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Pokora K, Kowalczyk K, Peterek R, Cwynar M, Stojko R, Madej P, Drosdzol-Cop A. COVID 19 vaccination as a trigger of acute genital ulcers in an immunocompromised adolescent-case study and literature review. BMC Womens Health 2024; 24:156. [PMID: 38443922 PMCID: PMC10913635 DOI: 10.1186/s12905-024-02930-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/25/2024] [Indexed: 03/07/2024] Open
Abstract
Acute genital ulcers can affect females of all ages. In children, they often appear as an emergency and remain a diagnostic challenge for pediatricians, gynecologists and dermatologists. Prompt diagnosis and identification of disease- related factors help to implement appropriate treatment. Firstly, it is crucial to properly compile the past medical history of the patient. Past infectious, autoimmune, malignant or traumatic conditions, as well as vaccinations may contribute to the occurrence of acute genital ulcers. Moreover, new infectious agents, such as severe acute respiratory syndrome coronavirus 2 and vaccinations against Coronavirus disease of 2019, may play a significant role in the development of atypical clinical symptoms. Here we present a case of a 12-year-old girl with acute genital ulcers. Additional symptoms accompanying the ulcer included: abdominal pain, nausea, vomiting, dysuria, vulvar pain and fever. Blood test showed leukocytosis, especially neutrophilia and monocytosis and increased levels of c-reactive protein and procalcitonin. Serological tests for the most common infections were negative. Moreover, the patient had a history of autoimmune diseases. She had periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome, and IgA vasculitis, also known as Henoch-Schönlein purpura in her past medical history. Additionally, she was vaccinated against SARS-CoV-2 shortly before the lesions appeared.
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Affiliation(s)
- Karolina Pokora
- Department of Endocrinological Gynecology, Medical University of Silesia, Katowice, Poland.
| | - Karolina Kowalczyk
- Department of Endocrinological Gynecology, Medical University of Silesia, Katowice, Poland
| | - Robert Peterek
- Department of Endocrinological Gynecology, Medical University of Silesia, Katowice, Poland
| | - Marlena Cwynar
- Department of Endocrinological Gynecology, Medical University of Silesia, Katowice, Poland
| | - Rafał Stojko
- Chair and Department of Gynecology, Obstetrics and Gynecological Oncology, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Paweł Madej
- Department of Endocrinological Gynecology, Medical University of Silesia, Katowice, Poland
| | - Agnieszka Drosdzol-Cop
- Chair and Department of Gynecology, Obstetrics and Gynecological Oncology, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
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Wu W, Lin Y, Farag MA, Li Z, Shao P. Dendrobium as a new natural source of bioactive for the prevention and treatment of digestive tract diseases: A comprehensive review with future perspectives. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 114:154784. [PMID: 37011417 DOI: 10.1016/j.phymed.2023.154784] [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: 12/21/2022] [Revised: 03/01/2023] [Accepted: 03/21/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The incidence of diseases related to the digestive tract is on the rise, with many types of complex etiologies. Dendrobium nobile Lindl. is a famous Traditional Chinese Medicine (TCM) rich in many bioactives proven to be beneficial in several health diseases related to inflammation and oxidative stress. PURPOSE At present, despite the availability of various therapeutic clinical drugs used for the treatment of digestive tract diseases, resistance emergence and existence of several side effects warrant for the developing of novel drugs for improved effects on digestive tract diseases. METHODS "Orchidaceae", "Dendrobium", "inflammation", "digestive tract", and "polysaccharide" were used as search terms to screen the literature. The therapeutic use of Dendrobium related to digestive tract diseases relative to known polysaccharides and other bioactive compounds were derived from online databases, including Web of Science, PubMed, Elsevier, Science Direct, and China National Knowledge Infrastructure, as well as relevant information on the known pharmacological actions of the listed phytochemicals. RESULTS To better capitalize upon Dendrobium for preventing and treating diseases related to digestive tract, this review summarizes bioactives in Dendrobium reported of potential in digestive tract diseases management and their underlying action mechanisms. Studies revealed that Dendrobium encompasses diverse classes including polysaccharides, phenolics, alkaloids, bibenzyls, coumarins, phenanthrene and steroids, with polysaccharide as the major class. Dendrobium exerts various health effects on a variety of disease related to the digestive tract. Action mechanisms involve antioxidant, anti-inflammatory, anti-apoptotic, antioxidant, anticancer, alongside the regulation of some key signaling pathways. CONCLUSION Overall, Dendrobium appears as a promising TCM source of bioactives that has the potential to be further developed into nutraceuticals for digestive tract diseases compared to current drug treatments. This review highlights for Dendrobium potential effects with future perspectives for needed future research to maximize the use of bioactive compounds from Dendrobium for digestive tract disease treatment. A compile of Dendrobium bioactives is also presented alongside methods for their extraction and enrichment for potential incorporation in nutraceuticals.
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Affiliation(s)
- Wenjun Wu
- Department of Food Science and Technology, Zhejiang University of Technology, Zhejiang, Hangzhou 310014, China; Zhejiang Sci-Tech University Shaoxing Academy of Biomedicine Co. Ltd., Zhejiang, Shaoxing 312000, China
| | - Yang Lin
- Department of Food Science and Technology, Zhejiang University of Technology, Zhejiang, Hangzhou 310014, China; Zhejiang Sci-Tech University Shaoxing Academy of Biomedicine Co. Ltd., Zhejiang, Shaoxing 312000, China
| | - Mohamed A Farag
- Pharmacognosy Department, College of Pharmacy, Cairo University, Kasr El Aini St., P.B., Cairo, Egypt
| | - Zhenhao Li
- Zhejiang ShouXianGu Botanical Drug Institute Co., Ltd., Zhejiang Hangzhou 321200 China
| | - Ping Shao
- Department of Food Science and Technology, Zhejiang University of Technology, Zhejiang, Hangzhou 310014, China; Eco-Industrial Innovation Institute ZJUT, Zhejiang, Quzhou 324000, China.
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Dermatologic Manifestations of Noninflammasome-Mediated Autoinflammatory Diseases. JID INNOVATIONS 2023; 3:100176. [PMID: 36876221 PMCID: PMC9982332 DOI: 10.1016/j.xjidi.2022.100176] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/14/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
Autoinflammatory diseases (AIDs) arise from disturbances that alter interactions of immune cells and tissues. They give rise to prominent (auto)inflammation in the absence of aberrant autoantibodies and/or autoreactive T cells. AIDs that are predominantly caused by changes in the inflammasome pathways, such as the NLRP3- or pyrin-associated inflammasome, have gained substantial attention over the last years. However, AIDs resulting primarily from other changes in the defense system of the innate immune system are less well-studied. These noninflammasome-mediated AIDs relate to, for example, disturbance in the TNF or IFN signaling pathways or aberrations in genes affecting the IL-1RA. The spectrum of clinical signs and symptoms of these conditions is vast. Thus, recognizing early cutaneous signs constitutes an important step in differential diagnoses for dermatologists and other physicians. This review provides an overview of the pathogenesis, clinical presentation, and available treatment options highlighting dermatologic aspects of noninflammasome-mediated AIDs.
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Key Words
- AID, autoinflammatory disease
- ANCA, antineutrophil cytoplasmic antibody
- AOSD, adult-onset Still disease
- BASDAI, Bath Ankylosing Spondylitis Activity Index
- CANDLE, chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature
- CAPS, cryopyrin-associated periodic syndrome
- CRD, cysteine-rich domain
- DIRA, deficiency of IL-1RA
- DITRA, deficiency of IL-36RA
- ER, endoplasmic reticulum
- ESR, erythrocyte sedimentation rate
- FMF, familial Mediterranean fever
- M-CSF, macrophage colony-stimulating factor
- MAS, macrophage activation syndrome
- NET, neutrophil extracellular trap
- NOS, nitrous oxide
- NSAID, nonsteroidal anti-inflammatory drug
- NUD, neutrophilic urticarial dermatosis
- PFAPA, periodic fever, aphthous stomatitis, pharyngitis, and adenitis
- PKR, protein kinase R
- PRAAS, proteosome-associated autoinflammatory disease
- SAPHO, synovitis, acne, pustulosis, hyperostosis, osteitis syndrome
- SAVI, STING-associated vasculopathy with onset in infancy
- STAT, signal transducer and activator of transcription
- SchS, Schnitzler syndrome
- TNFR, TNF receptor
- TRAPS, TNF receptor‒associated autoinflammatory disease
- Th17, T helper 17
- VAS, Visual Analog Scale
- sTNFR, soluble TNF receptor
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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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Espin Diaz PC, Singh K, Kher P, Avanthika C, Jhaveri S, Saad Y, Gosh S. Periodic Fever in Children: Etiology and Diagnostic Challenges. Cureus 2022; 14:e27239. [PMID: 36035053 PMCID: PMC9399680 DOI: 10.7759/cureus.27239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 11/05/2022] Open
Abstract
Periodic fever in children is an autoinflammatory illness with an unknown cause. Symptoms include frequent episodes of fever that are followed by an increase in inflammatory markers. A genetic background for periodic fever of unknown origin has been hypothesized, based on its family clustering and parallels to other autoinflammatory illnesses such as familial Mediterranean fever. Genome analysis has been used in studies to look for related gene variations in periodic fever of unknown origin in the pediatric population. Children with periodic fevers might be a diagnostic challenge. After ruling out the most prevalent causes, a wide variety of other possibilities are investigated. Infectious and noninfectious causes of periodic fever in children are discussed in this article. Inflammasomes (intracellular proteins that activate interleukin (IL)-1b and IL-18) and genetic/hereditary variations are thought to be implicated in the pathogenesis of periodic fever. Evaluation and ruling out possible infective or noninfective causes is vital in the diagnosis of periodic fever in children. Investigations demonstrate that there isn't a single gene linked to it, suggesting that it may have a multifactorial or polygenic origin, with an environmental trigger causing inflammasome activation and fever flares. Treatment is usually symptomatic, with drugs such as colchicine and cimetidine having shown promising results in trials. We explored the literature on periodic fever in children for its epidemiology, pathophysiology, the role of various genes and how they influence the disease and associated complications, and its various treatment modalities.
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Okamoto CT, Chaves HL, Schmitz MJ. Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome in children: a brief literature review. REVISTA PAULISTA DE PEDIATRIA 2022; 40:e2021087. [PMID: 35703722 PMCID: PMC9190469 DOI: 10.1590/1984-0462/2022/40/2021087in] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/06/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe clinical, diagnostic and therapeutic characteristics of the periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome. DATA SOURCE Literature review in the PubMed database by using specific descriptors to identify all articles published in the English language in the last three years; 38 articles were found. After performing selection of titles and abstract analysis, 13 out of the 38 articles were fully read. Relevant studies found in the references of the reviewed articles were also included. DATA SYNTHESIS The PFAPA syndrome (Periodic Fever, Aphthous Stomatitis, Pharyngitis and cervical Adenitis) is a medical condition grouped among the periodic fever syndromes. The etiology is uncertain, but possibly multifactorial, and its symptoms are accompanied by recurrent febrile episodes although weight and height development are preserved. It is a self-limiting disease of benign course with remission of two to three years without significant interference in the patient's overall development. Treatment consists of three pillars: interruption of febrile episodes, increase in the interval between episodes, and remission. CONCLUSIONS Despite several attempts to establish more sensitive and specific criteria, the diagnosis of PFAPA syndrome is still clinical and reached by exclusion, based on the modified Marshall's criteria. The most common pharmacological options for treatment include prednisolone and betamethasone; colchicine may be used as prophylaxis, and surgical treatment with tonsillectomy can be considered in selected cases.
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Zinterl C, Costa-Reis P, Esteves IC, Marques JG, Sousa AB, Fonseca JE, Oliveira Ramos F. The Added Value of a Multidisciplinary Clinic for Systemic Autoinflammatory Diseases. J Multidiscip Healthc 2022; 15:999-1010. [PMID: 35548670 PMCID: PMC9081005 DOI: 10.2147/jmdh.s351546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/05/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Carolina Zinterl
- Pediatric Rheumatology Unit, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Correspondence: Carolina Zinterl, Serviço de Reumatologia, Centro Hospitalar Lisboa Norte, Hospital de Santa Maria, EPE, R. Prof. Egas Moniz, Lisboa, 1700, Portugal, Tel +351 217805139, Email
| | - Patrícia Costa-Reis
- Pediatric Rheumatology Unit, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Pediatrics Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Isabel Castro Esteves
- Pediatrics Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - José Gonçalo Marques
- Pediatrics Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Ana Berta Sousa
- Pediatrics Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Department of Basic Immunology, Faculty of Medicine, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - João Eurico Fonseca
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Filipa Oliveira Ramos
- Pediatric Rheumatology Unit, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
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Okamoto CT, Chaves HL, Schmitz MJ. Síndrome da febre periódica, estomatite aftosa, faringite e adenite em crianças: uma breve revisão de literatura. REVISTA PAULISTA DE PEDIATRIA 2022. [DOI: 10.1590/1984-0462/2022/40/2021087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
RESUMO Objetivo: Descrever as características clínicas, diagnósticas e de tratamento da síndrome de febre periódica, estomatite aftosa, faringite e adenite (PFAPA). Fontes de dados: Revisão de literatura na base de dados PubMed, feita por meio de descritores específicos para identificar todos os artigos publicados em língua inglesa nos últimos três anos. Dos 38 artigos encontrados, foram encaminhados para leitura integral 13 publicações após seleção de títulos e análise de abstract. Estudos relevantes encontrados nas referências dos artigos revisados também foram incluídos. Síntese dos dados: A PFAPA é traduzida do inglês periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis. Caracterizada por etiologia ainda incerta e possivelmente multifatorial, seus sintomas são acompanhados por episódios recorrentes de febre associados a um desenvolvimento pôndero-estatural preservado. É uma doença autolimitada de curso benigno, com remissão em dois a três anos, sem interferências significativas no desenvolvimento do paciente pediátrico. O tratamento consiste em três pilares: interrupção da crise febril, aumento do intervalo entre crises e remissão. Conclusões: Apesar de várias tentativas de estabelecer critérios atuais mais sensíveis e específicos, o diagnóstico da síndrome PFAPA ainda é clínico e de exclusão com base nos critérios de Marshall modificados. As opções farmacológicas mais utilizadas para o tratamento são a prednisolona e betametasona; colchicina pode ser utilizada como profilaxia e o tratamento cirúrgico com tonsilectomia pode ser considerado em casos selecionados.
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Asna Ashari K, Rezaei N. PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) syndrome: an overview of genetic background. Clin Rheumatol 2021; 40:4437-4444. [PMID: 34014414 DOI: 10.1007/s10067-021-05770-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 02/02/2023]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is an autoinflammatory disorder with an uncertain origin. PFAPA manifestations occur in the form of regular attacks accompanied by a rise in inflammatory markers. Regarding the family clustering of PFAPA and its similarities with other autoinflammatory disorders such as familial Mediterranean fever, a genetic basis is suggested for the disease. Studies have conducted genome analysis in order to find possible gene variants in PFAPA. Associations with variations in several genes such as MEFV, NLRP, TNFRSF1A, CARD15/NOD2, and MVK have been suggested and analyzed. Inflammasomes, intracellular proteins that are members of innate immunity and activate interleukin-1b (IL-1b) and IL-18, are proposed to be involved in PFAPA pathogenesis. The investigations show that a single gene cannot be found in association with PFAPA, and that it might have a multifactorial or polygenic basis, in which an environmental trigger can provoke inflammasome activation and activate PFAPA flares.
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Affiliation(s)
- Kosar Asna Ashari
- Department of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Dr Qarib St, Keshavarz Blvd, 14194, Tehran, Iran. .,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. .,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
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Førsvoll J, Kristoffersen EK, Øymar K. The immunology of the periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome; what can the tonsils reveal. A literature review. Int J Pediatr Otorhinolaryngol 2020; 130:109795. [PMID: 31786522 DOI: 10.1016/j.ijporl.2019.109795] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES 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 regarding the immunological role of the tonsils in the PFAPA syndrome. METHODS We searched PubMed, Medline, EMBASE and Cochrane for papers written in English dated from 1 January 1987 to 30 April 2019. The search included all studies reporting histological, immunological or microbiological workup of tonsil specimens from children aged 0-18 years with PFAPA. RESULTS Thirteen articles reported histological, immunological or microbiological workup of tonsil specimens in children with PFAPA. The histology of tonsil specimens from children with PFAPA displayed chronic tonsillar inflammation with lymphoid hyperplasia. No uniform immunological pattern was identified, but some studies found fewer B-lymphocytes and smaller germinal centers in PFAPA compared to controls. A difference in tonsillar microbiota between PFAPA and controls was found in one study. CONCLUSION A uniform immunological or microbiological pattern explaining the clinical effect of TE in children with PFAPA has not been revealed. Future targeted immunological studies of tonsils in PFAPA patients could possibly illuminate the understanding of the immunology in this disease.
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Affiliation(s)
- Jostein Førsvoll
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Einar Klæboe Kristoffersen
- Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
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Jiang H, Yang Z. Severe Recurrent Fever Episodes With Clinical Diagnosis of Hemophagocytic Lymphohistiocytosis, Incomplete Kawasaki Disease and Systemic-Onset Juvenile Idiopathic Arthritis: A Case Report and Literature Review. Front Pediatr 2020; 8:93. [PMID: 32211357 PMCID: PMC7076133 DOI: 10.3389/fped.2020.00093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 02/24/2020] [Indexed: 12/14/2022] Open
Abstract
The pathogeneses of recurrent fever are quite complicated when excluding repeated infections. Recurrent fever is a common symptom for autoinflammatory diseases, relapse of Systemic-onset juvenile idiopathic arthritis (SoJIA) and recurrent Kawasaki disease (KD). There are no specific diagnostic laboratory tests for the diseases. Some studies showed that KD was the precursor of hemophagocytic lymphohistiocytosis (HLH). Macrophage activation syndrome (MAS) is another form of HLH in SoJIA. Cytokine disturbances are considered to be involved in the pathogenesis of the diseases. We describe a Chinese female toddler that developed three separate fever episodes with eventual diagnose of SoJIA within about 10 months. The first episode was diagnosed as IKD, immunoglobulin nonresponsive KD, and HLH. The second and third episodes were diagnosed as IKD and SoJIA, respectively. The fever was hard to be relieved by antipyretics, and the peak axillary temperature was above 40°C. For every fever episode, infections were excluded. For the first episode, trends over time of hemoglobin, platelets, fibrinogen, and triglycerides indicated HLH, which was finally diagnosed and treated according to the HLH-2004 protocol. For the second episode 6 months later, after excluding an HLH relapse and infections, IKD was finally diagnosed. Oral aspirin was administered, and the HLH treatment was ceased. The third episode occurred 3 months later, and SoJIA was finally diagnosed. For each episode, except for relative tests, we only tested for cytokines interleukin-1β, interleukin-6, and interferon-γ, due to limited laboratory test availability. These cytokines were elevated during remission and rose much higher in the fever phases. The case showed the difficulty to differentiating the recurrent fever in clinical practice. Surveillance of routine laboratory parameters over time might reveal a trend that indicates possible disease, even when parameter values do not meet diagnostic criteria. Changes in cytokine profiles are promising markers for differentiating recurrent fever diseases in future. An unknown immunological defect for the case may contribute to the recurrent immunological insults, and we are following up the recurrence of fever episode.
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Affiliation(s)
- Hongkun Jiang
- Department of Pediatrics, The First Hospital of China Medical University, Shenyang, China
| | - Zhiliang Yang
- Department of Pediatrics, The First Hospital of China Medical University, Shenyang, China
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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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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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