French protocol for the diagnosis and management of familial Mediterranean fever

Familial Mediterranean fever is the most common monogenic auto-inflammatory disease in the world. It mainly affects people originating from the Mediterranean region. The mutated gene is MEFV, which codes for pyrin. Transmission is autosomal recessive. Patients present with recurrent attacks of fever since childhood associated with abdominal and/or thoracic pain lasting an average of 2-3days and a biological inflammatory syndrome. Other symptoms include arthralgia or arthritis in large joints such as the knees and ankles, myalgia in the lower limbs and pseudo-erysipelas in the ankles. The most serious complication is inflammatory amyloidosis, which can lead to kidney failure. Treatment is based on colchicine, which helps to prevent flares and the onset of renal amyloidosis. This paper proposes national guidelines for the diagnosis, management and follow-up of familial Mediterranean fever in France, where we estimate there are between 5000 and 10,000 patients with the disease at all stages of life. The diagnosis is suspected on the basis of clinical and anamnestic factors and confirmed by genetic analysis. These guidelines also suggest a "treat-to-target" approach to disease management, particularly in case of suspected colchicine resistance - a very rare situation that should remain a diagnosis of elimination, especially after colchicine compliance has been verified. Two special situations are also addressed in these guidelines: kidney failure and pregnancy.

Is neutrophilic dermatosis a manifestation of familial Mediterranean fever?

Objectives: Familial Mediterranean fever (FMF) is the most frequent monogenic autoinflammatory disease. It is associated with MEFV mutations. Its main features are recurrent episodes of fever and serositis. Patients can display dermatological manifestations such as erysipelas-like erythema, generally considered as a neutrophilic dermatosis (ND). It has been suggested that FMF can be associated with other types of ND. Our aim was to perform a systematic review of the literature to assess the link between ND and FMF.Method: A systematic review of the literature was performed using MEDLINE from 1946 to 2018. Three independent investigators identified reports of non-erysipelas-like erythema neutrophilic dermatosis (NEND) associated with FMF, selected the criteria to establish the diagnosis of FMF and ND, and evaluated the link between the two conditions. FMF-associated NEND was supported by confirmation of both diagnoses and exclusion of other causes of ND.Results: Eighteen articles were selected. Nine articles reported FMF patients with the following NEND: neutrophilic panniculitis (n = 4), Sweet syndrome (n = 6), and pyoderma gangrenosum (n = 1). None of these cases was supported by histological confirmation, fulfilled diagnostic criteria for definitive or probable FMF, or confirmed the exclusion of all the most frequent diseases associated with NEND. As a result, there is insufficient evidence to support a potential relationship between NEND and FMF.Conclusions: The association between FMF and NEND remains unclear. In FMF patients with NEND, every differential diagnosis and alternative cause of NEND should be excluded before drawing any conclusions about a potential causal relationship.

La fièvre méditerranéenne familiale est-elle uns situation à risque de développer une forme grave d’infection par la COVID19 ? Résultat d’une étude rétrospective sur 627 patients en période et zone endémique en France

Introduction

La nouvelle pandémie mondiale (COVID19) causée par le coronavirus 2 du syndrome respiratoire aigu sévère (SRAS-CoV-2) est responsable de nombreux décès dans le monde entier au cours des derniers mois. Au cours des formes graves, il a été noté une réponse inflammatoire exagérée connue sous le nom de “orage cytokinique”. Ceci a soulevé la question de la sensibilité et de la gravité de l’infection par le SRAS-CoV2 chez les patients présentant une hyperactivation génétique de l’immunité innée tels que la fièvre méditerranéenne familiale (FMF). En outre, les patients avec FMF prennent de la colchicine au long cours, médicament qui a été testé chez des patients infectés par le SRAS-CoV2 avec des résultats contradictoires [1].

Patients et méthodes

Étude menée sur l’infection par le SRAS-CoV2 chez les patients atteints de FMF suivis dans 2 sites du centre de référence national des maladies autoinflammatoires en région parisienne et inclus dans la JIR cohorte, une base de données européenne multicentrique. Les patients adultes et pédiatriques inclus répondaient aux critères internationaux de FMF et avaient un diagnostic génétique confirmé.

Résultats

Les patients identifiés (n = 627) ont été invités à répondre à un bref questionnaire soit en consultation, soit par téléphone, soit par courrier électronique sur une possible infection par le SARS-CoV2 pendant la période de mars à juin 2020 ; 342 patients ont répondu à l’enquête. Le diagnostic était retenu si le patient présentait des symptômes cliniques avec PCR ou sérologie positive ou scanner thoracique typique. Au total, 27 patients FMF (7,8 % des répondants ; sexe ratio 1/1) ont contracté le virus. Tous les 27 patients FMF-COVID+ sauf un prenaient de la colchicine quotidiennement depuis une période médiane de 23 ans, la dose moyenne de colchicine était de 1 mg/jour. Quatre recevaient en plus un inhibiteur de l’IL-1. Parmi les 27 patients FMF-COVID+, sept symptomatiques ont été hospitalisés (25 %) et six ont eu besoin d’oxygène ; trois (11 %) ont développé un syndrome de détresse respiratoire aiguë nécessitant des soins intensifs pour une ventilation mécanique et une hémodialyse. Deux patients sont décédés (7 %) mais présentaient respectivement 3 et 4 comorbidités pour une infection grave par le SRAS-CoV2 ; le troisième patient, âgé de 40 ans, souffrait d’hypertension et d’obésité. Les patients âgés de plus de 65 ans représentaient 17 % de l’ensemble de la cohorte FMF-COVID +  ; 75 % ont été hospitalisés et ont eu besoin d’oxygène ; l’un d’eux est décédé. Trois patients FMF-COVID +  avaient une amylose AA : 2 ont été hospitalisés et un est décédé. Aucun traitement anti-viral supplémentaire n’a été administré. Les 5 survivants après hospitalisation sont rentrés chez eux. Aucun d’entre eux n’a présenté de signes cliniques de crise de FMF lors de l’infection par le SRAS-CoV2.

Discussion

Le profil des patients FMF atteints d’une forme grave ou potentiellement mortelle par le SRAS-CoV2 était le même que celui de la population générale. Ainsi, seuls les patients FMF présentant des facteurs de risque connus (tels que âge avancé, maladie rénale chronique, hypertension, maladie vasculaire, obésité et dysfonctionnement pulmonaire) ont développé une infection grave par le SARS-CoV2 [2]. Cette étude n’est pas en faveur d’un surrisque en soi de développer une infection sévère à SRAS-CoV2 en présence d’une maladie autoinflammatoire monogénique touchant un inflammasome. Aucune conclusion formelle ne peut être tirée sur l’effet préventif de la colchicinothérapie au long cours, bien que ce travail rétrospectif porte sur une large cohorte de patients traités par colchicine depuis plusieurs années. Il est difficile de conclure à l’efficacité du traitement par inhibiteur d’IL1 vis-à-vis l’infection par le SRAS-CoV-2 chez les patients FMF, mais 50 % des patients traités au long cours sont décédés mais avaient plusieurs comorbidités ; et des publications récentes semblent plaider en faveur de l’efficacité de l’anakinra dans l’infection grave par le SRAS-CoV-2 [3].

Conclusion

La FMF ne semble pas constituer un facteur de risque de développer une forme sévère d’infection par SARS-CoV2 chez les patients traités au long cours par de la colchicine quotidienne, par rapport à la population générale.

[Adult-onset Still's disease complications]

Adult-onset Still's disease (AOSD), first described in 1971 by Bywaters, is a rare systemic auto-inflammatory disorder of unknown etiology, characterized by a symptomatic triad associating prolonged fever, polyarthritis and rash. The management of this disease has significantly improved since its first description, and, although the overall prognosis of the AOSD is good, with a low attributable mortality, below 3% (but up to 18% depending on the series), some rare complications are still possible, can be life-threatening and change the prognosis of the disease. A literature search was performed to review AOSD's complications: reactive hemophagocytic lymphohystiocytosis, coagulation disorders, fulminant hepatitis, cardiovascular (pericarditis, myocarditis, HTAP) or pulmonary complications, neurologic, renal complications, and AA amyloidosis. For most of AOSD-related complications, corticosteroids remain the first-line treatment, in association with supportive care measures in case of severe complications. In case of inadequate response, multidisciplinary care with concil from a referral center is advised, and IL-1 or IL-6 blockers, but also ciclosporine, are the molecule to use in second intention.

[Familial Mediterranean fever]

Familial Mediterranean Fever (FMF) is the most frequent monogenic auto-inflammatory disease. FMF is an autosomal recessive disease, which affects populations from Mediterranean origin and is associated with MEFV gene mutations encoding for the protein pyrin. Pyrin activation enhances the secretion of interleukin 1 by myelo-monocytic cells. Main features of the disease are acute attacks of serositis mainly located on the abdomen, less frequently on chest and joints, accompanied by fever and biological inflammatory markers elevation. Usually attacks last 1 to 3 days and spontaneously stop. A daily oral colchicine intake of 1 to 2mg/day is able to prevent attack's occurrence, frequency, intensity and duration among most patients. Colchicine is also able to prevent the development of inflammatory amyloidosis, the most severe complication of FMF. This state of the art article will focus on the diagnosis of FMF, the treatment and an update on the pathophysiology including the recent described dominant form of MEFV-associated new auto-inflammatory diseases.

Subchondral tibial bone texture analysis predicts knee osteoarthritis progression: data from the Osteoarthritis Initiative: Tibial bone texture & knee OA progression

OBJECTIVES

To examine whether trabecular bone texture (TBT) parameters assessed on computed radiographs could predict knee osteoarthritis (OA) progression.

METHODS

This study was performed using data from the Osteoarthritis Initiative (OAI). 1647 knees in 1124 patients had bilateral fixed flexion radiographs acquired 48 months apart. Images were semi-automatically segmented to extract a patchwork of regions of interest (ROI). A fractal texture analysis was performed using different methods. OA progression was defined as an increase in the joint space narrowing (JSN) over 48 months. The predictive ability of TBT was evaluated using logistic regression and receiver operating characteristic (ROC) curve. An optimization method for features selection was used to reduce the size of models and assess the impact of each ROI.

RESULTS

Fractal dimensions (FD's) were predictive of the JSN progression for each method tested with an area under the ROC curve (AUC) up to 0.71. Baseline JSN grade was not correlated with TBT parameters (R < 0.21) but had the same predictive capacity (AUC 0.71). The most predictive model included the clinical covariates (age, gender, body mass index (BMI)), JSN and TBT parameters (AUC 0.77). From a statistical point of view we found higher differences in TBT parameters computed in medial ROI between progressors and non-progressors. However, the integration of TBT results from the whole patchwork including the lateral ROIs in the model provided the best predictive model.

CONCLUSIONS

Our findings indicate that TBT parameters assessed in different locations in the joint provided a good predictive ability to detect knee OA progression.

Developing and validating a practical decision support tool (DST) for biomass selection on marginal land

Marginal, often contaminated, sites exist in large areas across the world as a result of historic activities such as industry, transportation and mineral extraction. Remediation, or other improvements, of these sites is typically only considered for sites with high exploitation pressure and those posing the highest risks to human health or the environment. At the same time there is increasing competition for land resources for different needs such as biofuel production. Potentially some of this land requirement could be met by production of biomass on brownfield or other marginal land, thereby improving the land while applying the crop cultivation as part of an integrated management strategy. The design and decision making for such a strategy will be site specific. A decision support framework, the Rejuvenate DST (decision support tool) has been developed with the aim of supporting such site specific decision making. This tool is presented here, and has been tested by applying it to a number of case study sites. The consequent SWOT (strength, weakness, opportunities and threats) analysis is discussed and evaluated. The DST was found to be systematic, transparent, and applicable for diverse sites in France, Romania and Sweden, in addition to the sites to which it was applied through its development. The DST is regarded as especially useful if applied as a checklist in an iterative way throughout the decision process, from identifying potential crops to identifying knowledge gaps, working/non-working management strategies and potential risks. The DST also provides a structure promoting effective stakeholder engagement.