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Öner N, Çelikel E, Tekin ZE, Güngörer V, Tekgöz N, Sezer M, Karagöl C, Coşkun S, Kaplan MM, Polat MC, Acar BÇ. The effect of vitamin D supplementation on attacks in PFAPA syndrome patients with low vitamin D levels. Ir J Med Sci 2024; 193:823-830. [PMID: 37870706 DOI: 10.1007/s11845-023-03555-8] [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: 09/12/2023] [Accepted: 10/18/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND-AIM To evaluate the effect of vitamin D supplementation on the frequency and duration of attacks in patients of PFAPA syndrome with low vitamin D levels. METHODS This retrospective study comprised PFAPA patients with vitamin D deficiency/insufficiency between 2018 and 2023. The frequency and duration of PFAPA attacks before and after vitamin D supplementation were noted. RESULTS Seventy-one patients were included. Of the 71 patients, 24 (33.8%) had vitamin D insufficiency, and 47 (66.2%) had vitamin D deficiency. In patients with vitamin D insufficiency, mean attack frequency and mean attack duration before vitamin D supplementation were 4.3 ± 1.9/year and 2.2 ± 1.6 days, respectively, while mean attack frequency and mean attack duration after vitamin D supplementation were 3.5 ± 2.7/year per year and 1.3 ± 0.9 days respectively (p = 0.2, p = 0.2, respectively). In patients with vitamin D deficiency, mean attack frequency and mean attack duration before vitamin D supplementation were 7.4 ± 2.1/year and 2.2 ± 1.6 days, respectively, while mean attack frequency and mean attack duration after vitamin D supplementation were 3.3 ± 2.4/year and 1.3 ± 0.9 days respectively (p < 0.01, p = 0.04, respectively). When the vitamin D level and the frequency of attacks were compared, the cut-off value of vitamin D was found to be 29.7 nmol/L. CONCLUSIONS In PFAPA patients with low vitamin D levels, the frequency and duration of PFAPA attacks were reduced with vitamin D supplementation. Especially at vitamin D level cut-off > 29.7 nmol/L, the frequency of attacks reduced significantly.
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Affiliation(s)
- Nimet Öner
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey.
| | - Elif Çelikel
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey
| | - Zahide Ekici Tekin
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey
| | - Vildan Güngörer
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey
| | - Nilüfer Tekgöz
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey
| | - Müge Sezer
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey
| | - Cüneyt Karagöl
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey
| | - Serkan Coşkun
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey
| | - Melike Mehveş Kaplan
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey
| | - Merve Cansu Polat
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey
| | - Banu Çelikel Acar
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Bilkent, Ankara, 06800, Turkey
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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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3
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Nakamura H, Kikuchi A, Sakai H, Kamimura M, Watanabe Y, Onuma R, Takayama J, Tamiya G, Mashimo Y, Ebata R, Hamada H, Suenaga T, Onouchi Y, Kumaki S. Case Report: Identification of a CARD8 variant in all three patients with PFAPA syndrome complicated with Kawasaki disease. Front Pediatr 2024; 12:1340263. [PMID: 38510083 PMCID: PMC10952825 DOI: 10.3389/fped.2024.1340263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
Background Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA syndrome), and Kawasaki disease (KD) are both considered to be disorders of the innate immune system, and the potential role of inflammasome activation in the immunopathogenesis of both diseases has been previously described. Case presentation Herein, we report the clinical courses of three patients who presented a rare combination of PFAPA syndrome and KD. Two patients who presented KD later developed the PFAPA syndrome, of whom one developed recurrent KD 2 years after the initial diagnosis. The third patient developed KD one year after the onset of PFAPA syndrome. The presence of both of these conditions within individual patients, combined with the knowledge that inflammasome activation is involved in both PFAPA syndrome and KD, suggests a shared background of inflammatory dysregulation. To elucidate the mechanism underlying shared inflammatory dysregulation, we investigated the roles of Nod-like receptors (NLRs) and their downstream inflammasome-related genes. All the patients had a frameshift variant in CARD8 (CARD8-FS). A previous study demonstrated a higher frequency of CARD8-FS, whose product loses CARD8 activity and activates the NLRP3 inflammasome, in patients with the PFAPA syndrome. Additionally, the NLRP3 inflammasome is known to be activated in patients with KD. Together, these results suggest that the CARD8-FS variant may also be essential in KD pathogenesis. As such, we analyzed the CARD8 variants among patients with KD. However, we found no difference in the variant frequency between patients with KD and the general Japanese population. Conclusions We report the clinical courses of three patients with a rare combination of PFAPA syndrome and KD. All the patients had the CARD8-FS variant. However, we could not find a difference in the variant frequency between patients with KD and the general Japanese population. As the frequency of KD is much higher than that of PFAPA among Japanese patients, and the cause of KD is multifactorial, it is possible that only a small portion of patients with KD harbor CARD8-FS as a causative gene.
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Affiliation(s)
- Haruhiko Nakamura
- Department of Pediatrics, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Atsuo Kikuchi
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Hideyuki Sakai
- Department of Pediatrics, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Miki Kamimura
- Department of Pediatrics, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Yohei Watanabe
- Department of Pediatrics, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Ryoichi Onuma
- Department of Pediatrics, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Jun Takayama
- Department of Rare Disease Genomics, Tohoku University School of Medicine, Sendai, Japan
- Department of AI and Innovative Medicine, Tohoku University School of Medicine, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Statistical Genetics Team, RIKEN Center for Advanced Intelligence Project, Tokyo, Japan
| | - Gen Tamiya
- Department of Rare Disease Genomics, Tohoku University School of Medicine, Sendai, Japan
- Department of AI and Innovative Medicine, Tohoku University School of Medicine, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Statistical Genetics Team, RIKEN Center for Advanced Intelligence Project, Tokyo, Japan
| | - Yoichi Mashimo
- Department of Public Health, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ryota Ebata
- Department of Pediatrics, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hiromichi Hamada
- Department of Pediatrics, Tokyo Women’s Medical University Yachiyo Medical Center, Yachiyo, Japan
| | - Tomohiro Suenaga
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Yoshihiro Onouchi
- Department of Public Health, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoru Kumaki
- Department of Pediatrics, National Hospital Organization Sendai Medical Center, Sendai, Japan
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4
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Gazi U, Dalkan C, Sanlidag B, Cerit Z, Beyitler I, Narin Bahceciler N. Altered serum antibody levels in children with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis. Arch Rheumatol 2024; 39:99-106. [PMID: 38774691 PMCID: PMC11104745 DOI: 10.46497/archrheumatol.2023.9988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/02/2023] [Indexed: 05/24/2024] Open
Abstract
Objectives This study aimed to extend the literature by analyzing immunoglobulin (Ig) A, IgE, IgG, IgG2, IgG3, and IgM antibody levels in periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) patients. Patients and methods This study retrospectively analyzed the antibody test results of 20 pediatric patients (10 males, 10 females; mean age: 2.5±1.5 years; range, 0.5 to 5.4 years) with and without flare who were initially evaluated for a number of underlying diseases due to periodic fever/infectious symptoms but then diagnosed with PFAPA between January 2015 and December 2020. Antibody levels were determined by chemiluminescence microparticle immunoassay. The results were retrospectively compared with a group of healthy children after the PFAPA diagnosis was confirmed. Results The chemiluminescence microparticle immunoassay revealed 35%, 65%, 20%, 86.6%, and 55% of PFAPA cases with low serum levels of IgA, IgG, IgG2, IgG3, and IgM respectively, while 56.2% had high IgE levels. Moreover, low serum levels of at least two antibody classes or subclasses were reported in 80% of the PFAPA children. While cases with low IgG serum levels were with the highest incidence rates among the low IgG3 PFAPA patient population, both high IgE and low IgM cases were common in the rest of the patients. Conclusion Our results suggest an association between PFAPA and low serum antibody levels, particularly of IgG3. Future studies are needed to confirm our conclusion.
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Affiliation(s)
- Umut Gazi
- Medical Microbiology and Clinical Microbiology, Near East University, Nicosia, Cyprus
| | - Ceyhun Dalkan
- Department of Pediatrics, Near East University, Nicosia, Cyprus
| | - Burcin Sanlidag
- Department of Pediatrics, Near East University, Nicosia, Cyprus
| | - Zeynep Cerit
- Department of Pediatrics, Near East University, Nicosia, Cyprus
| | - Ilke Beyitler
- Department of Pediatrics, Near East University, Nicosia, Cyprus
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5
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Araya R, Men S, Uekusa Y, Yu Z, Kikuchi H, Daitoku K, Minakawa M, Kawaguchi S, Furukawa KI, Oshima Y, Imaizumi T, Seya K. The inhibitory effect of DIF-3 on polyinosinic-polycytidylic acid-induced innate immunity activation in human cerebral microvascular endothelial cells. J Pharmacol Sci 2024; 154:157-165. [PMID: 38395516 DOI: 10.1016/j.jphs.2024.01.005] [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: 08/07/2023] [Revised: 01/11/2024] [Accepted: 01/16/2024] [Indexed: 02/25/2024] Open
Abstract
For the treatment and prevention of autoinflammatory diseases, it is essential to develop the drug, regulating the innate immune system. Although differentiation-inducing factor (DIF) derivatives, extracted from the cellular slime mold, Dictyostelium discoideum, exhibit immunomodulatory effects, their effects on the regulation of innate immunity in brain are unknown. In this study, we used the human cerebral microvascular endothelial cell line, hCMEC/D3, to investigate the effects of DIF derivatives on the generation of C-X-C motif chemokine (CXCL) 10 and interferon (IFN)-β induced by polyinosinic-polycytidylic acid (poly IC). DIF-3 (1-10 μM), but not DIF-1 and DIF-2, dose-dependently inhibited the biosynthesis of not only CXCL10 but also CXCL16 and C-C motif chemokine 2 induced by poly IC. DIF-3 also strongly decreased IFN-β mRNA expression and protein release from the cells induced by poly IC through the prohibition of p65, a subtype of NF-ĸB, not interferon regulatory transcription factor 3 phosphorylation. In the docking simulation study, we confirmed that DIF-3 had a high affinity to p65. These results suggest that DIF-3 regulates the innate immune system by inhibiting TLR3/IFN-β signaling axis through the NF-ĸB phosphorylation inhibition.
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Affiliation(s)
- Ryusei Araya
- Department of Vascular Biology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Shihu Men
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Yoshinori Uekusa
- Division of Natural Medicines, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Zaiqiang Yu
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Haruhisa Kikuchi
- Division of Natural Medicines, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Kazuyuki Daitoku
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Masahito Minakawa
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Shogo Kawaguchi
- Department of Vascular Biology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Ken-Ichi Furukawa
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Yoshiteru Oshima
- Graduate School of Pharmaceutical Sciences, Tohoku University, Aoba-yama, Aoba-ku, Sendai, 980-8578, Japan
| | - Tadaatsu Imaizumi
- Department of Vascular Biology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Kazuhiko Seya
- Department of Vascular Biology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan.
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6
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Molina-López C, Hurtado-Navarro L, García CJ, Angosto-Bazarra D, Vallejo F, Tapia-Abellán A, Marques-Soares JR, Vargas C, Bujan-Rivas S, Tomás-Barberán FA, Arostegui JI, Pelegrin P. Pathogenic NLRP3 mutants form constitutively active inflammasomes resulting in immune-metabolic limitation of IL-1β production. Nat Commun 2024; 15:1096. [PMID: 38321014 PMCID: PMC10847128 DOI: 10.1038/s41467-024-44990-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 01/11/2024] [Indexed: 02/08/2024] Open
Abstract
Cryopyrin-associated periodic syndrome (CAPS) is an autoinflammatory condition resulting from monoallelic NLRP3 variants that facilitate IL-1β production. Although these are gain-of-function variants characterized by hypersensitivity to cell priming, patients with CAPS and animal models of the disease may present inflammatory flares without identifiable external triggers. Here we find that CAPS-associated NLRP3 variants are forming constitutively active inflammasome, which induce increased basal cleavage of gasdermin D, IL-18 release and pyroptosis, with a concurrent basal pro-inflammatory gene expression signature, including the induction of nuclear receptors 4 A. The constitutively active NLRP3-inflammasome of CAPS is responsive to the selective NLRP3 inhibitor MCC950 and its activation is regulated by deubiquitination. Despite their preactivated state, the CAPS inflammasomes are responsive to activation of the NF-κB pathway. NLRP3-inflammasomes with CAPS-associated variants affect the immunometabolism of the myeloid compartment, leading to disruptions in lipids and amino acid pathways and impaired glycolysis, limiting IL-1β production. In summary, NLRP3 variants causing CAPS form a constitutively active inflammasome inducing pyroptosis and IL-18 release without cell priming, which enables the host's innate defence against pathogens while also limiting IL-1β-dependent inflammatory episodes through immunometabolism modulation.
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Affiliation(s)
- Cristina Molina-López
- Molecular Inflammation Group, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla-IMIB, Murcia, Spain
| | - Laura Hurtado-Navarro
- Molecular Inflammation Group, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla-IMIB, Murcia, Spain
| | - Carlos J García
- Quality, Safety and Bioactivity of Plant-Derived Foods, Centro de Edafología y Biología Aplicada del Segura-Consejo Superior de Investigaciones Científicas (CEBAS-CSIC), Murcia, Spain
| | - Diego Angosto-Bazarra
- Molecular Inflammation Group, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla-IMIB, Murcia, Spain
| | - Fernando Vallejo
- Quality, Safety and Bioactivity of Plant-Derived Foods, Centro de Edafología y Biología Aplicada del Segura-Consejo Superior de Investigaciones Científicas (CEBAS-CSIC), Murcia, Spain
| | - Ana Tapia-Abellán
- Molecular Inflammation Group, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla-IMIB, Murcia, Spain
- Interfaculty Institute for Cell Biology, Department of Immunology, University of Tübingen, Auf der Morgenstelle 15, 72076, Tübingen, Germany
| | | | - Carmen Vargas
- Department of Rheumatology, Hospital Virgen de la Macarena, Sevilla, Spain
| | | | - Francisco A Tomás-Barberán
- Quality, Safety and Bioactivity of Plant-Derived Foods, Centro de Edafología y Biología Aplicada del Segura-Consejo Superior de Investigaciones Científicas (CEBAS-CSIC), Murcia, Spain
| | - Juan I Arostegui
- Department of Immunology, Hospital Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Pablo Pelegrin
- Molecular Inflammation Group, Instituto Murciano de Investigación Biosanitaria Pascual Parrilla-IMIB, Murcia, Spain.
- Department of Biochemistry and Molecular Biology B and Immunology, Faculty of Medicine, University of Murcia, 30120, Murcia, Spain.
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7
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Hill JA, Lee YJ, Vande Vusse LK, Xie H, Chung EL, Waghmare A, Cheng GS, Zhu H, Huang ML, Hill GR, Jerome KR, Leisenring WM, Zerr DM, Gharib SA, Dadwal S, Boeckh M. HHV-6B detection and host gene expression implicate HHV-6B as pulmonary pathogen after hematopoietic cell transplant. Nat Commun 2024; 15:542. [PMID: 38228644 PMCID: PMC10791683 DOI: 10.1038/s41467-024-44828-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/05/2024] [Indexed: 01/18/2024] Open
Abstract
Limited understanding of the immunopathogenesis of human herpesvirus 6B (HHV-6B) has prevented its acceptance as a pulmonary pathogen after hematopoietic cell transplant (HCT). In this prospective multicenter study of patients undergoing bronchoalveolar lavage (BAL) for pneumonia after allogeneic HCT, we test blood and BAL fluid (BALF) for HHV-6B DNA and mRNA transcripts associated with lytic infection and perform RNA-seq on paired blood. Among 116 participants, HHV-6B DNA is detected in 37% of BALs, 49% of which also have HHV-6B mRNA detection. We establish HHV-6B DNA viral load thresholds in BALF that are highly predictive of HHV-6B mRNA detection and associated with increased risk for overall mortality and death from respiratory failure. Participants with HHV-6B DNA in BALF exhibit distinct host gene expression signatures, notable for enriched interferon signaling pathways in participants clinically diagnosed with idiopathic pneumonia. These data implicate HHV-6B as a pulmonary pathogen after allogeneic HCT.
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Affiliation(s)
- Joshua A Hill
- Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA.
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA.
| | - Yeon Joo Lee
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
- Weill Cornell Medical College, 400 E 67th St, New York, NY, 10065, USA
| | - Lisa K Vande Vusse
- Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Hu Xie
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - E Lisa Chung
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Alpana Waghmare
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Guang-Shing Cheng
- Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Haiying Zhu
- Department of Laboratory Medicine and Pathology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Meei-Li Huang
- Department of Laboratory Medicine and Pathology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Geoffrey R Hill
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Keith R Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Department of Laboratory Medicine and Pathology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Danielle M Zerr
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Sina A Gharib
- Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Sanjeet Dadwal
- City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA, 91010, USA
| | - Michael Boeckh
- Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
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8
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Landy E, Carol H, Ring A, Canna S. Biological and clinical roles of IL-18 in inflammatory diseases. Nat Rev Rheumatol 2024; 20:33-47. [PMID: 38081945 DOI: 10.1038/s41584-023-01053-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 12/23/2023]
Abstract
Several new discoveries have revived interest in the pathogenic potential and possible clinical roles of IL-18. IL-18 is an IL-1 family cytokine with potent ability to induce IFNγ production. However, basic investigations and now clinical observations suggest a more complex picture. Unique aspects of IL-18 biology at the levels of transcription, activation, secretion, neutralization, receptor distribution and signalling help to explain its pleiotropic roles in mucosal and systemic inflammation. Blood biomarker studies reveal a cytokine for which profound elevation, associated with detectable 'free IL-18', defines a group of autoinflammatory diseases in which IL-18 dysregulation can be a primary driving feature, the so-called 'IL-18opathies'. This impressive specificity might accelerate diagnoses and identify patients amenable to therapeutic IL-18 blockade. Pathogenically, human and animal studies identify a preferential activation of CD8+ T cells over other IL-18-responsive lymphocytes. IL-18 agonist treatments that leverage the site of production or subversion of endogenous IL-18 inhibition show promise in augmenting immune responses to cancer. Thus, the unique aspects of IL-18 biology are finally beginning to have clinical impact in precision diagnostics, disease monitoring and targeted treatment of inflammatory and malignant diseases.
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Affiliation(s)
- Emily Landy
- Program in Microbiology and Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hallie Carol
- Division of Rheumatology and Immune Dysregulation Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Aaron Ring
- Translational Science and Therapeutics, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Scott Canna
- Program in Microbiology and Immunology, University of Pittsburgh, Pittsburgh, PA, USA.
- Division of Rheumatology and Immune Dysregulation Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Kapustova L, Banovcin P, Bobcakova A, Jurkova Malicherova E, Kapustova D, Petrovicova O, Slenker B, Markocsy A, Oleksak F, Vorcakova K, Jesenak M. The use of ketotifen as long-term anti-inflammatory prophylaxis in children with PFAPA syndrome. Front Immunol 2023; 14:1302875. [PMID: 38143757 PMCID: PMC10748580 DOI: 10.3389/fimmu.2023.1302875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA) is the most frequent periodic fever syndrome in children. Its pathogenesis is still unknown, but some disease-modifying factors were observed. Several medications were tested for the long-term prophylaxis of inflammatory flares; however, none are standardly used. Methods This prospective clinical trial enrolled 142 children (71 girls, 50%) meeting diagnostic criteria for PFAPA syndrome. We analysed selected clinical characteristics and compared laboratory parameters during the flare and attack-free period (at least two weeks after the attack). Moreover, we assessed the possible therapeutic effect of ketotifen on the duration of attack free-periods and clinical picture. Results The mean age of patients was 6.81 ± 3.03 years and the mean age of onset of symptoms was 2.31 ± 2.02 years. No significant differences were observed between genders.We recorded a positive family history for PFAPA in 31.69% of patients. Attacks lasted for 2.8 ± 1.2 days, with intervals between attacks of 4 ± 1 weeks. We administered ketotifen in 111 (77.8%) patients, and a positive effect was observed in 86 (77.5%) of patients. We observed prolonged attack-free intervals in patients treated with ketotifen (14.7 ± 8.9 days in comparison with 4.4 ± 1.9 days before the treatment; p<0.001). The used dose of ketotifen was 0.08 ± 0.01 mg/kg/day. Mild side effects were observed in four patients (restlessness, irritability, agitation and constipation). Discussion Our data supports the use of ketotifen for long-term prophylaxis in children with PFAPA syndrome with positive effects on the attenuation of disease activity and the prolongation of attack-free periods. Further well-designed studies should confirm the preliminary data.
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Affiliation(s)
- Lenka Kapustova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Peter Banovcin
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Anna Bobcakova
- Department of Pneumology and Phthisiology, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Eva Jurkova Malicherova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Daniela Kapustova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Otilia Petrovicova
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Branislav Slenker
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Adam Markocsy
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Filip Oleksak
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Karolina Vorcakova
- Clinic of Dermatovenerology, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
| | - Milos Jesenak
- Centre for Periodic Fever Syndromes, Department of Paediatrics, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
- Department of Pneumology and Phthisiology, University Hospital in Martin, Jessenius Faculty of Medicine of Comenius University in Bratislava, Martin, Slovakia
- Department of Clinical Immunology and Allergology, University Hospital in Martin, Martin, Slovakia
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Nozu T, Ohhira M, Ishioh M, Okumura T. Adult-onset Periodic Fever, Aphthous Stomatitis, Pharyngitis and Cervical Adenitis Syndrome Responsive to Colchicine. Intern Med 2023; 62:3555-3558. [PMID: 37062730 PMCID: PMC10749813 DOI: 10.2169/internalmedicine.1364-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/08/2023] [Indexed: 04/18/2023] Open
Abstract
We herein report a rare case of periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome that occurred in an 18-year-old man. He visited our hospital with recurrent episodes of a fever, pharyngitis and adenitis without suggestive findings of infection. These episodes resolved within 5 days and recurred quite regularly, with an interval of about 30 days. As the febrile episodes significantly impaired his quality of life, he was treated with colchicine (0.5 mg) as prophylaxis. This completely prevented the episodes during six months of follow-up. Colchicine may therefore be effective in cases of adult-onset PFAPA syndrome.
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Affiliation(s)
- Tsukasa Nozu
- Department of Regional Medicine and Education, Asahikawa Medical University, Japan
- Center for Medical Education, Asahikawa Medical University, Japan
| | - Masumi Ohhira
- Department of General Medicine, Asahikawa Medical University, Japan
| | - Masatomo Ishioh
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Toshikatsu Okumura
- Department of General Medicine, Asahikawa Medical University, Japan
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
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11
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Manthiram K. What is PFAPA syndrome? Genetic clues about the pathogenesis. Curr Opin Rheumatol 2023; 35:423-428. [PMID: 37467064 PMCID: PMC10538419 DOI: 10.1097/bor.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
PURPOSE OF REVIEW Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in childhood. Recent studies report genetic susceptibility variants for PFAPA syndrome and the efficacy of tonsillectomy in a broader cohort of patients with recurrent stereotypical fever. In this review, we highlight the findings of these studies and what they may reveal about the pathogenesis of PFAPA. RECENT FINDINGS Newly identified genetic susceptibility loci for PFAPA suggest that it is a complex genetic disorder linked to Behçet's disease and recurrent aphthous ulcers. Patients who have PFAPA with some features of Behçet's disease have been reported. Moreover, the efficacy of tonsillectomy has now been described in patients who do not meet the full diagnostic criteria for PFAPA, although the immunologic profile in the tonsils is different from those with PFAPA. Factors that predict response to tonsillectomy are also reported. SUMMARY These findings highlight the heterogeneous phenotypes that may be related to PFAPA due to common genetic susceptibility or response to therapy. These relationships raise questions about how to define PFAPA and highlight the importance of understanding of the genetic architecture of PFAPA and related diseases.
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Affiliation(s)
- Kalpana Manthiram
- Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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12
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Rigante D, Calò L, Ciavarro A, Galli J. A Potential Partnership between Genetics and the Oral Microbiome in Children Displaying Periodic Fever/Aphthosis/Pharyngitis/Adenitis Syndrome. Int J Mol Sci 2023; 24:15505. [PMID: 37958489 PMCID: PMC10648810 DOI: 10.3390/ijms242115505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 11/15/2023] Open
Abstract
Periodic fever/aphthosis/pharyngitis/adenitis (PFAPA) syndrome was initially described in a small cohort of American children [...].
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Affiliation(s)
- Donato Rigante
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.C.); (J.G.)
| | - Lea Calò
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.C.); (J.G.)
- Complex Unit of Otolaryngology, Department of Aging, Neurological, Orthopedic and Head and Neck Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Alessandro Ciavarro
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Via Cracovia 50, 00133 Rome, Italy;
| | - Jacopo Galli
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.C.); (J.G.)
- Complex Unit of Otolaryngology, Department of Aging, Neurological, Orthopedic and Head and Neck Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
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13
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Onur H, Onur AR. Diagnostic performance of routine blood parameters in periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. J Clin Lab Anal 2023; 37:e24934. [PMID: 37428978 PMCID: PMC10431407 DOI: 10.1002/jcla.24934] [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: 01/29/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND We aimed to investigate the difference between PFAPA and streptococcal tonsillitis (Strep Pharyngitis) by using blood parameters. We want to evaluate the relationship between periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome, and tonsillitis by using NLR. METHODS The data of 141 pediatric patients who had applied to our clinic between October 2016 and March 2019 and were diagnosed with PFAPA syndrome and tonsillitis were reviewed from hospital records. The demographic data of the study group were recorded, as were their WBC, neutrophil, and lymphocyte counts, NLR, and MPV values, which are obtained by proportioning these two counts. RESULTS CRP and ESR values were significantly higher in the PFAPA group (p = 0.026 and p < 0.001, respectively). No significant difference was determined between the groups in terms of platelet count or lymphocyte count. Receiver operating curve analyses were calculated. The AUC was 0.713 ± 0.04 according to age, and the CRP was 0.607 ± 0.04 (95% confidence interval). Using a cutoff point of >49 months for age, the sensitivity was 0.71 and the specificity was 0.67. CONCLUSION With simple laboratory parameters, PFAPA syndrome can be differentiated from a diagnosis of tonsillitis. This may reduce the costs associated with unnecessary antibiotic use. However, these findings still need to be confirmed by other future studies.
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Affiliation(s)
- Hakan Onur
- Department of PediatricsMemorial Private Diyarbakir HospitalDiyarbakirTurkey
| | - Arzu Rahmanali Onur
- Department of Medical MicrobiologyGazi Yasargil Education and Research HospitalDiyarbakirTurkey
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Hausmann J, Dedeoglu F, Broderick L. Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis Syndrome and Syndrome of Unexplained Recurrent Fevers in Children and Adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1676-1687. [PMID: 36958521 DOI: 10.1016/j.jaip.2023.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 03/25/2023]
Abstract
Children and adults with autoinflammatory disorders, who often experience recurrent fevers, rashes, cold-induced symptoms, conjunctivitis, lymphadenopathy, recurrent infections, aphthous stomatitis, and abnormal blood cell counts, may present to the allergist/immunologist because the symptoms mimic allergies and disorders of immunity. In recent years, there has been increased recognition of non-monogenic autoinflammatory disorders, including periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome and syndrome of undifferentiated recurrent fevers. For many clinical practitioners, the natural history, diagnostic criteria, differential diagnoses, and preferred therapies remain challenging because of the presumed rarity of patients and the evolving field of autoinflammation. Here, we aim to provide a practical framework for the clinical allergist/immunologist to evaluate and treat this patient population.
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Affiliation(s)
- Jonathan Hausmann
- Department of Medicine, Harvard Medical School, Boston, Mass; Program in Rheumatology, Division of Immunology, Boston Children's Hospital, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Fatma Dedeoglu
- Department of Medicine, Harvard Medical School, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Lori Broderick
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of California-San Diego, La Jolla, Calif; Rady Children's Foundation, Rady Children's Hospital, San Diego, Calif.
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15
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Zhang Y, Gao Y, Jiang Y, Ding Y, Chen H, Xiang Y, Zhan Z, Liu X. Histone demethylase KDM5B licenses macrophage-mediated inflammatory responses by repressing Nfkbia transcription. Cell Death Differ 2023; 30:1279-1292. [PMID: 36914768 PMCID: PMC10154333 DOI: 10.1038/s41418-023-01136-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 03/16/2023] Open
Abstract
Macrophages play a critical role in the immune homeostasis and host defense against invading pathogens. However, uncontrolled activation of inflammatory macrophages leads to tissue injury and even fuels autoimmunity. Hence the molecular mechanisms underlying macrophage activation need to be further elucidated. The effects of epigenetic modifications on the function of immune cells draw increasing attention. Here, we demonstrated that lysine-specific demethylase 5B (KDM5B), a classical transcriptional repressor in stem cell development and cancer, was required for the full activation of NF-κB signaling cascade and pro-inflammatory cytokine production in macrophages. KDM5B deficiency or inhibitor treatment protected mice from immunologic injury in both collagen-induced arthritis (CIA) model and endotoxin shock model. Genome-wide analysis of KDM5B-binding peaks identified that KDM5B was selectively recruited to the promoter of Nfkbia, the gene encoding IκBα, in activated macrophages. KDM5B mediated the H3K4me3 modification erasing and decreased chromatin accessibility of Nfkbia gene locus, coordinating the elaborate suppression of IκBα expression and the enhanced NF-κB-mediated macrophage activation. Our finding identifies the indispensable role of KDM5B in macrophage-mediated inflammatory responses and provides a candidate therapeutic target for autoimmune and inflammatory disorders.
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Affiliation(s)
- Yunkai Zhang
- Department of Pathogen Biology, Naval Medical University, Shanghai, 200433, China
- National Key Laboratory of Medical Immunology, Naval Medical University, Shanghai, 200433, China
| | - Ying Gao
- Department of Rheumatology, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
- Key Laboratory of Arrhythmias of the Ministry of Education of China, Research Center for Translational Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Yuyu Jiang
- Department of Pathogen Biology, Naval Medical University, Shanghai, 200433, China
| | - Yingying Ding
- Department of Pathogen Biology, Naval Medical University, Shanghai, 200433, China
| | - Huiying Chen
- Department of Pathogen Biology, Naval Medical University, Shanghai, 200433, China
| | - Yan Xiang
- Department of Pathogen Biology, Naval Medical University, Shanghai, 200433, China
| | - Zhenzhen Zhan
- Key Laboratory of Arrhythmias of the Ministry of Education of China, Research Center for Translational Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China.
- Department of Liver Surgery, Shanghai Institute of Transplantation, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.
| | - Xingguang Liu
- Department of Pathogen Biology, Naval Medical University, Shanghai, 200433, China.
- National Key Laboratory of Medical Immunology, Naval Medical University, Shanghai, 200433, China.
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Hara M, Morimoto N, Watabe T, Morisaki N, Matsumoto K. Can the effectiveness of tonsillectomy for PFAPA syndrome be predicted based on clinical factors. Int J Rheum Dis 2023; 26:480-486. [PMID: 36608697 DOI: 10.1111/1756-185x.14559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/28/2022] [Accepted: 12/26/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To evaluate the clinical factors associated with the outcome of tonsillectomy in children with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome, thereby clarifying who would most likely benefit from that surgery. METHODS This was a case-control study of 53 PFAPA patients who underwent tonsillectomy and were divided into a complete-resolution group and a postoperative-fever group. Logistic regression analyses were performed using 17 clinical factors as variables to identify factors associated with the surgical outcome. Hierarchical cluster analysis was also performed to evaluate for relationships between phenotypes and surgical outcomes. RESULTS Thirty-nine (73.6%) patients had complete resolution after tonsillectomy. In simple logistic regression analysis, the surgical outcome showed significant positive trends with late-onset (odds ratio [OR] 7.1, P = 0.02) and presence of headache (OR 6.5, P = 0.01). In stepwise multiple logistic regression analysis adjusted for age at onset, presence of headache was significantly associated with complete resolution (OR 6.5, P = 0.01). The complete resolution rates for each combination of headache status and age at onset were as follows: presence of headache/age at onset ≥36 months, 100% (14/14); presence of headache/age at onset <36 months, 76.9% (10/13); absence of headache/age at onset ≥36 months, 75.0% (6/8); and absence of headache/age at onset <36 months, 43.8% (7/16). In hierarchical cluster analysis, complete resolution, age at onset, and headache were in the same cluster. CONCLUSIONS PFAPA patients with headache and late onset responded well to tonsillectomy. The mechanisms underlying this association may warrant further investigation.
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Affiliation(s)
- Mariko Hara
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan.,Department of Otorhinolaryngology, National Center for Child Health and Development, Tokyo, Japan
| | - Noriko Morimoto
- Department of Otorhinolaryngology, National Center for Child Health and Development, Tokyo, Japan
| | - Takahisa Watabe
- Department of Otorhinolaryngology, National Center for Child Health and Development, Tokyo, Japan
| | - Naho Morisaki
- Division of Lifecourse Epidemiology, Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Kenji Matsumoto
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
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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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Sopeña B, Araújo O, Freire M, Barrera-López L, Hernández-Rodríguez J. Efficacy of canakinumab in a patient with adult-onset glucocorticoid-resistant periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome. Mod Rheumatol Case Rep 2023; 7:276-279. [PMID: 35639987 DOI: 10.1093/mrcr/rxac043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/10/2022] [Accepted: 04/30/2022] [Indexed: 01/07/2023]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome, a polygenic or multifactorial condition, is the most frequent autoinflammatory disease in children. There is increasing evidence that some patients may have a disease onset during adulthood. With regard to PFAPA syndrome treatment, single medium-to-high doses of glucocorticoids during flares constitute the therapy of choice in children and adults, colchicine may be useful in some patients, and tonsillectomy has been reported of utility mainly in paediatric patients. Interleukin-1 (IL-1) blockers have been sporadically used with good response in glucocorticoid-resistant cases. We report a patient with an adult onset of glucocorticoid-resistant PFAPA syndrome and inconsistent response to colchicine and anakinra, who later achieved a complete and sustained response to canakinumab. Although canakinumab seems to be a good therapeutic option in paediatric and adult patients with refractory PFAPA syndrome, the best anti-IL-1 agent and the sequence of administration have to be still determined in well-designed clinical trials.
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Affiliation(s)
- Bernardo Sopeña
- Department of Internal Medicine, Complejo Hospitalario Universitario de Santiago, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Olga Araújo
- Vasculitis Research Unit and Clinical Unit of Autoinflammatory Diseases, Department of Autoimmune Diseases, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Mayka Freire
- Department of Internal Medicine, Complejo Hospitalario Universitario de Santiago, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Lucía Barrera-López
- Department of Internal Medicine, Complejo Hospitalario Universitario de Santiago, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José Hernández-Rodríguez
- Vasculitis Research Unit and Clinical Unit of Autoinflammatory Diseases, Department of Autoimmune Diseases, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Kaynak D, Yildiz M, Sahin S, Haslak F, Gunalp A, Adrovic A, Barut K, Gunver MG, Kasapcopur O, Dasdemir S. NLRP3 gene variants and serum NLRP3 levels in periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome. Clin Rheumatol 2023; 42:245-251. [PMID: 36087224 DOI: 10.1007/s10067-022-06370-1] [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: 07/08/2022] [Revised: 08/25/2022] [Accepted: 09/05/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Although most of the autoinfammatory disorders have a confirmed genetic cause, periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome still has an unknown genetic background. However, familial cases of PFAPA syndrome have been reported suggesting a genetic its basis. PFAPA syndrome may also be considered an infammasome disorder as variants in infammasome-associated genes such as CARD8, NLRP3, and MEFV have been reported to contribute to the disease. METHODS Polymerase chain reaction (PCR)/Sanger sequencing analysis was performed for the detection of the variations in 71 PFAPA patients and 71 healthy controls. NLRP3 concentrations in serum were measured in 71 PFAPA patients and 71 healthy controls. RESULTS No statistically significant differences were observed in the allele or genotype frequencies of the NLRP3 polymorphisms between the controls and patients (P > 0.05). We found no significant differences for NLRP3 serum levels between PFAPA patients and controls (p > 0.05). Mutations in the MEFV gene were detected in 32.5% of our patients (13/40). CONCLUSIONS It seems that the synergistic effect of different genes plays a role in the formation of PFAPA syndrome. For this reason, it may be useful to examine the presence of mutations in genes such as NLRP3, MEFV, and CARD8 together while investigating the genetics of PFAPA syndrome. Key points • Familial cases of PFAPA syndrome have been reported suggesting a genetic basis for this syndrome. • Elevated serum or plasma levels of IL-1β, IL-6, and IL-18 have been demonstrated during PFAPA flares in several studies. • It seems that the synergistic effect of different genes plays a role in the formation of PFAPA syndrome.
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Affiliation(s)
- Damla Kaynak
- Department of Medical Biology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Yildiz
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Fatih Haslak
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Aybuke Gunalp
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mehmet Guven Gunver
- Department of Bioistatistics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Selcuk Dasdemir
- Department of Medical Biology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
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20
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Faydhi SA, Kanawi HMA, Al-Khatib T, Zawawi F. The Association Between Vitamin D Level and PFAPA Syndrome: A Systematic Review. Indian J Otolaryngol Head Neck Surg 2022; 74:5548-5555. [PMID: 36742791 PMCID: PMC9895145 DOI: 10.1007/s12070-021-02913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/02/2021] [Indexed: 02/07/2023] Open
Abstract
Periodic Fever, Aphthous Ulcers, Pharyngitis and Adenitis (PFAPA) Syndrome's etiology is not well understood. The objective of this study is to explore the association between vitamin D level and PFAPA syndrome. A systematic review of all publications addressing the association between vitamin D level and PFAPA syndrome prior to May 2019 was conducted. Data were collected from online medical databases namely, PubMed, Ovid Medline, Embase, Cochrane Library, Google Scholar, and Scopus. The review adhered to the PRISMA statement and was performed in 3 main phases; an initial screening review of abstracts was performed, followed by a detailed review of full articles based on inclusion and exclusion criteria, and lastly a final review to extract data from selected articles. 3 prospective review-based and one case report articles were included with a total of 281 patients, 98 of whom were cases of PFAPA, while 183 were controls. Vitamin D levels were deficient in 27% of PFAPA group as compared with the control. Vitamin D supplementation was given as an initial treatment in 25/98 of the patients. Only 1 patient received it as a second treatment. After vitamin D supplementation, a marked reduction of the number of febrile episodes and modification of the mean duration were recognized. There may be an association between Vitamin D deficiency and a higher frequency of PFAPA episodes. Vitamin D supplementation in children with PFAPA may reduce the frequency of episodes and help manage the condition.
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Affiliation(s)
- Sara A. Faydhi
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hala M. A. Kanawi
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Talal Al-Khatib
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Faisal Zawawi
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Banday AZ, Joshi V, Arora K, Sadanand R, Basu S, Pilania RK, Jindal AK, Vignesh P, Gupta A, Sharma S, Dhaliwal M, Rawat A, Singh S, Suri D. Challenges in the diagnosis of periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome in developing countries—A decade of experience from North India. Front Immunol 2022; 13:958473. [PMID: 36203600 PMCID: PMC9530276 DOI: 10.3389/fimmu.2022.958473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/25/2022] [Indexed: 12/04/2022] Open
Abstract
Background Reports of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome from developing countries are sparse. Recognizing PFAPA is often challenging in these regions due to a higher incidence of infectious illnesses and significant resource constraints. Herein, we present our experience from North India regarding the diagnosis and management of PFAPA syndrome. Methods We reviewed cases of non-monogenic periodic fever syndrome diagnosed at our center from January 2011 to December 2021. A total of 17 children who fulfilled the Marshall criteria for PFAPA syndrome were included. Data regarding basic clinical features, treatment/outcome, and performance of the recently proposed Eurofever/PRINTO and Takeuchi criteria were analyzed. Results Besides recurrent fever, the triad of oral aphthae, pharyngitis, and adenitis was noted in only 18% of patients. Episodes of exudative pharyngitis/tonsillitis were documented in 24%. These figures were lower than the values reported from developed countries. The Takeuchi and Eurofever/PRINTO criteria were fulfilled in 76% and 71% cases, respectively. In addition to antipyretics and supportive care, intermittent steroid therapy was the main treatment modality used. Additional treatment with colchicine (n = 3) and thalidomide (n = 1) was used successfully in a few patients. Before the diagnosis of PFAPA, all patients had received multiple courses of antimicrobials (without microbiological confirmation). These included multiple courses of antibacterials for fever, pharyngotonsillitis, and/or cervical adenitis in all patients and antivirals for fever and aphthous stomatitis in a patient. Empiric antitubercular therapy had also been administered in two patients. Conclusions A significant proportion of patients with PFAPA seem to remain undiagnosed in the Indian subcontinent. Increased awareness and improvement in basic healthcare facilities are crucial in enhancing the recognition of PFAPA, which would eliminate the unprecedented scale of undesirable antimicrobial use in such children.
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22
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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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Efthimiou P, Petryna O, Nakasato P, Kontzias A. New insights on multigenic autoinflammatory diseases. Ther Adv Musculoskelet Dis 2022; 14:1759720X221117880. [PMID: 36081748 PMCID: PMC9445512 DOI: 10.1177/1759720x221117880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/14/2022] [Indexed: 11/16/2022] Open
Abstract
Autoinflammatory diseases are disorders of the innate immune system, which can be either monogenic due to a specific genetic mutation or complex multigenic due to the involvement of multiple genes. The aim of this review is to explore and summarize the recent advances in pathogenesis, diagnosis, and management of genetically complex autoinflammatory diseases, such as Schnitzler's syndrome; adult-onset Still's disease; synovitis, acne, pustulosis, hyperostosis, osteitis syndrome/chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis; Adamantiades-Behçet's disease; Yao syndrome; and periodic fever with aphthous stomatitis, pharyngitis, and adenitis syndrome. The PubMed database was screened for relevant articles using free text words and specific search strings. The search was limited to English-language articles, reporting the results of studies in humans, published through March 2021. Evidence from literature suggest that these rare multigenic autoinflammatory diseases can present with different clinical features and the diagnosis of these diseases can be challenging due to a combination of nonspecific manifestations that can be seen in a variety of other conditions. Diagnostic delays and disease complications may occur due to low disease awareness and the lack of pathognomonic markers. The pathogeneses of these diseases are complex and in some cases precise pathogenesis is not clearly understood. Conventional treatments are commonly used for the management of these conditions, but biologics have shown promising results. Biologics targeting proinflammatory cytokines including IL-1, IL-6, TNF-α, IL-17A and IL-18 have been shown to ameliorate signs and symptoms of different multigenic autoinflammatory diseases.
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Affiliation(s)
- Petros Efthimiou
- New York Rheumatology Care, Ross University School of Medicine, New York, USA
| | - Olga Petryna
- NYU Grossman School of Medicine, New York, NY, USA
| | | | - Apostolos Kontzias
- Department of Rheumatology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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Lazea C, Damian L, Vulturar R, Lazar C. PFAPA Syndrome: Clinical, Laboratory and Therapeutic Features in a Single-Centre Cohort. Int J Gen Med 2022; 15:6871-6880. [PMID: 36061962 PMCID: PMC9439650 DOI: 10.2147/ijgm.s373942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study is to describe a group of Romanian children with periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome. Materials This consisted of 39 children diagnosed with PFAPA syndrome according to Thomas’ criteria (eight patients with an age at diagnosis <1 year and 31 patients with an age at diagnosis >1 year). Methods Retrospective analysis of the patients with PFAPA syndrome was focused on clinical features, laboratory findings and therapeutic methods. Comparison between the two groups divided by age at onset was also investigated. Results Median age at onset was 1.58 years, and median age at diagnosis was 2.97 years. The mean interval between episodes was 35.5 days and the mean duration per febrile episode was 4.1 days. The median diagnosis delay was 2.42 years. The patients presented pharyngitis (100%), adenitis (94.8%) and aphthous lesions (66.7%). The frequency of febrile attacks was higher in children with an age at diagnosis under 1 year (p = 0.0287). Younger age was associated with the presence of aphthae. The mean value of C-reactive protein (CRP) was 7.9mg/dl and the mean value of leucocytes was 14,839/mm3. In 95% of patients given oral corticosteroids, remission of symptoms was reported within 24 h. In three patients, tonsillectomy was performed with complete remission of the disease. Conclusion We present a cohort of children with PFAPA syndrome, with clinical and laboratory features similar to those described in the literature. Febrile attacks had a higher incidence in children with younger age at the onset of the disease. The patients had a favorable response to corticosteroids.
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Affiliation(s)
- Cecilia Lazea
- Department Pediatrics I, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Correspondence: Cecilia Lazea, Department Pediatrics I, University of Medicine and Pharmacy “Iuliu Hatieganu”, 68, Motilor street, Cluj-Napoca, 400370, Romania, Email ;
| | - Laura Damian
- Department of Rheumatology, County Emergency Clinical Hospital Cluj-Napoca, Centre for Rare Musculoskeletal Autoimmune and Autoinflammatory Diseases, Cluj-Napoca, Romania
| | - Romana Vulturar
- Department of Molecular Sciences, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Calin Lazar
- Department Pediatrics I, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
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25
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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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26
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The Preferential Use of Anakinra in Various Settings of FMF: A Review Applied to an Updated Treatment-Related Perspective of the Disease. Int J Mol Sci 2022; 23:ijms23073956. [PMID: 35409316 PMCID: PMC8999740 DOI: 10.3390/ijms23073956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 02/04/2023] Open
Abstract
Familial Mediterranean fever (FMF), the most frequent monogenic autoinflammatory disease, is manifested with recurrent and chronic inflammation and amyloid A (AA) amyloidosis, driven by overproduction of interleukin 1 (IL-1) through an activated pyrin inflammasome. Consequently, non-responsiveness to colchicine, the cornerstone of FMF treatment, is nowadays addressed by IL-1- blockers. Each of the two IL-1 blockers currently used in FMF, anakinra and canakinumab, has its own merits for FMF care. Here we focus on anakinra, a recombinant form of the naturally occurring IL-1 receptor antagonist, and explore the literature by using PubMed regarding the utility of anakinra in certain conditions of FMF. Occasionally we enrich published data with our own experience. To facilitate insights to anakinra role, the paper briefs some clinical, genetic, pathogenetic, and management aspects of FMF. The clinical settings of FMF covered in this review include colchicine resistance, AA amyloidosis, renal transplantation, protracted febrile myalgia, on- demand use, leg pain, arthritis, temporary suspension of colchicine, pediatric patients, and pregnancy and lactation. In many of these instances, either because of safety concerns or a necessity for only transient and short-term use, anakinra, due to its short half-life, is the preferred IL-1 blocker.
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27
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Calabrese L, Fiocco Z, Satoh TK, Peris K, French LE. Therapeutic potential of targeting IL-1 family cytokines in chronic inflammatory skin diseases. Br J Dermatol 2022; 186:925-941. [PMID: 34990008 DOI: 10.1111/bjd.20975] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/15/2021] [Accepted: 12/30/2021] [Indexed: 11/27/2022]
Abstract
The interleukin-1 (IL-1) family of cytokines is a central regulator of a myriad of immunological responses. It comprises several cytokines, including those belonging to the IL-1, IL-36 and IL-18 subfamilies, as well as IL-33. The IL-1 family primarily plays a role in orchestrating innate immune responses but also in adaptive immunity. Increased interest in the IL-1 family occurred following the discovery that dysregulation of IL-1 signalling underlies the pathogenesis of several monogenic auto-inflammatory diseases, characterized by sterile inflammation involving the skin and other organs. This also provided increased understanding of the role of innate immunity and the IL-1 family in polygenic auto-inflammatory skin conditions, such as neutrophilic dermatoses, as well as in some of the most common chronic inflammatory skin diseases, such as psoriasis or hidradenitis suppurativa. Several therapeutic agents have been developed to inhibit the IL-1 family members and their signalling pathways. These have shown therapeutic efficacy in several chronic inflammatory skin disorders. The aim of this review is to thoroughly describe the consequences of pathological dysregulation of IL-1, IL-33, IL-36, IL-18 pathways in dermatological conditions and to provide a forward-looking update on therapeutic strategies targeting signalling by IL-1 family cytokines.
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Affiliation(s)
- Laura Calabrese
- Institute of Dermatology, Catholic University of the Sacred Heart, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Zeno Fiocco
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Takashi K Satoh
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Ketty Peris
- Institute of Dermatology, Catholic University of the Sacred Heart, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lars E French
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany.,Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida
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28
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Oral Lesions in Children and Adolescents. Pediatr Dent 2022. [DOI: 10.1007/978-3-030-78003-6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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29
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Systemic Autoinflammatory Diseases: A Growing Family of Disorders of Overlapping Immune Dysfunction. Rheum Dis Clin North Am 2021; 48:371-395. [PMID: 34798958 DOI: 10.1016/j.rdc.2021.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Systemic autoinflammatory diseases (SAIDs) are characterized by unprovoked exaggerated inflammation on a continuum from benign recurrent oral ulceration to life-threatening strokes or amyloidosis, with renal failure as a potential sequela. The ability to discriminate these diagnoses rests on the genetic and mechanistic defect of each disorder, considering potential overlapping autoinflammation, autoimmunity, and immune deficiency. A comprehensive and strategic genetic investigation influences management as well as the consequential expected prognoses in these subsets of rare diseases. The ever-expanding therapeutic armamentarium reflects international collaborations, which will hasten genetic discovery and consensus-driven treatment.
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30
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Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome: A review. World J Otorhinolaryngol Head Neck Surg 2021; 7:166-173. [PMID: 34430824 PMCID: PMC8356195 DOI: 10.1016/j.wjorl.2021.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/20/2021] [Indexed: 01/13/2023] Open
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is the most common periodic fever condition in children, with most cases appearing by the age of 5. Although PFAPA is generally a self-limited condition, it can have a major impact on a child's quality of life, as well as that of their family. Recent research has continued to shed light on the genetic and immunologic factors that play a role in the pathogenesis of PFAPA. There also exists significant heterogeneity in treatment strategies, and progress has been made to develop evidence-based management strategies and establish a standard of care. This review will outline current knowledge regarding the pathogenesis of PFAPA, as well as treatment strategies and our clinical experience.
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31
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Dusser P, Koné-Paut I. Still's Disease in the Constellation of Hyperinflammatory Syndromes: A Link with Kawasaki Disease? J Clin Med 2021; 10:jcm10153244. [PMID: 34362028 PMCID: PMC8348569 DOI: 10.3390/jcm10153244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/18/2021] [Accepted: 07/21/2021] [Indexed: 12/17/2022] Open
Abstract
Still’s disease and Kawasaki disease (KD) today belong to the group of cytokine storm syndromes, a pathophysiological set related to excessive activation of the innate immune response. We present here a personal vision of what can link these two diseases, taking up their concepts at their beginning. By their many clinical and physiopathological similarities, we conclude that they constitute a common spectrum whose fate is modified by subtle differences in terms of adaptive response that could, in part, be driven by genetic factors.
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Affiliation(s)
- Perrine Dusser
- Paediatric Rheumatology Department, Université Paris-Saclay, APHP, Bicêtre Hospital, 94270 Le Kremlin-Bicêtre, France;
- Centre de Référence des Maladies Auto-Inflammatoires et des Amyloses Inflammatoire (CEREMAIA), Université Paris-Saclay, APHP, Bicêtre Hospital, 94270 Le Kremlin-Bicêtre, France
| | - Isabelle Koné-Paut
- Paediatric Rheumatology Department, Université Paris-Saclay, APHP, Bicêtre Hospital, 94270 Le Kremlin-Bicêtre, France;
- Centre de Référence des Maladies Auto-Inflammatoires et des Amyloses Inflammatoire (CEREMAIA), Université Paris-Saclay, APHP, Bicêtre Hospital, 94270 Le Kremlin-Bicêtre, France
- Correspondence:
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32
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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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33
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Gazi U, Ozkayalar H, Mujahed MIM, Tosun O, Dalkan C, Sanlidag B, Asım Safak M, Mocan G, Onder Bahceciler N. Altered tonsillar toll-like receptor (TLR)-1 and TLR-2 expression levels between periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA), and group A beta-hemolytic streptococcal (GAβHS) recurrent tonsillitis patients. Int J Pediatr Otorhinolaryngol 2021; 144:110674. [PMID: 33725589 DOI: 10.1016/j.ijporl.2021.110674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/16/2021] [Accepted: 03/07/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Tonsillar microenvironment is thought to contribute to innate immune dysregulation responsible for the periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) because of beneficial effects of tonsillectomy on treatment of the syndrome. Accordingly previous studies reported altered lymphocyte frequency, cytokine level and microbial composition in PFAPA tonsils. The aim of our study is to monitor expression levels of pro-inflammatory cell surface Toll-like receptors (TLRs) which have important role in induction of inflammation and maintaining tissue haemostasis. MATERIALS AND METHODS Seven patients with PFAPA syndrome, and eight patients with group A beta-hemolytic streptococcal (GAβHS) recurrent tonsillitis were included in our study. Tonsillar expression levels of TLR-1, -2, -4, -5, and -6 were monitored by immunohistochemistry (IHC). Expression levels were scored using semi-quantitative analysis method and were statistically analyzed by Two-Way Repeated Measures Analysis of Variance test. RESULTS IHC analysis demonstrated expression of all TLRs in tonsillar surface epithelium (SE) and lymphoid interior (LI) except for TLR-6 which was not present in the former. There has not been any statistically significant difference in TLR expression levels between PFAPA and GAβHS tonsils, except for TLR-1 and TLR-2 which were higher on LI and lower on SE of PFAPA tonsils, respectively, than that of the GAβHS samples. CONCLUSIONS Altered TLR expression levels may be involved in PFAPA pathogenesis. Future studies with higher patient number, uninflamed tonsils and cellular markers are required to further enlighten the role of TLRs in the development of syndrome.
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Affiliation(s)
- Umut Gazi
- Department of Medical Microbiology and Clinical Microbiology, Faculty of Medicine, Near East University, Nicosia, Cyprus.
| | - Hanife Ozkayalar
- Department of Pathology, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Monjed I M Mujahed
- Department of Medical Microbiology and Clinical Microbiology, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Ozgur Tosun
- Department of Biostatistics, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Ceyhun Dalkan
- Department of Pediatrics, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Burcin Sanlidag
- Department of Pediatrics, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Mustafa Asım Safak
- Department of Otorhinolaryngology, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Gamze Mocan
- Department of Pathology, Faculty of Medicine, Near East University, Nicosia, Cyprus
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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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Kuzu S, Günebakan Ç, Yıldız E, Kahveci OK, Bucak A. Vestibular involvement of PFAPA syndrome. Am J Otolaryngol 2021; 42:102903. [PMID: 33485050 DOI: 10.1016/j.amjoto.2021.102903] [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: 09/16/2020] [Revised: 12/23/2020] [Accepted: 12/29/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE PFAPA syndrome is derived from the initials of the English words of the findings that make up the syndrome ("Periodic Fever", "Aphthous Stomatitis", "Pharyngitis", "Adenitis"). This study aims to evaluate the vestibular system in patients with PFAPA syndrome by the cVEMP test and to give a general review of PFAPA syndrome in light of current literature. METHODS In this prospective study, 30 patients aged 4-6 who were diagnosed with PFAPA in a tertiary pediatrics clinic, between January 2016 and February 2020 and 30 children of the same age group who applied to a tertiary otorhinolaryngology clinic for other reasons and proven to have no hearing or vestibular problems were included and in addition to routine physical examination, electromyographic activity of the sternocleidomastoid muscle surface was measured. RESULTS We found that the amplitude difference between cVEMP p1-n1 in patients with PFAPA syndrome in both ears decreased compared to the healthy control group. CONCLUSION Our study proves there is a vestibular system involvement of PFAPA syndrome. This study is the first in the literature to search the relationship between PFAPA and the vestibular system.
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Affiliation(s)
- Selçuk Kuzu
- Otorhinolaryngology Department, Afyonkarahisar Health Sciences University Medical Faculty, İzmirYolu 8.km, 03300 Afyonkarahisar, Turkey.
| | - Çağlar Günebakan
- Otorhinolaryngology Department, Afyonkarahisar Health Sciences University Medical Faculty, İzmirYolu 8.km, 03300 Afyonkarahisar, Turkey
| | - Erkan Yıldız
- Otorhinolaryngology Department, Şuhut State Hospital, 03200 Şuhut, Afyonkarahisar, Turkey
| | - Orhan Kemal Kahveci
- Otorhinolaryngology Department, Afyonkarahisar Health Sciences University Medical Faculty, İzmirYolu 8.km, 03300 Afyonkarahisar, Turkey
| | - Abdulkadir Bucak
- Otorhinolaryngology Department, Afyonkarahisar Health Sciences University Medical Faculty, İzmirYolu 8.km, 03300 Afyonkarahisar, Turkey
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Ferreira Cristina S, Costa A, Toscano M, Kakoo Brioso E, Cipriano P. Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome: A Rare Etiology of Fever in Adults. Cureus 2021; 13:e14749. [PMID: 34084676 PMCID: PMC8164374 DOI: 10.7759/cureus.14749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
We report the case of a 28-year-old male, with a past history of recurrent pharyngitis and tonsillectomy, who presented to the emergency department with fever, pharyngitis, and cervical adenitis. Inflammatory markers were elevated and the patient was initially started on ceftriaxone with remission after four days. However, the symptoms recurred three weeks later and an autoinflammatory disease was suspected. After exclusion of other illnesses, a diagnosis of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome was confirmed. The patient was successfully treated with a single dose of 60 mg of prednisolone at the beginning of the flare. PFAPA syndrome has been classically diagnosed solely in children but cases in adults are being increasingly recognized. Despite the increasing evidence of the delayed onset of PFAPA syndrome during adulthood, no specific tools are available to detect it and diagnosis is currently based on clinical diagnostic criteria, which have very low specificity and are tailored to pediatric patients. This case report stresses the need to consider this entity seriously despite its rarity, even among the adult population, so as to reduce iatrogenesis, start appropriate therapy in a prompt manner, and improve the quality of life of PFAPA patients.
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Affiliation(s)
| | - Adriana Costa
- Pediatrics, Hospital Prof. Doutor Fernando Fonseca, Lisbon, PRT
| | - Manuel Toscano
- Internal Medicine, Hospital De Cascais Dr. José De Almeida, Lisbon, PRT
| | | | - Patrícia Cipriano
- Internal Medicine, Hospital De Cascais Dr. José De Almeida, Lisbon, PRT
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Stefania S, Colia R, Cinzia R, Corrado A, Cantatore FP. Off-label use of anti-IL-1 drugs in rheumatic diseases. Int J Immunopathol Pharmacol 2021; 35:20587384211006584. [PMID: 33855881 PMCID: PMC8056561 DOI: 10.1177/20587384211006584] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Interleukin-1 (IL-1) plays a key role in the pathogenesis of different rheumatic diseases. There are now several agents available on the market capable of blocking IL-1. The proven effectiveness and excellent safety of these drugs makes them a possible therapeutic option in the treatment of IL-1 driven diseases, when previous therapies are contraindicated or ineffective. This article discusses the European wide off-label use of these drugs for the treatment of rheumatic diseases.
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Affiliation(s)
- Silvia Stefania
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Ripalta Colia
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Rotondo Cinzia
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Addolorata Corrado
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Francesco Paolo Cantatore
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Batu ED, Vezir E, Öğüş E, Özbaş Demirel Ö, Akpınar G, Demir S, Özen S. Galectin-3: a new biomarker for differentiating periodic fever, adenitis, pharyngitis, aphthous stomatitis (PFAPA) syndrome from familial Mediterranean fever? Rheumatol Int 2021; 42:71-80. [PMID: 33709179 DOI: 10.1007/s00296-021-04827-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/01/2021] [Indexed: 10/21/2022]
Abstract
Differentiating PFAPA (periodic fever, aphthosis, pharyngitis, and adenitis) syndrome from familial Mediterranean fever (FMF) could be challenging in some cases. Galectin-3 is a lectin with regulatory functions in apoptosis and inflammation. We aimed to test whether galectin-3 could be a biomarker for differentiating PFAPA syndrome from FMF. Patients with PFAPA syndrome, FMF, cryopyrin-associated periodic syndrome (CAPS), and streptococcal pharyngitis, and healthy controls were included in this study. Serum galectin-3 levels were measured using enzyme-linked immunosorbent assay. Eighty-seven patients (36 with PFAPA, 39 with FMF, 8 with CAPS, 4 with streptococcal pharyngitis), and 17 healthy controls were included. Blood samples were drawn during attacks from 20 PFAPA and 7 FMF patients and attack-free periods from 22 PFAPA, 35 FMF, and 8 CAPS patients. The median serum galectin-3 level in the PFAPA-attack group (1.025 ng/ml) was significantly lower than the levels in healthy control (2.367 ng/ml), streptococcal pharyngitis (3.021 ng/ml), FMF attack (2.402 ng/ml), and FMF-attack-free groups (2.797 ng/ml) (p = 0.006, 0.03, 0.01, and < 0.001, respectively). PFAPA-attack-free group had lower galectin-3 levels than the FMF-attack-free group (1.794 vs. 2.797 ng/ml, respectively; p = 0.01). Galectin-3 levels did not differ significantly between CAPS and attack-free PFAPA patients (1.439 ng/ml vs. 1.794 ng/ml, respectively; p = 0.63). In our study, for the first time, we defined galectin-3 as a promising biomarker that differs between PFAPA and FMF patients during both disease flares and attack-free periods. Further studies with high number of patients could validate its role as a biomarker.
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Affiliation(s)
- Ezgi D Batu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey.
| | - Emine Vezir
- Division of Allergy and Immunology, Department of Pediatrics, Ankara Health Research and Application Center, University of Health Sciences, Ankara, Turkey
| | - Elmas Öğüş
- Department of Biochemistry, Ankara Health Research and Application Center, University of Health Sciences, Ankara, Turkey
| | - Özlem Özbaş Demirel
- Department of Biochemistry, Ankara Health Research and Application Center, University of Health Sciences, Ankara, Turkey
| | - Gizem Akpınar
- Department of Pediatrics, Ankara Health Research and Application Center, University of Health Sciences, Ankara, Turkey
| | - Selcan Demir
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
| | - Seza Özen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
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Lantto U, Koivunen P, Tapiainen T, Renko M. Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome: Relapse and Tonsillar Regrowth After Childhood Tonsillectomy. Laryngoscope 2021; 131:E2149-E2152. [PMID: 33630321 DOI: 10.1002/lary.29474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/14/2021] [Accepted: 02/12/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Tonsillectomy is an effective treatment for periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome, but the role of adenoidectomy, as well as later tonsillar regrowth, is unclear. To find out if the volume of lymphoid tissue is pivotal to the efficacy, we analyzed the association between the relapse of the symptoms of PFAPA syndrome and regrowth of tonsillar tissue after tonsillectomy or adenotonsillectomy. STUDY DESIGN Prospective cohort study of operated PFAPA pateints. METHODS We invited all patients that had undergone tonsillectomy or adenotonsillectomy due to PFAPA syndrome at the Oulu University Hospital, Oulu, Finland, between the years 1990 and 2007, at the age of ≤12 years, to a follow-up visit, after an average period of 9.8 years after their diagnoses. Out of the 132 invited, 94 (71%) participated in the follow-up study. RESULTS At the follow-up study visit, 5 (5%) of the 94 PFAPA syndrome cases experienced recurrent fevers. The regrowth of palatine tonsillar tissue was seen in four of them (80%) as compared to 19/89 (21%) of symptom-free patients (P = .006). Two of the patients with clear PFAPA relapse at the time of the study visit were reoperated with clear effect on the symptoms. At the time of the study visit, 59/63 (94%) of the patients who had undergone adenotonsillectomy and 30/31 of the patients (97%) who had undergone tonsillectomy earlier were free of fever flares (P = .99). CONCLUSION Palatine tonsil regrowth was associated with PFAPA syndrome relapse after tonsillectomy. Reoperation might be a treatment option in these patients. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2149-E2152, 2021.
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Affiliation(s)
- Ulla Lantto
- PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland.,Department of Otorhinolaryngology, Head and Neck Surgery, Oulu University Hospital, Oulu, Finland
| | - Petri Koivunen
- PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland.,Department of Otorhinolaryngology, Head and Neck Surgery, Oulu University Hospital, Oulu, Finland
| | - Terhi Tapiainen
- PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland.,Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
| | - Marjo Renko
- PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland.,Department of Pediatrics, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
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Betrains A, Staels F, Schrijvers R, Meyts I, Humblet-Baron S, De Langhe E, Wouters C, Blockmans D, Vanderschueren S. Systemic autoinflammatory disease in adults. Autoimmun Rev 2021; 20:102774. [PMID: 33609798 DOI: 10.1016/j.autrev.2021.102774] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/16/2020] [Indexed: 12/17/2022]
Abstract
Systemic autoinflammatory disorders comprise an expanding group of rare conditions. They are mediated by dysfunction of the innate immune system and share a core of phenotypic manifestations including recurrent attacks of fever, cutaneous signs, chest or abdominal pain, lymphadenopathy, vasculopathy, and musculoskeletal symptoms. Diagnosis is often established in childhood, but a growing number of adult patients are being recognized with systemic autoinflammatory disorders, including adult-onset disease. In this review, we provide a concise update on the pathophysiology, clinical presentation, and diagnostic approach of systemic autoinflammatory disorders with an emphasis on the adult patient population. Despite the recent advances in genetic testing, the diagnosis of autoinflammatory disease in adult patients is often based on a thorough knowledge of the clinical phenotype. Becoming acquainted with the clinical features of these rare disorders may assist in developing a high index of suspicion for autoinflammatory disease in patients presenting with unexplained episodes of fever or inflammation.
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Affiliation(s)
- Albrecht Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; KU Leuven, Department of Microbiology, Immunology, and Transplantation, Laboratory of Clinical Infectious and Inflammatory Disorders, Leuven, Belgium.
| | - Frederik Staels
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Immunogenetics Research Group, Leuven, Belgium; KU Leuven, Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, Leuven, Belgium
| | - Rik Schrijvers
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Immunogenetics Research Group, Leuven, Belgium; KU Leuven, Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, Leuven, Belgium
| | - Isabelle Meyts
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, Leuven, Belgium
| | - Stephanie Humblet-Baron
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Immunogenetics Research Group, Leuven, Belgium
| | - Ellen De Langhe
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium; KU Leuven, Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, Leuven, Belgium
| | - Carine Wouters
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium; KU Leuven, Department of Microbiology, Immunology and Transplantation, Laboratory of Adaptive Immunology & Immunobiology, Leuven, Belgium
| | - Daniel Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; KU Leuven, Department of Microbiology, Immunology, and Transplantation, Laboratory of Clinical Infectious and Inflammatory Disorders, Leuven, Belgium
| | - Steven Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; KU Leuven, Department of Microbiology, Immunology, and Transplantation, Laboratory of Clinical Infectious and Inflammatory Disorders, Leuven, Belgium
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41
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Managing PFAPA (periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis) in children. DRUGS & THERAPY PERSPECTIVES 2021. [DOI: 10.1007/s40267-020-00793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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42
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Tejesvi MV, Tapiainen T, Vänni P, Uhari M, Suokas M, Lantto U, Koivunen P, Renko M. Tonsil Mycobiome in PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis) Syndrome: A Case-Control Study. Front Cell Infect Microbiol 2021; 10:616814. [PMID: 33585283 PMCID: PMC7873641 DOI: 10.3389/fcimb.2020.616814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/08/2020] [Indexed: 11/27/2022] Open
Abstract
Periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA) is the most common periodic fever syndrome in children with unknown etiology, effectively treated with tonsillectomy. Earlier we have shown that tonsil microbiome is different in patients with PFAPA as compared to that in controls. Recently, fungal microbiome, mycobiome, has been linked to the pathogenesis of inflammatory diseases. We now investigated the role of mycobiome of tonsils in PFAPA. Random forest classification, a machine learning approach, was used for the analysis of mycobiome data. We examined tonsils from 30 children with PFAPA and 22 control children undergoing tonsillectomy for non-infectious reasons. We identified 103 amplicon sequence variants, mainly from two fungal phyla, Ascomycota and Basidiomycota. The mean relative abundance of Candida albicans in the tonsil mycobiome was 11% (95% CI: 19 to 27%) in cases and 3.4 % (95% CI: -0.8% to 8%) in controls, p =0.104. Mycobiome data showed no statistical difference in differentiating between PFAPA cases and controls compared to a random chance classifier (area under the curve (AUC) = 0.47, SD = 0.05, p = 0.809). In conclusion, in this controlled study, tonsillar mycobiome in children with PFAPA syndrome did not differ from that of the controls.
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Affiliation(s)
- Mysore V Tejesvi
- Ecology and Genetics, Faculty of Science, University of Oulu, Oulu, Finland.,Biocenter Oulu, University of Oulu, Oulu, Finland.,Genobiomics LLC, Oulu, Finland
| | - Terhi Tapiainen
- Biocenter Oulu, University of Oulu, Oulu, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland.,Department of Paediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
| | - Petri Vänni
- Genobiomics LLC, Oulu, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Matti Uhari
- Biocenter Oulu, University of Oulu, Oulu, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Marko Suokas
- Ecology and Genetics, Faculty of Science, University of Oulu, Oulu, Finland
| | - Ulla Lantto
- PEDEGO Research Unit, University of Oulu, Oulu, Finland.,Department of Otorhinolaryngology, Oulu University Hospital, Oulu, Finland
| | - Petri Koivunen
- PEDEGO Research Unit, University of Oulu, Oulu, Finland.,Department of Otorhinolaryngology, Oulu University Hospital, Oulu, Finland
| | - Marjo Renko
- PEDEGO Research Unit, University of Oulu, Oulu, Finland.,Department of Paediatrics, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
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Long X, Yang J, Zhang X, Yang Z, Li Y, Wang F, Li X, Kuang E. BRLF1 suppresses RNA Pol III-mediated RIG-I inflammasome activation in the early EBV lytic lifecycle. EMBO Rep 2021; 22:e50714. [PMID: 33225563 PMCID: PMC7788446 DOI: 10.15252/embr.202050714] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 09/29/2020] [Accepted: 10/19/2020] [Indexed: 11/09/2022] Open
Abstract
Latent infection with herpesviruses constitutively activates inflammasomes, while lytic replication suppresses their activation through distinct mechanisms. However, how Epstein-Barr virus (EBV) lytic replication inhibits the activation of inflammasomes remains unknown. Here, we reveal that the EBV immediate-early protein BRLF1 inhibits inflammasome activation, and BRLF1 deficiency significantly increases the activation of inflammasomes and pyroptosis during early lytic lifecycle. BRLF1 interacts with RNA polymerase III subunits to suppress immunostimulatory small RNA transcription, RIG-I inflammasome activation, and antiviral responses. Consequently, BRLF1-deficient EBV primary infection induces robust T-cell and NK cell activation and killing through IL-1β and IL-18. A BRLF1-derived peptide that inhibits inflammasome activation is sufficient to suppress T-cell and NK cell responses during BRLF1-deficient EBV primary infection in lymphocytes. These results reveal a novel mechanism involved in the evasion of inflammasome activation and antiviral responses during EBV early lytic infection and provide a promising approach for the manipulation of inflammasomes against infection of oncogenic herpesviruses.
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Affiliation(s)
- Xubing Long
- Institute of Human VirologyZhongshan School of MedicineSun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Jing Yang
- Institute of Human VirologyZhongshan School of MedicineSun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Xiaolin Zhang
- Institute of Human VirologyZhongshan School of MedicineSun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Ziwei Yang
- Institute of Human VirologyZhongshan School of MedicineSun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Yang Li
- Institute of Human VirologyZhongshan School of MedicineSun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Fan Wang
- Institute of Human VirologyZhongshan School of MedicineSun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Xiaojuan Li
- Institute of Human VirologyZhongshan School of MedicineSun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Ersheng Kuang
- Institute of Human VirologyZhongshan School of MedicineSun Yat‐Sen UniversityGuangzhouGuangdongChina
- Key Laboratory of Tropical Disease Control (Sun Yat‐Sen University)Ministry of EducationGuangzhouGuangdongChina
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Hara M, Morimoto N, Suzuki N, Tsuchihashi N, Komori M, Yoshihama K, Fujii K, Yamaguchi S, Tsunoda M, Tomisato S, Takahashi N, Oyake K, Okuba Y, Fujieda M, Matsumoto K. Transcriptome analysis reveals two distinct endotypes and putative immune pathways in tonsils from children with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome. Allergy 2021; 76:359-363. [PMID: 32593215 DOI: 10.1111/all.14477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/01/2020] [Accepted: 06/15/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Mariko Hara
- Department of Allergy and Clinical Immunology National Research Institute for Child Health and Development Tokyo Japan
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Noriko Morimoto
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Noriomi Suzuki
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Nana Tsuchihashi
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Manabu Komori
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Keisuke Yoshihama
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Kae Fujii
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Sota Yamaguchi
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Mayumi Tsunoda
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Syuta Tomisato
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Nozomi Takahashi
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Koichiro Oyake
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Yuzuru Okuba
- Department of Otolaryngology National Center for Child Health and Development Tokyo Japan
| | - Mikiya Fujieda
- Department of Pediatrics Kochi Medical School Kochi University Kochi Japan
| | - Kenji Matsumoto
- Department of Allergy and Clinical Immunology National Research Institute for Child Health and Development Tokyo Japan
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45
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Padgett C. Recurrence of Symptoms Associated with Menstruation in a Patient with a History of Periodic Fevers. J Pediatr Adolesc Gynecol 2020; 33:429-431. [PMID: 32224248 DOI: 10.1016/j.jpag.2020.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/07/2020] [Accepted: 03/18/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome is a cyclic autoinflammatory disease generally diagnosed in childhood. There have been studies suggesting a relationship between menstruation and other autoinflammatory syndromes such as familial Mediterranean fever (FMF), but not PFAPA specifically. CASE This case describes a patient with a diagnosis of PFAPA who experienced complete resolution with tonsillectomy only to have recurrence of symptoms with onset of menstruation. She experienced symptom control with initiation of oral contraceptives. SUMMARY AND CONCLUSION Prior to this case report, there had been no evidence in the literature suggesting a relationship between PFAPA and menstruation despite the observed association in other autoinflammatory syndromes. Onset of menses may be a trigger in PFAPA.
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Affiliation(s)
- Christina Padgett
- Department of Adolescent Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.
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46
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Lovšin E, Kovač J, Tesovnik T, Toplak N, Perko D, Rozmarič T, Debeljak M, Avčin T. PIK3AP1 and SPON2 Genes Are Differentially Methylated in Patients With Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis (PFAPA) Syndrome. Front Immunol 2020; 11:1322. [PMID: 32793186 PMCID: PMC7390842 DOI: 10.3389/fimmu.2020.01322] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/26/2020] [Indexed: 12/22/2022] Open
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is the most common autoinflammatory disease in children and is often grouped together with hereditary periodic fever syndromes, although its cause and hereditary nature remain unexplained. We investigated whether differential DNA methylation was present in DNA from peripheral blood mononuclear cells (PBMC) in patients with PFAPA vs. healthy controls. A whole-epigenome analysis (MeDIP and MBD) was performed using pooled DNA libraries enriched for methylated genomic regions and identified candidate genes, two of which were further evaluated with methylation-specific restriction enzymes coupled with qPCR (MSRE-qPCR). The analysis showed that the PIK3AP1 and SPON2 gene regions are differentially methylated in patients with PFAPA. MSRE-qPCR proved to be a quick, reliable, and cost-effective method of confirming results from MeDIP and MBD. Our findings indicate that a B-cell adapter protein (PIK3AP1), as the PI3K binding inhibitor of inflammation, and spondin-2 (SPON2), as a pattern recognition molecule and integrin ligand, could play a role in the etiology of PFAPA. Their role and the impact of changed DNA methylation in PFAPA etiology and autoinflammation need further investigation.
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Affiliation(s)
- Ema Lovšin
- Department of Allergology, Rheumatology and Clinical Immunology, University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jernej Kovač
- Department for Special Laboratory Diagnostics, University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia
| | - Tine Tesovnik
- Department for Special Laboratory Diagnostics, University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia
| | - Nataša Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Daša Perko
- Department for Special Laboratory Diagnostics, University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia
| | - Tomaž Rozmarič
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Maruša Debeljak
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department for Special Laboratory Diagnostics, University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia
| | - Tadej Avčin
- Department of Allergology, Rheumatology and Clinical Immunology, University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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47
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Carrozzo M, Eriksen JG, Bensadoun RJ, Boers-Doets CB, Lalla RV, Peterson DE. Oral Mucosal Injury Caused by Targeted Cancer Therapies. J Natl Cancer Inst Monogr 2020; 2019:5551364. [PMID: 31425602 DOI: 10.1093/jncimonographs/lgz012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/14/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023] Open
Abstract
Targeted cancer therapies have fundamentally transformed the treatment of many types of cancers over the past decade, including breast, colorectal, lung, and pancreatic cancers, as well as lymphoma, leukemia, and multiple myeloma. The unique mechanisms of action of these agents have resulted in many patients experiencing enhanced tumor response together with a reduced adverse event profile as well. Toxicities do continue to occur, however, and in selected cases can be clinically challenging to manage. Of particular importance in the context of this monograph is that the pathobiology for oral mucosal lesions caused by targeted cancer therapies has only been preliminarily investigated. There is distinct need for novel basic, translational, and clinical research strategies to enhance design of preventive and therapeutic approaches for patients at risk for development of these lesions. The research modeling can be conceptually enhanced by extrapolating "lessons learned" from selected oral mucosal conditions in patients without cancer as well. This approach may permit determination of the extent to which pathobiology and clinical management are either similar to or uniquely distinct from oral mucosal lesions caused by targeted cancer therapies. Modeling associated with oral mucosal disease in non-oncology patients is thus presented in this context as well. This article addresses this emerging paradigm, with emphasis on current mechanistic modeling and clinical treatment. This approach is in turn designed to foster delineation of new research strategies, with the goal of enhancing cancer patient treatment in the future.
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Affiliation(s)
- M Carrozzo
- Center for Oral Health Research, Oral Medicine Department, School of Dental Sciences, Newcastle University, UK
| | - J Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - R-J Bensadoun
- Institut Niçois de Cancérologie (INC), Centre de Haute Energie, Nice, France
| | - C B Boers-Doets
- CancerMed, Department of Medical Strategy, Wormer, The Netherlands.,Impaqtt Foundation, Department of Adverse Event Research & Valorisation, Wormer, The Netherlands
| | - R V Lalla
- Section of Oral Medicine, Department of Oral Health & Diagnostic Sciences, School of Dental Medicine, UConn Health, Farmington, CT
| | - D E Peterson
- Section of Oral Medicine, Department of Oral Health & Diagnostic Sciences, School of Dental Medicine & Neag Comprehensive Cancer Center, UConn Health, Farmington, CT
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48
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Manthiram K, Preite S, Dedeoglu F, Demir S, Ozen S, Edwards KM, Lapidus S, Katz AE, Feder HM, Lawton M, Licameli GR, Wright PF, Le J, Barron KS, Ombrello AK, Barham B, Romeo T, Jones A, Srinivasalu H, Mudd PA, DeBiasi RL, Gül A, Marshall GS, Jones OY, Chandrasekharappa SC, Stepanovskiy Y, Ferguson PJ, Schwartzberg PL, Remmers EF, Kastner DL. Common genetic susceptibility loci link PFAPA syndrome, Behçet's disease, and recurrent aphthous stomatitis. Proc Natl Acad Sci U S A 2020; 117:14405-14411. [PMID: 32518111 PMCID: PMC7322016 DOI: 10.1073/pnas.2002051117] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children. The disease appears to cluster in families, but the pathogenesis is unknown. We queried two European-American cohorts and one Turkish cohort (total n = 231) of individuals with PFAPA for common variants previously associated with two other oropharyngeal ulcerative disorders, Behçet's disease and recurrent aphthous stomatitis. In a metaanalysis, we found that a variant upstream of IL12A (rs17753641) is strongly associated with PFAPA (OR 2.13, P = 6 × 10-9). We demonstrated that monocytes from individuals who are heterozygous or homozygous for this risk allele produce significantly higher levels of IL-12p70 upon IFN-γ and LPS stimulation than those from individuals without the risk allele. We also found that variants near STAT4, IL10, and CCR1-CCR3 were significant susceptibility loci for PFAPA, suggesting that the pathogenesis of PFAPA involves abnormal antigen-presenting cell function and T cell activity and polarization, thereby implicating both innate and adaptive immune responses at the oropharyngeal mucosa. Our results illustrate genetic similarities among recurrent aphthous stomatitis, PFAPA, and Behçet's disease, placing these disorders on a common spectrum, with recurrent aphthous stomatitis on the mild end, Behçet's disease on the severe end, and PFAPA intermediate. We propose naming these disorders Behçet's spectrum disorders to highlight their relationship. HLA alleles may be factors that influence phenotypes along this spectrum as we found new class I and II HLA associations for PFAPA distinct from Behçet's disease and recurrent aphthous stomatitis.
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Affiliation(s)
- Kalpana Manthiram
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892;
| | - Silvia Preite
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115
| | - Selcan Demir
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey
| | - Kathryn M Edwards
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232
| | - Sivia Lapidus
- Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, Hackensack Meridian Health, Hackensack, NJ 07601
| | - Alexander E Katz
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Henry M Feder
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT 06106
| | - Maranda Lawton
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115
| | - Greg R Licameli
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115
| | - Peter F Wright
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756
| | - Julie Le
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Karyl S Barron
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Amanda K Ombrello
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Beverly Barham
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Tina Romeo
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Anne Jones
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Hemalatha Srinivasalu
- Division of Pediatric Rheumatology, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010
| | - Pamela A Mudd
- Division of Pediatric Otolaryngology, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010
| | - Roberta L DeBiasi
- Division of Pediatric Infectious Diseases, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010
- Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010
| | - Ahmet Gül
- Department of Internal Medicine, Division of Rheumatology, Istanbul Faculty of Medicine, Istanbul University, 34093 Istanbul, Turkey
| | - Gary S Marshall
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY 40202
| | - Olcay Y Jones
- Division of Pediatric Rheumatology, Walter Reed National Military Medical Center, Bethesda, MD 20889
| | | | - Yuriy Stepanovskiy
- Department of Pediatric Infectious Diseases and Pediatric Immunology, Shupyk National Medical Academy of Postgraduate Education, 04112 Kiev, Ukraine
| | - Polly J Ferguson
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Pamela L Schwartzberg
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Elaine F Remmers
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Daniel L Kastner
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892;
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49
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Soriano A, Soriano M, Espinosa G, Manna R, Emmi G, Cantarini L, Hernández-Rodríguez J. Current Therapeutic Options for the Main Monogenic Autoinflammatory Diseases and PFAPA Syndrome: Evidence-Based Approach and Proposal of a Practical Guide. Front Immunol 2020; 11:865. [PMID: 32655539 PMCID: PMC7325944 DOI: 10.3389/fimmu.2020.00865] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
Monogenic autoinflammatory diseases are rare conditions caused by genetic abnormalities affecting the innate immunity. Previous therapeutic strategies had been mainly based on results from retrospective studies and physicians' experience. However, during the last years, the significant improvement in their genetic and pathogenic knowledge has been accompanied by a remarkable progress in their management. The relatively recent identification of the inflammasome as the crucial pathogenic mechanism causing an aberrant production of interleukin 1β (IL-1β) in the most frequent monogenic autoinflammatory diseases led to the introduction of anti-IL-1 agents and other biologic drugs as part of the previously limited therapeutic armamentarium available. Advances in the treatment of autoinflammatory diseases have been favored by the use of new biologic agents and the performance of a notable number of randomized clinical trials exploring the efficacy and safety of these agents. Clinical trials have contributed to increase the level of evidence and provided more robust therapeutic recommendations. This review analyzes the treatment of the most frequent monogenic autoinflammatory diseases, namely, familial Mediterranean fever, tumor necrosis factor receptor-associated periodic fever syndrome, hyperimmunoglobulin D syndrome/mevalonate kinase deficiency, and cryopyrin-associated periodic syndromes, together with periodic fever with aphthous stomatitis, pharyngitis, and cervical adenitis syndrome, which is the most common polygenic autoinflammatory disease in children, also occurring in adult patients. Finally, based on the available expert consensus recommendations and the highest level of evidence of the published studies, a practical evidence-based guideline for the treatment of these autoinflammatory diseases is proposed.
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Affiliation(s)
- Alessandra Soriano
- Division of Internal Medicine, Department of Internal Medicine and Medical Specialties, Arcispedale S. Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Marco Soriano
- School of Medicine, Luigi Vanvitelli University, Naples, Italy
| | - Gerard Espinosa
- Clinical Unit of Autoinflammatory Diseases and Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Raffaele Manna
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Periodic Fevers Research Centre, Institute of Internal Medicine, Università Cattolica Sacro Cuore, Rome, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease, Rheumatology Unit of the Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - José Hernández-Rodríguez
- Clinical Unit of Autoinflammatory Diseases and Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
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50
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Why and How Should We Treat Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis (PFAPA) Syndrome? Paediatr Drugs 2020; 22:243-250. [PMID: 32342289 DOI: 10.1007/s40272-020-00393-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is characterized by recurrent fever flares accompanied by symptoms and signs forming the disease acronym and alternating with asymptomatic periods. Despite the disease having a generally favorable outcome, with spontaneous remission after a few years, it does have a major impact on the quality of life of the child and his or her relatives. Beside symptomatic medications during fever flares, the most used treatment consists of a single dose of corticosteroids at flare onset to interrupt the attack; fever resolves usually within a few hours, but often with a shorter interval between the attacks. For these patients, colchicine has been shown to decrease the frequency of the flares. Other medications were also reported in case series of patients with PFAPA syndrome. These include the interleukin-1 blocker anakinra to treat flares, cimetidine (which showed no convincing effect), and other drugs with anecdotal use. The pediatrician faces a difficult question: should they wait for spontaneous disease resolution and only treat the flares medically, or should they propose tonsillectomy that may induce remission? Due to the lack of strong evidence, the answer will vary on an individual basis, depending on the impact on the patient's quality of life. The choice of the best therapeutic strategy will be based on the response to the flare-based therapy and on disease severity (quality of life, school performances); long-term data on the remission rate under the different therapeutic strategies are currently missing. More randomized controlled studies are needed to help the treating physician to choose the best therapy, as well as real-life long-term data to evaluate the long-term outcome of children with PFAPA syndrome.
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