Παιδιατρική | Τόμος 65 • Τεύχος 5 • Σεπτέμβριος - Οκτώβριος 2002

COVER sEpT-OcT02

14-05-03

14:07

™ÂÏ›‰·1

ISSN 0377-2551

●

TEYXO™ 5

●

ETO™ 2002

™Â٤̂ÚÈÔ˜ - √ÎÙÒ‚ÚÈÔ˜ 2002 . ∆fiÌÔ˜ 65 . ∆‡¯Ô˜ 5

∞ƒ£ƒO ™À¡∆∞•∏™ ¶ÚÔ‚Ï‹Ì·Ù· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË

EDITORIAL 309

π. ¶·Ó·ÁÈÒÙÔ˘-∞ÁÁÂÏ·ÎÔÔ‡ÏÔ˘

I. Panagiotou-Aggelakopoulou

∞¡∞™∫O¶∏™∂π™ ¶ÚfiˆÚË Ú‹ÍË ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ. ™˘Ó¤ÂȘ ÁÈ· ÙÔ Î‡ËÌ· Î·È ÙÔ ÓÂÔÁÓfi

REVIEW ARTICLES 313

µ. ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘, K. ™·Ú·Ê›‰Ë˜

∏ Û·ÚÎÔ›‰ˆÛË ÛÙËÓ ·È‰È΋ ËÏÈΛ·: ÙÔ ·ÚÂÏıfiÓ, ·ÚfiÓ Î·È Ì¤ÏÏÔÓ Ì›·˜ ·ÈÓÈÁÌ·ÙÈ΋˜ ÓfiÛÔ˘

322

333

New advances in cardiac failure in children E. Apostolou, A. Tsilimigaki

Eƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™

ORIGINAL ARTICLES 346

∞. ∫ÔÓ‰‡Ï˘, ¶. ¢Ô˘Ú›‰·˜, ∞. ™·Î·Ï›‰Ô˘, ∑. ∫·Ú·Î·ÙÛ¿ÓË, ∫. ¶Ú›ÊÙ˘

The outcome of Infants with gastroesophageal reflux and persistent or recurrent wheezing A. Kondilis, P. Douridas, A. Sakalidou, Z. Karakatsani, K. Priftis

¶AI¢IATPIKH

●

TOMO™ 65

Sarcoidosis in childhood: past, present and future of an enigmatic disease V. Tsagris, N. Manakou

∂. ∞ÔÛÙfiÏÔ˘, ∞. ∆ÛÈÏÈÌÈÁοÎË

∞ÒÙÂÚË ¤Î‚·ÛË ‚ÚÂÊÒÓ Ì Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Î·È Â›ÌÔÓÔ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi

Premature rupture of membranes.

Fetal and neonatal consequences V. Drossou-Agakidou, K. Sarafidis

µ. ∆Û·ÁÚ‹˜, ¡. ª·Ó¿ÎÔ˘

¡ÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· ÛÙ· ·È‰È¿

Symptoms of asthma and gastroesophageal reflux

ªÂÙ·‚ÔϤ˜ ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ Ù˘ Ë·Ù›Ùȉ·˜ µ Û ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ: 20 ¯ÚfiÓÈ· ÂÌÂÈÚ›·˜

351

™. ∫ˆÛÙ·Ú›‰Ô˘, ™. ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘, π.¶. ¶·Ó·ÁÈÒÙÔ˘, ª. ∞ÓÙˆÓÈ¿‰Ë˜, ∞. ∆˙È‚¿Ú·˜, £. ™·Ófi˜, ™.∞. ÷˚‰¿˜

∏ Â›‰Ú·ÛË ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ÈÎÙ¤ÚÔ˘ ÛÙË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ∫. ™Ô‡ÏË, ™. °·‚Ú›ÏË, π. ∆˙·ÌÔ˘Ú¿ÓË, ∞. ∫·›ÎË, Ã. ∫ÒÛÙ·ÏÔ˜

∏ Û˘Ó¤¯ÂÈ· ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÛÙËÓ ÚÒÙË ÂÛˆÙÂÚÈ΋ ÛÂÏ›‰·

Changes in the incidence of HBV infection among children with hematologic malignancies: 20 year experience S. Kostaridou, S. Polychronopoulou, J.P. Panagiotou, M. Antoniadis, A. Tzivaras, Th. Spanos, S.A. Haidas

356

The effect of neonatal jaundice on biotinidase activity K.H. Schulpis, S. Gavrili, J. Tjamouranis, A. Kapiki, C. Costalos

Continuation of table of contents inside title page

September - October 2002 . Volume 65 . No 5

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·1

™Â٤̂ÚÈÔ˜ - √ÎÙÒ‚ÚÈÔ˜ 2002 . ∆fiÌÔ˜ 65 . ∆‡¯Ô˜ 5

™˘Ó¤¯ÂÈ· ÂÚȯÔÌ¤ÓˆÓ ∏ Â›‰Ú·ÛË ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ·ÈÌÔÏ˘ÙÈÎÔ‡ ÈÎÙ¤ÚÔ˘ ÛÙ· Â›‰· ¯·ÏÎÔ‡ ·›Ì·ÙÔ˜ ÙÂÏÂÈfiÌËÓˆÓ Î·È ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ

Continuation of table of contents 362

K.H. Schulpis, S. Gavrili, T. Karakonstantakis, G. Chronopoulou, C. Costalos, J. Papasotiriou

∫. ™Ô‡ÏË, ™. °·‚Ú›ÏË, £. ∫·Ú·ÎˆÓÛÙ·ÓÙ¿Î˘, °. ÃÚÔÓÔÔ‡ÏÔ˘, Ã. ∫ÒÛÙ·ÏÔ˜, π. ¶··ÛˆÙËÚ›Ô˘

CASE REPORTS

E¡¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™ £ÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜ Û ·ÛıÂÓ‹ Ì ·ÈÌÔÚÚÔÊÈÏ›· ∞

367

372

377

CURRENT ISSUES

∂¶π∫∞πƒ∞ £∂ª∞∆∞ 382

Etiology of six exanthematous diseases.

Recent data T. Tsivitanidou-Kakourou

T. ∆ÛÈ‚ÈÙ·Ó›‰Ô˘-∫¿ÎÔ˘ÚÔ˘

LITERATURE ABSTRACTS

¶∂ƒπ§∏æ∂π™ ∞ƒ£ƒø¡ ∞¶O ∆∏ µπµ§πO°ƒ∞ºπ∞ OÈ Û˘Ó¤ÂȘ ÙÔ˘ Ì‹ÎÔ˘˜ Ù˘ ‚ÂÏfiÓ·˜ ÛÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÙÔÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ÛÙÔ˘˜ Û˘Ó‹ıÂȘ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ Û ‚Ú¤ÊË ËÏÈΛ·˜ 4 ÌËÓÒÓ. ∆˘¯·ÈÔÔÈË̤ÓË ÂÏÂÁ¯fiÌÂÓË ÌÂϤÙË

Thrombotic incident in a neonate heterozygote for FV Leiden. Case report M. Anagnostakou, I. Zika, H. Platokouki, C. Koumanidou

ª. ∞Ó·ÁÓˆÛÙ¿ÎÔ˘, π. ∑‹Î·, ∂. ¶Ï·ÙÔÎÔ‡ÎË, Ã. ∫Ô˘Ì·Ó›‰Ô˘

∞›ÙÈ· ¤ÍÈ ÂÍ·ÓıËÌ·ÙÈÎÒÓ ÏÔÈÌÒ͈Ó. ¶ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ

Gelastic seizures in two children with hypothalamic hamartoma N. Vassilaki, H. Kotsalis, A. Syrigou-Papavassiliou

¡. µ·ÛÈÏ¿ÎË, Ã. ∫fiÙÛ·Ï˘, ∞. ™˘Ú›ÁÔ˘-¶··‚·ÛÈÏ›Ԣ

£ÚÔÌ‚ˆÙÈÎfi ÂÂÈÛfi‰ÈÔ Û ÓÂÔÁÓfi ÂÙÂÚÔ˙˘ÁÒÙË FV Leiden. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘

Renal vein thrombosis in a patient with haemophilia A A. Michos, D. Lazopoulou, S. Aroni-Vourna, E. Platokouki-Komitopoulou, E. Georgaki, E. Charokopos

∞. ª›¯Ô˜, ¢. §·˙ÔÔ‡ÏÔ˘, ™. ∞ÚÒÓË-µÔ˘ÚÓ¿, ∂. ¶Ï·ÙÔÎÔ‡ÎË-∫ÔÌÈÙÔÔ‡ÏÔ˘, ∂. °ÂˆÚÁ¿ÎË, E. ÷ÚÔÎfiÔ˜

°ÂÏ·ÛÙÈ΋ ÂÈÏË„›· Û ‰‡Ô ·È‰È¿ Ì ˘Ôı·Ï·ÌÈÎfi ·Ì¿Úو̷

The effect of neonatal haemolytic jaundice on serum copper levels in fullterm and premature newborns

312

Effect of needle length on incidence of local reactions to routine immunisation in infants aged 4 months: randomised controlled trial

Diggle L, Deeks J

Diggle L, Deeks J

∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ∫. ∆ÛÔ˘Ì¿Î·˜

Greek translation: K. Tsoumakas

™˘Ó¯›˙ÔÓÙ·È

Continued

September - October 2002 .Volume 65 .No 5

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·2

™Â٤̂ÚÈÔ˜ - √ÎÙÒ‚ÚÈÔ˜ 2002 . ∆fiÌÔ˜ 65 . ∆‡¯Ô˜ 5

™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ

∂›ÌÔÓË ÌfiÏ˘ÓÛË ·fi ·‰ÂÓÔ˚fi Î·È ¯ÚfiÓÈ· ·ÔÊÚ·ÎÙÈ΋ ‚ÚÔÁ¯›Ùȉ· ÛÙ· ·È‰È¿: À¿Ú¯ÂÈ Û¯¤ÛË;

Continuation of table of contents

350

Pichler M, Herrmann G, Schmidt H, Ahrens P, Zielen S ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜

∞ÓÙ·fiÎÚÈÛË ÛÙ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Î·È ·ÙÔ›· Û ·È‰È¿ 5-10 ÂÙÒÓ Ì ‚‹¯·

Pichler M, Herrmann G, Schmidt H, Ahrens P, Zielen S Greek translation: ª. ∞nthrakopoulos 361

McKenzie SA, Mylonopoulou M, Bridge PD ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜

∏ ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û ·È‰È¿ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Ô˘ÚÔÏԛ̈ÍË

366

Prophylactic antibiotics in children at risk for urinary tract infection Hellerstein S, Nickell E Greek translation: K. Stefanidis

∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: K. ™ÙÂÊ·Ó›‰Ë˜ 381

Taub JW, Konrad MA, Ge Y, Naber JM, Scott JS, Matherly LH et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ™. ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘∞Ó‰ÚÔ˘Ï·Î¿ÎË

ª·ÎÚfi¯ÚÔÓË ¯ËÌÂÈÔÚÔʇϷÍË ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ˘ÔÙÚÔÒÓ Ô˘ÚÔÏԛ̈͢ Û ·È‰È¿

Bronchodilator responsiveness and atopy in 5-10-yr-old coughers McKenzie SA, Mylonopoulou M, Bridge PD Greek translation: ª. ∞nthrakopoulos

Hellerstein S, Nickell E

À„ËÏ‹ Û˘¯ÓfiÙËÙ· ·Ó‡ÚÂÛ˘ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ·ÚÈÎÒÓ ÎÏÒÓˆÓ Û ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ÓÂÔÁÓÈÎÔ‡ ÁÂÓÂÙÈο screening ·È‰ÈÒÓ Ì µ-΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·

Persistent adenoviral infection and chronic obstructive bronchitis in children: Is there a link?

High frequency of leukemic clones in newborn screening blood samples of children with B-precursor acute lymphoblastic leukemia Taub JW, Konrad MA, Ge Y, Naber JM, Scott JS, Matherly LH et al Greek translation: S. PolychronopoulouAndroulakaki

386

Williams GJ, Lee A, Craig JC ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: K. ™ÙÂÊ·Ó›‰Ë˜

Long-term antibiotics for preventing recurrent urinary tract infection in children Williams GJ, Lee A, Craig JC Greek translation: K. Stefanidis

¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·

xiii

Scheduled Medical Meetings

™˘ÓÙÔÌÔÁڷʛ˜

xvii

Abbreviations

S e p t e m b e r - O c t o b e r 2 0 0 2 .V o l u m e 6 5 . N o 5

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·3

™Â٤̂ÚÈÔ˜ - √ÎÙÒ‚ÚÈÔ˜ 2002

.

∆fiÌÔ˜ 65

. ∆‡¯Ô˜

5

¢ÈÌËÓÈ·›· ¤Î‰ÔÛË E›ÛËÌÔ ¶ÂÚÈÔ‰ÈÎfi Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜

Bimonthly Publication The Official Journal of the Hellenic Paediatric Society

EΉfiÙ˘ K. °ÚÈ‚¤·˜

Publisher K. Griveas

I‰ÈÔÎÙ‹Ù˘© EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó·È 115 28

Owner© Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28

TËÏ.: 010-7771 140 / 010-7771 663, Fax: 010-7758 354

Tel.: 010-7771 140 / 010-7771 663, Fax: 010-7758 354

EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¶Úfi‰ÚÔ˜ : ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ¢È¢ı˘ÓÙ‹˜ : ™. ÷˚‰¿˜ M¤ÏË : º. Aı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘ : °. µ·ÚÏ¿Ì˘ : ª. ∏Ï›· : π. ¶··‰¿ÙÔ˜ : ¡. ¶··‰fiÔ˘ÏÔ˜ : ™. ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘ : ∫. ¶ÚÔ‡ÓÙ˙Ô˘-∫·ÛÛÈÔ‡ : ∫. ™ÙÂÊ·Ó›‰Ë˜ : ª. ∆ÛÔÏÈ¿ : ™. ºˆÙfiÔ˘ÏÔ˜

Scientific President Editor Members

ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ I. K·Ú·‚Ú¿ÓÔ˘

Manuscript Editing

∞ÏÏËÏÔÁÚ·Ê›· ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ªÈ¯·Ï·ÎÔÔ‡ÏÔ˘ 92 ∞ı‹Ó·È 115 28 ∆ËÏ: 010-7771 140 / 010-7771 663, Fax: 010-7758 354

Correspondence Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28 Tel: 010-7771 140 / 010-7771 663, Fax: 010-7758 354

™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜

Publishing Coordinator

E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ¶. ∆۷ω¿ÚË 3, 151 22 M·ÚÔ‡ÛÈ TËÏ.: 010-61 41 360-5 Fax: 010-61 41 366

SCIENTIFIC PUBLICATIONS Ltd P. Tsaldari 3, Marousi 151 22 Tel.: 010-61 41 360-5 Fax: 010-61 41 366

EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹

Annual Subscription

30 c

EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜: 15 c

Editorial Board : A. Constantopoulos : S. Haidas : F. Athanassiadou-Piperopoulou : G. Varlamis : M. Ilia : I. Papadatos : N. Papadopoulos : S. Polychronopoulou : K. Prountzou-Kassiou : C. Stefanidis : M. Tsolia : S. Fotopoulos

Greek Editing I. Karavranou

All foreign countries: US $ 30

S e p t e m b e r - O c t o b e r 2 0 0 2 .V o l u m e 6 5 .N o 5

πSSN 0377-2551 i

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·5

O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫H” Â›Ó·È Ë Â›ÛËÌË ÂÈÛÙËÌÔÓÈ΋ ¤Î‰ÔÛË Î·È È‰ÈÔÎÙËÛ›· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜. Œ¯ÂÈ ˆ˜ ‚·ÛÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ¤ÚÁÔ˘ ÛÙËÓ ∂ÏÏ¿‰· Î·È ÙË Û˘Ó¯‹ È·ÙÚÈ΋ ÂÓË̤ڈÛË Î·È ÂÈÌfiÚʈÛË ÙˆÓ EÏÏ‹ÓˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: ¿ÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ EÈÛÙËÌÔÓÈ΋˜ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜), ·Ó·ÛÎÔ‹ÛÂȘ, Â›Î·ÈÚ· ı¤Ì·Ù·, ÂÍÂÏ›ÍÂȘ ÛÙËÓ π·ÙÚÈ΋ ∂ÈÛÙ‹ÌË, ÚˆÙfiÙ˘˜ ÂÚ¢ÓËÙÈΤ˜ ÌÂϤÙ˜ Ì ·È‰È·ÙÚÈÎfi ‹ È·ÙÚÔÎÔÈÓˆÓÈÎfi ÂÚȯfiÌÂÓÔ, ÁÂÓÈο ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÙÔÓ ÚÔÁÚ·ÌÌ·ÙÈÛÌfi Î·È ÙËÓ ÔÚÁ¿ÓˆÛË Ù˘ È·ÙÚÈ΋˜ ÂÎ·›‰Â˘Û˘ Î·È ˘Á›·˜, ‚Ú·‚Â˘Ì¤Ó˜ ÂÚÁ·Û›Â˜, ÂÈÏÂÁ̤Ó˜ Û˘˙ËÙ‹ÛÂȘ ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ, ÂӉȷʤÚÔ˘Û˜ ÎÏÈÓÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ, ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ, ‚È‚ÏÈÔÎÚÈۛ˜, ÂÈÛÙÔϤ˜ ÚÔ˜ ÙË Û‡ÓÙ·ÍË, ÂÚÈÏ‹„ÂȘ Ù˘ ÂÏÏËÓÈ΋˜ Î·È Í¤Ó˘ ‚È‚ÏÈÔÁÚ·Ê›·˜, ·Ó·ÎÔÈÓÒÛÂȘ ÚÔÛ¯ÒÓ Û˘ÌÔÛ›ˆÓ Î·È Û˘Ó‰ڛˆÓ Û ı¤Ì·Ù· Û¯ÂÙÈο Ì ÙËÓ ¶·È‰È·ÙÚÈ΋ Î·È ·Ó·ÊÔÚ¤˜ Ó¤ˆÓ ÂΉfiÛˆÓ, ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ, ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜.

H EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi ÂӉȷʤÚÔÓ ¯ˆÚ›˜ Ó· ÙËÚÂ›Ù·È Ë ÛÂÈÚ¿ ˘Ô‚ÔÏ‹˜ Î·È Ó· ·ÔÊ·Û›˙ÂÈ ÁÈ· ÙË ‰ËÌÔÛ›Â˘ÛË ÂÚÁ·ÛÈÒÓ Ô˘ ¤¯Ô˘Ó ‚Ú·‚¢ı› ÛÙ· Ï·›ÛÈ· ÙÔ˘ ÂÙ‹ÛÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ, ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ È‰È·›ÙÂÚÔ˘ ÂӉȷʤÚÔÓÙÔ˜, Î·È ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. µ. ÀÔ‚ÔÏ‹ Î·È ¢ËÌÔÛ›Â˘ÛË ÙˆÓ ∂ÚÁ·ÛÈÒÓ OÈ ÂÚÁ·Û›Â˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÚÔ˜ ÎÚ›ÛË ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫H” ·ÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 115 28 Aı‹Ó· ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÂÈÛÙÔÏ‹, Ë ÔÔ›· ı· Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÛÙËÓ ÔÔ›· ı· ‰ËÏÒÓÂÙ·È fiÙÈ Ë ÂÚÁ·Û›· ‰ÂÓ ¤¯ÂÈ ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi Î·È fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ÂÁÎÚ›ÓÔ˘Ó ÙË ‰ËÌÔÛ›Â˘Û‹ Ù˘ ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫H”. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ - ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÁÚ·Ù‹ ‰‹ÏˆÛË ÙˆÓ Û˘ÁÁڷʤˆÓ fiÙÈ ¤ÁÈÓ·Ó ÌÂÙ¿ ·fi ÏËÚÔÊÔÚË̤ÓË Û˘Ó·›ÓÂÛË ÙˆÓ ÌÂÙ¯fiÓÙˆÓ ‹ ÙˆÓ ÓÔÌ›ÌˆÓ ÂÎÚÔÛÒˆÓ ÙÔ˘˜ Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. ŸÏ˜ ÔÈ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ıˆÚÔ‡ÓÙ·È È‰ÈÔÎÙËÛ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶∞π¢π∞∆ƒπ∫H” Î·È Ë ÔÏÈ΋ ‹ ÌÂ-

ÚÈ΋ ·Ó·‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ∏ ¶∞π¢π∞∆ƒπ∫∏ ÚÔÙ›ÓÂÈ Ó· ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÔÈ “∫ÔÈÓ¤˜ ¶ÚԉȷÁڷʤ˜ ÁÈ· ÃÂÈÚfiÁÚ·Ê· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û µÔ˚·ÙÚÈο ¶ÂÚÈÔ‰Èο” (Uniform Requirements for Manuscripts Submitted to Biomedical Journals) Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÛÙÔ JAMA 1997;277:927934, http://jama.ama-assn.org/info/auinst_req.html.

OÈ ·fi„ÂȘ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚËÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·fi ÙÔÓ EΉfiÙË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡.

EÊfiÛÔÓ Ë ÂÚÁ·Û›· Á›ÓÂÈ ·Ô‰ÂÎÙ‹, ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Û‡Ìʈӷ Ì ÙȘ ˘ԉ›ÍÂȘ ÙˆÓ ÎÚÈÙÒÓ Î·È ÂÎ Ó¤Ô˘ ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÂÙ·È ÛÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ Û˘Óԉ¢fiÌÂÓÔ ·fi ‰ÈÛΤٷ Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÚÁ·Û›· Û ÚfiÁÚ·ÌÌ· Word.doc ‹ MacWrite Î·È ÙÔ˘˜ ›Ó·Î˜, ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ, Û ÚfiÁÚ·ÌÌ· Excel ηıÒ˜ Î·È ÂÈÛÙÔÏ‹ fiÔ˘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ‹ ÔÈ ·ÓÙÈÚÚ‹ÛÂȘ ÛÙȘ ÚÔÙ¿ÛÂȘ ÙˆÓ ÎÚÈÙÒÓ. H ηı˘ÛÙ¤ÚËÛË Ù˘ Â·Ó˘Ô‚ÔÏ‹˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ ÎÂÈ̤ÓÔ˘ ¤Ú·Ó ÙˆÓ 30 ËÌÂÚÒÓ Û˘ÓÂ¿ÁÂÙ·È Ó¤· ˘Ô‚ÔÏ‹. °È· Ó· ÂÈÙ¢¯ı› Ë ¤ÁηÈÚË ‰ËÌÔÛ›Â˘ÛË Ù˘ ÂÚÁ·Û›·˜ Â›Ó·È ··Ú·›ÙËÙÔ Ó· ÂÈÛÙÚ¤ÊÂÙ·È ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Ù˘ÔÁÚ·ÊÈÎfi ‰ÔΛÌÈÔ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ̤۷ Û ‰‡Ô (2) Ë̤Ú˜.

T· ¤ÍÔ‰· ÙˆÓ ÊÈÏ̘ Î·È ÙˆÓ ·Ó·Ù‡ˆÓ ‚·Ú‡ÓÔ˘Ó ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Î·È Ú¤ÂÈ Ó· ÏËÚÒÓÔÓÙ·È Ì ÙËÓ ·ÔÛÙÔÏ‹ ÙÔ˘ ÚÒÙÔ˘ ‰ÔÎÈÌ›Ô˘ ηÙ¢ı›·Ó ÛÙÔÓ Ù˘ÔÁÚ¿ÊÔ.

T· ΛÌÂÓ· ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ÁÈ· ‰ËÌÔÛ›Â˘ÛË ‰ÂÓ ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·ÊÔ‡Ó, ÂÊfiÛÔÓ ˙ËÙËı›, Ù· Û¯‹Ì·Ù· Î·È ÔÈ ÊˆÙÔÁڷʛ˜ Ô˘ Ù· Û˘Óԉ‡ԢÓ. °. ™‡ÓÙ·ÍË ÙˆÓ ∂ÚÁ·ÛÈÒÓ TÔ Û‡ÓÔÏÔ Ù˘ ÂÚÁ·Û›·˜ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÈÓ¿ÎˆÓ Î·È ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÈÎfiÓˆÓ) Ú¤ÂÈ Ó· Â›Ó·È ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ ÛÙË ÌÈ· fi„Ë Ï¢ÎÔ‡ ¯·ÚÙÈÔ‡ ÌÂÁ¤ıÔ˘˜ A4 (21x29.7 cm) Ì ‰ÈÏfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÁÚ·ÌÌÒÓ Î·È Ê·Ú‰È¿ ÂÚÈıÒÚÈ· (2,5 cm) ÛÙȘ ‰‡Ô Ï¢ڤ˜.

TÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ¤¯ÂÈ ÙËÓ ·ÎfiÏÔ˘ıË ‰È¿Ù·ÍË: ÛÂÏ›‰· Ù›ÙÏÔ˘, ‚Ú·¯‡˜ Ù›ÙÏÔ˜, ÂÚ›ÏË„Ë ÛÙ· ÂÏÏËÓÈο Î·È Ù· ·ÁÁÏÈο, ΛÌÂÓÔ, ¢¯·ÚÈÛٛ˜ ηıÒ˜ Î·È ·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ, ηٿÏÔÁÔ˜ Û˘ÓÙÌ‹ÛˆÓ. K¿ı ¤Ó· ·fi Ù· ·Ú·¿Óˆ ÛÙÔȯ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û ¯ˆÚÈÛÙfi ʇÏÏÔ Î·È ÔÈ ÛÂÏ›‰Â˜ Ó· ·ÚÈıÌÔ‡ÓÙ·È ‰È·‰Ô¯Èο ·Ú¯›˙ÔÓÙ·˜ Ì ÙË ÛÂÏ›‰· Ù›ÙÏÔ˘.

v

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·6

H ¤ÎÙ·ÛË ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÁÈ· ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ Û 15-25, ÁÈ· ÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ Û 12-15 ÛÂÏ›‰Â˜, ÁÈ· Ù· Â›Î·ÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ Û 3-5 ‰·ÎÙ˘ÏÔÁÚ·ÊË̤Ó˜ ÛÂÏ›‰Â˜, ÂÓÒ ÁÈ· ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000 ϤÍÂȘ Î·È ÁÈ· ÙȘ ÂÈÛÙÔϤ˜ Û 250-300 ϤÍÂȘ. ™ÂÏ›‰· Ù›ÙÏÔ˘ ¶Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÙÔÓ Ù›ÙÏÔ (<14 ϤÍÂȘ) ηıÒ˜ Î·È ÙÔÓ ‚Ú·¯‡ Ù›ÙÏÔ (<5 ϤÍÂȘ) ÙÔ˘ ¿ÚıÚÔ˘. ¢ÂÓ ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ, - ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋, - ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ë ÂÚÁ·Û›·. ™Â ÂÚ›ÙˆÛË ¤ÏÏÂȄ˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ ΤÓÙÚ·, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È Ë È‰ÈfiÙËÙ· ÙÔ˘/ÙˆÓ Û˘ÁÁڷʤˆÓ (.¯. ȉÈÒÙ˘ ·È‰›·ÙÚÔ˜) Î·È Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙˆÓ, - ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›Ô Á›ÓÂÙ·È Ë ·ÏÏËÏÔÁÚ·Ê›·. ¶ÂÚÈÏ‹„ÂȘ H ÂÚ›ÏË„Ë Ú¤ÂÈ Ó· ·Ó·ÎÂÊ·Ï·ÈÒÓÂÈ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ÂÚÁ·Û›·˜, ÙË ÌÂıÔ‰ÔÏÔÁ›·, Ù· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘. ¢ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙȘ 250 ϤÍÂȘ. ™ÙËÓ ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ô Ù›ÙÏÔ˜ Ù˘ ÂÚÁ·Û›·˜ Î·È Ù· ÔÓfiÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ ÛÙ· ·ÁÁÏÈο. TÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ·ÁÁÏÈÎÔ‡ ÎÂÈ̤ÓÔ˘ ‰ÂÓ Ú¤ÂÈ Ó· ‰È·Ê¤ÚÂÈ ·fi ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÂÏÏËÓÈÎfi.

T· ¿ÚıÚ· Û‡ÓÙ·Í˘ Î·È ÔÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ¤¯Ô˘Ó ÌfiÓÔ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë.

K¿Ùˆ ·fi ÙËÓ ÂÏÏËÓÈ΋ Î·È ÙËÓ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë ÛËÌÂÈÒÓÔÓÙ·È ÙÚÂȘ ¤ˆ˜ ¤ÓÙ ϤÍÂȘ ÎÏÂȉȿ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔ ıÂÌ·ÙÈÎfi ¢ÚÂÙ‹ÚÈÔ.

K›ÌÂÓÔ OÈ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ÂÈÛ·ÁˆÁ‹, ÌÂıfi‰Ô˘˜, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘˙‹ÙËÛË. H ∂ÈÛ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ Ù˘ ¤Ú¢ӷ˜ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì· Ì ÙȘ ΢ÚÈfiÙÂÚ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ Î·È ÙÔ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙˆÓ ªÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜ ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. T· ∞ÔÙÂϤÛÌ·Ù· Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ۷ʋÓÂÈ· Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÙËÓ ··Ú·›ÙËÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. H ™˘˙‹ÙËÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ.

OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÈÛ·ÁˆÁ‹, ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË. OÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ ηÈ

vi

‚Ú·¯Â›· Û˘˙‹ÙËÛË Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ - ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Î·È ÚÈÓ ·fi ÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜.

TÈ̤˜ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ OÈ ÙÈ̤˜ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Ú¤ÂÈ Ó· ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ¢ÈÂıÓ¤˜ ™‡ÛÙËÌ· MÔÓ¿‰ˆÓ (SI Units) Î·È ÛÙÔ MÂÙÚÈÎfi (Conventional-™˘Ì‚·ÙÈÎfi) ™‡ÛÙËÌ· ̤۷ Û ·Ú¤ÓıÂÛË. ¶›Ó·Î˜ ÌÂÙ·ÙÚÔ‹˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ JAMA 1986;255:2329-2339. ™˘ÓÙÔÌÔÁڷʛ˜ OÈ Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ¤¯Ô˘Ó ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜ ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ Â·Ó·Ï·Ì‚¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ Ô ÔÔ›Ô˜ ˘Ô‚¿ÏÏÂÙ·È Ì·˙› Ì ÙËÓ ÂÚÁ·Û›·. OÈ Û˘ÓÙÔÌÔÁڷʛ˜ ·Ó·Ê¤ÚÔÓÙ·È Û ·Ú¤ÓıÂÛË ÌfiÓÔ ÛÙȘ ÂÚÈÏ‹„ÂȘ.

BÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó ÙȘ 70 ÛÙȘ ·Ó·ÛÎÔ‹ÛÂȘ, ÙȘ 30 ÛÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜, ÙȘ 12 ÛÙ· Â›Î·ÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ, ÙȘ 5 ÛÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ.

H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚԉȷÁڷʤ˜ Ù˘ International Committee of Medical Journal Editors / Uniform Requirements for Manuscripts Submitted to Biomedical Journals (JAMA 1997;277:927-934), http://jama.amaassn.org/info/auinst_req.html. OÈ Û˘ÓÙÌ‹ÛÂȘ ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ Á›ÓÔÓÙ·È Ì ‚¿ÛË ÙÔ Cumulated Index Medicus (List of Journals Indexed in Index Medicus, http://www.nlm.nih.gov). ¶·Ú·‰Â›ÁÌ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ I. ¶ÂÚÈÔ‰Èο AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ·Ó Â›Ó·È ÂÙ¿ ‹ ÂÚÈÛÛfiÙÂÚÔÈ ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ÚÒÙÔÈ ¤ÍÈ Î·È ÚÔÛÙ›ıÂÙ·È “et al” ‹ “Î·È Û˘Ó”.

T·ÎÙÈ΋ ¤Î‰ÔÛË ÂÚÈÔ‰ÈÎÔ‡: ∞ÏÂ͛Ԣ ¢, ª¿Ú· Ã, °È·ÓÓ·ÎÔÔ‡ÏÔ˘ Ã. ∂Ì‚fiÏÈ·, ·ÚfiÓ Î·È Ì¤ÏÏÔÓ: Â›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1996;59:272-279.

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·7

Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679.

elderly’s access and utilization [dissertation]. St. Louis (Mo): Washington Univ.; 1995.

™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19.

¶›Ó·Î˜ Î·È EÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó (¤Ó· ÚˆÙfiÙ˘Ô+‰‡Ô ʈÙÔ·ÓÙ›ÁÚ·Ê·). ¶Ú¤ÂÈ Ó· ¤¯Ô˘Ó Ï¿ÙÔ˜ ›ÛÔ Ì ÙÔ Ï¿ÙÔ˜ ÙÔ˘ ÌÔÓfiÛÙËÏÔ˘ (8 cm) ‹ Ì ÙÔ Ï¿ÙÔ˜ fiÏ˘ Ù˘ ÛÂÏ›‰·˜ (16,8 cm). TÔ Ì¤ÁÈÛÙÔ Ì‹ÎÔ˜ ÙÔ˘˜, Ì·˙› Ì ÙÔ˘˜ Ù›ÙÏÔ˘˜, ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·fi 22 cm.

OÈ ›Ó·Î˜ ·ÚÈıÌÔ‡ÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‚Ú·¯‡ Ù›ÙÏÔ Î·È ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÌ‹ÛÂˆÓ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜. ™ÙÔ˘˜ ›Ó·Î˜ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÔÈ Î¿ıÂÙ˜ ÁÚ·Ì̤˜. ŸÏÔ ÙÔ ·ÂÈÎÔÓÈÛÙÈÎfi ˘ÏÈÎfi (Û¯‹Ì·Ù·, ‰È·ÁÚ¿ÌÌ·Ù·, ʈÙÔÁڷʛ˜, ÎÏ.) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÂÈÎfiÓ˜. £· Ú¤ÂÈ Ó· Â›Ó·È ¿ÚÈÛÙ˘ ÔÈfiÙËÙ·˜ Ì ÌÔÚÊ‹ ʈÙÔÁÚ·ÊÈÒÓ ‹ Î·È ÚˆÙÔÙ‡ˆÓ. ™ÙÔ ›Ûˆ ̤ÚÔ˜ ÙˆÓ ÂÈÎfiÓˆÓ Ú¤ÂÈ Ó· ÛËÌÂÈÒÓÂÙ·È Ì ÌÔχ‚È Ô ·ÚÈıÌfi˜ Ù˘ ÂÈÎfiÓ·˜ Î·È ÙÔ fiÓÔÌ· ÙÔ˘ ÚÒÙÔ˘ Û˘ÁÁڷʤ·, ηıÒ˜ Î·È ¤Ó· ‚¤ÏÔ˜ ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÙÔ ¿Óˆ ̤ÚÔ˜ Ù˘ ÂÈÎfiÓ·˜. ™ÙȘ ʈÙÔÁڷʛ˜ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Ù·˘ÙfiÙËÙ¿ ÙÔ˘˜. OÈ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÓÔÌ·ÛÙÈο.

Èڛ˜ Û˘ÁÁڷʤ·: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù‡Ô˘ ¿ÚıÚÔ˘: ∫Ô˘Ú›‰Ë˜ Ã, ∫Ô˘Ú›‰Ë˜ °. ¶·¯˘Û·ÚΛ· Î·È ˘ÂÚÏÈȉ·ÈÌ›· Û ·È‰È¿ ‚ÔÚÂÈÔ‰˘ÙÈ΋˜ ∫‡ÚÔ˘ [¶ÂÚ›ÏË„Ë].

36Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ; 1998 5-7 πÔ˘Ó›Ô˘; ¶¿ÊÔ˜, ∫‡ÚÔ˜;1998. ÛÂÏ. 172.

Schreiner GF, Lange L. Ethanol modulation of macrophage influx in glomerulonephritis [abstract].

J Am Soc Nephrol 1991;2:562.

Should antileukotriene therapies be used instead of inhaled corticosteroids in asthma? [Editorial]. Am J Respir Crit Care Med 1998;158:1697-1701.

Laux-End R, Inaebnit D, Gerber HA, Bianchetti MG. Vasculitis associated with levamisole and circulating autoantibodies [letter]. Arch Dis Child 1996;75:355-356.

II. µÈ‚Ï›· ∫ÂÊ¿Ï·ÈÔ Û ‚È‚Ï›Ô: Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome. In: Barratt TM, Arner ED, Harmon WE, editors. Pediatric Nephrology. 4th ed. Baltimore: Lippincott William Wilkins; 1999. p. 742. ™‡ÁÁÚ·ÌÌ· ‹ ÌÔÓÔÁÚ·Ê›·: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990. ¢ËÌÔÛ›Â˘ÛË Û ÙfiÌÔ Ú·ÎÙÈÎÒÓ: Bauer AW. The two definitions of bacterial resistance. In: Smith AJ, Rogers CA, eds. Proceedings of the Third International Congress of Chemotherapy; 1962 May 29-31; New York: International Society of Chemotherapy; 1963. p. 484-500.

¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ÙËÓ ÂÚÁ·Û›· Û·˜ ‚‚·Èˆı›Ù fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÂÈÛÙÔÏ‹ ˘Ô‚ÔÏ‹˜ - ‰‹ÏˆÛË ÌË ÚÔÁÂÓ¤ÛÙÂÚ˘ ‰ËÌÔÛ›Â˘Û˘ Ù˘ ÂÚÁ·Û›·˜ - 3 ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ù˘ ÂÚÁ·Û›·˜ - ÛÂÏ›‰· Ù›ÙÏÔ˘ (¯ˆÚÈÛÙ‹ ÛÂÏ›‰·): ÂÚÈÏ·Ì‚¿ÓÂÈ - Ù›ÙÏÔ Î·È ‚Ú·¯‡ Ù›ÙÏÔ ÂÚÁ·Û›·˜ - fiÓÔÌ· Î·È ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜), ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›· - fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›· - ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋, ϤÍÂȘ ÎÏÂȉȿ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ηٿÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ΛÌÂÓÔ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ¢¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) - ‚È‚ÏÈÔÁÚ·Ê›· (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó - ÂÈÎfiÓ˜, Ì ‚¤ÏÔ˜ ÛÙÔ ›Ûˆ ̤ÚÔ˜ Ó· ‰Â›¯ÓÂÈ ÚÔ˜ Ù· Â¿Óˆ, ·ÚÈıÌË̤Ó˜, ÂȘ ÙÚÈÏÔ‡Ó - Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.

¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¡ÙÔ˘ÓÙÔ˘Ï¿Î˘ π. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ıÂÚ·›· ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ÂÍ·ÚıÚ‹Ì·ÙÔ˜ ÙÔ˘ ÈÛ¯›Ô˘ Û ·È‰È¿ οو ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜ [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979.

Kaplan SJ. Post hospital home health care: the

vii

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·309

¶·È‰È·ÙÚÈ΋ 2002;65:309-312

∞ƒ£ƒO ™À¡∆∞•∏™

Paediatriki 2002;65:309-312

EDITORIAL

¶ÚÔ‚Ï‹Ì·Ù· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË π. ¶·Ó·ÁÈÒÙÔ˘ - ∞ÁÁÂÏ·ÎÔÔ‡ÏÔ˘

Symptoms of asthma and gastroesophageal reflux I. Panagiotou - Aggelakopoulou

¶ÂÚ›ÏË„Ë: ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶) ‰ÂÓ Â›Ó·È Û·ÊÒ˜ ηıÔÚÈṲ̂ÓË. ªÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ Ì ¿ÛıÌ· ¤¯ÂÈ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, Ë ÔÔ›· ‰È·ÁÈÁÓÒÛÎÂÙ·È Ì 24ˆÚË pH-ÌÂÙÚ›·. ŸÙ·Ó ÙÂı› Û˘ÁÎÂÎÚÈ̤ÓË ‰È¿ÁÓˆÛË, Ë °O¶ ··ÈÙ› Ì·ÎÚfi¯ÚÔÓË ıÂÚ·›· Î·È ·Ú·ÎÔÏÔ‡ıËÛË. ∞ÓÙ·fiÎÚÈÛË ÛÙË ıÂÚ·›· ıˆÚÂ›Ù·È Ë ‚ÂÏÙ›ˆÛË ÙfiÛÔ ÙˆÓ ÎÚ›ÛÂˆÓ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÛÈÚÔÌÂÙÚ›·˜, fiÛÔ Î·È Ë ÂÏ¿ÙÙˆÛË ÙˆÓ ··ÈÙ‹ÛÂˆÓ Û ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Î·È ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë Ê¿Ú̷η. ¶Ó¢ÌÔÓ›· ·fi ÂÈÛÚfiÊËÛË Ô˘ Û˘Ó‰¤ÂÙ·È Ì °O¶ ÌÔÚ› Ó· ˘¿ÚÍÂÈ ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ÔÈÛÔÊ·Á›Ùȉ·˜. ∂›Ó·È ÛÎfiÈÌÔ ÛÙË ‰ÈÂÚ‡ÓËÛË Ó· ·ÔÎÏ›ÔÓÙ·È ¿ÏÏ· ·›ÙÈ· ˘‡ı˘Ó· ÁÈ· Ó¢ÌÔÓ›· ·fi ÂÈÛÚfiÊËÛË. ¢ÂÓ ˘¿Ú¯ÂÈ ÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË Ë ÔÔ›· Ó· ·Ô‰ÂÈÎÓ‡ÂÈ Û·ÊÒ˜ Î·È Ó· ÙÂÎÌËÚÈÒÓÂÈ ÙË Û˘Ì‚ÔÏ‹ Ù˘ °O¶ ÛÙËÓ Ó¢ÌÔÓ›· ·fi ÂÈÛÚfiÊËÛË. ∏ 24ˆÚË pH-ÌÂÙÚ›·, ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· Î·È Ë ·Ó·˙‹ÙËÛË Ì·ÎÚÔÊ¿ÁˆÓ ‹ Ï·ÎÙfi˙˘ (lipid laden macrophages) ÛÙÔ ‚ÚÔÁ¯ÈÎfi ¤ÎÏ˘Ì· Â›Ó·È ÂÍÂÙ¿ÛÂȘ Ô˘ ÂӉ¯Ô̤ӈ˜ ÂÓÈÛ¯‡Ô˘Ó ÙË ‰È¿ÁÓˆÛË.

Abstract: Symptoms of asthma are common in children with gastroesophageal reflux (GER).

Although a direct causal relationship between asthma and GER is rare, GEK seems to contribute in asthma severity. A great number of children with asthma have gastroesophageal reflux detectable by esophageal pH-monitoring. A prolonged and careful treatment of GER is required. This treatment improves clinical symptoms and spirometry parameters and reduces required doses of bronchodilators. GER related aspiration pneumonia exists in the absence of esophagitis. Before considering GER as potential cause of recurrent pneumonia it is important to exclude other causes.

Often the clinician must make management decisions based on inconclusive information.

Normal esophageal pH-monitoring does not exclude aspiration pneumonia. Pulmonary lavage for lipid laden macrophages or lastose has been utilized to detect aspiration. Negative scintigraphy study does not exclude the possibility that GER occurs infrequently with aspiration.

§¤ÍÂȘ ÎÏÂȉȿ: Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶), ¿ÛıÌ·, Ó¢ÌÔÓ›· ·fi ÂÈÛÚfiÊËÛË, 24ˆÚË pH-ÌÂÙÚ›·, ÛÈÓıËÚÔÁÚ¿ÊËÌ·, ÛÈÛ·Ú›‰Ë.

Key words: gastroesophageal reflux (GER), asthma, aspiration pneumonia, 24hour pH-metry, scintigraphy (milk-scanning), cisapride.

™ÙË ÛÂÏ›‰· 346 ·˘ÙÔ‡ ÙÔ˘ Ù‡¯Ô˘˜ ‰ËÌÔÛȇÂÙ·È ¿ÚıÚÔ Ì ٛÙÏÔ “∞ÒÙÂÚË ¤Î‚·ÛË ‚ÚÂÊÒÓ Ì Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Î·È Â›ÌÔÓÔ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi” ÙˆÓ ∞. ∫ÔÓ‰‡ÏË, ¶. ¢Ô˘Ú›‰·, ∞. ™·Î·Ï›‰Ô˘, ∑. ∫·Ú·Î·ÙÛ¿ÓË Î·È ∫. ¶Ú›ÊÙË, ÙÔ ÔÔ›Ô ÌÂÏÂÙ¿ Úfi‚ÏËÌ· ˘·ÚÎÙfi ·Ó ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛÙ› ÛˆÛÙ¿ Î·È ¤ÁηÈÚ·.

∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶) ‰ÂÓ Â›Ó·È Û·ÊÒ˜ ηıÔÚÈṲ̂ÓË. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ Û·ÊÒ˜ ¿ÌÂÛË ·ÈÙÈÔÏÔÁÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ¿ÛıÌ·ÙÔ˜ Î·È ·ÏÈÓ‰ÚfiÌËÛ˘, Ê·›ÓÂÙ·È fiÙÈ Ë Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÙfiÛÔ ÛÙË

∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

1st Pediatric Clinic of University of Athens, “Aghia Sophia” Children’s Hospital, Athens

309

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·310

¶·È‰È·ÙÚÈ΋ 2002;65:309-312

ÛÔ‚·ÚfiÙËÙ·, fiÛÔ Î·È ÛÙËÓ ÂÈÌÔÓ‹ ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ªÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ Ì ¿ÛıÌ· ¤¯ÂÈ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, Ë ÔÔ›· ‰È·ÁÈÁÓÒÛÎÂÙ·È Ì ÙË ‚Ô‹ıÂÈ· Ù˘ 24ˆÚ˘ ÔÈÛÔÊ·ÁÈ΋˜ pH-ÌÂÙÚ›·˜. ∏ ÂͤٷÛË ·˘Ù‹ Ê·›ÓÂÙ·È Ó· Â›Ó·È Î·ıÔÚÈÛÙÈ΋ ÛÙȘ ÂÚÈÙÒÛÂȘ ¿ÛıÌ·ÙÔ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì °O¶ (1-3). ™Â ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ Ë ‰È¿ÁÓˆÛË Ù˘ °O¶ Â›Ó·È ÂÚÁ·ÛÙËÚȷ΋, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ô ¿ÚÚˆÛÙÔ˜ Ì ¿ÛıÌ· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Î·Ì›· ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË ·fi ÙÔ ÂÙÈÎfi, fiˆ˜ Â̤ÙÔ˘˜, ‰˘ÛÊ·Á›· ‹ ÔÈÛıÔÛÙÂÚÈÓÈÎfi η‡ÛÔ, ÂÓÒ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÙÒÛÂȘ ¿ÛıÌ·ÙÔ˜ Ô˘ ‚ÂÏÙÈÒıËÎ·Ó Ì ·ÓÙÈ·ÏÈÓ‰ÚÔÌÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË (4). ¢‡Ô Â›Ó·È ÔÈ Èı·ÓÔ› Ì˯·ÓÈÛÌÔ› ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Ô˘ Û˘Ó‰¤ÂÙ·È Ì Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË: ·) ¿ÌÂÛË ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ ÚÔ˜ ÙÔ Ô͇ Î·È ‚) ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ· ÙˆÓ ‚ÚfiÁ¯ˆÓ ÚÔ˜ ÙÔ Ô͇. ∏ Ì·ÎÚfi¯ÚÔÓË ıÂÚ·›· Ù˘ °O¶ ‚ÂÏÙÈÒÓÂÈ ÙË Û˘Ìو̷ÙÔÏÔÁ›· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ Ù˘ ÛÈÚÔÌÂÙÚ›·˜, ÂÓÒ ·Ú¿ÏÏËÏ· Ê·›ÓÂ-

Paediatriki 2002;65:309-312

Ù·È Ó· Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ ··ÈÙ‹ÛÂˆÓ Û ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ê¿Ú̷η. ∂Ï¿¯ÈÛÙÔ˜ ¯ÚfiÓÔ˜ ıÂÚ·›·˜ ıˆÚÔ‡ÓÙ·È ÔÈ ÙÚÂȘ Ì‹Ó˜, ÂÓÒ ‰ÂÓ Â›Ó·È ÛˆÛÙ‹ Ë ÂÌÂÈÚÈ΋ ıÂÚ·›· Ù˘ °O¶ Û ·ÛıÂÓ›˜ ¯ˆÚ›˜ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ÂÙÈÎfi ‹ Û ·ÛıÂÓ›˜ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ pHÌÂÙÚ›· (5,6). ™ÙÔ ™¯‹Ì· 1 Ê·›ÓÂÙ·È Ô ·ÏÁfiÚÈıÌÔ˜ Ù˘ ıÂÚ·›·˜ ÁÈ· Ù· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ Ì Â›ÌÔÓÔ ¿ÛıÌ· Î·È Èı·Ó‹ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈÎË ·ÏÈÓ‰ÚfiÌËÛË. º¿ÚÌ·ÎÔ ÂÎÏÔÁ‹˜ ÛÙË ıÂÚ·›· ıˆÚÂ›Ù·È Ë ÛÈÛ·Ú›‰Ë, Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙȘ ·Ó·Áη›Â˜ ÚÔÊ˘Ï¿ÍÂȘ ÛÙË ¯ÔÚ‹ÁËÛ‹ Ù˘, ÔÈ Ôԛ˜ ¤¯Ô˘Ó ÙÂı› ·fi ÙËÓ ∂˘Úˆ·˚΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ Î·È ¢È·ÙÚÔÊ‹˜ (¶›Ó·Î·˜ 1) (7,8). ∞ÛıÂÓ›˜ Ì ¿ÛıÌ· Ô˘ ˘·ÎÔ‡Ô˘Ó ÛÙËÓ ·ÓÙÈ·ÏÈÓ‰ÚÔÌÈ΋ ıÂÚ·›· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙÔ˘ ÂÙÈÎÔ‡ (Â¿Ó ¤¯Ô˘Ó), ·Ú·ÈfiÙÂÚ˜ Î·È ËÈfiÙÂÚ˜ ÎÚ›ÛÂȘ ¿ÛıÌ·ÙÔ˜, Û¿ÓÈ· Ó˘ÎÙÂÚÈÓ¿ Û˘ÌÙÒÌ·Ù· (‚‹¯·˜, ‰‡ÛÓÔÈ·), Ù·¯‡ÙÂÚË ·Ó·ÎÔ‡ÊÈÛË ·fi ·˘Ù¿, ÂÏ¿ÙÙˆÛË ÙˆÓ ··ÈÙ‹ÛÂˆÓ Û ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ê¿Ú̷η Î·È Î·Ï‡ÙÂÚË ÔÈfiÙËÙ· ˙ˆ‹˜.

™¯‹Ì· 1. ∞ÏÁfiÚÈıÌÔ˜ ıÂÚ·›·˜ ÁÈ· ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ì Â›ÌÔÓÔ ¿ÛıÌ· Î·È Èı·Ó‹ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË.

310

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·311

¶·È‰È·ÙÚÈ΋ 2002;65:309-312

Paediatriki 2002;65:309-312

¶›Ó·Î·˜ 1. ¶ÚÔÊ˘Ï¿ÍÂȘ ÛÙË ¯ÔÚ‹ÁËÛË Ù˘ ÛÈÛ·Ú›‰Ë˜ ·) ¡· ·ÔʇÁÂÙ·È Ë Û˘Á¯ÔÚ‹ÁËÛË Ù˘ ÛÈÛ·Ú›‰Ë˜ Ì ¿ÏÏ· Ê¿Ú̷η, fiˆ˜ Ì·ÎÚÔÏ›‰Â˜ Î·È ·ÓÙÈÌ˘ÎËÙÈ·ÛÈο ‚) OÈ ÂӉ›ÍÂȘ ÁÈ· ÙË ¯ÔÚ‹ÁËÛ‹ Ù˘ Â›Ó·È ·˘ÛÙËÚ¿ ÂÚÈÔÚÈṲ̂Ó˜ Î·È ·fiÏ˘Ù˜ (·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì °O¶-ÔÈÛÔÊ·Á›ÙȘ) Á) ∏ ‰fiÛË Ù˘ Ó· ÌËÓ ˘ÂÚ‚·›ÓÂÈ Ù· 0,8 mg/kg/24ˆÚÔ (Û 3 ‹ 4 ‰fiÛÂȘ) ‰) ¡· Á›ÓÂÙ·È ÚÔÛ‰ÈÔÚÈÛÌfi˜ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÓÂÊÚÈ΋˜ Î·È Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ¯ÔÚ‹ÁËÛ‹˜ Ù˘ fiÙ·Ó ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙÔ Â) ¢È·ÎÔ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Û ÂÚÈÙÒÛÂȘ ÏÔÈÌÒ͈Ó, ÔÈ Ôԛ˜ ÂȉÂÈÓÒÓÔ˘Ó ËÏÂÎÙÚÔÏ˘ÙÈο ÙÔÓ ¿ÚÚˆÛÙÔ ÛÙ) ∫·Ú‰ÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Â·Ê›ÂÙ·È ÛÙËÓ ÎÚ›ÛË ÙÔ˘ ÎÏÈÓÈÎÔ‡. ∂¿Ó ·ÔÊ·ÛÈÛÙ›, ı· Á›ÓÂÙ·È ÚÈÓ ÙËÓ ¤Ó·ÚÍË Î·È ÙÚÂȘ Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜. ∂ÈÌ‹Î˘ÓÛË ÙÔ˘ Q-T ‰È·ÛÙ‹Ì·ÙÔ˜ >470 msec ÂÈ‚¿ÏÏÂÈ ÙË ‰È·ÎÔ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘

∂Ӊ›ÍÂȘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ıÂÚ·›·˜ (ıÔÏÔÏ·ÛÙÈ΋) ·ÔÙÂÏÔ‡Ó ÔÈ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ Ó¢ÌÔӛ˜, ÔÈ ÂÈ̤ÓÔ˘Û˜ ÎÚ›ÛÂȘ, ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ÂÍ·ÚÙÒÓÙ·È ·fi Ù· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ê¿Ú̷η Î·È ÂΛÓÔÈ Ô˘ Û˘Óԉ‡ÔÓÙ·È ·fi ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ fiˆ˜ ˘ÔÙÚÔÈ¿˙ÔÓÙ˜ Â̤ÙÔ˘˜, ‰˘ÛÙÚÔÊ›· ‹ ÔÈÛÔÊ·Á›Ùȉ·. ¶Ó¢ÌÔÓ›· ·fi ÂÈÛÚfiÊËÛË Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÔÊ›ÏÂÙ·È Î·È Û ¿ÏÏ· ·›ÙÈ· ÂÎÙfi˜ ·fi ÙË Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (9-11). ∂›Ó·È ÛÎfiÈÌÔ Û ÈÛÙÔÚÈÎfi Ó¢ÌÔÓ›·˜ ·fi ÂÈÛÚfiÊËÛË Ó· ·ÔÎÏ›ÔÓÙ·È ¿ÏÏ· ·›ÙÈ· fiˆ˜ ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ (Û˘Ú›ÁÁÈÔ Ù‡Ô˘ ∏), ·Û˘Ó¤ÚÁÂÈ· Ì˘ÒÓ Î·Ù¿ÔÛ˘, ÂÈÛÚfiÊËÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜, ∫π¡ ‹ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·. ∂›Ó·È ‰‡ÛÎÔÏÔ Ó· ÙÂÎÌËÚȈı› ÂÚÁ·ÛÙËÚȷο Ë Û˘Û¯¤ÙÈÛË °O¶ Î·È Ó¢ÌÔÓ›·˜ ·fi ÂÈÛÚfiÊËÛË.

OÌ¿‰Â˜ ·ÛıÂÓÒÓ Ì Ó¢ÚÔÌ˘˚Τ˜ ·ı‹ÛÂȘ ‹ „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË ıˆÚÔ‡ÓÙ·È ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ó¢ÌÔÓ›·˜ ·fi ÂÈÛÚfiÊËÛË (12-14).

OÈ ÂÍÂÙ¿ÛÂȘ Ô˘ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Ô‰ËÁ‹ÛÔ˘Ó ÛÙË ‰È¿ÁÓˆÛË Ù˘ °O¶ Û·Ó Èı·Ófi ·›ÙÈÔ Ó¢ÌÔÓ›·˜ ·fi ÂÈÛÚfiÊËÛË Â›Ó·È ·ÚÎÂÙ¤˜, ·ÏÏ¿ fi¯È ηıÔÚÈÛÙÈΤ˜: ·) 24ˆÚË pH-ÌÂÙÚ›·. ∏ Ê˘ÛÈÔÏÔÁÈ΋ pH-ÌÂÙÚ›· ‰ÂÓ ·ÔÎÏ›ÂÈ ÙË ‰È¿ÁÓˆÛË Ó¢ÌÔÓ›·˜ ·fi ÂÈÛÚfiÊËÛË. ∞·ÈÙÂ›Ù·È ÂÍ·ÈÚÂÙÈ΋ ÂÌÂÈÚ›·, ÙfiÛÔ ÛÙË ‰ÈÂÓ¤ÚÁÂÈ· Ù˘ ÂͤٷÛ˘, fiÛÔ Î·È ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. ‚) ™ÈÓıËÚÔÁÚ¿ÊËÌ· (milk scanning) ∆c-sulter colloid. ∏ ·Ó·ÊÂÚfiÌÂÓË Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ÙÔ˘ ÛÈÓıËÚÔÁÚ·Ê‹Ì·ÙÔ˜ Â›Ó·È 15%-59% Î·È 83%100%, ·ÓÙ›ÛÙÔȯ·. ∆Ô ÛÈÓıËÚÔÁÚ¿ÊËÌ· ·ÓȯÓ‡ÂÈ fiÍÈÓ· Î·È ·ÏηÏÈο ÂÂÈÛfi‰È· ·ÏÈÓ‰ÚfiÌËÛ˘, ÙÂÎÌËÚÈÒÓÂÈ ÙËÓ Ó¢ÌÔÓ›· ·fi ÂÈÛÚfiÊËÛË, ÂÓÒ ·ÚÓËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ‰ÂÓ ·ÔÎÏ›ÂÈ fiÙÈ Û˘Ó˘¿Ú¯ÂÈ Û¿ÓÈ· ·ÏÈÓ‰ÚfiÌËÛË Î·È ÂÈÛÚfiÊËÛË (15,16). Á) µÚÔÁ¯ÈÎfi ¤ÎÏ˘Ì·, fiÔ˘ ·ÓȯÓ‡ÔÓÙ·È Ì·ÎÚÔÊ¿Á· ÎÂÎÔÚÂṲ̂ӷ Ì ÏÈÔÂȉ‹ (lipid laden macrophages). ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÂͤٷÛ˘ ·˘Ù‹˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÂȉÈο, ·Ó Î·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯Ô˘Ó ·Ó·Ù˘¯ı› Ù¯ÓÈΤ˜ ÔÛÔÙÈÎÔÔ›ËÛ˘ ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ. ∏ ·Ó‡ÚÂÛË ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ ÛÙ· ÙÚ·¯Âȷο ÂÎÎڛ̷ٷ ‰ÂÓ Ê·›ÓÂÙ·È

Ó· ‰È·¯ˆÚ›˙ÂÈ ÙËÓ ÂÈÛÚfiÊËÛË ·fi °O¶ ·fi ÂÈÛÚfiÊËÛË Ô˘ ÔÊ›ÏÂÙ·È Û ¿ÏÏ· ·›ÙÈ· (16). ‰) ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ï·ÎÙfi˙˘ ÛÙÔ ‚ÚÔÁ¯ÈÎfi ¤ÎÏ˘Ì·. Â) ∞ÍÈÔÏfiÁËÛË ÙˆÓ Ì˯·ÓÈÛÌÒÓ ÚÔÛÙ·Û›·˜ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ Î·Ù¿ ÙËÓ Î·Ù¿ÔÛË (ÎÈÓËÌ·ÙÔ·ÎÙÈÓÔÁÚ¿ÊËÛË-ÂÓ‰ÔÛÎÔÈ΋ ÌÂϤÙË Î·Ù¿ÔÛ˘) Î·È ÂȉÈÎfi˜ Ó¢ÚÔ·ÈÛıËÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜. ™Â ÂÚÈÙÒÛÂȘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ ‹ ›ÓˆÛ˘ ÂÈ‚¿ÏÏÂÙ·È ¯ÚfiÓÈ· ·ÓÙÈ·ÏÈÓ‰ÚÔÌÈ΋ ıÂÚ·›· ‹, Û ÂÍ·ÙÔÌÈÎÂ˘Ì¤Ó˜ ÂÚÈÙÒÛÂȘ, ·ÓÙÈ·ÏÈÓ‰ÚÔÌÈ΋ Â¤Ì‚·ÛË. µÚ¿Á¯Ô˜ ʈӋ˜ Î·È ¯ÚfiÓÈÔ˜ ‚‹¯·˜ ¤¯Ô˘Ó Û˘Ó‰Âı› Ì °O¶. ÷ڷÎÙËÚÈÛÙÈο Ï·Ú˘ÁÁÔÛÎÔÈο Â˘Ú‹Ì·Ù· ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Â›Ó·È ÂÚ‡ıËÌ·, Ô›‰ËÌ·, ÎÔÎÎÈÒÌ·Ù· Î·È fi˙ÔÈ, Â˘Ú‹Ì·Ù· Ô˘ ··ÓÙÒÓÙ·È Û ·ÛıÂÓ›˜ ̠ϢÎÔϷΛ·. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ‰ÂÓ ıˆÚÔ‡ÓÙ·È ÂȉÈο Î·È ‰ÂÓ ·Ô‰›‰ÔÓÙ·È ··Ú·›ÙËÙ· ÛÙËÓ ·ÏÈÓ‰ÚfiÌËÛË, ÂÓÒ ·Ú¿ÏÏËÏ· Â›Ó·È ‰˘Ó·ÙfiÓ ÔÈ ›‰ÈÔÈ ·˘ÙÔ› ·ÛıÂÓ›˜ Ó· ÌËÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÎÏ·ÛÈο Û˘ÌÙÒÌ·Ù· ·ÏÈÓ‰ÚfiÌËÛ˘. ªÂϤÙ˜ ·Ó·Ê¤ÚÔ˘Ó ‚ÂÏÙ›ˆÛË ÙˆÓ Ï·Ú˘ÁÁÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÂÙ¿ ·fi ÈÛ¯˘Ú‹ Î·È Ì·ÎÚfi¯ÚÔÓË ·ÓÙÈ·ÏÈÓ‰ÚÔÌÈ΋ ıÂÚ·›·. OÈ ÌÂϤÙ˜ Â›Ó·È ÌÂÌÔӈ̤Ó˜ Î·È Ì¿ÏÈÛÙ· ÙÔÓ›˙Ô˘Ó ÙËÓ ˘ÔÙÚÔ‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ·fi ÙÔÓ Ï¿Ú˘ÁÁ· ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ıÂÚ·›·˜ (17). OÈ ÌÂϤÙ˜ ·˘Ù¤˜ ·ÊÔÚÔ‡Ó Î·Ù’ ÂÍÔ¯‹Ó ÂÓ‹ÏÈΘ Î·È Â›Ó·È ÌÂÌÔӈ̤Ó˜ ÛÙ· ·È‰È¿. ∏ ·Ô˘Û›· ÂȉÈÎÒÓ Ï·Ú˘ÁÁÔÛÎÔÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û ·ÛıÂÓ›˜ Ì ·ÏÈÓ‰ÚfiÌËÛË ‰˘Û¯ÂÚ·›ÓÂÈ Î·È ˘Ô‚·ıÌ›˙ÂÈ ÙËÓ ·ÍÈÔÈÛÙ›· Ù˘ ‰È¿ÁÓˆÛ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Buts JP, Barudi C, Moulin D, Claus D, Cornu G, Otte JB. Prevalence and treatment of silent gastro-esophageal reflux in children with recurrent respiratory disorders. Eur J Pediatr 1986;145:396-400.

2. Malfroot A, Vandenplas Y, Verlinden M, Piepsz A, Dab I. Gastroesophageal reflux and unexplained chronic respiratory disease in infants and children. Pediatr Pulmonol 1987;3:208-213.

3. Tucci F, Resti M, Fontana R, Novembre E, Lami CA, Vierucci A. Gastroesophageal reflux and bronchial asthma: prevalence and effect of cisapride therapy. J Pediatr Gastroenterol Nutr 1993;17:265-270.

311

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·312

¶·È‰È·ÙÚÈ΋ 2002;65:309-312

Paediatriki 2002;65:309-312

4. Field SK. A critical review of the studies of the effects of simulated or real gastroesophageal reflux on pulmonary function in asthmatic adults. Chest 1999;115:848-856.

5. Boyle JT, Tuchman DN, Altschuler SM, Nixon TE, Pack AI, Cohen S. Mechanisms for the association of gastroesophageal reflux and bronchospasm. Am Rev Respir Dis 1985;131:S16-20.

6. Chen PH, Chang MH, Hsu SC. Gastroesophageal reflux in children with chronic recurrent bronchopulmonary infection. J Pediatr Gastroenterol Nutr 1991;13:16-22.

7. Sheikh S, Goldsmith LJ, Howell L, Hamlyn J, Eid N. Lung function in infants with wheezing and gastroesophageal reflux. Pediatr Pulmonol 1999;27:236-241.

8. Andze GO, Brandt ML, St Vil D, Bensoussan AL, Blanchard H. Diagnosis and treatment of gastroesophageal reflux in 500 children with respiratory symptoms: the value of pH monitoring. J Pediatr Surg 1991;26:295299; discussion 299-300.

9. Gustafsson PM, Kjellman NI, Tibbling L. Bronchial asthma and acid reflux into the distal and proximal oesophagus.

Arch Dis Child 1990;65:1255-1258.

10. Vandenplas Y, Belli DC, Benatar A, Cadranel S, Cucchiara S, Dupont C et al. The role of cisapride in the treatment of pediatric gastroesophageal reflux. J Pediatr Gastroenterol Nutr 1999;28:515-528.

11. Martin ME, Grunstein MM, Larsen GL. The relationship of gastroesophageal reflux to nocturnal wheezing in children with asthma. Ann Allergy 1982;49:318-322.

12. Berquist WE, Rachelefsky GS, Kadden M, Siegel SC, Katz

13.

14.

15.

16.

17.

RM, Fonkalsrud EW et al. Gastroesophageal refluxassociated recurrent pneumonia and chronic asthma in children. Pediatrics 1981;68:29-35.

Harding SM, Richter JE, Guzzo MR, Schan CA, Alexander RW, Bradley LA. Asthma and gastroesophageal reflux: acid suppressive therapy improves asthma outcome. Am J Med 1996;100:395-405.

Field SK, Gelfand GA, McFadden SD. The effects of antireflux surgery on asthmatics with gastroesophageal reflux. Chest 1999;116:766-774.

Regelmann WE. Diagnosing the cause of recurrent and persistent pneumonia in children. Pediatr Ann 1993;22:561-568.

Colombo JL, Hallberg TK. Recurrent aspiration in children: lipid-laden alveolar macrophage quantitation. Pediatr Pulmonol 1987;3:86-89.

Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury.

Laryngoscope 1991;101:1-78.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 30-07-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 02-08-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: π. ¶·Ó·ÁÈÒÙÔ˘-∞ÁÁÂÏ·ÎÔÔ‡ÏÔ˘ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· OÈ Û˘Ó¤ÂȘ ÙÔ˘ Ì‹ÎÔ˘˜ Ù˘ ‚ÂÏfiÓ·˜ ÛÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÙÔÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ÛÙÔ˘˜ Û˘Ó‹ıÂȘ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ Û ‚Ú¤ÊË ËÏÈΛ·˜ 4 ÌËÓÒÓ. ∆˘¯·ÈÔÔÈË̤ÓË ÂÏÂÁ¯fiÌÂÓË ÌÂϤÙË1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË ÙˆÓ ÙÔÈÎÒÓ ·ÓÙȉڿÛÂˆÓ Û ۯ¤ÛË Ì ‰‡Ô ÌÂÁ¤ıË ‚ÂÏfiÓ·˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÛÂ Û˘Ó‹ıÂȘ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ ‚ÚÂÊÒÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∏ ÌÂϤÙË ‹Ù·Ó Ù˘¯·ÈÔÔÈË̤ÓË Î·È ÂÏÂÁ¯fiÌÂÓË. ÀÏÈÎfi Ù˘ ·ÔÙ¤ÏÂÛ·Ó ˘ÁÈ‹ ‚Ú¤ÊË ËÏÈΛ·˜ 16 ‚‰ÔÌ¿‰ˆÓ Ô˘ ÚÔÛ‹Ïı·Ó ÁÈ· ÙËÓ ÙÚ›ÙË ‰fiÛË ÙˆÓ ·Ú¯ÈÎÒÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ Û 8 ÁÂÓÈο È·ÙÚ›·. ¶ÂÚÈÂÏ‹ÊıËÛ·Ó 119 ‚Ú¤ÊË Î·È ·Ó·Ï‡ıËÎ·Ó ÛÙÔȯ›· ÁÈ· 110. OÈ ‚ÂÏfiÓ˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‹Ù·Ó 25 g/16 mm Î·È 23 g/25 mm. OÈ ÁÔÓ›˜ ÙˆÓ ‚ÚÂÊÒÓ ·Ó¤Ï·‚·Ó, ÁÈ· 3 Ë̤Ú˜ ÌÂÙ¿ ÙÔ˘˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜, Ó· ηٷÁÚ¿„Ô˘Ó ÙËÓ ÂÌÊ¿ÓÈÛË ÂÚ˘ıÚfiÙËÙ·˜, Ôȉ‹Ì·ÙÔ˜ ‹ ¢·ÈÛıËÛ›·˜ ÛÙÔ ÛËÌÂ›Ô Ù˘ ¤ÓÂÛ˘. ∞ÔÙÂϤÛÌ·Ù·: ∏ ÂÚ˘ıÚfiÙËÙ· Ô˘ ·Ú·ÙËÚ‹ıËΠÛÙ· ‚Ú¤ÊË Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÌÂÁ·Ï‡ÙÂÚË ‚ÂÏfiÓ· ·Ú¯Èο ·ÓÙÈÛÙÔȯԇÛ ÛÙ· 2/3 ÂΛӢ Ô˘ ·Ú·ÙËÚ‹ıËΠÛÙ· ‚Ú¤ÊË ÛÙ· ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÌÈÎÚfiÙÂÚË ‚ÂÏfiÓ· Î·È 3 Ë̤Ú˜ ·ÚÁfiÙÂÚ· ÌÂÈÒıËΠÛÙÔ 1/7. ∏ ÂÌÊ¿ÓÈÛË Ôȉ‹Ì·ÙÔ˜ Ô˘ ·Ú·ÙËÚ‹ıËΠÛÙ· ‚Ú¤ÊË Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÌÂÁ·Ï‡ÙÂÚË ‚ÂÏfiÓ· ·ÓÙÈÛÙÔȯԇÛ ÛÙÔ 1/3 ÂΛӢ Ô˘ ·Ú·ÙËÚ‹ıËΠÛÙ· ‚Ú¤ÊË ÛÙ· ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÌÈÎÚfiÙÂÚË ‚ÂÏfiÓ· Î·È Ë ‰È·ÊÔÚ¿ ·˘Ù‹ ·Ú¤ÌÂÈÓÂ Î·È ÁÈ· ÙȘ ÙÚÂȘ Âfi-

312

ÌÂÓ˜ Ë̤Ú˜. ∏ ÂÌÊ¿ÓÈÛË Â˘·ÈÛıËÛ›·˜ ÛÙÔ ÛËÌÂ›Ô Ù˘ ¤ÓÂÛ˘ ‹Ù·Ó Â›Û˘ ÌÈÎÚfiÙÂÚË ÛÙ· ‚Ú¤ÊË Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÌÂÁ·Ï‡ÙÂÚË ‚ÂÏfiÓ·. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ¯Ú‹ÛË Ù˘ ‚ÂÏfiÓ·˜ ÙˆÓ 25 mm ÁÈ· ÙÔ˘˜ ηıËÌÂÚÈÓÔ‡˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ ÙˆÓ ‚ÚÂÊÒÓ ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔÈÎÒÓ ·ÓÙȉڿÛˆÓ. ∫·Ù¿ ̤ÛÔ fiÚÔ, Ë ¯Ú‹ÛË Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ·ÓÙ› Ù˘ ÌÈÎÚfiÙÂÚ˘ ‚ÂÏfiÓ·˜ ÛÙÔ˘˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ ı· ·¤ÙÚÂ ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔÈÎÒÓ ·ÓÙȉڿÛÂˆÓ Û ¤Ó· ·Ó¿ ¤ÓÙ ‚Ú¤ÊË.

1

Diggle L, Deeks J Effect of needle length on incidence of local reactions to routine immunisation in infants aged 4 months: randomised controlled trial BMJ 2001;321:931-933

∆ÛÔ˘Ì¿Î·˜ ∫. ¢È¢ı˘ÓÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ¡ÔÛÔÎÔÌ›Ԣ ∫∞∆ ¢È‰¿ÎÙˆÚ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·313

¶·È‰È·ÙÚÈ΋ 2002;65:313-321

∞¡∞™∫O¶∏™∏

Paediatriki 2002;65:313-321

REVIEW ARTICLE

¶ÚfiˆÚË Ú‹ÍË ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ. ™˘Ó¤ÂȘ ÁÈ· ÙÔ Î‡ËÌ· Î·È ÙÔ ÓÂÔÁÓfi µ. ¢ÚfiÛÔ˘ - ∞Á·Î›‰Ô˘, K. ™·Ú·Ê›‰Ë˜

Premature rupture of membranes. Fetal and neonatal consequences V. Drossou - Agakidou, K. Sarafidis

¶ÂÚ›ÏË„Ë: ∏ ÚfiˆÚË Ú‹ÍË ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ (¶ƒ∂À), fiˆ˜ ÔÓÔÌ¿˙ÂÙ·È Ë Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ÚÈÓ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ÙÔÎÂÙÔ‡, ÂÈϤÎÂÈ ÂÚ›Ô˘ ÙÔ 10% ÙˆÓ Î˘‹ÛÂˆÓ Î·È Û˘Ó‰¤ÂÙ·È Ì ·˘ÍË̤ÓË ÓÂÔÁÓÈ΋ ıÓËÛÈÌfiÙËÙ· Î·È ÓÔÛËÚfiÙËÙ·. OÈ Î˘ÚÈfiÙÂÚ˜ Û˘Ó¤ÂȘ Ù˘ ¶ƒ∂À ÛÙÔ Î‡ËÌ· Î·È ÙÔ ÓÂÔÁÓfi Â›Ó·È Ë ÂÌ‚Ú˘˚΋ ‰˘Û¯¤ÚÂÈ·, Ë Ïԛ̈ÍË, Ë ÚÔˆÚfiÙËÙ· Î·È ÙÔ Û‡Ó‰ÚÔÌÔ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË ÓÂÔÁÓÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· Â›Ó·È Ë ËÏÈΛ· ·ËÛ˘ fiÔ˘ Û˘Ì‚·›ÓÂÈ Ë ¶ƒ∂À, Ë Ï·Óı¿ÓÔ˘Û· ÂÚ›Ô‰Ô˜, Ë ‚·Ú‡ÙËÙ· ÙÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘ Î·È Ë ÚÔÁÂÓÓËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ŸÙ·Ó Ë ¶ƒ∂À Û˘Ì‚Â› ÛÙÔ Ù¤ÏÔ˜ Ù˘ ·ËÛ˘, Û˘Ó‹ıˆ˜ ·ÎÔÏÔ˘ı› ÙÔÎÂÙfi˜ ÛÙȘ ÂfiÌÂÓ˜ 12-48 ÒÚ˜ Î·È Ù· Û˘¯ÓfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Â›Ó·È Ë ÂÌ‚Ú˘˚΋ ‰˘Û¯¤ÚÂÈ· Î·È Ë Ïԛ̈ÍË. ŸÙ·Ó Û˘Ì‚Â› ÚÈÓ ÙËÓ 34Ë Â‚‰ÔÌ¿‰·, ÚÔ¤¯Ô˘Ó Ë ÚÔˆÚfiÙËÙ· Î·È ÔÈ ÂÈÏÔΤ˜ Ù˘. π‰È·›ÙÂÚ· ÛÔ‚·Ú‹ Â›Ó·È Ë ¶ƒ∂À ÚÈÓ ·fi ÙËÓ 28Ë Â‚‰ÔÌ¿‰· ·ËÛ˘, ÏfiÁˆ Ù˘ ÌÂÁ¿Ï˘ ·ÓˆÚÈÌfiÙËÙ·˜ Î·È ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ Û˘Ó‰ÚfiÌÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘. ∆Ô Û‡Ó‰ÚÔÌÔ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÔÏÏ·Ϥ˜ ‰˘ÛÌÔÚʛ˜, ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘, ÂÌ‚Ú˘˚΋ ‰˘Û¯¤ÚÂÈ· Î·È Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›·. ™ÙËÓ ¶ƒ∂À ÚÈÓ ÙËÓ 34Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ Û˘ÛÙ‹ÓÂÙ·È Î·ı˘ÛÙ¤ÚËÛË ÙÔ˘ ÙÔÎÂÙÔ‡, ÂÊfiÛÔÓ ·˘Ùfi Â›Ó·È ‰˘Ó·Ùfi Î·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ·fiÏ˘Ù˜ ÂӉ›ÍÂȘ ÙÔÎÂÙÔ‡. ∏ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο ÙË ÓÂÔÁÓÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ·.

Abstract: Premature rupture of membranes (PROM), defined as the rupture of membranes before the onset of labor, occurs in about the 10% of pregnancies and is associated with high perinatal mortality and morbidity. The main fetalneonatal consequences include fetal distress, infection, prematurity and oligohydramnion syndrome. Neonatal morbidity and mortality depend on the gestational age at PROM, the latency period, the degree of oligohydramnion and the prenatal care offered. PROM near term is usually followed by delivery within 12-48 hours, the fetal distress and infections being the main causes of morbidity. When PROM occurs before the 34th week of gestation complications of prematurity are the main causes of morbidity. PROM prior to 28th week is associated with extreme prematurity and the oligohydramnion syndrome. The latter is manifested with multiple congenital abnormalities, intrauterine growth retardation, fetal distress and pulmonary hypoplasia. Before 32 weeks gestation, expectant management for premature rupture of membranes is chosen whenever possible in an effort to minimize the complications of prematurity.

Prenatal treatment with antibiotics and steroids is associated with lower perinatal mortality rate and morbidity.

§¤ÍÂȘ ÎÏÂȉȿ: ÓÂÔÁÓÈΤ˜ ÏÔÈÌÒÍÂȘ, Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›·, ¶ƒ∂À, ÚÔˆÚfiÙËÙ·, Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜.

Key words: chorioamnionitis, neonatal infections, prematurity, PROM, pulmonary hypoplasia, respiratory distress syndrome.

¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢ πÔÎÚ¿ÙÂÈÔ °.¶.¡., £ÂÛÛ·ÏÔÓ›ÎË

Department of Neonatology, Aristotelion University of Thessaloniki Ippokration Hospital, Thessaloniki

313

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·314

¶·È‰È·ÙÚÈ΋ 2002;65:313-321

OÚÈÛÌÔ› - ™˘¯ÓfiÙËÙ· ø˜ ÚfiˆÚË Ú‹ÍË ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ (¶ƒ∂À) ¯·Ú·ÎÙËÚ›˙ÂÙ·È Ë Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ÙÔÎÂÙÔ‡ (1). ∏ Ï·Óı¿ÓÔ˘Û· ÂÚ›Ô‰Ô˜, ‰ËÏ·‰‹ ÙÔ ÌÂÛԉȿÛÙËÌ· ÌÂٷ͇ ڋ͢ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ Î·È ¤Ó·Ú͢ ÙÔ˘ ÙÔÎÂÙÔ‡, Ô˘ ··ÈÙÂ›Ù·È ÒÛÙÂ Ë Ú‹ÍË Ó· ¯·Ú·ÎÙËÚÈÛÙ› ÚfiˆÚË, Î˘Ì·›ÓÂÙ·È, Û‡Ìʈӷ Ì ‰È¿ÊÔÚÔ˘˜ Û˘ÁÁÚ·Ê›˜, ·fi 0 ̤¯ÚÈ 12 ÒÚ˜ (1). ø˜ ·Ú·ÙÂٷ̤ÓË ¯·Ú·ÎÙËÚ›˙ÂÙ·È Ë ¶ƒ∂À Ì ϷÓı¿ÓÔ˘Û· ÂÚ›Ô‰Ô ÌÂÁ·Ï‡ÙÂÚË ·fi Ì›· ‚‰ÔÌ¿‰·. ∞Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ·ËÛ˘ (∏∫), Ë ¶ƒ∂À ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÙÂÏÂÈfiÌËÓË ¶ƒ∂À fiÙ·Ó Û˘Ì‚·›ÓÂÈ ÛÙÔ Ù¤ÏÔ˜ Ù˘ ·ËÛ˘ Î·È ˆ˜ ÚfiˆÚË ¶ƒ∂À (preterm premature rupture of membranes) fiÙ·Ó Â¤ÏıÂÈ ÚÈÓ ·fi ÙËÓ 37Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ (1). ∂ÈϤÔÓ, Ô fiÚÔ˜ Ôχ ÚfiˆÚË ¶ƒ∂À (very preterm premature rupture of membranes) ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ¶ƒ∂À Ô˘ Â¤Ú¯ÂÙ·È ÌÂٷ͇ 17˘ Î·È 27˘ ‚‰ÔÌ¿‰·˜ ·ËÛ˘. ∏ ‰È¿ÎÚÈÛË Ù˘ ¶ƒ∂À Û ηÙËÁÔڛ˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ∏∫ ¤¯ÂÈ ÛËÌ·Û›·, ÁÈ·Ù› Ë Ì·È¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Î·È ÔÈ ÓÂÔÁÓÈΤ˜ ÂÈÏÔΤ˜ Â›Ó·È ‰È·ÊÔÚÂÙÈΤ˜. ∏ ·Ó·ÊÂÚfiÌÂÓË Û˘¯ÓfiÙËÙ· Ù˘ ¶ƒ∂À ‰È·Ê¤ÚÂÈ Ôχ ·Ó¿ÏÔÁ· Ì ٷ ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ÏËı˘ÛÌÔ‡ Ô˘ ÌÂÏÂٿٷÈ, ÙȘ ÌÂıfi‰Ô˘˜ ·Ó›¯Ó¢Û˘, ÙË Ï·Óı¿ÓÔ˘Û· ÂÚ›Ô‰Ô Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·fi οıÂ Û˘ÁÁڷʤ· ÁÈ· ÙÔÓ ÔÚÈÛÌfi Ù˘ ¶ƒ∂À Î.Ï. ™˘ÓÔÏÈο, Ë ¶ƒ∂À ÂÈϤÎÂÈ ÙÔ 2%-15% ÙˆÓ Î˘‹ÛˆÓ, ÂÓÒ ÛÙÔ 10%-40% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Û˘Ì‚·›ÓÂÈ ÚÈÓ ÙËÓ 37Ë Â‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘ (1-4). ∏ Û˘¯ÓfiÙËÙ· Ù˘ ¶ƒ∂À Â›Ó·È ‰ÈÏ¿ÛÈ· ÛÙȘ Ôχ‰˘Ì˜ ΢‹ÛÂȘ (4). ∞ÈÙÈÔÏÔÁ›· Î·È ·ıÔÁ¤ÓÂÈ· ¶ƒ∂À ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ¶ƒ∂À ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË, ·Ó Î·È ÂȉËÌÈÔÏÔÁÈΤ˜ Î·È ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ÙËÓ ¤¯Ô˘Ó Û˘Û¯ÂÙ›ÛÂÈ Ì ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Â›Ó·È Ë Ïԛ̈ÍË ÙÔ˘ Ô˘ÚÔÁÂÓÓËÙÈÎÔ‡ ۈϋӷ Ù˘ ÌËÙ¤Ú·˜, Ë ÌËÙÚÔÏ·ÎÔ˘ÓÙȷ΋ ·ÈÌÔÚÚ·Á›· ÙÔ˘ 1Ô˘ ‹ 2Ô˘ ÙÚÈÌ‹ÓÔ˘, ÂÂÌ‚¿ÛÂȘ ÛÙÔÓ ÙÚ¿¯ËÏÔ, ‰˘Ûη̄›· ÙÚ·¯‹ÏÔ˘, ÂͤٷÛË ÙÔ˘ ÙÚ·¯‹ÏÔ˘, ˘ÂډȿٷÛË Ù˘ Ì‹ÙÚ·˜ (ÔÏ˘¸‰Ú¿ÌÓÈÔ, Ôχ‰˘ÌË Î‡ËÛË), ÚfiˆÚ˜ Û˘Û¿ÛÂȘ Î.¿ (4). ∂›Û˘, ÙÔ Î¿ÓÈÛÌ· Î·È Ë Î·Î‹ ‰È·ÙÚÔÊ‹ Ù˘ ÌËÙ¤Ú·˜ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ¶ƒ∂À ηÈ, Ì¿ÏÈÛÙ·, ÚfiˆÚ˘ ¶ƒ∂À (4). ∞fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ‡˜, ÛËÌ·ÓÙÈÎfiÙÂÚÔ˜ Â›Ó·È Ë Ïԛ̈ÍË ÙÔ˘ Ô˘ÚÔÁÂÓÓËÙÈÎÔ‡ ۈϋӷ Ù˘ ÌËÙ¤Ú·˜, fiˆ˜ ˘Ô‰ÂÈÎÓ‡ÂÙ·È ·fi ÙËÓ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ Î·È ÂÚÈÁÂÓÓËÙÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Û ÓÂÔÁÓ¿ Ì ¶ƒ∂À (2,4-6). ∏ Û˘ÓÔÏÈ΋ Û˘¯ÓfiÙËÙ· Ù˘ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ ÛÂ

314

Paediatriki 2002;65:313-321

΢‹ÛÂȘ Ì ¶ƒ∂À Â›Ó·È ÂÚ›Ô˘ 9%, ·ÏÏ¿ Êı¿ÓÂÈ Ì¤¯ÚÈ 50% Û ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ (7-9). OÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› Ô˘ ¤¯Ô˘Ó Û˘Ó‰Âı› Ì ¶ƒ∂À Â›Ó·È Ë N. gonorrhoeae, Group B streptococci, Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealiticum, Trichomonas vaginalis, Bacteroides spp (4,10).

OÈ Èı·ÓÔ› Ì˯·ÓÈÛÌÔ› Ì ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ ÙÔÈΤ˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ Ô˘ÚÔÁÂÓÓËÙÈÎÔ‡ ۈϋӷ Ù˘ ÌËÙ¤Ú·˜ ÚÔηÏÔ‡Ó ÂÍ·Ûı¤ÓËÛË Î·È Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ Â›Ó·È ÔÏÏÔ›. OÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› ·Ú¿ÁÔ˘Ó ÚˆÙÂÔÏ˘ÙÈο ¤Ó˙˘Ì· Î·È ·ÂÏ¢ıÂÚÒÓÔ˘Ó ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ ÌÈÎÚԂȷ΋˜ ÂÓ‰ÔÙÔ͛Ӣ (ÏÈÔÔÏ˘Û·Î¯·Ú›‰Ë), Ë ÔÔ›· Ì ÙË ÛÂÈÚ¿ Ù˘ ‰ÈÂÁ›ÚÂÈ ÙËÓ ÙÔÈ΋ ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË Î·È ÙËÓ ·ÂÏ¢ı¤ÚˆÛË Ï¢ÎÔ΢ÙÙ·ÚÈÎÒÓ ÚˆÙ·ÛÒÓ Î·È Î˘ÙÙ·ÚÔÎÈÓÒÓ, fiˆ˜ Â›Ó·È Ô ·Ú¿ÁÔÓÙ·˜ Ó¤ÎÚˆÛ˘ ÙˆÓ fiÁÎˆÓ (Tumor Necrosis Factor-·, TNF-·), Ë ÈÓÙÂÚÏ¢ΛÓË-1‚ Î·È Ë ÈÓÙÂÚÏ¢ΛÓË-6 (4,11-13).

OÈ Î˘ÙÙ·ÚÔΛÓ˜ ‰ÈÂÁ›ÚÔ˘Ó ÙË Û‡ÓıÂÛË Î·È ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÌÂÙ·ÏÏÔÚˆÙÂ˚Ó·ÛÒÓ Ì¤Û· ÛÙ· ·ÌÓÈÔ¯ÔÚȷο ·ÙÙ·Ú·, ÔÈ Ôԛ˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¿ÏÏ· ÚˆÙÂÔÏ˘ÙÈο ¤Ó˙˘Ì·, ˘ÂÚÓÈÎÔ‡Ó ÙÔ˘˜ ·ÓÙÈÚˆÙ·ÛÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ ۈϋӷ Î·È Ô‰ËÁÔ‡Ó Û ÂÍ·Ûı¤ÓËÛË Î·È Ú‹ÍË Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ (11-14). ™Â ÚfiÛÊ·ÙË ÌÂϤÙË ÙÔ˘˜ ÔÈ Woods Î·È Û˘Ó (2001) ÂÂÛ‹Ì·Ó·Ó ÙÔ ÚfiÏÔ ÙˆÓ ÂχıÂÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘ ÛÙË Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ Î·È ÙËÓ Èı·Ó‹ ÚÔÏËÙÈ΋ ‰Ú¿ÛË Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, fiˆ˜ ÙˆÓ ‚ÈÙ·ÌÈÓÒÓ C Î·È E, ÛÙËÓ ¤ÁÎ˘Ô (15). ∏ ·ÒÏÂÈ· ÙÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ ÌÂÙ¿ ÙË Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ÛÙÂÚ› ·fi ÙÔ Î‡ËÌ· ÙÔ Ê˘ÛÈÎfi ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓ, Ô˘ Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘Í‹ ÙÔ˘, ηıÒ˜ ÙÔ ·ÌÓÈ·Îfi ˘ÁÚfi ÚÔÛٷهÂÈ ÙÔ Î‡ËÌ· ·fi Ê˘ÛÈΤ˜ ηÎÒÛÂȘ Î·È ÏÔÈÌÒÍÂȘ Î·È ÂÈÙÚ¤ÂÈ ÙȘ ÎÈÓ‹ÛÂȘ ÙÔ˘, ‰È¢ÎÔχÓÔÓÙ·˜ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∂ÈϤÔÓ, ·ÔÙÚ¤ÂÈ ÙËÓ ›ÂÛË ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ Î·È ÙÔ˘ Ï·ÎÔ‡ÓÙ·, ÚÔÛٷهÔÓÙ·˜ ÙÔ Î‡ËÌ· ·fi ΢ÎÏÔÊÔÚÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ·ÓÂ¿ÚÎÂÈ· ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ (16). ∆Ô ·ÌÓÈ·Îfi ˘ÁÚfi ·˘Í¿ÓÂÙ·È ‚·ıÌÈ·›·, ̤¯ÚÈ ÂÚ›Ô˘ ÙËÓ 33Ë Â‚‰ÔÌ¿‰· Î·È Î·ÙfiÈÓ ·Ú·Ì¤ÓÂÈ ÛÙ·ıÂÚfi ̤¯ÚÈ ÙËÓ 38Ë Â‚‰ÔÌ¿‰· ·ËÛ˘. ªÂٷ͇ 39˘ Î·È 43˘ ‚‰ÔÌ¿‰·˜ ·Ú·ÙËÚÂ›Ù·È Ë ‚·ıÌÈ·›· ÂÏ¿ÙÙˆÛË ÙÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ Ù˘ ٿ͈˜ ÙÔ˘ 8% ÂÚ›Ô˘ (16). O ̤ÁÈÛÙÔ˜ fiÁÎÔ˜ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ Â›Ó·È 900-1000 mL Î·È ÂÏ·ÙÙÒÓÂÙ·È Ê˘ÛÈÔÏÔÁÈο ÚÔ˜ ÙÔ Ù¤ÏÔ˜ Ù˘ ·ËÛ˘ (16). ø˜ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ ÔÚ›˙ÂÙ·È ÔÛfi ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ ÌÈÎÚfiÙÂÚÔ ÙˆÓ 400 mL ÌÂÙ¿ ÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ (16).

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·315

¶·È‰È·ÙÚÈ΋ 2002;65:313-321

∂ÈÙÒÛÂȘ Ù˘ ¶ƒ∂À ÛÙÔ Î‡ËÌ· Î·È ÙÔ ÓÂÔÁÓfi OÈ ÂÈÙÒÛÂȘ Ù˘ ¶ƒ∂À ÛÙÔ Î‡ËÌ· Î·È ÙÔ ÓÂÔÁÓfi Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ∏∫ ηٿ ÙË Ú‹ÍË (17). ∞Ó Ë Ú‹ÍË Â¤ÏıÂÈ ÎÔÓÙ¿ ÛÙÔ Ù¤ÏÔ˜ Ù˘ ·ËÛ˘ (ÌÂÙ¿ ÙËÓ 34Ë Â‚‰ÔÌ¿‰·), ÙÔ ÈÔ Èı·Ófi Â›Ó·È fiÙÈ ı· ·ÎÔÏÔ˘ı‹ÛÂÈ ÙÔÎÂÙfi˜ ̤۷ ÛÙȘ ÂfiÌÂÓ˜ 24-72 ÒÚ˜ (17,18). ∆· Û˘¯ÓfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Û ÙÂÏÂÈfiÌËÓË ¶ƒ∂À Â›Ó·È Ë Ïԛ̈ÍË Î·È Ë ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÂÌ‚Ú˘˚΋˜ ‰˘Û¯¤ÚÂÈ·˜ Î·È ÂÚÈÁÂÓÓËÙÈ΋˜ ·ÛÊ˘Í›·˜ (17,18). ∞Ó Ë ¶ƒ∂À Û˘Ì‚Â› ÚÈÓ ·fi ÙËÓ 34Ë Â‚‰ÔÌ¿‰·, Ô ÛÔ‚·ÚfiÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ÁÈ· ÙÔ ÓÂÔÁÓfi Â›Ó·È Ë ÚÔˆÚfiÙËÙ· Î·È ÔÈ ÂÈÏÔΤ˜ Ù˘ (6,17,19,20). ∏ ·Ú·ÙÂٷ̤ÓË ¶ƒ∂À ÚÈÓ ·fi ÙËÓ 25Ë Â‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘ ¤¯ÂÈ ‚·ÚÈ¿ ÚfiÁÓˆÛË Î·È ˘„ËÏ‹ ıÓËÛÈÌfiÙËÙ·, ÁÈ·Ù› Û˘¯Ó¿ Û˘Óԉ‡ÂÙ·È ·fi Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· (21-23). π‰È·›ÙÂÚË ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· ·ÔÙÂÏ› Ë Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ÛÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘ (early amnion rupture). ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ‚·ÚȤ˜ ‰˘ÛϷۛ˜ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ ÎÂÊ¿ÏÈ (‰˘ÛÌÔÚʛ˜ ÚÔÛÒÔ˘ Î·È Ì·ÙÈÒÓ, ‰˘ÛϷۛ˜ ·˘ÙÈÒÓ, Û¯ÈÛٛ˜, ·ÓÂÁÎÂÊ·Ï›·, ÂÁÎÂÊ·ÏÔ΋ÏË, ÎÚ·ÓÈÔÛÙ¤ÓˆÛË), Ù· ¿ÎÚ· (ÂÏÏ›„ÂȘ ÙÌËÌ¿ÙˆÓ ÌÂÏÒÓ, ÔÏ˘‰·ÎÙ˘Ï›·, Û˘Ó‰·ÎÙ˘Ï›· Î.Ï.) Î·È ÙÔÓ ÎÔÚÌfi (ÂÏÏ›ÌÌ·Ù· ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ ÙÔȯÒÌ·ÙÔ˜, ÔÌÊ·ÏÔ΋ÏË, ‰˘ÛÌÔÚʛ˜ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜), ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ·ËÛ˘ ÛÙËÓ ÔÔ›· Â¤Ú¯ÂÙ·È Ë Ú‹ÍË. ∏ ÈÔ ·Ô‰ÂÎÙ‹ ıˆڛ· ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÈ· ÙˆÓ ‰˘ÛÏ·ÛÈÒÓ ·˘ÙÒÓ Â›Ó·È Ë ·Á›‰Â˘ÛË ÙÌËÌ¿ÙˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÛÙÔ ÛËÌÂ›Ô Ù˘ ڋ͢ Î·È Ë ·fiÊÚ·ÍË ·ÁÁ›ˆÓ Ì Â·ÎfiÏÔ˘ıË ÈÛ¯·ÈÌ›· Î·È Ó¤ÎÚˆÛË ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÙÌËÌ¿ÙˆÓ (24).

OÈ ÂÈÙÒÛÂȘ Ù˘ ¶ƒ∂À ÛÙÔ Î‡ËÌ· Î·È ÙÔ ÓÂÔÁÓfi ÌÔÚÔ‡Ó Ó· Ù·ÍÈÓÔÌËıÔ‡Ó Û ٤ÛÛÂÚȘ ηÙËÁÔڛ˜: ÂÈÏÔΤ˜ Ù˘ ·ËÛ˘ Î·È ÙÔ˘ ÙÔÎÂÙÔ‡, Ïԛ̈ÍË, ÚÔˆÚfiÙËÙ· Î·È Û‡Ó‰ÚÔÌÔ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘. ∂ÈÏÔΤ˜ Ù˘ ·ËÛ˘ Î·È ÙÔ˘ ÙÔÎÂÙÔ‡ ∏ ¶ƒ∂À Û˘Ó‰¤ÂÙ·È Ì ÔÏϤ˜ ÂÈÏÔΤ˜ Ù˘ ·ËÛ˘ Î·È ÙÔ˘ ÙÔÎÂÙÔ‡, fiˆ˜ Â›Ó·È ÙÔ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ, Ë ÚfiÙˆÛË ‹ ›ÂÛË ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘, Ë ·ÔÎfiÏÏËÛË ÙÔ˘ Ï·ÎÔ‡ÓÙ· Î·È Ô ‚Ú·¯‡˜ ÔÌÊ¿ÏÈÔ˜ ÏÒÚÔ˜. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÚfiÙˆÛ˘ ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ Û ¶ƒ∂À Â›Ó·È 0,3-1,7% Î·È Êı¿ÓÂÈ ÛÙÔ 2,03,2% fiÙ·Ó Ë ¶ƒ∂À Û˘Ì‚·›ÓÂÈ ÚÈÓ ÙËÓ 34Ë Â‚‰ÔÌ¿‰·, Û˘ÁÎÚÈÙÈο Ì ̛· Û˘¯ÓfiÙËÙ· 0,3-0,6% ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ Î˘‹ÛÂˆÓ (7). ∏ ÚfiÙˆÛË ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ‚·ÚÈ¿ ‚Ú·‰˘Î·Ú‰›· ÙÔ˘ ÂÌ‚Ú‡Ô˘, Ô˘ ÌÔÚ› Ó· ·Ԃ› ÌÔÈÚ·›·. ¶ÈÔ Û˘¯Ó‹ ÂÈÏÔ΋ Â›Ó·È Ë ›ÂÛË ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ ÏfiÁˆ ÙÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘. ∆Ô 75% ÙˆÓ ÂÌ‚Ú‡ˆÓ Ì ¶ƒ∂À ÂÌÊ·Ó›˙ÂÈ ÂÈ‚Ú¿‰˘ÓÛË ÙÔ˘ ηډȷÎÔ‡ Ú˘ıÌÔ‡ Û˘Ì‚·Ù‹ ÌÂ Û˘Ì›ÂÛË ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒ-

Paediatriki 2002;65:313-321

ÚÔ˘ (7). °È’ ·˘Ùfi ··ÈÙÂ›Ù·È ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ ηډȷÎÔ‡ Ú˘ıÌÔ‡, ηıÒ˜ Î·È Î·ıËÌÂÚÈÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ‚ÈÔÊ˘ÛÈÎÔ‡ ÚÔÊ›Ï ÙÔ˘ ÂÌ‚Ú‡Ô˘ (25). ∂›Û˘, Û ·Ú·ÙÂٷ̤ÓË ¶ƒ∂À ˘¿Ú¯ÂÈ ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ·ÔÎfiÏÏËÛ˘ ÙÔ˘ Ï·ÎÔ‡ÓÙ·, Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 2% ̤¯ÚÈ 12% (5,26), Û˘ÁÎÚÈÙÈο Ì 0,8% ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ Î˘‹ÛÂˆÓ (7). ¢ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› ·Ó Ë ·ÔÎfiÏÏËÛË ÙÔ˘ Ï·ÎÔ‡ÓÙ· ÔÊ›ÏÂÙ·È ÛÙËÓ ·fiÙÔÌË ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÁÎÔ˘ Ù˘ Ì‹ÙÚ·˜ ÌÂÙ¿ ÙËÓ ¶ƒ∂À, ·Ó ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÌÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ ‹ ·Ó ·ÔÙÂÏ› ÙËÓ ·ÈÙ›· Ù˘ ¶ƒ∂À (27). ∞ÎfiÌË, Ë Û˘¯ÓfiÙËÙ· Èۯȷ΋˜ ÚÔ‚ÔÏ‹˜ Â›Ó·È ·˘ÍË̤ÓË Î·È Î˘Ì·›ÓÂÙ·È ·fi 3,3% ̤¯ÚÈ 8,9% ÛÙȘ ΢‹ÛÂȘ Ô˘ ÂÈϤÎÔÓÙ·È Ì ¶ƒ∂À, Û˘ÁÎÚÈÙÈο Ì 3-4% ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ Î˘‹ÛÂˆÓ (7,17). ∏ Û˘¯ÓfiÙËÙ· Ù˘ Èۯȷ΋˜ ÚÔ‚ÔÏ‹˜ Â›Ó·È ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚË ÛÙȘ ÂÚÈÙÒÛÂȘ ÚfiˆÚ˘ ¶ƒ∂À (17%), ηıÒ˜ Î·È fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ (36-53%) (27). ∆¤ÏÔ˜, Ë ˘ÔÏÂÈfiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ·Ó¿Ù˘ÍË Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙȘ ΢‹ÛÂȘ Ô˘ ÂÈϤÎÔÓÙ·È Ì ¶ƒ∂À. £ÂˆÚÂ›Ù·È Èı·Ófi fiÙÈ ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ¶ƒ∂À ÚÔηÏÔ‡Ó ‰È·Ù·Ú·¯‹ Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ·‡ÍËÛ˘ (17). ŸÏ˜ ÔÈ ·Ú·¿Óˆ ÂÈÏÔΤ˜ ÌÔÚÔ‡Ó Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ÂÌ‚Ú˘˚΋ ‰˘ÛÊÔÚ›·, Ë ÔÔ›· ÂÈϤÎÂÈ ÙÔ 2-20% ÙˆÓ Î˘‹ÛÂˆÓ Ì ¶ƒ∂À (26). ∂ΉËÏÒÓÂÙ·È Ì ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ Ú˘ıÌÔ‡, ¯·ÌËÏfi Apgar score Î·È ·˘ÍË̤ÓË ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ·. ∏ ÛÔ‚·ÚfiÙËÙ· Ù˘ ÂÌ‚Ú˘˚΋˜ ‰˘ÛÊÔÚ›·˜ Î·È ÂÚÈÁÂÓÓËÙÈ΋˜ ·ÛÊ˘Í›·˜ ¤¯ÂÈ ¿ÌÂÛË Û¯¤ÛË Ì ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘ (25,27). §ÔÈÌÒÍÂȘ ª·È¢ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÏÔÈÌÒÍÂˆÓ Û ÓÂÔÁÓ¿ Ì ¶ƒ∂À Â›Ó·È Ë ÂÌÊ¿ÓÈÛË ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜, Ô ·ÔÈÎÈÛÌfi˜ Ù˘ ÌËÙ¤Ú·˜ Ì ÛÙÚÂÙfiÎÔÎÎÔ Ù˘ ÔÌ¿‰·˜ µ Î·È ÎÔÏÔ‚·ÎÙËÚ›‰ÈÔ, Ë ‰ÈÂÓ¤ÚÁÂÈ· ‰·ÎÙ˘ÏÈ΋˜ ÂͤٷÛ˘ ‹ ¿ÏÏˆÓ ‰È·ÎÔÏÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ, fiˆ˜ Ë ÙÔÔı¤ÙËÛË ËÏÂÎÙÚÔ‰›ˆÓ ÛÙÔ ¤Ì‚Ú˘Ô, ηıÒ˜ Â›Û˘ Î·È ÙÔ ¿ÚÚÂÓ Ê‡ÏÔ (5,7). OÈ Seaward Î·È Û˘Ó (1998) Û ÔÏ˘ÎÂÓÙÚÈ΋ ‰ÈÂıÓ‹ ÌÂϤÙË 5028 ΢‹ÛÂˆÓ Ì ÙÂÏÂÈfiÌËÓË ¶ƒ∂À ‚Ú‹Î·Ó fiÙÈ Ë Û˘ÓÔÏÈ΋ Û˘¯ÓfiÙËÙ· ÓÂÔÁÓÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ‹Ù·Ó 2,6% Î·È ·˘Í·ÓfiÙ·Ó Û 7% fiÙ·Ó Ô ÁÂÓÓËÙÈÎfi˜ ۈϋӷ˜ Ù˘ ÌËÙ¤Ú·˜ ‹Ù·Ó ·ÔÈÎÈṲ̂ÓÔ˜ ·fi ÛÙÚÂÙfiÎÔÎÎÔ Ù˘ ÔÌ¿‰·˜ µ Î·È 16% fiÙ·Ó ˘‹Ú¯Â ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·. ∏ ‰ÈÂÓ¤ÚÁÂÈ· ÂÚÈÛÛfiÙÂÚˆÓ ·fi 7 ‰·ÎÙ˘ÏÈÎÒÓ ÎÔÏÈÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Û˘Ó‰˘·˙fiÙ·Ó Ì ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÓÂÔÁÓÈÎÒÓ ÏÔÈÌÒÍÂˆÓ (4%) (5). ∂›Û˘, Ë ·ÚÔ˘Û›· ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘ Ì ‰Â›ÎÙË ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ ÌÈÎÚfiÙÂÚÔ˘ ÙˆÓ 5 cm ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ Î·È ÓÂÔÁÓÈ΋˜ Û‹„˘ (28).

315

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·316

¶·È‰È·ÙÚÈ΋ 2002;65:313-321

ªÂÁ¿ÏË ÛËÌ·Û›· ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÓÂÔÁÓÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ¤¯ÂÈ Ë ∏∫ ηٿ ÙËÓ ¶ƒ∂À Î·È Ë ‰È¿ÚÎÂÈ· Ù˘ Ï·Óı¿ÓÔ˘Û·˜ ÂÚÈfi‰Ô˘. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÓÂÔÁÓÈ΋˜ Û‹„˘ Û ÓÂÔÁÓ¿ Ì ¶ƒ∂À Â›Ó·È ÙÂÙÚ·Ï¿ÛÈ· Û ∏∫ 31-33 ‚‰ÔÌ¿‰ˆÓ Î·È ÂÓÙ·Ï¿ÛÈ· Û ∏∫ >37 ‚‰ÔÌ¿‰ˆÓ, Û˘ÁÎÚÈÙÈο Ì ٷ ÓÂÔÁÓ¿ ·ÚfiÌÔÈ·˜ ∏∫ ¯ˆÚ›˜ ¶ƒ∂À (29). ∂›Û˘, Ë Û˘¯ÓfiÙËÙ· Ù˘ ÓÂÔÁÓÈ΋˜ Û‹„˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‰È¿ÚÎÂÈ· Ù˘ Ï·Óı¿ÓÔ˘Û·˜ ÂÚÈfi‰Ô˘, ȉȷ›ÙÂÚ· Û ÙÂÏÂÈfiÌËÓË ¶ƒ∂À (5,10). ™ÙË ¢ÈÂıÓ‹ ¶ÔÏ˘ÎÂÓÙÚÈ΋ ªÂϤÙË ∆ÂÏÂÈfiÌËÓ˘ ¶ƒ∂À (1998) ‚Ú¤ıËΠÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÓÂÔÁÓÈ΋˜ Û‹„˘, fiÙ·Ó Ë ‰È¿ÚÎÂÈ· Ù˘ ¶ƒ∂À ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË ·fi 24 ÒÚ˜ (5). OÈ Chua Î·È Û˘Ó (1995) Û ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË 117 ΢‹ÛÂˆÓ Ì ¶ƒ∂À ‚Ú‹Î·Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÓÂÔÁÓÈ΋˜ Ïԛ̈͢ ·fi 9% ÂÚ›Ô˘ Û ¶ƒ∂À ‰È¿ÚÎÂÈ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 48 ˆÚÒÓ, ·˘Í·ÓfiÙ·Ó ¿Óˆ ·fi 33% Û ¶ƒ∂À ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ (10). OÚÈṲ̂Ó˜ ÌÂϤÙ˜ Û ÚfiˆÚ·, ÌÈÎÚfiÙÂÚ· ÙˆÓ 34 ‚‰ÔÌ¿‰ˆÓ, ‰ÂÓ ¤‰ÂÈÍ·Ó ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ‰È¿ÚÎÂÈ·˜ Ï·Óı¿ÓÔ˘Û·˜ ÂÚÈfi‰Ô˘ Î·È Û˘¯ÓfiÙËÙ·˜ ÓÂÔÁÓÈ΋˜ Û‹„˘ (6,30). øÛÙfiÛÔ, ÛÙ· ÚfiˆÚ·, fiˆ˜ Î·È ÛÙ· ÙÂÏÂÈfiÌËÓ·, Ô ·ÔÈÎÈÛÌfi˜ ÙÔ˘ ÎfiÏÔ˘ ·fi ÛÙÚÂÙfiÎÔÎÎÔ Ù˘ ÔÌ¿‰·˜ µ Î·È Ë ÂÌÊ¿ÓÈÛË ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›· ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Û‹„˘ (5).

OÈ Û˘¯ÓfiÙÂÚÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È Û ÓÂÔÁÓÈ΋ Û‹„Ë Ô˘ Û˘Ó‰¤ÂÙ·È Ì ¶ƒ∂À Â›Ó·È Ô ÛÙÚÂÙfiÎÔÎÎÔ˜ Ù˘ ÔÌ¿‰·˜ µ Î·È ÙÔ ÎÔÏÔ‚·ÎÙËÚ›‰ÈÔ (4,5,10). ¶ÚÔˆÚfiÙËÙ· ∏ ¶ƒ∂À ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ÙÔ 20-50% ÙˆÓ ÚfiˆÚˆÓ ÙÔÎÂÙÒÓ (4), ÂÓÒ ˘¿Ú¯ÂÈ ÈÛ¯˘Ú‹ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ¶ƒ∂À Î·È ÚÔˆÚfiÙËÙ·˜ (31). OÈ Verber Î·È Û˘Ó (1989) ·Ó·Ê¤ÚÔ˘Ó Û˘¯ÓfiÙËÙ· ¶ƒ∂À 3% Û ÓÂÔÁÓ¿ Ì ∏∫ ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 32 ‚‰ÔÌ¿‰ˆÓ, 28% Û ÓÂÔÁÓ¿ Ì ∏∫ 28-31 ‚‰ÔÌ¿‰ˆÓ Î·È 33% Û ÂΛӷ Ì ∏∫ ÌÈÎÚfiÙÂÚË ÙˆÓ 28 ‚‰ÔÌ¿‰ˆÓ (31). ∏ ÓÔÛËÚfiÙËÙ· ÙˆÓ ÚÔÒÚˆÓ Ì ¶ƒ∂À ¤¯ÂÈ Û¯¤ÛË Î˘Ú›ˆ˜ Ì ÙËÓ ∏∫, ηıÒ˜ Ù· ÚÔ‚Ï‹Ì·Ù· Ô˘ ÂÈÎÚ·ÙÔ‡Ó Â›Ó·È ÔÈ ÂÈÏÔΤ˜ Ù˘ ÚÔˆÚfiÙËÙ·˜. OÈ Kimberlin Î·È Û˘Ó (1999), ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÔÏÏ·Ï‹ ÏÔÁÈÛÙÈ΋ ·ÏÈÓ‰ÚÔÌÈ΋ ·Ó¿Ï˘ÛË, ‚Ú‹Î·Ó fiÙÈ Ë ¶ƒ∂À ‰ÂÓ ·˘Í¿ÓÂÈ ÙË ÓÂÔÁÓÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ÚÔÒÚˆÓ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÌÈÎÚfiÙÂÚÔ ÙˆÓ 1000 g, fiÙ·Ó ÁÈÓfiÙ·Ó ‰ÈfiÚıˆÛË ÁÈ· ÙËÓ ∏∫ (20). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ÂȂ‚·ÈÒÓÔ˘Ó Û ÚfiÛÊ·ÙË ÌÂϤÙË ÙÔ˘˜ ÔÈ Furman Î·È Û˘Ó (2001), ÔÈ ÔÔ›ÔÈ ÌÂϤÙËÛ·Ó 2326 ÚfiˆÚÔ˘˜ ÙÔÎÂÙÔ‡˜, ÛÙÔ˘˜ 376 ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ˘‹Ú¯Â ¶ƒ∂À. ¢ÂÓ ‚Ú‹Î·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· ™∞¢, ÂÓ‰Ô-

316

Paediatriki 2002;65:313-321

ÂÚÈÎÔÈÏȷ΋˜ ·ÈÌÔÚÚ·Á›·˜ III-IVÔ˘ ‚·ıÌÔ‡, ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜, ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜, ÓÂÔÁÓÈ΋˜ Ó¢ÌÔÓ›·˜, Û‹„˘ Î·È ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜ ÌÂٷ͇ ÙˆÓ ÚÔÒÚˆÓ Ì ¶ƒ∂À Î·È ÂÎÂ›ÓˆÓ Ì ·Î¤Ú·È˜ ÌÂÌ‚Ú¿Ó˜ (19). °È’ ·˘Ùfi, ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÚfiˆÚË ¶ƒ∂À ¯ˆÚ›˜ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ ‰ÂÓ ÂÈ‚·Ú‡ÓÂÈ Ù· ÓÂÔÁÓ¿ ÂÚÈÛÛfiÙÂÚÔ ·’ fiÙÈ Ë ›‰È· Ë ÚÔˆÚfiÙËÙ· (19). ∞Ó·ÊÔÚÈο Ì ÙË Û¯¤ÛË Ù˘ ¶ƒ∂À Ì ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (™∞¢), ÔÚÈṲ̂Ó˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ¶ƒ∂À ÂÌÊ·Ó›˙Ô˘Ó ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ· Î·È ‚·Ú‡ÙËÙ· ™∞¢, ÙËÓ ÔÔ›· ·Ô‰›‰Ô˘Ó Û ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ÛÙÂÚÔÂȉÒÓ ·fi Ù· ÂÈÓÂÊÚ›‰È· ÙÔ˘ ΢‹Ì·ÙÔ˜ ÏfiÁˆ ÙÔ˘ ¯ÚfiÓÈÔ˘ ÂÓ‰ÔÌ‹ÙÚÈÔ˘ stress (17). OÈ Namavar Jahromi Î·È Û˘Ó (2000) (32), ÔÈ ÔÔ›ÔÈ ÌÂϤÙËÛ·Ó 159 ÂÚÈÙÒÛÂȘ ÚfiˆÚ˘ ¶ƒ∂À Ì ∏∫ 24-37 ‚‰ÔÌ¿‰ˆÓ, ·Ú·Ù‹ÚËÛ·Ó ÚÔԉ¢ÙÈ΋ Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ™∞¢ ·fi 43% Û ¶ƒ∂À ‰È¿ÚÎÂÈ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 12 ˆÚÒÓ, Û 31% Û ¶ƒ∂À ‰È¿ÚÎÂÈ·˜ 12-24 ˆÚÒÓ Î·È 19% Û ¶ƒ∂À ‰È¿ÚÎÂÈ·˜ 24-48 ˆÚÒÓ. øÛÙfiÛÔ, Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ™∞¢ ·˘Í‹ıËΠ۠40%, fiÙ·Ó ÙÔ ÌÂÛԉȿÛÙËÌ· ÌÂٷ͇ ¶ƒ∂À Î·È ÙÔÎÂÙÔ‡ ÍÂ¤Ú·Û ÙȘ 48 ÒÚ˜, ÁÂÁÔÓfi˜ Ô˘ ·Ô‰fiıËΠÛÙËÓ Â›‰Ú·ÛË ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ ·Ú·ÙÂٷ̤Ó˘ ¶ƒ∂À, fiˆ˜ Â›Ó·È Ë ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·, Ë ÛË„·ÈÌ›· Î·È Ë Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· (32). OÈ Palta Î·È Û˘Ó (1996) ·Ó¤ÊÂÚ·Ó ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ™∞¢ [odds ratio (OR) 0,42, Ì 95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ (confidence interval, CI) 0,28-0,64] Û ¶ƒ∂À ‰È¿ÚÎÂÈ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 24 ˆÚÒÓ (33). ŒÓ· ¿ÏÏÔ ÛÔ‚·Úfi Úfi‚ÏËÌ· Ù˘ ÚÔˆÚfiÙËÙ·˜, Ô˘ Â›Ó·È Î·ıÔÚÈÛÙÈÎfi fi¯È ÌfiÓÔ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË ·ÏÏ¿ Î·È ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÂÈ˙Ô‡Ó, Â›Ó·È Ë ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·. ¶·Ú·ÙËÚÂ›Ù·È ÛÙÔ 20% ÂÚ›Ô˘ ÙˆÓ ÚÔÒÚˆÓ Ì ∏∫ ÌÈÎÚfiÙÂÚË ÙˆÓ 32 ‚‰ÔÌ¿‰ˆÓ (34,35). ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο Û ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ· (35) Î·È ÓÂÔÁÓÈ΋ Û‹„Ë (36,37). ∏ ·Ú·ÙÂٷ̤ÓË ¶ƒ∂À Û˘Ó‰˘¿˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Î·È ÌfiÓÈÌˆÓ Ó¢ÚÔ·Ó·Ù˘ÍÈ·ÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ (ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ Î.¿.) ÛÙ· Ï·›ÛÈ· Ù˘ ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ Î·È ÓÂÔÁÓÈÎÒÓ ÏÔÈÌÒÍÂˆÓ (6,35,36). À¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Ë ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ Ì ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙË ÌËÙ¤Ú· ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο ÙÔÓ Î›Ó‰˘ÓÔ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ (37). ™‡Ó‰ÚÔÌÔ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘ ∆Ô Û‡Ó‰ÚÔÌÔ ÙÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘ ÂÈϤÎÂÈ ÙË Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ÛÙÔ 2Ô ÙÚ›ÌËÓÔ,

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·317

¶·È‰È·ÙÚÈ΋ 2002;65:313-321

ÌÂٷ͇ 17˘ Î·È 28˘ ‚‰ÔÌ¿‰·˜ Î·È ¤¯ÂÈ È‰È·›ÙÂÚ· ‚·ÚÈ¿ ÚfiÁÓˆÛË. ∏ Û˘¯ÓfiÙËÙ· Î·È ‚·Ú‡ÙËÙ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ∏∫ ηٿ ÙËÓ ¶ƒ∂À, ÙËÓ ∏∫ ηٿ ÙÔÓ ÙÔÎÂÙfi, ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘ Î·È ÙË ‰È¿ÚÎÂÈ¿ ÙÔ˘ (22,23). ∆Ô Û‡Ó‰ÚÔÌÔ ÂΉËÏÒÓÂÙ·È Ì ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÙÂÙÚ¿‰· Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ‰˘ÛÌÔÚʛ˜ ÚÔÛÒÔ˘ Î·È ¿ÎÚˆÓ, ˘ÔÏÂÈfiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ·Ó¿Ù˘ÍË, ÂÌ‚Ú˘˚΋ ‰˘ÛÊÔÚ›· Î·È Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· (30,38).

OÈ ‰˘ÛÌÔÚʛ˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÌÔÈ¿˙Ô˘Ó Ì ÂΛӘ Ô˘ ÂÚȤÁÚ·„Â Ô Potter Û ÓÂÔÁÓ¿ Ì ·ÁÂÓÂÛ›· ÓÂÊÚÒÓ Î·È ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ. ∏ Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ Î˘Ì·›ÓÂÙ·È ·fi 12-46% (20). OÈ ÈÔ Û˘¯Ó¿ ÂÚÈÁÚ·ÊfiÌÂÓ˜ ‰˘ÛÌÔÚʛ˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰˘ÛÌÔÚʛ˜ ÙˆÓ ¿ÎÚˆÓ Î·È ·ÚıÚÔÁÚ‡ˆÛË, ˘ÔÏ·Û›· οو ÁÓ¿ıÔ˘, ¯·ÌËÏ‹ ÚfiÛÊ˘ÛË ·˘ÙÈÒÓ, ·ÔÏ·Ù˘Ṳ̂ÓË Ì‡ÙË, ÂÚ›ÛÛÂÈ· ‰¤ÚÌ·ÙÔ˜ Î·È ÎˆÓÔÂȉ‹ ·Ú·ÌfiÚʈÛË ÎÂÊ·ÏÈÔ‡ Û ÎÂÊ·ÏÈ΋ ÚÔ‚ÔÏ‹. OÈ ‰˘ÛÌÔÚʛ˜ ÙÔ˘ ÚÔÛÒÔ˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ›ÂÛ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÂÓÒ ÔÈ ‰˘ÛÌÔÚʛ˜ ÙˆÓ ¿ÎÚˆÓ Î·È Ë ÂÚ›ÛÛÂÈ· ‰¤ÚÌ·ÙÔ˜ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ÂÏ·Ùو̤Ó˘ ÎÈÓËÙÈÎfiÙËÙ·˜ (16,30). OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙË ÌÂÁ·Ï‡ÙÂÚË Û˘Û¯¤ÙÈÛË Ì ÙȘ ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ Â›Ó·È Ë ‚·Ú‡ÙËÙ· ÙÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘ Î·È Ë ‰È¿ÚÎÂÈ· Ù˘ Ï·Óı¿ÓÔ˘Û·˜ ÂÚÈfi‰Ô˘ (22,23). ∏ ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ ıˆÚÂ›Ù·È fiÙÈ ·ÔÙÂÏ› ÙÌ‹Ì· Ù˘ ÙÂÙÚ¿‰·˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘, ¯ˆÚ›˜ fï˜ Ó· ¤¯ÂÈ ÙÂÎÌËÚȈı› Ì›· ¿ÌÂÛË Â›‰Ú·ÛË ÙÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘ ÛÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ·Ó¿Ù˘ÍË (38,39). ∏ ÂÌ‚Ú˘˚΋ ‰˘ÛÊÔÚ›· Î·È Ë ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· ÂÈϤÎÔ˘Ó Û˘¯Ó¿ ÙÔ Û‡Ó‰ÚÔÌÔ, ˆ˜ Û˘Ó¤ÂÈ· Ù˘ ›ÂÛ˘ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ‹/Î·È ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘, ηıÒ˜ Î·È Ù˘ Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜. ∏ Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· ·ÔÙÂÏ› ÙË ÛÔ‚·ÚfiÙÂÚË ÂÈÏÔ΋ Ù˘ ¶ƒ∂À ÚÈÓ ·fi ÙËÓ 24Ë-25Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ Î·È Â›Ó·È Î·ıÔÚÈÛÙÈ΋ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË Î·È ÙË ÓÔÛËÚfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ. ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ Û ¶ƒ∂À ÙÔ˘ 2Ô˘ ÙÚÈÌ‹ÓÔ˘ Î˘Ì·›ÓÂÙ·È ·fi 9-33% (6,21-23,30) Î·È Êı¿ÓÂÈ Ì¤¯ÚÈ 95% ÛÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ÙÔ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ Û˘Óԉ‡ÂÙ·È ·fi ‰˘ÛÌÔÚʛ˜ (22,31,39). ∂ΉËÏÒÓÂÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Ì ÌÈÎÚ‹ ÂÚ›ÌÂÙÚÔ ıÒڷη Î·È ‚·ÚÈ¿ ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ·, ÁÈ· ÙËÓ ÔÔ›· ··ÈÙÂ›Ù·È ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË Ì Ôχ ˘„ËϤ˜ ıÂÙÈΤ˜ ȤÛÂȘ (>30 cm H2O) ÙfiÛÔ Î·Ù¿ ÙÔÓ ÙÔÎÂÙfi fiÛÔ Î·È ÛÙË Û˘Ó¤¯ÂÈ· (30,39). ™˘Ó‹ıˆ˜ Û˘Ó˘¿Ú¯ÂÈ Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË, ÏfiÁˆ ‰È·Ù·Ú·¯‹˜ Ù˘ ·Ó¿Ù˘Í˘ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ (38-40). ÕÏÏË Û˘¯Ó‹ ÂÈÏÔ΋ Â›Ó·È Ô Ó¢ÌÔıÒڷη˜, ÏfiÁˆ ÙˆÓ ˘„ËÏÒÓ ıÂÙÈÎÒÓ ȤÛÂˆÓ Ô˘ ··ÈÙÔ‡ÓÙ·È ÁÈ· ÙÔÓ ·ÂÚÈÛÌfi Î·È ÙËÓ Ô͢ÁfiÓˆÛË ÙˆÓ ÓÂÔÁÓÒÓ

Paediatriki 2002;65:313-321

·˘ÙÒÓ. ™Ù· ‚Ú¤ÊË Ô˘ ÂÈ˙Ô‡Ó ··ÈÙÂ›Ù·È ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÁÈ· ÔÏϤ˜ ‚‰ÔÌ¿‰Â˜. ÷ڷÎÙËÚÈÛÙÈο Â›Ó·È Ù· Â˘Ú‹Ì·Ù· ·fi ÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, fiÔ˘ ‰È·ÈÛÙÒÓÂÙ·È Ô Îˆ‰ˆÓÔÂȉ‹˜ ıÒڷη˜, Ì ÌÈÎÚ‹ ¤ÎÙ˘ÍË Ó¢ÌfiÓˆÓ Î·È ·Ó‡„ˆÛË ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ ¿Óˆ ·fi ÙËÓ 7Ë ÏÂ˘Ú¿ (30,38). ∏ ‚·ÚÈ¿ Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÙ·È ·fi ÛÔ‚·Ú¤˜ ‰˘ÛÌÔÚʛ˜, ·ÏÏ¿ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› Î·È Ì ‹Ș ‹ ηıfiÏÔ˘ ‰˘ÛÌÔÚʛ˜ (22,23,38,39). ∏ ·ıÔÁ¤ÓÂÈ· Ù˘ Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜ Û ¤Ì‚Ú˘· Ì ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ ‰ÈÂÚ¢ӋıËΠÂÎÙÂÓÒ˜ Û ÛÂÈÚ¿ ÂÈÚ·Ì·ÙÈÎÒÓ ÌÔÓ٤ψÓ, ·fi Ù· ÔÔ›· ÚԤ΢„·Ó ÂӉ›ÍÂȘ ÁÈ· ÂÌÏÔ΋ ‰‡Ô ‚·ÛÈÎÒÓ ·ıÔÁÂÓÂÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ, Ù˘ ‰È·Ù·Ú·¯‹˜ Ù˘ ‰˘Ó·ÌÈ΋˜ ÈÛÔÚÚÔ›·˜ ÙÔ˘ ÂÓ‰ÔÓ¢ÌÔÓÈÎÔ‡ ˘ÁÚÔ‡ Î·È Ù˘ ÂÏ¿ÙÙˆÛ˘ ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘ (38,39,41). ∆Ô ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ ÌÂÙ·‚¿ÏÏÂÈ ÙË ‰È·ÊÔÚ¿ ȤÛÂˆÓ ÙÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ ÌÂٷ͇ ÙÔ˘ ·ÌÓÈ·ÎÔ‡ Û¿ÎÔ˘ Î·È ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ Ó‡ÌÔÓ·, Ì ·ÔÙ¤ÏÂÛÌ· ÂÎÚÔ‹ ÙÔ˘ ÂÓ‰ÔÓ¢ÌÔÓÈÎÔ‡ ˘ÁÚÔ‡ ÚÔ˜ ÙËÓ ·ÌÓȷ΋ ÎÔÈÏfiÙËÙ·. ŒÙÛÈ, ÂÚÈÔÚ›˙ÂÙ·È Ô ÂÛˆÙÂÚÈÎfi˜ ¯ÒÚÔ˜ ÙÔ˘ Ó‡ÌÔÓ·, Ô ÔÔ›Ô˜ ·ÔÙÂÏ› ¤Ó·Ó ÂÛˆÙÂÚÈÎfi ˘ÁÚfi Ó¿ÚıËη, Á‡Úˆ ·fi ÙÔÓ ÔÔ›Ô ·Ó·Ù‡ÛÛÂÙ·È Ô ÂÌ‚Ú˘˚Îfi˜ Ó‡ÌÔÓ·˜. ÕÏÏÔ˜ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜ Â›Ó·È Ë ·ÚÂÌfi‰ÈÛË ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘, Ô˘ Â›Ó·È Ôχ ÛËÌ·ÓÙÈΤ˜ ÁÈ· ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ Ó¢ÌfiÓˆÓ. ŒÙÛÈ, Ë Î·Ù¿ÚÁËÛ‹ ÙÔ˘˜ ηٿ ÙËÓ ÎÚ›ÛÈÌË ÂÚ›Ô‰Ô ·Ó¿Ù˘Í˘ ÙˆÓ Ó¢ÌfiÓˆÓ Î·È Î˘Ú›ˆ˜ ηٿ ÙÔ ÛÙ¿‰ÈÔ Û¯ËÌ·ÙÈÛÌÔ‡ ÙˆÓ Î·ÙÒÙÂÚˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ (14Ë-28Ë Â‚‰ÔÌ¿‰· ·ËÛ˘), Û˘Ó‰¤ÂÙ·È Ì ˘ÔÏ·Û›· Ó¢ÌfiÓˆÓ. ∏ ÛËÌ·Û›· ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ‰ÈÂÚ¢ӋıËΠ۠ÎÏÈÓÈΤ˜ ÌÂϤÙ˜, ÛÙȘ Ôԛ˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ë ·Ô˘Û›· ÛÙ·ıÂÚÒÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Û˘Ó‰ÂfiÙ·Ó Ì ÙËÓ ·Ó¿Ù˘ÍË Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜ (41,43). ∏ ÛËÌ·Û›· Ù˘ ·˘ÍË̤Ó˘ Â͈ÙÂÚÈ΋˜ ›ÂÛ˘ ÛÙÔ ıÒڷη ¤¯ÂÈ ·ÌÊÈÛ‚ËÙËı›, ÁÈ·Ù› Ë ıˆÚ·ÎÈ΋ ÎÔÈÏfiÙËÙ· Â›Ó·È ‹‰Ë ηϿ ·Ó·Ù˘Á̤ÓË ÛÙÔ 2Ô ÙÚ›ÌËÓÔ (38). ∞fi ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ˘ÔÏ·Û›·˜ ÙÔ˘ Ó‡ÌÔÓ· ÛÙËÓ ¶ƒ∂À Â›Ó·È Û·Ê¤˜ fiÙÈ Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛ‹ Ù˘ Â›Ó·È Ë ∏∫ ÛÙËÓ ÔÔ›· Â¤Ú¯ÂÙ·È Ë Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ. ∏ ÎÚÈÙÈ΋ Ê¿ÛË Ù˘ ·Ó¿Ù˘Í˘ ÙˆÓ Ó¢ÌfiÓˆÓ Û˘ÌÏËÚÒÓÂÙ·È ÙËÓ 26Ë Â‚‰ÔÌ¿‰· ·ËÛ˘, ÒÛÙ ¶ƒ∂À ÌÂÙ¿ ·fi ÙËÓ ËÏÈΛ· ·˘Ù‹ ‰ÂÓ ·Ó·Ì¤ÓÂÙ·È Ó· ¤¯ÂÈ ‚·ÚȤ˜ Û˘Ó¤ÂȘ ÛÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ Ó¢ÌfiÓˆÓ (38,39). ∞ÏÏ¿ Î·È fiÙ·Ó Ë ¶ƒ∂À Û˘Ì‚Â› ÛÙÔ ÎÚ›ÛÈÌÔ ·˘Ùfi ‰È¿ÛÙËÌ·, Ë ·Ó¿Ù˘ÍË Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ¯ÚfiÓÔ Ô˘ ÌÂÛÔÏ·‚›

317

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·318

¶·È‰È·ÙÚÈ΋ 2002;65:313-321

ÌÂٷ͇ ¶ƒ∂À Î·È ÙÔÎÂÙÔ‡, ηıÒ˜ Î·È ·fi ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘. OÈ Kilbride Î·È Û˘Ó (1996) Û ÌÂϤÙË 115 ΢‹ÛÂˆÓ Ì ¶ƒ∂À ÚÈÓ ÙËÓ 25Ë Â‚‰ÔÌ¿‰· Ì ‚·Ú‡ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ (ı‡Ï·Î·˜ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ <2 ‹ 1 cm) ‚Ú‹Î·Ó fiÙÈ Ë ·Ú¿Ù·ÛË Ù˘ Ï·Óı¿ÓÔ˘Û·˜ ÂÚÈfi‰Ô˘ ÁÈ· ÂÚÈÛÛfiÙÂÚ˜ ·fi 14 Ë̤Ú˜ Û˘Û¯ÂÙÈ˙fiÙ·Ó Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜ (87%) Î·È ıÓËÙfiÙËÙ·˜ (91%) (23). ¶·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· Î·È Û˘ÓÂÚÁÈ΋ Â›‰Ú·ÛË ÌÂٷ͇ ‚·Ú‡ÙËÙ·˜ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘ Î·È Ï·Óı¿ÓÔ˘Û·˜ ÂÚÈfi‰Ô˘ ‰È·›ÛÙˆÛ·Ó ÔÈ Winn Î·È Û˘Ó (2000) (22). ∏ ‰È¿ÁÓˆÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜ Èı·ÓÔÏÔÁÂ›Ù·È ÚÔÁÂÓÓËÙÈο Ì ÙË ¯Ú‹ÛË ‰È·ÊfiÚˆÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ Ì ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 33% ¤ˆ˜ 100% (42,43). OÚÈṲ̂ÓÔÈ Û˘ÁÁÚ·Ê›˜ ıˆÚÔ‡Ó Ôχ ηÏfi ‰È·ÁÓˆÛÙÈÎfi ‰Â›ÎÙË ÙËÓ ·Ô˘Û›· ·Ó·Ó¢ÛÙÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘ (41,43), ÂÓÒ ¿ÏÏÔÈ ‰ÂÓ ‚Ú‹Î·Ó ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ·Ó·Ó¢ÛÙÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È Ù˘ Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜ (23). ªÂÙ¿ ÙË Á¤ÓÓËÛË, Ë ‰È¿ÁÓˆÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜ ‚·Û›˙ÂÙ·È ÛÙÔ Û˘Ó‰˘·ÛÌfi ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘, ¯·ÌËÏÔ‡ Apgar score, ‰˘ÛÌÔÚÊÈÒÓ Î·È ‚·ÚÈ¿˜ ·Ó·Ó¢ÛÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Ë ÔÔ›· ··ÈÙ› ÂÊ·ÚÌÔÁ‹ ˘„ËÏÒÓ ıÂÙÈÎÒÓ ȤÛÂˆÓ (30,39). ∂›Û˘, ÛËÌ·ÓÙÈ΋ Â›Ó·È Ë ‰È·ÁÓˆÛÙÈ΋ ‚Ô‹ıÂÈ· ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη. ∞Ó ÙÔ ÓÂÔÁÓfi ηٷϋÍÂÈ, Ë ‰È¿ÁÓˆÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜ ÙÂÎÌËÚÈÒÓÂÙ·È Ì ÙËÓ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ÂͤٷÛË, fiÔ˘ ‰È·ÈÛÙÒÓÂÙ·È ¯·ÌËÏ‹ Û¯¤ÛË ‚¿ÚÔ˘˜ Ó¢ÌfiÓˆÓ/ µ™ (<0,012 ÁÈ· ∏∫ >28 ‚‰ÔÌ¿‰Â˜ ηÈ<0,015 ÁÈ· ∏∫ <28 ‚‰ÔÌ¿‰Â˜), ÂÏ·Ùو̤ÓÔ ÔÏÈÎfi DNA ÙˆÓ Ó¢ÌfiÓˆÓ Î·È ¯·ÌËÏ‹ Û¯¤ÛË DNA Ó¢ÌfiÓˆÓ/ µ™ (39). ¶ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ· Î·È ÂͤÏÈÍË ÙˆÓ ÓÂÔÁÓÒÓ Ì ¶ƒ∂À ∏ ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ Ì ¶ƒ∂À ÂËÚ¿˙ÂÙ·È ÛËÌ·ÓÙÈο ·fi ÙËÓ ∏∫ ÛÙËÓ ÔÔ›· Û˘Ì‚·›ÓÂÈ Ë Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ Î·È ÙËÓ ∏∫ ÛÙÔÓ ÙÔÎÂÙfi (3,22). ŸÙ·Ó Ë ¶ƒ∂À Û˘Ì‚·›ÓÂÈ Û ∏∫ ÌÈÎÚfiÙÂÚË ÙˆÓ 25 ‚‰ÔÌ¿‰ˆÓ, Ë ıÓËÛÈÌfiÙËÙ· Â›Ó·È ÂÚ›Ô˘ 50% (41-54%), ÂÓÒ ÌÂÙ¿ ÙËÓ 25Ë Â‚‰ÔÌ¿‰· ‰ÂÓ ‰È·Ê¤ÚÂÈ ·fi ÙË ıÓËÛÈÌfiÙËÙ· ÓÂÔÁÓÒÓ ¯ˆÚ›˜ ¶ƒ∂À (2,3,6,21-23). ™Â Û¯¤ÛË Ì ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘, Ë ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ· ·fi 0-2,5% ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ¶ƒ∂À, ·Ó‚·›ÓÂÈ ÛÙÔ 7% ÛÙ· ÚfiˆÚ· Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 1501-2500 g Î·È ÛÙÔ 29% Û ÂΛӷ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 1000-1500 g. ∞Ó ˘¿Ú¯ÂÈ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ, Ë ıÓËÛÈÌfiÙËÙ· Êı¿ÓÂÈ Ì¤¯ÚÈ ÙÔ 69% (21). ¢˘ÛÌÂÓ‹˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔ-

318

Paediatriki 2002;65:313-321

ÓÙ·˜ Â›Ó·È Ë Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›·, Ô˘ ·Ó‚¿˙ÂÈ ÙË ıÓËÛÈÌfiÙËÙ· ÛÙÔ 95% (22,23). ∞Ó·ÊÔÚÈο Ì ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÓÔÛËÚfiÙËÙ· ÙˆÓ ‚ÚÂÊÒÓ Ì ¶ƒ∂À Ô˘ ÂÈ˙Ô‡Ó, ÔÈ KurkinenRaty Î·È Û˘Ó (1998), Û ·Ó·‰ÚÔÌÈ΋ Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË 78 ΢‹ÛÂˆÓ Ì ¶ƒ∂À ÌÂٷ͇ 17˘ Î·È 30˘ ‚‰ÔÌ¿‰·˜ Î·È 78 Ì·ÚÙ‡ÚˆÓ, ‚Ú‹Î·Ó fiÙÈ Ù· ‚Ú¤ÊË Ì ¶ƒ∂À ›¯·Ó ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋ ÓÔÛËÏ›· ÁÈ· ·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù· ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ 1Ô˘ ¯ÚfiÓÔ˘ ˙ˆ‹˜ (5 Ë̤Ú˜ Î·È 1 Ë̤ڷ, ·ÓÙ›ÛÙÔȯ·) Î·È ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· Û˘Ìو̷ÙÈ΋˜ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘ Û ËÏÈΛ· 1 ¤ÙÔ˘˜ (22% Î·È 9%, ·ÓÙ›ÛÙÔȯ·) (6). ∂›Û˘, ÔÈ Xiao Î·È Û˘Ó (2000) ‚Ú‹Î·Ó fiÙÈ ·fi Ù· ÂÈ˙‹Û·ÓÙ· ‚Ú¤ÊË Ì ¶ƒ∂À ÚÈÓ ÙËÓ 28Ë Â‚‰ÔÌ¿‰· ·ËÛ˘, Ù· ÌÈÛ¿ ÂÌÊ¿ÓÈÛ·Ó ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· (21). ∏ ÌÂÁ¿ÏË Û˘¯ÓfiÙËÙ· ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘ ÛÙȘ ·Ú·¿Óˆ ÌÂϤÙ˜ ÚÔÊ·ÓÒ˜ ¤¯ÂÈ Û¯¤ÛË Ì ÙË ÌÂÁ¿ÏË Û˘¯ÓfiÙËÙ· Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó (6,21). ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ Î˘‹ÛÂˆÓ Ì ¶ƒ∂À ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Î˘‹ÛÂˆÓ Ì ¶ƒ∂À ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ ΢‹Ì·ÙÔ˜ Î·È Ù˘ ÌËÙ¤Ú·˜, ηıÒ˜ Î·È ·fi ÙËÓ ∏∫. ∏ ‰ÈÂÓ¤ÚÁÂÈ· ÙÔÎÂÙÔ‡ ÂÈ‚¿ÏÏÂÙ·È ·Ó ˘¿Ú¯Ô˘Ó ÎÏÈÓÈΤ˜ ‹ ÂÚÁ·ÛÙËÚȷΤ˜ ÂӉ›ÍÂȘ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜, ‰È·ÛÙÔÏ‹ ÙÔ˘ ÙÚ·¯‹ÏÔ˘ ÌÂÁ·Ï‡ÙÂÚË ·fi 4-5 cm, ÂÈ̤ÓÔ˘Û˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ ηډȷÎÔ‡ Ú˘ıÌÔ‡, ·ÈÌÔÚÚ·Á›· ÂÓ‰ÂÈÎÙÈ΋ ÚfiˆÚ˘ ·ÔÎfiÏÏËÛ˘ ÙÔ˘ Ï·ÎÔ‡ÓÙ·, ıÂÙÈΤ˜ ηÏÏȤÚÁÂȘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ ‹ ·ÓÒÌ·ÏË ÚÔ‚ÔÏ‹ ÙÔ˘ ΢‹Ì·ÙÔ˜ Ì·˙› Ì ÛËÌ·ÓÙÈ΋ ‰È·ÛÙÔÏ‹ ÙÚ·¯‹ÏÔ˘. ∞Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó ÔÈ ÂÈÏÔΤ˜ ·˘Ù¤˜, Ô ¯ÚfiÓÔ˜ ÙÔÎÂÙÔ‡ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ∏∫ ηٿ ÙË Ú‹ÍË. ∞Ó Ë ¶ƒ∂À Û˘Ì‚Â› ÛÙÔ Ù¤ÏÔ˜ Ù˘ ·ËÛ˘, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÁÁÚ·Ê›˜ Û˘ÁÎÏ›ÓÔ˘Ó ÛÙËÓ ¿Ô„Ë fiÙÈ Ô ¯ÚfiÓÔ˜ ·Ó·ÌÔÓ‹˜ ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÙˆÓ 12-24 ˆÚÒÓ, ηıÒ˜ ÌÂÙ¿ ·fi ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο Ô Î›Ó‰˘ÓÔ˜ ÏÔÈÌÒÍÂˆÓ ÌËÙ¤Ú·˜ Î·È ·È‰ÈÔ‡ (10,18). ∞Ó ÛÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi ‰ÂÓ ·Ú¯›ÛÂÈ ÌfiÓÔ˜ ÙÔ˘ Ô ÙÔÎÂÙfi˜, Û˘ÓÈÛÙ¿Ù·È ÚfiÎÏËÛË ÙÔÎÂÙÔ‡, ÂÊfiÛÔÓ Ô ÙÚ¿¯ËÏÔ˜ Â›Ó·È ÒÚÈÌÔ˜. ∞Ó Ô ÙÚ¿¯ËÏÔ˜ ‰ÂÓ Â˘ÓÔ› ÙËÓ ÚfiÎÏËÛË Î·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂÈÏÔΤ˜, Û˘ÓÈÛÙ¿Ù·È ·Ó·ÌÔÓ‹ (18). ™Â ÂÚÈÙÒÛÂȘ fiÔ˘ Ë ¶ƒ∂À Â¤Ú¯ÂÙ·È ÚÈÓ ·fi ÙËÓ 34Ë Â‚‰ÔÌ¿‰·, Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ·Ú·Ù·ı› Ë Î‡ËÛË Ì¤¯ÚÈ ÙËÓ 34Ë Â‚‰ÔÌ¿‰· ‹ ÁÈ· fiÛÔ ‰È¿ÛÙËÌ· Â›Ó·È ‰˘Ó·Ùfi, ÂÊfiÛÔÓ Ë Î·Ù¿ÛÙ·ÛË Ù˘ ÌËÙ¤Ú·˜ Î·È ÙÔ˘ ΢‹Ì·ÙÔ˜ ÙÔ ÂÈÙÚ¤ÂÈ (44). ŒÙÛÈ, Û˘ÓÈÛÙ¿Ù·È Ë Ù‹ÚËÛË ÛÙ¿Û˘ ·Ó·ÌÔÓ‹˜ Î·È Ë ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂÁ·Ԣ Î·È ÙÔ˘

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·319

¶·È‰È·ÙÚÈ΋ 2002;65:313-321

΢‹Ì·ÙÔ˜. ∞Ó ÂÌÊ·ÓÈÛÙÔ‡Ó ÂӉ›ÍÂȘ Ïԛ̈͢, ÂÈ‚¿ÏÏÂÙ·È Ó· Á›ÓÂÈ ÙÔÎÂÙfi˜ (18). ∞Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó ÔÈ ÂӉ›ÍÂȘ Ïԛ̈͢, ÁÈ· ÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ Ë ˆÚÈÌfiÙËÙ· ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ Ó‡ÌÔÓ·, Ë ∏∫, Ë Ï·Óı¿ÓÔ˘Û· ÂÚ›Ô‰Ô˜, Ô ·ÔÈÎÈÛÌfi˜ ÙÔ˘ ÎfiÏÔ˘ ·fi ÛÙÚÂÙfiÎÔÎÎÔ Ù˘ ÔÌ¿‰·˜ µ, Ë ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ, Ë ‡·ÚÍË ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘ Î.¿. (2,18). ™Â ÂÚÈÙÒÛÂȘ Ì ¶ƒ∂À ÚÈÓ ÙËÓ 26Ë Â‚‰ÔÌ¿‰· Ì ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ, ÔÈ Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ÂÓ‰Ô·ÌÓȷΤ˜ ÂÁ¯‡ÛÂȘ ÈÛfiÙÔÓÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘ ‚ÔËıÔ‡Ó ÛÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ ÔÏÈÁÔ¸‰Ú·ÌÓ›Ô˘, ÛÙËÓ ·Ú¿Ù·ÛË Ù˘ Ï·Óı¿ÓÔ˘Û·˜ ÂÚÈfi‰Ô˘ Î·È ÛÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ÓÂÔÁÓÈ΋˜ ıÓËÛÈÌfiÙËÙ·˜ Î·È ÓÔÛËÚfiÙËÙ·˜ (45). ∞Ó·ÊÔÚÈο Ì ÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙËÓ ¤ÁÎ˘Ô Ì ¶ƒ∂À, ÌÂÌÔӈ̤Ó˜ ÌÂϤÙ˜ ·ÏÏ¿ Î·È Â˘Ú›˜ ·Ó·ÛÎÔ‹ÛÂȘ Î·È ÌÂÙ·-·Ó·Ï‡ÛÂȘ ¤‰ÂÈÍ·Ó fiÙÈ Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ Î·È ÙˆÓ ÓÂÔÁÓÈÎÒÓ ÏÔÈÌÒ͈Ó, ηٿ 50% ÂÚ›Ô˘ (2,37,46,47). ∂›Û˘, ‰È·ÈÛÙÒıËΠfiÙÈ ·Ú·Ù›ÓÂÈ ÙË ‰È¿ÚÎÂÈ· ·ËÛ˘, ÂÏ·ÙÙÒÓÔÓÙ·˜ ¤ÙÛÈ ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ ÚÔˆÚfiÙËÙ·˜, fiˆ˜ ÙÔ˘ ™∞¢ (Ì›ˆÛË Î·Ù¿ 17%), Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ (Ì›ˆÛË Î·Ù¿ 35-65%), Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ Î·È Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘ (2,47). Œ¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ‰È¿ÊÔÚ· ·ÓÙÈ‚ÈÔÙÈο Î·È Û˘Ó‰˘·ÛÌÔ› ÙÔ˘˜. ø˜ ηχÙÂÚÔ ıÂÚ·¢ÙÈÎfi Û¯‹Ì· ıˆÚÂ›Ù·È Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Â˘Ú¤ˆ˜ Ê¿ÛÌ·ÙÔ˜ ÁÈ· ÙȘ ÚÒÙ˜ 48 ÒÚ˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Û‡ÓÙÔÌË ıÂÚ·›· Û˘ÓÙ‹ÚËÛ˘ ·fi ÙÔ ÛÙfiÌ·. ™˘Ó‹ıˆ˜ ¯ÔÚËÁÂ›Ù·È Û˘Ó‰˘·ÛÌfi˜ ·ÌÈÎÈÏÏ›Ó˘ Ì ÂÚ˘ıÚÔÌ˘Î›ÓË ÂÓ‰ÔÊϤ‚È· Î·È Î·ÙfiÈÓ ·ÌÔ͢ÎÈÏÏ›Ó˘ Ì ÂÚ˘ıÚÔÌ˘Î›ÓË ·fi ÙÔ ÛÙfiÌ· (2). ¶ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ™∞¢ Û ÚfiˆÚ· Ì ¶ƒ∂À (34,36,48,49). OÈ Palta Î·È Û˘Ó (1996) Û˘Ó¤‰ÂÛ·Ó ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ Ì ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÓÂÔÁÓÈÎÔ‡ ı·Ó¿ÙÔ˘ (OR=0,2, CI=0,09-0,5), ™∞¢ (OR=0,52, CI=0,320,8) Î·È ÂÓ‰ÔÎÔÈÏȷ΋˜ ·ÈÌÔÚÚ·Á›·˜ (OR=0,37, CI=0,21-0,65) (34). OÈ Vermillion Î·È Û˘Ó (2000) ·Ó¤ÊÂÚ·Ó fiÙÈ Ë ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË Ì›·˜ ‰fiÛ˘ ÛÙÂÚÔÂȉÒÓ Û ÚfiˆÚ· (∏∫ 34-32 ‚‰ÔÌ¿‰Â˜) Ì ¶ƒ∂À Ì›ˆÛ ÛËÌ·ÓÙÈο ÙÔÓ Î›Ó‰˘ÓÔ ™∞¢ (OR=0,15, CI=0,1-0,4) Î·È ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ πππ-IVÔ˘ ‚·ıÌÔ‡ (OR=0,18, CI=0,1-0,4) (49). ∂›Û˘, ÔÈ Vermeulen Î·È Û˘Ó (2001) ‚Ú‹Î·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ Î›Ó‰˘ÓÔ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Û ÚfiˆÚ· Ô˘ ‹Ú·Ó ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÚÔÁÂÓÓËÙÈο (OR=0,33, CI=0,13-0,85), ·ÓÂÍ¿Ú-

Paediatriki 2002;65:313-321

ÙËÙ· ·fi ÙËÓ ‡·ÚÍË ¶ƒ∂À (36). øÛÙfiÛÔ, ȉȷ›ÙÂÚÔ ÚÔ‚ÏËÌ·ÙÈÛÌfi ÚÔηÏ› Ë Èı·ÓfiÙËÙ· ·‡ÍËÛ˘ Ù˘ Û˘¯ÓfiÙËÙ·˜ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ Î·È Û‹„˘ Ì ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ (8). OÚÈṲ̂ÓÔÈ Û˘ÁÁÚ·Ê›˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ, ÂÊfiÛÔÓ ¯ÔÚËÁÔ‡ÓÙ·È ·ÓÙÈ‚ÈÔÙÈο ÛÙË ÌËÙ¤Ú·, Ù· ÛÙÂÚÔÂȉ‹ ‰ÂÓ ·˘Í¿ÓÔ˘Ó ÛËÌ·ÓÙÈο ÙÔÓ Î›Ó‰˘ÓÔ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ Î·È ÓÂÔÁÓÈ΋˜ Û‹„˘ (48). OÈ Vermillion Î·È Û˘Ó (1999) ‚Ú‹Î·Ó fiÙÈ ÌfiÓÔ ÌÂÙ¿ ·fi ÔÏÏ·Ϥ˜ ‰fiÛÂȘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ·˘Í·ÓfiÙ·Ó Ô Î›Ó‰˘ÓÔ˜ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ Î·È ÓÂÔÁÓÈ΋˜ Û‹„˘ Û ΢‹ÛÂȘ Ì ¶ƒ∂À (48). ∞¿ÓÙËÛË ÛÙÔ ÂÚÒÙËÌ· ·˘Ùfi ÚÔÛ¿ıËÛ·Ó Ó· ‰ÒÛÔ˘Ó ‰‡Ô ÌÂÁ¿Ï˜ ÌÂÙ·-·Ó·Ï‡ÛÂȘ ·fi ÙÔ˘˜ Crowley Î·È Û˘Ó (1995) Î·È Harding Î·È Û˘Ó (2001), ÔÈ Ôԛ˜ η٤ÏËÍ·Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ Û ΢‹ÛÂȘ Ì ÚfiˆÚË ¶ƒ∂À ÂÏ·ÙÙÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ™∞¢ ÂÚ›Ô˘ ηٿ 50%, Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ ηٿ 50% ÂÚ›Ô˘, Ù˘ ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜ ηٿ 80%, ¯ˆÚ›˜ Ó· ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο ÙÔÓ Î›Ó‰˘ÓÔ ÓÂÔÁÓÈ΋˜ Û‹„˘ (8,9). ∂ÈϤÔÓ, ‰È·›ÛÙˆÛ·Ó Ì›· Ù¿ÛË ÁÈ· Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÓÂÔÁÓÈÎÔ‡ ı·Ó¿ÙÔ˘ ηٿ 32%, ¯ˆÚ›˜ fï˜ ·˘Ù‹ Ë Ì›ˆÛË Ó· Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (9). ªÂÙ¿ ·fi fiϘ ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜ Î·È ÌÂÙ·-·Ó·Ï‡ÛÂȘ, Ë ÂÈÎÚ·Ù¤ÛÙÂÚË ¿Ô„Ë Â›Ó·È fiÙÈ Ë ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÂÏ·ÙÙÒÓÂÈ ÙË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ÙˆÓ ÚÔÒÚˆÓ Ì ¶ƒ∂À, ÒÛÙÂ, Û‡Ìʈӷ Ì ÙÔ Û˘Ì¤Ú·ÛÌ· ÙˆÓ Harding Î·È Û˘Ó (2001), ‰ÂÓ ‰ÈηÈÔÏÔÁÂ›Ù·È Ë ‰ÈÂÓ¤ÚÁÂÈ· ÂÚÈÛÛfiÙÂÚˆÓ ÌÂÏÂÙÒÓ Û¯ÂÙÈο Ì ÙÔ ı¤Ì· ·˘Ùfi (9). øÛÙfiÛÔ, ·Ú·Ì¤ÓÔ˘Ó ·ÎfiÌË ÛËÌ›· Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚË ‰ÈÂÚ‡ÓËÛË, fiˆ˜ Â›Ó·È ÙÔ ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· (Ì›· ‹ ÔÏϤ˜ ‰fiÛÂȘ), ÙÔ Î·Ù·ÏÏËÏfiÙÂÚÔ Â›‰Ô˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉԇ˜ Î.Ï., Ù· ÔÔ›· ÈÛ¯‡Ô˘Ó ÁÂÓÈο ÁÈ· ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ Û ÂÈΛÌÂÓÔ ÚfiˆÚÔ ÙÔÎÂÙfi Î·È fi¯È ÂȉÈο ÁÈ· ÙȘ ΢‹ÛÂȘ Ì ¶ƒ∂À. ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÚÈÁÂÓÓËÙÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ÓÂÔÁÓÔ‡ ∫·Ù¿ ÙÔÓ ÙÔÎÂÙfi ÓÂÔÁÓÔ‡ Ì ¶ƒ∂À ı· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÂÙÔÈÌfiÙËÙ· ÁÈ· ·Ó¿ÓË„Ë, ÏfiÁˆ ÙÔ˘ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÚÈÁÂÓÓËÙÈ΋˜ ·ÛÊ˘Í›·˜. ∂ȉÈο ÁÈ· ÙȘ ΢‹ÛÂȘ Ì ¶ƒ∂À ÚÈÓ ·fi ÙËÓ 34Ë Â‚‰ÔÌ¿‰·, ÂӉ›ÎÓ˘Ù·È Ë ÂÓ‰ÔÌ‹ÙÚÈ· ÌÂÙ·ÊÔÚ¿ Û ÂÚÈÁÂÓÓËÙÈÎfi ΤÓÙÚÔ. ™Â ÂÚÈÙÒÛÂȘ ¶ƒ∂À ÚÈÓ ÙËÓ 28Ë Â‚‰ÔÌ¿‰·, Ù· ·Ó·ÌÂÓfiÌÂÓ· ÚÔ‚Ï‹Ì·Ù· Â›Ó·È È‰È·›ÙÂÚ· ÛÔ‚·Ú¿, ÒÛÙ ηٿ ÙÔÓ ÙÔÎÂÙfi ı· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ Û ÂÙÔÈÌfiÙËÙ· ÔÌ¿‰· ÂÂÈÚ·Ì¤ÓˆÓ ÓÂÔÁÓÔÏfiÁˆÓ. ∂¿Ó ˘¿Ú¯ÂÈ Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›·, Ô ÓÂÔÁÓÔÏfiÁÔ˜ ı· ¯ÚÂÈ·ÛÙ› Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙË ‚·ÚÈ¿ ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ·Ì¤Ûˆ˜ ÌÂÙ¿

319

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·320

¶·È‰È·ÙÚÈ΋ 2002;65:313-321

ÙÔÓ ÙÔÎÂÙfi. ∏ ¿ÌÂÛË ‰È·ÛˆÏ‹ÓˆÛË Î·È Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ Ì ˘„ËϤ˜ ıÂÙÈΤ˜ ȤÛÂȘ ÌÔÚ› Ó· ‰ÈÔÚıÒÛÂÈ ÙËÓ ˘ÂÚηÓ›·, ·ÏÏ¿ ‰‡ÛÎÔÏ· ı· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ˘ÔÍ·ÈÌ›·, ÛÙËÓ ÔÔ›· Û˘Ì‚¿ÏÏÂÈ Ë ÂӉ¯fiÌÂÓ· Û˘Ó˘¿Ú¯Ô˘Û· ÚˆÙÔ·ı‹˜ Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË (27). ∏ ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Ë ÂÊ·ÚÌÔÁ‹ ˘„›Û˘¯ÓÔ˘ ·ÂÚÈÛÌÔ‡ Î·È Ë ¯ÔÚ‹ÁËÛË ÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘ ‚ÂÏÙ›ˆÛ ÙËÓ ÂÈ‚›ˆÛË ÓÂÔÁÓÒÓ Ì Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· (50-52). øÛÙfiÛÔ, ·ÎfiÌË Î·È Ì ÙȘ ÓÂfiÙÂÚ˜ ÌÂıfi‰Ô˘˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Ì Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· ‰ÂÓ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ë ˘ÔÍ·ÈÌ›· (23,50). ∞Ó·ÊÔÚÈο Ì ÙȘ ÂÚÈÁÂÓÓËÙÈΤ˜ ÏÔÈÌÒÍÂȘ, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÁÁÚ·Ê›˜ ıˆÚÔ‡Ó ··Ú·›ÙËÙË ÙËÓ ÚÔÏËÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û ÓÂÔÁÓ¿ Ì ¶ƒ∂À fiÙ·Ó ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ Ïԛ̈͢ Ù˘ ÌËÙ¤Ú·˜ ‹ ·ÔÈÎÈÛÌfi˜ ÙÔ˘ ÎfiÏÔ˘ ·fi ÛÙÚÂÙfiÎÔÎÎÔ Ù˘ ÔÌ¿‰·˜ µ. ∞Ó ÔÈ ‰Â›ÎÙ˜ Ïԛ̈͢ Ù˘ ÌËÙ¤Ú·˜ Â›Ó·È ·ÚÓËÙÈÎÔ›, Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ‰È¿ÚÎÂÈ· Ù˘ ¶ƒ∂À. ™¯ÂÙÈο Ì ÙË ‰È¿ÚÎÂÈ· Ù˘ ¶ƒ∂À Ô˘ ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ¤Ó·Ú͢ ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ‰ÂÓ ˘¿Ú¯ÂÈ ÔÌÔʈӛ· (2,5,37,46). OÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÁÁÚ·Ê›˜ ıˆÚÔ‡Ó fiÙÈ Ï·Óı¿ÓÔ˘Û· ÂÚ›Ô‰Ô˜ ÌÂÁ·Ï‡ÙÂÚË ·fi 48 ÒÚ˜ ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ÚÔÏËÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ηıÒ˜ ÌÂÙ¿ ·fi ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi ·˘Í¿ÓÂÙ·È ÛËÌ·ÓÙÈο Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÓÂÔÁÓÈÎÒÓ ÏÔÈÌÒÍÂˆÓ (10). øÛÙfiÛÔ, Û ÔÏÏ¿ ÓÂÔÁÓÈο ÙÌ‹Ì·Ù·, ÚÔÏËÙÈ΋ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ¯ÔÚËÁÂ›Ù·È Û fiÏ· Ù· ÓÂÔÁÓ¿ Ì ¶ƒ∂À >24 ÒÚ˜, ̤¯ÚÈ Ó· ·ÔÎÏÂÈÛÙ› Ë Ïԛ̈ÍË. µÈ‚ÏÈÔÁÚ·Ê›· 1. Gregg AR. Introduction to premature rupture of membranes.

Obstet Gynecol Clin North Am 1992;19:241-249.

2. Mercer BM, Lewis R. Pretrm labor and preterm premature rupture of the membranes. Diagnosis and management.

Infect Dis North Am 1997;11:177-201.

3. Carroll SG, Blott M, Nicolaides KH. Preterm prelabor amniorrhexis: outcome of live births. Obstet Gynecol 1995;86:18-25.

4. French JI, McGregor JA. The pathobiology of premature rupture of membranes. Semin Perinatol 1996;20:344-368.

5. Seaward PG, Hannah ME, Myhr TL, Farine D, Ohlsson A, Wang EE et al. International multicenter term PROM study: evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. Am J Obstet Gynecol 1998;179:635-639.

6. Kurkinen-Raty M, Koivisto M, Jouppila P. Perinatal and neonatal outcome and late pulmonary sequelae in infants born after preterm premature rupture of membranes.

Obstet Gynecol 1998;92:408-415.

7. Merenstein GB, Weisman LE. Premature rupture of the membranes: neonatal consequences. Semin Perinatol

320

Paediatriki 2002;65:313-321

1996;20:375-380.

8. Crowley PA. Antenatal corticosteroid therapy: a metaanalysis of the randomized trials, 1972 to 1994. Am J Obstet Gynecol 1995;173:322-335.

9. Harding JE, Pang J, Knight DB, Liggins GC. Do antenatal corticosteroids help in the setting of preterm rupture of membranes? Am J Obstet Gynecol 2001;184:131-139.

10. Chua S, Arulkumaran S, Sailesh Kumar S, Selamat N, Ratnam SS. Prelabour rupture of membranes to delivery interval related to the incidence of maternal and neonatal infection. J Obstet Gynaecol 1995;21:367-372.

11. Vadillo-Ortega F, Hernandez A, Gonzalez-Avila G, Bermejo L, Iwata K, Strauss JF 3rd. Increased matrix metalloproteinase activity and reduced tissue inhibitor of metalloproteinases-1 levels in amniotic fluids from pregnancies complicated by premature rupture of membranes. Am J Obstet Gynecol 1996;174:1371-1376.

12. Fortunato SJ, Menon R, Lombardi SJ. Collagenolytic enzymes (gelatinases) and their inhibitors in human amniochorionic membrane. Am J Obstet Gynecol 1997;177:731-741.

13. Gomez R, Romero R, Ghezzi F, Yoon BH, Mazor M, Berry SM. The fetal inflammatory response syndrome. Am J Obstet Gynecol 1998;179:194-202.

14. Maymon E, Romero R, Chaiworapongsa T, Kim JC, Berman S, Gomez R et al. Value of amniotic fluid neutrophil collagenase concentrations in preterm premature rupture of membranes. Am J Obstet Gynecol 2001;185:1143-1148.

15. Woods JR Jr, Plessinger MA, Miller RK. Vitamins C and E: missing links in preventing preterm premature rupture of membranes? Am J Obstet Gynecol 2001;185:5-10.

16. Larmon JE, Ross BS. Utilizing sonography in a general obstetric practice. Clinical utility of amniotic fluid assessment. Obstet Gynecol Clin North Am 1998;25:639-661.

17. Klein JM. Neonatal morbidity and mortality secondary to premature rupture of membranes. Obstet Gynecol Clin North Am 1992;19:265-280.

18. Seince N, Biquard F, Sarfati R, Barjot P, Foucher F, Lassel L et al. Management of premature rupture of the membranes at term: how long to delay? Results of a prospective multicentric study in 713 cases. J Gynecol Obstet Biol Reprod 2001;30:42-50.

19. Furman B, Shoham-Vardi I, Bashiri A, Erez O, Mazor M. Preterm premature rupture of membranes is not an independent risk factor for neonatal morbidity. J Matern Fetal Med 2001;10:107-111.

20. Kimberlin DF, Hauth JC, Owen J, Bottoms SF, Iams JD, Mercer BM et al. Indicated versus spontaneous preterm delivery: An evaluation of neonatal morbidity among infants weighing ≤1000 grams at birth. Am J Obstet Gynecol 1999;180:683-689.

21. Xiao ZH, Andre P, Lacaze-Masmonteil T, Audibert F, Zupan V, Dehan M. Outcome of premature infants delivered after prolonged premature rupture of membranes before 25 weeks of gestation. Eur J Obstet Gynecol Reprod Biol 2000;90:67-71.

22. Winn HN, Chen M, Amon E, Leet TL, Shumway JB, Mostello D. Neonatal pulmonary hypoplasia and perinatal

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·321

¶·È‰È·ÙÚÈ΋ 2002;65:313-321

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

mortality in patients with midtrimester rupture of amniotic membranes - a critical analysis. Am J Obstet Gynecol 2000;182:1638-1644.

Kilbride HW, Yeast J, Thibeault DW. Defining limits of survival: lethal pulmonary hypoplasia after midtrimester premature rupture of membranes. Am J Obstet Gynecol 1996;175:675-681.

Wenstrom KD. Pulmonary hypoplasia and deformations related to premature rupture of membranes. Obstet Gynecol Clin North Am 1992;19:397-408.

Vintzileos AM, Campbell WA, Nochimson DJ, Weinbaum PJ. The use of the nonstress test in patients with premature rupture of the membranes. Am J Obstet Gynecol 1986;155:149-153.

Major CA, de Vecianna M, Lewis DF, Morgan MA. Preterm premature rupture of membranes and abruptio placentae: is there an association between these pregnancy complications? Am J Obstet Gynecol 1995;172:672-676.

Alexander JM, Cox SM. Clinical course of premature rupture of the membranes. Semin Perinatol 1996;20:369-374.

Vermillion ST, Kooba AM, Soper DE. Amniotic fluid index values after preterm premature rupture of the membranes and subsequent perinatal infection. Am J Obstet Gynecol 2000;183:271-276.

Seo K, McGregor JA, French JI. Preterm birth is associated with increased risk of maternal and neonatal infection.

Obstet Gynecol 1992;79:75-80.

Shumway JB, Al-Malt A, Amon E, Cohlan B, Amini S, Abboud M et al. Impact of oligohydramnios on maternal and perinatal outcomes of spontaneous premature rupture of the membranes at 18-28 weeks. J Matern Fetal Med 1999;8:20-23.

Verber IG, Pearce JM, New LC, Hamilton PA, Davies EG. Prolonged rupture of the fetal membranes and neonatal outcome. J Perinat Med 1989;17:469-476.

Namavar Jahromi B, Ardekany MS, Poorarian S. Relationship between duration of preterm premature rupture of membranes and pulmonary maturation. Int J Gynaecol Obstet 2000;68:119-122.

Palta M, Sadek M, Gabbert D, Brady W, Weinstein MR, McGuinness G et al. The relation of maternal complications to outcomes in very low birthweight infants in an era of changing neonatal care. Am J Perinatol 1996;13:109-114.

Batton DG, Holtrop P, De Witte D, Pryce C, Roberts C. Current gestational age-related incidence of major intraventricular hemorrhage. J Pediatr 1994;125:623-625.

Verma U, Tejani N, Klein S, Reale MR, Beneck D, Figueroa R et al. Obstetric antecedents of intraventricular hemorrhage and periventricular leukomalacia in the low-birth-weight neonate. Am J Obstet Gynecol 1997;176:275-281.

Vermeulen GM, Bruinse HW, Gerards LJ, de Vries LS. Perinatal risk factors for cranial ultrasound abnormalities in neonates born after spontaneous labour before 34 weeks.

Eur J Obstet Gynecol Reprod Biol 2001;94:290-295.

Egarter C, Leitich H, Karas H, Wieser F, Husslein P, Kaider A et al. Antibiotic treatment in preterm premature rupture of membranes and neonatal morbidity: a metaanalysis. Am J Obstet Gynecol 1996;174:589-597.

Richards DS. Complications of prolonged PROM and

Paediatriki 2002;65:313-321

oligohydramnios. Clin Obstet Gynecol 1991;34:759-768.

39. Thibeault DW, Beatty EC, Hall RT, Bowen SK, O’Neil DH. Neonatal pulmonary hypoplasia with premature rupture of fetal membranes and oligohydramnios. J Pediatr 1985;107:273-277.

40. Thibeault DW, Kilbride HK. Increased acinar arterial wall muscle in preterm infants with PROM and pulmonary dysplasia. Am J Perinatol 1997;14:457-460.

41. Roberts AB, Mitchell J. Pulmonary hypoplasia and fetal breathing in preterm premature rupture of membranes.

Early Hum Dev 1995;41:27-37.

42. Yoshimura S, Masuzaki H, Gotoh H, Fukuda H, Ishimaru T. Ultrasonographic prediction of lethal pulmonary hypoplasia: comparison of eight different ultrasonographic parameters. Am J Obstet Gynecol 1996;175:477-483.

43. van Eyck J, van der Mooren K, Wladimiroff JW. Ductus arteriosus flow velocity modulation by fetal breathing movements as a measure of fetal lung development. Am J Obstet Gynecol 1990;163:558-566.

44. Neerhof MG, Cravello C, Haney EI, Silver RK. Timing of labor induction after premature rupture of membranes between 32 and 36 weeks’ gestation. Am J Obstet Gynecol 1999;180:349-352.

45. Locatelli A, Vergani P, Di Pirro G, Doria V, Biffi A, Ghidini A. Role of amnioinfusion in the management of premature rupture of the membranes at <26 weeks’ gestation. Am J Obstet Gynecol 2000;183:878-882.

46. Vermillion ST, Soper DE, Chasedunn-Roark J. Neonatal sepsis after betamethasone administration to patients with preterm premature rupture of membranes. Am J Obstet Gynecol 1999;181:320-327.

47. Kenyon SL, Taylor DJ, Tarnow-Mordi W. Broad-spectrum antibiotics for preterm, prelabour rupture of fetal membranes: the ORACLE I randomised trial. ORACLE Collaborative Group. Lancet 2001;357:979-988.

48. Mehdi A, Collet F, Aiguier M, Miras T, Teyssier G, Seffert P. Premature rupture of the membranes between 28 and 34 weeks of amenorrhea. Retrospective study apropos of 71 cases. J Gynecol Obstet Biol Reprod 2000;29:599-606.

49. Vermillion ST, Soper DE, Bland ML, Newman RB. Effectiveness of antenatal corticosteroid administration after preterm premature rupture of the membranes. Am J Obstet Gynecol 2000;183:925-929.

50. Tubman TR, Halliday HL. Surfactant treatment for respiratory distress syndrome following prolonged rupture of membranes. Eur J Pediatr 1990;149:727-729.

51. Peliowski A, Finer NN, Etches PC, Tierney AJ, Ryan CA. Inhaled nitric oxide for premature infants after prolonged rupture of membranes. J Pediatr 1995;126:450-453.

52. Peters EA, Engle WA, Yoder MC. Pulmonary hypoplasia and persistent pulmonary hypertension: favorable clinical response to high-frequency jet ventilation. J Perinatol 1992;12:21-24.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-02-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 31-05-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: µ·ÛÈÏÈ΋ ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘ °ÏËÓÔ‡ 28, ∆.∫. 543 52, £ÂÛÛ·ÏÔÓ›ÎË E-mail: agaki@med.auth.gr

321

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·322

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

∞¡∞™∫O¶∏™∏

Paediatriki 2002;65:322-332

REVIEW ARTICLE

∏ Û·ÚÎÔ›‰ˆÛË ÛÙËÓ ·È‰È΋ ËÏÈΛ·: ÙÔ ·ÚÂÏıfiÓ, ·ÚfiÓ Î·È Ì¤ÏÏÔÓ Ì›·˜ ·ÈÓÈÁÌ·ÙÈ΋˜ ÓfiÛÔ˘ µ. ∆Û·ÁÚ‹˜, ¡. ª·Ó¿ÎÔ˘

Sarcoidosis in childhood: past, present and future of an enigmatic disease V. Tsagris, N. Manakou

¶ÂÚ›ÏË„Ë: ∏ Û·ÚÎÔ›‰ˆÛË Â›Ó·È Ì›· ¯ÚfiÓÈ·, ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋, ÎÔÎÎȈ̷Ù҉˘ ‰È·Ù·Ú·¯‹, Ë ÔÔ›· ÂÌÊ·Ó›˙ÂÙ·È Û¿ÓÈ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÙË Û˘Ó¿ıÚÔÈÛË ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÌÔÓÔ‡ÚËÓˆÓ Ê·ÁÔ΢ÙÙ¿ÚˆÓ, ÙËÓ ·ÚÔ˘Û›· ÌË Ù˘ÚÔÂȉÔÔÈËÌ¤ÓˆÓ ÂÈıËÏÈÔÂȉÒÓ ÎÔÎÎÈˆÌ¿ÙˆÓ Î·È ÙË ‰È·Ù¿Ú·ÍË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·Ú¯ÈÙÂÎÙÔÓÈ΋˜ ÙˆÓ ÈÛÙÒÓ. ŸÏ· Ù· Û˘ÛÙ‹Ì·Ù· Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÛ‚ÏËıÔ‡Ó Î·È ÂȉÈÎfiÙÂÚ· ÙÔ ·Ó·Ó¢ÛÙÈÎfi. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË. ∏ ·Ú¯È΋ ÂÌÊ¿ÓÈÛË ÔÈΛÏÏÂÈ Î·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÂÈ ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ÎfiˆÛË, ÔÛÙÈο ¿ÏÁË Î·È ·Ó·ÈÌ›·. ∏ ÔÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Ì ÙËÓ Î·Ù¿‰ÂÈÍË ÙÔ˘ Ù˘ÈÎÔ‡, ÌË Ù˘ÚÔÂȉÔÔÈË̤ÓÔ˘ ÎÔÎÎÈÒÌ·ÙÔ˜ Û ˘ÏÈÎfi ‚ÈÔ„›·˜.

Abstract: Sarcoidosis is a chronic, multisystemic, granulomatous disorder, which occurs rarely in childhood. It is characterized by an accumulation of T-lymphocytes and mononuclear phagocytes, noncaseating epithelioid granulomas and derangement of the normal tissue architecture. All parts of the body can be affected, especially the lung. The etiology of the disease remains unknown. The initial clinical presentation is variable and in most paediatric cases includes weight loss, fatigue, bone and joint pain and anemia. Definitive diagnosis is established by the demonstration of the characteristic noncaseating, granulomatous lesion in the biopsy specimen.

§¤ÍÂȘ ÎÏÂȉȿ: Û·ÚÎÔ›‰ˆÛË, ·È‰È΋ ËÏÈΛ·, ıÂÚ·›·.

Key words: sarcoidosis, childhood, treatment.

∂ÈÛ·ÁˆÁ‹ ∏ Û·ÚÎÔ›‰ˆÛË Â›Ó·È Ì›· ¯ÚfiÓÈ·, ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋, ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜ ÎÔÎÎȈ̷Ù҉˘ ÓfiÛÔ˜, Ë ÔÔ›· ·Ú·ÙËÚÂ›Ù·È Û¿ÓÈ· ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Û˘Ó¿ıÚÔÈÛË ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÌÔÓÔ‡ÚËÓˆÓ Ê·ÁÔ΢ÙÙ¿ÚˆÓ, ‰È·Ù·Ú·¯‹ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·Ú¯ÈÙÂÎÙÔÓÈ΋˜ ÙˆÓ ÈÛÙÒÓ Î·È ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ·ıÔÁÓˆÌÔÓÈÎÔ‡ ÁÈ· ÙË ÓfiÛÔ ÌË Ù˘ÚÔÂȉÔÔÈË̤ÓÔ˘ ÎÔÎÎÈÒÌ·ÙÔ˜. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÂÌÊ·Ó›˙ÂÈ ÂÍ·ÈÚÂÙÈ΋ ÔÈÎÈÏÔÌÔÚÊ›· - “ηӤӷ˜ ·ÛıÂÓ‹˜ ‰ÂÓ Â›Ó·È ›‰ÈÔ˜ Ì ÙÔÓ ¿ÏÏÔ” - Î·È fiÏ· Ù· Û˘ÛÙ‹Ì·Ù· Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÛ‚ÏËıÔ‡Ó. ™Ù· ·È‰È¿, Ë ÎÏÈÓÈ΋ ÛËÌÂÈÔÏÔÁ›· ·Ú·Ì¤ÓÂÈ ·Ì‚Ï˯ڋ, ¯·Ú·ÎÙËÚÈ˙fiÌÂÓË ·fi ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ·‰˘Ó·Ì›·, ηÎÔ˘¯›·,

·Ó·ÈÌ›· Î·È ·ÚıÚ·ÏÁ›Â˜, ÂÓÒ Ë ÚÔÛ‚ÔÏ‹ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘Ó‹ı˘ ·’ fi,ÙÈ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹.

¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¶.°.¡. “£ÚÈ¿ÛÈÔ”, ∂ÏÂ˘Û›Ó·

Pediatric Clinic, General Peripheral Hospital “Thriassio”, Elefsina

322

πÛÙÔÚÈο ÛÙÔȯ›· ∏ ·ÙÚfiÙËÙ· ÙÔ˘ fiÚÔ˘ “Û·ÚÎÔ›‰ˆÛË” ·Ô‰›‰ÂÙ·È ÛÙÔ ¡ÔÚ‚ËÁfi ‰ÂÚÌ·ÙÔÏfiÁÔ Caesar Boeck (1845-1917), Ô ÔÔ›Ô˜, ·ÍÈÔÔÈÒÓÙ·˜ ÙËÓ ÂÏÏËÓÈ΋ ϤÍË “Û¿Úη”, ÂÚȤÁÚ·„ ÙÔ 1899 ÙȘ ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜ Ù˘ ÓfiÛÔ˘ Û·Ó “ÔÏÏ·Ïfi ηÏfiËı˜ Û·ÚÎÔÂȉ¤˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜” (1). øÛÙfiÛÔ, Ë ÚÒÙË Î·Ù·ÁÚ·Ê‹ Ù˘ ÓfiÛÔ˘ ·Ô‰›‰ÂÙ·È ÛÙÔÓ Robert Willan, Ô ÔÔ›Ô˜ ÙÔ 1798, ÛÙËÓ Ú·ÁÌ·Ù›· ÙÔ˘ “°È· ÙȘ ¢ÂÚÌ·ÙÈΤ˜ ¶·ı‹ÛÂȘ”, ÂÚȤÁÚ·„ ÙÔ Ô˙҉˜ ÂÚ‡ıËÌ·.

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·323

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

™Ù· ·Ì¤Ûˆ˜ ÂfiÌÂÓ· ¯ÚfiÓÈ· ·ÎÔÏÔ˘ıÔ‡Ó ÔÏ˘¿ÚÈı̘ ·Ó·ÎÔÈÓÒÛÂȘ ·fi ÙÔ˘˜ Osler (ÂÚȤÁÚ·„ ÂÚ›ÙˆÛË Ì ¯ÚfiÓÈ· ‰ÈfiÁΈÛË ‰·ÎÚ˘˚ÎÒÓ Î·È ·ÚˆÙȉÈÎÒÓ ·‰¤ÓˆÓ), Kienbock, Rieder, Jungling Î.¿. O Schumaker, ÙÔ 1909, Â›Ó·È Ô ÚÒÙÔ˜ Ô˘ ÂÚÈÁÚ¿ÊÂÈ ÙË ¯·Ú·ÎÙËÚÈÛÙÈ΋ Ú·ÁÔÂȉ›Ùȉ· Ù˘ ÓfiÛÔ˘, ÂÓÒ Ùo 1913, Ô °ÂÚÌ·Ófi˜ ‰ÂÚÌ·ÙÔÏfiÁÔ˜ Josef Jadassohn (1863-1936) ‰È·ÈÛÙÒÓÂÈ fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ۷ÚÎÔ›‰ˆÛË ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÚÓËÙÈ΋ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Ê˘Ì·Ù›Ó˘, Ì›· ·Ú·Ù‹ÚËÛË Ô˘ ı· ·ÔÎÙ‹ÛÂÈ È‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ Û¯Â‰fiÓ ¤Ó·Ó ·ÈÒÓ· ·ÚÁfiÙÂÚ· (2). ∆Ô 1941, Ô ¡ÔÚ‚ËÁfi˜ ·ıÔÏÔÁÔ·Ó·ÙfiÌÔ˜ Morten Kveim ÂÚÈÁÚ¿ÊÂÈ ÙËÓ ÔÌÒÓ˘ÌË ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›·, ‚·ÛÈ˙fiÌÂÓÔ˜ Û ÂÚÁ·Û›· ÙˆÓ Williams Î·È Nickelson. ∏ ¤ÎÙ·ÛË Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙȘ ÂΉËÏÒÛÂȘ Ù˘ Û·ÚÎÔ›‰ˆÛ˘ ·Ó·Î·Ï‡ÙÂÙ·È ÌÂÙ¿ ÙÔÓ µ’ ¶·ÁÎfiÛÌÈÔ ¶fiÏÂÌÔ, Ì ÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘ Ì·˙È΋˜ (Î·È - ηٿ ÔÏÏÔ‡˜ ·ÓÂͤÏÂÁÎÙ˘!) ÌÈÎÚÔ·ÎÙÈÓÔÁÚ¿ÊËÛ˘ ÙÔ˘ ÏËı˘ÛÌÔ‡. ∏ Û˘¯Ó‹ ÂÈÓ¤ÌËÛË ÙˆÓ ˘Ï·›ˆÓ ÏÂÌÊ·‰¤ÓˆÓ Î·È ÙˆÓ Ó¢ÌfiÓˆÓ Ô‰ËÁ› Û˘¯Ó¿ ÛÙË Ï·Óı·Ṳ̂ÓË ‰È¿ÁÓˆÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘. ∆Ô 1975, Ô D. G. James, ¤Ó·˜ ·fi ÙÔ˘˜ ÛËÌ·ÓÙÈÎfiÙÂÚÔ˘˜ Û˘ÁÁÚ·Ê›˜-ÂÚ¢ÓËÙ¤˜ ÛÙÔ ·ÓÙÈΛÌÂÓÔ Ù˘ Û·ÚÎÔ›‰ˆÛ˘, ÛÙ· Ï·›ÛÈ· ÙÔ˘ 7Ô˘ ¢ÈÂıÓÔ‡˜ ™˘Ó‰ڛԢ ÁÈ· ÙË ™·ÚÎÔ›‰ˆÛË ÛÙË ¡. ÀfiÚÎË, ·Ó·ÎÔÈÓÒÓÂÈ ÙÔÓ ÔÚÈÛÌfi Ù˘ ÓfiÛÔ˘ (3). O ÔÚÈÛÌfi˜ ·˘Ùfi˜, Ì ÂÏ¿¯ÈÛÙ˜ ÙÚÔÔÔÈ‹ÛÂȘ, ÈÛ¯‡ÂÈ Î·È Û‹ÌÂÚ·: “∏ Û·ÚÎÔ›‰ˆÛË Â›Ó·È Ì›· ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ÓfiÛÔ˜, ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜, Ë ÔÔ›· Û˘Ó‹ıˆ˜ ÚÔÛ‚¿ÏÏÂÈ Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ Î·È ÂΉËÏÒÓÂÙ·È Û˘¯Ó¿ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ˘Ï·›· ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, Ó¢ÌÔÓÈ΋ ‰È‹ıËÛË, ‰ÂÚÌ·ÙÈΤ˜ Î·È ÔÊı·ÏÌÈΤ˜ ‚Ï¿‚˜. ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Ì ÌÂÁ·Ï‡ÙÂÚË ·ÎÚ›‚ÂÈ· fiÙ·Ó Ù· ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ˘ÔÛÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ÈÛÙÔÏÔÁÈ΋ ¤Ó‰ÂÈÍË ‰È¿Û·ÚÙˆÓ, ÌË Ù˘ÚÔÂȉÔÔÈËÌ¤ÓˆÓ ÂÈıËÏÈÔÂȉÒÓ ÎÔÎÎȈ̿وÓ, Û ÂÚÈÛÛfiÙÂÚ· ·fi ¤Ó· fiÚÁ·Ó·. À¿Ú¯ÂÈ Î·Ù·ÛÙÔÏ‹ Ù˘ ÂÈ‚Ú·‰˘ÓfiÌÂÓÔ˘ Ù‡Ô˘ ˘ÂÚ¢·ÈÛıËÛ›·˜, ‰È·Ù·Ú·¯‹ ÙÔ˘ ÏfiÁÔ˘ CD4/CD8, Û˘ÚÚÔ‹ ÙˆÓ ∆-‚ÔËıËÙÈÎÒÓ 1 ΢ÙÙ¿ÚˆÓ (Th1 cells) ÛÙȘ ÂÚÈÔ¯¤˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘, ˘ÂÚ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ µ ΢ÙÙ¿ÚˆÓ Î·È Î˘ÎÏÔÊÔÚ›· ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ. ¢Â›ÎÙ˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘ ·ÔÙÂÏÔ‡Ó Ù· ·˘ÍË̤ӷ Â›‰· ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘, Ô ·ıÔÏÔÁÈÎfi˜ ÌÂÙ·‚ÔÏÈÛÌfi˜ ·Û‚ÂÛÙ›Ô˘, Ë ıÂÙÈ΋ ·ÓÙ›‰Ú·ÛË Kveim-Siltzbach Î·È Ë ÂÓ‰ÔıˆÚ·ÎÈ΋ ÚfiÛÏË„Ë Ú·‰ÈÂÓÂÚÁÔ‡ Á·ÏÏ›Ô˘.” ™ÙËÓ ÂÔ¯‹ Ì·˜, ÔÈ Ú·Á‰·›Â˜ ÂÍÂÏ›ÍÂȘ ÛÙÔ ¯ÒÚÔ Ù˘ ªÔÚȷ΋˜ µÈÔÏÔÁ›·˜ Î·È ∞ÓÔÛÔÏÔÁ›·˜, Ë ÂÌ‚¿ı˘ÓÛË ÛÙÔ˘˜ ·ıÔÁÂÓÂÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜

Paediatriki 2002;65:322-332

Ù˘ ÓfiÛÔ˘, ÙÔ ·Ó·¿ÓÙËÙÔ ÙÔ˘ ·ÈÙ›Ô˘ Î·È Ë ÂÏ›‰· ÂÈÛ·ÁˆÁ‹˜ Ó¤ˆÓ ıÂÚ·¢ÙÈÎÒÓ ÌÂıfi‰ˆÓ, ‰È·ÙËÚÔ‡Ó ·Ì›ˆÙÔ ÙÔ ÂӉȷʤÚÔÓ Ù˘ ¢ÈÂıÓÔ‡˜ ∂ÈÛÙËÌÔÓÈ΋˜ ∫ÔÈÓfiÙËÙ·˜. ÷ڷÎÙËÚÈÛÙÈÎfi Â›Ó·È ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ·Ó·ÊÔÚÒÓ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·: ÌÂٷ͇ 1878 Î·È 1978 ÂÚÈÁÚ¿ÊÔÓÙ·È 7.000 ¿ÚıÚ· (4). ™‹ÌÂÚ·, Ô ·ÓÙ›ÛÙÔȯԘ ·ÚÈıÌfi˜ ÍÂÂÚÓ¿ Ù· 14.400 ¿ÚıÚ·. ∆· ÙÂÏÂ˘Ù·›· 40 ¯ÚfiÓÈ· ¤¯Ô˘Ó ‰ÈÔÚÁ·Óˆı› 16 ·ÁÎfiÛÌÈ· Û˘Ó¤‰ÚÈ· ÁÈ· ÙË Û·ÚÎÔ›‰ˆÛË. ∞ÈÙÈÔÏÔÁ›·: ¤Ó· ·Ó·¿ÓÙËÙÔ ÂÚÒÙËÌ· ∏ Û˘Û¯¤ÙÈÛË Ù˘ ·ÈÓÈÁÌ·ÙÈ΋˜ ·˘Ù‹˜ ÓfiÛÔ˘ Ì ÔÏ˘¿ÚÈı̘ ¿ÏϘ (΢ڛˆ˜ Ê˘Ì·Ù›ˆÛË, Ì˘ÎËÙÈ¿ÛÂȘ, ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·, ηÎÔ‹ıÂȘ, ‰ËÏËÙËÚÈ¿ÛÂȘ ·fi ÔÚÁ·ÓÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜) ˘‹ÚÍ ·ÚÎÂÙ¿ Û˘Ó‹ı˘ ηٿ ÙÔ ·ÚÂÏıfiÓ. ∏ ıˆڛ· Ù˘ ·fi‰ÔÛ‹˜ Ù˘ Û ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (Á‡ÚË ‡ΈÓ, ·ÔÛÌËÙÈο Û ÛÚ¤È, ·¤ÚÈ· ·fi Û·Ṳ̂Ó˜ Ï¿Ì˜ ÊıÔÚÈÛÌÔ‡) ˘‹ÚÍ ÂӉȷʤÚÔ˘Û·, ¯ˆÚ›˜, ˆÛÙfiÛÔ, Ó· ·Ô‰Âȯı› ·ÓıÂÎÙÈ΋ ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ÂÈÛÙËÌÔÓÈ΋ ·Ó¿Ï˘ÛË. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’70, Ô Hosoda (5), ·ÓÙÏÒÓÙ·˜ ÏËÚÔÊÔڛ˜ ·fi ÙȘ ÎÏ·ÛÈΤ˜ ÂÚÁ·Û›Â˜ ÙÔ˘ Siltzbach Î·È ‰È¢ڇÓÔÓÙ·˜ ÙÔ ‰›Ô ¤ÚÂ˘Ó¿˜ ÙÔ˘ ÌÂÏÂÙÒÓÙ·˜ ¯ÈÏÈ¿‰Â˜ π¿ˆÓ˜ ·ÛıÂÓ›˜, η٤ÛÙÚˆÛ ̛· ˘Ô‰ÂÈÁÌ·ÙÈ΋ Î·È ÂÎÙÂٷ̤ÓË ÂȉËÌÈÔÏÔÁÈ΋ ÌÂϤÙË, ηٷϋÁÔÓÙ·˜ ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë Û·ÚÎÔ›‰ˆÛË Â¿ÁÂÙ·È ·fi ÙË ‰Ú¿ÛË Î¿ÔÈÔ˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·Ú¿ÁÔÓÙ· Ô˘ ÂÓ‰ËÌ› Û „˘¯Ú¿ Îϛ̷ٷ Î·È fiÙÈ Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ ÂËÚ¿˙ÂÙ·È ·fi ÙË ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË Î·È ÙȘ ÔÈÎÔÏÔÁÈΤ˜ ÌÂÙ·‚ÔϤ˜.

OÈ Kataria (6) Î·È Semenzato (7) ÚfiÙÂÈÓ·Ó ÙË ÌÂÛÔÏ¿‚ËÛË ·ÓÔÛÔÏÔÁÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ÛÙË ÁÂÓÂÛÈÔ˘ÚÁfi ‰È·‰Èηۛ· Ù˘ Û·ÚÎÔ›‰ˆÛ˘. O Moller (8) ˘ÈÔıÂÙ› ÙËÓ ˘fiıÂÛË Ù˘ ‡·Ú͢ ÂÓfi˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ Ì˯·ÓÈÛÌÔ‡, Ô ÔÔ›Ô˜ ˘ÚÔ‰ÔÙÂ›Ù·È ·fi ¤Ó· ÌÂÙ·‰È‰fiÌÂÓÔ ÌÈÎÚÔ‚È·Îfi ‹ ¿ÏÏÔ ·Ú¿ÁÔÓÙ·. øÛÙfiÛÔ, Â·ÓÂÈÏËÌ̤Ó˜ ÚÔÛ¿ıÂȘ ·Ó›¯Ó¢Û˘ DNA ‹ RNA ÙÔ˘ ˘ÔÙÈı¤ÌÂÓÔ˘ ·˘ÙÔ‡ ·Ú¿ÁÔÓÙ· Û ˘ÏÈÎfi ‚ÈÔ„›·˜ Û·ÚÎÔ›‰ˆÛ˘, Ô‰ËÁÔ‡Ó Û ·ÓÙÈÊ·ÙÈο ·ÔÙÂϤÛÌ·Ù·.

O ÂÈÎÚ·Ù¤ÛÙÂÚÔ˜ ˘Ô„‹ÊÈÔ˜ ÌÔÈ¿˙ÂÈ Ó· Â›Ó·È ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘, DNA ÙÔ˘ ÔÔ›Ô˘ ·Ó¢ڤıËΠ۠˘ÏÈÎfi ‚ÈÔ„›·˜ ÙÔ 1992 (9). ∏ ıˆڛ· Ù˘ Èı·Ó‹˜ ‰Ú¿Û˘ ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ ÂÓÈÛ¯‡ÂÙ·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ·ÓÙÈÌ˘ÎÔ‚·ÎÙËÚȉȷ΋ ¿ÓÔÛË ·¿ÓÙËÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Ô‰ËÁ› Û ˘¤ÚÌÂÙÚË ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ∆ ΢ÙÙ¿ÚˆÓ, Ì ÙÂÏÈÎfi ¯·Ú·ÎÙ‹Ú· ·˘ÙÔ¿ÓÔÛ˘ ·ÓÙ›‰Ú·Û˘. ∏ ÌÂÙ¿‰ÔÛË ÙÔ˘ ·ÈÙ›Ô˘ Ì ÙÔÓ ·¤Ú· ı· ÌÔÚÔ‡ÛÂ, Â›Û˘, Ó· ÂÍËÁ‹ÛÂÈ ÙË Û˘¯Ó‹ ÚÔÛ‚ÔÏ‹ ÙˆÓ Ó¢ÌfiÓˆÓ, ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙˆÓ ÔÊı·ÏÌÒÓ ÛÙË

323

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·324

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

Û·ÚÎÔ›‰ˆÛË, ÔÚÁ¿ÓˆÓ Ô˘ ·Ú·Ì¤ÓÔ˘Ó ÂÎÙÂıÂÈ̤ӷ Û Â͈ÁÂÓ›˜ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∆ËÓ ·Ó·ÎÔ›ÓˆÛË ·˘Ù‹ ·ÎÔÏÔ‡ıËÛ·Ó ÔÏ˘¿ÚÈı̘ ¿ÏϘ, Ô‰ËÁÒÓÙ·˜ Û ·ÓÙÈÊ·ÙÈο ·ÔÙÂϤÛÌ·Ù· ‹ ηٷ‰ÂÈÎÓ‡ÔÓÙ·˜ ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ˆ˜ Èı·ÓÔ‡˜ ˘fiÙÔ˘˜, fiˆ˜ Ù· ÚÔÈÔÓÈ‚·ÎÙ‹ÚÈ· (΢ڛˆ˜ ÙÔ P. acnes) (10). ∏ ÂÍ·ÈÚÂÙÈ΋ ÔÈÎÈÏÔÌÔÚÊ›· ÛÙËÓ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘ ηıÈÛÙ¿ Èı·Ó‹ ÙËÓ ÂÌÏÔ΋ ÛÙËÓ ·ıÔÁ¤ÓÂÛ‹ Ù˘ ÂÚÈÛÛÔÙ¤ÚˆÓ ÙÔ˘ ÂÓfi˜ ·ÈÙÈÔÏÔÁÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ™ËÌ·ÓÙÈ΋ Â›Ó·È Ë ÂÚÈ‚·ÏÏÔÓÙÈ΋ Â›‰Ú·ÛË, ηıÒ˜ Î·È Ë ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË. ¶ÔÚÙÔÚÈηÓÔ› Ô˘ ˙Ô˘Ó ÛÙË ¡. ÀfiÚÎË ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ Û ۯ¤ÛË Ì ·˘ÙÔ‡˜ Ô˘ ·Ú¤ÌÂÈÓ·Ó ÛÙËÓ ·ÙÚ›‰· ÙÔ˘˜, ÂÓÒ ·Ó¿ÏÔÁ· Û˘ÌÂÚ¿ÛÌ·Ù· ÚÔ·ÙÔ˘Ó ·fi ÌÂϤÙË Á˘Ó·ÈÎÒÓ πÚÏ·Ó‰È΋˜ ηٷÁˆÁ‹˜ (11,12). ™‡Ìʈӷ Ì ٷ ·Ú·¿Óˆ, ·˘Ùfi ı· ÌÔÚÔ‡Û ӷ ·Ô‰Ôı› ÛÙÔ fiÙÈ Ë ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ÙˆÓ ·ÙfiÌˆÓ ·˘ÙÒÓ Ô‰ËÁ› ÛÙËÓ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘ fiÙ·Ó ÂÎÙÂıÔ‡Ó Û ·ÓÙÈÁÔÓÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, Ô˘ ÂÓÒ ˘¿Ú¯Ô˘Ó ÛÙȘ ∏¶∞, ·Ô˘ÛÈ¿˙Ô˘Ó ·fi ÙȘ ¯ÒÚ˜ ÚÔÔÚÈÛÌÔ‡. ∞˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·Ú·ÙËÚÂ›Ù·È ÛÙË Ì·‡ÚË Ê˘Ï‹ Î·È ÂȉÈο ÛÙÔ Á˘Ó·ÈÎÂ›Ô Ê‡ÏÔ. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ ÛÙÔ˘˜ ∞ÌÂÚÈηÓÔ‡˜ Ï¢΋˜ Ê˘Ï‹˜ ˘ÔÏÔÁ›˙ÂÙ·È Û 5/100.000, ÂÓÒ ÛÙÔ˘˜ ∞ÌÂÚÈηÓÔ‡˜ Ì·‡Ú˘ Ê˘Ï‹˜ Û 40/100.000 (13). °ÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ıˆÚÔ‡ÓÙ·È ˘‡ı˘ÓÔÈ Î·È ÁÈ· ÙËÓ ·Ú·ÙËÚÔ‡ÌÂÓË ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ ÂÓÙfi˜ ÔÈÎÔÁÂÓÂÈÒÓ (14). ∏ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ Û ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ˜, ‡ÛÙÂÚ· ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ·fi ‰fiÙ˜ Ì ۷ÚÎÔ›‰ˆÛË, ÂÓÈÛ¯‡ÂÈ ÛËÌ·ÓÙÈο ÙË ıˆڛ· ÙÔ˘ ÌÂÙ·‰È‰fiÌÂÓÔ˘ ·Ú¿ÁÔÓÙ· (15). ∏ ıˆڛ· Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ·˘ÙÔ¿ÓÔÛˆÓ Ì˯·ÓÈÛÌÒÓ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ÓfiÛÔ˘ ÎÂÚ‰›˙ÂÈ Û˘Ó¯Ҙ ¤‰·ÊÔ˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ˆÛÙfiÛÔ, Ù·˘Ùfi¯ÚÔÓ· Ì ÙË ‰ÈfiÁΈÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Û¯ÂÙÈ˙fiÌÂÓˆÓ Ì ·˘Ù‹ ·Ó·ÊÔÚÒÓ, ‰È¢ڇÓÂÙ·È ÙÔ ‰›Ô ·ÓÙÈ·Ú¿ıÂÛ˘ ÌÂٷ͇ ·˘ÙÒÓ Ô˘ ıˆÚÔ‡Ó ÙËÓ ·˘ÙÔ¿ÓÔÛË ·ÓÙ›‰Ú·ÛË ˆ˜ ÙËÓ ÚˆÙÔÁÂÓ‹ ‰È·Ù·Ú·¯‹ Î·È ·˘ÙÒÓ Ô˘ ÙË ıˆÚÔ‡Ó ·Ï¿ ·fiÙÔÎÔ Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ ÛÙÔÓ ·ÎfiÌ· ¿ÁÓˆÛÙÔ ·ÈÙÈÔÏÔÁÈÎfi ·Ú¿ÁÔÓÙ·.

OÈ Ì˯·ÓÈÛÌÔ› Û¯ËÌ·ÙÈÛÌÔ‡ ÎÔÎÎÈÒÌ·ÙÔ˜ ¤¯Ô˘Ó ÂÎÙÂÓÒ˜ ÌÂÏÂÙËı›. ∏ ‰ÈÂÚÁ·Û›· Û¯ËÌ·ÙÈÛÌÔ‡ ÙÔ˘˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Û·Ó ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÙË ‰È·Ù·Ú·¯‹ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÌÔÚ›ˆÓ Ù¿Í˘ ππ ÙÔ˘ ªÂ›˙ÔÓÔ˜ ™˘ÌϤÁÌ·ÙÔ˜ πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (MHC Class II molecules). ¶ÂÚ·ÈÙ¤Úˆ ¤Ú¢ӷ Â›Ó·È ‰˘Ó·Ùfi Ó· ·Ôηχ„ÂÈ ÙÔ ·Ó Ë ‰È·Ù·Ú·¯‹ ·˘Ù‹ ÔÊ›ÏÂÙ·È Û ·ÓˆÌ·Ï›· ÛÙËÓ ¤ÎÊÚ·ÛË ÂÓ‰ÔÁÂÓÔ‡˜ ÚˆÙ½Ó˘ ‹ Û Â͈ÁÂÓ‹ ·Ú·ÁˆÁ‹ ˘ÚËÓÈÎÒÓ ÔͤˆÓ, fiˆ˜ ı· Û˘Ó¤‚·ÈÓ ÁÈ· ·-

324

Paediatriki 2002;65:322-332

Ú¿‰ÂÈÁÌ· ÛÙ· Ï·›ÛÈ· ‰Ú¿Û˘ ÂÓfi˜ ÌÔÓÔ΢ÙÙ·ÚÔÙÚÔÈÎÔ‡ ÈÔ‡. ™˘ÓÔ„›˙ÔÓÙ·˜, Â›Ó·È Èı·Ófi fiÙÈ Ë Û·ÚÎÔ›‰ˆÛË ¤¯ÂÈ ÔÏÏ·Ï¿ ·›ÙÈ· Î·È fiÙÈ Ë ¤ÎÊÚ·Û‹ Ù˘ ÂËÚ¿˙ÂÙ·È ·fi ·˘ÙÔ¿ÓÔÛÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜, ηıÒ˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ Î·È ÁÂÓÂÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜.

O Û˘Ó¯‹˜ ·ÓÙÈÁÔÓÈÎfi˜ ÂÚÂıÈÛÌfi˜ Â›Ó·È Èı·Ófi Ó· Û˘Ì‚¿ÏÂÈ ÛÙË Á¤ÓÂÛË Ù˘ ÓfiÛÔ˘. ∏ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ‚¿ÛË ∏ ηٿ‰ÂÈÍË ÙÔ˘ ÌË Ù˘ÚÔÂȉÔÔÈË̤ÓÔ˘ ÎÔÎÎÈÒÌ·ÙÔ˜ Û ˘ÏÈÎfi ‚ÈÔ„›·˜ ·ÔÙÂÏ› ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÛÊÚ·Á›‰· (hallmark) Ù˘ ÓfiÛÔ˘. ⁄ÛÙÂÚ· ·fi ‰ÂηÂٛ˜ ‰È·ÊˆÓÈÒÓ Ù˘ ·Û¯ÔÏÔ‡ÌÂÓ˘ Ì ÙË Û·ÚÎÔ›‰ˆÛË ¶·ÁÎfiÛÌÈ·˜ ∫ÔÈÓfiÙËÙ·˜, Ë ÙÂÏÈ΋ ÔÌÔʈӛ· ÛÙÔ fiÙÈ Ë Î·Ù¿‰ÂÈÍË Ù˘ ¯·Ú·ÎÙËÚÈÛÙÈ΋˜ ·˘Ù‹˜ ‚Ï¿‚˘ Â›Ó·È Î·È Ë ÌfiÓË ·ıÔÁÓˆÌÔÓÈ΋ ÁÈ· ÙË ÓfiÛÔ, ·ÔÎÙ¿ ȉȷ›ÙÂÚË ÛËÌ·Û›·. ∆Ô ÎÔÎΛˆÌ· ·ÔÙÂÏ› Ì›· Ô˙Ò‰Ë ÊÏÂÁÌÔÓÒ‰Ë ‚Ï¿‚Ë, Ë ÔÔ›· ·ÔÙÂÏÂ›Ù·È ·fi Û˘Ó·ıÚÔÈṲ̂ӷ ÌÔÓÔ‡ÚËÓ· Ê·ÁÔ·ÙÙ·Ú·. ∆· ÎÔÎÎÈÒÌ·Ù· Ù˘ Û·ÚÎÔ›‰ˆÛ˘, Û ·ÓÙ›ıÂÛË Ì ·˘Ù¿ Ù˘ Ó¢ÌÔÓ›Ùȉ·˜ ·fi ˘ÂÚ¢·ÈÛıËÛ›·, ·Ú·Ì¤ÓÔ˘Ó ¿ÓÙ· ηϿ ÔÚÁ·ÓˆÌ¤Ó·. ™ÙÔÓ Ó‡ÌÔÓ·, Ë ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ‚Ï¿‚Ë Ù˘ ÓfiÛÔ˘ ÂÍÂÏ›ÛÛÂÙ·È Û 3 Ê¿ÛÂȘ: ÙËÓ Î˘„ÂÏ›Ùȉ·, ÙÔ ÎÔÎΛˆÌ· ηÈ, ÙÂÏÈο, ÙËÓ ›ÓˆÛË. ∏ ΢„ÂÏ›Ùȉ· Ù˘ Û·ÚÎÔ›‰ˆÛ˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Û˘ÛÛÒÚ¢ÛË ÂÓÙfi˜ ÙˆÓ Î˘„ÂÏȉÈÎÒÓ Û¯ËÌ·ÙÈÛÌÒÓ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ¿ÚˆÓ (΢ڛˆ˜ ÏÂÌÊÔ·ÙÙ·Ú·, ÌÔÓÔ·ÙÙ·Ú· Î·È Ì·ÎÚÔÊ¿Á·), Ù· ÔÔ›· ÚÔÂÍ¿Ú¯Ô˘Ó ÙˆÓ ÂÈıËÏÈÔÂȉÒÓ Î˘ÙÙ¿ÚˆÓ. ∆· ÎÔÎÎÈÒÌ·Ù· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ “ÌÔÓfiÙÔÓ·”, ÂÍ·ÈÙ›·˜ ÙÔ˘ fiÙÈ ÂÌÊ·Ó›˙ÔÓÙ·È fiÏ· ÛÙÔ ›‰ÈÔ ÛÙ¿‰ÈÔ ·Ó¿Ù˘Í˘. ¶ÚfiÎÂÈÙ·È ÁÈ· ÌÔÓÔ·ÙÙ·Ú· /Ì·ÎÚÔÊ¿Á· Ô˘ ÌÂÙ·ÌÔÚÊÒıËÎ·Ó Û ÂÈıËÏÈÔÂȉ‹ ·ÙÙ·Ú· Î·È ÌÂÁ¿Ï· ÔÏ˘‡ÚËÓ· ÁÈÁ·ÓÙÔ·ÙÙ·Ú· ‹ ·ÙÙ·Ú· Langerhans. ™˘¯Ó¿, ·Ú·ÙËÚÔ‡ÓÙ·È Û ·˘Ù¿ ·ÛÙÂÚÔÂȉ‹ ¤ÁÎÏÂÈÛÙ·, Ù· ·ÛÙÂÚÔÂȉ‹ ۈ̿ÙÈ·. ∆· ÚÔ˚fiÓÙ· ÙÔ˘ ÎÔÎÎÈÒÌ·ÙÔ˜ Ô‰ËÁÔ‡Ó Û ·˘ÍË̤ÓË ÈÓÔ‚Ï·ÛÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È ÂÓ·fiıÂÛË ÎÔÏÏ·ÁfiÓÔ˘. ∆Ô ÎÔÏÏ·ÁfiÓÔ Ù‡Ô˘ πππ (ÚÒÈÌÔ, ‰È·Ï˘Ùfi) ·ÓÙÈηı›ÛÙ·Ù·È ·fi Ù‡Ô˘ π (ÙÂÏÈÎfi, ·‰È¿Ï˘ÙÔ), ÙÔ ÔÔ›Ô ÙÂÏÈο Ô‰ËÁ› Û ÌfiÓÈÌË Î·È ÌË ·Ó·ÛÙÚ¤„ÈÌË ›ÓˆÛË (Ô˘ÏÔÔ›ËÛË). ∏ ÁÂÓÂÙÈ΋ ‚¿ÛË ∞Ó Î·È Ì¤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯ÂÈ ‚ÚÂı› Û·Ê‹˜ ÁÔÓȉȷ΋ Û˘Û¯¤ÙÈÛË Ù˘ ÓfiÛÔ˘, ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ¤ÌÌÂÛ˜ ÂӉ›ÍÂȘ fiÙÈ ·˘Ùfi ›Ûˆ˜ Û˘Ì‚Â› ÛÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ. ∏ ‰ÈÂıÓ‹˜ ‚È‚ÏÈÔÁÚ·Ê›· ÂÚÈÏ·Ì‚¿ÓÂÈ ·Ó·ÊÔÚ¤˜ ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 450 ÔÈÎÔÁ¤ÓÂȘ Ì ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚ· ̤ÏË ÌÂ Ê˘Ì·Ù›ˆÛË. ™ËÌ·ÓÙÈÎfiÙÂÚË ıˆÚÂ›Ù·È Ë ÌÂϤÙË Ù˘ µÚÂÙ·ÓÓÈ΋˜ ∂Ù·ÈÚ›·˜ £Òڷη Î·È º˘Ì·Ù›ˆÛ˘, Ë ÔÔ›·, ÙÔ

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·325

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

1973, Û˘ÌÂÚȤϷ‚ 59 ÔÈÎÔÁ¤ÓÂȘ Ì 121 ÂÚÈÙÒÛÂȘ (16). ∏ ÔÈÎÔÁÂÓ‹˜ Û·ÚÎÔ›‰ˆÛË Ê·›ÓÂÙ·È fiÙÈ ·ÊÔÚ¿ ΢ڛˆ˜ Ù· ı‹Ï· ¿ÙÔÌ·, ÂÓÒ, Û ۯÂÙÈο ÏÈÁÔÛÙ¤˜ ·Ó·ÊÔÚ¤˜, Ê·›ÓÂÙ·È fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Û ÌÔÓÔ˙˘ÁˆÙÈÎÔ‡˜ ·fi fiÙÈ Û ‰È˙˘ÁˆÙÈÎÔ‡˜ ‰È‰‡ÌÔ˘˜. ∏ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ Û ÔÈÎÔÁ¤ÓÂȘ ÌÔÚ› Ó· ·Ô‰Ôı› Û ÎÔÈÓÔ‡˜ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ‹/Î·È ÁÂÓÂÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ˆÛÙfiÛÔ, Ë ÂÙÂÚÔÁ¤ÓÂÈ· ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ÛÙÔȯ›ˆÓ ‰ÂÓ ÂÈÙÚ¤ÂÈ Û·Ê¤ÛÙÂÚË ·ÍÈÔÏfiÁËÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ. ∏ ÚÔÛ¿ıÂÈ· Û˘Û¯¤ÙÈÛ˘ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Î·È ÁÔÓȉȷÎÒÓ Ù‡ˆÓ ˘‹ÚÍ ·ÓÂÈÙ˘¯‹˜, ·Ó Î·È ÌÂÚÈÎÔ› HLA ·ÏfiÙ˘ÔÈ (fiˆ˜ Ô HLA-A1-B8) Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ÂÌÊ¿ÓÈÛË Ô˙Ò‰Ô˘˜ ÂÚ˘ı‹Ì·ÙÔ˜, ·ÚıÚ›Ùȉ·˜ ‹ ηϋ˜ ÙÂÏÈ΋˜ ÚfiÁÓˆÛ˘ (17). ∏ ÌÂϤÙË ÁÂÓÂÙÈÎÒÓ ‰ÂÈÎÙÒÓ, fiˆ˜ ÌÔÚ›ˆÓ Ù¿Í˘ π ÙÔ˘ ªÂ›˙ÔÓÔ˜ ™˘ÌϤÁÌ·ÙÔ˜ πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Î˘„ÂÏȉÈÎÒÓ Ì·ÎÚÔÊ¿ÁˆÓ, Â›Û˘ ‰ÂÓ ˘‹ÚÍ ȉȷ›ÙÂÚ· ‰È·ÊˆÙÈÛÙÈ΋.

O Evans (18) η٤ÏËÍ Û 4 ·Ú·ÙËÚ‹ÛÂȘ, Ô˘ ı· ÌÔÚÔ‡Û·Ó ÙÂÏÈο Ó· ·ÔÙÂϤÛÔ˘Ó Î·È ÙË Û‡ÓÔ„Ë Ù˘ ÁÓÒÛ˘ Ì·˜, ·fi ÁÂÓÂÙÈ΋ ÛÎÔÈ¿, ÁÈ· ÙË Û·ÚÎÔ›‰ˆÛË: ·) ÌÂϤÙ˜ Û ÔÈÎÔÁ¤ÓÂȘ ηٷ‰ÂÈÎÓ‡Ô˘Ó ÙË ‰Ú¿ÛË ªÂÓÙ¤ÏÂÈÔ˘ Ù‡Ô˘ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜, ‚) ÔÚÈṲ̂ÓÔÈ HLA ·ÏfiÙ˘ÔÈ ÌÔÚ› Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘, Á) Ô ·ÏfiÙ˘Ô˜ HLA ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ Î·È ‰) Â›Ó·È Èı·Ó‹ Ë ‚Ï¿‚Ë ÁÔÓȉ›ˆÓ, ÙˆÓ ÔÔ›ˆÓ Ô ÚfiÏÔ˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÚÔÛÙ·Û›· ·fi ÊÏÂÁÌÔÓÒ‰ÂȘ ÎÔÎÎȈ̷ÙÒ‰ÂȘ ‰ÈÂÚÁ·Û›Â˜. ∏ ·ÓÔÛÔÏÔÁÈ΋ ‚¿ÛË ∆· ÚÒÈÌ· - Î·È ·Ú¯Èο ıˆÚÔ‡ÌÂÓ· ˆ˜ ·Ú¿‰ÔÍ· - ·ÓÔÛÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ù˘ ˘ÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·˜ Î·È Ù˘ ‰ÂÚÌ·ÙÈ΋˜ ·ÓÂÚÁ›·˜, ¤ÁÈÓ ‰˘Ó·Ùfi Ó· ÂÚÌËÓ¢ÙÔ‡Ó ÌfiÏȘ ÚfiÛÊ·Ù· Î·È ˘fi ÙÔ Êˆ˜ Ù˘ ÂÚÌËÓ›·˜ Ù˘ ÔχÏÔ΢ ‰È·‰Èηۛ·˜ ÙÔ˘ Û¯ËÌ·ÙÈÛÌÔ‡ ÎÔÎÎÈÒÌ·ÙÔ˜. µ ·ÙÙ·Ú·: ¶·Ú¿ ÙËÓ ÔÏ˘ÎÏÔÓÈ΋ ˘ÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, Ù· ΢ÎÏÔÊÔÚÔ‡ÓÙ· µ ·ÙÙ·Ú· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·‰˘Ó·Ì›· ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ˘fi ÙËÓ Â›‰Ú·ÛË ÌÈÙÔÁfiÓˆÓ. ™Ù· ÎÔÎÎÈÒÌ·Ù·, ˆÛÙfiÛÔ, οو ·fi ÙËÓ Â›‰Ú·ÛË ‰È·Ï˘ÙÒÓ ÌÂÛÔÏ·‚ËÙÒÓ Ô˘ ·Ú¿ÁÔÓÙ·È ·fi ‚ÔËıËÙÈο ∆ ·ÙÙ·Ú·, ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ (΢ڛˆ˜ IgG) (19). ∆ ·ÙÙ·Ú·: ™ÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÎÔÎÎÈÒÌ·ÙÔ˜, ηıÒ˜ Î·È ÛÙË ‰ÈÂÚÁ·Û›· Ù˘ ΢„ÂÏ›Ùȉ·˜ ÂÈÎÚ·ÙÔ‡Ó Ù· ∆ ‚ÔËıËÙÈο ·ÙÙ·Ú· (CD4+ Th1 Î·È Th2 cells). ∆· ÏÂÌÊÔ·ÙÙ·Ú· ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂȈ̤ÓË ·¿ÓÙËÛË Û ÌÈÙÔÁfiÓ·, ÁÂÁÔÓfi˜ Ô˘ Èı·ÓfiÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· ‰È·Ï˘ÙÒÓ ˘Ô‰Ô¯¤ˆÓ ÈÓÙÂÚÏ¢ΛÓ˘ 2 (sIL2r) ÛÙË

Paediatriki 2002;65:322-332

‰È¿ÚÎÂÈ· Ù˘ ÂÓÂÚÁ‹˜ ÓfiÛÔ˘. ªÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ô Û˘Ó¯‹˜ ·ÓÙÈÁÔÓÈÎfi˜ ÂÚÂıÈÛÌfi˜ Â›Ó·È Ô ·Ú¿ÁÔÓÙ·˜ Ô˘ ÌÂÙ·ÙÚ¤ÂÈ Ù· ∆ ·ÙÙ·Ú· ·fi “·ÊÂÏ‹” (naive) Û ·ÙÙ·Ú· “ÌÓ‹Ì˘” (memory cells) (20). ∫˘„ÂÏȉÈο Ì·ÎÚÔÊ¿Á·: O ÚfiÏÔ˜ ÙÔ˘˜ ·Ú·Ì¤ÓÂÈ ·ÎfiÌ· ·Û·Ê‹˜. º·›ÓÂÙ·È fiÙÈ Ë ·Ú·ÁˆÁ‹ ·Ú¿ÁÔÓÙ· Ó¤ÎÚˆÛ˘ fiÁÎÔ˘ · (TNF-·) Ô˘ ¤¯ÂÈ Î·Ù·‰Âȯı› in vitro, Èı·ÓfiÓ Ó· ¤¯ÂÈ ·ıÔÁÂÓÂÙÈ΋ ÛËÌ·Û›· (21). ªË¯·ÓÈÛÌfi˜ ·ÚÔ˘Û›·Û˘ ·ÓÙÈÁfiÓÔ˘: ∞Ó Î·È ıˆÚÂ›Ù·È Èı·Ófi Ó· ··ÈÙÂ›Ù·È ÂÎÙfi˜ ·fi ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ Î·È Ì›· ‰È·Ù·Ú·¯‹ ÛÙÔ Ì˯·ÓÈÛÌfi ·ÚÔ˘Û›·Û‹˜ ÙÔ˘ ÛÙ· ·ÓÔÛÔ·ÙÙ·Ú· ÒÛÙ ӷ ÂÎÊÚ·ÛÙ› Ë ÓfiÛÔ˜, Ë ÏÂÙÔÌÂÚ‹˜ ÂÚÈÁÚ·Ê‹ ÙˆÓ ˘·Ú¯Ô˘ÛÒÓ ıˆÚÈÒÓ ÍÂʇÁÂÈ ·fi ÙÔ˘˜ ÛÎÔÔ‡˜ Ù˘ ·ÚÔ‡Û·˜ ·Ó·ÛÎfiËÛ˘. ∏ ÎÏÈÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘ ∏ ÓfiÛÔ˜ ¤¯ÂÈ ‰È·ÁÓˆÛı› Û ·ÛıÂÓ›˜ ËÏÈΛ·˜ ·fi 3 ÌËÓÒÓ ¤ˆ˜ 80 ÂÙÒÓ, ÂÓÒ Ë ÚÔÛ‚ÔÏ‹ Ù˘ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ıˆÚÂ›Ù·È Û¿ÓÈ· (17). ŒÚ¢Ó˜ Ì ̷˙È΋ ÌÈÎÚÔ·ÎÙÈÓÔÁÚ¿ÊËÛË Û ۯÔÏ›· Ù˘ π·ˆÓ›·˜ Î·È Ù˘ O˘ÁÁ·Ú›·˜ (22,23) ·ÔÎ¿Ï˘„·Ó ·ÚÎÂÙ¤˜ ·Û˘Ìو̷ÙÈΤ˜ ÂÚÈÙÒÛÂȘ, ‰Â›¯ÓÔÓÙ·˜ fiÙÈ Ë ÓfiÛÔ˜ ÂÌÊ·Ó›˙ÂÙ·È ÎÏÈÓÈο ÛȈËÏ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∏ ÂÈÛ‚ÔÏ‹ Ù˘ Û·ÚÎÔ›‰ˆÛ˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÔÍ›· (ÌÂ Û˘ÓËı¤ÛÙÂÚ˜ ÌÔÚʤ˜ ÙÔ Ô˙҉˜ ÂÚ‡ıËÌ· Î·È ÙË Ú·ÁÔÂȉ›Ùȉ·), ˘ÔÍ›· (Ì ÈÛÙÔÚÈÎfi Û˘ÌÙˆÌ¿ÙˆÓ ‰È¿ÚÎÂÈ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 2 ÂÙÒÓ) Î·È ¯ÚfiÓÈ· (Ì ÈÛÙÔÚÈÎfi ‰È¿ÚÎÂÈ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 2 ÂÙÒÓ). ™¯Â‰fiÓ Î¿ı fiÚÁ·ÓÔ ‹ Û‡ÛÙËÌ· Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÛ‚ÏËı›. ∆· ·È‰È¿ Ù˘ Ì·‡Ú˘ Ê˘Ï‹˜ Ù›ÓÔ˘Ó Ó· ÂÌÊ·Ó›˙Ô˘Ó ÛÔ‚·ÚfiÙÂÚË Û˘Ìو̷ÙÈ΋ ÔÚ›· ÛÙȘ ∏¶∞ (24). ∆· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ÛÙ· ·È‰È¿ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÙËÓ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÙˆÓ ·ÚıÚÒÛÂˆÓ Î·È ÙˆÓ ÔÊı·ÏÌÒÓ, ÙËÓ ÎÏ·ÛÈ΋ ÙÚÈ¿‰· Ù˘ Û·ÚÎÔ›‰ˆÛ˘ (25), Ô‰ËÁÒÓÙ·˜ Û˘¯Ó¿ ÛÙË Ï·Óı·Ṳ̂ÓË ‰È¿ÁÓˆÛË Ù˘ ÚÂ˘Ì·ÙÔÂȉԇ˜ ·ÚıÚ›Ùȉ·˜. ¶ÚÔÛ‚ÔÏ‹ Ù˘ ηډȿ˜ ‹ „˘¯È·ÙÚÈΤ˜ ÂΉËÏÒÛÂȘ ‰ÂÓ ÂÚÈÁÚ¿ÊÔÓÙ·È. ¶ÂÚÈÊÂÚÈ΋ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· Î·È ‰ÈfiÁΈÛË ‹·ÙÔ˜ Î·È ÛÏ‹Ó· Â›Ó·È Û˘¯ÓfiÙÂÚ˜ ÛÙ· ·È‰È¿ ·Ú¿ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ. ™Ô‚·Ú‹ ÂÈÓ¤ÌËÛË ÙˆÓ ÔÊı·ÏÌÒÓ Î·È Ô˙҉˜ ÂÚ‡ıËÌ· Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Û˘Ó‹ıË ÚÔ‚Ï‹Ì·Ù· Û ·È‰È¿ Ì ۷ÚÎÔ›‰ˆÛË ÛÙȘ ∏¶∞, ÂÓÒ Â›Ó·È Û¿ÓÈ· Û ·ÛÈ·ÙÈΤ˜ ¯ÒÚ˜ (13). OÈ Mayock Î·È D. G. James ηٷÁÚ¿ÊÔ˘Ó ÙË Û˘¯ÓfiÙËÙ· ÂÈÓ¤ÌËÛ˘ Ù˘ ÓfiÛÔ˘ Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ (¶›Ó·Î·˜ 1) (26). ∞Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·: ™ÙÔ˘˜ ÂÓ‹ÏÈΘ, ÙÔ ÔÛÔÛÙfi Û˘ÌÌÂÙÔ¯‹˜ ÙˆÓ Ó¢ÌfiÓˆÓ ·Ó¤Ú¯ÂÙ·È Û 94%. ™˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· ÂÌÊ·Ó›˙ÂÙ·È ÌfiÓÔ ÛÙÔ 60% ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ, ÂÓÒ ÙÔ ˘fiÏÔÈÔ 40% ·Ú·Ì¤ÓÂÈ ÎÏÈÓÈο

325

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·326

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

ÛȈËÚfi, ·ÎfiÌ· Î·È fiÙ·Ó Ë ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ‰Â›¯ÓÂÈ ÛËÌ·ÓÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ (17,27). §ÈÁfiÙÂÚÔ Û˘¯Ó‹, ¯ˆÚ›˜ ˆÛÙfiÛÔ Ó· ˘¿Ú¯Ô˘Ó ‰È·ı¤ÛÈÌ· ÛÙÔȯ›·, ıˆÚÂ›Ù·È Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ™ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ÂȉÈο, Ë ÚÔÛ‚ÔÏ‹ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ıˆÚÂ›Ù·È ÂÍ·ÈÚÂÙÈο ·Û˘Ó‹ıÈÛÙË. øÛÙfiÛÔ, ÙÔ 1999, ‰ËÌÔÛ›Â˘ÛË ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÙÔ˘ ·ÚfiÓÙÔ˜ ¿ÚıÚÔ˘ ÂÚÈÛÙ·ÙÈÎÔ‡ ‚ÚÂÊÈ΋˜ Û·ÚÎÔ›‰ˆÛ˘ Ì ÚÔÂÍ¿Ú¯Ô˘Û· Ó¢ÌÔÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· (28), ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ·ÚÎÂÙ¤˜ ·Ó¿ÏÔÁ˜ ·Ó·ÊÔÚ¤˜, ηıÈÛÙÒÓÙ·˜ ÙÂÏÈο ˆ˜ Èı·Ó‹ ÙËÓ ÂÓÈ·›· ÎÏÈÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ËÏÈΛ· ÂÌÊ¿ÓÈÛ˘. ∆· Û˘ÌÙÒÌ·Ù· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ¯ÚfiÓÈÔ ‚‹¯·, ‰‡ÛÓÔÈ·, Ù·¯‡ÓÔÈ·, Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ Î·È ıˆÚ·Î·ÏÁ›·, ÂÓÒ ·fi¯ÚÂÌ„Ë Î·È ·ÈÌfiÙ˘ÛË ‰ÂÓ ÂÚÈÁÚ¿ÊÔÓÙ·È ÛÙ· ·È‰È¿. ∆· Ê˘ÛÈο Â˘Ú‹Ì·Ù· ÌÔÚ› Ó· ÔÈΛÏÏÔ˘Ó ‹ Î·È Ó· ·Ô˘ÛÈ¿˙Ô˘Ó ÙÂÏ›ˆ˜. §ÂÌÊ·‰ÂÓÔ¿ıÂÈ·: OÈ ÙÚ·¯ËÏÈÎÔ› ÏÂÌÊ·‰¤Ó˜ ÚÔÛ‚¿ÏÏÔÓÙ·È Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È ·ÎÔÏÔ˘ıÔ‡Ó ÔÈ ˘Ï·›ÔÈ ÏÂÌÊ·‰¤Ó˜, Ë ÚÔÛ‚ÔÏ‹ ÙˆÓ ÔÔ›ˆÓ ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ·ÎÙÈÓÔÏÔÁÈ΋ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘. OÈ ÏÂÌÊ·‰¤Ó˜ Â›Ó·È Û˘Ó‹ıˆ˜ ·ÓÒ‰˘ÓÔÈ, ÛÎÏËÚÔ› Î·È ‰‡ÛÎÔÏ· ·ÔÛÙËÌ·ÙÔÔÈÔ‡ÓÙ·È.

OÊı·ÏÌÈΤ˜ ÂΉËÏÒÛÂȘ: OÈ Û˘¯ÓfiÙÂÚ˜ ÂΉËÏÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ÎÂÚ·ÙÔÂÈÂÊ˘Î›Ùȉ· Î·È Î˘Ú›ˆ˜ ÙËÓ ÚfiÛıÈ· Ú·ÁÔÂȉ›Ùȉ·. OÚÈṲ̂ӷ ÎÏÈÓÈο Û‡Ó‰ÚÔÌ· Û·ÚÎÔ›‰ˆÛ˘, ηϿ ÚÔÛ‰ÈÔÚÈṲ̂ӷ Û ÂÓ‹ÏÈΘ, fiˆ˜ Ë ¯ÚfiÓÈ· Ú·ÁÔÂȉ›Ùȉ· ÌÂ Û˘ÓÔ‰fi ¯ÂÈÌÂÙÏÔÂȉ‹ χÎÔ, Ë ÎÂÚ·ÙÔÂÈÂÊ˘Î›Ùȉ· sicca ‹ ÙÔ Û. Heerfordt, ‰ÂÓ ÂÚÈÁÚ¿ÊÔÓÙ·È Û ·È‰È¿. ¢ÂÚÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ: ∏ Û˘ÓÔÏÈ΋ Û˘¯ÓfiÙËÙ· ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ÂΉËÏÒÛÂˆÓ ·ÓÙÈÛÙÔȯ› Û 26%. ∞Ó, fï˜, ÂÍ·ÈÚÂı› ÙÔ Ô˙҉˜ ÂÚ‡ıËÌ· ˆ˜ Û˘Ó‹ı˘ ÂΉ‹ÏˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Löfgren (Û¿ÓÈÔ Û ·È‰È¿ Î·È ¯·Ú·ÎÙËÚÈ˙fiÌÂÓÔ ·fi ˘ÚÂÙfi, ·ÌÊÔÙÂÚfiÏ¢ÚË ˘Ï·›· ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, ÔÏ˘·ÚıÚ›Ùȉ· Î·È ÔÍ›· ÈÚ›Ùȉ·), Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ˘fiÏÔÈˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ÂΉËÏÒÛÂˆÓ ·ÓÙÈÛÙÔȯ› Û ÔÛÔÛÙfi ÌfiÓÔ 9%. ∞fi ·˘Ù¤˜, Ë Û˘¯ÓfiÙÂÚË ÛÙ· ·È‰È¿ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË ˘Ô‰fiÚÈˆÓ Ô˙ȉ›ˆÓ Ì ÔÈΛÏË ÂÓÙfiÈÛË (29). OÈ ‰È·Ù·Ú·¯¤˜ ‰È·ÎÚ›ÓÔÓÙ·È Û ÔÍ›˜ Î·È ¯ÚfiÓȘ. ™ÙËÓ ÚÒÙË Î·ÙËÁÔÚ›· ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÙÔ Ô˙҉˜ ÂÚ‡ıËÌ·, ÙÔ˘ ÔÔ›Ô˘ Ë ÔÍ›· ÂÌÊ¿ÓÈÛË Û˘Ó‹ıˆ˜ ÚÔ‰Èο˙ÂÈ Â˘ÓÔ˚΋ ÚfiÁÓˆÛË, Û ·ÓÙ›ıÂÛË Ì ÙȘ ¯ÚÔÓÈfiÙÂÚ˜ ÌÔÚʤ˜ ‰ÂÚÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ. ™˘¯Ó¿, ÙËÓ ÂÌÊ¿ÓÈÛË ‰ÂÚÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ Û˘ÓÔ‰Â‡Ô˘Ó ·ÚıÚ·ÏÁ›Â˜, ÔÈ Ôԛ˜ Û¿ÓÈ·, ˆÛÙfiÛÔ, Ô‰ËÁÔ‡Ó Û ·Ú·ÌÔÚʈÙÈΤ˜ ‚Ï¿‚˜. ¡Â˘ÚÈÎfi Û‡ÛÙËÌ·: ¶ÂÚÈÏ·Ì‚¿ÓÂÈ ÚÔÛ‚ÔÏ‹ ÎÚ·ÓÈ·ÎÒÓ Ó‡ڈÓ, ÙÔ˘ ∫¡™ Î·È ÙÔ˘ ¶¡™, ηıÒ˜

326

Paediatriki 2002;65:322-332

¶›Ó·Î·˜ 1. ™˘¯ÓfiÙËÙ· ÂÈÓ¤ÌËÛ˘ ‰È·ÊfiÚˆÓ ÔÚÁ¿ÓˆÓ ·fi ÙË Û·ÚÎÔ›‰ˆÛË Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ, ·fi ÙÔ˘˜ Mayock et al Î·È D.G. James ŸÚÁ·ÓÔ ¶Ó‡ÌÔÓ˜ ¶˘Ï·›ÔÈ ÏÂÌÊ·‰¤Ó˜ ∞ÓÒÙÂÚÔÈ ·ÂÚ·ÁˆÁÔ› §ÂÌÊ·‰¤Ó˜ ¢¤ÚÌ· O˙҉˜ ÂÚ‡ıËÌ· OÊı·ÏÌÔ› ◊·Ú ™Ï‹Ó·˜ OÛÙ¿ ™ÈÂÏÔÁfiÓÔÈ ·‰¤Ó˜ ¶·ÚˆÙȉÈÎÔ› ·‰¤Ó˜ ∫·Ú‰È¿ ¡Â˘ÚÈÎfi Û‡ÛÙËÌ· ∞ÚıÚÒÛÂȘ ∂Ó‰ÔÎÚÈÓ›˜ ·‰¤Ó˜ ¡ÂÊÚÔ› ¢·ÎÚ˘˚ÎÔ› ·‰¤Ó˜ ª·ÛÙÔ› °·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ·

% ÂÈÓ¤ÌËÛË Mayock et al D. G. James 94 11,2 73 32 8,2 21 21 18 14 6,1 4 5,1 5,1 5,1 5 4,3 3,2 1,1 0,7

41 80 22 26 17 15 6 3 4 -

Î·È „˘¯È·ÙÚÈΤ˜ ‰È·Ù·Ú·¯¤˜, Û˘ÓÈÛÙÒÓÙ·˜ ÙË Ó¢ÚÔÛ·ÚÎÔ›‰ˆÛË, Ô˘ ‰ÂÓ ÂÚÈÁÚ¿ÊÂÙ·È ˆÛÙfiÛÔ, Û ·È‰È¿. ¡ÂÊÚÔ› Î·È Ô˘ÚÔÔÈËÙÈÎfi Û‡ÛÙËÌ·: ∏ Û·ÚÎÔ›‰ˆÛË ÚÔÛ‚¿ÏÏÂÈ ÙÔ˘˜ ÓÂÊÚÔ‡˜ ¿ÌÂÛ·, Ì ·¢ı›·˜ ‰È‹ıËÛË ÙÔ˘ ÈÛÙÔ‡ ÙÔ˘˜ ·fi ÎÔÎÎÈÒÌ·Ù· Î·È ¤ÌÌÂÛ·, Ì ÂÓ·fiıÂÛË ·Û‚ÂÛÙ›Ô˘ Á‡Úˆ ‹ ÂÓÙfi˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ (ÓÂÊÚ·Û‚¤ÛÙˆÛË), ÏfiÁˆ Ù˘ Û˘Ó˘¿Ú¯Ô˘Û·˜ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·˜ ‹ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜, Ë Û˘¯ÓfiÙËÙ· Ù˘ ÔÔ›·˜ Êı¿ÓÂÈ ÙÔ 40% (30). ∏ ‰È·Ù·Ú·¯‹ ·˘Ù‹ ÈÛÙ‡ÂÙ·È fiÙÈ ÔÊ›ÏÂÙ·È Û ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË ÛÙÔÓ ÔÚfi ÙÔ˘ ÂÓÂÚÁÔ‡ ÌÂÙ·‚ÔÏ›ÙË Ù˘ ‚ÈÙ·Ì›Ó˘ D 1·, 25-‰È¸‰ÚÔ͢‚ÈÙ·Ì›ÓË D3 (ηÏÛÈÙÚÈfiÏË), ÏfiÁˆ Â͈ÓÂÊÚÈ΋˜ ·Ú·ÁˆÁ‹˜ Ù˘ ÙÂÏÂ˘Ù·›·˜. ™‹ÌÂÚ·, Ë ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ηÏÛÈÙÚÈfiÏ˘ ÛÙË Û·ÚÎÔ›‰ˆÛË ÈÛÙ‡ÂÙ·È fiÙÈ ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ú·ÁˆÁ‹ Ù˘ ·fi Ù· ΢„ÂÏȉÈο Ì·ÎÚÔÊ¿Á· (31). ∆· Û˘ÌÙÒÌ·Ù· Ù˘ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÎfiˆÛË, Ì˘˚΋ ·‰˘Ó·Ì›·, ‰›„· Î·È ‰˘ÛÎÔÈÏÈfiÙËÙ·. ∞ÓÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·: OÈ ‚ÏÂÓÓÔÁfiÓÔÈ Ù˘ ̇Ù˘ Î·È ÙÔ˘ Ï¿Ú˘ÁÁ· Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÛ‚ÏËıÔ‡Ó. ¶ÂÙÈÎfi Û‡ÛÙËÌ·: ∏ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÛÈÂÏÔÁfiÓˆÓ ·‰¤ÓˆÓ Î·È ÙÔ˘ ‹·ÙÔ˜ Â›Ó·È Û˘¯Ó‹. OÈ ‰È·Ù·Ú·¯¤˜ ·fi ÙÔ ‹·Ú ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ë·ÙÈο ÎÔÎÎÈÒÌ·Ù·, Ë·ÙÈ΋ ‰ÈfiÁΈÛË (Û˘¯Ó¿ Û˘Óԉ‡ÂÙ·È ·fi Ë·ÙÔÌÂÁ·Ï›·) Î·È ÂÓ‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË, ¯ˆÚ›˜ ˆÛÙfiÛÔ ·Ó¿ÏÔÁË Û˘Ìو̷ÙÔÏÔÁ›·. Ÿˆ˜ Î·È Û ÔÏϤ˜ ¿ÏϘ ÂÚÈÙÒÛÂȘ, Û˘¯Ó¿ ηı›ÛÙ·Ù·È È‰È·›ÙÂÚ· ‰‡ÛÎÔÏÔ Ó· ÚÔÛ‰ÈÔÚÈÛÙ› ÙÔ Î·Ù¿

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·327

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

fiÛÔ ÔÈ ·Ú·ÙËÚÔ‡ÌÂÓ˜ ‰È·Ù·Ú·¯¤˜ ÔÊ›ÏÔÓÙ·È ÛÙË ÓfiÛÔ per se ‹ Û ·ÓÂÈı‡ÌËÙË ‰Ú¿ÛË ÙˆÓ ıÂÚ·¢ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ÂȉÈο fiÙ·Ó ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·Ú¿ÁÔÓÙ˜ ÂÓ·ÏÏ·ÎÙÈÎÔ› ÙˆÓ ÛÙÂÚÔÂȉÒÓ. ∏ Û˘ÓÂÎÙ›ÌËÛË, Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, ÙˆÓ ‰ÂÈÎÙÒÓ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘ ·Ô‰ÂÈÎÓ‡ÂÙ·È ÔχÙÈÌË. ∞Û˘Ìو̷ÙÈ΋ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ¤¯ÂÈ Î·Ù·‰Âȯı› Û ÓÂÎÚÔ„›Â˜ ÂÓËϛΈÓ. ™ÙËÓ ·È‰È΋ ËÏÈΛ·, ˆÛÙfiÛÔ, ‰ÂÓ ÂÚÈÁÚ¿ÊÔÓÙ·È ‰È·Ù·Ú·¯¤˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘. ∞ÈÌÔÔÈËÙÈÎfi Î·È ÏÂÌÊÈÎfi Û‡ÛÙËÌ·: ∏ ÛÏËÓÈ΋ ‰ÈfiÁΈÛË ·Ú·Ì¤ÓÂÈ ·Û˘Ìو̷ÙÈ΋, ÂÓÒ ÂÓ›ÔÙ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÂÓ‰ÔÛÏËÓÈΤ˜ ·ÔÙÈÙ·ÓÒÛÂȘ. Œ¯ÂÈ ÂÚÈÁÚ·Ê› ·˘ÙfiÌ·ÙË Ú‹ÍË ÙÔ˘ ÛÏ‹Ó·, ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Î·È ˘ÂÚÛÏËÓÈÛÌfi˜ (32). OÈ ÏÂÌÊ·‰¤Ó˜ ÚÔÛ‚¿ÏÏÔÓÙ·È ÂÍ·ÈÚÂÙÈο Û˘¯Ó¿, ÌÂ Û˘ÌÌÂÙÔ¯‹ Ô˘ Êı¿ÓÂÈ ÙÔ 100%, ‡ÛÙÂÚ· ·fi ÌÂϤÙË ÓÂÎÚÔÙÔÌÈÎÔ‡ ˘ÏÈÎÔ‡ Û ÛÂÈÚ¤˜ ÂÓ‹ÏÈÎˆÓ ·ÛıÂÓÒÓ. ª˘ÔÛÎÂÏÂÙÈÎfi Û‡ÛÙËÌ·: ∏ ÔÛÙÈ΋ ÂÈÓ¤ÌËÛË ·ÊÔÚ¿ ΢ڛˆ˜ ÙȘ ÙÂÏÈΤ˜ Ê¿Ï·ÁÁ˜ ¯ÂÚÈÒÓ Î·È Ô‰ÈÒÓ, ¯·Ú·ÎÙËÚÈ˙fiÌÂÓË Î˘Ú›ˆ˜ ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÔÛÙÈÎÒÓ Î‡ÛÙˆÓ. ∏ ÔÛÙÈ΋ ÂÈÓ¤ÌËÛË ·ÔÙÂÏ› ηÎfi ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ·, ÂÎÊÚ¿˙ÔÓÙ·˜ Û˘Ó‹ıˆ˜ Ì·ÎÚÔ¯ÚfiÓÈ· Î·È ÌË ·Ó·ÛÙÚ¤„ÈÌË ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘. ∂È̤ÓÔ˘Û· ·ÏËı‹˜ ¯ÚfiÓÈ· ·ÚıÚ›Ùȉ· Â›Ó·È Û¿ÓÈ· Û ·ÛıÂÓ›˜ Ì ۷ÚÎÔ›‰ˆÛË. ™ÙË ÌÂÁ¿ÏË ·Ó·ÏÔÁ›· ÙˆÓ ÂÚÈÙÒÛˆÓ, Ë ÔÏ˘·ÚıÚ·ÏÁ›· ·ÔÙÂÏ› ¤Ó· ·fi Ù· ÛÙÔȯ›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Löfgren. ∫·È Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, Â›Ó·È Û˘¯Ó¿ ‰˘Û‰È¿ÎÚÈÙÔ ÙÔ Î·Ù¿ fiÛÔ Ë ·ÚıÚÈ΋ Û˘ÌÌÂÙÔ¯‹ ·ÔÙÂÏ› ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ ‹ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ıÂÚ·›·˜, ÂȉÈο fiÙ·Ó ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ù· ÁÓˆÛÙ¿ ÁÈ· ÙËÓ ÔÛÙÂÔÔÚˆÙÈ΋ ÙÔ˘˜ ‰Ú¿ÛË ÛÙÂÚÔÂȉ‹ (28,33). ∏ ÎÔÎÎȈ̷Ù҉˘ ÂÈÓ¤ÌËÛË ÙˆÓ Ì˘ÒÓ Ê·›ÓÂÙ·È Ó· ·ÊÔÚ¿ Û˘ÓËı¤ÛÙÂÚ· ÛÙÔ˘˜ Ì˘˜ ÙÔ˘ ıÒڷη, Ù˘ ˆÌÔÏ¿Ù˘, ÙÔ˘ ‚Ú·¯›ÔÓ· Î·È ÛÙÔ˘˜ Á·ÛÙÚÔÎÓ‹ÌÈÔ˘˜. ∏ ÚÔÛ‚ÔÏ‹ ·Ú·Ì¤ÓÂÈ ·Û˘Ìو̷ÙÈ΋ ‹, Û·ÓÈfiÙÂÚ·, Û˘Óԉ‡ÂÙ·È ·fi fiÓÔ, „ËÏ·ÊËÙ¿ Ô˙›‰È·, ·ÙÚÔÊ›· ‹ Î·È „¢‰Ô¸ÂÚÙÚÔÊ›·. ¢È¿ÁÓˆÛË Î·È ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘ ¶·Ú¿ ÙËÓ ÙÂÚ¿ÛÙÈ· ÚfiÔ‰Ô Ô˘ ¤¯ÂÈ ÂÈÙ¢¯ı› ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Î·Ù·ÓfiËÛË ÙˆÓ Ì˯·ÓÈÛÌÒÓ Ô˘ Ô‰ËÁÔ‡Ó ÛÙÔ Û¯ËÌ·ÙÈÛÌfi ÙÔ˘ ÎÔÎÎÈÒÌ·ÙÔ˜ Î·È ÙÂÏÈο ÛÙËÓ ›ÓˆÛË, η̛· ·fi ÙȘ ‚ÈÔ¯ËÌÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ô˘ ¤¯Ô˘Ó ·Ó·Ù˘¯ı› ‰ÂÓ Â›Ó·È ÎÏÈÓÈο ¯Ú‹ÛÈÌË ÛÙÔ Ó· ÚÔÛ‰ÈÔÚ›ÛÂÈ ÙÔÓ ‚·ıÌfi ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘. ∂ÈϤÔÓ, ·Ó Î·È Ì›· ÛÂÈÚ¿ ÌË ·ÚÂÌ‚·ÙÈÎÒÓ ÌÂıfi‰ˆÓ ÌÔÚ› Ó· ·Ô‰Âȯı› ¯Ú‹ÛÈÌË ÛÙÔ Ó· ÂÎÊÚ·ÛÙ› Ë ‰È·ÁÓˆÛÙÈ΋ ˘Ô„›·, ÂÓÙÔ‡ÙÔȘ, ··È-

Paediatriki 2002;65:322-332

ÙÂ›Ù·È ¿ÓÙ· Ë ÈÛÙÔÏÔÁÈ΋ ÂȂ‚·›ˆÛË (ηÈ, ηٿ Û˘Ó¤ÂÈ·, Ë ‚ÈÔ„›·), ÒÛÙ ӷ ÙÂı› Ì ‚‚·ÈfiÙËÙ· Ë ‰È¿ÁÓˆÛË. ∞ÂÈÎÔÓÈÛÙÈο ‰Â‰Ô̤ӷ ∞ÎÙÈÓÔÁÚ·Ê›· ıÒڷη: ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ 90% ÙˆÓ ÂÓËÏ›ÎˆÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·fi ÙÔ ıÒڷη ηٿ ÙÔ ¯ÚfiÓÔ Ù˘ ‰È¿ÁÓˆÛ˘ (34), Ë ‰È·ÁÓˆÛÙÈ΋ ·Í›· Ù˘ ·ÎÙÈÓÔÁÚ·Ê›·˜ ıÒڷη ÛÙËÓ ·È‰È΋ ËÏÈΛ· ·Ú·Ì¤ÓÂÈ Û¯ÂÙÈο ÌÂȈ̤ÓË, ÏfiÁˆ Ù˘ ÏÈÁfiÙÂÚÔ Û˘¯Ó‹˜ ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ŸÙ·Ó, ˆÛÙfiÛÔ, ÔÈ ‚Ï¿‚˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó, Ë ·Í›· Ù˘ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ·‰È·ÌÊÈÛ‚‹ÙËÙË. ∏ Ù·ÍÈÓfiÌËÛË Ô˘ ÂÈÎÚ·Ù› ‰ÈÂıÓÒ˜ (35) ηٷٿÛÛÂÈ Ù· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· Û 4 ÛÙ¿‰È· (¶›Ó·Î·˜ 2) (∂ÈÎfiÓ· 1). ∞ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ıÒڷη ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜: ∂›Ó·È ¯Ú‹ÛÈÌË ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ‚·ıÌÔ‡ ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÏÂÌÊ·‰ÂÓÈÎÒÓ ÔÌ¿‰ˆÓ, ηıÒ˜ Î·È ÛÙËÓ Î·Ù¿‰ÂÈÍË Ù˘ ΢„ÂÏ›Ùȉ·˜, Ì ÙË ¯·Ú·ÎÙËÚÈÛÙÈ΋ ‰ÈÎÙ˘ÔÎÔÎÎÒ‰Ë ÌÔÚÊ‹. ™ÈÓıËÚÔÁÚ¿ÊËÌ· Á·ÏÏ›Ô˘-67: ∆Ô Á¿ÏÏÈÔ-67 (67Ga), ¤Ó· ÈÛfiÙÔÔ Ì ¯ÚfiÓÔ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ 78 ÒÚ˜, Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠ·Ú¯Èο ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ, ‰È·ÈÛÙÒıËΠۇÓÙÔÌ· fiÙÈ ¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· Û˘ÁÎÂÓÙÚÒÓÂÙ·È Û ı¤ÛÂȘ ÔÍ›·˜ Î·È ¯ÚfiÓÈ·˜ ÊÏÂÁÌÔÓ‹˜. ∞Ó Î·È ÔÚÈṲ̂ÓÔ ·fi ÙÔ Û˘Ó‰Â‰Â̤ÓÔ Ì ÚˆÙ½Ó˜ ÙÔ˘ ÔÚÔ‡ (·Ï‚Ô˘Ì›ÓË, ·ÙÔÛÊ·ÈÚ›ÓË, ÙÚ·ÓÛÊÂÚÚ›ÓË) Á¿ÏÏÈÔ ÌÂٷʤÚÂÙ·È ÛÙ· Ï¢ÎÔ·ÙÙ·Ú·, Ô Ì˯·ÓÈÛÌfi˜ Ô˘ ÚÔÛ‰ÈÔÚ›˙ÂÈ ÙËÓ ÚfiÛÏË„Ë 67Ga ·fi ÙÔ˘˜ Ó‡ÌÔÓ˜ ‰ÂÓ Â›Ó·È ·ÎfiÌË ÁÓˆÛÙfi˜. ∆Ô ÛÈÓıËÚÔÁÚ¿ÊËÌ· 67Ga Â›Ó·È Â‡ÎÔÏÔ ÛÙËÓ ÂÊ·ÚÌÔÁ‹, ‡ÎÔÏ· ·ÓÂÎÙfi Î·È Ì ÌÈÎÚ‹ ¤ÎıÂÛË Û ·ÎÙÈÓÔ‚ÔÏ›· (36). °È· ÙË ÌÂϤÙË ÙÔ˘ ıÒڷη, ÂÁ¯¤ÂÙ·È ÂÓ‰ÔÊÏ‚›ˆ˜ ÎÈÙÚÈÎfi 67Ga (‰fiÛË 50 ÌCi/kg µ™) Î·È ÂϤÁ¯ÂÙ·È Ë Î·Ù·ÓÔÌ‹ ÙÔ˘ Ì ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÌÂÙ¿ ·fi 48-72 ÒÚ˜. ∞Ó Î·È ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÂӉȷʤÚÔÓ ÛÙË ÌÂϤÙË ÂÓËÏ›ÎˆÓ Ì ۷ÚÎÔ›‰ˆÛË ¤¯ÂÈ ÂÛÙÈ·ÛÙ› ÛÙËÓ ÚfiÛÏË„Ë ÙÔ˘ ÈÛfiÙÔÔ˘ ·fi Û¯ËÌ·ÙÈÛÌÔ‡˜ ÙÔ˘ ıÒڷη, ÛÙ· ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚË ‰È·ÁÓˆÛÙÈ΋ ·Í›· ıˆÚÂ›Ù·È fiÙÈ ¤¯ÂÈ Ë ÌÂϤÙË Ù˘ ÚfiÛÏË„‹˜ ÙÔ˘ ·fi Â͈ıˆÚ·ÎÈÎÔ‡˜ Û¯ËÌ·ÙÈÛÌÔ‡˜. ŒÙÛÈ, ·˘ÍË̤ÓË ÚfiÛÏË„Ë 67Ga ÌÔÚ› Ó· ·ÓȯÓ¢ı› ÛÙÔ˘˜ ·ÚˆÙȉÈÎÔ‡˜ ·‰¤Ó˜, ÙÔ˘˜ ÛÈÂÏÔÁfiÓÔ˘˜ ·‰¤Ó˜, ÙÔ˘˜ ‰·ÎÚ˘˚ÎÔ‡˜ ·‰¤Ó˜ (‰›ÓÔÓÙ·˜ ÙË ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÂÈÎfiÓ· “Û·Ó ·ÚÎÔ˘‰¿ÎÈ ¿ÓÙ· - panda sign”) (∂ÈÎfiÓ· 2), ÙÔ ÛÏ‹Ó·, ÙÔ ÚÈÓÈÎfi ‚ÏÂÓÓÔÁfiÓÔ, ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜, ÙÔ˘˜ ÎÔÈÏÈ·ÎÔ‡˜ ÏÂÌÊ·‰¤Ó˜, ÙȘ ·ÚıÚÒÛÂȘ, Ù· ÔÛÙ¿ Î·È ÙÔ ‰¤ÚÌ·. ŸÛÔÓ ·ÊÔÚ¿ ÛÙ· ÔÛÙ¿ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Î·È ÙÔ ‹·Ú, Ë ÂÚÌËÓ›· ÙÔ˘ ÛÈÓıËÚÔÁÚ·Ê‹Ì·ÙÔ˜ Â›Ó·È ‰‡ÛÎÔÏË, ÏfiÁˆ Ù˘ Ê˘ÛÈÔÏÔÁÈο ·˘ÍË̤Ó˘ ÚfiÛÏ˄˘ ÙÔ˘ 67Ga ÛÙÔ˘˜ ÈÛÙÔ‡˜ ·˘ÙÔ‡˜.

327

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·328

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

Paediatriki 2002;65:322-332

¶›Ó·Î·˜ 2. ∞ÎÙÈÓÔÁÚ·ÊÈο ÛÙ¿‰È· Î·È ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ Û·ÚÎÔ›‰ˆÛ˘ ™Ù¿‰ÈÔ

¶ÂÚÈÁÚ·Ê‹

™¯fiÏÈ·

0

º˘ÛÈÔÏÔÁÈ΋

ªÂÁ¿Ï˜ Èı·ÓfiÙËÙ˜ ·˘ÙfiÌ·Ù˘ ‡ÊÂÛ˘ Ù˘ ÓfiÛÔ˘

π

¶˘Ï·›· ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, ÂÈÓ¤ÌËÛË ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈÎÒÓ, ÙÚ·¯ÂÈÔ‚ÚÔÁ¯ÈÎÒÓ Î·È Û¿ÓÈ· ·Ú·ÙÚ·¯ÂÈ·ÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ, Û˘Ó‹ıˆ˜ ·ÌÊÔÙÂÚfiÏ¢ÚË Î·È Û˘ÌÌÂÙÚÈ΋

¢/¢ ·fi Ê˘Ì·Ù›ˆÛË Î·È Ï¤Ìʈ̷: ÛÙÔ Ï¤Ìʈ̷, Ë ÚÔÛ‚ÔÏ‹ ÙˆÓ ·Ú·ÙÚ·¯ÂÈ·ÎÒÓ ·‰¤ÓˆÓ Â›Ó·È Û˘¯Ó‹, ηıÒ˜ Î·È Ë ‰ÈfiÁΈÛË ÙˆÓ ÔÈÛıÔÛÙÂÚÓÈÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ (Û¿ÓÈ· ÛÙË Û·ÚÎÔ›‰ˆÛË)

ππ

¶˘Ï·›· ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· Î·È ·ÚÂÁ¯˘Ì·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ‰È¿¯˘Ù˜, ÔÌÔÈfiÌÔÚʘ, Û˘ÌÌÂÙÚÈΤ˜. ¢È¿ÌÂÛÔ˘ Ù‡Ô˘. ªÔÚÊ‹ ·fi ·ÌÈÁÒ˜ Ô˙҉˘ ˆ˜ ·ÌÈÁÒ˜ ‰ÈÎÙ˘ˆÙ‹, Û˘Ó‹ıˆ˜ ‰ÈÎÙ˘Ô-Ô˙҉˘

¢/¢ ·fi ίÚÔÂȉ‹ Ê˘Ì·Ù›ˆÛË, Ì˘ÎËÙÈ¿ÛÂȘ, ·Ú·ÛÈÙÒÛÂȘ, ˘ÚÈÙ›·ÛË, ȉÈÔ·ı‹ Ó¢ÌÔÓÈ΋ ›ÓˆÛË, Û. Goodpasture, ÈÛÙÈÔ·ÙÙˆÛË-Ã. ÷ÌËÏ¿ ÔÛÔÛÙ¿ ·˘ÙfiÌ·Ù˘ ‡ÊÂÛ˘, ÂͤÏÈÍË Û ›ÓˆÛË Û ÔÛÔÛÙfi 20%

πππ

¶·ÚÂÁ¯˘Ì·ÙÈΤ˜ ÂΉËÏÒÛÂȘ Ì ¯·Ú·ÎÙËÚÈÛÙÈο fiˆ˜ ÙÔ˘ ÛÙ·‰›Ô˘ ππ

¶·ÚfiÌÔÈ·

πV

ÿÓˆÛË. ∞ηÓfiÓÈÛÙ˜ ÁÚ·ÌÌÔÂȉ›˜ ‰ÂÛÌ›‰Â˜ ·fi ÙËÓ ‡ÏË ÚÔ˜ ÙËÓ ÂÚÈʤÚÂÈ·, ÂÌÊ˘ÛËÌ·ÙÈΤ˜ ·ÛÙÂȘ, bullae, ÂÈÎfiÓ· ÌÂÏÈÎËÚ‹ıÚ·˜

ªË ·Ó·ÛÙÚ¤„È̘ ‚Ï¿‚˜, ηٷÛÙÚÔÊ‹ Ù˘ ·Ú¯ÈÙÂÎÙÔÓÈ΋˜ ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜

∞˘ÍË̤ÓË ÚfiÛÏË„Ë Á·ÏÏ›Ô˘ ·fi Ó¢ÌÔÓÈÎÔ‡˜ ÈÛÙÔ‡˜ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ 65% ÙˆÓ ·ÛıÂÓÒÓ Ì ۷ÚÎÔ›‰ˆÛË, ¯ˆÚ›˜ ˆÛÙfiÛÔ Ó· ˘¿Ú¯Ô˘Ó ‰Â‰Ô̤ӷ ÁÈ· ÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi (37). ∆Ô ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ó¢ÌfiÓˆÓ Ì 67Ga ÂÌÊ·Ó›˙ÂÈ Â˘·ÈÛıËÛ›·, ·ÏÏ¿ fi¯È Î·È ÂȉÈÎfiÙËÙ·, ÛÙË ‰È¿ÁÓˆÛË Ù˘ Û·ÚÎÔ›‰ˆÛ˘, ηıÒ˜ ıÂÙÈÎÔÔÈÂ›Ù·È Û ÓÂÔÏ·ÛÌ·ÙÈΤ˜ ÓfiÛÔ˘˜, ‰È¿ÌÂÛ˜ Ó¢ÌÔÓ›Ùȉ˜ Î·È Ó¢ÌÔÓÔÎÔÓÈ¿ÛÂȘ. ∂ÈϤÔÓ, ·ıÔÏÔÁÈ΋ ÚfiÛÏË„Ë 67Ga ÌÔÚ› Ó· ·Ú·ÙËÚËı› Û ÛÈÂÏÔÁfiÓÔ˘˜ Î·È ·ÚˆÙȉÈÎÔ‡˜ ·‰¤Ó˜ ÛÙË Ê˘Ì·Ù›ˆÛË, ÛÙÔ Û‡Ó‰ÚÔÌÔ Sjögren Î·È ÌÂÙ¿ ·fi ·ÎÙÈÓÔıÂÚ·›·. øÛÙfiÛÔ, ÔÏÏÔ› Û˘ÁÁÚ·Ê›˜ ıˆÚÔ‡Ó fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ ·˘ÍË̤Ó˘ Ó¢ÌÔÓÈ΋˜ ÚfiÛÏ˄˘ 67Ga Î·È ·˘ÍËÌ¤ÓˆÓ ÂÈ¤‰ˆÓ ª∂∞ (ª∂∞: ªÂÙ·ÙÚÂÙÈÎfi ¤Ó˙˘ÌÔ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ π) ÛÙÔÓ ÔÚfi, Â›Ó·È ÂȉÈÎfi˜ ÁÈ· ÙË Û·ÚÎÔ›‰ˆÛË ÛÙÔ 99% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (38). ™˘ÓÔÙÈο, ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì Á¿ÏÏÈÔ-67 ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙË ‰È·›ÛÙˆÛË Ù˘ ‡·Ú͢ ΢„ÂÏ›Ùȉ·˜ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛ‹ Ù˘, ÁÈ· ÙË ÛÙ·‰ÈÔÔ›ËÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÌÂÙ¤ÂÈÙ· ÔÚ›·˜ ÙÔ˘˜ (Â›Ó·È ·Ú·‰ÂÎÙfi fiÙÈ ıÂÙÈÎÔÔÈÂ›Ù·È ÛÙËÓ ¤Í·ÚÛË Î·È ·ÚÓËÙÈÎÔÔÈÂ›Ù·È ÛÙËÓ ‡ÊÂÛË Ù˘ ÓfiÛÔ˘), ÁÈ· ÙË ‰È·ÎÚ›‚ˆÛË ‡·Ú͢ Â͈Ó¢ÌÔÓÈÎÒÓ ÂÓÙÔ›ÛÂˆÓ Î·È ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ı¤ÛÂˆÓ ‚ÈÔ„›·˜, ÂÓÒ ˘ÂÚÙÂÚ› Ù˘ ÌÂϤÙ˘ Ì BAL (‚ÚÔÁ¯Ô-΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì·) Û ·ÛıÂÓ›˜ Ì ÊÏÂÁÌÔÓÒ‰ÂȘ ÓfiÛÔ˘˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ (39). µÈÔ¯ËÌÈο Î·È ÔÚÔÏÔÁÈο ‰Â‰Ô̤ӷ ŒÓ·˜ ÛËÌ·ÓÙÈο ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ‚ÈÔ¯ËÌÈÎÒÓ ‹ ÔÚÔÏÔÁÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı›

328

ÁÈ· Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Ë ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÓfiÛÔ˘: ∆Ô ÌÂÙ·ÙÚÂÙÈÎfi ¤Ó˙˘ÌÔ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ π (ª∂∞ ‹ SACE) ‚Ú›ÛÎÂÙ·È Ê˘ÛÈÔÏÔÁÈο ÛÙÔ ·ÁÁÂÈ·Îfi ÂÓ‰Ôı‹ÏÈÔ ÔÏÏÒÓ ÔÚÁ¿ÓˆÓ (Ó‡ÌÔÓ˜, ÓÂÊÚÔ›, ÏÂÙfi ¤ÓÙÂÚÔ, ÚÔÛÙ¿Ù˘, ı˘ÚÔÂȉ‹˜, ÂÈÓÂÊÚ›‰È·, fiÚ¯ÂȘ) Î·È ÛÙ· ·ÙÙ·Ú· Ù˘ ÌÔÓÔ˘ÚËÓÈ΋˜ - Ê·ÁÔ΢ÙÙ·ÚÈ΋˜ ÛÂÈÚ¿˜. ™ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ·Ô‰›‰ÔÓÙ·È Ù· ·˘ÍË̤ӷ Â›‰· ª∂∞ ÛÙÔÓ ÔÚfi ·ÛıÂÓÒÓ Ì ۷ÚÎÔ›‰ˆÛË. OÈ ÁÓÒ̘ Û¯ÂÙÈο Ì ÙË ‰È·ÁÓˆÛÙÈ΋ ¯ÚËÛÈÌfiÙËÙ· ÙÔ˘ ª∂∞ ‰È›ÛÙ·ÓÙ·È. ªÂÚÈÎÔ› ‰ÂÓ ÙÔ˘ ·Ô‰›‰Ô˘Ó ȉȷ›ÙÂÚË ‰È·ÁÓˆÛÙÈ΋ ·Í›·, ÂÓÒ ¿ÏÏÔÈ ÙÔ ıˆÚÔ‡Ó ¯Ú‹ÛÈÌÔ Û˘ÌÏËڈ̷ÙÈÎfi ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ ÛÙË ‚ÈÔ„›· ‹ ÈÛÙÂ‡Ô˘Ó fiÙÈ ·˘ÍË̤ӷ Â›‰· ÙÔ˘ ÂÓ˙‡ÌÔ˘ Û ·ÛıÂÓ›˜ ÌÂ Ù˘È΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ηıÈÛÙÔ‡Ó ÙË ‚ÈÔ„›· ÂÚÈÙÙ‹. ∏ ‰È¯ÔÁӈ̛· ·˘Ù‹ ÔÊ›ÏÂÙ·È ÛÙË ‰È·ÊÔÚÂÙÈ΋ ·ÍÈÔÏfiÁËÛË ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Ù˘ ÂȉÈÎfiÙËÙ·˜ Î·È Â˘·ÈÛıËÛ›·˜ ÙÔ˘ ª∂∞ ÛÙË ‰È¿ÁÓˆÛË Ù˘ Û·ÚÎÔ›‰ˆÛ˘ (40). ∂Ó‰ÂÈÎÙÈο, ·˘ÍË̤ӷ Â›‰· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÛÙÔ 34-88% ÙˆÓ ·ÛıÂÓÒÓ (̤ÛÔ˜ fiÚÔ˜ 60%) ηÈ, ηٿ Û˘Ó¤ÂÈ·, Ë ‰È·ÁÓˆÛÙÈ΋ ÙÔ˘ ¢·ÈÛıËÛ›· Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË. ∏ ¢·ÈÛıËÛ›· Ù˘ ̤ÙÚËÛ˘ Â›Ó·È ‰˘Ó·Ùfi Ó· ·˘ÍËı› ÌÂÙ¿ ·fi ·ÔÌ¿ÎÚ˘ÓÛË ·fi ÙÔÓ ÔÚfi ÂÓfi˜ ÂÓ‰ÔÁÂÓÔ‡˜ ·Ó·ÛÙÔϤ· ÙÔ˘ ª∂∞. ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ ÂÓ˙‡ÌÔ˘ ‰ÂÓ ¤¯ÂÈ È‰È·›ÙÂÚË ÚÔÁÓˆÛÙÈ΋ ·Í›·, ÂÓÒ ·ÔÎÙ¿ ȉȷ›ÙÂÚË ÛËÌ·Û›· ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘, ηıÒ˜ Î·È ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÛÙËÓ ·ÁˆÁ‹. ∏ Ï˘ÛÔ˙‡ÌË, ¤Ó· ‚·ÎÙËÚÈÔÏ˘ÙÈÎfi ¤Ó˙˘ÌÔ, Û˘Ó‰ÂfiÌÂÓÔ fiˆ˜ Î·È ÙÔ ª∂∞ Ì ÙË ÌÔÓÔ˘ÚËÓÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ıˆÚÂ›Ù·È fiÙÈ ¤¯ÂÈ Û˘ÁÎÚÈÙÈο ÌÂȈ̤ÓË ¯ÚËÛÈÌfiÙËÙ· ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÓfiÛÔ˘.

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·329

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

∂ÈÎfiÓ· 1. OÈÛıÈÔÚfiÛıÈ· ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ·ÛıÂÓÔ‡˜ Ì ۷ÚÎÔ›‰ˆÛË Î·È ˘Ï·›· ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· (™Ù¿‰ÈÔ π) (The International Thoracic Teaching Resource: Diseases of Altered Immunity and Diseases of Uncertain Etiology, University of Iowa Virtual Hospital).

OÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ηÈ, Û˘ÁÎÂÎÚÈ̤ӷ, Ë ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· (Û˘¯ÓfiÙËÙ· 5-11%) Î·È Ë ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· (Û˘¯ÓfiÙËÙ· ¤ˆ˜ 40%) ıˆÚÂ›Ù·È fiÙÈ ¤¯Ô˘Ó Û˘ÁÎÚ›ÛÈÌË ÎÏÈÓÈ΋ ¯ÚËÛÈÌfiÙËÙ· Ì ÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ª∂∞.

OÈ ‰Â›ÎÙ˜ ÏÂÌÊÔ΢ÙÙ·ÚÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, fiˆ˜ Ë ‚-2 ÌÈÎÚÔÛÊ·ÈÚ›ÓË, Ë ·‰ÂÓÔÛ›ÓË ‰Â·ÌÈÓ¿ÛË, Ë ÙÚ·ÓÛÎÔ‚·Ï·Ì›ÓË ππ, Ë ÓÂÔÙÂÚ›ÓË Î·È Ë ÁÈÓÙÂÚÊÂÚfiÓË ÌÔÚ› Ó· Â›Ó·È ·˘ÍË̤ÓÔÈ. ∞‡ÍËÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘˜ ˘Ô‰ËÏÒÓÂÈ ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ÂÓÂÚÁÔÔ›ËÛË Î·È ·˘ÍË̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÓfiÛÔ˘.

OÈ ‰Â›ÎÙ˜ ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘, fiˆ˜ Ë ÎÔÏÏ·ÁÂÓ¿ÛË ÔÚÔ‡, ÙÔ Ù‡Ô˘ πππ ÚÔÎÔÏÏ·ÁfiÓÔ, ÙÔ ˘·ÏÔ˘ÚÔÓÈÎfi Ô͇ Î·È Ë ÈÓˆ‰ÔÓÂÎÙ›ÓË ÌÔÚ› Ó· ›ӷÈ, Â›Û˘, ·˘ÍË̤ÓÔÈ. ∞‡ÍËÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘˜ ˘Ô‰ËÏÒÓÂÈ ‰È·Ù·Ú·¯‹ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘ Î·È ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ˆ˜ ÎÚÈÙ‹ÚÈÔ ¤Ó·Ú͢ ıÂÚ·›·˜. ¢ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Kveim-Siltzbach ∏ ‰ÔÎÈÌ·Û›· ·˘Ù‹ ¤¯ÂÈ ˘„ËÏ‹ ¢·ÈÛıËÛ›· ÛÙË Û·ÚÎÔ›‰ˆÛË (¤ˆ˜ Î·È 79%), ˆÛÙfiÛÔ ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È È· ÙfiÛÔ Û˘¯Ó¿ ÏfiÁˆ Ù˘ ·‰˘Ó·Ì›·˜ ÚÔÌ‹ıÂÈ·˜ ÙÔ˘ ÂȉÈÎÔ‡ ·ÓÙÈÁfiÓÔ˘ (ÏÂÌÊÈÎfi˜ ÈÛÙfi˜ Ô˘ ÚÔÛ‚Ï‹ıËΠ·fi Û·ÚÎÔ›‰ˆÛË), ηıÒ˜ Î·È Ù˘ ηı˘ÛÙ¤ÚËÛ˘ ÛÙË Ï‹„Ë ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ (4-6 ‚‰ÔÌ¿‰Â˜), Ë ÔÔ›· Û˘ÓÂ¿ÁÂÙ·È Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜. ∏ ÔÏÔÎÏËڈ̤ÓË ÂÚÌËÓ›· Ù˘ ‰ÔÎÈÌ·Û›·˜ ··ÈÙ›, ¤Ú· ·fi ÙËÓ ÔÙÈ΋ ÂÎÙ›ÌËÛË Ù˘ ‰È‹ıËÛ˘, Î·È ÙË Ï‹„Ë ÈÛÙÔÙÂÌ·¯›Ô˘ ÁÈ· ‚ÈÔ„›·. §‹„Ë ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜ ™ÙÔ µ∫∂ ·È‰ÈÒÓ Ì ۷ÚÎÔ›‰ˆÛË, Ù· Â˘Ú‹Ì·Ù· ΢„ÂÏ›Ùȉ·˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·˘ÍË̤Ó˜ ÔÛfi-

Paediatriki 2002;65:322-332

∂ÈÎfiÓ· 2. ∂ÈÎfiÓ· “Û·Ó ·ÚÎÔ˘‰¿ÎÈ ¿ÓÙ·” ÏfiÁˆ Û˘ÌÌÂÙÚÈ΋˜ ÚfiÛÏ˄˘ Á·ÏÏ›Ô˘ ·fi ÙÔ˘˜ ‰·ÎÚ˘˚ÎÔ‡˜, ·ÚˆÙȉÈÎÔ‡˜ Î·È ˘ÔÁÓ¿ıÈÔ˘˜ ·‰¤Ó˜ (·fi ÙÔ ·Ú¯Â›Ô ÙˆÓ Û˘ÁÁڷʤˆÓ).

ÙËÙ˜ ÔÏÈ΋˜ ÚˆÙ½Ó˘, ·Ï‚Ô˘Ì›Ó˘, ‚1 ÛÊ·ÈÚ›Ó˘, IgG ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ (΢ڛˆ˜ IgG1 Î·È IgG3), ·˘ÍË̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, ·˘ÍË̤ÓÔ ÏfiÁÔ CD4/CD8 ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ·˘ÍË̤ÓË ·ÚÔ˘Û›· ˘Ô‰Ô¯¤ˆÓ ÙÔ˘ TNF-II (41,42). ∏ Ï‹„Ë µ∫∂ ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙÔÓ ·Ú¯ÈÎfi ¤ÏÂÁ¯Ô ·È‰ÈÔ‡ ‡ÔÙÔ˘ ÁÈ· Ó¢ÌÔÓÈ΋ Û·ÚÎÔ›‰ˆÛË, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂÓ‰¤¯ÂÙ·È Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó Î·ı˘ÛÙÂÚË̤ӷ. µÈÔ„›· ÈÛÙÒÓ ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Ù›ıÂÙ·È ÎÏ·ÛÈο ·fi ÙÔ Û˘Ó‰˘·ÛÌfi Û˘Ì‚·Ù‹˜ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, ‚ÈÔ¯ËÌÈÎÒÓ Î·È ÔÚÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È ÙËÓ Î·Ù¿‰ÂÈÍË ÙÔ˘ ·ıÔÁÓˆÌÔÓÈÎÔ‡ ÁÈ· ÙË ÓfiÛÔ ÌË Ù˘ÚÔÂȉÔÔÈË̤ÓÔ˘ ÎÔÎÎÈÒÌ·ÙÔ˜. OÚÈṲ̂ÓÔÈ Û˘ÁÁÚ·Ê›˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ‚ÈÔ„›· ‰ÂÓ Â›Ó·È ÂÓÙÂÏÒ˜ ··Ú·›ÙËÙË, ÁÈ·Ù› Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ Ë ÎÏÈÓÈ΋ ·ÚÔ˘Û›·ÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È Ôχ ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÁÈ· Û·ÚÎÔ›‰ˆÛË (43), ÂÓÒ ¿ÏÏÔÈ ıˆÚÔ‡Ó fiÙÈ Ô Î›Ó‰˘ÓÔ˜ Ù˘ Ï·Óı·Ṳ̂Ó˘ ‰È¿ÁÓˆÛ˘ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ÏfiÁˆ Ù˘ Û˘¯Ó‹˜ ·ÚÔ˘Û›·˜ ÏÔÈÌÒÍÂˆÓ ‹ ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ ·ı‹ÛÂˆÓ Ô˘ ÚÔ‚¿ÏÏÔ˘Ó Ì ·ÚfiÌÔÈ· ÂÈÎfiÓ·, ˘ÂÚ‚·›ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Ô˘ ÚÔ·ÙÂÈ ·fi ÙË ‰ÈÂÓ¤ÚÁÂÈ· ‚ÈÔ„›·˜ (17). ™Ù· ·È‰È¿, ˆÛÙfiÛÔ, Ë Û˘¯Ó¿ ¿Ù˘Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘ ηıÈÛÙ¿ ÙË ‰ÈÂÓ¤ÚÁÂÈ· ‚ÈÔ„›·˜ ·Ó·Áη›· ÁÈ· ÙË ‰È¿ÁÓˆÛË. ∏ ηı˘ÛÙÂÚË̤ÓË, Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ, ÚÔÛ‚ÔÏ‹ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ˘·ÁÔÚ‡ÂÈ ÙËÓ ÂͤٷÛË ‰˘Ó·ÙfiÙËÙ·˜ Ï‹„˘ ˘ÏÈÎÔ‡ ‚ÈÔ„›·˜ ·fi „ËÏ·ÊËÙÔ‡˜ ÏÂÌÊ·‰¤Ó˜ ‹ ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜. ∞Ó Î·È Ë ÓfiÛÔ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋, Ë ‚ÈÔ„›· ÂÓfi˜ ÔÚÁ¿ÓÔ˘ Â›Ó·È Û˘Ó‹ıˆ˜ Â·Ú΋˜ ÁÈ· ÙËÓ Â‰Ú·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘.

329

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·330

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

∏ ıÂÚ·›· Î·È ÙÔ Ì¤ÏÏÔÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘ ∏ ·‚‚·ÈfiÙËÙ· Û¯ÂÙÈο Ì ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ Û·ÚÎÔ›‰ˆÛ˘ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ô˘Û›· ÂȉÈ΋˜ ıÂÚ·›·˜. ∞Ó Î·È Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ·ÔÙÂÏÔ‡Ó ÙË ‚¿ÛË Ù˘ ıÂÚ·¢ÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ Ù˘ ÓfiÛÔ˘, ˘¿Ú¯Ô˘Ó ÛÔ‚·Ú¿ Î·È Â‡ÏÔÁ· ÂÚˆÙ‹Ì·Ù· Û¯ÂÙÈο Ì ÙË ¯ÚËÛÈÌfiÙËÙ· Î·È ·Ó·ÁηÈfiÙËÙ¿ ÙÔ˘˜. ∏ Û˘ÓÂÈÛÊÔÚ¿ ÙÔ˘˜ ÛÙËÓ ·ÔÊ˘Á‹ Ù˘ Ó¢ÌÔÓÈ΋˜ ›ÓˆÛ˘ ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› ̤¯ÚÈ Û‹ÌÂÚ·, ÂÓÒ Ë ÂÌÊ¿ÓÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Cushing ·ÔÙÂÏ› ¤Ó· ·Ó·fiÊ¢ÎÙÔ ÁÂÁÔÓfi˜ ÛÙË ıÂÚ·¢ÙÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘. ∞Ó Î·È Ú·ÎÙÈο Ë ıÂÚ·›· Ù˘ ·È‰È΋˜ Û·ÚÎÔ›‰ˆÛ˘ ۯ‰fiÓ ¿ÓÙ· ·ÔÙÂÏ› ÚÔ˚fiÓ ÂÍ·ÙÔÌ›Î¢Û˘, ÔÈ ÂӉ›ÍÂȘ ÁÈ· ÙËÓ ¤Ó·ÚÍ‹ Ù˘ ı· Ú¤ÂÈ ¿ÓÙ· Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ (44-47). ™˘Ó‹ıˆ˜, ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ú‰ÓÈ˙fiÓË ‹ Ú‰ÓÈ˙ÔÏfiÓË, Ë ¯ÔÚËÁÔ‡ÌÂÓË ‰fiÛË Â›Ó·È Ë ÌÈÎÚfiÙÂÚË ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È Ë ‰È¿ÚÎÂÈ· ıÂÚ·›·˜ ‰ÂÓ Â›Ó·È ‚Ú·¯‡ÙÂÚË ·fi 18 Ì‹Ó˜ (48).

OÈ Û¯ÂÙÈο ˘„ËϤ˜ ‰fiÛÂȘ ÎÔÚÙÈÎÔÂȉÒÓ Ô˘ ··ÈÙÔ‡ÓÙ·È ÒÛÙ ӷ ÂÈÙ¢¯ıÔ‡Ó ·ÍÈfiÏÔÁ· ·ÔÙÂϤÛÌ·Ù·, ηıÒ˜ Î·È ÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ·È‰ÈÒÓ Ì ÂÌ̤ÓÔ˘Û· ÂÓÂÚÁ‹ ‹ ÚÔ˚Ô‡Û· ÌÔÚÊ‹ ÓfiÛÔ˘ Ô˘ ÂÌÊ·Ó›˙ÂÈ ·ÓÙÔ¯‹ ÛÙËÓ ·ÁˆÁ‹, ˘·ÁfiÚÂ˘Û·Ó ÙË ¯Ú‹ÛË ·Ú·ÁfiÓÙˆÓ Ô˘ ÌÔÚÔ‡Ó Ó· ÌÂÈÒÛÔ˘Ó ÙËÓ ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ (steroid sparing agents). ∏ ¯Ú‹ÛË Î˘ÙÙ·ÚÔÙÔÍÈÎÒÓ, Ì ·ÚÈÔ ÂÎÚfiÛˆÔ ÙË ÌÂıÔÙÚÂÍ¿ÙË, Ê·›ÓÂÙ·È fiÙÈ Â˘ÓÔÂ›Ù·È ·fi ÙÔÓ Î‡ÚÈÔ fiÁÎÔ Ù˘ ÚfiÛÊ·Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ (49,50). OÈ Û˘ÁÁÚ·Ê›˜ ÙÔ˘ ·ÚfiÓÙÔ˜ ¿ÚıÚÔ˘ ‰ÔÎ›Ì·Û·Ó Ì ÂÈÙ˘¯›· ¤Ó· ‰ÈÂÙ¤˜ Û¯‹Ì· Ô˘ ÂÚÈÂÏ¿Ì‚·Ó ·Ú‹ÌÂÚË ¯ÔÚ‹ÁËÛË Ú‰ÓÈ˙ÔÏfiÓ˘ Î·È Â‚‰ÔÌ·‰È·›· ¯ÔÚ‹ÁËÛË IV ÌÂıÔÙÚÂÍ¿Ù˘ (Û ‰fiÛË 10-15 mg/‚‰ÔÌ¿‰·), Ë ÔÔ›· ‰È·ÈÛÙÒıËΠfiÙÈ ÏÂÔÓÂÎÙ› Û ۯ¤ÛË Ì ÙËÓ per os ¯ÔÚ‹ÁËÛË, Ë ÔÔ›· ÚÔÙ›ÓÂÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·fi ·ÚÎÂÙÔ‡˜ Û˘ÁÁÚ·Ê›˜. ∫·Ì›· ·fi ÙȘ ÁÓˆÛÙ¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ù˘ ÌÂıÔÙÚÂÍ¿Ù˘ ‰ÂÓ ·ÚÔ˘ÛÈ¿ÛÙËÎÂ, ÂÓÒ ÚÔÛ¿ıÂÈ· ÁÈ· ÙËÓ Ï‹ÚË ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ˘‹ÚÍ ·ÓÂÈÙ˘¯‹˜. ∏ ÌÂÏ·ÙÔÓ›ÓË ¯ÚËÛÈÌÔÔÈ‹ıËΠÚfiÛÊ·Ù·, ÏfiÁˆ Ù˘ ÁÓˆÛÙ‹˜ ·ÓÔÛÔÙÚÔÔÔÈËÙÈ΋˜ Ù˘ ‰Ú¿Û˘, Û ·ÛıÂÓ›˜ Ì ·ÓıÂÎÙÈ΋ ÛÙ· ÛÙÂÚÔÂȉ‹ Û·ÚÎÔ›‰ˆÛË, Ì ¢ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· (51). ŒÓ· ÂÈÛÓÂfiÌÂÓÔ ÛÙÂÚÔÂȉ¤˜ 3˘ ÁÂÓÈ¿˜, ÙÔ deflazocort, Ê·›ÓÂÙ·È fiÙÈ ÏÂÔÓÂÎÙ› ¤Ó·ÓÙÈ Ù˘ per os Ú‰ÓÈ˙fiÓ˘/Ú‰ÓÈ˙ÔÏfiÓ˘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Â›‰Ú·ÛË ÛÙÔ Ú˘ıÌfi ·‡ÍËÛ˘ Î·È ÛÙË ÛÎÂÏÂÙÈ΋ ˆÚ›Ì·ÓÛË ·È‰ÈÒÓ Ì ۷ÚÎÔ›‰ˆÛË, ¯ˆÚ›˜ ˆÛÙfiÛÔ Ó· Â›Ó·È ‚¤‚·ÈÔ fiÙÈ ÂÍ·ÛÊ·Ï›˙ÂÈ ÈηÓÔÔÈËÙÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· (52,53). ∏ ¯ÏˆÚÔΛÓË, Ë ÛÈÚÔÓÔÏ·ÎÙfiÓË, Ë ÂÓÙÔ͢-

330

Paediatriki 2002;65:322-332

Ê˘ÏÏ›ÓË, Ë Ë·Ú›ÓË, ·Ó·ÛÙÔÏ›˜ ÙÔ˘ ª∂∞, ηıÒ˜ Î·È Ë ·ÏÏÔÔ˘ÚÈÓfiÏË (54) ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·È‰È΋˜ Û·ÚÎÔ›‰ˆÛ˘, ¯ˆÚ›˜ ˆÛÙfiÛÔ Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ Ó· ˘ÔÛÙËÚ›˙ÔÓÙ·È ·fi Û˘ÁÎÚÈÙÈΤ˜ Î·È ·ÍÈfiÈÛÙ˜ ÂÚÁ·Û›Â˜. ∏ ¯Ú‹ÛË Ù˘ - ÂÚÈ‚fiËÙ˘ ÁÈ· ÙËÓ ÙÂÚ·ÙÔÁfiÓÔ ‰Ú¿ÛË Ù˘ - ı·ÏȉÔÌ›‰Ë˜ Û ¿ÏÏ· ÊÏÂÁÌÔÓÒ‰Ë ÓÔÛ‹Ì·Ù· ·ÔÙ¤ÏÂÛ ÙÔ ¤ÚÂÈÛÌ· ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ Î·È ÛÙË ıÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ Û·ÚÎÔ›‰ˆÛ˘ (55-58). ∏ ‰Ú¿ÛË Ù˘ ıˆÚÂ›Ù·È fiÙÈ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì¤Ûˆ Ù˘ ·Ó·ÛÙÔÏ‹˜ Ù˘ ‰Ú¿Û˘ ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ. ∏ ÂÌÂÈÚ›· ·fi ÙËÓ ·È‰È·ÙÚÈ΋ ¯Ú‹ÛË Ù˘ Â›Ó·È ÂÍ·ÈÚÂÙÈο ÂÚÈÔÚÈṲ̂ÓË. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚfiÛÊ·Ù· ÂȯÂÈÚÔ‡ÌÂÓË ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÚÎÔ›‰ˆÛ˘ ̤ۈ ·ÓÔÛÔÙÚÔÔÔÈËÙÈ΋˜ ·Ú¤Ì‚·Û˘, ÂÎÊÚ¿˙ÔÓÙ·È ÂÈÊ˘Ï¿ÍÂȘ ·fi ÔÏÏÔ‡˜ Û˘ÁÁÚ·Ê›˜. ™˘ÁÎÂÎÚÈ̤ӷ, Ë ·ÚÂÌfi‰ÈÛË ÙÔ˘ Û¯ËÌ·ÙÈÛÌÔ‡ ÎÔÎÎÈÒÌ·ÙÔ˜, Ì›·˜ Ê˘ÛÈÔÏÔÁÈ΋˜ ‰ÈÂÚÁ·Û›·˜ Ô˘ ‰ÂÓ ·ÔÛÎÔ› ·Ú¿ ÛÙÔÓ ·ÔÎÏÂÈÛÌfi ÙÔ˘ Èı·Ó¿ ˘‡ı˘ÓÔ˘ ·ÓÙÈÁfiÓÔ˘, ıˆÚÂ›Ù·È Èı·Ófi Ó· Ô‰ËÁ› ÛÙÔÓ ·ÂÁÎψ‚ÈÛÌfi ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ Î·È ÛÙËÓ ÂχıÂÚË ‰Ú¿ÛË ÙÔ˘. ™ÙËÓ ·˘Á‹ ÙÔ˘ Ó¤Ô˘ ·ÈÒÓ· ηı›ÛÙ·Ù·È È· ۷ʤ˜ ˆ˜ η̛· ÚÔÛ¿ıÂÈ· ıÂÚ·¢ÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ Ù˘ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ¢‰ÔÎÈÌ‹ÛÂÈ, ÂÊfiÛÔÓ ÙÔ ·›ÙÈÔ ·Ú·Ì¤ÓÂÈ ·ÎfiÌ· ¿ÁÓˆÛÙÔ. ∏ ÈÔ ÔÏÔÎÏËڈ̤ÓË Ì¤¯ÚÈ Û‹ÌÂÚ· ÚÔÛ¿ıÂÈ· ÚÔ˜ ·˘Ù‹ ÙËÓ Î·Ù‡ı˘ÓÛË ıˆÚÂ›Ù·È Ë ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË ACCESS (A Case Controlled Etiologic Study of Sarcoidosis). ∏ ˘fiıÂÛ‹ Ù˘ ÂÚÈÏ·Ì‚¿ÓÂÈ: ·) ÙËÓ Èı·ÓfiÙËÙ· ‡·Ú͢ ÁÂÓÂÙÈÎÔ‡ ˘ÔÛÙÚÒÌ·ÙÔ˜, ‚) ÙËÓ Èı·ÓfiÙËÙ· ‰Ú¿Û˘ ÂÓfi˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·Ú¿ÁÔÓÙ· Î·È Á) ÙËÓ Èı·ÓfiÙËÙ· ‰Ú¿Û˘ ÂÓfi˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ÌË ÊÏÂÁÌÔÓˆ‰ÒÓ ·Ú·ÁfiÓÙˆÓ. ∏ ÌÂϤÙË, Ë ÔÔ›· ÍÂΛÓËÛ ÙÔÓ πÔ‡ÏÈÔ ÙÔ˘ 1995, ‰ÈÂÍ¿ÁÂÙ·È Û 10 ΤÓÙÚ· ˘fi ÙËÓ ·ÈÁ›‰· ÙÔ˘ ∂ıÓÈÎÔ‡ ¶Ó¢ÌÔÓÔÏÔÁÈÎÔ‡, ∫·Ú‰ÈÔÏÔÁÈÎÔ‡ Î·È ∞ÈÌ·ÙÔÏÔÁÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÙˆÓ ∏¶∞ Î·È Ù· ·ÔÙÂϤÛÌ·Ù¿ Ù˘ ·Ó·Ì¤ÓÂÙ·È Û‡ÓÙÔÌ· Ó· ·Ó·ÎÔÈÓˆıÔ‡Ó. µÈ‚ÏÈÔÁÚ·Ê›· 1. Boeck C. Multiple benign sarcoid of the skin. J Cutan Dis 1899;17:543.

2. ÷˝Ó˘ ∫. ™·ÚÎÔ›‰ˆÛË. ∞ı‹Ó·: ∂ΉfiÛÂȘ ¶·Û¯·Ï›‰Ë˜ 1990.

3. James DG. The centenary of sarcoidosis. Proceedings of the 7th International Conference on Sarcoidosis. Ann NY Acad Sci 1976;278:736-741.

4. Romer FK. Clinical and Biochemical Aspects of sarcoidosis. Acta Med Scand 1984;690(Suppl):3-96.

5. Hosoda Y, Hiraga Y, Odaka M, Yangawa H, Ito Y, Shiegematsu I et al. A cooperative study of sarcoidosis in Asia and Africa: analytic epidemiology. Ann NY Acad Sci

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·331

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

1976;278:355-367.

6. Kataria YP, Sagone AL, Lo Buglio AG, Bromberg PA. In vitro observations on sarcoid lymphocytes and their correlation with cutaneus energy and clinical severity of disease. Am Rev Respir Dis 1973;108:767-776.

7. Semenzato G, James DG. The immunological approach to the enigma of sarcoidosis. Sarcoidosis 1984;1:24-35.

8. Moller DR. Etiology of sarcoidosis. Clin Chest Med 1997;18:695-706.

9. Saboor SA, Johnson NM, McFadden J. Detection of mycobacterial DNA in sarcoidosis and tuberculosis with polymerase chain reaction. Lancet 1992;339:1012-1015.

10. Ishige I, Usui Y, Takemura T, Eishi Y. Quantitative PCR of mycobacterial and propionibacterial DNA in lymph nodes of Japanese patients with sarcoidosis. Lancet 1999;354:120-123.

11. Sartwell PE. Racial differences in sarcoidosis. Proceedings of the 7th International Conference in Sarcoidosis. Ann NY Acad Sci 1976;278:368-370.

12. Teirstein AS, Siltzbach LE, Berger H. Patterns of sarcoidosis in three population groups in New York City.

Proceedings of the 7th International Conference in Sarcoidosis. Ann NY Acad Sci 1976;278:371-376.

13. James DG, Neville E, Siltzbach LE. A worldwide review of sarcoidosis. Ann NY Acad Sci 1976;278:321-334.

14. McGrath DS, Daniil Z, Foley P, du Bois JL, Lympany PA, Cullinan P et al. Epidemiology of familial sarcoidosis in the UK. Thorax 2000;55:751-754.

15. Heyll A, Meckenstock G, Aul C, Sohngen D, Borchard F, Hadding U et al. Possible transmission of sarcoidosis via allogeneic bone marrow transplantation. Bone Marrow Transplant 1994;14:161-164.

16. James DG, Neville E, Piyasena KH, Walker AN, Hamlyn AN. Possible genetic influences in familial sarcoidosis.

Postgrad Med J 1974;50:664-670.

17. Thrasher DR, Briggs DD Jr. Pulmonary sarcoidosis. Clin Chest Med 1982;3:537-563.

18. Evans MJ, Bils RF. Identification of cells labeled with tritiated thymidine in the pulmonary alveolar walls of the mouse. Am Rev Respir Dis 1969;100:372.

19. Hunninghake GW, Crystal RG. Mechanisms of hypergammaglobulinemia in pulmonary sarcoidosis. Site of increased antibody production and role of T lymphocytes. J Clin Invest 1981;67:86-92.

20. Kataria YP, Holter JF. Immunology of sarcoidosis. Clin Chest Med 1997;18:719-739.

21. Hino ∆, Nakamura ∏, Shibata À, Abe S, Kato S, Tomoike H. Elevated levels of type II soluble tumor necrosis factor receptors in the bronchoalveolar lavage fluids of patients with sarcoidosis. Lung 1997;175:187-193.

22. Nittu Y, Horikawa M, Suetake T, Hasegawa S, Komatsu S. Intrathoracic sarcoidosis in children. In: Iwai K, Hosoda Y, eds. Proceedings of the 6th International Conference on Sarcoidosis. Tokyo: Univ Tokyo Press; 1974. p. 507.

23. Loos T. Sarcoidosis in children. In: Bjuric B, ed.

Proceedings of the 3rd European Conference on Sarcoidosis. Yugoslavia: New Faculty; 1982. p. 335.

24. Heatheringhton S. Sarcoidosis in young children. Am J Dis Children 1982;136:13.

Paediatriki 2002;65:322-332

25. James DG, Jones Williams W. Sarcoidosis and other granulomatous disorders. London: DB Saunders; 1985. p.

186-195.

26. Mayock RL, Bertrand P, Morrison CE, Scott JH. Manifestations of sarcoidosis: analysis of 145 patients with a review of nine series selected from the literature. Am J Med 1963;35:67.

27. Gupta SK. Sarcoidosis: clinical aspects. State of the art.

In: Grassi C, Rizzato G, Pozzi E. Proceedings of the XI World Congress on Sarcoidosis. Ann NY Acad Sci 1988;756:397-406.

28. Tsagris VA, Liapi-Adamidou G. Sarcoidosis in infancy: a case with pulmonary involvement as a cardinal manifestation. Eur J Pediatr 1999;158:258-260.

29. Hosoda Y, Hiraga Y, Odaka M, Yangawa H, Ito Y, Shiegematsu I et al. A cooperative study of sarcoidosis in Asia and Africa: analytic epidemiology. Ann NY Acad Sci 1976;278:355-367.

30. Papadopoulos SE, Clemens TL, Fraher LJ, Lewin IG, Sandler LM, O’Riordan JL. 1,25-dihydroxycholecalciferol in the pathogenesis of the hypercalcemia of sarcoidosis.

Lancet 1979;1:627-630.

31. Adams JS, Sharma OP, Gacad MA, Singer FR. Metabolism of 25-hydroxyvitamin D3 by cultured pulmonary alveolar macrophages in sarcoidosis. J Clin Invest 1983;72:1856-1860.

32. Grofton J, Douglas A. Sarcoidosis. In: Respiratory Diseases. 2nd ed. Oxford London, Edinburgh, Melbourne: Blackwell Scientific Publications; 1975.

33. Lindsley CB, Petty RE. Overview and report on international registry of sarcoid arthritis in childhood. Curr Rheumatol Rep 2000;2:343-348.

34. Siltzbach LE, James DG, Neville E, Turiaf J, Battesti JP, Sharma OP et al. Course and prognosis of sarcoidosis around the world. Am J Med 1974;57:847-852.

35. DeRemee RA. The roentgenographic staging of sarcoidosis. Historic and contemporary perspectives.

Chest 1983;83:128-133.

36. Nelson B, Hayes RL, Edwards CL, Kniseley RM, Andrews GA. Distribution of gallium in human tissues after intravenous administration. J Nucl Med 1972;13:92-110.

37. Line BR, Hunninghake GW, Keogh BA, Jones AE, Johnston GS, Crystal RG. Gallium-67 scanning to stage the alveolitis of sarcoidosis: correlation with clinical studies, pulmonary function studies and bronchoalveovar lavage.

Am Rev Respir Dis 1981;123:440-446.

38. Nosal A, Schleissner LA, Mishkin FS, Lieberman J. Angiotensin-I-converting enzyme and gallium scan in noninvasive evaluation of sarcoidosis. Ann Intern Med 1979;90:328-331.

39. Sakurai Y, Nakajima M, Kamisue S, Nishimura Y, Ueda T, Miyagawa S et al. Preschool sarcoidosis mimicking juvenile rheumatoid arthritis: the significance of gallium scintigraphy and skin biopsy in the differential diagnosis.

Acta Paediatr Jpn 1997;39:74-78.

40. Romer FK, Hommelgaard P, Schou G. Sarcoidosis and cancer revisited: a long-term follow-up study of 555 Danish sarcoidosis patients. Eur Respir J 1998;12:906-912.

41. Hino ∆, Nakamura ∏, Shibata À, Abe S, Kato S, Tomoike H.

331

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·332

¶·È‰È·ÙÚÈ΋ 2002;65:322-332

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

Elevated levels of type II soluble tumor necrosis factor receptors in the bronchoalveolar lavage fluids of patients with sarcoidosis. Lung 1997;175:187-193.

Tessier V, Chadelat K, Baculard A, Housset B, Clement A. BAL in children: a controlled study of differential cytology and cytokine expression profiles by alveolar cells in pediatric sarcoidosis. Chest 1996;109:1430-1438.

Munkgaard S, Neukrich F. Comparison of biopsy procedures in intrathoracic sarcoidosis. Acta Med Scand 1979;205:179-184.

Wisuthsarewong W, Viravan S, Manonukul J. Preschool sarcoidosis. J Med Assoc Thai 2000;83:1415-1419.

Johns CJ, Michele TM. The clinical management of sarcoidosis. A 50-year experience at the Johns Hopkins Hospital. Medicine (Baltimore) 1999;78:65-111.

Shetty AK, Gedalia A. Sarcoidosis: a pediatric perspective.

Clin Pediatr (Phila) 1998;37:707-717.

Milman N, Hoffmann AL, Byg KE. Sarcoidosis in children.

Epidemiology in Danes, clinical features, diagnosis, treatment and prognosis. Acta Paediatr 1998;87:871-878.

Baculard A, Blanc N, Boule M, Fauroux B, Chadelat K, Boccon-Gibod L et al. Pulmonary sarcoidosis in children: a follow-up study. Eur Respir J 2001;17:628-635.

Gedalia A, Molina JF, Ellis GS Jr, Galen W, Moore C, Espinoza LR. Low-dose methotrexate therapy for childhood sarcoidosis. J Pediatr 1997;130:25-29.

Lower EE, Baughman RP. Prolonged use of methotrexate for sarcoidosis. Arch Intern Med 1995;155:846-851.

Cagnoni ML, Lombardi A, Cerinic MC, Dedola GL, Pignone A. Melatonin for treatment of chronic refractory sarcoidosis (letter). Lancet 1995;346:1229-1230.

332

Paediatriki 2002;65:322-332

52. Rizzato G, Riboldi A, Imbimbo B, Torresin A, Milani S. The long-term efficacy and safety of two different corticosteroids in chronic sarcoidosis. Respir Med 1997; 91:449-460.

53. Vignolo M, Milani S, Imbimbo B, Naselli A, Di Battista E, Piaggio G et al. Statural growth and skeletal maturation in rheumatic prepubertal children treated with a third generation glucocorticoid (deflazacort) versus prednisone. An interim study. Clin Exp Rheumatol 1991;9(Suppl 6):41-45.

54. El-Euch D, Mokni M, Trojjet S, Khouaja A, Ben Osman A. Sarcoidosis in a child treated successfully with allopurinol.

Br J Dermatol 1999;140:1184-1185.

55. Estines O, Revuz J, Wolkenstein P, Bressieux JM, Roujeau JC, Cosnes A. Sarcoidosis: thalidomide treatment in ten patients. Ann Dermatol Venereol 2001;128:611-613.

56. Rousseau L, Beylot-Barry M, Doutre MS, Beylot C. Cutaneous sarcoidosis successfully treated with low doses of thalidomide. Arch Dermatol 1998;134:1045-1046.

57. Carlesimo M, Giustini S, Rossi A, Bonaccorsi P, Calvieri S. Treatment of cutaneous and pulmonary sarcoidosis with thalidomide. J Am Acad Dermatol 1995;32:866-869.

58. Saano V. New therapeutic application of thalidomide.

Duodecim 1996;112:623-627.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 18-01-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 15-07-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: µ·Û›Ï˘ ∆Û·ÁÚ‹˜ ¶›Ó‰Ô˘ 26∞, ∆.∫. 154 51, ¡. æ˘¯ÈÎfi, ∞ı‹Ó· E-mail: billtsag@yahoo.com

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·333

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

∞¡∞™∫O¶∏™∏

Paediatriki 2002;65:333-345

REVIEW ARTICLE

¡ÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· ÛÙ· ·È‰È¿ ∂. ∞ÔÛÙfiÏÔ˘, ∞. ∆ÛÈÏÈÌÈÁοÎË

New advances in cardiac failure in children E. Apostolou, A. Tsilimigaki

¶ÂÚ›ÏË„Ë: ∏ ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· ÛÙ· ·È‰È¿ ·ÔÙÂÏ› ¤Ó· ÔÏ˘·Ú·ÁÔÓÙÈÎfi Û‡Ó‰ÚÔÌÔ. ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·, ÛËÌ·ÓÙÈ΋ ÂͤÏÈÍË ÛËÌÂÈÒÓÂÙ·È Û fi,ÙÈ ·ÊÔÚ¿ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÊ˘ÛÈÔÏÔÁ›·˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘. ∂›Ó·È ϤÔÓ ÁÓˆÛÙfi fiÙÈ Ë ·Ó¿Ù˘ÍË Î·È Ë ÂͤÏÈÍË Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÂÍ·ÚÙ¿Ù·È fi¯È ÌfiÓÔ ·fi ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ·ÏÏ¿ Î·È ·fi Ó¢ÚÔÔÚÌÔÓÈÎÔ‡˜, ÁÂÓÂÙÈÎÔ‡˜, ΢ÙÙ·ÚÈÎÔ‡˜ Î·È ·ÓÔÛÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ¶¿Óˆ Û ·˘Ù¤˜ ÙȘ Ӥ˜ ÁÓÒÛÂȘ ‚·Û›˙ÂÙ·È Ë ıÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·.

Abstract: Cardiac failure in children is a multifactorial syndrome. In the last decade, there is significant progress in understanding the pathophysiology of the syndrome. It is now well known that the development and progression of heart failure depends not only on the hemodynamic derangement of the cardiovascular system, but also on neurohormonal, genetic, cellular and immunologic factors. The therapeutic approach of heart failure in the pediatric population is based upon this knowledge.

§¤ÍÂȘ ÎÏÂȉȿ: ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·, ·È‰È¿, ·ıÔÊ˘ÛÈÔÏÔÁ›·, ıÂÚ·›·.

Key words: cardiac failure, children, pathophysiology, therapy.

∂ÈÛ·ÁˆÁ‹ ∏ ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· ÛÙÔÓ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi, ·Ú’ fiÏÔ Ô˘ ‰ÂÓ ·ÔÙÂÏ› Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜, fiˆ˜ Û˘Ì‚·›ÓÂÈ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ÂÓÙÔ‡ÙÔȘ, ·ÔÙÂÏ› Ì›· ·ÍÈÔÛËÌ›ˆÙË ·ÈÙ›· ÓÔÛËÚfiÙËÙ·˜, ıÓËÛÈÌfiÙËÙ·˜ Î·È ·Ó¿Á΢ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ (1). ™ËÌ·ÓÙÈ΋ ÚfiÔ‰Ô˜ ¤¯ÂÈ ÛËÌÂȈı› ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· Û fi,ÙÈ ·ÊÔÚ¿ ÛÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Î·È ÙË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ·Ú’ fiÏÔ Ô˘ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ·ÊÔÚÔ‡Ó ÂÓ‹ÏÈΘ. ∆Ô ·È‰›, fï˜, ‰ÂÓ Â›Ó·È ÌÈÎÚÔÁÚ·Ê›· ÙÔ˘ ÂÓ‹ÏÈη Î·È Ë Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· ÛÙÔÓ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi ·ÔÙÂÏ› Ì›· ÔχÏÔÎË ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ·.

OÚÈÛÌfi˜ ÁÈ· ÙËÓ Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ·, Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ Û‡Ó‰ÚÔÌÔ Û fiϘ ÙȘ ÌÔÚʤ˜ ÙÔ˘, ‰ÂÓ ˘¿Ú¯ÂÈ (2,3). °ÂÓÈο, Ë Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· ÛÙÔ ‚Ú¤ÊÔ˜ Î·È ÙÔ ·È‰› ÔÚ›˙ÂÙ·È ˆ˜ ÙÔ

ÎÏÈÓÈÎfi Û‡Ó‰ÚÔÌÔ Ô˘ Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÓÈηÓfiÙËÙ·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ Ó· ÂÍ·ÛÊ·Ï›ÛÂÈ ÈηÓÔÔÈËÙÈ΋ ·ÚÔ¯‹ ÁÈ· Ó· ·ÓÙ·ÔÎÚÈı› ÛÙȘ ÌÂÙ·‚ÔÏÈΤ˜ ·Ó¿ÁΘ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ηıÒ˜ Î·È Û ÂΛӘ ÙȘ ·Ó¿ÁΘ Ô˘ ·ÔÚÚ¤Ô˘Ó ·fi ÙË ‰È·‰Èηۛ· Ù˘ ·‡ÍËÛ˘ Î·È Ù˘ ·Ó¿Ù˘Í˘ (4). ∏ ¯ÚfiÓÈ· ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· Â›Ó·È Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ ηډȿ˜ ˆ˜ ·ÓÙÏ›·, Ô˘ Ì ÙËÓ ÂÓÂÚÁÔÔ›ËÛË Â·ÚÎÒÓ ·ÓÙÈÛÙ·ıÌÈÛÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ‰È·ÙËÚ› ÙËÓ ÔÌÔÈfiÛÙ·ÛË, Ì ϛÁ· ‹ ηıfiÏÔ˘ Û˘ÌÙÒÌ·Ù·. ∏ ÔÍ›· ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· Â›Ó·È Ë ·ÈÊÓ›‰È· ¿ÚÛË Ù˘ ΢ÎÏÔÊÔÚÈ΋˜ ·ÓÙÈÚÚfiËÛ˘ Î·È Ù˘ ÂÏ·Ùو̤Ó˘ Ì˘Ôηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ô˘ Ô‰ËÁ› Û ‰È·Ù·Ú·¯‹ Ù˘ ÔÌÔÈÔÛÙ·ÙÈ΋˜ ÈÛÔÚÚÔ›·˜ Î·È Û ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù·. ™Â ¤‰·ÊÔ˜ ¯ÚfiÓÈ·˜ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ·Ó ˘¿ÚÍÂÈ ÂÈ‚¿Ú˘ÓÛË Ù˘ ΢ÎÏÔÊÔÚÈ΋˜ ·ÓÙÈÚÚfiËÛ˘, ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÔÍ›· ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· Î·È Ó¢ÌÔÓÈÎfi

µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ µÂÓÈ˙¤ÏÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘

2nd Pediatric Clinic of Venizelion Hospital, Heraklion, Crete

333

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·334

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

Paediatriki 2002;65:333-345

Ô›‰ËÌ·. ∏ ÔÍ›· ηډÈÔÁÂÓ‹˜ ηٷÏËÍ›· Â›Ó·È Ë Î·Ù¿ÛÙ·ÛË Ù˘ ·ÈÊÓ›‰È·˜ ΢ÎÏÔÊÔÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜, Ì ·ÓÂÓÂÚÁÔ‡˜ ÙÔ˘˜ ·ÓÙÈÚÚÔÈÛÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜. ∞ÈÙÈÔÏÔÁ›· ∏ ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· ÛÙÔÓ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi Â›Ó·È ¤Ó· ÔÏ˘·Ú·ÁÔÓÙÈÎfi ÎÏÈÓÈÎfi Û‡Ó‰ÚÔÌÔ. ¶ÔÏϤ˜ Â›Ó·È ÔÈ Î·Ù·ÛÙ¿ÛÂȘ Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· (¶›Ó·Î·˜ 1). OÈ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ ·ÔÙÂÏÔ‡Ó ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· ·Ó¿Ù˘Í˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙË ‚ÚÂÊÈ΋ Î·È ÙËÓ ·È‰È΋ ËÏÈΛ·, ·Ó Î·È Ë Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÚÔÛ‰ÈÔÚÈÛÙ› (2). ¶ÂÚ›Ô˘ ÙÔ 80% ÙˆÓ ‚ÚÂÊÒÓ Ì ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· ·ÔÙÂÏÂ›Ù·È ·fi ‚Ú¤ÊË Î¿Ùˆ ÙÔ˘ ¤ÙÔ˘˜ ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· (5). ªÂٷ͇ ÙˆÓ ·È‰ÈÒÓ ÌÂ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, Ë Û˘¯ÓfiÙËÙ· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Â›Ó·È ¤ˆ˜ Î·È 20% (6). ∞fi ÙÔ ˘ÏÈÎfi Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ ÙËÓ ÙÂÏÂ˘Ù·›· ÙÚÈÂÙ›·, ·fi ÙÔÓ OÎÙÒ‚ÚÈÔ ÙÔ˘ 1998 ¤ˆ˜ ÙÔÓ OÎÙÒ‚ÚÈÔ ÙÔ˘ 2001, ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ 411 ·È‰ÈÒÓ ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙÔ ·È‰ÔηډÈÔÏÔÁÈÎfi È·ÙÚ›Ô, Ù· 33 (8%) ·ÚÔ˘Û›·Û·Ó ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·. ∞fi ·˘Ù¿, 26/33 (78%) ‹Ù·Ó ‚Ú¤ÊË ÌÈÎÚfiÙÂÚ· ÙˆÓ 3 ÌËÓÒÓ. ªÂÙ¿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ÙÔ ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÂÏ·ÙÙÒÓÂÙ·È ÛËÌ·ÓÙÈο (4). ∏ Ù·ÍÈÓfiÌËÛË ÙˆÓ ·ÈÙ›ˆÓ Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2 (7).

∏ Ì˘Ôηډ›Ùȉ·, Ë ÌÂÙ·‚ÔÏÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· Î·È Ë Ì˘ÔηډÈÔ¿ıÂÈ· ·fi ¤ÏÏÂÈ„Ë Î·ÚÓÈÙ›Ó˘ ÌÔÚÔ‡Ó Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·, ·ÎfiÌ· Î·È ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô (4,8). ∏ ·ÚÔ˘Û›· ·Ú·ÙÂٷ̤Ó˘ Ù·¯˘·ÚÚ˘ıÌ›·˜ ÛÙÔ ¤Ì‚Ú˘Ô, ÛÙÔ ÓÂÔÁÓfi ‹ Î·È ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ·È‰›, ı· Ô‰ËÁ‹ÛÂÈ Û ¯·ÌËÏ‹ ηډȷ΋ ·ÚÔ¯‹ Î·È Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ·, fiˆ˜ Î·È Ë ·ÚÔ˘Û›· Ï‹ÚÔ˘˜ ÎÔÏÔÎÔÈÏÈ·ÎÔ‡ ·ÔÎÏÂÈÛÌÔ‡ Ì ηډȷ΋ Û˘¯ÓfiÙËÙ· ÌÈÎÚfiÙÂÚË ·fi 50/min (4). ∂›Ó·È Û˘¯Ó‹ Ë ÂÌÊ¿ÓÈÛË Î·Ú‰È·Î‹˜ ·ÓÂ¿ÚÎÂÈ·˜ ÌÂÙ¿ ·fi ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜ (24). ™˘ÛÙËÌ·ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ fiˆ˜ Ë ˘ÔÍ·ÈÌ›·, Ë ·Ó·ÈÌ›·, Ë ÛË„·ÈÌ›·, Ë ‚·ÚÈ¿ ˘ÔÁÏ˘Î·ÈÌ›·, Ë ˘·Û‚ÂÛÙÈ·ÈÌ›· Î·È Ë ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›·, ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· ÛÙ· ÓÂÔÁÓ¿ (4,9). OÈ ·ÚÙËÚÈÔÊÏ‚҉ÂȘ ÂÈÎÔÈӈӛ˜ ·ÔÙÂÏÔ‡Ó ·›ÙÈ· ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô Ì η΋ ÚfiÁÓˆÛË (10). ∂›Û˘, Ë Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· ÌÔÚ› Ó· ÚÔÎÏËı› È·ÙÚÔÁÂÓÒ˜ ÌÂÙ¿ ·fi Ù·¯Â›· ¤Á¯˘ÛË ˘ÁÚÒÓ, ΢ڛˆ˜ ·›Ì·ÙÔ˜ Î·È ·Ï‚Ô˘Ì›Ó˘, ηıÒ˜ Î·È ÌÂÙ¿ ·fi ıÂÚ·›· Ì ¯ËÌÂÈÔıÂÚ·¢ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (4,5). ¶·ıÔÊ˘ÛÈÔÏÔÁ›· ∏ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙË ‚ÚÂÊÈ΋ Î·È ·È‰È΋ ËÏÈΛ· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙfiÛÔ ÙȘ ȉȷÈÙÂÚfiÙËÙ˜ Ù˘ ·Ó·Ù˘ÛÛfiÌÂÓ˘ ηډȿ˜, fiÛÔ Î·È ÙÔ˘˜ ·ÓÙÈÛÙ·ıÌÈÛÙÈÎÔ‡˜ Î·È Ó¢ÚÔÔÚÌÔÓÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÂͤÏÈÍË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ (¶›Ó·Î·˜ 3). ∏ ηډȷ΋

¶›Ó·Î·˜ 1. ∞›ÙÈ· ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙ· ·È‰È¿ ∞Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ (Û˘ÁÁÂÓ›˜ ‹ Â›ÎÙËÙ˜)

∞ÚÚ˘ı̛˜ §ÔÈÌÒÍÂȘ ¡fiÛÔÈ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡

ŸÁÎÔÈ º¿Ú̷η

∆Ô͛Ә

∞΢·ÓˆÙÈΤ˜ ηډÈÔ¿ıÂȘ Ì ·˘ÍË̤ÓË Ó¢ÌÔÓÈ΋ ÚÔ‹: ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·, ÎÔÈÓ‹ ÎÔÏÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·, ·ÓÔÈÎÙfi˜ ·ÚÙËÚÈ·Îfi˜ fiÚÔ˜ ∫˘·ÓˆÙÈΤ˜ ηډÈÔ¿ıÂȘ Ì ·˘ÍË̤ÓË Ó¢ÌÔÓÈ΋ ÚÔ‹: ÌÂÙ¿ıÂÛË ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ, ÔÏÈ΋ ·ÓÒÌ·ÏË Â΂ÔÏ‹ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÊÏ‚ÒÓ, ·ÙÚËÛ›· ÙÚÈÁÏÒ¯ÈÓÔ˜ ∞ÔÊÚ·ÎÙÈΤ˜ ‚Ï¿‚˜: ÛÙÂÓÒÛÂȘ ‚·Ï‚›‰ˆÓ, ÛÙ¤ÓˆÛË ÈÛıÌÔ‡ ·ÔÚÙ‹˜, Û‡Ó‰ÚÔÌÔ ˘ÔÏ·ÛÙÈ΋˜ ·ÚÈÛÙÂÚ‹˜ ηډ›·˜ ∞ÓÂ¿ÚÎÂȘ ‚·Ï‚›‰ˆÓ, Ì˘ÔηډÈÔ¿ıÂȘ, ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ µÚ·‰˘·ÚÚ˘ı̛˜, Ù·¯˘·ÚÚ˘ı̛˜ ª˘ÔÂÚÈηډȷΤ˜ ·ı‹ÛÂȘ ·fi ÈÔ‡˜, ‚·ÎÙ‹ÚÈ·, ̇ÎËÙ˜, ·Ú¿ÛÈÙ· ∞ÁÁÂÈ›Ùȉ˜ (ÓfiÛÔ˜ Kawasaki) ™˘ÁÁÂÓ›˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ¢È·Ù·Ú·¯¤˜ ÂÓ·fiıÂÛ˘ ÀÂÚı˘ÚÂÔÂȉÈÛÌfi˜ ∞ÓÂ¿ÚÎÂÈ· ÙˆÓ ÂÈÓÂÊÚȉ›ˆÓ ∞ÓÂ¿ÚÎÂÈ· ηÚÓÈÙ›Ó˘ ™Ô‚·Ú‹ ·Ó·ÈÌ›· µ-·Ó·ÛÙÔÏ›˜, ·ÓÙÈ·ÚÚ˘ıÌÈο ∞Ó·ÛÙÔÏ›˜ ÙˆÓ ‰È·‡ÏˆÓ ·Û‚ÂÛÙ›Ô˘ ÃËÌÂÈÔıÂÚ·¢ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∞ÓÙÈ-ÈÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∞Èı·ÓfiÏË, ÎÔη˝ÓË, ˘ÔÍ›·, ̤ٷÏÏ·

∆ÚÔÔÔÈË̤ÓÔ ·fi: Curr Probl Pediatr 2000;30:5-30

334

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·335

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

Paediatriki 2002;65:333-345

¶›Ó·Î·˜ 2. ∞›ÙÈ· ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ∂Ì‚Ú˘˚΋ ËÏÈΛ·

¶ÚfiˆÚÔ ÓÂÔÁÓfi

∆ÂÏÂÈfiÌËÓÔ ÓÂÔÁÓfi

µÚ¤ÊÔ˜

ªÂÁ·Ï‡ÙÂÚÔ ·È‰› Î·È ¤ÊË‚Ô˜

∞Ó·ÈÌ›· ·fi ·ÈÌfiÏ˘ÛË ‹ ·fi ÂÌ‚Ú˘ÔÌËÙÚÈ΋ ÌÂÙ¿ÁÁÈÛË §Ô›ÌˆÍË ·fi parvo-Èfi-B19, ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›· ∫ÔÈÏȷ΋ Î·È ˘ÂÚÎÔÈÏȷ΋ Ù·¯˘Î·Ú‰›·, ‚Ú·‰˘·ÚÚ˘ı̛˜ ÀÂÚÊfiÚÙÈÛË Ì ˘ÁÚ¿ ∞ÓÔÈÎÙfi˜ ·ÚÙËÚÈ·Îfi˜ fiÚÔ˜, ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· µÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›·, ˘¤ÚÙ·ÛË ª˘ÔηډÈÔ¿ıÂÈ· ∞ÚÙËÚÈÔÊÏÂÊÒ‰ÂȘ ÂÈÎÔÈӈӛ˜ ™Ù¤ÓˆÛË ÙÔ˘ ÈÛıÌÔ‡ Ù˘ ·ÔÚÙ‹˜ ÀÔÏ·ÛÙÈ΋ ·ÚÈÛÙÂÚ‹ ÎÔÈÏ›·, ÌÔÓ‹Ú˘ ÎÔÈÏ›· πÔÁÂÓ›˜ Ì˘Ôηډ›Ùȉ˜ ∂ÈÎÔÈӈӛ˜ ·ÚÈÛÙÂÚ¿-‰ÂÍÈ¿, ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·, ÎÔÈÓ‹ ÎÔÏÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· ∞ÈÌ·ÁÁ›ˆÌ· ∞ÓÒÌ·ÏË ¤ÎÊ˘ÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜ ªÂÙ·‚ÔÏÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· OÍ›· ˘¤ÚÙ·ÛË (Ô˘Ú·ÈÌÈÎfi-·ÈÌÔÏ˘ÙÈÎfi Û‡Ó‰ÚÔÌÔ) ÀÂÚÎÔÈÏȷ΋ Ù·¯˘Î·Ú‰›· ¡fiÛÔ˜ Kawasaki ƒÂ˘Ì·ÙÈÎfi˜ ˘ÚÂÙfi˜ OÍ›· ˘¤ÚÙ·ÛË (ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·) πÔÁÂÓ›˜ Ì˘Ôηډ›Ùȉ˜ £˘ÚÂÔÙÔ͛ΈÛË ∞ÈÌԯڈ̿وÛË-·ÈÌÔÛȉ‹ÚˆÛË ÃËÌÂÈÔıÂÚ·¢ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∂Ó‰Ôηډ›Ùȉ·, ΢ÛÙÈ΋ ›ÓˆÛË, Ì˘ÔηډÈÔ¿ıÂÈ· (‰È·Ù·ÙÈ΋ ‹ ˘ÂÚÙÚÔÊÈ΋), ÌÂÙ¿ ·fi Â¤Ì‚·ÛË ÁÈ· ‰ÈfiÚıˆÛË Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜

∆ÚÔÔÔÈË̤ÓÔ ·fi: Nelson Textbook of Pediatrics. 16th ed. 2000. p. 1441

·ÓÂ¿ÚÎÂÈ· ‰ÂÓ ·ÓÙÈÚÔÛˆ‡ÂÈ Ì›· ÛÙ·ÙÈ΋ ηٿÛÙ·ÛË, ·ÏÏ¿ Ì›· ‰˘Ó·ÌÈ΋ ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ·, ÌÂ Û˘Ó¯‹ ·ÏÏËÏÂ›‰Ú·ÛË ÌÂٷ͇ ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ Î·È ÙˆÓ Ó¢ÚÔÔÚÌÔÓÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ (™¯‹Ì· 1). ∞ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜: ∏ ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· ÚÔ·ÙÂÈ Â›Ù fiÙ·Ó ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ηډȷÎfi Ì˘ ÂÈ‚¿ÏÏÔÓÙ·È ·˘ÍË̤Ó˜ ··ÈÙ‹ÛÂȘ ¤ÚÁÔ˘ ‹ fiÙ·Ó ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÚˆÙÔ·ı›˜ ‰È·Ù·Ú·¯¤˜ ÛÙË Û˘ÛÙÔÏÈ΋ ‹ ÙË ‰È·ÛÙÔÏÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ù˘ ηډȿ˜. ŸÙ·Ó ·Ú·ÙËÚÂ›Ù·È ·‡ÍËÛË ÙÔ˘ ÚÔÊÔÚÙ›Ô˘, ‰ËÏ·‰‹ Ù˘ ÊÏ‚È΋˜ Â·Ó·ÊÔÚ¿˜, fiˆ˜ Û ÌÂÁ¿Ï˜ ÂÈÎÔÈӈӛ˜ ·ÚÈÛÙÂÚ¿-‰ÂÍÈ¿, ·ÓÂ¿ÚÎÂȘ ‚·Ï‚›‰ˆÓ Î·È Û˘ÛÙËÌ·ÙÈΤ˜ ·ÚÙËÚÈÔÊÏ‚҉ÂȘ ÂÈÎÔÈӈӛ˜, ·˘Í¿ÓÔÓÙ·È ÔÈ ȤÛÂȘ Ï‹ÚˆÛ˘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ Î·È ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛËÌ›· Ó¢ÌÔÓÈ΋˜ Î·È Û˘ÛÙËÌ·ÙÈ΋˜ Û˘ÌÊfiÚËÛ˘. ∏ ·‡ÍËÛË ÙÔ˘ ÌÂÙ·ÊÔÚÙ›Ô˘ Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÎÒÏ˘Ì· Ù˘ ÂÍÒıËÛ˘, fiˆ˜ ÛÙËÓ ·ÔÚÙÈ΋ ÛÙ¤ÓˆÛË, ÙËÓ Ó¢ÌÔÓÈ΋ ÛÙ¤ÓˆÛË, ÙË ÛÙ¤ÓˆÛË ÙÔ˘ ÈÛıÌÔ‡ Ù˘ ·ÔÚÙ‹˜ ‹ Û ÎÒÏ˘Ì· Ù˘ Â·Ó·ÊÔÚ¿˜, fiˆ˜ ÛÙË ÛÙ¤ÓˆÛË Ù˘ ÌÈÙÚÔÂȉԇ˜ Î·È ÙËÓ ·ÙÚËÛ›· Ù˘ ÙÚÈÁÏÒ¯ÈÓÔ˜, Ô‰ËÁ› Û ÌÈÎÚfiÙÂÚÔ fiÁÎÔ ·ÏÌÔ‡. °È· Ó· ‰È·ÙËÚËı› Ô Ê˘ÛÈÔÏÔÁÈÎfi˜ fiÁÎÔ˜ ·ÏÌÔ‡, ·˘Í¿ÓÂÙ·È Ë ÙÂÏԉȷÛÙÔÏÈ΋ ›ÂÛË Î·È Ô fiÁÎÔ˜ Û ‚·ıÌfi Ô˘ ÌÔÚ› Ó· ÚÔ·„Ô˘Ó ÛËÌ›· Û˘ÌÊfiÚËÛ˘ (4).

∏ Û˘ÛÙËÌ·ÙÈ΋ ηډȷ΋ ·ÚÔ¯‹ ÌÔÚ›, Â›Û˘, Ó· ÂËÚ·ÛÙ› ·fi ‰È·Ù·Ú·¯‹ Ù˘ Û˘ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ ηÈ, ηٿ Û˘Ó¤ÂÈ·, ·fi ÌÂȈ̤ÓË ÈηÓfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘ Ó· ·˘Í‹ÛÂÈ ÙÔÓ fiÁÎÔ ·ÏÌÔ‡ fiÙ·Ó ·˘Í¿ÓÂÙ·È ÙÔ ÚÔÊÔÚÙ›Ô. OÈ ‰È·Ù·Ú·¯¤˜ Ô˘ ÂËÚ¿˙Ô˘Ó ‰˘ÛÌÂÓÒ˜ ÙË Û˘ÛÙÔÏÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ηډȷÎÔ‡ Ì˘fi˜ ÚÔ·ÙÔ˘Ó ·fi ÊÏÂÁÌÔÓÒ‰ÂȘ ÓfiÛÔ˘˜, ‰È·Ù·Ú·¯¤˜ ÛÙÔ Â›Â‰Ô ÌÈÙÔ¯ÔÓ‰Ú›ˆÓ Î·È Ù˘ ÌÂÙ·ÊÔÚ¿˜ ÈfiÓÙˆÓ, ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÂÓ‰ÔÎÚÈÓÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Î·È ‚Ï¿‚˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ (11,12). ∆¤ÏÔ˜, Ë ‰È·ÛÙÔÏÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ì˘Ôηډ›Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÏ·Ùو̤ÓË ÂÓ‰ÔÙÈÎfiÙËÙ· ÙˆÓ ÎÔÈÏÈÒÓ Î·È ··ÈÙÂ›Ù·È ·˘ÍË̤ÓË ÊÏ‚È΋ ›ÂÛË ÁÈ· Ó· ‰È·ÙËÚËı› Â·Ú΋˜ ÎÔÈÏȷ΋ Ï‹ÚˆÛË. ∫·Ù·ÛÙ¿ÛÂȘ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË ‰È·ÛÙÔÏÈ΋ ÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ÔÈ ÛÙÂÓÒÛÂȘ ÙˆÓ ÎÔÏÔÎÔÈÏÈ·ÎÒÓ ‚·Ï‚›‰ˆÓ, Ë ·fiÊÚ·ÍË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÊÏ‚ÒÓ, Ë ˘ÂÚÙÚÔÊ›· Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜, Ë Û˘ÛÙËÌ·ÙÈ΋ ‹ Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË, ÔÈ Ù·¯˘·ÚÚ˘ı̛˜ Î·È ÔÈ Ì˘ÔηډÈÔ¿ıÂȘ (2-4,9). ¡Â˘ÚÔÔÚÌÔÓÈÎÔ›, ·ÓÔÛÔÏÔÁÈÎÔ› Î·È Î˘ÙÙ·ÚÈÎÔ› Ì˯·ÓÈÛÌÔ›: ŸÙ·Ó Û˘Ì‚Â› οÔÈ· Ì˘Ôηډȷ΋ ‚Ï¿‚Ë ‹ οÔÈ· ‰È·Ù·Ú·¯‹ ÛÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ÈÛÔÚÚÔ›· ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ·ÎÔÏÔ˘ı› Ì›ˆÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ Î·È Ù˘ ÂÚÈÊÂÚÈ΋˜ ·ÈÌ¿ÙˆÛ˘, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÔͤˆÓ Ì˯·ÓÈÛÌÒÓ ·ÓÙÈÚÚfiËÛ˘. ∏ ÚÔÙÂÚ·ÈfiÙËÙ·

335

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·336

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

Paediatriki 2002;65:333-345

¶›Ó·Î·˜ 3. ªË¯·ÓÈÛÌÔ› ·ÓÙÈÚÚfiËÛ˘ Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ªË¯·ÓÈÛÌfi˜ ∞‡ÍËÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡

∫·Ú‰È·Î‹ ˘ÂÚÙÚÔÊ›·

∂˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù·

¢˘ÛÌÂÓ‹ ·ÔÙÂϤÛÌ·Ù·

∆˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ ™˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ ∞ÁÁÂÈÔÛ‡Û·ÛË — Ù˘ ÊÏ‚È΋˜ Â·Ófi‰Ô˘ (ÚÔÊÔÚÙ›Ô) ∂ÚÁ·˙fiÌÂÓ˘ Ì˘˚΋˜ Ì¿˙·˜

∆˘ Û˘ÛÙÔÏ‹˜ ÙˆÓ ·ÚÙËÚȉ›ˆÓ ÙÔ˘ ÌÂÙ·ÊÔÚÙ›Ô˘ ∆ˆÓ ··ÈÙ‹ÛÂˆÓ Û Ô͢ÁfiÓÔ

ªË¯·ÓÈÛÌfi˜ Frank-Starling

∆Ô˘ fiÁÎÔ˘ ·ÏÌÔ‡

¡ÂÊÚÈ΋ ηٷÎÚ¿ÙËÛË Ó·ÙÚ›Ô˘ Î·È ÓÂÚÔ‡

∆˘ ÊÏ‚È΋˜ Â·Ófi‰Ô˘

∞‡ÍËÛË Ù˘ ÂÚÈÊÂÚÈ΋˜ ·fi‰ÔÛ˘ Û Ô͢ÁfiÓÔ

∆˘ ·ÚÔ¯‹˜ Ô͢ÁfiÓÔ˘

∆˘ ÙÔȯˆÌ·ÙÈ΋˜ Ù¿Û˘ ∆˘ ÛÙÂÊ·ÓÈ·›·˜ ÚÔ‹˜ ∆ˆÓ ··ÈÙ‹ÛÂˆÓ Û Ô͢ÁfiÓÔ ¶·ıÔÏÔÁÈΤ˜ Û˘ÛÙÔÏÈΤ˜ Î·È ‰È·ÛÙÔÏÈΤ˜ ȉÈfiÙËÙ˜ ÙÔ˘ ˘ÂÚÙÚÔÊÈÎÔ‡ Ì˘fi˜ ¶Ó¢ÌÔÓÈ΋ Î·È ·ÚÙËÚȷ΋ Û˘ÌÊfiÚËÛË ∆Ô˘ ÌÂÁ¤ıÔ˘˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜— T˘ ÙÔȯˆÌ·ÙÈ΋˜ Ù¿Û˘ Î·È ÙˆÓ ··ÈÙ‹ÛÂˆÓ Û Ô͢ÁfiÓÔ ¶Ó¢ÌÔÓÈ΋ Î·È Û˘ÛÙËÌ·ÙÈ΋ Û˘ÌÊfiÚËÛË ƒÂÓ›Ó˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ — Ù˘ ·ÁÁÂÈÔÛ˘ÛÙÔÏ‹˜ (ÌÂÙ·ÊÔÚÙ›Ô)

∆ÚÔÔÔÈË̤ÓÔ ·fi: Nelson Essentials of Pediatrics. 4th ed. 2002. p. 569

Â›Ó·È Ë ‰È·Ù‹ÚËÛË Ù˘ ÚÔ‹˜ Î·È Ù˘ ›ÂÛ˘ Û ˙ˆÙÈο fiÚÁ·Ó· Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ÂÓÂÚÁÔÔÈÂ›Ù·È ÙÔ Û˘Ì·ıËÙÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· Î·È ÙÔ Û‡ÛÙËÌ· ÚÂÓ›Ó˘-·ÁÁÂÈÔÙÂÓÛ›Ó˘-·Ï‰ÔÛÙÂÚfiÓ˘ (2-5,13, 14). ∏ ·ÓÙÈÛÙ·ıÌÈÛÙÈ΋ ·˘Ù‹ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ Ó¢ÚÔ¯˘ÌÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙÔ˘ ÚÔÊÔÚÙ›Ô˘ (Ì˯·ÓÈÛÌfi˜ FrankStarling), Ù˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜, Ù˘ Ì˘Ôηډȷ΋˜ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜, ÙËÓ ÂÎÏÂÎÙÈ΋ ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔÛ‡Û·ÛË, ÙËÓ Î·Ù·ÎÚ¿ÙËÛË ˘ÁÚÒÓ Î·È Na+ Î·È ÙË ‰È·Ù‹ÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. ∏ ·Ú·ÙÂٷ̤ÓË ‰Ú¿ÛË ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ¤¯ÂÈ ‰˘ÛÌÂÓ›˜ ÂȉڿÛÂȘ ÛÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. OÈ Î·Ù¯ÔϷ̛Ә ÂȉÚÔ‡Ó ·¢ı›·˜ ÛÙÔ Ì˘ÔηډȷÎfi ·ÙÙ·ÚÔ, ·˘Í¿ÓÔ˘Ó ÙË Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ Ca Î·È ÚÔηÏÔ‡Ó ÔÍÂȉˆÙÈÎfi stress, ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È ·fiÙˆÛË ÙˆÓ Ì˘ÔηډȷÎÒÓ Î˘ÙÙ¿ÚˆÓ. ∏ ÂÈÙ¿¯˘ÓÛË Ù˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ Î·È Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ Ô‰ËÁÔ‡Ó Û ·˘ÍË̤Ó˜ ··ÈÙ‹ÛÂȘ ÙÔ˘ Ì˘Ôηډ›Ô˘ Û Ô͢ÁfiÓÔ, ÂÓÒ Ë ˘ÂÚÙÚÔÊ›· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÚÚ˘ıÌÈÔÁ¤ÓÂÛË (13,15). ∆· Â›‰· Ù˘ ÓÔÚ·‰ÚÂÓ·Ï›Ó˘ ÛÙÔ Ï¿ÛÌ· ·˘Í¿ÓÔÓÙ·È ·Ó¿ÏÔÁ· Ì ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ÓfiÛÔ˘ Î·È ÔÈ ·ÛıÂÓ›˜ Ì ٷ ˘„ËÏfiÙÂÚ· Â›‰· ·˘ÙÔ‡ ÙÔ˘ Ó¢Úԉȷ‚È‚·ÛÙ‹ ¤¯Ô˘Ó ÙË ¯ÂÈÚfiÙÂÚË ÚfiÁÓˆÛË (1,3,15-18). ™¯Â‰fiÓ Ù·˘Ùfi¯ÚÔÓ· Ì ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÂÎχÂÙ·È Ô ÎÔÏÈÎfi˜ Ó·ÙÚÈÔ˘ÚËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, ÌÈ· ÚˆÙ½ÓË Ô˘ ÚÔηÏ› Ó·ÙÚÈÔ‡ÚËÛË, ‰ÈÔ‡ÚËÛË Î·È ·ÁÁÂÈԉȷÛÙÔÏ‹. O ÚfiÏÔ˜ ÙÔ˘ ÛÙ· ·Ú¯Èο ÛÙ¿‰È· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Â›Ó·È Ó· ·ÓÙÈÛÙ·ıÌ›ÛÂÈ ÙË ‰Ú¿ÛË ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹-

336

Ì·ÙÔ˜. ∏ ·‡ÍËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ‹˜ ÙÔ˘ ¤¯ÂÈ Û¯¤ÛË Ì ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ (2-4,19). ø˜ ·¿ÓÙËÛË Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ·Ú·ÙËÚÂ›Ù·È ‰È·Ù·Ú·¯‹ Ù˘ ‰Ú¿Û˘ ÙˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ Û ΢ÙÙ·ÚÈÎfi Â›‰Ô. º˘ÛÈÔÏÔÁÈο, ÔÈ Î·Ù¯ÔϷ̛Ә ‰ÈÂÁ›ÚÔ˘Ó ÙÔ˘˜ ‚1 Î·È ‚2 ˘ԉԯ›˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È ÙÚÔÔÔÈÔ‡Ó ÙË Ú˘ıÌÈÛÙÈ΋ G-ÚˆÙ½ÓË Î·È ÙÔ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ c-AMP. ™ÙË Ê˘ÛÈÔÏÔÁÈ΋ ηډȿ, ÙÔ 80% ÙˆÓ ‚-˘Ô‰Ô¯¤ˆÓ Â›Ó·È ‚1 Î·È ÙÔ 20% Â›Ó·È ‚2. ∞ÓÙ›ıÂÙ·, ÛÙËÓ Î·Ú‰È¿ Ô˘ ÂÌÊ·Ó›˙ÂÈ ·ÓÂ¿ÚÎÂÈ·, Ô ·ÚÈıÌfi˜ Î·È Ë ˘ÎÓfiÙËÙ· ÙˆÓ ‚1 ˘Ô‰Ô¯¤ˆÓ Â›Ó·È ÂÏ·Ùو̤ÓÔ˜, ÂÓÒ Ô ·ÚÈıÌfi˜ Î·È Ë ˘ÎÓfiÙËÙ· ÙˆÓ ‚2 ·Ú·Ì¤ÓÔ˘Ó ·Ó·ÏÏÔ›ˆÙ·, ·Ú’ fiÏÔ Ô˘ ·Ú·ÙËÚÂ›Ù·È ‰È·Ù·Ú·¯‹ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘˜ (3,15,17,20,21). ∏ ‰Ú¿ÛË ÙˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ ÛÙËÓ ÂÚÈʤÚÂÈ· ÂÈÙ˘Á¯¿ÓÂÙ·È ‰È¿ Ù˘ ÌÂÛÔÏ·‚‹Ûˆ˜ ÙˆÓ ·-˘Ô‰Ô¯¤ˆÓ, ÔÈ ÔÔ›ÔÈ ÚÔηÏÔ‡Ó ÙË Û‡Û·ÛË ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ·ÁÁ›ˆÓ Î·È ÙËÓ ·Ó·Î·Ù·ÓÔÌ‹ ÙÔ˘ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ fiÁÎÔ˘ ·›Ì·ÙÔ˜, ÂÍ·ÛÊ·Ï›˙ÔÓÙ·˜ ·ÚÔ¯‹ Ô͢ÁfiÓÔ˘ Û ˙ˆÙÈο fiÚÁ·Ó· fiˆ˜ Ô ÂÁΤʷÏÔ˜ Î·È Ë Î·Ú‰È¿, Ì ÂÏ¿ÙÙˆÛË Ù˘ ÚÔ‹˜ Û ÏÈÁfiÙÂÚÔ ÎÚ›ÛÈ̘ ÂÚÈÔ¯¤˜ fiˆ˜ ÙÔ ‰¤ÚÌ·, ÔÈ ÛÎÂÏÂÙÈÎÔ› ̇˜ Î·È ÔÈ ÓÂÊÚÔ› (15). OÈ ·-˘ԉԯ›˜ ˘¿Ú¯Ô˘Ó Î·È ÛÙÔ Ì˘ÔηډȷÎfi ·ÙÙ·ÚÔ Î·È Ê·›ÓÂÙ·È Ó· ·›˙Ô˘Ó ÚfiÏÔ ÛÙËÓ ·‡ÍËÛË Ù˘ ÂÓ‰ÔÙÈÎfiÙËÙ·˜ Î·È ÛÙËÓ ÚfiÎÏËÛË Ù˘ ˘ÂÚÙÚÔÊ›·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ (15,17). ™Â ÓÂfiÙÂÚ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Î·È ÔÈ ‚1 ˘ԉԯ›˜ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ˘ÂÚÙÚÔÊ›· ÙÔ˘ Ì˘Ôηډ›Ô˘ (22). ¶ÔÏÏ·ÏÔ› Ì˯·ÓÈÎÔ›, ÔÚÌÔÓÈÎÔ› Î·È ÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ› ÂÓÂÚÁÔÔÈÔ‡Ó ÙË ‰ËÌÈÔ˘ÚÁ›· ˘ÂÚÙÚÔÊ›·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘, fiˆ˜ Ë ÂÈÙ¿¯˘ÓÛË Ù˘

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·337

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

Paediatriki 2002;65:333-345

ª˘Ôηډȷ΋ ‚Ï¿‚Ë

∞ÓÙÈÛÙ·ıÌÈÛÙÈÎÔ› Ì˯·ÓÈÛÌÔ›

™.ƒ.∞.∞.

(+)

∞‡ÍËÛË Ù˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ ∞‡ÍËÛË Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ ∞‡ÍËÛË ÙÔ˘ ÚÔÊÔÚÙ›Ô˘ ∞ÓÙÈÚÚfiËÛË

(+)

™.¡.™.

(-) ÕÌÂÛË Î·Ú‰ÈÔÙÔÍÈÎfiÙËÙ· ∞‡ÍËÛË ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ ∞‡ÍËÛË Ù˘ ÚfiÛÏ˄˘ O2 ·fi ÙÔ Ì˘ÔοډÈÔ ∞‡ÍËÛË Ù˘ ÙÔȯˆÌ·ÙÈ΋˜ Ù¿Û˘ ¶ÚÔԉ¢ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ì˘Ôηډ›Ô˘ ∞ÒÏÂÈ· Ì˘ÔηډȷÎÒÓ Î˘ÙÙ¿ÚˆÓ (Ó¤ÎÚˆÛË, ·fiÙˆÛË)

ÕÚÛË Ù˘ ·ÓÙÈÚÚfiËÛ˘ ™.ƒ.∞.∞.: Û‡ÛÙËÌ· ÚÂÓ›Ó˘-·ÁÁÂÈÔÙÂÓÛ›Ó˘-·Ï‰ÔÛÙÂÚfiÓ˘ ™.¡.™.: Û˘Ì·ıËÙÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· TÚÔÔÔÈË̤ÓÔ ·fi: Progr Pediatr Cardiol 2000;11:178 ™¯‹Ì· 1. ∏ ‰Ú¿ÛË ÙˆÓ Ó¢ÚÔÔÚÌÔÓÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ÛÙËÓ ÂͤÏÈÍË Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜.

ÚˆÙÂ˚ÓÈ΋˜ Û‡ÓıÂÛ˘ Ì ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÂÌ‚Ú˘˚ÎÒÓ ÁÔÓȉ›ˆÓ (c-fos, c-jun, c-myc), Ô ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ÈÓÔ‚Ï·ÛÙÒÓ, Ë ·ÁÁÂÈÔÙÂÓÛ›ÓË ππ Î·È Ë ÂÓ‰ÔıËÏ›ÓË-π (3,4,23). ™Ù· ·Ú¯Èο ÛÙ¿‰È· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Ë ˘ÂÚÙÚÔÊ›· Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ¤¯ÂÈ Â˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù·, fiˆ˜ ÙË Ì›ˆÛË Ù˘ ÙÔȯˆÌ·ÙÈ΋˜ Ù¿Û˘ Î·È ÙËÓ ·‡ÍËÛË ÙÔ˘ fiÁÎÔ˘ ·ÏÌÔ‡. ™ÙË ¯ÚfiÓÈ· ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·, fï˜, Ô‰ËÁ› Û ‰È¿Ù·ÛË ÙˆÓ Î·Ú‰È·ÎÒÓ ÎÔÈÏÔًوÓ, ÂÏ¿ÙÙˆÛË Ù˘ ˘ÎÓfiÙËÙ·˜ ÙˆÓ ·ÁÁ›ˆÓ, ¤Ó‰ÂÈ· ÌÈÙÔ¯ÔÓ‰Ú›ˆÓ ηÈ, ηٿ Û˘Ó¤ÂÈ·, ¤Ó‰ÂÈ· ÂÓ¤ÚÁÂÈ·˜ (2-4,12). ™ÙËÓ ÔÚ›· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ÛËÌ·ÓÙÈÎfi ·ıÔÁÂÓÂÙÈÎfi ÚfiÏÔ ·›˙Ô˘Ó ·ÓÔÛÔÏÔÁÈΤ˜ Î·È ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÓÙȉڿÛÂȘ (24-26). OÈ ÚÔÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÔΛÓ˜, fiˆ˜ Ë ÈÓÙÂÚÏ¢ΛÓË-1, Ë ÈÓÙÂÚÏ¢ΛÓË-6, Ô ·Ú¿ÁÔÓÙ·˜ Ó¤ÎÚˆÛ˘ fiÁÎÔ˘ (TNF-a), Ô ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ (GM-CSF), Ô ÌÂÙ·ÙÚÂÙÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (TGF-‚1) Î·È ÔÈ CC-¯ËÌÔΛÓ˜ (27), ˘ÂÚÂÎÊÚ¿˙ÔÓÙ·È ÛÙËÓ Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ·. ∏ ÂÓÂÚÁÔÔ›ËÛ‹ ÙÔ˘˜ ¤¯ÂÈ ÛÙfi¯Ô ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ Ì˘Ôηډ›Ô˘ ·fi ηٷÛÙ¿ÛÂȘ stress, ·ÏÏ¿ Ë Ì·ÎÚÔ¯ÚfiÓÈ· ˘ÂÚ¤ÎÊÚ·Û‹ ÙÔ˘˜ ÚÔηÏ› ÚÔ·ÁˆÁ‹ Ù˘ ·ıËÚÔÛÎÏ‹Ú˘ÓÛ˘, ·ÚÓËÙÈ΋ ÈÓfiÙÚÔË ‰Ú¿ÛË Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ (24,26). ∏ ·Ó·‰È·ÌfiÚʈÛË (remodeling) Ù˘ ·ÚÈÛÙÂÚ‹˜

ÎÔÈÏ›·˜ ·ÊÔÚ¿ Û ·ÏÏ·Á¤˜ ÛÙÔ Ì¤ÁÂıfi˜ Ù˘ Ô˘ ‰ÂÓ ·ÔÚÚ¤Ô˘Ó ·fi Ì˯·ÓÈ΋ ˘ÂÚÊfiÚÙÈÛË Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ‰‡Ô ·ÓÂÍ¿ÚÙËÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜, ÙË Ó¤ÎÚˆÛË Î·È ÙËÓ ·fiÙˆÛË. ∏ Ó¤ÎÚˆÛË ÙˆÓ Ì˘ÔηډȷÎÒÓ Î˘ÙÙ¿ÚˆÓ Û˘Ì‚·›ÓÂÈ Ì¤Ûˆ ÔÈÎ›ÏˆÓ Î˘ÙÙ·ÚÔÙÔÍÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Î·È ·Ú·ÙËÚÂ›Ù·È ÙfiÛÔ Û ¯ÚfiÓÈ·, fiÛÔ Î·È Û ÔÍ›· Ì˘Ôηډȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. ∂›Ó·È Ì›· ·ıËÙÈ΋ ‰È·‰Èηۛ· Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ô›‰ËÌ· Î·È ÊÏÂÁÌÔÓ‹ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È ÚÔηÏÂ›Ù·È ·fi ¯˘ÌÈÎÔ‡˜ ÌÂÛÔÏ·‚ËÙ¤˜ Ù˘ ÊÏÂÁÌÔÓ‹˜, fiˆ˜ Ë ‚Ú·‰˘ÎÈÓ›ÓË, ÔÈ ÚÔÛÙ·ÁÏ·Ó‰›Ó˜ Î·È ÔÈ Î˘ÙÔΛÓ˜ (2,3,15,28). ™Â ÛÔ‚·Ú‹ ¯ÚfiÓÈ· ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·, Ë Ó¤ÎÚˆÛË ÙˆÓ Ì˘ÔηډȷÎÒÓ Î˘ÙÙ¿ÚˆÓ, ·ÏÏ¿ Î·È Ë ‰Ú¿ÛË Ù˘ ·Ï‰ÔÛÙÂÚfiÓ˘, ‰ÈÂÁ›ÚÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÈÓÔ‚Ï·ÛÙÒÓ, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·ÓÙÈηٿÛÙ·ÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÌÂ Û˘Ó‰ÂÙÈÎfi ÈÛÙfi (2,3,2931). ∏ ·fiÙˆÛË Â›Ó·È Ì›· ÂÓÂÚÁ‹ ‰ÈÂÚÁ·Û›· Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÁÔÓȉ›ˆÓ Ô˘ ÂÓÂÚÁÔÔÈÔ‡Ó ÙÔÓ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ Ì˘ÔηډȷÎfi ı¿Ó·ÙÔ Î·È ÙË ‰È¿Û·ÛË ÙÔ˘ DNA, ‰ÂÓ Û˘Óԉ‡ÂÙ·È ·fi ›ÓˆÛË Î·È Î·Ù·Ï‹ÁÂÈ ÛÂ Û˘Ó¯‹ ·ÒÏÂÈ· Ì˘ÔηډȷÎÒÓ Î˘ÙÙ¿ÚˆÓ (14,15,28,32). ∏ ·ÓÙÈÛÙ·ıÌÈÛÙÈ΋ ÂÓÂÚÁÔÔ›ËÛË ÂÚÈÊÂÚÈÎÒÓ ·ÁÁÂÈÔÛ˘ÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Û˘Óԉ‡ÂÙ·È ·fi ·ÒÏÂÈ· ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ Ú˘ıÌÈÛÙÈÎÒÓ ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÒÓ, fiˆ˜ Â›Ó·È ÙÔ ¡O Î·È ÔÈ ÚÔÛÙ·Î˘ÎϛӘ,

337

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·338

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

Ô‰ËÁÒÓÙ·˜ Û ÚÔԉ¢ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÙˆÓ ·ÁÁ›ˆÓ (33,34). ∏ ˘ÔÍ›·, ÔÈ ÂχıÂÚ˜ Ú›˙˜ Ô͢ÁfiÓÔ˘ Î·È ÔÈ ÚÔÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÔΛÓ˜ ‰ÈÂÁ›ÚÔ˘Ó ÙËÓ ˘ÂÚ·Ú·ÁˆÁ‹ ÂÓ‰ÔıËÏ›Ó˘ ·fi ÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙˆÓ ·ÁÁ›ˆÓ, ·ÏÏ¿ Î·È ·fi ÙÔ Ì˘ÔοډÈÔ (35,36). ∏ ÂÓ‰ÔıËÏ›ÓË Â›Ó·È ¤Ó·˜ ÈÛ¯˘Úfi˜ ÂÓ‰ÔÁÂÓ‹˜ ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÚÔηÏ› ·ÁÁÂÈÔÛ‡Û·ÛË ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜, ·ÏÏ¿ Î·È ÛÙȘ ÂÚÈÊÂÚÈΤ˜ ·ÚÙËڛ˜ Î·È ·˘Í¿ÓÂÈ ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË (35). ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ·ÏÏËÏÂ›‰Ú·ÛË ÌÂٷ͇ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÚÂÓ›Ó˘-·ÁÁÂÈoÙÂÓÛ›Ó˘·Ï‰ÔÛÙÂÚfiÓ˘ Î·È Ù˘ ÂÓ‰ÔıËÏ›Ó˘ ÚÔ¿ÁÂÈ ÙËÓ ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔÛ‡Û·ÛË (37). ∂›Û˘, Ë ÂÓ‰ÔıËÏ›ÓË Ê·›ÓÂÙ·È Ó· ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ‰ËÌÈÔ˘ÚÁ›· Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘ Î·È ÛÙËÓ ·Ó·‰È·ÌfiÚʈÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ (24,38). ∫·Ú‰È·Î‹ ˆÚÈÌfiÙËÙ·: ™Â Û‡ÁÎÚÈÛË Ì ÙËÓ Î·Ú‰È¿ ÙÔ˘ ÂÓ‹ÏÈη, Ë Î·Ú‰È¿ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ÙÔ˘ ‚Ú¤ÊÔ˘˜ Â›Ó·È ÌÔÓ·‰È΋, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂÌÊ¿ÓÈÛË, ÙȘ Ì˯·ÓÈΤ˜ Î·È ‚ÈÔ¯ËÌÈΤ˜ ȉÈfiÙËÙ˜ Î·È ÙËÓ ·˘ÙfiÓÔÌË Ó‡ڈۋ Ù˘. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ fi„ÈÌ˘ ÂÌ‚Ú˘˚΋˜ Î·È Ù˘ ÚÒÈÌ˘ ‚ÚÂÊÈ΋˜ ÂͤÏÈ͢ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ë ˆÚ›Ì·ÓÛË Ù˘ ËÏÂÎÙÚÔÌ˯·ÓÈ΋˜ Û‡˙¢Í˘, ηıÒ˜ Î·È Ë ‚ÈÔ¯ËÌÈ΋ Û‡ÓıÂÛË ÙˆÓ ÌÈÎÚÔ˚ÓȉȷÎÒÓ ÚˆÙÂ˚ÓÒÓ Ô˘ ·Ú¿ÁÔ˘Ó Î·È Î·Ù·Ó·ÏÒÓÔ˘Ó ÂÓ¤ÚÁÂÈ·. ∂ÈϤÔÓ, Ù· ÂÌ‚Ú˘˚ο Î·È Ù· ‚ÚÂÊÈο Ì˘Ôηډȷο ·ÙÙ·Ú· ¤¯Ô˘Ó ÌÈÎÚ‹ ‰È¿ÌÂÙÚÔ Î·È Â›Ó·È Ï›Á· Û ·ÚÈıÌfi, ¤ÙÛÈ ÒÛÙÂ Ë Û¯ÂÙÈ΋ ÂÚÈÂÎÙÈÎfiÙËÙ· Ù˘ ηډȿ˜ Û ÌË Û˘ÛÙ·ÏÙ‹ Ì¿˙·, ÌÈÙÔ¯fiÓ‰ÚÈ·, ˘Ú‹Ó˜ Î·È ÂÈÊ·ÓÂȷΤ˜ ÌÂÌ‚Ú¿Ó˜, Ó· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·’ fiÙÈ ·ÚÁfiÙÂÚ· ÛÙË ˙ˆ‹ (3,5). ∆Ô ·ÔÙ¤ÏÂÛÌ· Â›Ó·È ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ÈÛ¯‡Ô˜, ÌÂȈ̤ÓË ¤ÓÙ·ÛË Î·È Ù·¯‡ÙËÙ· ‚Ú¿¯˘ÓÛ˘, ηıÒ˜ Î·È ·‡ÍËÛË Ù˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ Û ‡‰ˆÚ ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ Ì˘Ôηډ›Ô˘ ηٿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜. ∏ ÌÂȈ̤ÓË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· Ù˘ Ó¤·˜ ηډȿ˜ ·ÓÙ·Ó·ÎÏ¿Ù·È ÛÙËÓ ÂÚÈÔÚÈṲ̂ÓË Ù˘ ÈηÓfiÙËÙ· Ó· ·˘Í‹ÛÂÈ ÙËÓ Î·Ú‰È·Î‹ ·ÚÔ¯‹ ÛÂ Û˘Óı‹Î˜ ÊfiÚÙÈÛ˘ fiÁÎÔ˘ ‹ Û ÂÚÈÙÒÛÂȘ ‚Ï·‚ÒÓ Ô˘ ·˘Í¿ÓÔ˘Ó ÙËÓ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ Î¤ÓˆÛ‹ Ù˘ (5). ∆Ô Ì˘ÔοډÈÔ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ÙÔ˘ ÓÂÔÁÓÔ‡ ÛÙÂÚÂ›Ù·È Ï‹ÚÔ˘˜ ·Ó¿Ù˘Í˘ Ù˘ Û˘Ì·ıËÙÈ΋˜ ÙÔ˘ Ó‡ڈÛ˘, Û ·ÓÙ›ıÂÛË Ì ÙË ¯ÔÏÈÓÂÚÁÈ΋. ™˘ÓÂÒ˜, Ë ÚÔÛ·ÚÌÔÁ‹ ÛÙËÓ Î·Ú‰È·Î‹ ηٷfiÓËÛË Â›Ó·È ÏÈÁfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ (5). OÈ Û˘ÛÙ·ÏÙ¤˜ ÚˆÙ½Ó˜, ·ÎÙ›ÓË Î·È Ì˘ÔÛ›ÓË, ¤¯Ô˘Ó ‰È·ÊÔÚÂÙÈΤ˜ ÌÔÚʤ˜ ÂÏ·ÊÚÒÓ Î·È ‚·Ú¤ˆÓ ·Ï‡ÛˆÓ ÛÙ· ‰È·ÊÔÚÂÙÈο ÛÙ¿‰È· Ù˘ ·Ó¿Ù˘Í˘ (2-4,39). ∏ ¢·ÈÛıËÛ›· ÙÔ˘˜ ÛÙÔ ·Û‚¤ÛÙÈÔ ·˘Í¿ÓÂÙ·È Ì ÙËÓ ˆÚ›Ì·ÓÛË Î·È ÂËÚ¿˙ÂÈ ÙË Û˘ÛÙ·ÏÙÈÎfiÙËÙ· Î·È ÙË ¯¿Ï·ÛË ÙÔ˘ Ì˘Ôηډ›Ô˘.

338

Paediatriki 2002;65:333-345

∫ÏÈÓÈ΋ ÂÈÎfiÓ· ∆· ÛËÌ›· Î·È Ù· Û˘ÌÙÒÌ·Ù· Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÈ ·ÛıÂÓ›˜ Ì ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· ÔÊ›ÏÔÓÙ·È ÁÂÓÈο ÙfiÛÔ ÛÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ, fiÛÔ Î·È ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ·ÓÙÈÛÙ·ıÌÈÛÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ (¶›Ó·Î·˜ 4). ∏ ÔÍ›· ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· Î·È ÙÔ Î·Ú‰ÈÔÁÂÓ¤˜ shock Â›Ó·È Â›ÁÔ˘Û˜ ηٷÛÙ¿ÛÂȘ ηÈ, Â¿Ó ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ¤ÁηÈÚ·, ·ÂÈÏËÙÈΤ˜ ÁÈ· ÙË ˙ˆ‹. ∆· ·È‰È¿ Ì ¯ÚfiÓÈ· ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· Î·È Â·ÚΛ˜ ·ÓÙÈÚÚÔÈÛÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ï›Á· ‹ ηıfiÏÔ˘ Û˘ÌÙÒÌ·Ù·. ∏ ÂΉ‹ÏˆÛË Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙÔÓ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi ÌÔÚ› Ó· ¯ˆÚÈÛÙ› Û ÙÚÂȘ ÂÚÈfi‰Ô˘˜: ÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô (0-3 ËÌÂÚÒÓ), ÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ÂÚ›Ô‰Ô (0-12 Ì‹Ó˜) Î·È ÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ÂÚ›Ô‰Ô. ∞˘Ùfi Á›ÓÂÙ·È ÏfiÁˆ Ù˘ ‰È·ÊÔÚ¿˜ ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È Ù˘ ‰È·ÊÔÚÂÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Û οı ËÏÈÎȷ΋ ÔÌ¿‰· (2-4). ™ÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô, Û¿ÓÈ· ·Ú·ÙËÚÂ›Ù·È Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ·, ÂÓÒ Â›Ó·È Û˘¯Ófi ÙÔ Î·Ú‰ÈÔÁÂÓ¤˜ shock, ÂÍ·ÈÙ›·˜ ÚˆÙÔ·ıÔ‡˜ ‹ ‰Â˘ÙÂÚÔ·ıÔ‡˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ (2). ∆Ô ÓÂÔÁÓfi Ì ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· ·ÚÔ˘ÛÈ¿˙ÂÈ Ù·¯‡ÓÔÈ·, Ù·¯˘Î·Ú‰›·, Ë·ÙÔÌÂÁ·Ï›·, ÂÊ›‰ÚˆÛË, ¯·ÌËÏ‹ ÈÛÙÈ΋ ·ÈÌ¿ÙˆÛË Î·È ˆ¯ÚfiÙËÙ·, ·‰˘Ó·Ì›· Û›ÙÈÛ˘, Ô›‰ËÌ· ‹ ηډÈÔÁÂÓ‹ ηٷÏËÍ›·.

OÈ Î˘·ÓˆÙÈΤ˜ ηډÈÔ¿ıÂȘ, fiˆ˜ Ë Ï‹Ú˘ ÌÂÙ¿ıÂÛË ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ Ì ·Ú¿ÏÏËϘ ΢ÎÏÔÊÔڛ˜, Ë ÔÏÈ΋ ·ÓÒÌ·ÏË Â΂ÔÏ‹ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÊÏ‚ÒÓ Î·È Ë ÛÔ‚·Ú‹ ÙÂÙÚ·ÏÔÁ›· Fallot Ì ·ÙÚËÛ›· Ù˘ Ó¢ÌÔÓÈ΋˜ ‚·Ï‚›‰·˜, ÚÔηÏÔ‡Ó ÚÒÈÌË Î˘¿ÓˆÛË Î·È Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ·. ™Ù· ÓÂÔÁÓ¿ Ì ·Î˘·ÓˆÙÈΤ˜ ηډÈÔ¿ıÂȘ, fiˆ˜ Ë ÛÔ‚·Ú‹ ·ÔÚÙÈ΋ ÛÙ¤ÓˆÛË, Ë ˘ÔÏ·ÛÙÈ΋ ·ÚÈÛÙÂÚ‹ ηډ›· Î·È Ë ÛÔ‚·Ú‹ ÛÙ¤ÓˆÛË ÙÔ˘ ÈÛıÌÔ‡ Ù˘ ·ÔÚÙ‹˜, Ë Û˘ÛÙËÌ·ÙÈ΋ ·ÈÌ¿ÙˆÛË ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ ·ÓÔÈÎÙfi ·ÚÙËÚÈ·Îfi fiÚÔ. ∫·ıÒ˜ ÎÏ›ÓÂÈ Ô ·ÚÙËÚÈ·Îfi˜ fiÚÔ˜, ÂÈ‚·Ú‡ÓÂÙ·È Ë Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›·, ÌÂ Û˘Ó¤ÂÈ· ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË, ÂÏ·Ùو̤ÓË ‰ÈÔ‡ÚËÛË Î·È ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ·. ™Ù· ‚Ú¤ÊË Ì ÂÈÎÔÈӈӛ˜ ·ÚÈÛÙÂÚ¿-‰ÂÍÈ¿, Ë ÙÒÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ Î·ıÔÚ›˙ÂÈ ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ Ó¢ÌÔÓÈ΋˜ Û˘ÌÊfiÚËÛ˘ Î·È Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. OÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÂËÚ¿˙ÔÓÙ·È ·fi ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜, ÙËÓ ·Ó·ÙÔÌÈ΋ ı¤ÛË Î·È ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ÂÈÎÔÈÓˆÓ›·˜ (2). ∆· ‚Ú¤ÊË Ì ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù·¯‡ÓÔÈ·, Ù·¯˘Î·Ú‰›·, ˘ÂÚȉڈۛ·, Ï‹ı·ÚÁÔ Î·È Î·Î‹ Û›ÙÈÛË. ∏ ·ÓÂ·Ú΋˜ ·Ó¿Ù˘ÍË Ô˘ ·Ú·ÙËÚÂ›Ù·È Ôχ Û˘¯Ó¿, Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ¯·ÌËÏ‹˜ Û˘ÛÙËÌ·ÙÈ΋˜ ÚÔ‹˜, ¯·ÌËÏ‹˜ ÈÛÙÈ΋˜ ·ÈÌ¿ÙˆÛ˘ Î·È ·˘ÍË̤ӈÓ

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·339

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

Paediatriki 2002;65:333-345

¶›Ó·Î·˜ 4. ™ËÌ›· Î·È Û˘ÌÙÒÌ·Ù· Û˘ÌÊÔÚËÙÈ΋˜ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ÔÈ Ì˯·ÓÈÛÌÔ› Î·È Ë ıÂÚ·›· ™ËÌ›· Î·È Û˘ÌÙÒÌ·Ù·

ªË¯·ÓÈÛÌÔ›

£ÂÚ·›·

ñ ™˘ÌÊfiÚËÛË Ó¢ÌÔÓÈÎÒÓ ÊÏ‚ÒÓ ∆·¯‡ÓÔÈ· ™˘ÚÈÁÌfi˜ ÀÁÚÔ› ÚfiÁ¯ÔÈ ¢˘ÛÎÔÏ›· Û›ÙÈÛ˘ ∂˘ÂÚÂıÈÛÙfiÙËÙ·

¶›ÂÛ˘ ·Ú. ÎÔÈÏ›·˜ ¢È¿ÌÂÛÔ Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· O›‰ËÌ· ‚ÚÔÁ¯ÈÔÏ›ˆÓ ¶Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· ŒÚÁÔ˘ ·Ó·ÓÔ‹˜ ªÂÙ·ÊÔÚ¿˜ Ô͢ÁfiÓÔ˘

¢ÈÔ˘ÚËÙÈο O͢ÁfiÓÔ ÃÂÈÚÔ˘ÚÁÈ΋ ıÂÚ·›·

ñ ™˘ÌÊfiÚËÛË Û˘ÛÙËÌ·ÙÈÎÒÓ ÊÏ‚ÒÓ ∏·ÙÔÌÂÁ·Ï›· ¶ÂÚÈÊÂÚÈÎfi Ô›‰ËÌ·

¶›ÂÛ˘ Ï‹ÚˆÛ˘ ‰ÂÍÈÒÓ ÎÔÈÏÔÙ‹ÙˆÓ ™˘ÌÊfiÚËÛË Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ ∫·Ù·ÎÚ¿ÙËÛË ˘ÁÚÒÓ, ·Ï‰ÔÛÙÂÚfiÓË

¢ÈÔ˘ÚËÙÈο ™ÈÚÔÓÔÏ·ÎÙfiÓË

ñ ªÂȈ̤ÓË Î·Ú‰È·Î‹ ·ÚÔ¯‹ ¢Ú·ÛÙËÚÈfiÙËÙ· ÚÔοډÈÔ˘ ∞ÚÙËÚȷΤ˜ ÛʇÍÂȘ ∆ÚȯÔÂȉÈ΋ Â·Ó·Ï‹ÚˆÛË

ªÂȈ̤ÓË Û˘ÛÙ·ÏÙÈÎfiÙËÙ· πÓfiÙÚÔË ÏÂÈÙÔ˘ÚÁ›· ™˘ÛÙËÌ·ÙÈ΋ ·ÈÌ¿ÙˆÛË ™˘ÛÙËÌ·ÙÈ΋ ·ÈÌ¿ÙˆÛË

¢·ÎÙ˘Ï›Ùȉ· ¡ÙÔ·Ì›ÓË ¡ÙÔÌÔ˘Ù·Ì›ÓË ∂Ï¿ÙˆÛË ÌÂÙ·ÊÔÚÙ›Ô˘ (·ÁÁÂÈԉȷÛÙ·ÏÙÈο)

ñ ÀÂÚÊfiÚÙˆÛË fiÁÎÔ˘ ¢Ú·ÛÙËÚÈfiÙËÙ· ÚÔοډÈÔ˘

∫·Ï·ÛÙÈÎfi˜ Ú˘ıÌfi˜

¢È¿Ù·ÛË ÎÔÈÏÔÙ‹ÙˆÓ ¢È·Ù‹ÚËÛË Ù˘ ÈÓfiÙÚÔ˘ ηٿÛÙ·Û˘ ¶Ï‹ÚˆÛ˘ ÎÔÈÏÈÒÓ

¢·ÎÙ˘Ï›Ùȉ· ¢ÈÔ˘ÚËÙÈο, ¯ÂÈÚÔ˘ÚÁÈ΋ ıÂÚ·›·

ñ ÀÂÚÊfiÚÙˆÛË ›ÂÛ˘ ∫·Ï·ÛÙÈÎfi˜ Ú˘ıÌfi˜ º˘Û‹Ì·Ù·

ªÂÙ·ÊÔÚÙ›Ô˘ ∂Ó‰ÔÙÈÎfiÙËÙ·˜ ªÂÙ·ÛÙÂÓˆÙÈ΋ ÛÙÚÔ‚ÈÏ҉˘ ÚÔ‹

∫·ıÂÙËÚÈ·ÛÌfi˜ Î·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÙ¤ÓˆÛ˘

ñ ∞ÓÙÈÛÙ·ıÌÈÛÙÈÎÔ› Ì˯·ÓÈÛÌÔ› ∆·¯˘Î·Ú‰›· ø¯ÚfiÙËÙ· OÏÈÁÔ˘Ú›· ∞ÓÂ·Ú΋˜ ·Ó¿Ù˘ÍË ÀÂÚȉڈۛ·

¡Â˘ÚÔÔÚÌÔÓÈÎÔ› Ì˯·ÓÈÛÌÔ› ‚1 ·‰ÚÂÓÂÚÁÈÎÔ› ˘ԉԯ›˜ ·1 Î·È ·ÁÁÂÈÔÙÂÓÛ›ÓË (·ÁÁÂÈÔÛ‡Û·ÛË) ∞ÈÌ¿ÙˆÛË ÓÂÊÚÒÓ ªÂÙ·‚ÔÏÈΤ˜ ·Ó¿ÁΘ ™˘Ì·ıËÙÈÎfi Î·È ¯ÔÏÈÓÂÚÁÈÎfi

¢·ÎÙ˘Ï›Ùȉ· µ-·Ó·ÛÙÔÏ›˜ ªÂ›ˆÛË ÌÂÙ·ÊÔÚÙ›Ô˘ (·ÁÁÂÈԉȷÛÙ·ÏÙÈο) ¡ÙÔ·Ì›ÓË

∆ÚÔÔÔÈË̤ÓÔ ·fi: Pediatr Clin North Am 1999;46:264

·Ó·ÁÎÒÓ Û Ô͢ÁfiÓÔ (40). ∏ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ÚÔηÏ› ‰˘ÛÎÔϛ˜ ÛÙË Û›ÙÈÛË, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·ÓÂ·Ú΋ ıÂÚÌȉÈ΋ ÚfiÛÏË„Ë, ÂÓÒ Ô ˘ÂÚÌÂÙ·‚ÔÏÈÛÌfi˜ ·˘Í¿ÓÂÈ ÙȘ ÂÓÂÚÁÂȷΤ˜ ··ÈÙ‹ÛÂȘ (41). ∂›Û˘, Ë ÂÌÊ¿ÓÈÛË Î·Ú‰È·Î‹˜ ·ÓÂ¿ÚÎÂÈ·˜ Û Ó·ڋ ËÏÈΛ· ÚÔηÏ› ÂÏ¿ÙÙˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÏÈÔ΢ÙÙ¿ÚˆÓ (42), ηıÒ˜ Î·È Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ˆÚ›Ì·ÓÛË ÂÓ˙‡ÌˆÓ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙË Ú‡ıÌÈÛË ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ÏÈÔ΢ÙÙ¿ÚˆÓ (43). ∏ ΢¿ÓˆÛË, Ë ˘ÔÙÔÓ›· Î·È Ë Î·Ù·ÏËÍ›· Â›Ó·È fi„ÈÌ· ÛËÌ›·. ∂›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÙÔÓ›ÛÔ˘Ì fiÙÈ Ë Ì¤ÙÚËÛË ÙˆÓ ·Ó·ÓÔÒÓ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ¤Ó· ÔÏfiÎÏËÚÔ ÏÂÙfi (9), ÂÍ·ÈÙ›·˜ Ù˘ ·ÓˆÌ·Ï›·˜ ÛÙÔÓ ·Ó·Ó¢ÛÙÈÎfi Ú˘ıÌfi Ô˘ Û˘¯Ó¿ ·Ú·ÙËÚÂ›Ù·È ÛÙ· ‚Ú¤ÊË (44). ∏ ÂÎÙ›ÌËÛË Ù˘ ÙÚȯÔÂȉÈ΋˜ Â·Ó·Ï‹ÚˆÛ˘ Î·È Ù˘ ıÂÚÌÔÎÚ·Û›·˜ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ ÌÔÚ› Ó· ·Ôηχ„ÂÈ „˘¯Ú¿ ¿ÎÚ· Î·È ‚Ú·‰Â›· ÙÚȯÔÂȉÈ΋ Â·Ó·Ï‹ÚˆÛË. ¶Ú¤ÂÈ, Â›Û˘, Ó· Á›ÓÂÙ·È ÚÔÛÂÎÙÈ΋ „ËÏ¿ÊËÛË ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ Ûʇ͈Ó, ηıÒ˜ Î·È Ì¤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚˆÓ. ∏ ·ÎÚfi·ÛË Ù˘ ηډȿ˜ ·ÔηχÙÂÈ ˘ÂÚ‰Ú·ÛÙ‹ÚÈÔ ÚÔοډÈÔ Î·È Î¿ÔȘ ÊÔÚ¤˜ Û˘ÛÙÔÏÈÎfi ʇÛËÌ· ‹ ·ÚÚ˘ı̛˜, ÂÓÒ Ì ÙËÓ ·ÎÚfi·ÛË ÙˆÓ Ó¢ÌfiÓˆÓ ‰È·ÈÛÙÒÓÔ˘Ì ˘ÁÚÔ‡˜ ÚfiÁ¯Ô˘˜, ·Ó ˘¿Ú¯ÂÈ Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ‹ Ó¢ÌÔ-

ÓÈÎfi Ô›‰ËÌ·. ∏ ·ÚÔ˘Û›· Ê˘Û‹Ì·ÙÔ˜ ηٿ ÙËÓ ·ÎÚfi·ÛË ÙÔ˘ ÎÚ·Ó›Ô˘ ÌÔÚ› Ó· ·Ôηχ„ÂÈ Î¿ÔÈ· ·ÚÙËÚÈÔÊÏÂ‚Ò‰Ë ÂÈÎÔÈÓˆÓ›·. ∏ „ËÏ¿ÊËÛË Ù˘ ÎÔÈÏ›·˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ë·ÙÔÌÂÁ·Ï›·˜. ∆· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ Ì ¯ÚfiÓÈ· ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· ÌÔÚ› Ó· ·Ó·Ê¤ÚÔ˘Ó Û˘ÁÎÂÎÚÈ̤ӷ ÂȉÈο Û˘ÌÙÒÌ·Ù·, fiˆ˜ η΋ ·ÓÔ¯‹ ÛÙËÓ ¿ÛÎËÛË Î·È ·‰˘Ó·Ì›· Ó· Û˘Ó¯›ÛÔ˘Ó ÙȘ ηıËÌÂÚÈÓ¤˜ ‰Ú·ÛÙËÚÈfiÙËÙ¤˜ ÙÔ˘˜, ÂÓÒ ÚÈÓ ÌÔÚÔ‡Û·Ó. ∂›Ó·È Èı·Ófi Ó· ·ÚÔ˘ÛÈ·ÛÙ› ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ ‹ ‰È¿Ù·ÛË, ˆ¯ÚfiÙËÙ·, Ù·¯‡ÓÔÈ· ‹ ‰‡ÛÓÔÈ· ÛÙËÓ ÚÔÛ¿ıÂÈ·. ∞fi ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ÌÔÚ› Ó· ‰È·ÈÛÙˆı› ·ÛΛÙ˘ ‹ ÂÚÈÊÂÚÈÎfi Ô›‰ËÌ·. OÈ ˘ÁÚÔ› ÚfiÁ¯ÔÈ Â›Ó·È Û¿ÓÈÔÈ Û ·˘Ù‹ ÙËÓ ËÏÈΛ· (9). ªÂ ÛÎÔfi ÙÔÓ ·ÓÙÈÎÂÈÌÂÓÈÎfi ηıÔÚÈÛÌfi Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ‰‡Ô Û˘ÛÙ‹Ì·Ù· ‚·ıÌÔÏfiÁËÛ˘: ¤Ó· Ô˘ ·ÊÔÚ¿ ‚Ú¤ÊË Î·È ¤Ó· Ô˘ ·Ó·Ê¤ÚÂÙ·È Û fiϘ ÙȘ ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜ (44,45). ∂ÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ªÂ ÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ÙËÏÂηډ›·˜ ‰È·ÈÛÙÒÓÂÙ·È ·‡ÍËÛË Ù˘ ηډȷÁÁÂȷ΋˜ ÛÎÈ¿˜ (∫£¢

339

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·340

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

>60%) Î·È ÛËÌ›· Ó¢ÌÔÓÈ΋˜ Û˘ÌÊfiÚËÛ˘, ·Ó ˘¿Ú¯Ô˘Ó (46). ªÂ ÙÔ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· ‰È·ÈÛÙÒÓÔÓÙ·È Ù˘¯fiÓ ˘¿Ú¯Ô˘Û˜ ‚Ú·‰˘·ÚÚ˘ı̛˜ ‹ Ù·¯˘·ÚÚ˘ı̛˜, ÂӉ›ÍÂȘ ÎÔÈÏȷ΋˜ ˘ÂÚÙÚÔÊ›·˜, ηıÒ˜ Î·È ÌË ÂȉÈÎÔ‡ Ù‡Ô˘ ·ÏÏÔÈÒÛÂȘ ÙÔ˘ ·̷ÙÔ˜ ∆ Î·È ÙÔ˘ ST ‰È·ÛÙ‹Ì·ÙÔ˜. ∆· ¯·ÌËÏ¿ ‰˘Ó·ÌÈο Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ·̷ÙÔ˜ ∆ Â›Ó·È ÂÓ‰ÂÈÎÙÈο ÛËÌ›· Ì˘Ôηډ›Ùȉ·˜ ‹ ÂÚÈηډ›Ùȉ·˜. ∏ ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈ΋ ÌÂϤÙË Â›Ó·È ÂΛÓË Ô˘ ı· ·Ôηχ„ÂÈ ÙË ‰ÔÌÈ΋ ·ÓˆÌ·Ï›· Ù˘ ˘ÔΛÌÂÓ˘ ηډÈÔ¿ıÂÈ·˜. ∂›Û˘, Ì ÙÔ ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ· ÌÂÙÚÒÓÙ·È ÔÈ ‰È·ÛÙ¿ÛÂȘ Ù˘ ·ÚÈÛÙÂÚ‹˜ Î·È Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜, ÙÔ ¿¯Ô˜ ÙˆÓ ÙÔȯˆÌ¿ÙˆÓ ÙÔ˘˜, ηıÒ˜ Î·È ÙÔ ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ (4). ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Â›Ó·È ¤Ó·˜ ÌË ÂÂÌ‚·ÙÈÎfi˜ Î·È ·ÎÚÈ‚‹˜ ÙÚfiÔ˜ ÚÔÛ¤ÁÁÈÛ˘ Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Ì¿˙·˜. ¶·Ú¤¯ÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙË ‚ȈÛÈÌfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘, ÙË Ì˘Ôηډȷ΋ ·ÈÌ¿ÙˆÛË Î·È ÙËÓ ·ÂÈÎfiÓÈÛË ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ. ∂›Ó·È ÚÔÁÓˆÛÙÈ΋˜ ÛËÌ·Û›·˜ Î·È ¤¯ÂÈ ¯·ÌËÏ‹ ¤ÎıÂÛË ÛÙËÓ ÈÔÓÈṲ̂ÓË ·ÎÙÈÓÔ‚ÔÏ›· (47). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ‚·ÚÈ¿ ·ÈÌÔ‰˘Ó·ÌÈ΋ ÂÈ‚¿Ú˘ÓÛË, ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ô Î·ıÂÙ‹Ú·˜ Swan-Ganz, Ì ÙÔÓ ÔÔ›Ô ÌÂÙÚ¿Ù·È Ë ›ÂÛË Ï‹ÚˆÛ˘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ Î·È ÚÔÛ‰ÈÔÚ›˙ÂÙ·È Ô ∫§O∞, ÛÙÔȯ›· Ô˘ ‚ÔËıÔ‡Ó ÛÙËÓ ·ÎÚÈ‚‹ ÂÎÙ›ÌËÛË Ù˘ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜. °È· Ó· ηıÔÚÈÛÙ› Ì ·ÎÚ›‚ÂÈ· Ë ˘ÔΛÌÂÓË Î·Ú‰ÈÔ¿ıÂÈ· Ô˘ Â›Ó·È ˘‡ı˘ÓË ÁÈ· ÙËÓ Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ·, Â›Ó·È ÔÏϤ˜ ÊÔÚ¤˜ ··Ú·›ÙËÙÔ˜ Ô Ï‹Ú˘ ηډȷÎfi˜ ηıÂÙËÚÈ·ÛÌfi˜, Ë ·ÁÁÂÈÔÁÚ·Ê›· ηÈ, ÂӉ¯Ô̤ӈ˜, Ë ‚ÈÔ„›· ÙÔ˘ Ì˘Ôηډ›Ô˘ (4,48). £ÂÚ·›· O ÛÙfi¯Ô˜ ÙˆÓ ıÂÚ·¢ÙÈÎÒÓ ÛÙÚ·ÙËÁÈÎÒÓ Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ·Ó·ÎÔ‡ÊÈÛË ·fi Ù· Û˘ÌÙÒÌ·Ù· Ù˘ Ó¢ÌÔÓÈ΋˜ Î·È Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏ‚È΋˜ Û˘ÌÊfiÚËÛ˘, ÙË ‚ÂÏÙ›ˆÛË Ù˘ Ì˘Ôηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ηÈ, ·Ó Â›Ó·È ‰˘Ó·Ùfi, ÙË ıÂÚ·›· Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘ (¶›Ó·Î·˜ 4). ∏ ıÂÚ·¢ÙÈ΋ ÛÙÚ·ÙËÁÈ΋ Ô˘ ·ÎÔÏÔ˘ıԇ̠ÛÙËÓ ÔÍ›· ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· Û˘Ó›ÛÙ·Ù·È ÛÙË ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ΢ÎÏÔÊÔÚ›·˜, ÙË Ì›ˆÛË Ù˘ ȤÛˆ˜ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÙÚȯÔÂȉÒÓ, ÙËÓ ·‡ÍËÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜, ÙË ‚ÂÏÙÈÛÙÔÔ›ËÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘, ÙËÓ Î·Ù¿ÏÏËÏË ÙÚÔÔÔ›ËÛË ÙÔ˘ ÚÔÊÔÚÙ›Ô˘, ÙËÓ ·‡ÍËÛË Ù˘ ηډȷ΋˜ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ Î·È ÙË ‰È·Ù‹ÚËÛË ÙÔ˘ ÈÛÔ˙˘Á›Ô˘ ÂÓ¤ÚÁÂÈ·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘. ∏ ıÂÚ·›· Ù˘ ¯ÚfiÓÈ·˜ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÂÍ·ÙÔÌÈ·ÂÙ·È Î·È ÙÚÔÔÔÈÂ›Ù·È Ì ‚¿ÛË ÙË ÁÓÒÛË Ì·˜ ÁÈ· ÙÔ˘˜ Ó¢ÚÔÔÚÌÔÓÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ Î·È ÙË Û˘Ì‚ÔÏ‹ ÙÔ˘˜ ÛÙË Ê˘ÛÈ΋ ÂͤÏÈÍË

340

Paediatriki 2002;65:333-345

Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È ¤¯ÂÈ ÂÚÈÛÛfiÙÂÚÔ Ì·ÎÚÔÚfiıÂÛÌÔ˘˜ ÛÙfi¯Ô˘˜, fiˆ˜ ÙË ‰È·Ù‹ÚËÛË Ù˘ Ì˘Ôηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÙËÓ ÚfiÏË„Ë Ù˘ ˘ÂÚÙÚÔÊ›·˜ Î·È Ù˘ ·Ó·‰È·ÌfiÚʈÛ˘, ·ÏÏ¿ Î·È ÙËÓ ÚÔÂÙÔÈÌ·Û›· ÁÈ· ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË.

O ¶›Ó·Î·˜ 5 ·Ú·ı¤ÙÂÈ Î¿ÔÈ· Û˘¯Ó¿ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ· Ê¿Ú̷η ÛÙË ıÂÚ·›· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È ·‰Ú¤˜ ‰ÔÛÔÏÔÁ›Â˜. ·) ¢ÈÔ˘ÚËÙÈο: ¶ÚÔÛʤÚÔ˘Ó ·ÈÌÔ‰˘Ó·ÌÈ΋ Î·È Û˘Ìو̷ÙÈ΋ ‚ÂÏÙ›ˆÛË Û ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó Û˘ÛÙËÌ·ÙÈ΋ ‹ Ó¢ÌÔÓÈ΋ Û˘ÌÊfiÚËÛË (2,4,49). ¶·ÚÂÌ‚·›ÓÔ˘Ó ÛÙËÓ Â·Ó·ÚfiÛÏË„Ë Ó·ÙÚ›Ô˘ Î·È ÓÂÚÔ‡ ·fi ÙÔ˘˜ ÓÂÊÚÔ‡˜ Î·È Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË Ì›ˆÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘, Ì ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË Ù˘ ‰È¿Ù·Û˘ ÙˆÓ ÎÔÈÏÈÒÓ Î·È ÙˆÓ ȤÛÂˆÓ Ï‹ÚˆÛ˘. ∂›Û˘, ÂÏ·ÙÙÒÓÔ˘Ó ÙÔ ÂÚÈÊÂÚÈÎfi Î·È ÙÔ Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· Î·È ‚ÂÏÙÈÒÓÔ˘Ó ÙËÓ ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ¶·Ú’ fiÏ· ·˘Ù¿, Ù· ‰ÈÔ˘ÚËÙÈο ‰ÂÓ ¤¯Ô˘Ó ı¤ÛË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÛıÂÓÒÓ ¯ˆÚ›˜ ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· Û˘ÌÊfiÚËÛ˘, ÂÍ·ÈÙ›·˜ Ù˘ Ó¢ÚÔÔÚÌÔÓÈ΋˜ ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÚÂÓ›ÓË-·ÁÁÂÈÔÙÂÓÛ›ÓË (2,3). ™Ù· ·È‰È¿ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘Ó‹ıˆ˜ ÙÚÂȘ Ù‡ÔÈ ‰ÈÔ˘ÚËÙÈÎÒÓ: i) Ù· ‰ÈÔ˘ÚËÙÈο Ù˘ ·Á·Ï˘, ΢ڛˆ˜ Ë ÊÔ˘ÚÔÛÂÌ›‰Ë, Ô˘ Â›Ó·È ‰Ú·ÛÙÈο Ê¿Ú̷η Î·È ‰È·ÙËÚÔ‡Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ ·ÎfiÌ· Î·È Û ÌÂȈ̤ÓÔ Ú˘ıÌfi ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (<5 ml/min). ∏ ·ÓÙ·fiÎÚÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Û ·˘Ù¿ Â›Ó·È ÂÏ·Ùو̤ÓË ÂÍ·ÈÙ›·˜ Ù˘ ·ÓˆÚÈÌfiÙËÙ·˜ ÙˆÓ ÂÎÎÚÈÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ÙˆÓ ÓÂÊÚÒÓ (2), ii) oÈ ıÂÈ·˙›‰Â˜, Ô˘ Â›Ó·È ‰ÈÔ˘ÚËÙÈο Ô˘ ‰ÚÔ˘Ó ÛÙ· ¿ˆ ÂÛÂÈڷ̤ӷ ÛˆÏËÓ¿ÚÈ·. ∏ ¯Ú‹ÛË ÙÔ˘˜ ÛÙ· ·È‰È¿ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË Î·È iii) Ù· ηÏÈÔÛ˘ÓÙËÚËÙÈο ‰ÈÔ˘ÚËÙÈο, fiˆ˜ Ë ÛÈÚÔÓÔÏ·ÎÙfiÓË, Ù· ÔÔ›· ‰ÚÔ˘Ó Â›Û˘ ÛÙ· ¿ˆ ÂÛÂÈڷ̤ӷ ÛˆÏËÓ¿ÚÈ·. ∂›Ó·È ·ÛıÂÓ‹ ‰ÈÔ˘ÚËÙÈο Ô˘ ÚÔÛÙ›ıÂÓÙ·È ÛÙË ıÂÚ·›· ÁÈ· Ó· ÂÍÔ˘‰ÂÙÂÚÒÛÔ˘Ó ÙËÓ ·ÒÏÂÈ· Î·Ï›Ô˘ ·fi Ù· ‰ÈÔ˘ÚËÙÈο Ù˘ ·Á·Ï˘ ‹ Ù· ıÂÈ·˙ȉÈο ‰ÈÔ˘ÚËÙÈο. ∂ӉȷʤÚÔ˘Û· Â›Ó·È Ë ÚfiÛÊ·ÙË ÁÓÒÛË ÁÈ· ÙËÓ ÂÈÚfiÛıÂÙË ‰Ú¿ÛË Ù˘ ÛÈÚÔÓÔÏ·ÎÙfiÓ˘ ÛÙË Ì›ˆÛË Ù˘ Ì˘Ôηډȷ΋˜ ›ÓˆÛ˘, ·Ó·ÛÙ¤ÏÏÔÓÙ·˜ ÙÔ˘˜ ˘ԉԯ›˜ Ù˘ ·Ï‰ÔÛÙÂÚfiÓ˘ ÛÙÔ˘˜ ÈÓÔ‚Ï¿ÛÙ˜ ÙÔ˘ ηډȷÎÔ‡ ÈÛÙÔ‡ (2,29,49). OÈ Ô˘‰¤ÙÂÚÔÈ ·Ó·ÛÙÔÏ›˜ Ù˘ ÂÓ‰ÔÂÙȉ¿Û˘ Â›Ó·È Ê¿Ú̷η ˘fi ÌÂϤÙË, Ô˘ ¤¯Ô˘Ó ‰ÈÔ˘ÚËÙÈ΋ ‰Ú¿ÛË Î·È Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ Ì˘Ôηډ›Ô˘, ÂÂȉ‹ ‰ÂÓ ·ÚÂÌ‚·›ÓÔ˘Ó ÛÙÔ Û‡ÛÙËÌ· ÚÂÓ›Ó˘-·ÁÁÂÈÔÙÂÓÛ›Ó˘ (2,49). ‚) πÓÔÙÚfi·: ¶·ÚÂÌ‚·›ÓÔ˘Ó ÛÙËÓ ·ÏÏËÏÔ˘¯›· Ù˘ ·ÂÏ¢ı¤ÚˆÛ˘ Î·È Â·Ó·ÚfiÛÏ˄˘ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ·fi Ù· Ì˘Ôηډȷο ·ÙÙ·Ú·, Ì ÛÙfi¯Ô ÙËÓ ·‡ÍËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ Ca ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ·. ¢È·ÎÚ›ÓÔÓÙ·È Û c-AMP ÂÍ·ÚÙÒÌÂÓ· Î·È Û c-AMP ·ÓÂÍ¿ÚÙËÙ·.

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·341

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

Paediatriki 2002;65:333-345

¶›Ó·Î·˜ 5. ∆· Û˘Ó‹ıË Ê¿Ú̷η Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË ıÂÚ·›· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙ· ·È‰È¿ Î·È ÔÈ ‰ÔÛÔÏÔÁ›Â˜ º¿ÚÌ·ÎÔ

¢fiÛË

ñ ¢·ÎÙ˘Ï›Ùȉ· ¢·ÎÙ˘ÏȉÈÛÌfi˜

¶ÚfiˆÚÔ ÓÂÔÁÓfi: 10-20 Ìg/kg p.o. ∆ÂÏÂÈfiÌËÓÔ: 20-30 Ìg/kg p.o.

5-10 ÂÙÒÓ: 20-30 Ìg/kg p.o. >10 ÂÙÒÓ: 10-15 Ìg/kg p.o. ∏ i.v. ‰fiÛË Â›Ó·È ÙÔ 80% Ù˘ p.o.

5-10 Ìg/kg/24ˆÚÔ p.o.

¢fiÛË Û˘ÓÙ‹ÚËÛ˘ ñ ¢ÈÔ˘ÚËÙÈο ºÔ˘ÚÔÛÂÌ›‰Ë ™ÈÚÔÓÔÏ·ÎÙfiÓË ñ πÓÔÙÚfi· ¡ÙÔ·Ì›ÓË ¡ÙÔÌÔ˘Ù·Ì›ÓË ∞ÌÚÈÓfiÓË ªÈÏÚÈÓfiÓË ñ ∞ÁÁÂÈԉȷÛÙ·ÏÙÈο ¡ÈÙÚÔÁÏ˘ÎÂÚ›ÓË À‰Ú·Ï·˙›ÓË ¡ÈÙÚÔÚˆÛÈÎfi ñ ∞-ª∂∞ ∫·ÙÔÚ›ÏË ∂Ó·Ï·Ú›ÏË ñ µ-·Ó·ÛÙÔÏ›˜ ¶ÚÔÚ·ÓÔÏfiÏË ªÂÙÔÚÔÏfiÏË ∫·Ú‚‰ÈÏfiÏË ñ ¶ÚÔÛÙ·ÁÏ·Ó‰›ÓË ∂1 ñ ªÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ (¡O)

1mg i.v ‹ p.o. ÛÙË ‰fiÛË ª¤ÁÈÛÙË ‰fiÛË: 4-5 mg/kg/24ˆÚÔ 1-3,5 mg/kg/24ˆÚÔ p.o. i.v ¤Á¯˘ÛË: 2-20 Ìg/kg/min i.v ¤Á¯˘ÛË: 2-20 Ìg/kg/ min ºfiÚÙÈÛË: 1-3 mg/kg i.v. Û 30 min ™˘Ó¯‹˜ ¤Á¯˘ÛË: 5-10 Ìg/kg/min ºfiÚÙÈÛË:0,1 mg/kg i.v Û 15-30 min ™˘Ó¯‹˜ ¤Á¯˘ÛË: 0,5-0,75 Ìg/kg/min 0,5-3 Ìg/kg/ min i.v.

0,1-0,5 mg/kg/‰fiÛË i.v. (max: 20 mg) 0,25-0,75 mg/kg/‰fiÛË p.o.

0,5-3 Ìg/kg/min i.v.

0,1-0,5 mg/kg/‰fiÛË Î¿ı 8 ÒÚ˜ 0,1-0,4 mg/kg/24ˆÚÔ 0,01 mg/kg i.v ·Ú¯Èο Î·È 3-5 mg/kg/24ˆÚÔ p.o.

1-2 mg/kg/24ˆÚÔ p.o. Û ‰‡Ô ‰fiÛÂȘ ∞Ú¯È΋ ‰fiÛË: 0,05 mg/kg/24ˆÚÔ Û ‰‡Ô ‰fiÛÂȘ, ˆ˜ 0,4-0,5 mg/kg/‰fiÛË (max: 25-50 mg p.o.) ∞Ú¯È΋ ‰fiÛË: 0,05 Ìg/kg/ min, ˆ˜ 0,1-0,15 Ìg/kg/ min 1-40 ppm Û ÂÈÛÓÔ‹

∞fi: Moss and Adams’, Heart disease in infants, children and adolescents. 6th ed. 2001 p.o.: ·fi ÙÔ ÛÙfiÌ·, i.v.: ÂÓ‰ÔÊϤ‚È·

OÈ Ì˯·ÓÈÛÌÔ› ‰Ú¿Û˘ ÙˆÓ c-∞ªƒ ÂÍ·ÚÙÒÌÂÓˆÓ ÈÓÔÙÚfiˆÓ Â›Ó·È Ë ‰È¤ÁÂÚÛË ÙˆÓ ‚-˘Ô‰Ô¯¤ˆÓ (ÓÙÔ·Ì›ÓË, ÓÙÔÌÔ˘Ù·Ì›ÓË, ·‰ÚÂÓ·Ï›ÓË, ÓÔÚ·‰ÚÂÓ·Ï›ÓË) Î·È Ë ·Ó·ÛÙÔÏ‹ Ù˘ ʈÛÊÔ‰ÈÂÛÙÂÚ¿Û˘ (·ÌÚÈÓfiÓË Î·È ÌÈÏÚÈÓfiÓË) (2,49). ∆· c-AMP ÂÍ·ÚÙÒÌÂÓ· ÈÓÔÙÚfi· ÚÔηÏÔ‡Ó ÂÏ¿ÙÙˆÛË Ù˘ ÙÔȯˆÌ·ÙÈ΋˜ Ù¿Û˘ ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ‚ÂÏÙ›ˆÛ˘ Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ Î·È Ù˘ ÂÚÈÊÂÚÈ΋˜ ·ÁÁÂÈԉȷÛÙÔÏ‹˜. ∏ ‰È¤ÁÂÚÛË ÙˆÓ ‚-·‰ÚÂÓÂÚÁÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ Â›Ó·È ¯Ú‹ÛÈÌË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÛıÂÓÒÓ Ì ηډÈÔÁÂÓ¤˜ shock Î·È Ì ÔÍ›· ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ·. Œ¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı›, Â›Û˘, ÁÈ· ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÌÂÙ·ÊÔÚÙ›Ô˘ Û ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ ÌÈÙÚÔÂȉÈ΋ ‹ ·ÔÚÙÈ΋ ·ÓÂ¿ÚÎÂÈ· (2). OÈ ·Ó·ÛÙÔÏ›˜ Ù˘ ʈÛÊÔ‰ÈÂÛÙÂÚ¿Û˘ Â›Ó·È Î˘Ú›ˆ˜ ·ÁÁÂÈԉȷÛÙ·ÏÙÈο Ô˘ ‰ÚÔ˘Ó ÛÙ· ·ÁÁ›· ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ Î·È ‚ÂÏÙÈÒÓÔ˘Ó ¿ÌÂÛ· ÙÔ ÌÂÙ·ÊÔÚÙ›Ô Î·È ÙË Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘. ¶·Ú’ fiÏÔ Ô˘ ¤¯Ô˘Ó ·ÓÂÈı‡ÌËÙ˜ ·ÚÂÓ¤ÚÁÂȘ (˘fiÙ·ÛË, ·ÚÚ˘ı̛˜, ıÚÔÌ‚Ô΢ÙÙÔÂÓ›·), Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ·ÛÊ·Ï‹ ÁÈ· Ù· ÓÂÔÁÓ¿ fiÙ·Ó

¯ÔÚËÁÔ‡ÓÙ·È ÁÈ· ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (2,49). ∞fi Ù· c-AMP ·ÓÂÍ¿ÚÙËÙ· ÈÓÔÙÚfi· Ê¿Ú̷η, ·˘Ùfi Ô˘ ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› Î·È ¯ÔÚËÁÂ›Ù·È ÛÙ· ·È‰È¿ Â›Ó·È Ë ‰·ÎÙ˘Ï›Ùȉ·. ∏ ‰ÈÁÔÍ›ÓË Â›Ó·È Î·Ú‰È·Î‹ ÁÏ˘ÎÔÛ›‰Ë Ô˘ ·Ó·ÛÙ¤ÏÏÂÈ ÙË Ì˘Ôηډȷ΋ ·ÓÙÏ›· ¡a-∫. ŒÙÛÈ, ·˘Í¿ÓÂÙ·È Ë ÂÓ‰Ô΢ÙÙ¿ÚÈ· Û˘ÁΤÓÙÚˆÛË ¡a, ÂÓÂÚÁÔÔÈÂ›Ù·È Ë ÚfiÛÏË„Ë Ca ̤۷ ÛÙÔ Î‡ÙÙ·ÚÔ Ì ÙÔ Ì˯·ÓÈÛÌfi ·ÓÙ·ÏÏ·Á‹˜ ¡a-Ca Î·È ‚ÂÏÙÈÒÓÂÙ·È Ë Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘. ∏ ‰ÈÁÔÍ›ÓË ¤¯ÂÈ, Â›Û˘, ¢ÓÔ˚Τ˜ Ó¢ÚÔÔÚÌÔÓÈΤ˜ ÂȉڿÛÂȘ, ·ÓÂÍ¿ÚÙËÙ˜ ·fi ÙȘ ·ÈÌÔ‰˘Ó·ÌÈΤ˜. ªÂϤÙ˜ ¿Óˆ Û’ ·˘Ùfi ‰ÂÓ ¤¯Ô˘Ó ·Ó·ÊÂÚı› Û ·È‰È¿ Î·È ÔÈ ÁÓÒÛÂȘ Ì·˜ ÛÙËÚ›˙ÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Û ÌÂϤÙ˜ ÂÓËÏ›ÎˆÓ (2,49). OÈ Î·Ú‰È·Î¤˜ ÁÏ˘ÎÔÛ›‰Â˜ ÚÔηÏÔ‡Ó Ì›ˆÛË Ù˘ ‰Ú¿Û˘ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÔÈ Ó¢ÚÔÔÚÌÔÓÈΤ˜ ÂȉڿÛÂȘ ÙÔ˘˜ ÚÔËÁÔ‡ÓÙ·È Ù˘ ÈÓfiÙÚÔ˘ ‰Ú¿Û˘. ∂›Û˘, ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ˆ˜ ·Ú¯È΋ ıÂÚ·›· Û ·ÚÚ˘ı̛˜ (2,4). ¶·Ú’ fiÏ· ·˘Ù¿, Ë ‰Ú¿ÛË Ù˘ ‰ÈÁÔ͛Ӣ ÛÙËÓ Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· Â›Ó·È ·ÌÊÈÏÂÁfiÌÂÓË (50,51).

341

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·342

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

Á) ∞ÁÁÂÈԉȷÛÙ·ÏÙÈο: ∏ ·ÁÁÂÈԉȷÛÙ·ÏÙÈ΋ ıÂÚ·›· ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ÙfiÛÔ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, fiÛÔ Î·È ÛÙ· ·È‰È¿, ÁÈ· Ó· ÂÓÈÛ¯‡ÛÂÈ ÙËÓ Î·Ú‰È·Î‹ ·ÚÔ¯‹, ÌÂÙ·‚¿ÏÏÔÓÙ·˜ ÙÔ ÚÔÊÔÚÙ›Ô Î·È/‹ ÙÔ ÌÂÙ·ÊÔÚÙ›Ô ÚÔηÏÒÓÙ·˜ ¯¿Ï·ÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ ÙˆÓ ·ÁÁ›ˆÓ (52). ∂›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÁÓˆÚ›˙Ô˘Ì ÙÔÓ ÙfiÔ ‰Ú¿Û˘ ÙÔ˘ ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÔ‡ fiÙ·Ó ı· ÙÔ ¯ÚËÛÈÌÔÔÈ‹ÛÔ˘Ì ÛÙË ıÂÚ·›· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ·È‰ÈÒÓ Ì ÂÈÎÔÈӈӛ˜ ÙˆÓ Î·Ú‰È·ÎÒÓ ÎÔÈÏÔًوÓ. ™Â ηډȷΤ˜ ·ı‹ÛÂȘ ¯ˆÚ›˜ ÂÓ‰Ôηډȷ΋ ÂÈÎÔÈÓˆÓ›·, fiˆ˜ Ë ‰È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· Î·È Ë ÌÈÙÚÔÂȉÈ΋ ‹ ·ÔÚÙÈ΋ ·ÓÂ¿ÚÎÂÈ·, Ë ˘‰Ú·Ï·˙›ÓË Î·È ÙÔ ÓÈÙÚÔÚˆÛÈÎfi ‚ÂÏÙÈÒÓÔ˘Ó ÙËÓ Î·Ú‰È·Î‹ ·ÚÔ¯‹ Ì ÙÔ Ì˯·ÓÈÛÌfi Ì›ˆÛ˘ ÙÔ˘ ÌÂÙ·ÊÔÚÙ›Ô˘ (2,4). ∆Ô ÓÈÙÚÔÚˆÛÈÎfi Î·È Ë ÓÈÙÚÔÁÏ˘ÎÂÚ›ÓË ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ÌÂÙ¿ ·fi ηډȷ΋ Â¤Ì‚·ÛË ÁÈ· ÙËÓ ·‡ÍËÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ Û ·È‰È¿ fiÏˆÓ ÙˆÓ ËÏÈÎÈÒÓ.

OÈ ·Ó·ÛÙÔÏ›˜ ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ (∞ª∂∞), (ηÙÔÚ›ÏË, ÂÓ·Ï·Ú›ÏË, ÏÈÛÈÓÔÚ›ÏË) ·Ó‹ÎÔ˘Ó ÛÙ· ÓÂfiÙÂÚ· Ê¿Ú̷η Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË ıÂÚ·›· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙ· ·È‰È¿. ∏ ‰Ú¿ÛË ÙÔ˘˜ ·ÔÙÂÏÂ›Ù·È ·fi ÙÚÂȘ Ì˯·ÓÈÛÌÔ‡˜: i) ·Ó·ÛÙÔÏ‹ ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘, ‰ËÏ·‰‹ ·Ó·ÛÙÔÏ‹ Ù˘ Û‡ÓıÂÛ˘ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÌÂÙ·ÊÔÚÙ›Ô˘ Î·È ÙË ‚ÂÏÙ›ˆÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜, ii) ·Ó·ÛÙÔÏ‹ Ù˘ ‚Ú·‰˘ÎÈÓ›Ó˘ Ô˘ ÚÔ¿ÁÂÈ ÙË ¯¿Ï·ÛË ÙˆÓ ·ÁÁ›ˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÌÂÙ·ÊÔÚÙ›Ô˘ Î·È iii) ·Ó·ÛÙÔÏ‹ Ù˘ ¤ÎÎÚÈÛ˘ ÓÔÚ·‰ÚÂÓ·Ï›Ó˘ ·fi ÙȘ Û˘Ì·ıËÙÈΤ˜ ·ÔÏ‹ÍÂȘ. ™Â ÌÂϤÙ˜ in vitro ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÔÈ ∞ª∂∞ ·ÔÙÚ¤Ô˘Ó ÙË Û‡ÓıÂÛË ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘ Î·È ·ÓÙÈÛÙÚ¤ÊÔ˘Ó ÙË Ì˘Ôηډȷ΋ ›ÓˆÛË (2,49). £· Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È Û ·ÛıÂÓ›˜ Ì ÂÈÎÔÈӈӛ˜ ‰ÂÍÈ¿-·ÚÈÛÙÂÚ¿, ÂÍ·ÈÙ›·˜ Ù˘ Èı·ÓfiÙËÙ·˜ Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙË Û˘ÛÙËÌ·ÙÈ΋ ·ÚÔ¯‹ Û ‚¿ÚÔ˜ Ù˘ Ó¢ÌÔÓÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ (4). ™¯ÂÙÈ΋ ·ÓÙ¤Ó‰ÂÈÍË ·ÔÙÂÏÔ‡Ó ÔÈ ·ÛıÂÓ›˜ Ì ¯·ÌËÏ‹ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ‹ Ì ÓÂÊÚ·ÁÁÂȷ΋ ˘¤ÚÙ·ÛË. Œ¯Ô˘Ó ·Ô‰ÂȯÙ› ·ÔÙÂÏÂÛÌ·ÙÈο Û ÂÚÈÙÒÛÂȘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Ô˘ ÔÊ›ÏÂÙ·È Û ˘¤ÚÙ·ÛË, ÛÙË Ì˘ÔηډÈÔ¿ıÂÈ·, ·ÎfiÌ· Î·È Û ÂÈÎÔÈӈӛ˜ ·ÚÈÛÙÂÚ¿-‰ÂÍÈ¿, fiˆ˜ Ë ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· (53). ‰) µ-·Ó·ÛÙÔÏ›˜: ¡ÂfiÙÂÚ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ÛÙËÓ Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ Ì·ÎÚÔ¯ÚfiÓȘ ¢ÓÔ˚Τ˜ ÂȉڿÛÂȘ ÛÙÔ Ì˘ÔοډÈÔ. ¶·ÚÂÌ‚¿ÏÏÔÓÙ·È ÛÙË ‰Ú¿ÛË ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ·ÓÙ·ÁˆÓ›˙ÔÓÙ·È Ù· ·ÓÂÈı‡ÌËÙ· ·ÔÙÂϤÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ·˘Ù‹. ∆· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ Â›Ó·È Ì·ÎÚÔÚfiıÂÛÌ· Î·È Û˘Ó›ÛÙ·ÓÙ·È ÛÙË ‚ÂÏÙ›ˆÛË

342

Paediatriki 2002;65:333-345

Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ‚ÈÔÏÔÁÈÎÒÓ ·ÏÏ·ÁÒÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙÔ Ì˘ÔηډȷÎfi ·ÙÙ·ÚÔ, ÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ ÎÏ¿ÛÌ·ÙÔ˜ ÂÍÒıËÛ˘ Î·È ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ ÎÔÈÏÈÒÓ (2,6,49,54-58). ∏ ‰Ú¿ÛË ÙÔ˘˜ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÔÊ›ÏÂÙ·È, Â›Û˘, ÛÙËÓ ·Ó·ÛÙÔÏ‹ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÚÂÓ›ÓË-·ÁÁÂÈÔÙÂÓÛ›ÓË-·Ï‰ÔÛÙÂÚfiÓË Î·È ÙËÓ ·Ó·ÛÙÔÏ‹ Ù˘ ·ÂÏ¢ı¤ÚˆÛ˘ ÂÓ‰ÔıËÏ›Ó˘ (16). ™‹ÌÂÚ·, ˘¿Ú¯Ô˘Ó ÙÚÂȘ Ù‡ÔÈ ‚-·Ó·ÛÙÔϤˆÓ: ÔÈ ÂÎÏÂÎÙÈÎÔ› ‚1 ·Ó·ÛÙÔÏ›˜ (ÌÂÙÔÚÔÏfiÏË, ‚ÈÛÔÚÔÏfiÏË), ÔÈ ‚1 Î·È ‚2 ·Ó·ÛÙÔÏ›˜ (ÚÔÚ·ÓÔÏfiÏË, ‚Ô˘ÎÈÓ‰ÔÏfiÏË) Î·È ÔÈ ÓÂfiÙÂÚÔÈ ‚1 Î·È ‚2 Î·È ·1 ·Ó·ÛÙÔÏ›˜ (ηڂ‰ÈÏfiÏË). ªÂϤÙ˜ Û ·È‰È¿ ¤¯Ô˘Ó Á›ÓÂÈ Ì ÙË ¯Ú‹ÛË Ù˘ ÚÔÚ·ÓÔÏfiÏ˘ Î·È Ù˘ ÌÂÙÔÚÔÏfiÏ˘, Ì Ôχ ¢ÓÔ˚ο Ì·ÎÚÔÚfiıÂÛÌ· ·ÔÙÂϤÛÌ·Ù· (6,54,56-58). ∏ ¯Ú‹ÛË ÙÔ˘˜ Â›Ó·È Ôχ ÂÚÈÔÚÈṲ̂ÓË ÂÍ·ÈÙ›·˜ ÙˆÓ ·Ú¯ÈÎÒÓ ·ÚÓËÙÈÎÒÓ ÈÓÔÙÚfiˆÓ ÂȉڿÛˆÓ. OÈ ÓÂfiÙÂÚÔÈ ÌË ÂÎÏÂÎÙÈÎÔ› ‚-·Ó·ÛÙÔÏ›˜, fiˆ˜ Ë Î·Ú‚Â‰ÈÏfiÏË, ¤¯Ô˘Ó Î·È ·ÁÁÂÈԉȷÛÙ·ÏÙÈ΋ ‰Ú¿ÛË, ·ÊÔ‡ ·Ó·ÛÙ¤ÏÏÔ˘Ó Î·È ÙÔ˘˜ ·˘ԉԯ›˜ (16). ∏ ηڂ‰ÈÏfiÏË ¤¯ÂÈ, Â›Û˘, ·ÓÙÈÔÍÂȉˆÙÈ΋ ‰Ú¿ÛË ÛÙÔ Ì˘ÔοډÈÔ (16), ·ÓÔÛÔÚÚ˘ıÌÈÛÙÈΤ˜ ȉÈfiÙËÙ˜ (25) Î·È ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·fiÙˆÛË ÙˆÓ Ì˘ÔηډȷÎÒÓ Î˘ÙÙ¿ÚˆÓ (32). Œ¯ÂÈ Á›ÓÂÈ ÌÂϤÙË Ù˘ ¯Ú‹Û˘ Ù˘ ηڂ‰ÈÏfiÏ˘ Û ·È‰È¿, Ì ¯ÔÚ‹ÁËÛ‹ Ù˘ ÁÈ· ÙÚÂȘ Ì‹Ó˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ Î‡ÚÈ· ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹ Î·È ·Ú·ÙËÚ‹ıËΠ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘Ìو̿وÓ, ηıÒ˜ Î·È Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ (55). ∞ÓÙ·ÁˆÓÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘: ∏ ÏÔ˙·ÚÙ¿ÓË ·Ó‹ÎÂÈ Û ̛· ÓÂfiÙÂÚË Î·ÙËÁÔÚ›· Ê·ÚÌ¿ÎˆÓ Ô˘ ·ÓÙ·ÁˆÓ›˙ÔÓÙ·È ÙËÓ ÚfiÛÏË„Ë ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ ·fi ÙÔ˘˜ ∞∆1 ˘ԉԯ›˜ (59). ªÂϤÙ˜ ÁÈ· ÙË ¯Ú‹ÛË ÙÔ˘˜ Û ·È‰È¿ ‰ÂÓ ¤¯Ô˘Ó ·Ó·ÊÂÚı›. ÕÏÏ· ıÂÚ·¢ÙÈο ̤ÙÚ· ™Â ·ÛıÂÓ›˜ Ì ÔÍ›· ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· Î·È Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë ıÂÈÈ΋ ÌÔÚÊ›ÓË ÁÈ· ÙË Ì›ˆÛË Ù˘ ÊÏ‚È΋˜ Â·Ófi‰Ô˘ Î·È ÙÔ˘ ¿Á¯Ô˘˜, ÂÓ‰ÔÊϤ‚È· ·ÁÁÂÈԉȷÛÙ·ÏÙÈο (ÓÈÙÚÔÁÏ˘ÎÂÚ›ÓË), ηıÒ˜ Î·È ·ÌÈÓÔÊ˘ÏÏ›ÓË ÁÈ· ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹. ™Ù· ‚Ú¤ÊË Ì Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë Û˘Ó¯‹˜ ıÂÙÈ΋ ›ÂÛË ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, ηıÒ˜ Î·È ÙÔ ÂÈÛÓÂfiÌÂÓÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ (¡O) ÁÈ· ÙË ‰È·ÛÙÔÏ‹ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ. ∏ ·˘ÍËÙÈ΋ ÔÚÌfiÓË, Ë ÔÔ›· ‰Ú· ÌfiÓË Ù˘ ‹ ̤ۈ ÙÔ˘ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· π Ô˘ ¤¯ÂÈ Û¯¤ÛË Ì ÙË ÛˆÌ·ÙỔ›ÓË, ıˆÚËÙÈο ¤¯ÂÈ ı¤ÛË ÛÙË ıÂÚ·›· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó Â˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· Ù˘ ˘Ô‰fiÚÈ·˜ ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ıÂÚ·›·, fiˆ˜ ‚ÂÏÙ›ˆÛË ÙˆÓ

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·343

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

˯ÔηډÈÔÁÚ·ÊÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È Ù˘ ·ÓÙÔ¯‹˜ ÛÙËÓ ¿ÛÎËÛË (60-62). ¶ÚÔÛÙ·ÁÏ·Ó‰›ÓË ∂1: ŸÙ·Ó Ë Û˘ÛÙËÌ·ÙÈ΋ ·ÈÌ¿ÙˆÛË ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·Ú·ÌÔÓ‹ ·ÓÔÈÎÙÔ‡ ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ fiÚÔ˘ (˘ÔÏ·ÛÙÈ΋ ·ÚÈÛÙÂÚ‹ ÎÔÈÏ›·, ÛÙ¤ÓˆÛË ÙÔ˘ ÈÛıÌÔ‡ Ù˘ ·ÔÚÙ‹˜), Ë ¯ÔÚ‹ÁËÛË Ù˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ˙ˆ‹˜ (4). ¢›·ÈÙ·: ŒÓ· ·fi Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÛËÌ›· Ù˘ ıÂÚ·›·˜ Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙÔÓ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi Â›Ó·È Ë ‰È·ÙÚÔÊ‹. ∏ ·ÓÂ·Ú΋˜ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜ ÂÓfi˜ ·È‰ÈÔ‡ Ì ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· ıˆÚÂ›Ù·È ·ÔÙ˘¯›· Ù˘ Ê·Ú̷΢ÙÈ΋˜ ıÂÚ·›·˜ Î·È Û˘ÓÈÛÙ¿ ¤Ó‰ÂÈÍË ÁÈ· ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË (2,49). ∆· ‚Ú¤ÊË Ì ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·, ÏfiÁˆ ·ÓÂ·ÚÎÔ‡˜ ÚfiÛÏ˄˘ ‚¿ÚÔ˘˜, ¯ÚÂÈ¿˙ÔÓÙ·È ·‡ÍËÛË ÙˆÓ ËÌÂÚ‹ÛÈˆÓ ÚÔÛÏ·Ì‚·ÓfiÌÂÓˆÓ ıÂÚÌ›‰ˆÓ, ˆ˜ Î·È 150 Kcal/kg ÙËÓ Ë̤ڷ ‹ Î·È ÂÚÈÛÛfiÙÂÚÔ, Ì ÛÙfi¯Ô Ó· ‰È·ÙËÚ‹ÛÔ˘Ó Â·Ú΋ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜. ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È ıÂÚÌȉÈο ‰È·Ï‡Ì·Ù· Ì ‚¿ÛË ÙÔ˘˜ ˘‰·Ù¿ÓıڷΘ (΢ڛˆ˜ ÙË ÁÏ˘Îfi˙Ë) ‹ Ì ‚¿ÛË ¤Ï·È·. ™Â ÂÚÈÙÒÛÂȘ ·‰˘Ó·Ì›·˜ Â·ÚÎÔ‡˜ Û›ÙÈÛ˘, ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Ì ÚÈÓÔÁ·ÛÙÚÈÎfi ηıÂÙ‹Ú· (63). ™Ù· ·È‰È¿ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ÊÏ‚È΋ Û˘ÌÊfiÚËÛË Î·È ÂÚÈÊÂÚÈÎfi Ô›‰ËÌ· Û˘ÓÈÛÙ¿Ù·È ‰›·ÈÙ· ÂχıÂÚË ¿Ï·ÙÔ˜. ™Ù· ‚Ú¤ÊË Î·È Ù· ·È‰È¿ ÌÂ Ì˘ÔηډÈÔ¿ıÂÈ· ÂÍ·ÈÙ›·˜ ¤ÏÏÂȄ˘ ηÚÓÈÙ›Ó˘, Á›ÓÂÙ·È ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ì ¯ÔÚ‹ÁËÛË Î·ÚÓÈÙ›Ó˘ (8).

O͢ÁfiÓÔ: ∏ Ù¿ÛË ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ Ô͢ÁfiÓÔ˘ Â›Ó·È Û˘Ó‹ıˆ˜ ÂÏ·Ùو̤ÓË ÛÙ· ‚Ú¤ÊË Ì ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·. ∏ ¯ÔÚ‹ÁËÛË Ô͢ÁfiÓÔ˘ ‚ÔËı¿ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ Ô͢ÁfiÓˆÛ˘ ÙˆÓ ÈÛÙÒÓ. ∞ÓÙ¤Ó‰ÂÈÍË ·ÔÙÂÏÔ‡Ó Ù· ‚Ú¤ÊË ÛÙ· ÔÔ›· Ë Û˘ÛÙËÌ·ÙÈ΋ ·ÈÌ¿ÙˆÛË ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ ·ÓÔÈÎÙfi ·ÚÙËÚÈ·Îfi fiÚÔ, ÁÈ·Ù› Ë ·‡ÍËÛË Ù˘ ÌÂÚÈ΋˜ ›ÂÛ˘ ÙÔ˘ Ô͢ÁfiÓÔ˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Û‡Û·ÛË ÙÔ˘ fiÚÔ˘ (4). £ÂÚ·›· Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘: ∂›Ó·È ··Ú·›ÙËÙË Ë ·Ó·ÁÓÒÚÈÛË Î·È Ë ¤ÁηÈÚË ıÂÚ·›· Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘ Ô˘ Ô‰‹ÁËÛ Û ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·, fiˆ˜ Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙȘ ÏÔÈÌÒÍÂȘ, Ë ·ÔηٿÛÙ·ÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ηډȷÎÔ‡ Ú˘ıÌÔ‡, Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î.¿. ™ËÌ·ÓÙÈ΋ ›ӷÈ, Â›Û˘, Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ù˘¯fiÓ ˘ÔΛÌÂÓ˘ Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜. ÃÂÈÚÔ˘ÚÁÈ΋ ıÂÚ·›·: ∏ ıÂÚ·›· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ¤¯ÂÈ - Û Ôχ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi - ÛÙÂÓ‹ Û¯¤ÛË Ì ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ÚÔÛ¤ÁÁÈÛË. ™‹ÌÂÚ·, Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Î·ıÔÚ›˙ÂÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ·Ó·ÙÔÌÈ΋˜ ·ÓˆÌ·Ï›·˜ Ù˘ ηډȿ˜, ·fi ÙËÓ ·ÔÙ˘¯›· Ù˘ Ê·Ú̷΢ÙÈ΋˜ ıÂÚ·›·˜, ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ıÚ¤„˘, ηıÒ˜ Î·È ·fi ÙËÓ ÔÚ›· Î·È ÙÔ ÛÙ¿‰ÈÔ Ù˘

Paediatriki 2002;65:333-345

Ì˘Ôηډȷ΋˜ ·Ó·‰È·ÌfiÚʈÛ˘ (2). ª¿ÏÈÛÙ·, Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË Ù˘ ˘ÔΛÌÂÓ˘ ηډÈÔ¿ıÂÈ·˜ ÌÔÚ› Ó· ·ÓÙÈÛÙÚ¤„ÂÈ ÙËÓ ÔÚ›· ÙfiÛÔ Ù˘ ÔÍ›·˜, fiÛÔ Î·È Ù˘ ¯ÚfiÓÈ·˜ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ (2,49). OÈ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙËÓ ·È‰È·ÙÚÈ΋ Â›Ó·È ÔÈ ·Ó·ÎÔ˘ÊÈÛÙÈΤ˜, ÔÈ ‰ÈÔÚıˆÙÈΤ˜ Î·È Ù¤ÏÔ˜ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ (9). °È· Ù· ·È‰È¿ Ì ηډÈÔÁÂÓ‹ ηٷÏËÍ›·, Â›Ó·È ‰È·ı¤ÛÈ̘ Û˘Û΢¤˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ΢ÎÏÔÊÔÚ›·˜, ΢ڛˆ˜ Û·Ó Á¤Ê˘Ú· ‰È·Ù‹ÚËÛ˘ Ù˘ ˙ˆ‹˜ ˆ˜ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ë ÂÓ‰Ô·ÔÚÙÈ΋ ·ÓÙÏ›·, Ë Û˘Û΢‹ Â͈ۈ̷ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ (ECMO) Î·È Â͈ÙÂÚÈΤ˜ Û˘Û΢¤˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜, ·ÏÏ¿ fi¯È ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. ¡ÂfiÙÂÚ˜ ıÂÚ·›˜: OÈ ÓÂfiÙÂÚ˜ ıÂÚ·¢ÙÈΤ˜ ̤ıÔ‰ÔÈ Ô˘ ‰ÔÎÈÌ¿˙ÔÓÙ·È ÛÙË ıÂÚ·›· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ¤¯Ô˘Ó ÛÙfi¯Ô ÙËÓ ÚfiÏË„Ë Ù˘ ·Ó·‰È·ÌfiÚʈÛ˘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ Î·È ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘. ∆¤ÙÔȘ ̤ıÔ‰ÔÈ Â›Ó·È ÔÈ ·Ú¿ÁÔÓÙ˜ Ú‡ıÌÈÛ˘ Ù˘ ¤ÎÊÚ·Û˘ ÙˆÓ Î˘ÙÔÎÈÓÒÓ (·ÌÏÔ‰È›ÓË, ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔÈ ‰È·Ï˘ÙÔ› ˘ԉԯ›˜ ΢ÙÔÎÈÓÒÓ, ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù·, ÂȉÈÎÔ› ·ÓÙ·ÁˆÓÈÛÙ¤˜ ÙˆÓ Î˘ÙÔÎÈÓÒÓ) (40), ÔÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ÂÓ‰ÔıËÏ›Ó˘ (64), Û˘Ó‰˘·ÛÌÔ› ∞-ª∂∞ Î·È ·Ó·ÛÙÔϤˆÓ Ù˘ ÚfiÛÏ˄˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘, ÔÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜ Ù˘ ÚÂÓ›Ó˘, ¢·ÈÛıËÙÔÔÈËÙ¤˜ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ (Ï‚ÔÛÈÌÂÓÙ¿ÓË, ÈÌÔÌÂÓÙ¿ÓË), ·ÓÙ·ÁˆÓÈÛÙ¤˜ Ù˘ ·ÙÚÈÔÂÙȉ¿Û˘ (ηÓÙÔÙ·Í›ÏË) Î·È ÎÂÓÙÚÈÎÔ› Ó¢ÚÔÔÚÌÔÓÈÎÔ› Ú˘ıÌÈÛÙ¤˜ (65,49). º¿ÚÌ·ÎÔ ˘fi ÌÂϤÙË Â›Ó·È Î·È Ë ‚ÂÛÓ·ÚÈÓfiÓË, Ì ıÂÙÈ΋ ÈÓfiÙÚÔË ‰Ú¿ÛË Î·È ·ÓÔÛÔηٷÛÙ·ÏÙÈΤ˜ ȉÈfiÙËÙ˜ (65). ™ËÌ·ÓÙÈ΋ ÚÔÛ¿ıÂÈ· ÛÙË ıÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ‰›‰ÂÙ·È ÛÙËÓ ÚfiÏË„Ë Ù˘ ·fiÙˆÛ˘ ÙˆÓ Ì˘ÔηډȷÎÒÓ Î˘ÙÙ¿ÚˆÓ (66,67). ∏ ηχÙÂÚË Î·Ù·ÓfiËÛË ÙˆÓ Ì˯·ÓÈÛÌÒÓ Ú‡ıÌÈÛ˘ Ù˘ ·fiÙˆÛ˘ ı· ‰ÒÛÂÈ Î·ÈÓÔ‡ÚÁȘ ıÂÚ·¢ÙÈΤ˜ ÌÂıfi‰Ô˘˜, fiˆ˜ ÁÔÓȉȷ΋ ıÂÚ·›· Ô˘ ı· ÂËÚ¿˙ÂÈ ÙËÓ ·Ó·‰È·ÌfiÚʈÛË ÙˆÓ Î·Ú‰È·ÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ Î·È ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∂ÌÊ·Ó›˜ ÛÙfi¯ÔÈ Â›Ó·È Ù· η„ȉȷο ¤Ó˙˘Ì· Î·È Ù· ·ÓÙÈ·ÔÙˆÙÈο bcl-2, Ô˘ Â›Ó·È ÔÈ ÎÂÓÙÚÈÎÔ› Ú˘ıÌÈÛÙ¤˜ Ù˘ ·fiÙˆÛ˘ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ (65). µÈ‚ÏÈÔÁÚ·Ê›· 1. Spicer RL. Carvedilol - a new dimension in pediatric heart failure therapy. J Pediatr 2001;138:457-458.

2. Balaguru D, Artman M, Auslender M. Management of heart failure in children. Curr Probl Pediatr 2000;30:5-30.

3. Auslender M. Pathophysiology of pediatric heart failure.

Prog Pediatr Cardiol 2000;11:175-184.

343

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·344

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

4. Talner SN. Heart failure. In: Emmanoulides GC, Allen HD, Riemenchneider TA, Gutgesell HP, editors. Moss and Adams heart disease in infants, children, and adolescents.

Baltimore: Williams and Wilkins; 1995. p. 1746-1771.

5. Braunwald E. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia: WB Saunders Co; 1997. p.

629-659.

6. Buchhorn R, Hulpke-Wette M, Hilgers R, Bartmus D, Wessel A, Bursch J. Propranolol treatment of congestive heart failure in infants with congenital heart disease: The CHF-PRO-INFANT Trial. Int J Cardiol 2001;79:167-173.

7. Behrman ER, Kliegman MR, Jenson BH. Nelson Textbook of pediatrics. 16th ed. Philadelphia: WB Saunders Co; 2000. p. 1441.

8. Pierpont ME, Breningstall GN, Stanley CA, Singh A. Familial carnitine transporter defect: A treatable cause of cardiomyopathy in children. Am Heart J 2000;139:96-106.

9. O’Laughlin MP. Congestive heart failure in children. Pediatr Clin North Am 1999;46:263-273.

10. McConnell ME, Aronin P, Vitek JJ. Congestive heart failure in neonates due to intracranial arteriovenous malformation: endovascular treatment. Pediatr Cardiol 1993;14:102-106.

11. Marin-Garcia J, Goldenthal MJ. Mitochondrial cardiomyopathy: molecular and biochemical analysis. Pediatr Cardiol 1997;18:251-260.

12. Marin-Garcia J, Goldenthal MJ, Moe GW. Mitochondrial pathology in cardiac failure. Cardiovasc Res 2001;49:17-26.

13. Buchhorn R, Ross RD, Bartmus D, Wessel A, Hulpke-Wette M, Bursch J. Activity of the renin-angiotensin-aldosterone and sympathetic nervous system and their relation to hemodynamic and clinical abnormalities in infants with leftto-right shunts. Int J Cardiol 2001;78:225-230.

14. Scammell AM, Diver MJ. Plasma renin activity in infants with congenital heart disease. Arch Dis Child 1987; 62:1136-1138.

15. Packer M. Beta-blockade in heart failure. Basic concepts and clinical results. Am J Hypertens 1998;11:23S-37S. 16. Ross RD, Daniels SR, Schwartz DC, Hannon DW, Shukla R, Kaplan S. Plasma norepinephrine levels in infants and children with congestive heart failure. Am J Cardiol 1987; 59:911-914.

17. Wu JR, Chang HR, Chen SS, Huang TY. Circulating noradrenaline and beta-adrenergic receptors in children with congestive heart failure. Acta Paediatr 1996;85:923-927.

18. Isnard R, Pousset F, Trochu J, Chafirovskaia O, Carayon A, Golmard J et al. Prognostic value of neurohormonal activation and cardiopulmonary exercise testing in patients with chronic heart failure. Am J Cardiol 2000;86:417-421.

19. Kikuchi K, Nishioka K, Ueda T, Shiomi M, Takahashi Y, Sugawara A et al. Relationship between plasma atrial natriuretic polypeptide concentration and hemodynamic measurements in children with congenital heart diseases.

J Pediatr 1987;111:335-342.

20. Wu JR, Chang HR, Huang TY, Chiang CH, Chen SS. Reduction in lymphocyte beta-adrenergic receptor density in infants and children with heart failure secondary to congenital heart disease. Am J Cardiol 1996;77:170-174.

21. Kozlik R, Kramer HH, Wicht H, Krian A, Ostermeyer J, Reinhardt D. Myocardial beta-adrenoceptor density and

344

Paediatriki 2002;65:333-345

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

the distribution of beta 1- and beta 2- adrenoceptor subpopulations in children with congenital heart disease.

Eur J Pediatr 1991;150:388-394.

Schafer M, Ponicke K, Heinroth-Hoffmann I, Brodde OE, Piper HM, Schluter KD. Beta-adrenoceptor stimulation attenuates the hypertrophic effect of alpha-adrenoceptor stimulation in adult rat ventricular cardiomyocytes. J Am Coll Cardiol 2001;37:300-307.

Colucci WS. Myocardial endothelin. Does it play a role in myocardial failure? Circulation 1996;93:1069-1072.

Sharma R, Coats AJ, Anker S. The role of inflammatory mediators in chronic heart failure: cytokines, nitric oxide, and endothelin-1. Int J Cardiol 2000;72:175-186.

Ohtsuka T, Hamada M, Hiasa G, Sasaki O, Suzuki M, Hara Y et al. Effect of beta-blockers on circulating levels of inflamatory amd anti-inflamatory cytokines in patients with dilated cardiomyopathy. J Am Coll Cardiol 2001;37:412-416. ¶·Ú›Û˘ I. ∏ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙÔ Î·ÙÒÊÏÈ ÙÔ˘ 2000. ∏ ıˆڛ· ÙˆÓ Î˘ÙÔÎÈÓÒÓ. ∂ÏÏËÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂ÈıÂÒÚËÛË 2000;41(™˘Ìϋڈ̷ °):°165-°167.

Aukrust P, Ueland T, Muller F, Andreassen AK, Nordoy I, Aas H et al. Elevated circulating levels of C-C chemokines in patients with congestive heart failure. Circulation 1998;97:1136-1143.

Venugopalan P, Agarwal AK, Worthing EA. Chronic cardiac failure in children due to dilated cardiomyopathy: diagnostic approach, pathophysiology and management.

Eur J Pediatr 2000;159:803-810.

Tsutamoto T, Wada A, Maeda K, Mabuchi N, Hayashi M, Tsutsui T et al. Spironolactone inhibits the transcardiac extraction of aldosterone in patients with congestive heart failure. J Am Coll Cardiol 2000;36:838-844.

Shirani J, Pick R, Roberts WC, Maron BJ. Morphology and significance of the left ventricular collagen network in young patients with hypertrophic cardiomyopathy and sudden cardiac death. J Am Coll Cardiol 2000;35:36-44.

Williams B. Angiotensin II and the pathophysiology of cardiovascular remodeling. Am J Cardiol 2001;87:10C-17C. Rossig L, Haendeler J, Mallat Z, Hugel B, Freyssinet JM, Tedgui A et al. Congestive heart failure induces endothelial cell apoptosis: protective role of carvedilol. J Am Coll Cardiol 2000;36:2081-2089.

Ramrakha PS, Gibbs JS. Nitric oxide in heart failure. Int J Cardiol 2000;73:131-134.

Celermajer DS. Endothelial dysfunction: does it matter? Is it reversible? J Am Coll Cardiol 1997;30:325-333.

Wei CM, Lerman A, Rodeheffer RJ, McGregor CG, Brandt RR, Wright S et al. Endothelin in human congestive heart failure. Circulation 1994;89:1580-1586.

Benigni A, Remuzzi G. Endothelin antagonists. Lancet 1999;353:133-138.

Rossi GP, Sacchetto A, Cesari M, Pessina AC. Interactions between endothelin-1 and the renin-angiotensinaldosterone system. Cardiovasc Res 1999;43:300-307.

Tsutamoto T, Wada A, Hisanaga T, Maeda K, Ohnishi M, Mabuchi N et al. Relationship between endothelin-1 extraction in the peripheral circulation and systemic vascular resistance in patients with severe congestive

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·345

¶·È‰È·ÙÚÈ΋ 2002;65:333-345

heart failure. J Am Coll Cardiol 1999;33:530-537.

39. Bowling N, Walsh RA, Song G, Estridge T, Sandusky GE, Fouts RL et al. Increased protein kinase C activity and expression of Ca++-sensitive isoforms in the failing human heart. Circulation 1999;99:384-391.

40. Varan B, Tokel K, Yilmaz G. Malnutrition and growth failure in cyanotic and acyanotic congenital heart disease with and without pulmonary hypertension. Arch Dis Child 1999;81:49-52.

41. Farrell AG, Schamberger MS, Olson IL, Leitch CA. Large left-to-right shunts and congestive heart failure increase total energy expenditure in infants with ventricular septal defect. Am J Cardiol 2001;87:1128-1131.

42. Baum D, Beck R, Kodama A, Brown B. Early heart failure as a cause of growth and tissue disorders in children with congenital heart disease. Circulation 1980;62:1145-1151.

43. Kantor PF, Robertson MA, Coe JY, Lopaschuk GD. Volume overload hypertrophy of the newborn heart slows the maturation of enzymes involved in the regulation of fatty acid metabolism. J Am Coll Cardiol 1999;33:1724-1733.

44. Ross RD, Bollinger RO, Pinsky WW. Grading the severity of congestive heart failure in infants. Pediatr Cardiol 1992;13:72-75.

45. Connolly D, Rutkowski M, Auslender M, Artman M. The New York University Pediatric Heart Failure Index: a new method of quantifying chronic heart failure severity in children. J Pediatr 2001;138:644-648.

46. Summers R, Woodward L, Kolb J. Correlation of radiographic cardiothoracic ratio with cardiac function in patients with acute congestive heart failure. Em Radiol 1999;6:153-156.

47. Rajappan K, Bellenger N, Anderson L, Pennell DJ. The role of cardiovascular magnetic resonance in heart failure. Eur J Heart Fail 2000;2:241-252.

48. Parikh RS, Girod AD. Role of selective coronary angiography in pediatric heart disease. ACC Curr J Rev 1997;57-61.

49. Auslender M, Artman M. Overview of the management of pediatric heart failure. Prog Pediatr Cardiol 2000;11:231-241.

50. Kimball TR, Daniels SR, Meyer RA, Hannon DW, Tian J, Shukla R et al. Effect of digoxin on contractility and symptoms in infants with a large ventricular septal defect.

Am J Cardiol 1991;68:1377-1382.

51. Seguchi M, Nakazawa M, Momma K. Further evidence suggesting a limited role of digitalis in infants with circulatory congestion secondary to large ventricular septal defect. Am J Cardiol 1999;83:1408-1411.

52. Beekman RH, Rocchini AP, Dick M, Crowley DC, Rosenthal A. Vasodilator therapy in children: acute and chronic effects in children with left ventricular dysfunction or mitral regurgitation. Pediatrics 1984;73:43-51.

53. Webster MW, Neutze JM, Calder AL. Acute hemodynamic effects of converting enzyme inhibition in children with intracardiac shunts. Pediatr Cardiol 1992;13:129-135.

54. Shaddy RE, Tani LY, Gidding SS, Pahl E, Orsmond GS, Gilbert EM et al. Beta-blocker treatment of dilated cardiomyopathy with congestive heart failure in children: a

Paediatriki 2002;65:333-345

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

multi-institutional experience. J Heart Lung Transplant 1999;18:269-274.

Bruns LA, Chrisant MK, Lamour JM, Shaddy RE, Pahl E, Blume ED et al. Carvedilol as therapy in pediatric heart failure: an initial multicenter experience. J Pediatr 2001;138:505-511.

Buchhorn R, Bartmus D, Siekmeyer W, Hulpke-Wette M, Schulz R, Bursch J. Beta-blocker therapy of severe heart failure in infants with left to right shunts. Am J Cardiol 1998;81:1366-1368.

Buchhorn R, Ross DR, Hulpke-Wette M, Bartmus D, Wessel A, Schultz R et al. Effectiveness of low dose captopril versus propranolol therapy in infants with severe congestive heart failure due to left-to-right shunts. Int J Cardiol 2000;76:227-233.

Shaddy RE. Beta-blocker therapy in young children with congestive heart failure under consideration for heart transplantation. Am Heart J 1998;136:19-21.

Bruner-La Rocca HP, Vaddadi G, Esler MD. Recent insight into therapy of congestive heart failure: focus on ACE inhibition and angiotensin-II antagonism. J Am Coll Cardiol 1999;33:1163-1173.

Clark R. Growth hormone and insulin-like growth factor 1: new endocrine therapies in cardiology? TCM 1997; 7:264-268.

Tritos NA, Mantzoros CS. Recombinant human growth hormone: old and novel uses. Am J Med 1998;105:44-57.

Silverman BL, Friedlander JR. Is growth hormone good for the heart? J Pediatr 1997;131:S70-74.

Schwarz SM, Gewitz MH, See CC, Berezin S, Glassman MS, Medow CM et al. Enteral nutrition in infants with congenital heart disease and growth failure. Pediatrics 1990;86:368-373.

Bauersachs J, Fraccarollo D, Galuppo P, Widder J, Ertl G. Endothelin-receptor blockade improves endothelial vasomotor dysfunction in heart failure. Cardiovasc Res 2000;47:142-149.

Auslender M. New drugs in the treatment of heart failure.

Prog Pediatr Cardiol 2000;12:119-124.

Westaby S, Franklin O, Burch M. New developments in the treatment of cardiac failure. Arch Dis Child 1999;81:276-277.

Dzau VJ, Gibbons GH, Mann M, Braun-Dullaeus R. Future horizons in cardiovascular molecular therapeutics. Am J Cardiol 1997;80:33i-39i.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 28-11-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 25-07-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞Ì·Ï›· ∆ÛÈÏÈÌÈÁοÎË ∏ÚÔ‰fiÙÔ˘ 214, ¡¤· ∞ÏÈηÚÓ·ÛÛfi˜ ∆.∫. 716 01, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘

345

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·346

¶·È‰È·ÙÚÈ΋ 2002;65:346-350

∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

Paediatriki 2002;65:346-350

ORIGINAL ARTICLE

∞ÒÙÂÚË ¤Î‚·ÛË ‚ÚÂÊÒÓ Ì Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Î·È Â›ÌÔÓÔ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi ∞. ∫ÔÓ‰‡Ï˘2, ¶. ¢Ô˘Ú›‰·˜1, ∞. ™·Î·Ï›‰Ô˘1, ∑. ∫·Ú·Î·ÙÛ¿ÓË2, ∫. ¶Ú›ÊÙ˘1

The outcome of Ènfants with gastroesophageal reflux and persistent or recurrent wheezing A. Kondilis2, P. Douridas1, A. Sakalidou1, Z. Karakatsani2, K. Priftis1

¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË Ù˘ ·ÒÙÂÚ˘ ¤Î‚·Û˘ ‚ÚÂÊÒÓ Ì Â›ÌÔÓÔ Û˘ÚÈÁÌfi Î·È Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶). ÀÏÈÎfi ·ÔÙ¤ÏÂÛ·Ó 82 ‚Ú¤ÊË Î·È ·È‰È¿ 228 ÌËÓÒÓ (‰È¿ÌÂÛË ËÏÈΛ· 6 Ì‹Ó˜) Ì Â›ÌÔÓÔ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÈηÓÔÔÈËÙÈο ÛÙËÓ ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ Î·È ‰ÂÓ ˘‹Ú¯Â ˘ÔΛÌÂÓÔ ÓfiÛËÌ·. ÀÔ‚Ï‹ıËÎ·Ó Û ÂÈÎÔÛÈÙÂÙÚ¿ˆÚË Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ pH Î·È ·ÏÏÂÚÁÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Ì ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ηÈ/‹ Rast. ÃÔÚËÁ‹ıËΠ·ÓÙÈ-°O¶ Î·È ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ Û‡Ìʈӷ Ì ÙȘ ·Ó¿ÁΘ. ¶·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó Â› 12-38 Ì‹Ó˜ (‰È¿ÌÂÛË ‰È¿ÚÎÂÈ· 17 Ì‹Ó˜) Î·È Î·Ù·ÁÚ¿ÊËÎÂ Ô Ì¤ÛÔ˜ ·ÚÈıÌfi˜ ÂÂÈÛÔ‰›ˆÓ Ì ·Ó·Ó¢ÛÙÈο Û˘ÌÙÒÌ·Ù· Î·È ËÌÂÚÒÓ ÌÂ Û˘ÌÙÒÌ·Ù· ·Ó¿ Ì‹Ó·. ¶·ıÔÏÔÁÈ΋ ηٷÁÚ·Ê‹ pH ‚Ú¤ıËΠ۠50/82 ·È‰È¿ (61%). πηÓÔÔÈËÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Â›¯·Ó 74/82 ·È‰È¿ (90,2%), Ù· 46/50 Ì ÂÈÎfiÓ· °O¶ (ÔÌ¿‰· ∞) Î·È Ù· 28/32 ¯ˆÚ›˜ ÂÈÎfiÓ· °O¶ (ÔÌ¿‰· µ). ™ËÌ·ÓÙÈο ÏÈÁfiÙÂÚ· ÂÂÈÛfi‰È· ·Ó¿ Ì‹Ó· ·Ó¤ÊÂÚ·Ó Ù· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ∞ Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· µ (0,28±0,25 ¤Ó·ÓÙÈ 0,41±0,31, p=0,04), ηıÒ˜ Î·È ÛËÌ·ÓÙÈο ÏÈÁfiÙÂÚ˜ Ë̤Ú˜ ÌÂ Û˘ÌÙÒÌ·Ù· ·Ó¿ Ì‹Ó·. ∞ÙÔ›· ·Ó¤Ù˘Í·Ó Û˘¯ÓfiÙÂÚ· Ù· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ∞ (39,1%) ·fi ÂΛӷ Ù˘ ÔÌ¿‰·˜ µ (17,8%, p=0,009). ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ °O¶ ÛÙ· ‚Ú¤ÊË Ì Â›ÌÔÓË ‹ ˘ÔÙÚÔÈ¿˙Ô˘Û· ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ÌÂÈÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Î·È ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙÔ˘˜. ¶Èı·ÓÔÏÔÁÂ›Ù·È ·ÈÙÈÔÏÔÁÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ °O¶ Î·È ·ÙÔ›·˜.

Abstract: The aim of this study was to determine the outcome of infants with recurrent or persistent wheezing and gastroesophageal reflux (GER) after the antireflux therapy. Eighty-two infants and children aged 2-28 months (median 6 months) attended for recurrent or persistent wheezing not responding to anti-asthmatic treatment without any underline disease took part in the study. They underwent a 24-h esophageal pH probe monitoring and skin prick testing and/or Rast. Antiasthmatic and anti-GER treatment was given to all of them according to the indications. They were followed up for 12-38 months (median 17 months) and the mean number of respiratory episodes and symptomatic days per month were reported.

Positive pH studies were found in 50/82 (61%) children. 74/82 (90.2%) were followed up regularly, 46 GER subjects (Group A) and 28/32 without GER findings (Group B). Significantly less wheezing episodes per month (0.28±0.25 versus 0.41±0.31, p=0.04) as well as significantly less symptomatic days per month were reported by group A children compared to group B. Atopy was developed more often in group A subjects (39.1%) compared to those with negative (17.8%, p=0.009). It is concluded that GER treatment in infants with persistent or recurrent wheezing and silent GER reduces the frequency and the duration of their symptoms. A possible causal correlation between GER and atopy might exist.

1 ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ∞ı‹Ó· 2 °·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎfi π·ÙÚÂ›Ô µ’ ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ∞ı‹Ó·

1 Division of Allergy, Penteli Children’s General Hospital, Athens 2 Gastroenterology Clinic, 2nd Pediatric Division of Penteli Children’s General Hospital, Athens

346

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·347

¶·È‰È·ÙÚÈ΋ 2002;65:346-350

Paediatriki 2002;65:346-350

§¤ÍÂȘ ÎÏÂȉȿ: ̤ÙÚËÛË ÔÈÛÔÊ·ÁÈÎÔ‡ pH, ·ÏÏÂÚÁ›·, ¿ÛıÌ·.

Key words: pH-metry, allergy, asthma.

∂ÈÛ·ÁˆÁ‹ O ˘ÔÙÚÔÈ¿˙ˆÓ Î·È Ô Â›ÌÔÓÔ˜ Û˘ÚÈÁÌfi˜ ηٿ ÙË ‚ÚÂÊÈ΋ Î·È ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· ·ÔÙÂÏÔ‡Ó Û˘¯Ó‹ ·ÈÙ›· Â›Û΄˘ ÙˆÓ ÌÈÎÚÒÓ ·ÛıÂÓÒÓ ÛÙ· ·È‰È·ÙÚÈο È·ÙÚ›·. ™˘ÓËı¤ÛÙÂÚÔÈ ·ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÙÔ˘ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Î·È ÙÔ˘ Â›ÌÔÓÔ˘ Û˘ÚÈÁÌÔ‡ Û ·˘Ù‹ ÙËÓ ËÏÈΛ· Â›Ó·È ÔÈ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ·ÏÏ¿ Û˘¯Ó¿ ÂÓÔ¯ÔÔÈÂ›Ù·È Î·È Ë Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶).

O ‚·ıÌfi˜ Û˘Û¯¤ÙÈÛ˘ Ù˘ °O¶ Î·È Ù˘ Â›ÌÔÓ˘ ·Ó·Ó¢ÛÙÈ΋˜ Û˘Ìو̷ÙÔÏÔÁ›·˜ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ‰ÂÓ Â›Ó·È Â·ÎÚÈ‚Ò˜ ÁÓˆÛÙfi˜ (1-4). ∂ÈϤÔÓ, ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ó·ÊÔÚÒÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ Èı·ÓÔÏÔÁÔ‡ÌÂÓÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜, ̤ۈ ÙˆÓ ÔÔ›ˆÓ Ë °O¶ ÌÔÚ› Ó· ÚÔηÏ› ˘ÔÙÚÔÈ¿˙ÔÓÙ· ‹ Â›ÌÔÓÔ Û˘ÚÈÁÌfi (4-7). ∏ ·ÒÙÂÚË ¤Î‚·ÛË ÙˆÓ ·È‰ÈÒÓ Ì ˘ÔÙÚÔÈ¿˙Ô˘Û· ‹ Â›ÌÔÓË ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Â›Ó·È Û˘Ó‹ıˆ˜ ηϋ Î·È Û‡Ìʈӷ Ì ÙËÓ ÎÏ·ÛÈ΋ ÌÂϤÙË ÙÔ˘ Martinez ÂÚÈÁÚ¿ÊÂÙ·È ˆ˜ ·ÚÔ‰ÈÎfi˜ Û˘ÚÈÁÌfi˜ (8). ¢ÂÓ ˘¿Ú¯ÂÈ fï˜ Â·Ú΋˜ ‚È‚ÏÈÔÁÚ·ÊÈ΋ ·Ó·ÊÔÚ¿ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÒÙÂÚ˘ ¤Î‚·Û˘ ÙˆÓ ‚ÚÂÊÒÓ Ì ٤ÙÔÈ· Û˘Ìو̷ÙÔÏÔÁ›· Î·È ‰È·ÈÛو̤ÓË °O¶. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Û ‚Ú¤ÊË ¤‰ÂÈÍ·Ó fiÙÈ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ °O¶ Î·È Ù˘ ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜, ¯ˆÚ›˜ Ó· ‰È¢ÎÚÈÓ›˙ÂÙ·È Ô ÚfiÏÔ˜ Ù˘ ·ÏÏÂÚÁ›·˜ ÛÙËÓ ÂÚ›ÙˆÛË Û˘Ó˘¿Ú¯Ô˘Û·˜ ·Ó·Ó¢ÛÙÈ΋˜ ÓfiÛÔ˘ (9). ™ÎÔfi˜ ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË Ù˘ ·ÒÙÂÚ˘ ¤Î‚·Û˘ ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Â›ÌÔÓË ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Î·È °O¶, ηıÒ˜ Â›Û˘ Ë ‰È¢ÎÚ›ÓÈÛË ÙÔ˘ ÚfiÏÔ˘ ÙÔ˘ ·ÏÏÂÚÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·.

ÛÔÊ·ÁÈÎÔ‡ pH Ì ηıÂÙ‹Ú· 2 ÛËÌ›ˆÓ (Digitraper ED, Synetics Medical). ø˜ ·ıÔÏÔÁÈÎfi ·ÔÙ¤ÏÂÛÌ· ıˆڋıËΠÂΛÓÔ Ô˘ ÙÔ pH ‹Ù·Ó <4 Â› >4% ÙÔ˘ ¯ÚfiÓÔ˘ ηٷÁÚ·Ê‹˜. ∆· ·È‰È¿ ·˘Ù¿ ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ÔÌ¿‰· ∞, ÂÓÒ Ù· ˘fiÏÔÈ· ÙËÓ ÔÌ¿‰· µ. ŸÏ· Ù· ·È‰È¿ ˘Ô‚Ï‹ıËÎ·Ó Û ·ÏÏÂÚÁÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Ì ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ó˘ÁÌÔ‡ ηÈ/‹ Rast ÛÙ· ·Ú·Î¿Ùˆ ‚·ÛÈο ÙÚÔÊÈο Î·È ÂÈÛÓÂfiÌÂÓ· ·ÏÏÂÚÁÈÔÁfiÓ·: Á¿Ï· ·ÁÂÏ¿‰·˜, Ì›ÁÌ· ‰ËÌËÙÚÈ·ÎÒÓ, ·˘Áfi, „¿ÚÈ, Ì›ÁÌ· ÁÚ·ÛȉÈÔ‡, ÂÚ‰ÈοÎÈ (ƒ. officinalis), ÂÏÈ¿, ¿Î·ÚÈ Ù˘ ÛÎfiÓ˘ ÙÔ˘ ÛÈÙÈÔ‡ (D. Pteronysinnus) Î·È Ì›ÁÌ· Ì˘Î‹ÙˆÓ. °È· ÙȘ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Âί˘Ï›ÛÌ·Ù· Stallergen. ø˜ ıÂÙÈΤ˜ ıˆڋıËÎ·Ó ÂΛӘ Ô˘ ·ÚÔ˘Û›·˙·Ó ÔÌÊfi ̤Û˘ ‰È·Ì¤ÙÚÔ˘ ≥3 mm, ÂÓÒ ˆ˜ ıÂÙÈο ıˆڋıËÎ·Ó Ù· Rast Ù¿Í˘ 2 Î·È ¿Óˆ.

OÈ ·ÛıÂÓ›˜ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ·Ó¿ Ù·ÎÙ¿ ‰È·ÛÙ‹Ì·Ù· 1-4 ÌËÓÒÓ ÛÙÔ ·ÏÏÂÚÁÈÔÏÔÁÈÎfi ‹ Á·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎfi ∂π Î·È ˙ËÙ‹ıËΠ·fi ÙÔ˘˜ ÁÔÓ›˜ Ó· ÙËÚËı› ·Ïfi ËÌÂÚÔÏfiÁÈÔ Î·Ù·ÁÚ·Ê‹˜ ÙˆÓ Û˘Ìو̿وÓ. ÀÔÏÔÁ›ÛÙËÎÂ Ô Ì¤ÛÔ˜ ·ÚÈıÌfi˜ ·Ó·Ó¢ÛÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Î·È Ô Ì¤ÛÔ˜ ·ÚÈıÌfi˜ ËÌÂÚÒÓ ÌÂ Û˘ÌÙÒÌ·Ù· ·Ó¿ Ì‹Ó·. ∏ ¯ÔÚËÁÔ‡ÌÂÓË ·ÓÙÈ-°O¶ ·ÁˆÁ‹ ÂÚÈÂÏ¿Ì‚·Ó ·ÓÙ·ÁˆÓÈÛÙ‹ ÙˆÓ ∏2 ˘Ô‰Ô¯¤ˆÓ Î·È ÚÔÎÈÓËÙÈÎfi ·Ú¿ÁÔÓÙ· Â› fiÛÔ ¯ÚfiÓÔ ¯ÚÂÈ·˙fiÙ·Ó Û‡Ìʈӷ Ì ٷ ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ·. ∏ ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ ηıÔÚ›ÛÙËÎÂ, Â›Û˘, Û‡Ìʈӷ Ì ÙȘ ÎÏÈÓÈΤ˜ ÂӉ›ÍÂȘ. °È· ÙË ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· ÂÊ·ÚÌfiÛÙËÎÂ Ë ‰ÔÎÈÌ·Û›· x2 ÁÈ· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ÔÈÔÙÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ Î·È Ë ‰ÔÎÈÌ·Û›· ηٿ ˙‡ÁË ÁÈ· ÙË Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ÙˆÓ ÔÛÔÙÈÎÒÓ ‰Â‰Ô̤ӈÓ.

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ÀÏÈÎfi ·ÔÙ¤ÏÂÛ·Ó 82 ‚Ú¤ÊË Î·È ·È‰È¿ (50 ·ÁfiÚÈ·) ËÏÈΛ·˜ 2-28 ÌËÓÒÓ (‰È¿ÌÂÛË ËÏÈΛ· 6 Ì‹Ó˜) Ì Â›ÌÔÓÔ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÈηÓÔÔÈËÙÈο ÛÙËÓ ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ Ì ÂÈÛÓÂfiÌÂÓ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Î·È Ú˘ıÌÈÛÙÈο Ê¿Ú̷η ÁÈ· ÂÚ›Ô‰Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ 3-6 ‚‰ÔÌ¿‰ˆÓ. ø˜ Â›ÌÔÓÔ˜ Û˘ÚÈÁÌfi˜ ıˆڋıËΠÂΛÓÔ˜ Ô˘ ›¯Â ‰È¿ÚÎÂÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 3 ‚‰ÔÌ¿‰Â˜, ÂÓÒ ˆ˜ ˘ÔÙÚÔÈ¿˙ˆÓ fiÙ·Ó ·Ó·Ê¤ÚÔÓÙ·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ 3 ÂÂÈÛfi‰È·. ¢ÂÓ ÂÚÈÏ‹ÊıËÎ·Ó ·È‰È¿ Ì ΢ÛÙÈ΋ ›ÓˆÛË, ·ÓÔÛÔÏÔÁÈ΋ ·ÓÂ¿ÚÎÂÈ·, ¯ÚfiÓÈ· ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ ÙˆÓ ÚÔÒÚˆÓ, „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË ‹ ¿ÏÏÔ ˘ÔΛÌÂÓÔ ·Ó·Ó¢ÛÙÈÎfi ÓfiÛËÌ·. ÀÔ‚Ï‹ıËÎ·Ó Û ÂÈÎÔÛÈÙÂÙÚ¿ˆÚË Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ÔÈ-

∞ÔÙÂϤÛÌ·Ù· ¶·ıÔÏÔÁÈ΋ ηٷÁÚ·Ê‹ pH ‚Ú¤ıËΠ۠50 ·fi Ù· 82 (61%) ·È‰È¿. ∂·Ú΋ ·Ú·ÎÔÏÔ‡ıËÛË Â›¯·Ó Ù· 74 (90,2%) Â› 12-38 Ì‹Ó˜ (‰È¿ÌÂÛË ‰È¿ÚÎÂÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ 17 Ì‹Ó˜). ∆· 46/50 ‹Ù·Ó ·fi ÙËÓ ÔÌ¿‰· ∞ Î·È 28/32 ·fi ÙËÓ ÔÌ¿‰· µ. ª·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ Ì ڢıÌÈÛÙÈο Ê¿Ú̷η ¯ÔÚËÁ‹ıËΠ۠40/46 Î·È 21/28 ·È‰È¿ ·ÓÙ›ÛÙÔȯ·, ÂÓÒ Ë ·ÓÙÈ-°O¶ ·ÁˆÁ‹ ÛÙ· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ∞ ¯ÔÚËÁ‹ıËΠÂ› 2,2-9,8 Ì‹Ó˜ (‰È¿ÌÂÛË ‰È¿ÚÎÂÈ· 3,8 Ì‹Ó˜). ™ËÌ·ÓÙÈο ÏÈÁfiÙÂÚ· ÂÂÈÛfi‰È· Ì ·Ó·Ó¢ÛÙÈο Û˘ÌÙÒÌ·Ù· ·Ó¿ Ì‹Ó· ·Ó¤ÊÂÚ·Ó Ù· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ∞ Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· µ (0,28±0,25 ¤Ó·ÓÙÈ 0,41±0,31, p=0,04) Î·È ÛËÌ·ÓÙÈο ÏÈÁfiÙÂÚ˜ Ë̤Ú˜ ÌÂ Û˘ÌÙÒÌ·Ù· ·Ó¿ Ì‹Ó· (3,4±2,7 ¤Ó·ÓÙÈ 6,1±3,8, p<0,001) ·Ó¤ÊÂÚ·Ó, Â›Û˘, Ù· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ∞. ∞ÙÔ›· ‰È·ÈÛÙÒıËΠÛÙ· 18/46 (39,1%) ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ∞ ¤Ó·ÓÙÈ 5/28 (17,8%) Ù˘ ÔÌ¿‰·˜ µ (p=0,009). ™ÙÔ ÈÛÙfiÁÚ·ÌÌ· Ù˘ ∂ÈÎfiÓ·˜ 1

347

14-05-03

14:10

™ÂÏ›‰·348

¶·È‰È·ÙÚÈ΋ 2002;65:346-350

™˘˙‹ÙËÛË ∞fi Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù‹˜ Ù˘ ÂÚÁ·Û›·˜ ÚÔ·ÙÂÈ fiÙÈ ÛÙ· ‚Ú¤ÊË Ì Â›ÌÔÓÔ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û˘Ó˘¿Ú¯Ô˘Û·˜ °O¶ ‚ÂÏÙÈÒÓÂÈ ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÓfiÛÔ˘. ∆· ·È‰È¿ Ô˘ Û˘ÌÌÂÙ›¯·Ó Û ·˘Ù‹ ÙË ÌÂϤÙË ‰ÂÓ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙËÓ ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹, Ë ÔÔ›· ÙÔ˘˜ ¯ÔÚËÁ‹ıËΠ·Ú¯Èο Â› ÌÂÚÈΤ˜ ‚‰ÔÌ¿‰Â˜. ™˘ÓÂÒ˜, ‰ÂÓ ÂÚfiÎÂÈÙÔ ÁÈ· ÂÚÈÙÒÛÂȘ ·ÏÔ‡ ‚ÚÂÊÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. ∞ÔÎÏ›ÛÙËÎ·Ó ·ÎfiÌ· ÔÈ ÂÚÈÙÒÛÂȘ ÙÔ˘ Â›ÌÔÓÔ˘ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌÔ‡ ÏfiÁˆ ¿ÏÏÔ˘ ˘ÔΛÌÂÓÔ˘ ÓÔÛ‹Ì·ÙÔ˜ (΢ÛÙÈ΋ ›ÓˆÛË, ·ÓÔÛÔÏÔÁÈ΋ ·ÓÂ¿ÚÎÂÈ·, ¯ÚfiÓÈ· ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ ÙˆÓ ÚÔÒÚˆÓ, æ∫∫). ∆· ÂÚÈÛÛfiÙÂÚ· (61%) ·ÚÔ˘Û›·˙·Ó ıÂÙÈ΋ pHÌÂÙÚ›·. ∏ ¢ÓÔ˚ÎfiÙÂÚË ·ÒÙÂÚË ¤Î‚·ÛË Ô˘ ·Ú·ÙËÚ‹ıËΠ۠·˘Ù¿ Ù· ·È‰È¿ ı· Ú¤ÂÈ Ì¿ÏÏÔÓ Ó· ¤¯ÂÈ Û¯¤ÛË Ì ÙËÓ ÂÈϤÔÓ ·ÓÙÈ-°O¶ ·ÁˆÁ‹, ·ÊÔ‡ Ë ·ÓÙÈ·ÛıÌ·ÙÈ΋ ‹Ù·Ó ÎÔÈÓ‹ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ Î·È Â›¯Â ¿ÏψÛÙ ÚÔËÁËı›.

O ‚·ıÌfi˜ Û˘Û¯¤ÙÈÛ˘ Ù˘ °O¶ ÌÂ Û˘Ó˘¿Ú¯Ô˘Û· ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ÛÙË ‚ÚÂÊÈ΋ ·ÏÏ¿ Î·È ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ‹ ·È‰È΋ ËÏÈΛ· ·Ú·Ì¤ÓÂÈ ı¤Ì· ·ÌÊÈÏÂÁfiÌÂÓÔ (4-7). ∆· ·ÔÙÂϤÛÌ·Ù· ÌÂÏÂÙÒÓ, Ô˘ ·Ó·˙ËÙÔ‡Ó Ó· ‰È·ÈÛÙÒÛÔ˘Ó Û ·È‰È¿ Ì ¯ÚfiÓÈ· ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ ÂӉ¯fiÌÂÓË Û˘Ó‡·ÚÍË °O¶, ÔÈΛÏÔ˘Ó ·fi 25% ̤¯ÚÈ 80% ·Ó¿ÏÔÁ· Ì ٷ ÎÚÈÙ‹ÚÈ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ °O¶ (1). ∞ÓÙ›ıÂÙ·, Û ÚfiÛÊ·ÙË ‰ËÌÔÛ›Â˘ÛË ÙˆÓ Nelson Î·È Û˘Ó ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· ‰ˆ‰ÂοÌËÓ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ 63 ‚ÚÂÊÒÓ Ì ·Ó·ÁˆÁ¤˜ Î·È ¿ÏÏˆÓ 92 ¯ˆÚ›˜ ·˘Ù¤˜, ÛÙËÓ ÔÔ›· ‰ÂÓ ‰È·ÈÛÙÒÓÂÙ·È ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙÔÓ ·ÚÈıÌfi ÂÂÈÛÔ‰›ˆÓ Û˘ÚÈÁÌÔ‡ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ (2). ∆¤ÏÔ˜, Û ‰‡Ô ¿ÏϘ ÌÂϤÙ˜ ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ Ë ·ÓÙÈ-°O¶ ·ÁˆÁ‹ ‚ÂÏÙÈÒÓÂÈ ÙË Û˘Ó˘¿Ú¯Ô˘Û· ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· (10,11).

348

% 16 14 12 10 8 6 4 2 0

OÌ¿‰· ∞ OÌ¿‰· µ

·Á ÂÏ ¢Ë ¿‰ ÌË Ô˜ ÙÚ È· ο ∞˘ Á¿ æ ¿ °Ú ÚÈ ¶Â ·Û› Ú‰ ‰È Èο ÎÈ ∂Ï È¿ ÕÎ · ª ‡Î ÚÈ Ë٠˜

·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ·Ó·Ï˘ÙÈο Ù· ·ÏÏÂÚÁÈÔÁfiÓ· ÛÙ· ÔÔ›· ‰È·ÈÛÙÒıËΠ¢·ÈÛıËÙÔÔ›ËÛË ·Ó¿ ÔÌ¿‰·. ∞ÓÙ›‰Ú·ÛË ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ Ù‡Ô˘ ‰ÂÓ ·ÚÔ˘Û›·Û ηӤӷ ·fi Ù· ·È‰È¿, ÂÓÒ 3 Î·È 1 ·ÓÙ›ÛÙÔȯ· ·Ó¤ÊÂÚ·Ó fiÙÈ ·ÚÔ˘Û›·Û·Ó ÎÓȉˆÙÈÎfi ÂÍ¿ÓıËÌ·. ∞ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÂΉ‹ÏˆÛ·Ó 13 (Ù· 9 ¢·ÈÛıËÙÔÔÈË̤ӷ) ·fi Ù· 46 (27,9%) Ù˘ ÔÌ¿‰·˜ ∞ Î·È 4 (Ù· 3 ¢·ÈÛıËÙÔÔÈË̤ӷ) ·fi Ù· 28 (14,4%) Ù˘ ÔÌ¿‰·˜ µ (p=0,009). ∆· 6 ·È‰È¿ (5 ÛÙËÓ ÔÌ¿‰· ∞ Î·È 1 ÛÙË µ) Ô˘ ›¯·Ó ¢·ÈÛıËÙÔÔ›ËÛË ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜ Ù¤ıËÎ·Ó Û ‰›·ÈÙ· Ì ˘Ô·ÏÏÂÚÁÈÎfi Á¿Ï· Î·È ÌÂÙ¿ ·fi ‰È¿ÛÙËÌ· 8-18 ÌËÓÒÓ Â·Ó‹Ïı·Ó ÔÌ·Ï¿ ÛÙÔ ÂχıÂÚÔ ‰È·ÈÙÔÏfiÁÈÔ.

Paediatriki 2002;65:346-350

°¿ Ï·

sEpT-OcT-02

∂ÈÎfiÓ· 1. ∂˘·ÈÛıËÙÔÔ›ËÛË Û ‚Ú¤ÊË Ì Â›ÌÔÓÔ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi Î·È °O¶ (ÔÌ¿‰· ∞) ‹ ¯ˆÚ›˜ °O¶ (ÔÌ¿‰· µ).

º·›ÓÂÙ·È fiÙÈ Ë °O¶ ‰ÂÓ ˘ÚÔ‰ÔÙ› Û fiÏ· Ù· ·È‰È¿ ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·, fiˆ˜, Â›Û˘, ‰ÂÓ ÂÌϤÎÂÙ·È ·ÈÙÈÔÏÔÁÈο Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ Û˘Ó˘¿Ú¯ÂÈ Ì Â›ÌÔÓ· ·Ó·Ó¢ÛÙÈο Û˘ÌÙÒÌ·Ù·. O ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜, ¿ÏψÛÙÂ, ̤ۈ ÙÔ˘ ÔÔ›Ô˘ Û˘Ó‰¤ÂÙ·È Ë °O¶ Ì ÙËÓ Ó¢ÌÔÓÈ΋ ÓfiÛÔ, ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ˜. ∫·Ù’ ·Ú¯¿˜, Ô ÎÏ·ÛÈÎfi˜ Û˘Ó‰ÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Â›Ó·È ÂΛÓÔ˜ ÙˆÓ ÌÈÎÚÔÂÈÛÚÔÊ‹ÛÂˆÓ (12). øÛÙfiÛÔ, ÈÛÙ‡ÂÙ·È fiÙÈ Ù· ·Ó·Ó¢ÛÙÈο Û˘ÌÙÒÌ·Ù· Â›Ó·È ·fiÙÔη ·Ú·Û˘Ì·ıËÙÈÎÔ‡ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÔ‡, ÙÔ ÔÔ›Ô ÂÎχÂÙ·È ·fi ÙÔ Á·ÛÙÚÈÎfi ˘ÁÚfi Ô˘ ·ÏÈÓ‰ÚÔÌ› ÛÙÔÓ ÔÈÛÔÊ¿ÁÔ ‹ ÙÔÓ Ï¿Ú˘ÁÁ· (13). º·›ÓÂÙ·È fiÙÈ Û ÌÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜, fiˆ˜ Â›Ó·È ÔÈ ·ÛıÌ·ÙÈÎÔ›, ·Ú·ÙËÚÂ›Ù·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·˘ÙfiÓÔÌÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (14) Î·È ÙÔ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ·˘Ùfi ÂÓÂÚÁÔÔÈÂ›Ù·È Â˘ÎÔÏfiÙÂÚ· ·fi fiÙÈ Û ¿ÏÏÔ˘˜. ∂ȉÈÎfiÙÂÚ·, Ë ·ÈÙÈÔÏÔÁÈ΋ Û‡Ó‰ÂÛË Ù˘ °O¶ Ì ÙÔ ¿ÛıÌ· ·Ú·Ì¤ÓÂÈ ÛËÌÂ›Ô ·ÌÊÈÏÂÁfiÌÂÓÔ, ·ÊÔ‡ Ù· ̤¯ÚÈ ÙÒÚ· ‰Â‰Ô̤ӷ ÚÔ¤Ú¯ÔÓÙ·È Î˘Ú›ˆ˜ ·fi ÎÏÈÓÈΤ˜ ‹ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜. ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ ıˆÚÔ‡ÓÙ·È Ôχ ¯Ú‹ÛÈÌ·, ·ÏÏ¿ ‰ÂÓ ÌÔÚÔ‡Ó ·ԉ›ÍÔ˘Ó ÙËÓ ‡·ÚÍË Û¯¤Û˘ “·ÈÙ›Ô˘-·ÈÙÈ·ÙÔ‡” (15-17). ™ÙÔ ‚·ıÌfi Ô˘ Ë °O¶ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ¿ÛıÌ·, ·Ó·Ì¤ÓÂÙ·È Â›Û˘ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÂÌÊ·Ó‹˜ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ·ÓÙÈ-°O¶ ·ÁˆÁ‹˜. ∆Ô fiÊÂÏÔ˜ ·fi ÙËÓ ·ÓÙÈ°O¶ ·ÁˆÁ‹ Ô˘ ‰È·ÈÛÙÒıËΠÛÙË ÌÂϤÙË Ì·˜ Û˘ÓËÁÔÚ› ˘¤Ú Ù˘ ·ıÔÁÂÓÂÙÈ΋˜ Û‡Ó‰ÂÛ˘ Ù˘ °O¶ Ì ÙÔÓ Â›ÌÔÓÔ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi. ∞ÓÙ›ıÂÙ·, Ë ·Ó·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜ ÌfiÓÔ Ô˘ ›¯Â ÚÔËÁÔ˘Ì¤Óˆ˜ ¯ÔÚËÁËı›, ‰ÂÓ ÛËÌ·›ÓÂÈ ˘Ô¯ÚˆÙÈο fiÙÈ ‰ÂÓ Û˘Ó˘‹Ú¯Â ÙÔ ·ÛıÌ·ÙÈÎfi ÛÙÔȯ›Ô, ·ÊÔ‡ Ë °O¶ ÌÔÚ› Ó· ÙÔ Â·Ó·ÙÚÔÊÔ‰ÔÙÔ‡Û ·ÈÙÈÔÏÔÁÈο Î·È ¤ÙÛÈ Û˘ÓÙËÚÔ‡Û ÙÔ Ê·‡ÏÔ Î‡ÎÏÔ. ∞Ó¿ÏÔÁ·

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·349

¶·È‰È·ÙÚÈ΋ 2002;65:346-350

·ÔÙÂϤÛÌ·Ù· ¿ÏψÛÙ ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Î·È ·fi ¿ÏÏÔ˘˜ Û˘ÁÁÚ·Ê›˜ (1,18,19). ∏ Û˘¯ÓfiÙÂÚË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ·ÏÏÂÚÁÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙ· ‚Ú¤ÊË Ì °O¶ ¤¯ÂÈ ‹‰Ë ·Ó·ÊÂÚı› ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· (9,21). ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, Û ۯÂÙÈο ÚfiÛÊ·ÙË ÈÙ·ÏÈ΋ ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ ÛÙÔ 41,8% ÙˆÓ ‚ÚÂÊÒÓ Ì °O¶ Û˘Ó˘¿Ú¯ÂÈ ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜, ·ÓÂÍ·Úًو˜ ·Ó ÚfiÎÂÈÙ·È ÁÈ· IgE ÌÂÛÔÏ·‚Ô‡ÌÂÓË ‹ fi¯È (9). ™ÙË ÌÂϤÙË ·˘Ù‹ ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È Ë Û˘¯ÓfiÙËÙ· ¢·ÈÛıËÙÔÔ›ËÛ˘ Û ¿ÏÏ· ·ÏÏÂÚÁÈÔÁfiÓ·, Ô‡ÙÂ Ë Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ Â›ÌÔÓÔ˘ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌÔ‡, ·Ú¿ ÌfiÓÔ fiÙÈ ‰ÂÓ ‰È·ÈÛÙÒıËΠ‰È·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ·Ó·Ó¢ÛÙÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ ÛÙ· ‚Ú¤ÊË Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜ ·fi ÂΛӷ Ô˘ ‰ÂÓ Â›¯·Ó. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË fï˜, ÙÔ ÛËÌÂ›Ô ÂÎΛÓËÛ˘ Â›Ó·È Ù· ‚Ú¤ÊË Ì Â›ÌÔÓÔ ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi Î·È Ë ‰È·›ÛÙˆÛË Â›Ó·È fiÙÈ ·˘Ù¿ Ì °O¶ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Â˘·ÈÛıËÙÔÔ›ËÛË Û˘¯ÓfiÙÂÚ·, fi¯È ÌfiÓÔ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜, ·ÏÏ¿ Î·È ÛÙ· ˘fiÏÔÈ· ÎÔÈÓ¿ ÙÚÔÊÈο Î·È ÂÈÛÓÂfiÌÂÓ· ·ÏÏÂÚÁÈÔÁfiÓ· (22,23). ¢ÂÓ ÂϤÁ¯ıËΠ·Ó ˘¿Ú¯ÂÈ ·ÏÏÂÚÁ›· ÌË IgE ÌÂÛÔÏ·‚Ô‡ÌÂÓË. ∆Ô Â‡ÚËÌ· ·˘Ùfi Ù˘ ÌÂϤÙ˘ Ì·˜ ÂÓÈÛ¯‡ÂÈ ÙËÓ ¿Ô„Ë fiÙÈ ÛÙËÓ ÔÌ¿‰· ∞ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·Ó ÔÏÏ¿ ‚Ú¤ÊË ·ÏÏÂÚÁÈο ηÈ, ηٿ ¿Û· Èı·ÓfiÙËÙ·, ·ÛıÌ·ÙÈο, Ô˘ ÏfiÁˆ Ù˘ Û˘Ó‡·Ú͢ Ù˘ °O¶ ‰ÂÓ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÈηÓÔÔÈËÙÈο ÛÙËÓ ·Ú¯È΋ ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹. ∞ÓÙ›ıÂÙ·, ÂΛӷ Ù˘ ÔÌ¿‰·˜ µ ·ÚÔ˘Û›·˙·Ó ÙÔÓ ·ÔηÏÔ‡ÌÂÓÔ “·ÚÔ‰ÈÎfi Û˘ÚÈÁÌfi” Ô˘ ÔÊ›ÏÂÙ·È Û ¿ÏϘ ·Èٛ˜ ÌË ·ÛıÌ·ÙÈÎÔ‡ Ù‡Ô˘ Î·È ¤ÙÛÈ Ù· Û˘ÌÙÒÌ·Ù· Â¤ÌÂÈÓ·Ó ÂÚÈÛÛfiÙÂÚÔ (8). ∏ Û¯¤ÛË ·ÏÏÂÚÁ›·˜ Î·È °O¶ ·fi ¿Ô„Ë ·ıÔÁÂÓÂÙÈ΋ Âȉ¤¯ÂÙ·È ÔÏϤ˜ ÂÚÌËÓ›˜. ªÔÚ› Ó· ÚÔËÁÂ›Ù·È Ë Â˘·ÈÛıËÙÔÔ›ËÛË, ÛÙ· Ï·›ÛÈ· ÙˆÓ ÂΉËÏÒÛÂˆÓ Ù˘ Á·ÛÙÚÂÓÙÂÚÈ΋˜ ·ÏÏÂÚÁ›·˜ Ó· ·Ó·Ù‡ÛÛÂÙ·È Ë °O¶ ηÈ, ˆ˜ Û˘Ó¤ÂÈ· ·˘Ù‹˜, ‰Â˘ÙÂÚÔ·ıÒ˜ Ó· ÂΉËÏÒÓÂÙ·È Ë ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·. øÛÙfiÛÔ, ı· ÌÔÚÔ‡ÛÂ Ë ·ÏÏÂÚÁ›· Ó· ‰È¢ÎÔχÓÂÈ ÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ Â›ÌÔÓÔ˘ Û˘ÚÈÁÌÔ‡ Î·È Ë °O¶ Ó· ·ÔÙÂÏ› ‰Â˘ÙÂÚÔ·ı‹ ÂΉ‹ÏˆÛË Ô˘ ÂȉÂÈÓÒÓÂÈ ÙËÓ ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· (24,25). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ì ‚¿ÛË Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Ê·›ÓÂÙ·È fiÙÈ Ë °O¶ ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· Ô˘ ÂÈÙ›ÓÂÈ ÙÔÓ ‚ÚÂÊÈÎfi Û˘ÚÈÁÌfi Î·È Ë ·ÓÙÈ-°O¶ ·ÁˆÁ‹ Û˘ÓÙ›ÓÂÈ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘. O ·ÎÚÈ‚‹˜ ÚfiÏÔ˜ ÙÔ˘ ·ÏÏÂÚÁÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙËÓ ÂΉ‹ÏˆÛË Ù˘ °O¶ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ˜. ¶ÂÚ·ÈÙ¤Úˆ ¤Ú¢ӷ ··ÈÙÂ›Ù·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÛ·ÊËÓÈÛÙ› Ë ·ÈÙÈÔÏÔÁÈ΋ ÙÔ˘˜ Û˘Û¯¤ÙÈÛË.

Paediatriki 2002;65:346-350

µÈ‚ÏÈÔÁÚ·Ê›· 1. Orenstein SR, Orenstein DM. Gastroesophageal reflux and respiratory disease in children. J Pediatr 1988;112: 847-857.

2. Nelson SP, Chen EH, Syniar GM, Christoffel KK. One-year follow-up of symptoms of gastroesophageal reflux during infancy. Pediatric Practice Research Group. Pediatrics 1998;102:E67.

3. Sheikh S, Goldsmith LJ, Howell L, Hamlyn J, Eid N. Lung function in infants with wheezing and gastroesophageal reflux. Pediatr Pulmonol 1999;27:236-341.

4. ∫Ô˘ÌÔ˘ÚÏ‹˜ ∞. °·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÂÈÛÚÔÊ‹ÛÂȘ. ¶Ú·ÎÙÈο 10˘ ¢ÈËÌÂÚ›‰·˜ ¶·È‰È·ÙÚÈÎÒÓ ∞Ó·Ó¢ÛÙÈÎÒÓ ¶·ı‹ÛˆÓ. ∞ı‹Ó·; 2001. ÛÂÏ. 25-36.

5. Richter JE. Gastroesophageal reflux disease and asthma: the two are directly related. Am J Med 2000;108 (Suppl 4a):153S-158S. 6. Vijayaratnam V, Lin CH, Simpson P, Tolia V. Lack of significant proximal esophageal acid reflux in infants presenting with respiratory symptoms. Pediatr Pulmonol 1999;27:231-235.

7. Harding SM. GERD, airway disease, and the mechanisms of interaction. In: Stein MR, editor. Gastroesophageal reflux disease and airway disease: lung biology in health and disease. Vol. 129. New York: Marcel Dekker; 1999. p.

139-178.

8. Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med 1995;332:133-138.

9. Iacono G, Carroccio A, Cavataio F, Montalto G, Kazmierska I, Lorello D et al. Gastroesophageal reflux and cow’s milk allergy in infants: a prospective study. J Allergy Clin Immunol 1996;97:822-827.

10. Sheikh S, Stephen T, Howell L, Eid N. Gastroesophageal reflux in infants with wheezing. Pediatr Pulmonol 1999;28:181-186.

11. Eid NS, Shepherd RW, Thomson MA. Persistent wheezing and gastroesophageal reflux in infants. Pediatr Pulmonol 1994;18:39-44.

12. Colombo JL, Sammut PH. Aspiration syndromes. In: Taussig LM, Landau LI, LeSouef PN, Morgan WJ, Martinez FD, Sly PD, editors. Pediatric Respiratory Medicine. St. Louis: Mosby; 1999. p. 435.

13. Boyle JT, Tuchman DN, Altschuler SM, Nixon TE, Pack AI, Cohen S. Mechanisms for the association of gastroesophageal reflux and bronchospasm. Am Rev Respir Dis 1985;131:S16-20.

14. Lodi U, Harding SM, Coghlan HC, Guzzo MR, Walker LH. Autonomic regulation in asthmatics with gastroesophageal reflux. Chest 1997;111:65-70.

15. Sontag SJ. Why do the published data fail to clarify the relationship between gastroesophageal reflux and asthma? Am J Med 2000;108 (Suppl 4a):159S-169S. 16. Vandenplas Y. Asthma and gastroesophageal reflux. J Pediatr Gastroenterol Nutr 1997;24:89-99.

17. •˘ÓÈ¿˜ π, ∫·Ú·Ù˙¿˜ ∂, ™‡ÚÔÁÏÔ˘ ∫, ∆۷ӿη˜ π, ∫·Ú·Ù˙¿˜ ¡, ¶··ÛÙ·‡ÚÔ˘ £ Î·È Û˘Ó. ∞ÓıÂÎÙÈÎfi ÛÙË ıÂÚ·›·

349

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·350

¶·È‰È·ÙÚÈ΋ 2002;65:346-350

18.

19.

20.

21.

22.

23.

¿ÛıÌ·: O ÚfiÏÔ˜ Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘.

38Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ; 2000. ÛÂÏ. 415.

Field SK, Sutherland LR. Does medical antireflux therapy improve asthma in asthmatics with gastroesophageal reflux?: a critical review of the literature. Chest 1998; 114:275-283.

Gibson PG, Henry RL, Coughlan JL. Gastro-oesophageal reflux treatment for asthma in adults and children.

Cochrane Database Syst Rev 2000;(2):CD001496. ∫·ÙÛÈÁÈ·ÓÓ¿ÎË ∂, ∞ÁÁÂÏfiÔ˘ÏÔ˜ ¢, µÂϤÓÙ˙·˜ ¶, ∞Ó·ÛÙ·ÛÈ¿‰Ë˜ °, ∫ÔÙÛÒÓ˘ ∫, ¶··ÏÔ˘Î¿ ∂ Î·È Û˘Ó. °·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶) Û ÓÂÔÁÓ¿, ‚Ú¤ÊË Î·È ·È‰È¿ - O ÚfiÏÔ˜ Ù˘ ÙÚÔÊÈ΋˜ ‰˘Û·ÓÂÍ›·˜/·ÏÏÂÚÁ›·˜. 35Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ; 1997. ÛÂÏ. 229µ∞.

Cavataio F, Iacono G, Montalto G, Soresi M, Tumminello M, Carroccio A. Clinical and pH-metric characteristics of gastro-oesophageal reflux secondary to cows’ milk protein allergy. Arch Dis Child 1996;75:51-56.

Hattevig G, Kjellman B, Johansson SG, Bjorksten B. Clinical symptoms and IgE responses to common food proteins in atopic and healthy children. Clin Allergy 1984;14:551-559.

Kulig M, Bergmann R, Klettke U, Wahn V, Tacke U, Wahn

Paediatriki 2002;65:346-350

U. Natural course of sensitization to food and inhalant allergens during the first 6 years of life. J Allergy Clin Immunol 1999;103:1173-1179.

24. Astarita C, Gargano D, Cutajar M, Napolitano A, Manguso F, Abbate GF. Gastroesophageal reflux disease and asthma: an intriguing dilemma. Allergy 2000;55 (Suppl 61):52-55.

25. Cavataio F, Carroccio A, Iacono G. Milk-induced reflux in infants less than one year of age. J Pediatr Gastroenterol Nutr 2000;30 (Suppl):S36-44.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 18-01-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 01-08-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞Ó‰Ú¤·˜ ∫ÔÓ‰‡Ï˘ °·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎfi π·ÙÚÂ›Ô µ’ ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ∆.∫. 152 36, ¶. ¶ÂÓÙ¤ÏË

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∂›ÌÔÓË ÌfiÏ˘ÓÛË ·fi ·‰ÂÓÔ˚fi Î·È ¯ÚfiÓÈ· ·ÔÊÚ·ÎÙÈ΋ ‚ÚÔÁ¯›Ùȉ· ÛÙ· ·È‰È¿: À¿Ú¯ÂÈ Û¯¤ÛË;1 ∂ÈÛ·ÁˆÁ‹: ∏ ¯ÚfiÓÈ· ·ÔÊÚ·ÎÙÈ΋ ‚ÚÔÁ¯›Ùȉ· Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÈηÓÔÔÈËÙÈο ÛÙ· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ Î·È Ù· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ê¿Ú̷η Â›Ó·È ÌÈ· Ì¿ÏÏÔÓ Û¿ÓÈ· ‰È·Ù·Ú·¯‹ ÛÙ· ·È‰È¿. ∏ Â›ÌÔÓË ÌfiÏ˘ÓÛË ·fi ·‰ÂÓÔ˚fi ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ˆ˜ Èı·Ófi ·›ÙÈÔ Ù˘ ¯ÚfiÓÈ·˜, ÌË ‚ÂÏÙÈÔ‡ÌÂÓ˘ (remitting) ·fiÊڷ͢ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 11 ·È‰È¿ Ì ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ¯ÚfiÓÈ·˜ ‚ÚÔÁ¯È΋˜ ·fiÊڷ͢. ŒÁÈÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜ (HR-CT) Ô˘ ¤‰ÂÈÍ ÂÈÎfiÓ· ˘ÂډȿٷÛ˘, ηıÒ˜ Î·È “ÂÈÎfiÓ· ıÔÏ‹˜ ˘¿ÏÔ˘”. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ¤ÁÈÓ ‰È·‚ÚÔÁ¯È΋ ‹ ·ÓÔÈÎÙ‹ ‚ÈÔ„›· Ó‡ÌÔÓÔ˜. ∏ ¯ÚÒÛË ÙÔ˘ ˘ÏÈÎÔ‡ ¤ÁÈÓ Ì ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ·‰ÂÓÔ˚Ô‡ Î·È ·ÎÔÏÔ‡ıËÛ ÌÈÎÚÔÛÎfiËÛË Ì ÙÔ ÊˆÙÔÌÈÎÚÔÛÎfiÈÔ. ∂›Û˘, Ú·ÁÌ·ÙÔÔÈ‹ıËΠηÏÏȤÚÁÂÈ· ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜, ηıÒ˜ Î·È ‰ÔÎÈ̷ۛ˜ ÂȉÈÎÒÓ ·ÓÙÈÁfiÓˆÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÌÔÓˆı› Ô ·‰ÂÓÔ˚fi˜.

350

∞ÔÙÂϤÛÌ·Ù·: ∞Ó Î·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ˘‹ÚÍ ·ԉ‰ÂÈÁ̤ÓË ÌfiÏ˘ÓÛË ·fi ·‰ÂÓÔ˚fi ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÓfiÛÔ˘, ÂÓÙÔ‡ÙÔȘ, Û η̛· ÂÚ›ÙˆÛË ‰ÂÓ ‚Ú¤ıËΠÂ›ÌÔÓË ÌfiÏ˘ÓÛË ·fi ÙÔÓ Èfi. ™˘ÌÂÚ¿ÛÌ·Ù·: ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ë ÌfiÏ˘ÓÛË ·fi ·‰ÂÓÔ˚fi ÌÔÚ› Ó· ÚÔηÏ› ÙËÓ ¤Ó·ÚÍË Ù˘ ¯ÚfiÓÈ·˜ ·ÔÊÚ·ÎÙÈ΋˜ ‚ÚÔÁ¯›Ùȉ·˜ Û ·È‰È¿, ÁÈ· ÙË ¯ÚÔÓÈfiÙËÙ· Ù˘ ÓfiÛÔ˘ fï˜ ÌÔÚ› Ó· ¢ı‡ÓÔÓÙ·È ¿ÏÏÔÈ ·ıÔÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ› ¤Ú·Ó Ù˘ Â›ÌÔÓ˘ ÌfiÏ˘ÓÛ˘ ·fi ·‰ÂÓÔ˚fi.

1 Pichler M, Herrmann G, Schmidt H, Ahrens P, Zielen S Persistent adenoviral infection and chronic obstructive bronchitis in children: Is there a link?

Pediatr Pulmonol 2001;32:367-371

ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·351

¶·È‰È·ÙÚÈ΋ 2002;65:351-355

∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

Paediatriki 2002;65:351-355

ORIGINAL ARTICLE

ªÂÙ·‚ÔϤ˜ ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ Ù˘ Ë·Ù›Ùȉ·˜ µ Û ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ: 20 ¯ÚfiÓÈ· ÂÌÂÈÚ›·˜ ™. ∫ˆÛÙ·Ú›‰Ô˘1, ™. ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘1, π. ¶. ¶·Ó·ÁÈÒÙÔ˘1, ª. ∞ÓÙˆÓÈ¿‰Ë˜1, ∞. ∆˙È‚¿Ú·˜2, £. ™·Ófi˜2, ™. ∞. ÷˚‰¿˜1

Changes in the incidence of HBV infection among children with hematologic malignancies: 20 year experience S. Kostaridou1, S. Polychronopoulou1, J. P. Panagiotou1, M. Antoniadis1, A. Tzivaras2, Th. Spanos2, S. A. Haidas1

¶ÂÚ›ÏË„Ë: ∆· ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ, ÏfiÁˆ ÙˆÓ Û˘¯ÓÒÓ ÌÂÙ·ÁÁ›ÛÂˆÓ ·›Ì·ÙÔ˜ Î·È ·Ú·ÁÒÁˆÓ ÙÔ˘ ÛÙȘ Ôԛ˜ ˘Ô‚¿ÏÏÔÓÙ·È, ·ÔÙÂÏÔ‡Ó ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ïԛ̈͢ ·fi ÙÔ˘˜ ÈÔ‡˜ Ù˘ Ë·Ù›Ùȉ·˜. ™ÎÔfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛÂ Ë ·ÔÙ‡ˆÛË Ù˘ ‰È·¯ÚÔÓÈ΋˜ ÔÚ›·˜ Î·È ÂͤÏÈ͢ ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡ Ù˘ Ë·Ù›Ùȉ·˜ µ (HBV) ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ÙÔ˘ ∆Ì‹Ì·Ùfi˜ Ì·˜ ηٿ ÙËÓ ÂÈÎÔÛ·ÂÙ›· 1977-1997. ªÂÏÂÙ‹ıËÎ·Ó 64 ·È‰È¿ Ì ÔÍ›· Ï¢¯·ÈÌ›· Ù· ÔÔ›· ‰È·ÁÓÒÛÙËÎ·Ó Î·È ÓÔÛËχıËÎ·Ó Î·Ù¿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô 1977-1990 (ÔÌ¿‰· ∞) Î·È 68 ·È‰È¿, 65 Ì ÔÍ›· Ï¢¯·ÈÌ›· Î·È 3 Ì nonHodgkin ϤÌʈ̷ (ÔÌ¿‰· µ), ÛÙ· ÔÔ›· Ë ‰È¿ÁÓˆÛË Î·È ÓÔÛËÏ›· ¤ÁÈÓ ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 19931997. O ¤ÏÂÁ¯Ô˜ ÙˆÓ ‰ÂÈÎÙÒÓ Ïԛ̈͢ Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ¤ÁÈÓ ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Î·È Â·ÓÂÏ‹ÊıË ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ºÂ‚ÚÔ˘·Ú›Ô˘-¢ÂÎÂÌ‚Ú›Ô˘ 1990 ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ∞ Î·È π·ÓÔ˘·Ú›Ô˘-πÔ˘Ï›Ô˘ 1998 ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ µ. ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ ˘ÔÏÔÁ›ÛÙËÎ·Ó ÔÈ ÌÔÓ¿‰Â˜ ÙˆÓ ·Ú·ÁÒÁˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ Ô˘ ¯ÔÚËÁ‹ıËÎ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘˜. O ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘ ·›Ì·ÙÔ˜ ÂÚÈÂÏ¿Ì‚·Ó ÚÔ ÙÔ˘ 1990 ¤ÏÂÁ¯Ô ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÂÈÊ·Ó›·˜ ÙÔ˘ HBV (HBsAg) Î·È ¤ÏÂÁ¯Ô ÁÈ· Û˘Ê›Ïȉ·, ÂÓÒ ·fi ÙÔ 1985 ÂÈϤÔÓ ¤ÏÂÁ¯Ô Î·È ÁÈ· ÙÔÓ Èfi Ù˘ Â›ÎÙËÙ˘ ·ÓÔÛÔÏÔÁÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ (HIV). ªÂÙ¿ ÙÔ 1990 ÚÔÛÂÙ¤ıË ÛÙÔÓ ¤ÏÂÁ¯Ô Ë ·Ó›¯Ó¢ÛË ÙÔ˘ ÈÔ‡ Ù˘ Ë·Ù›Ùȉ·˜ C (HCV) Î·È ·˘ÙÔÌ·ÙÔÔÈ‹ıËÎ·Ó ÔÈ Ì¤ıÔ‰ÔÈ ÂϤÁ¯Ô˘ fiÏˆÓ ÙˆÓ ‰ÂÈÎÙÒÓ Ë·Ù›Ùȉ·˜ Î·È HIV. ¶·Ú¿ÏÏËÏ· Ì ÙË ‰È·ÊÔÚÔÔ›ËÛË Ù˘ ÔÏÈÙÈ΋˜ ÂϤÁ¯Ô˘ Ù˘ ·ÈÌÔ‰ÔÛ›·˜, ·fi ÙÔ 1992 Î·È ÂÓÙ‡ıÂÓ Î·ıÈÂÚÒıËΠÛÙÔ ∆Ì‹Ì· Ì·˜ Ô ÚÔÊ˘Ï·ÎÙÈÎfi˜

Abstract: Children with hematologic malignancies belong to the high risk population for hepatitis B infection due to the multiple blood products that they receive during the periods of intensive treatment. The aim of our study was to document the changes in the incidence of hepatitis B virus (HBV) infection in patients with hematologic malignancies observed during the twenty year period 1977-1997. The study included 64 patients with acute leukemia diagnosed and treated in our Department during the years 1977-1990 (group A), and 68 patients (group B) 65 with acute leukemia, 3 with non-Hodgkin lymphoma, diagnosed and treated during the years 1993-1997. Hepatitis markers were investigated in all patients in group A at the time of initial diagnosis and again during February-December 1990, while in group B patients during January-July 1998. The number of blood product units transfused during treatment was documented for each group of patients.

Before 1990, blood products screening, included HBsAg and syphilis detection while investigation for HIV infection has been established since 1985.

After 1990, hepatitis B and HIV examination became totally automatized and investigation for HCV was added to the screening. Prophylactic immunization in all our patients was initiated in 1992 in parallel to the Blood Bank transfusion unit policy regarding the safety control of blood products. The Elisa method for Hepatitis B markers (HBsAg, Anti-HBc, Anti-HBs) was used. Twenty two percent (22%) of Group A patients were found to be infected while 9.3% remained chronic HBsAg carriers. Liver biopsies were performed in 2/6 of the chronic carriers and found to be compatible with

1 ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-OÁÎÔÏÔÁ›·˜ 2 ªÔÓ¿‰· ∞ÈÌÔ‰ÔÛ›·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

1 Department of Pediatric Hematology-Oncology 2 Blood Transfusion Unit, “Aghia Sophia” Children’s Hospital, Athens

351

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·352

¶·È‰È·ÙÚÈ΋ 2002;65:351-355

Paediatriki 2002;65:351-355

ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ Ë·Ù›Ùȉ·˜ µ. O ¤ÏÂÁ¯Ô˜ ÙˆÓ ‰ÂÈÎÙÒÓ HBsAg, Anti-HBc, Anti-HBs ¤ÁÈÓÂ Î·È ÛÙȘ ‰‡Ô ÂÚÈfi‰Ô˘˜ Ì ·ÓÔÛÔÂÓ˙˘ÌÈ΋ ̤ıÔ‰Ô. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜ ∞ ‚Ú¤ıËΠfiÙÈ 14/64 ·ÛıÂÓ›˜ (22%) ›¯·Ó ÌÔÏ˘Óı› ·fi ÙÔÓ HBV, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ 6/64 (9,3%) ·Ú¤ÌÂÈÓ·Ó ¯ÚfiÓÈÔÈ ÊÔÚ›˜ HBsAg. ∆· Â˘Ú‹Ì·Ù· Ù˘ ‚ÈÔ„›·˜ ‹·ÙÔ˜ Ô˘ ¤ÁÈÓ Û 2 ·fi ÙÔ˘˜ 6 ¯ÚfiÓÈÔ˘˜ ÊÔÚ›˜ ‹Ù·Ó Û˘Ì‚·Ù¿ Ì ΛÚÚˆÛË. ŒÓ·˜ ·ÛıÂÓ‹˜ ·fi 10ÂÙ›·˜ Û ·ÈÌ·ÙÔÏÔÁÈ΋ ‡ÊÂÛË, ÌÂÙ¿ ·fi ÊÔÚ›· Î·È ÂÓÂÚÁfi Ïԛ̈ÍË 8 ÂÙÒÓ, ·Ó¤Ù˘Í Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ Î·È Î·Ù¤ÏËÍÂ. ™ÙËÓ ÔÌ¿‰· µ 56/68 ·ÛıÂÓ›˜ (82,4%) ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó Î·Ù¿ Ù˘ Ë·Ù›Ùȉ·˜ µ. ∂Í ·˘ÙÒÓ, 15 ·ÛıÂÓ›˜ (26,8%) ›¯·Ó ÔÏÔÎÏËÚÒÛÂÈ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÚÔ Ù˘ ÓfiÛËÛ˘, 28 (50%) ¿Ú¯ÈÛ·Ó ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË, ÂÓÒ 13 (23,2%) Û˘ÌÏ‹ÚˆÛ·Ó ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜ µ, ÌfiÓÔ 1/68 ·ÛıÂÓ›˜ (1,4%), Ô˘ ·Ó‹Î ÛÙÔ˘˜ 12 ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó (17,6%), ‚Ú¤ıËΠӷ ¤¯ÂÈ ÌÔÏ˘Óı› ·fi ÙÔÓ HBV Î·È Ó· ¤¯ÂÈ ·Ó·Ù‡ÍÂÈ Ê˘ÛÈ΋ ·ÓÔÛ›·. ∂›ÎÔÛÈ ¤ÍÈ ·fi ÙÔ˘˜ 56 ·ÛıÂÓ›˜ (46%) Ô˘ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ‚Ú¤ıËÎ·Ó Ó· ‰È·ÙËÚÔ‡Ó ÚÔÛٷ٢ÙÈÎÔ‡˜ Ù›ÙÏÔ˘˜ Anti-HBs ηı’ fiÏË ÙË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ê·›ÓÂÙ·È fiÙÈ ÛÙ· ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ÙÔ˘ ∆Ì‹Ì·Ùfi˜ Ì·˜, Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ Ë·Ù›Ùȉ·˜ µ ÌÂÈÒıËΠÛËÌ·ÓÙÈο ηٿ ÙȘ ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, ÁÂÁÔÓfi˜ Ô˘ ·Ô‰›‰ÂÙ·È ÛÙË ‚ÂÏÙ›ˆÛË ÌÂıfi‰ˆÓ ÂÈÏÔÁ‹˜ ÙˆÓ ·ÈÌÔ‰ÔÙÒÓ Î·È ÂϤÁ¯Ô˘ ÙÔ˘ ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘ ·›Ì·ÙÔ˜, ·ÏÏ¿ Î·È ÛÙËÓ Î·ıȤڈÛË ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ηٿ Ù˘ Ë·Ù›Ùȉ·˜ µ, ÙfiÛÔ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜, fiÛÔ Î·È ÛÙÔÓ Â˘Ú‡ÙÂÚÔ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi.

hepatic cirrhosis. One (1) out of the 6 HBsAg chronic carriers (ALL patient) developed hepatocellular carcinoma and finally succumbed while in complete hematological remission for 10 years, following an 8 year chronic active hepatitis state. In group B patients, 56/68 were vaccinated: 15 (26.8%) were completely vaccinated before ALL diagnosis, in 28 (50%) vaccination was performed soon after diagnosis and in 13 (23.2%) vaccination was continued and completed after the establishment of the diagnosis. Only 1/68 patients (1.4%) was infected during the course of the disease/treatment, but she finally seroconverted.

This patient belonged to the minority of patients of this group (12, 8,4%) who had not been vaccinated. Twenty-six of the 56 vaccinated patients (46%) in group B, maintained protective anti-HBs during the follow-up period. The incidence of hepatitis B infection among children with hematologic malignancies has been drastically reduced during the last decade. This could be attributed both to the refinement of Blood Bank policy (selection of donors, control of blood products for hepatitis infection) and to the practice of routine prophylactic immunization against HBV in all the immunocompromized patients with hematologic malignancies as well as in the general pediatric population.

§¤ÍÂȘ ÎÏÂȉȿ: ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ, Ïԛ̈ÍË Ì HBV, ÂÌ‚ÔÏÈ·ÛÌfi˜, ·È‰È΋ ËÏÈΛ·.

Key words: hematologic malignancies, HBV infection, vaccination, childhood.

∂ÈÛ·ÁˆÁ‹ O ΛӉ˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ ÈÔ‡ Ù˘ Ë·Ù›Ùȉ·˜ B (HBV) Ì ÙȘ ÌÂÙ·ÁÁ›ÛÂȘ ·›Ì·ÙÔ˜ Î·È ·Ú·ÁÒÁˆÓ ÙÔ˘ ÌÂÈÒıËΠÛËÌ·ÓÙÈο ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·, ÁÂÁÔÓfi˜ ÙÔ ÔÔ›Ô ·Ô‰›‰ÂÙ·È: ·) ÛÙË ÏÂÙÔÌÂÚ‹ ÂÈÏÔÁ‹ ÙˆÓ ·ÈÌÔ‰ÔÙÒÓ Î·È ‚) ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ¢·ÈÛıËÛ›·˜ ÙˆÓ ÌÂıfi‰ˆÓ ÂϤÁ¯Ô˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÂÈÊ·Ó›·˜ ÙÔ˘ ÈÔ‡ Ù˘ Ë·Ù›Ùȉ·˜ µ (HBsAg) (1). øÛÙfiÛÔ, ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÔÙÂÏ› ̤¯ÚÈ Û‹ÌÂÚ· ˘·ÚÎÙfi ΛӉ˘ÓÔ ÓÔÛËÚfiÙËÙ·˜ ÁÈ· ÙÔ˘˜ ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘˜ ·ÛıÂÓ›˜. ªÂ ÙË “¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ·Ú·ı‡ÚÔ˘” ÙˆÓ 59 ËÌÂÚÒÓ, Ô ˘ÔÏÂÈfiÌÂÓÔ˜ ΛӉ˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ HBV ˘ÔÏÔÁ›˙ÂÙ·È Û‹ÌÂÚ· Û 5,6, 15,8 Î·È 20 ÂÚÈÙÒÛÂȘ/106 ÌÔÓ¿-

‰Â˜ ·›Ì·ÙÔ˜ ÁÈ· ÙË °·ÏÏ›·, °ÂÚÌ·Ó›· Î·È ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ ·ÓÙ›ÛÙÔȯ· (1-3).

O ÌÈÎÚfi˜, ·ÏÏ¿ ˘·ÚÎÙfi˜, ΛӉ˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ HBV ·ÔÎÙ¿ ‰È·ÊÔÚÂÙÈΤ˜ ‰È·ÛÙ¿ÛÂȘ ÁÈ· ÙÔ˘˜ ÔÏ˘ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘˜ ·ÛıÂÓ›˜. ∆· ·È‰È¿ Ì ηÎÔ‹ıË ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù·, ÏfiÁˆ ÙˆÓ Û˘¯ÓÒÓ ÌÂÙ·ÁÁ›ÛÂˆÓ ·Ú·ÁÒÁˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙȘ Ôԛ˜ ˘Ô‚¿ÏÏÔÓÙ·È, ·ÔÙÂÏÔ‡Ó ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÌfiÏ˘ÓÛ˘ ·fi HBV (4). ∆· ÙÂÏÂ˘Ù·›· ¤ÙË, Ë ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Ù›ÓÂÈ Û˘Ó¯Ҙ Ó· ÂÓÙ·ÙÈÎÔÔÈÂ›Ù·È ÁÈ· ÙȘ ÔÌ¿‰Â˜ Ï¢¯·ÈÌ›·˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ∆Ô‡ÙÔ ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ Î·È ‚·Ú‡ÙËÙ·˜ ‰È·ÛÙ‹Ì·Ù·

352

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·353

¶·È‰È·ÙÚÈ΋ 2002;65:351-355

·Ï·Û›·˜ Î·È ·ÓÔÛÔηٷÛÙÔÏ‹˜, ˘ÔÛÙ‹ÚÈÍË Ì ÂÚÈÛÛfiÙÂÚ˜ ÌÂÙ·ÁÁ›ÛÂȘ ·Ú·ÁÒÁˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÌfiÏ˘ÓÛ˘ Ì HBV (5). ™ÎÔfi Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ·ÔÙÂÏ› Ë ‰ÈÂÚ‡ÓËÛË Ù˘¯fiÓ ‰È·ÊÔÚÔÔ›ËÛ˘ ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ ÙÔ˘ HBV Û ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ÛÙȘ ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎÂ Û˘ÁÎÚÈÙÈο Ë Û˘¯ÓfiÙËÙ· ÌfiÏ˘ÓÛ˘ Ì HBV ‰‡Ô ÔÌ¿‰ˆÓ ·ÛıÂÓÒÓ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ (ÔÌ¿‰ˆÓ ∞ Î·È µ). ∏ ‰È¿ÎÚÈÛË ÙˆÓ ·ÛıÂÓÒÓ Û ÔÌ¿‰Â˜ ¤ÁÈÓ Ì ‚¿ÛË ÙÔ ¯ÚfiÓÔ ‰È¿ÁÓˆÛ˘, ÂÈÛ·ÁˆÁ‹˜ Î·È ÓÔÛËÏ›·˜ ÛÙÔ ∆Ì‹Ì· Ì·˜. ∆ËÓ ÔÌ¿‰· ∞ ·ÔÙ¤ÏÂÛ·Ó 64 ·È‰È¿ (43 ·ÁfiÚÈ·, 21 ÎÔÚ›ÙÛÈ·), ËÏÈΛ·˜ 3-21,5 ÂÙÒÓ (‰È¿ÌÂÛË ËÏÈΛ· 10 ¤ÙË) Ì ÔÍ›· Ï¢¯·ÈÌ›·, ÛÙ· ÔÔ›· Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ¤ÁÈÓ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô 1977-1990. OÈ ‰Â›ÎÙ˜ Ïԛ̈͢ HBsAg, AntiHBc, Anti-HBs ÂϤÁ¯ıËÎ·Ó Û ‰‡Ô ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜: ·) ·Ú¯Èο, ηٿ ÙÔ ¯ÚfiÓÔ ‰È¿ÁÓˆÛ˘ Î·È ‚) ÂÈÚfiÛıÂÙ·, ηٿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ÙÔ˘ ºÂ‚ÚÔ˘·Ú›Ô˘-¢ÂÎÂÌ‚Ú›Ô˘ 1990, fiÙ·Ó fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ›¯·Ó Û˘ÌÏËÚÒÛÂÈ ÙË ıÂÚ·›· ÂÈÛ·ÁˆÁ‹˜ ÛÙËÓ ‡ÊÂÛË Î·È ÛÙ·ıÂÚÔÔ›ËÛ˘ Î·È Â›¯·Ó Ï¿‚ÂÈ ÙÔ Ì¤ÁÈÛÙÔ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÌÂÙ·ÁÁ›ÛÂÒÓ ÙÔ˘˜. ∆ËÓ ÔÌ¿‰· µ ·ÔÙ¤ÏÂÛ·Ó 68 ·È‰È¿ (38 ·ÁfiÚÈ·, 30 ÎÔÚ›ÙÛÈ·), ËÏÈΛ·˜ 2-19 ÂÙÒÓ (‰È¿ÌÂÛË ËÏÈΛ· 8,8 ¤ÙË). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ (65 ÔÍ›· Ï¢¯·ÈÌ›·, 3 non-Hodgkin ϤÌʈ̷) ¤ÁÈÓ ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1993-1997. OÈ ‰Â›ÎÙ˜ Ïԛ̈͢ ·fi HBV ÂϤÁ¯ıËηÓ, fiˆ˜ Î·È ÛÙËÓ ÚÔËÁÔ‡ÌÂÓË ÔÌ¿‰·, ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Î·È Î·Ù¿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô π·ÓÔ˘·Ú›Ô˘-πÔ˘Ó›Ô˘ 1998. ∞fi ÙÔ 1992 Î·È ÌÂÙ¿ ηıÈÂÚÒıËΠÛÙÔ ∆Ì‹Ì· Ì·˜ Ô ÚÔÊ˘Ï·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ Ë·Ù›Ùȉ·˜ µ, Ô ÔÔ›Ô˜ ÂÚÈÂÏ¿Ì‚·Ó ÂÓÙ·ÙÈÎÔÔÈË̤ÓÔ ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·: 3 ·Ú¯ÈΤ˜ ‰fiÛÂȘ Ì ÌÂÛԉȿÛÙËÌ· ÂÓfi˜ ÌËÓfi˜ Î·È ·Ó·ÌÓËÛÙÈ΋ ‰fiÛË 6 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ‰fiÛË. ∏ οı ‰fiÛË ÂÌ‚ÔÏ›Ô˘ ‹Ù·Ó 20 mcg Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ·ÓÂÍ·Úًو˜ ËÏÈΛ·˜. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ µ, Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ Ë·Ù›Ùȉ·˜ µ ›¯Â ÚÔËÁËı› (Û‡Ìʈӷ Ì ÙÔ ÂÊ·ÚÌÔ˙fiÌÂÓÔ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi Û¯‹Ì·) Ù˘ ÓfiÛËÛ˘ Û 15/68 ·È‰È¿, ¿Ú¯ÈÛ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË ‹ Û˘ÌÏËÚÒıËΠ۠28/68 Î·È Û 13/68 ·È‰È¿ ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏfiÁÔ˘˜ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó 12/68 ·È‰È¿. ¶ÚÈÓ ÙÔ 1990 Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘ ·›Ì·ÙÔ˜ ÂÚÈÂÏ¿Ì‚·ÓÂ: ·) ¤ÏÂÁ¯Ô ÁÈ· HBsAg, ‚) ¤ÏÂÁ¯Ô ÁÈ· HIV (·fi ÙÔ ™Â٤̂ÚÈÔ ÙÔ˘ 1995) Î·È Á) ¤ÏÂÁ¯Ô ÁÈ· Û˘Ê›Ïȉ·. ªÂÙ¿ ÙÔ ºÂ‚ÚÔ˘¿ÚÈÔ ÙÔ˘ 1992 ÚÔÛÙ¤ıËΠÛÙÔÓ ¤ÏÂÁ¯Ô Ë ·Ó·˙‹ÙËÛË Î·È ¿ÏÏˆÓ ÏÔÈÌÔÁfiÓˆÓ ·Ú·ÁfiÓÙˆÓ (.¯. HCV) Ô˘ ÌÂÙ·‰›‰ÔÓÙ·È Î·Ù¿ ÙÔÓ ›‰ÈÔ ÙÚfiÔ Ì ÙÔÓ HBV. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ‚Ô‹ıËÛ ÛÙÔÓ ÂÓÙÔÈÛÌfi ÙˆÓ ·ÙfïÓ-ÊÔÚ¤ˆÓ Î·È ÙÔ˘ HBV. ¶·Ú¿ÏÏËÏ·, ‚ÂÏÙÈÒıËÎ·Ó ÔÈ Ì¤ıÔ‰ÔÈ ÂϤÁ¯Ô˘ ÙÔ˘ ·›Ì·ÙÔ˜ ÁÈ· Ù˘¯fiÓ ¿ÏϘ ÏÔÈÌÒÍÂȘ (ÂÊ·ÚÌÔÁ‹ ‰‡Ô ‰ÔÎÈÌ·ÛÈÒÓ-·˘ÙÔÌ·ÙÔÔ›ËÛË ÙˆÓ ÌÂıfi‰ˆÓ).

O ¤ÏÂÁ¯Ô˜ ÙˆÓ ‰ÂÈÎÙÒÓ HBsAg (·ÓÙÈÁfiÓÔ ÂÈÊ·Ó›·˜),

Paediatriki 2002;65:351-355

Anti-HBC (·Óٛۈ̷ ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ core ÙÔ˘ HBV), Anti-HBs (·Óٛۈ̷ ÂÈÊ·Ó›·˜ ¤Ó·ÓÙÈ ÙÔ˘ HBV), ¤ÁÈÓ Ì ·ÓÔÛÔÂÓ˙˘ÌÈ΋ ̤ıÔ‰Ô. ∂› ÂӉ›ÍˆÓ, Ô ¤ÏÂÁ¯Ô˜ Û˘ÌÏËÚÒıËÎÂ Î·È Ì ¿ÏÏÔ˘˜ ‰Â›ÎÙ˜ Ïԛ̈͢ ·fi HBV, fiˆ˜ HbeAg (·ÓÙÈÁfiÓÔ e Ù˘ Ë·Ù›Ùȉ·˜ µ), Anti-Hbe (·Óٛۈ̷ e Ù˘ Ë·Ù›Ùȉ·˜ µ), Anti-Hb IgM (·Óٛۈ̷ ÙÔ˘ ˘Ú‹Ó· Ù‡Ô˘ IgM), HBV-DNA (DNA ÙÔ˘ ÈÔ‡ Ù˘ Ë·Ù›Ùȉ·˜ µ). ∂ÈϤÔÓ, Û 2/6 ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ∞ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‰È·ÈÛÙÒıËÎ·Ó ‚ÈÔ¯ËÌÈο Â˘Ú‹Ì·Ù· ¯ÚfiÓÈ·˜ Ë·ÙÈ΋˜ ‚Ï¿‚˘, ¤ÁÈÓÂ Î·È ‚ÈÔ„›· ‹·ÙÔ˜. ∆¤ÏÔ˜, ˘ÔÏÔÁ›ÛÙËÎÂ Ô ·ÚÈıÌfi˜ ÌÔÓ¿‰ˆÓ ·Ú·ÁÒÁˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ Ô˘ ¯ÔÚËÁ‹ıËÎ·Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ Î·È ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ.

∞ÔÙÂϤÛÌ·Ù· ™ÙËÓ ÔÌ¿‰· ∞ fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ ‹Ù·Ó ÔÚÔ·ÚÓËÙÈÎÔ› ÁÈ· HBsAg, Anti-HBc Î·È Anti-HBs ηٿ ÙË ‰È¿ÁÓˆÛË. ∫·Ù¿ ÙÔ ¯ÚfiÓÔ Â·ÓÂϤÁ¯Ô˘, 14/64 ·ÛıÂÓ›˜ (22%) ‚Ú¤ıËÎ·Ó Ó· ¤¯Ô˘Ó ÌÔÏ˘Óı› ·fi ÙÔÓ HBV (¶›Ó·Î·˜ 1). ∞Ó·Ï˘ÙÈÎfiÙÂÚ·, 6/64 (9,3%) ·ÛıÂÓ›˜ ·Ó¤Ù˘Í·Ó Ê˘ÛÈ΋ ·ÓÔÛ›·. ¢‡Ô ·ÛıÂÓ›˜ (3,1%) ‚Ú¤ıËÎ·Ó Ì ·ÓÙÈÛÒÌ·Ù· Anti-HBc (IgG). ¶·Ú¿ÏÏËÏ·, 6/64 ·ÛıÂÓ›˜ (9,3%) ÌÔχÓıËÎ·Ó ·fi ÙÔÓ HBV Î·È ·Ú¤ÌÂÈÓ·Ó ¯ÚfiÓÈÔÈ ÊÔÚ›˜ ÙÔ˘ ÈÔ‡. ™Â ‚ÈÔ„›· ‹·ÙÔ˜ ˘Ô‚Ï‹ıËÎ·Ó 2/6 ¯ÚfiÓÈÔ˘˜ ÊÔÚ›˜, Ë ÔÔ›· ¤‰ÂÈÍ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Û˘Ì‚·Ù‹ Ì ΛÚÚˆÛË. ∂Í ·˘ÙÒÓ, Ô ¤Ó·˜ Ì ÔÍ›· Ï¢¯·ÈÌ›· ·fi 10ÂÙ›·˜ Û ·ÈÌ·ÙÔÏÔÁÈ΋ ‡ÊÂÛË, ÌÂÙ¿ ·fi ÊÔÚ›· Î·È ÂÓÂÚÁfi Ïԛ̈ÍË 8 ÂÙÒÓ, ·Ó¤Ù˘Í Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ ·fi ÙÔÓ ÔÔ›Ô Î·È Î·Ù¤ÏËÍÂ.

OÈ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ∞ ÌÂÙ·ÁÁ›ÛÙËÎ·Ó Î·Ù¿ ̤ÛÔ fiÚÔ Ì 7,3 ÌÔÓ¿‰Â˜ Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ, 4,0 ÌÔÓ¿‰Â˜ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È 5,2 ÌÔÓ¿‰Â˜ Ï¿ÛÌ·ÙÔ˜ ·Ó¿ ·ÛıÂÓ‹. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ µ, ÌfiÓÔÓ 1/68 (1,4%) ÌÔχÓıËΠ·fi ÙÔÓ HBV ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ıÂÚ·›· ÂÊfi‰Ô˘ Î·È ·Ó¤Ù˘ÍÂ Ê˘ÛÈ΋ ·ÓÔÛ›· (Anti-HBs Î·È Anti-HBc). ∞ӋΠÛÙÔ˘˜ 12 ·ÛıÂÓ›˜ Ô˘ ÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏfiÁÔ˘˜ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛÙËηÓ. ∫·Ó¤Ó·˜ ¿ÏÏÔ˜ ·ÛıÂÓ‹˜ ·fi ÙÔ˘˜ 56 Ô˘ ÂÌ‚ÔÏÈ¿ÛÙËηÓ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÓÙ·fiÎÚÈÛË, ‰ÂÓ ÌÔχÓıËÎÂ. ∞fi ÙÔ˘˜ 56 ÂÌ‚ÔÏÈ·Ûı¤ÓÙ˜ ·ÛıÂÓ›˜, ÔÈ 26 (46%) ‰È·Ù‹ÚËÛ·Ó ÛÙ·ıÂÚ¿ ηٿ ÙȘ Ê¿ÛÂȘ ÂϤÁ¯Ô˘ ÚÔÛٷ٢ÙÈÎÔ‡˜ Ù›ÙÏÔ˘˜ antiHBs (>10 miu/ml). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ µ ¯ÔÚËÁ‹ıËÎ·Ó Î·Ù¿ ̤ÛÔ fiÚÔ 8,7 ÌÔÓ¿‰Â˜ Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ, 5,1 ÌÔÓ¿‰Â˜ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È 3,1 ÌÔÓ¿‰Â˜ Ï¿ÛÌ·ÙÔ˜ ·Ó¿ ·ÛıÂÓ‹. ™˘˙‹ÙËÛË ∏ Ë·Ù›Ùȉ· ÌÂÙ¿ ·fi ÌÂÙ¿ÁÁÈÛË ·Ú·ÁÒÁˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÔÙÂÏ› ̤¯ÚÈ Û‹ÌÂÚ· ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· (3). ∞Ó Î·È ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ë·Ù›Ùȉ·˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙȘ ÌÂÙ·ÁÁ›ÛÂȘ ·ÊÔÚ¿ ÌÂÙ¿‰ÔÛË ÈÒÓ ÙÔ˘ Ù‡Ô˘ ÌË-∞, ÌË-µ,

353

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·354

¶·È‰È·ÙÚÈ΋ 2002;65:351-355

Paediatriki 2002;65:351-355

ÌË-C, Ô Î›Ó‰˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ HBV Â›Ó·È ˘·ÚÎÙfi˜ Î·È ÚfiÛÊ·Ù· ÂÎÙÈÌ‹ıËΠ۠5,6-20 ÂÚÈÙÒÛÂȘ/106 ÌÔÓ¿‰ˆÓ ·›Ì·ÙÔ˜ (1-3). ∆· ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ÏfiÁˆ Ù˘ ıÂÚ·›·˜ ÛÙËÓ ÔÔ›· ˘Ô‚¿ÏÏÔÓÙ·È Î·È ÙˆÓ Û˘ÓÔ‰ÒÓ ·ÚÂÓÂÚÁÂÈÒÓ Ù˘ (Ì˘ÂÏÔÙÔÍÈÎfiÙËÙ·, ‰È·Ù·Ú·¯¤˜ Ì˯·ÓÈÛÌÔ‡ ‹Í˘ Î.¿.), ¤¯Ô˘Ó ·Ó¿ÁÎË ˘ÔÛÙËÚÈÎÙÈ΋˜ ·ÁˆÁ‹˜ ÌÂ Û˘¯Ó¤˜ ÌÂÙ·ÁÁ›ÛÂȘ Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ, ·ÈÌÔÂÙ·Ï›ˆÓ Î·È Ï¿ÛÌ·ÙÔ˜. ∫·Ù¿ Û˘Ó¤ÂÈ·, ıˆÚÔ‡ÓÙ·È fiÙÈ ·ÔÙÂÏÔ‡Ó ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÌfiÏ˘ÓÛ˘ ·fi ÙÔÓ HBV (4). ∂ÈϤÔÓ, Ù· Û‡Á¯ÚÔÓ· ÚˆÙfiÎÔÏÏ· ¯ËÌÂÈÔıÂÚ·›·˜ Ù›ÓÔ˘Ó Û˘Ó¯Ҙ Ó· ÂÓÙ·ÙÈÎÔÔÈÔ‡ÓÙ·È ÛÙȘ ÔÌ¿‰Â˜ Ï¢¯·ÈÌ›·˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ηÈ, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, ÔÈ ÂÚ›Ô‰ÔÈ Ì˘ÂÏÈ΋˜ ·Ï·Û›·˜ ÂÈÌË·ÓÔÓÙ·È, ÔÈ ·Ó¿ÁΘ ÁÈ· ÌÂÙ·ÁÁ›ÛÂȘ ÏËı·›ÓÔ˘Ó Î·È Ô Î›Ó‰˘ÓÔ˜ ÌfiÏ˘ÓÛ˘ ·fi ÙÔÓ HBV ·˘Í¿ÓÂÈ (5). ∏ ¤ÓÙÔÓË Î·È ·Ú·ÙÂٷ̤ÓË ·ÓÔÛÔηٷÛÙÔÏ‹ ÛÙËÓ ÔÔ›· ‚Ú›ÛÎÔÓÙ·È ÔÈ ·ÛıÂÓ›˜ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ, ÏfiÁˆ Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ ·ÏÏ¿ Î·È ÏfiÁˆ ÙÔ˘ ˘ÔΛÌÂÓÔ˘ ÓÔÛ‹Ì·ÙÔ˜, ÙÚÔÔÔÈ› ÙË Ê˘ÛÈ΋ ÔÚ›· Î·È ÙËÓ ÂͤÏÈÍË Ù˘ Ïԛ̈͢ ·fi ÙÔÓ HBV Î·È ÙËÓ Ô‰ËÁ› Û˘¯ÓfiÙÂÚ· Û ¯ÚfiÓÈ· Ë·Ù›Ùȉ· ÂÓÂÚÁfi ‹ ÂÈ̤ÓÔ˘Û·. ¶·Ú¿ÏÏËÏ·, ÛËÌÂÈÒÓÂÙ·È fiÙÈ Ë ¯ÚfiÓÈ· ÊÔÚ›· ÂÓ‰¤¯ÂÙ·È Ó· ηٷϋÍÂÈ Û ΛÚÚˆÛË ÙÔ˘ ‹·ÙÔ˜, Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ (4,6). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Ô ÂÈÔÏ·ÛÌfi˜ ÙÔ˘ HBV ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ÙÔ˘ ∆Ì‹Ì·Ùfi˜ Ì·˜ Ù˘ ÚÒÙ˘ ‰ÂηÂÙ›·˜ ‚Ú¤ıËÎÂ

˘„ËÏfi˜ (22%) Î·È ‹Ù·Ó ·Ó¿ÏÔÁÔ˜ ·ÚfiÌÔÈˆÓ ‰ÈÂıÓÒÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ ÁÈ· ÙËÓ ›‰È· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô (7). ∂ÈϤÔÓ, ÙÔ 9,3% ·˘ÙÒÓ ·Ú¤ÌÂÈÓ ¯ÚfiÓÈÔ˜ ÊÔÚ¤·˜ ÙÔ˘ HBV Ì ‚ÈÔ¯ËÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∏ ‚ÈÔ„›· ‹·ÙÔ˜ Û 2/6 ·ÛıÂÓ›˜ ›¯Â Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ΛÚÚˆÛË Î·È ¤Ó·˜ ÂÍ ·˘ÙÒÓ, ÌÂÙ¿ ·fi ÊÔÚ›· Î·È ÂÓÂÚÁfi Ïԛ̈ÍË 8 ÂÙÒÓ, ·Ó¤Ù˘Í Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ Î·È Î·Ù¤ÏËÍÂ. ∫·Ù¿ ÙË ‰Â‡ÙÂÚË ‰ÂηÂÙ›· ˘‹ÚÍ·Ó ÚÈ˙ÈΤ˜ ÙÔ̤˜ ‰ÈÂıÓÒ˜ ˆ˜ ÚÔ˜ ÙËÓ ·ÓÙ›ÏË„Ë ÁÈ· ÙËÓ ÂÌ‚ÔÏÈ·ÛÙÈ΋ Î¿Ï˘„Ë ÙˆÓ ·È‰ÈÒÓ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ (8). ™ÙÔ ∆Ì‹Ì· Ì·˜: ·) ¤¯ÔÓÙ·˜ ·ÔÙ˘ÒÛÂÈ ÙÔÓ ÂÈÔÏ·ÛÌfi Ù˘ HBV Ïԛ̈͢ ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ (9) Î·È ‚) Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙȘ ·ÏÏ·Á¤˜ ÛÙË Û˘ÓÔÏÈ΋ ÂÌ‚ÔÏÈ·ÛÙÈ΋ Î¿Ï˘„Ë ÙˆÓ ∂ÏÏËÓÔ·›‰ˆÓ ÁÈ· ÙÔÓ HBV ÌÂÙ¿ ÙÔ 1992 (10), ÚÔ¯ˆÚ‹Û·Ì Û ÂÌ‚ÔÏÈ·ÛÌfi fiÏˆÓ ÙˆÓ ÓÂԉȷÁÓˆÛı¤ÓÙˆÓ ·ÛıÂÓÒÓ Ì·˜. ™ÙËÓ ÚÔÒıËÛË ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙÔ˘˜ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ Û˘ÓÂÙ¤ÏÂÛÂ Î·È Ë ·ÛÊ¿ÏÂÈ· Ô˘ ·Ú¤¯ÂÈ Ë ¯ÚËÛÈÌÔÔ›ËÛË ÂÌ‚ÔÏ›Ô˘ Ô˘ ·Ú¿ÁÂÙ·È Ì Ù¯ÓÈΤ˜ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ DNA (10). ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ηıȤڈÛ˘ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ηٿ Ù˘ Ë·Ù›Ùȉ·˜ µ ÙfiÛÔ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÙÔ˘ ∆Ì‹Ì·Ùfi˜ Ì·˜ (11), fiÛÔ Î·È ÛÙÔÓ Â˘Ú‡ÙÂÚÔ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi ·È‰ÈÒÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ (10,12) ‹ ÓÔÛÔ‡ÓÙˆÓ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ (13-15), ηıÒ˜ Î·È Ë ·˘ÛÙËÚ‹ ÂÈÏÔÁ‹ ÙˆÓ ·ÈÌÔ‰ÔÙÒÓ Ì ÙËÓ ·Ú¿ÏÏËÏË ‚ÂÏÙ›ˆÛË ÙˆÓ Ù¯ÓÈÎÒÓ ÂϤÁ¯Ô˘ ÙÔ˘ ¯ÔÚËÁÔ‡ÌÂÓÔ˘ ·›Ì·ÙÔ˜ ˆ˜ ÚÔ˜

¶›Ó·Î·˜ 1. ∞ÛıÂÓ›˜ ÌÔÏ˘Óı¤ÓÙ˜ ·fi ÙÔÓ HBV ηٿ Ù· ¤ÙË ·Ú·ÎÔÏÔ‡ıËÛ˘ 1977-1990 (ÔÌ¿‰· ∞) Î·È 1990-1997 (ÔÌ¿‰· µ) OÌ¿‰· ∞ º‡ÏÔ

∏ÏÈΛ· (¤ÙË)

∏µsAg

Anti-HBc

Anti-HBs

¢È·Ù·Ú·¯¤˜ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜

1. ∞ 2. ∞ 3. ∞ 4. ∞ 5. ∞ 6. ∞ 7. ∞ 8. ∞ 9. ∞ 10. ∞ 11. ∞ 12. ∞ 13. ∞ 14. £

15 2 3 7 5 13 7 9 14 15 16 21 17 9

+ + + + + +

+ + + + + + + + + -

+ + + + + + -

Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È

15. £

2

-

+

+

Ÿ¯È

OÌ¿‰· µ Anti-HBc (IgM) ÛÙÔ˘˜ ·ÛıÂÓ›˜ 1, 2: ·ÚÓËÙÈÎfi Anti-HBs >20 mIU/mL HbeAg: ·ÚÓËÙÈÎfi, Anti-Hbe: ıÂÙÈÎfi Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ıÂÙÈÎfi HBsAg

354

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·355

¶·È‰È·ÙÚÈ΋ 2002;65:351-355

ÙÔÓ Î›Ó‰˘ÓÔ ÌÂÙ¿‰ÔÛ˘ ÈÒÓ, ·¤‰ˆÛ·Ó ÂÓÙ˘ˆÛȷο ·ÔÙÂϤÛÌ·Ù· ηٿ ÙË ‰Â‡ÙÂÚË ‰ÂηÂÙ›·. ŒÙÛÈ, ÛÙË ÌÂϤÙË Ì·˜ ÌfiÓÔÓ ¤Ó·˜ ·ÛıÂÓ‹˜ ÌÔχÓıËΠηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜, Ô ÔÔ›Ô˜ ÙÂÏÈÎÒ˜ ·ÓÙ·ÔÎÚ›ıËΠÛÙË Ê˘ÛÈ΋ Ïԛ̈ÍË Ì ·Ó¿Ù˘ÍË Ê˘ÛÈ΋˜ ·ÓÔÛ›·˜. ∂ÈÚfiÛıÂÙ·, ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ ‰ÂÓ ‰È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· ÌÂÙ·ÁÁ›ÛÂˆÓ ·Ú·ÁÒÁˆÓ ·›Ì·ÙÔ˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ, ·Ú¿ ÙËÓ ÂÓÙ·ÙÈÎÔÔ›ËÛË ÙˆÓ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓˆÓ ÚˆÙÔÎfiÏÏˆÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙȘ ÔÌ¿‰Â˜ Ï¢¯·ÈÌ›·˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ÚÔÊ·ÓÒ˜ ÏfiÁˆ ·Ú¿ÏÏËÏ˘ ‰È·ÊÔÚÔÔ›ËÛ˘ Ù˘ ÔÏÈÙÈ΋˜ ÙˆÓ ÌÂÙ·ÁÁ›ÛˆÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ê·›ÓÂÙ·È fiÙÈ Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ Ë·Ù›Ùȉ·˜ µ ÌÂÈÒıËΠÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ÙÔ˘ ∆Ì‹Ì·Ùfi˜ Ì·˜. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ‰ÂÓ Ú¤ÂÈ Ó· ‰ËÌÈÔ˘ÚÁ› ÂÊËÛ˘¯·ÛÌÔ‡˜. ¶ÚfiÛÊ·Ù·, ÙÔ ™˘ÓÙÔÓÈÛÙÈÎfi ∫¤ÓÙÚÔ ∞ÈÌÔÂ·ÁÚ‡ÓËÛ˘, Û ÂȉËÌÈÔÏÔÁÈ΋ ÌÂϤÙË ÁÈ· ÙȘ ÏÔÈÌÒÍÂȘ Ô˘ ÌÂÙ·‰›‰ÔÓÙ·È Ì ÙÔ ·›Ì· ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ˘ËÚÂÛÈÒÓ ·ÈÌÔ‰ÔÛ›·˜ Ù˘ ¯ÒÚ·˜ Ì·˜, ·Ó·Ê¤ÚÂÈ fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ HBsAg Â›Ó·È ˘„ËÏ‹ Û ۯ¤ÛË Ì ٷ ‰Â‰Ô̤ӷ ¿ÏÏˆÓ ∂˘Úˆ·˚ÎÒÓ ¯ˆÚÒÓ (2.176 ÌÔÓ¿‰Â˜ ·›Ì·ÙÔ˜ HBsAg ıÂÙÈΤ˜/402.336 ÂÏÂÁ¯ı›Û˜ ÌÔÓ¿‰Â˜) [(™˘ÓÙÔÓÈÛÙÈÎfi ∫¤ÓÙÚÔ ∞ÈÌÔÂ·ÁÚ‡ÓËÛ˘ (™.∫.∞∂.): ™Ùfi¯ÔȧÂÈÙÔ˘ÚÁ›·. ¶ÚÒÙ· ·ÔÙÂϤÛÌ·Ù· (1996-1997)]. ∞·ÈÙ›ٷÈ, Û˘ÓÂÒ˜, Â·ÁÚ‡ÓÈÛË Î·È ÙˆÓ ·ÈÌÔ‰ÔÛÈÒÓ Û ۯ¤ÛË Ì ÙȘ ÏÔÈÌÒÍÂȘ Ô˘ ÌÂÙ·‰›‰ÔÓÙ·È Ì ÙÔ ·›Ì·, ·ÏÏ¿ Î·È ÙˆÓ ıÂÚ·fiÓÙˆÓ È·ÙÚÒÓ ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ ÂÓÙ·ÙÈÎÔÔÈËÌ¤ÓˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÔ‡. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ·ÚÔ‡Û· ÌÂϤÙË ·Ú·ı¤ÙÂÈ Ì·ÎÚ¿ ÂÌÂÈÚ›· ·Ú·ÎÔÏÔ‡ıËÛ˘ (20 ÂÙÒÓ) ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÂÚÈÛÙ·ÙÈÎÒÓ ·fi ¤Ó· ÂÏÏËÓÈÎfi ∫¤ÓÙÚÔ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜/OÁÎÔÏÔÁ›·˜. ∞Ó·‰ÂÈÎÓ‡ÂÈ ÙË ‰È·¯ÚÔÓÈο Êı›ÓÔ˘Û· Û˘¯ÓfiÙËÙ· ÌfiÏ˘ÓÛ˘ ·fi ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ µ, ÏfiÁˆ Ù˘ ¢Ú›·˜ Î·È ¤ÁηÈÚ˘ ÔÏÈÙÈ΋˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙÔ ∆Ì‹Ì·, ÙˆÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚˆÓ ÌÂıfi‰ˆÓ ÂϤÁ¯Ô˘ ÙÔ˘ ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘ ·›Ì·ÙÔ˜ Î·È Ù˘ ¢ڇÙÂÚ˘ ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÏËı˘ÛÌÔ‡ Ù˘ ¯ÒÚ·˜ Ì·˜. ∆¤ÏÔ˜, ·Ó·Ï‡ÂÈ ÙËÓ ˘¿Ú¯Ô˘Û· ÁÓÒÛË Î·È ‰›ÓÂÈ ÚfiÛÊ·Ù· ÛÙÔȯ›· Â› ÙÔ˘ ı¤Ì·ÙÔ˜, ηıÒ˜ Ë ÌÂÙ¿‰ÔÛË ÏÔÈÌÔÁfiÓˆÓ ·Ú·ÁfiÓÙˆÓ Ì ÙȘ ÌÂÙ·ÁÁ›ÛÂȘ ·›Ì·ÙÔ˜ Î·È ·Ú·ÁÒÁˆÓ ÙÔ˘ ·Ú·Ì¤ÓÂÈ ¿ÓÙ· ¤Ó· Â›Î·ÈÚÔ Î·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜ ı¤Ì·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Schreiber GB, Busch MP, Kleinman SH, Korelitz JJ. The risk of transfusion-transmitted viral infections. N Engl J Med 1996;334:1685-1690.

Paediatriki 2002;65:351-355

2. Courouce AM, Pillonel J. Transfusion-transmitted viral infections. Retrovirus and Viral Hepatitis Working Groups of the French Society of Blood Transfusion. N Engl J Med 1996;335:1609-1610.

3. Makris GT. Transfusion-transmitted infections: epidemiology, risks and prevention. Haema 2001;4:24-38.

4. Tabor E, Gerety RJ, Mott M, Wilbur J. Prevalence of hepatitis B in a high-risk setting: a serologic study of patients and staff in a pediatric oncology unit. Pediatrics 1978;61:711-714.

5. Riehm H, Gadner H, Henze G, Kornhuber B, Lampert F, Niethamer D et al. Results and significance of six randomized trials in four consecutive ALL-BFM trials.

Haematol Blood Transfus 1995;33:439-450.

6. Naoumov NV, Eddleston AL. Host immune response and variations in the virus genome: pathogenesis of liver damage caused by hepatitis B virus. Gut 1994;35:1013-1017.

7. Locasciulli A, Santamaria M, Masera G, Schiavon E, Alberti A, Realdi G. Hepatitis B virus markers in children with acute leukemia: the effect of chemotherapy. J Med Virol 1985;15:29-34.

8. Januszkiewicz D, Wysocki J, Nowak J. Hepatitis B and C virus infection in Polish children with malignancies. Eur J Pediatr 1997;156:454-456.

9. ¶·Ó·ÁÈÒÙÔ˘ π¶, ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘-∞Ó‰ÚÔ˘Ï·Î¿ÎË ™, ∫ˆÛÙ·Ú›‰Ô˘ ™, ∆˙È‚¿Ú·˜ ∞, ÷˚‰¿˜ ™. ¢Â›ÎÙ˜ Ë·Ù›Ùȉ·˜ µ Î·È C Û ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù·. ¶·È‰È·ÙÚÈ΋ 1994;57:324-329.

10. ∫·ÙÙ¿Ì˘ Ã. ∂Ì‚fiÏÈÔ ∏·Ù›Ùȉ·˜ µ. 25Ë ∂Ù‹ÛÈ· ¶·È‰È·ÙÚÈ΋ £ÂÚ·¢ÙÈ΋ ∂ÓË̤ڈÛË. ∞ı‹Ó· 1992.

11. Polychronopoulou-Androulakaki S, Panagiotou JP, Kostaridou S, Kyratzopoulou A, Haidas S. Immune response of immunocompromised children with malignancies to a recombinant hepatitis B vaccine. Pediatr Hematol Oncol 1996;13:425-431.

12. Reuman PD, Rathore MH, Ayoub EM. Childhood immunization update. Adv Pediatr 1993;40:33-57.

13. Alanko S, Pelliniemi TT, Salmi TT. Recovery of blood Blymphocytes and serum immunoglobulins after chemotherapy for childhood acute lymphoblastic leukemia.

Cancer 1992;69:1481-1486.

14. Rokicka-Milewska R, Jackowska T, Sopylo B, Kacperska E, Seyfried H. Active immunization of children with leukemias and lymphomas against infection by hepatitis B virus. Acta Paediatr Jpn 1993;35:400-403.

15. Arbeter AM, Granowetter L, Starr SE, Lange B, Wimmer R, Plotkin SA. Immunization of children with acute lymphoblastic leukemia with live attenuated varicella vaccine without complete suspension of chemotherapy. Pediatrics 1990;85:338-344.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 31-01-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-06-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™Ù·˘ÚԇϷ ∫ˆÛÙ·Ú›‰Ô˘ ∫ÔÏÔÎÔÙÚÒÓË 88, ∆.∫. 164 51 ∞ÚÁ˘ÚÔ‡ÔÏË, ∞ı‹Ó· E-mail: stakost@hol.gr

355

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·356

¶·È‰È·ÙÚÈ΋ 2002;65:356-361

∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

Paediatriki 2002;65:356-361

ORIGINAL ARTICLE

∏ Â›‰Ú·ÛË ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ÈÎÙ¤ÚÔ˘ ÛÙË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ∫. ™Ô‡ÏË1, ™. °·‚Ú›ÏË2, π. ∆˙·ÌÔ˘Ú¿ÓË1, ∞. ∫·›ÎË2, Ã. ∫ÒÛÙ·ÏÔ˜2

The effect of neonatal jaundice on biotinidase activity K. H. Schulpis1, S. Gavrili2, J. Tjamouranis1, A. Kapiki2, C. Costalos2

¶ÂÚ›ÏË„Ë: O ›ÎÙÂÚÔ˜ Â›Ó·È ¤Ó· Û˘¯Ófi Úfi‚ÏËÌ· Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙ· ÓÂÔÁÓ¿. ∆ÂÏÂ˘Ù·›·, Ë Ì¤ÙÚËÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ (µi) ¤¯ÂÈ ÚÔÛÙÂı› Û ÔÏÏ¿ ÂıÓÈο ÚÔÁÚ¿ÌÌ·Ù· ÚÔÏËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÓÂÔÁÓÒÓ (screening). ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ Ì·˜ ‹Ù·Ó Ó· ÌÂÏÂÙ‹ÛÔ˘Ì ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ÈÎÙ¤ÚÔ˘ ÛÙË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi Û ÙÂÏÂÈfiÌËÓ·, ÚfiˆÚ· Î·È ÂÏÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿. ªÂÏÂÙ‹Û·Ì 1296 ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ (Ì¿ÚÙ˘Ú˜ 426), 246 ÚfiˆÚ· (Ì¿ÚÙ˘Ú˜ 86) Î·È 156 ÂÏÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿ Ì ›ÎÙÂÚÔ (Ì¿ÚÙ˘Ú˜ 38). ∆fiÛÔ ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜, fiÛÔ Î·È ÛÙ· ÓÂÔÁÓ¿ Ì ›ÎÙÂÚÔ ˘ÔÏÔÁ›Û·Ì ÙȘ ‚ÈÔ¯ËÌÈΤ˜ Ë·ÙÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ ÌÂ Û˘Ó‹ıÂȘ ÌÂıfi‰Ô˘˜ Î·È ÙË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ Ì ÊıÔÚÈÔÌÂÙÚÈ΋ ̤ıÔ‰Ô. ∏ ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi ‹Ù·Ó Û·ÊÒ˜ ÌÂȈ̤ÓË ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ ÙˆÓ ÚÔÒÚˆÓ Î·È ÙˆÓ ÂÏÏÈÔ‚·ÚÒÓ ÓÂÔÁÓÒÓ (3,54±1,2 Î·È 3,8±0,8 mmol/min/l) Û˘ÁÎÚÈÓfiÌÂÓË ÌÂ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ (4,99±1,1 mmol/min/l, p<0,001). ∆fiÛÔ Ë ÔÏÈ΋ ¯ÔÏÂÚ˘ıÚ›ÓË, fiÛÔ Î·È Ù· Â›‰· ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÛÙÔÓ ÔÚfi ¤‰ÂÈÍ·Ó ·ÚÓËÙÈ΋ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p<0,001) Û˘Û¯¤ÙÈÛË Ì ÙË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi. ™˘ÌÂÚ·ÛÌ·ÙÈο: i) Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi ‹Ù·Ó ÌÂȈ̤ÓË ÛÙ· ÚfiˆÚ· Î·È Ù· ÂÏÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿, ·ÏÏ¿ Î·È ÛÙ· ÙÂÏÂÈfiÌËÓ· Ì ›ÎÙÂÚÔ, ii) Ù· ˘„ËÏ¿ Â›‰· Ù˘ ÔÏ. ¯ÔÏÂÚ˘ıÚ›Ó˘ ı· ÌÔÚÔ‡Û·Ó Ó· ·›˙Ô˘Ó ÚfiÏÔ “·Ó·ÛÙÔϤ·” ÙÔ˘ ÂÓ˙‡ÌÔ˘ Î·È iii) ÙfiÛÔ Ë ËÏÈΛ· ·ËÛ˘, fiÛÔ Î·È Ù· Â›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ Ú¤ÂÈ Ó· ÁÚ¿ÊÔÓÙ·È ÛÙȘ οÚÙ˜ Guthrie ÁÈ· ÙË ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘.

Abstract: Jaundice is the most common and one of the vexing problems that can occur in neonates.

Newborn screening test for biotinidase deficiency has been added to many national screening programmes. To clarify the problem of false positive screening tests in neonates, especially in fullterms, we have evaluated the biotinidase activities in the serum of fullterms, prematures and small-for-dates with jaundice. 1296 fullterms (controls N=426), 246 prematures (controls N=86) and 156 small-for-dates (controls N=38) aged 2-3 days, with jaundice took part in the study. In jaundiced neonates and controls 3.0 ml blood was drawn for the evaluation of total bilirubin, liver enzymes and biotinidase activity in the serum using a fluorimetric method. Biotinidase activities in the groups of controls of prematures (3.54±1.2 mmol/min/l) and small-for-dates newborns (3.8±0.8 mmol/min/l) were lower as compared to those of fullterms (4.99±1.1 mmol/min/l, p<0.001).

Total bilirubin and liver enzymes showed a statistically significant inverse correlation with biotinidase activity (p<0.001) in all the jaundiced infants of this study. In conclusion: i) low biotinidase activities were found in fullterms, prematures and small for dates with jaundice, ii) the low activities of the enzyme could be due to their impaired liver function, iii) the high total bilirubin levels in the studied groups, could play the role of an “inhibitor” of the enzyme, iv) gestational age as well as t. bilirubin levels should be always written on Guthrie cards for a correct evaluation of biotinidase activity.

§¤ÍÂȘ ÎÏÂȉȿ: ›ÎÙÂÚÔ˜, ‚ÈÔÙÈÓȉ¿ÛË, ÚfiˆÚ·, ÂÏÏÈÔ‚·Ú‹.

Key words: jaundice, biotinidase, prematures, small-for-dates.

1 πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á. ™ÔÊ›·”, ∞ı‹Ó· 2 ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ª·È¢ÙËÚ›Ô˘ “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó·

1 Institute of Child Health, “Agia Sophia” Children’s Hospital, Athens 2 Department of Neonatology, “Alexandra” Maternity Clinic, Athens

356

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·357

¶·È‰È·ÙÚÈ΋ 2002;65:356-361

Paediatriki 2002;65:356-361

∂ÈÛ·ÁˆÁ‹ ∏ ‚ÈÔÙÈÓȉ¿ÛË (µi) Â›Ó·È ÙÔ ·Ó·Áη›Ô ¤Ó˙˘ÌÔ ÁÈ· ÙËÓ ·Ó·Î‡ÎψÛË Ù˘ ‚ÈÔÙ›Ó˘ Ô˘ Â›Ó·È ··Ú·›ÙËÙË Û ٤ÛÛÂÚȘ ÌÈÙÔ¯ÔÓ‰ÚȷΤ˜ ηڂÔÍ˘Ï¿Û˜ (1). ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÌÂÚÈ΋˜ Î·È Ù˘ ÔÏÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Ù˘ µi Â›Ó·È ÂÚ›Ô˘ 1:40.000 ÁÂÓÓ‹ÛÂȘ. OÈ ÌË ÂÓÙÔÈ˙fiÌÂÓÔÈ Ì ÙÔ screening ·ÛıÂÓ›˜, ·fi ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜, ÂÌÊ·Ó›˙Ô˘Ó ·ÏˆÂΛ·, ÛÌËÁÌ·ÙÔÚÚÔ˚Îfi ÂÍ¿ÓıËÌ·, Û·ÛÌÔ‡˜, ˘ÔÙÔÓ›·, ÌÂȈ̤ÓË fiÚ·ÛË Î·È ·ÎÔ‹, ÔÚÁ·ÓÈ΋ ÔÍÂÔ˘Ú›· Î.¿.

(1). O ÚÔÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÓÂÔÁÓÒÓ (screening) ÁÈ· ÙËÓ ·ÓÂ¿ÚÎÂÈ· Ù˘ µi ¤¯ÂÈ ÂÈÛ·¯ı› Û ÔÏϤ˜ ¯ÒÚ˜ Î·È Ë ÂȂ‚·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ Á›ÓÂÙ·È Ì ÙË Ì¤ÙÚËÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÛÙÔÓ ÔÚfi ‹ Ù· ÂÚ˘ıÚÔ·ÙÙ·Ú· (2,3). ∏ ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ·Ï‹ Î·È Û˘Ó›ÛÙ·Ù·È ÛÙË ¯ÔÚ‹ÁËÛË ‚ÈÔÙ›Ó˘, Ë ÔÔ›· ıÂÚ·‡ÂÈ ÙȘ ‰ÂÚÌ·ÙÔÏÔÁÈΤ˜ Î·È ‚ÂÏÙÈÒÓÂÈ ÙȘ Ó¢ÚÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ ÙˆÓ ·Û¯fiÓÙˆÓ (4,5). ∏ ÂÌÊ¿ÓÈÛË ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ÈÎÙ¤ÚÔ˘ Â›Ó·È Ôχ Û˘¯Ó‹ Î·È ·ÊÔÚ¿ Û ÓÂÔÁÓ¿ Ô˘ Â›Ó·È Î·Ù¿ Ù· ¿ÏÏ· ˘ÁÈ‹ (7,8). OÈ ÓÂÔÁÓÔÏfiÁÔÈ ·Ú·ÎÔÏÔ˘ıÔ‡Ó ÛÙÂÓ¿ Ù· Â›‰· Ù˘ ÔÏÈ΋˜ ¯ÔÏÂÚ˘ıÚ›Ó˘ (OÃ), ‰ÈfiÙÈ Ù· ˘„ËÏ¿ Â›‰¿ Ù˘ Â›Ó·È ÙÔÍÈο ÛÙÔÓ ÂÁΤʷÏÔ (˘ÚËÓÈÎfi˜ ›ÎÙÂÚÔ˜) (9,10). ∂Âȉ‹ Ë ÌÂÁ·Ï‡ÙÂÚË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi ¢ڤıË ÛÙÔ ‹·Ú Î·È ÙÔÓ ÔÚfi (11) Î·È Ë ÌÈÎÚfiÙÂÚË ÛÙÔÓ ÂÁΤʷÏÔ (12), Â·ÎfiÏÔ˘ıÔ ‹Ù·Ó Ó· ÌÂÙÚ‹ÛÔ˘Ì ÙË ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÛÙÔÓ ÔÚfi ÓÂÔÁÓÒÓ Ì ›ÎÙÂÚÔ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∆ÂÏÂÈfiÌËÓ·: 1296 ÓÂÔÁÓ¿, ËÏÈΛ·˜ 2-3 ËÌÂÚÒÓ, Ì ËÏÈΛ· ·ËÛ˘ 40±2 ‚‰ÔÌ¿‰Â˜, ¯ˆÚ›ÛÙËÎ·Ó Û 5 ÔÌ¿‰Â˜ Û‡Ìʈӷ Ì ٷ Â›‰· ÔÏÈ΋˜ ¯ÔÏÂÚ˘ıÚ›Ó˘ (OÃ) ÛÙÔÓ ÔÚfi ÙÔ˘˜: ÔÌ¿‰· ∞ (Ì¿ÚÙ˘Ú˜ ¡=426) Ì Oà 1-4 mg/dl, ÔÌ¿‰· µ (¡=217) Ì Â›‰· Oà 4-8 mg/dl. ™ÙËÓ ÔÌ¿‰· ° (¡=231), Ë Oà ‹Ù·Ó 8-12 mg/dl, ÛÙËÓ ÔÌ¿‰· ¢ (¡=226) ·fi 12-16 mg/dl, ÂÓÒ ÛÙËÓ ÔÌ¿‰· ∂ (¡=196) Ù· Â›‰· Ù˘ Oà ‹Ù·Ó ˘„ËÏfiÙÂÚ· ÙˆÓ 16 mg/dl ÛÙÔ ·›Ì· ÙÔ˘˜. ŒÓ·˜

ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ÓÂÔÁÓÒÓ (25%) ¤·Û¯Â ·fi ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ G6PD, ÂÓÒ ÁÈ· Ù· ˘fiÏÔÈ· ‰ÂÓ ‚Ú¤ıËÎÂ Ë ·ÈÙ›· ÙÔ˘ ÈÎÙ¤ÚÔ˘ ÙÔ˘˜. ¶ÚfiˆÚ·: ¡ÂÔÁÓ¿ (¡=246) ËÏÈΛ·˜ 2-3 ËÌÂÚÒÓ, Ì ËÏÈΛ· ·ËÛ˘ 32±2,5 ‚‰ÔÌ¿‰Â˜ ¯ˆÚ›ÛÙËÎ·Ó Û 4 ÔÌ¿‰Â˜ Û‡Ìʈӷ Ì ٷ ÚÔ·Ó·ÊÂÚfiÌÂÓ· Â›‰· OÃ. ∏ ÔÌ¿‰· ∞ (Ì¿ÚÙ˘Ú˜ ¡=86), Ë ÔÌ¿‰· µ (¡=46), Ë ÔÌ¿‰· ° (¡=79), Ë ÔÌ¿‰· ¢ (¡=46) Î·È Ë ÔÌ¿‰· ∂ (¡=20) ¤Ï·‚·Ó ̤ÚÔ˜ ÛÙËÓ ÂÚÁ·Û›· Ì·˜. °È· Ù· Ï›ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ ‰ÂÓ Â˘Ú¤ıË Ë ·ÈÙ›· ÙÔ˘ ÈÎÙ¤ÚÔ˘ ÙÔ˘˜, ÂÓÒ ÙÔ 19% ¤·Û¯Â ·fi ·ÓÂ¿ÚÎÂÈ· G6PD. EÏÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿: ∏ ÔÌ¿‰· ∞ (¡=48), Ë ÔÌ¿‰· µ (¡=34), Ë ÔÌ¿‰· ° (¡=36), Ë ÔÌ¿‰· ¢ (¡=29) Î·È Ë ÔÌ¿‰· ∂ (¡=19) ‹Ù·Ó ÔÈ ÔÌ¿‰Â˜ ÙˆÓ ÂÏÏÈÔ‚·ÚÒÓ ÓÂÔÁÓÒÓ, fiˆ˜ ‰È·¯ˆÚ›ÛÙËÎ·Ó Ì ٷ ÚÔ·Ó·ÊÂÚı¤ÓÙ· ÎÚÈÙ‹ÚÈ·. ∏ ̤ÛË ËÏÈΛ· ·ËÛ˘ ‹Ù·Ó 38±1,8 ‚‰ÔÌ¿‰Â˜. ∏ ·ÓÂ¿ÚÎÂÈ· G6PD ‹Ù·Ó Ë ·ÈÙ›· ÈÎÙ¤ÚÔ˘ ÛÙÔ 16% ÙˆÓ ÓÂÔÁÓÒÓ, ÂÓÒ ÁÈ· Ù· ˘fiÏÔÈ· ‰ÂÓ Â˘Ú¤ıË Ë ·ÈÙ›·. ∞fi fiÏ· Ù· ÓÂÔÁÓ¿ ÂÏ‹ÊıËÛ·Ó ÂÈϤÔÓ 3,0 ml ·›Ì· Ì ÙËÓ Â˘Î·ÈÚ›· οÔÈ·˜ ·ÈÌÔÏË„›·˜, .¯. ÁÈ· ÙË Ì¤ÙÚËÛË Hb ‹ Ù˘ OÃ. ∆fiÛÔ Ë OÃ, fiÛÔ Î·È Ù· Ë·ÙÈο ¤Ó˙˘Ì· ÌÂÙÚ‹ıËÎ·Ó ÛÙÔÓ ÔÚfi Ì ÙȘ Û˘Ó‹ıÂȘ ‚ÈÔ¯ËÌÈΤ˜ ÌÂıfi‰Ô˘˜. ∏ ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi ÛÙÔÓ ÔÚfi ˘ÔÏÔÁ›ÛÙËΠ̠ÙË Ì¤ıÔ‰Ô ÙˆÓ Ebrahim Î·È Dekisnamur (13) Û ÊıÔÚÈÔʈÙfiÌÂÙÚÔ (Perkin Elmer LS 3). ∏ ∞¡OV∞ Î·È ÙÔ Student’s test, fiˆ˜ Â›Û˘ Ë Ì¤ıÔ‰Ô˜ ÔÏÏ·Ï‹˜ ·ÏÈÓ‰ÚfiÌËÛ˘, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÁÈ· ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. ƒ<0,05 ıˆڋıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi.

∞ÔÙÂϤÛÌ·Ù· Ÿˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1, Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi ‹Ù·Ó ÌÂȈ̤ÓË Û fiϘ ÙȘ ÔÌ¿‰Â˜ ÙˆÓ ÓÂÔÁÓÒÓ Ì ›ÎÙÂÚÔ, Û˘ÁÎÚÈÓfiÌÂÓË Ì ÂΛÓË ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ™ÙÔÓ ¶›Ó·Î· 1· Ê·›ÓÂÙ·È fiÙÈ Ù· Ë·ÙÈο ¤Ó˙˘Ì· Î·È È‰È·ÈÙ¤Úˆ˜ Ë LDH ‹Ù·Ó ·˘ÍË̤ӷ Û fiϘ ÙȘ ÔÌ¿‰Â˜ Ì ›ÎÙÂÚÔ, ÂÓÒ Ë ÔÏÈ΋ ÚˆÙ½ÓË Î·È Ë ·Ï‚Ô˘Ì›ÓË ‰ÂÓ ¤‰ÂÈÍ·Ó ÌÂÙ·‚ÔÏ‹.

O ¶›Ó·Î·˜ 2 ‰Â›¯ÓÂÈ ÙË ÌÂȈ̤ÓË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi Û ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ›ÎÙÂÚÔ, fiˆ˜ Î·È Ô

¶›Ó·Î·˜ 1. ∂›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ ·›Ì·ÙÔ˜ Î·È ‰Ú·ÛÙÈÎfiÙËÙ· ‚ÈÔÙÈÓȉ¿Û˘ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ OÌ¿‰Â˜

∞ÚÈıÌfi˜ ÓÂÔÁÓÒÓ

A B ° ¢ E ™‡ÓÔÏÔ

426 217 231 226 196 1.296

µ¿ÚÔ˜ Á¤ÓÓËÛ˘ (g) 3635 3343 3440 3321 3420

± ± ± ± ±

345 350 360 390 320

OÏ. ¯ÔÏÂÚ˘ıÚ›ÓË (mg/dl)

¢Ú·ÛÙÈÎfiÙËÙ· ‚ÈÔÙÈÓȉ¿Û˘ (mmol/min/l)

2,5 ± 0,6 7,2 ± 0,8 10,4 ± 1,2 13,7 ± 1,2 16,1 ± 0,8

4,99 ± 1,1a 4,02 ± 1,8b 2,33 ± 0,5c 1,79 ± 0,4d 1,69 ± 0,4e

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË a/b, a/c, a/d, a/d, a/e p<0,0001 b/c, b/d, b/e, c/d p=0,001, d/c = NS (ÌË ÛÙ·Ù. ÛËÌ·ÓÙÈΤ˜ ÙÈ̤˜)

357

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·358

¶·È‰È·ÙÚÈ΋ 2002;65:356-361

Paediatriki 2002;65:356-361

¶›Ó·Î·˜ 1·. ∏·ÙÈΤ˜ ‚ÈÔ¯ËÌÈΤ˜ ·Ú¿ÌÂÙÚÔÈ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ OÌ¿‰Â˜ A B ° ¢ E

OÏ. ¯ÔÏ. (mg/dl)

SGOT (U/l)

SGPT (U/l)

ÁGt (U/l)

LDH (U/l)

(0-4) (4-8) (8-12) (12-16) (>16)

18 ± 10a 28 ± 9,0b 24 ± 10c 26 ± 15d 66 ± 8,0e

26 ± 10a 74 ± 10b 76 ± 8,0c 72 ± 10d 75 ± 9,0e

14 ± 9,5a 120 ± 12b 168 ± 30c 196 ± 56d 189 ± 10e

150 ± 36a 318 ± 20b 450 ± 80c 758 ± 140d 869 ± 130c

OÏ. ÚˆÙ½ÓË (g/l) 6,9 6,8 6,5 6,3 6,0

± ± ± ± ±

0,4 0,4 0,6 0,5 0,5

AÏ‚Ô˘Ì›ÓË (g/l) 4,5 4,0 4,2 4,3 4,8

± ± ± ± ±

0,8 1,0 0,5 0,4 0,8

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË SGOT: a/b, a/c, a/d, a/e p<0,0001, b/c, b/d, c/d = ª™ b/e, c/e, d/e p<0,0001 SGPT: a/b, a/c, a/d, a/e p<0,0001, b/c, b/d, b/e, c/d, c/e, d/e = ª™ ÁGt: a/b, a/c, a/d, a/e p<0,0001, b/c, b/d, b/e p<0,001, c/d, c/e, d/e = ª™ LDH: a/b, a/c, a/d, a/c, b/c, b/d, b/e p<0,0001, c/d, c/e, d/e p<0,001 OÈ ÙÈ̤˜ ·Ï‚Ô˘Ì›Ó˘ Î·È ÔÏ. ÚˆÙ½Ó˘: ª™ ª™: ªË ÛÙ·ÙÈÛÙ. ÛËÌ·ÓÙÈ΋ ÙÈÌ‹ ¶›Ó·Î·˜ 2. ∂›‰· ÔÏÈ΋˜ ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È ‰Ú·ÛÙÈÎfiÙËÙ· ‚ÈÔÙÈÓȉ¿Û˘ Û ÚfiˆÚ· ÓÂÔÁÓ¿ OÌ¿‰Â˜

∞ÚÈıÌfi˜ ÓÂÔÁÓÒÓ

A B ° ¢ E ™‡ÓÔÏÔ

86 46 39 46 29 246

µ¿ÚÔ˜ (g) 1480 1390 1350 1380 1395

± ± ± ± ±

160 185 175 168 180

OÏ. ¯ÔÏ. (mg/dl)

¢Ú·ÛÙ. ‚ÈÔÙÈÓȉ¿Û˘ (mmol/min/l)

3,0 ± 1,0 6,9 ± 1,4 10,8 ± 1,2 13,0 ± 1,0 16,2 ± 1,5

3,54 ± 1,2a 1,85 ± 0,8b 1,76 ± 0,8c 1,68 ± 0,5d 1,70 ± 0,6e

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË a/b, a/c, a/d, a/e p<0,0001 b/c, b/d, b/e, c/d , c/e = ª™ ª™: ªË ÛÙ·Ù. ÛËÌ·ÓÙÈ΋ ÙÈÌ‹

¶›Ó·Î·˜ 2· ‰Â›¯ÓÂÈ Ù· ·˘ÍË̤ӷ Â›‰· ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÛÙËÓ ›‰È· ÔÌ¿‰· ·ÛıÂÓÒÓ. ™Ù· ÂÏÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿, Â›Û˘, ÂÌÊ·Ó›˙ÂÙ·È ÌÂȈ̤ÓË Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi (¶›Ó·Î·˜ 3). ∞ÓÙ›ıÂÙ·, ·˘ÍË̤Ó˜ ÂÌÊ·Ó›˙ÔÓÙ·È (¶›Ó·Î·˜ 3·) ÔÈ Ë·ÙÈÎÔ› ‚ÈÔ¯ËÌÈÎÔ› ·Ú¿ÌÂÙÚÔÈ, ÏËÓ Ù˘ ·Ï‚Ô˘Ì›Ó˘ Î·È Ù˘ ÔÏÈ΋˜ ÚˆÙ½Ó˘. ™ËÌ·ÓÙÈο ÛÙ·ÙÈÛÙÈ΋ ·ÓÙ›ÛÙÚÔÊË Û˘Û¯¤ÙÈÛË ‚Ú¤ıËΠÌÂٷ͇ Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ µi Î·È ÙÔ˘ ÂÈ¤‰Ô˘ ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Î·È Ù˘ Oà (¶›Ó·Î·˜ 4). ∂›Û˘, Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ ¯ˆÚ›˜ ›ÎÙÂÚÔ ‹Ù·Ó Û·ÊÒ˜ ˘„ËÏfiÙÂÚË, Û˘ÁÎÚÈÓfiÌÂÓË Ì ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÙˆÓ ÚfiˆÚˆÓ Î·È ÙˆÓ ÂÏÏÈÔ‚·ÚÒÓ ÓÂÔÁÓÒÓ. ™˘˙‹ÙËÛË O ÓÂÔÁÓÈÎfi˜ ›ÎÙÂÚÔ˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÌÊ·ÓÈÛÙ› ·ÎfiÌË Î·È ÛÙÔ 50% ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜ Î·È ÌÔÚ› Ó· ÂÈÌ›ÓÂÈ Î·È ¤Ú·Ó Ù˘ 14˘ Ë̤ڷ˜ Û ÂΛӷ Ô˘ ıËÏ¿˙Ô˘Ó (14,15). ∏ ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì Â›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ >4 mg/dl ¤‰ÂÈÍ ÙÒÛË Ô˘ ¤Êı·Û ÛÙÔ minimum, fiÙ·Ó Ë ÔÏ. ¯ÔÏÂÚ˘ıÚ›ÓË ˘ÂÚ¤‚·ÈÓ ٷ 16 mg/dl. ∞ÓÙ›ıÂÙ·, Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi ‹Ù·Ó

358

Û·ÊÒ˜ ˘„ËÏfiÙÂÚË ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ¯ˆÚ›˜ ›ÎÙÂÚÔ Û˘ÁÎÚÈÓfiÌÂÓË Ì ÂΛÓË ÙˆÓ ÚfiˆÚˆÓ Î·È ÙˆÓ ÂÏÏÈÔ‚·ÚÒÓ. ∆· ·Ó·ÊÂÚfiÌÂÓ· Û ˘ÁÈ‹ ÓÂÔÁÓ¿ Â˘Ú‹Ì·Ù¿ Ì·˜ Û˘ÌʈÓÔ‡Ó Ì ÂΛӷ ÙˆÓ Suormala Î·È Û˘Ó (16,17). ™‡Ìʈӷ Ì ÙË ‚È‚ÏÈÔÁÚ·Ê›·, ÔÈ Ó¢ÚÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ Î·È ÂΛӘ ·fi Ù· Ì¿ÙÈ· Î·È Ù· ·˘ÙÈ¿ ·Ú·ÙËÚÔ‡ÓÙ·È Û ÂΛÓÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÔÏÈ΋ ·ÓÂ¿ÚÎÂÈ· Ù˘ µi (16,17). ∏ ·Ô˘Û›· ÙˆÓ ÚÔ·Ó·ÊÂÚfiÌÂÓˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÛÙ· ÓÂÔÁÓ¿ Ì ›ÎÙÂÚÔ Èı·Ófiٷٷ ÔÊ›ÏÂÙ·È ÛÙËÓ “Â›ÎÙËÙË” ÌÂÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ (16). Ÿˆ˜ ¤¯ÂÈ ·Ó·ÎÔÈÓˆı›, Ë ˘„ËÏfiÙÂÚË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi ‚Ú¤ıËΠÛÙÔ ‹·Ú Î·È ÙÔÓ ÔÚfi (18,19) Î·È Ë ¯·ÌËÏfiÙÂÚË ÛÙÔÓ ÂÁΤʷÏÔ (18).

O Pispa (19) ‚ڋΠ50% Ì›ˆÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘ Û ÔÓÙÈÎÔ‡˜ Ì ÌÂÚÈ΋ Ë·ÙÂÎÙÔÌ‹ Î·È Û˘Ì¤Ú·Ó fiÙÈ ÙÔ ‹·Ú Â›Ó·È Ô Èı·ÓfiÙÂÚÔ˜ ÙfiÔ˜ ·Ú·ÁˆÁ‹˜ Ù˘ µi. ∂›Û˘, ¿ÏÏÔÈ ÂÚ¢ÓËÙ¤˜ (20,21) ·Ú·Ù‹ÚËÛ·Ó fiÙÈ Ë ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ·Ó¢ÚÈÛÎfiÙ·Ó ÛÙ· ¯·ÌËÏfiÙÂÚ· Ê˘ÛÈÔÏÔÁÈο Â›‰· Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ. OÈ Suormala Î·È Û˘Ó (17) ‚Ú‹Î·Ó ÌÂȈ̤ÓË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi Û ·È‰È¿ Ì ÂËÚ·Ṳ̂ÓË Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ™Â ÂÚÁ·Û›Â˜ Ì·˜ (22,23) ·Ú·ÙËÚ‹Û·Ì ÌÂȈ̤ÓË ÙË ‰Ú·ÛÙÈÎfiÙËÙ·

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·359

¶·È‰È·ÙÚÈ΋ 2002;65:356-361

Paediatriki 2002;65:356-361

¶›Ó·Î·˜ 2·. ∏·ÙÈΤ˜ ‚ÈÔ¯ËÌÈΤ˜ ·Ú¿ÌÂÙÚÔÈ Û ÚfiˆÚ· ÓÂÔÁÓ¿ OÌ¿‰Â˜ A B ° ¢ E

OÏ. ¯ÔÏ. (mg/dl)

SGOT (U/l)

SGPT (U/l)

ÁGt (U/l)

LDH (U/l)

(0-4) (4-8) (8-12) (12-16) (>16)

19 ± 12a 33 ± 10b 29 ± 12c 29 ± 18d 69 ± 8,0e

28 ± 10a 80 ± 10b 84 ± 12c 73 ± 12d 82 ± 9,0e

14 ± 10a 136 ± 12b 189 ± 28c 190 ± 48d 204 ± 12e

160 ± 36a 340 ± 28b 484 ± 90c 796 ± 136d 980 ± 136c

OÏ. ÚˆÙ½ÓË (g/l) 6,5 6,8 6,6 6,5 6,3

± ± ± ± ±

0,5 0,5 0,6 0,4 0,5

∞Ï‚Ô˘Ì›ÓË (g/l) 4,4 ± 0,5 4,3 ± 1,0 4,3 ± 1,0 4,1 ± 1,0 3,98 ± 1,2

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË SGOT: a/b, a/c, a/d, a/e, b/e, c/e, d/e p<0,0001, b/c, b/d, c/d = ª™ SGPT: a/b, a/c, a/d, a/e p<0,0001, b/c, b/d, b/e, c/d, c/e, d/e = ª™ ÁGt: a/b, a/c, a/d, a/e, b/c, b/d, b/e p<0,0001, c/d, c/e, d/e = ª™ LDH: a/b, a/c, a/d, a/d, b/c, b/d, b/e, c/d, c/e p<0,0001, d/e p<0,001 ∆È̤˜ ÔÏ. ÚˆÙ½Ó˘, ·Ï‚Ô˘Ì›Ó˘: ª™ ª™: ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÙÈÌ‹ ¶›Ó·Î·˜ 3. ∂›‰· ÔÏ. ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È ‰Ú·ÛÙÈÎfiÙËÙ· ‚ÈÔÙÈÓȉ¿Û˘ Û ÂÏÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿ OÌ¿‰Â˜

∞ÚÈıÌfi˜ ÓÂÔÁÓÒÓ

A B ° ¢ E ™‡ÓÔÏÔ

38 34 36 29 19 456

µ¿ÚÔ˜ ÁÂÓ. (g) 1904 1880 1790 1775 1890

± ± ± ± ±

130 155 160 150 145

OÏ. ¯ÔÏ. (mg/dl)

¢Ú·ÛÙ. ‚ÈÔÙÈÓȉ¿Û˘ (mmol/min/l)

2,8 ± 1,2 6,5 ± 1,3 11,0 ± 1,2 12,8 ± 1,3 16,2 ± 1,2

3,80 ± 0,8a 1,96 ± 0,9b 1,82 ± 1,2c 1,76 ± 1,3d 1,62 ± 0,9e

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË a/b, a/c, a/d, a/e p<0,0001 b/c, b/d, b/e, c/d, c/e, d/e = ª™ ª™: ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÙÈÌ‹ ¶›Ó·Î·˜ 3·. ∏·ÙÈÎÔ› ‚ÈÔ¯ËÌÈÎÔ› ·Ú¿ÌÂÙÚÔÈ Û ÂÏÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿ OÌ¿‰Â˜ A B ° ¢ E

OÏ. ¯ÔÏ. (mg/dl)

SGOT (U/l)

SGPT (U/l)

ÁGt (U/l)

LDH (U/l)

(0-4) (4-8) (8-12) (12-16) (>16)

16 ± 10a 30 ± 9,0b 26 ± 10c 28 ± 16d 69 ± 8,0e

27 ± 9,0a 78 ± 9,0b 78 ± 10c 76 ± 8,0d 78 ± 10e

14 ± 9,0a 128 ± 14b 176 ± 26c 185 ± 52d 296 ± 32e

150 ± 40a 323 ± 26b 476 ± 80c 770 ± 140d 910 ± 140c

OÏ. ÚˆÙ½ÓË (g/l) 6,5 6,8 6,4 6,3 6,6

± ± ± ± ±

0,4 0,5 0,5 0,5 0,4

∞Ï‚Ô˘Ì›ÓË (g/l) 4,3 4,3 4,1 4,0 4,0

± ± ± ± ±

0,6 1,0 1,0 1,0 1,2

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË SGOT: a/b, a/c, a/d, a/e, b/e, d/e p<0,0001, b/c, b/d, c/d = ª™ SGPT: a/b, a/c, a/d, a/e p<0,0001, b/c, b/d, b/e, c/d, c/e, d/e = ª™ ÁGt: a/b, a/c, a/d, a/e, b/c, b/d, b/e, c/d, c/e p<0,0001, d/e p<0,01 LDH: a/b, a/c, a/d, a/e, b/d, b/e, c/e, d/e p<0,001 ∆È̤˜ ÚˆÙ½Ó˘, ·Ï‚Ô˘Ì›Ó˘: ª™ ª™: ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÙÈÌ‹

ÙÔ˘ ÂÓ˙‡ÌÔ˘ Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ ˘fi ıÂÚ·›· Ì ‚·ÏÚÔ˚Îfi Ô͇ Î·È ÈÛÔÙÚÂÙÈÓÔ˝ÓË ·ÓÙ›ÛÙÔȯ·. ∞ԉ›ͷÌ fiÙÈ ÙÔ Â‡ÚËÌ¿ Ì·˜ ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ú·ÙËÚÔ‡ÌÂÓË Ë·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ·fi ÙË ¯ÔÚ‹ÁËÛË ÙˆÓ ÚÔ·Ó·ÊÂÚfiÌÂÓˆÓ Ê·Ú̿ΈÓ. ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË, Ô˘ ·ÊÔÚ¿ ÛÙ· ÓÂÔÁÓ¿ Ì ÓÂÔÁÓÈÎfi ›ÎÙÂÚÔ, ‰Â›Í·Ì ·ÚÓËÙÈ΋ ÛÙ·ÙÈÛÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ µi Î·È ÙˆÓ ·˘ÍËÌ¤ÓˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Î·È Ù˘ ÔÏ. ¯ÔÏÂÚ˘ıÚ›Ó˘. ∆· ÙÂÏÂ˘Ù·›· ·˘Ù¿ Â˘Ú‹Ì·Ù· ı· ÌÔÚÔ‡Û·Ó, Â›Û˘, Ó· ·Ô‰ÔıÔ‡Ó ÛÙË ‰È·Ù·Ú·Á̤ÓË Ë·ÙÈ΋

ÏÂÈÙÔ˘ÚÁ›· Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙÔÓ ›ÎÙÂÚÔ. ∞ÎfiÌË, ı· ÌÔÚÔ‡Û·Ì ӷ ˘Ôı¤ÛÔ˘Ì fiÙÈ Ë ˘„ËÏ‹ ÛÙ¿ıÌË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ·›˙ÂÈ ÚfiÏÔ “·Ó·ÛÙÔϤ·” ÙÔ˘ ÂÓ˙‡ÌÔ˘, ηı’ fiÛÔÓ ıˆÚÂ›Ù·È Ë·ÙÔÙÔÍÈ΋ Î·È ¤¯ÂÈ ·ÓÙ›ÛÙÚÔÊË Û¯¤ÛË Ì ÙË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi. ÕÏψÛÙÂ, Ë ¯·ÌËÏ‹ ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ·Ú·ÙËÚ‹ıËΠ۠fiϘ ÙȘ ÔÌ¿‰Â˜ ÙˆÓ ÓÂÔÁÓÒÓ Ì·˜ Ì ›ÎÙÂÚÔ. ™˘ÌÂÚ·ÛÌ·ÙÈο: i) ¯·ÌËÏ‹ ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ µi ‚Ú¤ıËΠ۠fiϘ ÙȘ ÔÌ¿‰Â˜ ÙˆÓ ÓÂÔÁÓÒÓ (ÙÂÏÂÈfiÌËÓ·, ÚfiˆÚ· Î·È ÂÏÏÈÔ‚·Ú‹) Ì ›ÎÙÂÚÔ, ii) Ë

359

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·360

¶·È‰È·ÙÚÈ΋ 2002;65:356-361

Paediatriki 2002;65:356-361

¶›Ó·Î·˜ 4. ™˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ‚ÈÔÙÈÓȉ¿Û˘ Î·È Ë·ÙÈÎÒÓ ‚ÈÔ¯ËÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ∆ÂÏÂÈfiÌËÓ·

¶ÚfiˆÚ·

∂ÏÏÈÔ‚·Ú‹

OÌ¿‰Â˜ A B ° ¢ E A B ° ¢ E A B ° ¢ E

µÈÔÙÈÓȉ¿ÛË

OÏ. ¯ÔÏ.

-0,21*** -0,18*** -0,23*** -0,26*** -0,28*** -0,26** -0,37** -0,42** -0,45** -0,46** -0,40** -0,44** -0,42** -0,39** -0,46**

SGOT -0,16* -0,14* -0,16* -0,16* -0,18* -0,16* -0,19* -0,21* -0,21* -0,24* -0,28* -0,26* -0,31* -0,30* -0,36*

SGPT -0,17* -0,16* -0,18* -0,18* -0,16* -0,18* -0,18* -0,20** -0,19* -0,26* -0,30* -0,28* -0,30* -0,31* -0,38*

°Gt -0,21*** -0,20*** -0,26*** -0,25*** -0,30*** -0,26** -0,29** -0,44** -0,43** -0,45** -0,41** -0,46** -0,44** -0,40** -0,46**

LDH -0,24*** -0,21*** -0,21*** -0,27*** -0,27*** -0,27** -0,36** -0,44** -0,46** -0,47** -0,41** -0,45** -0,44** -0,42** -0,48**

***p<0,001, **p<0,01, *p<0,05 ¢Ú·ÛÙ. ‚ÈÔÙÈÓȉ¿Û˘ / ÔÏ. ÚˆÙ½ÓË, ·Ï‚Ô˘Ì›ÓË: ªË ÛÙ·Ù. ÛËÌ·ÓÙÈ΋ ÙÈÌ‹

¯·ÌËÏ‹ ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ Èı·Ófiٷٷ ÔÊ›ÏÂÙ·È Û Ë·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, iii) Ë ˘„ËÏ‹ ÛÙ¿ıÌË Ù˘ ÔÏ. ¯ÔÏÂÚ˘ıÚ›Ó˘ Â›Ó·È Ë·ÙÔÙÔÍÈ΋ Î·È ı· ÌÔÚÔ‡Û ӷ ·›ÍÂÈ ÚfiÏÔ “·Ó·ÛÙÔϤ·” ÙÔ˘ ÂÓ˙‡ÌÔ˘, iv) Ë ËÏÈΛ· ·ËÛ˘, ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È Ù· Â›‰· ÔÏ. ¯ÔÏÂÚ˘ıÚ›Ó˘ ı· Ú¤ÂÈ ¿ÓÙÔÙ ӷ ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙȘ οÚÙ˜ Guthrie ÁÈ· ÙË ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ µi ÛÙ· ÓÂÔÁÓ¿. ∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ÙËÓ Î. ÕÓÓ· ™Ù·Ì¿ÙË ÁÈ· ÙËÓ ÂÈÌÂÏË̤ÓË ‰·ÎÙ˘ÏÔÁÚ¿ÊËÛË Ù˘ ÂÚÁ·Û›·˜.

BÈ‚ÏÈÔÁÚ·Ê›· 1. Wolf B. Disorders of biotin metabolism. In: Scriver et al, eds. The metabolic and molecular basis of inherited disease. N. York: McGraw Hill; 1995. p. 3151.

2. Wolf B, Miller JB, Hymes J, Secor Mc Voy J, Ishikawa Y, Shapira E. Immunological comparison of biotinidase in serum from normal and biotinidase deficient individuals.

Clin Chim Acta 1987;164:27-30.

3. Chauhan J, Dakshinamurti K. Purification and characterization of human serum biotinidase. J Biol Chem 1986;261:4268-4290.

4. Schubiger G, Caflisch U, Baumgartner R, Suormala T, Bachmann C. Biotinidase deficiency: clinical course and biochemical findings. J Inherit Metab Dis 1984;7:129-132.

5. Suormala TM, Baumgartner R, Wick H, Scheibenreiter S, Schweitzer S. Comparison of patients with complete and partial biotinidase deficiency: biochemical studies. J Inherit Metab Dis 1990;13:76-80.

6. Maisels MJ. Jaundice. In: Avery GB, Fletcher MA, Mac Donald MC, eds. Neonatology and management of the newborn. 4th ed. J.P. Lippincott Company Phila; 1994. p.

630-719.

7. Cashore WJ. The neurotoxicity of bilirubin. Clin PerinatÔl 1990;17:437-439.

360

8. Matsui A, Dodoriki M. Screening for biliary atresia. Lancet 1995;345:1181.

9. McDonagh AF. Is bilirubin good for you? Clin Perinatol 1990;17:359-380.

10. Ostrea EM Jr, Ongtengco EA, Tolia VA, Apostol E. The occurrence and significance of bilirubin species, including delta bilirubin, in jaundiced infants. J Pediatr Gastroenterol Nutr 1988;7:511-519.

11. Wolf B, Heard GS, Mc Voy JR, Grier RE. Biotinidase deficiency. Ann NY Acad Sci 1985;457:252-258.

12. Wolf B, Heard GS. Disorders of biotin metabolism: In: Scriver J et al, eds. The metabolic and molecular bases of inherited diseases. 7th ed. New York: Mc Graw Hill; 1995. p. 2083-2103.

13. Ebrahim H, Dakshinamurti K. A flluorometric assay for biotinidase. Anal Biochem 1986;154:282-286.

14. Hannam S, Mc Donnell M, Rennie JM. Investigation of prolonged neonatal jaundice. Acta Paediatr 2000; 89:694-697.

15. Jansen PLM, Mulder GJ, Burchell B, Bock KW. New developments in glucuronidation research: report of a workshop on “glucuronidation, its role in health and disease”. Hepatology 1992;15:532-536.

16. Suormala TM, Baumgartner ER, Wick H, Scheibenreiter S, Schweitzer S. Comparison of patients with complete and partial biotindase deficiency: biochemical studies. J Inherit Metab Dis 1990;13:76-92.

17. Suormala TM, Wick H, Baumgartner ER. Low biotinidase activity in plasma of some preterm infants: possible source of false-positive screening results. Eur J Pediatr 1988;147:478-480.

18. Mc Voy JR, Levy HL, Lawler M, Schmidt MA, Ebers DD, Hart PS et al. Partial biotinidase deficiency: clinical and biochemical features. J Pediatr 1990;116:78-83.

19. Pispa J. Animal biotinidase. Ann Med Exp Biol Fenn 1985;43(Suppl 5):5-38.

20. Grier RE, Heard GS, Watkins P, Wolf B. Low biotinidase activities in the sera of patients with impaired liver function: evidence that the liver is the source of serum biotinidase.

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·361

¶·È‰È·ÙÚÈ΋ 2002;65:356-361

Paediatriki 2002;65:356-361

Clin Chim Acta 1990;186:397-400.

21. Nagamine T, Saito S, Yamada S, Arai T, Takehara K, Fukui T. Biotinidase activity in patients with liver disease. Scand J Gastroenterol 1993;28:899-906.

22. Schulpis KH, Georgala S, Papakonstantinou ED, Michas T, Karikas GA. The effect of isotretinoin on biotinidase activity.

Skin Pharmacol Appl Skin Physiol 1999;12:28-33.

23. Schulpis KH, Karikas GA, Tjamouranis J, Regoutas S, Tsakiris S. Low serum biotinidase activity in children with valproic acid monotherapy. Epilepsia 2001;42:1359-1362.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 15-04-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-07-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ÏÂÔ¿ÙÚ· ∂. ™Ô‡ÏË πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á. ™ÔÊ›·”, ∆.∫. 115 27, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∞ÓÙ·fiÎÚÈÛË ÛÙ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Î·È ·ÙÔ›· Û ·È‰È¿ 5-10 ÂÙÒÓ Ì ‚‹¯·1 ∂ÈÛ·ÁˆÁ‹: ∆Ô ¿ÛıÌ· Ô˘ ÂÎÊÚ¿˙ÂÙ·È ·ÔÎÏÂÈÛÙÈο Ì ‚‹¯· (cough variant asthma, CVA) ıˆÚÂ›Ù·È ·fi ÔÏÏÔ‡˜ ˆ˜ ¤Ó·˜ ·fi ÙÔ˘˜ Ê·ÈÓfiÙ˘Ô˘˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ∞ÎfiÌË, Ë ‡·ÚÍË ··ÓÙËÙÈÎfiÙËÙ·˜ ÛÙ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ê¿Ú̷η (bronchodilator responsiveness, BDR) ·ÔÙÂÏ› ·‰È·ÌÊÈÛ‚‹ÙËÙÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ÓfiÛÔ˘. ∆¤ÏÔ˜, ÙÔ 90% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÂΉËÏÒÓÔ˘Ó Û˘ÚÈÁÌfi ηٿ ÙË Û¯ÔÏÈ΋ ËÏÈΛ·, ¤¯ÂÈ ·ÙÔ›·. ∆›ıÂÙ·È, ÂÔ̤ӈ˜, ÙÔ ÂÚÒÙËÌ·: ª‹ˆ˜ Ù· ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ‚‹¯· Î·È BDR Â›Ó·È Â›Û˘ ·ÙÔÈο; ¢ÈfiÙÈ, Â¿Ó ÈÛ¯‡ÂÈ Î¿ÙÈ Ù¤ÙÔÈÔ, ÙfiÙÂ Ë ‰È¿ÁÓˆÛ‹ ÙÔ˘ ·ÊÔÚ¿ Û ·˘Ù¿ ·ÎÚÈ‚Ò˜ Ù· ·È‰È¿. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∏ ·ÓÙ›ÛÙ·ÛË ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ ÌÂÙÚ‹ıËΠ̠ÙËÓ Ù¯ÓÈ΋ Ù˘ ‰È·ÎÔ‹˜ Ù˘ ·Ó·ÓÔ‹˜ (Rint) ÚÈÓ Î·È ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË Û·Ï‚Ô˘Ù·ÌfiÏ˘ Û ÔÌ¿‰· ÂϤÁ¯Ô˘ (n=73), Û ·È‰È¿ Ì ‚‹¯· (n=63) Î·È Û ·È‰È¿ Ì ÈÛÙÔÚÈÎfi Û˘ÚÈÁÌÔ‡ (n=63) ËÏÈΛ·˜ 5-10 ÂÙÒÓ. ∂›Û˘, ÌÂÙÚ‹ıËÎÂ Ë ·ÓÔÛÔÛÊ·ÈÚ›ÓË (Ig)-E ÛÙȘ ÔÌ¿‰Â˜ ÙˆÓ ·È‰ÈÒÓ Ì ‚‹¯· Î·È Û˘ÚÈÁÌfi. ∏ BDR ÂÎÊÚ¿ÛÙËΠˆ˜ Ô ÏfiÁÔ˜ Ù˘ ÙÈÌ‹˜ Ù˘ Rint ÚÈÓ, ÚÔ˜ ÙËÓ ÙÈÌ‹ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË Û·Ï‚Ô˘Ù·ÌfiÏ˘. ∞ÔÙÂϤÛÌ·Ù·: ∆· ·È‰È¿ ÙˆÓ ÙÚÈÒÓ ÔÌ¿‰ˆÓ ›¯·Ó ·ÚfiÌÔȘ ËÏÈ˘ (̤ÛË ÙÈÌ‹: 6,7, ‡ÚÔ˜: 5-9,9 ¤ÙË). ∏ ÁˆÌÂÙÚÈ΋ ̤ÛË ÙÈÌ‹ Ù˘ Rint Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÔ‡ ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÙˆÓ ·È‰ÈÒÓ Ì ‚‹¯· (0,66 Î·È 0,68 kPaØL-1Øs). ∏ ÙÈÌ‹ Ù˘ Rint ÙˆÓ ·È‰ÈÒÓ ÌÂ Û˘ÚÈÁÌfi ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÔ‡ (0,73 kPaØL-1Øs) ‚Ú¤ıËΠ˘„ËÏfiÙÂÚË Ù˘

·ÓÙ›ÛÙÔȯ˘ ÙˆÓ ·È‰ÈÒÓ Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ (p=0,05), fï˜ ‰ÂÓ ‰È¤ÊÂÚ ·fi ÂΛÓË Ù˘ ÔÌ¿‰·˜ ÙˆÓ ·È‰ÈÒÓ Ì ‚‹¯· (p=0,17). ∏ ÁˆÌÂÙÚÈ΋ ̤ÛË ÙÈÌ‹ Ù˘ BDR ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·È‰ÈÒÓ Ì ‚‹¯· ‹Ù·Ó 1,22, ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ 1,13 Î·È ÛÙËÓ ÔÌ¿‰· ÌÂ Û˘ÚÈÁÌfi 1,30 (p=0,01 ÔÌ¿‰· ‚‹¯· ¤Ó·ÓÙÈ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘, p=0,08 ÔÌ¿‰· ‚‹¯· ¤Ó·ÓÙÈ ÔÌ¿‰·˜ Û˘ÚÈÁÌÔ‡, p<0,001 ÔÌ¿‰· ÂϤÁ¯Ô˘ ¤Ó·ÓÙÈ ÔÌ¿‰·˜ Û˘ÚÈÁÌÔ‡). ∏ IgE ‚Ú¤ıËΠ¯·ÌËÏfiÙÂÚË ÛÙ· ·È‰È¿ Ì ‚‹¯· ¤Ó·ÓÙÈ ÙˆÓ ·È‰ÈÒÓ ÌÂ Û˘ÚÈÁÌfi (ÁˆÌÂÙÚÈΤ˜ ̤Û˜ ÙÈ̤˜ 36 Î·È 364 IUØL-1, p<0,001) Î·È ‰ÂÓ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙËÓ BDR Û ηÌÈ¿ ·fi ÙȘ ‰‡Ô ÔÌ¿‰Â˜. ™˘ÌÂÚ¿ÛÌ·Ù·: ∂Ó Î·Ù·ÎÏ›‰È, Ë ‡·ÚÍË ·ÙÔ›·˜, ·ÏÏ¿ fi¯È Ë ··ÓÙËÙÈÎfiÙËÙ· ÛÙ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο, ÌÔÚ› Ó· ͯˆÚ›ÛÂÈ Ù· ·È‰È¿ Ì ‚‹¯· ·fi ÂΛӷ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘ÚÈÁÌfi. ∏ ‰È¿ÁÓˆÛË ÙÔ˘ CVA ‰ÂÓ Â›Ó·È ‰fiÎÈÌË Ô‡Ù ÁÈ· Ù· ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ‚‹¯·, Ù· ÔÔ›· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ··ÓÙËÙÈÎfiÙËÙ· ÛÙ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ê¿Ú̷η.

1

McKenzie SA, Mylonopoulou M, Bridge PD Bronchodilator responsiveness and atopy in 5-10-yr-old coughers Eur Respir J 2001;18:977-981

ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜

361

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·362

¶·È‰È·ÙÚÈ΋ 2002;65:362-366

∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

Paediatriki 2002;65:362-366

ORIGINAL ARTICLE

∏ Â›‰Ú·ÛË ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ·ÈÌÔÏ˘ÙÈÎÔ‡ ÈÎÙ¤ÚÔ˘ ÛÙ· Â›‰· ¯·ÏÎÔ‡ ·›Ì·ÙÔ˜ ÙÂÏÂÈfiÌËÓˆÓ Î·È ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ ∫. ™Ô‡ÏË1, ™. °·‚Ú›ÏË3, £. ∫·Ú·ÎˆÓÛÙ·ÓÙ¿Î˘2, °. ÃÚÔÓÔÔ‡ÏÔ˘2, Ã. ∫ÒÛÙ·ÏÔ˜3, π. ¶··ÛˆÙËÚ›Ô˘2

The effect of neonatal haemolytic jaundice on serum copper levels in fullterm and premature newborns K. H. Schulpis1, S. Gavrili3, T. Karakonstantakis2, G. Chronopoulou2, C. Costalos3, J. Papassotiriou2

¶ÂÚ›ÏË„Ë: O ÓÂÔÁÓÈÎfi˜ ›ÎÙÂÚÔ˜ Â›Ó·È ·fi ÙȘ ϤÔÓ Û˘¯Ó¤˜ ·Èٛ˜ ÓÔÛËÏ›·˜ ÙÂÏÂÈfiÌËÓˆÓ Î·È ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. O ¯·ÏÎfi˜ (Ã∞) Â›Ó·È ··Ú·›ÙËÙÔ˜ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ·Ó·ÈÌ›·˜ Î·È Ù˘ Ï¢ÎÔÂÓ›·˜, fiˆ˜ Â›Û˘ ÁÈ· ÙËÓ ˆÚ›Ì·ÓÛË ÙÔ˘ ÛÎÂÏÂÙÔ‡ Î·È ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ‹Ù·Ó Ë Ì¤ÙÚËÛË ¯·ÏÎÔ‡ ÛÙÔÓ ÔÚfi ˘ÁÈÒÓ Î·È ÈÎÙÂÚÈÎÒÓ ÙÂÏÂÈfiÌËÓˆÓ Î·È ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. 102 ÙÂÏÂÈfiÌËÓ· Î·È 97 ÚfiˆÚ· ÓÂÔÁÓ¿ ËÏÈΛ·˜ 2-4 ËÌÂÚÒÓ ¯ˆÚ›ÛÙËÎ·Ó Û 3 ÔÌ¿‰Â˜ ·Ó¿ÏÔÁ· Ì ٷ Â›‰· ÔÏÈ΋˜ ¯ÔÏÂÚ˘ıÚ›Ó˘ (OÃ) ÛÙÔ ·›Ì· ÙÔ˘˜. ∆fiÛÔ Ë OÃ, fiÛÔ Î·È Ù· Ë·ÙÈο ¤Ó˙˘Ì· ÌÂÙÚ‹ıËÎ·Ó Ì ÌÂıfi‰Ô˘˜ ÚÔ˘Ù›Ó·˜, ÂÓÒ ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ Ã∞ ÛÙÔÓ ÔÚfi ÌÂÙÚ‹ıËÎ·Ó Ì ·ÙÔÌÈ΋ ·ÔÚÚfiÊËÛË. ∆· Â›‰· ÙÔ˘ Ã∞ ÛÙ· ˘ÁÈ‹ ÚfiˆÚ· ‹Ù·Ó Û·ÊÒ˜ ¯·ÌËÏfiÙÂÚ· (25±5 ng/dl) Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ (40±8 ng/dl, p<0,001).

OÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ Ã∞ ÙÚÈÏ·ÛÈ¿˙ÔÓÙ·Ó ÛÙÔÓ ÔÚfi ÙˆÓ ÚÔÒÚˆÓ Ì ›ÎÙÂÚÔ Î·È ÙÔ Ì¤Ù·ÏÏÔ ¤‰ÂÈÍ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ٷ Â›‰· ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Î·È ÙËÓ OÃ. ™˘ÌÂÚ·ÛÌ·ÙÈο: i) Ù· Â›‰· Ã∞ ‹Ù·Ó ¯·ÌËÏfiÙÂÚ· ÛÙ· ˘ÁÈ‹ ÚfiˆÚ· Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ, ii) Ô Ã∞ ¢ڤıË ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ˜ ÛÙÔÓ ÔÚfi ÙfiÛÔ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ fiÛÔ Î·È ÙˆÓ ÚfiˆÚˆÓ ÈÎÙÂÚÈÎÒÓ ÓÂÔÁÓÒÓ, iii) Ù· ˘„ËÏ¿ Â›‰· Ã∞ ÙˆÓ ÈÎÙÂÚÈÎÒÓ Èı·Ófiٷٷ Â›Ó·È ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ ÚÔ¤Ï¢Û˘, iv) Ù· ÚfiˆÚ· ÈÎÙÂÚÈο ÓÂÔÁÓ¿ ÎÈÓ‰˘ÓÂ‡Ô˘Ó fi¯È ÌfiÓÔÓ ·fi ˘ÚËÓÈÎfi ›ÎÙÂÚÔ, ·ÏÏ¿ Î·È ·fi ÙËÓ ÂÓ·fiıÂÛË ÙÔ˘ Ã∞ ÛÙÔÓ ÂÁΤʷÏfi ÙÔ˘˜ Î·È v) Ù· Â›‰· Ã∞ ı· ÌÔÚÔ‡Û·Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ˆ˜ ÚfiÛıÂÙÔ˜ ‰Â›ÎÙ˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ·ÈÌÔÏ˘ÙÈÎÔ‡ ÈÎÙ¤ÚÔ˘.

Abstract: The aim of the study was to evaluate serum copper levels in healthy and jaundiced premature and fullterm infants. 102 fullterm neonates and 97 prematures were divided into 3 groups according to their total bilirubin (t.Bil) levels. t.Bil levels and liver enzymes were measured with routine methods whereas copper serum levels with atomic absorption. None of the newborns suffered from obstructive jaundice.

Copper levels were found remarkably decreased in healthy prematures as compared to fullterms (25±5 vs 40±8 ng/dl, p<0.001). The metal was almost 3-fold increased in the jaundiced infants especially in prematures. Copper statistically significantly correlated with t.Bil and liver enzymes (p<0.001). In conclusion: i) copper levels were found decreased in healthy prematures as compared to those of fullterms, ii) copper levels were found elevated in all the studied newborns with jaundice, iii) the high copper levels in jaundiced neonates may be of intracellular origin, iv) premature jaundiced newborns might be at risk for developing kernicterus and copper accumulation in their brain and v) copper levels could be a useful additional marker of the severity of neonatal jaundice.

1 πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 2 µÈÔ¯ËÌÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 3 ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ª·È¢ÙËÚ›Ô˘ “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó·

1 Institute of Child Health, “Agia Sophia” Children’s Hospital, Athens 2 Chemical and Biological Laboratory, “Agia Sophia” Children’s Hospital, Athens 3 Department of Neonatology, “Alexandra” Maternity Clinic, Athens

362

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·363

¶·È‰È·ÙÚÈ΋ 2002;65:362-366

Paediatriki 2002;65:362-366

§¤ÍÂȘ ÎÏÂȉȿ: ÓÂÔÁÓÈÎfi˜ ›ÎÙÂÚÔ˜, ¯·ÏÎfi˜, ÚfiˆÚ·.

Key words: neonatal jaundice, copper, prematures.

∂ÈÛ·ÁˆÁ‹ O ÓÂÔÁÓÈÎfi˜ ›ÎÙÂÚÔ˜ ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È ÙÔ ϤÔÓ Û˘¯Ófi Úfi‚ÏËÌ· ηٿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Î·È Ë ϤÔÓ Û˘¯Ó‹ ·ÈÙ›· ÂÈÛ·ÁˆÁ‹˜ Û ÓÂÔÁÓÔÏÔÁÈο ÙÌ‹Ì·Ù· ηٿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜ (1). ™˘Ó‹ıˆ˜, Ë ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Î·È Ë ÛÔ‚·ÚfiÙËÙ· ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ÈÎÙ¤ÚÔ˘ ¤¯ÂÈ ¿ÌÂÛË Û¯¤ÛË Ì ٷ Â›‰· Ù˘ ÔÏÈ΋˜ ¯ÔÏÂÚ˘ıÚ›Ó˘ (OÃ) ÛÙÔÓ ÔÚfi ÙÔ˘˜ (2). O ¯·ÏÎfi˜ (Ã∞) Û˘ÌÌÂÙ¤¯ÂÈ ÛÙÔ Û‡ÛÙËÌ· ÔÏÏÒÓ ÂÓ˙‡ÌˆÓ, fiˆ˜ Ù˘ ΢ÙÙÔ¯ÚˆÌÈ΋˜-c-ÔÍÂȉ¿Û˘ Î·È Ù˘ ÙÔ˘ ˘ÂÚÔÍÂȉ›Ô˘ ‰ÈÛÌÔ˘Ù¿Û˘ (3).

O Ã∞ ıˆÚÂ›Ù·È ·Ó·Áη›Ô˜ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ·Ó·ÈÌ›·˜ Î·È Ù˘ Ï¢ÎÔÂÓ›·˜, Ù˘ ˆÚ›Ì·ÓÛ˘ ÙÔ˘ ÛÎÂÏÂÙÔ‡ Î·È È‰È·›ÙÂÚ· ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘ (4). ∏ Ì›ˆÛË ÙÔ˘ ÂÈ¤‰Ô˘ ÙÔ˘ Ã∞ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ¢¿ıÂÈ· ÛÙȘ ÏÔÈÌÒÍÂȘ, fiˆ˜ Û˘Ì‚·›ÓÂÈ Û ·ÛıÂÓ›˜ Ì ÙË ÓfiÛÔ Menke, ¤Ó· ÎÏËÚÔÓÔÌÈÎfi ÓfiÛËÌ· Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¯·ÌËÏ¿ Â›‰· ÙÔ˘ ÌÂÙ¿ÏÏÔ˘ ÛÙÔÓ ÔÚfi (5). ∆Ô ÙÂÏÂÈfiÌËÓÔ ÓÂÔÁÓfi ÁÂÓÓÈ¤Ù·È Ì Â·ÚΛ˜ ÔÛfiÙËÙ˜ Ã∞ (6). ŸÌˆ˜, Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ·Ó·Ê¤ÚÂÙ·È Û ·ÚÎÂÙ¤˜ ‰ËÌÔÛȇÛÂȘ (7-9) fiÙÈ Â›Ó·È ‰˘Ó·Ù‹ Ë ÂÌÊ¿ÓÈÛË ÌÂȈ̤Ó˘ ÛÙ¿ıÌ˘ ÙÔ˘ Ã∞, Ë ÔÔ›· Û˘Ó‰˘¿˙ÂÙ·È Ì ·Ó·ÈÌ›·, Ô˘‰ÂÙÂÚÔÂÓ›· Î·È ·ÔÌÂÙ¿ÏψÛË ÙˆÓ ÔÛÙÒÓ. ∞ÓÙ›ıÂÙ·, Ë ·˘ÍË̤ÓË ÛÙ¿ıÌË ÙÔ˘ ÌÂÙ¿ÏÏÔ˘ Û˘Óԉ‡ÂÙ·È Ì ÙËÓ ÂÓ·fiıÂÛ‹ ÙÔ˘ Û ÔÔÈÔ‰‹ÔÙ fiÚÁ·ÓÔ, ȉȷÈÙ¤Úˆ˜ ÛÙÔ ‹·Ú, ÙÔÓ ÂÁΤʷÏÔ Î.Ï. (10). Œ¯ÔÓÙ·˜ ˘’ fi„ÈÓ ÙË ÛÔ˘‰·ÈfiÙËÙ· ÙÔ˘ Ã∞ ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, ÌÂÙÚ‹Û·Ì ٷ Â›‰¿ ÙÔ˘ ÛÙÔÓ ÔÚfi ˘ÁÈÒÓ ÙÂÏÂÈfiÌËÓˆÓ Î·È ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·È Ù· Û˘ÁÎÚ›Ó·Ì Ì ٷ ·ÓÙ›ÛÙÔȯ· ÓÂÔÁÓÒÓ Ì ›ÎÙÂÚÔ.

ÔÌ¿‰· ° (¡=32) Ù· Â›‰· Ù˘ Oà ‹Ù·Ó 16,8±2 mg/dl. ∏ ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ G6PD ¢ڤıË ˆ˜ ·ÈÙ›· ÛÙÔ 68% ÙˆÓ ÓÂÔÁÓÈÎÒÓ ÈÎÙ¤ÚˆÓ, ¤Ó· ¤·Û¯Â ·fi ·ÙÚËÛ›· ¯ÔÏËÊfiÚˆÓ, ÂÓÒ ÁÈ· Ù· ˘fiÏÔÈ· ÙÚÈ¿ÓÙ· ¤Ó· (¡=31) ÓÂÔÁÓ¿ ‰ÂÓ Â˘Ú¤ıË Ë ·ÈÙ›· ÙÔ˘ ÈÎÙ¤ÚÔ˘ ÙÔ˘˜ (11). ¶ÚfiˆÚ·: ŒÓ·˜ Û˘ÓÔÏÈÎfi˜ ·ÚÈıÌfi˜ ÚÔÒÚˆÓ (¡=97) Ì ›ÎÙÂÚÔ, ËÏÈΛ·˜ 3-5 ËÌÂÚÒÓ Î·È ËÏÈΛ· ·ËÛ˘ 29±2,5 ‚‰ÔÌ¿‰ˆÓ, ‰È·¯ˆÚ›ÛÙËΠ۠3 ÔÌ¿‰Â˜. ™ÙËÓ ÔÌ¿‰· ∞ (¡=36) Ù· Â›‰· Oà ‹Ù·Ó 3,0±1,0 mg/dl, ÛÙËÓ ÔÌ¿‰· µ (¡=29) 11,8±1,2 mg/dl Î·È ÛÙËÓ ÔÌ¿‰· ° (¡=32) Ù· Â›‰¿ Ù˘ ‹Ù·Ó 16,2±1,5 mg/dl. ∞ÓÂ¿ÚÎÂÈ· ÙÔ˘ G6PD ·Ú·ÙËÚ‹ıËΠÛÙÔ 39% ÙˆÓ ÈÎÙÂÚÈÎÒÓ ÓÂÔÁÓÒÓ Î·È ‰ÂÓ Â˘Ú¤ıË Ë ·ÈÙ›· ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ÈÎÙ¤ÚÔ˘ ÁÈ· ÙȘ ˘fiÏÔÈ˜ ÂÚÈÙÒÛÂȘ (11). ∞fi fiϘ ÙȘ ÔÌ¿‰Â˜ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ Î·È ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ ÂÏ‹ÊıËÛ·Ó 3,0 ml ·›Ì·ÙÔ˜ Ì ÙËÓ Â˘Î·ÈÚ›· ··Ú·›ÙËÙ˘ ·ÈÌÔÏË„›·˜, .¯. ÁÈ· ÙË Ì¤ÙÚËÛË Ù˘ Hb ‹ Ù˘ OÃ. ∆fiÛÔ Ù· Â›‰· Ù˘ OÃ, fiÛÔ Î·È ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ì ÌÂıfi‰Ô˘˜ ÚÔ˘Ù›Ó·˜. OÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ Ã∞ ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ÌÂÙÚ‹ıËÎ·Ó Ì ʷÛÌ·ÙÔÌÂÙÚ›· ·ÙÔÌÈ΋˜ ·ÔÚÚfiÊËÛ˘ (Perkin Elmer Atomic absorption A-Analyst 800). °È· ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ ‰ÔÎÈ̷ۛ˜ Student’s test Î·È ÔÏÏ·Ï‹˜ ·ÏÈÓ‰ÚfiÌËÛ˘. ∆È̤˜ p<0,05 ıˆڋıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜.

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∆ÂÏÂÈfiÌËÓ·: ∞ÚÈıÌfi˜ ÓÂÔÁÓÒÓ (¡=102) ËÏÈΛ·˜ 2-3 ËÌÂÚÒÓ, ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ 3340±136 g, 40±2 ‚‰ÔÌ¿‰ˆÓ ·ËÛ˘, ¯ˆÚ›ÛÙËΠ۠3 ÔÌ¿‰Â˜ ·Ó¿ÏÔÁ· Ì ٷ Â›‰· ÔÏÈ΋˜ ¯ÔÏÂÚ˘ıÚ›Ó˘ (OÃ) ÛÙÔ ·›Ì· ÙÔ˘˜. ∏ ÔÌ¿‰· ∞ (¡=42) ›¯Â Oà 1-4 mg/dl, Ë ÔÌ¿‰· µ (¡=28) 10,4±2,2 mg/dl Î·È ÛÙËÓ

∞ÔÙÂϤÛÌ·Ù· ∆ÂÏÂÈfiÌËÓ·: Ÿˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1, Ù· Â›‰· Ã∞ ÙˆÓ ÔÌ¿‰ˆÓ µ Î·È ° ‹Ù·Ó Û·ÊÒ˜ ˘„ËÏfiÙÂÚ· Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ Ù˘ ÔÌ¿‰·˜ ∞. ∂›Û˘, Ù· Ë·ÙÈο ¤Ó˙˘Ì· ÙˆÓ ÓÂÔÁÓÒÓ Ì ˘„ËÏ‹ Oà (ÔÌ¿‰Â˜ µ Î·È °) ›¯·Ó Û·ÊÒ˜ ˘„ËÏfiÙÂÚ· Â›‰· Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ Ù˘ ÔÌ¿‰·˜ ∞. ¶ÚfiˆÚ·: ∆Ô ›‰ÈÔ ·Ú·ÙËÚÂ›Ù·È Î·È ÛÙȘ ÔÌ¿‰Â˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ (¶›Ó·Î·˜ 2). ∆· Â›‰· Ã∞ ۯ‰fiÓ ÙÚÈÏ·ÛÈ¿˙ÔÓÙ·È ÛÙËÓ ÔÌ¿‰· ° Ì ٷ ˘„ËÏ¿ Â›‰· Ù˘ OÃ Î·È ‰ÈÏ·ÛÈ¿˙ÔÓÙ·È Û ÂΛӷ Ù· ÓÂÔÁÓ¿ Ì ÙÔÓ ËÈfiÙÂÚÔ ›ÎÙÂÚÔ (¶›Ó·Î·˜ 2). ∆· ÏÔÈ¿ ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2 ‰Â›¯ÓÔ˘Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο

¶›Ó·Î·˜ 1. ∏·ÙÈΤ˜ ‚ÈÔ¯ËÌÈΤ˜ ·Ú¿ÌÂÙÚÔÈ Î·È Â›‰· ¯·ÏÎÔ‡ ÛÙÔÓ ÔÚfi ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ OÌ¿‰Â˜ ∞ (N=42) B (N=28) ° (N=32)

OÏ. ¯ÔÏ. (mg/dl)

SGOT (U/l)

SGPT (U/l)

ÁGt (U/l)

LDH (U/l)

÷ÏÎfi˜ (Ìg/dl)

2,5 ± 0,6 10,4 ± 2,2 16,8 ± 2,1

28 ± 9,0a 36 ± 10,0b 56 ± 9,5c

26 ± 10a 36 ± 10b 57 ± 9,0c

60 ± 95a 110 ± 30b 150 ± 36c

150 ± 36a 350 ± 80b 658 ± 140c

42 ± 8a 68 ± 10b 79 ± 8c

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË SGPT, SGOT: a/b, b/c p<0,01, a/c p<0,001 LDH, ÁGt: a/b, b/c, a/c p<0,0001 ÷ÏÎfi˜: a/b, a/c p<0,0001, b/c p<0,007 OÈ ÙÈ̤˜ ·Ï‚Ô˘Ì›Ó˘ Î·È ÔÏÈ΋˜ ÚˆÙ½Ó˘: ªË ÛÙ·ÙÈÛÙ. ÛËÌ·ÓÙÈΤ˜

363

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·364

¶·È‰È·ÙÚÈ΋ 2002;65:362-366

Paediatriki 2002;65:362-366

·˘ÍË̤ӷ Â›‰· ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÛÙȘ ÔÌ¿‰Â˜ µ Î·È ° Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÙËÓ ÔÌ¿‰· ∞. ™ÙÔÓ ¶›Ó·Î· 3 Ê·›ÓÔÓÙ·È ÔÈ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ıÂÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ÙfiÛÔ ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ OÃ, ·ÏÏ¿ Î·È ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Ì ٷ Â›‰· ÙÔ˘ Ã∞. ™˘˙‹ÙËÛË ¡ÂÔÁÓÈÎfi˜ ›ÎÙÂÚÔ˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËı› ·ÎfiÌË Î·È ÛÙÔ 50% ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ, ȉȷ›ÙÂÚ· Û ÂΛӷ Ô˘ ıËÏ¿˙Ô˘Ó (12,13). ∆· Â›‰· Ã∞ ÛÙ· ÚfiˆÚ· ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ· Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ (14,15). ∆Ô Â‡ÚËÌ· ·˘Ùfi ÂÍËÁÂ›Ù·È ÙfiÛÔ ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô Ã∞ Êı¿ÓÂÈ ¤Ó· ̤ÁÈÛÙÔ Â›Â‰Ô Û˘ÁΤÓÙÚˆÛ˘ ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ ÙÚÈÌ‹ÓÔ˘ Ù˘ ·ËÛ˘, fiÛÔ Î·È ·fi ÙÔ fiÙÈ ÙÔ ‹·Ú ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Â›Ó·È ·ÓÒÚÈÌÔ ÁÈ· ÙËÓ ·Ôı‹Î¢ÛË ÙÔ˘ ÌÂÙ¿ÏÏÔ˘ (15). ™ÙË ÌÂϤÙË Ì·˜ Ù· Â›‰· Ã∞ ÛÙÔÓ ÔÚfi ‰ÈÏ·ÛÈ¿˙ÔÓÙ·È ÙfiÛÔ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ fiÛÔ Î·È ÛÙ· ÚfiˆÚ· Ì ‹ÈÔ ›ÎÙÂÚÔ Î·È Û¯Â‰fiÓ ÙÚÈÏ·ÛÈ¿˙ÔÓÙ·È Û ÂΛӷ Ì ÛÔ‚·Úfi ›ÎÙÂÚÔ (ÔÌ¿‰Â˜ °). ∆· Ï›ÛÙ· ÙˆÓ ÓÂÔÁÓÒÓ ÛÙËÓ ÂÚÁ·Û›· Ì·˜ ¤·Û¯·Ó ·fi ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈÎÔ‡ ÂÓ˙‡ÌÔ˘ G6PD (ÔÍ›· ·ÈÌfiÏ˘ÛË), ÂÓÒ ÛÙ· ˘fiÏÔÈ· ‰ÂÓ ‚Ú¤ıËÎÂ Ô ·ÈÙÈÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙÔ˘ ÈÎÙ¤ÚÔ˘. ŒÓ· ÓÂÔÁÓfi Ì ·fiÊÚ·ÍË ÙˆÓ ¯ÔÏËÊfiÚˆÓ Â›¯Â Ê˘ÛÈÔÏÔÁÈο Â›‰· Ã∞ Î·È ‰ÂÓ Û˘ÓÂÎÙÈÌ‹ıËΠÛÙË ÌÂϤÙË Ì·˜. ∂ӉȷʤÚÔÓ ı· ‹Ù·Ó Ó· ÂÎÙÈÌ‹ÛÔ˘Ì ٷ Â›‰· Ã∞ Î·È Û ÔÌ¿‰· ÓÂÔ-

ÁÓÒÓ Ì ›ÎÙÂÚÔ ÌË ·ÈÌÔÏ˘ÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜, ·Ú’ fiÏÔ Ô˘ Ù¤ÙÔÈ· ÂÚÈÛÙ·ÙÈο Â›Ó·È Û·ÓÈfiÙÂÚ·. ∆· ·˘ÍË̤ӷ Â›‰· Ã∞ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËıÔ‡Ó ·fi ‰È¿ÊÔÚ˜ ·Èٛ˜ (10). ∂Âȉ‹ ÙÔ ‹·Ú ¤¯ÂÈ ·˘ÍË̤ÓË ‰˘Ó·ÙfiÙËÙ· Ó· ·Ô‚¿ÏÂÈ ÙÔÓ Ã∞, Ë ¯ÚfiÓÈ· ÊfiÚÙÈÛË Ì Ã∞ Â›Ó·È Û¿ÓÈ·. ¶·Ú’ fiÏ· ·˘Ù¿, Û ÔÏÏÔ‡˜ ·ÛıÂÓ›˜ Ì Ë·ÙÈ΋ ÓfiÛÔ, .¯. Ì ›ÎÙÂÚÔ, ¤¯ÂÈ ·Ú·ÙËÚËı› Ì›· ̤ÙÚÈ· ·‡ÍËÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ ÌÂÙ¿ÏÏÔ˘ Î·È ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ÂÓ·fiıÂÛ‹ ÙÔ˘ ÛÙÔ ‹·Ú. ŸÌˆ˜, Ô ·ÎÚÈ‚‹˜ ÚfiÏÔ˜ Ù˘ ÂÓ·fiıÂÛ˘ ÙÔ˘ Ã∞ ÛÙËÓ Ë·ÙÈ΋ ‰È·Ù·Ú·¯‹ ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› (16). ™Â ¿ÏϘ ÂÚÈÙÒÛÂȘ, fiˆ˜ ÛÙË ÛË„·ÈÌ›·, Ë Ë·ÙÈ΋ ‰È·Ù·Ú·¯‹ ÂÈϤÎÂÙ·È Ì ÙËÓ ·Ú·ÙËÚÔ‡ÌÂÓË ·˘ÍË̤ÓË ·ÈÌfiÏ˘ÛË Î·È ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ Ã∞ Ô˘ ÚÔηÏ› ÔÍ›· Ë·ÙÈ΋ ‰È·Ù·Ú·¯‹, fiˆ˜ Î·È ÛÙËÓ ·ÈÌfiÏ˘ÛË ·fi ·ÓÂ¿ÚÎÂÈ· G6PD (17). ∏ ÂÈÚfiÛıÂÙË Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ·fi ÙËÓ ÂÓ·fiıÂÛË ÙÔ˘ ÌÂÙ¿ÏÏÔ˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ë·ÙÔ΢ÙÙ·ÚÈ΋ ηٷÛÙÚÔÊ‹ Î·È ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ Ã∞ ÛÙÔ ·›Ì· Û ·˘ÍË̤ӷ Â›‰· (17). OÈ Suzuki Î·È Û˘Ó (18) ·Ú·Ù‹ÚËÛ·Ó fiÙÈ Ô ¯·Ú·ÎÙËÚÈ˙fiÌÂÓÔ˜ ÂχıÂÚÔ˜ Ã∞ ‚Á·›ÓÂÈ ·fi Ù· ηÙÂÛÙÚ·Ì̤ӷ Ë·ÙÔ·ÙÙ·Ú· Î·È ÂÈÎÔÏÏ¿Ù·È Â›Ù ÛÙÔ ÂÚ˘ıÚÔ·ÙÙ·ÚÔ, ›Ù Û οÔÈ· ·Ï‚Ô˘Ì›ÓË.

O Ã∞ Â›Û˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·fi ÙȘ ÂχıÂÚ˜ Ú›˙˜ ΢ÙÙ·ÚÈ΋ ηٷÛÙÚÔÊ‹. O ÚfiÏÔ˜ ÙÔ˘ Ã∞ ÛÙ· ‰‡Ô ¤Ó˙˘Ì·, ÙËÓ ÙÔ˘ ˘ÂÚÔÍÂȉ›Ô˘ ‰˘ÛÌÔ˘Ù¿ÛË Î·È ÙËÓ Î˘ÙÙÔ¯ÚˆÌÈ΋-c-ÔÍÂȉ¿ÛË Ô˘ ‰›ÓÂÈ ËÏÂÎÙÚfiÓÈ· ÛÙ· ÌÈÙÔ¯fiÓ‰ÚÈ· Â›Ó·È ÁÓˆÛÙfi˜

¶›Ó·Î·˜ 2. ∏·ÙÈΤ˜ ‚ÈÔ¯ËÌÈΤ˜ ·Ú¿ÌÂÙÚÔÈ Î·È Â›‰· ¯·ÏÎÔ‡ ÛÙÔÓ ÔÚfi ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ OÌ¿‰Â˜ ∞ (N=36) B (N=29) ° (N=32)

OÏ. ¯ÔÏ. (mg/dl)

SGOT (U/l)

SGPT (U/l)

ÁGt (U/l)

LDH (U/l)

÷ÏÎfi˜ (Ìg/dl)

3,0 ± 1,0 11,8 ± 1,2 16,2 ± 1,5

29 ± 12a 43 ± 10b 65 ± 8c

36 ± 10a 73 ± 12b 80 ± 19c

64 ± 5a 120 ± 28b 180 ± 30a

168 ± 36a 484 ± 90b 796 ± 136c

25 ± 5a 45 ± 8b 90 ± 12c

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË a/b, b/c p<0,01 a/c p<0,001 ¶›Ó·Î·˜ 3. ™˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ÂÈ¤‰ˆÓ ¯·ÏÎÔ‡ Î·È Ë·ÙÈÎÒÓ ‚ÈÔ¯ËÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ OÌ¿‰Â˜ ∆ÂÏÂÈfiÌËÓ· A B ° ¶ÚfiˆÚ·

OÏ. ¯ÔÏ.

0,38*** 0,33*** 0,36***

SGOT 0,29* 0,28* 0,28*

SGPT 0,29* 0,28* 0,28*

ÁGT 0,35*** 0,36*** 0,35***

LDH 0,34*** 0,31*** 0,37***

0,36*** 0,37*** 0,35***

0,30* 0,29* 0,31*

0,29* 0,28* 0,29*

0,36*** 0,39*** 0,34***

0,37*** 0,36*** 0,39***

÷ÏÎfi˜ A B °

***p<0,001, *p<0,05 ∂›‰· ¯·ÏÎÔ‡ vs ·Ï‚Ô˘Ì›ÓË ‹ ÔÏ. ÚˆÙ½ÓË: ªË ÛÙ·Ù. ÛËÌ·ÓÙÈο

364

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·365

¶·È‰È·ÙÚÈ΋ 2002;65:362-366

(19,20). ∂Ӊ›ÍÂȘ ÏÈȉÈ΋˜ ˘ÂÚÔÍ›‰ˆÛ˘ Î·È ÌÈÙÔ¯ÔÓ‰ÚÈ΋˜ ηٷÛÙÚÔÊ‹˜ ÙfiÛÔ ÛÙËÓ ÂÈÚ·Ì·ÙÈ΋, ·ÏÏ¿ Î·È ÛÙËÓ ÎÏÈÓÈο ·Ú·ÙËÚÔ‡ÌÂÓË ˘ÂÚÊfiÚÙÈÛË Ì Ã∞, ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ÚÔ·Ó·ÊÂÚfiÌÂÓË ˘fiıÂÛË Î·È ·Ô‰ÂÈÎÓ‡Ô˘Ó ÙÔ ‰˘Ó·ÌÈÎfi ıÂÚ·¢ÙÈÎfi ÚfiÏÔ Ù˘ ·-ÙÔÎÔÊÂÚfiÏ˘ Î·È ¿ÏÏˆÓ ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ë·ÙÈ΋˜ ÊfiÚÙÈÛ˘ Ì ÙÔ Ì¤Ù·ÏÏÔ (21,22). ∂›Ó·È, ‚¤‚·È·, ÂÌÊ·Ó¤˜ fiÙÈ Ô ›ÎÙÂÚÔ˜ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÌÂÏÂÙ‹Û·ÌÂ Â›Ó·È ·ÈÌÔÏ˘ÙÈÎfi˜. ø˜ Â·ÎfiÏÔ˘ıÔ, Ù· ·Ú·ÙËÚÔ‡ÌÂÓ· ˘„ËÏ¿ Â›‰· ÙÔ˘ Ã∞ ÛÙÔ ·›Ì· ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ Â›‰· Ù˘ OÃ Î·È ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, ÚÔ¤Ú¯ÔÓÙ·È ·fi Ù· ηÙÂÛÙÚ·Ì̤ӷ Ë·ÙÔ·ÙÙ·Ú· Î·È Î˘Ú›ˆ˜ Ù· ÂÚ˘ıÚÔ·ÙÙ·Ú· (ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˜ Ã∞). Ÿˆ˜ ‹‰Ë ·ÚÔ˘ÛÈ¿ÛÙËΠ۠ÚÔËÁÔ‡ÌÂÓË ÂÚÁ·Û›· (23), Û˘ÁÎÂÓÙÚÒÛÂȘ Ã∞ 1,5-2,7 micrograms/ml ÛÙÔÓ ÔÚfi ›¯·Ó ˆ˜ Â·ÎfiÏÔ˘ıÔ Ë·ÙÈ΋ ‰È·Ù·Ú·¯‹. ∆· ÚÔ·Ó·ÊÂÚı¤ÓÙ· ·ÔÙÂϤÛÌ·Ù· ‰Â›¯ÓÔ˘Ó ÙË ‚ÈÔÏÔÁÈ΋ Î·È ÙÔÍÈ΋ ‰Ú¿ÛË ÙÔ˘ ÌË-Û˘Ó‰ÂfiÌÂÓÔ˘ Ì ÌÂÙ·ÏÏÔıÂÈÔÓ›Ó˜ Ã∞ ÛÙÔ ‹·Ú LEC ·ÚÔ˘Ú·›Ô˘ (ÂÈÚ·Ì·ÙÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘ Ù˘ ÓfiÛÔ˘ Wilson). ∂›Û˘, ¤¯Ô˘Ó ·Ú·ÙËÚËı› Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙ· ‚·ÛÈο Á¿ÁÁÏÈ· ·ÛıÂÓÒÓ Ì ·˘ÍË̤ӷ Â›‰· ÙÔ˘ ÌÂÙ¿ÏÏÔ˘ (24). OÈ ·ÎÚȂ›˜ Ì˯·ÓÈÛÌÔ› Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ÂÌÊ¿ÓÈÛË ·˘ÙÒÓ ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ ‰ÂÓ Â›Ó·È ‰˘ÛÙ˘¯Ò˜ ÁÓˆÛÙÔ›. ™ÙËÓ ÂÚ›ÙˆÛË ÙˆÓ ÓÂÔÁÓÒÓ Î·È È‰È·›ÙÂÚ· ÙˆÓ ÚfiˆÚˆÓ Ì ˘„ËÏfi ›ÎÙÂÚÔ, fiˆ˜ ÙˆÓ ÔÌ¿‰ˆÓ °, ı· ÌÔÚÔ‡Û·Ì ӷ ˘Ôı¤ÛÔ˘Ì fiÙÈ Â˘Ú›ÛÎÔÓÙ·È Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ÂÌÊ·Ó›ÛÔ˘Ó ˘ÚËÓÈÎfi ›ÎÙÂÚÔ, Â¿Ó ‰ÂÓ Á›ÓÂÈ ·Ì¤Ûˆ˜ ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛË. ¢ÂÓ ÌÔÚÔ‡ÌÂ, ÂÈϤÔÓ, Ó· ·ÔÎÏ›ÛÔ˘Ì fiÙÈ Ù· ·˘ÍË̤ӷ Â›‰· ÙÔ˘ Ã∞ ÛÙÔÓ ÔÚfi ÙÔ˘˜ ı· ÌÔÚÔ‡Û·Ó Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ó ÂÈÚfiÛıÂÙ· ÚÔ‚Ï‹Ì·Ù· Ì›·˜ Ù¤ÙÔÈÔ˘ ›‰Ô˘˜ ÂÁÎÂÊ·ÏÈ΋˜ ‚Ï¿‚˘. ∂ÎÙfi˜ ÙˆÓ ·ÓˆÙ¤Úˆ ·Ó·ÊÂÚı¤ÓÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛˆÓ, ı· Ú¤ÂÈ Ó· ÚÔÛÙÂıÔ‡Ó Î·È ¿ÏϘ, fiˆ˜ ÂΛӘ ·fi ÙÔ˘˜ ÓÂÊÚÔ‡˜ (Û‡Ó‰ÚÔÌÔ Fanconi), ÙËÓ Î·Ú‰È¿ Î.Ï. ·fi ÙËÓ ÂÓ·fiıÂÛË ÙÔ˘ Ã∞ (10,25). ™˘ÌÂÚ·ÛÌ·ÙÈο: i) Ù· Â›‰· Ã∞ ÛÙ· ˘ÁÈ‹ ÚfiˆÚ· Â›Ó·È Û·ÊÒ˜ ¯·ÌËÏfiÙÂÚ· ·fi ÂΛӷ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ, ii) ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ Ã∞ ‹Û·Ó Û·ÊÒ˜ ˘„ËÏfiÙÂÚ˜ ÛÙ· ÓÂÔÁÓ¿ Ì ›ÎÙÂÚÔ fiÏˆÓ ÙˆÓ ÔÌ¿‰ˆÓ, iii) ÔÈ ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ Ã∞ Èı·Ófiٷٷ ÚÔ¤Ú¯ÔÓÙ·È ·fi Ù· ηÙÂÛÙÚ·Ì̤ӷ ÂÚ˘ıÚÔ·ÙÙ·Ú· Î·È Ë·ÙÔ·ÙÙ·Ú·, iv) Ù· ·˘ÍË̤ӷ Â›‰· Ã∞ ‰‡Ó·ÓÙ·È Ó· ÂËÚ¿ÛÔ˘Ó ÔÔÈÔ‰‹ÔÙ fiÚÁ·ÓÔ (‹·Ú, ÂÁΤʷÏÔ, ÓÂÊÚÔ‡˜ Î.Ï.), v) Ù· ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ˘„ËÏ‹ ÛÙ¿ıÌË OÃ Â›Ó·È Û ΛӉ˘ÓÔ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ˘ÚËÓÈÎfi ›ÎÙÂÚÔ, ·ÏÏ¿ Î·È ÚfiÛıÂÙË Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙËÓ

Paediatriki 2002;65:362-366

Èı·Ó‹ ÂÓ·fiıÂÛË ÙˆÓ ÔÚÁ¿ÓˆÓ ÙÔ˘˜ Ì ÙÔ Ì¤Ù·ÏÏÔ Î·È vi) Ù· Â›‰· Ã∞ ÛÙÔ ·›Ì· ı· ÌÔÚÔ‡Û·Ó Ó· ¯ÚËÛÈ̇ÛÔ˘Ó ˆ˜ ÚfiÛıÂÙÔÈ ‰Â›ÎÙ˜ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ·ÈÌÔÏ˘ÙÈÎÔ‡ ÈÎÙ¤ÚÔ˘. ∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ÙËÓ Î. ÕÓÓ· ™Ù·Ì¿ÙË ÁÈ· ÙËÓ ÙfiÛÔ ÂÈÌÂÏË̤ÓË ‰·ÎÙ˘ÏÔÁÚ¿ÊËÛË ·˘Ù‹˜ Ù˘ ÂÚÁ·Û›·˜.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Kumar RK. Neonatal jaundice. ∞n update for family physicians. Aust Fam Physician 1999;28:670-682.

2. Moyer VA, Ahn C, Sneed S. Accuracy of clinical judgment in neonatal jaundice. Arch Pediatr Adsolesc Med 2000;154:391-394.

3. Ostermeier C, Iwata S, Michel H. Cytochrome c oxidase.

Curr Opin Struct Biol 1996;6:460-466.

4. Sullivan JL, Ochs HD. Copper deficiency and the immune system. Lancet 1978;2:686.

5. Vyas D, Chandra RK. Thymic factor activity, lymphocyte stimulation response and antibody producting cells in copper deficiency. Nutr Res 1983;3:343-350.

6. Widdowson EM. Trace elements in fetal and early postnatal development. Proc Nutr Soc 1974;33:275-284.

7. Al-Rashid RA, Spangler J. Neonatal copper deficiency. N Engl J Med 1971;285:841-843.

8. Ashkenazi A, Levin S, Djaldetti M, Fishel E, Benvenisti D. The syndrome of neonatal copper deficiency. Pediatrics 1973;52:523-533.

9. Williams DM. Copper deficiency in humans. Semin Hematol 1983;20:118-128.

10. Bremner I. Manifestations of copper excess. Am J Clin Nutr 1998;67(5 Suppl):1069-1073.

11. Hannam S, Mc Donnell M, Rennie JM. Investigation of prolonged neonatal jaundice. Acta Paediatr 2000;89:694-697.

12. Jansen PL, Mulder GJ, Burchell B, Bock KW. New developments in glucuronidation research: report of a workshop on “glucuronidation, its role in health and disease”. Hepatology 1992;15:532-536.

13. Maisel JM. Jaundice in neonatology pathophysiology and management of the newborn. In: Avery GB, Fletcher MA, McDonald MG, eds. 4th ed. Philadelphia: J.B. Lippincott Company; 1994. p. 630-660.

14. O’Leary JA. Serum copper levels as a measure of placental function. Am J Obstet Gynecol 1969;105:636-637.

15. Rossipal E, Krachler M, Li F, Micetic-Turk D. Investigation of the transport of trace elements across barriers in humans: studies of placental and mammary transfer. Acta Paediatr 2000;89:1190-1195.

16. Schilsky ML, Scheinberg IH, Sternlieb I. Liver transplantation for Wilson’s disease: indications and outcome. Hepatology 1994;19:583-587.

17. Strand S, Hofmann WJ, Grambihler A, Hug H, Volkmann M, Otto G et al. Hepatic failure and liver cell damage in acute Wilson’s disease involve CD95 (APO-1/Fas) mediated apoptosis. Nat Med 1998;4:588-593.

18. Suzuki KT, Shiobara Y, Tachibana A, Ogra Y, Matsumoto K. Copper increases in both plasma and red blood cells at

365

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·366

¶·È‰È·ÙÚÈ΋ 2002;65:362-366

19.

20.

21.

22.

23.

the onset of acute hepatitis in LEC rats. Res Commun Mol Pathol Pharmacol 1999;103:189-194.

Sokol RJ. Antioxidant defenses in metal-induced liver damage. Semin Liver Dis 1996;16:39-46.

Fridovich I. Superoxide anion radical (O2-) superoxide dismutases and related matters. J Biol Chem 1997;272:515-517.

Sokol RJ, McKim JM Jr, Devereaux MW. Alpha-tocopherol ameliorates oxidant injury of isolated copper overloaded rat hepatocytes. Am J Clin Nutr 1998;67(Suppl):1012-1016.

Fridovich I. Superoxide radical and superoxide dismutases. Ann Rev Biochem 1995;64:97-112.

Rui M, Suzuki KT. Copper in plasma reflects its status and subsequent toxicity in the liver of LEC rats. Res Commun Mol Pathol Pharmacol 1997;98:335-346.

Paediatriki 2002;65:362-366

24. Van Wassenaer-van Hall HN. Neuroimaging in Wilson disease. Metab Brain Dis 1996;12:1-19.

25. Cuthbert JA. Wilson’s disease. Update of a systemic disorder with protean manifestations. Gastroenterol Clin North Am 1998;27:665-682.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 15-04-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-07-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ÏÂÔ¿ÙÚ· ∂. ™Ô‡ÏË πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, T.K. 115 27, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∏ ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û ·È‰È¿ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Ô˘ÚÔÏԛ̈ÍË1 ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ™ÙË ÌÂϤÙË ·˘Ù‹ ÂÚÈÁÚ¿ÊÂÙ·È Ë ¤Î‚·ÛË 66 ·È‰ÈÒÓ (58 ÎÔÚÈÙÛÈÒÓ Î·È 8 ·ÁÔÚÈÒÓ) Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Ô˘ÚÔÏԛ̈ÍË, Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ÚÔÊ˘Ï·ÎÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·È ÌÂÙ¿ ·fi 3,7±2,2 ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘. ∞ÔÙÂϤÛÌ·Ù·: ™ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ¯ËÌÂÈÔÚÔʇϷ͢ ‰ÂÓ ·ÚÔ˘Û›·Û ԢÚÔÏԛ̈ÍË Î·Ó¤Ó· ·fi Ù· ·ÁfiÚÈ· Ù˘ ÌÂϤÙ˘, ÂÓÒ Û 13/58 ÎÔÚ›ÙÛÈ· (22%) ‰È·ÈÛÙÒıËΠÙÔ Úfi‚ÏËÌ· ·˘Ùfi. ∆· ·È‰È¿ Ì ‰˘ÛÏÂÈÙÔ˘ÚÁÈ΋ Ô‡ÚËÛË Î·È ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÙÔ˘ ·ÓÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ›¯·Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Ô˘ÚÔÏԛ̈ÍË. ∞ÓÙ›ıÂÙ·, ÛÙË Ì·ÎÚfi¯ÚÔÓË ·Ú·ÎÔÏÔ‡ıËÛË, ‰È·ÈÛÙÒıËΠԢÚÔÏԛ̈ÍË Û 28/66 ·È‰È¿, Û 43% ÙˆÓ ÎÔÚÈÙÛÈÒÓ Î·È ÛÙÔ 37% ÙˆÓ ·ÁÔÚÈÒÓ. OÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· ‰È·ÈÛÙÒıËΠ۠13 ·È‰È¿ Î·È Î˘ÛÙ›Ùȉ· Û 15. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ 7/13 ·È‰È¿ fiÙ·Ó ·ÚÔ˘Û›·Û·Ó ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· ˘fi ¯ËÌÂÈÔÚÔʇϷÍË Î·È 3/7 ·È‰È¿ ›¯·Ó ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË. ∂›Û˘, 11/13 ·È‰È¿ Ì ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· ·ÚÔ˘Û›·Û·Ó ÙÔ Úfi‚ÏËÌ· ·˘Ùfi Û ËÏÈΛ· ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 5 ÂÙÒÓ. ∆· ·È‰È¿ Ì ‰˘ÛÏÂÈÙÔ˘ÚÁÈ΋ Ô‡ÚËÛË Î·È Î˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË 3Ô˘ ‹ ÌÂÁ·Ï‡ÙÂÚÔ˘ ‚·ıÌÔ‡ ·ÚÔ˘Û›·Û·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfiÙÂÚÔ Î›Ó‰˘ÓÔ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Ô˘ÚÔÏԛ̈ÍË. ∂ÈϤÔÓ, Ù· ·È‰È¿ Ì ‰˘ÛÏÂÈÙÔ˘ÚÁÈ΋ Ô‡ÚË-

366

ÛË ·ÚÔ˘Û›·˙·Ó Û˘¯ÓfiÙÂÚ· ΢ÛÙ›Ùȉ·, ÂÓÒ Ù· ·È‰È¿ Ì ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË 3Ô˘ ‹ ÌÂÁ·Ï‡ÙÂÚÔ˘ ‚·ıÌÔ‡ ·ÚÔ˘Û›·˙·Ó Û˘¯ÓfiÙÂÚ· ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ·. ™˘ÌÂÚ¿ÛÌ·Ù·: ∆· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈÎfi˜ ΛӉ˘ÓÔ˜ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Ô˘ÚÔÏԛ̈ÍË Ù· ·È‰È¿ Ì ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, Ô˘ ‰ÂÓ ¤¯Ô˘Ó ‰˘ÛÏÂÈÙÔ˘ÚÁÈ΋ Ô‡ÚËÛË, ·ÎfiÌË Î·È ·Ó ‰ÂÓ ÙÔ˘˜ ¯ÔÚËÁÂ›Ù·È ¯ËÌÂÈÔÚÔʇϷÍË. OÈ ·Ú·ÙËÚ‹ÛÂȘ ·˘Ù¤˜ ÌÔÚ› Ó· Â›Ó·È ¯Ú‹ÛÈ̘ ÁÈ· ÙÔ Û¯Â‰È·ÛÌfi ÌÂϤÙ˘ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·Í›·˜ Ù˘ ÚÔÊ˘Ï·ÎÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û ·È‰È¿ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Ô˘ÚÔÏԛ̈ÍË.

1 Hellerstein S, Nickell E Prophylactic antibiotics in children at risk for urinary tract infection Pediatr Nephrol 2002;17:506-510

™ÙÂÊ·Ó›‰Ë˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·367

¶·È‰È·ÙÚÈ΋ 2002;65:367-371

∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

Paediatriki 2002;65:367-371

CASE REPORT

£ÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜ Û ·ÛıÂÓ‹ Ì ·ÈÌÔÚÚÔÊÈÏ›· ∞ ∞. ª›¯Ô˜1, ¢. §·˙ÔÔ‡ÏÔ˘1, ™. ∞ÚÒÓË - µÔ˘ÚÓ¿2, ∂. ¶Ï·ÙÔÎÔ‡ÎË - ∫ÔÌÈÙÔÔ‡ÏÔ˘2, ∂. °ÂˆÚÁ¿ÎË3, E. ÷ÚÔÎfiÔ˜1

Renal vein thrombosis in a patient with haemophilia A A. Michos1, D. Lazopoulou1, S. Aroni - Vourna2, E. Platokouki - Komitopoulou2, E. Georgaki3, E. Charokopos1

¶ÂÚ›ÏË„Ë: H ·ÈÌ·ÙÔ˘Ú›· Â›Ó·È ·Û˘Ó‹ı˘ ÂÈÏÔ΋ Û ·È‰È¿ Ì ·ÈÌÔÚÚÔÊÈÏ›· ∞ ÌÈÎÚfiÙÂÚ· ÙˆÓ 12 ÂÙÒÓ. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 9 ÂÙÒÓ Ì ·ÈÌÔÚÚÔÊÈÏ›· ∞ ‚·ÚÈ¿˜ ÌÔÚÊ‹˜, Ô˘ ·ÚÔ˘Û›·˙ Â·ÓÂÈÏËÌ̤ӷ ÂÂÈÛfi‰È· ·ÈÌ·ÙÔ˘Ú›·˜. ªÂÙ¿ ·fi ¤Ó· ·Ú·ÙÂٷ̤ÓÔ ÂÂÈÛfi‰ÈÔ ·ÈÌ·ÙÔ˘Ú›·˜, ÏÂÙÔÌÂÚ‹˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·ÔÎ¿Ï˘„Â Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ıÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜. ™˘˙ËÙÔ‡ÓÙ·È ÔÈ Èı·ÓÔ› Ì˯·ÓÈÛÌÔ›, ηıÒ˜ Î·È Ë ÛËÌ·Û›· Ù˘ Â͈ÁÂÓÔ‡˜ Ô‰Ô‡ Ù˘ ‹Í˘ ÛÙË ‰ËÌÈÔ˘ÚÁ›· ıÚfiÌ‚Ô˘, ÂÓÒ ÂÈϤÔÓ ÙÔÓ›˙ÂÙ·È fiÙÈ Î¿ı ÂÚ›ÙˆÛË ·ÈÌ·ÙÔ˘Ú›·˜ Û ·ÈÌÔÚÚÔÊÈÏÈÎfi ‰ÂÓ ı· Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È Î·ÏÔ‹ı˘.

Abstract: Urinary tract bleeding is nÔt a frequent manifestation in children with haemophilia A less than 12 years of age. A case of a 9 year old boy with severe haemophilia A is described, who had recurrent episodes of hematuria. Following a prolonged episode of hematuria, a thorough investigation of the urinary tract was performed and revealed findings indicative of renal vein thrombosis. The probable mechanism of thrombosis as well as the importance of the extrinsic pathway of haemostasis in the production of thrombus are discussed. It is emphasized that every case of hematuria in a haemophilic patient should not always be considered as being a benign event.

§¤ÍÂȘ ÎÏÂȉȿ: ·ÈÌÔÚÚÔÊÈÏ›· ∞, ·ÈÌ·ÙÔ˘Ú›·, ıÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜, ÊÏ‚È΋ ıÚfiÌ‚ˆÛË.

Key words: haemophilia A, hematuria, renal vein thrombosis, venous thrombosis.

∂ÈÛ·ÁˆÁ‹ ∏ ·ÈÌ·ÙÔ˘Ú›· ·ÔÙÂÏ› Û¿ÓÈ· ÂÈÏÔ΋ Ù˘ ·ÈÌÔÚÚÔÊÈÏ›·˜ ∞ ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·, Û ·ÓÙȉȷÛÙÔÏ‹ Ì ٷ ·›Ì·ÚıÚ· Ô˘ ·ÔÙÂÏÔ‡Ó ÙË Û˘¯ÓfiÙÂÚË ÂÈÏÔ΋ Ù˘ ÓfiÛÔ˘. ªÔÚ› Ó· Û˘Ì‚Â› ·˘ÙfiÌ·Ù· ‹ ÏfiÁˆ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ‹ Ïԛ̈͢ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡. ∂›Ó·È Û˘Ó‹ıˆ˜ ·ÚÔ‰È΋ Î·È ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË, ÂÓÒ Û·ÓÈfiÙÂÚ· ÌÔÚ› Ó· ÂÈ̤ÓÂÈ Î·È Ó· ¯ÚÂÈ·ÛÙ› ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ì ¯ÔÚ‹ÁËÛË ·Ú¿ÁÔÓÙ· VIII. OÈ ÂÈÏÔΤ˜ ·fi ÙËÓ ·ÈÌ·ÙÔ˘Ú›· ‰ÂÓ ıˆÚÔ‡ÓÙ·È Û˘Ó‹ıÂȘ, ÁÈ’ ·˘Ùfi Î·È ÁÂÓÈο ‰ÂÓ Û˘ÛÙ‹ÓÂÙ·È ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ (1,2). ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·È‰ÈÔ‡ Ì ·ÈÌÔÚÚÔÊÈÏ›· ∞, ÙÔ ÔÔ›Ô ÂÌÊ¿ÓÈ˙ Â·ÓÂÈÏËÌ̤ӷ ÂÂÈ-

Ûfi‰È· Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜. ∞fi ·˘Ù¿, ÙÔ ÙÂÏÂ˘Ù·›Ô ‹Ù·Ó ȉȷ›ÙÂÚ· ·Ú·ÙÂٷ̤ÓÔ, ÁÈ’ ·˘Ùfi Î·È ¤ÁÈÓ ÏÂÙÔÌÂÚ¤ÛÙÂÚÔ˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ô˘ ·ÔÎ¿Ï˘„Â Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ıÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜.

¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”, Aı‹Ó· 1 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 2 ªÔÓ¿‰· ∞ÈÌÔÚÚ·ÁÈÎÒÓ ¢È·ı¤ÛÂˆÓ 3 ¡ÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì·

“Agia Sophia” Children’s Hospital, Athens 1 1st Department of Pediatrics of Athens University 2 Hemophilia and Hemostatic Unit 3 Department of Nephrology

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 9 ÂÙÒÓ Ô˘ ¿Û¯ÂÈ ·fi ·ÈÌÔÚÚÔÊÈÏ›· ∞ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÏfiÁˆ Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜ ·fi 15̤ÚÔ˘. ∂ΉËÏÒÛÂȘ ·ÈÌÔÚÚ·ÁÈ΋˜ ‰È¿ıÂÛ˘ ‰ÂÓ ·Ó·Ê¤ÚÔÓÙ·È ¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ, ÔfiÙ ¿Ú¯ÈÛ ӷ ·ÚÔ˘ÛÈ¿˙ÂÈ Â‡ÎÔÏ· Âί˘ÌÒÛÂȘ, ·ÎfiÌË Î·È ÌÂÙ¿ ·fi ÂÊ·ÚÌÔÁ‹ ÂÏ·ÊÚ¿˜ ›ÂÛ˘. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ¤ÁÈÓÂ

367

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·368

¶·È‰È·ÙÚÈ΋ 2002;65:367-371

ÛÙËÓ ËÏÈΛ· ÙˆÓ 2,5 ÂÙÒÓ, fiÙ·Ó ÌÂÙ¿ ·fi ÂÌ‚ÔÏÈ·ÛÌfi ÛÙÔ ÁÏÔ˘Ùfi ·ÚÔ˘Û›·Û ÂÎÙÂٷ̤ÓÔ ·È̿و̷, ÂÈ̤ÓÔ˘Û· ¯ˆÏfiÙËÙ· Î·È ¿ÏÁÔ˜ ÛÙÔ Û‡ÛÙÔÈ¯Ô ¿ÎÚÔ. ∆fiÙ ‰È·ÈÛÙÒıËΠfiÙÈ ¿Û¯ÂÈ ·fi ‚·ÚÈ¿ ·ÈÌÔÚÚÔÊÈÏ›· ∞ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜, Ì Â›‰· ·Ú¿ÁÔÓÙ· VIII <1 u/dl. ŒÎÙÔÙÂ, ÙÔ ·È‰› ÂÏ¿Ì‚·Ó ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ì ·Ú¿ÁÔÓÙ· VIII Â› ·ÈÌÔÚÚ·ÁÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ. ªÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ ÙÔ ·È‰› ·ÚÔ˘Û›·˙Â Û˘¯Ó¿ ·›Ì·ÚıÚ·, ΢ڛˆ˜ ÛÙȘ ηٿ ÁfiÓ˘ ·ÚıÚÒÛÂȘ. ∆ÔÓ ÙÂÏÂ˘Ù·›Ô ¯ÚfiÓÔ, ÏfiÁˆ Û˘¯ÓÒÓ Î·È ÛÔ‚·ÚÒÓ ·ÈÌ¿ÚıÚˆÓ, ·Ú¤ÌÂÈÓ ÎÏÈÓ‹Ú˜ ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ì ·ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ ‰ÂÍÈÔ‡ οو ÛΤÏÔ˘˜ Û Ô›ÛıÈÔ Ó¿ÚıËη. ™ÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘ ·È‰ÈÔ‡ ·Ó·Ê¤ÚÔÓÙ·È 2 ÂÂÈÛfi‰È· Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜, ·fi Ù· ÔÔ›· ÙÔ ÚÒÙÔ ÛËÌÂÈÒıËΠ۠ËÏÈΛ· 5 ÂÙÒÓ Î·È ÙÔ ¿ÏÏÔ Û ËÏÈΛ· 8 ÂÙÒÓ. ∞ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÂÓ˘‰¿ÙˆÛË Î·È ¯ÔÚ‹ÁËÛË ·Ú¿ÁÔÓÙ· VIII. ŒÓ· Ì‹Ó· ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ÛÙÔ ÙÌ‹Ì· Ì·˜, ·ÚÔ˘Û›·Û ˘ÚÂÙfi ¤ˆ˜ 40ÔC, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ Î·È ‰È·ÚÚÔ˚Τ˜ ·ÈÌÔÚÚ·ÁÈΤ˜ ÎÂÓÒÛÂȘ Ô˘ ‰È‹ÚÎÂÛ·Ó 2 Ë̤Ú˜ Î·È ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÛÙÔ Û›ÙÈ. ∫·Ù¿ ÙËÓ ÂÚ›Ô‰Ô ·˘Ù‹ ÂÏ¿Ì‚·Ó ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ì ·Ú¿ÁÔÓÙ· VIII, ÏfiÁˆ Û˘Ó‡·Ú͢ ·ÈÌ¿ÚıÚÔ˘ ÛÙÔ ·ÚÈÛÙÂÚfi ÁfiÓ·ÙÔ. ¢Âη¤ÓÙ ̤Ú˜ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜, ÂÌÊ¿ÓÈÛ ̷ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· Î·È fiÓÔ ÛÙËÓ ·ÚÈÛÙÂÚ‹ ÔÛÊ˘˚΋ ¯ÒÚ·. ∂Âȉ‹ Ë ·ÈÌ·ÙÔ˘Ú›· Û˘Ó¯È˙fiÙ·Ó Û fiϘ ÙȘ Ô˘Ú‹ÛÂȘ ηٿ ÙȘ ÂfiÌÂÓ˜ Ë̤Ú˜, ÙÔ ·È‰› ÚÔÛ‹Ïı ÁÈ· ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ·ÚÔ˘Û›·˙ ̤ÙÚÈ· ÂËÚ·Ṳ̂ÓË ÁÂÓÈ΋ ηٿÛÙ·ÛË Î·È ‹Ù·Ó ˆ¯Úfi. ∏ ·ÚÙËÚȷ΋ ›ÂÛË ‹Ù·Ó 130/90 mmHg (>95Ë ∂£) Î·È Â›¯Â 100 ÛʇÍÂȘ/min. ∞fi ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ·ÚÔ˘Û›·˙ ԛ‰ËÌ· Î·È ıÂÚÌfiÙËÙ· ÛÙË ‰ÂÍÈ¿ ηٿ ÁfiÓ˘ ¿ÚıÚˆÛË, ·›Ì·ÚıÚÔ Ì ۇÛÙÔÈ¯Ë ·ÙÚÔÊ›· ÙÔ˘ ÙÂÙڷΤʷÏÔ˘ Ì˘fi˜, ηıÒ˜ Î·È Âί˘ÌÒÛÂȘ ÛÙ· οو ¿ÎÚ·. ∫·Ù¿ ÙËÓ Ï‹ÍË Ù˘ ÓÂÊÚÈ΋˜ ¯ÒÚ·˜ ‰ÂÓ ·ÚÔ˘Û›·˙ ¢·ÈÛıËÛ›· Î·È ·fi ÙËÓ „ËÏ¿ÊËÛË Ù˘ ÎÔÈÏÈ¿˜ ‰ÂÓ ‰È·ÈÛÙÒıËΠοÙÈ ·ıÔÏÔÁÈÎfi. O ·Ú¯ÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: °ÂÓÈ΋ ·›Ì·ÙÔ˜: Hb: 8,2 g/dl, Ht: 24,3%, PLT: 276.000, WBC: 7300/Ìl, Gr: 48,4%, Ly: 47,2%, Mo: 4,4%, °ÂÓÈ΋ Ô‡ÚˆÓ: ∂.µ.: 1020, Ph: 6,5, ˘Ô: 1-2 Î.Ô.., ÂÚ˘ıÚ¿ >200 Î.Ô.., ÌÈÎÚÔÛÎfiËÛË ·ÓÙ›ıÂÛ˘ Ê¿Ûˆ˜ (phase contrast): 50% ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÛÂÈÚ·Ì·ÙÈ΋˜ ÚÔ¤Ï¢Û˘. O ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. §fiÁˆ Ù˘ ÌÈÎÚ‹˜ ËÏÈΛ·˜ ¤Ó·Ú͢ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·ÈÌ·ÙÔ˘Ú›·˜, Ù˘ Û˘¯Ó‹˜ ÂÌÊ·ÓÈÛ‹˜ ÙÔ˘˜ Î·È Ù˘ ·Ú·ÙÂٷ̤Ó˘ ‰È¿ÚÎÂÈ·˜ ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ ÂÂÈÛÔ‰›Ô˘, ÎÚ›ıËΠÛÎfiÈÌÔ˜ ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∞fi ÙÔÓ ÂÚÁ·-

368

Paediatriki 2002;65:367-371

ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, Ì ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ, ASTO, antiDNAse, ·ÓÔÛÔÛÊ·ÈÚ›Ó˜, C3, C4, ÚÔÛ‰ÈÔÚÈÛÌfi ËÏÂÎÚÔÏ˘ÙÒÓ Ô‡ÚˆÓ 24ÒÚÔ˘ (Ca, P, Ô˘ÚÈÎfi Ô͇, ÔÍ·ÏÈο, ¡a), ∞¡∞, antiDNA, ÌÈÎÚÔÏÂ˘ÎˆÌ·Ù›Ó˘ Ô‡ÚˆÓ, ·1, ‚2, ÌÈÎÚÔÛÊ·ÈÚÈÓÒÓ Ô‡ÚˆÓ, ÚÂÓ›Ó˘ ÔÚÔ‡, ‰ÂÓ ˘‹ÚÍ οÔÈÔ ·ıÔÏÔÁÈÎfi ‡ÚËÌ·. ∞fi ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, Ë ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ÓÂÊÚÒÓ-Ô˘ÚËÙ‹ÚˆÓ-·ÛÙ˘ ‹Ù·Ó ¯ˆÚ›˜ Â˘Ú‹Ì·Ù· ÏÈı›·Û˘. ™ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÂÈÎfiÓ· ˘‰ÚÔÓ¤ÊÚˆÛ˘ ‹ ‰È¿Ù·ÛË ÙˆÓ Ô˘ÚËÙ‹ÚˆÓ, ˆÛÙfiÛÔ ‰È·ÈÛÙÒıËΠÂÏ¿ÙÙˆÛË ÙÔ˘ ¿¯Ô˘˜ ÙÔ˘ ·ÚÂÁ¯‡Ì·ÙÔ˜ ÛÙËÓ ÚfiÛıÈ· ÂÈÊ¿ÓÂÈ· ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÓÂÊÚÔ‡. §fiÁˆ ÙÔ˘ Â˘Ú‹Ì·ÙÔ˜ ·˘ÙÔ‡, Ô ¤ÏÂÁ¯Ô˜ Û˘Ó¯›ÛÙËΠ̠ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ (DMSA), fiÔ˘ ¢ڤıË Ô ‰ÂÍÈfi˜ ÓÂÊÚfi˜ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÌÔÚÊÔÏÔÁ›· Î·È ÏÂÈÙÔ˘ÚÁ›·, ÂÓÒ Ô ·ÚÈÛÙÂÚfi˜ ÓÂÊÚfi˜ Ì ÂÏ·ÊÚÒ˜ ÌÈÎÚfiÙÂÚÔ Ì¤ÁÂıÔ˜, ϤÙ˘ÓÛË ÙÔ˘ ·ÚÂÁ¯‡Ì·ÙÔ˜, ‰È¿¯˘Ù· ÌÂȈ̤ÓË Î·ı‹ÏˆÛË ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ Î·È ·Ó¿ÏÔÁË ¤ÎÙˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ (∂ÈÎfiÓ· 1). ∏ Û¯ÂÙÈ΋ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÁÈ· ÙÔ ‰ÂÍÈfi ÓÂÊÚfi ‹Ù·Ó 69%, ÂÓÒ ÁÈ· ÙÔÓ ·ÚÈÛÙÂÚfi 31%, Ì ·fiÏ˘ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· 18% Î·È 8% ·ÓÙ›ÛÙÔȯ·. ∏ Û˘ÌÌÂÙÚÈÎfiÙËÙ· ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÓÂÊÚÔ‡ Û ۯ¤ÛË Ì ÙÔ ‰ÂÍÈfi Î·È Ë ÔÌÔÈÔÁÂÓ‹˜, ·Ó Î·È ÌÂȈ̤ÓË ÚfiÛÏË„Ë Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘, ·ÔÌ¿ÎÚ˘Ó·Ó ·fi ÙË ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰˘ÛÏ·Û›·˜, Ë ÔÔ›· Û˘Ó‹ıˆ˜ ·ÊÔÚ¿ ÙÌ‹Ì· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. °È· ÙË ‰ÈÂÚ‡ÓËÛË ÂӉ¯fiÌÂÓ˘ ·ÚÂÏıÔ‡Û·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ ¤ÁÈÓ ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›·, Ë ÔÔ›· ‹Ù·Ó ·ÚÓËÙÈ΋ ÁÈ· ·ÏÈÓ‰ÚfiÌËÛË, ÂÓÒ ÂÈϤÔÓ ‰ÂÓ Â˘Ú¤ıËÛ·Ó ÙÌËÌ·ÙÈΤ˜ ‚Ï¿‚˜ ÛÙÔ DMSA. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰ÈÂÚ¢ÓËı› ÂÚ·ÈÙ¤Úˆ Ë Èı·ÓfiÙËÙ· ıÚfiÌ‚ˆÛ˘ ÓÂÊÚÈ΋˜ ÊϤ‚·˜, ¤ÁÈÓÂ

∂ÈÎfiÓ· 1. ™Ù·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· (DMSA) ÓÂÊÚÒÓ: Ê·›ÓÂÙ·È Ô ·ÚÈÛÙÂÚfi˜ ÓÂÊÚfi˜ Ì ‰È¿¯˘Ù· ÌÂȈ̤ÓË Î·ı‹ÏˆÛË ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ Î·È Ï¤Ù˘ÓÛË ÙÔ˘ ·ÚÂÁ¯‡Ì·ÙÔ˜.

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·369

¶·È‰È·ÙÚÈ΋ 2002;65:367-371

Paediatriki 2002;65:367-371

∂ÈÎfiÓ· 2. ¢˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· (DTPA) ÓÂÊÚÒÓ: ·Ú¿Ù·ÛË Ù˘ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ Ê¿Û˘ Ù˘ ÓÂÊÚÔÁÚ·ÊÈ΋˜ ηÌ‡Ï˘ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÓÂÊÚÔ‡ Û ۯ¤ÛË Ì ÙË Ê˘ÛÈÔÏÔÁÈ΋ ηÌ‡ÏË ÙÔ˘ ‰ÂÍÈÔ‡ ÓÂÊÚÔ‡. ¶›Ó·Î·˜ 1. ∞›ÙÈ· ıÚfiÌ‚ˆÛ˘ ÓÂÊÚÈ΋˜ ÊϤ‚·˜ ¡ÂÔÁÓ¿

¶·È‰È¿

∞ÛÊ˘Í›· ∞Ê˘‰¿ÙˆÛË (¤ÌÂÙÔÈ, ‰È¿ÚÚÔȘ) ∫·Ù·ÏËÍ›· ™ËÙÈΤ˜ ηٷÛÙ¿ÛÂȘ ¡ÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ ∞Ê˘‰¿ÙˆÛË ¡ÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ ÃÚ‹ÛË ·ÎÙÈÓÔÛÎÈÂÚÒÓ Ô˘ÛÈÒÓ §ÔÈÌÒÍÂȘ

triplex ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ, ÙÔ ÔÔ›Ô Î·Ù¿ ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ÌÂϤÙË Ì doppler ¤‰ÂÈÍ ·ÒÏÂÈ· Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ‰È·Î‡Ì·ÓÛ˘ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙȘ Ê¿ÛÂȘ ÙÔ˘ ηډȷÎÔ‡ ·ÎÏÔ˘ ÛÙËÓ ·ÚÈÛÙÂÚ‹ ÓÂÊÚÈ΋ ÊϤ‚·, ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ‡Ï˘ Î·È ÙÔ˘˜ ÂÓ‰ÔÓÂÊÚÈÎÔ‡˜ ÎÏ¿‰Ô˘˜, ÂÓÒ Â›¯Â ·Ó·Ù˘¯ı› Î·È ·Ú¿Ï¢ÚË Î˘ÎÏÔÊÔÚ›·, Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ıÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜. ∞ÓÙ›ıÂÙ·, Ë Î˘Ì·ÙÔÌÔÚÊ‹ ÙÔ˘ ‰ÂÍÈÔ‡ ÓÂÊÚÔ‡ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. °È· ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô, ¤ÁÈÓ ·ÎfiÌË ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· (DTPA) ÓÂÊÚÒÓ Ô˘ ¤‰ÂÈÍ ·Ú¿Ù·ÛË Ù˘ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ Ê¿Û˘ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ·Ô¯¤Ù¢ÛË ÛÙÔÓ ·ÚÈÛÙÂÚfi ÓÂÊÚfi (∂ÈÎfiÓ· 2) Ô˘ ·ÔÙÂÏ› ÛÙÔÈ¯Â›Ô ÌÂȈ̤Ó˘ ·ÈÌ¿ÙˆÛ˘, ÂÓÒ Ô ‰ÂÍÈfi˜ ÓÂÊÚfi˜ ·ÚÔ˘Û›·˙ ÙËÓ ÎÏ·ÛÈ΋ Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÔÁÚ·ÊÈ΋ ηÌ‡ÏË, Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ÙËÓ ÂÈÎfiÓ· ÙÔ˘ DMSA Î·È ÙÔ˘ tripplex ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ. ∏ ÂÎÏÂÎÙÈ΋ ·ÁÁÂÈÔÁÚ·Ê›· ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·Ù‹ ÏfiÁˆ Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, ÂÓÒ ·ÍÔÓÈ΋ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ‰ÂÓ ıˆڋıËΠfiÙÈ ı· ‚ÔËıÔ‡Û·Ó ÛÙË ‰È¿ÁÓˆÛË. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÎÏÂÈÛÙÔ‡Ó ÎÏËÚÔÓÔÌÈÎÔ› ‹ Â›ÎÙËÙÔÈ ıÚÔÌ‚ÔÊÈÏÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· Úԉȷı¤ÛÔ˘Ó Û ıÚfiÌ‚ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÊϤ‚·˜, ÂÏ‹ÊıË Ô ÂÍ‹˜ ¤ÏÂÁ¯Ô˜: ÚˆÙ½ÓË C (PC), ÚˆÙ½ÓË S (PS), ·ÓÙÈıÚÔÌ‚›ÓË (∞∆), Ï·ÛÌÈÓÔÁfiÓÔ (plg), ·ÓÙÈ-

ËÎÙÈÎfi χÎÔ˘, ·ÓÙÈÛÒÌ·Ù· ηډÈÔÏÈ›Ó˘, ÌÂÙ¿ÏÏ·ÍË ÛÙÔ ÁÔÓ›‰ÈÔ ÙÔ˘ FV (FV Leiden) Î·È ÙÔ˘ II Î·È ÔÌÔ΢ÛÙ½ÓË. ∫·Ó¤Ó·˜ ·fi ÙÔ˘˜ ·Ú·¿Óˆ ıÚÔÌ‚ÔÊÈÏÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ‰ÂÓ ‚Ú¤ıËΠ·ıÔÏÔÁÈÎfi˜. ∞fi Ù· ·›ÙÈ· Ô˘ ÚÔηÏÔ‡Ó ıÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜ (¶›Ó·Î·˜ 1) ıˆڋıËΠˆ˜ ÈÔ Èı·Ófi Ë ·Ê˘‰¿ÙˆÛË. ÃÚÔÓÈο, Ë ıÚfiÌ‚ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÊϤ‚·˜ ÙÔÔıÂÙ‹ıËΠ¤Ó· Ì‹Ó· ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘, fiÙ·Ó ÙÔ ·È‰› ·ÚÔ˘Û›·Û ÂÌ‡ÚÂÙË Á·ÛÙÚÂÓÙÂÚ›Ùȉ· Ì ·ÈÌÔÚÚ·ÁÈΤ˜ ÎÂÓÒÛÂȘ, ÂÓÒ Û˘Á¯ÚfiÓˆ˜ ÂÏ¿Ì‚·Ó ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ì ·Ú¿ÁÔÓÙ· VIII ÏfiÁˆ ÙˆÓ ·ÈÌ¿ÚıÚˆÓ. ∫·Ù¿ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÙÔ ·È‰› ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠¯ÔÚ‹ÁËÛË ¿ÊıÔÓˆÓ ˘ÁÚÒÓ ÂÓ‰ÔÊÏ‚›ˆ˜, Ì ¤Á¯˘ÛË Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÏfiÁˆ Ù˘ ÛÔ‚·Ú‹˜ ·Ó·ÈÌ›·˜ (Hb: 6,5 gr/dl) Ô˘ ·ÚÔ˘Û›·ÛÂ Î·È ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ ÌÂ Û˘Ì˘Îӈ̤ÓÔ ·Ú¿ÁÔÓÙ· VIII. ∆ËÓ 4Ë Ë̤ڷ ÓÔÛËÏ›·˜ Ë ·ÈÌ·ÙÔ˘Ú›· ÛÙ·Ì¿ÙËÛÂ. ™Â Â·ÓÂÈÏËÌ̤Ó˜ ÌÂÙÚ‹ÛÂȘ, Ë ·ÚÙËÚȷ΋ ›ÂÛË ÙÔ˘ ·È‰ÈÔ‡ ‚ÚÈÛÎfiÙ·Ó ÌÂٷ͇ 90˘ Î·È 95˘ ı¤Û˘ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘. ∆Ô ·È‰› ÂÍ‹Ïı ¯ˆÚ›˜ ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·. ∫·Ù¿ ÙÔÓ Â·Ó¤ÏÂÁ¯Ô ÌÂÙ¿ 6 Ì‹Ó˜, ÛÙÔ DMSA ‰È·ÈÛÙÒıËΠÌÈÎÚ‹ ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÓÂÊÚÔ‡ (∂ÈÎfiÓ· 3) Ì ·fiÏ˘ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ‰ÂÍÈÔ‡ ÓÂÊÚÔ‡ 17% Î·È ·ÚÈÛÙÂÚÔ‡ 10%. ∆Ô ÙÂÏÂ˘Ù·›Ô ·˘Ùfi ‡ÚËÌ· ·Ô‰ÂÈÎÓ‡ÂÈ ÙËÓ ¤ÎÙˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÓÂÊÚÔ‡ ˆ˜ Û˘Ó¤ÂÈ· Ù˘ ‰È·ÈÛÙˆı›۷˜ ‚Ï¿‚˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ. ∫·Ù¿ ÙË ÌÂϤÙË Ì doppler ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ ÂȂ‚·ÈÒıËÎ·Ó Ù· Â˘Ú‹Ì·Ù· ÙÔ˘ ÚÔËÁÔ‡ÌÂÓÔ˘ ÂϤÁ¯Ô˘ Ì ÙËÓ ·ÚÔ˘Û›· ·Û˘ÌÌÂÙÚ›·˜ ÛÙË Ê·ÛÌ·ÙÈ΋ ·Ó¿Ï˘ÛË Ù·¯˘Ù‹ÙˆÓ ÛÙ· ÓÂÊÚÈο ·ÁÁ›· Î·È ·Ó¿Ù˘ÍË ·Ú¿Ï¢Ú˘

369

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·370

¶·È‰È·ÙÚÈ΋ 2002;65:367-371

∂ÈÎfiÓ· 3. ™Ù·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· (DMSA) ÓÂÊÚÒÓ: Ê·›ÓÂÙ·È Ô ·ÚÈÛÙÂÚfi˜ ÓÂÊÚfi˜ Ì ÌÈÎÚ‹ ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ¿˜ ÙÔ˘, Ë ÔÔ›· fï˜ ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È ÛËÌ·ÓÙÈο ÌÂȈ̤ÓË.

΢ÎÏÔÊÔÚ›·˜. ™ÙÔ ·È‰› Û˘ÛÙ‹ıËΠÂÚÈÔ‰ÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È Û ÂÚ›ÙˆÛË Ô˘ ·˘Ù‹ ‚Ú›ÛÎÂÙ·È ÛÙ·ıÂÚ¿ Û ˘„ËÏ¿ Â›‰· ¤Ó·ÚÍË ·ÓÙȸÂÚÙ·ÛÈ΋˜ ·ÁˆÁ‹˜. ™˘˙‹ÙËÛË ∞ÈÌÔÚÚ·Á›· ·fi ÙÔ Ô˘ÚÔÔÈËÙÈÎfi Û‡ÛÙËÌ· ıˆÚÂ›Ù·È ·Û˘Ó‹ı˘ ÂΉ‹ÏˆÛË Ù˘ ·ÈÌÔÚÚÔÊÈÏ›·˜ Û ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 12 ÂÙÒÓ. ∂ÂÈÛfi‰È· ·ÈÌ·ÙÔ˘Ú›·˜ Â›Ó·È ÈÔ Û˘¯Ó¿ Û ·ÛıÂÓ›˜ 12-21 ÂÙÒÓ, ηı’ fiÙÈ ÙÔ 62,5% ÙˆÓ ·ÛıÂÓÒÓ ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ·˘Ù‹Ó ÙËÓ ÂΉ‹ÏˆÛË, ÂÓÒ ÂÚ›Ô˘ ÙÔ 90% ÙˆÓ ·ÈÌÔÚÚÔÊÈÏÈÎÒÓ ı· ÂÌÊ·Ó›ÛÂÈ ¤Ó· ‹ ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È· ·ÈÌ·ÙÔ˘Ú›·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘˜ (1,2). ™˘Ó‹ıˆ˜, Ù· ÂÂÈÛfi‰È· ÂÌÊ·Ó›˙ÔÓÙ·È ·˘ÙfiÌ·Ù·, ÂÓÒ Û·ÓÈfiÙÂÚ· Û ʿÛË ÏÔÈÌÒÍÂˆÓ ‹ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡. ∏ ‰È¿ÚÎÂÈ¿ ÙÔ˘˜ Â›Ó·È ÌÈÎÚ‹ Î·È Î·Ù¿ ηÓfiÓ· ˘Ô¯ˆÚÔ‡Ó ·fi ÌfiÓ· ÙÔ˘˜, ¯ˆÚ›˜ Ó· ¯ÚÂÈ·ÛÙ› ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ (3). O ·ÛıÂÓ‹˜ Ì·˜ ÛÙÔ ·ÚÂÏıfiÓ Â›¯Â ·ÚÔ˘ÛÈ¿ÛÂÈ ‰‡Ô Ù¤ÙÔÈ· ÂÂÈÛfi‰È· Ô˘ ‹Ù·Ó fï˜ ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ Î·È ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓ·. ∂ÈϤÔÓ, ¤¯ÂÈ ‚ÚÂı› fiÙÈ 20% ÙˆÓ ·ÙfiÌˆÓ Ì ·ÈÌÔÚÚÔÊÈÏ›· ·ÚÔ˘ÛÈ¿˙ÂÈ ˘ÔÎÏÈÓÈο ÂÂÈÛfi‰È· ÌÈÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜ (2). §fiÁˆ ·ÓÂ·ÚÎÒÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ‹ Ë ·ÎÚÈ‚‹˜ Û˘¯ÓfiÙËÙ· Û˘Û¯¤ÙÈÛ˘ Ù˘ ·ÈÌÔÚÚÔÊÈÏ›·˜ Ì ÌfiÓÈ̘ ÓÂÊÚÈΤ˜ ·ÏÏÔÈÒÛÂȘ, ıˆÚÔ‡ÓÙ·È fï˜ ÁÂÓÈο Û¿ÓȘ (1). ¢È·Ù·Ú·¯¤˜ ·fi ÙÔ Ô˘ÚÔÔÈËÙÈÎfi Ô˘ ηٷÁÚ¿ÊÔÓÙ·È Â›Ó·È ˘‰ÚÔÓ¤ÊÚˆÛË Î·È ·fiÊÚ·ÍË ÛÙËÓ ·Ô¯ÂÙ¢ÙÈ΋ ÌÔ›Ú· ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ ÏfiÁˆ ËÁÌ¿ÙˆÓ, ÔÍ›· ÛˆÏËÓ·-

370

Paediatriki 2002;65:367-371

Úȷ΋ Ó¤ÎÚˆÛË, ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ, ÓÂÊÚÔ¿ıÂÈ· ·fi ·Ó·ÏÁËÙÈο Î·È ¯ÚfiÓÈ· ˘ÂÏÔÓÂÊÚ›Ùȉ· (2-4). ∏ Û˘ÓËı¤ÛÙÂÚË ÂÈÏÔ΋ ÏfiÁˆ Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜ Â›Ó·È Ô Û¯ËÌ·ÙÈÛÌfi˜ ‹ÁÌ·ÙÔ˜ ·›Ì·ÙÔ˜ ÛÙËÓ ·Ô¯ÂÙ¢ÙÈ΋ ÌÔ›Ú· ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Ô˘ ÂΉËÏÒÓÂÙ·È Ì ΈÏÈÎÔÂȉ¤˜ ¿ÏÁÔ˜ ÛÙËÓ ÔÛʇ Î·È ‰˘ÛÔ˘ÚÈο ÂÓԯϋ̷ٷ, ÂÓÒ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Â›Û˘ ·fiÊÚ·ÍË ÙÔ˘ Ô˘ÚËÙ‹Ú·, ˘‰ÚÔÓ¤ÊÚˆÛË ‹ Î·È ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∞ÂÈÎÔÓÈÛÙÈο ÌÔÚ› Ó· ÂÌÊ·Ó›˙ÂÙ·È ˆ˜ ‰È¿Ù·ÛË ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ‹ ÙÔ˘ Ô˘ÚËÙ‹Ú·, ·Ú·ÌfiÚʈÛË ÙˆÓ Î·Ï‡ÎˆÓ, ÂÚÈÓÂÊÚÈÎfi ‹ ÔÈÛıÔÂÚÈÙÔÓ·˚Îfi ·È̿و̷ ‹ Ó· ·Ú·ÙËÚÔ‡ÓÙ·È ÌÂÌÔӈ̤ӷ ÂÏÏ›ÌÌ·Ù· ·ÂÈÎfiÓÈÛ˘, Â˘Ú‹Ì·Ù· Ô˘ ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ÛÙÔÓ ·ÛıÂÓ‹ Ì·˜ (4). ¶·Ú’ fiÙÈ Ê·›ÓÂÙ·È ·Ú¿‰ÔÍÔ˜ Ô Û¯ËÌ·ÙÈÛÌfi˜ ıÚfiÌ‚Ô˘ Û ·ÈÌÔÚÚÔÊÈÏÈÎÔ‡˜ ·ÛıÂÓ›˜, ÂÓÙÔ‡ÙÔȘ ·˘Ùfi Â›Ó·È ÂÊÈÎÙfi, ÏfiÁˆ Ù˘ ·ÚÔ˘Û›·˜ ·Ú¿ÁÔÓÙ· ·ÚfiÌÔÈÔ˘ Ì ÙËÓ ÈÛÙÈ΋ ıÚÔÌ‚ÔÏ·ÛÙ›ÓË ÛÙÔ Ô˘ÚÔÔÈËÙÈÎfi Û‡ÛÙËÌ·, Ô ÔÔ›Ô˜ ·Ó¢ڛÛÎÂÙ·È ÛÙÔ˘˜ ·ÈÌÔÚÚÔÊÈÏÈÎÔ‡˜ ÛÙ· ›‰È· Â›‰· Ì ٷ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· (2,4). ∏ Â͈ÁÂÓ‹˜ Ô‰fi˜ Ù˘ ‹Íˆ˜ ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ‹Íˆ˜, Ô˘ ‰ÚÔÌÔÏÔÁÂ›Ù·È Î˘Ú›ˆ˜ Ì ÙÔÓ ÈÛÙÈÎfi ·Ú¿ÁÔÓÙ·. ∏ Â͈ÁÂÓ‹˜ Ô‰fi˜ ÏÂÈÙÔ˘ÚÁ› ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÚÔ˘Û›· ‹ ÌË ÙÔ˘ ·Ú¿ÁÔÓÙ· VIII, Ô ÔÔ›Ô˜ Û˘ÌÌÂÙ¤¯ÂÈ Û ÚÒÈÌ· ÛÙ¿‰È· Ù˘ ÂÓ‰ÔÁÂÓÔ‡˜ Ô‰Ô‡ (5). ŒÙÛÈ, Â¿Ó ÁÈ· οÔÈÔ ÏfiÁÔ ÂÓÂÚÁÔÔÈËı› Ë Â͈ÁÂÓ‹˜ Ô‰fi˜ (.¯. ·Ê˘‰¿ÙˆÛË), ı· ÌÔÚÔ‡Û ӷ Ô‰ËÁ‹ÛÂÈ Û ıÚfiÌ‚ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÊϤ‚·˜ (ÂÈ‚Ú¿‰˘ÓÛË Ù˘ ÚÔ‹˜ ÙÔ˘ ·›Ì·ÙÔ˜), ÏfiÁˆ ·˘ÍË̤Ó˘ ÁÏÔÈfiÙËÙ·˜, Û˘ÓÂÈÎÔ˘ÚÔ‡Û˘ Î·È Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÎÈÓËÙÔÔ›ËÛ˘. ∂ÈϤÔÓ, ÛÙÔÓ ·ÛıÂÓ‹ Ì·˜ ÙÔ ·ÈÌÔÛÙ·ÙÈÎfi ¤ÏÏÂÈÌÌ· (·ÓÂ¿ÚÎÂÈ·) ›¯Â ÌÂÚÈÎÒ˜ ‰ÈÔÚıˆı› Ì ÙȘ Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ÂÁ¯‡ÛÂȘ ·Ú¿ÁÔÓÙ· VIII, ÏfiÁˆ ÙˆÓ Û˘¯ÓÒÓ ·ÈÌ¿ÚıÚˆÓ Ô˘ ·ÚÔ˘Û›·˙Â. ¶ÂÚÈÙÒÛÂȘ ıÚÔÌ‚ÒÛÂˆÓ ÊÏ‚ÒÓ ÁÂÓÈο Û ·ÈÌÔÚÚÔÊÈÏÈÎÔ‡˜ ¤¯Ô˘Ó ηٷÁÚ·Ê›, ·ÏÏ¿ ·ÊÔÚÔ‡Ó Û ÊϤ‚˜ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ ÌÂÙ¿ ·fi ÂÁ¯Â›ÚËÛË ‹ ÌÂÁ¿ÏÔ ‰È¿ÛÙËÌ· ηٿÎÏÈÛ˘ Î·È ·ÎÈÓËÛ›·˜ (6,7). ™ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì·˜ ‰È·ÈÛÙÒıËÎ·Ó Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ıÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜, ÂÈÏÔ΋ Ô˘ ‰ÂÓ Î·Ù·ÁÚ¿ÊÂÙ·È ÛÙËÓ ÚÔÛÈÙ‹ Û ÂÌ¿˜ ‚È‚ÏÈÔÁÚ·Ê›·. ∏ ıÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÓÂÊÚÈ΋˜ ÛÙ¿Û˘, ‰Â˘ÙÂÚÔ·ıÒ˜ ÏfiÁˆ ·ÈÌÔÛ˘Ì‡ÎÓˆÛ˘ ‹ ÌÂȈ̤Ó˘ ÓÂÊÚÈ΋˜ ·ÈÌ¿ÙˆÛ˘ (8,9). ∏ ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Ô˘ ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ÛÙËÓ ÔÍ›· Ê¿ÛË Â›Ó·È ·ÈÌ·ÙÔ˘Ú›·, ¿ÏÁÔ˜ ÛÙËÓ ÔÛʇ Î·È „ËÏ·ÊËÙ‹ Ì¿˙· ÛÙË ÓÂÊÚÈ΋ ÂÚÈÔ¯‹ (10,11). ∞fi ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ·È‰È΋

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·371

¶·È‰È·ÙÚÈ΋ 2002;65:367-371

ËÏÈΛ·, ÌfiÓÔ ÙÔ 30% Û˘Ì‚·›ÓÂÈ ÂÎÙfi˜ Ù˘ ÓÂÔÁÓÈ΋˜ ÂÚÈfi‰Ô˘ (12,13). ∏ ˘ÔΛÌÂÓË ÓfiÛÔ˜, Ë ÔÔ›· Û˘Ó‹ıˆ˜ ¤¯ÂÈ ıÔÚ˘‚Ò‰Ë Û˘Ìو̷ÙÔÏÔÁ›·, ÌÔÚ› Ó· ÂÈηχÙÂÈ Ù· Û˘ÌÙÒÌ·Ù· Ù˘ ıÚfiÌ‚ˆÛ˘, Ì ·ÔÙ¤ÏÂÛÌ· Û˘¯Ó¿ Ó· ÌËÓ ‰È·ÁÈÁÓÒÛÎÂÙ·È ÎÏÈÓÈο Î·È ‹ Ó· χÂÙ·È Ô ıÚfiÌ‚Ô˜ ·˘ÙfiÌ·Ù· ‹ Ó· ·Ó·Î·Ï‡ÙÂÙ·È Û ÓÂÎÚÔÙÔÌÈÎfi ˘ÏÈÎfi (8,9). ∏ ‰È¿ÁÓˆÛË Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÌÔÚ› Ó· Á›ÓÂÈ Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË Doppler ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ Î·È Ì¤ÙÚËÛË Ù˘ ÚÔ‹˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ (13,15-18). ∏ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÌÔÚ› ÌÂÓ Ó· ·ÔηٷÛÙ·ı› Ï‹Úˆ˜, ¯ˆÚ›˜ ÂÓÙÔ‡ÙÔȘ Ó· ·ÔÎÏ›ÂÙ·È ÛÙÔ Ì¤ÏÏÔÓ Ë ÚfiÎÏËÛË ÔÈÎ›ÏˆÓ ‚Ï·‚ÒÓ, fiˆ˜ ÚÈÎÓfi˜ ÓÂÊÚfi˜, ÙÌËÌ·ÙÈ΋ ›ÓˆÛË ÙÔ˘ ÓÂÊÚÔ‡ Ì ¤ÎÙˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘, ÓÂÊÚ·ÁÁÂȷ΋ ˘¤ÚÙ·ÛË, ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ, ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·, ¯ÚfiÓÈ· ˘ÂÏÔÓÂÊÚ›Ùȉ· Î·È ÛˆÏËÓ·Úȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· (9,10,14). ∏ Â›ÙˆÛË Ù˘ ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘ ÌÂÙ¿ ·fi ıÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜ Â›Ó·È ÛËÌ·ÓÙÈ΋ (1730%) (10,13), ÁÂÁÔÓfi˜ Ô˘ ηıÈÛÙ¿ ·Ó·Áη›· ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ¤Ó·ÚÍË Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜ fiÔ˘ Â›Ó·È ·Ó·Áη›Ô. ™ÙÔÓ ·ÛıÂÓ‹ Ì·˜ ˘‹ÚÍ ÌÈÎÚ‹ ‚ÂÏÙ›ˆÛË ÛÙÔÓ Â·Ó·ÏËÙÈÎfi ÓÂÊÚÈÎfi ¤ÏÂÁ¯Ô, ÔÈ ÔÚȷΤ˜ fï˜ ÙÈ̤˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ÙÔ˘ ·È‰ÈÔ‡ ηıÈÛÙÔ‡Ó ÂÈÊ˘Ï·ÎÙÈ΋ ÙËÓ ÚfiÁÓˆÛË. ∆Ô Û‡Ì‚·Ì· ıÚfiÌ‚ˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÊϤ‚·˜ Û ·È‰› Ì ‚·ÚÈ¿ ‰È·Ù·Ú·¯‹ Ù˘ ·ÈÌfiÛÙ·Û˘ ‰Â›¯ÓÂÈ ˆ˜ ÙÔ ·ÈÌÔÛÙ·ÙÈÎfi ¤ÏÏÂÈÌÌ· ‰ÂÓ ·ÔÎÏ›ÂÈ ÙÔ ıÚÔÌ‚ˆÙÈÎfi ÂÂÈÛfi‰ÈÔ, fiÙ·Ó Û˘Ó˘¿Ú¯Ô˘Ó ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ ¢ԉÒÓÔ˘Ó ÙËÓ ·Ó¿Ù‡ÍË ıÚfiÌ‚Ô˘. ∂ÈϤÔÓ, Ë Î·Ï‹ ÚfiÁÓˆÛË Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜ Û ¿ÙÔÌ· Ì ·ÈÌÔÚÚÔÊÈÏ›· ‰ÂÓ Â›Ó·È ¿ÓÙ· ‰Â‰Ô̤ÓË, ·ÏÏ¿ ÂӉ¯Ô̤ӈ˜ Ó· ˘ÔÎÚ‡ÙÔÓÙ·È ¿ÏÏ· ·›ÙÈ·, ÁÈ’ ·˘Ùfi Û Â›ÌÔÓ˜ ÂÚÈÙÒÛÂȘ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ï‹Ú˘ ¤ÏÂÁ¯Ô˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜.

BÈ‚ÏÈÔÁÚ·Ê›· 1. Small S, Rose PE, McMillan N, Belch JJ, Rolfe EB, Forbes CD et al. Haemophilia and the kidney: assessment after 11year follow-up. Br Med J 1982;285:1609-1611.

2. Forbes CD, Prentice CRM. Renal disorders in haemophilia A and B. Scand J Haematol 1977;30(Suppl):43-50.

3. Beck P, Evans KT. Renal abnormalities in patients with haemophilia and Christmas disease. Clin Radiol 1972;23:349-354.

4. Prentice CRM, Lindsay RM, Barr RD, Forbes CD, Kennedy AC, McNicol GP et al. Renal complications in haemophilia and Christmas disease. Q J Med 1971;40:47-61.

Paediatriki 2002;65:367-371

5. Beutler E, Lichtman MA, Coller BS, Kipps TJ, Seligsohn U. Molecular biology and biochemistry of the coagulation factors and pathways of hemostasis. In: Williams Hematology. 6th edition. McGraw-Hill; 2001. p. 1409-1434.

6. Stewart AJ, Manson LM, Dennis R, Allan PL, Ludlam CA. Thrombosis in a duplicated superficial femoral vein in a patient with haemophilia A. Haemophilia 2000;6:47-49.

7. Ritchie B, Woodman RC, Poon MC. Deep venous thrombosis in haemophilia A. Am J Med 1992;93:699-700.

8. Brenner BM. Pathogenesis of renal disease. In: Brenner and Rector’s: The Kidney. 5th ed. WB Saunders Company; 1995. p. 1432-1434.

9. Ricci MA, Lloyd DA. Renal venous thrombosis in infants and children. Arch Surg 1990;125:1195-1199.

10. Zigman A, Yazbeck S, Emil S, Nguyen L. Renal vein thrombosis: a 10-year review. J Pediatr Surg 2000; 35:1540-1542.

11. Ewalt DH. Renal infection, abscess, vesicoureteral reflux, urinary lithiasis and renal vein thrombosis. In: O’Nerill JA, Rowe MI, Grosfeld JL et al, editors. Pediatric Surgery. St Louis, MO: Mosby; 1998. p. 1609-1621.

12. Bokenkamp A, von Kries R, Nowak-Gottl U, Gobel U, Hoyer PF. Neonatal renal thrombosis in Germany between 1992 and 1994: epidemiology, treatment and outcome. Eur J Pediatr 2000;159:44-48.

13. Hibbert J, Howlett DC, Greenwood KL, MacDonald LM, Saunders AJS. The ultrasound appearances of neonatal renal vein thrombosis. Br J Radiol 1997;70:1191-1194.

14. Belman AB. Renal vein thrombosis in infancy and childhood. Clin Pediatr 1976;15:1033-1042.

15. Sutor AH, Uhl M. Diagnosis of thromboembolic disease during infancy and childhood. Semin Thromb Hemost 1997;23:237-246.

16. Helenon O, Melki P, Correas JM, Boyer JC, Moreau JF. Renovascular diasease: Doppler ultrasound. Semin Ultrasound CT MR 1997;18:136-146.

17. Wright NB, Blanch G, Walkinshaw S, Pilling DW. Antenatal and neonatal renal vein thrombosis: new ultrasonic features with high frequency transducers. Pediatr Radiol 1996;26:686-689.

18. Laplante S, Patriquin HB, Robitaille P, Filiatrault D, Grignon A, Decarie JC. Renal vein thrombosis in children: evidence of early flow recovery with Doppler US. Radiology 1993;189:37-42.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 12-07-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 16-04-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ı·Ó¿ÛÈÔ˜ °. ª›¯Ô˜ ¶·ÓfiÚÌÔ˘ 26-28, ∞ÌÂÏfiÎËÔÈ ∆.∫. 115 23, ∞ı‹Ó· E-mail: athanmic@yahoo.com

371

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·372

¶·È‰È·ÙÚÈ΋ 2002;65:372-376

∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

Paediatriki 2002;65:372-376

CASE REPORT

°ÂÏ·ÛÙÈ΋ ÂÈÏË„›· Û ‰‡Ô ·È‰È¿ Ì ˘Ôı·Ï·ÌÈÎfi ·Ì¿Úو̷ ¡. µ·ÛÈÏ¿ÎË, Ã. ∫fiÙÛ·Ï˘, ∞. ™˘Ú›ÁÔ˘ - ¶··‚·ÛÈÏ›Ԣ

Gelastic seizures in two children with hypothalamic hamartoma N. Vassilaki, C. Kotsalis, A. Syrigou - Papavassiliou

¶ÂÚ›ÏË„Ë: ∏ ÁÂÏ·ÛÙÈ΋ ÂÈÏË„›· (°∂) Â›Ó·È Ì›· Û¿ÓÈ· ÌÔÚÊ‹ ÂÛÙȷ΋˜ ÂÈÏË„›·˜ (∂), Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ ÎÚ›ÛÂȘ ·ÎÔ‡ÛÈÔ˘, ·ÈÊÓ›‰ÈÔ˘ Î·È ÛÙÂÚÂfiÙ˘Ô˘ Á¤ÏÈÔ˘. ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ‰‡Ô ·ÛıÂÓ›˜ Ì °∂, Ô˘ ÔÊ›ÏÂÙ·È Û ·Ì¿Úو̷ ÙÔ˘ ˘Ôı·Ï¿ÌÔ˘, ˆ˜ Û¯ÂÙÈο Û¿ÓÈ· ÔÓÙfiÙËÙ· Î·È Ì ÛÎÔfi Ó· ˘ÔÁÚ·ÌÌÈÛÙ› Ë ‰È·ÊÔÚÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·Ì·ÚÙˆÌ¿ÙˆÓ ·˘ÙÒÓ ÛÙËÓ Î¿ı ÂÚ›ÙˆÛË. ∏ ÂÈÏË„›· Î·È ÛÙÔ˘˜ ‰‡Ô ·ÛıÂÓ›˜ ÂÌÊ·Ó›ÛÙËΠ̠ÙËÓ ›‰È· Û¿ÓÈ· ÌÔÚÊ‹ ÙˆÓ ÁÂÏ·ÛÙÈÎÒÓ ÎÚ›ÛÂˆÓ Î·È Ë Ê‡ÛË, fiˆ˜ Î·È Ë ÂÓÙfiÈÛË Ù˘ ‚Ï¿‚˘, ‹Ù·Ó ›‰È· Î·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ. ∏ ÎÏÈÓÈ΋ fï˜ ÔÚ›·, ηıÒ˜ Î·È Ë ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ Î·È ÔÈ ÂÈÙÒÛÂȘ Ù˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜, ‹Ù·Ó ÙÂÏ›ˆ˜ ‰È·ÊÔÚÂÙÈ΋ Î·È Â›Ó·È Û·Ê¤˜ fiÙÈ Ë ‰È·ÊÔÚ¿ ·˘Ù‹ ¤ÁÎÂÈÙ·È ÛÙÔ Ì¤ÁÂıÔ˜ Ù˘ Ì¿˙·˜, ÙÔÓ ÙÚfiÔ ÂÁηٿÛÙ·Û˘ Ù˘ ÓfiÛÔ˘ (ÚÔԉ¢ÙÈο ‹ Ì ڷÁ‰·›· Âȉ›ӈÛË) Î·È ÛÙËÓ ÎÏÈÓÈ΋ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ, ÙfiÛÔ ˆ˜ ÚÔ˜ ÙËÓ ÂÈÏË„›· fiÛÔ Î·È ˆ˜ ÚÔ˜ Ù· Û˘ÓÔ‰¿ Ê·ÈÓfiÌÂÓ·. ∆¤ÏÔ˜, ÙÔÓ›˙ÂÙ·È Ë ÛËÌ·Û›· Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘, Ô˘ ÌÔÚ› Ó· ·Ô‰Ôı› Û „˘¯ÔÁÂÓ‹ ·ÈÙÈÔÏÔÁ›· Â› ·Ú¯Èο ·ÚÓËÙÈÎÔ‡ ·ÂÈÎÔÓÈÛÙÈÎÔ‡ ÂϤÁ¯Ô˘, ηıÒ˜ Â›Û˘ Ë ·Ó·ÁηÈfiÙËÙ· Â·Ó·ÏËÙÈÎÒÓ Ì·ÁÓËÙÈÎÒÓ ÙÔÌÔÁÚ·ÊÈÒÓ ÂÁÎÂÊ¿ÏÔ˘ ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÛÙ·ÛÈÌfiÙËÙ·˜ ÙÔ˘ ÌÂÁ¤ıÔ˘˜ Ù˘ Ì¿˙·˜.

Abstract: Gelastic epilepsy (GE) is a rare form of partial epilepsy (E) characterized by short-term episodes of involuntary, spontaneous and stereotyped laughter. Two patients with gelastic epilepsy, caused by a hypothalamic hamartoma, are described as a relatively rare phenomenon, in order to emphasize the difference in the behavior of these hamartomas in each case. Epilepsy appeared in both patients with the same rare form of gelastic seizures and the nature as well as the location of the damage was identical in both cases.

The clinical course though, as well as the evolution and the sequelae of the disease, were completely different for each patient, a finding that could be contributed to the difference in the size of the mass, the nature of the disease onset (gradual or dramatic), and the clinical course of the patients in regards to the epilepsy as well as its associated phenomena. Finally, the importance of the disease diagnosis is stressed, since it can be misdiagnosed as of psychogenic aetiology if the neuroimaging examination is initially negative, as well as the necessity in performing repetitive magnetic resonance imaging of the brain, for the surveillance of the mass size.

§¤ÍÂȘ ÎÏÂȉȿ: ÁÂÏ·ÛÙÈ΋ ÂÈÏË„›·, Ê·ÚÌ·ÎÔ·ÓıÂÎÙÈ΋ ÂÈÏË„›·, MRI ÂÁÎÂÊ¿ÏÔ˘, ˘Ôı·Ï·ÌÈÎfi ·Ì¿Úو̷.

Key words: gelastic seizures, drug resistant epilepsy, brain MRI, hypothalamic hamartomas.

∂ÈÛ·ÁˆÁ‹ ∏ ÁÂÏ·ÛÙÈ΋ ÂÈÏË„›· (°∂) Â›Ó·È Ì›· Û¿ÓÈ· ÌÔÚÊ‹ ÂÛÙȷ΋˜ ÂÈÏË„›·˜ (∂), Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ ÎÚ›ÛÂȘ ·ÎÔ‡ÛÈÔ˘, ·ÈÊÓ›-

‰ÈÔ˘ Î·È ÛÙÂÚÂfiÙ˘Ô˘ Á¤ÏÈÔ˘. ∞Ú¯Èο ÂÌÊ·Ó›˙ÔÓÙ·È ÔÈ ÁÂÏ·ÛÙÈΤ˜ ÎÚ›ÛÂȘ Ô˘ ÌÔÚ› Ó· ‰È·Ê‡ÁÔ˘Ó Ù˘ ÚÔÛÔ¯‹˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÚÔÛÙ›ıÂÓÙ·È ÎÈ ¿ÏÏÔÈ Ù‡ÔÈ Û·ÛÌÒÓ Ô˘ Ô‰ËÁÔ‡Ó ÛÂ

¡Â˘ÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ∞ı‹Ó·

Department of Neurology, Penteli Children’s Hospital, Athens

372

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·373

¶·È‰È·ÙÚÈ΋ 2002;65:372-376

Ê·ÚÌ·ÎÔ·ÓıÂÎÙÈ΋ ÂÈÏË„›·. ™˘ÓËı¤ÛÙÂÚ· ·›ÙÈ· ÁÂÏ·ÛÙÈÎÒÓ ÎÚ›ÛÂˆÓ Â›Ó·È: ·) ÙÔ ·Ì¿Úو̷ ÙÔ˘ ˘Ôı·Ï¿ÌÔ˘, ‚) Ô fiÁÎÔ˜ Ù˘ ˘fiÊ˘Û˘, Á) ÙÔ ·ÛÙÚÔ·Ùو̷ ÙˆÓ Ì·ÛÙ›ˆÓ Î·È ‰) ÔÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘.

O ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜ ÚfiÎÏËÛ˘ ÙÔ˘ ·ÎÔ‡ÛÈÔ˘ Á¤ÏÈÔ˘ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙÔ˜, ÂÓÒ ˘¿Ú¯Ô˘Ó ÈÛ¯˘Ú¤˜ ÂӉ›ÍÂȘ fiÙÈ Ô Ù‡Ô˜ ·˘Ùfi˜ Ù˘ ÂÈÏË„›·˜ Û˘Ó‰¤ÂÙ·È Ì ÔÚÁ·ÓÈΤ˜ ‚Ï¿‚˜ ÙÔ˘ ÊÏÔÈÔ‡ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (ÌÂÙˆÈ·›Ô˜ Î·È ÎÚÔÙ·ÊÈÎfi˜ ÏÔ‚fi˜) Î·È ÙÔ˘ ‰ÈÂÁÎÂÊ¿ÏÔ˘. Œ¯Ô˘Ó ·Ó·ÊÂÚı› ÂÚÈÙÒÛÂȘ °∂ ¯ˆÚ›˜ Ó· ÂÓÙÔÈÛÙ› ·Ó·ÙÔÌÈ΋ ‚Ï¿‚Ë (ÎÚ˘„ÈÁÂÓ‹˜ °∂). ∆· ˘Ôı·Ï·ÌÈο ·Ì·ÚÙÒÌ·Ù· ·Ó‹ÎÔ˘Ó ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ‰ÈÂÁÎÂÊ¿ÏÔ˘ Î·È ‰ÂÓ ·ÔÙÂÏÔ‡Ó ·ÏËı‹ ÓÂÔÏ¿ÛÌ·Ù·. ∂›Ó·È ·ÓÒ̷Ϙ ÚÔÛÂ΂ÔϤ˜ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÈÛÙÔ‡ Û ¤ÎÙÔ˜ ı¤ÛÂȘ, ΢ڛˆ˜ ÛÙÔÓ ˘Ôı¿Ï·ÌÔ. ∂›Ó·È, Â›Û˘, ‰˘Ó·ÙfiÓ Ó· ÂÓÙÔÈÛÙÔ‡Ó ÛÙËÓ ÂÚÈÎÔÈÏȷ΋ Î·È ˘ÔÊÏÔÈÒ‰Ë ÂÚÈÔ¯‹. ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ‰‡Ô ·ÛıÂÓ›˜ Ì °∂ Ô˘ ÔÊ›ÏÂÙ·È Û ·Ì¿Úو̷ ÙÔ˘ ˘Ôı·Ï¿ÌÔ˘ ˆ˜ Û¯ÂÙÈο Û¿ÓÈ· ÔÓÙfiÙËÙ· Î·È Ì ÛÎÔfi Ó· ˘ÔÁÚ·ÌÌÈÛÙ› Ë ‰È·ÊÔÚÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·Ì·ÚÙˆÌ¿ÙˆÓ ·˘ÙÒÓ ÛÙËÓ Î¿ı ÂÚ›ÙˆÛË. ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ¶ÂÚ›ÙˆÛË ÚÒÙË ¶ÚfiÎÂÈÙ·È ÁÈ· ÎÔÚ›ÙÛÈ ËÏÈΛ·˜ 6 ÂÙÒÓ Ì ÂχıÂÚÔ ÂÚÈÁÂÓÓËÙÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ∞fi ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ ·Ó·Ê¤ÚÔÓÙ·È ÎÚ›ÛÂȘ ·Ó·›ÙÈÔ˘ Î·È ÂÎÚËÎÙÈÎÔ‡ Á¤ÏÈÔ˘. ∆Ô ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· ÂÁÚ‹ÁÔÚÛ˘ Î·È ‡ÓÔ˘ ›¯Â ηϋ ‚·ÛÈ΋ ÔÚÁ¿ÓˆÛË Î·È ‚Ú·‰¤· ‰ ·̷ٷ ‰ÂÍÈ¿ ÈÓȷο Ì ·ÚÔ͢ÛÌÈ΋ ÂÌÊ¿ÓÈÛË. ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ‹Ù·Ó ·ÚÓËÙÈ΋ ÁÈ· ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ·ÛıÂÓ‹˜ ÂÙ¤ıË Û ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹, ¯ˆÚ›˜ Ó· ÂÈÙ¢¯ı› ·fiÏ˘ÙÔ˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÎÚ›ÛˆÓ, ·Ú¿ Ù· ‰È·ÊÔÚÂÙÈο ηٿ ηÈÚÔ‡˜ Ê·Ú̷΢ÙÈο Û¯‹Ì·Ù·. ªÂÙ¿ ÙËÓ ¿ÚÔ‰Ô 3 ÂÚ›Ô˘ ÂÙÒÓ, Ë ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ۇÓıÂÙ˜ ÂÛÙȷΤ˜ ÎÚ›ÛÂȘ Ì ۇÓÙÔÌË ÌÂÙ·‚ÔÏ‹ ÙÔ˘ ÂÈ¤‰Ô˘ Û˘ÓÂȉ‹Ûˆ˜, ˘fi ÌÔÚÊ‹ ·Ê·›ÚÂÛ˘, ·˘ÙÔÌ·ÙÈÛÌÔ‡˜ Î·È ÌÂÙ·ÎÚÈÙÈ΋ ÎÂÊ·Ï·ÏÁ›·. ™ÙË ‰Â‡ÙÂÚË MRI, Ô˘ ¤ÁÈÓ ηٿ ÙÔ 4Ô ¤ÙÔ˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘, ·Ó¢ڤıË Ôχ ÌÈÎÚ‹, ÌË ÂÍ·ÈÚ¤ÛÈÌË Ì¿˙· ÛÙÔÓ ˘Ôı¿Ï·ÌÔ. ªÂÙ¿ ÙËÓ ÙÚÔÔÔ›ËÛË ÙÔ˘ ıÂÚ·¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜, ÔÈ ÎÚ›ÛÂȘ ·˘Ù¤˜ ÂϤÁ¯ıËÎ·Ó Î·È ¤¯Ô˘Ó ·Ú·Ì›ÓÂÈ ÌfiÓÔÓ ÔÈ ÁÂÏ·ÛÙÈΤ˜ ÎÚ›ÛÂȘ. Œ¯ÂÈ Â›ÁÓˆÛË ÙˆÓ ÎÚ›ÛÂˆÓ Î·È ·Ó·Ê¤ÚÂÈ fiÙÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Á¤ÏÈÔ˘ ·ÈÛı¿ÓÂÙ·È “ÂÚ›ÂÚÁ·”. OÈ ÎÚ›ÛÂȘ Ù˘ Â›Ó·È ‚Ú·¯Â›·˜ ‰È¿ÚÎÂÈ·˜ Î·È ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂ Û˘¯ÓfiÙËÙ· ¤ˆ˜ ÙÂÛÛ¿ÚˆÓ ÂÂÈÛÔ‰›ˆÓ ÙËÓ Ë̤ڷ, ¯ˆÚ›˜ fï˜ Ó· ·Ó·-

Paediatriki 2002;65:372-376

ÛÙ¤ÏÔ˘Ó ÙȘ ÏÔÈ¤˜ ÏÂÈÙÔ˘ÚÁ›Â˜ Ù˘. ∫·Ù¿ ÙË ‰ÂηÙÚÈ¿¯ÚÔÓË ÔÚ›· Ù˘ ÓfiÛÔ˘, Ë ·ÛıÂÓ‹˜ ›¯Â ̤ÁÈÛÙÔ ‰È¿ÛÙËÌ· ÂχıÂÚÔ ÎÚ›ÛÂˆÓ 15 ËÌÂÚÒÓ, ·Ú¿ ÙË Û˘Ó¯È˙fiÌÂÓË ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹. ¶·Ú·ÎÔÏÔ˘ı› Û ηÓÔÓÈÎfi Û¯ÔÏÂ›Ô Î·È ·ÓÙ·ÔÎÚ›ÓÂÙ·È Î·Ï¿ ÛÙȘ ··ÈÙ‹ÛÂȘ ÙˆÓ Ì·ıËÌ¿ÙˆÓ. ∏ ۈ̷ÙÈ΋ Ù˘ ·Ó¿Ù˘ÍË Î·È Ë Â¤Ï¢ÛË Ù˘ ÂÊ˂›·˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜. ¶ÂÚ›ÙˆÛË ‰Â‡ÙÂÚË ∞ÁfiÚÈ ËÏÈΛ·˜ 18 ÌËÓÒÓ, ¤Ó·˜ ·fi ‰È˙˘ÁˆÙÈÎÔ‡˜ ‰È‰‡ÌÔ˘˜, Ì ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi ·Ó·ÌÓËÛÙÈÎfi, ·ÚÔ˘Û›·Û ÙÚ›· ÂÈÏËÙÈο ÂÂÈÛfi‰È· Ì ·ÎÔ‡ÛÈÔ Á¤ÏÈÔ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË, Ô˘ Û˘Ó¯›ÛÙËÎ·Ó Ì Ï‹ÚË ·ÒÏÂÈ· Û˘Ó›‰ËÛ˘ Î·È ‚ÔÏ‚ÔÛÙÚÔÊ‹. ∏ MRI ÂÁÎÂÊ¿ÏÔ˘ ¤‰ÂÈÍ ÌÂÁ¿ÏÔ˘ ÌÂÁ¤ıÔ˘˜ ˘Ôı·Ï·ÌÈÎfi ·Ì¿Úو̷ ̤Û˘ ÁÚ·ÌÌ‹˜. ∆Ô ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· ¤‰ÂÈÍ ηϋ ‚·ÛÈ΋ ÔÚÁ¿ÓˆÛË ÛÙËÓ ÂÁÚ‹ÁÔÚÛË Î·È ÛÙÔÓ ‡ÓÔ Î·È ÂÈÏËÙÔÁÂÓ‹ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ Ù‡Ô˘ ÙˆÓ Ô͇ÌÔÚÊˆÓ Î˘Ì¿ÙˆÓ ·ÚÈÛÙÂÚ¿ ÎÚÔÙ·ÊÈο. ŒÎÙÔÙÂ, ‚Ú›ÛÎÂÙ·È ˘fi ·ÓÙÈÂÈÏËÙÈ΋ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, ¯ˆÚ›˜ fï˜ ÂÈÙ˘¯‹ ¤ÏÂÁ¯Ô ÙˆÓ ÎÚ›ÛˆÓ, Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Î·ıËÌÂÚÈÓ¿ 3 Ì 4 ÊÔÚ¤˜. O ·ÛıÂÓ‹˜ Û‹ÌÂÚ· Â›Ó·È 14 ¯ÚÔÓÒÓ Î·È ÔÈ ÎÚ›ÛÂȘ ÙÔ˘ ÙÚÔÔÔÈ‹ıËÎ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÚ›·˜ Ù˘ ÓfiÛÔ˘. ∂ÌÊ·Ó›˙ÂÈ ÙÒÚ· Î·È Û‡ÓıÂÙ˜ ÂÛÙȷΤ˜ ÎÚ›ÛÂȘ, ÂÓÒ Î·Ù¿ ÂÚÈfi‰Ô˘˜ ÂÌÊ·Ó›˙ÂÈ ÁÂÓÈÎÂ˘Ì¤Ó˜ ÎÚ›ÛÂȘ Ì ÌÂÙ·ÎÚÈÙÈ΋ ˘ÓËÏ›·. ¶ÔÏÏ¿ ·fi Ù· ÂÂÈÛfi‰È· ÍÂÎÈÓÔ‡Ó Ì ÁÂÏ·ÛÙÈΤ˜ ÎÚ›ÛÂȘ, ·ÏÏ¿ Û¿ÓÈ· ÛÙ·Ì·ÙÔ‡Ó ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ Û‡Ìو̷. ™Â ËÏÈΛ· 7 ÂÙÒÓ ·ÚÔ˘Û›·Û ÚfiˆÚË ‹‚Ë, ÔfiÙÂ Î·È ÂÙ¤ıË Û ·ÁˆÁ‹ Ì Arvekap ÁÈ· ‰‡Ô ¯ÚfiÓÈ·. ¶·ÚÔ˘ÛÈ¿˙ÂÈ ÛÔ‚·Ú¤˜ ‰˘ÛÎÔϛ˜ Ì¿ıËÛ˘, ηıÒ˜ ¤¯ÂÈ ÛÔ‚·ÚfiÙ·ÙË ‰È¿Û·ÛË ÚÔÛÔ¯‹˜ Î·È ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ Ù‡Ô˘ Ù˘ ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·˜. ¶·Ú·ÎÔÏÔ˘ı› Û ÂȉÈÎfi Û¯ÔÏ›Ô. OÈ Â·Ó·ÏËÙÈΤ˜ MRI ÂÁÎÂÊ¿ÏÔ˘ Ô˘ ¤ÁÈÓ·Ó ÛÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘, ¤‰ÂÈÍ·Ó ÛÙ·ÛÈÌfiÙËÙ· ÛÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ fiÁÎÔ˘. ™˘˙‹ÙËÛË ¶·ÚÔ˘ÛÈ¿˙Ô˘Ì ÙȘ ‰‡Ô ·˘Ù¤˜ ÂÚÈÙÒÛÂȘ, Ô˘ ÂÌÊ·Ó›ÛÙËÎ·Ó Ì ̛· Û¿ÓÈ· ÌÔÚÊ‹ ÂÈÏË„›·˜ ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·, ÁÈ· Ó· ÙÔÓ›ÛÔ˘Ì ÙȘ ÌÂÁ¿Ï˜ ‰È·ÊÔÚ¤˜ Ô˘ ÌÔÚ› Ó· ˘Ê›ÛÙ·ÓÙ·È ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û ‰‡Ô ·ÛıÂÓ›˜ Ì ¯ˆÚÔηٷÎÙËÙÈΤ˜ ‚Ï¿‚˜ ÛÙÔÓ ˘Ôı¿Ï·ÌÔ. ∏ ÂÈÏË„›· Î·È ÛÙÔ˘˜ ‰‡Ô ·ÛıÂÓ›˜ ÂÌÊ·Ó›ÛÙËΠ̠ÙËÓ ›‰È· Û¿ÓÈ· ÌÔÚÊ‹ ÙˆÓ ÁÂÏ·ÛÙÈÎÒÓ ÎÚ›ÛÂˆÓ Î·È Ë Ê‡ÛË, fiˆ˜ Î·È Ë ÂÓÙfiÈÛË Ù˘ ‚Ï¿‚˘, Â›Ó·È ›‰È· Î·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ. ∏ ÎÏÈÓÈ΋ fï˜ ÔÚ›· Î·È ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘, ηıÒ˜ Î·È ÔÈ ÂÈÙÒÛÂȘ Ù˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜, Â›Ó·È ÙÂÏ›ˆ˜ ‰È·ÊÔÚÂÙÈ΋. ∂›Ó·È ۷ʤ˜ fiÙÈ Ë ‰È·ÊÔÚ¿ ¤ÁÎÂÈÙ·È ÛÙÔ Ì¤ÁÂıÔ˜ Ù˘ Ì¿˙·˜,

373

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·374

¶·È‰È·ÙÚÈ΋ 2002;65:372-376

∂ÈÎfiÓ· 1. ¶ÂÚ›ÙˆÛË ÚÒÙË. ª·ÁÓËÙÈÎfi˜ Û˘ÓÙÔÓÈÛÌfi˜ ÂÁÎÂÊ¿ÏÔ˘ Û ԂÂÏÈ·›· ÙÔÌ‹, Ô˘ ‰Â›¯ÓÂÈ ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ ·ÓÂÁ¯Â›ÚËÙÔ ·Ì¿Úو̷ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ Ê·ÈÔ‡ ʇ̷ÙÔ˜, ›‰È·˜ ¤ÓÙ·Û˘ Û‹Ì·ÙÔ˜ Ì ÙË Ê·È¿ Ô˘Û›·.

‰Â‰Ô̤ÓÔ˘ fiÙÈ ÛÙÔÓ ‰Â‡ÙÂÚÔ ·ÛıÂÓ‹ Ë ÚÒÙË MRI, Û ËÏÈΛ· 1ó ¤ÙÔ˘˜, ¤ıÂÛ ÙË ‰È¿ÁÓˆÛË, ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ Û ̤ÁÂıÔ˜ ˘Ôı·Ï·ÌÈÎÔ‡ ·Ì·ÚÙÒÌ·ÙÔ˜ Ô˘ ·Ó¢ڤıË, ÂÓÒ ÛÙËÓ ÚÒÙË ·ÛıÂÓ‹ Ë Ì¿˙· ·ÓȯÓ‡ÙËΠ۠‰Â‡ÙÂÚË ÂͤٷÛË, 4 ¯ÚfiÓÈ· ÌÂÙ¿ ·fi ÙËÓ ÚÒÙË. ¢ÂÓ Â›Ó·È ÁÓˆÛÙfi Â¿Ó ·˘Ùfi ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ Ë ‰Â‡ÙÂÚË ÂͤٷÛË ¤ÁÈÓ Ì Ì˯¿ÓËÌ· ÓÂfiÙÂÚÔ Î·È ÂÔ̤ӈ˜ Ì ηχÙÂÚË ‰È·ÎÚÈÙÈ΋ ÈηÓfiÙËÙ·. ∞˘Ùfi fï˜ Ê·›ÓÂÙ·È Èı·ÓfiÙÂÚÔ ·fi ÙÔ Ó· ÂÌÊ·Ó›ÛÙËÎÂ Ë Ì¿˙· ·ÈÊÓ›‰È· ‹ Ó· ·˘Í‹ıËΠ̤۠ÁÂıÔ˜, ¯ˆÚ›˜ Ô˘ÛÈ·ÛÙÈο Ó· ¤¯ÂÈ ·ÏÏ¿ÍÂÈ Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ·ÛıÂÓÔ‡˜. ∏ ÂÁηٿÛÙ·ÛË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ·ÛıÂÓ‹ ›¯Â ÚÔԉ¢ÙÈÎfi ¯·Ú·ÎÙ‹Ú·, Ì ÛÙ·‰È·Î‹ ÂÌÊ¿ÓÈÛË Î·È Û‡ÓıÂÙˆÓ ÂÛÙÈ·ÎÒÓ Û·ÛÌÒÓ ÌÂÙ¿ ·fi ÙȘ ÁÂÏ·ÛÙÈΤ˜ ÎÚ›ÛÂȘ, ÂÓÒ ÛÙÔÓ ·ÛıÂÓ‹ Ë ÂÈÛ‚ÔÏ‹ Ù˘ ÓfiÛÔ˘ ‹Ù·Ó ‰Ú·Ì·ÙÈ΋ Î·È Ë Âȉ›ӈÛË Ú·Á‰·›·, Ì ÂÌÊ¿ÓÈÛË Û‡ÓıÂÙˆÓ ÂÛÙÈ·ÎÒÓ ÎÚ›ÛÂˆÓ Î·È ÁÂÓÈÎÂ˘Ì¤ÓˆÓ Û·ÛÌÒÓ. ∂›Û˘, Ôχ ‰È·ÊÔÚÂÙÈ΋ ¤¯ÂÈ ˘¿ÚÍÂÈ Ë ÎÏÈÓÈ΋ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ, ÙfiÛÔ ˆ˜ ÚÔ˜ ÙËÓ ÂÈÏË„›· fiÛÔ Î·È ˆ˜ ÚÔ˜ Ù· Û˘ÓÔ‰¿ Ê·ÈÓfiÌÂÓ·. ∏ 1Ë ·ÛıÂÓ‹˜ ¤¯ÂÈ ‹È·˜ ÌÔÚÊ‹˜ ÎÚ›ÛÂȘ, ·ÓıÂÎÙÈΤ˜ ÌÂÓ ÛÙË ıÂÚ·›·, ·ÏÏ¿ ¯ˆÚ›˜ Ù¿ÛË Âȉ›ӈÛ˘. O ‰Â‡ÙÂÚÔ˜ ·ÛıÂÓ‹˜ ¤¯ÂÈ ÛÔ‚·Ú¤˜ ÎÚ›ÛÂȘ Ô˘ ‰È·Ù·Ú¿ÛÛÔ˘Ó ÛËÌ·ÓÙÈο ÙËÓ Î·ıËÌÂÚÈÓ‹ ÙÔ˘ ˙ˆ‹. ∏ ÚÒÙË ·ÛıÂÓ‹˜ Â›Ó·È Ì›· Â˘Ê˘‹˜ ¤ÊË‚Ë Ô˘ ÊÔÈÙ¿ Ì ÂÈÙ˘¯›· ÛÙÔ Û¯ÔÏÂ›Ô Î·È ¤¯ÂÈ ·fiÏ˘Ù· Ê˘ÛÈÔÏÔÁÈ΋, ÁÈ· ÙËÓ ËÏÈΛ· Ù˘, Û˘ÌÂÚÈÊÔÚ¿. ∞ÓÙ›ıÂÙ·, Ô ‰Â‡ÙÂÚÔ˜ ·ÛıÂÓ‹˜, ÌÔÏÔÓfiÙÈ ·È‰› ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÈηÓfiÙËÙ˜, ÂËÚ¿ÛÙËΠÛÔ‚·Ú¿ ˆ˜ ÚÔ˜ ÙË Ì¿ıËÛË, ÏfiÁˆ Ù˘ ‚·Ú‡Ù·Ù˘ ‰È¿Û·Û˘ ÚÔÛÔ¯‹˜, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ‰›ÓÂÈ ÙËÓ ÂÓÙ‡ˆÛË ·È‰ÈÔ‡ Ì ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, ÂÓÒ ‰ÂÓ

374

Paediatriki 2002;65:372-376

›ӷÈ. ∏ ˘ÂÚÎÈÓËÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ η٤ÛÙËÛ ÙË ÊÔ›ÙËÛ‹ ÙÔ˘ Û ηÓÔÓÈÎfi Û¯ÔÏÂ›Ô ÙÂÏ›ˆ˜ ·‰‡Ó·ÙË. ∂Ô̤ӈ˜, Ù· Û˘ÓÔ‰¿ ÚÔ‚Ï‹Ì·Ù· ÙÔ˘ ·È‰ÈÔ‡, Ì·˙› Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÂÈÏË„›·˜, ÚÔοÏÂÛ·Ó ÙËÓ ÂÌÊ¿ÓÈÛË ·Ó·ËÚ›·˜ Û ·ÓÙ›ıÂÛË Ì ÙËÓ 1Ë ·ÛıÂÓ‹ Ì·˜.

OÈ ÁÂÏ·ÛÙÈΤ˜ ÎÚ›ÛÂȘ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÌÊ·Ó›˙ÔÓÙ·È: ·) ˆ˜ ÌÂÌÔӈ̤ÓÔ Úfi‚ÏËÌ·, ‚) ˆ˜ Û‡Ìو̷ Ó¢ÚÔÁÂÓÂÙÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜, fiˆ˜ .¯. ÛÙËÓ Ô˙Ò‰Ë ÛÎÏ‹Ú˘ÓÛË Î·È Á) ÛÙ· Ï·›ÛÈ· ÂÓfi˜ Û¿ÓÈÔ˘ Û˘Ó‰ÚfiÌÔ˘ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ·Ì¿Úو̷ ˘Ôı·Ï¿ÌÔ˘, ÚfiˆÚË ‹‚Ë Î·È ·ÓıÂÎÙÈ΋ ÂÈÏË„›·. ™ÙÔ Û‡Ó‰ÚÔÌÔ ·˘Ùfi ·Ó‹ÎÂÈ Ê¿ÛÌ· ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛˆÓ, Ô˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÂÓÙfiÈÛË ÙÔ˘ ·Ì·ÚÙÒÌ·ÙÔ˜, ÙÔ ÔÔ›Ô ·ÔÙÂÏ› Î·È ÙËÓ ÂÛÙ›· Á¤ÓÂÛ˘ ÙÔ˘ ÂÈÏËÙÔÁÂÓÔ‡˜ ÂÚÂı›ÛÌ·ÙÔ˜, ηıÒ˜ Î·È ·fi ÙÔ ‚·ıÌfi ‰È·ÛÔÚ¿˜ ÙÔ˘ ÂÚÂı›ÛÌ·ÙÔ˜. ∏ ÂÈÏËÙÔÁÂÓ‹˜ ‰Ú·ÛÙËÚÈfiÙËÙ· ÂÓÂÚÁÔÔÈ› ηٿ ÙÔ ¤Ú·ÛÌ¿ Ù˘ ÙȘ ‰Ô̤˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ô˘ ·Ú¿ÁÔ˘Ó ÙÔÓ ·ÎÔ‡ÛÈÔ ÎÈ ·ÚfiÎÏËÙÔ ·ÚÔ͢ÛÌÈÎfi Á¤ÏˆÙ·, Ô˘ ·ÔÙÂÏ› ÙÔ Î‡ÚÈÔ Û‡Ìو̷ ÙˆÓ ÎÚ›ÛÂˆÓ ·˘ÙÒÓ. ∞fi ÂΛ ÌÂÙ·‰›‰ÂÙ·È Û ¿ÏϘ ÂÚÈÔ¯¤˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, fiˆ˜ ÙÔ ÊÏÔÈfi, ÙÔÓ ·Ì˘Á‰·ÏÔÂȉ‹ ˘Ú‹Ó·, ÙÔÓ ÈfiηÌÔ Î.¿. (1). ∏ ÚˆÙÔÁÂÓ‹˜ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈ΋ ·ÓˆÌ·Ï›· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔηÏÂ›Ù·È ·fi Ì›· ‰È¿¯˘ÙË ˘ÂÚ‰ÈÂÁÂÚÛÈÌfiÙËÙ· ÙÔ˘ ÊÏÔÈÔ‡ Ô˘ ˘ÚÔ‰ÔÙ› ‰Â˘ÙÂÚÔÁÂÓÒ˜ ÙȘ ı·Ï·ÌÔÊÏÔÈÒ‰ÂȘ Ó¢ÚÈΤ˜ Ô‰Ô‡˜. ¶ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜, Ô˘ ·ÊÔÚÔ‡Ó ÙË Á¤ÓÂÛË ÙÔ˘ Á¤ÏˆÙ·, ‰Â›¯ÓÔ˘Ó fiÙÈ Ô ËÏÂÎÙÚÈÎfi˜ ÂÚÂıÈÛÌfi˜ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÂÚÈÔ¯ÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Ì ÂÌÊ˘ÙÂ˘Ì¤Ó· ËÏÂÎÙÚfi‰È·, ÂÎχÂÈ ÙÔ Á¤ÏÈÔ (2-4). ™˘ÁÎÂÎÚÈ̤ӷ, ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ô ÂÚÂıÈÛÌfi˜ Ù˘ ÚfiÛıÈ·˜ ·ÁÎÈÛÙÚˆÙ‹˜ ¤ÏÈη˜ ÙÔ˘ ÌÂÙˆÈ·›Ô˘ ÏÔ‚Ô‡ Ô‰ËÁ› Û ‚›·ÈÔ, ·ÎÔ‡ÛÈÔ Î·È Ì˯·ÓÈÎfi Á¤ÏˆÙ· ¯ˆÚ›˜ ˘ÔΛÌÂÓÔ ·›ÛıËÌ· ¢ÊÔÚ›·˜. ŒÙÛÈ, Û˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ë ÂÚÈÔ¯‹ ·˘Ù‹ Â›Ó·È ˘‡ı˘ÓË ÁÈ· ÙÔ ÎÈÓËÙÈÎfi ̤ÚÔ˜ ÙÔ˘ Á¤ÏˆÙ·, ÂÓÒ ÛÙÔ Û˘Ó·ÈÛıËÌ·ÙÈÎfi ÂÚȯfiÌÂÓÔ ÙÔ˘ Á¤ÏÈÔ˘ ÂÌϤÎÔÓÙ·È ÔÈ ‰Ô̤˜ ÙÔ˘ ‚·ÛÈÎÔ‡ ÎÚÔÙ·ÊÈÎÔ‡ ÏÔ‚Ô‡, ‰ËÏ·‰‹ Ë ·ÙÚ·ÎÙÔÂȉ‹˜ Î·È Ë ·Ú·˚ÔοÌÂÈÔ˜ ¤ÏÈη.

OÈ ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ Ô˘ Û˘¯Ó¿ Û˘ÓÔ‰Â‡Ô˘Ó ÙÔ Û‡Ó‰ÚÔÌÔ, fiˆ˜ Â›Ó·È Ë ‰È·Ù·Ú·¯‹ ÂÏÏÂÈÌÌ·ÙÈ΋˜ ÚÔÛÔ¯‹˜ Î·È Ë ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· (5), ηıÒ˜ Â›Û˘ ÔÈ Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ Î·È Ë ÁÓˆÛȷ΋ ·Ô‰ÈÔÚÁ¿ÓˆÛË, ‰ËÏ·‰‹ Ë ‰È·Ù·Ú·¯‹ ÛÙËÓ ÂÓۈ̿وÛË ÌÈ·˜ ÏËÚÔÊÔÚ›·˜ ÛÙË ‰È·‰Èηۛ· Ù˘ ÌÓ‹Ì˘, ÈÛÙ‡ÂÙ·È fiÙÈ Â›Ó·È Â›Û˘ ÙÔ ¿ÌÂÛÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ‰È·Ù·Ú·¯‹˜ ÛÙËÓ ·ÁˆÁ‹ ÙÔ˘ ÂÚÂı›ÛÌ·ÙÔ˜ (1). ∞ÎfiÌË, ¤Ó· ·̷ ‰È·ÛÔÚ¿˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÓÂÚÁÔÔÈ‹ÛÂÈ ÙÔÓ ˘Ôı¿Ï·ÌÔ-˘ÔÊ˘ÛÈ·Îfi ¿ÍÔÓ·, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÚÔ͢ÛÌÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·375

¶·È‰È·ÙÚÈ΋ 2002;65:372-376

∂ÈÎfiÓ· 2. ¶ÂÚ›ÙˆÛË ÚÒÙË. ª·ÁÓËÙÈÎfi˜ Û˘ÓÙÔÓÈÛÌfi˜ ÂÁÎÂÊ¿ÏÔ˘ Û ÔÚÈ˙fiÓÙÈ· ÙÔÌ‹. ∞Ì¿Úو̷ ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ ÛÙÔÓ ‰ÂÍÈfi ˘Ôı¿Ï·ÌÔ Ô˘ ÚÔ‚¿ÏÏÂÈ ÂÓÙfi˜ Ù˘ ÙÚ›Ù˘ ÎÔÈÏ›·˜.

ÙÔ˘ (6,7). ∆· Â›‰· ÙˆÓ ÔÚÌÔÓÒÓ ÙÔ˘ ¿ÍÔÓ· ÛÙÔ Ï¿ÛÌ· ·Ó¢ڛÛÎÔÓÙ·È ·Ó¿ ÂÚ›ÙˆÛË ·˘ÍË̤ӷ. ŒÙÛÈ, Ï.¯. Ë ·ÚÔ͢ÛÌÈ΋ ·ÂÏ¢ı¤ÚˆÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙÔ ·›Ì· Ô‰ËÁ› Û ÚfiˆÚË ˆÚ›Ì·ÓÛË ÙˆÓ ÔÛÙÒÓ Î·È, Û˘ÓÂÒ˜, Û ÚfiˆÚË ·‡ÍËÛË ‡„Ô˘˜ Î·È ‚¿ÚÔ˘˜. ∞Ó¿ÏÔÁ· ÂÎÎÚ›ÓÔÓÙ·È Ë ACTH (Ì ‰Â˘ÙÂÚÔÁÂÓ‹ ·‡ÍËÛË ÎÔÚÙÈ˙fiÏ˘), Ë ÓÔÚÂÈÓÂÊÚ›ÓË, Ë GnRH (ÔÚÌfiÓË ·ÂÏ¢ı¤ÚˆÛ˘ ÁÔÓ·‰ÔÙÚÔÈÓÒÓ) Î.¿. ¶ÚÔ˜ ‰È¢ÎÚ›ÓÈÛË ·Ú·Ì¤ÓÂÈ Ô ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜ ¤ÎÎÚÈÛ˘ Ù˘ GnRH, Ë ÔÔ›· ¢ı‡ÓÂÙ·È ÁÈ· Ù· ·˘ÍË̤ӷ Â›‰· ÁÔÓ·‰ÔÙÚÔÈÓÒÓ ÛÙÔ Ï¿ÛÌ· ηÈ, Û˘ÓÂÒ˜, ÙËÓ ÚfiˆÚË ‹‚Ë, ηıÒ˜ Â›Û˘ Ô Ì˯·ÓÈÛÌfi˜ ·ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ Î·Ù·ÛÙ·ÏÙÈÎÒÓ Ù˘ GnRH Ì˯·ÓÈÛÌÒÓ. ∆Ô Î‡Ì· ‰È·ÛÔÚ¿˜ ‰‡Ó·Ù·È Â›Û˘ Ó· ÂÓÂÚÁÔÔÈ‹ÛÂÈ ¿ÌÂÛ· ÙÔ ÌÂٷȯÌÈ·Îfi Î·È ·Ú·ÌÂٷȯÌÈ·Îfi Û‡ÛÙËÌ·, ÙÔÓ ÚÔÌ‹ÎË Ì˘ÂÏfi Î·È ÙÔ ·˘ÙfiÓÔÌÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·. ŒÙÛÈ ÂÍËÁÂ›Ù·È Ë ÂÌÊ¿ÓÈÛË ·˘ÍË̤Ó˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, Ù·¯˘Î·Ú‰›·˜, Ù·¯‡ÓÔÈ·˜, ηıÒ˜ Î·È ÂÚÈÊÂÚÈ΋˜ ·ÁÁÂÈÔÛ˘ÛÙÔÏ‹˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÎÚ›ÛÂˆÓ (8). ÕÏÏ· Û˘ÌÙÒÌ·Ù· Û ·Ì·ÚÙÒÌ·Ù· ˘Ôı·Ï¿ÌÔ˘ Â›Ó·È Ë ÌÂÙˆÈ·›· ÎÂÊ·Ï·ÏÁ›·, Ë ·ÓÔÚÂÍ›·, Ë Î·Ù·‚ÔÏ‹, Ë Â˘ÂÚÂıÈÛÙfiÙËÙ·, Ë Û‡Á¯˘ÛË Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ ÛÙËÓ fiÚ·ÛË, fiÙ·Ó Ë Ì¿˙· ÚÔÛ‚¿ÏÏÂÈ ÙËÓ ÔÙÈ΋ Ô‰fi. ∆· ·Ì·ÚÙÒÌ·Ù· ÙÔ˘ ˘Ôı·Ï¿ÌÔ˘, ÂÚÈÁÚ¿ÊËÎ·Ó ÚÒÙË ÊÔÚ¿ ÙÔ 1934 ·fi ÙÔ˘˜ Le Marquand et Russell (9). ∂›Ó·È ÚÔÛÂ΂ÔϤ˜ ÂÁÎÂÊ·ÏÈÎÔ‡ ÈÛÙÔ‡ ÌÂ Ì›Û¯Ô Î·È ·ÔÙÂÏÔ‡ÓÙ·È ·fi Ê˘ÛÈÔÏÔÁÈο Ó¢ÚÈο ·ÙÙ·Ú· ÙÔ˘ Ê·ÈÔ‡ ʇ̷ÙÔ˜, ηıÒ˜ Â›Û˘ ·fi ÁÏÔ›·. ™˘Ó‹ıˆ˜ ÂÓÙÔ›˙ÔÓÙ·È ÌÂٷ͇ Ì·ÛÙ›ˆÓ Î·È Ì›Û¯Ô˘ ˘fiÊ˘Û˘, ÁÂÌ›˙ÔÓÙ·˜ ¤ÙÛÈ ÙÔÓ

Paediatriki 2002;65:372-376

∂ÈÎfiÓ· 3. ¶ÂÚ›ÙˆÛË ‰Â‡ÙÂÚË. OÚÈ˙fiÓÙÈ· ÙÔÌ‹ ÂÁÎÂÊ¿ÏÔ˘. ∂˘Ì¤ÁÂı˜ ·Ì¿Úو̷ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ˘Ôı·Ï¿ÌÔ˘.

ÂχıÂÚÔ ¯ÒÚÔ ÌÂٷ͇ Á¤Ê˘Ú·˜ Î·È ÔÙÈÎÔ‡ ¯È¿ÛÌ·ÙÔ˜. ∫·Ù¿ ηÓfiÓ· ‰ÂÓ ·ÚÂÎÙÔ›˙Ô˘Ó ÙÔÓ ˘Ôı¿Ï·ÌÔ ‹ ¿ÏϘ ‰Ô̤˜ Ù˘ ‚¿Û˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÂÎÙfi˜ ÎÈ ·Ó ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜ Â›Ó·È ·Û˘Ó‹ıÈÛÙ· ÌÂÁ¿ÏÔ. ∂ÌÊ·Ó›˙ÔÓÙ·È Û ›‰È· Û˘¯ÓfiÙËÙ· ÛÙ· ‰‡Ô ʇϷ Î·È ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È ÛÙËÓ 1Ë ‹ 2Ë ‰ÂηÂÙ›· ˙ˆ‹˜. ™ÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÙÔ ÌfiÚʈ̷ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ˆ˜ Ì·Ï·Îfi˜ ÈÛÙfi˜ ›‰È·˜ ¤ÓÙ·Û˘ Û‹Ì·ÙÔ˜ Ì ÙË Ê·È¿ Ô˘Û›·. ∏ ¤ÓÙ·ÛË ‰ÂÓ ·˘Í¿ÓÂÙ·È Ì ÙËÓ ÚÔÛı‹ÎË ÛÎÈ·ÁÚ·ÊÈÎÔ‡. ∞˘Ùfi ÙÔ Â‡ÚËÌ· ·ÔÙÂÏ› ÛËÌÂ›Ô ‰È¿ÁÓˆÛ˘. ∆· ·Ì·ÚÙÒÌ·Ù· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÌÔÈÔÁ¤ÓÂÈ·, ‰ÂÓ ÂÚÓÔ‡Ó ÙÔÓ ·ÈÌ·ÙÔÂÁÎÂÊ·ÏÈÎfi ÊÚ·ÁÌfi, ‰ÂÓ ·ÔÙÈÙ·ÓÒÓÔÓÙ·È Î·È ·ÊÔÚ›˙ÔÓÙ·È Û·ÊÒ˜ ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ ∂¡À. ™ËÌÂÈÒÓÂÙ·È Â‰Ò fiÙÈ ¤Ó·˜ ·ÛıÂÓ‹˜ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ì ÌfiÓ˜ ÙȘ ÁÂÏ·ÛÙÈΤ˜ ÎÚ›ÛÂȘ ‹ ÙËÓ ÚfiˆÚË ‹‚Ë Î·È ¤¯ÂÈ ÙËÓ ·Ú·¿Óˆ ¯·Ú·ÎÙËÚÈÛÙÈ΋ Ó¢ÚÔ·ÂÈÎfiÓÈÛË, ·ÔÙÂÏ› ·ÛıÂÓ‹ ˘„ËÏ‹˜ ˘Ô„›·˜ ÁÈ· ÙÔ Û‡Ó‰ÚÔÌÔ. ∞fi ·ÂÈÎÔÓÈÛÙÈ΋˜ ÏÂ˘Ú¿˜, Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÈ: ·) ÙÔ ÎÚ·ÓÈÔÊ·Ú˘ÁÁ›ˆÌ·, ‚) Ù· ˘Ôı·Ï·ÌÈο ÁÏÔÈÒÌ·Ù· Î·È Á) Ù· Á·ÁÁÏÈÔÁÏÔÈÒÌ·Ù·, Ù· ÔÔ›· fï˜ ‰È·Ê¤ÚÔ˘Ó ˆ˜ ÚÔ˜ ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘˜, Ô˘ ÛËÌ·›ÓÂÈ fiÙÈ Ì ÙËÓ ÚÔÛı‹ÎË ÛÎÈ·ÁÚ·ÊÈÎÔ‡ ·˘Í¿ÓÂÙ·È Ë ¤ÓÙ·ÛË ÙÔ˘ Û‹Ì·Ùfi˜ ÙÔ˘˜, ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÌÔÈÔÁ¤ÓÂÈ· Î·È Û˘¯Ó¿ ·ÔÙÈÙ·ÓÒÓÔÓÙ·È. ª›· Â›Û˘ ¯Ú‹ÛÈÌË Ì¤ıÔ‰Ô˜ ·Ó›¯Ó¢Û˘ Î·È ·ÍÈÔÏfiÁËÛ˘ Ù˘ Ì¿˙·˜, ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÎÚ›ÛˆÓ, Â›Ó·È ÙÔ SPECT, fiÔ˘ ·Ú·ÙËÚÂ›Ù·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ ·‡ÍËÛË ÛÙËÓ ·ÈÌ¿ÙˆÛË ÙÔ˘ ·Ì·ÚÙÒÌ·ÙÔ˜ Î·È ÙˆÓ ÁÂÈÙÔÓÈÎÒÓ ‰ÔÌÒÓ (4,6), Ú¿ÁÌ· Ô˘ ÂÓÈÛ¯‡ÂÈ ÙËÓ ˘Ô„›· fiÙÈ ÙÔ ÌfiÚʈ̷ ·ÔÙÂÏ› ÙËÓ ÂÛÙ›· Á¤ÓÂÛ˘ ÙÔ˘ ÂÈÏËÙÔÁÂÓÔ‡˜ ÂÚÂı›ÛÌ·ÙÔ˜

375

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·376

¶·È‰È·ÙÚÈ΋ 2002;65:372-376

(10). ™Ù· ÌÂÛԉȷÛÙ‹Ì·Ù· ÙˆÓ ÎÚ›ÛÂˆÓ ÙÔ SPECT ÂÌÊ·Ó›˙ÂÙ·È Ê˘ÛÈÔÏÔÁÈÎfi, ÂÓÒ ÂÓÙ‡ˆÛË ÚÔηÏ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÎÚ›ÛÂˆÓ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ˘ÂÚ·ÈÌ¿ÙˆÛË ÙÔ˘ ÊÏÔÈÔ‡ ‹ Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜ (4). øÛÙfiÛÔ, Û ÌÂÙ·ÎÚÈÙÈÎfi SPECT, ‰È·ÈÛÙÒÓÂÙ·È ˘Ô·ÈÌ¿ÙˆÛË ÙˆÓ ËÌÈÛÊ·ÈÚ›ˆÓ ÙÔ˘˜ ·ÓÙ›ÛÙÔȯ· (10). ™ÙË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ ÂÚÈÏ·Ì‚¿ÓÂÙ·È: ·) Ë Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ÌÂ Û˘Ó‰˘·ÛÌfi Ê·Ú̿ΈÓ. O ηÓfiÓ·˜ Â›Ó·È Ë ÔÏ˘Ê·Ú̷Λ· ÏfiÁˆ ·ÓıÂÎÙÈÎfiÙËÙ·˜ ÙˆÓ ÎÚ›ÛˆÓ, fï˜ ˘¿Ú¯Ô˘Ó ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó Î·È ÙÔ ·ÓÙ›ıÂÙÔ. πηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·, Ì ¿ÌÂÛË ÔÌ·ÏÔÔ›ËÛË ÙˆÓ ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È ÂÍ·Ê¿ÓÈÛË ÙˆÓ ÎÚ›ÛˆÓ, ¤¯Ô˘Ó ·Ó·ÊÂÚı› Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ¯ÔÚ‹ÁËÛ˘ Ê·ÚÌ¿ÎˆÓ fiˆ˜: i) methoxy-progesterone acetate (9) Î·È ii) Vigabatrin (11), ‚) Ë ÌÂÚÈ΋ (12) ‹ ÔÏÈ΋ (13) ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÍ·›ÚÂÛË Ù˘ ‚Ï¿‚˘ Î·È Á) Ë ÛÙÂÚÂÔÙ·ÎÙÈ΋ ·ÎÙÈÓÔ¯ÂÈÚÔ˘ÚÁÈ΋ (4,14). ∫·Ì›· ·fi ÙȘ Ù¯ÓÈΤ˜ ·˘Ù¤˜ ‰ÂÓ Û˘ÛÙ‹ıËΠÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜ ·fi Ó¢ÚÔ¯ÂÈÚÔ˘ÚÁÔ‡˜ ÛÙËÓ ∂ÏÏ¿‰· Î·È ÛÙÔ Â͈ÙÂÚÈÎfi. ™˘ÌÂÚ·ÛÌ·ÙÈο, ı· Ú¤ÂÈ Ó· ·Ó·ÊÂÚı› Ë ÛËÌ·Û›· Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ¤¯ÂÈ Û˘Ì‚Â› Ó· ·Ô‰Ôı› Û „˘¯ÔÁÂÓ‹ ·ÈÙÈÔÏÔÁ›·, fiÙ·Ó Ô ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·Ô‚·›ÓÂÈ ·ÚÓËÙÈÎfi˜, ηıÒ˜ Â›Û˘ Ë ·Ó·ÁηÈfiÙËÙ· Ù˘ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ ÛÙËÓ Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì °∂ ÁÈ· ÙËÓ ÂÓÙfiÈÛË Ù˘ ‚Ï¿‚˘ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂͤÏÈÍ‹˜ Ù˘. ¢ÂÓ ÁÓˆÚ›˙Ô˘ÌÂ Â¿Ó ÔÈ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙÔ˘˜ ‰‡Ô ·ÛıÂÓ›˜ Ì·˜ ÌÔÚÔ‡Ó Ó· ·Ô‰ÔıÔ‡Ó ·ÔÎÏÂÈÛÙÈο ÛÙÔ Ì¤ÁÂıÔ˜ Ù˘ Ì¿˙·˜. ∂›Ó·È ‚¤‚·È· Èı·Ófi, ·ÏÏ¿ Ë Û˘ÌÌÂÙÔ¯‹ Î·È ¿ÏψÓ, ÌË ÔÚ·ÙÒÓ ·ÂÈÎÔÓÈÛÙÈο, ÂÚÈÔ¯ÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ‰ÂÓ ÌÔÚ› Ó· ·ÔÎÏÂÈÛÙ› ÛÙÔ 2Ô ·ÛıÂÓ‹ Ì·˜. ∆Ô ÙÂÏÂ˘Ù·›Ô ˘ÔÛÙËÚ›Í·Ó Î·È ÔÈ Sisodiya et al ÙÔ 1997 (15), ‰È·Ù˘ÒÓÔÓÙ·˜ ÙËÓ ˘fiıÂÛË fiÙÈ Ë Ùˆ¯‹ ·ÓÙ·fiÎÚÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ˘Ôı·Ï·ÌÈο ·Ì·ÚÙÒÌ·Ù· Î·È ÁÂÏ·ÛÙÈΤ˜ ÎÚ›ÛÂȘ ÛÙËÓ ·ÁˆÁ‹, ı· ÌÔÚÔ‡Û ӷ ÔÊ›ÏÂÙ·È Û ‰È¿¯˘Ù˜ ‚Ï¿‚˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÌË Û¯ÂÙÈ˙fiÌÂÓ˜ Ì ÙÔ ·Ì¿Úو̷.

Paediatriki 2002;65:372-376

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

a case with a frontal focus; review of the literature and pathophysiological hypotheses. Epileptic Disord 1999;1:221-228.

Kuzniecky R, Guthrie B, Mountz J, Bebin M, Faught E, Gilliam F et al. Intrinsic epileptogenesis of hypothalamic hamartomas in gelastic epilepsy. Ann Neurol 1997; 42:60-67.

Deonna T, Ziegler AL. Hypothalamic hamartoma, precocious puberty and gelastic seizures: a special model of “epileptic” developmental disorder. Epileptic Disord 2000;2:33-37.

Arroyo S, Santamaria J, Sanmarti F, Lomena F, Catafau A, Casamitjana R et al. Ictal laughter associated with paroxysmal hypothalamopituitary dysfunction. Epilepsia 1997;38:114-117.

Rivarola A, Belgorosky A, Mendilaharzu H, Vidal G. Precocious puberty in children with tumours of the suprasellar and pineal areas: organic central precocious puberty. Acta Paediatr 2001;90:751-756.

Cerullo A, Tinuper P, Provini F, Contin M, Rosati A, Marini C et al. Autonomic and hormonal ictal changes in gelastic seizures from hypothalamic hamartomas. Electroencephalogr Clin Neurophysiol 1998;107:317-322.

Shah P, Patkar D, Patankar T, Shah J, Srinivasa P, Krishnan A. MR imaging features in hypothalamic hamartoma: a report of three cases and review of literature. J Postgrad Med 1999;45:84-86.

Iannetti P, Spalice A, Raucci U, Atzei G, Cipriani C. Gelastic epilepsy: video-EEG, MRI and SPECT characteristics. Brain Dev 1997;19:418-421.

Garcia A, Gutierrez MA, Barrasa J, Herranz JL. Cryptogenic gelastic epilepsy of frontal lobe origin: a paediatric case report. Seizure 2000;9:297-300.

Watanabe T, Enomoto T, Uemura K, Tomono Y, Nose T. Gelastic seizures treated by partial resection of a hypothalamic hamartoma. No Shinkei Geka 1998;26:923-928.

Georgakoulias N, Vize C, Jenkins A, Singounas E. Hypothalamic hamartomas causing gelastic epilepsy: two cases and a review of the literature. Seizure 1998; 7:167-171.

Munari C, Kahane P, Francione S, Hoffmann D, Tassi L, Cusmai R et al. Role of the hypothalamic hamartoma in the genesis of gelastic fits (a video-stereo-EEG study).

Electroencephalogr Clin Neurophysiol 1995;95:154-160.

Sisodiya SM, Free SL, Stevens JM, Fish DR, Shorvon SD. Widespread cerebral structural changes in two patients with gelastic seizures and hypothalamic hamartomata.

Epilepsia 1997;38:1008-1010.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Frattali CM, Liow K, Craig GH, Korenman LM, Makhlouf F, Sato S et al. Cognitive deficits in children with gelastic seizures and hypothalamic hamartoma. Neurology 2001;57:43-46.

2. Arroyo S, Lesser RP, Gordon B, Uematsu S, Hart J, Schwerdt P et al. Mirth, laughter and gelastic seizures.

Brain 1993;116:757-780.

3. Sartori E, Biraben A, Taussig D, Bernard AM, Scarabin JM. Gelastic seizures: video-EEG and scintigraphic analysis of

376

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 25-01-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 26-04 2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÓÙÈÁfiÓË ™˘Ú›ÁÔ˘-¶··‚·ÛÈÏ›Ԣ ¡Â˘ÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘ ¶·Ï·È¿ ¶ÂÓÙ¤ÏË, ∆.∫. 152 36, ∞ı‹Ó·

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·377

¶·È‰È·ÙÚÈ΋ 2002;65:377-381

∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

Paediatriki 2002;65:377-381

CASE REPORT

£ÚÔÌ‚ˆÙÈÎfi ÂÂÈÛfi‰ÈÔ Û ÓÂÔÁÓfi ÂÙÂÚÔ˙˘ÁÒÙË FV Leiden. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ª. ∞Ó·ÁÓˆÛÙ¿ÎÔ˘1, π. ∑‹Î·1, ∂. ¶Ï·ÙÔÎÔ‡ÎË2, Ã. ∫Ô˘Ì·Ó›‰Ô˘3

Thrombotic incident in a neonate heterozygote for FV Leiden. Case report M. Anagnostakou1, I. Zika1, H. Platokouki2, C. Koumanidou3

¶ÂÚ›ÏË„Ë: ∆· ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· Â›Ó·È ·Û˘Ó‹ıË, ·ÏÏ¿ ÛÔ‚·Ú¿ Û˘Ì‚¿Ì·Ù· ÛÙË ÓÂÔÁÓÈ΋ ÌÔÓ¿‰· ÓÔÛËÏ›·˜. ™˘Ó‹ıˆ˜ Û˘Ì‚·›ÓÔ˘Ó Û ¿Û¯ÔÓÙ· ÓÂÔÁÓ¿ Î·È Ù· ÂÚÈÛÛfiÙÂÚ· Û¯ÂÙ›˙ÔÓÙ·È Ì ·ÁÁÂÈ·ÎÔ‡˜ ÎÂÓÙÚÈÎÔ‡˜ ηıÂÙ‹Ú˜. ¶ÂÚÈÁÚ¿ÊÂÙ·È ¤Ó· ÙÂÏÂÈfiÌËÓÔ ÓÂÔÁÓfi, ÙÔ ÔÔ›Ô ·ÓÙÈÌÂÙˆ›ÛÙËΠÛÙËÓ ·Ú¯‹ Ì ıÚÔÌ‚ÔÏ˘ÙÈ΋ (·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˜ ÈÛÙÈÎfi˜ ÂÓÂÚÁÔÔÈËÙ‹˜ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘) ηÈ, ÂÓ Û˘Ó¯›·, Ì ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ (¯·ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ Ë·Ú›ÓË), ÏfiÁˆ ·ÔÚÙÈ΋˜ ıÚfiÌ‚ˆÛ˘ ηٿ ÙË 2Ë Ë̤ڷ ˙ˆ‹˜. ∆Ô ÓÂÔÁÓfi ÁÚ‹ÁÔÚ· ‚ÂÏÙÈÒıËΠÎÏÈÓÈο Î·È Ë ıÂÚ·›· Û˘Ó¯›ÛÙËΠÁÈ· 26 Ë̤Ú˜. O ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ‹ ıÚÔÌ‚ÔÊÈÏ›· ·¤‰ÂÈÍ fiÙÈ Ô ·ÛıÂÓ‹˜ Â›Ó·È ÂÙÂÚÔ˙˘ÁÒÙ˘ ˆ˜ ÚÔ˜ ÙË ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· V (FV Leiden). ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ô ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ‹ ıÚÔÌ‚ÔÊÈÏ›· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Û˘ÛÙËÌ·ÙÈο ÁÈ· οı ÓÂÔÁÓfi Ì ÊÏ‚È΋ ‹ ·ÚÙËÚȷ΋ ıÚfiÌ‚ˆÛË. ∏ ¤ÁηÈÚË ıÂÚ·›· ‚ÂÏÙÈÒÓÂÈ ÙËÓ ÚfiÁÓˆÛË Î·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË (ıÚÔÌ‚ÂÎÙÔÌ‹) ÌÔÚ› Ó· ·ÔÊ¢¯ı›.

Abstract: Thromboses are infrequent but serious complications of patients in the neonatal intensive care unit. Thromboses tend to occur in very sick neonates and most of them are related to central vascular catheters. The case of a full term infant which was treated at first with fibrinolytics (recombinant tissue plasminogen activator, rt-PA) and secondly with systematic anti-coagulation therapy (low molecular weight heparin) at the second day of life because of aortic thrombosis is reported.

The neonate was clinically improved very soon and the therapy was continued for 26 days. The investigation for congenital thrombophilia revealed a heterozygous mutation for factor V (FV Leiden). It is suggested that a thorough investigation for congenital thrombophilia should be systematically performed in a newborn infant with venous or artery thrombosis. Early treatment improves the prognosis and invasive surgical procedures (thrombectomy) could be avoided.

§¤ÍÂȘ ÎÏÂȉȿ: ıÚfiÌ‚ˆÛË, ÓÂÔÁÓfi, ·Ú¿ÁˆÓ V Leiden, ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˜ ÈÛÙÈÎfi˜ ÂÓÂÚÁÔÔÈËÙ‹˜ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘, ¯·ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ Ë·Ú›ÓË.

Key words: thrombosis, newborn, factor V Leiden, recombinant tissue plasminogen activator, low molecular weight heparin.

∂ÈÛ·ÁˆÁ‹ ∆· ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· Â›Ó·È Û¿ÓÈ· ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ∏ ÓfiÛÔ˜ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ô Û¯ËÌ·ÙÈÛÌfi˜ ÂÓfi˜ ·ÔÊÚ·ÎÙÈÎÔ‡ ıÚfiÌ‚Ô˘ Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ·ÏÏËÏÂȉڿÛÂˆÓ ÌÂٷ͇ ÁÂÓÂÙÈÎÒÓ Î·È ÂÚÈ‚·ÏÏÔÓÙÈ-

ÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∏ ÂÓ‰Âϯ‹˜ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ÂÎÙ›ÌËÛË ÙÔ˘ ÓÂÔÁÓÔ‡, Ù· ·ÓÙÈËÎÙÈο Ê¿Ú̷η, Ë ıÚÔÌ‚ÔÏ˘ÙÈ΋ ·ÁˆÁ‹ Î·È Û·Ó›ˆ˜ Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ıÚÔÌ‚ÂÎÙÔÌ‹ ··ÚÙ›˙Ô˘Ó ÙË ıÂÚ·¢ÙÈ΋ ÂÈÏÔÁ‹ ÂÓfi˜ ıÚÔÌ‚ˆÙÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘.

1 µ’ ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á. ™ÔÊ›·”, ∞ı‹Ó· 2 ªÔÓ¿‰· ∞ÈÌfiÛÙ·Û˘ Î·È ∞ÈÌÔÚÚÔÊÈÏ›·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á. ™ÔÊ›·”, ∞ı‹Ó· 3 ∞ÎÙÈÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á. ™ÔÊ›·”, ∞ı‹Ó·

1 2nd Neonatal Intensive Care Unit, “Aghia Sophia” Children’s Hospital, Athens 2 Hemophilia and Hemostasis Unit, “Aghia Sophia” Children’s Hospital, Athens 3 Radiological Department, “Aghia Sophia” Children’s Hospital, Athens

377

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·378

¶·È‰È·ÙÚÈ΋ 2002;65:377-381

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· ı‹Ï˘ ÓÂÔÁÓfi, ÙÔ ÔÔ›Ô ÁÂÓÓ‹ıËΠ̠ηÈÛ·ÚÈ΋ ÙÔÌ‹ ¤ÂÈÙ· ·fi ·ËÛË ‰È¿ÚÎÂÈ·˜ 37 ‚‰ÔÌ¿‰ˆÓ Î·È Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 3.200 g. ∆Ô Apgar score ·Ó·Ê¤ÚıËΠfiÙÈ ‹Ù·Ó 9/1’ Î·È 10/5’. ∞̤ۈ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛ‹ ÙÔ˘ ·Ú·ÙËÚ‹ıËΠfiÙÈ ÙÔ ˘ÔÁ¿ÛÙÚÈÔ, ÔÈ ÁÏÔ˘ÙÔ› Î·È Ù· οو ¿ÎÚ· ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó ˆ¯ÚÔ΢·ÓˆÙÈο Î·È „˘¯ÚfiÙÂÚ· ÙˆÓ ¿Óˆ. OÈ ÌËÚÈ·›Â˜ ·ÚÙËڛ˜ „ËÏ·ÊÒÓÙÔ Ï›·Ó ·ÛıÂÓÒ˜ Î·È Ô Û˘Ó¯‹˜ ‰È·‰ÂÚÌÈÎfi˜ ÎÔÚÂÛÌfi˜ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ ‹Ù·Ó 67-72%, ÂÓÒ ÙˆÓ ¿Óˆ ¿ÎÚˆÓ ‹Ù·Ó 95%. ∆Ô ÓÂÔÁÓfi ·Ú·¤ÌÊıËΠÛÙÔ ÙÌ‹Ì· Ì·˜ Û ËÏÈΛ· ‰‡Ô ˆÚÒÓ ÁÈ· ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË. ªÂÙ¿ ·fi ÏÂÙÔÌÂÚ‹ ηډÈÔÏÔÁÈ΋ ÂͤٷÛË ·ÔÎÏ›ÛÙËΠÙÔ ÂӉ¯fiÌÂÓÔ ÛÙ¤ÓˆÛ˘ ÙÔ˘ ÈÛıÌÔ‡ Ù˘ ·ÔÚÙ‹˜, ηıÒ˜ Î·È ÔÈ·Û‰‹ÔÙ ¿ÏÏ˘ Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜. ªÂ ÙËÓ ˘Ô„›· Ù˘ Èı·Ó‹˜ ·ÚÙËÚȷ΋˜ ıÚfiÌ‚ˆÛ˘ ÂÛÙ¿ÏË ¤ÏÂÁ¯Ô˜ ·ÈÌfiÛÙ·Û˘: ·ÈÌÔÂÙ¿ÏÈ· 215.000/mm3, ¯ÚfiÓÔ˜ ıÚÔÌ‚›Ó˘ 13,3” (º∆: 10-14”), ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ 14,9”(º∆: 11-13”), ∞ƒ∆∆ 37,9 (º∆ <40”), ÈÓˆ‰ÔÁfiÓÔ (I) 185 mg/dl (º∆: 200-400 mg/dl), ·Ú¿ÁˆÓ VII 31% (º∆: 60-120%), ·Ú¿ÁˆÓ IX 30% (º∆: 50-150%), D-dimers 4 Ìg/ml (º∆ <0,5 Ìg/ml), ÚˆÙ½ÓË C (PC) 20% (º∆: 60-140%), ÚˆÙ½ÓË S (PS) 56% (º∆: 60-140%). ªÂ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ (∂ÈÎfiÓ· 1) ·ÂÈÎÔÓ›ÛÙËΠıÚfiÌ‚Ô˜ ÛÙËÓ Î·ÙÈÔ‡Û· ·ÔÚÙ‹ οوıÂÓ ÙÔ˘ ÔÌÊ·ÏÔ‡ Ô˘ ÂÂÎÙÂÈÓfiÙ·Ó ¤ˆ˜ ÙÔ ‰È¯·ÛÌfi ·˘Ù‹˜, ÛÙȘ ‰‡Ô Ï·ÁfiÓȘ ·ÚÙËڛ˜ Î·È Ô˘ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ¯·ÌËÏ‹ ·ÈÌ·ÙÈ΋ ÚÔ‹. ™ÙÔ Triplex ·ÁÁ›ˆÓ ÂÌÊ·Ó›ÛÙËΠ¯·ÌËÏ‹ ·ÈÌ·ÙÈ΋ ÚÔ‹ Î·È ‰ËÌÈÔ˘ÚÁ›· ·Ú·χÚÔ˘ ΢ÎÏÔÊÔÚ›·˜. µ¿ÛÂÈ ÙˆÓ ·ÓˆÙ¤Úˆ ¢ÚËÌ¿ÙˆÓ ·ÔÊ·Û›ÛÙËÎÂ, ηٿ ÙË ‰Â‡ÙÂÚË Ë̤ڷ ˙ˆ‹˜ Î·È ÓÔÛËÏ›·˜, Ë ¯ÔÚ‹ÁËÛË ıÚÔÌ‚ÔÏ˘ÙÈ΋˜ ηÈ, ÂÓ Û˘Ó¯›·, ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜. ™˘ÁÎÂÎÚÈ̤ӷ, ¯ÔÚËÁ‹ıËΠ·Ó·-

∂ÈÎfiÓ· 1. £ÚfiÌ‚ˆÛË ÎÔÈÏȷ΋˜ ·ÔÚÙ‹˜ Î·È Ï·ÁfiÓÈˆÓ ·ÚÙËÚÈÒÓ. ·) ÀÂÚ˯ÔÁÚ·ÊÈ΋ ·ÂÈÎfiÓÈÛË Û ÂÈÌ‹ÎË Î·È ÂÁοÚÛÈ· ÙÔÌ‹ ÙÔ˘ ¢ÌÂÁ¤ıÔ˘˜ ıÚfiÌ‚Ô˘ (‚¤ÏË) ÛÙÔÓ ·˘Ïfi Ù˘ ÎÔÈÏȷ΋˜ ·ÔÚÙ‹˜. ‚) ÀÂÚ˯ÔÁÚ·ÊÈ΋ ·ÂÈÎfiÓÈÛË ÙˆÓ ıÚfiÌ‚ˆÓ (ÎÂʷϤ˜ ‚ÂÏÒÓ) ÛÙÔÓ ·˘Ïfi ÙˆÓ Ï·ÁfiÓÈˆÓ ·ÚÙËÚÈÒÓ.

378

Paediatriki 2002;65:377-381

Û˘Ó‰˘·Ṳ̂ÓÔ˜ ÈÛÙÈÎfi˜ ÂÓÂÚÁÔÔÈËÙ‹˜ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘ rt-PA (actilyse - Boehringer Ing.) Û ‰fiÛË ÂÊfi‰Ô˘ 0,5 mg/kg Û ÛÙ¿Á‰ËÓ ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË Î·È ·ÎÔÏÔ‡ıˆ˜ 0,1 mg/kg ·Ó¿ ÒÚ· ÂÓ‰ÔÊÏ‚›ˆ˜, ÁÈ· Ù¤ÛÛÂÚȘ ÒÚ˜. ¢¤Î· ÒÚ˜ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ¤ÁÈÓÂ Ó¤Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ıÚfiÌ‚Ô˘, Ô ÔÔ›Ô˜ Â·ÓÂϤÁ¯ıËΠÛÙËÓ ·ÔÚÙ‹ Î·È ÛÙȘ ‰‡Ô Ï·ÁfiÓȘ ·ÚÙËڛ˜ Û ÌÈÎÚfiÙÂÚ˜ ‰È·ÛÙ¿ÛÂȘ. ∂›Û˘, ¤ÁÈÓ ӤԘ ¤ÏÂÁ¯Ô˜ ·ÈÌfiÛÙ·Û˘ Ô˘ ‹Ù·Ó ÈηÓÔÔÈËÙÈÎfi˜ (‰ÂÓ ÛËÌÂÈÒıËΠÙÒÛË ÙÔ˘ ÈÓˆ‰ÔÁfiÓÔ˘: π >150 mg/dl). ∞ÎÔÏÔ‡ıˆ˜, ·ÔÊ·Û›ÛÙËÎÂ Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜. ™˘ÁÎÂÎÚÈ̤ӷ, ‰fiıËΠӷ‰ÚÔ·Ú›ÓË, ¯·ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ Ë·Ú›ÓË (Fraxiparine) Û ‰fiÛË 0,01 ml/kg ·Ó¿ 12 ÒÚ˜. ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ıÚfiÌ‚Ô˘ ÁÈÓfiÙ·Ó Ì ηıËÌÂÚÈÓfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜, ηıÒ˜ Î·È Ì ٷÎÙfi ¤ÏÂÁ¯Ô ·ÈÌfiÛÙ·Û˘ ÙÔ˘ ÓÂÔÁÓÔ‡. ∆ÚÈ¿ÓÙ· ¤ÍÈ ÒÚ˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ıÚÔÌ‚ÔÏ˘ÙÈ΋˜ ·ÁˆÁ‹˜, Û ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ Ô˘ ¤ÁÈÓÂ, ‰È·ÈÛÙÒıËΠÂÚ·ÈÙ¤Úˆ Ì›ˆÛË ÙˆÓ ‰È·ÛÙ¿ÛÂˆÓ ÙÔ˘ ıÚfiÌ‚Ô˘ ÂÓÙfi˜ Ù˘ ÎÔÈÏȷ΋˜ ·ÔÚÙ‹˜, ηıÒ˜ Î·È Â˘Ì¤ÁÂı˜ ÌfiÚʈ̷ ‰È·Ì¤ÙÚÔ˘ 4,7 mm Ì ÂÙÂÚÔÁÂÓ‹ Û‡ÛÙ·ÛË ÛÙÔ ·ÚÈÛÙÂÚfi ÂÈÓÂÊÚ›‰ÈÔ, ÂÈÎfiÓ· Û˘Ì‚·Ù‹ Ì ·È̿و̷. ∂Í¿ÏÏÔ˘, ÔÈ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ VMA Ô‡ÚˆÓ 24ÒÚÔ˘ ·¤ÎÏÂÈÛ·Ó ÙÔ Ó¢ÚÔ‚Ï¿Ûو̷. ∆ËÓ 4Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÓÔÛËÏ›·˜ ‰È·ÈÛÙÒıËΠÌÈÎÚÔ‡ ‚·ıÌÔ‡ ÛÌ›ÎÚ˘ÓÛË ÙÔ˘ ·ÈÌ·ÙÒÌ·ÙÔ˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÂÈÓÂÊÚȉ›Ô˘, ηıÒ˜ Î·È ÂÚ·ÈÙ¤Úˆ ·‡ÍËÛË Ù˘ ÚÔ‹˜ ÂÓÙfi˜ Ù˘ ·ÔÚÙ‹˜. ∆Ë 12Ë Ë̤ڷ ˙ˆ‹˜, ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜, ˘‹Ú¯Â Û·Ê‹˜ ‚ÂÏÙ›ˆÛË ˆ˜ ÚÔ˜ ÙÔ Ì¤ÁÂıÔ˜ Î·È ÙË Û‡ÛÙ·ÛË ÙÔ˘ ÁÓˆÛÙÔ‡ ıÚfiÌ‚Ô˘ ÛÙËÓ ·ÔÚÙ‹. OÈ Ó¤Â˜ ‰È·ÛÙ¿ÛÂȘ ÙÔ˘ ·ÈÌ·ÙÒÌ·ÙÔ˜ ÛÙÔ ·ÚÈÛÙÂÚfi ÂÈÓÂÊÚ›‰ÈÔ ‹Ù·Ó Û·ÊÒ˜ ÌÈÎÚfiÙÂÚ˜ (2,5 x 1,2 cm). ∂›Û˘, ‰È·ÈÛÙÒıËΠÌÈÎÚ‹ Ì›ˆÛË ÙÔ˘ ıÚfiÌ‚Ô˘ ÛÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚·. ∏ ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ ‰ÈÂÎfiË ÙËÓ 26Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÙÔ Triplex ·ÁÁ›ˆÓ Ô˘ ¤ÁÈÓ ÙËÓ ›‰È· Ë̤ڷ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi. ™ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ·Ú¤ÌÂÓÂ Ô ıÚfiÌ‚Ô˜ ÛÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚·, ÂÓ Ì¤ÚÂÈ ÛËÚ·ÁÁÔÔÈË̤ÓÔ˜, ‰È·Ì¤ÙÚÔ˘ 1,5 cm. ∂›Û˘, ÙÔ ·È̿و̷ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÂÈÓÂÊÚȉ›Ô˘ ›¯Â Û·ÊÒ˜ ÂÏ·ÙÙˆı› Û ‰È·ÛÙ¿ÛÂȘ (∂ÈÎfiÓ· 2). OÈ ·Ú¿ÁÔÓÙ˜ ‹Íˆ˜ (PC, d-dimers), ÔÈ ÔÔ›ÔÈ ÂϤÁ¯ÔÓÙ·Ó Î·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÁˆÁ‹˜, ›¯·Ó Î·È ·˘ÙÔ› ÛÙ·‰È·Î¿ ·ÔηٷÛÙ·ı›. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÁÈ· ÙËÓ ·ÈÙ›· Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ·ÚÙËÚȷ΋˜ ıÚfiÌ‚ˆÛ˘ ÛÙÔ ÓÂÔÁÓfi ‰ÂÓ ‰È·ÈÛÙÒıËΠÂÎÏ˘ÙÈÎfi ·›ÙÈÔ ‹ ˘ÔΛÌÂÓÔ ÓfiÛËÌ·, fiˆ˜ ÛË„·ÈÌ›·, ÈÔÁÂÓ‹˜ Ïԛ̈ÍË, ηÎÔ‹ıÂÈ· ‹ ·˘ÙÔ¿ÓÔÛÔ ÓfiÛËÌ·. ™˘ÁÎÂÎÚÈ̤ӷ, ‰È·ÈÛÙÒÛ·ÌÂ: Hbs Ag (-), HIV (-), Abs ÁÈ· Û˘ÁÁÂÓ›˜

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·379

¶·È‰È·ÙÚÈ΋ 2002;65:377-381

ÏÔÈÌÒÍÂȘ (-), ANA (-), Anti-DNA (-), ·ÓÙÈ-ʈÛÊÔÏÈȉÈο ·ÓÙÈÛÒÌ·Ù· (-), Abs ηډÈÔÏÈ›Ó˘ (-), ¤ÏÂÁ¯Ô˜ Ïԛ̈͢-ÛË„·ÈÌ›·˜ (-).

O ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ‹ ıÚÔÌ‚ÔÊÈÏ›· ·¤‰ÂÈÍ fiÙÈ ÙÔ ÓÂÔÁÓfi Â›Ó·È ÂÙÂÚÔ˙˘ÁÒÙ˘ ˆ˜ ÚÔ˜ ÙË ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· V (FV Leiden). O ÁÂÓÂÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÁÔÓ¤ˆÓ ·¤‰ÂÈÍ fiÙÈ Ë ÌËÙ¤Ú· Â›Ó·È ÊÔÚ¤·˜ Ù˘ ÁÔÓȉȷ΋˜ ‚Ï¿‚˘ ÛÙÔ ÌfiÚÈÔ ÙÔ˘ ·Ú¿ÁÔÓÙ· V, ‰ËÏ·‰‹ ÚfiÎÂÈÙ·È ÁÈ· ÌÂÙ¿ÏÏ·ÍË ÛÙË ı¤ÛË 1691 G->A. ∫·Ù¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘, ÙËÓ 30Ë Ë̤ڷ ˙ˆ‹˜, ÙÔ ÓÂÔÁÓfi ‹Ù·Ó Û Ôχ ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË, ›¯Â Ê˘ÛÈÔÏÔÁÈÎfi ¯ÚÒÌ· Î·È Ë ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Î·Ù¿ Û˘ÛÙ‹Ì·Ù· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ™Â ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ÙÔ˘ ÓÂÔÁÓÔ‡ Ô˘ ¤ÁÈÓ Û ËÏÈΛ· 5 ÌËÓÒÓ, ÔÈ ‰È·ÛÙ¿ÛÂȘ ÙÔ˘ ıÚfiÌ‚Ô˘ ÛÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚· ›¯·Ó ÂÚ·ÈÙ¤Úˆ ÌÂȈı› (∂ÈÎfiÓ· 3). ∆Ô ÓÂÔÁÓfi Ù¤ıËΠ̷۠ÎÚÔ¯ÚfiÓÈ· ÎÏÈÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË. ™˘˙‹ÙËÛË ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ıÚÔÌ‚ˆÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ‰ÂÓ Â›Ó·È ·ÎÚÈ‚Ò˜ ÁÓˆÛÙ‹. ™ÙÔÓ ∫·Ó·‰¿ ·Ó·Ê¤ÚÂÙ·È Ì›· ÂÚ›ÙˆÛË ÁÈ· οı ΤÓÙÚÔ ÂÙËÛ›ˆ˜ (ηٷÁÚ·Ê‹ 97 ÂÚÈÙÒÛÂˆÓ Û 33 ΤÓÙÚ· Û ‰È¿ÛÙËÌ· 3,5 ÂÙÒÓ) (1). ™ÙË °ÂÚÌ·Ó›· ηٷÁÚ¿ÊÔÓÙ·È ÂÚ›Ô˘ 5,1 ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ÁÂÓÓ‹ÛÂȘ ˙ÒÓÙˆÓ ÓÂÔÁÓÒÓ (2). OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ·ÊÔÚÔ‡Ó Û ÓÂÔÁÓ¿ Ì ÎÂÓÙÚÈÎÔ‡˜ ηıÂÙ‹Ú˜. ™˘ÌÙÒÌ·Ù· ıÚfiÌ‚ˆÛ˘ ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ÌfiÓÔ ÛÙÔ 1% ÙˆÓ Î·ıÂÙËÚÈ·Ûı¤ÓÙˆÓ ÓÂÔÁÓÒÓ, ÂÓÒ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·Û˘Ìو̷ÙÈÎÒÓ ıÚÔÌ‚ÒÛÂˆÓ Û ·˘Ù¿ Ù· ÓÂÔÁÓ¿ ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 20% (‡ÚÔ˜ 3-95%) (3). Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ ˘¿Ú¯Ô˘Ó ‰È·ÊÔÚ¤˜ ÛÙÔ Û‡ÛÙËÌ· ‹Í˘ Î·È ÛÙÔ Û‡ÛÙËÌ· ÈÓˆ‰fiÏ˘Û˘ ÌÂٷ͇ ÓÂÔÁÓÒÓ, ·È‰ÈÒÓ Î·È ÂÓËÏ›ÎˆÓ (3,4). ∂ȉÈÎfiÙÂÚ·, ÛÙÔ Ï¿ÛÌ· ÙˆÓ ÓÂÔÁÓÒÓ ÔÈ ·Ú¿ÁÔÓÙ˜ ‹Í˘, ÔÈ ÂÍ·ÚÙÒÌÂÓÔÈ ·fi ÙË ‚ÈÙ·Ì›ÓË ∫ (II, VII, IX, X), fiˆ˜ Î·È ÔÈ ·Ú¿ÁÔÓÙ˜ XI, XII, ÚÔηÏÏÈÎÚ½ÓË, ›-

∂ÈÎfiÓ· 2. ÀÂÚ˯ÔÁÚ·ÊÈ΋ ·ÂÈÎfiÓÈÛË Ù˘ ÛÌ›ÎÚ˘ÓÛ˘ ÙÔ˘ ·ÈÌ·ÙÒÌ·ÙÔ˜ (‚¤ÏË) ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÓÂÊÚÔ‡ Û ‰È¿ÛÙËÌ· ÂÓfi˜ ÌËÓfi˜.

Paediatriki 2002;65:377-381

Ó·È ÂÚ›Ô˘ ÙÔ 50% ÙˆÓ ÙÈÌÒÓ ÙˆÓ ÂÓËϛΈÓ. OÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ·˘Ù¤˜ ·˘Í¿ÓÔÓÙ·È ÁÚ‹ÁÔÚ· ÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ ˙ˆ‹˜ Î·È Êı¿ÓÔ˘Ó ÙȘ ÙÈ̤˜ ÙˆÓ ÂÓËÏ›ÎˆÓ ÛÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ ˙ˆ‹˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÈÓˆ‰ÔÏ˘ÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ ÓÂÔÁÓÔ‡, ÙÔ Ï·ÛÌÈÓÔÁfiÓÔ Â›Ó·È ¯·ÌËÏfi, ÂÓÒ ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙˆÓ t-PA (tissue-Plasminogen Activator) Î·È PAI-1 (Plasminogen Activator Inhibitor-1) Â›Ó·È ˘„ËÏfiÙÂÚ˜ ÛÙ· ÓÂÔÁÓ¿ Û ۯ¤ÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ. ∂›Û˘, ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙˆÓ Ê˘ÛÈÎÒÓ ·Ó·ÛÙ·ÏÙÒÓ Ù˘ ‹Í˘ (·ÓÙÈıÚÔÌ‚›ÓË, Û˘Ì·Ú¿ÁˆÓ II Ù˘ Ë·Ú›Ó˘, ÚˆÙ½ÓË C Î·È ÚˆÙ½ÓË S) Â›Ó·È ¯·ÌËÏfiÙÂÚ˜ Û ۯ¤ÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ (ÂÚ›Ô˘ ÙÔ 50% ÙˆÓ ÙÈÌÒÓ ÙˆÓ ÂÓËϛΈÓ). ∂ÓÙÔ‡ÙÔȘ, Ô ·Ó·ÛÙÔϤ·˜ ·2-Ì·ÎÚÔÛÊ·ÈÚ›ÓË Â›Ó·È ·ÍÈÔÛËÌ›ˆÙ· ·˘ÍË̤ÓÔ˜ ηÈ, Û˘ÁÎÂÎÚÈ̤ӷ, Ë ÙÈÌ‹ ÙÔ˘ ÛÙË Á¤ÓÓËÛË Â›Ó·È ÂÚ›Ô˘ ‰ÈÏ¿ÛÈ· Û ۯ¤ÛË Ì ·˘Ù‹ ÙˆÓ ÂÓËϛΈÓ. ¶·Ú’ fiϘ ·˘Ù¤˜ ÙȘ ‰È·ÊÔÚ¤˜, ÙÔ ·ÈÌÔÛÙ·ÙÈÎfi Û‡ÛÙËÌ· ‚Ú›ÛÎÂÙ·È ÛÂ Û˘Ó¯‹ ÈÛÔÚÚÔ›· Î·È Ù· ˘ÁÈ‹ ÓÂÔÁÓ¿ Ô‡Ù ·ÈÌÔÚÚ·ÁÔ‡Ó, Ô‡Ù ıÚÔÌ‚ÒÓÔ˘Ó. ŸÌˆ˜, ÔÈ ¯·ÌËÏfiÙÂÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙˆÓ Ê˘ÛÈÎÒÓ ·Ó·ÛÙ·ÏÙÒÓ Ù˘ ‹Í˘, ı¤ÙÔ˘Ó Û ΛӉ˘ÓÔ ¿ÚÚˆÛÙ· ÓÂÔÁÓ¿ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ıÚÔÌ‚ˆÙÈÎÒÓ ÂÈÏÔÎÒÓ. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ÙfiÛÔ ·fi ÙË ÌËÙ¤Ú· (‰È·‚‹Ù˘ ÌËÙ¤Ú·˜, ‰È·Ï·ÎÔ˘ÓÙȷ΋ ›ÛÔ‰Ô˜ ·ÓÙÈ-ηډÈÔÏÈȉÈÎÒÓ Î·È ·ÓÙÈ-ʈÛÊÔÏÈȉÈÎÒÓ Abs) (5), fiÛÔ Î·È ·fi ÙÔ ÓÂÔÁÓfi (6) (ÓÂÔÁÓ¿ Ì ·ÁÁÂÈ·ÎÔ‡˜ ηıÂÙ‹Ú˜, ÛË„·ÈÌ›·, ·Ê˘‰¿ÙˆÛË, ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·, Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·, ÎÏËÚÔÓÔÌÈ΋ ıÚÔÌ‚ÔÊÈÏ›·) (7), ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ıÚfiÌ‚ˆÛ˘ ÛÙ· ÓÂÔÁÓ¿ (3). ™ÙË ‰È΋ Ì·˜ ÂÚ›ÙˆÛË, ‰È·ÈÛÙÒıËΠÂÚÁ·ÛÙËÚȷο ÌÂÁ¿ÏË ·‡ÍËÛË ÙˆÓ D-dimers Î·È ÂÏ¿ÙÙˆÛË Ù˘ ÚˆÙ½Ó˘ C. ∆· D-dimers Â›Ó·È ‰¤ÏÙ·-‰ÈÌÂÚ‹-ÔÏÈο ÚÔ˚fiÓÙ· Ù˘ ·Ô‰fiÌËÛ˘ ÙÔ˘ ÈÓÒ‰Ô˘˜, Ù· ÔÔ›·, fiÙ·Ó Â›Ó·È ˘„ËÏ¿, Â›Ó·È ÂÓ‰ÂÈÎÙÈο

∂ÈÎfiÓ· 3. ÀÂÚ˯ÔÁÚ·ÊÈ΋ ·ÂÈÎfiÓÈÛË Ù˘ ÚÔԉ¢ÙÈ΋˜ ÛÌ›ÎÚ˘ÓÛ˘ ÙÔ˘ ıÚfiÌ‚Ô˘ (‚¤ÏË) ÂÓÙfi˜ Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜ Û ‰È¿ÛÙËÌ· 5 ÌËÓÒÓ. ∏ ÛÌ›ÎÚ˘ÓÛË ·ÊÔÚ¿ ÛÙÔ Ì‹ÎÔ˜ Î·È ÙË ‰È¿ÌÂÙÚÔ ÙÔ˘ ıÚfiÌ‚Ô˘. ∂ÈϤÔÓ, ·Ú·ÙËÚÂ›Ù·È ÂÏ¿ÙÙˆÛË ÙÔ˘ ‚·ıÌÔ‡ ·Û‚ÂÛÙÔÔ›ËÛ‹˜ ÙÔ˘.

379

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·380

¶·È‰È·ÙÚÈ΋ 2002;65:377-381

ıÚfiÌ‚ˆÛ˘. ∏ ÂÏ¿ÙÙˆÛË Ù˘ ÚˆÙ½Ó˘ C Û˘Ó˘¿Ú¯ÂÈ ˆ˜ ÂÈϤÔÓ ·Ú¿ÁˆÓ, ¯ˆÚ›˜ fï˜ Ó· ·ÔÙÂÏ› ÙÔ ·›ÙÈÔ ÙÔ˘ ıÚfiÌ‚Ô˘. ∏ ÙÈÌ‹ Ù˘ ÛÙ·‰È·ÎÒ˜ ·ÔηٷÛÙ¿ıËΠ¤ˆ˜ ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜. ™˘ÓÂÒ˜, Ë ·ÓÂ¿ÚÎÂÈ· Ô˘ ‰È·ÈÛÙÒıËΠ‹Ù·Ó ·ÚÔ‰È΋ Î·È Û˘Ì‚·Ù‹ Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ÓÂÔÁÓÔ‡. ∞fi ÙÔÓ Ï‹ÚË ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Î·È Ì ÌÔÚȷΤ˜ Ù¯ÓÈΤ˜ (PCR - Polymerase Chain Reaction) ·‰›¯ıË fiÙÈ ÙÔ ÓÂÔÁÓfi Â›Ó·È ÂÙÂÚÔ˙˘ÁÒÙ˘ ˆ˜ ÚÔ˜ ÙË ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· V (FV Leiden), ‰È·Ù·Ú·¯‹ ÙËÓ ÔÔ›· ¤¯ÂÈ ÎÏËÚÔÓÔÌ‹ÛÂÈ ·fi ÙË ÌËÙ¤Ú· ÙÔ˘ Î·È Ë ÔÔ›· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ·ÓÙ›ÛÙ·ÛË ÛÙË ‰Ú¿ÛË Ù˘ ÂÓÂÚÁÔÔÈË̤Ó˘ ÚˆÙ½Ó˘ C (activated protein C resistance - APCR). ∆Ô ÓÂÔÁÓfi ÂÙ¤ıË Û ̷ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË, ÁÈ·Ù› ·˘Ù¿ Ù· ÓÂÔÁÓ¿ ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Â·Ó¿Ï˄˘ ÙÔ˘ ıÚÔÌ‚ˆÙÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ (8). ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÁÔÓȉȷ΋˜ ‚Ï¿‚˘ FV Leiden (G1691A) (9) ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi ·Ó¤Ú¯ÂÙ·È ÛÙÔ 2% ¤ˆ˜ 7%, ÂÓÒ ÁÈ· ÙËÓ ∂ÏÏ¿‰· Î·È ÙËÓ ∫‡ÚÔ ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 8% (10). ¢ÂÓ ˘¿Ú¯Ô˘Ó ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ÁÈ· ÙË Û˘¯ÓfiÙËÙ· Ô˘ ÚÔ‚¿ÏÏÂÈ Ë ·Ú·¿Óˆ ÁÔÓȉȷ΋ ‚Ï¿‚Ë ÛÙ· ÓÂÔÁÓ¿ Ì ıÚfiÌ‚ˆÛË. ŸÌˆ˜, Û ÔÛÔÛÙfi 4060% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ì ıÚÔÌ‚ÒÛÂȘ ·Ó¢ڛÛÎÂÙ·È Ë ·Ú·¿Óˆ ÌÂÙ¿ÏÏ·ÍË. °È· Ù· ÓÂÔÁÓ¿, ÂÎÙfi˜ ·fi ÌÂÌÔӈ̤Ó˜ ·Ó·ÎÔÈÓÒÛÂȘ ÂÚÈÛÙ·ÙÈÎÒÓ, ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂÎÙÂٷ̤Ó˜ ÌÂϤÙ˜ ÒÛÙ ӷ ·Ó·Ê¤ÚÂÙ·È ÙÔ ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘, ·ÏÏ¿ Û ۯ¤ÛË Ì ¿ÏϘ ËÏÈ˘ ·È‰ÈÒÓ, Ù· ÓÂÔÁÓ¿ Â›Ó·È ÈÔ ÂÈÚÚÂ‹ ÛÙËÓ ·Ó¿Ù˘ÍË ıÚfiÌ‚ˆÛ˘, ÏfiÁˆ Ù˘ Û˘Ó‡·Ú͢ Û˘¯ÓfiÙÂÚ· ÂÈ‚·Ú˘ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (fiˆ˜ ÛË„·ÈÌ›·, ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·, ηıÂÙËÚÈ·ÛÌfi˜ ÔÌÊ·ÏÈÎÒÓ ·ÁÁ›ˆÓ) (3). ∏ ÈÔ ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ıÚfiÌ‚Ô˘ (3,11) Â›Ó·È Ë ·ÁÁÂÈÔÁÚ·Ê›·. ¶ÔχÙÈ̘, Â›Û˘, Î·È ·ÍÈfiÈÛÙ˜ ̤ıÔ‰ÔÈ Â›Ó·È Ë ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·, ηıÒ˜ Î·È Ë Ì·ÁÓËÙÈ΋ ·ÁÁÂÈÔÁÚ·Ê›· Ù˘ ‡ÔÙ˘ ÂÚÈÔ¯‹˜. ∆Ô Ë¯ÔηډÈÔÁÚ¿ÊËÌ· ‚ÔËı¿ ÁÈ· ÙȘ ÂÓ‰ÔηډȷΤ˜ ıÚÔÌ‚ÒÛÂȘ, ηıÒ˜ Î·È ÙȘ ıÚÔÌ‚ÒÛÂȘ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ. ∂›Û˘, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Doppler ‚ÔËı¿ ÛÙË ‰È¿ÁÓˆÛË. ∆Ô ·ÚÓËÙÈÎfi, fï˜, ·ÔÙ¤ÏÂÛÌ· ‰ÂÓ ·ÔÎÏ›ÂÈ ÙË ‰È¿ÁÓˆÛË. O ıÚfiÌ‚Ô˜ ÛÙËÓ ·ÔÚÙ‹ ÛÙË ‰È΋ Ì·˜ ÂÚ›ÙˆÛË, ηÙ‰›¯ıË ·fi ÙËÓ ·Ú¯‹ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ Î·È ÂȂ‚·ÈÒıËΠÙÔ Â‡ÚËÌ· Ì Triplex ·ÁÁ›ˆÓ Ù˘ ÂÚÈÔ¯‹˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ıÂÚ·›·, ÚÔÙ›ÓÂÙ·È ·ÓÙÈËÎÙÈ΋ ‹ Î·È ıÚÔÌ‚ÔÏ˘ÙÈ΋ ·ÁˆÁ‹ ‹/ηÈ, Û·Ó›ˆ˜, Ë ıÚÔÌ‚ÂÎÙÔÌ‹. ¢ÂÓ ˘¿Ú¯Ô˘Ó, fï˜, ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ Ô˘ Ó· ·ÊÔÚÔ‡Ó Û ·È‰È¿ Î·È ÔÈ Ôԛ˜ Ó· ¯ÚËÛÈÌÂ‡Ô˘Ó ˆ˜ Ô‰ËÁÔ› ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Î·È ıÂÚ·›· ÙˆÓ ıÚÔÌ‚ˆÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ. ™ÙÚ·ÙËÁÈ-

380

Paediatriki 2002;65:377-381

Τ˜ ÁÈ· ÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤Ï·Û‹ Î·È ıÂÚ·›· ÙÔ˘˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÌÂϤÙ˜ ÂÓËÏ›ÎˆÓ Î·È ·È‰ÈÒÓ Ô˘ ›Ûˆ˜ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ÂÊ·ÚÌÔÛÙÔ‡Ó ÛÙ· ÓÂÔÁÓ¿ (6). ™‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ Ù˘ ªÔÓ¿‰·˜ ∞ÈÌfiÛÙ·Û˘ Î·È ∞ÈÌÔÚÚÔÊÈÏ›·˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì·˜, ÙÔ ÓÂÔÁÓfi ÂÙ¤ıË ÛÙËÓ ·Ú¯‹ Û ıÚÔÌ‚ÔÏ˘ÙÈ΋ Î·È ÂÓ Û˘Ó¯›· Û ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹. ¶ÔÏÏÔ› ÂÚ¢ÓËÙ¤˜ ÚÔÙ›ÓÔ˘Ó ÙË ¯Ú‹ÛË ÙÔ˘ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ ÈÛÙÈÎÔ‡ ÂÓÂÚÁÔÔÈËÙ‹ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘ (rtPA) Û ÓÂÔÁÓ¿ Ì ÂÎÙÂٷ̤ÓË ıÚfiÌ‚ˆÛË (6,12). ™Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ rt-PA Û˘ÁηٷϤÁÔÓÙ·È Ô ‚Ú·¯‡˜ ¯ÚfiÓÔ˜ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ (<15 min), Ë ·¢ı›·˜ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘, Ë ÌË ÂÓÂÚÁÔÔ›ËÛ‹ ÙÔ˘ ·fi ÙËÓ ·2-·ÓÙÈÏ·ÛÌ›ÓË Î·È, ΢ڛˆ˜, Ë ÙÔÈ΋ ‰Ú¿ÛË ÙÔ˘ (ÙÔÈ΋ χÛË ÙÔ˘ ıÚfiÌ‚Ô˘) (12). ∏ ¯·ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ Ë·Ú›ÓË ıˆÚÂ›Ù·È ÂÚÈÛÛfiÙÂÚÔ ·ÛÊ·Ï‹˜ ˆ˜ ÚÔ˜ ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ·ÚÂÓÂÚÁÂÈÒÓ Ù˘ Ë·Ú›Ó˘ (·ÈÌÔÚÚ·Á›Â˜, ıÚÔÌ‚ÔÂÓ›·). §fiÁˆ ‰Â Ù˘ ‚ÈԉȷıÂÛÈÌfiÙËÙ¿˜ Ù˘, Â›Ó·È Ôχ ‡ÎÔÏË Ë ¯Ú‹ÛË Ù˘ Û ÓÂÔÁÓ¿ Î·È ·ÔʇÁÔÓÙ·È ÔÈ Û˘¯Ó¤˜ ·ÈÌÔÏË„›Â˜ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ·ÓÙÈËÎÙÈ΋˜ ‰Ú¿Û˘. ∏ ‰ËÌÈÔ˘ÚÁ›· ÙÔ˘ ·ÈÌ·ÙÒÌ·ÙÔ˜ ÛÙÔ ·ÚÈÛÙÂÚfi ÂÈÓÂÊÚ›‰ÈÔ Î·Ù¿ ÙÔ 3Ô 24ˆÚÔ ÓÔÛËÏ›·˜ ‰ÂÓ ·Ô‰fiıËΠ̠‚‚·ÈfiÙËÙ· ÛÙË ıÚÔÌ‚ÔÏ˘ÙÈ΋ ·ÁˆÁ‹. O ÏfiÁÔ˜ ‹Ù·Ó fiÙÈ ÂÌÊ·Ó›ÛÙËΠ̷۠ÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙË ıÚÔÌ‚fiÏ˘ÛË (¯ÚfiÓÔ˜ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ ÙÔ˘ rtPA <15 min). ¢ÂÓ ·Ó¢ڤıË, fï˜, Ô‡Ù οÔÈ· ¿ÏÏË ·ÈÙ›· ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ÙÔ˘. ∆Ô ÓÂÔÁÓfi ‰ÂÓ ·ÚÔ˘Û›·Û Ïԛ̈ÍË ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘ Î·È ·Ú¤ÌÂÓ ·ÈÌÔ‰˘Ó·ÌÈο ÛÙ·ıÂÚfi. ÕÏÏË ÂÈÏÔ΋ ‰ÂÓ ·ÚÔ˘ÛÈ¿ÛÙËΠηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜. ¶ÈÛÙ‡ԢÌ fiÙÈ Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ıÂÚ·›· Ù˘ ıÚfiÌ‚ˆÛ˘ ‚Ô‹ıËÛ ÙÔ ÓÂÔÁÓfi. µÂÏÙÈÒıËΠÎÏÈÓÈο Û ÛËÌ·ÓÙÈÎfi ‚·ıÌfi ·fi ÙËÓ 1Ë Ë̤ڷ ıÂÚ·›·˜ Î·È ‰ÂÓ ·ÚÔ˘Û›·Û η̛· ÂÈÏÔ΋ ·fi ÙËÓ ·ÔÚÙÈ΋ ıÚfiÌ‚ˆÛË (˘¤ÚÙ·ÛË, ·ÓÔ˘Ú›·). ∂›Û˘, ·Ôʇ¯ıËÎÂ Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË (ıÚÔÌ‚ÂÎÙÔÌ‹). µÈ‚ÏÈÔÁÚ·Ê›· 1. Schmidt B, Andrew M. Neonatal thrombosis: report of a prospective Canadian and international registry. Pediatrics 1995;96:939-943.

2. Nowak-Gottl U, von Kries R, Gobel U. Neonatal symptomatic thromboembolism in Germany: two year survey.

Arch Dis Child Fetal Neonatal Ed 1997;76:F163-167.

3. Edstrom CS, Christensen RD. Evaluation and treatment of thrombosis in the neonatal intensive care unit. Clin Perinatol 2000;27:623-641.

4. Ries M, Klinge J, Rauch R. Age-related reference values for activation markers of the coagulation and fibrinolytic

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·381

¶·È‰È·ÙÚÈ΋ 2002;65:377-381

systems in children. Thromb Res 1997;85:341-344.

5. Deally C, Hancock BJ, Giddins N, Hawkins L, Odim J. Primary antiphospholipid syndrome: a cause of catastrophic shunt thrombosis in the newborn. J Cardiovasc Surg 1999;40:261-264.

6. Nowak-Gottl U, Kosch A, Schlegel N. Thromboembolism in newborns, infants and children. Thromb Haemost 2001;86:464-474.

7. Ehrenforth S, Junker R, Koch HG, Kreuz W, Munchow N, Scharrer I et al. Multicentre evaluation of combined prothrombotic defects associated with thrombophillia in childhood. Childhood Thrombophilia Study Group. Eur J Pediatr 1999;158 (Suppl 3):S97-104.

8. Nowak-Gottl U, Junker R, Kreuz W, von Eckardstein A, Kosch A, Nohe N et al. Risk of recurrent venous thrombosis in children with combined prothrombotic risk factors. Blood 2001;97:858-862.

9. Beauchamp NJ, Daly ME, Cooper PC, Preston FE, Peake

Paediatriki 2002;65:377-381

IR. Rapid two-stage PCR for detecting factor V G1691A mutation. Lancet 1994;344:694-695.

10. Bertina RM, Reitsma PH, Rosendaal FR, Vandenbroucke JP. Resistance to activated protein C and factor V Leiden as risk factors for venous thrombosis. Thromb Haemost 1995;74:449-453.

11. Manco-Johnson MJ. Diagnosis and management of thromboses in the perinatal period. Semin Perinatol 1990;14:393-402.

12. Weiner GM, Castle VP, DiPietro MA, Faix RG. Successful treatment of neonatal arterial thromboses with recombinant tissue plasminogen activator. J Pediatr 1998;133:133-136.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 14-05-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 02-08-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›Ó· ∞Ó·ÁÓˆÛÙ¿ÎÔ˘ ∞Á. ºˆÙÂÈÓ‹˜ 37, ¡¤· ™Ì‡ÚÓË

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· À„ËÏ‹ Û˘¯ÓfiÙËÙ· ·Ó‡ÚÂÛ˘ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ·ÚÈÎÒÓ ÎÏÒÓˆÓ Û ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ÓÂÔÁÓÈÎÔ‡ ÁÂÓÂÙÈο screening ·È‰ÈÒÓ Ì µ-΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·1 ∂ÈÛ·ÁˆÁ‹: ∏ ·Ó›¯Ó¢ÛË Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Û οÚÙ˜ ÁÂÓÂÙÈÎÔ‡ screening ÓÂÔÁÓÒÓ (οÚÙ˜ Guthrie test) ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ·È‰ÈÒÓ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (O§§), ηıÒ˜ Î·È Ë ·ÓÙ›ÛÙÔÈ¯Ë ·Ó›¯Ó¢ÛË Û ·ÚÎÂÙ¿ ˙‡ÁË ÌÔÓÔˆÔ˚ÎÒÓ ‰È‰‡ÌˆÓ Ô˘ ÂÓ Û˘Ó¯›· ·Ó·Ù‡ÛÛÔ˘Ó O§§ Ì ·ÓÔÌÔÈfiÙ˘Ô˘˜ Ê·ÈÓÔÙ˘ÈÎÔ‡˜ Î·È ¯ÚˆÌÔۈ̷ÙÈÎÔ‡˜ ‰Â›ÎÙ˜, ¤¯ÂÈ ‰ÒÛÂÈ ÈηӤ˜ ÂӉ›ÍÂȘ fiÙÈ Ë ·È‰È΋ O§§ ‰‡Ó·Ù·È Ó· ¤¯ÂÈ ÙËÓ ·Ú¯‹ Ù˘, ‹‰Ë, ÂÓ‰ÔÌËÙÚ›ˆ˜. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÂȯÂÈÚ‹ıËΠ·Ó·‰ÚÔÌÈο Û ̛· Ù˘¯·›· ÔÌ¿‰· ·È‰ÈÒÓ Ì µÎ˘ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘ O§§, Ô ¤ÏÂÁ¯Ô˜ Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ·ÚÔ˘Û›·˜ Ï¢¯·ÈÌÈÎÒÓ ÎÏÒÓˆÓ ‹‰Ë ÚÔ Ù˘ Á¤ÓÓËÛ˘, ̤ۈ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙÔ˘˜ Û ·›Ì· ÓÂÔÁÓÈÎÒÓ Î·ÚÙÒÓ ÂϤÁ¯Ô˘ ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ (screening cards). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: OÈ ·ÛıÂÓ›˜ Ì O§§ Ô˘ ·Ó·Ï‡ıËÎ·Ó Â›¯·Ó ÂӉȿÌÂÛË ËÏÈΛ· 46 ÌËÓÒÓ (·fi 18 ÌËÓÒÓ ¤ˆ˜ 13 ÂÙÒÓ) Î·È ÂӉȿÌÂÛË ÙÈÌ‹ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ O§§, Ù˘ ٿ͈˜ ÙˆÓ 10.950/mL (Ì ‰È·Î‡Ì·ÓÛË ·fi 2.900 ¤ˆ˜ 70.300/mL). ªÂıÔ‰ÔÏÔÁÈο, Ë ÎψÓÈ΋ ·Ó·‰È¿Ù·ÍË ÙÔ˘ ÁfiÓÔ˘ Ù˘ ‚·Ú›·˜ ·Ï‡ÛÛÔ˘ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ (IgH) Ô˘ ·ÓȯÓ‡ÙËÎÂ Î·È Ù·˘ÙÔÔÈ‹ıËΠ۠οı ·È‰› Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË ÛÙÔ ‚Ï·ÛÙÈÎfi ÏËı˘ÛÌfi Ù˘ ÓfiÛÔ˘ ÙÔ˘ ̤ۈ ÂȉÈÎÒÓ ÁÈ· ÙÔÓ Î¿ı ·ÛıÂÓ‹ ηٷÛ΢·ÛÌ¤ÓˆÓ primers, ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Î·È ÁÈ· ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙÔ˘ DNA, ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ·›Ì·ÙÔ˜ ÙˆÓ Î·ÚÙÒÓ ÙÔ˘ ›‰ÈÔ˘ ·ÛıÂÓ‹. ∞ÔÙÂϤÛÌ·Ù·: ™Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ÂÈÛËÌ·›ÓÂÙ·È fiÙÈ Û 12 ·fi ÙÔ˘˜ 17 ÌÂÏÂÙËı¤ÓÙ˜ ·ÛıÂÓ›˜ (ÔÛÔÛÙfi 71%) ·ÓȯÓ‡ÙËÎ·Ó ·Ó·‰È·Ù¿ÍÂȘ Ù˘ IgH ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ̤ۈ Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ Ù˘ ÔÏ˘ÌÂÚ¿Û˘ (seminested PCR) Î·È Ë Ù·˘ÙfiÙËÙ· ÙˆÓ ·Ó·‰È·Ù¿ÍÂˆÓ ·˘ÙÒÓ Ì ·˘Ù‹ ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ ‚Ï·ÛÙÒÓ Ù˘ ÌÂÙ¤ÂÈÙ· ÓfiÛÔ˘ ÙÔ˘˜ ·ԉ›¯ıËΠÌÔÚȷο (̤ۈ DNA sequencing). ∆· Â˘Ú‹Ì·Ù·

·˘Ù¿ ÈÛ¯˘Ú¿ ·Ô‰ÂÈÎÓ‡Ô˘Ó ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ “Ï¢¯·ÈÌÈÎÔ‡” ÎÏÒÓÔ˘, ‹‰Ë ηٿ ÙË Á¤ÓÓËÛË ÙÔ˘ ·È‰ÈÔ‡. ∂ÈÚfiÛıÂÙ·, fiˆ˜ ‰È·ÈÛÙÒıËΠÛÙË ÌÂϤÙË, ‰ÂÓ ‚Ú¤ıËÎ·Ó ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ "ıÂÙÈÎÒÓ" ÁÈ· ÙËÓ ·ÚÔ˘Û›· “Ï¢¯·ÈÌÈÎÔ‡ ÎÏÒÓÔ˘” Î·È ÙˆÓ ·ÚÓËÙÈÎÒÓ ·ÛıÂÓÒÓ, fiÛÔÓ ·ÊÔÚÔ‡Û ÛÙȘ ·Ú·Ì¤ÙÚÔ˘˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ‹ ÙËÓ ËÏÈΛ· ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ O§§. ∂›Û˘, fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ (6) Ì ˘ÂÚ‰ÈÏÔÂȉÈÛÌfi ÂÌÊ¿ÓÈÛ·Ó ·ÓȯÓ‡ÛÈÌÔ˘˜ “Ï¢¯·ÈÌÈÎÔ‡˜” ÎÏÒÓÔ˘˜ ÛÙȘ οÚÙ˜ ÙÔ˘˜. ™˘ÌÂÚ¿ÛÌ·Ù·: Ÿˆ˜ ÈÛÙÂ‡Ô˘Ó ÔÈ Û˘ÁÁÚ·Ê›˜ Ù˘ ÌÂϤÙ˘, Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ¿Ô„Ë fiÙÈ Ë Ï¢¯·ÈÌÔÁ¤ÓÂÛË Û ¤Ó· ˘„ËÏfi ÔÛÔÛÙfi Ù˘ µ-΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘ O§§ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÂÌÊ·Ó›˙ÂÙ·È ÂÓ‰ÔÌËÙÚ›ˆ˜, ÌÔÏÔÓfiÙÈ ÙÔÓ›˙ÂÙ·È fiÙÈ Ù· ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÂÈÛ˘Ì‚·›ÓÔÓÙ· ÁÂÁÔÓfiÙ· ÌÔÚÔ‡Ó Â›Û˘ Ó· Û˘Ì‚¿ÏÔ˘Ó Î·ıÔÚÈÛÙÈο ÛÙË Ï¢¯·ÈÌÔÁ¤ÓÂÛË.

1 Taub JW, Konrad MA, Ge Y, Naber JM, Scott JS, Matherly LH et al High frequency of leukemic clones in newborn screening blood samples of children with Bprecursor acute lymphoblastic leukemia Blood 2002;99:2992-2996

¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘-∞Ó‰ÚÔ˘Ï·Î¿ÎË ™ÔÊ›· ¶·È‰›·ÙÚÔ˜-∞ÈÌ·ÙÔÏfiÁÔ˜-OÁÎÔÏfiÁÔ˜ ∂ÈÌÂÏ‹ÙÚÈ· ∞’ ÙÔ˘ ∆Ì‹Ì·ÙÔ˜ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-OÁÎÔÏÔÁ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”

381

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·382

¶·È‰È·ÙÚÈ΋ 2002;65:382-386

E¶π∫∞πƒ∞ £∂ª∞∆∞

Paediatriki 2002;65:382-386

CURRENT ISSUES

∞›ÙÈ· ¤ÍÈ ÂÍ·ÓıËÌ·ÙÈÎÒÓ ÏÔÈÌÒ͈Ó. ¶ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ T. ∆ÛÈ‚ÈÙ·Ó›‰Ô˘ - ∫¿ÎÔ˘ÚÔ˘

Etiology of six exanthematous diseases. Recent data T. Tsivitanidou - Kakourou

¶ÂÚ›ÏË„Ë: ™ÙÔ ¿ÚıÚÔ ·˘Ùfi ·Ó·ÛÎÔÂ›Ù·È Ë ÚfiÛÊ·ÙË ‚È‚ÏÈÔÁÚ·Ê›·, ȉȷ›ÙÂÚ· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÈÙÈÔÏÔÁ›·, ¤ÍÈ ÂÍ·ÓıËÌ·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. ∆Ô ÏÔÈÌ҉˜ ÂÚ‡ıËÌ· Î·È ÙÔ Û‡Ó‰ÚÔÌÔ ÙˆÓ ‚Ï·ÙȉÔÔÚÊ˘ÚÈÎÒÓ Á·ÓÙÈÒÓ Î·È Î·ÏÙÛÒÓ Û˘Ó‰¤ÔÓÙ·È ·ÈÙÈÔÏÔÁÈο Ì ÙÔÓ ·Ú‚Ô˚fi µ19. ∏ ÚÔ‰fi¯ÚÔ˘˜ ÈÙ˘Ú›·ÛË Î·È ÙÔ ·ÈÊÓ›‰ÈÔ ÂÍ¿ÓıËÌ· ÔÊ›ÏÔÓÙ·È Î˘Ú›ˆ˜ ÛÙÔ˘˜ ÂÚËÙÔ˚Ô‡˜ 7 Î·È 6, ·ÓÙ›ÛÙÔȯ·. °È· ÙÔ Û‡Ó‰ÚÔÌÔ Gianotti-Crosti ·Ú¯Èο ÂÓÔ¯ÔÔÈ‹ıËÎÂ Ô Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ µ, ÂÓÒ ·ÚÁfiÙÂÚ· Î·È ¿ÏÏÔÈ ÏÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ Î·È ÂÌ‚ÔÏÈ·ÛÌÔ›, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘, ÙÂÏÂ˘Ù·›·, ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ηٿ Ù˘ ÈÏ·Ú¿˜, Ù˘ ÂÚ˘ıÚ¿˜ Î·È Ù˘ ·ÚˆÙ›Ùȉ·˜. ∆¤ÏÔ˜, Ë ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ÂÙÂÚfiÏ¢ÚÔ˘ Ï·ÁÈÔıˆÚ·ÎÈÎÔ‡ ÂÍ·Óı‹Ì·ÙÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Â›Ó·È Èı·ÓÒ˜ ÔÏ˘·Ú·ÁÔÓÙÈ΋.

Abstract: The recent literature, particularly on the aetiology of six exanthematous diseases is reviewed. Erythema infectiosum and papularpurpuric gloves and socks syndrome are associated with parvovirus B19. Pityriasis rosea and exanthem subitum are usually caused by herpesviruses 7 and 6 respectively. Gianotti-Crosti syndrome was first associated with hepatitis B infection and later with a variety of other infectious agents as well as immunizations, including measles, mumps and rubella vaccination. Finally, the etiology of unilateral laterothoracic exanthem of childhood seems to be multifactorial.

§¤ÍÂȘ ÎÏÂȉȿ: ·Ú‚Ô˚fi˜ µ19, ÂÚËÙÔ˚Ô› 6 Î·È 7, ÂÌ‚fiÏÈÔ ÈÏ·Ú¿˜, ÂÚ˘ıÚ¿˜, ·ÚˆÙ›Ùȉ·˜, ÂÙÂÚfiÏ¢ÚÔ Ï·ÁÈÔıˆÚ·ÎÈÎfi ÂÍ¿ÓıËÌ·.

Key words: parvovirus B19, herpesviruses 6 and 7, MMR vaccination, unilateral laterothoracic exanthem.

∂ÈÛ·ÁˆÁ‹ OÈ ÈÒÛÂȘ ·ÔÙÂÏÔ‡Ó ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· ÂÍ·Óı‹Ì·ÙÔ˜ ÛÙ· ·È‰È¿. ŸÛÔ ÌÈÎÚfiÙÂÚÔ Â›Ó·È ÙÔ ·È‰›, ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚË Â›Ó·È Ë Èı·ÓfiÙËÙ· Ë ÈÔÁÂÓ‹˜ Ïԛ̈ÍË Ó· Û˘Óԉ‡ÂÙ·È ·fi ÂÍ¿ÓıËÌ·. ∞ӷʤÚÂÙ·È fiÙÈ Û ·È‰È¿ οو ÙˆÓ 4 ÂÙÒÓ Ì ›ˆÛË, Ë Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÂÍ·Óı‹Ì·ÙÔ˜ Â›Ó·È Ì¤¯ÚÈ 50%. ∂˘Ù˘¯Ò˜, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÈÔÁÂÓ›˜ ÂÍ·ÓıËÌ·ÙÈΤ˜ ÏÔÈÌÒÍÂȘ ‰È·‰Ú¿ÌÔ˘Ó ‹È· ÛÙ· ˘ÁÈ‹ ·È‰È¿. ŸÌˆ˜, ÔÈ ‹Ș ·˘Ù¤˜ ÏÔÈÌÒÍÂȘ Û˘¯Ó¿ ·ÔÙÂÏÔ‡Ó Î›Ó‰˘ÓÔ ÁÈ· Ù· ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ ¿ÙÔÌ· ‹ ÁÈ· ÙÔ ¤Ì‚Ú˘Ô, fiÙ·Ó Ë ¤ÁÎ˘Ô˜ ¤ÚıÂÈ Û Â·Ê‹ Ì ÙÔ ·È‰› Ô˘ ¿Û¯ÂÈ. ∂Ô̤ӈ˜, Ë ¤ÁηÈÚË ·Ó·ÁÓÒ-

ÚÈÛË ÙÔ˘ ÂÍ·ÓıËÌ·ÙÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜ ¤¯ÂÈ ıÂÌÂÏÈÒ‰Ë ÛËÌ·Û›· ÁÈ· ÙË ‰ËÌfiÛÈ· ˘Á›·. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ·Ó¿Ù˘ÍË Ó¤ˆÓ Ù¯ÓÈÎÒÓ, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· Ë ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ (PCR), ¤Î·Ó ‰˘Ó·Ù‹ ÙËÓ Ù·˘ÙÔÔ›ËÛË ÈÒÓ Î·È ÙËÓ ·Ó·ÁÓÒÚÈÛË ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ· Û ÓÔÛ‹Ì·Ù· Ô˘ ‹‰Ë ‹Ù·Ó ÁÓˆÛÙ¿ ·fi ‰ÂηÂٛ˜. ∆¤ÙÔÈ· ÓÔÛ‹Ì·Ù· ı· ·Ó·Ù˘¯ıÔ‡Ó Î·ÙˆÙ¤Úˆ.

∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

1st Department of Paediatrics, Athens University “Agia Sophia” Children’s Hospital

∂ÈÛ‹ÁËÛË ÛÙËÓ 1Ë ËÌÂÚ›‰· Ù˘ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ¶·È‰È·ÙÚÈ΋˜ ¢ÂÚÌ·ÙÔÏÔÁ›·˜, 1Ë ¢ÂÎÂÌ‚Ú›Ô˘ 2001, ∞ı‹Ó·

Presentation at the 1st Meeting of the Hellenic Society of Paediatric Dermatology, December 1st 2001, Athens

382

§ÔÈÌ҉˜ ÂÚ‡ıËÌ· - ¶¤ÌÙË ÂÍ·ÓıËÌ·ÙÈ΋ ÓfiÛÔ˜ ∆Ô ÏÔÈÌ҉˜ ÂÚ‡ıËÌ· ÚˆÙÔÂÚÈÁÚ¿ÊËΠ·fi ÙÔÓ ÕÁÁÏÔ ‰ÂÚÌ·ÙÔÏfiÁÔ Robert Willan Â‰Ò Î·È ‰‡Ô ·ÈÒÓ˜, ÙÔ fiÓÔÌ¿ ÙÔ˘ ‰Â, ÔÊ›ÏÂÙ·È ÛÙÔÓ

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·383

¶·È‰È·ÙÚÈ΋ 2002;65:382-386

°ÂÚÌ·Ófi ·ıÔÏfiÁÔ Stricker (1899). ∞ÊÔÚ¿ ΢ڛˆ˜ Û ·È‰È¿ ËÏÈΛ·˜ 5-14 ÂÙÒÓ. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÂÚ‡ıËÌ· Ì ÂÚÈÊÂÚÈÎfi fi¯ıÔ Ô˘ ÂÓÙÔ›˙ÂÙ·È Û˘ÌÌÂÙÚÈο ÛÙ· Ì¿ÁÔ˘Ï· Û·Ó Ú¿ÈÛÌ·. ª›· ¤ˆ˜ 4 Ë̤Ú˜ ·ÚÁfiÙÂÚ·, ÂÌÊ·Ó›˙ÂÙ·È ÂÚ˘ıËÌ·Ù҉˜ ÎËÏȉԂϷÙȉ҉˜ ÂÍ¿ÓıËÌ· ÛÙËÓ ¤Íˆ ÂÈÊ¿ÓÂÈ· ÙˆÓ ÂÁÁ‡˜ ¿ÎÚˆÓ. ¶ÚÔԉ¢ÙÈο, ÙÔ ÂÍ¿ÓıËÌ· ÂÂÎÙ›ÓÂÙ·È ÚÔ˜ Ù· οو Î·È ÙËÓ ¤Ûˆ ÂÈÊ¿ÓÂÈ· ÙˆÓ ¿ÎÚˆÓ, Ê›‰ÂÙ·È fï˜ ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ. ™Â Ì›· ‚‰ÔÌ¿‰· ÂÚ›Ô˘, ÙÔ ÂÍ¿ÓıËÌ· ·Ú¯›˙ÂÈ Ó· ˘Ô¯ˆÚ›, ÂÓÒ Î¿ı ÌÂÌÔӈ̤ÓË ‚Ï¿‚Ë ÂÍ·Ê·Ó›˙ÂÙ·È ·fi ÙÔ Î¤ÓÙÚÔ ÚÔ˜ ÙËÓ ÂÚÈʤÚÂÈ¿ Ù˘, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ‰ËÌÈÔ˘ÚÁÂ›Ù·È ‰ÈÎÙ˘ˆÙ‹ ÂÌÊ¿ÓÈÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜ (∂ÈÎfiÓ· 1). ∆Ô ÛÙ¿‰ÈÔ ·˘Ùfi ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ˘Ê¤ÛÂȘ Î·È ÂÍ¿ÚÛÂȘ Ô˘ ‰È·ÚÎÔ‡Ó Â‚‰ÔÌ¿‰Â˜. ∆Ô ÂÍ¿ÓıËÌ· Û˘Óԉ‡ÂÙ·È Û˘Ó‹ıˆ˜ ·fi ÁÚÈÒ‰Ë Û˘Ó‰ÚÔÌ‹, fiˆ˜ Î˘Ó¿Á¯Ë, ÎÂÊ·Ï·ÏÁ›·, ˘ÚÂÙfi, ‚‹¯·, ·ÓÔÚÂÍ›·, Â̤ÙÔ˘˜, ‰È¿ÚÚÔÈ·, ·ÚıÚ·ÏÁ›Â˜. ∏ ·ÚıÚ·ÏÁ›· Î·È Ë ·ÚıÚ›Ùȉ· Â›Ó·È Û¿ÓȘ ÛÙ· ·È‰È¿, ÂÓÒ Â›Ó·È Û˘¯Ó¤˜ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ fï˜ ÙÔ ÂÍ¿ÓıËÌ· Â›Ó·È ¿Ù˘Ô (1). ∏ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ Û ÂȉË̛˜, ΢ڛˆ˜ ¯ÂÈÌÒÓ· Î·È ¿ÓÔÈÍË, Ù· Û˘ÓÔ‰¿ Û˘ÌÙÒÌ·Ù· Î·È Ë ÔÚ›· Ù˘ ÓfiÛÔ˘ ηÙˇı˘Ó·Ó ÙË ÛΤ„Ë fiÙÈ ÙÔ ·›ÙÈÔ ‹Ù·Ó ÏÔÈÌ҉˜. ◊‰Ë ·fi ÙÔ 1983 Ù¤ıËÎÂ Ë ˘Ô„›· fiÙÈ ÙÔ ÏÔÈÌ҉˜ ÂÚ‡ıËÌ· ÔÊ›ÏÂÙ·È Û ·Ú‚Ô˚fi (2) Î·È Û‹ÌÂÚ· Â›Ó·È Ï‹Úˆ˜ ÙÂÎÌËÚȈ̤ÓÔ fiÙÈ ÔÊ›ÏÂÙ·È ÛÙÔÓ ·Ú‚Ô˚fi µ19. O ¯ÚfiÓÔ˜ ÂÒ·Û˘ Â›Ó·È 17-18 Ë̤Ú˜, Ô ‰Â ¿Û¯ˆÓ ÌÂÙ·‰›‰ÂÈ ÙÔÓ Èfi ÂÚ›Ô˘ Ì›· ‚‰ÔÌ¿‰· ÚÈÓ ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜ (3). ™‡Ó‰ÚÔÌÔ ‚Ï·ÙȉÔÔÚÊ˘ÚÈÎÒÓ Á·ÓÙÈÒÓ Î·È Î·ÏÙÛÒÓ (papular-purpuric gloves and socks syndrome) ∆Ô Û‡Ó‰ÚÔÌÔ ÚˆÙÔÂÚÈÁÚ¿ÊËΠ·fi ÙÔ˘˜ Harms Î·È Û˘Ó ÙÔ 1990 (4). ŒÓ· ¯ÚfiÓÔ ·ÚÁfiÙÂÚ·

∂ÈÎfiÓ· 1. §ÔÈÌ҉˜ ÂÚ‡ıËÌ·. ¢ÈÎÙ˘ˆÙfi ÛÙ¿‰ÈÔ ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜.

Paediatriki 2002;65:382-386

ÂÓÔ¯ÔÔÈ‹ıËÎÂ Ô ·Ú‚Ô˚fi˜ µ19 ˆ˜ ·›ÙÈÔ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ (5). ∞ÊÔÚ¿ ΢ڛˆ˜ Û ÂÊ‹‚Ô˘˜ Î·È ÂÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ ¿ÓÔÈÍË Î·È Î·ÏÔη›ÚÈ. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÂÍ¿ÓıËÌ· Ô˘ ÂÓÙÔ›˙ÂÙ·È Û˘ÌÌÂÙÚÈο ÛÙ· ¿ÎÚ· ¯¤ÚÈ· Î·È fi‰È·. ∆Ô ¿Û¯ÔÓ ‰¤ÚÌ· ·ÊÔÚ›˙ÂÙ·È Û·ÊÒ˜ ·fi ÙÔ ˘ÁȤ˜, ÛÙÔ˘˜ ηÚÔ‡˜ Î·È Ù· ÛÊ˘Ú¿. ∞Ú¯Èο ÂÌÊ·Ó›˙ÂÙ·È Ô›‰ËÌ· Î·È ÂÚ‡ıËÌ· Ô˘ ÚÔԉ¢ÙÈο ÂÍÂÏ›ÛÛÂÙ·È Û ‚Ï·Ù›‰Â˜ Î·È ÂÙ¤¯È˜. ¶·ÚfiÌÔÈÔ ÂÍ¿ÓıËÌ· ÌÔÚ› Ó· ˘¿Ú¯ÂÈ Û˘ÌÌÂÙÚÈο ÛÙÔ˘˜ ·ÁÎÒÓ˜, Ù· ÁfiÓ·Ù·, ÙÔ˘˜ ÁÏÔ˘ÙÔ‡˜, ÛÙȘ ‚Ô˘‚ˆÓÈΤ˜ Ù˘¯¤˜ Î·È ÙÔ˘˜ ¤Ûˆ ÌËÚÔ‡˜. ™ÙÔ ÛÙÔÌ·ÙÈÎfi ‚ÏÂÓÓÔÁfiÓÔ ˘¿Ú¯Ô˘Ó Û˘Ó‹ıˆ˜ ÂÍÂÏÎÒÛÂȘ, ÛÙË ÛÎÏËÚ¿ ˘ÂÚÒ· ÂÙ¤¯È˜ Î·È Ô›‰ËÌ· ÛÙ· ¯Â›ÏË. OÈ Û˘ÛÙËÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·ÓÔÚÂÍ›·, ˘ÚÂÙfi, ·ÚıÚ·ÏÁ›Â˜. ∆Ô ÂÍ¿ÓıËÌ· ˘Ô¯ˆÚ› Û 1-2 ‚‰ÔÌ¿‰Â˜. ∂ÎÙfi˜ ·fi ÙÔÓ ·Ú‚Ô˚fi µ19 Î·È ¿ÏÏÔÈ ÈÔ› ¤¯Ô˘Ó Û˘Ó‰Âı› ·ÈÙÈÔÏÔÁÈο Ì ÙÔ Û‡Ó‰ÚÔÌÔ ÙˆÓ ‚Ï·ÙȉÔÔÚÊ˘ÚÈÎÒÓ Á·ÓÙÈÒÓ Î·È Î·ÏÙÛÒÓ, fiˆ˜ Ô ÂÚËÙÔ˚fi˜ 6, Ô coxsackie B6 Î·È Ô Èfi˜ ÙˆÓ ÌÂÁ·ÏÔ΢ÙÙ·ÚÈÎÒÓ ÂÁÎÏ›ÛÙˆÓ (6-8). ™ËÌÂÈÒÓÂÙ·È, fï˜, fiÙÈ ÌfiÓÔ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ·Ú‚Ô˚fi µ19 ˘¿Ú¯ÂÈ Ï‹Ú˘ ÂÚÁ·ÛÙËÚȷ΋ ÙÂÎÌËÚ›ˆÛË (·ÔÌfiÓˆÛË ÙÔ˘ ÈÔ‡ Ì PCR, Ù·˘Ùfi¯ÚÔÓ·, ÛÙÔ ¿Û¯ÔÓ ‰¤ÚÌ· Î·È ·›Ì· Î·È ·ÎÔÏÔ‡ıˆ˜ ·‡ÍËÛË ·ÓÙÈۈ̿وÓ) (9). ¶ÔÈÔ Â›Ó·È ÙÔ Ú·ÎÙÈÎfi fiÊÂÏÔ˜ ÛÙÔ fiÙÈ ÁÓˆÚ›˙Ô˘Ì fiÙÈ Ù· ‰‡Ô ·˘Ù¿ ÓÔÛ‹Ì·Ù· Ô˘ ‰È·‰Ú¿ÌÔ˘Ó ‹È· ÛÙ· ˘ÁÈ‹ ¿ÙÔÌ· ÔÊ›ÏÔÓÙ·È ÛÙÔÓ ·Ú‚Ô˚fi µ19; ∏ Ïԛ̈ÍË ·fi ·Ú‚Ô˚fi µ19: ·) Û ¿ÙÔÌ· Ì ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂÈ· ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÔ‚·Ú‹ ·Ï·ÛÙÈ΋ ÎÚ›ÛË, ‚) ÛÙ· ¿ÙÔÌ· Ì ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ· Â›Ó·È Û˘Ó‹ıˆ˜ ¯ÚfiÓÈ· Î·È Ô‰ËÁ› Û ‚·ÚÈ¿ ·Ó·ÈÌ›·, ÂÓÒ Á) ÛÙȘ ÂÁ·Ԣ˜, fiÙ·Ó Û˘Ì‚Â› ÛÙȘ ÚÒÙ˜ 20 ‚‰ÔÌ¿‰Â˜ Ù˘ ·ËÛ˘, ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·Ô‚ÔÏ‹ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ·fi ÂÌ‚Ú˘˚Îfi ‡‰Úˆ· (9%). ™ËÌÂÈÒÓÂÙ·È fiÙÈ 50% ÙˆÓ Á˘Ó·ÈÎÒÓ ·Ó··Ú·ÁˆÁÈ΋˜ ËÏÈΛ·˜ Â›Ó·È Â›ÓÔÛ˜ ÛÙÔÓ ·Ú‚Ô˚fi µ19. ∂Ô̤ӈ˜, Ë ·Ó·ÁÓÒÚÈÛË ÙÔ˘ ÂÍ·ÓıËÌ·ÙÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜ ÛÙÔ ¿ÌÂÛÔ ÂÚÈ‚¿ÏÏÔÓ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ÚfiÏË„Ë Î·È ¤ÁηÈÚË ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘ ÛÙȘ ÂȉÈΤ˜ ÔÌ¿‰Â˜ (10,11). ƒÔ‰fi¯ÚÔ˘˜ ÈÙ˘Ú›·ÛË (pityriasis rosea) ∂›Ó·È ÔÍ›· ·˘ÙÔ˚ÒÌÂÓË ‰ÂÚÌ·ÙÔ¿ıÂÈ·. OÊ›ÏÂÈ ÙÔ fiÓÔÌ· Ù˘ ÛÙÔÓ °¿ÏÏÔ ·ıÔÏfiÁÔ Gilbert (1860). OÈ ÌÈÛ¤˜ ÂÚÈÙÒÛÂȘ ·ÊÔÚÔ‡Ó Û ¿ÙÔÌ· ÌÈÎÚfiÙÂÚ· ÙˆÓ 20 ÂÙÒÓ. ¶¿ÓÙˆ˜, fiÛÔ ÌÈÎÚfiÙÂÚË Â›Ó·È Ë ËÏÈΛ·, ÙfiÛÔ ÌÈÎÚfiÙÂÚË Ë Èı·ÓfiÙËÙ· ÓfiÛËÛ˘ ·fi ÚÔ‰fi¯ÚÔ˘ ÈÙ˘Ú›·ÛË. ªÓËÌÔÓÔÙ¯ÓÈο ·Ó·Ê¤ÚÂÙ·È fiÙÈ Û ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 4 ÂÙÒÓ Ë

383

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·384

¶·È‰È·ÙÚÈ΋ 2002;65:382-386

Èı·ÓfiÙËÙ· ÓfiÛËÛ˘ Â›Ó·È 4%. ∆Ô ÂÍ¿ÓıËÌ· Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi. ™ÙÔ 70-80% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·Ú¯Èο ÂÌÊ·Ó›˙ÂÙ·È ÌÔÓ‹Ú˘, ÂÚ˘ıËÌ·Ù҉˘, ÂÏ·ÊÚ¿ ÂËṲ́ÓË ˆÔÂȉ‹˜ Ͽη ‰È·Ì¤ÙÚÔ˘ ̤¯ÚÈ 5 cm, Ì ÈÙ˘ÚÒ‰Ë ·ÔϤÈÛË ÛÙËÓ ÂÚÈʤÚÂÈ·, Ô˘ fï˜ ‰ÂÓ Î·Ï‡ÙÂÈ ÙÔ ÂÚ›ÁÚ·ÌÌ· Ù˘ ‚Ï¿‚˘ (Úfi‰ÚÔÌÔ˜ Ͽη, herald patch). §›Á˜ Ë̤Ú˜ ·ÚÁfiÙÂÚ· (515) ÂÌÊ·Ó›˙ÔÓÙ·È ÔÏϤ˜ ÌÈÎÚfiÙÂÚ˜ ·ÚfiÌÔȘ ‚Ï¿‚˜ ÛÙÔÓ ÎÔÚÌfi Î·È Ù· ¿ÎÚ·, ̤¯ÚÈ ÙÔ˘˜ ·ÁÎÒÓ˜ Î·È Ù· ÁfiÓ·Ù·. ™¿ÓÈ·, ÙÔ ÂÍ¿ÓıËÌ· ηٷϷ̂¿ÓÂÈ Î·È ÙÔ ÚfiÛˆÔ. ™ÙÔÓ ÎÔÚÌfi ÔÈ ‚Ï¿‚˜ Â›Ó·È Û˘ÌÌÂÙÚÈΤ˜ Î·È ÂÎÙ›ÓÔÓÙ·È Î·Ù¿ Ì‹ÎÔ˜ ÙˆÓ Ï¢ÚÒÓ, ¤ÙÛÈ ÒÛÙ ÙÔ Û‡ÓÔÏfi ÙÔ˘˜ Ó· ‰›ÓÂÈ ÙËÓ ÂÈÎfiÓ· ¯ÚÈÛÙÔ˘ÁÂÓÓÈ¿ÙÈÎÔ˘ ‰¤ÓÙÚÔ˘ (∂ÈÎfiÓ· 2). ™Ù· ·È‰È¿, Ô ÎÓËÛÌfi˜ Â›Ó·È ‹ÈÔ˜ ¤ˆ˜ ·Ó‡·ÚÎÙÔ˜. ∆Ô ÂÍ¿ÓıËÌ· ˘Ô¯ˆÚ› Û˘Ó‹ıˆ˜ Û 3-6 ‚‰ÔÌ¿‰Â˜. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ Ë ÚÔ‰fi¯ÚÔ˘˜ ÈÙ˘Ú›·ÛË ÂÌÊ·Ó›˙ÂÙ·È Û ÌÈÎÚ¤˜ ÂȉË̛˜ (¿ÓÔÈÍË Î·È ÊıÈÓfiˆÚÔ), ‰ÂÓ ˘ÔÙÚÔÈ¿˙ÂÈ Î·È ÌÂÚÈÎÔ› ¿ÚÚˆÛÙÔÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Úfi‰ÚÔÌ· Û˘ÌÙÒÌ·Ù· ΢ڛˆ˜ ·fi ÙȘ ·ÓÒÙÂÚ˜ ·Ó·Ó¢ÛÙÈΤ˜ Ô‰Ô‡˜, ηÙˇı˘Ó ·fi ÓˆÚ›˜ ÙË ÛΤ„Ë fiÙÈ ÙÔ ·›ÙÈÔ Ù˘ ÓfiÛÔ˘ ‹Ù·Ó ÏÔÈÌ҉˜. ∆Ô 1997 ÔÈ Drago Î·È Û˘Ó, Û Ôχ ηϿ ÙÂÎÌËÚȈ̤ÓË ÂÚÁ·Û›· ÙÔ˘˜, Û˘Û¯¤ÙÈÛ·Ó ÙË ÚÔ‰fi¯ÚÔ˘ ÈÙ˘Ú›·ÛË Ì ÙÔÓ ÂÚËÙÔ˚fi 7. ™˘ÁÎÂÎÚÈ̤ӷ, Û 12 ¿ÙÔÌ· Ì ÚÔ‰fi¯ÚÔ˘ ÈÙ˘Ú›·ÛË ·ÔÌfiÓˆÛ·Ó DNA ÙÔ˘ ÈÔ‡ ÛÙȘ ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜, ÛÙ· ÌÔÓÔ·ÙÙ·Ú· ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ÂχıÂÚÔ Èfi ÛÙÔ Ï¿ÛÌ· (12). ∆· ÂfiÌÂÓ· ¯ÚfiÓÈ· ·ÎÔÏÔ‡ıËÛ·Ó ‰È¿ÊÔÚ˜ ÂÚÁ·Û›Â˜ Ô˘ ÂȂ‚·ÈÒÓÔ˘Ó ‹ fi¯È ÙË Û˘Û¯¤ÙÈÛË Ù˘ ÚÔ‰fi¯ÚÔ˘ ÈÙ˘Ú›·Û˘ Ì ÙÔÓ ÂÚËÙÔ˚fi 7 (1316). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ÂÚËÙÔ˚Ô›, ÌÂÙ¿ ÙËÓ ÚˆÙÔÏԛ̈͋ ÙÔ˘˜, Ï·ıÚÔ‚ÈÔ‡Ó ÛÙ· Ï¢ÎÔ·ÙÙ·Ú·. ∂Ô̤ӈ˜, ıˆÚÂ›Ù·È ÔÍ›· Ïԛ̈ÍË ÌfiÓÔ fiÙ·Ó Ô Èfi˜ ·ÔÌÔÓˆı› ÂχıÂÚÔ˜ ÛÙÔ Ï¿ÛÌ·, ‰ËÏ·‰‹ ÏËÊı› ·›Ì· Û ʿÛË È·ÈÌ›·˜. ∞˘Ùfi ·ÔÙÂÏ› ‰˘ÛÎÔÏ›· ÁÈ· ÔÌÔÈÔÁ¤ÓÂÈ· ÛÙȘ ÌÂϤÙ˜. ¶¿ÓÙˆ˜, ·Ó fi¯È ·ÔÎÏÂÈÛÙÈο, ÙÔ˘Ï¿¯ÈÛÙÔÓ Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi, Ô ÂÚËÙÔ˚fi˜ 7 ¢ı‡ÓÂÙ·È ÁÈ· ÙË ÚÔ‰fi¯ÚÔ˘ ÈÙ˘Ú›·ÛË (17). ∞ÈÊÓ›‰ÈÔ ÂÍ¿ÓıËÌ· ∞ÊÔÚ¿ ΢ڛˆ˜ Û ̈ڿ ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 2 ÂÙÒÓ Î·È Â›Ó·È Û¿ÓÈÔ Û ËÏÈ˘ ÌÈÎÚfiÙÂÚ˜ ÙˆÓ 3 ÌËÓÒÓ ‹ ÌÂÁ·Ï‡ÙÂÚ˜ ÙˆÓ 4 ÂÙÒÓ. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi Ôχ ˘„ËÏfi ˘ÚÂÙfi ‰È¿ÚÎÂÈ·˜ ÂÚ›Ô˘ 3 ËÌÂÚÒÓ, ÂÓÒ ÙÔ ‚Ú¤ÊÔ˜ Â›Ó·È Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË. ™˘¯Ó¿ Û˘Óԉ‡ÂÙ·È ·fi ˘ÚÂÙÈÎÔ‡˜ Û·ÛÌÔ‡˜. ªÂ ÙËÓ ÙÒÛË ÙÔ˘ ˘ÚÂÙÔ‡ ÂÌÊ·Ó›˙ÂÙ·È ÈÏ·ÚÔÂȉ¤˜ ÂÍ¿ÓıËÌ· ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜. ∆Ô

384

Paediatriki 2002;65:382-386

∂ÈÎfiÓ· 2. ƒÔ‰fi¯ÚÔ˜ ϿΘ Ì ÈÙ˘ÚÒ‰Ë ·ÔϤÈÛË. ƒÔ‰fi¯ÚÔ˘˜ ÈÙ˘Ú›·ÛË.

1988, ÛÙËÓ π·ˆÓ›·, ÙÔ ·ÈÊÓ›‰ÈÔ ÂÍ¿ÓıËÌ· Û˘Ó‰¤ıËΠ·ÈÙÈÔÏÔÁÈο Ì ÙÔÓ ÂÚËÙÔ˚fi 6 (18) Î·È ·fi ÙfiÙÂ Ë Û˘Û¯¤ÙÈÛË ·˘Ù‹ ¤¯ÂÈ ÙÂÎÌËÚȈı› Ì ·ÚÎÂÙ¤˜ ÂÚÁ·Û›Â˜ (19-23). ™ÙÔ˘˜ ÂÓ‹ÏÈΘ, Ë ÚˆÙÔ·ı‹˜ Ïԛ̈ÍË ·fi ÙÔÓ ÂÚËÙÔ˚fi 6 ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÈÎfiÓ· ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘ Î·È Û¿ÓÈ· ÂÁÎÂÊ·Ï›Ùȉ·. ™ËÌÂÈÒÓÂÙ·È ·ÎfiÌË fiÙÈ Ô ÂÚËÙÔ˚fi˜ 6 ¤¯ÂÈ Û˘Ó‰Âı› ·ÈÙÈÔÏÔÁÈο Ì ÙË ÛÎÏ‹Ú˘ÓÛË Î·Ù¿ Ͽη˜ (24,25). µÏ·Ùȉ҉˘ ·ÎÚÔ‰ÂÚÌ·Ù›Ùȉ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (Û‡Ó‰ÚÔÌÔ Gianotti-Crosti) ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÌÔÓfiÌÔÚÊÔ ÂÍ¿ÓıËÌ· Ô˘ ·ÊÔÚ¿ Û ÂÚ˘ıÚˆ¤˜, Â›‰˜ ÛÙËÓ ÎÔÚ˘Ê‹ ÙÔ˘˜ ‚Ï·Ù›‰Â˜ ‰È·Ì¤ÙÚÔ˘ 0,1-1 cm, Ô˘ ÂÓÙÔ›˙ÔÓÙ·È Û˘ÌÌÂÙÚÈο ÛÙËÓ ÂÎÙ·ÙÈ΋ ÂÈÊ¿ÓÂÈ· ÙˆÓ ¿ÎÚˆÓ, ÙÔ˘˜ ÁÏÔ˘ÙÔ‡˜, ÙÔ ÚfiÛˆÔ Î·È Û·ÓÈfiÙÂÚ· ÛÙÔÓ ÎÔÚÌfi (∂ÈÎfiÓ· 3). ¶ÚÔԉ¢ÙÈο ÔÈ ‚Ï·Ù›‰Â˜ ·ÔÎÙÔ‡Ó Î·ÊÂÔÂȉ¤˜ ¯ÚÒÌ·, ·ÔÏÂ›˙ÔÓÙ·È Î·È ÙÂÏÈο ˘Ô¯ˆÚÔ‡Ó ÂÚ›Ô˘ Û ÙÚÂȘ ‚‰ÔÌ¿‰Â˜. ™¿ÓÈ· ÙÔ ÂÍ¿ÓıËÌ· ÌÔÚ› Ó· Â›Ó·È ‚Ï·ÙȉÔÊ˘Û·ÏÏȉ҉˜ ‹ ·ÈÌÔÚÚ·ÁÈÎfi. ªÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó ÁÂÓÈÎÂ˘Ì¤ÓË Ì¤ÙÚÈ· ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· Î·È Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·. OÈ ÙÚ·ÓÛ·ÌÈÓ¿Û˜ Î·È Ë ¯ÔÏÂÚ˘ıÚ›ÓË ‚Ú›ÛÎÔÓÙ·È ÂÏ·ÊÚ¿ ·˘ÍË̤Ó˜. ™ËÌÂÈÒÓÂÙ·È fiÙÈ Ë Ë·Ù›Ùȉ· ÂΉËÏÒÓÂÙ·È 1-2 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜. ∞Ú¯Èο, ÙÔ Û‡Ó‰ÚÔÌÔ ·Ô‰fiıËΠ۠·ÓÙÈÁÔÓ·ÈÌ›· ·fi ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ µ. ™‹ÌÂÚ·, ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È Î·È ¿ÏÏÔÈ ÏÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ fiˆ˜ Ô Èfi˜ Epstein-Barr, Ô coxsackie, Ô Èfi˜ ÙˆÓ ÌÂÁ·ÏÔ΢ÙÙ·ÚÈÎÒÓ ÂÁÎÏ›ÛÙˆÓ, Ô ·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜, Î·È ÂÌ‚ÔÏÈ·ÛÌÔ›, fiˆ˜ ηٿ ÙÔ˘ ÙÂÙ¿ÓÔ˘, Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜, ÙÔ˘ ÎÔηÙË, Ù˘ Ê˘Ì·Ù›ˆÛ˘ ηÈ, ÙÂÏÂ˘Ù·›·, Ù˘ ÈÏ·Ú¿˜, Ù˘ ÂÚ˘ıÚ¿˜ Î·È Ù˘ ·ÚˆÙ›Ùȉ·˜.

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·385

¶·È‰È·ÙÚÈ΋ 2002;65:382-386

∂ÈÎfiÓ· 3. ∂ÎÙÂٷ̤ÓÔ ‚Ï·Ùȉ҉˜ ÂÍ¿ÓıËÌ· Û˘Ì‚·Ùfi Ì ۇӉÚÔÌÔ Gianotti-Crosti.

∞ÓÂÍ¿ÚÙËÙ· ·fi ÙÔÓ ·ÈÙÈÔÏÔÁÈÎfi ·Ú¿ÁÔÓÙ·, Ë ÚfiÁÓˆÛË Â›Ó·È Î·Ï‹ (26,27).

EÙÂÚfiÏ¢ÚÔ Ï·ÁÈÔıˆÚ·ÎÈÎfi ÂÍ¿ÓıËÌ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ∆Ô 1962 ÔÈ Brunner Î·È Û˘Ó ÂÚȤÁÚ·„·Ó ÂÙÂÚfiÏ¢ÚÔ ‚Ï·Ùȉ҉˜ ÂÍ¿ÓıËÌ·, “¤Ó· ηÈÓÔ‡ÚÁÈÔ ÂÍ¿ÓıËÌ·”, Û ·È‰È¿ ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 5 ÂÙÒÓ (28). ∆ÚÈ¿ÓÙ· ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, ÔÈ Bodemer Î·È Prost (1992) ‰ËÌÔÛ›Â˘Û·Ó ¿ÚıÚÔ Ì 18 ÂÚÈÛÙ·ÙÈο Ô˘ ·ÊÔÚÔ‡Û Û ÌÈÎÚ¿ ·È‰È¿, Ì ·ÚfiÌÔÈÔ ÂÍ¿ÓıËÌ·, ÙÔ ÔÔ›Ô ÔÓfiÌ·Û·Ó ÂÙÂÚfiÏ¢ÚÔ Ï·ÁÈÔıˆÚ·ÎÈÎfi ÂÍ¿ÓıËÌ·. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ·ÚÎÂÙ¿ ·fi Ù· ·È‰È¿ ·˘Ù¿ ›¯·Ó ÚÈÓÔÊ·Ú˘ÁÁ›Ùȉ·, ·ÚÎÂÙ¤˜ ‰Â ÂÚÈÙÒÛÂȘ ˘‹ÚÍ·Ó ÛÙËÓ ›‰È· ÔÈÎÔÁ¤ÓÂÈ·, ÙÔ˘˜ Ô‰‹ÁËÛ ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ÙÔ ·›ÙÈÔ ‹Ù·Ó ›Ûˆ˜ ÏÔÈÌÔÁfiÓÔ˜ Èfi˜ (29). ∆Ô ÂÙÂÚfiÏ¢ÚÔ Ï·ÁÈÔıˆÚ·ÎÈÎfi ÂÍ¿ÓıËÌ· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÚ˘ıÚˆ¤˜ ‚Ï·Ù›‰Â˜, ‰È·Ì¤ÙÚÔ˘ 1 mm, Ì ˆ¯Ú¿ ¿Ïˆ, Ô˘ ÂÓÙÔ›˙ÔÓÙ·È ÂÙÂÚfiÏ¢ڷ ÛÙË Ì·Û¯¿ÏË Î·È ÙË ‚Ô˘‚ˆÓÈ΋ ¯ÒÚ·. ¶ÚÔԉ¢ÙÈο ÔÈ ‚Ï¿‚˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÔϤÈÛË Î·È ˘Ô¯ˆÚÔ‡Ó Û 4-6 ‚‰ÔÌ¿‰Â˜, ·Ó Î·È ÙÔ ÂÍ¿ÓıËÌ· ÌÔÚ› Ó· ‰È·ÚΤÛÂÈ ÁÈ· Ì‹Ó˜ (26). ∞fi ÙÔ 1992 ·ÎÔÏÔ‡ıËÛ·Ó ·ÚÎÂÙ¤˜ ‰ËÌÔÛȇÛÂȘ. ™ÙÔ 70% ÙˆÓ ·È‰ÈÒÓ ÚÔËÁÔ‡ÓÙ·È ‹ Û˘Ó˘¿Ú¯Ô˘Ó Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi ‹ ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ·. ªÂÌÔӈ̤ӷ ÂÚÈÛÙ·ÙÈο ¤¯Ô˘Ó Û˘Ó‰Âı› ·ÈÙÈÔÏÔÁÈο Ì ÙÔ Î·Ì˘ÏÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ÂÈÏÂÔ‡, ÙÔÓ Èfi Ù˘ ·Ú·˚ÓÊÏÔ˘¤ÓÙ˙·˜ Î·È ÙËÓ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·. ¶Èı·Ó¿, Ë ·ÈÙÈÔÏÔÁ›· Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ (26,30,31). µÈ‚ÏÈÔÁÚ·Ê›· 1. Mancini AJ. Exanthems in childhood: an update. Pediatr ∞nn 1998;27:163-170.

2. Anderson MJ, Jones SE, Fisher-Hoch SP, Lewis E, Hall SM, Bartlett CL et al. Human parvovirus, the cause of

Paediatriki 2002;65:382-386

erythema infectiosum (fifth disease)? Lancet 1983;1:1378.

3. Magro CM, Dawood MR, Crowson AN. The cutaneous manifestations of human parvovirus B19 infection. Hum Pathol 2000;31:488-497.

4. Harms M, Feldmann R, Saurat JH. Papular-purpuric “gloves and socks” syndrome. J Am Acad Dermatol 1990;23:850-854.

5. Bagot M, Revuz J. Papular-purpuric “gloves and socks” syndrome: primary infection with parvovirus B19? J Am Acad Dermatol 1991;25:341.

6. Ruzicka T, Kalka K, Diercks K, Schuppe HC. Papularpurpuric “gloves and socks” syndrome associated with human herpesvirus 6 infection. Arch Dermatol 1998;134:242-244.

7. Carrascosa JM, Bielsa I, Ribera M, Ferrandiz C. Papularpurpuric gloves-and-socks syndrome related to cytomegalovirus infection. Dermatology 1995;191:269-270.

8. Feldmann R, Harms M, Saurat JH. Papular-purpuric “gloves and socks” syndrome: not only parvovirus B19.

Dermatology 1994;188:85-87.

9. Grilli R, Izquierdo MJ, Farina MC, Kutzner H, Gadea I, Martin L et al. Papular-purpuric “gloves and socks” syndrome: polymerase chain reaction demonstration of parvovirus B19 DNA in cutaneous lesions and sera. J Am Acad Dermatol 1999;41:793-796.

10. Serjeant BE, Hambleton IR, Kerr S, Kilty CG, Serjeant GR. Haematological response to parvovirus B19 infection in homozygous sickle-cell disease. Lancet 2001; 358:1779-1780.

11. Miller E, Fairley CK, Cohen BJ, Seng C. Immediate and long term outcome of human parvovirus B19 infection in pregnancy. Br J Obstet Gynaecol 1998;105:1337-1338.

12. Drago F, Ranieri E, Malaguti F, Battifoglio MC, Losi E, Rebora A. Human herpesvirus 7 in patients with pityriasis rosea. Electron microscopy investigations and polymerase chain reaction in mononuclear cells, plasma and skin.

Dermatology 1997;195:374-378.

13. Watanabe T, Sugaya M, Nakamura K, Tamaki K. Human herpesvirus 7 and pityriasis rosea. J Invest Dermatol 1999;113:288-289.

14. Kempf W, Adams V, Kleinhans M, Burg G, Panizzon RG, Campadelli-Fiume G et al. Pityriasis rosea is not associated with human herpesvirus 7. Arch Dermatol 1999; 135:1070-1072.

15. Yoshida M. Detection of human herpesvirus 7 in patients with pityriasis rosea and healthy individuals. Dermatology 1999;199:197-198.

16. Kosuge H, Tanaka-Taya K, Miyoshi H, Amo K, Harada R, Ebihara T et al. Epidemiological study of human herpesvirus-6 and human herpesvirus-7 in pityriasis rosea.

Br J Dermatol 2000;143:795-798.

17. Drago F, Rebora A. Pityriasis rosea: one virus, two viruses, more viruses? Br J Dermatol 2001;144:1090.

18. Yamanishi K, Okuno T, Shiraki K, Takahashi M, Kondo T, Asano Y et al. Identification of human herpesvirus-6 as a causal agent for exanthem subitum. Lancet 1988;1:1065-1067.

19. Okada K, Ueda K, Kusuhara K, Miyazaki C, Tokugawa K,

385

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·386

¶·È‰È·ÙÚÈ΋ 2002;65:382-386

20.

21.

22.

23.

24.

25.

26.

Hirose M et al. Exanthema subitum and human herpesvirus 6 infection: clinical observations in fifty-seven cases. Pediatr Infect Dis 1993;12:204-208.

Suga S, Yoshikawa T, Kajita Y, Ozaki T, Asano Y. Prospective study of persistence and excretion of human herpesvirus-6 in patients with exanthem subitum and their parents. Pediatrics 1998;102:900-904.

Kosuge H. HHV-6, 7 and their related diseases. J Dermatol Sci 2000;22:205-212.

Leach CT. Human herpesvirus-6 and -7 infections in children: agents of roseola and other syndromes. Curr Opin Pediatr 2000;12:269-274.

Abe T, Yoshikawa T, Ihira M, Suzuki K, Suga S, Nishida M et al. Quantitation of human herpesvirus 6 DNA in infant with exanthem subitum by microplate PCR-hybridization assay. Pediatr Int 2001;43:372-378.

Caserta MT, Mock DJ, Dewhurst S. Human herpesvirus 6.

Clin Infect Dis 2001;33:829-833.

Campadelli-Fiume G, Mirandola P, Menotti L. Human herpesvirus 6: an emerging pathogen. Emerg Infect Dis 1999;5:353-366.

Nelson JS, Stone MS. Update on selected viral exanthems. Curr Opin Pediatr 2000;12:359-364.

Paediatriki 2002;65:382-386

27. Velangi SS, Tidman MJ. Gianotti-Crosti syndrome after measles, mumps and rubella vaccination. Br J Dermatol 1998;139:1122-1123.

28. Brunner MJ, Rubin L, Dunlap F. A new papular erythema of childhood. Arch Dermatol 1962;85:539-540.

29. Bodemer C, de Prost Y. Unilateral laterothoracic exanthem in children: a new disease? J Am Acad Dermatol 1992;27:693-696.

30. Fort DW, Greer KE. Unilateral laterothoracic exanthem in a child with acute lymphoblastic leukemia. Pediatr Dermatol 1998;15:51-52.

31. Coustou D, Leaute-Labreze C, Bioulac-Sage P, Labbe L, Taieb A. Asymmetric periflexural exanthem of childhood: a clinical, pathologic, and epidemiologic prospective study.

Arch Dermatol 1999;135:799-803.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 30-01-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 28-05-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∆¿ÏÈ· ∆ÛÈ‚ÈÙ·Ó›‰Ô˘-∫¿ÎÔ˘ÚÔ˘ ¶·Ú›ÙÛÈ 26, ∆.∫. 154 51, ¡. æ˘¯ÈÎfi E-mail: kakst@otenet.gr

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ª·ÎÚfi¯ÚÔÓË ¯ËÌÂÈÔÚÔʇϷÍË ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ˘ÔÙÚÔÒÓ Ô˘ÚÔÏԛ̈͢ Û ·È‰È¿1 ∂ÈÛ·ÁˆÁ‹: OÈ Ô˘ÚÔÏÔÈÌÒÍÂȘ Â›Ó·È ¤Ó· Û˘¯Ófi Úfi‚ÏËÌ· ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ª¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ ÂÙ¿ ÂÙÒÓ, ÙÔ 8,4% ÙˆÓ ÎÔÚÈÙÛÈÒÓ Î·È ÙÔ 1,7% ÙˆÓ ·ÁÔÚÈÒÓ ¤¯ÂÈ ·ÚÔ˘ÛÈ¿ÛÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ÂÂÈÛfi‰ÈÔ Ô˘ÚÔÏԛ̈͢. ŒÓ·˜ ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ Ô˘ ¤¯Ô˘Ó ·ÚÔ˘ÛÈ¿ÛÂÈ Ô˘ÚÔÏԛ̈ÍË, ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ̷ÎÚfi¯ÚÔÓË ¯ËÌÂÈÔÚÔʇϷÍË ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ˘ÔÙÚÔÒÓ, Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÚfiÎÏËÛË ÌfiÓÈÌˆÓ ‚Ï·‚ÒÓ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. ŸÌˆ˜, Ë ¯ËÌÂÈÔÚÔʇϷÍË Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔηϤÛÂÈ ·ÚÂÓ¤ÚÁÂȘ, ηıÒ˜ Î·È ÙËÓ ·Ó¿Ù˘ÍË ·ÓıÂÎÙÈÎÒÓ ‚·ÎÙËÚȉ›ˆÓ. ™Ùfi¯Ô˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ·ÍÈÔÏfiÁËÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ fiÏˆÓ ÙˆÓ ÌÂÏÂÙÒÓ Ù˘ ÂÚÈfi‰Ô˘ 1966-2001, Ô˘ Û˘Ó¤ÎÚÈÓ·Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ Ì·ÎÚfi¯ÚÔÓ˘ ¯ËÌÂÈÔÚÔʇϷ͢ Ì ÙËÓ ¯ÔÚ‹ÁËÛË placebo ‹ ÙË ÌË ¯ÔÚ‹ÁËÛË Ê·Ú̿ΈÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∆ÚÂȘ ÌÂϤÙ˜ Ì 151 ·ÛıÂÓ›˜ ÏËÚÔ‡Û·Ó Ù· ÚÔËÁÔ‡ÌÂÓ· ÎÚÈÙ‹ÚÈ· Î·È ÌfiÓÔ Ì›· ›¯Â Â·Ú΋ ̤ıÔ‰Ô ÔÌ·‰ÔÔ›ËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ. ∏ ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙȘ ÌÂϤÙ˜ ·˘Ù¤˜ ‹Ù·Ó 2,5-12 Ì‹Ó˜. ∞ÔÙÂϤÛÌ·Ù·: ÀÔÙÚÔ‹ Ù˘ Ô˘ÚÔÏԛ̈͢ ·ÚÔ˘Û›·Û ÙÔ 63% (48/76) ÙˆÓ ·È‰ÈÒÓ Ô˘ ‰ÂÓ ÙÔ˘˜ ¯ÔÚËÁ‹ıËΠ¯ËÌÂÈÔÚÔʇϷÍË. O Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (RR) ÂÌÊ¿ÓÈÛ˘ Ô˘ÚÔÏԛ̈͢ ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ˜ ÛÙ· ·È‰È¿ Ô˘ ‰fiıËΠ̷ÎÚfi¯ÚÔÓË ¯ËÌÂÈÔÚÔʇϷÍË (RR 0,36). ¢ÂÓ ·Ó·Ê¤ÚıËÎ·Ó ÂÈÏÔΤ˜ Ù˘ ¯ËÌÂÈÔÚÔʇϷ͢ Û η̛· ·fi ÙȘ ÙÚÂȘ ÌÂϤÙ˜. ™Â Ì›· ·fi ÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ¤ÁÈÓÂ

386

Û‡ÁÎÚÈÛË Ù˘ ¯ËÌÂÈÔÚÔʇϷ͢ Ì ÙÚÈÌÂıÔÚ›ÌË Û ۯ¤ÛË Ì ÓÈÙÚÔÊÔ˘Ú·ÓÙÔ˝ÓË. ¢È·ÈÛÙÒıËΠfiÙÈ Ë ÓÈÙÚÔÊÔ˘Ú·ÓÙÔ˝ÓË ‹Ù·Ó ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·fi ÙËÓ ÙÚÈÌÂıÔÚ›ÌË ÛÙËÓ ÚfiÏË„Ë Ô˘ÚÔÏÔÈÌÒÍÂˆÓ (RR 0,48). ŸÌˆ˜, Ù· ·È‰È¿ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÓÈÙÚÔÊÔ˘Ú·ÓÙÔ˝ÓË Â›¯·Ó ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· (RR 3,17) ·fi Ù· ·È‰È¿ Û ÙÚÈÌÂıÔÚ›ÌË Ó· ‰È·Îfi„Ô˘Ó ÙË ¯ËÌÂÈÔÚÔʇϷÍË ÏfiÁˆ ·ÚÂÓÂÚÁÂÈÒÓ, ΢ڛˆ˜ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ. ™˘ÌÂÚ¿ÛÌ·Ù·: ∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂÚÈÛÛÔÙ¤ÚˆÓ ÌÂÏÂÙÒÓ ‹Ù·Ó ·Ó·ÍÈfiÈÛÙ· ÏfiÁˆ ηÎÔ‡ ۯ‰ȷÛÌÔ‡ ÙÔ˘˜. ∂›Ó·È ··Ú·›ÙËÙÔ Ó· ‰ÈÂÓÂÚÁËıÔ‡Ó ‰ÈϤ˜ Ù˘ÊϤ˜ ÌÂϤÙ˜ Ì ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ ÁÈ· Ó· ·ÍÈÔÏÔÁËı› Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ Ì·ÎÚfi¯ÚÔÓ˘ ¯ËÌÂÈÔÚÔʇϷ͢ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ Ô˘ÚÔÏÔÈÌÒÍÂˆÓ ÛÙ· ·È‰È¿.

1 Williams GJ, Lee A, Craig JC Long-term antibiotics for preventing recurrent urinary tract infection in children Cochrane Database Syst Rev 2001:CD001534

™ÙÂÊ·Ó›‰Ë˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·389

¶PO™EXH ™YNE¢PIA

14-15 ™ÂÙÂÌ‚Ú›Ô˘ 2002

2Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ÀÔÂȉÈÎÔÙ‹ÙˆÓ Ù˘ ¶·È‰È·ÙÚÈ΋˜ ¶ÏËÚÔÊÔڛ˜: C&C International A.E. Conventions & Congresses ∆ËÏ.: 010 - 68 89 100 Fax: 010 - 68 44 777 E-mail: congress@cnc.gr

∞ı‹Ó·

14-15 ™ÂÙÂÌ‚Ú›Ô˘ 2002

12Ë ∂ÈÛÙËÌÔÓÈ΋ ∂Ή‹ÏˆÛË ¶·È‰È·ÙÚÈ΋˜ ¶·È‰È·ÙÚÈ΋ ƒÂ˘Ì·ÙÔÏÔÁ›· °Ú·ÌÌ·Ù›·: ¡. ª·ÚÎԇ̷ ∆ËÏ.: 06510 - 97 546 & 97 544 Fax: 06510 - 97 032 & 97 038 E-mail: paediatr@cc.uoi.gr

πˆ¿ÓÓÈÓ·

27-29 ™ÂÙÂÌ‚Ú›Ô˘ 2002

6Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ Ì ¢ÈÂıÓ‹ ™˘ÌÌÂÙÔ¯‹ Ù˘ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ÁÈ· ÙË ÛÎÏ‹Ú˘ÓÛË Î·Ù¿ Ͽη˜

£ÂÛÛ·ÏÔÓ›ÎË

28 ™ÂÙÂÌ‚Ú›Ô˘ 2002

∏ÌÂÚ›‰· Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎÒÓ Û˘Ó‰ÚfiÌˆÓ ∂ÏÏËÓÈ΋˜ ∞ÈÌ·ÙÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ ¶ÏËÚÔÊÔڛ˜: ∂æπ§O¡ ∆ËÏ.: 010 - 72 54 360-2 Fax: 010 - 72 54 363 E-mail: epsilon@hol.gr

¡·‡ÏÈÔ

10-12 OÎÙˆ‚Ú›Ô˘ 2002

2Ô ¶·ÓËÂÈÚˆÙÈÎfi π·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ •ÂÓÔ‰Ô¯Â›Ô “Du Lac”

πˆ¿ÓÓÈÓ·

12-13 OÎÙˆ‚Ú›Ô˘ 2002

∂ÊË‚È΋ π·ÙÚÈ΋ 2002 ¶ÏËÚÔÊÔڛ˜: ∫¤ÓÙÚÔ ¢ËÌÔÛ›ˆÓ ™¯¤ÛˆÓ, ∂ϤÓË Ã·Ï˘‚›‰Ô˘ ∆ËÏ.: 010 - 77 11 673 & 77 56 336 Fax: 010 - 77 11 289

∞ı‹Ó·

19 OÎÙˆ‚Ú›Ô˘ 2002

16Ô ™ÂÌÈÓ¿ÚÈÔ ∂›ÁÔ˘Û·˜ Î·È ∞ı‹Ó· ∂ÓÙ·ÙÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ “∞Ù˘¯‹Ì·Ù·-∫·ÎÒÛÂȘ Î·È ∂ÓÙ·ÙÈ΋ £ÂÚ·›·” ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” ¶ÏËÚÔÊÔڛ˜: °ÂˆÚÁ›· ™È‰¤ÚË ∆ËÏ.: 010 - 77 98 033

xiii

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·390

¶PO™EXH ™YNE¢PIA

19-23 OÎÙˆ‚Ú›Ô˘ 2002

American Academy of Pediatrics 2002 Annual Meeting ¶ÏËÚÔÊÔڛ˜: Congress Secretariat Tel.: 847-228-5005 Fax: 847-228-5059

22-27 OÎÙˆ‚Ú›Ô˘ 2002

49th Annual Meeting of the American San Francisco, CA Academy of Child and Adolescent Psychiatry Tel.: 202-966-7300 Fax: 202-966-2891 E-mail: meetings@aacap.org

28-29 OÎÙˆ‚Ú›Ô˘ 2002

3rd European Conference on Pediatric Asthma ¶ÏËÚÔÊÔڛ˜: Conference Secretariat Castle House Medical Conferences Tel.: 44-0-1892-539-606 Fax: 44-0-1892-517-773 E-mail: asthma@castlehouse.co.uk

London, England

29 ¡ÔÂÌ‚Ú›Ô˘1 ¢ÂÎÂÌ‚Ú›Ô˘ 2002

6Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ º˘ÛÈ΋˜ π·ÙÚÈ΋˜ Î·È ∞ÔηٿÛÙ·Û˘ “¶ÔÈfiÙËÙ· ˙ˆ‹˜ - ¶ÔÈfiÙËÙ· ÊÚÔÓÙ›‰·˜” Triaena Tours & Congress A.E. ∆ËÏ.: 010 - 749 9300 Fax: 010 - 770 5752 E-mail: congress@triaenatours.gr

£ÂÛÛ·ÏÔÓ›ÎË

6-8 ¢ÂÎÂÌ‚Ú›Ô˘ 2002

6Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ æ˘¯ÔÎÔÈÓˆÓÈ΋˜ OÁÎÔÏÔÁ›·˜ ¶ÏËÚÔÊÔڛ˜: ∂æπ§O¡ ∆ËÏ.: 010 - 72 54 360-2 Fax: 010 - 72 54 363 E-mail: epsilonb@hol.gr

∞ı‹Ó·

xiv

Boston, MA

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·391

™YNTOMO°PAºIE™

ABBREVIATIONS

™˘ÓÙÔÌÔÁڷʛ˜

EÏÏËÓÈÎÔ› fiÚÔÈ

AÁÁÏÈÎÔ› fiÚÔÈ

AIDS

Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·˜

AMP, ADP, ATP

ÌÔÓÔ-, ‰È-, ÙÚÈʈÛÊÔÚÈ΋ ·‰ÂÓÔÛ›ÓË

ATPase cal CSF ‹ ENY CNS ‹ ∫¡™ cm CoA cmÑ cm2 cAMP ÆC CRP DNA ECG ‹ ∏∫° EEG ‹ ∏∂° ELISA ESR ‹ ∆∫∂ EDTA g Hct Hb HLA

ÙÚÈʈÛÊ·Ù¿ÛË Ù˘ ·‰ÂÓÔÛ›Ó˘ ıÂÚÌ›‰· ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÂηÙÔÛÙfi Û˘Ó¤Ó˙˘ÌÔ ∞ ΢‚ÈÎfi ÂηÙÔÛÙfi ÙÂÙÚ·ÁˆÓÈÎfi ÂηÙÔÛÙfi ΢ÎÏÈÎfi AMP ‚·ıÌfi˜ KÂÏÛ›Ô˘ C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË ‰ÂÔ͢ÚÈ‚Ô˙ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· ¤Ó˙˘ÌÔ-Û˘Ó‰¤Ù˘ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù·¯‡ÙËÙ· ηıÈ˙‹Ûˆ˜ ÂÚ˘ıÚÒÓ Âı˘ÏÂÓԉȷÌÈÓÔÙÂÙÚ·ÔÍÂ˚Îfi Ô͇ ÁÚ·ÌÌ¿ÚÈo ·ÈÌ·ÙÔÎÚ›Ù˘ ·ÈÌÔÛÊ·ÈÚ›ÓË ·ÓÙÈÁfiÓÔ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜

Ig ICU ‹ ª∂£ IU i.m. ‹ ∂.ª. i.p. ‹ ∂.¶. i.v. ‹ ∂.º.

L log mol ªW ‹ MB MCH MCV mRNA m min n N NS ‹ ª™ Ôsm % PCR pH PCO2 PO2 p

·ÓÔÛÔÛÊ·ÈÚ›ÓË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂÚ·›·˜ ‰ÈÂıÓ‹˜ ÌÔÓ¿‰· ÂÓ‰ÔÌ˘˚ο ÂÓ‰ÔÂÚÈÙÔÓ·˚ο ÂÓ‰ÔÊϤ‚È· Ï›ÙÚÔ(·) ÏÔÁ¿ÚÈıÌÔ˜ ÁÚ·ÌÌÔÌfiÚÈÔ ÌÔÚÈ·Îfi ‚¿ÚÔ˜ ̤ÛË ·ÈÌÔÛÊ·ÈÚ›ÓË ÂÚ˘ıÚÒÓ Ì¤ÛÔ˜ fiÁÎÔ˜ ÂÚ˘ıÚÒÓ ·ÁÁÂÏÈÔÊfiÚÔ˜ RNA ̤ÙÚÔ ÏÂÙfi ·ÚÈıÌfi˜ Ó¢ÙÒÓÈÔ ÌË ÛËÌ·ÓÙÈÎfi ÔÛÌÒÏÈÔ Â› ÙÔȘ ÂηÙfi ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ Û˘ÁΤÓÙÚˆÛË ÈfiÓÙˆÓ ˘‰ÚÔÁfiÓÔ˘ ÌÂÚÈ΋ Ù¿ÛË CO2 ÌÂÚÈ΋ Ù¿ÛË Ô͢ÁfiÓÔ˘ Èı·ÓfiÙËÙ·

acquired immunodeficiency syndrome adenosine 5mono-, di-, triphosphate adenosine triphosphatase calorie cerebrospinal fluid central nervous system centimeter coenzyme A cubic centimeter square centimeter cyclic AMP degree(s) Celsius C-reactive protein deoxyribonucleic acid electrocardiogram electroencephalogram enzyme-linked immunoabsorbent assay erythrocyte sedimentation rate ethylenediaminetetracetate gram haematocrit haemoglobin (human) histocompatibility leucocyte antigen immunoglobulin intensive care unit international Unit intramuscular intraperitoneal intravenous liter logarithm mole molecular weight mean corpuscular haemoglobin mean corpuscular volume messenger RNA meter minute number newton not significant osmole percent polymerase chain reaction potentia hydrogenii carbon dioxide pressure oxygen pressure probability

xvii

sEpT-OcT-02

14-05-03

14:10

™ÂÏ›‰·392

™˘ÓÙÔÌÔÁڷʛ˜

·fi ÙÔ ÛÙfiÌ· Ú·‰ÈÔ·ÓÔÛÔ·ÔÚÚÔÊËÙÈ΋ ‰ÔÎÈÌ·Û›· ÚÈ‚ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÈ·˜ ‰Â˘ÙÂÚfiÏÂÙÔ ˘Ô‰fiÚÈ· ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÛÙ·ıÂÚfi ÛÊ¿ÏÌ· ÌÔÓ¿‰·

p.o.

RIA RNA RDS sec s.c. ‹ À.¢.

SD SE U

™˘Ó‰˘·˙fiÌÂÓ· ÚÔı¤Ì·Ù· 12

tera- (10 ) giga- (10 ) mega-(10 ) kilo- (10 ) hecto(10 ) deca (10 ) deci (10 ) centi- (10 ) milli(10 ) micro (10 ) nano (10 ) pico (10 ) femto (10 ) atto (10 ) 9

6

3

2

1

-1

-2

-3

-6

-9

-12

-15

-18

xviii

EÏÏËÓÈÎÔ› fiÚÔÈ

Combining prefixes T G M k h da d c m Ì n p f a

AÁÁÏÈÎÔ› fiÚÔÈ by mouth radioimmunoassay ribonucleic acid respiratory distress syndrome second subcutaneous standard deviation standard error unit