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Özaslan Z, Şen A, Uçar SA, Çakan M, Sanisoğlu B, Kaya F, Otar Yener G, Demir F, Tanatar A, Özdel S, Öztürk K, Şahin N, Sönmez HE, Aktay Ayaz N, Sözeri B. Exploring factors for predicting colchicine responsiveness in children with PFAPA. Eur J Pediatr 2024:10.1007/s00431-024-05703-3. [PMID: 39085658 DOI: 10.1007/s00431-024-05703-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/22/2024] [Accepted: 07/24/2024] [Indexed: 08/02/2024]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA) are the most common autoinflammatory syndromes in children. This study aimed to evaluate the clinical and laboratory parameters that may predict colchicine responsiveness.This retrospective, multicenter, cross-sectional study involved nine pediatric rheumatology centers from our country., The patients diagnosed with PFAPA were compared on the basis of their responses to colchicine. In the 806 (42.3% female 57.7% male) patients, the most common clinical findings were fever (100%), exudative tonsillitis (86.5%), pharyngitis (80.9%), and aphthous stomatitis (50.5%). The mean attack frequency was 13.5 ± 6.8 attacks per year lasting for a mean of 3.9 ± 1.1 days. Colchicine treatment was attempted in 519 (64.4%) patients, with 419 (80.7%) showing a favorable response. In patients who underwent MEFV gene analysis (70.8%), the most common variant was M694V heterozygous (16.8%). The presence of pharyngitis (p = 0.03, 95% CI 0.885 to 0.994), the presence of arthralgia (p = 0.04, 95% CI 0.169 to 0.958), and having more frequent attacks (p = 0.001, 95% CI 0.028 to 0.748) were found to be associated with colchicine unresponsiveness, whereas the carriage of the M694V variant (p = 0.001, 95% CI 0.065 to 0.242) was associated with colchicine responsiveness. CONCLUSION This study identified the presence of pharyngitis, arthralgia, and increased attack frequency in patients with PFAPA as factors predicting colchicine unresponsiveness, whereas the carriage of the M694V variant emerged as a predictor of colchicine responsiveness. Predicting colchicine response at disease onset may facilitate a more effective management of PFAPA. WHAT IS KNOWN • Colchicine treatment can be used in the prophylaxis of PFAPA disease. • Having the MEFV variant is the most commonly known factor in predicting response to colchicine. WHAT IS NEW • The presence of pharyngitis or arthralgia, and more frequent attacks in PFAPA disease were found to be independently associated with colchicine unresponsiveness. • Carrying the M694V variant was identified as the sole factor predicting colchicine responsiveness.
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Affiliation(s)
- Zeynep Özaslan
- Department of Pediatric Rheumatology, Faculty of Medicine, MD, Kocaeli University, Kocaeli, Turkey.
| | - Abdulvahap Şen
- Department of Pediatric Rheumatology, Ankara Etlik City Hospital, Ankara, Turkey
| | - Sıla Atamyıldız Uçar
- Department of Pediatric Rheumatology, Health Sciences University, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Çakan
- Department of Pediatric Rheumatology, Zeynep Kamil Training and Research Hospital, Istanbul, Turkey
| | - Bengisu Sanisoğlu
- Department of Pediatrics, Department of Pediatric Rheumatology, İstanbul University, Istanbul, Turkey
| | - Feray Kaya
- Department of Pediatric Rheumatology, İstanbul Medeniyet University, İstanbul, Turkey
| | - Gülçin Otar Yener
- Department of Pediatric Rheumatology, Eskişehir City Hospital, Eskişehir, Turkey
| | - Ferhat Demir
- Department of Pediatric Rheumatology, Acıbadem Ataşehir Hospital, Istanbul, Turkey
| | - Ayşe Tanatar
- Department of Pediatric Rheumatology, Gaziantep City Hospital, Gaziantep, Turkey
| | - Semanur Özdel
- Department of Pediatric Rheumatology, Ankara Etlik City Hospital, Ankara, Turkey
| | - Kübra Öztürk
- Department of Pediatric Rheumatology, İstanbul Medeniyet University, İstanbul, Turkey
| | - Nihal Şahin
- Department of Pediatric Rheumatology, Faculty of Medicine, MD, Kocaeli University, Kocaeli, Turkey
| | - Hafize Emine Sönmez
- Department of Pediatric Rheumatology, Faculty of Medicine, MD, Kocaeli University, Kocaeli, Turkey
| | - Nuray Aktay Ayaz
- Department of Pediatrics, Department of Pediatric Rheumatology, İstanbul University, Istanbul, Turkey
| | - Betül Sözeri
- Department of Pediatric Rheumatology, Health Sciences University, Umraniye Training and Research Hospital, Istanbul, Turkey
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Bagrul İ, Aydin EA, Tuncez S, Baglan E, Özdel S, Bülbül M. Effect of Colchicine Treatment on Clinical Course in Children with PFAPA Syndrome. KLINISCHE PADIATRIE 2024. [PMID: 38387479 DOI: 10.1055/a-2274-9046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA) is the most common periodic fever condition in children. There is no consensus on treatment to prevent attacks and reduce their frequency. In this study, we aimed to evaluate the effectiveness of colchicine treatment in PFAPA syndrome. In addition, we described the demographic and clinical features of PFAPA patients. MATERIALS AND METHODS We retrospectively analyzed 58 PFAPA patients who were started on colchicine treatment between January 2017 and January 2022. Demographic data, clinical features, laboratory tests, genetic analysis of MEditerranean FeVer (MEFV) mutations, and autoinflammatory disease activity index (AIDAI) scores of all patients were evaluated. In addition, patients were divided into two groups according to MEFV variants and compared. RESULTS Attack frequency, duration, and AIDAI scores decreased in all patients after colchicine treatment. Duration of follow-up was 13.53±6.65 months. The median±IQR age at diagnosis was 3.2 (2-5) years. Thirty three (56.9%) patients had heterozygous mutations of MEFV. The most common MEFV variants were M694V (63.6%). There was no significant difference between the two groups in terms of colchicine responses. CONCLUSION Colchicine treatment is effective and safe in patients with PFAPA who have frequent attacks. No association was established between the presence of heterozygous mutations of MEFV and colchicine response.
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Affiliation(s)
- İlknur Bagrul
- Department of Pediatric Rheumatology, Ankara Etlik Integrated Health Campus, ANKARA, Turkey
| | - Elif Arslanoglu Aydin
- Department of Pediatric Rheumatology, Ankara Etlik Integrated Health Campus, ANKARA, Turkey
| | - Serife Tuncez
- Department of Pediatric Rheumatology, Ankara Etlik Integrated Health Campus, ANKARA, Turkey
| | - Esra Baglan
- Department of Pediatric Rheumatology, Ankara Etlik Integrated Health Campus, ANKARA, Turkey
| | - Semanur Özdel
- Department of Pediatric Rheumatology, Ankara Etlik Integrated Health Campus, ANKARA, Turkey
| | - Mehmet Bülbül
- Department of Pediatric Nephrology, Dr Sami Ulus Gynecology Obstetrics and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
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Kapustova L, Banovcin P, Bobcakova A, Jurkova Malicherova E, Kapustova D, Petrovicova O, Slenker B, Markocsy A, Oleksak F, Vorcakova K, Jesenak M. The use of ketotifen as long-term anti-inflammatory prophylaxis in children with PFAPA syndrome. Front Immunol 2023; 14:1302875. [PMID: 38143757 PMCID: PMC10748580 DOI: 10.3389/fimmu.2023.1302875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA) is the most frequent periodic fever syndrome in children. Its pathogenesis is still unknown, but some disease-modifying factors were observed. Several medications were tested for the long-term prophylaxis of inflammatory flares; however, none are standardly used. Methods This prospective clinical trial enrolled 142 children (71 girls, 50%) meeting diagnostic criteria for PFAPA syndrome. We analysed selected clinical characteristics and compared laboratory parameters during the flare and attack-free period (at least two weeks after the attack). Moreover, we assessed the possible therapeutic effect of ketotifen on the duration of attack free-periods and clinical picture. Results The mean age of patients was 6.81 ± 3.03 years and the mean age of onset of symptoms was 2.31 ± 2.02 years. No significant differences were observed between genders.We recorded a positive family history for PFAPA in 31.69% of patients. Attacks lasted for 2.8 ± 1.2 days, with intervals between attacks of 4 ± 1 weeks. We administered ketotifen in 111 (77.8%) patients, and a positive effect was observed in 86 (77.5%) of patients. We observed prolonged attack-free intervals in patients treated with ketotifen (14.7 ± 8.9 days in comparison with 4.4 ± 1.9 days before the treatment; p<0.001). The used dose of ketotifen was 0.08 ± 0.01 mg/kg/day. Mild side effects were observed in four patients (restlessness, irritability, agitation and constipation). Discussion Our data supports the use of ketotifen for long-term prophylaxis in children with PFAPA syndrome with positive effects on the attenuation of disease activity and the prolongation of attack-free periods. Further well-designed studies should confirm the preliminary data.
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Affiliation(s)
- Lenka Kapustova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Peter Banovcin
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Anna Bobcakova
- Department of Pneumology and Phthisiology, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Eva Jurkova Malicherova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Daniela Kapustova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Otilia Petrovicova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Branislav Slenker
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Adam Markocsy
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Filip Oleksak
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Karolina Vorcakova
- Clinic of Dermatovenerology, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Milos Jesenak
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
- Department of Pneumology and Phthisiology, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
- Department of Clinical Immunology and Allergology, University Hospital in Martin, Martin, Slovakia
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Nozu T, Ohhira M, Ishioh M, Okumura T. Adult-onset Periodic Fever, Aphthous Stomatitis, Pharyngitis and Cervical Adenitis Syndrome Responsive to Colchicine. Intern Med 2023; 62:3555-3558. [PMID: 37062730 PMCID: PMC10749813 DOI: 10.2169/internalmedicine.1364-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/08/2023] [Indexed: 04/18/2023] Open
Abstract
We herein report a rare case of periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome that occurred in an 18-year-old man. He visited our hospital with recurrent episodes of a fever, pharyngitis and adenitis without suggestive findings of infection. These episodes resolved within 5 days and recurred quite regularly, with an interval of about 30 days. As the febrile episodes significantly impaired his quality of life, he was treated with colchicine (0.5 mg) as prophylaxis. This completely prevented the episodes during six months of follow-up. Colchicine may therefore be effective in cases of adult-onset PFAPA syndrome.
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Affiliation(s)
- Tsukasa Nozu
- Department of Regional Medicine and Education, Asahikawa Medical University, Japan
- Center for Medical Education, Asahikawa Medical University, Japan
| | - Masumi Ohhira
- Department of General Medicine, Asahikawa Medical University, Japan
| | - Masatomo Ishioh
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Toshikatsu Okumura
- Department of General Medicine, Asahikawa Medical University, Japan
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
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Konte EK, Haslak F, Yildiz M, Gucuyener N, Ulkersoy I, Gunalp A, Aslan E, Adrovic A, Sahin S, Barut K, Kasapcopur O. Gray zone in the spectrum of autoinflammatory diseases: familial Mediterranean fever accompanying periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome: single-center experience. Eur J Pediatr 2023; 182:5473-5482. [PMID: 37777601 DOI: 10.1007/s00431-023-05209-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 10/02/2023]
Abstract
Despite the advanced knowledge concerning autoinflammatory diseases (AID), more data regarding the optimal treatment options and outcomes of the children who met the criteria of more than one AID are required. This study aimed to describe the demographic and clinical characteristics of children from familial Mediterranean fever (FMF)-endemic countries who meet both the FMF and the periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome criteria. Moreover, we aimed to measure the response rates to colchicine and tonsillectomy and evaluate the factors affecting the colchicine response in these patients. The study was conducted at pediatric rheumatology tertiary centre. A total of 131 patients (58 females; 73 males) who met both the modified Marshall and pediatric FMF criteria were included. The median age at onset was 18 months (1-77 months), and the mean age at diagnosis was 47 ± 21.88 months. The median interval between episodes was 21 (7-90) days. The median disease duration was 46 (6-128) months. Consanguineous marriage was detected in 17 (13%) of the patients. The most common clinical finding was fever (100%), followed by exudative pharyngitis (88.5%), abdominal pain (86.3%), arthralgia (61.8%), stomatitis (51.1%), adenitis (42%), myalgia (28.7%), chest pain (16%), maculopapular rash (12.2%), arthritis (8.4%), and erysipelas-like rash (4.6%). MEFV gene variants were identified in 106 (80.9%) patients. The most common variants were M694V heterozygous (29%). We found that patients with tonsillopharyngitis, aphthous stomatitis, and PFAPA family history were more likely to be colchicine-resistant and tonsillectomy responsive, while those with exon 10 MEFV gene mutations were more prone to have a favorable response to colchicine. Conclusion: PFAPA syndrome patients with exon 10 MEFV gene mutation, showing typical FMF symptoms, should be treated with colchicine, even after tonsillectomy. In multivariate analysis, PFAPA family history and lack of exon 10 MEFV gene mutations were independent risk factors for colchicine resistance. Thus, tonsillectomy may be recommended as a possible treatment option for these patients. It has yet to be clarified when colchicine treatment will be discontinued in patients whose attacks ceased after tonsillectomy that was performed due to colchicine unresponsiveness. What is Known: • A certain number of patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome concomitantly fulfill the familial Mediterranean fever (FMF) criteria. • While colchicine is proposed as a first treatment choice in familial Mediterranean fever (FMF), corticosteroids are recommended as a first-line treatment in PFAPA syndrome patients. What is New: • In patients with concomitant PFAPA syndrome and FMF, PFAPA family history and lack of exon 10 MEFV gene mutation are predictive factors of colchicine resistance. • The presence of exon 10 MEFV gene mutations in patients with concomitant FMF and PFAPA syndrome has a favourable effect on response to colchicine treatment.
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Affiliation(s)
- Elif Kilic Konte
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Fatih Haslak
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mehmet Yildiz
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Neslihan Gucuyener
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ipek Ulkersoy
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Aybuke Gunalp
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Esma Aslan
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey.
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Manthiram K. What is PFAPA syndrome? Genetic clues about the pathogenesis. Curr Opin Rheumatol 2023; 35:423-428. [PMID: 37467064 PMCID: PMC10538419 DOI: 10.1097/bor.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
PURPOSE OF REVIEW Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in childhood. Recent studies report genetic susceptibility variants for PFAPA syndrome and the efficacy of tonsillectomy in a broader cohort of patients with recurrent stereotypical fever. In this review, we highlight the findings of these studies and what they may reveal about the pathogenesis of PFAPA. RECENT FINDINGS Newly identified genetic susceptibility loci for PFAPA suggest that it is a complex genetic disorder linked to Behçet's disease and recurrent aphthous ulcers. Patients who have PFAPA with some features of Behçet's disease have been reported. Moreover, the efficacy of tonsillectomy has now been described in patients who do not meet the full diagnostic criteria for PFAPA, although the immunologic profile in the tonsils is different from those with PFAPA. Factors that predict response to tonsillectomy are also reported. SUMMARY These findings highlight the heterogeneous phenotypes that may be related to PFAPA due to common genetic susceptibility or response to therapy. These relationships raise questions about how to define PFAPA and highlight the importance of understanding of the genetic architecture of PFAPA and related diseases.
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Affiliation(s)
- Kalpana Manthiram
- Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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Abstract
Children with intermittent fevers present to pediatricians and other primary care child health providers for evaluation. Most patients will have self-limited, benign infectious illnesses. However, the possibility of a periodic fever syndrome should be considered if febrile episodes become recurrent over an extended period and are associated with particular signs and symptoms during each attack. This review discusses the current conceptualization of autoinflammatory diseases with specific focus and detail on familial Mediterranean fever; tumor necrosis factor receptor-associated periodic syndrome; mevalonate kinase deficiency; NLRP3-associated autoinflammatory disease; and periodic fever, aphthous stomatitis, pharyngitis, and adenitis. The genetic mutations associated with these clinical entities are identified, along with the historical nomenclature that predates the current pathogenetic understanding of these diseases. The episodic signs and symptoms seen across these periodic fever syndromes can be overlapping, but there are some distinguishing features that can be useful, and these are described. The disease course and potential complications, particularly amyloidosis, which is a variable risk in these conditions and a potential source of significant morbidity and mortality, are addressed. Treatment strategies are outlined, highlighting the advances in therapy that have resulted from the advent of proinflammatory cytokine-targeting biological agents.
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Affiliation(s)
- Christina Schutt
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY
| | - David M Siegel
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY
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Hausmann J, Dedeoglu F, Broderick L. Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis Syndrome and Syndrome of Unexplained Recurrent Fevers in Children and Adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1676-1687. [PMID: 36958521 DOI: 10.1016/j.jaip.2023.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 03/25/2023]
Abstract
Children and adults with autoinflammatory disorders, who often experience recurrent fevers, rashes, cold-induced symptoms, conjunctivitis, lymphadenopathy, recurrent infections, aphthous stomatitis, and abnormal blood cell counts, may present to the allergist/immunologist because the symptoms mimic allergies and disorders of immunity. In recent years, there has been increased recognition of non-monogenic autoinflammatory disorders, including periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome and syndrome of undifferentiated recurrent fevers. For many clinical practitioners, the natural history, diagnostic criteria, differential diagnoses, and preferred therapies remain challenging because of the presumed rarity of patients and the evolving field of autoinflammation. Here, we aim to provide a practical framework for the clinical allergist/immunologist to evaluate and treat this patient population.
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Affiliation(s)
- Jonathan Hausmann
- Department of Medicine, Harvard Medical School, Boston, Mass; Program in Rheumatology, Division of Immunology, Boston Children's Hospital, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Fatma Dedeoglu
- Department of Medicine, Harvard Medical School, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Lori Broderick
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of California-San Diego, La Jolla, Calif; Rady Children's Foundation, Rady Children's Hospital, San Diego, Calif.
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Otar Yener G, Aktaş İ, Altıntaş Meşe C, Çakan M. Does having MEFV gene sequence variants affect the clinical course and colchicine response in children with PFAPA syndrome? Eur J Pediatr 2023; 182:411-417. [PMID: 36376520 PMCID: PMC9663282 DOI: 10.1007/s00431-022-04709-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
UNLABELLED The primary aim of this study was to document the treatment modalities used in periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome and look for the efficacy and safety of colchicine in the treatment of PFAPA patients. The secondary aim was to search for whether having MEFV (Mediterranean fever) gene sequence variants affect the clinical course and response to colchicine. The study was conducted in 2 pediatric rheumatology centers. The patients that have been diagnosed with PFAPA syndrome between December 2017 and December 2021 were evaluated retrospectively. The study included 157 patients with PFAPA syndrome (54.8% boys and 45.2% girls). The median follow-up duration was 18 (IQR: 12-30) months. One hundred and fifty-five patients (98.7%) had exudative pharyngitis, 120 patients (76.4%) had aphthous stomatitis, and 82 patients (52.2%) had cervical lymphadenitis during the attacks. Clinical features during attacks were not affected by the presence or absence of the MEFV gene sequence variants. Corticosteroid treatment during attacks was given to 152 patients (96.8%). The frequency of fever attacks did not change in 57 patients (37.5%), increased in 57 patients (37.5%), and decreased in 38 patients (25%) after corticosteroid use. Colchicine was given to 122 patients (77.7%) in the cohort. After colchicine treatment, complete/near-complete resolution of the attacks was observed in 57 patients (46.7%). Colchicine led to partial resolution of the attacks in 59 patients (48.4%). In only 6 patients (4.9%), no change was observed in the nature of the attacks with colchicine treatment. The median duration of the attacks was 4 (IQR: 4-5) days before colchicine treatment, and it was 2 (IQR: 1-2.5) days after colchicine treatment. Also, a significant decrease in the frequency of the attacks was observed before and after colchicine treatment [every 4 (IQR: 3-4) weeks versus every 10 (IQR: 8-24) weeks, respectively, (p < 0.001)]. The overall response to colchicine was not affected by MEFV sequence variants. It was seen that the frequency of fever attacks decreased dramatically in both groups, and children with MEFV variants had significantly less attacks than children without MEFV variants after colchicine treatment (every 11 weeks vs every 9.5 weeks, respectively, p: 0.02). CONCLUSION Colchicine seems to be an effective and safe treatment modality in PFAPA treatment. It led to a change in the nature of the attacks either in the frequency, duration, or severity of the attacks in 95.1% of the patients. This study has shown that having MEFV gene sequence variants did not affect the clinical course or response to colchicine. We recommend that colchicine should be considered in all PFAPA patients to see the response of the patient, irrespective of the MEFV gene mutations. WHAT IS KNOWN • Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is the most common periodic fever syndrome in the world. Familial Mediterranean fever (FMF) is the most common cause of periodic fever syndrome in Turkey. • Colchicine has become a new treatment option in PFAPA. WHAT IS NEW • Some PFAPA patients have Mediterranean fever (MEFV) gene variants, and it is speculated that PFAPA patients with MEFV gene mutations respond better to colchicine. • The aim of this study was to look for this hypothesis. We have seen that the clinical phenotype and colchicine response of PFAPA patients were not affected by MEFV gene sequence variants.
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Affiliation(s)
- Gülçin Otar Yener
- Department of Pediatric Rheumatology, Şanlıurfa Training and Research Hospital, Yenice Mah Yenice Yolu No:1 Eyyubiye, 63300, Şanlıurfa, Turkey.
| | - İlke Aktaş
- Department of Pediatric Rheumatology, Zeynep Kamil Women and Children’s Diseases Training and Research Hospital, Üsküdar 34668 Istanbul, Turkey
| | - Ceren Altıntaş Meşe
- Department of Pediatric Rheumatology, Zeynep Kamil Women and Children’s Diseases Training and Research Hospital, Üsküdar 34668 Istanbul, Turkey
| | - Mustafa Çakan
- Department of Pediatric Rheumatology, Zeynep Kamil Women and Children’s Diseases Training and Research Hospital, Üsküdar 34668 Istanbul, Turkey
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Raeeskarami SR, Sadeghi P, Vahedi M, Asna Ashari K, Mousavi T. M, Ziaee V. Colchicine versus cimetidine: the better choice for Periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome prophylaxis, and the role of MEFV gene mutations. Pediatr Rheumatol Online J 2022; 20:72. [PMID: 36045426 PMCID: PMC9428878 DOI: 10.1186/s12969-022-00733-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/17/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND During childhood, the most common periodic fever is periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. The effective treatment and prevention of febrile attacks improve these patients' and their families' quality of life. However, there is no single strategy or evidence-based guideline to manage this syndrome, and most of them are based on consensus treatment plans. METHODS This randomized controlled trial was carried out on 67 PFAPA patients referred to three tertiary centers of pediatric rheumatology. The patients were divided into two groups, including group 1 (n = 36) receiving prednisolone plus colchicine and group 2 (n = 31) receiving prednisolone plus cimetidine. Demographic characteristics and the number of febrile episodes were compared between the two groups before and after the intervention. RESULTS In both groups, the number of febrile episodes after the treatment decreased (P ≤ 0.001). Statistical Analysis showed no significant difference between the two groups (P = 0.88). Moreover, 44 patients from both groups were checked for the MEFV gene. There were no statistical differences between MEFV positive and negative subgroups in response to colchicine (P = 1). CONCLUSION This study showed that both drug regimens are significantly effective in preventing febrile attacks in PFAPA syndrome, and the presence of a MEFV gene mutation might not be the only significant risk factor for a response to colchicine. TRIAL REGISTRATION IRCT, IRCT20191222045847N1. Registered 23 October 2019, https://fa.irct.ir/search/result?query=IRCT20191222045847N1.
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Affiliation(s)
- Seyed Reza Raeeskarami
- grid.414574.70000 0004 0369 3463Department Of Pediatrics, Imam Khomeini Hospital Complex, Tehran University Of Medical Sciences, Tehran, Iran ,grid.411705.60000 0001 0166 0922Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
| | - Payman Sadeghi
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran. .,Children's Medical Center, Pediatrics Center of Excellence, Tehran, Iran. .,Pediatric Rheumatology Research Group, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mahdieh Vahedi
- Clinical Research Development Unit of Akbar Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. .,Department of Pediatrics, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Kosar Asna Ashari
- grid.411705.60000 0001 0166 0922Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran ,grid.414206.5Children’s Medical Center, Pediatrics Center of Excellence, Tehran, Iran
| | - Mahdieh Mousavi T.
- grid.411705.60000 0001 0166 0922Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran ,Bahrami Children’s Hospital, Tehran, Iran
| | - Vahid Ziaee
- grid.411705.60000 0001 0166 0922Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran ,grid.414206.5Children’s Medical Center, Pediatrics Center of Excellence, Tehran, Iran ,grid.411705.60000 0001 0166 0922Pediatric Rheumatology Research Group, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Dastoli S, Nisticò SP, Morrone P, Patruno C, Leo A, Citraro R, Gallelli L, Russo E, De Sarro G, Bennardo L. Colchicine in Managing Skin Conditions: A Systematic Review. Pharmaceutics 2022; 14:pharmaceutics14020294. [PMID: 35214027 PMCID: PMC8878049 DOI: 10.3390/pharmaceutics14020294] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 12/13/2022] Open
Abstract
(1) Background: Colchicine is a natural alkaloid with anti-inflammatory properties used to treat various disorders, including some skin diseases. This paper aims to incorporate all the available studies proposing colchicine as a treatment alternative in the management of cutaneous conditions. (2) Methods: In this systematic review, the available articles present in various databases (PubMed, Scopus-Embase, and Web of Science), proposing colchicine as a treatment for cutaneous pathological conditions, have been selected. Exclusion criteria included a non-English language and non-human studies. (3) Results: Ninety-six studies were included. Most of them were case reports and case series studies describing colchicine as single therapy, or in combination with other drugs. Hidradenitis suppurativa, pyoderma gangrenosum, erythema nodosum, erythema induratum, storage diseases, perforating dermatosis, bullous diseases, psoriasis, vasculitis, acne, urticaria, stomatitis, actinic keratosis, and pustular dermatosis were the main diseases discussed in literature. Although the therapeutic outcomes were variable, most of the studies reported, on average, good clinical results (4) Conclusions: Colchicine could be, as a single therapy or in combination with other drugs, a possible treatment to manage several skin diseases.
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Affiliation(s)
- Stefano Dastoli
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (S.D.); (S.P.N.); (C.P.); (A.L.); (R.C.); (L.G.); (E.R.); (G.D.S.)
| | - Steven Paul Nisticò
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (S.D.); (S.P.N.); (C.P.); (A.L.); (R.C.); (L.G.); (E.R.); (G.D.S.)
| | | | - Cataldo Patruno
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (S.D.); (S.P.N.); (C.P.); (A.L.); (R.C.); (L.G.); (E.R.); (G.D.S.)
| | - Antonio Leo
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (S.D.); (S.P.N.); (C.P.); (A.L.); (R.C.); (L.G.); (E.R.); (G.D.S.)
| | - Rita Citraro
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (S.D.); (S.P.N.); (C.P.); (A.L.); (R.C.); (L.G.); (E.R.); (G.D.S.)
| | - Luca Gallelli
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (S.D.); (S.P.N.); (C.P.); (A.L.); (R.C.); (L.G.); (E.R.); (G.D.S.)
| | - Emilio Russo
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (S.D.); (S.P.N.); (C.P.); (A.L.); (R.C.); (L.G.); (E.R.); (G.D.S.)
| | - Giovambattista De Sarro
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (S.D.); (S.P.N.); (C.P.); (A.L.); (R.C.); (L.G.); (E.R.); (G.D.S.)
| | - Luigi Bennardo
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (S.D.); (S.P.N.); (C.P.); (A.L.); (R.C.); (L.G.); (E.R.); (G.D.S.)
- Azienda Ospedaliera di Cosenza, 87100 Cosenza, Italy;
- Correspondence: ; Tel.: +39-09-613627195
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12
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Ohnishi T, Sato S, Uejima Y, Kawano Y, Suganuma E. Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome: Clinical characteristics and treatment outcomes - a single center study in Japan. Pediatr Int 2022; 64:e15294. [PMID: 36134651 DOI: 10.1111/ped.15294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 06/27/2022] [Accepted: 07/07/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is an autoinflammatory disease occurring in children. Although PFAPA is the most common periodic fever syndrome found in children, there are only a few studies defining the clinical characteristics and the efficacy of treatment strategies among Japanese children. This study aimed to clarify the demographic characteristics and clinical features of patients with PFAPA syndrome and to evaluate treatment efficacy. METHODS We retrospectively reviewed the clinical features of children with PFAPA who visited Saitama Children's Medical Center between January and December 2019. We also evaluated treatment strategies and their efficacy; abortive treatment with corticosteroids, prophylaxis with cimetidine or colchicine, and surgical management with tonsillectomy. RESULTS A total of 100 Japanese children (61% male) with PFAPA were included. Median age of onset was 3 years, median duration of fever episodes was 5 days, and median interval between episodes was 4 weeks. The symptoms (frequencies) were pharyngitis (89%), exudate on tonsils (71%), cervical adenitis (50%), and aphthous stomatitis (49%). Approximately 37% of patients took prednisolone for aborting fever attacks, showing a 100% response; 93% were treated with cimetidine, showing an 79.6% response, and 18% were treated with colchicine, showing a 66.7% response. Only one patient underwent tonsillectomy. CONCLUSIONS Among Japanese children with PFAPA, 28% of them were ≥5 years with a male predominance. Pharyngitis is the most frequent symptom associated with fever. Cimetidine is suitable for initial therapy because of its safety and efficacy.
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Affiliation(s)
- Takuma Ohnishi
- Division of Infectious Diseases and Immunology, Saitama Children's Medical Center, Saitama, Japan
| | - Satoshi Sato
- Division of Infectious Diseases and Immunology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoji Uejima
- Division of Infectious Diseases and Immunology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Kawano
- Division of Infectious Diseases and Immunology, Saitama Children's Medical Center, Saitama, Japan
| | - Eisuke Suganuma
- Division of Infectious Diseases and Immunology, Saitama Children's Medical Center, Saitama, Japan
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Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome: A review. World J Otorhinolaryngol Head Neck Surg 2021; 7:166-173. [PMID: 34430824 PMCID: PMC8356195 DOI: 10.1016/j.wjorl.2021.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/20/2021] [Indexed: 01/13/2023] Open
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is the most common periodic fever condition in children, with most cases appearing by the age of 5. Although PFAPA is generally a self-limited condition, it can have a major impact on a child's quality of life, as well as that of their family. Recent research has continued to shed light on the genetic and immunologic factors that play a role in the pathogenesis of PFAPA. There also exists significant heterogeneity in treatment strategies, and progress has been made to develop evidence-based management strategies and establish a standard of care. This review will outline current knowledge regarding the pathogenesis of PFAPA, as well as treatment strategies and our clinical experience.
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Boyadzhieva Z, Ruffer N, Krusche M. [Colchicine: old medication with new benefits : Use in rheumatology and beyond]. Z Rheumatol 2021; 80:647-657. [PMID: 34097101 PMCID: PMC8181537 DOI: 10.1007/s00393-021-01017-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2021] [Indexed: 12/22/2022]
Abstract
Colchicin, das Gift der Herbstzeitlosen, hat verschiedene antiinflammatorische Effekte. Aus diesem Grund kommt es zur Behandlung von rheumatologischen Erkrankungen aus dem autoinflammatorischen Formenkreis, wie z. B. der Arthritis urica oder dem familiären Mittelmeerfieber (FMF), zum Einsatz. Darüber hinaus gibt es erste Daten, die einen positiven Nutzen von Colchicin bei kardiovaskulären Erkrankungen nahelegen. Des Weiteren werden aktuell verschiedene antiinflammatorische Therapieansätze in der COVID-19-Behandlung in Studien erprobt. Hier gibt es ebenfalls erste Publikationen, die einen potenziellen Nutzen von Colchicin in bestimmten Krankheitsphasen der Virusinfektion nahe legen. Dieser Beitrag will einen Überblick über die Wirkweise, den Nutzen und Nebenwirkungen sowie die verschiedenen Einsatzmöglichkeiten von Colchicin in der Rheumatologie geben. Weiterhin soll ein kurzer Ausblick in neue Einsatzgebiete dieses Medikamentes gegeben werden.
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Affiliation(s)
- Z Boyadzhieva
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité Universitätsmedizin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - N Ruffer
- Abteilung für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - M Krusche
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité Universitätsmedizin, Charitéplatz 1, 10117, Berlin, Deutschland.
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15
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The role of Mediterranean fever gene variants in patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. Eur J Pediatr 2021; 180:1051-1058. [PMID: 33051715 DOI: 10.1007/s00431-020-03840-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/27/2020] [Accepted: 10/09/2020] [Indexed: 01/14/2023]
Abstract
This study was conducted to investigate the relationship between clinic features and Mediterranean fever gene (MEFV) variants in patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome. In total, 167 patients with PFAPA syndrome were included in the study. Female:male ratio of the patients was 0.75 (72 females, 95 males). In total 59.9% of patients with PFAPA had at least one MEFV variant and the most common heterozygous variants were M694V in 29.3% of the patients (40/167), E148Q in 8.3% (14/167), and V726A in 7.1% (12/167). The median age at the disease onset was significantly higher and the median duration of the episodes was significantly lower in patient with variants in exon 10 comparing to the others (both p = 0.01). Similarly, the median age at the disease onset was significantly higher (p = 0.01) and the median duration of the episodes was significantly lower (p = 0.04) in patient with MEFV variants than in the remaining patients. There were no significant differences according to the genotypes of the patients in terms of both treatment response and the frequency of clinical findings.Conclusion: In PFAPA syndrome, MEFV variants may be a modifier for disease onset and attack duration. What is Known: • Due to periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome having clinical findings resembling familial Mediterranean fever (FMF), it can be difficult to distinguish PFAPA syndrome and FMF especially in endemic regions for FMF. • Underlying MEFV mutations could affect the periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome's clinical presentation and response to treatment. What is New: • Having one of the underlying MEFV variants is related to later disease onset and shorter episode duration in patients with PFAPA syndrome.
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16
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Quintana-Ortega C, Seoane-Reula E, Fernández L, Camacho M, Olbrich P, Neth O, Murias S, Udaondo C, Remesal A, Calvo C, Alcobendas R. Colchicine treatment in children with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome: A multicenter study in Spain. Eur J Rheumatol 2021; 8:73-78. [PMID: 32966191 PMCID: PMC8133885 DOI: 10.5152/eurjrheum.2020.20102] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/22/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of colchicine therapy in pediatric patients with PFAPA syndrome who present with an incomplete response to the standard treatment or with frequent episodes (an interval of less than 14 days between two disease flares). METHODS A multicenter cohort study of children diagnosed with PFAPA syndrome and treated with colchicine was performed in three separate hospitals located in Spain. The patients clinical and laboratory data were reviewed by accessing their medical records. Response to colchicine was evaluated after 12 months of treatment for frequency, duration, and intensity of PFAPA episodes. RESULTS A total of 13 children were included in our study, 43% of whom were boys. Median age of the colchicine therapy initiation was 6 years (interquartile range (IQR)=3-9.5). Following a 12-month period of colchicine therapy (median dosage of 0.02 mg/kg/day; IQR=0.02-0.03), a significant decrease in the median number of flares (median 8; IQR=7-14 vs 3; IQR=2-4; p=0.005) and the duration of disease episodes (median 4 days; IQR=3.25-5.125 vs 1 day; IQR=1-2; p=0.003) was observed. Furthermore, the highest degree of fever during disease flares was reduced from median 40ºC (IQR=39.5-40) to 38.5ºC (IQR=37.7-38.9) (p=0.002). CONCLUSION Colchicine therapy decreased the frequency and intensity of PFAPA. The use of colchicine could be an effective treatment in pediatric patients with PFAPA syndrome who present with frequent or severe relapses.
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Affiliation(s)
- Cristian Quintana-Ortega
- Department of Pediatric Rheumatology, La Paz Children’s Hospital, Madrid, Spain
- Department of Pediatric Infectious Diseases and Tropical Medicine, La Paz Children’s Hospital, Madrid, Spain
| | - Elena Seoane-Reula
- Department of Pediatric Allergy and Immunology, Gregorio Marañón Children’s Hospital, Madrid, Spain
| | - Laura Fernández
- Division of Pediatric Infectious Diseases, Department of Rheumatology and Inmunology, Virgen del Rocío Children’s Hospital, Sevilla, Spain
| | - Marisol Camacho
- Division of Pediatric Infectious Diseases, Department of Rheumatology and Inmunology, Virgen del Rocío Children’s Hospital, Sevilla, Spain
| | - Peter Olbrich
- Division of Pediatric Infectious Diseases, Department of Rheumatology and Inmunology, Virgen del Rocío Children’s Hospital, Sevilla, Spain
| | - Olaf Neth
- Division of Pediatric Infectious Diseases, Department of Rheumatology and Inmunology, Virgen del Rocío Children’s Hospital, Sevilla, Spain
| | - Sara Murias
- Department of Pediatric Rheumatology, La Paz Children’s Hospital, Madrid, Spain
| | - Clara Udaondo
- Department of Pediatric Rheumatology, La Paz Children’s Hospital, Madrid, Spain
| | - Agustín Remesal
- Department of Pediatric Rheumatology, La Paz Children’s Hospital, Madrid, Spain
| | - Cristina Calvo
- Department of Pediatric Infectious Diseases and Tropical Medicine, La Paz Children’s Hospital, Madrid, Spain
| | - Rosa Alcobendas
- Department of Pediatric Rheumatology, La Paz Children’s Hospital, Madrid, Spain
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Welzel T, Ellinghaus M, Wildermuth AL, Deschner N, Benseler SM, Kuemmerle-Deschner JB. Colchicine Effectiveness and Safety in Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis. Front Pediatr 2021; 9:759664. [PMID: 34900867 PMCID: PMC8655689 DOI: 10.3389/fped.2021.759664] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/12/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) is the most common fever syndrome in childhood. High disease activity (DA) dramatically impacts the health-related quality of life. Thus, effective and safe treatment is crucial. Colchicine might be effective, but data are still lacking. Study aimed to assess colchicine safety and effectiveness in PFAPA. Methods: This single center study was conducted between 03/2012 and 05/2021 in PFAPA patients without variants in genetic panel testing aged ≤ 18 years fulfilling Marshall criteria and classification criteria of Gattorno et al. Exclusion criteria were elevated liver enzymes, impaired kidney function, celiac disease, lactose intolerance, previous/ongoing biologics, known colchicine-intolerance. Demographics, clinical characteristics, treatment, DA, colchicine effectiveness and safety were recorded at baseline, first and last visit. Colchicine was started at 0.5-1.0 mg/day. DA was captured by physician (PGA) and patient/parent (PPGA) global assessment on a 10 cm visual analog scale, categorized as mild (<2), moderate (2-4), and high (≥5). Adverse event (AE) monitoring included gastrointestinal symptoms, liver enzyme/creatinine elevation, leukopenia, neutropenia. Primary outcome included response (R; composite of PPGA + PGA decrease ≥2) at last follow-up. Secondary outcomes were partial response (PR; PGA decrease = 1 + PPGA decrease ≥1), no response (NR; unchanged/worsened PGA/PPGA), colchicine safety, flare characteristics. Results: Twenty-seven PFAPA patients were included, 52% were female, median age was 5.8 years (1-10.75), median follow-up time was 13 months. At baseline, median PPGA was high; median PGA moderate. All patients had febrile flares. Median flare frequency was every 4-5 weeks; median duration 5-6 days. Nine patients were pre-treated with corticosteroids, increasing flare frequency in 8/9. Primary Outcome: 17 patients (63%) were responders. Secondary outcomes: PR was achieved in 15%; NR in 22% at last follow-up. DA decreased significantly (p <0.0001). At last follow-up, 52% reported no flares, median flare duration decreased to 1-2 days. At first follow-up, 22% reported mild abdominal pain/diarrhea. Moderate abdominal pain/diarrhea occurred with ≥1 mg/day. Mild asymptomatic liver enzyme elevation or leucopenia were rare; no severe AE or colchicine discontinuation were observed. Conclusion: Colchicine seems to be safe, well-tolerated, and effective in PFAPA patients. It can be considered in children with moderate/high DA even those without corticosteroid-benefit.
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Affiliation(s)
- Tatjana Welzel
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Maren Ellinghaus
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Anna L Wildermuth
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Norbert Deschner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Susanne M Benseler
- Rheumatology, Department of Paediatrics, Alberta Children's Hospital, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Jasmin B Kuemmerle-Deschner
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
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Yildiz M, Haslak F, Adrovic A, Gucuyener N, Ulkersoy I, Koker O, Sahin S, Unlu G, Barut K, Kasapcopur O. Independent risk factors for resolution of periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome within 4 years after the disease onset. Clin Rheumatol 2020; 40:1959-1965. [PMID: 33067771 DOI: 10.1007/s10067-020-05466-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND/OBJECTIVE Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is a polygenic disease with unknown etiology. In this retrospective cohort study, we aimed to evaluate the risk factors for the resolution of PFAPA syndrome within 4 years after the onset. METHODS In total, 466 patients with PFAPA syndrome that are being followed up our department were included into the study. Between May 2020 and September 2020, medical charts of the patients were reviewed retrospectively. RESULTS The median age of the patients at the time of the study and at disease onset were 8.6 (2.9-20.5; IQR 6.9-10.6) years and 18 (1-84; IQR 11-31) months. On univariate analysis age at disease onset (p = 0.003), positive family history of PFAPA syndrome (p = 0.04), absence of myalgia (p = 0.04), and absence of headache (p = 0.003) were all associated with the resolution of PFAPA syndrome within 4 years after the onset. Multivariate logistic regression analysis revealed that age at disease onset (OR 1.04, 95% CI 1.01-1.07, p = 0.002), positive family history of PFAPA syndrome (OR 2.69, 95% CI 1.12-6.48, p = 0.02), and absence of headache (OR 0.2, 95% CI 0.05-0.74, p = 0.01) were independent risk factors for the resolution of PFAPA syndrome within 4 years after the onset. CONCLUSION We report later age of disease onset, positive family history of PFAPA syndrome, and absence of headache as independent risk factors for resolution of PFAPA syndrome within 4 years after the onset. KEY POINTS • Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is a multifactorial disease with unknown etiology. • Although, PFAPA syndrome usually resolves within 3-5 years after the disease onset, it can persist for years and even continue into adulthood. With our current knowledge, there is no clue to predict which patients will have a long disease course and which patients will not. • Later age of disease onset, positive family history of PFAPA syndrome and absence of headache as independent risk factors for resolution of PFAPA syndrome within 4 years after the onset.
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Affiliation(s)
- Mehmet Yildiz
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Fatih Haslak
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Neslihan Gucuyener
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ipek Ulkersoy
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Oya Koker
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Gulcin Unlu
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey.
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Soriano A, Soriano M, Espinosa G, Manna R, Emmi G, Cantarini L, Hernández-Rodríguez J. Current Therapeutic Options for the Main Monogenic Autoinflammatory Diseases and PFAPA Syndrome: Evidence-Based Approach and Proposal of a Practical Guide. Front Immunol 2020; 11:865. [PMID: 32655539 PMCID: PMC7325944 DOI: 10.3389/fimmu.2020.00865] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
Monogenic autoinflammatory diseases are rare conditions caused by genetic abnormalities affecting the innate immunity. Previous therapeutic strategies had been mainly based on results from retrospective studies and physicians' experience. However, during the last years, the significant improvement in their genetic and pathogenic knowledge has been accompanied by a remarkable progress in their management. The relatively recent identification of the inflammasome as the crucial pathogenic mechanism causing an aberrant production of interleukin 1β (IL-1β) in the most frequent monogenic autoinflammatory diseases led to the introduction of anti-IL-1 agents and other biologic drugs as part of the previously limited therapeutic armamentarium available. Advances in the treatment of autoinflammatory diseases have been favored by the use of new biologic agents and the performance of a notable number of randomized clinical trials exploring the efficacy and safety of these agents. Clinical trials have contributed to increase the level of evidence and provided more robust therapeutic recommendations. This review analyzes the treatment of the most frequent monogenic autoinflammatory diseases, namely, familial Mediterranean fever, tumor necrosis factor receptor-associated periodic fever syndrome, hyperimmunoglobulin D syndrome/mevalonate kinase deficiency, and cryopyrin-associated periodic syndromes, together with periodic fever with aphthous stomatitis, pharyngitis, and cervical adenitis syndrome, which is the most common polygenic autoinflammatory disease in children, also occurring in adult patients. Finally, based on the available expert consensus recommendations and the highest level of evidence of the published studies, a practical evidence-based guideline for the treatment of these autoinflammatory diseases is proposed.
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Affiliation(s)
- Alessandra Soriano
- Division of Internal Medicine, Department of Internal Medicine and Medical Specialties, Arcispedale S. Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Marco Soriano
- School of Medicine, Luigi Vanvitelli University, Naples, Italy
| | - Gerard Espinosa
- Clinical Unit of Autoinflammatory Diseases and Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Raffaele Manna
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Periodic Fevers Research Centre, Institute of Internal Medicine, Università Cattolica Sacro Cuore, Rome, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease, Rheumatology Unit of the Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - José Hernández-Rodríguez
- Clinical Unit of Autoinflammatory Diseases and Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Why and How Should We Treat Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis (PFAPA) Syndrome? Paediatr Drugs 2020; 22:243-250. [PMID: 32342289 DOI: 10.1007/s40272-020-00393-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is characterized by recurrent fever flares accompanied by symptoms and signs forming the disease acronym and alternating with asymptomatic periods. Despite the disease having a generally favorable outcome, with spontaneous remission after a few years, it does have a major impact on the quality of life of the child and his or her relatives. Beside symptomatic medications during fever flares, the most used treatment consists of a single dose of corticosteroids at flare onset to interrupt the attack; fever resolves usually within a few hours, but often with a shorter interval between the attacks. For these patients, colchicine has been shown to decrease the frequency of the flares. Other medications were also reported in case series of patients with PFAPA syndrome. These include the interleukin-1 blocker anakinra to treat flares, cimetidine (which showed no convincing effect), and other drugs with anecdotal use. The pediatrician faces a difficult question: should they wait for spontaneous disease resolution and only treat the flares medically, or should they propose tonsillectomy that may induce remission? Due to the lack of strong evidence, the answer will vary on an individual basis, depending on the impact on the patient's quality of life. The choice of the best therapeutic strategy will be based on the response to the flare-based therapy and on disease severity (quality of life, school performances); long-term data on the remission rate under the different therapeutic strategies are currently missing. More randomized controlled studies are needed to help the treating physician to choose the best therapy, as well as real-life long-term data to evaluate the long-term outcome of children with PFAPA syndrome.
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Alekberova ZS, Nasonov EL. PROSPECTS FOR USING COLCHICINE IN MEDICINE: NEW EVIDENCE. RHEUMATOLOGY SCIENCE AND PRACTICE 2020. [DOI: 10.14412/1995-4484-2020-183-190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | - E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology;
I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
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22
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Amarilyo G, Rothman D, Manthiram K, Edwards KM, Li SC, Marshall GS, Yildirim-Toruner C, Haines K, Ferguson PJ, Lionetti G, Cherian J, Zhao Y, DeLaMora P, Syverson G, Nativ S, Twilt M, Michelow IC, Stepanovskiy Y, Thatayatikom A, Harel L, Akoghlanian S, Tucker L, Marques MC, Srinivasalu H, Propst EJ, Licameli GR, Dedeoglu F, Lapidus S. Consensus treatment plans for periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA): a framework to evaluate treatment responses from the childhood arthritis and rheumatology research alliance (CARRA) PFAPA work group. Pediatr Rheumatol Online J 2020; 18:31. [PMID: 32293478 PMCID: PMC7157990 DOI: 10.1186/s12969-020-00424-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/03/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children. There is considerable heterogeneity in management strategies and a lack of evidence-based treatment guidelines. Consensus treatment plans (CTPs) are standardized treatment regimens that are derived based upon best available evidence and current treatment practices that are a way to enable comparative effectiveness studies to identify optimal therapy and are less costly to execute than randomized, double blind placebo controlled trials. The purpose of this project was to develop CTPs and response criteria for PFAPA. METHODS The CARRA PFAPA Working Group is composed of pediatric rheumatologists, infectious disease specialists, allergists/immunologists and otolaryngologists. An extensive literature review was conducted followed by a survey to assess physician practice patterns. This was followed by virtual and in-person meetings between 2014 and 2018. Nominal group technique (NGT) was employed to develop CTPs, as well as inclusion criteria for entry into future treatment studies, and response criteria. Consensus required 80% agreement. RESULTS The PFAPA working group developed CTPs resulting in 4 different treatment arms: 1. Antipyretic, 2. Abortive (corticosteroids), 3. Prophylaxis (colchicine or cimetidine) and 4. Surgical (tonsillectomy). Consensus was obtained among CARRA members for those defining patient characteristics who qualify for participation in the CTP PFAPA study. CONCLUSION The goal is for the CTPs developed by our group to lead to future comparative effectiveness studies that will generate evidence-driven therapeutic guidelines for this periodic inflammatory disease.
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Affiliation(s)
- Gil Amarilyo
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | - Kalpana Manthiram
- grid.280128.10000 0001 2233 9230National Human Genome Research Institute, National Institutes of Health, Bethesda, MD USA
| | - Kathryn M. Edwards
- grid.152326.10000 0001 2264 7217Vanderbilt University School of Medicine, Nashville, TN USA
| | - Suzanne C. Li
- Joseph M Sanzari Children’s Hospital, Hackensack Meridian Health, Hackensack, NJ USA
| | - Gary S. Marshall
- grid.266623.50000 0001 2113 1622Department of Pediatrics, University of Louisville, Louisville, KY USA
| | | | - Kathleen Haines
- Joseph M Sanzari Children’s Hospital, Hackensack Meridian Health, Hackensack, NJ USA
| | - Polly J. Ferguson
- grid.214572.70000 0004 1936 8294Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA USA
| | - Geraldina Lionetti
- grid.414016.60000 0004 0433 7727UCSF Benioff Children’s Hospital Oakland, Oakland, CA USA
| | - Julie Cherian
- grid.412695.d0000 0004 0437 5731Stony Brook University Hospital, Stony Brook, NY USA
| | - Yongdong Zhao
- grid.34477.330000000122986657Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - Patricia DeLaMora
- grid.5386.8000000041936877XWeill Cornell Medical College, New York, NY USA
| | - Grant Syverson
- grid.30760.320000 0001 2111 8460Medical College of Wisconsin, Wauwatosa, WI USA
| | - Simona Nativ
- grid.429583.1Goryeb Children’s Hospital, Morristown, NJ USA
| | - Marinka Twilt
- grid.22072.350000 0004 1936 7697Rheumatology, Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta Canada
| | - Ian C. Michelow
- grid.40263.330000 0004 1936 9094Alpert Medical School of Brown University, Providence, RI USA
| | - Yuriy Stepanovskiy
- grid.415616.10000 0004 0399 7926Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
| | - Akaluck Thatayatikom
- grid.15276.370000 0004 1936 8091Department of Pediatrics, University of Florida, Gainesville, FL USA
| | - Liora Harel
- grid.12136.370000 0004 1937 0546Pediatric Rheumatology Unit, Schneider Children’s Medical Center of Israel, Petach Tikva; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shoghik Akoghlanian
- grid.240344.50000 0004 0392 3476Nationwide Children’s Hospital, Columbus, OH USA
| | - Lori Tucker
- grid.414137.40000 0001 0684 7788BC Children’s Hospital, Vancouver, BC Canada
| | - Mariana Correia Marques
- grid.38142.3c000000041936754XBoston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Hemalatha Srinivasalu
- grid.239560.b0000 0004 0482 1586Children’s National Medical Center, Washington, DC USA
| | - Evan J. Propst
- grid.17063.330000 0001 2157 2938Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - Greg R. Licameli
- grid.38142.3c000000041936754XBoston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Fatma Dedeoglu
- grid.38142.3c000000041936754XBoston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Sivia Lapidus
- Joseph M Sanzari Children’s Hospital, Hackensack Meridian Health, Hackensack, NJ USA
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Long-term management of patients with PFAPA syndrome. Eur Arch Otorhinolaryngol 2020; 277:2335-2339. [PMID: 32239314 DOI: 10.1007/s00405-020-05943-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the long-term treatment results of patients with PFAPA syndrome and to determine their need for tonsillectomy. MATERIALS AND METHODS The clinical characteristics, treatments and long-term results of 16 patients admitted to the Pediatric and Otorhinolaryngology Clinic between 2015 and 2019 were retrospectively analyzed. RESULTS Twelve male and four female patients were examined between 1.5 and 8 years (mean age 4.8 ± 1.1) (75% male, 25% female). The mean duration of attacks was 4.4 ± 1.4 weeks. Twelve patients recovered completely with single-dose steroid therapy. In the 4-year follow-up of 12 patients who were given a single dose of steroid therapy, there were no relapses. Surgical decisions were made for four patients whose attacks did not pass with steroid treatment. Two patients (75%) underwent adenotonsillectomy, and one patient underwent tonsillectomy While three of these patients did not have an attack again, one patient continued to have an attack every 8 weeks. At the age of 9, his attacks were completely resolved spontaneously. All patients had fever. The most common concomitant symptoms were pharyngitis (94%), cervical adenitis (82%) and aphthous stomatitis (77%). Exudative tonsillitis was present in 25% of the patients. CONCLUSION Medical treatment should be the first treatment option in patients with PFAPA syndrome. Although single-dose steroid treatment is effective in these patients, tonsillectomy is an important treatment option in refractory cases.
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Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome persisting to adulthood - an example of a diagnostic and therapeutic challenge. Reumatologia 2019; 57:292-296. [PMID: 31844343 PMCID: PMC6911254 DOI: 10.5114/reum.2019.89523] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/25/2019] [Indexed: 11/24/2022] Open
Abstract
Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is the most common cause of periodic fever in childhood. Reports of adult patients are sparse. In adults the clinical picture is more heterogeneous than in children, so PFAPA can be a real diagnostic challenge. Data regarding treatment efficacy and disease outcome are available mainly for children, whereas for adult patients they are limited and conflicting. Our aim is to increase the awareness about PFAPA among clinical practitioners. We present a case of PFAPA beginning in childhood and without resolution of symptoms in maturity. In our case the diagnostic delay was 15 years. We treated the patient with a prophylactic dose of colchicine. Colchicine helped to control flares and significantly improved the patient’s quality of life. Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis in adults is a rare disease, but it should be included in the differential diagnosis of fever of unknown origin in adults.
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Soylu A, Yıldız G, Torun Bayram M, Kavukçu S. IL-1β blockade in periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome: case-based review. Rheumatol Int 2019; 41:183-188. [PMID: 31324971 DOI: 10.1007/s00296-019-04389-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/17/2019] [Indexed: 02/05/2023]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome and familial Mediterranean fever (FMF) are considered as inflammasome disorders associated with uncontrolled interleukin (IL)-1β production. Anti-IL1 agents are used in colchicine-resistant cases of FMF. Increase in pro-inflammatory mediators even between febrile attacks in PFAPA suggests that anti-IL1 treatment might be beneficial in these patients. We describe a child presenting with recurrent, self-limited febrile attacks at 1 year of age who was diagnosed as FMF being heterozygous for M694 V mutation. Her clinical findings were only controlled by the addition of canakinumab (2 mg/kg/8 week) to colchicine treatment. However, she developed typical PFAPA attacks during this treatment at 3 years of age. We conducted a literature search focusing on English articles with keywords including PFAPA, anakinra, canakinumab, and rilonacept. Five children and one adult patient with PFAPA were found and evaluated. Anakinra was reported to abort PFAPA attacks in children, while the adult patient first responded and then became resistant to anakinra. Canakinumab was effective in preventing febrile attacks in this patient. Failure of canakinumab to prevent PFAPA attacks in our case may arise from the differences in the pathophysiology of PFAPA and FMF. Thus, further experience with higher doses or shorter intervals of canakinumab is needed in children with PFAPA.
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Affiliation(s)
- Alper Soylu
- Department of Pediatric Nephrology and Rheumatology, Medical Faculty, Dokuz Eylül University, Izmir, Turkey.
- Department of Pediatric Nephrology, Medical Faculty, Dokuz Eylül University, Izmir, Turkey.
| | - Gizem Yıldız
- Department of Pediatric Nephrology, Medical Faculty, Dokuz Eylül University, Izmir, Turkey
| | - Meral Torun Bayram
- Department of Pediatric Nephrology, Medical Faculty, Dokuz Eylül University, Izmir, Turkey
| | - Salih Kavukçu
- Department of Pediatric Nephrology and Rheumatology, Medical Faculty, Dokuz Eylül University, Izmir, Turkey
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Familial Mediterranean Fever: Assessing the Overall Clinical Impact and Formulating Treatment Plans. Mediterr J Hematol Infect Dis 2019; 11:e2019027. [PMID: 31205631 PMCID: PMC6548206 DOI: 10.4084/mjhid.2019.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/07/2019] [Indexed: 12/24/2022] Open
Abstract
Recurrent self-limited attacks of fever and short-lived inflammation in the serosal membranes, joints, and skin are the leading features of familial Mediterranean fever (FMF), the most common autoinflammatory disorder in the world, transmitted as autosomal recessive trait caused by MEFV gene mutations. Their consequence is an abnormal function of pyrin, a natural repressor of inflammation, apoptosis, and release of cytokines. FMF-related mutant pyrins are hypophosphorylated following RhoA GTPases’ impaired activity and show a propensity to relapsing uncontrolled systemic inflammation with inappropriate response to inflammatory stimuli and leukocyte spread to serosal membranes, joints or skin. Typical FMF phenotype 1 consists of brief episodes of inflammation and serositis, synovitis, and/or erysipelas-like eruption, whereas phenotype 2 is defined by reactive amyloid-associated (AA) amyloidosis, which is the most ominous complication of FMF, in otherwise asymptomatic individuals. Furthermore, FMF phenotype 3 is referred to the presence of two MEFV mutations with neither clinical signs of FMF nor AA amyloidosis. The influence of epigenetic and/or environmental factors can contribute to the variable penetrance and phenotypic heterogeneity of FMF. Colchicine, a tricyclic alkaloid with anti-microtubule and anti-inflammatory properties, is the bedrock of FMF management: daily administration of colchicine prevents the recurrence of FMF attacks and the development of secondary AA amyloidosis. Many recent studies have also shown that anti-interleukin-1 treatment is the best therapeutic option for FMF patients nonresponsive or intolerant to colchicine. This review aims to catch readers’ attention to the clinical diversity of phenotypes, differential diagnosis, and management of patients with FMF.
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Recurrence of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome after tonsillectomy: case-based review. Rheumatol Int 2019; 39:1099-1105. [PMID: 31020337 DOI: 10.1007/s00296-019-04310-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/16/2019] [Indexed: 12/24/2022]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is a recurrent fever syndrome for which tonsillectomy is a therapeutic option curing the disease in most patients. Recurrence after remission with tonsillectomy is extremely rare. Increasing number of reports on diverse disease manifestations in PFAPA could give us clues about the disease etiopathogenesis. We aimed to describe a patient with recurrence of PFAPA syndrome after tonsillectomy and to review the previous studies including similar cases. We report a 17-year-old boy with PFAPA syndrome who experienced remission for 3 years after tonsillectomy and was later found to harbor an MEFV mutation when the disease relapsed. He responded well to colchicine treatment at relapse. The literature review revealed 14 articles describing 24 similar PFAPA patients. The therapeutic options include single-dose corticosteroids and nonsteroidal anti-inflammatory drugs during attacks, cimetidine, and resurgery. The presented case was the only one heterozygous for an MEFV mutation and treated with colchicine at disease relapse. Albeit rare, the reoccurrence of PFAPA after tonsillectomy could occur. The presence of such patients opposes with the hypothesis that the trigger or immune dysregulation in PFAPA pathogenesis resides in tonsils.
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Haytoglu Z, Gundeslioglu OO. Mediterranean fever gene variants and colchicine therapy in periodic fever, aphthous stomatitis pharyngitis, adenitis syndrome in a Mediterranean region. Expert Rev Clin Immunol 2019; 15:571-575. [PMID: 30887853 DOI: 10.1080/1744666x.2019.1591275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Periodic fever, aphthous stomatitis, pharyngitis, adenitis syndrome is characterized by recurrent episodes of fever. Attenuated disease severity was considered in patients with Mediterranean fever (MEFV) gene variations. Corticosteroids are highly effective in controlling the symptoms but usually cause more frequent episodes. Frequent fever episodes either initiated after the steroid therapy or as an initial disease characteristics are the most challenging feature. METHODS Sixty-seven patients were prospectively followed from September 2015 to January 2018. MEFV variants were searched in all patients. Colchicine therapy was initiated in patients with MEFV variants and with shortened intervals after the initiation of steroid therapy. RESULTS Heterozygous MEFV gene variants were detected in 23 patients (34.3%). Higher exon 10 allel frequencies were found in patients with frequent fever episodes. Among 26 patients with increased episodes, colchicine treatment decreased the number of the episodes in 8 of 10 (80%) and 4 of 16 (25%) patients with and without variants, respectively (p = 0.022). Fever duration decreased (3.26 ± 1.38 vs. 1.57 ± 0.57 days, p < 0.001) at the third month of therapy in variant(+) patients. CONCLUSION In variant positive patients colchicine prophylaxis reduced the duration of attacks at the third months of therapy. Shortened intervals due to steroid therapy were increased at the sixth months of colchicine therapy.
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Affiliation(s)
- Zeliha Haytoglu
- a Faculty of Medicine, Department of Pediatrics , Cukurova University , Adana , Turkey
| | - Ozlem Ozgur Gundeslioglu
- b Faculty of Medicine, Department of Pediatrics, Division of Pediatric Infectious Disease , Cukurova University , Adana , Turkey
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Bueno LA, Paiva DM, Carvalho PHPD. Síndrome PFAPA: Diagnóstico e Tratamento na Atenção Primária à Saúde. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2019. [DOI: 10.5712/rbmfc14(41)1815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Objetivo: Apresentar informações sobre o diagnóstico e tratamento da síndrome PFAPA na Atenção Primária à Saúde. Métodos: Revisão sistemática de literatura baseada na recomendação PRISMA e realizada nas bases de dados Scielo, Lilacs, Medline, IBECS e PubMed, incluindo estudos publicados no período de 2004 a 2018, além da consulta a outros documentos específicos da síndrome PFAPA. Resultados: Após busca e seleção, foram incluídos 31 artigos. Avaliação e Diagnóstico: A síndrome PFAPA acomete principalmente crianças, sendo caracterizada por febre periódica acompanhada por faringite, estomatite aftosa e/ou adenite cervical. Seu diagnóstico é clínico e por exclusão, baseado em critérios estabelecidos. Recomendações: Os episódios costumam responder a prednisona e, em graus variáveis, a cimetidina e colchicina. Casos refratários e acompanhados de hipertrofia tonsilar são candidatos a tonsilectomia, devendo ser encaminhados à avaliação otorrinolaringológica.
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30
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Batu ED. Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome: main features and an algorithm for clinical practice. Rheumatol Int 2019; 39:957-970. [PMID: 30798384 DOI: 10.1007/s00296-019-04257-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/14/2019] [Indexed: 01/20/2023]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is a recurrent fever syndrome of early childhood with increasing number of adult-onset cases. Although it is a self-limited disease, it may negatively affect the quality of life. The aim of this review is to present a detailed analysis of PFAPA syndrome and an algorithm for diagnosis, therapeutic options, and evaluation of outcome. A comprehensive literature search was conducted through the Cochrane Library, Scopus, and MEDLINE/PubMed databases. The main topics covered are the epidemiology, clinical manifestations, diagnosis, differential diagnosis, etiopathogenesis, genetics, management, disease course and prognosis, disease in adults, unsolved issues, and unmet needs in PFAPA. The diagnosis of PFAPA is mainly based on clinical classification criteria. The most relevant hypothesis for pathogenesis is that dysregulated immune system in a genetically predisposed individual responds to a yet unidentified trigger in an exaggerated way. The pedigree analyses suggest a genetic background for the disease with an autosomal dominant pattern of inheritance. For management, single-dose corticosteroids during attacks and tonsillectomy remain the most effective therapies, while colchicine is a promising option to decrease attack frequency. There remain unsolved issues in PFAPA such as the exact etiopathogenesis and genetic background, the reason why the inflammation is restricted to the oropharyngeal lymphoid tissue, reasons for clock-work regularity of attacks, and self-limited disease course. There is need for a valid diagnostic criteria set with a high performance for both children and adults and consensus on management of PFAPA.
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Affiliation(s)
- Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, Ankara Training and Research Hospital, University of Health Sciences, 06100, Ankara, Turkey.
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31
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Wekell P. Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome - PFAPA syndrome. Presse Med 2019; 48:e77-e87. [PMID: 30683466 DOI: 10.1016/j.lpm.2018.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/07/2018] [Indexed: 01/04/2023] Open
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is a complex autoinflammatory disease with a clinical phenotype characterised by recurrent episodes of fever, systemic inflammation and symptoms and signs depicted in disease acronym. Although PFAPA is the most common autoinflammatory disease among children in many parts of the world, the condition is still an enigma, which include the regular episodes, the prompt responses to corticosteroids, the genetic bases for the familial clustering and therapeutic effects of tonsillectomy. This review explores PFAPA syndrome with the aim of describing the current clinical and scientific understanding of the condition.
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Affiliation(s)
- Per Wekell
- Department of Pediatrics, NU-Hospital Group, 45180 Uddevalla, Sweden; Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Aktas O, Aytuluk HG, Caliskan SK, Erdur O, Cirik AA. Long-term follow-up of tonsillectomy efficacy in children with PFAPA syndrome. Braz J Otorhinolaryngol 2019; 85:78-82. [PMID: 29203159 PMCID: PMC9442901 DOI: 10.1016/j.bjorl.2017.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/22/2017] [Accepted: 10/27/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction The role of tonsillectomy in the periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome, is controversial. Although some studies reported high success rates with tonsillectomy, further investigations are needed with larger numbers of patients. Objective To seek the long-term outcomes of tonsillectomy in periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. Methods Case series; multi-center study. The study comprised 23 patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome who underwent surgery (tonsillectomy with or without adenoidectomy) between January 2009 and November 2014. Results 21 (91%) of 23 patients had complete resolution immediately after surgery. One patient had an attack 24 h after surgery, but has had no further attacks. One patient had three attacks with various intervals, and complete remission was observed after 3 months. Conclusions Tonsillectomy is a good option for the treatment of periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome.
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Gaggiano C, Rigante D, Sota J, Grosso S, Cantarini L. Treatment options for periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome in children and adults: a narrative review. Clin Rheumatol 2018; 38:11-17. [PMID: 30488366 DOI: 10.1007/s10067-018-4361-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/05/2018] [Indexed: 12/20/2022]
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Familial Mediterranean Gene (MEFV) Mutation in Parents of Children with Familial Mediterranean Fever: What Are the Exceptions? Int J Inflam 2018; 2018:1902791. [PMID: 30402217 PMCID: PMC6191955 DOI: 10.1155/2018/1902791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/14/2018] [Indexed: 02/01/2023] Open
Abstract
Objectives Familial Mediterranean Fever (FMF) is one of the most prevalent periodic fever syndromes; MEFV, the responsible gene for the disease, is in the short arm of chromosome16. In the considerable count of the FMF patients, only one mutation is found in the MEFV and parents, who were the obligatory carriers for that mutation, were asymptomatic. The aim of this study was to evaluate these asymptomatic parents in regard to mutation in MEFV gene and similarity between parents and offspring patients. Methods In this cross-sectional study, asymptomatic parents of FMF patients enrolled the study were referred to periodic fever clinic or pediatric rheumatology clinic of Tehran University of Medical Sciences. The patients should have at least one mutation in MEFV gene and none of them had any family history of autoinflammatory disease. Twelve mutations in MEFV gene were assessed in the parents by Vienna Lab FMF Strip Assay kit by MAS PCR/Reverse hybridization. Results Forty-three patients and their parents participated in the study. Sixty-three percent (27) of patients were male. Onset of disease symptoms in 31 patients (72%) was before 4 years of old. Nine (21%) of the patients had homozygote, 16 (37%) compound heterozygote, and 17(40%) heterozygote for MEFV mutation; there was a case of complex alleles mutations (2%). M694V/M694V in 4 patients (9%) was the most homozygote genotype, and M694V/R761H in 4 (9%) and E148Q in 7 (16%) were the most compound heterozygote and heterozygote genotype, respectively. M694V, M680I, and E148Q were the most mutation in the parents. Overall, 41 patients had mutations similar to their parents' mutation, except 2 whose parents had no mutation, but a patient did. Conclusion It seems that occurrence of new mutations in offspring is not prevalent among FMF patients and there are other reasons for different clinical presentation in similar mutation carriers. On the other hand, in ethnicities with high prevalence of FMF, new mutation in descendant may occur, infrequently.
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Adrovic A, Sahin S, Barut K, Kasapcopur O. Familial Mediterranean fever and periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome: shared features and main differences. Rheumatol Int 2018; 39:29-36. [PMID: 30019226 DOI: 10.1007/s00296-018-4105-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 07/13/2018] [Indexed: 11/30/2022]
Abstract
Autoinflammatory diseases are characterized by fever attacks of varying durations, associated with variety of symptoms including abdominal pain, lymphadenopathy, polyserositis, arthritis, etc. Despite the diversity of the clinical presentation, there are some common features that make the differential diagnosis of the autoinflammatory diseases challenging. Familial Mediterranean fever (FMF) is the most commonly seen autoinflammatory conditions, followed by syndrome associated with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA). In this review, we aim to evaluate disease characteristics that make a diagnosis of FMF and PFAPA challenging, especially in a regions endemic for FMF. The ethnicity of patient, the regularity of the disease attacks, and the involvement of the upper respiratory systems and symphonies could be helpful in differential diagnosis. Current data from the literature suggest the use of biological agents as an alternative for patients with FMF and PFAPA who are non-responder classic treatment options. More controlled studies are needed to evaluate the efficacy and safety of this strategy.
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Affiliation(s)
- Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey.
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An Underlooked Cause of Periodic Fever (PFAPA) in an Adult Patient with No Response to Tonsillectomy. Case Rep Rheumatol 2018; 2018:6580835. [PMID: 29854539 PMCID: PMC5954889 DOI: 10.1155/2018/6580835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 03/26/2018] [Indexed: 12/05/2022] Open
Abstract
Periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA) is an autoinflammatory disease manifested as recurrent febrile episodes associated with one of the following cardinal features: aphthous ulceration, pharyngitis, and cervical adenitis. It was initially described in children and thought to be a disease of pediatric age group. Few adult cases were also reported in the literature. We describe the case of a 39-year-old female affected by PFAPA who presented with a history of febrile episodes associated with aphthous ulceration, stomatitis, and tonsillitis for 4 years. The febrile episodes occurred at a regular interval of 4 weeks and resolved within 5 days. The patient underwent tonsillectomy without any significant improvement. The patient responded only to a single high dose of steroid during the attack. Although PFAPA was initially thought to be a disease of pediatric age group, it should be considered in patients with recurrent febrile illness in all age groups.
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Førsvoll J, Øymar K. The role of tonsillectomy in the Periodic Fever, Aphthous stomatitis, Pharyngitis and cervical Adenitis syndrome; a literature review. BMC EAR, NOSE, AND THROAT DISORDERS 2018; 18:3. [PMID: 29483843 PMCID: PMC5824547 DOI: 10.1186/s12901-017-0049-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/20/2017] [Indexed: 11/10/2022]
Abstract
Background Tonsillectomy (TE) or adenotonsillectomy (ATE) may have a beneficial effect on the clinical course in children with the Periodic Fever, Aphthous stomatitis, Pharyngitis and cervical Adenitis (PFAPA) syndrome. However, an immunological reason for this effect remains unknown. This literature review summarizes the current knowledge of the effect of TE or ATE in the PFAPA syndrome. Methods A search of PubMed, Medline, EMBASE and Cochrane was conducted for papers written in English dated from 1 January 1987 to 31 December 2016. The search included all studies reporting outcomes after TE or ATE from children aged 0 to 18 years with PFAPA. Results Two randomized controlled trials reported significantly faster resolution of febrile episodes after TE or ATE in children with PFAPA compared to controls (non-surgery groups). We identified 28 case series including 555 children with PFAPA. The diagnosis was set prospectively before surgery in 440 children and retrospectively after surgery in 115 of the children. TE or ATE had a curative effect in 509 of the 555 children with PFAPA (92%), but few studies were of high quality. Conclusion TE or ATE may have a curative effect on children with PFAPA, but the evidence is of moderate quality. Further high-quality randomized controlled studies are still needed. Electronic supplementary material The online version of this article (10.1186/s12901-017-0049-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jostein Førsvoll
- 1Department of Paediatrics, Stavanger University Hospital, PO BOX 8100, 4068 Stavanger, Norway.,2Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Knut Øymar
- 1Department of Paediatrics, Stavanger University Hospital, PO BOX 8100, 4068 Stavanger, Norway.,2Department of Clinical Science, University of Bergen, Bergen, Norway
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Pehlivan E, Adrovic A, Sahin S, Barut K, Kul Cınar O, Kasapcopur O. PFAPA Syndrome in a Population with Endemic Familial Mediterranean Fever. J Pediatr 2018; 192:253-255. [PMID: 29031862 DOI: 10.1016/j.jpeds.2017.08.078] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/22/2017] [Accepted: 08/30/2017] [Indexed: 01/14/2023]
Abstract
We reviewed the medical records of patients with periodic fever, aphthosis, pharyngitis, and adenitis (PFAPA) to investigate the clinical course, treatment response, and association with MEFV gene mutation. Familial Mediterranean fever should be considered in patients with PFAPA who do not respond to adenotonsillectomy.
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Affiliation(s)
- Esra Pehlivan
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Ovgu Kul Cınar
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey.
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Abstract
Autoinflammatory diseases (AID) are characterized by seemingly unprovoked self-limited attacks of fever and systemic inflammation potentially leading to amyloidosis. Familial Mediterranean fever (FMF) is the most common AID and therefore the most studied. Besides FMF, the other main hereditary AID are tumor necrosis factor-associated periodic fever syndrome (TRAPS), mevalonate kinase deficiency (MKD), and cryopyrin-associated periodic fever syndrome (CAPS). These hereditary diseases result from a mutant gene that is involved in the regulation of inflammation, resulting in a characteristic clinical phenotype. The differential diagnosis of AID can be challenging due to a wide overlap in clinical manifestations. Moreover, a considerable proportion of patients present with autoinflammatory symptoms but without a pathogenetic variant on genetic analysis. Furthermore, non-hereditary AID, such as the periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome, which is the most common AID in children worldwide, must be excluded in certain circumstances. Herein we shall review the main AID and describe a practical approach to diagnosis in a patient with a clinical suspicion of AID.
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Affiliation(s)
- Merav Lidar
- Rheumatology Unit, Sheba Medical Center, Tel HaShomer Hospital, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- To whom correspondence should be addressed. E-mail:
| | - Eitan Giat
- Rheumatology Unit, Sheba Medical Center, Tel HaShomer Hospital, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Gentileschi S, Vitale A, Frediani B, Galeazzi M, Rigante D, Cantarini L. Challenges and new horizons in the periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1279049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Stefano Gentileschi
- Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Bruno Frediani
- Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Mauro Galeazzi
- Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
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Vanoni F, Theodoropoulou K, Hofer M. PFAPA syndrome: a review on treatment and outcome. Pediatr Rheumatol Online J 2016; 14:38. [PMID: 27349388 PMCID: PMC4924332 DOI: 10.1186/s12969-016-0101-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/21/2016] [Indexed: 12/17/2022] Open
Abstract
The syndrome of periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA syndrome) is the most common cause of periodic fever in childhood. The current pharmacological treatment includes corticosteroids, which usually are efficacious in the management of fever episodes, colchicine, for the prophylaxis of febrile episodes, and other medication for which efficacy has not been proven so far. Tonsillectomy is an option for selected patients. Usually PFAPA syndrome resolves during adolescence, but there is increasing evidence that this condition may persist into adulthood.
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Affiliation(s)
- Federica Vanoni
- Pediatric Department of Southern Switzerland, Ospedale Regionale di Bellinzona e Valli, Bellinzona, 6500, Switzerland.
| | - Katerina Theodoropoulou
- Unité Romande d’Immuno-rhumatologie Pédiatrique (URIRP), Département Femme-Mère-Enfant (DFME), CHUV, University of Lausanne, Rue du Bugnon 46, Lausanne, 1011 Switzerland
| | - Michaël Hofer
- Unité Romande d’Immuno-rhumatologie Pédiatrique (URIRP), Département Médico - Chirurgical de Pédiatrie (DFME), CHUV, University of Lausanne, Rue du Bugnon 46, Lausanne, 1011 Switzerland
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