On Tuesday, I challenged readers to figure out the cause of a girl’s jaw swelling and pain. Over 130 people read the story, and seven people submitted their responses on this website. You can read the original case here. Read below for the complete case, in addition to comments about the correct diagnosis. Continue reading Jaw swelling and pain: a biography of CRMO
Autoinflammatory diseases are a relatively new category of illnesses caused by disorders of one arm of the immune system. Many of these diseases are characterized by recurrent fevers, rash, chest and abdominal pain, and evidence of systemic inflammation on blood tests; these manifestations often mimic infectious or other illnesses, and it may take several years for the diagnosis to be made.
Most autoinflammatory diseases are genetic (inherited), start in childhood, and persist throughout adult life. These diseases are often present in several members of a family. Other autoinflammatory diseases appear to be acquired, perhaps due to the interplay of genetic and environmental factors, and can present at any time during childhood or adulthood.
The list of autoinflammatory diseases continues to grow every month. Here is a list of the autoinflammatory diseases as they stand so far:
- Familial Mediterranean Fever (FMF)
- TNF receptor associated periodic syndrome (TRAPS)
- Hyperimmunoglobulin-D syndrome (Hyper-IgD syndrome, HIDS, also known as mevalonate kinase deficiency, MVK)
- Cryopyrin-associated periodic syndromes (CAPS):
- Familial cold autoinflammatory syndrome (FCAS, also known as familial cold urticaria)
- Muckle-Wells syndrome
- Neonatal onset multisystem inflammatory disease (NOMID, also known as CINCA)
- Deficiency of the interleukin-1-receptor antagonist (DIRA)
- Deficiency of the interleukin-36-receptor antagonist (DITRA)
- Periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA)
- Blau syndrome
- Pyogenic sterile arthritis, Pyoderma gangrenosum, Acne (PAPA)
- Synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome (SAPHO)
- Adult-onset Still’s disease (AOSD)
- Macrophage activation syndrome (MAS)
- Behcet’s disease
- Schnitzler’s syndrome
- Chronic recurrent multifocal osteomyelitis (CRMO, also known as chronic non bacterial osteomyelitis (CNO))
- Deficiency of adenosine deaminase 2 (DADA2)
- STING-associated vasculopathy of infancy (SAVI)
When I was little, I used to get a lot of fevers. With my fevers, I would develop pain in one or both of my ears, and I felt so drained that I just wanted to be left alone to watch TV (or play Atari). If my fever spiked in the middle of the night, my parents would soak me in a tub of lukewarm water to lower my temperature (how I hated those baths!). On the following day, I would visit my pediatrician, who would invariably diagnose me with an ear infection. He prescribed a delicious bubble-gum flavored antibiotic that my parents kept at the top shelf in the refrigerator (out of my reach so I wouldn’t overdose). I’m not sure if it was the taste or the active ingredient, but this antibiotic always made me feel better. After what seemed like the millionth episode of fever, my pediatrician recommended that I get tubes in my ears, and the episodes of fever and ear pain subsided.
Recurrent infections, like those I had when I was a child, are the most common cause of frequent fevers in children. Usually, these infections are due to viruses, such as the ones that cause the common cold. Children with colds often develop symptoms attributable to the virus, including a runny nose, nasal congestion, or cough. Multiple infections, one after the other, are especially common in children attending daycare or school, where they trade viruses like I used to trade baseball cards with my friends. When I see these the worried parents of these children in my office, I have to remind them that it is normal for a child to have 9-12 colds every year. Fortunately, these children continue to grow and gain weight without difficulty, and they are healthy between episodes. “As your child grows,” I tell the parents, “her immune system will become better at fighting infections, and the frequency and severity of fevers will diminish.” Aside from stressing the importance of hand washing among all family members, there is not much that can (or needs) to be done about these episodes.
However, if the episodes do not clearly match the above description, other diagnoses should be considered. In this post, I will provide some tips that may help parents and physicians recognize a rare cause of fever in children: autoinflammatory diseases. The most common autoinflammatory disease in children is called PFAPA, which stands for Periodic Fevers, Aphthous stomatitis (canker sores or oral ulcers), Pharyngitis (sore throat) and Adenitis (enlarged glands in the neck). This disease usually presents in children less than 5 years of age, and causes episodes of fevers in addition to the features that make up the name of the disease (oral ulcers, sore throat, enlarged glands in the neck). The fever usually lasts about 4 days, and it recurs at regular intervals, usually every month. What is unique about PFAPA is that parents can usually predict when the child is “due” to get ill. The episodes of fever are so regular as to be predictable. This regularity is rare in most other diseases. PFAPA is commonly misdiagnosed as frequent Strep infections, and testing for Strep throat is usually negative. Patients do not readily respond to antibiotics, although their symptoms can disappear with one dose of steroids.
Another clue that the child may have an autoinflammatory disease is that all of the episodes of fever look alike. For example, if the child always develops abdominal and joint pain with the fevers, then he may have familial Mediterranean fever (FMF). If, in addition to fever, she always develops a painful rash, muscle pain, and red eyes, then she may have TNF-receptor associated periodic fever (TRAPS). If he develops fevers, rashes, and joint pain after exposure to cold weather, then the child may have familial cold-induced autoinflammatory syndrome (FCAS).
The length and frequency of fever, associated symptoms, and age at which the fevers began can help differentiate between these (and other) autoinflammatory diseases. Thus, it is very helpful to keep a fever diary, specifying the characteristics of each episode. Because many of these autoinflammatory diseases are inherited (genetic), there is often a history of other family members having similar symptoms. In addition, it is important to note that some autoinflammatory diseases are more common in people of certain ethnic backgrounds, such as FMF in Sephardic Jews, Turks, and Armenians.
In addition to autoinflammatory diseases, there are some features of recurrent fevers that should warrant a closer look by a child’s pediatrician. These include prolonged episodes of fever (more than one week), recurrent fever without symptoms attributable to a viral infection, difficulty growing or gaining weight, or if the child does not return to his baseline between episodes. Other causes of fever that should be considered in these instances include:
- Immunodeficiencies: problems in the immune system that makes the child more susceptible to infections
- Anatomic and metabolic abnormalities: abnormalities in certain organs that make them more prone to infections (like my ears), or diseases such as cystic fibrosis
- Inflammatory bowel disease: inflammation of the intestines
- Cancer: such as leukemia or lymphoma
With this knowledge, parents and pediatricians alike can help distinguish between the majority of children that develop recurrent fevers because of frequent viruses, from causes which may require additional workup or treatment.
This month, an interesting article about PFAPA appeared in the journal Rheumatology. PFAPA (periodic fevers, aphthous stomatitis, pharyngitis, and adenitis) is an autoinflammatory disease that affects children. It is manifested by episodes of fevers lasting a few days, in addition to the features that make up the name of the disease. Unlike other autoinflammatory diseases, episodes of fever occur at very specific intervals (parents mention that the fevers occur “like clockwork,” and they can predict when the next episode will occur on a calendar). Fortunately, most patients respond well to steroids during fever episodes, and the disease usually resolves within a few years without sequellae.
This study represents the largest group of patients with PFAPA ever published. They found that the average age of onset of symptoms was about 2 years of age, and it often took several years to make the diagnosis of PFAPA. Most patients were diagnosed before age 6. On average, episodes of fever lasted 4 days, and recurred every 4 weeks. Only 44% of patients with PFAPA had the classic triad of apthous ulcers (oral ulcers), adenitis (swollen, tender lymph nodes in the neck), and pharyngitis (sore throat); the rest had only one or two of these symptoms. Interestingly, children often complained of abdominal pain, joint pain, muscle pain, and headaches during episodes.
This study highlights one of the biggest difficulties of PFAPA–making an accurate diagnosis. Patients don’t need to have the classic triad of symptoms to be diagnosed with PFAPA, and many children complain of additional symptoms during episodes that are likely underrecognized. Perhaps it is time to create new diagnostic criteria for this disease!
What do you think? Have you or a loved one been diagnosed with PFAPA? How long did it take for your doctors to make the diagnosis?
Autoinflammatory diseases have a variety of causes. Some are clearly genetic–they are caused by single mutations in specific genes. These abnormal genes produce abnormal proteins that cause unprovoked episodes of inflammation. If you have the abnormal gene (for the most part) you develop the disease. If you don’t have the gene, you don’t develop the disease. Familial Mediterranean Fever (MEFV), cryopyrin associated periodic syndrome (NLRP3), and the TNF-receptor associated periodic syndrome (TNFRSF1A), are examples of autoinflammatory diseases associated with mutations in single genes. These diseases are often called hereditary periodic fever syndromes, although they are not always “hereditary” (passed down from parent to child); many are caused by new mutations that arise in the embryo.
Some types of autoinflammatory diseases have associations with specific genes, such as Behcet’s disease with the gene HLA-B51. Behcet’s is characterized by recurrent oral and genital ulcers, rash, and episodes of eye inflammation (uveitis). Unlike the genetic diseases above, having the gene HLA-B51 is not sufficient to have the disease. This complex disease is likely caused by interplay between HLA-B51, other genes, and the environment (it is interesting to note that patients with Behcet’s that live in the Middle East have a more severe disease than patients with Behcet’s that live in the United States).
Finally, some autoinflammatory diseases do not appear to be associated with any specific gene. PFAPA (periodic fevers, aphthous stomatitis, pharyngitis, and adenitits), is such an example. This is an autoinflammatory disease that commonly affects children, and it is characterized by periodic episodes of fever and the associated symptoms that give it its name. To date, no specific gene has been associated with the development of this disease. The fact that removal of the tonsils appears to be curative for many patients suggests that perhaps an infection that resides in the tonsils contributes to the expression of this disease.
We are still just beginning to understand the causes of these fascinating autoinflammatory diseases. It is still unclear what makes patients with the same genetic mutation have mild or severe disease. We also don’t know how the environment plays a role in the expression of this disease. Further research over the next few years should be able to give us better answers to these important questions.
To review the wide variety of autoinflammatory syndromes (and their specific causes), please refer to this comparison chart by the Autoinflammatory Alliance, by far the most complete chart of autoinflammatory diseases I’ve seen.