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Broide M, Levinsky Y, Tal R, Harel L, Shoham S, Ahmad SA, Butbul Aviel Y, Amarilyo G. Extreme Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA): a discrete group of patients. Pediatr Rheumatol Online J 2023; 21:93. [PMID: 37658370 PMCID: PMC10474755 DOI: 10.1186/s12969-023-00880-1] [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: 06/13/2023] [Accepted: 08/21/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVE Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children; by definition, episodes occur every 2 to 8 weeks. However, in a subset of our patients, we noticed a higher frequency of attacks, of less than 2 weeks, which we refer to as extreme PFAPA (ePFAPA). This group consisted of patients who were extreme upon presentation of PFAPA, and those who became extreme after initiation of abortive corticosteroid treatment. We aimed to characterize demographic and clinical features of ePFAPA, including the two groups, and to compare them to patients with non-extreme PFAPA (nPFAPA). STUDY DESIGN The medical records of 365 patients with PFAPA who attended Schneider Children's Medical Center of Israel from March 2014 to April 2021 were reviewed. Patients with concomitant familial Mediterranean fever were excluded. Characteristics of the ePFAPA (including subgroups) and nPFAPA groups were compared using Wilcoxon rank sum, Pearson's chi-squared, and Fisher's exact tests. RESULTS Forty-seven patients (12.9%) were identified as having ePFAPA. Among patients with ePFAPA, compared to patients with nPFAPA, the median (interquartile range) age at disease onset was earlier: 1.5 years (0.7-2.5) vs. 2.5 years (1.5-4.0), P < 0.001; and diagnosis was younger: 2.6 years (2.0-3.6) vs. 4.5 years (3.0-6.2), P < 0.001. A higher proportion of patients with ePFAPA than nPFAPA were treated with colchicine prophylaxis (53% vs. 19%, P < 0.001), but symptoms and signs during flares did not differ significantly between these groups. Demographic and clinical characteristics were similar between patients with ePFAPA from presentation of PFAPA (22, 47% of those with ePFAPA) and ePFAPA from after corticosteroid treatment. CONCLUSION About half the patients categorized with ePFAPA syndrome already had extreme features upon presentation. Patients with ePFAPA compared to nPFAPA presented and were diagnosed at an earlier age.
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Affiliation(s)
- Mor Broide
- Department of Pediatrics A, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
| | - Yoel Levinsky
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rotem Tal
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liora Harel
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shoval Shoham
- Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Sabreen Abu Ahmad
- Department of Pediatrics B, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Yonatan Butbul Aviel
- Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Amarilyo
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rydenman K, Fjeld H, Hätting J, Berg S, Fasth A, Wekell P. Epidemiology and clinical features of PFAPA: a retrospective cohort study of 336 patients in western Sweden. Pediatr Rheumatol Online J 2022; 20:82. [PMID: 36109811 PMCID: PMC9479440 DOI: 10.1186/s12969-022-00737-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is generally regarded as the most common autoinflammatory disease, but the epidemiology of the disease is largely unknown. The objectives of this study were to estimate the annual incidence and describe the clinical features of PFAPA in a large cohort from western Sweden. METHODS The study retrospectively included children < 18 years of age diagnosed with PFAPA between 2006 and 2017 at three hospitals: NU Hospital Group, Skaraborg Hospital and Queen Silvia Children's Hospital. Patients were identified by searching for relevant diagnostic ICD-10 codes in the comprehensive electronic medical records and data were retrieved by reviewing case records. To estimate incidence, patients with symptom onset from January 1, 2006, to December 31, 2016, were included. Population data for the study area during this period were retrieved from Statistics Sweden. RESULTS In this study, 336 patients with PFAPA were identified. Of these, 156 (46%) were girls and 180 (54%) were boys. Almost 90% of the children with PFAPA (291 patients) experienced their first symptoms before the age of 5 years and fewer than 3% presented at ages above 10 years. Pharyngitis was the most common symptom during febrile episodes, followed by cervical adenitis and aphthous stomatitis. Fourteen percent of the patients displayed atypical features, of which skin rash was the most common. To calculate incidence, 251 patients with symptom onset during the study period were identified. The mean annual incidence was estimated at 0.86/10,000 for children < 18 years of age and 2.6/10,000 for children < 5 years of age. CONCLUSIONS This study adds to the understanding of the epidemiology of PFAPA syndrome by presenting incidence rates based on a large cohort and in different age groups in a population-based setting. It also shows the distribution of age of onset of PFAPA, with a peak in 1-year-olds and waning at older ages. Signs and symptoms of PFAPA syndrome were similar in children with symptom onset before vs. after 5 years of age.
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Affiliation(s)
- Karin Rydenman
- Department of Pediatrics, NU Hospital Group, Uddevalla, Sweden. .,Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden.
| | - Hanna Fjeld
- grid.459843.70000 0004 0624 0259Department of Medical Internship, NU Hospital Group, Trollhättan, Sweden
| | - Josefine Hätting
- grid.416029.80000 0004 0624 0275Department of Pediatrics, Skaraborg Hospital, Lidköping, Sweden
| | - Stefan Berg
- grid.8761.80000 0000 9919 9582Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden ,grid.415579.b0000 0004 0622 1824Department of Pediatric Rheumatology and Immunology, Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Anders Fasth
- grid.8761.80000 0000 9919 9582Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden ,grid.415579.b0000 0004 0622 1824Department of Pediatric Rheumatology and Immunology, Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Per Wekell
- grid.459843.70000 0004 0624 0259Department of Pediatrics, NU Hospital Group, Uddevalla, Sweden ,grid.8761.80000 0000 9919 9582Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
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Lemus R, Milks K, Stilphen C, Barson W, Sivaraman V. When All Is Not as It Seems: Recurrent Fever and New-onset Joint Pain in a 17-Month-old Girl. Pediatr Infect Dis J 2022; 41:681-682. [PMID: 38285981 DOI: 10.1097/inf.0000000000003348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | | | | | | | - Vidya Sivaraman
- Division of Rheumatology, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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Luu I, Nation J, Page N, Carvalho D, Magit A, Jiang W, Leuin S, Bliss M, Bothwell M, Brigger M, Kearns D, Pransky S, Broderick L. Undifferentiated recurrent fevers in pediatrics are clinically distinct from PFAPA syndrome but retain an IL-1 signature. Clin Immunol 2021; 226:108697. [PMID: 33636366 PMCID: PMC8089050 DOI: 10.1016/j.clim.2021.108697] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 02/20/2021] [Accepted: 02/20/2021] [Indexed: 11/18/2022]
Abstract
Autoinflammatory disorders of the innate immune system present with recurrent episodes of inflammation often beginning in early childhood. While there are now more than 30 genetically-defined hereditary fever disorders, many patients lack a clear diagnosis. Many pediatric patients are often grouped with patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome despite failing to meet diagnostic criteria. Here, we categorize these patients as syndrome of undifferentiated recurrent fever (SURF), and identify the unique features which distinguish them from the PFAPA syndrome. SURF patients were more likely to report gastrointestinal symptoms of nausea, vomiting and abdominal pain, and experienced inconsistent responses to on-demand steroid therapy compared to PFAPA patients. For this previously undefined cohort, an optimal course of therapy remains uncertain, with medical and surgical therapies largely driven by parental preference. A subset of patients with SURF underwent tonsillectomy with complete resolution. Flow cytometric evaluation demonstrates leukocytic populations distinct from PFAPA patients, with reduced CD3+ T cell numbers. SURF patient tonsils were predominantly characterized by an IL-1 signature compared to PFAPA, even during the afebrile period. Peripheral blood signatures were similar between groups suggesting that PFAPA and SURF patient tonsils have localized, persistent inflammation, without clinical symptoms. These data suggest that SURF is a heterogenous syndrome on the autoinflammatory disease spectrum.
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Affiliation(s)
- Irene Luu
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, University of California-San Diego, La Jolla, CA, United States of America
| | - Javan Nation
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Nathan Page
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Daniela Carvalho
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Anthony Magit
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Wen Jiang
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Shelby Leuin
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Morgan Bliss
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Marcella Bothwell
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Matthew Brigger
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Donald Kearns
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Seth Pransky
- Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America; Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, United States of America
| | - Lori Broderick
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, University of California-San Diego, La Jolla, CA, United States of America; Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America.
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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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Amarilyo G, Harel L, Abu Ahmad S, Abu Rumi M, Brik R, Hezkelo N, Bar-Yoseph R, Mei-Zahav M, Ohana O, Levinsky Y, Chodick G, Butbul-Aviel Y. Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis Syndrome - Is It Related to Ethnicity? An Israeli Multicenter Cohort Study. J Pediatr 2020; 227:268-273. [PMID: 32805260 DOI: 10.1016/j.jpeds.2020.08.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/22/2020] [Accepted: 08/12/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To evaluate the ethnic distribution of Israeli patients with the syndrome of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA). STUDY DESIGN The medical records of patients with PFAPA attending 2 pediatric tertiary medical centers in Israel from March 2014 to March 2019 were retrospectively reviewed. Patients with concomitant familial Mediterranean fever were excluded. Ethnicity was categorized as Mediterranean, non-Mediterranean, and multiethnic. Findings were compared with patients with asthma under treatment at the same medical centers during the same period. RESULTS The cohort included 303 patients with PFAPA and 475 with asthma. Among the patients with PFAPA, 178 (58.7%) were of Mediterranean descent (Sephardic Jews or Israeli Arabs), 96 (33.0%) were multiethnic, and 17 (5.8%) were of non-Mediterranean descent (all Ashkenazi Jews). Patients with PFAPA had a significantly higher likelihood of being of Mediterranean descent than the patients with asthma (58.7% vs 35.8%; P < .0001). The Mediterranean PFAPA subgroup had a significantly earlier disease onset than the non-Mediterranean subgroup (2.75 ± 1.7 vs 3.78 ± 1.9 years, P < .04) and were younger at disease diagnosis (4.77 ± 2.3 vs 6.27 ± 2.9 years, P < .04). CONCLUSIONS PFAPA was significantly more common in patients of Mediterranean than non-Mediterranean descent. Further studies are needed to determine the genetic background of these findings.
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Affiliation(s)
- Gil Amarilyo
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
| | - Liora Harel
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Sabreen Abu Ahmad
- Department of Pediatrics B, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Maryam Abu Rumi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Riva Brik
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Nofar Hezkelo
- Department of Medicine F-Recanati, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Ronen Bar-Yoseph
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Pediatric Pulmonary Institute, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Meir Mei-Zahav
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel; Pediatric Pulmonary Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orly Ohana
- Department of Pediatrics C, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Yoel Levinsky
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Gabriel Chodick
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel; Maccabi Institute for Research & Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Yonatan Butbul-Aviel
- Department of Pediatrics B, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
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7
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Manti S, Filosco F, Parisi GF, Finocchiaro GG, Papale M, Giugno A, Barone P, Leonardi S. Proposal for a new therapeutic high dosage of Pidotimod in children with periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome: a randomized controlled study. Ital J Pediatr 2020; 46:106. [PMID: 32711565 PMCID: PMC7382793 DOI: 10.1186/s13052-020-00871-y] [Citation(s) in RCA: 2] [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: 04/23/2020] [Accepted: 07/16/2020] [Indexed: 01/01/2023] Open
Abstract
Background Despite to PFAPA syndrome is considered a benign and self-limited condition in childhood its impact on patients and families can be remarkable in many cases. Currently, the therapeutic options for managing are non-specific and no consensus exists about the best treatment to use. Pidotimod has been suggested as a new potential treatment in PFAPA syndrome for its immunodulatory effects. We conducted a preliminary, prospective, controlled, open, cross-over trial to assess the efficacy and the safety of Pidotimod in the treatment of children with PFAPA syndrome. Methods 22 children with PFAPA syndrome were randomly allocated to treatment with pidotimod (with 2 vials of 400 mg daily) in combination with betamethasone 0.5–1 mg on need, based on parents/caregivers’ decision (group A) or betamethasone 0.5-1 mg on need, based on parents/caregivers’ decision (group B). Each treatment period was for 3 months (Phase 1), after that patients were switched to the other arm for other 3 months (Phase 2). Efficacy was expressed in terms of number of episodes of fever, pharyngitis, or aphthous stomatitis, as well as the additional use of betamethasone on need. Safety and tolerability of the Pidotimod were evaluated on the basis of the number and type of adverse events (AEs) recorded during the treatment. Results Patients receiving Pidotimod and use betametasone showed a significant decrease in frequency of fevers (p = 0.002); number of episodes of pharyngitis (p = 0.049); aphthous stomatitis (p = 0.036) as well as the betamethasone use on need (p = 0.007). Overall, 19/22 (86.4%) showed benefits from Pidotimod administration. The safety profile of Pidotimod was excellent as no serious adverse events have been reported in the treated groups. Conclusions We firstly showed that high dosage of Pidotimod could be an effective and safe to reduce the PFAPA attacks in children.
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Affiliation(s)
- Sara Manti
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Federica Filosco
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Giuseppe Fabio Parisi
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy.
| | - Giuseppe Germano Finocchiaro
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Maria Papale
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Andrea Giugno
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Patrizia Barone
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Salvatore Leonardi
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
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8
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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: 24] [Impact Index Per Article: 6.0] [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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9
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Haploinsufficiency of A20 and other paediatric inflammatory disorders with mucosal involvement. Curr Opin Rheumatol 2019; 30:506-513. [PMID: 29916847 DOI: 10.1097/bor.0000000000000532] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review aims at summarizing the current knowledge of A20 haploinsufficiency and other paediatric inflammatory disorders with mucosal involvement. RECENT FINDINGS A20 haploinsufficiency is a newly described autoinflammatory disease caused by loss-of-function mutations in TNFAIP3 that result in the activation of the nuclear factor (NF)-kB pathway. Patients may present with dominantly inherited, early-onset systemic inflammation and a Behçet-like disease, or a variety of autoinflammatory and autoimmune features. In Behçet disease, recent literature provides insights into genetic susceptibility and emerging treatment options; in addition, the first paediatric classification criteria were published. Recent advances in periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA) suggest that the disease has a complex underlying genetic mechanism and in some cases is inherited in an autosomal dominant pattern with reduced penetrance phenotype in many family members. Activation of the pyrin inflammasome through the RoA signalling pathway uncovers an interesting molecular connection between hyperimmunoglobulinemia D syndrome and familial Mediterranean fever. The description of new monogenic types of inflammatory bowel disease (IBD) may provide novel insights into disease pathogenesis. Finally, recent studies highlighted the role of gut microorganisms and dysbiosis in IBD. SUMMARY Monogenic diseases such as A20 haploinsufficiency may help to advance our understanding of disease pathogenesis and to develop targeted therapies for more common, multifactorial disorders with mucosal inflammation.
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10
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Cyclical Fevers in a 4-year-old Boy with IgA Deficiency. REPORTS 2019. [DOI: 10.3390/reports2020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
While immunodeficiencies, such as (Immunoglobulin A) IgA deficiency, may predispose pediatric patients to respiratory illnesses, they are also associated with autoinflammatory conditions. Distinguishing between these possible complications requires an awareness of these uncommon conditions. We report a case of a four-year-old boy with a history of IgA deficiency presenting to his primary care provider with fever of one week’s duration accompanied by abdominal, ear, and throat pain. The patient’s mother reported that he had these symptoms twice a month for the prior ten months during which he occasionally developed oral ulcers. Between episodes, the patient fully recovered without complications. Considering the patient’s history of IgA deficiency, it was originally assumed that the patient had strep throat and coincidental resolution of his symptoms after initiation of antibiotic therapy supported this diagnosis. However, due to the recurrent nature of his symptoms, a preliminary diagnosis of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) was made. A referral to an otolaryngologist was made, and findings of adenopathy and tonsillitis suggestive of PFAPA were confirmed. The patient was scheduled for adenoidectomy and tonsillectomy, which were performed without complication, leading to the cessation of these episodes.
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11
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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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12
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Costagliola G, Maiorino G, Consolini R. Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome (PFAPA): A Clinical Challenge for Primary Care Physicians and Rheumatologists. Front Pediatr 2019; 7:277. [PMID: 31334209 PMCID: PMC6624732 DOI: 10.3389/fped.2019.00277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/20/2019] [Indexed: 01/31/2023] Open
Abstract
Objective: To show the different physician's approaches and the difficulties in the diagnosis and management of the Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis (PFAPA) syndrome, and to quantify the impact of the disease on the families and on the healthcare system. Study Design: Retrospective analysis on 40 patients diagnosed with PFAPA, focusing on the clinical phenotype, the process of diagnosis, and the management of the febrile episodes. The direct and indirect annual economic cost related to PFAPA in the period preceding the diagnosis were also investigated. Results: The median age of patients at disease onset was 1.75 years and the median time to diagnosis was 14.5 months. During the diagnostic process, only 45% of our patients was firstly addressed to rheumatologic consultation, 32.5% to otorinolaryngologist (ORL), and 22.5% to immunologic consultation. Genetic investigations were performed in the 20% of the cohort. Overall population experienced a median of 60 annual days of fever and, during the critical phase, 40% of patients received more than 5 cycles of antibiotic/year. Seventy five percent required laboratory investigations, 18 (45%) needed to access to emergency department and 15 (37.5%) have been hospitalized. The annual mean direct cost was 1659.5 € for each patient, and the estimated mean indirect cost was 5811.6 € for each parent. Conclusion: Despite a benign clinical course, PFAPA syndrome is associated with a significant impact on the patients, their families and the national healthcare system. PFAPA patients require a large number of medical examinations and laboratory or instrumental investigations during the diagnostic approach and often receive inappropriate treatments. Therefore, we suggest the necessity of a greater awareness and knowledge of the disease among primary care physicians and, finally, of the adoption of more specific diagnostic criteria.
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Affiliation(s)
- Giorgio Costagliola
- Laboratory of Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuseppe Maiorino
- Laboratory of Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rita Consolini
- Laboratory of Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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13
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Abstract
Fever is a common symptom in children. Some children may present to their primary care physician with undifferentiated fever; that is, fever for which there is no obvious source from the history or physical examination. Undifferentiated fevers may be prolonged or recurrent. Distinguishing between the two is helpful for narrowing the differential diagnosis, which can be broad and include infections and inflammatory diseases and, rarely, malignancies and autoinflammatory disorders. The evaluation of such children requires a step-wise approach. Taking a detailed history, performing a thorough physical examination, and reviewing a fever and symptom diary is crucial in recognizing clues that may ultimately lead to a diagnosis. Some children who look good and whose fever disappears may never have a diagnosis, whereas referral to a specialist may be prudent for others. [Pediatr Ann. 2018;47(9):e347-e353.].
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14
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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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15
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Abstract
Background Chronic recurrent multifocal osteomyelitis (CRMO), also known as chronic nonbacterial osteomyelitis, is a rare, noninfectious inflammatory disorder that causes multifocal bone lesions with swelling and pain. Lytic and sclerotic bone lesions could be found on X-ray. Short tau inversion recovery magnetic resonance imaging (STIR MRI) shows bone marrow oedema, bone expansion, lytic areas and periosteal reaction. CRMO is characterized by periodic exacerbations and remissions of unclear/unknown pathogenesis. Case presentation A 10 years old girl, suffering from pain in her right shoulder since the age of 9 years presented to our Department. Thanks to clinical data, laboratoristic and radiological findings and bone biopsy CRMO was diagnosed. So patient started anti-inflammatory treatment and her conditions improved. Conclusions In a child with bone pain should be considered also rare condition as CRMO to perform a correct diagnosis and start an adequate treatment avoiding complications such as bone damage. This condition should be suspected in a child with recurrent bone pain, modest increase of inflammatory indices, lytic or sclerotic bone lesion on X Ray. Typical CRMO localizations are metaphyses of long bones, pelvis, clavicle, vertebral column, sternum, ribs, jaw, but any bone can be involved. The most common CRMO differential diagnosis is represented by infections, malignant bone tumors, Langerhans Cells Histiocytosis (LCH).
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