Autoinflammatory diseases: the hereditary periodic fever syndromes

Autoinflammatory diseases: the hereditary periodic fever syndromes93Table 1. Proposed classification of the human autoinflammatorydiseases (1)Hereditary periodic fever syndromesFamilial Mediterranean feverHyperimmunoglobulinemia D and periodic fever syndromeTumor necrosis factor receptor superfamily 1A-associatedperiodic syndromeFamilial urticarial syndromesFamilial cold urticariaMuckle-Wells syndromeComplement disordersHereditary angioedemaGranulomatous disordersChronic granulomatous synovitis with uveitis and cranialneuropathy (Blau syndrome)Metabolic disordersGoutFamilial chondrocalcinosis (pseudogout)Storage diseasesGaucher’s diseaseHermansky-Pudlak syndromeFibrosing disordersIdiopathic pulmonary fibrosisVasculitic syndromesBehçet’s diseaselife-threatening complication of both FMF and TRA-PS, whereas it has not been till now reported in HIDS(3) (Table 2). Often such affections remain unrecognizedand undiagnosed for years and the patient’s historyencompasses extensive diagnostic investigations,including laparoscopies or laparotomies. The HPFSmolecular bases have been described only in the lastdecades. In this paper, the most recent information onHPFSs is reviewed and summarized.Familial Mediterranean feverFMF, the most common and the longest knownHPFS, is an autosomal recessive disease affecting predominantlythe populations surrounding the Mediterraneanbasin, such as Jews (mostly Sephardic), Armenians,Turks and Arabs, but well-documented cases innon-Mediterranean ethnic groups have also been reported(7). FMF generally develops in childhood oradolescence (7). A late-onset usually corresponds to aclinically more benign disease (8). The affection occursin form of recurrent acute episodes of fever, variablyassociated with serosal, synovial and cutaneous inflammation,usually lasting from 12 to 96 hours andspontaneously subsiding (3,7) (Table 2). Flares may beprecipitated by menses, emotional stress, exercise, infectionsor surgery (7). Fever is generally above 38°C,with a rapid rise accompanied by chills. Constitutionalsymptoms are common (9). The sterile serositis is representedmostly by peritonitis and pleurisy, rarely bypericarditis or acute scrotum (3, 7, 9) (Table 2).Among cutaneous signs, the erysipelas-like erythema,usually unilateral and located on the extensor surfaceof the leg, ankle or foot dorsum, is regarded as pathognomonic(3, 7, 9). Severe, protracted myalgia is infrequent(3, 7). Non-erosive monoarthritis with effusion,affecting mostly leg large joints, is common and maybe the sole manifestation of an attack in 75% of patients(3, 7). Chronic destructive arthritis (predominantlyin hips or knees) or migratory polyarthritis areinfrequent (3, 7). An unusual manifestation is spondylarthropathy,always HLA-B27 negative and with minimalradiographic spinal involvement (10). The mostsevere manifestation of FMF is the development ofamyloidosis, due to the serum amyloid A (SAA) depositionin various organs, with kidney predilection(7). Notably, amyloidosis may occur independently ofthe disease severity, and in phenotype II constitutesthe FMF presenting manifestation (7, 9, 11). The incidenceof this phenotype ranges from 7% to 25% ofthe patients with amyloidosis (11).FMF is due to recessive mutations in the MEFV(for MEditerranean FeVer) gene, located on the shortarm of the chromosome 16 (16p13.3), consisting of 10exons and 781 codons (12). The type and combinationof the mutations define a severely or weakly expressedphenotype (phenotype I) (13-15), but, on the otherhand, subjects carrying two mutations may not expressthe disease (phenotype III) (16). The mutation penetranceis probably incomplete in females, being themale : female ratio greater than 1 (7). At present, morethan forty mutations have been detected, mostly ofmissense type, among which M694V (replacement of