Inoue Chiyoko N, Matsutani Sachiko, Ishidoya Masako, Homma Rikako, Chiba Yasushi, Nagasaka Takako
Department of Pediatrics, Red Cross Sendai Hospital, Sendai, Japan.
Adv Otorhinolaryngol. 2011;72:53-6. doi: 10.1159/000324605. Epub 2011 Aug 18.
Henoch-Schönlein purpura (HSP) and IgA nephropathy (IgAN) are both IgA1-related vasculitis caused by vascular deposition of IgA1-containing immune complexes. A pathological role of the tonsils in the development of HSP and IgAN has been suggested. Tonsils are a mucosaassociated lymphoid organ. Since oral and sinonasal cavities are anatomically directly connected to the tonsils, delivering exogenous antigens into the tonsils to induce local and systemic antibody responses, we examined the infectious status of these cavities when we treated HSP and IgAN. In 40 HSP children (6.7±2.5 years), apical periodontitis, rhinosinusitis, and otitis media were identified in 21 (53%, 4.9±2.8 affected teeth), 19 (48%), and 4 (10%) of them, whereas in 11 IgAN children (10.4±2.5 years), these diseases were observed in 6 (55%, 5.8±4.6 affected teeth), 2 (18%), and 0 (0%) of them, respectively. We first treated the patients with extensive eradiation of infectious foci, including antimicrobial treatment and root canal therapy. In 31 HSP patients, such dental and/or ENT therapy resulted in a complete cure without development of nephritis or recurrent attacks. For the remaining 9 HSP and 11 IgAN patients, we further performed tonsillectomy plus methylprednisolone (MP) pulse therapy to control their intractable symptoms, including aggravated purpura, recurrent HSP attacks or nephritis. Using this therapeutic strategy, all of the HSP patients attained clinical remission. All of the IgAN patients with various histological grades also achieved normalization of urinalysis by 7.2±5.7 months after the start of steroid therapy. No relapses were observed in both diseases during followup for 2-10 years. In pediatric HSP and IgAN, apical periodontitis and rhinosinusitis may be involved in abnormal immune responses in both the tonsils and whole body. We conclude that extensive elimination of these infectious foci is beneficial to optimize the effect of tonsillectomy plus MP pulse therapy.
过敏性紫癜（HSP）和IgA肾病（IgAN）均为与IgA1相关的血管炎，由含IgA1免疫复合物的血管沉积引起。已有研究提示扁桃体在HSP和IgAN发病过程中具有病理作用。扁桃体是一个黏膜相关淋巴器官。由于口腔和鼻窦在解剖学上与扁桃体直接相连，可将外源性抗原输送至扁桃体以诱导局部和全身抗体反应，因此我们在治疗HSP和IgAN时检查了这些腔隙的感染状况。在40例HSP患儿（6.7±2.5岁）中，分别有21例（53%，患牙4.9±2.8颗）、19例（48%）和4例（10%）被诊断为根尖周炎、鼻窦炎和中耳炎；而在11例IgAN患儿（10.4±2.5岁）中，上述疾病的发生率分别为6例（55%，患牙5.8±4.6颗）、2例（18%）和0例（0%）。我们首先对患者进行广泛的感染灶清除治疗，包括抗菌治疗和根管治疗。在31例HSP患者中，这种牙科和/或耳鼻喉科治疗使患者完全治愈，未发生肾炎或复发。对于其余9例HSP患者和11例IgAN患者，我们进一步进行了扁桃体切除术加甲泼尼龙（MP）冲击治疗，以控制其难治性症状，包括紫癜加重、HSP复发或肾炎。采用这种治疗策略，所有HSP患者均实现临床缓解。所有不同组织学分级的IgAN患者在开始类固醇治疗后7.2±5.7个月时尿检也均恢复正常。在2至10年的随访期间，两种疾病均未观察到复发。在儿童HSP和IgAN中，根尖周炎和鼻窦炎可能参与了扁桃体及全身的异常免疫反应。我们得出结论，广泛清除这些感染灶有利于优化扁桃体切除术加MP冲击治疗的效果。
