Clinical improvement with infliximab in a child with amyloidosis secondary to familial Mediterranean fever

A narrative review on the role of cytokines in the pathogenesis and treatment of familial Mediterranean fever: an emphasis on pediatric cases

Familial Mediterranean Fever (FMF) is a hereditary autoinflammatory disease characterized by an early onset of recurrent fever and serositis episodes. FMF is caused by mutations in the MEFV gene which encodes the pyrin protein, an IL-1β mediated inflammation regulator. Recent findings have identified a plethora of molecules and pathways involved in the regulation of inflammation and innate immunity, hence increasing our understanding of the etiology and inflammatory nature of FMF. Cytokines, in particular, have been found to play a key role in the pathogenesis and treatment of the disease. Indeed, various studies associated cytokines' genetic variations and expression with susceptibility to and severity of the disease, which was further supported by the positive response of patients, both children and adults, to targeted cytokine blocking therapies. These studies highlighted the potential use of cytokines as biomarkers and target in resistant/intolerant patients and contributed to improving the early detection of FMF in children, thus enhancing their quality of life and providing alternative treatment for severe cases. The aim of this review is to provide the latest updates on the pivotal role of cytokines in FMF and to discuss the efficacy and safety of anti-cytokine biologics by primarily focusing on pediatric FMF cases.

Efficacy and safety of biologic treatments in Familial Mediterranean Fever

OBJECTIVE

Colchicine is the mainstay treatment for Familial Mediterranean Fever (FMF). However 5% to 10% of the patients with FMF are unresponsive or intolerant to colchicine. Biologics are efficient in many rheumatic diseases, including rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, cryopyrin-associated periodic syndromes. We performed a systematic review to analyze patients with FMF, including juvenile patients who received treatment with biologics.

METHODS

A MEDLINE search, including articles published in English language between 1990 and May 2012, was performed. Patients who had Mediterranean fever variants but could not be classified as FMF according to Tel-Hashomer criteria were excluded.

RESULTS

There is no controlled trial on the efficacy and safety of biologics in FMF. Fifty-nine (32 female and 27 male) patients with FMF who had been treated with biologics (infliximab, etanercept, adalimumab, anakinra, and canakinumab) were reported in 24 single reports and 7 case series. There were 16 children and 43 adults (7- to 68-year olds). Five patients were reported to have colchicine intolerance or had adverse events related to colchicine use, and the rest 54 were unresponsive to colchicine treatment.

CONCLUSIONS

The current data are limited to case reports, and it is difficult to obtain a quantitative evaluation of response to biologic treatments. However, on the basis of reported cases, biologic agents seem to be an alternative treatment for patients with FMF who are unresponsive or intolerant to colchicine therapy and seem to be safe. Controlled studies are needed to better evaluate the safety and efficacy of biologics in the treatment of patients with FMF.

Monogenic autoinflammatory diseases: concept and clinical manifestations

The objective of this review is to describe the clinical manifestations of the growing spectrum of monogenic autoinflammatory diseases including recently described syndromes. The autoinflammatory diseases can be grouped based on clinical findings: 1. the three classic hereditary "periodic fever syndromes", familial Mediterranean Fever (FMF); TNF receptor associated periodic syndrome (TRAPS); and mevalonate kinase deficiency/hyperimmunoglobulinemia D and periodic fever syndrome (HIDS); 2. the cryopyrin associated periodic syndromes (CAPS), comprising familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS) and neonatal-onset multisystem inflammatory disease (NOMID) or CINCA, and; 3. pediatric granulomatous arthritis (PGA); 4. disorders presenting with skin pustules, including deficiency of interleukin 1 receptor antagonist (DIRA); Majeed syndrome; pyogenic arthritis, pyoderma gangrenosum and acne (PAPA) syndrome; deficiency of interleukin 36 receptor antagonist (DITRA); CARD14 mediated psoriasis (CAMPS), and early-onset inflammatory bowel diseases (EO-IBD); 5. inflammatory disorders caused by mutations in proteasome components, the proteasome associated autoinflammatory syndromes (PRAAS) and 6. very rare conditions presenting with autoinflammation and immunodeficiency.

Effects of anti-tumor necrosis factor agents for familial mediterranean fever patients with chronic arthritis and/or sacroiliitis who were resistant to colchicine treatment

BACKGROUND

Effectiveness of anti-tumor necrosis factor (anti-TNF) agents in colchicine-resistant familial Mediterranean fever (FMF) patients has attracted attention in recent years.

OBJECTIVE

We analyzed the effect of anti-TNF agents on clinical findings of colchicine-resistant FMF patients with chronic arthritis and/or sacroiliitis.

METHODS

Data from 10 FMF patients (5 male and 5 female patients: mean age, 30.1 [SD, 8.5] years) with chronic arthritis and/or sacroiliitis who were on anti-TNF agents are reviewed. Frequency of FMF attacks before and after treatment with anti-TNF agents was recorded from hospital files. The effects of the anti-TNF treatment were determined by using the number of tender and/or swollen joints, serum acute phase reactant levels, and Bath Ankylosing Spondylitis Disease Activity Index scores. Change in urine protein loss was also evaluated in patients with amyloidosis. In 6 patients, FMF attacks had been considered to be unresponsive to colchicine, and 4 patients were partial responders before treatment with anti-TNF agents.

RESULTS

Mean attack frequency of the patients in the 3 months' period before anti-TNF agent treatment was 3.8 (SD, 3.1). After anti-TNF treatment, in 3 patients, FMF attack frequency decreased, and in the remaining 7 patients, no attack occurred. Serum acute phase reactant levels were decreased significantly at 3 and 6 months after anti-TNF treatment (P < 0.05 for all). After anti-TNF treatment Bath Ankylosing Spondylitis Disease Activity Index scores were also decreased significantly (6.2 [SD], 1.7 vs. 2.1 [SD], 1.7; P = 0.012). In all 3 patients with amyloidosis, urine protein loss decreased without any increase in serum creatinine levels.

CONCLUSION

Anti-TNF treatment can have beneficial effects for controlling FMF attacks in FMF patients with chronic arthritis and/or sacroiliitis.

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

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

Systemic amyloidosis in inflammatory bowel disease: retrospective study on its prevalence, clinical presentation, and outcome

BACKGROUND

Systemic amyloidosis is a rare but life-threatening complication of inflammatory bowel disease (IBD), most cases being reported among Crohn's disease (CD) patients. The only two available retrospective studies showed a prevalence ranging from 0.9% to 3% among CD patients.

AIMS

To evaluate the prevalence of secondary systemic amyloidosis in a large IBD cohort of a referral centre, and to describe its clinical characteristics and outcome.

METHODS

Patients diagnosed with amyloidosis were identified among 1006 IBD patients included in the IBD database of our centre, and their medical records were carefully reviewed.

RESULTS

Among a total of 1006 IBD patients, 5 cases of amyloidosis were identified, all of them with CD, resulting in a prevalence of 0.5% for IBD and 1% for CD. Two patients died after developing renal failure. Two patients were treated with anti-TNF agents, showing a clinical improvement of their amyloidosis.

CONCLUSIONS

Secondary amyloidosis occurs mainly in long-lasting, complicated, Crohn's disease and seems to be as prevalent among IBD patients as previously reported.

Coexistence of familial Mediterranean fever and juvenile idiopathic arthritis with osteoporosis successfully treated with etanercept

Familial Mediterranean fever (FMF) is an autoinflammatory disorder characterized by recurrent febrile polyserositis and arthritis attacks. Accompanying seronegative spondyloarthropathy has been reported in FMF in addition to its own joint involvement. However, the coexistence of FMF with juvenile idiopathic arthritis (JIA) is very rare, only three cases with severe joint involvement and mortal outcome have been reported in the literature. Here, we present another case with FMF and JIA with osteoporosis, successfully treated with etanercept with a four-year follow-up.

Current perspectives on familial Mediterranean fever

PURPOSE OF REVIEW

The gene responsible for familial Mediterranean Fever (FMF), MEditerranean FeVer (MEFV), was identified two decades ago; however, only recent studies have shed light on its pathogenesis. This review focuses on recent studies that have led us to more fully understand FMF pathogenesis.

RECENT FINDINGS

The vast majority of FMF-associated mutations are located in the B30.2 (SPRY) domain, which functions as a ligand binding or a signal transduction domain, at the carboxy terminus of the protein. As a result, B30.2 mutations may lead to postponed apoptosis and inflammation due to the reduced ability of pyrin to control interleukin-1beta (IL-1beta) activation. Development of AA amyloidosis is rare in FMF patients without amyloidogenic single nucleotide polymorphisms (SNPs) (713T allele) of the SAA1 gene. High macrophage inflammatory protein-1alpha levels during FMF attacks might be responsible for the enhancement of T-cell mediated immunity in FMF. IL-1beta-511 (C/T), IL-1beta+3953 (C/T) and IL-1Ra VNTR polymorphisms were not associated with the development of amyloid in FMF patients.

SUMMARY

Future studies should focus on defining the impact of MEFV and other mutations on the pathological course of FMF, and to understand the exact pathophysiology of those patients who are unresponsive to colchicine, which may help to develop novel therapeutic options for the management and improvement of prognosis.

Dysregulation of innate immunity: hereditary periodic fever syndromes

The hereditary periodic fever syndromes encompass a rare group of diseases that have lifelong recurrent episodes of inflammatory symptoms and an acute phase response in common. Clinical presentation can mimic that of lymphoproliferative disorders and patients often go undiagnosed for many years. These syndromes follow an autosomal inheritance pattern, and the major syndromes are linked to specific genes, most of which are involved in regulation of the innate immune response through pathways of apoptosis, nuclear factor kappaBeta activation and cytokine production. In others, the link between the protein involved and inflammation is less clear. The recurrent inflammation can lead to complications, such as renal impairment due to amyloidosis and vasculitis, visual impairment, hearing loss, and joint destruction, depending on the specific syndrome. In recent years, treatment options for these diseases have improved significantly. Early establishment of an accurate diagnosis and start of appropriate therapy improves prognosis in these patients.