A Japanese case of familial Mediterranean fever with onset in the fifties

The grandfather's fever

An 86-year-old Caucasian man had prior episodes of fever (up to 38 °C), mild abdominal pain, tachycardia, and malaise in the last 3 months, lasting 2-3 days. He never suffered from abdominal or chest pain, rash, or arthralgia. Major causes of fever were excluded (pulmonary, urinary, abdomen, skin infections, neoplasms, and major rheumatologic disorders). The patient was native of Altamura with a family history of familial Mediterranean fever (FMF). The genetic testing confirmed the presence of MEFV gene variants c.442G>C (E148Q) on exon 2 and c.2282G>A (R761H) on exon 10, all in heterozygosity. Mildly elevated serum transaminases suggested an ongoing form of FMF hepatitis on nonalcoholic liver steatosis. The patient started colchicine 1 mg/day that induced symptom control and normalization of inflammatory markers, hyperbilirubinemia, and markers of cholestasis. Symptoms of FMF can appear at any age in life and our patient represents a very late-onset clinical case. The Apulian region has a consistent clustering of MEFV variants and FMF families with affected individuals in multiple consecutive generations. Families show unique clinical features and rare signs of secondary amyloidosis without kidney damage. Genetic and environmental bases of this phenotypic variant are under scrutiny. Colchicine lifetime remains the mainstay of treatment in FMF patients. KEY POINTS: • Familial Mediterranean fever (FMF) is the most frequent hereditary monogenic recurrent fever syndrome, and symptoms can appear at any age in life. • Late-onset FMF approaches 30% in late adulthood, but in general, onset of FMF after the age of 40 (late onset FMF) is rare, usually associated with M694V heterozygosity. • In a local cluster of FMF families (Altamura, Puglia, Southern Italy), we report a very late-onset FMF (variants E148Q, R761H) in an 86-year-old patient with a positive family history of FMF in two generations of descendants. • While lifetime colchicine remains the mainstay of treatment in FMF patients, prospective studies need to identify the characteristics of several phenotypic variants accounting for (very)-late onset FMF.

Three patients with familial Mediterranean fever: a possible underdiagnosed entity in Japan

Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterized by periodic fever and serosal inflammation. FMF is mostly reported in the Mediterranean region and is considered to be rare in Japan with estimated 292 cases. We treated three unrelated FMF patients in one year in a city with 144,000 residents. Two of the three patients were over 70 years old. FMF may therefore be underdiagnosed in Japan.

An atypical familial Mediterranean fever patient who developed ulcers in the terminal ileum and recurrent abscess-like lesions in multiple organs

We herein describe the case of a 25-year-old woman who suffered from atypical familial Mediterranean fever for more than a decade. She presented with a periodic fever, abdominal pain and persistent ulcers in the terminal ileum. Colchicine was effective, and familial Mediterranean fever was diagnosed. A genetic study showed a heterozygous E148Q mutation in the MEFV gene. Multiple, recurrent, abscess-like lesions developed asynchronously in the spleen, liver, and a lung. Infliximab was administered when colchicine treatment became ineffective. However, infliximab treatment soon became ineffective, probably because antibodies were generated against it. Therefore, etanercept treatment was started, and the patient showed an immediate response.

Familial Mediterranean fever with onset at 66 years of age

The patient was a 68-year-old woman who had experienced recurrent febrile episodes since 66 years of age. Despite various examinations and treatments, the etiology remained unclear. Further examinations following another referral failed to uncover the cause. Therefore, despite her age, it was presumed that she had familial Mediterranean fever. An analysis of the familial Mediterranean fever (MEFV) gene detected heterozygous L110P, E148Q, and R202Q mutations. No further febrile episodes occurred after colchicine treatment was initiated. Familial Mediterranean fever presenting in patients in their sixties is extremely rare.

Clinical and Genetic Features of Familial Mediterranean Fever in Japan

Objective.

Familial Mediterranean fever (FMF) is thought to be a rare disorder in Japan, and the clinical features of Japanese patients with FMF remain unclear. Our aim was to elucidate the clinical characteristics of FMF in Japanese patients.

Methods.

We analyzed clinical and genetic data of 80 patients based on the results of a nationwide questionnaire survey and review of the literature.

Results.

From clinical findings of 80 Japanese patients, high-grade fever was observed in 98.8%, chest attacks (pleuritis symptoms) in 61.2%, abdominal attacks (peritonitis symptoms) in 55.0%, and arthritis in 27.5%. Twenty-four percent of patients experienced their first attacks before 10 years of age, 40% in their teens, and 36% after age 20 years. Colchicine was effective in many patients at a relatively low dose (< 1.0 mg/day). AA amyloidosis was seen in only 1 patient. Common MEFV mutation patterns were E148Q/M694I (25.0%), M694I alone (17.5%), and L110P/E148Q/M694I (17.5%), and no patient carried the M694V mutation, the most common mutation in Mediterranean patients with FMF.

Conclusion.

A larger than expected number of patients with FMF exist in Japan, and the clinical presentation of Japanese FMF patients seems to be relatively milder than those of Mediterranean FMF patients. AA amyloidosis rarely occurs in Japanese patients, probably due to difference in patterns of the MEFV genotype between Japanese and Mediterranean patients.

[Familial Mediterranean fever: MEFV gene mutations and treatment]

Familial Mediterranean fever (FMF) is an autosomal recessive disease which predominantly affects certain ethnic groups mainly Sephardic Jews, Turks, Arabs and Armenians. FMF has been rarely reported in Japan. Characteristic symptoms include self-limited recurrent attacks of fever with serositis such as peritonitis, pleuritis, and arthritis. The most serious complications of FMF are secondary AA amyloidosis and subsequent chronic renal failure. FMF is caused by mutations in MEFV gene which encodes a protein called pyrin. Pyrin regulates processing of IL-1beta, NF-kappaB activation and apoptosis. Dysregulated function of pyrin results in excessive production of proinflammatory cytokine thereby evoking inflammatory attacks. The mainstay of treatment is colchicine which is effective for both relieving symptoms and preventing secondary amyloidosis.