Ревматизм или новая нозологическая форма? (клинический случай)

Abstract

PANDAS — синдром є відносно новим захворюванням, ще не увійшло до Міжнародної класифікації хвороб X перегляду. Це обумовлено великою схожістю даного захворювання з ГРЛ. Нами представлений клінічний випадок хлопчика 8 років, який поступив в клініку зі скаргами на «шмигання носом», спастичні скорочення м’язів передньої черевної стінки, покашлювання, порушення почерку, ходи, «витягування» шиї, при ходьбі — виведення правої лопатки, дратівливість, запальність, плаксивість. Всі вищеописані симптоми спостерігалися тільки протягом дня, вночі зникали. Захворювання почалося після перенесеного ГРВІ. Сімейний анамнез обтяжений по ревматизму. При обстеженні було виділено бета-гемолітичний стафілокок групи А, титр АСЛО - 400 МО. Проведена терапія через місяць після аденектомії: біовен моно №10 з розрахунку 0,2 г/кг щодня протягом 10 днів, далі галавіт, поліоксідоній протягом місяця. При контрольному обстеженні через 6 місяців спостерігалося значне поліпшення стану дитини; PANDAS – синдром является относительно новым заболеванием, еще не нашедшим своего места в Международной классификации болезней X пересмотра. Это обусловлено большим сходством данного заболевания с ОРЛ. Нами представлен клинический случай ребенка 8 лет, который поступил в клинику с жалобами на «шмыганье носом», спастические сокращения мышц передней брюшной стенки, покашливание, нарушение почерка, походки, «вытягивание» шеи, при ходьбе – выведение правой лопатки, раздражительность, вспыльчивость, плаксивость. Все вышеописанные симптомы наблюдались только в течение дня, ночью исчезали. Заболевание началось после перенесенного ОРВИ. Семейный анамнез отягощен по ревматизму. При обследовании был выделен бета-гемолитический стафилококк группы А, титр АСЛО – 400 МЕ. Проводимая терапия через месяц после аденэктомии: биовен моно №10 из расчета 0,2 г/кг ежедневно в течении 10 дней, далее галавит, полиоксидоний в течении месяца. При контрольном обследовании через 6 месяцев наблюдалось значительное улучшение состояния ребенка; PANDAS syndrome (Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection) is a disease that is not included in the International Classification Disease of X Revisions. Scientists from different countries did not come to the same opinion on clinical symptoms and treatment options for this disease. There is a great similarity in the symptoms of PANDAS syndrome and acute rheumatic fever. The purpose of the study was to draw the attention of pediatricians to the problem of rheumatic diseases in children and to a new nosological form — PANDAS syndrome. To object and methods of the study: we present the clinical case of the boy K., 8 years old, who was observed at the clinic diagnosed with PANDAS syndrome during 1 year. The results obtained and their discussion: the child was admitted to the clinic in March 2016 with complaints about «nose sniffing», spasmodic contractions of the muscles of the anterior abdominal wall, coughing, handwriting, gait, neck stretching, walking — irritability, tearfulness. All the above symptoms were observed only during the day, at night they disappeared. From the history of the disease it is known that the first symptoms appeared at the age of 5 years 2 months after the acute respiratory infection. Throughout the time of illness the child was observed by different specialists (neurologist, otolaryngologist, immunologist, cardiorevmatologist, vertebrologist, infectious disease specialist). He received various treatment: antibiotic therapy, antiviral therapy, nonsteroidal anti-inflammatory drugs, nootropic drugs, sedatives, vitamins, physiotherapy. As the mother said, the child’s condition improved periodically, the symptoms of the disease became less seen, however, after tolerable acute viral infection or stress, a acute attack occurred. A family history is of great interest. Acute viral infection, after which the first symptoms of the disease in the child appeared, were transferred by mother and the eldert daughter. After 2 weeks, the mother had pain in the right wrist joint and right shoulder joint. Anti-inflammatory therapy did not give any effect. Significant improvement in the condition occurred after a course of antibiotic therapy. The eldert daughter after a previous acute respiratory viral infection began often to get sick, an ENT doctor and an immunologist follwed her up. Thus, the information obtained makes it possible to suspect family carriage of beta-hemolytic streptococcus group A with various clinical manifestations. Discussing the various treatment protocols described in the literature, we used the recommendations developed by V.I. Kharitonov, Yu.M. Vinnikom, G.I. Selyukov (TMO «Psychiatry», Kiev). After the treatment, the child’s condition improved significantly, but the sniffing and coughing persisted. In connection with the long chronic process, frequent exacerbations, it was decided to conduct tonsilectomy in a planned manner. A month after the operation, the child was given a course of immunomodulating therapy bioven mono № 10. It is recommended to continue treatment: galavit, polyoxidonium within a month. In January 2017, during the control examination, we observed a significant improvement in the child’s condition. There was a complete disappearance of symptoms of abnormal gait, handwriting. Improved compulsive movements of the hands, tick-like hyperkinesia of facial muscles, muscles of the anterior abdominal wall, neck. ASLO — negative. However, infrequent «sniffing» of the nose is preserved. The child attends school, continued his studies at the music school by the guitar class. At the moment, clinical and laboratory remission is 8 months. Conclusions. Thus, this clinical case is an example of successful therapy and draws attention to the complexity of diagnosis and treatment of PANDAS syndrome.