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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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Türkuçar S, Bülbül G, Ünsal E, Özer E, Erdağ TK, Erkoç E, Makay B. Exploring the immunological basis of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome: immunohistochemical staining features of palatine tonsils. Clin Rheumatol 2023:10.1007/s10067-023-06563-2. [PMID: 36892710 DOI: 10.1007/s10067-023-06563-2] [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: 01/16/2023] [Revised: 02/09/2023] [Accepted: 02/24/2023] [Indexed: 03/10/2023]
Abstract
OBJECTIVES Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is the most common periodic fever syndrome during early childhood period with regular febrile attacks of sterile upper airway inflammation. The cessation of attacks following tonsillectomy points to fundamental role of tonsil tissue on etiopathogenesis of disease, which is not clarified satisfactorily. The aim of this study is to explore the immunological basis of PFAPA by evaluating the cellular properties of tonsils, and microbial exposition such as Helicobacter pylori on tonsillectomy materials. METHODS The paraffinized tonsil samples of 26 PFAPA and 29 control patients with obstructive upper airway disorder were compared in terms of immunohistochemical staining features including CD4, CD8, CD123, CD1a, CD20, and H. pylori. RESULTS The median number of CD8+ cells was 1485 (1218-1287) in PFAPA while it was 1003 (852-1261.5) in control group and the difference was statistically significant (p=0.001). Similarly, CD4+ cell counts were statistically higher in PFAPA group than control (833.5 vs 622). The ratio of CD4/CD8 did not differ between two groups; also, there was no statistically difference in terms of the other immunohistochemical staining results, such as CD20, CD1a, CD123 and H. pylori. CONCLUSION This is the largest number of pediatric tonsillar tissue study of PFAPA patients in current literature and we emphasized the triggering effects of CD8+ and CD4+ T-cells on PFAPA tonsils. KEY POINTS • The cessation of attacks following tonsillectomy points to fundamental role of tonsil tissue on etiopathogenesis of disease, which is not clarified satisfactorily. • In current study, 92.3% of our patients did not experience any attacks following operation similarly with literature. • We observed the increased number of CD4+ and CD8+ T cell counts on PFAPA tonsils compared to control group and emphasized the active role of both CD4+ and CD8+ cells localized on PFAPA tonsils in immune dysregulation. • Some other cell types evaluated in this study such as CD19+ (B cells), CD1a (dendritic cells), and CD123 (IL-3 receptors, for pluripotent stem cells) and H. pylori did not differ in PFAPA patients compared to the control group.
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Affiliation(s)
- Serkan Türkuçar
- Department of Pediatric Rheumatology, Dokuz Eylul University, Izmir, Turkey.
- Division of Pediatric Rheumatology, Konya City Hospital, Karatay/Konya, Turkey.
| | - Göksenil Bülbül
- Department of Medical Pathology, Dokuz Eylul University, Izmir, Turkey
| | - Erbil Ünsal
- Department of Pediatric Rheumatology, Dokuz Eylul University, Izmir, Turkey
| | - Erdener Özer
- Department of Medical Pathology, Dokuz Eylul University, Izmir, Turkey
| | - Taner Kemal Erdağ
- Department of Otorhinolaryngology, Dokuz Eylul University, Izmir, Turkey
| | - Erdal Erkoç
- Department of Otorhinolaryngology, Dokuz Eylul University, Izmir, Turkey
| | - Balahan Makay
- Department of Pediatric Rheumatology, Dokuz Eylul University, Izmir, Turkey
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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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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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Sasaki Y, Arimochi H, Otsuka K, Kondo H, Tsukumo SI, Yasutomo K. Blockade of the CXCR3/CXCL10 axis ameliorates inflammation caused by immunoproteasome dysfunction. JCI Insight 2022; 7:152681. [PMID: 35393946 PMCID: PMC9057626 DOI: 10.1172/jci.insight.152681] [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: 06/25/2021] [Accepted: 02/23/2022] [Indexed: 11/17/2022] Open
Abstract
Immunoproteasomes regulate the degradation of ubiquitin-coupled proteins and generate peptides that are preferentially presented by MHC class I. Mutations in immunoproteasome subunits lead to immunoproteasome dysfunction, which causes proteasome-associated autoinflammatory syndromes (PRAAS) characterized by nodular erythema and partial lipodystrophy. It remains unclear, however, how immunoproteasome dysfunction leads to inflammatory symptoms. Here, we established mice harboring a mutation in Psmb8 (Psmb8-KI mice) and addressed this question. Psmb8-KI mice showed higher susceptibility to imiquimod-induced skin inflammation (IMS). Blockade of IL-6 or TNF-α partially suppressed IMS in both control and Psmb8-KI mice, but there was still more residual inflammation in the Psmb8-KI mice than in the control mice. DNA microarray analysis showed that treatment of J774 cells with proteasome inhibitors increased the expression of the Cxcl9 and Cxcl10 genes. Deficiency in Cxcr3, the gene encoding the receptor of CXCL9 and CXCL10, in control mice did not change IMS susceptibility, while deficiency in Cxcr3 in Psmb8-KI mice ameliorated IMS. Taken together, these findings demonstrate that this mutation in Psmb8 leads to hyperactivation of the CXCR3 pathway, which is responsible for the increased susceptibility of Psmb8-KI mice to IMS. These data suggest the CXCR3/CXCL10 axis as a new molecular target for treating PRAAS.
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Affiliation(s)
- Yuki Sasaki
- Department of Immunology and Parasitology, Graduate School of Medicine
| | - Hideki Arimochi
- Department of Immunology and Parasitology, Graduate School of Medicine
| | - Kunihiro Otsuka
- Department of Immunology and Parasitology, Graduate School of Medicine.,Department of Interdisciplinary Research for Medicine and Photonics, Institute of Post-LED Photonics, Tokushima, and
| | - Hiroyuki Kondo
- Department of Immunology and Parasitology, Graduate School of Medicine
| | - Shin-Ichi Tsukumo
- Department of Immunology and Parasitology, Graduate School of Medicine.,Department of Interdisciplinary Research for Medicine and Photonics, Institute of Post-LED Photonics, Tokushima, and
| | - Koji Yasutomo
- Department of Immunology and Parasitology, Graduate School of Medicine.,Department of Interdisciplinary Research for Medicine and Photonics, Institute of Post-LED Photonics, Tokushima, and.,The Research Cluster Program on Immunological Diseases, Tokushima University, Tokushima, Japan
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Kanik A, Eliacik K, Kanik ET, Tekindal MA. Clinical Usefulness of Acute-Phase Markers in Distinguishing between PFAPA and Other Exudative Tonsillitis Causes: A Methodological Study. J Trop Pediatr 2021; 67:6067639. [PMID: 33411886 DOI: 10.1093/tropej/fmaa124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We investigated the practical use of procalcitonin (PCT), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and complete blood count (CBC) parameters in distinguishing periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA) attacks from exudative tonsillitis associated with group A streptococcus (GAS) and Epstein-Barre virus (EBV). METHODS The study population consisted of cases with exudative tonsillitis who had been subsequently diagnosed as PFAPA, EBV, and GAS tonsillitis through a period of 6 years. We retrieved the CBC, ESR, CRP and PCT data from patients' medical records. RESULTS Of the patients, 47 (35.6%) had PFAPA, 36 (27.3%) had GAS and 49 (37.1%) had EBV tonsillitis. Median CRP, ESR and PCT values of patients with PFAPA were 78 (17-92) mg/dl, 44 (11-83) mm/h, 0.16 (0.01-1.45) ng/ml, respectively. The CRP and ESR levels were significantly higher in PFAPA and GAS groups compared with the EBV group (p = 0.001). There was no significant difference between the groups regarding the PCT levels. CONCLUSION The study indicated no benefit of PCT in distinguishing PFAPA from the others. However, we found that CRP, ESR, and CBC parameters could be useful in identifying PFAPA and GAS than EBV tonsillitis.
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Affiliation(s)
- Ali Kanik
- Department of Pediatrics, İzmir Katip Çelebi University, Faculty of Medicine, İzmir, Turkey
| | - Kayı Eliacik
- Department of Pediatrics, Tepecik Teaching and Research Hospital, İzmir, Turkey
| | - Esra Toprak Kanik
- Department of Pediatric Allergy and Immunology, Dr. Behcet Uz Childrens Hospital, İzmir, Turkey
| | - Mustafa Agah Tekindal
- Faculty of Veterinary Medicine, Department of Biostatistics, Selcuk University, Konya, Turkey
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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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Førsvoll J, Kristoffersen EK, Øymar K. The immunology of the periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome; what can the tonsils reveal. A literature review. Int J Pediatr Otorhinolaryngol 2020; 130:109795. [PMID: 31786522 DOI: 10.1016/j.ijporl.2019.109795] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Tonsillectomy (TE) or adenotonsillectomy (ATE) may have a beneficial effect on the clinical course in children with the periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome. However, an immunological reason for this effect remains unknown. This literature review summarizes the current knowledge regarding the immunological role of the tonsils in the PFAPA syndrome. METHODS We searched PubMed, Medline, EMBASE and Cochrane for papers written in English dated from 1 January 1987 to 30 April 2019. The search included all studies reporting histological, immunological or microbiological workup of tonsil specimens from children aged 0-18 years with PFAPA. RESULTS Thirteen articles reported histological, immunological or microbiological workup of tonsil specimens in children with PFAPA. The histology of tonsil specimens from children with PFAPA displayed chronic tonsillar inflammation with lymphoid hyperplasia. No uniform immunological pattern was identified, but some studies found fewer B-lymphocytes and smaller germinal centers in PFAPA compared to controls. A difference in tonsillar microbiota between PFAPA and controls was found in one study. CONCLUSION A uniform immunological or microbiological pattern explaining the clinical effect of TE in children with PFAPA has not been revealed. Future targeted immunological studies of tonsils in PFAPA patients could possibly illuminate the understanding of the immunology in this disease.
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Affiliation(s)
- Jostein Førsvoll
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Einar Klæboe Kristoffersen
- Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
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Características y evolución de una cohorte de niños con síndrome PFAPA en la Comunidad de Madrid. ACTA ACUST UNITED AC 2019; 15:355-359. [DOI: 10.1016/j.reuma.2017.10.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 10/21/2017] [Accepted: 10/28/2017] [Indexed: 12/12/2022]
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10
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Renko M, Lantto U, Tapiainen T. Towards better diagnostic criteria for periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome. Acta Paediatr 2019; 108:1385-1392. [PMID: 30901126 DOI: 10.1111/apa.14792] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/04/2019] [Accepted: 03/19/2019] [Indexed: 12/13/2022]
Abstract
AIM Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is the most common cause of a periodic fever in childhood. The exact pathogenesis and the aetiology of PFAPA are still unknown. METHODS We conducted a non-systematic review of published articles about PFAPA syndrome and summarised the evidence for diagnostic criteria and treatment options for PFAPA. RESULTS The first proposed diagnostic criteria for PFAPA, in addition to periodic fever, included aphthous stomatitis, pharyngitis or cervical lymphadenitis in children younger than five years at the beginning of the symptoms. C-reactive protein (CRP) levels and leucocyte counts increase in most patients during episodes. Recent research reveals that tonsillectomy provides an immediate and long-lasting cure for PFAPA, even in the absence of classic criteria of aphthous stomatitis, pharyngitis or cervical adenitis and in children older than five years. CONCLUSION We suggest that PFAPA can be diagnosed in children with at least five regularly occurring fever episodes without any other explanation, even in the absence of aphthous stomatitis, pharyngitis or cervical lymphadenitis and also in children older than five years.
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Affiliation(s)
- Marjo Renko
- Department of Paediatrics University of Eastern Finland and Kuopio University Hospital Kuopio Finland
- PEDEGO Research Unit University of Oulu Oulu Finland
| | - Ulla Lantto
- PEDEGO Research Unit University of Oulu Oulu Finland
- Department of Otorhinolaryngology Oulu University Hospital Oulu Finland
| | - Terhi Tapiainen
- PEDEGO Research Unit University of Oulu Oulu Finland
- Department of Children and Adolescents Oulu University Hospital Oulu Finland
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11
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Batu ED. Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome: main features and an algorithm for clinical practice. Rheumatol Int 2019; 39:957-970. [PMID: 30798384 DOI: 10.1007/s00296-019-04257-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/14/2019] [Indexed: 01/20/2023]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is a recurrent fever syndrome of early childhood with increasing number of adult-onset cases. Although it is a self-limited disease, it may negatively affect the quality of life. The aim of this review is to present a detailed analysis of PFAPA syndrome and an algorithm for diagnosis, therapeutic options, and evaluation of outcome. A comprehensive literature search was conducted through the Cochrane Library, Scopus, and MEDLINE/PubMed databases. The main topics covered are the epidemiology, clinical manifestations, diagnosis, differential diagnosis, etiopathogenesis, genetics, management, disease course and prognosis, disease in adults, unsolved issues, and unmet needs in PFAPA. The diagnosis of PFAPA is mainly based on clinical classification criteria. The most relevant hypothesis for pathogenesis is that dysregulated immune system in a genetically predisposed individual responds to a yet unidentified trigger in an exaggerated way. The pedigree analyses suggest a genetic background for the disease with an autosomal dominant pattern of inheritance. For management, single-dose corticosteroids during attacks and tonsillectomy remain the most effective therapies, while colchicine is a promising option to decrease attack frequency. There remain unsolved issues in PFAPA such as the exact etiopathogenesis and genetic background, the reason why the inflammation is restricted to the oropharyngeal lymphoid tissue, reasons for clock-work regularity of attacks, and self-limited disease course. There is need for a valid diagnostic criteria set with a high performance for both children and adults and consensus on management of PFAPA.
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Affiliation(s)
- Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, Ankara Training and Research Hospital, University of Health Sciences, 06100, Ankara, Turkey.
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12
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Wekell P. Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome - PFAPA syndrome. Presse Med 2019; 48:e77-e87. [PMID: 30683466 DOI: 10.1016/j.lpm.2018.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/07/2018] [Indexed: 01/04/2023] Open
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is a complex autoinflammatory disease with a clinical phenotype characterised by recurrent episodes of fever, systemic inflammation and symptoms and signs depicted in disease acronym. Although PFAPA is the most common autoinflammatory disease among children in many parts of the world, the condition is still an enigma, which include the regular episodes, the prompt responses to corticosteroids, the genetic bases for the familial clustering and therapeutic effects of tonsillectomy. This review explores PFAPA syndrome with the aim of describing the current clinical and scientific understanding of the condition.
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Affiliation(s)
- Per Wekell
- Department of Pediatrics, NU-Hospital Group, 45180 Uddevalla, Sweden; Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Førsvoll J, Øymar K. The role of tonsillectomy in the Periodic Fever, Aphthous stomatitis, Pharyngitis and cervical Adenitis syndrome; a literature review. BMC EAR, NOSE, AND THROAT DISORDERS 2018; 18:3. [PMID: 29483843 PMCID: PMC5824547 DOI: 10.1186/s12901-017-0049-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/20/2017] [Indexed: 11/10/2022]
Abstract
Background Tonsillectomy (TE) or adenotonsillectomy (ATE) may have a beneficial effect on the clinical course in children with the Periodic Fever, Aphthous stomatitis, Pharyngitis and cervical Adenitis (PFAPA) syndrome. However, an immunological reason for this effect remains unknown. This literature review summarizes the current knowledge of the effect of TE or ATE in the PFAPA syndrome. Methods A search of PubMed, Medline, EMBASE and Cochrane was conducted for papers written in English dated from 1 January 1987 to 31 December 2016. The search included all studies reporting outcomes after TE or ATE from children aged 0 to 18 years with PFAPA. Results Two randomized controlled trials reported significantly faster resolution of febrile episodes after TE or ATE in children with PFAPA compared to controls (non-surgery groups). We identified 28 case series including 555 children with PFAPA. The diagnosis was set prospectively before surgery in 440 children and retrospectively after surgery in 115 of the children. TE or ATE had a curative effect in 509 of the 555 children with PFAPA (92%), but few studies were of high quality. Conclusion TE or ATE may have a curative effect on children with PFAPA, but the evidence is of moderate quality. Further high-quality randomized controlled studies are still needed. Electronic supplementary material The online version of this article (10.1186/s12901-017-0049-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jostein Førsvoll
- 1Department of Paediatrics, Stavanger University Hospital, PO BOX 8100, 4068 Stavanger, Norway.,2Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Knut Øymar
- 1Department of Paediatrics, Stavanger University Hospital, PO BOX 8100, 4068 Stavanger, Norway.,2Department of Clinical Science, University of Bergen, Bergen, Norway
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Gentileschi S, Vitale A, Frediani B, Galeazzi M, Rigante D, Cantarini L. Challenges and new horizons in the periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1279049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Stefano Gentileschi
- Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Bruno Frediani
- Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Mauro Galeazzi
- Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
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Kraszewska-Głomba B, Matkowska-Kocjan A, Miśkiewicz K, Szymańska-Toczek Z, Wójcik M, Banyś D, Szenborn L. Mumps, measles and rubella vaccination in children with PFAPA syndrome. Vaccine 2016; 34:5903-5906. [PMID: 27997341 DOI: 10.1016/j.vaccine.2016.10.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 10/12/2016] [Accepted: 10/13/2016] [Indexed: 11/26/2022]
Abstract
There is no published data regarding immunologic response to vaccinations in children with PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis). The aim of this study was to evaluate mumps, measles and rubella immunity in children with PFAPA. 31 children with PFAPA syndrome and 22 healthy children (control group - CG) were recruited to the study. All children were previously vaccinated with one dose of MMR vaccine according to the Polish obligatory vaccination schedule. The patients from both groups were evaluated for anti-measles, anti-mumps and anti-rubella IgG antibodies concentrations (ELISA tests; the reference values for protective antibody levels were 150IU/L, 16RU/L and 11IU/ml respectively). The percentage of patients with protective antibodies levels was as follows: measles - 93.55% of PFAPA and 95.45% of CG patients (p=0.77); mumps - 74.19% of PFAPA and 95.45% of CG patients (p=0.02); rubella - 80.65% of PFAPA and 90.9% of CG patients (p=0.30). CONCLUSIONS Children with PFAPA syndrome present a good response to the measles and rubella component of the MMR vaccine, however immunity against mumps after one dose of MMR may not be sufficient. Further investigation concerning immunity against vaccine-preventable diseases and the safety of vaccinations in children with periodic fever syndromes is required.
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Affiliation(s)
- Barbara Kraszewska-Głomba
- Department and Clinic of Paediatric Infectious Diseases, Wrocław Medical University, 2-2A Chałubińskiego, 50-368 Wrocław, Poland.
| | - Agnieszka Matkowska-Kocjan
- Department and Clinic of Paediatric Infectious Diseases, Wrocław Medical University, 2-2A Chałubińskiego, 50-368 Wrocław, Poland.
| | - Katarzyna Miśkiewicz
- Department and Clinic of Paediatric Infectious Diseases, Wrocław Medical University, 2-2A Chałubińskiego, 50-368 Wrocław, Poland.
| | - Zofia Szymańska-Toczek
- Department and Clinic of Paediatric Infectious Diseases, Wrocław Medical University, 2-2A Chałubińskiego, 50-368 Wrocław, Poland.
| | - Marta Wójcik
- Department and Clinic of Paediatric Infectious Diseases, Wrocław Medical University, 2-2A Chałubińskiego, 50-368 Wrocław, Poland.
| | - Dorota Banyś
- Department and Clinic of Paediatric Infectious Diseases, Wrocław Medical University, 2-2A Chałubińskiego, 50-368 Wrocław, Poland.
| | - Leszek Szenborn
- Department and Clinic of Paediatric Infectious Diseases, Wrocław Medical University, 2-2A Chałubińskiego, 50-368 Wrocław, Poland.
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Wekell P, Karlsson A, Berg S, Fasth A. Review of autoinflammatory diseases, with a special focus on periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome. Acta Paediatr 2016; 105:1140-51. [PMID: 27426283 PMCID: PMC5095866 DOI: 10.1111/apa.13531] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 06/09/2016] [Accepted: 07/14/2016] [Indexed: 12/11/2022]
Abstract
There have been remarkable developments in the field of autoinflammatory diseases over the last 20 years. Research has led to definitions of new conditions, increased understanding of disease mechanisms and specific treatment. The polygenic autoinflammatory condition of periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) is the most common autoinflammatory disorder among children in many parts of the world. The clinical features often include clockwork regularity of episodes, prompt responses to corticosteroids and therapeutic effects of tonsillectomy, but the disease mechanisms are largely unknown. Conclusion This review discusses the emerging understanding of autoinflammatory diseases, with special emphasis on PFAPA.
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Affiliation(s)
- Per Wekell
- Department of Pediatrics NU‐Hospital Group Uddevalla Sweden
- Department of Pediatrics Institute of Clinical Sciences, University of Gothenburg Gothenburg Sweden
| | - Anna Karlsson
- Department of Rheumatology and Inflammation Research Institute of Medicine, University of Gothenburg Gothenburg Sweden
| | - Stefan Berg
- Department of Pediatrics Institute of Clinical Sciences, University of Gothenburg Gothenburg Sweden
- The Queen Silvia Children's Hospital Gothenburg Sweden
| | - Anders Fasth
- Department of Pediatrics Institute of Clinical Sciences, University of Gothenburg Gothenburg Sweden
- The Queen Silvia Children's Hospital Gothenburg Sweden
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Ali NS, Sartori-Valinotti JC, Bruce AJ. Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome. Clin Dermatol 2016; 34:482-6. [DOI: 10.1016/j.clindermatol.2016.02.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis (PFAPA) Syndrome: a Review of the Pathogenesis. Curr Rheumatol Rep 2016; 18:18. [DOI: 10.1007/s11926-016-0567-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Kraszewska-Głomba B, Szymańska-Toczek Z, Szenborn L. Procalcitonin and C-reactive protein-based decision tree model for distinguishing PFAPA flares from acute infections. Bosn J Basic Med Sci 2016; 16:157-61. [PMID: 27131024 PMCID: PMC4852999 DOI: 10.17305/bjbms.2016.974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 02/09/2016] [Accepted: 02/10/2016] [Indexed: 02/03/2023] Open
Abstract
As no specific laboratory test has been identified, PFAPA (periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis) remains a diagnosis of exclusion. We searched for a practical use of procalcitonin (PCT) and C-reactive protein (CRP) in distinguishing PFAPA attacks from acute bacterial and viral infections. Levels of PCT and CRP were measured in 38 patients with PFAPA and 81 children diagnosed with an acute bacterial (n=42) or viral (n=39) infection. Statistical analysis with the use of the C4.5 algorithm resulted in the following decision tree: viral infection if CRP≤19.1 mg/L; otherwise for cases with CRP>19.1 mg/L: bacterial infection if PCT>0.65ng/mL, PFAPA if PCT≤0.65 ng/mL. The model was tested using a 10-fold cross validation and in an independent test cohort (n=30), the rule’s overall accuracy was 76.4% and 90% respectively. Although limited by a small sample size, the obtained decision tree might present a potential diagnostic tool for distinguishing PFAPA flares from acute infections when interpreted cautiously and with reference to the clinical context.
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DNA damage and oxidative status in PFAPA syndrome. Auris Nasus Larynx 2015; 42:406-11. [DOI: 10.1016/j.anl.2015.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 03/15/2015] [Accepted: 03/20/2015] [Indexed: 11/21/2022]
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The Pathogenesis of Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome: A Review of Current Research. Mediators Inflamm 2015; 2015:563876. [PMID: 26457006 PMCID: PMC4589634 DOI: 10.1155/2015/563876] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/08/2015] [Indexed: 01/26/2023] Open
Abstract
Background. PFAPA syndrome is a chronic disease that is characterized by recurrent episodes of high fever, aphthous stomatitis, pharyngitis, and cervical adenitis. Knowledge regarding the etiology of PFAPA is limited. Objectives. To provide up-to-date information considering etiology of PFAPA syndrome, by summarizing what has been explored and established in this area so far. Materials and Methods. PubMed, Web of Science, and Scopus databases were searched for pertinent reports. Eventually 19 articles were selected. The results were classified into categories regarding three areas of interest: familial occurrence, genetic basis, and immunological mechanisms of PFAPA. Results. Recent findings suggest that there is a familial tendency to PFAPA but the level of evidence does not warrant definite conclusions. The absence of a clear monogenic trait indicates a heterogenous, polygenic, or complex inheritance of PFAPA syndrome. As two mutations with a possible functional effect on the inflammasomes (MEFV E148Q and NLRP3 Q703K) have been found in several PFAPA cohorts, the role of inflammasome-related genes in PFAPA pathogenesis cannot be excluded. Immunological mechanisms of PFAPA involve an abnormal, IL-1β dependent innate immune response to an environmental trigger, which leads to Th1-driven inflammation expressed by recruitment of T-cells to the periphery.
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Førsvoll J, Janssen EAM, Møller I, Wathne N, Skaland I, Klos J, Kristoffersen EK, Øymar K. Reduced Number of CD8+ Cells in Tonsillar Germinal Centres in Children with the Periodic Fever, Aphthous Stomatitis, Pharyngitis and Cervical Adenitis Syndrome. Scand J Immunol 2015; 82:76-83. [DOI: 10.1111/sji.12303] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 04/09/2015] [Indexed: 01/08/2023]
Affiliation(s)
- J. Førsvoll
- Department of Pediatrics; Stavanger University Hospital; Stavanger Norway
| | - E. A. M. Janssen
- Department of Pathology; Stavanger University Hospital; Stavanger Norway
| | - I. Møller
- Department of Otolaryngology; Stavanger University Hospital; Stavanger Norway
| | - N. Wathne
- Department of Otolaryngology; Stavanger University Hospital; Stavanger Norway
| | - I. Skaland
- Department of Pathology; Stavanger University Hospital; Stavanger Norway
| | - J. Klos
- Department of Pathology; Stavanger University Hospital; Stavanger Norway
| | - E. K. Kristoffersen
- Department of Clinical Science; University of Bergen; Bergen Norway
- Department of Immunology and Transfusion Medicine; Haukeland University Hospital; Bergen Norway
| | - K. Øymar
- Department of Pediatrics; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
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Interleukin-1 as a common denominator from autoinflammatory to autoimmune disorders: premises, perils, and perspectives. Mediators Inflamm 2015; 2015:194864. [PMID: 25784780 PMCID: PMC4345261 DOI: 10.1155/2015/194864] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/25/2014] [Indexed: 02/07/2023] Open
Abstract
A complex web of dynamic relationships between innate and adaptive immunity is now evident for many autoinflammatory and autoimmune disorders, the first deriving from abnormal activation of innate immune system without any conventional danger triggers and the latter from self-/non-self-discrimination loss of tolerance, and systemic inflammation. Due to clinical and pathophysiologic similarities giving a crucial role to the multifunctional cytokine interleukin-1, the concept of autoinflammation has been expanded to include nonhereditary collagen-like diseases, idiopathic inflammatory diseases, and metabolic diseases. As more patients are reported to have clinical features of autoinflammation and autoimmunity, the boundary between these two pathologic ends is becoming blurred. An overview of monogenic autoinflammatory disorders, PFAPA syndrome, rheumatoid arthritis, type 2 diabetes mellitus, uveitis, pericarditis, Behçet's disease, gout, Sjögren's syndrome, interstitial lung diseases, and Still's disease is presented to highlight the fundamental points that interleukin-1 displays in the cryptic interplay between innate and adaptive immune systems.
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Dytrych P, Krol P, Kotrova M, Kuzilkova D, Hubacek P, Krol L, Katra R, Hrusak O, Kabelka Z, Dolezalova P, Kalina T, Fronkova E. Polyclonal, newly derived T cells with low expression of inhibitory molecule PD-1 in tonsils define the phenotype of lymphocytes in children with Periodic Fever, Aphtous Stomatitis, Pharyngitis and Adenitis (PFAPA) syndrome. Mol Immunol 2015; 65:139-47. [PMID: 25656804 DOI: 10.1016/j.molimm.2015.01.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 12/15/2014] [Accepted: 01/08/2015] [Indexed: 01/30/2023]
Abstract
PURPOSE PFAPA syndrome is a benign, recurrent inflammatory disease of childhood. Tonsillectomy is one of the therapeutic options with a yet unexplained biological mechanism. We tested whether specific lymphocyte subsets recruited from blood to human tonsils participate in PFAPA pathogenesis. METHODS Paired tonsils/peripheral blood (PB) samples were investigated (a) from children with PFAPA that successfully resolved after tonsillectomy (n=10) (b) from children with obstructive sleep apnoea syndrome as controls (n=10). The lymphocyte profiles were analysed using 8-colour flow cytometry, immunoglobulin (IGH) and T-cell receptor (TCR) gene rearrangements via PCR and next generation sequencing; a TREC/KREC analysis was performed using qPCR. RESULTS The PFAPA tonsils in the asymptomatic phase had a lower percentage of B-lymphocytes than controls; T-lymphocyte counts were significantly higher in PB. The percentages of cytotoxic CD8pos T-lymphocytes were approximately 2-fold higher in PFAPA tonsils; the transitional B cells and naïve stages of both the CD4pos and CD8pos T-lymphocytes with a low expression of PD-1 molecule and high numbers of TREC were also increased. With the exception of elevated plasmablasts, no other differences were significant in PB. The expression levels of CXCL10, CXCL9 and CCL19 genes were significantly higher in PFAPA tonsils. The IGH/TCR pattern showed no clonal/oligoclonal expansion. DNA from the Epstein-Barr virus, Human Herpervirus-6 or adenovirus was detected in 7 of 10 PFAPA tonsils but also in 7 of 9 controls. CONCLUSIONS Our findings suggest that the uninhibited, polyclonal response of newly derived lymphocytes participate in the pathogenesis of PFAPA. Because most of the observed changes were restricted to tonsils and were not present in PB, they partly explain the therapeutic success of tonsillectomy in PFAPA syndrome.
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MESH Headings
- Adenoviridae/genetics
- Adenoviridae/isolation & purification
- B-Lymphocytes/immunology
- CD8-Positive T-Lymphocytes/immunology
- Chemokine CCL19/biosynthesis
- Chemokine CXCL10/biosynthesis
- Chemokine CXCL9/biosynthesis
- Child
- Child, Preschool
- Female
- Fever of Unknown Origin/complications
- Fever of Unknown Origin/immunology
- Fever of Unknown Origin/surgery
- Herpesvirus 4, Human/genetics
- Herpesvirus 4, Human/isolation & purification
- Herpesvirus 6, Human/genetics
- Herpesvirus 6, Human/isolation & purification
- Humans
- Infant
- Lymphadenitis/complications
- Lymphadenitis/immunology
- Lymphadenitis/surgery
- Lymphocyte Count
- Male
- Palatine Tonsil/cytology
- Palatine Tonsil/immunology
- Palatine Tonsil/surgery
- Pharyngitis/complications
- Pharyngitis/immunology
- Pharyngitis/surgery
- Programmed Cell Death 1 Receptor/biosynthesis
- Receptors, Antigen, T-Cell/genetics
- Sleep Apnea, Obstructive/immunology
- Sleep Apnea, Obstructive/surgery
- Stomatitis, Aphthous/complications
- Stomatitis, Aphthous/immunology
- Stomatitis, Aphthous/surgery
- T-Lymphocyte Subsets/immunology
- Tonsillectomy
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Affiliation(s)
- Petra Dytrych
- Department of ENT, Charles University, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, Czech Republic
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Mehregan FF, Ziaee V, Ahmadinejad Z, Tahghighi F, Sabouni F, Moradinejad MH. Periodic Fever, Aphthous Stomatitis, Pharyngitis and Cervical Adenitis (PFAPA) Syndrome in Iranian Children First Report of Iranian Periodic Fever and Autoinflammatory Registry (IPFAIR). IRANIAN JOURNAL OF PEDIATRICS 2014; 24:598-602. [PMID: 25793068 PMCID: PMC4359414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 09/23/2014] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is a nonhereditary idiopathic febrile syndrome belonging to the group of autoinflammatory diseases. No longtime sequel was reported in this disease. Early diagnosis can lead physicians to treatment of this disorder with a short course steroid application and provide satisfaction of the patient's family. METHODS This study is a prospective review of patients diagnosed with PFAPA syndrome who were registered in Iranian Periodic Fever and Autoinflammatory Registry (IPFAIR) through periodic fever clinic in the Children's Medical Center, Pediatric Center of Excellence in Tehran, Iran from January 2013 to March 2014. FINDINGS One hundred thirty patients were registered in our databases. Twenty-one (16.1%) patients including 15 males and 6 females had PFAPA. Normal growth was seen in all patients. The median age at onset was 18 months. The mean duration of fever was 4 days and the mean duration of intervals between fever episodes 21 days. Along with fever, all patients had characteristic symptoms. All patients were asymptomatic between fever episodes. Steroid was used in all patients and causing immediate reduction by 84.61%. Two patients received both steroid and colchicine because of their clinical feature and positive laboratory tests for PFAPA and familial Mediterranean fever. No patient received biological therapy or a tonsillectomy. CONCLUSION The long diagnostic delay of PFAPA gives cause to concern indicating a need for greater awareness of the disease so that the diagnosis may be made timely.
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Affiliation(s)
- Fatemeh Fereshteh Mehregan
- Children’s Medical Center, Pediatrics Center of Excellence,Shahid Beheshti University of Medical Sciences
| | - Vahid Ziaee
- Pediatric Rheumatology Research Group, Rheumatology Research Center,Department of Pediatrics,Corresponding Author: Address: Division of Pediatric Rheumatology, Children's Medical Center, No. 62 Dr. Gharib St., Keshavarz Blvd, Tehran 14194, Iran
| | - Zahra Ahmadinejad
- Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Tahghighi
- Children’s Medical Center, Pediatrics Center of Excellence,Department of Pediatrics
| | - Farah Sabouni
- Children’s Medical Center, Pediatrics Center of Excellence,Department of Pediatrics
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