FAMILIAL MEDITERRANEAN FEVER (FMF) RAKAN TELFAH not MD, not PHD

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1 FAMILIAL MEDITERRANEAN FEVER (FMF) RAKAN TELFAH not MD, not PHD

2 FMF Is a hereditary autoinflammatory disease caused by mutations in Mediterranean fever gene (MEFV). It is inherited in an autosomal recessive pattern and presents as intermittent self-limited attacks of fever and polyserositis.

3 Familial Inherited Autosomal recessive MEFV gene Mediterranean usually occurs in people of Mediterranean origin : Armenians Sephardic Jews Mizrahi Jews Azerbaijanis Arabs Greeks Turks Fever Occurs as attacks of FEVER, peritonitis, pleuritis and others..

4 GENETICS MEFV gene is located on the short arm of chromosome 16 on the position 13.3 It encodes the protein PYRIN (MARENOSTRIN) which has a role in inflammation suppression.

5 PATHOPYSIOLOGY Caspase-1 Cleavage Prointerlukin-1 beta Inactive form Inetrlukin-1 beta Active Lymphocyte activation and proleferation Pyrogenic activity Inflammatory pain by cyclooxygenase-2 FEVER AND INFLAMMATION

6 PYRIN act to suppress the function of caspase-1 and when it's not active due to a mutation in MEFV gene, there will be over activation of caspase-1 and IL-1b and uncontrolled inflammation will take place.

7 Clinical features Almost all patient have their first attack before the age of 18. The attacks lasts from 6 hrs up to 7 days ( typically 12 hrs to 3 days ). They have a sudden onset and rapid development. Attacks include : Fever (most common) Abdomen Chest Joints Skin MSS

8 Abdominal (peritoneal) symptoms Abdominal pain that may mimc appendicitis, cholesystitis, and renal colic, and patient may have a surgery due to misdiagnosis. May progress to peritonitis and cause tenderness and rigidity and reduced bowel sounds. Many patients develop constipation during the attack and diarrhea after it. Abdominal involvement is very common 95 %. * Inflammation may proceed to the tunica vaginalis and cause severe pain and swelling of the scrotum that mimics the pain of testicular torsion.

9 Chest (pleural & pericardial) symptoms Patients with pleuritic involvement have chest wall tenderness and shallow breathing, X-Ray shows pleural effusion, friction rub is rare. Pericarditis may develop and cause chest pain,shortness of breath and palpitations. but tamponade and constrictive pericarditis are rare. The flask-shape appearance of cardiac shadow in X-ray appears when the case is severe.

10 MSS INVOLVEMENT Symptoms of inflammation in the synovium (hotness, pain, redness, swelling) Knee, ankle,hip, wrist are most commonly affected. Non erosive in general but may cause erosions in the hip and patients may need hip replacement Joints are normal between attacks. Synovial attacks usually last longer than other attacks. May be the only manifestation so we must consider FMF if family history is positive or in the endemic area. Synovial symptoms rate varies 25-75%. Seronegative spondylarthritis may develop. Severe myalgia.

11 SKIN INVOLVEMENT Erysipelas like rash below the knees Superficial / Painful /erythematous /well demarcated /warm / rapidly enlarging rashes that come and go spontaneously.

12 PELVIS INVOLVEMENT In females, there may be episodes of pelvic inflammatory disease ; an Inflammatory disorder in the Upper female genital tract (uterus / fallopian tubes) Lower abdominal pain / abnormal vaginal discharge. May produce Tubo-ovarian abscess. Pain on movement / tender and enlarged ovaries.

13 INVESTIGATIONS In CBC we find an increase in leukocytes especially PMNs that goes to the baseline after the attack. High level of acute phase reactant like SAA / CRP.. Gene test can help but it is not diagnostic. Inflammation is sterile and no microorganism can be found because the reason is a defect in regulation of the inflammation,not an infection. DIAGNOSIS is based on the clinical findings.

14 DIAGNOSIS Tel-Hashomer diagnosis criteria Two major or one major and two minor Major criteria Recurrent febrile episodes with serositis (peritonitis, synovitis or pleuritis) Amyloidosis of AA type without a predisposing disease Favorable response to regular colchicine treatment Minor criteria Recurrent febrile episodes Erysipelas-like erythema FMF in a first-degree relative

15 DIAGNOSIS Simplified FMF diagnosis criteria suggested by Livneh et al. One major or two minor. Major criteria Minor criteria Typical attacks Incomplete attacks involving either or both of the following sites 1- Generalized peritonitis 1- Chest 2- Unilateral pleuritis or pericarditis 2- Joint 3- Monoarthritis (hip, knee, ankle) 3- Exertional leg pain 4- Fever alone 4- favorable response to colchicine 5- Incomplete abdominal attack

16 Typical attacks : Recurrent (3 days) / febrile (rectal temperature 38 C) / short duration (12 hrs 3 days). Incomplete attacks : Recurrent and differ from typical attacks in one or two of the following : Temperature < 38 C / short (min 6 hrs) or long (max 7 days) / no signs of peritonitis / localized abdominal attacks / arthritis other than in knee hib or ankle.

17 COMPLICATIONS Amyloidosis Deposition of serum amyloid A (SAA) which is an acute phse reactant that increases from 3 mg/l to 2000 mg/l during inflammation Is the most common complication and lead to renal problems like Nephrotic syndrome and End stage renal disease, so proteinuria must be evaluated regularly. Investigations to detect amyloidosis include skin fat biopsy and kidney biopsy. Peritoneal mesothelioma due to chronic inflammation.

18 Vasculitis Behcet disease. Henoch-Schönlein purpura. Polyarteritis nodosa Hip destruction And may need replacement.

19 TREATMENT Acute management (when we have an attack ) Prophylaxis (to avoid attacks and amyloidosis ) Analgesics NSAID COLCHICINE If not responding :5 10% of patients IL-1 antagonist ANTI IL-1B

20 Colchicine dosage Depends on the age and the tolerance to the side effects of the drug (diarrhea,nausia and vomiting / muscle weakness and pain / abdomial pain and cramping ). Age group < >= Dose (mg/day)

21 If patient can't tolerate colchicine we give half dose twice a day. If still can't tolerate it.. we give colchicine IV once a week If patient doesn't respond to colchicine we give : IL-1 antagonist (anakinra/rilonacept) Anti IL-1b anti-body (canakinumab) TNF antagonists Interfernoe alpha antagonists

22 THANK YOU

Familial Mediterranean Fever. By:Ismaeel Qattam

Familial Mediterranean Fever. By:Ismaeel Qattam Familial Mediterranean Fever By:Ismaeel Qattam FMF : It s characterized by auto inflammatory condition that causes recurrent fevers and painful inflammation of the abdomen, lungs, joints, etc. It s an