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Küçükali B, Bayraktar EÖ, Yıldız Ç, Gönen S, Kutlar M, Karaçayır N, Belder N, Acun B, Esmeray Şenol P, Sunar Yayla EN, Gezgin Yıldırım D, Bakkaloğlu SA. Clinical Associations of E148Q Heterozygosity: What to Expect From E148Q? J Clin Rheumatol 2024; 30:229-234. [PMID: 39093307 DOI: 10.1097/rhu.0000000000002119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
OBJECTIVE The exact effects of MEFV variants on inflammation are still under investigation, and reports on variants of unknown significance, particularly the E148Q variant, have been conflicting. Therefore, this study aims to investigate patients exhibiting E148Q heterozygosity, focusing on diagnoses and disease courses to assist physicians in interpreting the variant. METHODS Data of pediatric patients presenting to the Pediatric Rheumatology clinic between November 2016 and September 2023, exhibiting only E148Q heterozygosity in MEFV gene analysis, were extracted. Patients who were lost before 9 months of follow-up have been excluded to ensure the completion of initial diagnostic tests and evaluations. RESULTS Among the 119 patients with E148Q variant, the diagnoses were as follows: healthy, 51.3%; IgA vasculitis, 10.1%; Familial Mediterranean Fever (FMF), 7.6%; Periodic fever, Aphtous stomatitis, Pharyngitis, Adenitis (PFAPA), 6.7%; and other diagnoses, 19.3%. IgA vasculitis patients experienced articular, gastrointestinal, and renal involvement at rates of 91.7%, 58.3%, and 16.7%, respectively. Complete response, partial response, and no response to colchicine were 37.5%, 12.5%, and 50%, respectively, in PFAPA patients. All FMF patients responded to colchicine treatment resulting in reduced mean FMF episode counts in 6 months from 3.22 ± 0.92 to 0.56 ± 0.52. CONCLUSIONS The E148Q variant may amplify inflammation and modify disease courses. Patients with the E148Q variant experiencing typical FMF episodes should receive colchicine, but clinicians should exercise caution regarding alternative diagnoses. Additionally, the E148Q variant may increase acute phase reactants and disease severity in IgA vasculitis. However, to reach definitive conclusions on its treatment-modifying role in PFAPA, universal diagnosis and treatment response criteria should be adopted.
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Affiliation(s)
- Batuhan Küçükali
- From the Department of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | | | - Çisem Yıldız
- From the Department of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sevim Gönen
- Tissue Typing Laboratory, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Merve Kutlar
- From the Department of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Nihal Karaçayır
- From the Department of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Nuran Belder
- From the Department of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Büşra Acun
- From the Department of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Pelin Esmeray Şenol
- From the Department of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | | | - Deniz Gezgin Yıldırım
- From the Department of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sevcan A Bakkaloğlu
- From the Department of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
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Bagrul İ, Aydin EA, Tuncez S, Baglan E, Özdel S, Bülbül M. Effect of Colchicine Treatment on Clinical Course in Children with PFAPA Syndrome. KLINISCHE PADIATRIE 2024; 236:296-300. [PMID: 38387479 DOI: 10.1055/a-2274-9046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA) is the most common periodic fever condition in children. There is no consensus on treatment to prevent attacks and reduce their frequency. In this study, we aimed to evaluate the effectiveness of colchicine treatment in PFAPA syndrome. In addition, we described the demographic and clinical features of PFAPA patients. MATERIALS AND METHODS We retrospectively analyzed 58 PFAPA patients who were started on colchicine treatment between January 2017 and January 2022. Demographic data, clinical features, laboratory tests, genetic analysis of MEditerranean FeVer (MEFV) mutations, and autoinflammatory disease activity index (AIDAI) scores of all patients were evaluated. In addition, patients were divided into two groups according to MEFV variants and compared. RESULTS Attack frequency, duration, and AIDAI scores decreased in all patients after colchicine treatment. Duration of follow-up was 13.53±6.65 months. The median±IQR age at diagnosis was 3.2 (2-5) years. Thirty three (56.9%) patients had heterozygous mutations of MEFV. The most common MEFV variants were M694V (63.6%). There was no significant difference between the two groups in terms of colchicine responses. CONCLUSION Colchicine treatment is effective and safe in patients with PFAPA who have frequent attacks. No association was established between the presence of heterozygous mutations of MEFV and colchicine response.
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Affiliation(s)
- İlknur Bagrul
- Department of Pediatric Rheumatology, Ankara Etlik Integrated Health Campus, ANKARA, Turkey
| | - Elif Arslanoglu Aydin
- Department of Pediatric Rheumatology, Ankara Etlik Integrated Health Campus, ANKARA, Turkey
| | - Serife Tuncez
- Department of Pediatric Rheumatology, Ankara Etlik Integrated Health Campus, ANKARA, Turkey
| | - Esra Baglan
- Department of Pediatric Rheumatology, Ankara Etlik Integrated Health Campus, ANKARA, Turkey
| | - Semanur Özdel
- Department of Pediatric Rheumatology, Ankara Etlik Integrated Health Campus, ANKARA, Turkey
| | - Mehmet Bülbül
- Department of Pediatric Nephrology, Dr Sami Ulus Gynecology Obstetrics and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
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Gazi U, Dalkan C, Sanlidag B, Cerit Z, Beyitler I, Narin Bahceciler N. Altered serum antibody levels in children with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis. Arch Rheumatol 2024; 39:99-106. [PMID: 38774691 PMCID: PMC11104745 DOI: 10.46497/archrheumatol.2023.9988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/02/2023] [Indexed: 05/24/2024] Open
Abstract
Objectives This study aimed to extend the literature by analyzing immunoglobulin (Ig) A, IgE, IgG, IgG2, IgG3, and IgM antibody levels in periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) patients. Patients and methods This study retrospectively analyzed the antibody test results of 20 pediatric patients (10 males, 10 females; mean age: 2.5±1.5 years; range, 0.5 to 5.4 years) with and without flare who were initially evaluated for a number of underlying diseases due to periodic fever/infectious symptoms but then diagnosed with PFAPA between January 2015 and December 2020. Antibody levels were determined by chemiluminescence microparticle immunoassay. The results were retrospectively compared with a group of healthy children after the PFAPA diagnosis was confirmed. Results The chemiluminescence microparticle immunoassay revealed 35%, 65%, 20%, 86.6%, and 55% of PFAPA cases with low serum levels of IgA, IgG, IgG2, IgG3, and IgM respectively, while 56.2% had high IgE levels. Moreover, low serum levels of at least two antibody classes or subclasses were reported in 80% of the PFAPA children. While cases with low IgG serum levels were with the highest incidence rates among the low IgG3 PFAPA patient population, both high IgE and low IgM cases were common in the rest of the patients. Conclusion Our results suggest an association between PFAPA and low serum antibody levels, particularly of IgG3. Future studies are needed to confirm our conclusion.
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Affiliation(s)
- Umut Gazi
- Medical Microbiology and Clinical Microbiology, Near East University, Nicosia, Cyprus
| | - Ceyhun Dalkan
- Department of Pediatrics, Near East University, Nicosia, Cyprus
| | - Burcin Sanlidag
- Department of Pediatrics, Near East University, Nicosia, Cyprus
| | - Zeynep Cerit
- Department of Pediatrics, Near East University, Nicosia, Cyprus
| | - Ilke Beyitler
- Department of Pediatrics, Near East University, Nicosia, Cyprus
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Kapustova L, Banovcin P, Bobcakova A, Jurkova Malicherova E, Kapustova D, Petrovicova O, Slenker B, Markocsy A, Oleksak F, Vorcakova K, Jesenak M. The use of ketotifen as long-term anti-inflammatory prophylaxis in children with PFAPA syndrome. Front Immunol 2023; 14:1302875. [PMID: 38143757 PMCID: PMC10748580 DOI: 10.3389/fimmu.2023.1302875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA) is the most frequent periodic fever syndrome in children. Its pathogenesis is still unknown, but some disease-modifying factors were observed. Several medications were tested for the long-term prophylaxis of inflammatory flares; however, none are standardly used. Methods This prospective clinical trial enrolled 142 children (71 girls, 50%) meeting diagnostic criteria for PFAPA syndrome. We analysed selected clinical characteristics and compared laboratory parameters during the flare and attack-free period (at least two weeks after the attack). Moreover, we assessed the possible therapeutic effect of ketotifen on the duration of attack free-periods and clinical picture. Results The mean age of patients was 6.81 ± 3.03 years and the mean age of onset of symptoms was 2.31 ± 2.02 years. No significant differences were observed between genders.We recorded a positive family history for PFAPA in 31.69% of patients. Attacks lasted for 2.8 ± 1.2 days, with intervals between attacks of 4 ± 1 weeks. We administered ketotifen in 111 (77.8%) patients, and a positive effect was observed in 86 (77.5%) of patients. We observed prolonged attack-free intervals in patients treated with ketotifen (14.7 ± 8.9 days in comparison with 4.4 ± 1.9 days before the treatment; p<0.001). The used dose of ketotifen was 0.08 ± 0.01 mg/kg/day. Mild side effects were observed in four patients (restlessness, irritability, agitation and constipation). Discussion Our data supports the use of ketotifen for long-term prophylaxis in children with PFAPA syndrome with positive effects on the attenuation of disease activity and the prolongation of attack-free periods. Further well-designed studies should confirm the preliminary data.
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Affiliation(s)
- Lenka Kapustova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Peter Banovcin
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Anna Bobcakova
- Department of Pneumology and Phthisiology, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Eva Jurkova Malicherova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Daniela Kapustova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Otilia Petrovicova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Branislav Slenker
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Adam Markocsy
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Filip Oleksak
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Karolina Vorcakova
- Clinic of Dermatovenerology, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Milos Jesenak
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
- Department of Pneumology and Phthisiology, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
- Department of Clinical Immunology and Allergology, University Hospital in Martin, Martin, Slovakia
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Konte EK, Haslak F, Yildiz M, Gucuyener N, Ulkersoy I, Gunalp A, Aslan E, Adrovic A, Sahin S, Barut K, Kasapcopur O. Gray zone in the spectrum of autoinflammatory diseases: familial Mediterranean fever accompanying periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome: single-center experience. Eur J Pediatr 2023; 182:5473-5482. [PMID: 37777601 DOI: 10.1007/s00431-023-05209-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 10/02/2023]
Abstract
Despite the advanced knowledge concerning autoinflammatory diseases (AID), more data regarding the optimal treatment options and outcomes of the children who met the criteria of more than one AID are required. This study aimed to describe the demographic and clinical characteristics of children from familial Mediterranean fever (FMF)-endemic countries who meet both the FMF and the periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome criteria. Moreover, we aimed to measure the response rates to colchicine and tonsillectomy and evaluate the factors affecting the colchicine response in these patients. The study was conducted at pediatric rheumatology tertiary centre. A total of 131 patients (58 females; 73 males) who met both the modified Marshall and pediatric FMF criteria were included. The median age at onset was 18 months (1-77 months), and the mean age at diagnosis was 47 ± 21.88 months. The median interval between episodes was 21 (7-90) days. The median disease duration was 46 (6-128) months. Consanguineous marriage was detected in 17 (13%) of the patients. The most common clinical finding was fever (100%), followed by exudative pharyngitis (88.5%), abdominal pain (86.3%), arthralgia (61.8%), stomatitis (51.1%), adenitis (42%), myalgia (28.7%), chest pain (16%), maculopapular rash (12.2%), arthritis (8.4%), and erysipelas-like rash (4.6%). MEFV gene variants were identified in 106 (80.9%) patients. The most common variants were M694V heterozygous (29%). We found that patients with tonsillopharyngitis, aphthous stomatitis, and PFAPA family history were more likely to be colchicine-resistant and tonsillectomy responsive, while those with exon 10 MEFV gene mutations were more prone to have a favorable response to colchicine. Conclusion: PFAPA syndrome patients with exon 10 MEFV gene mutation, showing typical FMF symptoms, should be treated with colchicine, even after tonsillectomy. In multivariate analysis, PFAPA family history and lack of exon 10 MEFV gene mutations were independent risk factors for colchicine resistance. Thus, tonsillectomy may be recommended as a possible treatment option for these patients. It has yet to be clarified when colchicine treatment will be discontinued in patients whose attacks ceased after tonsillectomy that was performed due to colchicine unresponsiveness. What is Known: • A certain number of patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome concomitantly fulfill the familial Mediterranean fever (FMF) criteria. • While colchicine is proposed as a first treatment choice in familial Mediterranean fever (FMF), corticosteroids are recommended as a first-line treatment in PFAPA syndrome patients. What is New: • In patients with concomitant PFAPA syndrome and FMF, PFAPA family history and lack of exon 10 MEFV gene mutation are predictive factors of colchicine resistance. • The presence of exon 10 MEFV gene mutations in patients with concomitant FMF and PFAPA syndrome has a favourable effect on response to colchicine treatment.
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Affiliation(s)
- Elif Kilic Konte
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Fatih Haslak
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mehmet Yildiz
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Neslihan Gucuyener
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ipek Ulkersoy
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Aybuke Gunalp
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Esma Aslan
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey.
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Dermatologic Manifestations of Noninflammasome-Mediated Autoinflammatory Diseases. JID INNOVATIONS 2023; 3:100176. [PMID: 36876221 PMCID: PMC9982332 DOI: 10.1016/j.xjidi.2022.100176] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/14/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
Autoinflammatory diseases (AIDs) arise from disturbances that alter interactions of immune cells and tissues. They give rise to prominent (auto)inflammation in the absence of aberrant autoantibodies and/or autoreactive T cells. AIDs that are predominantly caused by changes in the inflammasome pathways, such as the NLRP3- or pyrin-associated inflammasome, have gained substantial attention over the last years. However, AIDs resulting primarily from other changes in the defense system of the innate immune system are less well-studied. These noninflammasome-mediated AIDs relate to, for example, disturbance in the TNF or IFN signaling pathways or aberrations in genes affecting the IL-1RA. The spectrum of clinical signs and symptoms of these conditions is vast. Thus, recognizing early cutaneous signs constitutes an important step in differential diagnoses for dermatologists and other physicians. This review provides an overview of the pathogenesis, clinical presentation, and available treatment options highlighting dermatologic aspects of noninflammasome-mediated AIDs.
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Key Words
- AID, autoinflammatory disease
- ANCA, antineutrophil cytoplasmic antibody
- AOSD, adult-onset Still disease
- BASDAI, Bath Ankylosing Spondylitis Activity Index
- CANDLE, chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature
- CAPS, cryopyrin-associated periodic syndrome
- CRD, cysteine-rich domain
- DIRA, deficiency of IL-1RA
- DITRA, deficiency of IL-36RA
- ER, endoplasmic reticulum
- ESR, erythrocyte sedimentation rate
- FMF, familial Mediterranean fever
- M-CSF, macrophage colony-stimulating factor
- MAS, macrophage activation syndrome
- NET, neutrophil extracellular trap
- NOS, nitrous oxide
- NSAID, nonsteroidal anti-inflammatory drug
- NUD, neutrophilic urticarial dermatosis
- PFAPA, periodic fever, aphthous stomatitis, pharyngitis, and adenitis
- PKR, protein kinase R
- PRAAS, proteosome-associated autoinflammatory disease
- SAPHO, synovitis, acne, pustulosis, hyperostosis, osteitis syndrome
- SAVI, STING-associated vasculopathy with onset in infancy
- STAT, signal transducer and activator of transcription
- SchS, Schnitzler syndrome
- TNFR, TNF receptor
- TRAPS, TNF receptor‒associated autoinflammatory disease
- Th17, T helper 17
- VAS, Visual Analog Scale
- sTNFR, soluble TNF receptor
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Kaynak D, Yildiz M, Sahin S, Haslak F, Gunalp A, Adrovic A, Barut K, Gunver MG, Kasapcopur O, Dasdemir S. NLRP3 gene variants and serum NLRP3 levels in periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome. Clin Rheumatol 2023; 42:245-251. [PMID: 36087224 DOI: 10.1007/s10067-022-06370-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/25/2022] [Accepted: 09/05/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Although most of the autoinfammatory disorders have a confirmed genetic cause, periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome still has an unknown genetic background. However, familial cases of PFAPA syndrome have been reported suggesting a genetic its basis. PFAPA syndrome may also be considered an infammasome disorder as variants in infammasome-associated genes such as CARD8, NLRP3, and MEFV have been reported to contribute to the disease. METHODS Polymerase chain reaction (PCR)/Sanger sequencing analysis was performed for the detection of the variations in 71 PFAPA patients and 71 healthy controls. NLRP3 concentrations in serum were measured in 71 PFAPA patients and 71 healthy controls. RESULTS No statistically significant differences were observed in the allele or genotype frequencies of the NLRP3 polymorphisms between the controls and patients (P > 0.05). We found no significant differences for NLRP3 serum levels between PFAPA patients and controls (p > 0.05). Mutations in the MEFV gene were detected in 32.5% of our patients (13/40). CONCLUSIONS It seems that the synergistic effect of different genes plays a role in the formation of PFAPA syndrome. For this reason, it may be useful to examine the presence of mutations in genes such as NLRP3, MEFV, and CARD8 together while investigating the genetics of PFAPA syndrome. Key points • Familial cases of PFAPA syndrome have been reported suggesting a genetic basis for this syndrome. • Elevated serum or plasma levels of IL-1β, IL-6, and IL-18 have been demonstrated during PFAPA flares in several studies. • It seems that the synergistic effect of different genes plays a role in the formation of PFAPA syndrome.
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Affiliation(s)
- Damla Kaynak
- Department of Medical Biology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Yildiz
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Fatih Haslak
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Aybuke Gunalp
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mehmet Guven Gunver
- Department of Bioistatistics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Selcuk Dasdemir
- Department of Medical Biology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
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Raeeskarami SR, Sadeghi P, Vahedi M, Asna Ashari K, Mousavi T. M, Ziaee V. Colchicine versus cimetidine: the better choice for Periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome prophylaxis, and the role of MEFV gene mutations. Pediatr Rheumatol Online J 2022; 20:72. [PMID: 36045426 PMCID: PMC9428878 DOI: 10.1186/s12969-022-00733-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/17/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND During childhood, the most common periodic fever is periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. The effective treatment and prevention of febrile attacks improve these patients' and their families' quality of life. However, there is no single strategy or evidence-based guideline to manage this syndrome, and most of them are based on consensus treatment plans. METHODS This randomized controlled trial was carried out on 67 PFAPA patients referred to three tertiary centers of pediatric rheumatology. The patients were divided into two groups, including group 1 (n = 36) receiving prednisolone plus colchicine and group 2 (n = 31) receiving prednisolone plus cimetidine. Demographic characteristics and the number of febrile episodes were compared between the two groups before and after the intervention. RESULTS In both groups, the number of febrile episodes after the treatment decreased (P ≤ 0.001). Statistical Analysis showed no significant difference between the two groups (P = 0.88). Moreover, 44 patients from both groups were checked for the MEFV gene. There were no statistical differences between MEFV positive and negative subgroups in response to colchicine (P = 1). CONCLUSION This study showed that both drug regimens are significantly effective in preventing febrile attacks in PFAPA syndrome, and the presence of a MEFV gene mutation might not be the only significant risk factor for a response to colchicine. TRIAL REGISTRATION IRCT, IRCT20191222045847N1. Registered 23 October 2019, https://fa.irct.ir/search/result?query=IRCT20191222045847N1.
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Affiliation(s)
- Seyed Reza Raeeskarami
- grid.414574.70000 0004 0369 3463Department Of Pediatrics, Imam Khomeini Hospital Complex, Tehran University Of Medical Sciences, Tehran, Iran ,grid.411705.60000 0001 0166 0922Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
| | - Payman Sadeghi
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran. .,Children's Medical Center, Pediatrics Center of Excellence, Tehran, Iran. .,Pediatric Rheumatology Research Group, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mahdieh Vahedi
- Clinical Research Development Unit of Akbar Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. .,Department of Pediatrics, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Kosar Asna Ashari
- grid.411705.60000 0001 0166 0922Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran ,grid.414206.5Children’s Medical Center, Pediatrics Center of Excellence, Tehran, Iran
| | - Mahdieh Mousavi T.
- grid.411705.60000 0001 0166 0922Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran ,Bahrami Children’s Hospital, Tehran, Iran
| | - Vahid Ziaee
- grid.411705.60000 0001 0166 0922Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran ,grid.414206.5Children’s Medical Center, Pediatrics Center of Excellence, Tehran, Iran ,grid.411705.60000 0001 0166 0922Pediatric Rheumatology Research Group, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Lazea C, Damian L, Vulturar R, Lazar C. PFAPA Syndrome: Clinical, Laboratory and Therapeutic Features in a Single-Centre Cohort. Int J Gen Med 2022; 15:6871-6880. [PMID: 36061962 PMCID: PMC9439650 DOI: 10.2147/ijgm.s373942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study is to describe a group of Romanian children with periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome. Materials This consisted of 39 children diagnosed with PFAPA syndrome according to Thomas’ criteria (eight patients with an age at diagnosis <1 year and 31 patients with an age at diagnosis >1 year). Methods Retrospective analysis of the patients with PFAPA syndrome was focused on clinical features, laboratory findings and therapeutic methods. Comparison between the two groups divided by age at onset was also investigated. Results Median age at onset was 1.58 years, and median age at diagnosis was 2.97 years. The mean interval between episodes was 35.5 days and the mean duration per febrile episode was 4.1 days. The median diagnosis delay was 2.42 years. The patients presented pharyngitis (100%), adenitis (94.8%) and aphthous lesions (66.7%). The frequency of febrile attacks was higher in children with an age at diagnosis under 1 year (p = 0.0287). Younger age was associated with the presence of aphthae. The mean value of C-reactive protein (CRP) was 7.9mg/dl and the mean value of leucocytes was 14,839/mm3. In 95% of patients given oral corticosteroids, remission of symptoms was reported within 24 h. In three patients, tonsillectomy was performed with complete remission of the disease. Conclusion We present a cohort of children with PFAPA syndrome, with clinical and laboratory features similar to those described in the literature. Febrile attacks had a higher incidence in children with younger age at the onset of the disease. The patients had a favorable response to corticosteroids.
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Affiliation(s)
- Cecilia Lazea
- Department Pediatrics I, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Correspondence: Cecilia Lazea, Department Pediatrics I, University of Medicine and Pharmacy “Iuliu Hatieganu”, 68, Motilor street, Cluj-Napoca, 400370, Romania, Email ;
| | - Laura Damian
- Department of Rheumatology, County Emergency Clinical Hospital Cluj-Napoca, Centre for Rare Musculoskeletal Autoimmune and Autoinflammatory Diseases, Cluj-Napoca, Romania
| | - Romana Vulturar
- Department of Molecular Sciences, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Calin Lazar
- Department Pediatrics I, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
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10
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Kanık A, Eliaçık K, Kanık ET, Demirçelik Y, Demir BK. A comparative study for the clinical features in children with PFAPA syndrome who were diagnosed before and after the age of five. Int J Pediatr Otorhinolaryngol 2022; 158:111153. [PMID: 35500396 DOI: 10.1016/j.ijporl.2022.111153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/16/2022] [Accepted: 04/20/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Ali Kanık
- İzmir Katip Çelebi University, Faculty of Medicine, Department of Pediatrics, İzmir, Turkey.
| | - Kayı Eliaçık
- Tepecik Education and Training Hospital, Department of Pediatrics, İzmir, Turkey
| | - Esra Toprak Kanık
- Dr. Behcet Uz Children's Hospital, Department of Pediatric Allergy and Immunology, İzmir, Turkey
| | - Yavuz Demirçelik
- Tepecik Education and Training Hospital, Department of Pediatrics, İzmir, Turkey
| | - Belde Kasap Demir
- İzmir Katip Çelebi University, Faculty of Medicine, Department of Pediatric Rheumatology, İzmir, Turkey
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11
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Batu ED, Basaran O, Bilginer Y, Ozen S. Familial Mediterranean Fever: How to Interpret Genetic Results? How to Treat? A Quarter of a Century After the Association with the Mefv Gene. Curr Rheumatol Rep 2022; 24:206-212. [PMID: 35435612 DOI: 10.1007/s11926-022-01073-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW To provide an up-to-date approach to diagnosis and management of FMF patients. RECENT FINDINGS Familial Mediterranean fever (FMF) is the most common monogenic autoinflammatory disease and prototype monogenic autoinflammatory recurrent fever syndrome. Although it is one of the well-known autoinflammatory disorders, evaluations in the etiopathogenesis and genetics of the disease have shown that FMF is more complex than previously known. Since the number of reported MEFV variants increased, evaluating the genetic test results has become more challenging. Here, we suggest a roadmap for clinicians to facilitate their decisions regarding diagnosis, treatment, and follow-up in FMF patients with different genotype-phenotype combinations. The correct interpretation of genetic test results is crucial for timely diagnosis, appropriate treatment, and follow-up of FMF patients.
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Affiliation(s)
- Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, 06100, Turkey
| | - Ozge Basaran
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, 06100, Turkey
| | - Yelda Bilginer
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, 06100, Turkey
| | - Seza Ozen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, 06100, Turkey.
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12
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Abouzaid M, Hassib N, Hamed K, Taher M, Sokkar M, Eltaweel N, El-Bassyouni H. Oro-dental features in Egyptian patients with familial mediterranean fever. SPECIAL CARE IN DENTISTRY 2021; 42:376-382. [PMID: 34902169 DOI: 10.1111/scd.12687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Familial Mediterranean fever (FMF) is an episodic inflammatory disease that is inherited as an autosomal recessive trait. It is primarily featured by fever, pain in joints, chest, and abdomen due to Serositis. AIM This study delineated the oro-facial structures presented associated with FMF, as well as, the determination of the potential influences of the long-term inflammatory process of FMF on several oral structures. METHODS Fifty eight Egyptian FMF patients were examined to define different oro-facial structures. Serum amyloid A (SAA) was requested for the selected patients, MEFV gene mutation was also investigated. RESULTS The clinical examination revealed peritonitis in 79%, fever in 63.7%, and arthritis in 55% of FMF patients examined, while, oral features as high arched palate, enamel defect, dental malocclusion, and macroglossia in 32%, 27.5%. 26%, and 13.5%, respectively. The previous symptoms might be attributed to the pathology of the disease. Macroglossia when tested versus SAA levels, a highly significant difference was detected. The ROC curve when examining the SAA value to assess macroglossia, displayed reasonable sensitivity and specificity values of, 87.5% and 77.8%, respectively. CONCLUSION The noticed oro-dental in FMF patients might be influenced by the chronic inflammatory process.
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Affiliation(s)
- Maha Abouzaid
- Oro-dental Genetics department, National Research Centre, Cairo, Egypt
| | - Nehal Hassib
- Oro-dental Genetics department, National Research Centre, Cairo, Egypt
| | - Khaled Hamed
- Clinical Genetics department, National Research Centre, Cairo, Egypt
| | - Mohamed Taher
- Clinical Genetics department, National Research Centre, Cairo, Egypt
| | - Mona Sokkar
- Molecular Genetics and Enzymology department, National Research Centre, Cairo, Egypt
| | - Noha Eltaweel
- Medical Molecular Genetics department, National Research Centre, Cairo, Egypt
| | - Hala El-Bassyouni
- Clinical Genetics department, National Research Centre, Cairo, Egypt
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13
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Asna Ashari K, Rezaei N. PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) syndrome: an overview of genetic background. Clin Rheumatol 2021; 40:4437-4444. [PMID: 34014414 DOI: 10.1007/s10067-021-05770-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 02/02/2023]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is an autoinflammatory disorder with an uncertain origin. PFAPA manifestations occur in the form of regular attacks accompanied by a rise in inflammatory markers. Regarding the family clustering of PFAPA and its similarities with other autoinflammatory disorders such as familial Mediterranean fever, a genetic basis is suggested for the disease. Studies have conducted genome analysis in order to find possible gene variants in PFAPA. Associations with variations in several genes such as MEFV, NLRP, TNFRSF1A, CARD15/NOD2, and MVK have been suggested and analyzed. Inflammasomes, intracellular proteins that are members of innate immunity and activate interleukin-1b (IL-1b) and IL-18, are proposed to be involved in PFAPA pathogenesis. The investigations show that a single gene cannot be found in association with PFAPA, and that it might have a multifactorial or polygenic basis, in which an environmental trigger can provoke inflammasome activation and activate PFAPA flares.
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Affiliation(s)
- Kosar Asna Ashari
- Department of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Dr Qarib St, Keshavarz Blvd, 14194, Tehran, Iran. .,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. .,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
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14
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The role of Mediterranean fever gene variants in patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. Eur J Pediatr 2021; 180:1051-1058. [PMID: 33051715 DOI: 10.1007/s00431-020-03840-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/27/2020] [Accepted: 10/09/2020] [Indexed: 01/14/2023]
Abstract
This study was conducted to investigate the relationship between clinic features and Mediterranean fever gene (MEFV) variants in patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome. In total, 167 patients with PFAPA syndrome were included in the study. Female:male ratio of the patients was 0.75 (72 females, 95 males). In total 59.9% of patients with PFAPA had at least one MEFV variant and the most common heterozygous variants were M694V in 29.3% of the patients (40/167), E148Q in 8.3% (14/167), and V726A in 7.1% (12/167). The median age at the disease onset was significantly higher and the median duration of the episodes was significantly lower in patient with variants in exon 10 comparing to the others (both p = 0.01). Similarly, the median age at the disease onset was significantly higher (p = 0.01) and the median duration of the episodes was significantly lower (p = 0.04) in patient with MEFV variants than in the remaining patients. There were no significant differences according to the genotypes of the patients in terms of both treatment response and the frequency of clinical findings.Conclusion: In PFAPA syndrome, MEFV variants may be a modifier for disease onset and attack duration. What is Known: • Due to periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome having clinical findings resembling familial Mediterranean fever (FMF), it can be difficult to distinguish PFAPA syndrome and FMF especially in endemic regions for FMF. • Underlying MEFV mutations could affect the periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome's clinical presentation and response to treatment. What is New: • Having one of the underlying MEFV variants is related to later disease onset and shorter episode duration in patients with PFAPA syndrome.
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15
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Batu ED, Vezir E, Öğüş E, Özbaş Demirel Ö, Akpınar G, Demir S, Özen S. Galectin-3: a new biomarker for differentiating periodic fever, adenitis, pharyngitis, aphthous stomatitis (PFAPA) syndrome from familial Mediterranean fever? Rheumatol Int 2021; 42:71-80. [PMID: 33709179 DOI: 10.1007/s00296-021-04827-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/01/2021] [Indexed: 10/21/2022]
Abstract
Differentiating PFAPA (periodic fever, aphthosis, pharyngitis, and adenitis) syndrome from familial Mediterranean fever (FMF) could be challenging in some cases. Galectin-3 is a lectin with regulatory functions in apoptosis and inflammation. We aimed to test whether galectin-3 could be a biomarker for differentiating PFAPA syndrome from FMF. Patients with PFAPA syndrome, FMF, cryopyrin-associated periodic syndrome (CAPS), and streptococcal pharyngitis, and healthy controls were included in this study. Serum galectin-3 levels were measured using enzyme-linked immunosorbent assay. Eighty-seven patients (36 with PFAPA, 39 with FMF, 8 with CAPS, 4 with streptococcal pharyngitis), and 17 healthy controls were included. Blood samples were drawn during attacks from 20 PFAPA and 7 FMF patients and attack-free periods from 22 PFAPA, 35 FMF, and 8 CAPS patients. The median serum galectin-3 level in the PFAPA-attack group (1.025 ng/ml) was significantly lower than the levels in healthy control (2.367 ng/ml), streptococcal pharyngitis (3.021 ng/ml), FMF attack (2.402 ng/ml), and FMF-attack-free groups (2.797 ng/ml) (p = 0.006, 0.03, 0.01, and < 0.001, respectively). PFAPA-attack-free group had lower galectin-3 levels than the FMF-attack-free group (1.794 vs. 2.797 ng/ml, respectively; p = 0.01). Galectin-3 levels did not differ significantly between CAPS and attack-free PFAPA patients (1.439 ng/ml vs. 1.794 ng/ml, respectively; p = 0.63). In our study, for the first time, we defined galectin-3 as a promising biomarker that differs between PFAPA and FMF patients during both disease flares and attack-free periods. Further studies with high number of patients could validate its role as a biomarker.
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Affiliation(s)
- Ezgi D Batu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey.
| | - Emine Vezir
- Division of Allergy and Immunology, Department of Pediatrics, Ankara Health Research and Application Center, University of Health Sciences, Ankara, Turkey
| | - Elmas Öğüş
- Department of Biochemistry, Ankara Health Research and Application Center, University of Health Sciences, Ankara, Turkey
| | - Özlem Özbaş Demirel
- Department of Biochemistry, Ankara Health Research and Application Center, University of Health Sciences, Ankara, Turkey
| | - Gizem Akpınar
- Department of Pediatrics, Ankara Health Research and Application Center, University of Health Sciences, Ankara, Turkey
| | - Selcan Demir
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
| | - Seza Özen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
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16
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[Clinical features of children with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome: an analysis of 13 cases]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23. [PMID: 33627208 PMCID: PMC7921540 DOI: 10.7499/j.issn.1008-8830.2008097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To study the clinical features of children with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome, a polygenic and multifactorial autoinflammatory disease with unknown pathogenesis. METHODS A retrospective analysis was performed on the medical data of 13 children with PFAPA syndrome. RESULTS All 13 children had disease onset within the age of 3 years, with a mean age of onset of (14±10) months. They all had periodic fever, with 8-18 attacks each year. The mean interictal period of fever was (30±5) days. Pharyngitis, cervical adenitis, and aphthous stomatitis were the three cardinal symptoms, with incidence rates of 100% (13/13), 85% (11/13), and 38% (5/13) respectively. There were increases in white blood cells, C-reactive protein, and erythrocyte sedimentation rate during fever. Of all the 13 children, 6 underwent whole exome sequencing and 7 underwent panel gene detection for autoinflammatory disease, and the results showed single heterozygous mutations in the MEFV gene in 6 children (46%). Recurrent fever in all children gradually returned to normal without antibiotics. Ten children were treated with a single dose of glucocorticoids, and fever was relieved after treatment. Of all the children, 4 were treated with cimetidine, among whom 2 had response; 4 children were treated with colchicine, among whom 2 had response and 2 were withdrawn from the drug due to adverse reactions. Tonsillectomy was performed for 2 children, among whom 1 was followed up for 3 years without recurrence and 1 still had recurrence. CONCLUSIONS For children with unexplained periodic fever with early onset accompanied by pharyngitis, cervical adenitis, aphthous stomatitis, elevated inflammatory indices, and good response to glucocorticoids, PFAPA syndrome should be considered. This disorder has good prognosis, and early diagnosis can avoid the long-term repeated use of antibiotics.
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17
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Veres T, Amarilyo G, Abu Ahmad S, Abu Rumi M, Brik R, Hezkelo N, Ohana O, Levinsky Y, Chodick G, Butbul Aviel Y. Familial Periodic Fever, Aphthous Stomatitis, Pharyngitis and Adenitis Syndrome; Is It a Separate Disease? Front Pediatr 2021; 9:800656. [PMID: 35310141 PMCID: PMC8929572 DOI: 10.3389/fped.2021.800656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA) is the most common periodic fever syndrome in the pediatric population, yet its pathogenesis is unknown. PFAPA was believed to be sporadic but family clustering has been widely observed. OBJECTIVE To identify demographic and clinical differences between patients with PFAPA and a positive family history (FH+) as compared to those with no family history (FH-). METHODS In a database comprising demographic and clinical data of 273 pediatric PFAPA patients treated at two tertiary centers in Israel, 31 (14.3%) had FH+. Data from patients with FH+ were compared to data from those with FH-. Furthermore, family members (FMs) of those with FH+ were contacted via telephone for more demographic and clinical details. RESULTS The FH+ group as compared to the FH- group had more myalgia (56 vs. 19%, respectively, p = 0.001), headaches (32 vs. 2%, respectively, p = 0.016), and a higher carrier frequency of M694V mutation (54% vs. 25%, respectively, p = 0.05). Colchicine was seen to be a more beneficial treatment for the FH+ group as compared to the FH- group; however, with no statistical significance (p = 0.096). FMs displayed almost identical characteristics to patients in the FH+ group except for greater arthralgia during flares (64 vs. 23%, respectively, p = 0.008), and compared to the FH- group they had more oral aphthae (68 vs. 43%, respectively, p = 0.002), myalgia/arthralgia (64 vs. 19%/16%, respectively, p < 0.0001), and higher rates of FH of Familial Mediterranean fever (FMF) (45 vs.15%, respectively, p = 0.003). CONCLUSIONS Our findings suggest that patients with a FH+ likely experience a different subset of disease with higher frequency of family history of FMF, arthralgia, myalgia, and might have a better response to colchicine compared to FH-. Colchicine prophylaxis for PFAPA should be considered in FH+.
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Affiliation(s)
- Tamar Veres
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Amarilyo
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Sabreen Abu Ahmad
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Pediatrics B, Rambam Medical Center, Ruth Rappaport Children's Hospital, Haifa, Israel
| | - Maryam Abu Rumi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Riva Brik
- Department of Pediatrics B, Rambam Medical Center, Ruth Rappaport Children's Hospital, Haifa, Israel.,Pediatric Rheumatology Service, Rambam Medical Center, Ruth Rappaport Children's Hospital, Haifa, Israel
| | - Nofar Hezkelo
- Department of Medicine F-Recanati, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Orly Ohana
- Department of Pediatrics C, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Yoel Levinsky
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Gabriel Chodick
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Yonatan Butbul Aviel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Pediatrics B, Rambam Medical Center, Ruth Rappaport Children's Hospital, Haifa, Israel.,Pediatric Rheumatology Service, Rambam Medical Center, Ruth Rappaport Children's Hospital, Haifa, Israel
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18
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Welzel T, Ellinghaus M, Wildermuth AL, Deschner N, Benseler SM, Kuemmerle-Deschner JB. Colchicine Effectiveness and Safety in Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis. Front Pediatr 2021; 9:759664. [PMID: 34900867 PMCID: PMC8655689 DOI: 10.3389/fped.2021.759664] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/12/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) is the most common fever syndrome in childhood. High disease activity (DA) dramatically impacts the health-related quality of life. Thus, effective and safe treatment is crucial. Colchicine might be effective, but data are still lacking. Study aimed to assess colchicine safety and effectiveness in PFAPA. Methods: This single center study was conducted between 03/2012 and 05/2021 in PFAPA patients without variants in genetic panel testing aged ≤ 18 years fulfilling Marshall criteria and classification criteria of Gattorno et al. Exclusion criteria were elevated liver enzymes, impaired kidney function, celiac disease, lactose intolerance, previous/ongoing biologics, known colchicine-intolerance. Demographics, clinical characteristics, treatment, DA, colchicine effectiveness and safety were recorded at baseline, first and last visit. Colchicine was started at 0.5-1.0 mg/day. DA was captured by physician (PGA) and patient/parent (PPGA) global assessment on a 10 cm visual analog scale, categorized as mild (<2), moderate (2-4), and high (≥5). Adverse event (AE) monitoring included gastrointestinal symptoms, liver enzyme/creatinine elevation, leukopenia, neutropenia. Primary outcome included response (R; composite of PPGA + PGA decrease ≥2) at last follow-up. Secondary outcomes were partial response (PR; PGA decrease = 1 + PPGA decrease ≥1), no response (NR; unchanged/worsened PGA/PPGA), colchicine safety, flare characteristics. Results: Twenty-seven PFAPA patients were included, 52% were female, median age was 5.8 years (1-10.75), median follow-up time was 13 months. At baseline, median PPGA was high; median PGA moderate. All patients had febrile flares. Median flare frequency was every 4-5 weeks; median duration 5-6 days. Nine patients were pre-treated with corticosteroids, increasing flare frequency in 8/9. Primary Outcome: 17 patients (63%) were responders. Secondary outcomes: PR was achieved in 15%; NR in 22% at last follow-up. DA decreased significantly (p <0.0001). At last follow-up, 52% reported no flares, median flare duration decreased to 1-2 days. At first follow-up, 22% reported mild abdominal pain/diarrhea. Moderate abdominal pain/diarrhea occurred with ≥1 mg/day. Mild asymptomatic liver enzyme elevation or leucopenia were rare; no severe AE or colchicine discontinuation were observed. Conclusion: Colchicine seems to be safe, well-tolerated, and effective in PFAPA patients. It can be considered in children with moderate/high DA even those without corticosteroid-benefit.
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Affiliation(s)
- Tatjana Welzel
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Maren Ellinghaus
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Anna L Wildermuth
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Norbert Deschner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Susanne M Benseler
- Rheumatology, Department of Paediatrics, Alberta Children's Hospital, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Jasmin B Kuemmerle-Deschner
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
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19
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Yildiz M, Haslak F, Adrovic A, Gucuyener N, Ulkersoy I, Koker O, Sahin S, Unlu G, Barut K, Kasapcopur O. Independent risk factors for resolution of periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome within 4 years after the disease onset. Clin Rheumatol 2020; 40:1959-1965. [PMID: 33067771 DOI: 10.1007/s10067-020-05466-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND/OBJECTIVE Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is a polygenic disease with unknown etiology. In this retrospective cohort study, we aimed to evaluate the risk factors for the resolution of PFAPA syndrome within 4 years after the onset. METHODS In total, 466 patients with PFAPA syndrome that are being followed up our department were included into the study. Between May 2020 and September 2020, medical charts of the patients were reviewed retrospectively. RESULTS The median age of the patients at the time of the study and at disease onset were 8.6 (2.9-20.5; IQR 6.9-10.6) years and 18 (1-84; IQR 11-31) months. On univariate analysis age at disease onset (p = 0.003), positive family history of PFAPA syndrome (p = 0.04), absence of myalgia (p = 0.04), and absence of headache (p = 0.003) were all associated with the resolution of PFAPA syndrome within 4 years after the onset. Multivariate logistic regression analysis revealed that age at disease onset (OR 1.04, 95% CI 1.01-1.07, p = 0.002), positive family history of PFAPA syndrome (OR 2.69, 95% CI 1.12-6.48, p = 0.02), and absence of headache (OR 0.2, 95% CI 0.05-0.74, p = 0.01) were independent risk factors for the resolution of PFAPA syndrome within 4 years after the onset. CONCLUSION We report later age of disease onset, positive family history of PFAPA syndrome, and absence of headache as independent risk factors for resolution of PFAPA syndrome within 4 years after the onset. KEY POINTS • Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is a multifactorial disease with unknown etiology. • Although, PFAPA syndrome usually resolves within 3-5 years after the disease onset, it can persist for years and even continue into adulthood. With our current knowledge, there is no clue to predict which patients will have a long disease course and which patients will not. • Later age of disease onset, positive family history of PFAPA syndrome and absence of headache as independent risk factors for resolution of PFAPA syndrome within 4 years after the onset.
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Affiliation(s)
- Mehmet Yildiz
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Fatih Haslak
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Neslihan Gucuyener
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ipek Ulkersoy
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Oya Koker
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Gulcin Unlu
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey.
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20
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Yıldız M, Haşlak F, Adrovic A, Barut K, Kasapçopur Ö. Autoinflammatory Diseases in Childhood. Balkan Med J 2020; 37:236-246. [PMID: 32338845 PMCID: PMC7424192 DOI: 10.4274/balkanmedj.galenos.2020.2020.4.82] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 04/26/2020] [Indexed: 01/06/2023] Open
Abstract
Autoinflammatory diseases are characterized by recurrent fevers and clinical findings of impaired natural immunity and can involve various organ systems. The concept of autoinflammatory disease emerged after the definition of familial Mediterranean fever and tumor necrosis factor receptor-associated periodic syndrome. This new disease group was considered to differ from the standard concept of autoimmune diseases, which is relatively better known in terms of basic features, such as defects in innate immunity and the absence of antibodies. A better understanding has been achieved regarding the genetic and pathogenetic mechanisms of this relatively new disease group over the past 20 years since they were first diagnosed, which have led to some changes in the concept of autoinflammatory diseases. The recent definition classifies autoinflammatory disease to be a wide range of diseases with different clinical features, mainly accompanied by changes in innate immune and rarely in humoral immunity. The spectrum of autoinflammatory diseases is rapidly expanding owing to recent developments in molecular sciences and genetics. This review article discusses the clinical features, classification criteria, treatment options, and long-term prognosis of periodic fever, aphthous stomatitis, pharyngitis, adenitis syndrome, and other common autoinflammatory diseases in the light of current literature.
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Affiliation(s)
- Mehmet Yıldız
- Department of Pediatric Rheumatology, İstanbul University-Cerrahpaşa Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Fatih Haşlak
- Department of Pediatric Rheumatology, İstanbul University-Cerrahpaşa Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, İstanbul University-Cerrahpaşa Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, İstanbul University-Cerrahpaşa Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Özgür Kasapçopur
- Department of Pediatric Rheumatology, İstanbul University-Cerrahpaşa Cerrahpaşa School of Medicine, İstanbul, Turkey
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21
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Soriano A, Soriano M, Espinosa G, Manna R, Emmi G, Cantarini L, Hernández-Rodríguez J. Current Therapeutic Options for the Main Monogenic Autoinflammatory Diseases and PFAPA Syndrome: Evidence-Based Approach and Proposal of a Practical Guide. Front Immunol 2020; 11:865. [PMID: 32655539 PMCID: PMC7325944 DOI: 10.3389/fimmu.2020.00865] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
Monogenic autoinflammatory diseases are rare conditions caused by genetic abnormalities affecting the innate immunity. Previous therapeutic strategies had been mainly based on results from retrospective studies and physicians' experience. However, during the last years, the significant improvement in their genetic and pathogenic knowledge has been accompanied by a remarkable progress in their management. The relatively recent identification of the inflammasome as the crucial pathogenic mechanism causing an aberrant production of interleukin 1β (IL-1β) in the most frequent monogenic autoinflammatory diseases led to the introduction of anti-IL-1 agents and other biologic drugs as part of the previously limited therapeutic armamentarium available. Advances in the treatment of autoinflammatory diseases have been favored by the use of new biologic agents and the performance of a notable number of randomized clinical trials exploring the efficacy and safety of these agents. Clinical trials have contributed to increase the level of evidence and provided more robust therapeutic recommendations. This review analyzes the treatment of the most frequent monogenic autoinflammatory diseases, namely, familial Mediterranean fever, tumor necrosis factor receptor-associated periodic fever syndrome, hyperimmunoglobulin D syndrome/mevalonate kinase deficiency, and cryopyrin-associated periodic syndromes, together with periodic fever with aphthous stomatitis, pharyngitis, and cervical adenitis syndrome, which is the most common polygenic autoinflammatory disease in children, also occurring in adult patients. Finally, based on the available expert consensus recommendations and the highest level of evidence of the published studies, a practical evidence-based guideline for the treatment of these autoinflammatory diseases is proposed.
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Affiliation(s)
- Alessandra Soriano
- Division of Internal Medicine, Department of Internal Medicine and Medical Specialties, Arcispedale S. Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Marco Soriano
- School of Medicine, Luigi Vanvitelli University, Naples, Italy
| | - Gerard Espinosa
- Clinical Unit of Autoinflammatory Diseases and Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Raffaele Manna
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Periodic Fevers Research Centre, Institute of Internal Medicine, Università Cattolica Sacro Cuore, Rome, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease, Rheumatology Unit of the Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - José Hernández-Rodríguez
- Clinical Unit of Autoinflammatory Diseases and Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
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22
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Gattorno M, Hofer M, Federici S, Vanoni F, Ruperto N. Some clarifications on the new classification criteria for recurrent fevers. Semin Arthritis Rheum 2020; 50:1550-1551. [PMID: 32416999 DOI: 10.1016/j.semarthrit.2020.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 03/20/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Marco Gattorno
- IRCCS Istituto Giannina Gaslini, UOSD Centro Malattie Autoinfiammatorie e Immunodeficienze, Genoa, Italy.
| | - Michael Hofer
- Department of Paediatrics, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Silvia Federici
- UO Reumatologia, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Federica Vanoni
- Department of Paediatrics, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland; Istituto Pediatrico della Svizzera Italiana, Bellinzona, Switzerland
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
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23
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Sag E, Ozen S. Response to letter to the editor. Semin Arthritis Rheum 2020; 50:1553. [PMID: 32408986 DOI: 10.1016/j.semarthrit.2020.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Erdal Sag
- Department of Pediatric Rheumatology, Hacettepe University, Turkey.
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University, Turkey.
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24
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Amarilyo G, Rothman D, Manthiram K, Edwards KM, Li SC, Marshall GS, Yildirim-Toruner C, Haines K, Ferguson PJ, Lionetti G, Cherian J, Zhao Y, DeLaMora P, Syverson G, Nativ S, Twilt M, Michelow IC, Stepanovskiy Y, Thatayatikom A, Harel L, Akoghlanian S, Tucker L, Marques MC, Srinivasalu H, Propst EJ, Licameli GR, Dedeoglu F, Lapidus S. Consensus treatment plans for periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA): a framework to evaluate treatment responses from the childhood arthritis and rheumatology research alliance (CARRA) PFAPA work group. Pediatr Rheumatol Online J 2020; 18:31. [PMID: 32293478 PMCID: PMC7157990 DOI: 10.1186/s12969-020-00424-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/03/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children. There is considerable heterogeneity in management strategies and a lack of evidence-based treatment guidelines. Consensus treatment plans (CTPs) are standardized treatment regimens that are derived based upon best available evidence and current treatment practices that are a way to enable comparative effectiveness studies to identify optimal therapy and are less costly to execute than randomized, double blind placebo controlled trials. The purpose of this project was to develop CTPs and response criteria for PFAPA. METHODS The CARRA PFAPA Working Group is composed of pediatric rheumatologists, infectious disease specialists, allergists/immunologists and otolaryngologists. An extensive literature review was conducted followed by a survey to assess physician practice patterns. This was followed by virtual and in-person meetings between 2014 and 2018. Nominal group technique (NGT) was employed to develop CTPs, as well as inclusion criteria for entry into future treatment studies, and response criteria. Consensus required 80% agreement. RESULTS The PFAPA working group developed CTPs resulting in 4 different treatment arms: 1. Antipyretic, 2. Abortive (corticosteroids), 3. Prophylaxis (colchicine or cimetidine) and 4. Surgical (tonsillectomy). Consensus was obtained among CARRA members for those defining patient characteristics who qualify for participation in the CTP PFAPA study. CONCLUSION The goal is for the CTPs developed by our group to lead to future comparative effectiveness studies that will generate evidence-driven therapeutic guidelines for this periodic inflammatory disease.
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Affiliation(s)
- Gil Amarilyo
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | - Kalpana Manthiram
- grid.280128.10000 0001 2233 9230National Human Genome Research Institute, National Institutes of Health, Bethesda, MD USA
| | - Kathryn M. Edwards
- grid.152326.10000 0001 2264 7217Vanderbilt University School of Medicine, Nashville, TN USA
| | - Suzanne C. Li
- Joseph M Sanzari Children’s Hospital, Hackensack Meridian Health, Hackensack, NJ USA
| | - Gary S. Marshall
- grid.266623.50000 0001 2113 1622Department of Pediatrics, University of Louisville, Louisville, KY USA
| | | | - Kathleen Haines
- Joseph M Sanzari Children’s Hospital, Hackensack Meridian Health, Hackensack, NJ USA
| | - Polly J. Ferguson
- grid.214572.70000 0004 1936 8294Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA USA
| | - Geraldina Lionetti
- grid.414016.60000 0004 0433 7727UCSF Benioff Children’s Hospital Oakland, Oakland, CA USA
| | - Julie Cherian
- grid.412695.d0000 0004 0437 5731Stony Brook University Hospital, Stony Brook, NY USA
| | - Yongdong Zhao
- grid.34477.330000000122986657Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - Patricia DeLaMora
- grid.5386.8000000041936877XWeill Cornell Medical College, New York, NY USA
| | - Grant Syverson
- grid.30760.320000 0001 2111 8460Medical College of Wisconsin, Wauwatosa, WI USA
| | - Simona Nativ
- grid.429583.1Goryeb Children’s Hospital, Morristown, NJ USA
| | - Marinka Twilt
- grid.22072.350000 0004 1936 7697Rheumatology, Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta Canada
| | - Ian C. Michelow
- grid.40263.330000 0004 1936 9094Alpert Medical School of Brown University, Providence, RI USA
| | - Yuriy Stepanovskiy
- grid.415616.10000 0004 0399 7926Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
| | - Akaluck Thatayatikom
- grid.15276.370000 0004 1936 8091Department of Pediatrics, University of Florida, Gainesville, FL USA
| | - Liora Harel
- grid.12136.370000 0004 1937 0546Pediatric Rheumatology Unit, Schneider Children’s Medical Center of Israel, Petach Tikva; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shoghik Akoghlanian
- grid.240344.50000 0004 0392 3476Nationwide Children’s Hospital, Columbus, OH USA
| | - Lori Tucker
- grid.414137.40000 0001 0684 7788BC Children’s Hospital, Vancouver, BC Canada
| | - Mariana Correia Marques
- grid.38142.3c000000041936754XBoston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Hemalatha Srinivasalu
- grid.239560.b0000 0004 0482 1586Children’s National Medical Center, Washington, DC USA
| | - Evan J. Propst
- grid.17063.330000 0001 2157 2938Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - Greg R. Licameli
- grid.38142.3c000000041936754XBoston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Fatma Dedeoglu
- grid.38142.3c000000041936754XBoston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Sivia Lapidus
- Joseph M Sanzari Children’s Hospital, Hackensack Meridian Health, Hackensack, NJ USA
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Sag E, Demirel D, Demir S, Atalay E, Akca U, Bilginer Y, Ozen S. Performance of the new 'Eurofever/PRINTO classification criteria' in FMF patients. Semin Arthritis Rheum 2019; 50:172-175. [PMID: 31471011 DOI: 10.1016/j.semarthrit.2019.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 07/16/2019] [Accepted: 08/06/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Recently a new set of criteria proposed for the classification of auto inflammatory recurrent fevers including familial Mediterranean Fever (FMF). We aimed to compare the sensitivity and specificity of the new Eurofever/PRINTO classification criteria with those of the Tel Hashomer and Yalcinkaya-Ozen criteria. METHODS 151 consecutive FMF patients between February and May 2019 who were followed at Hacettepe University Department of Pediatric Rheumatology were included in this study. A group of 82 patients with periodic fever 66 periodic fever, aphthosis, pharyngitis and adenitis syndrome (PFAPA), nine cryopyrin-associated periodic syndrome (CAPS) and seven mevalonate kinase deficiency/hyperimmunoglobulin D syndrome (MKD/HIDS) patients) served as controls. GraphPad 6.0 was used for statistical analysis. RESULTS Three different classification criteria were analyzed in 151 FMF patients with a median age at diagnosis of 5 years and in 82 controls with a median age at diagnosis of 3 years. The sensitivity of the new Eurofever/PRINTO criteria (96%) was highest (Tel Hashomer criteria-88.4% and Yalcinkaya-Ozen criteria-93.4%). However, the specificity of these criteria (73.1%) was lowest (Tel Hashomer criteria-92.6% and Yalcinkaya-Ozen criteria-84.1%). The new Eurofever/PRINTO criteria achieved the highest sensitivity (100%) in biallelic exon 10 mutation patients (Tel Hashomer criteria-87.4% and Yalcinkaya-Ozen criteria-94.2%). However, the new set had the lowest sensitivity (88.2%) in heterozygote exon 10 mutation patients (Tel Hashomer criteria 94.1% and Yalcinkaya-Ozen criteria 94.1%). CONCLUSION In this Turkish cohort, the new Eurofever/PRINTO criteria have a better sensitivity but lower specificity with higher misclassifications than other two well-known criteria. The combination of clinical manifestations with genotype increased the sensitivity. The lower specificity may be due to the high carrier rate in our population. Although the ethnicity information lowers the specificity, 'clinical-only' criteria set may still guide the clinician to perform appropriate genetic testing in patients with recurrent fever.
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Affiliation(s)
- Erdal Sag
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Dilara Demirel
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Selcan Demir
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Erdal Atalay
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Ummusen Akca
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Yelda Bilginer
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Seza Ozen
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey.
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Evaluation of co-existing diseases in children with familial Mediterranean fever. Rheumatol Int 2019; 40:57-64. [PMID: 31352561 DOI: 10.1007/s00296-019-04391-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/21/2019] [Indexed: 01/03/2023]
Abstract
Familial Mediterranean fever (FMF) is A common periodic fever syndrome. The causative gene of the FMF is named Mediterranean Fever gene (MEFV). Increased inflammation in FMF may play a role as a trigger for the development of some diseases. The objective of the study is to evaluate the frequency of comorbid disorders in children followed up with diagnosis of FMF. Additionally, we aimed to assess the association between FMF and other inflammatory conditions in a large pediatric FMF cohort. A total of 686 FMF patients were included in the cross-sectional study. A questionnaire including questions about characteristics of fever episodes, presence of arthralgia, arthritis, abdominal pain, chest pain during and co-existence of any other disease diagnosed by a physician was filled out by face-to-face interviews with patients or their parents. Female-male ratio was 0.85. Median age at the time of study, age at disease onset and at the time of diagnosis were 12.9 (1.7-22.3), 3 (0.08-17), and 6 (0.75-17) years, respectively. In 130 (18.9%) FMF patients we detected co-existing inflammatory condition. The most common co-existing diseases were: juvenile idiopathic arthritis 42 (6.1%), asthma/reactive airway disease 29 (4.2%), Henoch-Schönlein purpura 20 (2.9%), uveitis 12 (1.7%) and inflammatory bowel disease 10 (1.4%). Except for asthma/reactive airway disease and inflammatory bowel disease, there was no significant difference regarding the type of MEFV gene mutation. We have reported increased frequencies of various inflammatory conditions and decreased frequency of asthma in patients with FMF.
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Westwell-Roper C, Niemietz I, Tucker LB, Brown KL. Periodic fever syndromes: beyond the single gene paradigm. Pediatr Rheumatol Online J 2019; 17:22. [PMID: 31088470 PMCID: PMC6515597 DOI: 10.1186/s12969-019-0324-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 04/30/2019] [Indexed: 12/16/2022] Open
Abstract
Familial Mediterranean fever (FMF) is the most common monogenic autoinflammatory disease in Canada and is characterized by a clinical syndrome of episodic inflammatory symptoms. Traditionally, the disease is defined by autosomal recessive inheritance of MEFV gene variants, yet FMF also not uncommonly manifests in individuals with only one identified disease-associated allele. Increasing availability and affordability of gene sequencing has led to the identification of multiple MEFV variants; however, they are often of unknown clinical significance. Variants in other genes affecting overlapping or distinct inflammatory signaling pathways - together with gene-environment interactions including epigenetic modulation - likely underlie the significant genetic and phenotypic heterogeneity seen among patients with this disease. We review recent evidence of the expanding spectrum of FMF genotype and phenotype and suggest that current drug funding schemes restricting biologic agents to patients with homozygous mutations have not kept pace with our biological understanding of the disease.
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Affiliation(s)
- Clara Westwell-Roper
- 0000 0001 2288 9830grid.17091.3eDivision of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada ,0000 0001 0684 7788grid.414137.4BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Iwona Niemietz
- 0000 0001 2288 9830grid.17091.3eDepartment of Microbiology & Immunology, University of British Columbia, Vancouver, Canada ,0000 0001 0684 7788grid.414137.4BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Lori B. Tucker
- 0000 0001 2288 9830grid.17091.3eDivision of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada ,0000 0001 0684 7788grid.414137.4BC Children’s Hospital, K4-124 4480 Oak St, Vancouver, BC V6H 3N1 Canada
| | - Kelly L. Brown
- 0000 0001 2288 9830grid.17091.3eDivision of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada ,0000 0001 0684 7788grid.414137.4BC Children’s Hospital Research Institute, Vancouver, Canada
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28
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Recurrence of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome after tonsillectomy: case-based review. Rheumatol Int 2019; 39:1099-1105. [PMID: 31020337 DOI: 10.1007/s00296-019-04310-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/16/2019] [Indexed: 12/24/2022]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is a recurrent fever syndrome for which tonsillectomy is a therapeutic option curing the disease in most patients. Recurrence after remission with tonsillectomy is extremely rare. Increasing number of reports on diverse disease manifestations in PFAPA could give us clues about the disease etiopathogenesis. We aimed to describe a patient with recurrence of PFAPA syndrome after tonsillectomy and to review the previous studies including similar cases. We report a 17-year-old boy with PFAPA syndrome who experienced remission for 3 years after tonsillectomy and was later found to harbor an MEFV mutation when the disease relapsed. He responded well to colchicine treatment at relapse. The literature review revealed 14 articles describing 24 similar PFAPA patients. The therapeutic options include single-dose corticosteroids and nonsteroidal anti-inflammatory drugs during attacks, cimetidine, and resurgery. The presented case was the only one heterozygous for an MEFV mutation and treated with colchicine at disease relapse. Albeit rare, the reoccurrence of PFAPA after tonsillectomy could occur. The presence of such patients opposes with the hypothesis that the trigger or immune dysregulation in PFAPA pathogenesis resides in tonsils.
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Haytoglu Z, Gundeslioglu OO. Mediterranean fever gene variants and colchicine therapy in periodic fever, aphthous stomatitis pharyngitis, adenitis syndrome in a Mediterranean region. Expert Rev Clin Immunol 2019; 15:571-575. [PMID: 30887853 DOI: 10.1080/1744666x.2019.1591275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Periodic fever, aphthous stomatitis, pharyngitis, adenitis syndrome is characterized by recurrent episodes of fever. Attenuated disease severity was considered in patients with Mediterranean fever (MEFV) gene variations. Corticosteroids are highly effective in controlling the symptoms but usually cause more frequent episodes. Frequent fever episodes either initiated after the steroid therapy or as an initial disease characteristics are the most challenging feature. METHODS Sixty-seven patients were prospectively followed from September 2015 to January 2018. MEFV variants were searched in all patients. Colchicine therapy was initiated in patients with MEFV variants and with shortened intervals after the initiation of steroid therapy. RESULTS Heterozygous MEFV gene variants were detected in 23 patients (34.3%). Higher exon 10 allel frequencies were found in patients with frequent fever episodes. Among 26 patients with increased episodes, colchicine treatment decreased the number of the episodes in 8 of 10 (80%) and 4 of 16 (25%) patients with and without variants, respectively (p = 0.022). Fever duration decreased (3.26 ± 1.38 vs. 1.57 ± 0.57 days, p < 0.001) at the third month of therapy in variant(+) patients. CONCLUSION In variant positive patients colchicine prophylaxis reduced the duration of attacks at the third months of therapy. Shortened intervals due to steroid therapy were increased at the sixth months of colchicine therapy.
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Affiliation(s)
- Zeliha Haytoglu
- a Faculty of Medicine, Department of Pediatrics , Cukurova University , Adana , Turkey
| | - Ozlem Ozgur Gundeslioglu
- b Faculty of Medicine, Department of Pediatrics, Division of Pediatric Infectious Disease , Cukurova University , Adana , Turkey
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Batu ED. Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome: main features and an algorithm for clinical practice. Rheumatol Int 2019; 39:957-970. [PMID: 30798384 DOI: 10.1007/s00296-019-04257-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/14/2019] [Indexed: 01/20/2023]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is a recurrent fever syndrome of early childhood with increasing number of adult-onset cases. Although it is a self-limited disease, it may negatively affect the quality of life. The aim of this review is to present a detailed analysis of PFAPA syndrome and an algorithm for diagnosis, therapeutic options, and evaluation of outcome. A comprehensive literature search was conducted through the Cochrane Library, Scopus, and MEDLINE/PubMed databases. The main topics covered are the epidemiology, clinical manifestations, diagnosis, differential diagnosis, etiopathogenesis, genetics, management, disease course and prognosis, disease in adults, unsolved issues, and unmet needs in PFAPA. The diagnosis of PFAPA is mainly based on clinical classification criteria. The most relevant hypothesis for pathogenesis is that dysregulated immune system in a genetically predisposed individual responds to a yet unidentified trigger in an exaggerated way. The pedigree analyses suggest a genetic background for the disease with an autosomal dominant pattern of inheritance. For management, single-dose corticosteroids during attacks and tonsillectomy remain the most effective therapies, while colchicine is a promising option to decrease attack frequency. There remain unsolved issues in PFAPA such as the exact etiopathogenesis and genetic background, the reason why the inflammation is restricted to the oropharyngeal lymphoid tissue, reasons for clock-work regularity of attacks, and self-limited disease course. There is need for a valid diagnostic criteria set with a high performance for both children and adults and consensus on management of PFAPA.
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Affiliation(s)
- Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, Ankara Training and Research Hospital, University of Health Sciences, 06100, Ankara, Turkey.
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Wekell P. Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome - PFAPA syndrome. Presse Med 2019; 48:e77-e87. [PMID: 30683466 DOI: 10.1016/j.lpm.2018.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/07/2018] [Indexed: 01/04/2023] Open
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is a complex autoinflammatory disease with a clinical phenotype characterised by recurrent episodes of fever, systemic inflammation and symptoms and signs depicted in disease acronym. Although PFAPA is the most common autoinflammatory disease among children in many parts of the world, the condition is still an enigma, which include the regular episodes, the prompt responses to corticosteroids, the genetic bases for the familial clustering and therapeutic effects of tonsillectomy. This review explores PFAPA syndrome with the aim of describing the current clinical and scientific understanding of the condition.
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Affiliation(s)
- Per Wekell
- Department of Pediatrics, NU-Hospital Group, 45180 Uddevalla, Sweden; Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Adrovic A, Sahin S, Barut K, Kasapcopur O. Familial Mediterranean fever and periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome: shared features and main differences. Rheumatol Int 2018; 39:29-36. [PMID: 30019226 DOI: 10.1007/s00296-018-4105-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 07/13/2018] [Indexed: 11/30/2022]
Abstract
Autoinflammatory diseases are characterized by fever attacks of varying durations, associated with variety of symptoms including abdominal pain, lymphadenopathy, polyserositis, arthritis, etc. Despite the diversity of the clinical presentation, there are some common features that make the differential diagnosis of the autoinflammatory diseases challenging. Familial Mediterranean fever (FMF) is the most commonly seen autoinflammatory conditions, followed by syndrome associated with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA). In this review, we aim to evaluate disease characteristics that make a diagnosis of FMF and PFAPA challenging, especially in a regions endemic for FMF. The ethnicity of patient, the regularity of the disease attacks, and the involvement of the upper respiratory systems and symphonies could be helpful in differential diagnosis. Current data from the literature suggest the use of biological agents as an alternative for patients with FMF and PFAPA who are non-responder classic treatment options. More controlled studies are needed to evaluate the efficacy and safety of this strategy.
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Affiliation(s)
- Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey.
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Abstract
PURPOSE OF REVIEW One purpose of this review was to raise awareness for the new autoinflammatory syndromes. These diseases are increasingly recognized and are in the differential diagnosis of many disease states. We also aimed to review the latest recommendations for the diagnosis, management, and treatment of these patients. RECENT FINDINGS Familial Mediterranean fever (FMF), cryopyrin-associated periodic syndrome (CAPS), tumor necrosis factor receptor-associated periodic fever syndrome (TRAPS), and hyperimmunoglobulinemia D and periodic fever syndrome/mevalonate kinase deficiency (HIDS/MVKD) are the more common autoinflammatory diseases that are characterized by periodic fevers and attacks of inflammation. Recently much collaborative work has been done to understand the characteristics of these patients and to develop recommendations to guide the physicians in the care of these patients. These recent recommendations will be summarized for all four diseases. FMF is the most common periodic fever disease. We need to further understand the pathogenesis and the role of single mutations in the disease. Recently, the management and treatment of the disease have been nicely reviewed. CAPS is another interesting disease associated with severe complications. Anti-interleukin-1 (anti-IL-1) treatment provides cure for these patients. TRAPS is characterized by the longest delay in diagnosis; thus, both pediatricians and internists should be aware of the characteristic features and the follow-up of these patients. HIDS/MVKD is another autoinflammatory diseases characterized with fever attacks. The spectrum of disease manifestation is rather large in this disease, and we need further research on biomarkers for the optimal management of these patients.
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Affiliation(s)
- Erdal Sag
- Institute of Child Health, Pediatric Autoinflammatory Disease Programme, Hacettepe University, Ankara, Turkey
| | - Yelda Bilginer
- Department of Pediatric Rheumatology, Hacettepe University Ihsan Dogramaci Children's Hospital, 06230, Sihhiye, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University Ihsan Dogramaci Children's Hospital, 06230, Sihhiye, Ankara, Turkey.
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Harel L, Hashkes PJ, Lapidus S, Edwards KM, Padeh S, Gattorno M, Marshall GS. The First International Conference on Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis Syndrome. J Pediatr 2018; 193:265-274.e3. [PMID: 29246466 DOI: 10.1016/j.jpeds.2017.10.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 10/11/2017] [Accepted: 10/13/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Liora Harel
- Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tiva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Philip J Hashkes
- Pediatric Rheumatology Unit, Department of Pediatrics, Shaare Zedek Medical Center, Jerusalem, Israel; Hadassah Hebrew University School of Medicine, Jerusalem, Israel
| | - Sivia Lapidus
- Pediatric Rheumatology Division, Department of Pediatrics, Goryeb Children's Hospital, Morristown, NJ; Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Kathryn M Edwards
- Department of Pediatrics and Vaccine Research Program, Vanderbilt University School of Medicine, Nashville, TN; Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Shai Padeh
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Pediatrics B, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Italy
| | - Marco Gattorno
- Rheumatology Unit, Department of Pediatrics G, Gaslini Scientific Institute for Children, Genoa, Italy; University of Genoa, Genoa, Italy
| | - Gary S Marshall
- Divison of Pediatric Infectious Diseases, University of Louisville School of Medicine, Louisville, KY
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Pehlivan E, Adrovic A, Sahin S, Barut K, Kul Cınar O, Kasapcopur O. PFAPA Syndrome in a Population with Endemic Familial Mediterranean Fever. J Pediatr 2018; 192:253-255. [PMID: 29031862 DOI: 10.1016/j.jpeds.2017.08.078] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/22/2017] [Accepted: 08/30/2017] [Indexed: 01/14/2023]
Abstract
We reviewed the medical records of patients with periodic fever, aphthosis, pharyngitis, and adenitis (PFAPA) to investigate the clinical course, treatment response, and association with MEFV gene mutation. Familial Mediterranean fever should be considered in patients with PFAPA who do not respond to adenotonsillectomy.
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Affiliation(s)
- Esra Pehlivan
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Ovgu Kul Cınar
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey.
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Moreira A, Torres B, Peruzzo J, Mota A, Eyerich K, Ring J. Skin symptoms as diagnostic clue for autoinflammatory diseases. An Bras Dermatol 2017; 92:72-80. [PMID: 28225960 PMCID: PMC5312182 DOI: 10.1590/abd1806-4841.20175208] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 11/12/2015] [Indexed: 12/18/2022] Open
Abstract
Autoinflammatory disorders are immune-mediated diseases with increased production of inflammatory cytokines and absence of detectable autoantibodies. They course with recurrent episodes of systemic inflammation and fever is the most common symptom. Cutaneous manifestations are prevalent and important to diagnosis and early treatment of the syndromes. The purpose of this review is to emphasize to dermatologists the skin symptoms present in these syndromes in order to provide their early diagnosis.
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Affiliation(s)
- Alvaro Moreira
- Department of Dermatology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.,Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland
| | - Barbara Torres
- Department of Dermatology and Venereology, Faculty of Medicine of the University of Porto, Porto, Portugal.,Unidade de Saúde Familiar Vale de Sorraia, Coruche, Portugal
| | - Juliano Peruzzo
- Faculdade de Medicina - Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre (RS), Brazil
| | - Alberto Mota
- Department of Dermatology and Venereology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Kilian Eyerich
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| | - Johannes Ring
- Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland.,Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
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Unraveling the pathogenesis of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis through genetic, immunologic, and microbiologic discoveries: an update. Curr Opin Rheumatol 2017; 29:493-499. [DOI: 10.1097/bor.0000000000000418] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gunes M, Cekic S, Kilic SS. Is colchicine more effective to prevent periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis episodes in Mediterranean fever gene variants? Pediatr Int 2017; 59:655-660. [PMID: 28207965 DOI: 10.1111/ped.13265] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 12/19/2016] [Accepted: 02/07/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is the most frequent repetitive fever syndrome in childhood. It is characterized by fever episodes lasting for approximately 3-6 days, once every 3-8 weeks. METHODS Clinical and laboratory data for PFAPA syndrome patients between January 2010 and December 2014 followed up at a tertiary pediatric care hospital were reviewed. RESULTS Four hundred children (256 male, 144 female; mean age at diagnosis, 4.2 ± 2.2 years), were enrolled in the study. During the episodes, mean leukocyte number was high (12 725/mm3 ) with predominant neutrophils. The mean number of monocytes was 1256/mm3 , and 90.2% had monocytosis. Serum amyloid A and C-reactive protein were high in 84.6% and in 77.8% of the patients, respectively. Mediterranean fever (MEFV) gene heterozygous mutation was identified in 57 of the 231 patients (24.7%) in whom genetic analysis had been performed. The most frequent mutation was heterozygous M694V (10%, n = 23). Extension of between-episode interval following prophylaxis was noted in 85% of those on regular colchicine treatment (n = 303). In the colchicine group, between-episode interval was prolonged from 18.8 ± 7.9 days (before colchicine treatment) to 49.5 ± 17.6 days on prophylactic colchicine therapy; also, prophylactic treatment was more effective in reducing episode frequency in patients with MEFV gene variant (n = 54, 96%) than in those without (n = 122, 80%; P = 0.003). CONCLUSIONS This study has involved the largest number of PFAPA syndrome patients in the literature. It is particularly important to assess and to demonstrate the high rate of response to colchicine prophylaxis in PFAPA syndrome patients, especially those with MEFV variant. On blood screening, neutrophilia associated with monocytosis and low procalcitonin could contribute to diagnosis.
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Affiliation(s)
- Muhammed Gunes
- Departments of Pediatric Immunology-Rheumatology, Uludag University Faculty of Medicine, Görükle, Bursa, Turkey
| | - Sukru Cekic
- Departments of Pediatric Immunology-Rheumatology, Uludag University Faculty of Medicine, Görükle, Bursa, Turkey
| | - Sara Sebnem Kilic
- Departments of Pediatric Immunology-Rheumatology, Uludag University Faculty of Medicine, Görükle, Bursa, Turkey
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Batu ED, Kara Eroğlu F, Tsoukas P, Hausmann JS, Bilginer Y, Kenna MA, Licameli GR, Fuhlbrigge RC, Özen S, Dedeoğlu F. Periodic Fever, Aphthosis, Pharyngitis, and Adenitis Syndrome: Analysis of Patients From Two Geographic Areas. Arthritis Care Res (Hoboken) 2016; 68:1859-1865. [DOI: 10.1002/acr.22901] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/25/2016] [Accepted: 03/29/2016] [Indexed: 01/09/2023]
Affiliation(s)
| | | | | | - Jonathan S. Hausmann
- Boston Children's Hospital and Beth Israel Deaconess Medical Center; Boston Massachusetts
| | | | | | | | - Robert C. Fuhlbrigge
- Boston Children's Hospital and Brigham and Women's Hospital; Boston Massachusetts
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Is colchicine an effective treatment in periodic fever, aphtous stomatitis, pharyngitis, cervical adenitis (PFAPA) syndrome? Joint Bone Spine 2016; 83:406-11. [DOI: 10.1016/j.jbspin.2015.08.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 08/27/2015] [Indexed: 11/17/2022]
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41
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Ali NS, Sartori-Valinotti JC, Bruce AJ. Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome. Clin Dermatol 2016; 34:482-6. [DOI: 10.1016/j.clindermatol.2016.02.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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42
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Vanoni F, Theodoropoulou K, Hofer M. PFAPA syndrome: a review on treatment and outcome. Pediatr Rheumatol Online J 2016; 14:38. [PMID: 27349388 PMCID: PMC4924332 DOI: 10.1186/s12969-016-0101-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/21/2016] [Indexed: 12/17/2022] Open
Abstract
The syndrome of periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA syndrome) is the most common cause of periodic fever in childhood. The current pharmacological treatment includes corticosteroids, which usually are efficacious in the management of fever episodes, colchicine, for the prophylaxis of febrile episodes, and other medication for which efficacy has not been proven so far. Tonsillectomy is an option for selected patients. Usually PFAPA syndrome resolves during adolescence, but there is increasing evidence that this condition may persist into adulthood.
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Affiliation(s)
- Federica Vanoni
- Pediatric Department of Southern Switzerland, Ospedale Regionale di Bellinzona e Valli, Bellinzona, 6500, Switzerland.
| | - Katerina Theodoropoulou
- Unité Romande d’Immuno-rhumatologie Pédiatrique (URIRP), Département Femme-Mère-Enfant (DFME), CHUV, University of Lausanne, Rue du Bugnon 46, Lausanne, 1011 Switzerland
| | - Michaël Hofer
- Unité Romande d’Immuno-rhumatologie Pédiatrique (URIRP), Département Médico - Chirurgical de Pédiatrie (DFME), CHUV, University of Lausanne, Rue du Bugnon 46, Lausanne, 1011 Switzerland
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Celiksoy MH, Ogur G, Yaman E, Abur U, Fazla S, Sancak R, Yildiran A. Could familial Mediterranean fever gene mutations be related to PFAPA syndrome? Pediatr Allergy Immunol 2016; 27:78-82. [PMID: 26360812 DOI: 10.1111/pai.12490] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND The cause and pathophysiology of PFAPA syndrome is unknown. The aim of this study was to determine all MEFV gene variants relevant to familial Mediterranean fever in children with PFAPA syndrome. METHODS All MEFV gene variants were analyzed in patients with PFAPA syndrome. All patients were evaluated using the Gaslini scoring system. Serum immunoglobulin levels were also determined upon admission. RESULTS We evaluated 64 patients with PFAPA syndrome. The median age at diagnosis was 37.5 (min-max: 6-96) months, and the percentage of male patients was 55.0%. The Gaslini diagnostic score for periodic fever was high in 81.0% of the patients. An MEFV gene mutation was found in 42 (66.0%) children. Mostly, heterozygous or compound heterozygous variants of the MEFV gene were found. Two patients were homozygous for R202Q. MEFV gene mutations were not detected in 22 (34.0%) patients. No significant differences in clinical or laboratory findings were observed between the two groups (p > 0.05), and there were no significant differences in period and duration of the fever episodes (p > 0.05). The fever of all 47 patients (100.0%) who received prednisolone during the episodes decreased within hours and did not recur. Eighteen of the patients using prednisolone underwent prophylaxis with colchicine, and the fever episodes of 9/18 (50.0%) patients using colchicine decreased within months. CONCLUSIONS Most patients presenting with PFAPA syndrome have heterozygous MEFV gene mutations. Whether carrying a heterozygous MEFV gene is the primary cause of this syndrome requires further investigation.
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Affiliation(s)
- Mehmet H Celiksoy
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Gonul Ogur
- Department of Genetic Disease, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Elif Yaman
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Ummet Abur
- Department of Genetic Disease, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Semanur Fazla
- Department of Genetic Disease, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Recep Sancak
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Alisan Yildiran
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
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Butbul Aviel Y, Tatour S, Gershoni Baruch R, Brik R. Colchicine as a therapeutic option in periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis (PFAPA) syndrome. Semin Arthritis Rheum 2016; 45:471-4. [DOI: 10.1016/j.semarthrit.2015.07.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 07/02/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
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The Pathogenesis of Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome: A Review of Current Research. Mediators Inflamm 2015; 2015:563876. [PMID: 26457006 PMCID: PMC4589634 DOI: 10.1155/2015/563876] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/08/2015] [Indexed: 01/26/2023] Open
Abstract
Background. PFAPA syndrome is a chronic disease that is characterized by recurrent episodes of high fever, aphthous stomatitis, pharyngitis, and cervical adenitis. Knowledge regarding the etiology of PFAPA is limited. Objectives. To provide up-to-date information considering etiology of PFAPA syndrome, by summarizing what has been explored and established in this area so far. Materials and Methods. PubMed, Web of Science, and Scopus databases were searched for pertinent reports. Eventually 19 articles were selected. The results were classified into categories regarding three areas of interest: familial occurrence, genetic basis, and immunological mechanisms of PFAPA. Results. Recent findings suggest that there is a familial tendency to PFAPA but the level of evidence does not warrant definite conclusions. The absence of a clear monogenic trait indicates a heterogenous, polygenic, or complex inheritance of PFAPA syndrome. As two mutations with a possible functional effect on the inflammasomes (MEFV E148Q and NLRP3 Q703K) have been found in several PFAPA cohorts, the role of inflammasome-related genes in PFAPA pathogenesis cannot be excluded. Immunological mechanisms of PFAPA involve an abnormal, IL-1β dependent innate immune response to an environmental trigger, which leads to Th1-driven inflammation expressed by recruitment of T-cells to the periphery.
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The myths we believed in familial Mediterranean fever: what have we learned in the past years? Semin Immunopathol 2015; 37:363-9. [PMID: 25832989 DOI: 10.1007/s00281-015-0484-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/23/2015] [Indexed: 12/18/2022]
Abstract
Familial Mediterranean fever is the most common monogenic periodic fever syndrome over the world especially in the eastern Mediterranean. It presents with recurrent and self-limited inflammatory attacks of fever and polyserositis along with high acute-phase reactants. The disease is associated with mutations in the MEFV gene that encodes pyrin, a component of inflammasome, which leads to exaggerated inflammatory response through uncontrolled production of interleukin 1. With the identification of the gene associated with the disease, we believed that everything was solved and that this was an ordinary monogenic disease with autosomal recessive inheritance. However, through the breathtaking progress in the basic research field as well as the clinical care of these patients, we have understood that the picture for this monogenic disorder was more complicated than we had anticipated. In this review, we have discussed the myths we believed in familial Mediterranean fever and how they have evolved during the past years.
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Abstract
During the past 15 years, a growing number of monogenic inflammatory diseases have been described and their respective responsible genes identified. The proteins encoded by these genes are involved in the regulatory pathways of inflammation and are mostly expressed in cells of the innate immune system. Diagnosis remains clinical, with genetic confirmation where feasible. Although a group of patients exhibit episodic systemic inflammation (periodic fevers), these disorders are mediated by continuous overproduction and release of pro-inflammatory mediators, such as IL-1 and IL-6, and TNF and are best considered as autoinflammatory diseases rather than periodic fevers. Treatment with biologic agents that block these cytokines, particularly IL-1, has proved to be dramatically effective in some patients. Still, in many cases of autoinflammation no genetic abnormalities are detected and treatment remains suboptimal, raising the question of novel pathogenic mutations in unexplored genes and pathways.
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Affiliation(s)
- Ricardo A G Russo
- Service of Immunology and Rheumatology, Hospital de Pediatría Garrahan, Buenos Aires, Argentina, University College London Institute of Child Health and Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Paul A Brogan
- Service of Immunology and Rheumatology, Hospital de Pediatría Garrahan, Buenos Aires, Argentina, University College London Institute of Child Health and Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK. Service of Immunology and Rheumatology, Hospital de Pediatría Garrahan, Buenos Aires, Argentina, University College London Institute of Child Health and Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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Ling E, Israeli M, Klein T, Amir J, Harel L. Periodic fever, aphthous stomatitis, pharyngitis and cervical adenopathy syndrome is associated with activation of GM-CSF and burst-like expression of IL-8 in peripheral blood. Mod Rheumatol 2014; 24:997-1000. [DOI: 10.3109/14397595.2014.895122] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
While autoimmunity as cause of disease is well-established, other categories of immune-mediated diseases that are not produced by targeting of self-antigens by antibodies is in the process of being described. These so-called autoinflammatory diseases arise when an inappropriate activation of antigen-independent mechanisms occurs. Autoinflammatory diseases course with recurrent attacks of fever and multisystemic inflammation; however, the skin may also be affected by a variety of inflammatory manifestations that often alert the clinician about the presence of an autoinflammatory disease. Recognizing the cutaneous features of these syndromes will aid for prompt diagnosis and early treatment that is key for the quality of life and survival of the affected patients. In this paper, we focus on the skin manifestations of autoinflammatory diseases in children, which is the usual period of appearing of the first symptoms and signs.
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Bens S, Zichner T, Stütz AM, Caliebe A, Wagener R, Hoff K, Korbel JO, von Bismarck P, Siebert R. SPAG7 is a candidate gene for the periodic fever, aphthous stomatitis, pharyngitis and adenopathy (PFAPA) syndrome. Genes Immun 2014; 15:190-4. [PMID: 24452265 DOI: 10.1038/gene.2013.73] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 12/15/2013] [Accepted: 12/16/2013] [Indexed: 12/20/2022]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis and adenopathy (PFAPA) syndrome is an auto-inflammatory disease for which a genetic basis has been postulated. Nevertheless, in contrast to the other periodic fever syndromes, no candidate genes have yet been identified. By cloning, following long insert size paired-end sequencing, of a de novo chromosomal translocation t(10;17)(q11.2;p13) in a patient with typical PFAPA syndrome lacking mutations in genes associated with other periodic fever syndromes we identified SPAG7 as a candidate gene for PFAPA. SPAG7 protein is expressed in tissues affected by PFAPA and has been functionally linked to antiviral and inflammatory responses. Haploinsufficiency of SPAG7 due to a microdeletion at the translocation breakpoint leading to loss of exons 2-7 from one allele was associated with PFAPA in the index. Sequence analyses of SPAG7 in additional patients with PFAPA point to genetic heterogeneity or alternative mechanisms of SPAG7 deregulation, such as somatic or epigenetic changes.
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Affiliation(s)
- S Bens
- Institute of Human Genetics, Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Kiel, Germany
| | - T Zichner
- European Molecular Biology Laboratory (EMBL), Genome Biology Research Unit, Heidelberg, Germany
| | - A M Stütz
- European Molecular Biology Laboratory (EMBL), Genome Biology Research Unit, Heidelberg, Germany
| | - A Caliebe
- Institute of Human Genetics, Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Kiel, Germany
| | - R Wagener
- Institute of Human Genetics, Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Kiel, Germany
| | - K Hoff
- 1] Institute of Human Genetics, Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Kiel, Germany [2] Department of Congenital Heart Disease and Pediatric Cardiology, Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Kiel, Germany
| | - J O Korbel
- European Molecular Biology Laboratory (EMBL), Genome Biology Research Unit, Heidelberg, Germany
| | - P von Bismarck
- Department of Pediatrics, Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Kiel, Germany
| | - R Siebert
- Institute of Human Genetics, Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Kiel, Germany
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