Peritoneal adhesions and intestinal obstructions in patients with familial Mediterranean fever--are they more frequent?

Adhesive small-bowel obstruction as a challenging complication of familial Mediterranean fever: A case-based review

Familial Mediterranean fever (FMF) is the most common inherited autoinflammatory disorder, characterized by recurrent and self-limiting episodes of fever and serosal inflammation. Recurrent serositis may rarely lead to the formation of adhesions in the peritoneum, which may result in mechanical bowel obstruction. The symptoms, such as abdominal pain and vomiting, may mimic typical FMF attacks, resulting in misdiagnosis and severe morbidity, including strangulation and intestinal necrosis. Physicians are generally aware of other complications associated with FMF but reports on peritoneal adhesions and intestinal obstruction in English-language literature are inadequate to increase clinicians' awareness. Therefore, it is crucial to meticulously evaluate FMF patients presenting with abdominal pain and ileus because these symptoms could be due to adhesive small-bowel obstruction (ASBO). Furthermore, patients presenting with ASBO without a history of abdominal surgery should also be thoroughly evaluated, especially as it could be an initial presentation for an autoinflammatory disease. Herein, we present a pediatric case of FMF with the M694V homozygous mutation, complicated by ASBO while under colchicine treatment. Additionally, we provide a comprehensive review of the available literature on ASBO in FMF.

Paediatric adhesive bowel obstruction: a systematic review

Adhesions following abdominal surgery remain a common cause of bowel obstruction. The incidence is between 1 and 12.6% in children who have had previous abdominal surgery. While conservative management is usually trialled in all patients (including children) suspected of having ASBO, the majority will require surgical intervention. New materials such as Seprafilm^® have been studied in the paediatric population, with promising results of its use in index abdominal surgeries to prevent the formation of adhesions. In this article, we conducted a systematic review to present an overview of the current knowledge on the incidence, aetiology, pathophysiology, clinical presentation, and management of ASBO.

A novel cluster of patients with Familial Mediterranean Fever (FMF) in southern Italy

BACKGROUND

Familial Mediterranean Fever (FMF) is an autosomal recessive autoinflammatory disorder characterised by recurrent attacks of fever and serositis (peritonitis, pleuritic or synovitis) affecting mainly populations of Mediterranean origin.

AIM

To describe a relatively new cluster of FMF subjects from Apulia and Basilicata regions (southern Italy).

PATIENTS AND METHODS

Subjects were screened for FMF using the Tel-Hashomer criteria and genetic analysis. Demographic data were taken from patients' files and direct interviews. Patients were investigated about attack duration, intensity and site, body temperature, skin manifestations and overall quality of life before and after treatment with colchicine. Inflammatory parameters were also measured between these periods.

RESULTS

Forty-nine subjects had FMF (M : F = 26 : 23, age 38 years ± 2 SE) and followed-up up to 8 years. The age at disease onset was 22·1 years ± 1·2SE and the diagnostic delay was 15·5 years ± 1·9SE. The majority of patients (82%) suffered from abdominal pain, and 35% had undergone prior abdominal surgery or laparotomy. Severity score (ISSF) was mild in 43% of patients and intermediate in 57% of patients. Serum amyloid A (SAA) was increased in 20% of patients (16·9 ± 3·7, normal range < 6·4 mg/dL). In over 95% of patients, inflammation markers, duration and intensity of febrile painful attacks, quality of life and ISSF score improved dramatically following colchicine treatment.

CONCLUSION

The Apulia region represents a new endemic area for FMF. Clinical presentation of FMF can be misleading and requires a complete and early workup to recognise the disease and avoid unjustified surgery. Colchicine remains the gold standard therapy to prevent FMF attacks and fatal long-term complications.

Familial Mediterranean fever

PURPOSE OF REVIEW

Familial Mediterranean fever (FMF) is the oldest and most common of the hereditary autoinflammatory diseases (AIDs). A large body of information has been accumulated over recent years on the pathophysiology, diagnosis and treatment of these diseases. The purpose of this review is to bring an up-to-date summary of the clinic manifestations, diagnostic criteria and treatment of FMF.

RECENT FINDINGS

An overview of the pathophysiologic basis of FMF as part of the AID is discussed. Over the last year, attempts to establish new criteria for childhood FMF, new guidelines for treatment and follow-up of disease and novel treatment for FMF were made. A comparison of the different disease severity scores for research purposes suggests that a new score is needed. New evidence for antiinterleukin-1 blockade as a new treatment modality is described.

SUMMARY

New diagnostic criteria, disease severity score, treatment and follow-up guidelines have been proposed, and need validation in the next several years.

Mir-155 is overexpressed in systemic sclerosis fibroblasts and is required for NLRP3 inflammasome-mediated collagen synthesis during fibrosis

BACKGROUND

Despite the important role that microRNAs (miRNAs) play in immunity and inflammation, their involvement in systemic sclerosis (SSc) remains poorly characterized. miRNA-155 (miR-155) plays a role in pulmonary fibrosis and its expression can be induced with interleukin (IL)-1β. SSc fibroblasts have activated inflammasomes that are integrally involved in mediating the myofibroblast phenotype. In light of this, we investigated whether miR-155 played a role in SSc and if its expression was dependent on inflammasome activation.

METHODS

miR-155 expression was confirmed in SSc dermal and lung fibroblasts by quantitative polymerase chain reaction (PCR). Wild-type and NLRP3-deficient murine fibroblasts were utilized to explore the regulation of miR-155 during inflammasome activation. miR-155-deficient fibroblasts and retroviral transductions with a miR-155 expression or control vectors were used to understand the contribution of miR-155 in fibrosis.

RESULTS

miR-155 was significantly increased and the highest expressing miRNA in SSc lung fibroblasts. Its expression was dependent on inflammasome activation as miR-155 expression could be blocked when inflammasome signaling was inhibited. In the absence of miR-155, inflammasome-mediated collagen synthesis could not be induced but was restored when miR-155 was expressed in miR-155-deficient fibroblasts.

CONCLUSIONS

miR-155 is upregulated in SSc. These results suggest that the inflammasome promotes the expression of miR-155 and that miR-155 is a critical miRNA that drives fibrosis.

Clinical Review: Familial Mediterranean Fever-An Overview of Pathogenesis, Symptoms, Ocular Manifestations, and Treatment

Familial Mediterranean fever is an autoinflammatory multisystem disease, which most commonly affects patients from the Mediterranean basin. This review discusses the common polymorphisms in the MEFV gene as well as the role of pyrin in disease pathogenesis. Patients with familial Mediterranean fever typically develop peritonitis, pleuritis, arthritis, and fever. In addition, a number of authors have reported ophthalmic features. These case reports and series are further explored in this review. Colchicine has transformed the prognosis for patients with familial Mediterranean fever. The rationale for the use of colchicine, as well as the evidence for newer biologic agents is also covered.

Familial Mediterranean fever: An updated review

Familial Mediterranean Fever (FMF) is a hereditary autoinflammatory disorder characterised by acute attacks of fever and serosal inflammation. FMF primarily affects Jewish, Armenian, Turkish, and Arab populations. The disease is accompanied by a marked decrease in quality of life due to the effects of attacks and subclinical inflammation in the attack-free periods. Untreated or inadequately treated patients run the risk of amyloidosis, which is an important cause of morbidity and mortality. In this review, the current information available on FMF is summarised.

Pitfalls in familial mediterranean fever: acute intestinal strangulation/obstruction due to primary adhesions

Familial Mediterranean Fever (FMF) presents in 90% of patients with painful attacks of peritoneal inflammation, which may mimic an acute surgical abdomen. These episodes characteristically resolve spontaneously within 72 hours. However, recurrent episodes of primary peritonitis may lead to the development of primary intraperitoneal adhesions, even in the absence of previous abdominal surgery. When an atypical bout of pain fails to resolve spontaneously and rapidly, the surgeon must consider the diagnosis of intestinal obstruction due to an adhesive band with the associated risk of strangulation with bowel necrosis. In this case report, we describe this rare but classical presentation of FMF for which any delay in diagnosis or treatment may result in severe morbidity.

Anti-TNF agents in familial Mediterranean fever: report of three cases and review of the literature

Familial Mediterranean fever (FMF) is an autoinflammatory disease characterized by recurrent fever, peritonitis/pleuritis, or arthritis attacks. Patients may have FMF-associated mutations of pyrin. The role of biologics such as anti-tumor necrosis factor (TNF) agents (infliximab, etanercept, adalimumab, golimumab) and anakinra, canakinumab, or rilonacept in the treatment of FMF needs to be clarified. Herein we present reports of three patients (all were positive for HLA B27) with typical spondylitis associated with FMF who were successfully managed with anti-TNF agents, along with a literature review. The patients were a 37-year-old man with concomitant Crohn's disease and amyloidosis who was treated with infliximab (INF, 5 mg/kg for 3 years) and switched to adalimumab (ADA), and two female patients (a 24-year-old and a 31-year-old) with FMF who developed severe spondylitis and who were also treated with ADA. Anti-TNF agents can control FMF attacks quite effectively and they reveal a promising role in the treatment of FMF-associated amyloidosis and spondylitis.

Delay in Diagnosis of Intestinal Obstruction in a Patient with Familial Mediterranean Fever

Familial Mediterranean Fever (FMF) is a recurrent disease characterized by inflammatory process effecting synovial membranes such as peritoneum, pericardium and joints. It usually presents with acute abdominal pain. Intestinal obstruction secondary to adhesions may be observed in FMF patients. Sometimes diagnosing intestinal obstruction can be a challenging problem. We were presented a patient with FMF and adhesive intestinal obstruction. He was operated on after 10 days of symptoms. Delay in diagnosis and treatment of the case discussed with literature review.

Frequency of abdominal surgery in patients with familial Mediterranean fever

OBJECTIVE

Familial Mediterranean fever (FMF) is characterized by recurrent episodes of peritonitis. Abdominal FMF attacks can be indistinguishable from those of an acute abdominal emergency, and patients may undergo one or more laparotomies before the true nature of their disease is documented. The objectives of this study were to investigate the frequency and reasons for abdominal surgeries performed on patients with FMF.

METHODS

We retrospectively reviewed the files of 254 patients with FMF (127 males, 127 females, mean age 27.2+/-6.3 years). We also included 182 healthy individuals for this study (89 males, 93 females, mean age 27.6+/-5 years; range 11-43) to make a comparison between FMF and healthy controls (HC) with respect to frequency of abdominal operations.

RESULTS

The number of patients with abdominal surgery in FMF group was 74 (29.1%). The number of surgeries performed in 74 patients with FMF was 92. The first abdominal surgery before the diagnosis of FMF was appendectomy in 68 patients (26.6%). In HC group, the number of abdominal operations was found to be 16 (8.7%). Of these abdominal operations, 9 (4.9%) were due to appendectomy. The rate of total abdominal operations and appendectomy were significantly higher in FMF group than in HC group (p=0.0001).

CONCLUSION

Abdominal attacks of FMF patients may cause an unnecessary laparotomy prior to the diagnosis of FMF. FMF patients can present with abdominal emergency while they are receiving colchicine. Therefore, each abdominal pain should be carefully determined according to clinical findings. The purpose of this study was to emphasize the misdiagnosis of appendicitis.

The frequency of sacroiliitis in familial Mediterranean fever and the role of HLA-B27 and MEFV mutations in the development of sacroiliitis

The objective of this study was to investigate the frequency of sacroiliitis in familial Mediterranean fever (FMF) patients and the role of HLA-B27 and MEFV mutations in the development of sacroiliitis. The study group consisted of 256 FMF patients (male 128, female 128, mean age 27.2 +/- 6.3 years). After evaluation of the medical records, 70 patients (27.4%) were determined to have one or more of musculoskeletal manifestations. Sacroiliitis was determined in 18 (32.7%) FMF patients. The frequency of sacroiliitis among all FMF patients was found to be 7%. HLA-B27 was 47% and 6.3% in FMF patients with and without sacroiliitis, respectively. The frequency of M694V mutations in FMF patients with sacroiliitis was 93.7%. Sacroiliitis may be seen more frequently in FMF patients than expected. HLA-B27 positivity and/or M694V mutation may play a role in the development of sacroiliitis and the severity of seronegative spondyloarthropathy.

Cytokine orchestration in post-operative peritoneal adhesion formation

Peritoneal adhesions are a near inevitable occurrence after laparotomy and a major cause of both patient and physician misery. To date, clinical attempts at their amelioration have concentrated on manipulating the physical factors that affect their development despite a wealth of experimental data elucidating the molecular mechanisms that underlie their initiation, development and maturation. However, the advent of targeted, specific anti-cytokine agents as directed therapy for inflammatory and neoplastic conditions raises the prospect of a new era for anti-adhesion strategies. To harness this potential will require considerable cross-disciplinary collaboration and that surgeon-scientists propel themselves to the forefront of this emerging field.

Auto-inflammatory fever syndromes

Human autoinflammatory diseases (except for PFAPA) are a heterogeneous group of genetically determined diseases characterized by seemingly unprovoked inflammation in the absence of autoimmune or infective causes (Table 2). The last decade has witnessed tremendous advances in the understanding of these disorders. These advances have allowed therapeutic interventions resulting in improvement in the short-term and long-term morbidity of all of these diseases. Future research into the molecular mechanisms underlying these inflammatory diseases should lead to a better understanding of inflammatory diseases in general and, it is hoped, to better and more targeted therapies.