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
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.
When I meet someone for the first time and tell them that I’m a rheumatologist, I usually get blank stares, as if I had spoken to them in a foreign language. It doesn’t matter if they are a medical student, family member, or even an immigration officer. It doesn’t matter if they have a Ph.D. or they are a high school dropout. I even see patients in my rheumatology clinic who have no idea what rheumatology is, nor how I’m supposed to help them.
I can’t blame them. Rheumatology is a weird field. Just look at the origin of the word “rheumatology.” The prefix “rheuma,” meaning “to flow,” was first used by a Greek physician 2000 years ago, referring to the phlegm that flows from the nose when a person is ill. But rheumatology, as it is practiced today, has nothing to do with phlegm (talk about false advertising!). Cardiologists don’t have this identity problem because they, of course, manage the heart. Dermatologists treat your skin. Proctologists…well, you get the picture.
A quick web search about rheumatology is not fruitful either. Rheumatology is defined as: “the medical specialty that manages rheumatic diseases.” My rheumatology textbook doesn’t even try to define what field is all about.
In addition, we’re not a popular specialty. I don’t know of one famous rheumatologist. We’re not usually in the news. We’re not the heroes in any movie. In fact, I don’t think I’ve ever seen a TV character who is a rheumatologist (even though there is at least one paleontologist on TV!). The TV character that most closely approximates what a rheumatologist does is my hero Dr. House (no relation, unfortunately) on the TV show House, MD. He is actually board certified in nephrology and infectious diseases, but he gets consulted on very complicated cases, much like rheumatologists often do. However, he’d make a lousy rheumatologist because, according to him, “it’s never lupus!”
As I see it, rheumatology is the study of inflammation (swelling, redness, warmth, and pain) occurring in the structures that hold up the body, such as the bones, muscles, and joints. Arthritis, or inflammation of the joints, is the most common disease that we see, both in children and adults (kids get arthritis too!). Arthritis comes in a variety of flavors, including juvenile, rheumatic, psoriatic, gouty, osteoarthritis, etc..
We also take care of complex diseases such as systemic lupus erythematosus, systemic sclerosis, and dermatomyositis, in which the immune system attacks various different organs. Vasculitis, or inflammation of a blood vessel, is another disease which we treat. Other strange illnesses (with even stranger names) such as Kawasaki disease, Sjögren syndrome, and relapsing polychondritis are all within the field of rheumatology.
Most of the above-mentioned diseases are considered autoimmune, in which the immune system loses the ability to recognize self from non-self. When a cell of the immune system passes through the kidney, it should be able to recognize it and say: “Hello! You are my kidney, I will protect you against infections!” However, in autoimmune diseases, the immune cell gets confused and says: “Whoa! What is this bean-shaped organ doing here? You look foreign, I will fight you to the death!” As a result, the immune cell begins a process of inflammation that causes organ damage. Many different organs can be affected in autoimmune diseases, and the name of the disease depends on which organ is affected.
At the other end of the rheumatology spectrum are autoinflammatory diseases (my favorite!). These diseases occur when the machine that produces inflammation goes awry. Immune cells are tightly regulated to produce inflammation only when needed (such as in response to a microbe or to damaged tissue). However, in most autoinflammatory diseases, there is a mutation in the inflammation machine that causes it to produce inflammation at inappropriate times. The immune cell in autoinflammatory diseases says: “Darn, I’m leaking inflammatory fluid yet again!” Thus, the patient develops episodes of fevers, rashes, and joint pain without any other explanation.
As you can see, rheumatologists manage a wide variety of illnesses that affect many different organs. Most of these diseases do not have clear causes, which makes rheumatology a fascinating field to study. At least until a smart marketing team comes up with a better name for our specialty (I vote for “inflammatology!”), you won’t have to look at me weird when I tell you what I do for a living.
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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.
Last week during our weekly physician conference, I discussed a patient with an autoinflammatory disease. An elderly male, he had a history of recurrent fevers, hives, and elevated inflammatory markers, which had gone untreated for many years. Eventually, he developed renal amyloidosis (accumulation of amyloid fibers in the kidney causing kidney failure), and was finally referred to rheumatology clinic for further evaluation. Although he had many of the classic signs and symptoms of an autoinflammatory disease, his physicians had not recognized it. Even at the conference, some physicians were unaware of these group of diseases.
Autoinflammatory diseases are a newly described set of illnesses that cause systemic inflammation due to problems in the innate immune system. The innate immune system includes several types of white blood cells such as neutrophils, macrophages, and natural killer cells. These cells are the first responders to an infection because any one of them is able to recognize common patterns that are present in many types of pathogens (such as the cell wall in a bacteria). In response to a pathogen, these cells secrete inflammatory molecules (cytokines) that alert other cells of the immune system and get the body ready to fight.
Autoinflammatory diseases are often caused by genetic mutations within the cells of the innate immune system. These mutations lead to episodes of unprovoked activation of the immune system (production of inflammatory cytokines, recruitment macrophages, neutrophils, etc). In a sense, the body acts as if an infection were present, even when there is none. This is why many of the symptoms of autoinflammatory diseases–such as fever, rashes, joint pain–mimic infections, and why these diseases are often difficult to diagnose. The best characterized autoinflammatory condition is Familial Mediterranean Fever, which causes recurrent, brief attacks (12 to 72 hours) of fever, abdominal pain, chest pain, joint pain, and evidence of inflammation on blood tests.
In contrast, autoimmune diseases arise from problems in the adaptive (humoral) immune system. The adaptive immune system is more sophisticated than the innate, and is made up of very specialized B cells and T cells. Each B and T cell in our body is unique, and is only able to recognize a specific pathogen. Thus, it takes much longer for a B or T cell to recognize that a pathogen has invaded the body. However, once the pathogen is identified, the cell divides and multiplies, leading to a very effective and direct attack on the pathogen. B cells also produce antibodies, which help to neutralize the pathogen. Unlike the innate immune system, the humoral immune system develops “memory,” so that it is better able to fight the pathogen when it reencounters it in the future.
In autoimmune diseases such as lupus, the B and T cells of the adaptive immune system lose the ability to differentiate self from non-self. That is, they start seeing specific organs in the body as foreign (almost as if they were pathogens!), and thus begin to mount an attack against those organs, often leading to organ damage or destruction. In lupus, B and T cells often target the kidney, lungs, or heart, often leading to damage or destruction of these organs. However, autoimmune diseases can target almost any organ in the body. For example, in multiple sclerosis, cells attack the brain. In rheumatoid arthritis, the joint is the target organ. In pemphigus, the body attacks the skin. For reasons that are still unknown, autoimmune diseases more often affect women, whereas autoinflammatory diseases usually affect both sexes equally.
In the end, I think my patient may have had Muckle-Wells syndrome, an autoinflammatory disease caused by mutations in the NLRP3 gene. Autoinflammatory disorders are are still underdiagnosed and poorly understood. It seems like every month, a new autoinflammatory disease is discovered (take a look at this week’s New England Journal of Medicine). Furthermore, various pathways that are abnormal in autoinflammatory diseases have been implicated to play a role in more common diseases such as heart disease and diabetes. Thus, by understanding these rare disorders, we may gain a better understanding of diseases that afflict millions of people throughout the world.