儿童自身炎症性疾病诊断与治疗专家共识
doi: 10.12376/j.issn.2097-0501.2022.03.011
Experts Consensus on Diagnosis and Treatment of Autoinflammatory Diseases
-
摘要: 自身炎症性疾病(AIDs)是由基因突变引起其编码蛋白发生改变,造成固有免疫系统失调而引起全身炎症反应的一组疾病。这组疾病以反复或持续的炎症反应为特点(急性时相炎症蛋白升高),缺乏适应性免疫系统的参与(缺乏自身反应性T细胞和自身抗体)。AIDs种类繁多,临床表现和发病机制多样,根据其临床特点及发病机制分为不同种类。对于起病年龄小、具有反复发作性的发热和其他全身炎症反应表现及家族史的患儿需考虑到AIDs的可能,明确诊断依赖于病史、临床表现和基因检测结果的综合分析。治疗AIDs的常用药物包括非甾体类抗炎药、糖皮质激素、免疫抑制剂和生物制剂。早期诊断并积极治疗AIDs可有效减轻全身炎症、缓解脏器损伤、降低远期并发症的发生率。为规范AIDs的诊治,中华医学会儿科学分会风湿病学组等特制订AIDs诊断与治疗专家共识。Abstract: Autoinflammatory diseases(AIDs) are a group of diseases caused by gene mutations that change coding proteins, leading to the imbalance of innate immune system and leads to systemic inflammatory response. This group of diseases is characterized by repeated or continuous inflammatory response(increased acute phase inflammatory protein) and lack of synergy of the adaptive immune system(lack of autoreactive T cells and autoantibodies). AIDs have a wide variety of clinical manifestations and pathogenesis. They can be divided into different types according to clinical characteristics and pathogenesis. For patients with a young onset age, the possibility of AIDs should be considered if manifestations of recurrent fever in addition to other systemic inflammatory manifestations are seen, along with family history. It is clear that the diagnosis depends on the comprehensive analysis of medical history, clinical manifestations and gene test results. Drugs for the treatment of AIDs include non-steroidal anti-inflammatory drugs, glucocorticoids, immunosuppressants and biological agents. Early diagnosis and active treatment of AIDs can effectively reduce systemic inflammation, alleviate organ injury and reduce the incidence of long-term complications. In order to standardize the diagnosis and treatment of AIDs, the Subspecialty Group of Rheumatology, the Society of Pediatrics, Chinese Medical Association specially formulated the experts consensus on the diagnosis and treatment of AIDs.
-
Key words:
- autoinflammatory disease /
- diagnosis /
- treatment /
- consensus
-
图 1 AIDs诊断流程图
FMF: 家族性地中海热; HIDS: 高IgD综合征: TRAPS: 肿瘤坏死因子受体相关周期性发热综合征; CINCA: 慢性婴儿神经皮肤关节综合征; MWS: 穆克勒-韦尔斯综合征; FCAS: 家族性寒冷性自身炎症综合征; SAVI: 婴幼儿起病的STING相关血管病; AGS: Aicardi-Goutieres综合征; DADA2:腺苷脱氨酶2缺乏症; PAPA: 化脓性无菌性关节炎-坏疽性脓皮病-痤疮综合征; PAAND: 与pyrin相关的伴有嗜中性粒细胞性皮肤病的自身炎症性疾病; DIRA: 白介素1受体拮抗剂缺乏症; PRAAS: 蛋白酶体相关的自身炎症综合征; ORAS: OTULIN相关的自身炎症性疾病
Figure 1. Diagnostic flowchart of autoinflammatory diseases
表 1 自身炎症性疾病按临床表型的分类
Table 1. Classification of autoinflammatory diseases by clinical phenotype
临床表型 疾病 非特异性斑丘疹伴复发性周期性发热和腹痛 短时间内反复发热(典型<7 d) FMF、HIDS 持续时间较长的反复发热(典型>7 d) TRAPS 嗜中性粒细胞荨麻疹 发热反复发作但持续时间短(通常<24 h) CAPS/FCAS、CAPS/MWS 持续发热 CAPS/CINCA 肉芽肿样皮肤病变伴低热 Blau综合征 脓疱性皮疹和间歇性发热 伴炎性骨病 DIRA、Majeed综合征 伴化脓性关节炎 PAPA谱系疾病 伴炎性肠病 早发IBD 伴其他脏器受累 DITRA、CAMPS 非典型中性粒细胞性皮肤病,有组织样细胞浸润 PRAAS 具有自身炎症和免疫缺陷的综合征 PLAID、APLAID、HOIL-1缺陷 FMF:家族性地中海热;HIDS:高IgD综合征;TRAPS:肿瘤坏死因子受体相关周期性综合征;CAPS/FCAS:冷炎素相关周期性综合征/家族性寒冷性自身炎症综合征;CAPS/MWS:冷炎素相关周期性综合征/穆克勒-韦尔斯综合征;CAPS/CINCA:冷炎素相关周期性综合征/慢性婴儿神经皮肤关节综合征;DIRA:白细胞介素1受体拮抗剂缺乏症;PAPA:化脓性关节炎、坏疽性脓皮病和痤疮综合征;IBD:炎性肠病;DITRA:白细胞介素36受体拮抗剂缺乏症;CAMPS:CARD14介导的银屑病;PRAAS:蛋白酶体相关的自身炎症综合征;PLAID:PLCγ-2相关的抗体缺陷和免疫紊乱;APLAID:PLCγ-2相关的自身炎症、抗体缺陷和免疫紊乱;HOIL-1:氧化血红素IRP2泛素连接酶-1 表 2 根据参与自身炎症性疾病发病机制的主要炎症信号通路的分类及各类疾病相应的临床表现
Table 2. Classification of main inflammatory signaling pathways involved in the pathogenesis of autoinflammatory diseases and clinical manifestations of various diseases
疾病 遗传方式 突变基因 临床表现 IL-1信号通路疾病 CAPS(FCAS、MWS和CINCA) AD或新发突变 NLRP3 FCAS:寒冷诱发的荨麻疹、发热、关节痛 MWS:发热、皮疹、关节痛、感音神经性耳聋 CINCA:新生儿期起病的发热、无菌性脑膜炎、感音神经性耳聋 FMF AR MEFV 周期性发热、浆膜炎、皮疹、淀粉样变性 PAAND AD MEFV 发热,脓疱性痤疮,脓皮病,嗜中性粒细胞性皮肤病,关节痛 NLRC4-MAS AD NLRC4 反复MAS,肠炎,寒冷诱发的发热和荨麻疹,中枢神经系统炎症 NAIAD AD/AR NLRP1 全身炎症,关节炎,角化不良 HIDS/MKD AR MVK 发热,坏疽,皮疹,淋巴结大,腹痛,呕吐 PAPA谱系疾病 AD PSTPIP1 脓皮病,化脓性关节炎,严重的囊肿性痤疮 APLAID AD PLCG2 寒冷性荨麻疹,肺间质病变,复发性水疱,关节痛,眼部炎症,小肠结肠炎和抗体缺乏 PFIT AR WDR1 周期性发热、免疫缺陷、血小板减少 Majeed综合征 AR LPIN2 贫血,骨髓炎,嗜中性粒细胞性皮肤病 DIRA AR IL1RN 骨炎,脓疱性皮损 IFN信号通路疾病 PRAAS(CANDLE、NNS和JMP) AR PSMB8、PSMB4、PSMA3、PSMB9、POMPv 发热,全身炎症反应,嗜中性粒细胞性皮肤病,肌炎,脂膜炎,基底节钙化 SAVI AR TMEM173 血管炎,血栓性微血管病,肺间质疾病 AGS AR或AD TREX1、RNASEH2A、RNASEH2B、RNASEH2C、SAMHD1、ADAR、IFIH1 基底节钙化,冻疮样皮疹,长期的认知缺陷 Singleton-Merten综合征 AD DDX58 (RIG-I) 青光眼,骨骼异常,主动脉钙化,银屑病 SPENCDI AR ACP5 中轴骨发育不良、颅内钙化和自身免疫性疾病(如溶血性贫血、自身免疫性甲状腺炎或系统性红斑狼疮) NF-κB信号通路疾病 NLRP12相关疾病 AD NLRP12 寒冷诱发的发热,皮疹,关节痛,肌痛 Blau综合征 AD或新发突变 NOD2 早发结节病,葡萄膜炎,肉芽肿性多关节炎 CARD14介导的银屑病 AD CARD14 银屑病,红糠疹,脓疱型银屑病 HA20 AD TNFAIP3 发热、口腔和外生殖器溃疡、关节炎、眼部炎症 ORAS AR FAM105B(Otulin) 发热,嗜中性粒细胞性皮肤病,脂肪营养不良,发育不良 蛋白折叠障碍疾病 TRAPS AD TNFSRF1A 长期周期性发热,腹痛,眶周水肿 其他细胞因子介导 DITRA AR IL36RN 周期性发热,脓疱性皮疹 IL-10缺乏症 AR IL10、IL10RA、IL10RB 早发IBD 其他分类不明确疾病 SIFD AR TNRT1 铁粒幼细胞贫血,B细胞缺陷,发热,发育延迟 DADA2 AR CECR1 早发中风,血管炎(结节性多动脉炎、网状青斑)、免疫缺陷、贫血 CAPS:冷炎素相关周期性综合征;FCAS:家族性寒冷性自身炎症综合征;MWS:穆克勒-韦尔斯综合征;CINCA:慢性婴儿神经皮肤关节综合征;FMF:家族性地中海热;PAAND:与pyrin相关的伴有嗜中性粒细胞性皮肤病的自身炎症性疾病;NLRC4-MAS:NLRC4相关的巨噬细胞活化综合征;NAIAD:伴关节炎和角化不良的NLRP1相关的自身炎症性疾病;HIDS:高IgD综合征;MKD:甲羟戊酸激酶缺乏症;PAPA:化脓性无菌性关节炎-坏疽性脓皮病-痤疮综合征;APLAID:PLCγ-2相关的自身炎症、抗体缺陷和免疫紊乱;PFIT:周期性发热、免疫缺陷和血小板减少;DIRA:IL-1受体拮抗剂缺陷;PRAAS:蛋白酶体相关的自身炎症综合征;CANDLE:慢性非典型中性粒细胞性皮炎伴脂肪营养不良和发热;NNS:中条-西村综合征;JMP:关节挛缩-肌萎缩-小细胞性贫血-脂膜炎相关脂营养不良;SAVI:婴幼儿起病的STING相关血管病;AGS:Aicardi-Goutieres综合征;SPENCDI:椎体软骨发育不良伴免疫调节失调;NF:核因子;HA20:A20的单倍体不足;ORAS:OTULIN相关的自身炎症性疾病;TRAPS:肿瘤坏死因子受体相关周期性发热综合征;DITRA:IL-36受体拮抗剂缺陷;SIFD:铁粒细胞性贫血-免疫缺陷-发热-发育迟缓;DADA2:腺苷脱氨酶2缺乏症;AD:常染色体显性遗传;AR:常染色体隐性遗传;MAS:巨噬细胞活化综合征;IBD:炎性肠病 表 3 非甾体类抗炎药的用法及剂量
Table 3. The usage and dose of non steroidal anti-inflammatory drugs
药物 开始年龄 剂量[mg/(kg·d)] 用法(次/日) 最大剂量(mg/d) 双氯芬酸钠 6个月 1~3 3 150 萘普生 2岁 10~15 2 400 布洛芬 6个月 30~40 3~4 1200 塞来昔布 2岁 6~1 2 400 表 4 IL-1β抑制剂的作用机制及剂量
Table 4. The mechanism and dose of IL-1β antagonists
药物 结构 半衰期 用法与剂量 阿那白滞素(anakinra) 重组IL-1受体拮抗剂 4~6 d 皮下注射
起始剂量:1~2 mg/(kg·d),最大剂量100 mg
维持剂量:2~3 mg/(kg·d)列洛西普(rilonacept) 人IgG1的Fc段与IL-1受体、IL-1受体辅助蛋白结合的融合蛋白 8.6 d 皮下注射
负荷剂量:4.4 mg/(kg·周),最大剂量320 mg
维持剂量:2.2 mg/(kg·周),最大剂量160 mg卡那单抗(canakinumab) 人源化的IL-1β IgG1/κ亚型单克隆抗体 28 d 皮下注射
体质量>40 kg:150 mg,每8周1次
体质量15~40 kg:2 mg/kg,每8周1次,反应不佳者可增加至3 mg/kg格沃吉珠单抗(gevokizumab) 人源化的IL-1β IgG1/κ亚型单克隆抗体 23 d 静脉注射或皮下注射
0.3 mg/kg,每8周1次 -
[1] Pathak S, Mcdermott MF, Savic S. Autoinflammatory diseases: update on classification diagnosis and management[J]. J Clin Pathol, 2017, 70: 1-8. doi: 10.1136/jclinpath-2016-203810 [2] Ben-Chetrit E, Gattorno M, Gul A, et al. Consensus proposal for taxonomy and definition of the autoinflammatory diseases(AIDs): a Delphi study[J]. Ann Rheum Dis, 2018, 77: 1558-1565. doi: 10.1136/annrheumdis-2017-212515 [3] Almeida DJA, Goldbach-Mansky R. Monogenic autoinflammatory diseases: concept and clinical manifestations[J]. Clin Immunol, 2013, 147: 155-174. doi: 10.1016/j.clim.2013.03.016 [4] Grateau G, Hentgen V, Stojanovic KS, et al. How should we approach classification of autoinflammatory diseases?[J]. Nat Rev Rheumatol, 2013, 9: 624-629. doi: 10.1038/nrrheum.2013.101 [5] Kastner DL, Aksentijevich I, Goldbach-Mansky R. Autoinflammatory disease reloaded: a clinical perspective[J]. Cell, 2010, 140: 784-790. doi: 10.1016/j.cell.2010.03.002 [6] Manthiram K, Zhou Q, Aksentijevich I, et al. The mono-genic autoinflammatory diseases define new pathways in human innate immunity and inflammation[J]. Nat Immunol, 2017, 18: 832-842. doi: 10.1038/ni.3777 [7] Federici S, Gattorno M. A practical approach to the diagnosis of autoinflammatory diseases in childhood[J]. Best Pract Res Clin Rheumatol, 2014, 28: 263-276. doi: 10.1016/j.berh.2014.05.005 [8] Gómez-Arias PJ, Gómez-García F, Hernández-Parada J, et al. Efficacy and safety of Janus kinase inhibitors in type I Interferon-Mediated monogenic autoinflammatory disorders: a scoping review[J]. Dermatol Ther(Heidelb), 2021, 11: 733-750. doi: 10.1007/s13555-021-00517-9 [9] Morand EF, Furie R, Tanaka Y, et al. Trial of anifrolumab in active systemic lupus erythematosus[J]. N Engl J Med, 2020, 382: 211-221. doi: 10.1056/NEJMoa1912196 -