛË Î·È ¯ÂÈÚfiÙÂÚË ÚfiÁÓˆÛË.

Paediatriki 2007;70:422-423

∏ ·ÓÂÚ¯fiÌÂÓË Kingella kingae ∏ Kingella kingae ÁÂÓÈÎÒ˜ ıˆÚÂ›Ù·È ˆ˜ ·ıÔÁfiÓÔ ‰Â˘ÙÂÚÂ‡Ô˘Û·˜ ÛËÌ·Û›·˜ ÛÙȘ ÔÛÙÂÔ·ÚıÚÈΤ˜ ÏÔÈÌÒÍÂȘ, fiÔ˘ Ì¿ı·Ì ӷ ÂÈÎÚ·ÙÔ‡Ó Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, Ô ‚-·ÈÌÔÏ˘ÙÈÎfi˜ ÛÙÚÂÙfiÎÔÎÎÔ˜ Î·È Ô ·ÈÌfiÊÈÏÔ˜ Ù˘ ÁÚ›˘ Ù‡Ô˘ b. øÛÙfiÛÔ, ÌÂϤÙË ·fi ÙË §˘fiÓ Ù˘ °·ÏÏ›·˜ (Ped Infect Dis J 2007;26:377) Ì PCR ˘„ËÏ‹˜ ¢·ÈÛıËÛ›·˜ ·Ó·‰ÂÈÎÓ‡ÂÈ ÙËÓ K. kingae ˆ˜ ÙÔ Û˘¯ÓfiÙÂÚÔ ·ıÔÁfiÓÔ ÔÛÙÂÔ·ÚıÚÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙ· ·È‰È¿ (39% ¤Ó·ÓÙÈ 25% ÙÔ˘ ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘) Î·È Ì¿ÏÈÛÙ· ÛÙ· ÌÈÎÚfiÙÂÚ· (6 ÌËÓÒÓ ¤ˆ˜ 3 ÂÙÒÓ). ∆Ô Î·Ïfi Ì ÙËÓ K. kingae Â›Ó·È fiÙÈ ·Ú·Ì¤ÓÂÈ Â˘·›ÛıËÙË Û ÔÏÏ¿ ·ÓÙÈ‚ÈÔÙÈο, ÙÔ Î·Îfi Â›Ó·È fiÙÈ Ì ÙȘ Û˘ÓËıÈṲ̂Ó˜ ηÏÏȤÚÁÂȘ ˘ԉȷÁÈÁÓÒÛÎÂÙ·È. ∆· ÂÌ‚fiÏÈ· οÓÔ˘Ó Î·Ïfi Î·È ÛÙÔ˘˜ ÁÔÓ›˜ To ÂÙ·‰‡Ó·ÌÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ ÛÙ· ·È‰È¿ ÌÂÈÒÓÂÈ ÙȘ Ó¢ÌÔӛ˜ Î·È ÛÙÔ˘˜ ÁÔÓ›˜: ÛÙȘ ∏¶∞ (Lancet 2007;369:1179 Î·È 1144), ÔÈ Û˘ÓÔÏÈΤ˜ ÂÈÛ·ÁˆÁ¤˜ ÁÈ· Ó¢ÌÔÓ›· ÌÂÈÒıËÎ·Ó ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ηٿ 39% ÁÈ· Ù· ‚ÚÂÊÔÓ‹È· ·ÏÏ¿ Î·È Î·Ù¿ 26% ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ 18-39 ÂÙÒÓ. ∏ ÂÍ‹ÁËÛË Â›Ó·È Â‡ÏÔÁË: ÔÈ ÁÔÓ›˜ ·ı·›ÓÔ˘Ó ÏÈÁfiÙÂÚ˜ Ó¢ÌÔӛ˜ ÂÂȉ‹ Ù· ·È‰È¿ ʤÚÔ˘Ó ÏÈÁfiÙÂÚÔ˘˜ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘˜. ∏ ÂÔ¯‹ ÌÂÙ¿ ÙÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ ∆Ô Ù‡¯Ô˜ πÔ˘Ó›Ô˘ ÙÔ˘ Pediatr Infect Dis J ÊÈÏÔÍÂÓ› 4 ÌÂϤÙ˜ ÁÈ· ÙÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ (2007;26:461, 468, 473, 540). ™ÙÔ ∆¤Í·˜, ÔÈ ‰ÈÂÈÛ‰˘ÙÈΤ˜ Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ ÏÔÈÌÒÍÂȘ ˘Ô‰ÈÏ·ÛÈ¿ÛÙËÎ·Ó ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, ˆÛÙfiÛÔ ÔÈ ÔÚfiÙ˘ÔÈ Ô˘ ‰ÂÓ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ ·Ú·Ì¤ÓÔ˘Ó Úfi‚ÏËÌ·, ȉȷ›ÙÂÚ· Ô 19∞ Ô˘ ¤¯ÂÈ Î·È ·˘ÍË̤ÓË ·ÓÙÔ¯‹ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο. ∫·È ÛÙË ª·Û·¯Ô˘Û¤ÙË, Ô ÔÚfiÙ˘Ô˜ 19∞ Â›Ó·È ÙÔ Î‡ÚÈÔ ·ıÔÁfiÓÔ Î·È ÂÈϤÔÓ Ù·˘ÙÔÔÈ‹ıËΠÔÏ˘·ÓıÂÎÙÈÎfi˜ ÎÏÒÓÔ˜. ™ÙÔ µ·ÓÎÔ‡‚ÂÚ, ÔÈ ‰ÈÂÈÛ‰˘ÙÈΤ˜ Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ ÏÔÈÌÒÍÂȘ ˘Ô¯ÒÚËÛ·Ó ı·̷ÙÈο ÌÂÙ¿ ÙÔ ÂÌ‚fiÏÈÔ, Ì ÙËÓ ÈÔ ÌÂÁ¿ÏË ÙÒÛË (85%) Ó· ·Ú·ÙËÚÂ›Ù·È ÛÙ· ‚ÚÂÊÔÓ‹È· 6-23 ÌËÓÒÓ.

Paidiatriki 5 final

12-10-07

16:29

Page 423

PAEDIATRIC NEWS IN BRIEF ∂Ì‚fiÏÈÔ ·ÓÂÌ¢ÏÔÁÈ¿˜: ÌÈ· ‰fiÛË ‰ÂÓ ÊÙ¿ÓÂÈ √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì›ˆÛ ‰Ú·Ì·ÙÈο (85%) ÙËÓ Â›ÙˆÛË Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ÛÙȘ ∏¶∞, ˆÛÙfiÛÔ 9,5% ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌ¤ÓˆÓ ·È‰ÈÒÓ ‰ÂÓ ·¤Ê˘Á·Ó ÙË ÓfiÛÔ ÎÈ fiÛÔ ÂÚÓÔ‡ÛÂ Ô Î·ÈÚfi˜ ·fi ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi, ÙfiÛÔ Û˘¯ÓfiÙÂÚ· Î·È ÛÔ‚·ÚfiÙÂÚ· ‹Ù·Ó Ù· ÎÚÔ‡ÛÌ·Ù· (N Engl J Med 2007;356:1121). ªÂ ÙËÓ ·Ú·Ù‹ÚËÛË ·˘Ù‹, ÔÈ Û˘ÛÙ¿ÛÂȘ Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ™˘Ì‚Ô˘Ï¢ÙÈ΋˜ ∂ÈÙÚÔ‹˜ ∂Ì‚ÔÏÈ·ÛÌÒÓ ÁÈ· Ì›· ÌfiÓÔ ‰fiÛË ÛÙ· ·È‰È¿ ¿ÏÏ·Í·Ó ÚfiÛÊ·Ù· (ACIP, 22 πÔ˘Ó›Ô˘ 2007 Î·È MMWR 2007; 56(RR04):1-40). ∆ÒÚ· Û˘ÓÈÛÙÒÓÙ·È 2 ‰fiÛÂȘ ÁÈ· fiÏ· Ù· ·È‰È¿, Ë ÚÒÙË ÛÙÔ˘˜ 12-15 Ì‹Ó˜ Î·È Ë ‰Â‡ÙÂÚË ÛÙ· 4-6 ¤ÙË ‹ Î·È ÓˆÚ›ÙÂÚ· (·ÏÏ¿ ÙÔ˘Ï¿¯ÈÛÙÔÓ 3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÚÒÙË ‰fiÛË). ™Â ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ì ·Ó·ÌÓËÛÙÈÎfi 1 ÌfiÓÔ ‰fiÛ˘ Û˘ÓÈÛÙ¿Ù·È ¿ÏÏË 1. ∆Ô ÂÌ‚fiÏÈÔ Û˘ÓÈÛÙ¿Ù·È Î·È ÁÈ· ÙȘ 3-5 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤ÎıÂÛË ·ÓÂÌ‚ÔÏ›·ÛÙÔ˘ Û ÎÚÔ‡ÛÌ·. ªÂÙ··Ó¿Ï˘ÛË ÛÙÔ Ù‡¯Ô˜ ∞˘ÁÔ‡ÛÙÔ˘ ÙÔ˘ Pediatr Infect Dis J (2007;26:572-576) ˘Ô‰ÂÈÎÓ‡ÂÈ fiÙÈ Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Â›Ó·È ·ÓÔÛÔÁÔÓÈÎfi˜ Î·È ÛÙȘ ÈÔ ÌÈÎÚ¤˜ ËÏÈ˘ ÙˆÓ 12-14 ÌËÓÒÓ. º˘Ì·Ù›ˆÛË: ÓÂfiÙÂÚ· ÛÙË ‰È¿ÁÓˆÛË ∏ ‰È¿ÁÓˆÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘ ÛÙ· ·È‰È¿ ‰˘Û¯ÂÚ·›ÓÂÙ·È ·fi ÙË ‰˘ÛÎÔÏ›· ·Ú·ÁˆÁ‹˜ Ù˘¤ÏˆÓ ÌÂÙ¿ ·fi¯ÚÂ̄˘ Î·È ÙËÓ ÂÓÔ¯ÏËÙÈ΋ ̤ıÔ‰Ô Ï‹„˘ Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡. ∏ ‰ÂÈÁÌ·ÙÔÏË„›· Ù˘¤ÏˆÓ ÌÂÙ¿ ·fi ÚfiÎÏËÛË Ì ÓÂÊÂÏÔÔÈË̤ÓÔ ˘¤ÚÙÔÓÔ ¯ÏˆÚÔÓ·ÙÚÈÔ‡¯Ô ‰È¿Ï˘Ì· ¤¯ÂÈ ‚ÔËı‹ÛÂÈ ÛËÌ·ÓÙÈο. ™Â ÌÂϤÙË ÂÓËÏ›ÎˆÓ Ì Ó¢ÌÔÓÈ΋ Ê˘Ì·Ù›ˆÛË ·fi ÙÔ §ÔÓ‰›ÓÔ (Clin Inf Dis πÔ‡Ó 2007;44:1415-1420), Ë ÂͤٷÛË 3 ‰ÂÈÁÌ¿ÙˆÓ ÚÔÎÏËÙÒÓ Ù˘¤ÏˆÓ ‚Ú¤ıËΠÈÔ Â˘·›ÛıËÙË ·fi ÙˆÓ 3 Á·ÛÙÚÈÎÒÓ ÂÎÏ˘Ì¿ÙˆÓ (39% ¤Ó·ÓÙÈ 30%, p=0,03). ªÂϤÙË ·È‰ÈÒÓ Ì Ó¢ÌÔÓÈ΋ Ê˘Ì·Ù›ˆÛË ·fi ÙËÓ √˘ÁοÓÙ· (Arch Dis Child ∞‡Á 2007;92:693-696) ‰Â›¯ÓÂÈ Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· Î·È Ì ÙËÓ ÂͤٷÛË ˘ÏÈÎÔ‡ ·fi ÚÈÓÔÊ·Ú˘ÁÁÈ΋ ·Ó·ÚÚfiÊËÛË (ıÂÙÈ΋ ¯ÚÒÛË 8,5% Î·È ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· 23,9%, ÂÚ›Ô˘ fiÛÔ Î·È Ì ٷ ÚÔÎÏËÙ¿ Ù‡ÂÏ·). H PCR ÚÈÓÔÊ·Ú˘ÁÁÈÎÔ‡ ›¯Â ¢·ÈÛıËÛ›· 62% Î·È ÂȉÈÎfiÙËÙ· 98%. ÃÂψӛÙÛ˜ Î·È ™·ÏÌÔÓ¤ÏϘ √È ÌÈÎÚ¤˜ (Î¤Ï˘ÊÔ˜ ÌÈÎÚfiÙÂÚÔ ÙˆÓ 10 ÂηÙÔÛÙÒÓ) ¯ÂÏÒÓ˜ Û ÂÓ˘‰Ú›· ‹Ù·Ó ÚÔÛÊÈÏ›˜ ÛÙ· ·È‰È¿, ˆÛÙfiÛÔ Ë ÒÏËÛ‹ ÙÔ˘˜ ··ÁÔÚ‡ıËΠÛÙȘ ∏¶∞ ÌÂÙ¿ ÙË ‰È·›ÛÙˆÛË ÊÔÚ›·˜ Î·È ÎÚÔ˘ÛÌ¿ÙˆÓ Û·ÏÌÔÓ¤ÏψÛ˘ Î·È ÛÙȘ ¯ÂψӛÙÛ˜ Î·È ÛÙ· ·È‰È¿ Ô˘ ¤·È˙·Ó Ì·˙› ÙÔ˘˜. ™‡Ìʈӷ Ì ÙÔ˘˜ ÂΉfiÙ˜ ÙÔ˘ Pediatr Inf Dis J (Newsletter August 2007), ÔÈ ÌÔÏ˘Ṳ̂Ó˜ ¯ÂÏÒÓ˜ ÛÙȘ ∏¶∞ ÚÔ¤Ú¯ÔÓÙ·Ó ·fi ÙÔ ›‰ÈÔ ÂÎÙÚÔÊÂ›Ô ÛÙË §Ô˘È˙È¿Ó·. ªÂÙ¿ ·fi Â›ÔÓ˜ ÚÔÛ¿ıÂȘ, ÔÈ ¯ÂÏÒÓ˜ Â›Ó·È ¿ÏÈ Î·ı·Ú¤˜ Î·È ÛÙÔ Ì¤ÏÏÔÓ ›Ûˆ˜ ͷӷοÓÔ˘Ó ·Ú¤· ÛÙ· ·È‰È¿. øÛÙfi-

423

ÛÔ, ÚfiÛÊ·ÙË ·Ó·ÎÔ›ÓˆÛË ÙÔ˘ ·ÌÂÚÈηÓÈÎÔ‡ CDC (MMWR 6 πÔ˘Ï›Ô˘ 2007;56:649-652) ˘ÂÓı˘Ì›˙ÂÈ fiÙÈ ·Ó·ÊÔÚ¤˜ ÌÂÙ¿‰ÔÛ˘ Û·ÏÌÔÓÂÏÏÒÓ ·fi ¯ÂÏÒÓ˜ ÛÙÔÓ ¿ÓıÚˆÔ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ˘¿Ú¯Ô˘Ó, Ì ¤Ó· ÚfiÛÊ·ÙÔ Ì¿ÏÈÛÙ· ı·Ó¿ÛÈÌÔ ÎÚÔ‡ÛÌ· Û ‚Ú¤ÊÔ˜.

¶·Ú¤· Ì ˙Ò· ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ªÂÁ¿ÏË ÁÂÚÌ·ÓÈ΋ ÌÂϤÙË (13 ·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›·, 748 ·È‰È¿ Ì ÊÏÂÁÌÔÓÒ‰Ë ÓfiÛÔ ÙÔ˘ ÂÓÙ¤ÚÔ˘, 1481 ·È‰È¿ ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘) Û˘ÌÂÚ·›ÓÂÈ fiÙÈ Ë Û˘¯Ó‹ Â·Ê‹ Ì ˙Ò· ·ÁÚÔÎÙ‹Ì·ÙÔ˜ (‚ÔÔÂȉ‹, ÁÔ˘ÚÔ‡ÓÈ·, ·ÈÁÔÚfi‚·Ù·) ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Û¯ÂÙ›˙ÂÙ·È Ì ÌÂȈ̤ÓË Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ÓfiÛÔ˘ Crohn Î·È ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ ·ÚÁfiÙÂÚ· (Pediatrics 2007;120:354-361). ∂ÎÊÔ‚ÈÛÌfi˜ ÛÙÔ Û¯ÔÏÂ›Ô Î·È ÌÂÙ¤ÂÈÙ· „˘¯È΋ ˘Á›· ™ÙË ºÈÓÏ·Ó‰›·, 2540 ·ÁfiÚÈ· ÁÂÓÓË̤ӷ ÙÔ 1981 ÌÂÏÂÙ‹ıËÎ·Ó Û ËÏÈΛ· 8 ÂÙÒÓ ÁÈ· ÙÔ ·Ó ›¯·Ó ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ·¤Ó·ÓÙÈ ÛÙÔ˘˜ Û˘ÌÌ·ıËÙ¤˜ ÙÔ˘˜ ‹ ·Ó ˘‹ÚÍ·Ó ı‡Ì·Ù· ÂÈıÂÙÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ·fi Û˘ÌÌ·ıËÙ¤˜. ∆· ›‰È· ·È‰È¿ ÌÂÏÂÙ‹ıËÎ·Ó ·ÚÁfiÙÂÚ·, Û ËÏÈΛ· 18-23 ÂÙÒÓ ·fi Ù· ÛÙÚ·ÙÔÏÔÁÈο ˘ÁÂÈÔÓÔÌÈο ·Ú¯Â›·. ∆· ·È‰È¿ Ì ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ‹Ù·Ó ÈÔ Èı·Ófi Ó· ‚ÚÂıÔ‡Ó ·ÚÁfiÙÂÚ· Ì ·ÓÙÈÎÔÈÓˆÓÈ΋ ‰È·Ù·Ú·¯‹ ÚÔÛˆÈÎfiÙËÙ·˜ Î·È Ù· ·È‰È¿-ı‡Ì·Ù· Ì ·Á¯Ò‰ÂȘ ‰È·Ù·Ú·¯¤˜. ∆· ·È‰È¿ Ô˘ ˘‹ÚÍ·Ó Î·È ÙÚ·ÌÔ‡ÎÔÈ Î·È ı‡Ì·Ù· ÂÎÊÔ‚ÈÛÌÔ‡ ‚ÚÈÛÎfiÙ·Ó ÈÔ Û˘¯Ó¿ Î·È Ì ·ÓÙÈÎÔÈÓˆÓÈ΋ ‰È·Ù·Ú·¯‹ ÚÔÛˆÈÎfiÙËÙ·˜ Î·È Ì ·Á¯Ò‰ÂȘ ‰È·Ù·Ú·¯¤˜ (Pediatrics 2007;120:397-404). ∂ȉËÌ›· ÈÏ·Ú¿˜ Û ۯÔÏÂ›Ô ÛÙË °ÂÚÌ·Ó›· ™ÙÔ Duisburg (504.000 οÙÔÈÎÔÈ) Ù˘ °ÂÚÌ·Ó›·˜ ÛËÌÂÈÒıËΠÙËÓ ¿ÓÔÈÍË ÙÔ˘ 2006 ÌÂÁ¿ÏË ÂȉËÌ›· ÈÏ·Ú¿˜ Ì 614 ÎÚÔ‡ÛÌ·Ù·, 54% Û ¿ÙÔÌ· ËÏÈΛ·˜ 10 ÂÙÒÓ Î·È ¿Óˆ. ™ÙËÓ ›‰È· fiÏË Â›¯·Ó ηٷÁÚ·Ê› ÌfiÏȘ 4 ÎÚÔ‡ÛÌ·Ù· ÙËÓ ÚÔËÁÔ‡ÌÂÓË ÂÓÙ·ÂÙ›· 2001-2005. ∆Ô Úfi‚ÏËÌ· ¤Ï·‚ ÎÔÈÓˆÓÈΤ˜ ‰È·ÛÙ¿ÛÂȘ ηıÒ˜ Ì¿ÏÈÛÙ· ÛÙËÓ Â˘Ú‡ÙÂÚË ÂÚÈÔ¯‹ ¤ÁÈÓ·Ó 16 ·fi ÙÔ˘˜ 24 ·ÁÒÓ˜ ÙÔ˘ Ô‰ÔÛÊ·ÈÚÈÎÔ‡ World Cup Î·È ·ÚÎÂÙ¤˜ ¯ÒÚ˜ Âͤ‰ˆÛ·Ó Ù·ÍȉȈÙÈΤ˜ Ô‰ËÁ›Â˜ ÁÈ· ÙÔ˘˜ ÊÈÏ¿ıÏÔ˘˜. ªÂÏÂÙ‹ıËΠÙÔ ·Ó·ÌÓËÛÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û ‰ËÌfiÛÈÔ Û¯ÔÏÂ›Ô Ì 1250 Ì·ıËÙ¤˜ ËÏÈΛ·˜ 10-21 ÂÙÒÓ Î·È 53 ÎÚÔ‡ÛÌ·Ù·. ∏ ÓÔÛËÚfiÙËÙ· ‹Ù·Ó 53% ÛÙÔ˘˜ ·ÓÂÌ‚ÔÏ›·ÛÙÔ˘˜ Ì·ıËÙ¤˜, 1% Û ÂΛÓÔ˘˜ Ì 1 ‰fiÛË Î·È 0,4% Û ÂΛÓÔ˘˜ Ì ‰˘Ô ‰fiÛÂȘ ·ÓıÈÏ·ÚÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘. ∆Ô ÂÌ‚fiÏÈÔ ·¤‰ÂÈÍ ÙËÓ ·Í›· ÙÔ˘ Û fiÛÔ˘˜ ÙÔ Â›¯·Ó οÓÂÈ, ˆÛÙfiÛÔ ÔÈ Û˘ÁÁÚ·Ê›˜ ηٷϋÁÔ˘Ó (Pediatr Infect Dis J ™ÂÙ 2007;26:782-786) fiÙÈ ÌfiÓÔ Ë Ôχ ¢Ú›· Î¿Ï˘„Ë ÌÔÚ› Ó· ·ÔÙÚ¤„ÂÈ Ù¤ÙÔȘ ÂȉË̛˜, Û˘¯Ó¿ ÂÈÛ·ÁfiÌÂÓ˜- Ë Û˘ÁÎÂÎÚÈ̤ÓË ÂȉËÌ›· Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ Â›¯Â ÚԤϢÛË ·fi ÙËÓ √˘ÎÚ·Ó›·. ¶·È‰È·ÙÚÈ΋ 2007;70:422-423

Paidiatriki 5 final

12-10-07

16:29

Page 424

424

¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√

µ’ ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·

¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜, ¶·È‰›·ÙÚÔ˜, ∞ÏÏÂÚÁÈÔÏfiÁÔ˜

AÏÏËÏÔÁÚ·Ê›·: ¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜ npg@allergy.gr

πÛÙÔÛÂÏ›‰Â˜ ÁÈ· Ù· ÊıÈÓÔˆÚÈÓ¿ ÎÚ˘ÔÏÔÁ‹Ì·Ù· ∆Ô ÊıÈÓfiˆÚÔ ‹ÚıÂ, Î·È Ï›ÁÔ Ôχ fiÏÔÈ Ì·˜ ͯ·Ṳ̂ÓÔÈ ÛÙȘ ·Ó·ÌÓ‹ÛÂȘ ÙÔ˘ ηÏÔηÈÚÈÔ‡ Î·È ÙˆÓ ˘„ËÏÒÓ ıÂÚÌÔÎÚ·ÛÈÒÓ Ô˘ ÙÔ Û˘Óԉ‡ԢÓ, ‡ÎÔÏ· ÁÈÓfiÌ·ÛÙ ٷ ÚÒÙ· ı‡Ì·Ù· ÂÓfi˜ ÊıÈÓÔˆÚÈÓÔ‡ ÎÚ˘ÔÏÔÁ‹Ì·ÙÔ˜. ∆Ô ‰È·‰›ÎÙ˘Ô ÚÔÛʤÚÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· fi¯È ÌfiÓÔ Ó· ÂÓËÌÂÚˆıԇ̠·ÏÏ¿ ·ÎfiÌË Î·È Ó· ÚÔÏ¿‚Ô˘ÌÂ Î·È Ó· ıÂÚ·‡ÛÔ˘Ì ٤ÙÔÈÔ˘ ›‰Ô˘˜ ·ÓÂÈı‡ÌËÙ· Î·È ÂÓÔ¯ÏËÙÈο Û˘ÌÙÒÌ·Ù· Ô˘ ÚÔηÏÔ‡Ó Ù· ÎÚ˘ÔÏÔÁ‹Ì·Ù· Ù˘ ÂÔ¯‹˜.

¶ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙÔ ÎÚ˘ÔÏfiÁËÌ· - www.commoncold.org ∆Ô ·Ó·Óˆ̤ÓÔ site ·Ú¤¯ÂÈ Ì ·Ïfi Î·È ÂÚÈÂÎÙÈÎfi ÙÚfiÔ fiϘ ÙȘ ··Ú·›ÙËÙ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔ ÎÔÈÓfi ÎÚ˘ÔÏfiÁËÌ· Ô˘ ·ÊÔÚ¿ ÂÍ›ÛÔ˘ ÁÔÓ›˜ Î·È ·È‰È¿. ÈÚÈṲ̂ÓÔ Û 8 ˘ÔηÙËÁÔڛ˜, ‰›ÓÂÈ ··ÓÙ‹ÛÂȘ Û ÂÚˆÙ‹Ì·Ù· Ô˘, ·Ó Î·È ·ÎÔ‡ÁÔÓÙ·È Û˘¯Ó¿, ÂÏ¿¯ÈÛÙÔÈ ÁÓˆÚ›˙Ô˘Ó ÙËÓ ·¿ÓÙËÛ‹ ÙÔ˘˜. ªÂÚÈο ·fi ·˘Ù¿ ›ӷÈ: “∆È Â›Ó·È ÙÔ ÎÚ˘ÔÏfiÁËÌ·;”, “∆È ÚÔηÏ› Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ÎÚ˘ÔÏÔÁ‹Ì·ÙÔ˜;”. ∆ÚfiÔÈ ÚfiÏ˄˘, ıÂÚ·›·˜ ·ÏÏ¿ Î·È ÂÍ·ÈÚÂÙÈΤ˜ Û˘ÓÙ·Á¤˜ Ì·ÁÂÈÚÈ΋˜ Ì ‰È¿ÊÔÚ˜ Á‡ÛÂȘ ÁÈ· fiÏ· Ù· ÁÔ‡ÛÙ·, ¤Ú¯ÔÓÙ·È Ó· Ì·˜ ı˘Ì›ÛÔ˘Ó ÙȘ “ηϤ˜” Ï¢ڤ˜ ÙÔ˘ ÎÚ˘ÔÏÔÁ‹Ì·ÙÔ˜.

√‰ËÁfi˜ ÁÈ· (Ó¤Ô˘˜) ÁÔÓ›˜ - www.kidshealth.org “ÃÚ˘Ûfi √‰ËÁfi” Î·È ‰Ë ÁÈ· Ó¤Ô˘˜ ÁÔÓ›˜ ·ÔÙÂÏ› ÙÔ site ·˘Ùfi, ηıÒ˜ ÂÚȤ¯ÂÈ ·Ó·Ï˘ÙÈÎfiٷ٘ Û˘Ì‚Ô˘Ï¤˜ Î·È ÁÓÒÛÂȘ ÁÈ· fi,ÙÈ ÌÔÚ› Ó· ÙÔ˘˜ ··Û¯ÔÏ› Û¯ÂÙÈο Ì ÙÔ ·È‰› ÙÔ˘˜. ∫·Ï‡ÙÔÓÙ·˜ ÂÓ· ¢ڇ Ê¿ÛÌ· ıÂÌ·ÙÔÏÔÁ›·˜, fiˆ˜ ÔÈ ÚÒÙ˜ ‚Ô‹ıÂȘ, ˙ËÙ‹Ì·Ù· Á‡Úˆ ·fi ÙËÓ „˘¯ÔÏÔÁ›· ÙÔ˘ ·È‰ÈÔ‡ Î·È fiÏ· fiÛ· Ú¤ÂÈ Ó· ÁÓˆÚ›˙Ô˘Ì ÁÈ· ÙËÓ ˘Á›·, Û ¤Ó· ηϿ ‰ÔÌË̤ÓÔ site, ¯ˆÚÈṲ̂ÓÔ Û ÂÓfiÙËÙ˜, ÚÔÛʤÚÂÙ·È ÙfiÛÔ ÁÈ· ÏËÚÔÊfiÚËÛË fiÛÔ Î·È ÁÈ· Û˘Ì‚Ô˘Ï¤˜ Î·È ˘ԉ›ÍÂȘ. ∏ Ì˯·Ó‹ ·Ó·˙‹ÙËÛ˘ Ô˘ ‰È·ı¤ÙÂÈ ‰›ÓÂÈ ÛÙÔÓ ÂÈÛΤÙË ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ı¤ÛÂÈ ÂÚˆÙ‹Ì·Ù· ‹ ϤÍÂȘ ÎÏÂȉȿ, Ï·Ì‚¿ÓÔÓÙ·˜ ··ÓÙ‹ÛÂȘ ·fi ÂȉÈÎÔ‡˜ ÂÈÛÙ‹ÌÔÓ˜. ™ÙËÓ Î·ÙËÁÔÚ›· pregnancy and newborns ‚Ú›ÛÎÂÈ Î·Ó›˜ ÛËÌ·ÓÙÈΤ˜ ËÚÔÊÔڛ˜ ÁÈ· ÙÔ˘˜ Ì‹Ó˜ Ù˘ ·ËÛ˘ ·ÏÏ¿ Î·È ÁÈ· ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ ÂÓfi˜ ·È‰ÈÔ‡, Ôχ ¯Ú‹ÛÈ̘ ÁÈ· Ó¤Ô˘˜ ÁÔÓ›˜.

Paediatriki 2007;70:424-425

Paidiatriki 5 final

12-10-07

16:29

Page 425

NEWS FROM THE INTERNET

425

∆· ¿ÓÙ· ÁÈ· ÙȘ ·ÏÏÂÚÁ›Â˜ - www.allergychannel.net ∆Ô allergy channel Â›Ó·È ¤Ó·˜ ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ Ì ηÙËÁÔڛ˜ Ô˘ ηٷÚÙ›˙Ô˘Ó ÙÔÓ ÂÈÛΤÙË ÁÈ· ı¤Ì·Ù· Ô˘ ÙÔÓ ÚÔ‚ÏËÌ·Ù›˙Ô˘Ó Î·ıËÌÂÚÈÓ¿. £¤Ì·Ù· fiˆ˜ Ë ÂÍ¿ÚÙËÛË ·fi ÙÔ Î¿ÓÈÛÌ·, Ë ‰È·ÙÚÔÊ‹, Ë ·¯˘Û·Î›· Î·È ÙÔ ¿Á¯Ô˜ ‰È·ÊˆÙ›˙ÔÓÙ·È Ì ÙÚfiÔ ÏÈÙfi Î·È ÂÚÈÂÎÙÈÎfi, ·Ó¿ÏÔÁ· Ì ÙËÓ Î·ÙËÁÔÚ›· ÙÔ˘ ÎÔÈÓÔ‡ ÛÙËÓ ÔÔ›· ·¢ı‡ÓÔÓÙ·È. ŒÙÛÈ, ¿ÙÔÌ· fiÏˆÓ ÙˆÓ ËÏÈÎÈÒÓ ÌÔÚÔ‡Ó Â‡ÎÔÏ· Ó· Ï¿‚Ô˘Ó ÌÈ· ÛÊ·ÈÚÈ΋ ÏËÚÔÊfiÚËÛË Î·È Ó· χÛÔ˘Ó ÙȘ ·Ôڛ˜ ÙÔ˘˜. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ ÎÚ˘ÔÏfiÁËÌ·, Ë ÈÛÙÔÛÂÏ›‰· ¤¯ÂÈ ·ÊÈÂÚÒÛÂÈ Û ·˘Ùfi ¤Ó· ͯˆÚÈÛÙfi link, ÛÙÔ ÔÔ›Ô ·Ó·Ê¤ÚÔÓÙ·È fiÏ· Ù· Û˘ÌÙÒÌ·Ù· Î·È ·Ú¿ÏÏËÏ· ÚÔÙ›ÓÔÓÙ·È ıÂÚ·¢ÙÈΤ˜ ̤ıÔ‰ÔÈ. ∆Ô site ¤¯ÂÈ ˙ˆÓÙ·Ó¿ ¯ÚÒÌ·Ù·, Î·È Â›Ó·È Ï‹Úˆ˜ ÂÓËÌÂڈ̤ÓÔ. ¢È·ı¤ÙÂÈ ÂÓËÌÂÚˆÙÈο video Î·È Ù· ÈÔ ÚfiÛÊ·Ù· Ó¤· ÁÈ· ÙËÓ ÂͤÏÈÍË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜. ∆¤ÏÔ˜, ÂÚȤ¯ÂÙ·È ÂÓÙ˘ˆÛȷ΋ ÔÛfiÙËÙ· Î·È ÔÈfiÙËÙ· ÏËÚÔÊÔÚÈÒÓ Á‡Úˆ ·fi ÙËÓ ·ÏÏÂÚÁ›·, ηıÒ˜ Î·È ÂȉÈο ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ·ÔÎÏÂÈÛÙÈο È·ÙÚÔ‡˜.

™¯ÂÙÈο Ì ÙÔÓ Èfi Ù˘ ÁÚ›˘ - www.msnbc.msn.com ªÈ· ÂÓÙ˘ˆÛȷο ÂÓËÌÂڈ̤ÓË Î·È ÔÈÔÙÈο ‰ÔÌË̤ÓË ÈÛÙÔÛÂÏ›‰·, Ì ÏÂÙÔ̤ÚÂȘ ÁÈ· ÙÔ ÎÚ˘ÔÏfiÁËÌ· Î·È ÙÔÓ Èfi Ù˘ ÁÚ›˘. ∂ÈÛÙËÌÔÓÈΤ˜ ÌÂϤÙ˜, ¿ÚıÚ·, ·ÏÏ¿ Î·È ·Ôχو˜ ηٷÓÔËÙ¿ ‰ÔṲ̂Ó˜ ÏËÚÔÊÔڛ˜, ηıÈÛÙÔ‡Ó ÙËÓ ÈÛÙÔÛÂÏ›‰· ͯˆÚÈÛÙ‹. ∂ÌÏÔ˘ÙÈṲ̂ÓË Ì ÔÈΛÏÔ ıÂÌ·ÙÈÎfi ˘ÏÈÎfi, Û˘ÓÈÛÙ¿ ËÁ‹ ÁÓÒÛ˘ Ô˘ ·ÔÎÙ¿Ù·È Â‡ÎÔÏ· Î·È Â˘¯¿ÚÈÛÙ·, ηıÒ˜ ¤Ú¯ÂÙ·È Ó· ·ÔÙÂϤÛÂÈ ¤Ó·Ó ¯Ú‹ÛÈÌÔ Î·È Â‡¯ÚËÛÙÔ Ô‰ËÁfi fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ˘Á›· Ì·˜ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË. ∏ ÈÛÙÔÛÂÏ›‰· ¯ˆÚ›˙ÂÙ·È Û ‰‡Ô ÌÂÁ¿Ï˜ ηÙËÁÔڛ˜, Û ·˘Ù‹ Ù˘ ˘Á›·˜ Î·È ÛÙËÓ Î·ÙËÁÔÚ›· ÙÔ˘ ÎÚ˘ÔÏÔÁ‹Ì·ÙÔ˜ Î·È ÙÔ˘ ÈÔ‡ Ù˘ ÁÚ›˘. ªÂ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ ‰›ÓÂÙ·È Ë ‰˘Ó·ÙfiÙËÙ· ÌÈ·˜ ÁÂÓÈÎfiÙÂÚ˘ ÏËÚÔÊfiÚËÛ˘ ÁÈ· ÙËÓ ˘Á›·, ·ÏÏ¿ Î·È ‰ÈÂÍÔ‰È΋˜ ÁÓÒÛ˘ ÁÈ· ÙÔ ÎÚ‡ˆÌ· Î·È ÙË ÁÚ›Ë.

¶·È‰È·ÙÚÈ΋ 2007;70:424-425

Paidiatriki 5 final

426

12-10-07

16:29

Page 426

CLINICAL QUIZ

∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏

∏ ÛˆÛÙ‹ ·¿ÓÙËÛË Â›Ó·È “§È҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜”. ∏ ÏÈ҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜ Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ·ÈÙ›· ˘ÂÚÙÚ·ÓÛ·ÌÈÓ·Û·ÈÌ›·˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·, ÌÂ Û˘¯ÓfiÙËÙ· Ô˘ ˘ÔÏÔÁ›˙ÂÙ·È ÂÚ›Ô˘ Á‡Úˆ ÛÙÔ 7-10% ÙÔ˘ ÁÂÓÈÎÔ‡ ·È‰È·ÙÚÈÎÔ‡ ÏËı˘ÛÌÔ‡. ∏ ÏÈ҉˘ ‰È‹ıËÛË ÔÊ›ÏÂÙ·È ÛÙËÓ ÂÓ·fiıÂÛË Ï›Ô˘˜ ÛÙÔ Ë·ÙÈÎfi ·Ú¤Á¯˘Ì· Î·È ÂÌÊ·Ó›˙ÂÙ·È Û ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ Ô˘ Î˘Ì·›ÓÔÓÙ·È ÌÂٷ͇ 10-80% ÛÙ· ·¯‡Û·Úη ·È‰È¿. ∏ ÏÈ҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜ ÂÌÊ·Ó›˙ÂÙ·È ÈÔ Û˘¯Ó¿ Û ·ÁfiÚÈ· Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ·ã fi,ÙÈ Û ÎÔÚ›ÙÛÈ· Î·È ·Ó·Î·Ï‡ÙÂÙ·È ·fi ÙÔÓ ·È‰›·ÙÚÔ ÛÂ Ù˘¯·›Ô ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, fiÔ˘ ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓË SGPT. ™Â ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ‹·ÙÔ˜ ÂȂ‚·ÈÒÓÂÙ·È Ë ÏÈ҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜. ™Ù· ·È‰È¿ ·˘Ù¿ Û˘Ó˘¿Ú¯ÂÈ Û˘Ó‹ıˆ˜ ·˘ÍË̤ÓË ¯ÔÏËÛÙÂÚfiÏË, ÙÚÈÁÏ˘ÎÂÚ›‰È· Î·È ÈÓÛÔ˘Ï›ÓË ÔÚÔ‡. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙË Û˘Ìو̷ÙÔÏÔÁ›·, Ù· ·È‰È¿ Â›Ó·È ·Ú¯Èο ·Û˘Ìو̷ÙÈο, ˆÛÙfiÛÔ ·ÚÁfiÙÂÚ· ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÔ˘Ó ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜. ∆Ô ÏÈ҉˜ ‹·Ú ÌÔÚ› Ó· ÂÍÂÏȯı› Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ Û ÌË ·ÏÎÔÔÏÈ΋ ÛÙ·ÙÔË·Ù›Ùȉ· (nonalcoholic steatohepatitis), Ì›· ÓfiÛÔ Ô˘ Ï‹ÙÙÂÈ ÔÛÔÛÙfi 20% ÙˆÓ ·¯‡Û·ÚÎˆÓ ÂÊ‹‚ˆÓ ÛÙȘ ∏.¶.∞. √ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ù˘ ·Ó¿Ù˘Í˘ ÌË ·ÏÎÔÔÏÈ΋˜ ÛÙ·ÙÔË·Ù›Ùȉ·˜ ·Ú·Ì¤-

Paediatriki 2007;70:426-426

ÓÂÈ ¿ÁÓˆÛÙÔ˜, ·ÏÏ¿ Èı·ÓÔÏÔÁÔ‡ÓÙ·È ‰È¿ÊÔÚ· ·›ÙÈ· fiˆ˜ ÙÔ ÔÍÂȉˆÙÈÎfi ÛÙÚ¤˜, Î·È Ë ‰Ú¿ÛË - ˆ˜ ‰È·ÌÂÛÔÏ·‚ËÙ¤˜ - ÙˆÓ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ, ÙˆÓ ‚·ÎÙËÚȉȷÎÒÓ ÂÓ‰ÔÙÔÍÈÓÒÓ ·fi ÙÔ ¤ÓÙÂÚÔ Î.¿. ∏ ıÂÚ·›· ÙÔ˘ ·È‰ÈÔ‡ Ì ÏÈÒ‰Ë ‰È‹ıËÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÚÔÛ¿ıÂÈ· ÁÈ· ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Ì ‰›·ÈÙ· ¯·ÌËÏ‹ Û ÏÈ·Ú¿ Î·È ˘‰·Ù¿ÓıڷΘ, ¿ÓÙ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¿ÛÎËÛË. ∞ÓÙÈÔÍÂȉˆÙÈ΋ ıÂÚ·›· Ì ‚ÈÙ·Ì›ÓË C, E, Ô˘ÚÛÔ‰ÂoÍÈÎÔÏÈÎfi Ô͇ Î·È ÌÂÙÊÔÚÌ›ÓË ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› ¯ˆÚ›˜ ÌÂÁ¿ÏË ÂÈÙ˘¯›· Û ۯ¤ÛË Ì placebo. ™˘ÓÈÛÙ¿Ù·È ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Û Ë·ÙÔÏÔÁÈÎfi ΤÓÙÚÔ ÁÈ· ·ÚÎÂÙ¿ ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÁÈ·Ù› Ô ¤ÊË‚Ô˜ ·ÛıÂÓ‹˜ Ì ÌË ·ÏÎÔÔÏÈ΋ ÛÙ·ÙÔË·Ù›Ùȉ· ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ Î›ÚÚˆÛË ÙÔ˘ ‹·ÙÔ˜.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Pall H. and Jonas MM. Acute and chronic hepatitis In: Wyllie R, Hyams JS, editors. Pediatric Gastrointestinal and Liver Disease. Philadephia, USA: Saunders-Elsevier; 2006. p. 925-949.

2. Schwimmer JB, Deutsch R, Lavine JE, Behling C et al. The population prevalence of fatty liver. J Pediatr Gastronterol Nutr 2005;41:513.

3. Schwimmer JB, Behling C, Newbury R, Deutsch R, Nievergelt C, Shork NJ, et al. Histopathology of pediatric nonalcoholic fatty liver disease. Hepatology 2005;42:641-649.

Paidiatriki 5 final

12-10-07

16:29

Page 429

xix

¶ƒ√™∂Ã∏ ™À¡∂¢ƒπ∞ 4-6 √ÎÙˆ‚Ú›Ô˘ 2007

19Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ Ù˘ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ Î·È ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ ÛÂ Û˘Ó‰ÈÔÚÁ¿ÓˆÛË Ì ÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ∫·Ú‰›ÙÛ·˜ Ì ı¤Ì·: "¶·È‰› - √ÈÎÔÁ¤ÓÂÈ· ÛÙÔÓ 21Ô ·ÈÒÓ·" ∫ÙËÓÈ·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·Ï›·˜, Contact: ª·Ú›· ∂ÏÏËÓÈÎÔ‡, ¶·Ó·ÁÈÒÙ˘ ∫Ï¿·˜ Tel.: 210-7462208, 7462253 e-mail: mellin@med.uoa.gr, e-mail: pklappas@med.uoa.gr Website: www.socped.gr

∫·Ú‰›ÙÛ·

6-7 √ÎÙˆ‚Ú›Ô˘ 2007

∂Ù‹ÛÈÔ ™˘Ó¤‰ÚÈÔ ∆Ô̤· ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ Website: http://users.uoi.gr/paediatr

πˆ¿ÓÓÈÓ·

2-6 √ÎÙˆ‚Ú›Ô˘ 2007

Child Neurology - 2007 Contact: Harvard Medical School CME Office Tel.: 617-384-8600 Fax: 617-384-8686 E-mail: hms-cme@hms.harvard.edu

Cambridge, MA, USA

3-6 √ÎÙˆ‚Ú›Ô˘ 2007

IV Congreso Iberoamericano de Neonatología XXI Congreso Nacional de Medicina Perinatal II Congreso de la SEMP Contact: Dr. Maria J. Castro Tel.: 58-212-472-77-87 Fax: 58-212-472-77-87 E-mail: chefacastro@gmail.com

Granada, Spain

6-8 √ÎÙˆ‚Ú›Ô˘ 2007

48th Annual Meeting of the European Society for Paediatric Research – ESPR Contact: ESPR Secretariat Tel.: 41-229-080-488 Fax: 41-227-322-852 E-mail: espr07@kenes.com

Prague, Czech Republic

12-13 √ÎÙˆ‚Ú›Ô˘ 2007 VI Simposio Internacional de Neonatologia Contact: Luis Alfonso Perez Vera Tel.: 64-33-335 Fax: 64-74-786 E-mail: ascon.santander@intercable.net.co

Bucaramanga, Colombia

13 √ÎÙˆ‚Ú›Ô˘ 2007

∞ı‹Ó·

∂ÈÛÙËÌÔÓÈ΋ ∏ÌÂÚ›‰·: ∂›Î·ÈÚ· £¤Ì·Ù· Î·È ∞ÓÙÈÁӈ̛˜ ÛÙËÓ ¶·È‰È·ÙÚÈ΋ •ÂÓÔ‰Ô¯Â›Ô "King George" Contact: ∫∂°ª - Congress world - ª. ¶···Ó·ÁÈÒÙÔ˘ Tel: 210-7210001, 7210052 Fax: 210-7210051 E-mail: info@congressworld.gr Website:www.congressworld.gr

Paidiatriki 5 final

12-10-07

16:29

Page 430

xx

17-20 √ÎÙˆ‚Ú›Ô˘ 2007 ESH-EHA Conference: Focus on Paediatric Haematology and Oncology Contact: Conference Secretariat: European School of Haematology (ESH), Centre Hayem, Hôpital Saint-Louis, 1, av. Claude Vellefaux Cedex 10, 75475 Paris Tel.: 33-142-066-540 Fax: 33-142-060-587 E-mail: ghyslaine_lebougault@at)paris7.jussieu.fr

Barcelona, Spain

18-22 √ÎÙˆ‚Ú›Ô˘ 2007 19th International Congress of Pediatrics Contact: Dr GhR Walizadeh, Dr A Habibolahi Tel.: 982 166 428 998 Fax: 982 166 923 054 E-mail: pedcong@tums.ac.ir

Tehran, Iran

24-27 √ÎÙˆ‚Ú›Ô˘ 2007 International Congres of Pediatric Hepatology, Gastroenterology and Nutrition Contact: Mortada El-Shabrawi Tel.: 20-123-133-705 Fax: 20-237-619-012 E-mail: mortada_elshabrawi@yahoo.com

Sharm El-Sheikh, Egypt

30 √ÎÙˆ‚Ú›Ô˘ 3 ¡ÔÂÌ‚Ú›Ô˘ 2007

SIOP 2007: 39th International Society of Paediatric Oncology Annual Meeting Contact: Conference Secretariat: SIOP 2007 Secretrariat, Varriance Conferences & Events, 37/900, Adarsh Nagar Century Bazaar, Worli, 400 03 Mumbai Tel.: 912-224-381-068 Fax: 912-224-385-021 E-mail: siop2007@varriance.com

Mumbai, India

1-4 ¡ÔÂÌ‚Ú›Ô˘ 2007

XI Congress of Pediatric Radiology-SLARP Contact: Silvia Moguillansky Tel.: 54 1-147-918-110 Fax: 541-147-918-110 E-mail: moguil@intramed.net.ar

Vina del Mar, Chile

8 ¢ÂÎÂÌ‚Ú›Ô˘ 2007

7Ô ∂Ù‹ÛÈÔ ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜, H·ÙÔÏÔÁ›·˜ Î·È ¢È·ÙÚÔÊ‹˜ ∞›ÁÏË ∑·›Ԣ, ∞ı‹Ó· Website: www.helspghan.org

∞ı‹Ó·

14-17 ¢ÂÎÂÌ‚Ú›Ô˘ 2007 7Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∞ÓÔÛÔÏÔÁ›·˜ •ÂÓÔ‰Ô¯Â›Ô Makedonia Palace, £ÂÛÛ·ÏÔÓ›ÎË Website: http://www.mednet.gr/hsi/

£ÂÛÛ·ÏÔÓ›ÎË

16-19 √ÎÙˆ‚Ú›Ô˘ 2008 13th Meeting of the European Society for Immunodeficiencies (ESID) Theater aan de Parade 's-Hertogenbosch, Website: http://www.esid2008.org/

The Netherlands