KINDERGNK: INFECTIES EN
IMMUNITEIT
PROF. ISABELLE MEYTS
Lessen metabole ziekten en evt andere: zullen via opname gebeuren (minder bevraagd op het examen)
Kindergeneeskunde vereist een brede algemene kennis
De “klinische blik” is vaak doorslaggevend, vaak brede DD
Wees kritisch, het is niet altijd zo makkelijk als het lijkt
Bekijk het kind en / in zijn omgeving
Terug naar de basics: ken je microbiologie, fysiologie, genetica
INHOUDSOPGAVE
H1-2: INFECTIES EN IMMUNITEIT .................................................................................................. 7
1. ALGEMENE PRINCIPES ........................................................................................................................7
2. HET KIND MET KOORTS........................................................................................................................7
3. LEVENSBEDREIGENDE INFECTIES ......................................................................................................... 10
3.1 Bacteriële meningitis ............................................................................................................. 10
3.2 Virale meningitis .................................................................................................................... 13
3.3 HSV encefalitis ...................................................................................................................... 13
3.4 Toxic Shock Syndrome ........................................................................................................... 14
3.5 Necrotiserende fasciitis ......................................................................................................... 15
3.6 Hemorragische pneumonie (PVL) ........................................................................................... 15
4. SPECIFIEKE BACTERIËLE INFECTIES....................................................................................................... 16
4.1 Meningokok .......................................................................................................................... 16
4.2 Pneumokok ........................................................................................................................... 17
4.3 Haemophilus influenzae type b .............................................................................................. 18
4.4 S. aureus & GAS .................................................................................................................... 19
5. FREQUENT VOORKOMENDE VIRALE INFECTIES ......................................................................................... 20
5.1 Herpes simplex ..................................................................................................................... 20
5.2 Varicella ............................................................................................................................... 21
5.3 EBV (Mononucleose) ............................................................................................................. 22
5.4 HHV6/7 (Roseola) .................................................................................................................. 23
5.5 Parvovirus B19 ...................................................................................................................... 24
5.6 Enterovirus ............................................................................................................................ 24
6. (NU) MINDER FREQUENTE VIRUSSEN .................................................................................................... 25
7. PROLONGED FEVER ......................................................................................................................... 26
, Differentiële diagnose ................................................................................................................. 26
7.1 Ziekte van Kawasaki ............................................................................................................... 27
7.2 Tuberculose .......................................................................................................................... 29
7.3. LYME DISEASE ..................................................................................................................... 30
7.4. HIV BIJ KINDEREN................................................................................................................. 31
8. PRIMAIRE IMMUUNDEFICIËNTIES (PID) ........................................................................................ 31
IMMUUNDYSREGULATIE ............................................................................................................. 38
SARS-CoV-2 BIJ KINDEREN .......................................................................................................... 38
tabel .......................................................................................................................................... 39
PREVENTIE VAN INFECTIES: VACCINATIE .................................................................................................... 40
H3: INBORN ERRORS OF METABOLISM (IEM) .................................................................................41
1. ALGEMENE PRINCIPES ...................................................................................................................... 41
2. WANNEER DENKEN AAN EEN METABOLE AANDOENING?............................................................................. 41
3. ACUTE METABOLE ONTREGELING ......................................................................................................... 42
4. ACIDOSE MET VERHOOGDE ANION GAP ................................................................................................. 43
5. HYPERAMMONEMIE ......................................................................................................................... 43
6. ORGANISCHE ACIDEMIE .................................................................................................................... 44
7. PHENYLKETONURIE (PKU) ................................................................................................................ 45
8. GLYCOGEENSTAPELINGSZIEKTEN (GSD) ............................................................................................... 45
9. LYSOSOMALE STAPELINGSZIEKTEN ....................................................................................................... 46
10. LIPIDEMETABOLISME DEFECTEN ........................................................................................................ 48
11. MITOCHONDRIALE ZIEKTEN .............................................................................................................. 48
12. CDG (PMM2) ............................................................................................................................. 48
13. ACUTE BEHANDELING IEM .............................................................................................................. 49
14. CHRONISCHE BEHANDELING............................................................................................................ 49
15. DENK AAN IEM BIJ: ........................................................................................................................ 49
VOORBEELDVRAGEN............................................................................................................................ 50
Casus 1 ...................................................................................................................................... 50
Casus 2 ...................................................................................................................................... 51
NOTITIES TOLEDO: AANGEBOREN METABOLE AANDOENINGEN ......................................................................... 52
Mechanismen van aangeboren metabole aandoeningen: .............................................................. 54
Abnormale synthese of transport ................................................................................................. 59
H4: RESPIRATORY DISORDERS .....................................................................................................60
1. INLEIDING – BELANG ........................................................................................................................ 60
2. RISICOFACTOREN VOOR LUCHTWEGINFECTIES ........................................................................................ 60
3. RESPIRATOIRE DISTRESS – ERNSTINSCHATTING ....................................................................................... 60
A. BOVENSTE LUCHTWEGinfecties (BLW infecties) ....................................................................... 61
B. EXTRATHORACALE OBSTRUCTIE – STRIDOR............................................................................. 64
B. INTRATHORACALE OBSTRUCTIE – WHEEZING .......................................................................... 69
C. PNEUMONIE .......................................................................................................................... 70
4. ASTMA........................................................................................................................................ 72
4.1 Wheezing bij jonge kinderen .............................................................................................. 72
4.2 Early transient wheeze ........................................................................................................... 73
4.3 Viral episodic wheeze ............................................................................................................ 73
4.4 Persistent / multi-trigger wheeze ............................................................................................ 73
4.5 Diagnose astma (>6 jaar) ........................................................................................................ 74
4.6 Diagnostiek astma ................................................................................................................. 75
4.7 behandeling .......................................................................................................................... 76
, 5. RECIDIVERENDE OF PERSISTERENDE HOEST – DIFFERENTIËLE DIAGNOSE ........................................................ 80
6. HERHAALDE PNEUMONIE .................................................................................................................. 81
7. MUCOVISCIDOSE (CYSTIC FIBROSIS) .......................................................................................... 81
7.1 Pathofysiologie ...................................................................................................................... 82
7.2 Diagnose............................................................................................................................... 82
7.3 Behandeling .......................................................................................................................... 82
7.4 CFTR modulator therapie ....................................................................................................... 83
8. PRIMAIRE CILIAIRE DYSKINESIE ................................................................................................... 84
9. GESTOORDE ADEMHALING TIJDENS SLAAP ................................................................................. 84
10. TRACHEOSTOMIE .......................................................................................................................... 85
H5: MALIGNANT DISEASES ...........................................................................................................86
1. BELANG EN EPIDEMIOLOGIE ............................................................................................................... 86
2. ETIOLOGIE VAN KINDERONCOLOGIE ..................................................................................................... 86
2.1 Multifactorieel ....................................................................................................................... 86
2.2 Voorbeelden genetische syndromen....................................................................................... 86
2.3 Specifieke associaties ........................................................................................................... 87
3. KLINISCHE PRESENTATIE ................................................................................................................... 88
3.1 Algemene alarmsymptomen .................................................................................................. 88
3.2 Lokale symptomen ................................................................................................................ 88
4. DIAGNOSTIEK................................................................................................................................. 88
5. BEHANDELING ............................................................................................................................... 89
5.1 Chemotherapie ..................................................................................................................... 89
5.2 Radiotherapie........................................................................................................................ 89
5.3 Chirurgie ............................................................................................................................... 90
5.4 Nieuwe therapieën ................................................................................................................ 90
Tumor lysis syndroom ................................................................................................................. 91
8. SUPPORTIVE CARE ........................................................................................................................... 91
8.1 Infecties bij neutropenie......................................................................................................... 91
8.2 Malnutritie ............................................................................................................................ 92
8.3 Psychosociale ondersteuning ................................................................................................ 92
9. BELANGRIJKSTE PEDIATRISCHE TUMOREN .............................................................................................. 93
9.1 Leukemie .............................................................................................................................. 93
9.2 Lymfomen ............................................................................................................................. 93
9.3 CNS tumoren ........................................................................................................................ 94
9.4 Neuroblastoom ..................................................................................................................... 96
9.5 Retinoblastoom ..................................................................................................................... 97
9.6 Nephroblastoom (Wilms tumor) ............................................................................................. 97
9.7 Bottumoren ........................................................................................................................... 98
9.8 Soft tissue sarcoma ............................................................................................................... 98
10. LONG-TERM SURVIVORS.................................................................................................................. 99
ZELFTEST ........................................................................................................................................ 100
Casus 1 .................................................................................................................................... 100
Casus 2 .................................................................................................................................... 100
Casus 3 .................................................................................................................................... 101
Casus 4 .................................................................................................................................... 101
Casus 5 .................................................................................................................................... 102
Casus 6 .................................................................................................................................... 102
H6: HAEMATOLOGICAL DISORDERS ........................................................................................... 104
, 1. HEMATOPOËSE ........................................................................................................................ 104
2. ANEMIE .................................................................................................................................... 104
2.1 Definitie (leeftijdsafhankelijk) ............................................................................................... 104
2.2 Indeling van anemie ............................................................................................................. 105
2.3 Acute red cell aplasia .......................................................................................................... 105
2.4 IJzerdeficiëntie anemie ........................................................................................................ 107
2.5 Hemolytische anemieën ...................................................................................................... 107
2.6 Differentiatie ijzertekort vs thalassemie ................................................................................ 111
3. BLOEDINGSSTOORNISSEN ....................................................................................................... 112
3.1 Overzicht ............................................................................................................................ 112
3.2 Anamnese bij bloedingsneiging ............................................................................................ 112
3.3 Screening testen ................................................................................................................. 112
3.4 Hemofilie ............................................................................................................................ 112
3.5 Von Willebrand ziekte .......................................................................................................... 113
3.6 ITP (Immune thrombocytopenia) .......................................................................................... 114
3.7 Erfelijke trombocytopenieën ................................................................................................ 115
4. TROMBOSE BIJ KINDEREN ......................................................................................................... 115
4.1 Belangrijk ............................................................................................................................ 115
4.2 Aangeboren protrombotische oorzaken ................................................................................ 115
4.3 Verworven protrombotische oorzaken .................................................................................. 115
5. RODE VLAGGEN ............................................................................................................................ 115
6. SAMENVATTEND BESLISSCHEMA........................................................................................................ 116
7. ZELFTEST .................................................................................................................................... 116
Casus 1 .................................................................................................................................... 116
Casus 2 .................................................................................................................................... 117
Casus 3 .................................................................................................................................... 118
Casus 4 .................................................................................................................................... 119
Casus 5 .................................................................................................................................... 120
Casus 6 .................................................................................................................................... 121
H7: ALLERGY ............................................................................................................................. 123
1. ALGEMEEN ............................................................................................................................... 123
2. PATHOGENESE ......................................................................................................................... 123
3. PREVENTIE ............................................................................................................................... 123
4. ECZEEM (ATOPISCHE DERMATITIS) ............................................................................................ 124
1. Epidemiologie en context ....................................................................................................... 124
2. Pathofysiologie (ZEER BELANGRIJK) ....................................................................................... 124
3. Kliniek................................................................................................................................... 124
4. Triggers (exacerbaties) ........................................................................................................... 125
5. Behandeling .......................................................................................................................... 125
6. Prognose .............................................................................................................................. 126
7. Risicofactoren voor ernstig verloop ......................................................................................... 126
5. ALLERGISCHE RHINOCONJUNCTIVITIS...................................................................................... 127
6. VOEDSELALLERGIE ................................................................................................................... 128
1. Belangrijke cave .................................................................................................................... 128
2. Epidemiologie ....................................................................................................................... 128
3. Pathofysiologische types ....................................................................................................... 128
4. Kliniek................................................................................................................................... 128
5. Diagnostiek (ZEER BELANGRIJK) ............................................................................................. 128
6. Koemelkallergie (CMPA/KMPA) .............................................................................................. 128
IMMUNITEIT
PROF. ISABELLE MEYTS
Lessen metabole ziekten en evt andere: zullen via opname gebeuren (minder bevraagd op het examen)
Kindergeneeskunde vereist een brede algemene kennis
De “klinische blik” is vaak doorslaggevend, vaak brede DD
Wees kritisch, het is niet altijd zo makkelijk als het lijkt
Bekijk het kind en / in zijn omgeving
Terug naar de basics: ken je microbiologie, fysiologie, genetica
INHOUDSOPGAVE
H1-2: INFECTIES EN IMMUNITEIT .................................................................................................. 7
1. ALGEMENE PRINCIPES ........................................................................................................................7
2. HET KIND MET KOORTS........................................................................................................................7
3. LEVENSBEDREIGENDE INFECTIES ......................................................................................................... 10
3.1 Bacteriële meningitis ............................................................................................................. 10
3.2 Virale meningitis .................................................................................................................... 13
3.3 HSV encefalitis ...................................................................................................................... 13
3.4 Toxic Shock Syndrome ........................................................................................................... 14
3.5 Necrotiserende fasciitis ......................................................................................................... 15
3.6 Hemorragische pneumonie (PVL) ........................................................................................... 15
4. SPECIFIEKE BACTERIËLE INFECTIES....................................................................................................... 16
4.1 Meningokok .......................................................................................................................... 16
4.2 Pneumokok ........................................................................................................................... 17
4.3 Haemophilus influenzae type b .............................................................................................. 18
4.4 S. aureus & GAS .................................................................................................................... 19
5. FREQUENT VOORKOMENDE VIRALE INFECTIES ......................................................................................... 20
5.1 Herpes simplex ..................................................................................................................... 20
5.2 Varicella ............................................................................................................................... 21
5.3 EBV (Mononucleose) ............................................................................................................. 22
5.4 HHV6/7 (Roseola) .................................................................................................................. 23
5.5 Parvovirus B19 ...................................................................................................................... 24
5.6 Enterovirus ............................................................................................................................ 24
6. (NU) MINDER FREQUENTE VIRUSSEN .................................................................................................... 25
7. PROLONGED FEVER ......................................................................................................................... 26
, Differentiële diagnose ................................................................................................................. 26
7.1 Ziekte van Kawasaki ............................................................................................................... 27
7.2 Tuberculose .......................................................................................................................... 29
7.3. LYME DISEASE ..................................................................................................................... 30
7.4. HIV BIJ KINDEREN................................................................................................................. 31
8. PRIMAIRE IMMUUNDEFICIËNTIES (PID) ........................................................................................ 31
IMMUUNDYSREGULATIE ............................................................................................................. 38
SARS-CoV-2 BIJ KINDEREN .......................................................................................................... 38
tabel .......................................................................................................................................... 39
PREVENTIE VAN INFECTIES: VACCINATIE .................................................................................................... 40
H3: INBORN ERRORS OF METABOLISM (IEM) .................................................................................41
1. ALGEMENE PRINCIPES ...................................................................................................................... 41
2. WANNEER DENKEN AAN EEN METABOLE AANDOENING?............................................................................. 41
3. ACUTE METABOLE ONTREGELING ......................................................................................................... 42
4. ACIDOSE MET VERHOOGDE ANION GAP ................................................................................................. 43
5. HYPERAMMONEMIE ......................................................................................................................... 43
6. ORGANISCHE ACIDEMIE .................................................................................................................... 44
7. PHENYLKETONURIE (PKU) ................................................................................................................ 45
8. GLYCOGEENSTAPELINGSZIEKTEN (GSD) ............................................................................................... 45
9. LYSOSOMALE STAPELINGSZIEKTEN ....................................................................................................... 46
10. LIPIDEMETABOLISME DEFECTEN ........................................................................................................ 48
11. MITOCHONDRIALE ZIEKTEN .............................................................................................................. 48
12. CDG (PMM2) ............................................................................................................................. 48
13. ACUTE BEHANDELING IEM .............................................................................................................. 49
14. CHRONISCHE BEHANDELING............................................................................................................ 49
15. DENK AAN IEM BIJ: ........................................................................................................................ 49
VOORBEELDVRAGEN............................................................................................................................ 50
Casus 1 ...................................................................................................................................... 50
Casus 2 ...................................................................................................................................... 51
NOTITIES TOLEDO: AANGEBOREN METABOLE AANDOENINGEN ......................................................................... 52
Mechanismen van aangeboren metabole aandoeningen: .............................................................. 54
Abnormale synthese of transport ................................................................................................. 59
H4: RESPIRATORY DISORDERS .....................................................................................................60
1. INLEIDING – BELANG ........................................................................................................................ 60
2. RISICOFACTOREN VOOR LUCHTWEGINFECTIES ........................................................................................ 60
3. RESPIRATOIRE DISTRESS – ERNSTINSCHATTING ....................................................................................... 60
A. BOVENSTE LUCHTWEGinfecties (BLW infecties) ....................................................................... 61
B. EXTRATHORACALE OBSTRUCTIE – STRIDOR............................................................................. 64
B. INTRATHORACALE OBSTRUCTIE – WHEEZING .......................................................................... 69
C. PNEUMONIE .......................................................................................................................... 70
4. ASTMA........................................................................................................................................ 72
4.1 Wheezing bij jonge kinderen .............................................................................................. 72
4.2 Early transient wheeze ........................................................................................................... 73
4.3 Viral episodic wheeze ............................................................................................................ 73
4.4 Persistent / multi-trigger wheeze ............................................................................................ 73
4.5 Diagnose astma (>6 jaar) ........................................................................................................ 74
4.6 Diagnostiek astma ................................................................................................................. 75
4.7 behandeling .......................................................................................................................... 76
, 5. RECIDIVERENDE OF PERSISTERENDE HOEST – DIFFERENTIËLE DIAGNOSE ........................................................ 80
6. HERHAALDE PNEUMONIE .................................................................................................................. 81
7. MUCOVISCIDOSE (CYSTIC FIBROSIS) .......................................................................................... 81
7.1 Pathofysiologie ...................................................................................................................... 82
7.2 Diagnose............................................................................................................................... 82
7.3 Behandeling .......................................................................................................................... 82
7.4 CFTR modulator therapie ....................................................................................................... 83
8. PRIMAIRE CILIAIRE DYSKINESIE ................................................................................................... 84
9. GESTOORDE ADEMHALING TIJDENS SLAAP ................................................................................. 84
10. TRACHEOSTOMIE .......................................................................................................................... 85
H5: MALIGNANT DISEASES ...........................................................................................................86
1. BELANG EN EPIDEMIOLOGIE ............................................................................................................... 86
2. ETIOLOGIE VAN KINDERONCOLOGIE ..................................................................................................... 86
2.1 Multifactorieel ....................................................................................................................... 86
2.2 Voorbeelden genetische syndromen....................................................................................... 86
2.3 Specifieke associaties ........................................................................................................... 87
3. KLINISCHE PRESENTATIE ................................................................................................................... 88
3.1 Algemene alarmsymptomen .................................................................................................. 88
3.2 Lokale symptomen ................................................................................................................ 88
4. DIAGNOSTIEK................................................................................................................................. 88
5. BEHANDELING ............................................................................................................................... 89
5.1 Chemotherapie ..................................................................................................................... 89
5.2 Radiotherapie........................................................................................................................ 89
5.3 Chirurgie ............................................................................................................................... 90
5.4 Nieuwe therapieën ................................................................................................................ 90
Tumor lysis syndroom ................................................................................................................. 91
8. SUPPORTIVE CARE ........................................................................................................................... 91
8.1 Infecties bij neutropenie......................................................................................................... 91
8.2 Malnutritie ............................................................................................................................ 92
8.3 Psychosociale ondersteuning ................................................................................................ 92
9. BELANGRIJKSTE PEDIATRISCHE TUMOREN .............................................................................................. 93
9.1 Leukemie .............................................................................................................................. 93
9.2 Lymfomen ............................................................................................................................. 93
9.3 CNS tumoren ........................................................................................................................ 94
9.4 Neuroblastoom ..................................................................................................................... 96
9.5 Retinoblastoom ..................................................................................................................... 97
9.6 Nephroblastoom (Wilms tumor) ............................................................................................. 97
9.7 Bottumoren ........................................................................................................................... 98
9.8 Soft tissue sarcoma ............................................................................................................... 98
10. LONG-TERM SURVIVORS.................................................................................................................. 99
ZELFTEST ........................................................................................................................................ 100
Casus 1 .................................................................................................................................... 100
Casus 2 .................................................................................................................................... 100
Casus 3 .................................................................................................................................... 101
Casus 4 .................................................................................................................................... 101
Casus 5 .................................................................................................................................... 102
Casus 6 .................................................................................................................................... 102
H6: HAEMATOLOGICAL DISORDERS ........................................................................................... 104
, 1. HEMATOPOËSE ........................................................................................................................ 104
2. ANEMIE .................................................................................................................................... 104
2.1 Definitie (leeftijdsafhankelijk) ............................................................................................... 104
2.2 Indeling van anemie ............................................................................................................. 105
2.3 Acute red cell aplasia .......................................................................................................... 105
2.4 IJzerdeficiëntie anemie ........................................................................................................ 107
2.5 Hemolytische anemieën ...................................................................................................... 107
2.6 Differentiatie ijzertekort vs thalassemie ................................................................................ 111
3. BLOEDINGSSTOORNISSEN ....................................................................................................... 112
3.1 Overzicht ............................................................................................................................ 112
3.2 Anamnese bij bloedingsneiging ............................................................................................ 112
3.3 Screening testen ................................................................................................................. 112
3.4 Hemofilie ............................................................................................................................ 112
3.5 Von Willebrand ziekte .......................................................................................................... 113
3.6 ITP (Immune thrombocytopenia) .......................................................................................... 114
3.7 Erfelijke trombocytopenieën ................................................................................................ 115
4. TROMBOSE BIJ KINDEREN ......................................................................................................... 115
4.1 Belangrijk ............................................................................................................................ 115
4.2 Aangeboren protrombotische oorzaken ................................................................................ 115
4.3 Verworven protrombotische oorzaken .................................................................................. 115
5. RODE VLAGGEN ............................................................................................................................ 115
6. SAMENVATTEND BESLISSCHEMA........................................................................................................ 116
7. ZELFTEST .................................................................................................................................... 116
Casus 1 .................................................................................................................................... 116
Casus 2 .................................................................................................................................... 117
Casus 3 .................................................................................................................................... 118
Casus 4 .................................................................................................................................... 119
Casus 5 .................................................................................................................................... 120
Casus 6 .................................................................................................................................... 121
H7: ALLERGY ............................................................................................................................. 123
1. ALGEMEEN ............................................................................................................................... 123
2. PATHOGENESE ......................................................................................................................... 123
3. PREVENTIE ............................................................................................................................... 123
4. ECZEEM (ATOPISCHE DERMATITIS) ............................................................................................ 124
1. Epidemiologie en context ....................................................................................................... 124
2. Pathofysiologie (ZEER BELANGRIJK) ....................................................................................... 124
3. Kliniek................................................................................................................................... 124
4. Triggers (exacerbaties) ........................................................................................................... 125
5. Behandeling .......................................................................................................................... 125
6. Prognose .............................................................................................................................. 126
7. Risicofactoren voor ernstig verloop ......................................................................................... 126
5. ALLERGISCHE RHINOCONJUNCTIVITIS...................................................................................... 127
6. VOEDSELALLERGIE ................................................................................................................... 128
1. Belangrijke cave .................................................................................................................... 128
2. Epidemiologie ....................................................................................................................... 128
3. Pathofysiologische types ....................................................................................................... 128
4. Kliniek................................................................................................................................... 128
5. Diagnostiek (ZEER BELANGRIJK) ............................................................................................. 128
6. Koemelkallergie (CMPA/KMPA) .............................................................................................. 128
