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Morbus Still im Kindes- und Erwachsenenalter

Still’s disease in children and adults

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Zusammenfassung

Die systemische juvenile idiopathische Arthritis (sJIA) ist durch Fieber, Arthritis und weitere Symptome systemischer Inflammation gekennzeichnet. Historisch ist sie nach ihrem Erstbeschreiber George Frederic Still als Morbus Still benannt. Tritt die Erkrankung bei Erwachsenen auf, wird sie als adulte Still-Erkrankung („adult onset Still’s disease“, AOSD) bezeichnet. Die Pathophysiologie der sJIA und der AOSD wird inkomplett verstanden. Die gesteigerte Aktivierung von Inflammasomen und die Expression proinflammatorischer Zytokine spielen eine zentrale Rolle. S100-Proteine, die durch die Aktivierung von Toll-like-Rezeptoren als positiver Verstärker wirken, sind ebenso erhöht im Serum von sJIA-Patienten messbar. Reduzierte Produktion des immunmodulatorischen Zytokins IL-10 könnte zudem zur Aktivierung von Immunzellen und der Produktion inflammatorischer Botenstoffe beitragen. In diesem Beitrag werden die klinische Präsentation, die Differenzialdiagnostik, der aktuelle Wissensstand zur Pathophysiologie sowie Therapieoptionen der sJIA und der AOSD diskutiert.

Abstract

Systemic juvenile idiopathic arthritis (sJIA) is characterized by fever, arthritis, and other signs of systemic inflammation. Historically, sJIA was named Still’s disease after George Frederic Still, who first reported patients. Individuals who manifest after the 16th birthday are diagnosed with adult onset Still’s disease (AOSD). The pathophysiology of sJIA and AOSD are incompletely understood. Increased activation of inflammasomes and the expression of proinflammatory cytokines play a central role. S100 proteins, which can activate Toll-like receptors, thus, maintaining positive feedback loops, have also been detected at increased levels in sera from sJIA patients. Reduced expression of the immune-modulatory cytokine IL-10 may further contribute to immune cell activation and the production of proinflammatory molecules. Here, we discuss the clinical picture, differential diagnoses, the current pathophysiological understanding, and treatment options in sJIA and AOSD.

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Authors and Affiliations

  1. Arbeitsbereich Pädiatrische Rheumatologie und Immunologie, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland

    C. M. Hedrich

  2. Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Deutschland

    C. Günther

  3. Bereich Rheumatologie, Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Deutschland

    M. Aringer

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  1. C. M. Hedrich
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Correspondence to C. M. Hedrich.

Ethics declarations

Interessenkonflikt

C.M. Hedrich nahm an Advisory Boards der Fa. Novartis zum Thema systemische juvenile idiopathische Arthritis teil und erhielt Honorare für Vorträge zur sJIA durch die Firma Roche. M. Aringer nahm an Advisory boards von AbbVie, Chugai, MSD, Pfizer und Roche teil. C. Günther gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Additional information

Redaktion

M. Meurer, Dresden

S. Ständer, Münster

E. von Stebut-Borschitz, Mainz

R.-M. Szeimies, Recklinghausen

CME-Fragebogen

CME-Fragebogen

Sie betreuen ein 8‑jähriges Mädchen mit hohem Fieber (bis 40 °C) seit 2 Wochen, Oligoarthritis, Hepatosplenomegalie und tiefrotem Exanthem. Welche der folgenden Differenzialdiagnosen trifft anhand der berichteten Klinik nicht zu?

Systemische juvenile idiopathische Arthritis

Leukämie

Disseminiertes Granuloma anulare

Lymphom

Infektiöse Mononukleose

Welches der folgenden Symptome ist kein Klassifikationskriterium für die systemische juvenile idiopathische Arthritis?

Hohes Fieber seit 2 Wochen

Exanthem

Lymphadenopathie

Arthralgien

Hepatomegalie

Welche der folgenden Therapien ist aktuell nicht für die Therapie der sJIA mit Polyarthritis zugelassen?

Methotrexat

Anakinra

Canakinumab

Tocilizumab

Ibuprofen

Welche der folgenden Komplikationen ist bei der systemischen JIA eher unwahrscheinlich?

Amyloidose

Schwere destruierende Polyarthritis

Wachstumsverzögerung

Kachexie

ZNS-Verkalkungen

Welche der folgenden Erkrankungen erfüllt nicht die Kriterien, um als „klassische“ autoinflammatorische Erkrankung eingeordnet zu werden?

TRAPS (TNF-Rezeptor assoziiertes periodisches Syndrom)

Systemische JIA

Adulter Morbus Still

Systemischer Lupus erythematodes

Familiäres Mittelmeerfieber

Welche der folgenden Aussagen über die sJIA trifft nicht zu?

Es gibt chronische Verläufe mit anhaltend hoher systemischer Entzündung.

Das Makrophagenaktivierungssyndrom ist eine vital bedrohliche Komplikation.

Es gibt zeitlich begrenzte monophasische Verläufe.

Bei einem Teil der Patienten sind IgM-Rheumafaktoren nachweisbar.

Bei Jungen über 6 Jahren gilt HLA-B27-Positivität als Ausschlusskriterium.

Welcher deutlich auffällige Laborbefund würde nicht zu einer AOSD passen?

ANA hochtitrig positiv

Anämie chronischer Erkrankungen

CRP deutlich erhöht

Ferritin deutlich erhöht

Serum-Amyloid A deutlich erhöht

Bei einer jungen Erwachsenen hat sich aus einer AOSD eine seronegative chronische Polyarthritis entwickelt. Methotrexat hält die Erkrankung nicht ausreichend unter Kontrolle. Welches Biologikum ist jetzt aufgrund von Beobachtungen in größeren Fallserien Erfolg versprechend?

Abatacept

Anakinra

Etanercept

Rituximab

Tocilizumab

Welche Aussage trifft zu? Das Exanthem beim Morbus Still …

erscheint einige Tage nach beginnender Abheilung der Erkrankung.

tritt bevorzugt während der Fieberschübe mittags oder abends auf.

tritt nie in Zusammenhang mit Fieber auf.

erscheint in den frühen Morgenstunden.

erscheint mit den Fieberschüben an Händen und Fußsohlen.

Welche Aussage trifft zu? Das Exanthem zeigt sich in Form von …

flüchtigen blassrosa bis lachsfarbenen Makulä am Stamm.

girlandenförmigen schuppenden Plaques an den Extremitäten.

über mindestens 24 h bestehenden urtikariellen Infiltraten.

disseminiert makulopustulösen Effloreszenzen mit Betonung der Beugen.

über 3 Wochen persistierenden makulopapulösen Infiltraten am Stamm.

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Hedrich, C.M., Günther, C. & Aringer, M. Morbus Still im Kindes- und Erwachsenenalter. Hautarzt 68, 497–511 (2017). https://doi.org/10.1007/s00105-017-3983-7

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