No regression of renal amyloid mass despite remission of nephrotic syndrome in a patient with TRAPS following etanercept therapy

Reactive systemic (AA) amyloidosis leading to renal failure is the most severe complication of tumor necrosis factor receptor-associated periodic syndrome (TRAPS). There is now growing evidence to suggest that anti-tumor necrosis factor (anti-TNF) agents may be an attractive treatment option for amyloidosis not only in TRAPS but in several forms of secondary amyloidosis complicating inflammatory rheumatic diseases. In most of the reported cases, anti-TNF agents were deemed successful on the basis of regression of proteinuria and either improvement or stabilization of creatinine clearance, while objective proof of renal amyloid regression either by serum amyloid P scintigraphy or biopsy is limited. We herein report a case of TRAPS complicated with nephrotic syndrome due to AA amyloidosis in which treatment with etanercept was associated with remission of the nephrotic syndrome but no regression of amyloid mass on the follow-up renal biopsy. Indeed, amyloid deposition was noted to be more pronounced on the second renal biopsy, particularly at tubular basement membranes. Although the variable relation between reduction in amyloid load and changes in organ function is well-known, the basis for renal recovery in association with stable or even progressive amyloid deposition is challenging. We suggest that in patients with secondary AA amyloidosis, mechanisms other than the reduction of amyloid mass could have contributed to the observed improvement of renal function with anti-TNF agents.

A case of familial Mediterranean fever associated with compound heterozygosity for the pyrin variant L110P-E148Q/M680I in Japan

Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterized by recurrent and self-limited fever attacks and serositis/arthritis. The M694V, M694I, M680I, V726A, and E148Q mutations in MEFV, the gene responsible for FMF, account for most FMF cases in Mediterranean populations. In Japan, M694I and E148Q are most frequently detected; M694V, M680I, and V726A have not been identified so far. We report the first case of FMF associated with M680I in Japan.

[Thoracic impairment from familial Mediterranean fever: review of the literature and a case study]

Familial Mediterranean fever (FMF) is a recessive autosomal disease, predominantly affecting the population around the Mediterranean. The main clinical signs consist of attacks of fever associated with abdominal, articular and thoracic pain. Based on a case report, the authors describe the main thoracic forms of this illness comprising pleural pain, pleural effusion and pulmonary amyloidosis. The authors also discuss the association of mesothelioma and FMF. Colchicine is successfully used in the treatment of FMF.

Use of canakinumab in the cryopyrin-associated periodic syndrome

BACKGROUND

The cryopyrin-associated periodic syndrome (CAPS) is a rare inherited inflammatory disease associated with overproduction of interleukin-1. Canakinumab is a human anti-interleukin-1beta monoclonal antibody.

METHODS

We performed a three-part, 48-week, double-blind, placebo-controlled, randomized withdrawal study of canakinumab in patients with CAPS. In part 1, 35 patients received 150 mg of canakinumab subcutaneously. Those with a complete response to treatment entered part 2 and were randomly assigned to receive either 150 mg of canakinumab or placebo every 8 weeks for up to 24 weeks. After the completion of part 2 or at the time of relapse, whichever occurred first, patients proceeded to part 3 and received at least two more doses of canakinumab. We evaluated therapeutic responses using disease-activity scores and analysis of levels of C-reactive protein (CRP) and serum amyloid A protein (SAA).

RESULTS

In part 1 of the study, 34 of the 35 patients (97%) had a complete response to canakinumab. Of these patients, 31 entered part 2, and all 15 patients receiving canakinumab remained in remission. Disease flares occurred in 13 of the 16 patients (81%) receiving placebo (P<0.001). At the end of part 2, median CRP and SAA values were normal (<10 mg per liter for both measures) in patients receiving canakinumab but were elevated in those receiving placebo (P<0.001 and P=0.002, respectively). Of the 31 patients, 28 (90%) completed part 3 in remission. In part 2, the incidence of suspected infections was greater in the canakinumab group than in the placebo group (P=0.03). Two serious adverse events occurred during treatment with canakinumab: one case of urosepsis and an episode of vertigo.

CONCLUSIONS

Treatment with subcutaneous canakinumab once every 8 weeks was associated with a rapid remission of symptoms in most patients with CAPS. (ClinicalTrials.gov number, NCT00465985.)

In vivo regulation of interleukin 1beta in patients with cryopyrin-associated periodic syndromes

The investigation of interleukin 1beta (IL-1beta) in human inflammatory diseases is hampered by the fact that it is virtually undetectable in human plasma. We demonstrate that by administering the anti-human IL-1beta antibody canakinumab (ACZ885) to humans, the resulting formation of IL-1beta-antibody complexes allowed the detection of in vivo-produced IL-1beta. A two-compartment mathematical model was generated that predicted a constitutive production rate of 6 ng/d IL-1beta in healthy subjects. In contrast, patients with cryopyrin-associated periodic syndromes (CAPS), a rare monogenetic disease driven by uncontrolled caspase-1 activity and IL-1 production, produced a mean of 31 ng/d. Treatment with canakinumab not only induced long-lasting complete clinical response but also reduced the production rate of IL-1beta to normal levels within 8 wk of treatment, suggesting that IL-1beta production in these patients was mainly IL-1beta driven. The model further indicated that IL-1beta is the only cytokine driving disease severity and duration of response to canakinumab. A correction for natural IL-1 antagonists was not required to fit the data. Together, the study allowed new insights into the production and regulation of IL-1beta in man. It also indicated that CAPS is entirely mediated by IL-1beta and that canakinumab treatment restores physiological IL-1beta production.

[Familial Mediterranean fever as representative autoinflammatory disease]

Familial Mediterranean fever (FMF) is the most common of the hereditary periodic fevers. FMF is an autosomal recessive disease that affects populations among non-Ashkenazi Jews, Arabs, Turks, and Armenians. Yet, it is observed worldwide, and approximately 90 FMF patients have been reported in Japan. FMF is caused by mutations in the MEFV gene, which encodes the pyrin protein. Pyrin protein is associated with the interleukin (IL)-1-related inflammation cascade and involved in the regulation of apoptosis and inflammation. The clinical characteristics of FMF attacks are fever, abdominal pain, chest pain, and arthritis as symptoms of serositis. Reactive or secondary AA amyloidosis is the most devastating complication of FMF. As amyloid slowly accumulates in various organs and tissues, organ dysfunction ensues prominently in the kidneys. Colchicine has been used in the treatment of FMF, and has markedly changed the course of the disease. Although over 80 mutations in the MEFV gene have been reported, the majority of cases are caused by four mutations in exon 10: M694V, M694I, V726A, and M680I. The majority of Japanese FMF patients are compound heterozygous for M694I/E148Q. E148Q, which is found in populations of Japanese and Chinese, is considered to be a functional polymorphism. It is intriguing that about 10% of Japanese FMF patients have the L110P mutation in addition to E148Q in the same allele. Allelic frequencies of MEFV mutations and polymorphisms in 500 normal Japanese individuals were 0% for M694I and 23% for E148Q, respectively. In conclusion, FMF is not a rare disease in Japan, and it is necessary to consider FMF when a patient experiences recurrent attacks of fever and serositis.

Clinical features of familial Mediterranean fever: an Italian overview

Familial Mediterranean Fever (FMF) is the most frequent periodic febrile syndrome among the autoinflammatory syndromes (AS), nowadays considered as innate immunity disorders, characterized by absence of autoantibodies and autoreactive T lymphocytes. FMF is a hereditary autosomal recessive disorder, characterized by recurrent, self-limiting episodes of short duration (mean 24e72 h) of fever and serositis. In FMF, periodic attacks show inter- and intra-individual variability in terms of frequency and severity. Usually, they are triggered by apparently innocuous stimuli and may be preceded by a prodromal period. The Mediterranean FeVer gene (MEFV) responsible gene maps on chromosome 16 (16p13) encoding the Pyrine/Marenostrin protein. The precise pathologic mechanism is still to be definitively elucidated; however a new macromolecular complex, called inflammasome, seems to play a major role in the control of inflammation and it might be involved in the pathogenesis of FMF. The most severe long-term complication is type AA amyloidosis, causing chronic renal failure. Two types of risk factors, genetic and non-genetic, have been identified for this complication. Currently, the only effective treatment of FMF is the colchicine. New drugs in a few colchicine resistant patients are under evaluation

Type 1 diabetes mellitus associated with autoimmune thyroid disease, celiac disease and familial Mediterranean fever: case report

It is known that type 1 diabetes mellitus (type 1 DM) may be associated with other autoimmune diseases. Recently, a patient with an association of type 1 DM and familial Mediterranean fever (FMF) was reported in the medical literature. A 10.5-year-old boy was brought to our clinic with complaints of polydipsia, polyuria and weight loss and was diagnosed as diabetic ketoacidosis due to autoimmune type 1 DM. Insulin therapy was started. Elevated thyroid antibodies associated with diffuse goiter and hypothyroidism led to the diagnosis of autoimmune thyroid disease (ATD), and elevated antiendomysial antibodies and abnormal intestinal biopsy findings led to the diagnosis of celiac disease (CD). L-thyroxine therapy and gluten-free diet were initiated accordingly. At the third-year of follow-up, acute attacks of fever, abdominal pain and chest pain developed. Laboratory investigations, which were normal between the attacks, revealed elevated erythrocyte sedimentation rate, fibrinogen, white blood cell count and pleural effusion on chest X-ray during the attacks. Molecular analysis for FMF revealed compound heterozygous M694I and V726A. The patient responded well to colchicine therapy started at a dose of 1.5 mg/day. We present the second patient with type 1 DM associated with FMF who also had ATD and CD.

The inherited autoinflammatory syndrome: a decade of discovery

The hereditary autoinflammatory diseases arise from mutations of genes regulating the innate immune system. These rare disorders are well characterized, both clinically and in terms of their molecular pathogenesis. The recurrent attacks of febrile polyserositis of Familial Mediterranean Fever (FMF) are due to defective pyrin, a protein that down-regulates inflammation. The Hyperimmunoglobulinemia D Syndrome (HIDS), which mimics FMF, results from a genetically conferred deficiency of mevalonate kinase. TRAPS (TNF Receptor Associated Periodic Syndrome), formerly known as Familial Hibernian Fever, is caused by a defective membrane receptor for TNF. Three other hereditary disorders which overlap in their clinical expression - Familial Cold Autoinflammatory Syndrome, the Muckle Wells syndrome, and Neonatal Onset Multisystem Inflamatory Disease (NOMID) - are a consequence of gain-of-function mutations of the gene encoding cryopyrin, the scaffolding protein of the inflammasome. The PAPA syndrome (Pyogenic Arthritis, Pyoderma gangrenosum, Acne) results from mutations of a gene that increases the binding of its product (PSPSTPIP1) to pyrin, thereby blunting the inhibitory effect of pyrin on inflammasome activation.

Frequency of abdominal surgery in patients with familial Mediterranean fever

OBJECTIVE

Familial Mediterranean fever (FMF) is characterized by recurrent episodes of peritonitis. Abdominal FMF attacks can be indistinguishable from those of an acute abdominal emergency, and patients may undergo one or more laparotomies before the true nature of their disease is documented. The objectives of this study were to investigate the frequency and reasons for abdominal surgeries performed on patients with FMF.

METHODS

We retrospectively reviewed the files of 254 patients with FMF (127 males, 127 females, mean age 27.2+/-6.3 years). We also included 182 healthy individuals for this study (89 males, 93 females, mean age 27.6+/-5 years; range 11-43) to make a comparison between FMF and healthy controls (HC) with respect to frequency of abdominal operations.

RESULTS

The number of patients with abdominal surgery in FMF group was 74 (29.1%). The number of surgeries performed in 74 patients with FMF was 92. The first abdominal surgery before the diagnosis of FMF was appendectomy in 68 patients (26.6%). In HC group, the number of abdominal operations was found to be 16 (8.7%). Of these abdominal operations, 9 (4.9%) were due to appendectomy. The rate of total abdominal operations and appendectomy were significantly higher in FMF group than in HC group (p=0.0001).

CONCLUSION

Abdominal attacks of FMF patients may cause an unnecessary laparotomy prior to the diagnosis of FMF. FMF patients can present with abdominal emergency while they are receiving colchicine. Therefore, each abdominal pain should be carefully determined according to clinical findings. The purpose of this study was to emphasize the misdiagnosis of appendicitis.

Prevention of amyloidosis in familial Mediterranean fever with colchicine: a case-control study in Armenia

OBJECTIVE

To determine whether or not the use of colchicine decreases the risk of amyloidosis among Armenian patients with familial Mediterranean fever (FMF).

SUBJECTS AND METHODS

The study included 99 Armenian patients from the Center of Medical Genetics database with genetically ascertained FMF; 33 had renal amyloidosis and 66 were randomly selected control patients without renal amyloidosis. Self- reported colchicine use was assessed by interviewer-based questionnaire.

RESULTS

The patients with incident amyloidosis were more likely to be older men, but younger at the time of disease onset, and more likely to have had a family history of amyloidosis and M694F mutation in the MEFV gene compared to patients without amyloidosis. The risk of amyloidosis decreased with adequate colchicine use rather than nonadequate use (adjusted odds ratio, OR, 0.48, 95% confidence interval, CI, 0.16-1.43), continuous colchicine use rather than interrupted use (adjusted OR 0.15, 95% CI 0.04-0.53), earlier rather than later initiation age of colchicine treatment (adjusted OR 0.95, 95% CI 0.90-1.01), current colchicine rather than ever/never colchicine use (adjusted OR 0.20, 95% CI 0.05-0.89).

CONCLUSION

The study demonstrated that colchicine treatment is effective in preventing amyloidosis among Armenian patients with FMF and that earlier initiation and continuous therapy at an adequate dose of 1.2-1.8 mg/day may be associated with a decreased amyloidosis risk among Armenian patients with FMF.

Anakinra suppresses familial Mediterranean fever crises in a colchicine-resistant patient

We describe a 34-year-old male patient suffering from familial Mediterranean fever and experiencing an increase in both the frequency and severity of disease attacks, suggesting resistance to chronic treatment with colchicine. Since no alternative treatment is established, anakinra, an interleukin-1 receptor antagonist, was administered, not daily, as it has been previously reported, but only during crises, with successful outcome.

Increased asymmetric dimethylarginine levels in young men with familial Mediterranean fever (FMF): is it early evidence of interaction between inflammation and endothelial dysfunction in FMF?

OBJECTIVE

Unlike in many other chronic inflammatory rheumatic diseases, studies investigating endothelial dysfunction and atherosclerosis in familial Mediterranean fever (FMF) are limited, and the results are controversial. Asymmetric dimethylarginine (ADMA) is considered an indicator for endothelial dysfunction and a sensitive marker for cardiovascular risk. There have been no reports on serum ADMA levels in patients with FMF.

METHODS

We aimed (1) to determine serum ADMA concentrations in 38 young male patients with FMF and 23 age- and body mass index-matched healthy volunteers; (2) to evaluate its correlations with MEFV mutations, C-reactive protein (CRP) levels, and lipid profile; and (3) to compare effects of colchicine on circulating ADMA concentrations.

RESULTS

In patients with FMF, ADMA and CRP levels were higher than in healthy controls. The mean levels of ADMA and CRP were higher during acute attacks than in attack-free periods. Patients taking colchicine had lower serum ADMA levels than non-colchicine users. There was a positive strong correlation between ADMA and CRP in patients with FMF. Stepwise linear regression analysis in patients with FMF revealed that age and CRP levels were independently associated with serum ADMA levels.

CONCLUSION

Our data imply that higher serum ADMA levels in FMF may indicate inflammation-related "endothelial dysfunction." It seems likely that regular use of colchicine is effective in preventing the development of and reversing not only amyloidosis but also endothelial dysfunction in patients with FMF.

Interferon-alpha as a treatment modality for colchicine- resistant familial Mediterranean fever

OBJECTIVE

Previous reports on interferon-alpha (IFN-alpha) were conflicting with respect to its efficacy in familial Mediterranean fever (FMF) refractory to colchicine treatment. We investigated the effect of IFN-alpha in patients with colchicine-resistant FMF.

METHODS

In a prospective, patient self-controlled, open-label study evaluating the safety and efficacy of IFN-alpha in patients with FMF with a severe phenotype, refractory to intensified (oral plus intravenous) colchicine therapy, we advised patients to subcutaneously inject IFN-alpha, 3 million international units, at the onset of the FMF attack. Attacks not treated with IFN-alpha of the same patients and in the same sites served as control attacks. Features of each attack were recorded in a questionnaire, eventually used to compare between IFN-alpha-treated and non-treated attacks.

RESULTS

Ten patients with a total of 80 attacks were recruited. Compared to 22 untreated attacks, a > 20% and > 50% reduction in the duration of the attacks was noted in 100% and 90% of the 58 IFN-alpha-treated attacks, respectively (p < 0.001 for both). The severity (degree of pain) of the IFN-alpha-treated attacks was attenuated by > 20% and > 50% in 88% and 49% of these attacks, respectively (p < 0.001 for both). The most common drug-related adverse events were chills and fatigue.

CONCLUSION

Early intervention with IFN-alpha injections was associated with reduced attack length and/or severity in a substantial number of bouts, with an acceptable cost of adverse events.