The efficacy of anakinra in an adolescent with colchicine-resistant familial Mediterranean fever

Colchicine is the treatment of choice in familial Mediterranean fever (FMF) for the prevention of both attacks and secondary amyloidosis. The overall nonresponder rate is about 5-10%. Anakinra is known to have good effectiveness in a severe autoinflammatory syndrome [chronic infantile neurological cutaneous and articular (CINCA) syndrome] and other recurrent hereditary periodic fevers. Pyrin--the protein involved in FMF--has a role in activating the proinflammatory cytokine interleukin (IL)-1beta. We report the effectiveness of the addition of an IL-1-receptor inhibitor (anakinra) to colchicine in controlling the febrile attacks and acute phase response in an adolescent with FMF resistant to colchicine.

[Recurrent pleurisy as sole manifestation of familial Mediterranean fever]

Recurrent pleurisy as sole manifestation offamilial Mediterranean fever. An 18-year-old woman of Turkish descent visited our outpatient department with a 12-year history of recurrent self-limiting febrile attacks accompanied by chest pain. At first the symptoms were attributed to recurrent lower airway infections. However, the persistent nature of the attacks combined with her ethnic background and the spontaneous recovery from the short paroxysmal episodes, led to the consideration of familial Mediterranean fever (FMF). After undergoing treatment with colchicine the patient was free of symptoms. Later it became clear that her 28-year-old brother had the same clinical manifestations of FMF. He was also successfully treated with colchicine. The often long interval from disease onset to correct diagnosis reflects the unfamiliarity of physicians with this disease and the frequency with which it is confused with other syndromes. In patients with paroxysmal febrile attacks and chest pain, especially if they originate from the eastern Mediterranean area, FMF should be considered and colchicine be prescribed to relieve symptoms and prevent amyloidosis.

A rare cause of ascites: Familial Mediterranean fever

Familial Mediterranean fever is an autosomal recessive disorder characterized by sporadic, paroxysmal attacks of fever and serosal inflammation. In Familial Mediterranean fever, peritoneal effusion during abdominal attacks is usually mild, is not detected by clinical evaluation, and disappears during clinical remission. Chronic ascites has rarely been described in patients with Familial Mediterranean fever. Genetic analysis is highly specific and sensitive for diagnosis of Familial Mediterranean fever. All of the four cases discussed in our study had no benign or malignant pathology that could explain the ascites. They had suffered from repetitive periods of fever and ascites since childhood. Genetic analysis of these four cases revealed that one was M694V/M694V homozygote, one was M694V/? heterozygote, and the other two were M694V/V726A compound heterozygote. Ascites regressed with colchicine therapy. Since Familial Mediterranean fever is common our country, it should be kept in mind in the differential diagnosis in patients with ascites of unknown etiology.

Is Familial Mediterranean Fever a thrombotic disease or not?

The aim of our study was to show how the progression and severity of Familial Mediterranean Fever (FMF) is affected by procoagulant activity and alterations in the markers of thrombosis and fibrinolysis. The study cohort comprised 64 FMF patients who were classified as attack-free patients (Group 1; n = 34 patients, aged 3-19 years) and attack patients (Group 2; n = 30 patients, aged 3-21 years). All patients were on colchicine treatment with the exception the newly diagnosed patients in Group 2. A total of 14 healthy subjects between 5-12 years of age were enrolled as controls (Group 3). Laboratory tests, including leukocyte and thrombocyte counts, erythrocyte sedimentation rate, CRP, fibrinogen, PT, aPTT, Factor VIII, vW factor, D-dimer, P-selectin, tPA and PAI-1, were carried out on all patients. Inflammation continued both during the attack and attack-free period in FMF. The prolongation of PT was observed during attacks (PT = 13.6 s in Group 2, and PT = 12.6 s in Group 3; p = 0.002). tPA levels increased in FMF patients (tPA levels of group 1, 2 and 3 were 12.6, 13.2 and 9.7 ng/ml, respectively; p = 0.01). P-selectin was lower in both patient groups than in the control group. During attack periods PAI-1 levels increased (PAI-1 level of Group 1: 89.6 ng/ml and PAI-1 level of Group 2: 335.7 ng/ml, p = 0.000). Inflammation with increased acute phase reactants continued during both attack and attack-free periods in FMF patients. Prolongation of PT and differences in tPA and P-selectin levels suggest that hypercoagulability may have a role in the etiopathogenesis of FMF. It may be possible to use PAI-1 as a marker for the attacks of FMF.

Development of interferon induced sarcoidosis in a patient with familial mediterranean fever

A 42-year-old male patient, who had been on colchicine therapy for familial mediterranean fever admitted with dyspnea on exertion. He had a history of interferon-alpha (IFN-alpha) administration. The chest X-ray showed diffuse distribution of reticulonodular opacities in both lungs. A computerized tomography scan of the lungs revealed mediastinal and bilateral hilar lymphadenopathies, translucent densities, consolidations, reticular opacities and subpleural milimetric cystic spaces. Pulmonary-function studies demonstrated defects in diffusing and vital capacity. Histopathological evaluation was compatible with granulomatous lymphadenitis. The patient was diagnosed as having pulmonary sarcoidosis. He reflects the characteristics of IFN-induced sarcoidosis, but the duration between the cessation of IFN therapy and the development of symptoms is 42 months, which is longer than usually expected. In this case, history of IFN-alpha administration led us to suspect sarcoidosis because of a possible association between IFN therapy and the development of sarcoidosis.

An unusual association between familial mediterranean fever and IgM nephropathy

OBJECTIVE

To report a case with the diagnosis of IgM nephropathy and familial Mediterranean fever (FMF).

CLINICAL PRESENTATION AND INTERVENTION

A 9-year-old boy was admitted to our hospital with recurrent abdominal pain since the age of 4 years. Laboratory investigations revealed a sedimentation rate of 88 mm/h, C-reactive protein: 83.2 mg/l (0-10 mg/l), white blood cell count: 12,700/mm(3), fibrinogen: 622 mg/dl (200-400 mg/dl) and serum amyloid A: 186 mg/l (0-5.8 mg/l). Urinalysis revealed +2 proteinuria. A 24-hour urinary protein excretion was 12 mg/m(2)/h. M694V homozygous mutation was identified in exon 10. Percutaneous renal biopsy showed mesangial cell proliferation and increased mesangial matrix in the glomeruli, without amyloid accumulation. Immunofluorescence study showed IgM (+1) and C1q (+1) deposits. Treatment with 1 mg/day colchicine was started. Six weeks later, proteinuria had disappeared and the patient was asymptomatic.

CONCLUSION

This case illustrates the unusual association of FMF with non-amyloid glomerulopathy. Glomerular diseases such as IgM nephropathy may be seen as a manifestation of FMF.

An overview of familial Mediterranean fever with emphasis on pyrin and colchicine

Familial Mediterranean fever (FMF) is the earliest known autoinflammatory disease, characterized by symptoms such as arthritis, peritonitis, pleuritis, erysipelas-like erythema, and most importantly amyloidosis. This disease is very common in populations of the Mediterranean area, and due to its high carrier frequency and occurrence rate in these populations, it has been the focus of much research work. Such research has allowed greater insights into the genetics of FMF, leading to the discovery of the responsible gene in 1997 and the determination of mutations and their effect on the phenotype of patients, as well as the interactions and roles of the pyrin protein, which seems to have various roles in regulation of innate immunity, inflammation, and apoptosis. Colchicine has been used as preventive treatment since 1972, and recent studies have allowed the determination of its mode of action.

Familial Mediterranean fever in three Japanese patients, and a comparison of the frequency of MEFV gene mutations in Japanese and Mediterranean populations

We report on three Japanese patients (two families) with familial Mediterranean fever (FMF), a rare disease in the Far East. Two of the patients (siblings with definite FMF) were heterozygous for both E148Q and M694I, and the remaining patient (with probable FMF and no family history of the disease) was heterozygous for both P369S and R408Q. Although the M694I mutation is less common among Mediterranean populations, it was present in 22 (76%) of 29 Japanese patients with FMF (previously reported cases). We therefore investigated the allele frequency of M694I in the healthy Japanese population, as well as other FMF-causing mutations in exon 10 (M680I, M694V, and V726A) and polymorphisms (E148Q, P369S, and R408Q) of the Mediterranean fever gene (MEFV). The allele frequencies of disease-causing mutations, even M694I, were <0.001. While those of E148Q, P369S, and R408Q were 0.23, 0.057, and 0.054, respectively. Because of the low allele frequencies of disease-causing mutations, FMF is an extremely rare disease among Japanese individuals. However, FMF is an important component of hereditary autoinflammatory syndrome, and a diagnosis of FMF is crucial for the choice of treatment, because of the benefit of colchicine therapy.

A Single Testing of Serum Amyloid A Levels as a Tool for Diagnosis and Treatment Dilemmas in Familial Mediterranean Fever

OBJECTIVES

In a significant proportion of patients with familial Mediterranean fever (FMF), serum amyloid A (SAA) remains elevated during attack-free periods, thereby increasing the risk of developing amyloidosis. The aim of the study was to determine various correlates of elevated SAA and evaluate the role of SAA measurement in the diagnosis and management of FMF.

METHODS

We reviewed the medical files of all 204 patients from our FMF center in whom SAA measurements were performed. SAA levels and the resulting diagnostic and therapeutic decisions were analyzed in relation to the reasons of SAA testing and to several clinical and genetic parameters.

RESULTS

SAA measurements were made for diagnostic purposes in 29% of the patients. In the remainder, SAA measurements were used for adjustment of colchicine dose. Elevated SAA levels are found in a third of FMF patients during an attack-free period. The highest rate of elevated SAA levels was found in patients with proteinuria (60% of this patient group), followed by noncompliant (40%) and genetically positive asymptomatic patients (38%). Elevated SAA levels during remission were associated with family history of FMF, M694V homozygosity, and elevated C-reactive protein (CRP) (P<0.05 for each). Patients homozygous for the M694V mutation had the highest level of SAA. SAA measurement led to a change in colchicine dose in 30% of the patients, predominantly in noncompliant patients and patients with proteinuria or with atypical manifestations.

CONCLUSIONS

Measurement of SAA level may help in the diagnosis of FMF and in adjustment of the colchicine dose.

Can a Multi-Dimensional Health Assessment Questionnaire (MDHAQ) and Routine Assessment of Patient Index Data (RAPID) scores be informative in patients with all rheumatic diseases?

A multidimensional health assessment questionnaire (MDHAQ) is useful in standard care of patients with all rheumatic diseases in a busy clinical setting. The MDHAQ was adapted from the classical health assessment questionnaire (HAQ) for feasibility in standard clinical care, with reduction of the number of activities from 20 to 10, visual analog scales (VAS) as 21 circles rather than 10 cm lines, availability of all core data set patient self-report measures and scoring templates on the front side, and a review of systems symptom checklist and review of recent medical history on the reverse side of a single page. Scoring templates are also available for routine assessment of patient index data (RAPID) scores, based on a composite of the three patient reported outcome (PRO) measures from the core data set included on the HAQ and MDHAQ, physical function pain, and patient estimate of global status. Flow sheets illustrating use of the MDHAQ in standard clinical care of patients with various rheumatic diseases, including psoriatic arthritis, systemic lupus erythematosus, ankylosing spondylitis, gout, scleroderma, vasculitis, fibromyalgia, inflammatory bowel disease arthritis, Behcet's syndrome, and familial Mediterranean fever, are presented to illustrate use of this simple questionnaire to add to clinical decisions and document patient courses and outcomes in standard clinical care of patients with all rheumatic diseases.

Familial Mediterranean fever: clinical, molecular and management advancements

Familial Mediterranean fever (FMF), the most frequent of the periodic fever syndromes, is an autosomal recessive disease, predominantly affecting people of Mediterranean descent. The disease is caused by mutations in the MEFV gene, encoding the pyrin protein thought to be associated with the interleukin-1 related inflammation cascade. The condition manifests as attacks of serositis, commonly involving the abdomen, chest or joints, typically accompanied by fever and elevated acute phase reactants. Attacks subside spontaneously within one to three days, without residue. Continuous treatment with colchicine, at a daily dose of 1 to 2 mg, reduces attack frequency, duration and intensity in the majority of patients, and also prevents the development of secondary amyloidosis, the most dreaded complication of the disease. In this communication we review the current state of the art in the diagnosis and care of FMF patients, starting with the presentation of a typical case.

[Periodic fever syndromes]

Periodic fever syndromes comprise a group of disorders characterized by attacks of seemingly unprovoked inflammation. The genetic causes of five hereditary autoinflammatory syndromes have been identified in the last few years: familial Mediterranean fever, the cryopyrinopathies [Muckle-Wells, chronic infantile neurological, cutaneous, articular syndrome (CINCA) and familial autoinflammatory syndromes], TNF-receptor associated periodic syndrome, cyclic neutropenia syndrome and periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. The study of periodic fever syndromes has progressed from clinical characterization to genetic analysis and to the definition of the functional defects linking genes or domains to apoptotic proteins and signal transduction pathways. This new research opens the way for more specific treatment options with a further improvement in prognosis and outcome.

[TNF receptor-associated periodic syndrome (TRAPS) in Japan: clinical characterization, pathogenesis, diagnostic criteria, and treatment]

TNF receptor-associated periodic syndrome (TRAPS) is an autosomal dominant inherited disease characterized by prolonged episodes of periodic fever and localized inflammation. The hypothetical pathogenesis of TRAPS is defective TNF receptor 1 (TNFRSF1A) shedding from cell membranes in response to a stimulus including TNFalpha. This mechanism has recently been shown to account for a minor population of TRAPS patients and other mechanisms are reported to explain the disease, such as resistance to apoptosis, TNFRSF1A internalization, or TNFRSF1A misfolding and aggregation, leading to NF-kappaB activation and apoptosis. Until now 15 TRAPS patients from 5 pedigree including 5 different mutations (C30R, C30Y, T61I, C70S, C70G) had been reported in Japan. There were many sporadic cases of TRAPS without TNFRSF1A mutation in our epidemiological study. In this issue, we described the clinical characterization, pathogenesis, diagnostic criteria, and treatment of TRAPS according to our case and literature.

Enfermedades autoinflamatorias sistémicas hereditarias. Síndromes hereditarios de fiebre periódica

Systemic autoinflammatory diseases are an heterogeneous group of systemic disorders clinically characterized by recurrent or persistent inflammatory episodes, which occur in the absence of infectious, neoplastic or autoimmune etiology. During the past years, genetic defects affecting different proteins involved in the regulation of inflammatory processes have been identified in these diseases. These advances offer new genetic tools to clinicians, in order to achieve an accurate and definitive diagnostic, and to establish a tailored treatment. Present review is an updated and comprehensive overview on hereditary systemic autoinflammatory diseases, and it has been organized in 2 separate and independent parts. The first of them will introduce the group of hereditary periodic fever syndromes, which includes familial Mediterranean fever, hyperimmunoglobulinemia D with periodic fever syndrome (HIDS), and tumour necrosis factor receptor-associated periodic syndrome (TRAPS).

Overlap syndrome between FMF and TRAPS in a patient carrying MEFV and TNFRSF1A mutations

OBJECTIVE

Familial Mediterranean Fever (FMF) and TNF-Receptor Associated Periodic Syndrome (TRAPS) are two inheritable inflammatory disorders. They share some clinical manifestations but their treatments are different. We present here the case of an overlap syndrome of FMF and TRAPS in a patient carrying a mutation in both the MEFV and TNFRSF1A genes.

CASE REPORT

A 20-year-old woman of Mediterranean origin had suffered since childhood from attacks of fever and arthritis, with skin and ophthalmic manifestations. The initial diagnosis was FMF. The symptoms responded poorly to colchicine but regressed with steroids. Genetic analysis revealed a homozygous M694V mutation in MEFV and a heterozygous R92Q mutation in TNFRSF1A. We discuss the complexity of this combined FMF-TRAPS phenotype.

CONCLUSION

This case shows that mutations in MEFV and TNFRSF1A can occur together in a single patient, a condition that may modify its response to treatment. It would be interesting to evaluate the role of the R92Q mutation in TNFRSF1A in patients of Mediterranean origin with FMF unresponsive to colchicine.