... konulu sunumlar: "SIK ATEŞLENEN ÇOCUK Dr. Mustafa Bakır"— Sunum transkripti:
1SIK ATEŞLENEN ÇOCUK Dr. Mustafa Bakır Marmara Üniversitesi Tıp FakültesiGöztepe EAH, 22 Mart 2011
2Tanımlar Rekürran/Periodik Ateş Düzenli/düzensiz aralıklarla ve normal vücut ısısı dönemleriyle birbirinden ayrılan ateş tekrarlarıKaynağı bilinmeyen ateş (FUO)>3 hf süren ve 1 hf yoğun incelemeye rağmen tanısı belirsiz ateşBefore I go into the literature and the confusion begins, I want to present a working definition that I propose we use – a sort of compromise between what is in the literature and what our consultants use – because I think it will help us keep clarity in the data I’m about to discuss.The main difference in our discussion between the two definitions is that recurrent/periodic fever is separated by periods of return to normal temperature whereas FUO is not. This is not hard and fast in the literature, as people sometimes incorporate recurrent/periodic fever into FUO, but I think this is an important distinction to make for our discussion today.
3Rekürran Ateş John & Gilsdorf 2003 “ 6 aylık periyotta tanımlanmış bir hastalık olmaksızın en az 7 gün aralıklarla gelen ≥3 ateş atağı”So keeping our working definitions in mind, what does the literature say?Arbitrary definition by John and Gilsdorf 2002, the authors of the only review article on recurrent fevers in children, arbitrary definition of recurrent fever.Lots of numbers and specific time intervals determined arbitrarily.
4Rekürran/Periyodik Ateş Long 2005Rekürran Ateş“Ateş ve diğer belirti ve bulguların azalıp arttığı tek bir hastalık”Periyodik Ateş“Ateşin ana belirti olduğu tekrarlayan hastalık atakları; haftalar-aylar süren tam iyilik dönemleri. Ataklar düzenli veya düzensiz periyotlarla gelebilir”Sarah Long, a pediatric infection disease specialist, takes a different approach and defines recurrent and periodic fever a little differently. Here, she uses a return to normal in between periods of fever to distinguish between recurrent and periodic fever. Her definition of recurrent fever is a little more like our definition of FUO, and her definition of periodic fever matches better to our definition of recurrent fever. Her criteria for timing in between febrile episodes also differs from John and Gilsdorf.So you see, it seems that everyone uses slightly different criteria for each entity.
5Kaynağı Bilinmeyen Ateş Petersdorf & Beeson 1961“>3 hf süren, birkaç kez en az 38,3oC ölçülen, >1 hf süren yoğun incelemelere rağmen tanısı belirlenemeyen ateş”Finally, there is controversy over what the definition of FUO is too.An adult definition that has been extrapolated to children. There is no consensus in the literature as to time intervals or temperature needed to fulfill this diagnosis.“prolongation of fever without finding any cause, which is disturbing to the medical staff and causes anxiety for the family” may be a more useful working definition.”
6Etyoloji “Nadir belirtilerle seyreden yaygın hastalıklar” İNFEKSİYON İnflamatuar/OtoimmünTanımlanamamış (rekürran)/Neoplazma (FUO)Well with all these differences between the entities of recurrent fever and FUO, are there ANY similarities?Well, it turns out that the BROAD diagnostic categories causing both entities are similar. It is simply the specific diagnoses that differ.Infection is number one in both recurrent fevers and FUO by far, followed by inflammatory/autoimmune diagnoses. The third most common etiology differs between the two entities, with no diagnosis being more common in recurrent fever and neoplasms being more common in FUO.Common things being common, however, the literature reminds us that the cause of recurrent fevers/fevers of unknown origin are still most likely to be common disorders with uncommon presentations. This has implications before we go hunting for those really rare diseases that are in the differential for both entities.
7Etyoloji Enfeksiyöz Otoimmün/ İnflamatuar Malign Tanısız Diğer McClung 1972 (n=99)28%14%8%11%16%Pizzo et al (n=100)52%20%6%12%10%Feigen and Shearer 1976 (n=20)35%5%30%Lohr and Hendley 1977 (n=54)33%21%13%19%15%Problems, problems, and more problems.Looking to the literature for the rates of each of these categories as a cause of recurrent fevers is problematic because the literature is fraught with the same confusion over definitions as we described earlier, and many study samples include both those with recurrent fevers and fever of unknown origin.Above are the rates of each broad diagnostic category that likely better reflects the incidence of each etiology in FUO rather than recurrent fever because FUO patients were better represented in the studies that reported their numbers of constant versus recurrent fevers. Most didn’t even make this distinction however.There is no data in the literature looking only at truly recurrent fever. This is likely because this problem is dealt with by so many separate specialties after they are referred by primary care physicians, and therefore, no one has looked at this group as a whole after the diagnosis is made. This is the best available information we have however.We see in these older studies done in developed countries (USA) that…Miscellaneous category includes drug fever, factitious fever, habitual/familial fever, hypersensitivity states, hemoglobinopathies, and dehydration.Pizzo et al. included both constant fever and recurrent fevers in their patient population. No reference to how many patients in each group. Height, pattern, duration of fever did not correlate with diagnosis or severity of illness.Feigen and Shearer no mention of pattern of fever in FUO.
8Etyoloji Etyoloji FUO (n=102) Etyoloji FUO (n=185) Ciftci et al. 2003 Pasic et al. 2006Etyoloji FUO (n=102)İnfeksiyon 44.2%Kollajen vasküler 6.8%Malinite 11.7%Diğer. 24.5%Tanısız 12.8%Etyoloji FUO (n=185)İnfeksiyon 37.8%Otoimmün 12.9%Kawasaki hastalığı 6.4%Malinite 6.4%Diğer. 8.1%Tanısız 30%More recently in developing countries…Ciftci et al Turkey – no mention of pattern of feversPasic et al Serbia – no mention of pattern of feversOf special note is that Kawasaki’s Disease is an important diagnosis not to miss in those with constant fever, although this is not the population we’re focusing on today.
9Ayırıcı Tanı Ateş Aralıkları Rekürran AteşAyırıcı Tanı Ateş AralıklarıSo now that we know what the broad categories causing recurrent fever are, what is the specific differential diagnosis for recurrent fevers?This is perhaps best divided into those entities that present at regularly recurring intervals and those that return at irregular intervals.Düzenli?Düzensiz?
10Düzenli Aralıklı Ateş Hep düzenli aralık var Bazen düzenli aralık var PFAPA sendromuSiklik nötropeni“Relapsing fever” (Borrelia spp. Burgdorferri hariç)Tanımlanamamış sebepBazen düzenli aralık varFMFHiper-IgD sendromu,TRAPSKriyopirin sendromlarıEBV infeksiyonuFevers at regular intervals are the most helpful because the differential is short. These etiologies for fever occurring at regular intervals generally are well in between.Periodic fever, apthous stomatitis, pharyngitis, adenitis (PFAPA) – most common cause of regular interval, no long-term sequelaeCyclic neutropenia – spontaneous recovery without medical treatmentRelapsing fever – potential mortality, ask about history of exposures to ticks/liceJohn and Gilsdorf 2002
11PFAPA Periodic Fever Adenopathy Aphthous ulcers Pharyngitis genellikle 3-5 gün3-4 hf arayla tekrarlarAphthous ulcersKüçük, yüzeyel, hızla düzelirPharyngitis+ eksüdaAdenopathyServikalGenellikle bilateral ve kısa süreliCilt, solunum, GI veya eklem tutulumu yokCRP, Lökosit, ESP çok yüksekIt was characterized by a primary complaint ofFever, which was brief, recurring in a periodic, timely manner and save associated oral ulcers, pharyngitis, and adenopathy, was without more serious focal or systemic signs of illness.The aphthous ulcers have been noted to occur in 60-70% of cases in the United states. They are typically few to several, shallow and small, ( <5mm in diameter), short-lived (resolving) in 5-10 days, and show no predilection for specific mucosal locations as do herpanginaPharyngitis is more variable, with the presence or absence of exudate having no diagnostic implicationsFinally adenopathy, which is typically bilateral, rapid to appear and resolve, and typically discrete and non-fluctuant
12Tanı Kriterleri Periyodik ateş başlangıcı < 5y ÜSYE Sx olmaması ve şunlardan >1 :Aftöz stomatitServikal LAPFarenjit1-2 doz 2mg/kg prednisolon: dramatik cevapSiklik nötropeni ekarteAtaklar arasında hasta asemptomatik
13PFAPA: Tedavi Prednisone Tonsillektomi Cimetidine Kolşisin? 2mg/kg/g x 1-2 dozTonsillektomiCimetidine150mg/gKolşisin?There are no universally accepted curative treatments, but, there are several options besides reassurance and symptomatic relief.Prednisone or equivalent steroid at 2mg/kg/day in 1-2 doses terminates the fever, and has even been proposed as a diagnostic criterion, but has also been noted in some series to shorten the duration to the next fever.Tonsillectomy, whether for treatment of recurrent pharyngitis or in trials of PFAPA treatment has been successful at ending PFAPA in 50-90% in studies and case series.Cimetidine, known to have immunomodulatory effects has been noted in the literature to have varying success in treating PFAPA.
18Düzenli Aralıklı Ateş “Relapsing Fever” Borrelia türü spiroketler (burgdorferi dışı)Ateş 1-6 gün, 4-14 gün aralıkla“kriz” (KB,kalp hızı) sonrasında aşırı terleme, ateşin düşmesi, KB Kriz sırasında tedavi edilmemiş. ateşe bağlı mortaliteTx: penicillin veya tetracyclineBorrelia burdorferi causes Lyme DiseaseBorrelia endemic to N.America? Yes, reported cases include Canada.18
19FMF Sık rastlanan periyodik ateş sendromu Otozomal resesif Yahudi, Ermeni, Kuzey Afrikalı, Türk, Yunan, İtalyanPyrin proteinini kodlayan MEFV geninde mutasyonPyrin: IL-1 üretimi regülasyonunda rol alır1-3 gün süren ateş + Karin ağrısı +serozit, sinovitPersistan inflamasyon: Sekonder AmiloidozKolşisin19
20Hiper IgD Sendromu Otozomal resesif Mevalonat kinaz (MVK) geninde mutasyon>2/3’si 1 yaşından önce3-7 günlük ateş ataklarıTitremeServikal LAPKarın ağrısı, bulantı-kusma, başağrısı,Artralji, artit, aftöz stomatit, pleomorfik döküntüSplenomegali20
21Hiper IgD SendromuAtak aşılama, viral infeksiyon, travma ve stres ile uyarılabilirÇoğu hastada IgD >100 IU/ml, %80’inde yüksek IgA düzeyiAkut faz reaktanları yükselirTedavi: NSAD, Oral kortikosteroidTNF-alfa inhibitörleri: olgu sunumlarıRekombinant human interlökin 1 reseptor antagonisti (anakinra)21
22TRAPS (TNF receptor-1 associated periodic syndrome) Familial Hibernian ateş/ familial periyodik ateşOtozomal dominant, inkomplet penetrans55 kDa TNFR-1 gen defektiSütçocukluğu – 40’lı yaşlar arasında başlayabilirİrlandalı (Hibernian) ve İskoç orijinlilerde daha sıkAteş 5 gün - >2 hafta sürerKonjonktivit, periorbital ödem,fokal migratuar miyaljiDöküntükarın ağrısımonoartrit22
23TRAPS (Tedavi) Semptomatik: Glukokortikoidler ve NSAID’ler Kronik tedavi: Anti-TNF (Etanercept)Amiloidozu önler?Anti-TNF’e dirençli ise IL-1 ra (anakinra)Kolşisin’e cevap zayıf23
24Kriyopirin ile birlikte periyodik sendromlar Mutant kriyopirine bağlı aşırı IL-1 beta üretimiAilevi soğuk otoinflamatuar sendromMuckle-Wells sendromuIntermittent ateş, urtiker, artralji/artritProgressif sensörinöral işitme kaybıSekonder amiloidoz ve nöropatiNeonatal başlangıçlı multisistem inflamatuar hastalıkAnakinra: amiloidozu da önleyebiliyor24
25Periyodik Ateş Sendromları Periyodisite Diğer Sx Kalıtım Etyoloj_______PFAPA E H H HS. Nötropeni E Gingivitis OD ELA2AOM, Sinus Apop KİFMF H Poliserözit OR MEFVDöküntü PyrinHIDS E/H Karın Ağr. OR MVKDöküntü MVKaseArtrit IsoprenoidlerTRAPS H Miyalji OD TNFRSF1APeriorb ödem TNF reseptör
26Düzensiz Aralıklı Ateş Fever at irregular intervals presents more of a challenge in terms of the differential diagnosis because it is much lengthier, but I have highlighted boxes on the table to draw your attention to the most common causes of recurrent fevers at irregular intervals. Specifically, repeated viral infections (EBV being most common), and inflammatory conditions. It is also important to note, however, that no diagnosis can be made.The list of possible etiologies is generated from multiple case reports and series on recurrent fevers.Under neoplasms, lymphomas, leukemias, and neuroblastomas have all been noted to cause fevers.John and Gilsdorf 200226
27Yaklaşım Dikkatli öykü & FM Ateş paternine karar ver (ateş günlüğü) Sabit mi? Rekürran mı?SüreEşlik eden belirtilerHematolojik muayeneHSMLAPIn the approach the child with recurrent fevers, we recognize that most of the time, these previously well children do not need immediate intervention or empirical treatment from us on their behalf. However, we can be very helpful to our colleagues who we refer these patients onto by gathering some of the initial information and investigations before they arrive for further care.As always, with every patient, the approach to the child with recurrent fever begins with a careful history and physical exam. In our case, this is mainly to rule out any obvious localizing symptoms/signs that would point to an immediate cause of the fever. In particular, our colleagues state that the above points are most helpful to our consultants and having the patient keep a fever diary will be immensely helpful to those who we refer onto.
28Ne zaman konsültasyon? Pediatric Infectious Diseases: ≥3 rekürran ateş atağıEven before that, when to refer?There is no literature to support when you would start investigations in a patient with truly recurrent fever.Dr. Susan Kuhn from our ID department thinks it would be reasonable to start investigations after 3 episodes given that the likelihood of repeat viral infections decreases as episodes increase. This is reflected in literature on recurrent fever that notes that it is rare for children to have more than two viral infections with no symptoms (localizing symptom) other than fever.1 time – common, 2 times – unlucky, 3 times – start looking for another diagnosis other than viral infection
29Hangi Testler İstenmeli? İnfeksiyonhastalıklarıTestler:CBCTİTKan CxESR/CRPEBV serolojisi (IgM/IgG)QIGDuruma göre:AC Gr – solunum belirtileriGaita incelemesi – ishalİnce/kalın kan yayması –≤1 yıl endemik bölgeye seyahatDr. Kuhn suggest the above.ESR/CRP should be done both when the patient is febrile and afebrile. ESR/CRP generally remain elevated in diseases requiring specific interventions (occult bacterial infection, Crohn’s Disease, systemic JRA) whereas they decrease in conditions that either do not require intervention (PFAPA, HIDS) or require it primarily for intervention (FMF).Quantitative immunoglobulins as a screen for immune deficiency.
30Hangi Testler İstenmeli? Pediatrik GI:Ek olarak:Hepatobiliyer (ALT, GGT, ALP, lipaz)Fe testleri (ferritin, Fe)Albumin (kayıplar/azalmış. üretim)Gaita testleri (antijen)Liver and pancreatic enzymes – IBD can have hepatic and pancreatic involvementIron studies – IBD can have subtle blood losses or absorption issuesAlbumin – IBD can cause increased losses or chronic inflammation leading to decreased productionStool studies – remember that infection can also cause inflammatory bowel disease
31Hangi Testler İstenmeli? Pediatrik Romatoloji:Doğrudan romatoloji kliniğine gönderilecekse:CBCKreatinin, ÜreESR/CRP ateşin 1, 5, 10. günleriFerritinIgDİdrar Rutin+Mikroskopiİdrar Mevalonik AsidDr. Miettunen would not order anything other than what infectious diseases would order as infection is still the most common cause of recurrent fever. However, if the story is suspicious for a rheumatologic cause, she would have us order the above prior to the patient being seen in the Rheumatology Clinic.
32Hangi Testler İstenmeli? Pediatrik Onkoloji:TestlerCBCAC grafisiLAP, HSM, SM, karında kitle vs varsaIn terms of the oncologic entities that would cause recurrent fever (lymphoma, leukemia, and neuroblastoma), they would be seen with the combination of physical exam (specifically the above findings) and investigations. Children with neuroblastoma will have other symptoms accompanying the fever.Neuroblastoma - spectrum of neuroblastic tumors (including neuroblastomas, ganglioneuroblastomas, and ganglioneuromas) that arise from primitive sympathetic ganglion cells.
33Sık Ateşlenen Çocuk: Prognoz Genellikle çok iyiİncelemelerden sonra tanı yoksaAteş düşmüşBüyüme/gelişme etkilenmemişYeni belirti/bulgu olmadıkça başka teste gerek yokIf children with recurrent fevers are investigated and no diagnosis is reached, these kids generally have excellent prognosis. Although an observation was made in a retrospective review of 40 children that those with recurrent fevers had higher than expected neurologic sequelae, (ADHD, developmental delay), no relation to the recurrent fevers has been shown.Petit mal seizures developed in one patient with periodic fever, and another had mitochondrial encephalopathy. Four children with periodic fevers have attention-deficit hyperactivity disorder, and two have developmental delays. (n=29) – Miller et al J Pediatr 129: