소아에서 전신성 낭창의 임상적 고찰

A clinical study of systemic lupus erythematosus in children

  • 김지태 (연세대학교 의과대학 소아과학교실) ;
  • 남영미 (연세대학교 의과대학 소아과학교실) ;
  • 이재승 (연세대학교 의과대학 소아과학교실) ;
  • 김동수 (연세대학교 의과대학 소아과학교실)
  • Kim, Ji Tae (Department of Pediatrics, Severance Children's Hospital, Yonsei University Medical Center) ;
  • Nam, Young Mee (Department of Pediatrics, Severance Children's Hospital, Yonsei University Medical Center) ;
  • Lee, Jae Seung (Department of Pediatrics, Severance Children's Hospital, Yonsei University Medical Center) ;
  • Kim, Dong Soo (Department of Pediatrics, Severance Children's Hospital, Yonsei University Medical Center)
  • 투고 : 2006.10.13
  • 심사 : 2006.12.19
  • 발행 : 2007.01.15

초록

목 적 : 전신성 홍반성 낭창(systemic lupus erythematosus, SLE)은 장기간에 걸쳐 다양한 임상경과를 나타내며 여러장기를 침범하는 자가 면역성 질환으로 유전적, 환경적, 면역학적 요인 등에 의한 면역 조절계의 이상으로 생각되고 있다. 소아에서는 갑작스럽게 발병하며, 경과가 빠르게 악화되며 여러 장기를 동시에 침범한다. 따라서 소아에서 조기 진단하여 조기 치료하는 것이 SLE의 예후 개선에 더욱 중요한 점으로 생각된다. 이에 저자들은 소아에서 발생한 SLE 환아의 임상 양상, 검사 소견, 예후에 대해 전반적으로 고찰하여 질환의 진단 및 예후의 향상을 기대하고자 한다. 방 법 : 1996년 1월부터 2005년 12월까지 10년간 신촌 세브란스 병원 소아과에서 전신성 홍반성 낭창으로 진단받은 45례의 환아를 대상으로 의무기록을 후향적으로 고찰하였다. 결 과 : 진단 당시 평균발병 연령은 $10.8{\pm}3.8$(0-15)세였으며 10-15세 사이에서 호발(68.9%)했으며 환아의 남녀비는 1:4였다. 진단시 초기증상으로 안면 부종(51.1%), 나비모양 홍반(44.4%), 발열(28.9%), 관절통(15.6%), 빈혈(13.3%) 및 광과민성(11.1%)순 이였다. SLE의 ARA 진단 기준중 항목별 양성률은 형광항핵항체(97.8%), 항ds DNA항체(82.2%), 루프스 신염(71.1%), 나비형 홍반(71.1%) 및 혈액학적 이상(66.7%)의 순이었다. 진단 당시 루프스 신염이 동반 되었던 경우는 45례 중 23례(51.1%)였으며 치료 중 8례가 루프스 신염으로 새로 진단되어 그 빈도가 71.1%로 조사되었고 신생검상 WHO class IV 병변인 미만성 증식성 사구체 신염(43.8%)이 가장 많았다. 2례는 완치되었으며, 2례 모두 신생아 루프스였다. 우리나라 아동에서 외국에 비하여 발열, 광과민성, 입궤양, 관절통, 늑막염은 적게 관찰되는 양상을 보였다. 결 론 : 소아에서 전신성 홍반성 낭창의 임상 양상과 예후는 다양하다. 장기적인 추적 관찰이 필요하며 예후의 향상을 위해 조기 진단과 적극적인 치료가 중요하며, 향후 이 질환에 대한 심도 있는 연구가 지속되어야 할 것이다.

Purpose : Systemic lupus erythematosus (SLE) is a chronic multisystemic autoimmune disease with complex clinical manifestations. It probably involves genetic, environmental and immunologic factors. In this study, we investigated the clinical manifestations, laboratory findings and prognosis of pediatric SLE to aid clinical care of pediatric SLE. Methods : The data of 45 patients who were diagnosed as pediatric SLE in Severance Children's Hospital from Jan. 1996 to Dec. 2005 were analysed retrospectively. Results : The mean age at diagnosis was 10.8 (0-15) years old. And the ratio of male to female patients was 1:4. The initial manifestations were facial edema (51.1 percent), malar rash (44.4 percent), and fever (28.9 percent). The ANA (97.8 percent), anti-ds DNA antibody (82.2 percent), lupus nephritis (71.1 percent), malar rash (71.1 percent), and cytopenia (66.7 percent) were the most common findings among the classification criteria by ACR (American College of Rhematology, 1997). Conclusion : Clinical manifestations and prognosis are various in pediatric SLE. Intensive studies of SLE in children should be continued for more effective treatment.

키워드

참고문헌

  1. Font J, Cervera R, Espinosa G, Pallares L, Ramos-Casals M, Jimenez S, et al. Systemic lupus erythcmatosus(SLE) in childhood: Analysis of clinical and immunological findings in 34 patients and comparison with SLE characteristics in adults. Ann Rheum Dis. 1998;57:456-9 https://doi.org/10.1136/ard.57.8.456
  2. Kim CH, Lee SY, Kye YC, Moon KC, Kim SN. A clinical observation on systemic lupus erythematosus. Kor J Dermatol 1994;32:258-70
  3. Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheumatol 1997:40:1725
  4. Emery H. Clinical aspects of SLE. Pediatr Clin North Am 1986;33:1177-90 https://doi.org/10.1016/S0031-3955(16)36114-4
  5. Tucker LB, Menon S, Schaller JG, Isenberg DA. Adult and childhood-onset systemic lupus erythematosus: A comparison of onset, clinical features, serology, and outcome. Br J Rheumatol 1995;34:866-72 https://doi.org/10.1093/rheumatology/34.9.866
  6. Iqbal S, Sher MR, Good RA, Cawkwell GD. Diversity in presenting manifestations of systemic lupus erythematosus in children. J Pediatr 1999;135:500-5 https://doi.org/10.1016/S0022-3476(99)70174-5
  7. Benseler SM, Siverman ED. Systemic lupus erythematosus. Pediatr Clin North Am 2005;52:443-67 https://doi.org/10.1016/j.pcl.2005.01.010
  8. Bogdanovic R, Nikolic V, Pasic S, Dimitrijevic J, Lipkovska-Markovic J, Eric-Marinkovic J, et al. Lupus nephritis in childhood: A review of 53 patients followed at a single center. Pediatr Nephrol 2004;19:36-44 https://doi.org/10.1007/s00467-003-1278-y
  9. Miettunen PM, Ortiz-Alvarez O, Petty RE, Cimaz R, Malleson PN, Cabral DA, et al. Gender and ethnic origin have no effect on longterm outcome of childhood-onset systemic lupus erythematosus. J Rheumatol 2004;31:1650-4
  10. Sibbitt WL Jr, Brandt JR, Johnson CR, Maldonado ME, Patel SR, Ford CC, et al. The incidence and prevalence of neuropsychiatric syndromes in pediatric onset systemic lupus erythematosus. J Rheumatol 2002;29:1536-42
  11. Brunner HI, Silverman ED, To T, Bombardier C, Feldman BM. Risk factors for damage in childhood-onset systemic lupus erythematosus: Cumulative disease activity and medication use predict disease damage. Arthritis Rheum 2002;46:436-44 https://doi.org/10.1002/art.10072
  12. Lo JT, Tsai MJ, Wang LH, Huang MT, Yang YH, Lin YT, et al. Sex differences in pediatric systemic lupus erythematosus : A retrospective analysis of 135 cases. J Microbiol Immunol Infect 1999;32:173-8
  13. Yoo HW, Cheong HI, Lee HJ, Choi Y, Kim YI, Ko KW. A clinical observation on systemic lupus erythematosus in children. J Korean Pediatr Soc 1987;30:527-35
  14. David S. Pisetsky. Systemic lupus erythematosus. Med Clin North Am 1986;70:337-53 https://doi.org/10.1016/S0025-7125(16)30957-9
  15. King KK, Korneich HK. A long term immunological study of childhood onset systemic lupus erythematosus. Ann Rheum Dis 1992;51:45-51 https://doi.org/10.1136/ard.51.1.45
  16. Jeong JA, Kim YM, Suh ES, Kim SH, Kang CM, Lee SS, et al. Four cases of childhood systemic Lupus erythematosus. J Korean Pediatr Soc 1990;33:264-73
  17. Park JN, Choi JK, Lee HB, Lee H. A clinical observation in 14 children with SLE. J Korean Pediatr Soc 1994;37:510-22
  18. Kim YJ, Kim YD, Park JH, Kim SY, Park HJ. A clinical study of childhood systemic lupus erythematosus. J Korean Pediatr Soc 1994;37:1235-47
  19. Park JM, Shin J1, Kim BK, Lee JS. Clinical manifestation and treatment outcome of lupus nephritis in children. J Korean Soc Pediatr Nephrol 2002;10:155-68
  20. Hargraves MM, Richmond H, Morton R. Presentation of two bone marrow elements. The target cell and the LE cell. Prec Staff Meet Mayo Clin 1948;23:25
  21. Allison AC. Autoimmune diseases: Concepts of pathogenesis and control in autoimmunity: Genetic, immunologic, virologic and clinical aspects, edited by Talal N, New York, Academic press. 1977;92-139
  22. Schwartz RS. Immunologic and genetic aspects of SLE. Kindey Int 1981;19:474-84
  23. Chrisrian CL. Role of viruses in etiology of SLE. Am J Kid Dis 2(Suppl) 1982;114-8
  24. Stichweh D, Pascual V. Systemic lupus erythematosus in children. An Pediatr(Barc) 2005;63(4):319-27
  25. James JA, Kaufman KM, Farris AD, Taylor-Albert E, Lehman TJ, Harley JB. An increased prevalence of Epstein-Barr virus infection in young patients suggests a possible etiology for systemic lupus erythematosus. J Clin Invest 1997;100:3019-26 https://doi.org/10.1172/JCI119856
  26. Moon UY, Park SJ, Oh ST, Kim WU, Park SH, Lee SH, et al. Patients with systemic lupus erythematosus have abnormally elevated Epstein-Barr virus load in blood. Arthritis Res Ther 2004;6:R295-302 https://doi.org/10.1186/ar1181
  27. Block SR, Winfield JB, Lockshin MD, D'Angelo WA, Christian CL. Studies of twins with systemic lupus erythematosus. A review of the literature and presentation of 12 additional sets. Am J Med 1975;59:533-52 https://doi.org/10.1016/0002-9343(75)90261-2
  28. Deapen D, Escalante A, Weinrib L, Horwitz D, Bachman B, Roy-Burman P, et al. A revised estimate of twin concordance in systemic lupus erythematosus. Arthritis Rheum 1992;35:311-8 https://doi.org/10.1002/art.1780350310
  29. Schaller JG, Gilliard GB, Ochs HD. Severe systemic lupus erythematosus with nephritis in a boy woth deficeincy of the fourth component of complement. Arthritis Rheum 1977;20:656-9
  30. Manderson AP, Botto M, Walport MJ. The role of complement in the development of systemic lupus erythematosus. Annu Rev Immunol 2004;22:431-56 https://doi.org/10.1146/annurev.immunol.22.012703.104549
  31. Lim CS, Chin HJ, Jung YC, Kim YS, Ahn C, Han JS. Prognostic factor of diffuse proliferative lupus nephritis. Clin Nephrol 1999;52:139-47
  32. Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield NF, et al. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheumatol 1982;25:1271-7 https://doi.org/10.1002/art.1780251101