1
|
Ezeh UC, Kahn PJ, April MM. Management of Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis with Intracapsular Tonsillectomy. Laryngoscope 2024; 134:1967-1969. [PMID: 37597172 DOI: 10.1002/lary.30969] [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: 05/24/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE This study aimed to present 2 children clinically diagnosed with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome and treated with intracapsular tonsillectomy with adenoidectomy (ITA). METHODS We conducted a retrospective analysis of 2 children who were referred for an otolaryngology consultation between 2019 and 2022 for surgical treatment of PFAPA syndrome. Both patients had symptoms strongly suggestive of PFAPA and were at risk for total tonsillectomy (TT) complications. ITA was performed using a microdebrider. Both patients were followed up postoperatively to assess for symptomatic resolution and complications. RESULTS Two children exhibited recurrent febrile episodes prior to ITA. The procedure was efficacious in both patients, with neither experiencing postoperative complications or recurring PFAPA symptoms for over 1 year after surgery. CONCLUSION Our study reported on the use of ITA as a surgical treatment option for PFAPA. We showed that ITA eliminated febrile attacks and was safely performed without postoperative complications in 2 pediatric patients after 1-year follow-up. Future studies involving larger cohorts of PFAPA patients and lengthier follow-ups will need to be conducted to further evaluate ITA as a surgical option. Laryngoscope, 134:1967-1969, 2024.
Collapse
Affiliation(s)
- Uche C Ezeh
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Philip J Kahn
- Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone Medical Center, New York, New York, U.S.A
| | - Max M April
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, New York, U.S.A
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Batu ED, Kaya Akca U, Basaran O, Bilginer Y, Özen S. Probiotic use in the prophylaxis of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome: a retrospective cohort study. Rheumatol Int 2022; 42:1207-1211. [PMID: 34994815 DOI: 10.1007/s00296-021-05084-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is an autoinflammatory recurrent fever syndrome that mainly affects children. Probiotics are currently used to prevent upper respiratory tract infections and flares of diseases associated with immune dysregulation. We aimed to evaluate the response to probiotic treatment in PFAPA patients. Patients with PFAPA syndrome who received probiotics and were followed between July 2019 and July 2021 were included in this retrospective study. Demographic and clinical features and response to probiotics were assessed. Twenty out of 111 children with PFAPA syndrome (F/M:1) were included. The median (min-max) ages at symptoms onset and diagnosis were 24 (3-72) and 51.5 (11-120) months, respectively. All 20 patients received probiotics during the disease course. The probiotic preparation they received included a combination of two lactobacilli as Lactobacillus plantarum HEAL9 (Lp HEAL9) and Lactobacillus paracasei 8700:2 (Lpa 8700:2). The median age at probiotic onset was 60 (33-192) months, while the duration of probiotic use was 4.5 (3-19) months. All patients except one experienced a decrease in attack frequency with probiotic use. After probiotic treatment, the median number of episodes during 3 months decreased from 3 to 1 (p < 0.001). Eight (40%) patients had no attacks during the 3 months after probiotic initiation. And, 5 (45%) of 11 patients who had ≥ 1 attacks on probiotics mentioned that the attack severity decreased significantly after probiotic initiation. Our results suggest that probiotic strains Lactobacillus plantarum HEAL9 and Lactobacillus paracasei 8700:2 could be beneficial in PFAPA patients by decreasing the attack frequency.
Collapse
Affiliation(s)
- Ezgi D Batu
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey.
| | - Ummusen Kaya Akca
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Ozge Basaran
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Yelda Bilginer
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Seza Özen
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| |
Collapse
|
6
|
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.
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
Welzel T, Ellinghaus M, Wildermuth AL, Deschner N, Benseler SM, Kuemmerle-Deschner JB. Colchicine Effectiveness and Safety in Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis. Front Pediatr 2021; 9:759664. [PMID: 34900867 PMCID: PMC8655689 DOI: 10.3389/fped.2021.759664] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/12/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) is the most common fever syndrome in childhood. High disease activity (DA) dramatically impacts the health-related quality of life. Thus, effective and safe treatment is crucial. Colchicine might be effective, but data are still lacking. Study aimed to assess colchicine safety and effectiveness in PFAPA. Methods: This single center study was conducted between 03/2012 and 05/2021 in PFAPA patients without variants in genetic panel testing aged ≤ 18 years fulfilling Marshall criteria and classification criteria of Gattorno et al. Exclusion criteria were elevated liver enzymes, impaired kidney function, celiac disease, lactose intolerance, previous/ongoing biologics, known colchicine-intolerance. Demographics, clinical characteristics, treatment, DA, colchicine effectiveness and safety were recorded at baseline, first and last visit. Colchicine was started at 0.5-1.0 mg/day. DA was captured by physician (PGA) and patient/parent (PPGA) global assessment on a 10 cm visual analog scale, categorized as mild (<2), moderate (2-4), and high (≥5). Adverse event (AE) monitoring included gastrointestinal symptoms, liver enzyme/creatinine elevation, leukopenia, neutropenia. Primary outcome included response (R; composite of PPGA + PGA decrease ≥2) at last follow-up. Secondary outcomes were partial response (PR; PGA decrease = 1 + PPGA decrease ≥1), no response (NR; unchanged/worsened PGA/PPGA), colchicine safety, flare characteristics. Results: Twenty-seven PFAPA patients were included, 52% were female, median age was 5.8 years (1-10.75), median follow-up time was 13 months. At baseline, median PPGA was high; median PGA moderate. All patients had febrile flares. Median flare frequency was every 4-5 weeks; median duration 5-6 days. Nine patients were pre-treated with corticosteroids, increasing flare frequency in 8/9. Primary Outcome: 17 patients (63%) were responders. Secondary outcomes: PR was achieved in 15%; NR in 22% at last follow-up. DA decreased significantly (p <0.0001). At last follow-up, 52% reported no flares, median flare duration decreased to 1-2 days. At first follow-up, 22% reported mild abdominal pain/diarrhea. Moderate abdominal pain/diarrhea occurred with ≥1 mg/day. Mild asymptomatic liver enzyme elevation or leucopenia were rare; no severe AE or colchicine discontinuation were observed. Conclusion: Colchicine seems to be safe, well-tolerated, and effective in PFAPA patients. It can be considered in children with moderate/high DA even those without corticosteroid-benefit.
Collapse
Affiliation(s)
- Tatjana Welzel
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Maren Ellinghaus
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Anna L Wildermuth
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Norbert Deschner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Susanne M Benseler
- Rheumatology, Department of Paediatrics, Alberta Children's Hospital, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Jasmin B Kuemmerle-Deschner
- Pediatric Rheumatology and Autoinflammatory Reference Center Tübingen, University Children's Hospital Tübingen, University of Tübingen, Tübingen, Germany.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| |
Collapse
|
9
|
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
| |
Collapse
|
10
|
Karayağmurlu A, Aytaç İ. Pre- and postoperative quality of life and emotional/behavioural problems in children with PFAPA. Int J Pediatr Otorhinolaryngol 2020; 137:110239. [PMID: 32896352 DOI: 10.1016/j.ijporl.2020.110239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 06/26/2020] [Accepted: 06/27/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effects of surgical intervention on quality of life, emotional/behavioural problems and school absenteeism in children with periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA.) METHOD: A total of 56 children aged between 4 and 12 years, diagnosed with PFAPA and undergoing tonsillectomy with/without adenoidectomy at a tertiary hospital were included in the study. The Questionnaire for Quality of Life Assessment for Children and Adolescents Parent Form (Kid-KINDL) and the Strengths and Difficulties Questionnaires (SDQ) were used to evaluate quality of life and emotional/behavioural problems, respectively. The cases were assessed before and three months after surgery. RESULTS The mean (SD) age of the children was 6.64 (3.03) years, and 58.9% (n = 33) were boys. The numbers of pre- and post-operative periodic fever episodes were 3.0 (1.7) and 0.6 (0.9) (p < 0.001), those for school absenteeism were 10.28 (5.53) and 2.85 (2.95) days (p < 0.001) and those for hospital presentations were 3.8 (2.5) and 1.1 (1.1) (p < 0.001), respectively, all of which were significantly lower in children with PFAPA at three months after the operation. The surgical procedures were effective in improving quality of life and emotional/behavioural problems, as evidenced by the significant differences between the pre- and post-treatment scores in outcome measures, including SDQ and Kid-KINDL (p < 0.001). CONCLUSIONS This study demonstrated that the surgical approach exhibited positive effects in terms of improving quality of life and reducing emotional/behavioural problems and school absenteeism in children with PFAPA.
Collapse
Affiliation(s)
- Ali Karayağmurlu
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Istanbul University, İstanbul, Turkey.
| | - İsmail Aytaç
- Department of Otorhinolaryngology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| |
Collapse
|
11
|
Manti S, Filosco F, Parisi GF, Finocchiaro GG, Papale M, Giugno A, Barone P, Leonardi S. Proposal for a new therapeutic high dosage of Pidotimod in children with periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome: a randomized controlled study. Ital J Pediatr 2020; 46:106. [PMID: 32711565 PMCID: PMC7382793 DOI: 10.1186/s13052-020-00871-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/16/2020] [Indexed: 01/01/2023] Open
Abstract
Background Despite to PFAPA syndrome is considered a benign and self-limited condition in childhood its impact on patients and families can be remarkable in many cases. Currently, the therapeutic options for managing are non-specific and no consensus exists about the best treatment to use. Pidotimod has been suggested as a new potential treatment in PFAPA syndrome for its immunodulatory effects. We conducted a preliminary, prospective, controlled, open, cross-over trial to assess the efficacy and the safety of Pidotimod in the treatment of children with PFAPA syndrome. Methods 22 children with PFAPA syndrome were randomly allocated to treatment with pidotimod (with 2 vials of 400 mg daily) in combination with betamethasone 0.5–1 mg on need, based on parents/caregivers’ decision (group A) or betamethasone 0.5-1 mg on need, based on parents/caregivers’ decision (group B). Each treatment period was for 3 months (Phase 1), after that patients were switched to the other arm for other 3 months (Phase 2). Efficacy was expressed in terms of number of episodes of fever, pharyngitis, or aphthous stomatitis, as well as the additional use of betamethasone on need. Safety and tolerability of the Pidotimod were evaluated on the basis of the number and type of adverse events (AEs) recorded during the treatment. Results Patients receiving Pidotimod and use betametasone showed a significant decrease in frequency of fevers (p = 0.002); number of episodes of pharyngitis (p = 0.049); aphthous stomatitis (p = 0.036) as well as the betamethasone use on need (p = 0.007). Overall, 19/22 (86.4%) showed benefits from Pidotimod administration. The safety profile of Pidotimod was excellent as no serious adverse events have been reported in the treated groups. Conclusions We firstly showed that high dosage of Pidotimod could be an effective and safe to reduce the PFAPA attacks in children.
Collapse
Affiliation(s)
- Sara Manti
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Federica Filosco
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Giuseppe Fabio Parisi
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy.
| | - Giuseppe Germano Finocchiaro
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Maria Papale
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Andrea Giugno
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Patrizia Barone
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Salvatore Leonardi
- Pediatric Respiratory Unit - San Marco Hospital, Department of Clinical and Experimental Medicine, University of Catania, Viale Carlo Azeglio Ciampi, 95121, Catania, Italy
| |
Collapse
|
12
|
Bulut F, Cumbul A, Safak AS. An analysis of the histomorphometric and clinical significance of mucosal biofilm in tonsil tissue of the children with a history of recurrent/chronic tonsillitis in both the mother and father. Eur Arch Otorhinolaryngol 2020; 277:3381-3389. [PMID: 32577899 DOI: 10.1007/s00405-020-06111-7] [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: 12/26/2019] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study is to analyse the histomorphometric and clinical features of the mucosal biofilm in tonsil tissue of children with a history of recurrent/chronic tonsillitis in both the mother and father. METHODS This study enrolled 82 children (between 3 and 14 years of age). These children were divided into two main groups according to the present of recurrent/chronic tonsillitis. Patients in group 1 were divided into four subgroups (A, B, C, D) according to the history of recurrent/chronic tonsillitis in mother and/or father. 30 patients in group 1 were underwent tonsillectomy and the 52 patients in control group (2) have not had history of recurrent/chronic tonsillitis. To that end, among children with a history of recurrent/chronic tonsillitis certain changes in the volume and thickness of mucosal biofilm in tonsil tissue have been exhibited with respect to it is histomorphometric and clinical significance. RESULTS The children with a parental history of recurrent/chronic tonsillitis in group A, an increase in the thickness and volume of mucosal biofilm samples was detected according to the other subgroups (B, C, D). Parents history of group A patients statistically significant differences were detected with respect to halitosis symptoms, attack age of the first tonsillitis and resistant fever despite antibiotic treatment for children under the age of 3 years. CONCLUSIONS This study showed that children under the age of 3 years of age with a history of recurrent/chronic tonsillitis in both the mother and father, halitosis symptoms, attack age of the first tonsillitis and resistant fever despite antibiotic treatment are collectively linked.
Collapse
Affiliation(s)
- Fuat Bulut
- Department of Otorhinolaryngology, Rumeli University REYAP Hospital, Istanbul, Turkey.
| | - Alev Cumbul
- Histology and Embryology, Yeditepe University Faculty of Medicine, Istanbul, Turkey
| | - Ayse Sezim Safak
- Department of Otorhinolaryngology, Private Gebze Central Hospital, Gebze, Kocaeli, Turkey
| |
Collapse
|
13
|
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.
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Luu I, Sharma A, Guaderrama M, Peru M, Nation J, Page N, Carvalho D, Magit A, Jiang W, Leuin S, Bliss M, Bothwell M, Brigger M, Kearns D, Newbury R, Pransky S, Gilbert JA, Broderick L. Immune Dysregulation in the Tonsillar Microenvironment of Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA) Syndrome. J Clin Immunol 2019; 40:179-190. [PMID: 31807979 DOI: 10.1007/s10875-019-00724-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/24/2019] [Indexed: 01/10/2023]
Abstract
Periodic Fever, Aphthous stomatitis, Pharyngitis and Adenitis (PFAPA) syndrome is an inflammatory disorder of childhood classically characterized by recurrent fevers, pharyngitis, stomatitis, cervical adenitis, and leukocytosis. While the mechanism is unclear, previous studies have shown that tonsillectomy can be a therapeutic option with improvement in quality of life in many patients with PFAPA, but the mechanisms behind surgical success remain unknown. In addition, long-term clinical follow-up is lacking. In our tertiary care center cohort, 62 patients with PFAPA syndrome had complete resolution of symptoms after surgery (95.3%). Flow cytometric evaluation demonstrates an inflammatory cell population, distinct from patients with infectious pharyngitis, with increased numbers of CD8+ T cells (5.9% vs. 3.8%, p < 0.01), CD19+ B cells (51% vs. 35%, p < 0.05), and CD19+CD20+CD27+CD38-memory B cells (14% vs. 7.7%, p < 0.01). Cells are primed at baseline with increased percentage of IL-1β positive cells compared to control tonsil-derived cells, which require exogenous LPS stimulation. Gene expression analysis demonstrates a fivefold upregulation in IL1RN and TNF expression in whole tonsil compared to control tonsils, with persistent activation of the NF-κB signaling pathway, and differential microbial signatures, even in the afebrile period. Our data indicates that PFAPA patient tonsils have localized, persistent inflammation, in the absence of clinical symptoms, which may explain the success of tonsillectomy as an effective surgical treatment option. The differential expression of several genes and microbial signatures suggests the potential for a diagnostic biomarker for PFAPA syndrome.
Collapse
Affiliation(s)
- Irene Luu
- Department of Pediatrics, Division of Allergy, Immunology and Kawasaki Disease, University of California San Diego, La Jolla, CA, USA
| | - Anukriti Sharma
- Department of Pediatrics and Scripps Institution of Oceanography, University of California San Diego, La Jolla, CA, USA
| | - Marisela Guaderrama
- Department of Pediatrics, Division of Allergy, Immunology and Kawasaki Disease, University of California San Diego, La Jolla, CA, USA
| | - Michelle Peru
- Department of Pediatrics, Division of Allergy, Immunology and Kawasaki Disease, University of California San Diego, La Jolla, CA, USA
| | - Javan Nation
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Nathan Page
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Daniela Carvalho
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Anthony Magit
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Wen Jiang
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Shelby Leuin
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Morgan Bliss
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Marcella Bothwell
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Matthew Brigger
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Donald Kearns
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Robert Newbury
- Department of Pathology, University of California San Diego, La Jolla, CA, 92093, USA
| | - Seth Pransky
- Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.,Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA
| | - Jack A Gilbert
- Department of Pediatrics and Scripps Institution of Oceanography, University of California San Diego, La Jolla, CA, USA
| | - Lori Broderick
- Department of Pediatrics, Division of Allergy, Immunology and Kawasaki Disease, University of California San Diego, La Jolla, CA, USA. .,Rady Children's Foundation, Rady Children's Hospital, San Diego, San Diego, CA, 92123, USA.
| |
Collapse
|
16
|
Takeuchi Y, Shigemura T, Kobayashi N, Nagumo H, Furumoto M, Ogasawara K, Fujii H, Takizawa M, Soga T, Matoba H, Masumoto J, Fukushima K, Migita K, Ojima T, Umeda Y, Agematsu K. Clinical features and new diagnostic criteria for the syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis. Int J Rheum Dis 2019; 22:1489-1497. [PMID: 31131563 DOI: 10.1111/1756-185x.13610] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 05/03/2019] [Accepted: 05/05/2019] [Indexed: 11/29/2022]
Abstract
AIM The syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) is a common inflammatory disease that presents with periodic fever. We aimed to establish more specific diagnostic criteria for PFAPA based on the clinical characteristics of PFAPA patients in our directory. METHOD The clinical, laboratory, genetic, and family history details of 257 Japanese PFAPA patients treated at our and other affiliated hospitals between April 2000 and April 2018 were analyzed along with quantitative measurements of the number of CD64 molecules on neutrophils, and the levels of serum inflammatory cytokines. The sensitivity and specificity of the criteria were calculated for several diseases. RESULTS Because recurrent fevers were crucial findings, they were defined as the required criterion. Tonsillitis/pharyngitis with white moss were important accompanying signs. Other symptoms associated with febrile episodes were cervical lymphadenitis with tenderness, aphthous stomatitis, sore throat, vomiting, and headache but not cough. A total of 159 (62%) patients had a family history of recurrent fevers, indicating autosomal dominant inheritance. C-reactive protein levels were extremely elevated during febrile attacks but normal in attack-free periods. Serum immunoglobulin D levels were high in 72 of the 199 tested patients. Oral glucocorticoid and cimetidine were extremely effective in all and 51.6% of the patients, respectively. We defined the above as supportive criteria. These criteria were sensitive and specific enough to distinguish PFAPA from other recurrent fever diseases. Raised serum interferon-γ levels and remarkable CD64 expression on neutrophils during flare-ups were recognized, indicating they contributed to diagnosis. CONCLUSION Our new criteria are useful for diagnosing PFAPA.
Collapse
Affiliation(s)
- Yusuke Takeuchi
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomonari Shigemura
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Norimoto Kobayashi
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Haruo Nagumo
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | | | - Kyo Ogasawara
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hitomi Fujii
- Department of Pediatrics, Azumino Red Cross Hospital, Azumino, Japan
| | - Masahiro Takizawa
- Department of Pediatrics, Azumino Red Cross Hospital, Azumino, Japan
| | - Takashi Soga
- Children's Medical Center, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Hisanori Matoba
- Department of Infection and Host Defense, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | - Junya Masumoto
- Department of Pathology, Proteo-Science Center and Graduate School of Medicine, Ehime University, Toon, Japan
| | - Keitaro Fukushima
- Department of Pediatrics, Dokkyo Medical University, Shimotsuga, Japan
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Toshiyuki Ojima
- Department of Community Health and Preventive Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yoh Umeda
- Children's Medical Center, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Kazunaga Agematsu
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan.,Children's Medical Center, Northern Yokohama Hospital, Showa University, Yokohama, Japan.,Department of Infection and Host Defense, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| |
Collapse
|
17
|
Recurrence of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome after tonsillectomy: case-based review. Rheumatol Int 2019; 39:1099-1105. [PMID: 31020337 DOI: 10.1007/s00296-019-04310-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/16/2019] [Indexed: 12/24/2022]
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is a recurrent fever syndrome for which tonsillectomy is a therapeutic option curing the disease in most patients. Recurrence after remission with tonsillectomy is extremely rare. Increasing number of reports on diverse disease manifestations in PFAPA could give us clues about the disease etiopathogenesis. We aimed to describe a patient with recurrence of PFAPA syndrome after tonsillectomy and to review the previous studies including similar cases. We report a 17-year-old boy with PFAPA syndrome who experienced remission for 3 years after tonsillectomy and was later found to harbor an MEFV mutation when the disease relapsed. He responded well to colchicine treatment at relapse. The literature review revealed 14 articles describing 24 similar PFAPA patients. The therapeutic options include single-dose corticosteroids and nonsteroidal anti-inflammatory drugs during attacks, cimetidine, and resurgery. The presented case was the only one heterozygous for an MEFV mutation and treated with colchicine at disease relapse. Albeit rare, the reoccurrence of PFAPA after tonsillectomy could occur. The presence of such patients opposes with the hypothesis that the trigger or immune dysregulation in PFAPA pathogenesis resides in tonsils.
Collapse
|
18
|
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.
Collapse
Affiliation(s)
- Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, Ankara Training and Research Hospital, University of Health Sciences, 06100, Ankara, Turkey.
| |
Collapse
|
19
|
Costagliola G, Maiorino G, Consolini R. Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome (PFAPA): A Clinical Challenge for Primary Care Physicians and Rheumatologists. Front Pediatr 2019; 7:277. [PMID: 31334209 PMCID: PMC6624732 DOI: 10.3389/fped.2019.00277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/20/2019] [Indexed: 01/31/2023] Open
Abstract
Objective: To show the different physician's approaches and the difficulties in the diagnosis and management of the Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis (PFAPA) syndrome, and to quantify the impact of the disease on the families and on the healthcare system. Study Design: Retrospective analysis on 40 patients diagnosed with PFAPA, focusing on the clinical phenotype, the process of diagnosis, and the management of the febrile episodes. The direct and indirect annual economic cost related to PFAPA in the period preceding the diagnosis were also investigated. Results: The median age of patients at disease onset was 1.75 years and the median time to diagnosis was 14.5 months. During the diagnostic process, only 45% of our patients was firstly addressed to rheumatologic consultation, 32.5% to otorinolaryngologist (ORL), and 22.5% to immunologic consultation. Genetic investigations were performed in the 20% of the cohort. Overall population experienced a median of 60 annual days of fever and, during the critical phase, 40% of patients received more than 5 cycles of antibiotic/year. Seventy five percent required laboratory investigations, 18 (45%) needed to access to emergency department and 15 (37.5%) have been hospitalized. The annual mean direct cost was 1659.5 € for each patient, and the estimated mean indirect cost was 5811.6 € for each parent. Conclusion: Despite a benign clinical course, PFAPA syndrome is associated with a significant impact on the patients, their families and the national healthcare system. PFAPA patients require a large number of medical examinations and laboratory or instrumental investigations during the diagnostic approach and often receive inappropriate treatments. Therefore, we suggest the necessity of a greater awareness and knowledge of the disease among primary care physicians and, finally, of the adoption of more specific diagnostic criteria.
Collapse
Affiliation(s)
- Giorgio Costagliola
- Laboratory of Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuseppe Maiorino
- Laboratory of Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rita Consolini
- Laboratory of Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| |
Collapse
|
20
|
Gaggiano C, Rigante D, Sota J, Grosso S, Cantarini L. Treatment options for periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome in children and adults: a narrative review. Clin Rheumatol 2018; 38:11-17. [PMID: 30488366 DOI: 10.1007/s10067-018-4361-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/05/2018] [Indexed: 12/20/2022]
|
21
|
Adrovic A, Sahin S, Barut K, Kasapcopur O. Familial Mediterranean fever and periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome: shared features and main differences. Rheumatol Int 2018; 39:29-36. [PMID: 30019226 DOI: 10.1007/s00296-018-4105-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 07/13/2018] [Indexed: 11/30/2022]
Abstract
Autoinflammatory diseases are characterized by fever attacks of varying durations, associated with variety of symptoms including abdominal pain, lymphadenopathy, polyserositis, arthritis, etc. Despite the diversity of the clinical presentation, there are some common features that make the differential diagnosis of the autoinflammatory diseases challenging. Familial Mediterranean fever (FMF) is the most commonly seen autoinflammatory conditions, followed by syndrome associated with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA). In this review, we aim to evaluate disease characteristics that make a diagnosis of FMF and PFAPA challenging, especially in a regions endemic for FMF. The ethnicity of patient, the regularity of the disease attacks, and the involvement of the upper respiratory systems and symphonies could be helpful in differential diagnosis. Current data from the literature suggest the use of biological agents as an alternative for patients with FMF and PFAPA who are non-responder classic treatment options. More controlled studies are needed to evaluate the efficacy and safety of this strategy.
Collapse
Affiliation(s)
- Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey.
| |
Collapse
|