Highly suspected case of FAPA (periodic fever, aphthous stomatitis, pharyngitis and adenitis) syndrome

Recurrent Aphthous Stomatitis: Treatment and Management

Background

Recurrent aphthous stomatitis consists of the presence of abrasions or ulcerations located on mucosae (oral or genital).

Objectives

The aim of this article is to review the current literature providing the main causes related to recurrent aphthous stomatitis and insights into treatment and management of this clinical condition.

Methods

Articles matching terms that correlated with "recurrent aphthous stomatitis" were searched on PubMed, EMBASE, and Cochrane Library and selected according to their pertinence.

Results

Several forms of aphthous stomatitis have been described, based on the extent (minor, major), morphology (herpetiform) and associations to other signs (Behçet syndrome or more complex inflammatory syndromes). Topical as well as systemic treatments have been described to obtain a faster remission of the aphthosis or to reduce associated symptoms such as pain.

Conclusions

Recurrent aphthous stomatitis can have a mild-to-severe clinical appearance, being mainly localized on the oral mucosa or at the level of the genital area. Different strategies have been described so far for its management and treatment.

Health-related quality of life in children with PFAPA syndrome

BACKGROUND

Conventionally, PFAPA syndrome is considered as a benign disease compared to other recurrent fevers because it completely passes before adulthood. However, in our clinical practice, fever episodes have a huge impact on daily activities.

METHODS

Observational cohort study using the Pediatric Quality of Life Inventory (PedsQL™ 4.0) Generic Core and Fatigue Scales. PedsQL™ uses a modular approach to measure the HRQOL in children with acute and chronic health conditions. We used pediatric FMF patients as the control group.

RESULTS

We included 33 children with PFAPA and compared them to 27 FMF patients matched for age: preschool-age children (2 to 7 years) and school-age children and youths (8 to18 years). PedsQL™ self-reported scores of children with PFAPA were systematically lower than those of FMF peers for general quality of life and physical and psychosocial functioning (significant only in the preschool-age group). PedsQL™ self-reported fatigue scores of children with PFAPA were significantly lower than those of FMF peers for both preschoolers and school-age children and youths. Parent proxy-reports were not significantly different, even though scores were systematically lower for the parents of PFAPA children.

CONCLUSION

Our study demonstrates, for the first time, that the wellbeing of PFAPA children is poor, with a major impact on psychosocial functioning and increased fatigue. The quality of life of PFAPA children appears to be even lower than that of FMF patients, for whom a lower than normal HRQOL has already been demonstrated.

[Periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome]

Periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome is a non-hereditary autoinflammatory disease, characterized by relatively regular recurrence of febrile episodes of 3-6 days duration, accompanied by aphthous stomatitis, pharyngitis/tonsillitis, and/or cervical adenititis. It is considered to be the most common periodic fever syndrome in Japan. Although no responsible gene is identified, some genetic factors may confer the predisposition toward this disorder. Important differential diagnosis includes hereditary periodic syndromes and cyclic neutropenia. Although its etiology is still to be elucidated, a recent study suggested an environmentally triggered activation of complement and IL-1β/IL-18 during PFAPA syndrome flares, with induction of Th1-chemokines and subsequent retention of activated T cells in peripheral tissues. This study also demonstrated the possibility that IP-10/CXCL10 might serve as a potential biomarker to differentiate PFAPA syndrome from other periodic fever syndromes. Therapeutic strategy for PFAPA syndrome has not been well established. Recent advances in the understating of etiology and pathophysiology might lead to re-evaluation of recent therapeutic options and/or development of new treatment.

Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) is a disorder of innate immunity and Th1 activation responsive to IL-1 blockade

The syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) is the most common periodic fever disease in children. However, the pathogenesis is unknown. Using a systems biology approach we analyzed blood samples from PFAPA patients whose genetic testing excluded hereditary periodic fevers (HPFs), and from healthy children and pediatric HPF patients. Gene expression profiling could clearly distinguish PFAPA flares from asymptomatic intervals, HPF flares, and healthy controls. During PFAPA attacks, complement (C1QB, C2, SERPING1), IL-1-related (IL-1B, IL-1RN, CASP1, IL18RAP), and IFN-induced (AIM2, IP-10/CXCL10) genes were significantly overexpressed, but T cell-associated transcripts (CD3, CD8B) were down-regulated. On the protein level, PFAPA flares were accompanied by significantly increased serum levels of chemokines for activated T lymphocytes (IP-10/CXCL10, MIG/CXCL9), G-CSF, and proinflammatory cytokines (IL-18, IL-6). PFAPA flares also manifested a relative lymphopenia. Activated CD4(+)/CD25(+) T-lymphocyte counts correlated negatively with serum concentrations of IP-10/CXCL10, whereas CD4(+)/HLA-DR(+) T lymphocyte counts correlated positively with serum concentrations of the counterregulatory IL-1 receptor antagonist. Based on the evidence for IL-1β activation in PFAPA flares, we treated five PFAPA patients with a recombinant IL-1 receptor antagonist. All patients showed a prompt clinical and IP-10/CXCL10 response. Our data suggest an environmentally triggered activation of complement and IL-1β/-18 during PFAPA flares, with induction of Th1-chemokines and subsequent retention of activated T cells in peripheral tissues. IL-1 inhibition may thus be beneficial for treatment of PFAPA attacks, with IP-10/CXCL10 serving as a potential biomarker.

Oral ulcers: clinical aspects. A tool for dermatologists. Part I. Acute ulcers

Oral ulcers are generally painful lesions that are related to various conditions developing within the oral cavity. They can be classified as acute or chronic according to their presentation and progression. Acute oral ulcers are be associated with conditions such as trauma, recurrent aphthous stomatitis, Behçet's disease, bacterial and viral infections, allergic reactions or adverse drug reactions. Chronic oral ulcers are associated with conditions such as oral lichen planus, pemphigus vulgaris, mucosal pemphigoid, lupus erythematosus, mycosis and some bacterial and parasitic diseases. The correct differential diagnosis is necessary to establish the appropriate treatment, taking into account all the possible causes of ulcers in the oral cavity. In the first part of this two-part review, acute oral ulcers are reviewed.

Oral mucosal disease: Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS; aphthae; canker sores) is common worldwide. Characterised by multiple, recurrent, small, round, or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or grey floors, it usually presents first in childhood or adolescence. Its aetiology and pathogenesis is not entirely clear, but there is genetic predisposition, with strong associations with interleukin genotypes, and sometimes a family history. Diagnosis is on clinical grounds alone, and must be differentiated from other causes of recurrent ulceration, particularly Behçet disease - a systemic disorder in which aphthous-like ulcers are associated with genital ulceration, and eye disease (particularly posterior uveitis). Management remains unsatisfactory, as topical corticosteroids and most other treatments only reduce the severity of the ulceration, but do not stop recurrence.

Mucosal disease series. Number VI. Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS; aphthae; canker sores) is a common condition which is characterized by multiple recurrent small, round or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or grey floors typically presenting first in childhood or adolescence. RAS occurs worldwide although it appears most common in the developed world. The aetiology of RAS is not entirely clear. Despite many studies trying to identify a causal microorganism, RAS does not appear to be infectious. A genetic predisposition is present, as shown by strong associations with genotypes of IL-1beta; IL-6 in RAS patients, and a positive family history in about one-third of patients with RAS. Haematinic deficiency is found in up to 20% of patients. Cessation of smoking may precipitate or exacerbate RAS in some cases. Ulcers similar to RAS may be seen in human immunodeficiency virus disease and some other immune defects, and drugs, especially non-steroidal anti-inflammatory drugs and nicorandil may produce lesions clinically similar to RAS. Topical corticosteroids can often control RAS. However, the treatment of RAS remains unsatisfactory, as most therapies only reduce the severity of the ulceration and do not stop recurrence.

PFAPA syndrome mimicking familial Mediterranean fever: report of a Turkish child

The PFAPA (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitidis) syndrome is characterized by periodic fever, adenitis, pharyngitis, and aphthous stomatitis. Herein, we present a Turkish child with PFAPA syndrome mimicking familial Mediterranean fever because of a rare presentation. A 9-year-old boy was admitted with recurrent fever, aphthous stomatitis, sore throat, headache, and general body pains, lasting 2 to 3 days since 3.5 years of age. He was completely symptom-free between the attacks. He was diagnosed as having familial Mediterranean fever according to the clinical findings when he was 6 years of age and Colchicum tablet was administrated. Despite colchicines therapy for 8 months, his attacks did not subside; therefore, the drug was discontinued. He had high fever, a painful cervical lymphadenopathy, aphthous stomatitis, and tonsillo-pharyngitis. The patient was then diagnosed as having PFAPA syndrome. He was given a single dose of prednisolone (0.35 mg/kg/dose). His complaints dramatically and completely disappeared 3 h after administration of the drug. During the 8th month of follow-up, a similar febrile attack lasting only 1 day was noted and it was controlled with a single dose of prednisolone (0.5 mg/kg/day). At this writing the patient is in the 12th month of follow-up, and there have been no symptoms after the second attack. In conclusion, our patient shows that PFAPA syndrome can be confused with familial Mediterranean fever. We also would like to emphasize that the typical PFAPA syndrome can be easily diagnosed by detailed history-taking and physical findings.