The Cutaneous Manifestations in Children with Familial Mediterranean Fever (Recurrent Hereditary Polyserositis). A Six-year Study

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1 Quarterly Journal of edicine, New Series 75, No. 78, pp , June 0 The Cutaneous anifestations in Children with amilial editerranean ever (Recurrent Hereditary Polyserositis). A Six-year Study H. A. AJEED, Z. QUABAZARD*, Z. HIJAZI*, S. ARWANA* and. HARSHANI* rom the Departments of Pediatrics, aculty of edicine, University of Kuwait and ubarak Hospital (Teaching)*, Kuwait Accepted October 8 SUARY In a six-year study of 6 children with familial editerranean fever (recurrent hereditary polyserositis), 0 children ( per cent) developed cutaneous manifestations. Ten children had 8 episodes of erysipelas-like erythema which proved to be specific for the disease. Twelve children (6 per cent) had episodes of non-specific purpuric rash and six children ( per cent) had nine episodes of Henoch-Schonlein purpura. Other manifestations included diffuse erythema of the face, and/or trunk, angioneurotic oedema, diffuse erythema of the palms and soles followed by mild desquamation of the skin, Raynaud's phenomenon and a subcutaneous nodule. The mean frequency of the cutaneous lesions was.6/parient/year before colchicine therapy and 0./patient/year after colchicine therapy (p = ). The high incidence of cutaneous manifestations and their response to colchicine strongly suggest that skin involvement is an integral part familial editerranean fever. Downloaded from by guest on arch, 06 INTRODUCTION amilial editerranean fever, also known as recurrent hereditary polyserositis, is an inherited multisystem disease of unknown aetiology, characterized by recurrent, painful, self-limiting episodes of peritonitis, pleuritis or synovitis, occurring singly or in combination [, ]. amilial editerranean fever characteristically affects certain ethnic groups - mainly Arabs, sephardic Jews and Armenians [-5]. However, the increase in travel means that pediatricians worldwide may see such patients. There are various cutaneous manifestations of familial editerranean fever, with erysipelas-like erythema being the best studied; of the 70 patients described by Sohar el al., almost half developed this characteristic lesion []. Other cutaneous manifestations, including Henoch-Schonlein purpura [,6, 7], angioneurotic oedema [8, ], non-specific purpuric rash [0, ] and subcutaneous nodules [, ] have also been reported, but the significance of such associations is difficult to interpret. Address correspondence to Dr. H. A. ajeed, Professor, Department of Pediatrics, aculty of edicine, Kuwait University, P.O. Box, 0 Safat, Kuwait. Oxford University Press 0

2 608 H. A. ajeed and others To the best of our knowledge, there has been no report devoted to the study of the cutaneous manifestations of patients with familial editerranean fever. Similarly, the therapeutic effect of colchicine on such manifestations has not yet been reported. orty-six children were admitted to this study between June 8 and ay 88, and they were observed until ay 8. Twenty of these children ( per cent) developed cutaneous manifestations. This report describes these cutaneous manifestations and their response to colchicine. PATIENTS AND ETHODS The children were referred to our familial editerranean fever clinic by their family physicians or were admitted directly to the in-patient service of the pediatric department. The following tests were performed on all the children: haemoglobin, white cell count, platelet count, ESR, dipstick urine test for blood and protein, sickling test, agglutination tests for infectious mononucleosis and brucellosis, liver and renal function tests (SAC 0, Technicon, USA), antinuclear antibodies, anti-double-stranded DNA antibody, rheumatoid factor, anti-streptolysin O titre, C and C. A coagulation profile, including bleeding time, Hess' test, thrombin time, prothrombin time, activated partial thromblastin time, factor VIII and factor Vlll-related antigen, was obtained in two patients. Skin biopsy was performed in one patient. The diagnosis of familial editerranean fever was made according to Heller's criteria []. Once the diagnosis was established, children were treated with colchicine ( mg daily). Children were seen once every - months and more frequently during the acute stage. At each out-patient visit, a careful history was taken with special attention to skin and joint symptoms, fever, and abdominal and chest pain. A complete physical examination was also carried out. Statistical analysis Statistical analysis for differences in frequency was performed utilising the x test and the significance of differences was assessed using Student's t test. Downloaded from by guest on arch, 06 RESULTS All of the 6 children were of Arab origin; 0 (65 per cent) were Palestinians, eight (7 per cent) Lebanese, four ( per cent) Syrians, three (7 per cent) Egyptians and one ( per cent) Kuwaiti. Twenty children ( per cent) developed cutaneous manifestations; of these six (0 per cent) were boys and (70 per cent) were girls. The family history was positive in 60 per cent of the children. The age at onset ranged between one and years with a mean of five years, and they had been observed for between two and six years, with a mean of. years. Sixteen children (80 per cent) developed peritonitis, 7 (85 per cent) developed arthritis and four (0 per cent) developed pleuritis. Of the 6 children who did not develop cutaneous manifestations, (6 per cent) were boys and (5 per cent) were girls. The family history was positive in 6 per cent of these children, and the age at onset ranged from. to eight years, with a mean of. years. They had been observed for one to six years, with a mean of four years. Twenty-three children (88 per cent) developed peritonitis, ( per cent) developed arthritis and 5 (58 per cent) developed pleuritis. Table shows the various cutaneous manifestations encountered.

3 Cutaneous anifestations of amilial editerranean ever TABLE. The cutaneous manifestations in 6 children with familial editerranean fever 60 Skin lesion Purpuric rash Erysipelas-like erythema Henoch-Schonlein purpura Angioneurotic oedema Diffuse erythema of palms and soles Diffuse erythema of the face Peeling of palms and soles Raynaud's phenomenon Subcutaneous nodule No. of children (%) (6) 0() 6() 5() () () () () () No. of episodes 8 5 Downloaded from by guest on arch, 06 IG. I. Typical erysipelas-like erythema over a swollen ankle joint and dorsum of left foot {Case, Table ).

4 60 H. A. ajeed and others Erysipelas-like erythema (ig. ) IG.. Henoch-Schonlein purpura rash {Case 0, Table ). These lesions were seen only in patients who had arthritis, alone or in combination with other symptoms. They usually developed over the joint and the dorsa of the feet and at the same time as unilateral or bilateral ankle arthritis; one patient with knee arthritis developed erythema on the leg. Ten patients ( per cent) had 8 such episodes. Downloaded from by guest on arch, 06 Henoch-Schonlein purpura (ig. ) Six patients ( per cent) had nine episodes of Henoch-Schonlein purpura; three patients developed two episodes each. The rash involved mainly the extensor surfaces of the upper and lower extremities. However, unlike the classical distribution of this condition, the face and trunk were frequently involved, but the buttocks were involved in only two episodes. With the exception of two severe episodes associated with fever, the general condition of the patients was good and the course of the disease was mild and short (- weeks); remissions occurred spontaneously, without the use of corticosteroids. One patient developed two episodes before the onset of familial editerranean fever; five episodes occurred in four patients at the onset of familial editerranean fever, and one patient suffered two episodes after the onset of familial editerranean fever. A skin biopsy of the rash in Patient 0 (Table ) showed leucocytoclastic vasculitis (ig. ); immunofluorescent studies showed deposits of IgG and C in the walls of the vessels in the upper dermis (IgA was not assayed). Non-specific purpura (ig. ) Twelve patients (6 per cent) had episodes of pink petechiae or blue/black spots with a diameter of - cm which were macular or just palpable and did not disappear on pressure.

5 Cutaneous anifestations of amilial editerranean ever TABLE. Cutaneous manifestations before and after colchicine therapy in individual patients 6 Case Sex Age at onset (Years) Age at onset C L-' oi skein lesion Skin lesions before colchicine No. Duration (Years) Skin lesions after colchicine No. Duration (Years) (.H.) (N.N.) (N.H.) (L.Y.) 5 (.T.) 6 (L.T.) 7 (J.I.) 8(.A.). (H.N.) 0(R.S.) (S.G.) (R.I.) (.I.) (N.E.) 5(B.S.) 6(D..) 7 (D.I.) 8 (.R.) (S.A.) 0 (D..) Total ean Three episodes Colchicine refused; no follow up Downloaded from by guest on arch, 06 = familial editerranean fever. They appeared on the face, trunk and extremities including the feet without a special predilection for special sites. Unlike the Henoch-Schonlein-like rash, they were scattered and not confluent. This rash usually disappeared within - weeks and was not associated with fever of pruritis. Three patients developed the rash before the onset of familial editerranean fever, in seven patients the two conditions were simultaneous, and two patients developed the rash after the onset of the familial editerranean fever. Diffuse erythema of the face and/or trunk One patient experienced three such episodes; one episode was associated with purpuric rash on the trunk and diffuse erythema of the palm and soles followed by peeling of the skin, simulating Kawasaki disease. Another patient developed diffuse erythema on the back and anterior chest wall. Angioneurotic oedema ive patients developed angioneurotic oedema, involving the hands in three patients, the face in one and the scrotum in one.

6 6 H. A. ajeed and others IG.. Photomicrograph showing leucocytoclastic vasculitis (arrow) involving dermal capillaries (Haematoxylin and Eosin, x 0). Downloaded from by guest on arch, 06 IG.. Atypical erysipelas-like erythema with scattered purpuric spots over the left lower limb and dorsum of left foot (Case, Table ). TABLE. The effect of colchicine on the cutaneous manifestations Colchicine No. of ollow-up Observation No. of children (years, period cutaneous mean) (patients/year) I episodes ean frequency (patient/year) Before After * 0.* =

7 Raynaud's phenomenon Cutaneous anifestations of amilial editerranean ever 6 One patient had one episode of Raynaud's disease involving the hands and feet, which lasted for three days. This was not associated with other signs or symptoms, and preceded the onset of familial editerranean fever. Erythema and peeling of palms and soles (ig. 5) Diffuse erythema and punctate erythema of the palms and soles were each seen in two patients. This was followed by mild desquamation of the skin, in two patients. Subcutaneous nodule One patient developed a x cm, firm, non-tender subcutaneous nodule behind the left ankle joint during an episode of bilateral ankle arthritis. Effect of colchicine Table shows the cutaneous manifestations before and after colchicine therapy in the individual patients. Table summarizes the effect of colchicine on the cutaneous manifestations. CASE REPORTS Patient.H. {Case, Table ), an Arab Palestinian girl, was born in ebruary 8. In ebruary 8 she developed a scattered purpuric rash on the face which lasted for five days; the end of the same month she developed Raynaud's phenomenon of the hands and feet which lasted for three days. One week later she developed a la-day illness with reddening of the face and diffuse erythema of the palms and soles, followed by mild desquamation. During ay and September 8 she developed mild redness of the face and scattered purpuric spots on the abdomen; each attack lasted for 0 days. In January 85 a few purpuric spots appeared on the face and lasted for a week. In November 86 and arch 87 she developed Henoch- Schonlein purpura which spared the buttocks but was associated with scattered purpuric spots over the face and trunk and oedema of the hands. Each episode was mild and lasted for three weeks. In late April 87 she developed a classical pleuritic familial editerranean fever episode with no rash which lasted for two days. This was followed by frequent recurrent peritoneal episodes of familial editerranean fever; one episode was associated with a red face and purpuric spots over the trunk. Colchicine therapy started in ay 87, and until ay 8 she had only a few mild peritoneal episodes, only two or three hours, and three episodes of purpuric spots on the trunk. Downloaded from by guest on arch, 06 Patient N.N. (Case, Table ), an Egyptian Arab girl, was born in June 85. In April 87 she developed severe abdominal pain; at appendicectomy there was turbid peritoneal fluid (no growth on culture) and a normal appendix. In September 87 she developed a Henoch- Schonlein purpura-like rash which spared the buttocks and lasted for three weeks; this was

8 6 H. A. ajeed and others IG. 5. Bilateral erythema and disquamation of palms {Case, Table ). associated with oedema of both hands. Between November 87 and ay 88 she had two episodes of right ankle arthritis, one associated with erysipelas-like erythema, two episodes of scattered purpuric spots on the trunk, two peritoneal familial editerranean fever episodes and one episode of Henoch-Schonlein purpura rash involving the buttocks and associated with oedema of the hands and right knee arthritis. Colchicine therapy was started in ay 88 and she remained well. Downloaded from by guest on arch, 06 Patient At the age of nine years, R.S. (Case 0 Table ), a Palestine Arab boy, developed right knee arthritis which lasted for three days and was associated with scattered purpuric spots over the trunk. Two months later he developed low grade fever and flitting arthritis involving the right ankle, right knee and left ankle, over a period of 0 days. The heart was normal. The ESR and ASO titer were raised. A diagnosis of acute rheumatic fever was made.,00,000 I.U. of benzathin penicillin G was given intramuscular at monthly intervals. Two months later he had two successive episodes of Henoch-Schonlein purpura with fever, abdominal pain and arthritis; the buttocks were involved in one episode. Each episode lasted three weeks. Skin biopsy of the rash showed leucocytoclastic vasculitis (ig. 5). Penicillin was stopped and colchicine treatment started in April 88. He remained well. DISCUSSION The cutaneous manifestations of familial editerranean fever have been described in

9 Cutaneous anifestations of amilial editerranean ever 65 scattered reports [, 5-], making their significance difficult to interpret. These manifestations were neglected in large series describing the clinical profile of familial editerranean fever in different ethnic groups [-]. This study reports the incidence and significance of cutaneous symptoms and their response to colchicine therapy in a group of patients with familial editerranean fever, and seems to be the first such report. Data from this study showed that per cent of the 6 children had skin lesions. This high frequency suggests that they are manifestations of the disease, rather than mere associations. urthermore the good response of the cutaneous manifestations to colchicine (Table ) strongly suggests that they are an integral part of the disease. The data also showed that the cutaneous manifestations were more frequent in girls and in episodes of arthritis but were infrequent in patients with pleuritis. The erysipelas-like erythema was the best studied [] and is now considered to be characteristic of familial editerranean fever. The wide variation in the clinical features, duration and the clinical course of joint involvement in children with familial editerranean fever causes frustrating diagnostic difficulties in the differentiation of familial editerranean fever arthritis from that of acute rheumatic fever, juvenile rheumatoid arthritis, brucellosis, and the seronegative juvenile spondyloarthropathies [5]. In our experience, the erysipelaslike erythema proved to be a specific clinical sign of familial editerranean fever and of great diagnostic help; it was not present in any of the other diseases mimicking familial editerranean fever arthritis. The association of Henoch-Schonlein purpura and familial editerranean fever has been previously described [, 6, 7]. Rotem and edergruen described seven familial editerranean patients who also had severe Henoch-Schonlein purpura [6]. Similarly, latau et al. described eight familial editerranean fever patients with ten severe and protracted episodes of Henoch-Schonlein purpura [7]. Of the 70 familial editerranean fever patients described by Sohar et al., 7 had Henoch-Schonlein purpura []. It is interesting that six of the seven patients described by Rotem and edergruen [6], six of the eight patients in latau et al. [7] and the 7 patients in Sohar et al. [] were children. Six of our patients developed nine episodes of Henoch-Schonlein purpura. The rash in our patients involved the extensor surfaces of the upper and lower extremities, but showed some differences when compared to the rash described by other authors [6, 7]. The trunk and face were frequently involved in our patients but the buttocks were involved in only two episodes. urthermore, with the exception of two episodes, the disease in our patients was mild with a short course, in contrast to the severe, stormy and protracted course described by other investigators [6, 7]. The occurrence of non-specific purpuric rash was hardly mentioned in the large series describing the clinical profile of familial editerranean fever in different ethnic groups [-]. However this association was beautifully illustrated in the patients described by Reiman [0] and by Althausen et al. []. Of the 6 members of a family with 'periodic arthralgia' described by Reiman, ten (6 per cent) developed recurrent lesions [0]. Of the eight patients with 'Henoch's purpura and the abdominal allergy' reported by Althausen et al., five (6 per cent) developed such lesions []. However the true nature of the disease (almost certainly familial editerranean fever) and the significance of these associations were not appreciated by these investigators. Data from this study show that the non-specific purpuric rash is the most common cutaneous manifestation of familial editerranean fever; (6 per cent) of our patients developed this rash, which helped in reaching a diagnosis. There are few reports of the histopathology of the cutaneous manifestations of familial editerranean fever [7,,, 5]. Skin biopsy in one our patients showed leucocytoclastic vasculitis with deposits of IGg and C in the vessel walls of the upper dermis. Skin biopsies of four of the eight patients described by latau et al. also showed vasculitis [7]. Immune Downloaded from by guest on arch, 06

10 66 H. A. ajeed and others complex deposition in the walls of the dermal and subcutaneous vessels, leading to vasculitis could give rise to the clinical cutaneous manifestations of familial editerranean fever. A study of biopsies from a large number of patients is needed. In conclusion, in our experience, the erysipelas like erythema proved to be specific of familial editerranean fever. We also believe that the cutaneous manifestations of familial editerranean fever are probably an integral part of the disease, with an underlying pathology of vasculitis. The occurrence of atypical of recurrent Henoch-Schonlein purpura, non-specific purpuric rash or angioneurotic oedema, especially if they are recurrent, should alert the physician to the possibility of familial editerranean fever, particularly when the presenting complaint is arthritis. REERENCES. Sohar E, Gafni J, Pras, Heller H. amilial editerranean fever. A survey of 70 cases and review of the literature. Am J ed 86; : Barakat, Karnick A, ajeed HA. amilial editerranean fever (recurrent hereditary polyserositis) in Arabs. A study of 75 patients and review of the literature. Q J ed 86; 60: Schwabe AD, Peters RS. amilial editerranean fever in Armenians. Analysis of 00 cases. edicine (Baltimore) 7; 5: Armenian HK, Khachadurian AK. amilial paroxysmal polyserositis. Clinical findings in 0 cases. Leb ed J 7; 6: ajeed HA, Barakat. amilial editerranean fever (recurrent hereditary polyserositis) in children: analysis of 88 cases. Eur J Pediatr 8; 8: Rotem Y, edergruen A. Schoenlein-Henoch syndrome in familial editerranean fever. Harefuah 6; 6: latau E, Kohn D, Schiller D, Lurie, Levy E. Schonlein-Henoch syndrome in patients with familial editerranean fever. Arthritis Rheum 8; 5: Reiman NA. Periodic disease. edicine 5; 0: -5.. Priest RJ, Nixon RK. amilial recurring polyserositis. A disease entity. Ann Intern ed 5; 5: Reiman HA, Angelides AP. Periodic arthralgia in twenty three members of five generations of a family. JAA 5; 6: Althausen TL, Deamer WC, Kerr WJ. The false 'acute abdomen'. II. Henoch's purpura and abdominal allergy. Ann Surg 7; 06: -5.. Danar AV, Kwan HT, Stern RS, Kasdon JE, Birnbaum SP, Brown SR. Panniculitis in familial editerranean fever. Case report with histopathological findings.. Heller H, Sohar E, Sherf L. amilial editerranean fever. Arch Intern ed 58; 0: Schlesinger, Kopolovic J, Viskoper R, Ron N. A case of familial editerrean fever with cutaneous vasculitis and immune complex nephritis: light, electron and immunofluorescent study of renal biopsy. Am J Clin Pathol 8; 80: Azizi E, isher BK. Cutaneous manifestations of familial editerranean fever. Arch Dermatol 76; :6-66. Downloaded from by guest on arch, 06