Bone mineral density in children with familial Mediterranean fever

The influence of vitamin D administration on the clinical presentation, body mass index, and osteoprotegerin (OPG) level in a sample of Egyptian children with familial Mediterranean fever

Background

Familial Mediterranean fever (FMF) is autosomal recessive chronic disease represents by recurring attacks of polyserositis, fever, and joint pain. Vitamin D deficiency in FMF children has been recently mentioned in literature and linked to delayed physical growth. Osteoporosis in FMF patients can be linked to low levels of vitamin D, too. Osteoprotegerin (OPG) might be used as an indicator for osteoporosis. Therefore, this work aimed to investigate the impact of vitamin D administration on clinical status, BMI, and bone mineral density represented by alterations in the OPG serum levels in a group of Egyptian children with FMF. This was a prospective longitudinal study carried out on 33 children, aged 4–16 years, with FMF cases. Patients were on colchicine 0.5–2 mg/day and received vitamin D3 oral drops 2800 IU/ml; each drop contains 100 IU in a dose of 600 IU/day for 6 months. The effect of vitamin D administration was evaluated clinically, anthropometrically and by assessment of serum vitamin D and osteoprotegerin at baseline and 6 months later.

Results

Serum vitamin D levels were below the normal range before intervention and showed significant improvement (p < 0.001) 6 months after intervention. Significant increase in both BMI Z scores (p < 0.05) and OPG serum levels and improvement in the clinical status as illustrated by significant decrease in the number of cases with fever, arthritis, and abdominal pain and significant decrease in the frequency and duration of the attacks (p < 0.001).

Conclusion

Our results intensely indicate that vitamin D supplementation improved the clinical condition, BMI, and bone mineral density in children with FMF.

Oro-dental features in Egyptian patients with familial mediterranean fever

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.

Predictors of persistent inflammation in children with familial Mediterranean fever

OBJECTIVES

Persistent inflammation is an insidious feature of familial Mediterranean fever (FMF) that may cause chronic complications. This study aimed to investigate the predictors of persistent inflammation in children with FMF.

METHODS

The medical charts of 1077 paediatric FMF patients were retrospectively collected. The patients were divided into two groups: with and without subclinical inflammation.

RESULTS

A total of 133 (12%) patients had persistent inflammation. M694V homozygosity, colchicine resistance, positive family history for FMF, erysipelas-like erythema, leg pain, arthritis, chest pain, inflammatory comorbidities, early disease onset, high PRAS score, and long attack duration were established as independent predictors of persistent inflammation (P < .001, P < .001, P < .001, P < .001, P = 0.006, P < .001, P < .001, P = .014, P < .001, P < .001, and P < .001, respectively). However, gender, abdominal pain, fever, and attack frequency were not found to be independent risk factors for predicting persistent inflammation (P = .412, P = .531, P = .451, and P = .693, respectively).

CONCLUSIONS

M694V homozygosity, colchicine resistance, positive family history, erysipelas-like erythema, leg pain, arthritis, chest pain, inflammatory comorbidities, early disease onset, high activity score, and long attack duration may be predictors of persistent inflammation in FMF. These predictors may help clinicians suspect the occurrence of subclinical inflammation and should aid in better disease management in FMF.

Predictors of persistent inflammation in familial Mediterranean fever and association with damage

OBJECTIVE

Persistent inflammation is an insidious and less studied feature of FMF. We investigated clinical determinants of persistent inflammation and its associations with individual damage items.

METHODS

This is a cross-sectional analysis of 917 FMF patients, who fulfilled the Tel Hashomer criteria and had at least 6 months' follow-up. Patients were stratified based on whether they had persistent inflammation. We used logistic regression analysis to investigate independent predictors of persistent inflammation and the associated individual damage items.

RESULTS

One hundred and forty-two (15%) patients had persistent inflammation. Active FMF (54%) was the most prominent reason for the persistent inflammation. Spondylarthritis (16%), other inflammatory arthritis (8%) and IBD (2%) were other frequent reasons. Male gender, history of exertional leg pain, inflammatory comorbidities, M694V homozygosity, colchicine resistance, lower education levels and musculoskeletal attack dominance were found to be the independent predictors of persistent inflammation. Earlier disease onset led to a tendency towards persistent inflammation. Patients with persistent inflammation were more likely to suffer damage. There is an increased risk of developing proteinuria, amyloidosis and renal insufficiency.

CONCLUSION

We identified, for the first time, the predictors of persistent inflammation in adult FMF patients and related individual damage items of the Autoinflammatory Disease Damage Index. Persistent inflammation is insidious and one of the chief causes of damage; therefore, especially patients with these predictors should be followed up more closely. If detected, underlying inflammatory comorbidities should be assessed meticulously as early detection and proper treatment strategies may favourably impact the natural history of the disease.

Periodic fever syndromes and the autoinflammatory diseases (AIDs)

Innate immune system represents the ancestral defense against infectious agents preserved along the evolution and species; it is phylogenetically older than the adaptive immune system, which exists only in the vertebrates. Cells with phagocytic activity such as neutrophils, macrophages, and natural killer (NK) cells play a key role in innate immunity. In 1999 Kastner et al. first introduced the term “autoinflammation” describing two diseases characterized by recurrent episodes of systemic inflammation without any identifiable infectious trigger: Familial Mediterranean Fever (FMF) and TNF Receptor Associated Periodic Syndrome (TRAPS). Autoinflammatory diseases (AIDs) are caused by self-directed inflammation due to an alteration of innate immunity leading to systemic inflammatory attacks typically in an on/off mode. In addition to inflammasomopathies, nuclear factor (NF)-κB-mediated disorders (also known as Rhelopathies) and type 1 interferonopathies are subjects of more recent studies.

This review aims to provide an overview of the field with the most recent updates (see “Most recent developments in..” paragraphs) and a description of the newly identified AIDs.

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Autoinflammatory diseases are caused by self-directed inflammation.

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Alteration of innate immunity leads to systemic inflammation attacks.

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The autoinflammatory field is exponentially expanding.

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The advances in AIDs have led to new insights into immune system understanding.

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Autoimmunity and autoinflammation features may be simultaneously present.

Osteoporosis in Systemic Autoinflammatory Diseases: A Case-Control Study

Objective: To assess if patients affected by systemic autoinflammatory diseases (SAIDs) present an increased risk of osteoporosis (OP). Methods: Forty adults patients referred to the Rheumatology Unit of Padova University Hospital affected by Familial Mediterranean Fever (FMF), TNF-Receptor Associated Periodic Syndrome (TRAPS), and Mevalonate Kinase Deficiency (MKD) and 40 healthy subjects were enrolled. Blood and urine samples were collected in order to define phosphocalcic metabolism, including Receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin (OPG), and among inflammatory markers serum amyloid A (SAA). Femur and lumbar dual-energy X-ray absorptiometry (DXA) scans were performed and Trabecular Bone Score (TBS) was calculated on DXA lumbar images. Results: We did not observe a statistically significant difference between Bone Mineral Density (BMD) and TBS of patients compared to controls. Also, the values of phosphocalcic metabolites in patients did not statistically differ from those in controls. However, SAA and OPG levels were significantly higher in patients compared to healthy subjects (p = 0.0244 and p = 0.0064, respectively). Conclusion: Patients of our cohort affected by FMF, TRAPS, and MKD do not present an increased risk of OP compared to the healthy controls. TBS and BMD are similar between the two groups underlining a preserved bone quality in patients. High OPG levels could suggest a protective role and a bone re-balancing action in response to an inflammatory background. Finally, it should be taken into account a modulatory role played by a pro-inflammatory cytokine such as SAA on bone homeostasis.

[Serum calgranulin C is a highly sensitive autoinflammation activity indicator in patients with familial periodic fevers]

AIM

To determine the possibility of using the serum proinflammatory calcium-binding protein, or calgranulin C (S100A12), to assess activity and therapeutic efficiency in patients with periodic disease (PD) and other familial periodic fevers (FPFs).

SUBJECTS AND METHODS

Thirty-five patients with PD and other FPDs, which were verified by molecular genetic study, were examined. In accordance with the disease activity, the patients were divided into 2 groups. The investigators determined the concentration of S100A12 by solid-phase enzyme immunoassay and that of other acute-phase inflammatory markers (erythrocyte sedimentation rate (ERT), neutrophil counts, and fibrinogen and C-reactive protein (CRP) concentrations).

RESULTS

The serum concentration of S100A12 in the stage of disease activity was 466.7 (265.22--851.7) ng/ml, which was significantly higher than in remission (244.29 (118.93--409.85) ng/ml (p=0.000002). The highest S100A12 concentrations were noted in the patients with PD; these were 758.95 (434.80--1035.95) ng/ml; the S100A12 level in the majority of PD patients even during remission remained moderately higher. An investigation of the relationship of A100A12 to genetic variants found no differences between the patients homozygous for M694V and those with other genotypes (p=0.37). Estimation of the time course of therapy-induced changes in the serum S100A12 concentration revealed its considerable reduction (р=0.0018). However, normalization of S100A12 levels was not achieved in PD. The remaining increased S100A12 concentration in these patients may be suggestive of the activity of PD despite the absence of its clinical manifestations. S100A12 as a highly sensitive marker allows more exact evaluation of the anti-inflammatory effect of therapy. The S100A12 identification of the subclinical activity of autoinflammatory diseases made all the more important since traditional inflammatory markers, such as ERT, CRP, fibrinogen, and leukocyte counts, are less sensitive for these purposes. In our study, these markers were within the reference range in remission. No differences were found in the S100A12 levels between the groups with and without amyloidosis (p=0.62).

CONCLUSION

S100A12 is a highly sensitive marker for the activity of autoinflammatory diseases and the efficiency of their therapy. The serum level of S100A12 in PD may be used to diagnose the subclinical activity of inflammation, which is of importance in monitoring the risk of amyloidosis.

Serum bone markers levels and bone mineral density in familial mediterranean Fever

[Purpose] The aim of this study was to measure bone mineral density, serum and urinary bone turnover parameters, and to evaluate the influence of demographic and genetic factors on these parameters in FMF patients. [Subjects and Methods] Twenty-seven attack-free patients who were diagnosed with FMF (in accordance with Tel Hashomer criteria) were recruited at outpatient rheumatology clinics. We investigated whether there were any differences between the FMF patients and a control group in terms of lumbar and femur bone mineral density (BMD), standard deviation scores (Z scores and T scores) and bone markers. [Results] In terms of the median values of lumbar BMD (p = 0.21), lumbar T (p = 0.098) and Z (p = 0.109) scores, femoral neck BMD, femoral T and Z scores and total femur BMD, T (p = 0.788) and Z scores, there were no significant differences. [Conclusion] In our study, no statistically significant differences were found between FMF patients and a control group in terms of osteoporosis. The 25-OH vitamin D was found to be significantly lower in FMF patients than in the control group.

Cephalometric evaluation of children with familial Mediterranean fever

OBJECTIVE

To test the null hypothesis that no differences exist in craniofacial morphology between patients with familial Mediterranean fever (FMF) and the healthy population.

MATERIALS AND METHODS

Standardized lateral cephalograms of 32 FMF patients (mean age, 11.50 ± 2.72 years) and 32 healthy controls (mean age, 11.86 ± 2.19 years) were obtained. Cranial and dentofacial parameters were measured using a cephalometric analysis program (Nemoceph Imaging Cephalometric and Tracing Software S.L., Spain). All statistical analyses were conducted using SPSS version 17.0.0 (SPSS Inc., Chicago, Ill). Descriptive statistics were calculated for all measurements, and the independent t-test was used to evaluate intergroup differences.

RESULTS

The ANB angle was significantly greater in the FMF group (P < .05). Differences in SNA and SNB angles were insignificant. Anterior (P < .001) and posterior (P < .05) face heights were significantly shorter in the FMF group. Mandibular body length (P < .001) and condylion to gnathion (P < .05) measurements were significantly shorter in the FMF group. The upper lip was more protrusive in the FMF group (P < .05). U1-NA (mm; P < .001) and L1-NB (mm; P < .05) measurements were significantly shorter in the FMF group.

CONCLUSION

The hypothesis is rejected. Significant differences exist between the craniofacial morphology of patients with FMF and the healthy population.

Chronic inflammation in FMF: markers, risk factors, outcomes and therapy

Familial Mediterranean fever (FMF) is the most common of the hereditary periodic fever syndromes. Although the typical clinical course of FMF is characterized by bouts of painful inflammation, this presentation represents only the tip of the iceberg. In many patients inflammation can persist in attack-free periods, as shown by high levels of acute-phase proteins, cytokines and inflammation-induced proteins. This subclinical inflammation puts patients at risk of developing complications such as anemia, splenomegaly, decreased bone mineral density, heart disease and life-threatening amyloid A amyloidosis, among others. In this article, we review the published data on markers and other factors involved in the persistence of inflammation in patients with FMF during attack-free periods, examine the risk factors for the development of this subclinical inflammation, summarize the complications of chronic inflammation in FMF and propose a new strategy for treatment, based on these data.

Bone mineral density in patients with familial Mediterranean fever

This study was carried out to determine lumbar and femoral bone mineral density (BMD) in patients with familial Mediterranean fever (FMF), an autosomal-recessive disease characterized by recurrent episodes of peritonitis, pleuritis, and arthritis, which are usually associated with fever. In patients with FMF and control subjects, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured. BMD was determined at the lumbar spine (L1-4) and the femoral regions (neck and total) using dual energy X-ray absorptiometry. Twenty-eight FMF patients and 30 control subjects without a history of inflammatory disease participated in our study. The demographic variables, such as age, sex and body mass index were similar between patients and controls (P > 0.05). We found statistically significant difference in ESR and CRP between FMF patients and controls (P < 0.01, P < 0.05 respectively). There was statistically significant difference in lumbar spine, femoral neck, and total femur BMD between FMF patients and control groups (P < 0.001, P < 0.01, P < 0.01 respectively).Our study indicates that lumbar spine and femoral neck and total femur BMD in patients with FMF may be lower than in healthy subjects.

Decreased bone mineral density in adult familial Mediterranean fever patients: a pilot study

We investigated the association between familial Mediterranean fever (FMF) and osteoporosis (OP) in adult patients. Thirty-five attack-free FMF patients (28 females, 7 males; mean age 36.9 +/- 5.7 years) were individually matched to control subjects on the basis of age (within 2 years) and sex. All patients were taking regular colchicine. Subjects having any condition that can cause decreased bone mineral density (BMD) were excluded from the study. BMD was measured at the spine and femur by dual X-ray absorptiometry (DXA). Data was given as the median (IQR). T scores of the spine were -0.700 (-1.097 to -0.262) and -0.450 (-0.830 to 0.112) in FMF patients and healthy controls, respectively (p > 0.05). T scores of the femur neck were -0.900 (-1.480 to -0.570) and -0.430 (-1.472 to 0.247) in FMF patients and healthy controls, respectively (p > 0.05). Total femur T scores were significantly lower in FMF patients than healthy controls (-0.780 [-1.222 to -0.085] vs. -0.100 [-0.765 to 0.537], respectively, p = 0.021). Total femur T scores were significantly decreased in adult patients with FMF. Ongoing subclinical inflammation may be associated with decreased bone mineral content in those patients.