儿童巨噬细胞活化综合征的发病机制与生物标志物研究进展

巨噬细胞活化综合征是一种继发于风湿免疫性疾病, 由多种原因引起的危及生命的综合征。巨噬细胞活化综合征是由于T细胞和巨噬细胞持续激活和增殖导致免疫过度刺激和致炎介质的瀑布样释放, 最终诱发细胞因子风暴和多器官衰竭。巨噬细胞活化综合征主要临床表现及实验室检查结果异常包括发热, 血细胞减少, 肝、脾、淋巴结肿大, 凝血障碍, 肝功能损害, 高铁蛋白血症, 高甘油三酯血症及骨髓噬血现象。该文从流行病学、发病机制、生物标志物方面的研究进展进行综述, 以期为巨噬细胞活化综合征的进展快、病死率较高的并发症的早期识别和诊断提供新思路。     

川崎病并发巨噬细胞活化综合征的研究进展

巨噬细胞活化综合征是川崎病一种罕见的并发症,因其有起病隐匿、进展快、影响全身多器官系统、致死率高等特点,需要给予更多的重视。由于目前国际上暂无统一的川崎病合并巨噬细胞活化综合征的诊断标准和治疗方案,因此常被漏诊或误诊。文章就川崎病并发巨噬细胞活化综合征的流行病学、免疫学机制、诊断和治疗等研究进展进行综述。     

巨噬细胞活化综合征专题讨论会纪要

为提高广大儿科医生对巨噬细胞活化综合征（MAS）的认识,2006年3月25至26日,《中华儿科杂志》编辑委员会邀请部分儿科临床免疫、血液、肾脏病专家和部分成人临床专家在广东省广州市召开了“巨噬细胞活化综合征专题讨论会”。会议希望通过与会专家积极、严谨、深入的讨论,在MAS的发病机制、诊断、治疗、儿童流行病学资料收集等方面取得一些进展,以期提高广大儿科临床工作者的认识和救治MAS的水平。现将讨论会主要内容介绍如下：     

细胞因子与全身型幼年特发性关节炎的研究进展

随着经济和医疗水平的发展, 慢性疾病成为影响儿童身心发展越来越突出的问题。其中, 幼年特发性关节炎是临床上常见的儿童风湿性疾病。细胞因子作为机体免疫反应的重要介质, 其在全身型幼年特发性关节炎及其并发症巨噬细胞活化综合征中的作用愈发受到重视。研究发现多种细胞因子在全身型幼年特发性关节炎及巨噬细胞活化综合征的发生与发展中起到致炎或抗炎的作用。该文就全身型幼年特发性关节炎及巨噬细胞活化综合征相关细胞因子的具体作用机制及临床意义归纳总结, 另对细胞因子相关药物治疗进展进行汇总, 通过探究全身型幼年特发性关节炎的发病机制, 以期为寻找新兴治疗靶点提供理论依据。     

EB病毒相关淋巴细胞增生性噬血综合征研究进展

噬血综合征(hemophagocytic syndrome,HPS)是一组以良性巨噬细胞增生和活化伴随其吞噬血细胞现象的一类综合征。遗传因素、感染、肿瘤、自身免疫性疾病、药物等多种因素均可引起HPS,感染因素中以Epstein-Barr病毒(EBV)最为常见,称为EB病毒相关淋巴细胞增生性噬血综合征(Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis,EBV-HLH)。现就EBV-HLH的发病机制、临床表现、诊断、鉴别诊断等方面的研究进展进行讨论。     

儿童期系统性红斑狼疮与巨噬细胞活化综合征

在儿童,巨噬细胞活化综合征是风湿性疾病(特别是全身型幼年特发性关节炎)或炎症性疾病严重的、有时是致死性的并发症。然而,系统性红斑狼疮合并巨噬细胞活化综合征的临床报告多见于成人。文章重点对巨噬细胞活化等相关概念、感染致病、临床识别和治疗予以介绍。     

巨噬细胞活化综合征问题解答

阅读贵刊2005年11期874页“幼年特发性关节炎全身型并发巨噬细胞活化综合征一例”,查阅教科书和其他儿科专著,没有关于巨噬细胞活化综合征的介绍,有以下几点疑问：     

儿童风湿病国际相关诊治指南系列解读之四——儿童风湿病合并巨噬细胞活化综合征诊治指南解读

巨噬细胞活化综合征（MAS）是一种继发性噬血细胞性淋巴组织细胞增多症,是儿童风湿性疾病常见的致命并发症。MAS最常见的原发病是全身型幼年特发性关节炎（SJIA）,约10%的SJIA可并发MAS。早期诊断和快速启动免疫抑制是有效治疗MAS的关键。随着对MAS病理生理学的深入理解和新疗法的出现,广泛的免疫抑制治疗方法正在被“靶向抗细胞因子疗法”所取代。随着对儿童风湿性疾病中MAS早期识别意识的提高,结合有效、毒性较小的细胞因子“靶向治疗”的使用,应该可以降低这类致死性较高疾病的病死率。     

巨噬细胞活化综合征

巨噬细胞活化综合征(MAS)是幼年特发性关节炎全身型(soJIA)严重而致命的并发症,及时诊断和处理是必要的。本文综述了soJIA并MAS的触发因素和发病机制、临床表现、实验室和组织病理检查、诊断以及治疗。典型的MAS表现为持续发热,肝脾和淋巴结大,急剧的血沉降低和全血细胞减少,严重的肝功能损害,凝血障碍及神经系统受累。血沉下降和高血清铁蛋白血症是MAS最为突出的特点之一;骨髓和其他器官发现大量具有显著噬血活性的非肿瘤性组织细胞增生。环孢素A是治疗的首选药物。     

糖皮质激素耐药性原发性肾病综合征的常见问题

激素耐药性肾病综合征存在许多临床问题，本研究从激素耐药性肾病综合征的定义、早期诊断、治疗方案与选择、肾脏病理类型与肾病综合征激素耐药之间的关系、发病机制等方面着手，引申出一些值得临床思考和面对的问题。     

Griscelli syndrome: a case report

A 10-year-old boy presented with partial albinism and typical clinical features of a macrophage activation syndrome (hepatosplenomegaly, fever, and pancytopenia), suggesting the diagnosis of Griscelli syndrome. The diagnosis was confirmed by light microscopic evaluation of hair that showed characteristic large aggregates of pigment granules irregularly distributed along the hair shaft. Immunosuppressive therapy controlled his macrophage activation syndrome successfully. Since early diagnosis is life saving and simple methods confirm the diagnosis, finding of partial albinism in children should alert clinicians to consider Griscelli syndrome.     

Macrophage activation syndrome linked to Epstein-Barr virus

Epstein-Barr virus infection is one of the etiologies that should be discussed in patients with macrophage activation syndrome. We report a case that is consistent with this diagnosis. The role of the Epstein-Barr virus in the etiologic diagnosis of VAHS (virus-associated hemophagocytic syndrome) is specified. In pediatric patients with VAHS, the other causes of macrophage activation should also be discussed.     

Macrophage activation syndrome as initial presentation of systemic lupus erythematosus

Macrophage activation syndrome (MAS) is known to be a severe and potentially life-threatening complication of rheumatic disorder, especially systemic juvenille rheumatoid arthritis. It is very rare for MAS to be an initial presentation of systemic lupus erythematosus (SLE). Here, we report a 14-year-old girl in whom MAS developed as an initial presentation of SLE. With early diagnosis and administration of cyclosporine A, she had a fair outcome. Further testing showed positive anti-dsDNA about 8 months later.     

Peripheral precocious puberty: clinical, diagnostic and therapeutical principles

Peripheral precocious puberty (PPP) is the result of the presence of precocious puberty due to the increase of sex steroids with no evidence of activation of the hypothalamic-pituitary-gonadal axis. It is much less common than central precocious puberty (CPP) and it is secondary to either genetic disorders or very heterogeneous acquired diseases. In recent years, molecular advances have made remarkable progress in understanding the pathophysiology of some of these disorders, most notably in McCune-Albright syndrome and testotoxicosis. In addition, new imaging techniques and better hormone assays have improved the early diagnosis of acquired disorders, particularly tumour disease causing PPP. Unfortunately, medical advances in the diagnosis of these disorders have not been reflected in the medical treatment of McCune-Albright syndrome and testotoxicosis. Despite having tried various treatment options in both disorders, the results are very disappointing, especially in patients with McCune-Albright syndrome. To our knowledge, this failure is based on the absence of well-designed clinical trials that include an adequate number of patients followed up until the end of their growth.     

Early revealing of Williams-Beuren syndrome by digestive disorders]

Williams-Beuren syndrome is a rare syndrome for which diagnosis is usually made during early childhood. It includes mental retardation, friendly outgoing personality, typical facies, supravalvular aortic stenosis and hypercalcemia. CASE REPORT: We report the case of a newborn whose gastroesophageal reflux led to the diagnosis of Williams-Beuren syndrome. Hypercalcemia is known to precipitate digestive symptoms but was not present in this case. CONCLUSION: Announcing such a diagnosis in the neonatal period is difficult and may destabilize the family, but at least allows early care of the cardiovascular pathologies that may lead to death.     

Arthrogryposis multiplex congenita‐like syndrome associated with median cleft lip and palates: First prenatally detected case

An early second‐trimester prenatal ultrasound diagnosis of an arthrogryposis multiplex congenita‐like syndrome associated with median clefts is reported. A molecular biological work‐up was performed to search for a potentially overlapping syndrome and dysostosis. Autopsy and postmortem radiogram were performed to confirm the ultrasound diagnosis. Prenatal diagnosis enabled early detection of multiple fetal malformations, thus allowing early termination of pregnancy. Moreover, three‐dimensional ultrasound with volume rendering in the maximum surface mode demonstrated its value in diagnosing oro‐facial clefts, even at an early stage of fetal development.     

Evolving phenotype of Marfan's syndrome

AIM: To examine evolution of the physical characteristics of Marfan's syndrome throughout childhood. METHODS: 40 children were ascertained during the development of a regional register for Marfan's syndrome. Evolution of the clinical characteristics was determined by repeat evaluation of 10 patients with sporadic Marfan's syndrome and 30 with a family history of the condition. DNA marker studies were used to facilitate diagnosis in those with the familial condition. RESULTS: Musculoskeletal features predominated and evolved throughout childhood. Gene tracking enabled early diagnosis in children with familial Marfan's syndrome. CONCLUSIONS: These observations may aid the clinical diagnosis of Marfan's syndrome in childhood, especially in those with the sporadic condition. Gene tracking has a role in the early diagnosis of familial Marfan's syndrome, allowing appropriate follow up and preventive care.     

Two cases of 22q11.2 deletion syndrome with anorectal anomalies and growth retardation

Clinical features associated with the deletion of 22q11.2 are highly variable. Most are diagnosed by cardinal congenital heart disease or hypoparathyroidism. In cases without major features, an early accurate diagnosis of 22q11.2 deletion syndrome is difficult. Congenital anorectal malformations (ARM), which can be detected soon after birth, have been rarely reported in 22q11.2 deletion syndrome. We report two cases of 22q11.2 deletion syndrome with ARM who showed growth retardation. ARM was detected in both patients without congenital heart disease or hypoparathyroidism at early infancy and they were followed by pediatric surgeons. Later, failure to thrive or short stature became evident, and they consulted with pediatric endocrinologists who subsequently confirmed the diagnosis of 22q11.2 deletion by fluorescent in situ hybridization analysis. The combination of ARM and growth retardation may lead to an early diagnosis of 22q11.2 deletion syndrome.     

Multisystem inflammatory syndrome associated with COVID-19 from the pediatric emergency physician's point of view

ObjectiveMultisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19) is a rare and challenging diagnosis requiring early treatment. The diagnostic criteria involve clinical, laboratory, and complementary tests. This review aims to draw pediatrician attention to this diagnosis, suggesting early treatment strategies, and proposing a pediatric emergency care flowchart.SourcesThe PubMed/MEDLINE/WHO COVID-19 databases were reviewed for original and review articles, systematic reviews, meta-analyses, case series, and recommendations from medical societies and health organizations published through July 3, 2020. The reference lists of the selected articles were manually searched to identify any additional articles.Summary of the findingsCOVID-19 infection is less severe in children than in adults, but can present as MIS-C, even in patients without comorbidities. There is evidence of an exacerbated inflammatory response with potential systemic injury, and it may present with aspects similar to those of Kawasaki disease, toxic shock syndrome, and macrophage activation syndrome. MIS-C can develop weeks after COVID-19 infection, suggesting an immunomediated cause. The most frequent clinical manifestations include fever, gastrointestinal symptoms, rash, mucous membrane changes, and cardiac dysfunction. Elevated inflammatory markers, lymphopenia, and coagulopathy are common laboratory findings. Supportive treatment and early immunomodulation can control the intense inflammatory response and reduce complications and mortality.ConclusionsMIS-C associated with COVID-19 is serious, rare, and potentially fatal. The emergency department pediatrician must recognize and treat it early using immunomodulatory strategies to reduce systemic injury. Further studies are needed to identify the disease pathogenesis and establish the most appropriate treatment.     

Genetic Basis of Congenital Nephrotic Syndrome

A young girl presented at 1 month of age with nephrotic syndrome. By incorporating clinical and pathologic data, the diagnosis of congenital nephrotic syndrome, Finnish type, was made. The differential diagnosis of early onset nephrotic syndrome, as it pertains to this patient is discussed. This article highlights recently discovered glomerular filtration proteins and their relationship to the pathophysiology of inherited kidney disease.