Extreme Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA): a discrete group of patients

Mor Broide; Yoel Levinsky; Rotem Tal; Liora Harel; Shoval Shoham; Sabreen Abu Ahmad; Yonatan Butbul Aviel; Gil Amarilyo

doi:10.1186/s12969-023-00880-1

Extreme Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA): a discrete group of patients

Pediatr Rheumatol Online J. 2023 Sep 1;21(1):93. doi: 10.1186/s12969-023-00880-1.

Authors

Mor Broide¹, Yoel Levinsky^{2

3}, Rotem Tal^{2

3}, Liora Harel^{2

3}, Shoval Shoham⁴, Sabreen Abu Ahmad⁵, Yonatan Butbul Aviel^{6

7}, Gil Amarilyo^{2

3}

Affiliations

¹ Department of Pediatrics A, Schneider Children's Medical Center of Israel, Petach Tikva, Israel. morbrd@gmail.com.
² Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
³ Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
⁴ Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
⁵ Department of Pediatrics B, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.
⁶ Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.
⁷ The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.

Abstract

Objective: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children; by definition, episodes occur every 2 to 8 weeks. However, in a subset of our patients, we noticed a higher frequency of attacks, of less than 2 weeks, which we refer to as extreme PFAPA (ePFAPA). This group consisted of patients who were extreme upon presentation of PFAPA, and those who became extreme after initiation of abortive corticosteroid treatment. We aimed to characterize demographic and clinical features of ePFAPA, including the two groups, and to compare them to patients with non-extreme PFAPA (nPFAPA).

Study design: The medical records of 365 patients with PFAPA who attended Schneider Children's Medical Center of Israel from March 2014 to April 2021 were reviewed. Patients with concomitant familial Mediterranean fever were excluded. Characteristics of the ePFAPA (including subgroups) and nPFAPA groups were compared using Wilcoxon rank sum, Pearson's chi-squared, and Fisher's exact tests.

Results: Forty-seven patients (12.9%) were identified as having ePFAPA. Among patients with ePFAPA, compared to patients with nPFAPA, the median (interquartile range) age at disease onset was earlier: 1.5 years (0.7-2.5) vs. 2.5 years (1.5-4.0), P < 0.001; and diagnosis was younger: 2.6 years (2.0-3.6) vs. 4.5 years (3.0-6.2), P < 0.001. A higher proportion of patients with ePFAPA than nPFAPA were treated with colchicine prophylaxis (53% vs. 19%, P < 0.001), but symptoms and signs during flares did not differ significantly between these groups. Demographic and clinical characteristics were similar between patients with ePFAPA from presentation of PFAPA (22, 47% of those with ePFAPA) and ePFAPA from after corticosteroid treatment.

Conclusion: About half the patients categorized with ePFAPA syndrome already had extreme features upon presentation. Patients with ePFAPA compared to nPFAPA presented and were diagnosed at an earlier age.

Keywords: Colchicine; Corticosteroids; PFAPA.

MeSH terms

Child
Familial Mediterranean Fever* / complications
Familial Mediterranean Fever* / diagnosis
Familial Mediterranean Fever* / drug therapy
Humans
Infant
Lymphadenitis* / complications
Lymphadenitis* / diagnosis
Lymphadenopathy*
Pharyngitis* / diagnosis
Pharyngitis* / drug therapy
Stomatitis, Aphthous* / diagnosis
Syndrome