Per Wekell

Increased Intracellular Oxygen Radical Production in Neutrophils During Febrile Episodes of Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome

OBJECTIVE Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is an autoinflammatory disease of unknown etiology that primarily affects preschool-aged children. PFAPA syndrome is characterized by recurrent attacks of fever and symptoms of inflammation consistent with the disease acronym. Since autoinflammatory diseases are, by definition, mediated by cells of the innate immune system, the aim of this study was to evaluate the functional features of neutrophils, the most abundant innate immune cell in the circulation, in children with PFAPA syndrome. METHODS Blood polymorphonuclear leukocytes (PMNs), obtained from patients with PFAPA syndrome during both febrile and asymptomatic, afebrile phases of the disease, as well as from healthy children (afebrile controls) and children with fever and abdominal pain (febrile controls), were analyzed for 3 key neutrophil characteristics: 1) apoptosis (measured by annexin V/7-aminoactinomycin D staining), 2) production of reactive oxygen species (ROS) (measured by luminol/isoluminol-amplified chemiluminescence), and 3) priming status (measured as responsiveness to galectin-3 and up-regulation of CD11b). RESULTS Compared to PMNs obtained from patients with PFAPA syndrome during an afebrile interval and those from febrile controls, PMNs obtained from patients during a PFAPA syndrome flare produced elevated levels of intracellular NADPH oxidase-derived ROS, had significantly diminished rates of spontaneous apoptosis, and displayed signatures of priming. In contrast, PMNs from afebrile patients with PFAPA syndrome had a significantly elevated rate of spontaneous apoptosis compared to PMNs from afebrile controls. CONCLUSION These findings demonstrate that 3 key aspects of neutrophil innate immune function, namely, apoptosis, priming, and generation of an intracellular oxidative burst, are altered, most prominently during febrile attacks, in children with PFAPA syndrome.

Familial Mediterranean Fever -- an increasingly important childhood disease in Sweden.

To characterize Familial Mediterranean Fever (FMF) in western Sweden, focusing on genotype, clinical picture, prevalence and age of onset as well as time to diagnosis.

Toward an Inclusive, Congruent, and Precise Definition of Autoinflammatory Diseases

Autoinflammatory disease was introduced as a concept in 1999, demarcating an entirely new group of diseases in clinical, immunological, and conceptual terms. During recent years, the preconditions for the definition of autoinflammatory conditions have changed. This includes the recent discovery of a number of monogenic autoinflammatory conditions with complex phenotypes that combine autoinflammation with defects of the adaptive and/or innate immune system, resulting in the occurrence of infection, autoimmunity, and/or uncontrolled hyperinflammation in addition to autoinflammation. Further, there are strong indications that classical IL-1-driven autoinflammatory diseases are associated with activation of adaptive immunity. As suggested by this development, we are of the opinion that an all-encompassing definition of autoinflammatory diseases should regard autoinflammatory conditions and innate dysregulation as inseparable and integral parts of the immune system as a whole. Hence, in this article, we try to advance the conceptual understanding of autoinflammatory disease by, proposing a modification of the definition by Daniel Kastner et al., which allows for a congruent and precise description of conditions that expand the immunological spectrum of autoinflammatory disease.

Review of autoinflammatory diseases, with a special focus on periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome

There have been remarkable developments in the field of autoinflammatory diseases over the last 20 years. Research has led to definitions of new conditions, increased understanding of disease mechanisms and specific treatment. The polygenic autoinflammatory condition of periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) is the most common autoinflammatory disorder among children in many parts of the world. The clinical features often include clockwork regularity of episodes, prompt responses to corticosteroids and therapeutic effects of tonsillectomy, but the disease mechanisms are largely unknown.

On the road to discovery in periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome

Although the condition is rare, every pediatrician is likely to encounter at least one case of periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome during her or his career (1). PFAPA primarily affects preschool-age children and has a major impact on the daily life of the entire family. It is a nonhereditary disease of unknown etiology in which autoinflammatory attacks occur with an often remarkable periodicity. In the absence of a genetic or molecular marker, diagnosis relies exclusively on clinical phenotype, detailed case history, and the exclusion of other diseases (2). Although previous works have improved the clinical picture and diagnosis of PFAPA, the diagnostic criteria still fails to definitively exclude other periodic fevers of hereditary or unknown etiology and may inadvertently conceal different diseases from a pathophysiological perspective. Improved diagnostic methods can shorten the diagnostic delay and advance the quality of care for patients and their families as well as ensure that research studies aimed to improve our understanding of PFAPA can enlist clinically well defined patients.

Using scenario-based training to promote information literacy among on-call consultant pediatricians

Background Traditionally, teaching hospital staff to search for medical information relies heavily on educator-defined search methods. In contrast, the authors describe our experiences using real-time scenarios to teach on-call consultant pediatricians information literacy skills as part of a two-year continuing professional development program. Case Presentation Two information-searching workshops were held at Sahlgrenska University Hospital in Gothenburg, Sweden. During the workshops, pediatricians were presented with medical scenarios that were closely related to their clinical practice. Participants were initially encouraged to solve the problems using their own preferred search methods, followed by group discussions led by clinical educators and a medical librarian in which search problems were identified and overcome. The workshops were evaluated using questionnaires to assess participant satisfaction and the extent to which participants intended to implement changes in their clinical practice and reported actual change. Conclusions A scenario-based approach to teaching clinicians how to search for medical information is an attractive alternative to traditional lectures. The relevance of such an approach was supported by a high level of participant engagement during the workshops and high scores for participant satisfaction, intended changes to clinical practice, and reported benefits in actual clinical practice.

Neutrophils from patients with SAPHO syndrome show no signs of aberrant NADPH oxidase-dependent production of intracellular reactive oxygen species

Objective. We aimed to investigate if aberrant intracellular production of NADPH oxidase-derived reactive oxygen species (ROS) in neutrophils is a disease mechanism in the autoinflammatory disease SAPHO syndrome, characterized by synovitis, acne, pustulosis, hyperostosis and osteitis, as has previously been suggested based on a family with SAPHO syndrome-like disease. Methods. Neutrophil function was explored in a cohort of four patients with SAPHO syndrome, two of whom were sampled during both inflammatory and non-inflammatory phase. Intracellular neutrophil ROS production was determined by luminol-amplified chemiluminescence in response to phorbol myristate acetate. Results. Cells from all patients produced normal amounts of ROS, both intra- and extracellularly, when compared with internal controls as well as with a large collection of healthy controls assayed in the laboratory over time (showing an extensive inter-personal variability in a normal population). Further, intracellular production of ROS increased during the inflammatory phase. Neutrophil activation markers were comparable between patients and controls. Conclusion. Dysfunctional generation of intracellular ROS in neutrophils is not a generalizable feature in SAPHO syndrome. Secondly, serum amyloid A appears to be a more sensitive inflammatory marker than CRP during improvement and relapses in SAPHO syndrome.

MPO deficiency confers impaired processing of neutrophil reactive oxygen species in a patient with severe CRMO.

We report a severe case of chronic recurrent multifocal osteomyelitis (CRMO) associated with total myeloperoxidase (MPO) deficiency. The etiology of CRMO is in most cases unknown, and this is to our knowledge the first case associated with MPO-deficiency. Leukocyte MPO-deficiency renders neutrophils unable to process superoxide to secondary reactive oxygen species (ROS). Partial MPO deficiency is seldom associated with pathology but little is known about the effects of total MPO deficiency.

Pediatric chronic non-bacterial osteomyelitis in Goteborg, Sweden

Chronic non-bacterial osteomyelitis (CNO) is today included among the autoinflammatory bone diseases. An alternative term in the literature is chronic recurrent multifocal osteomyelitis (CRMO). The etiology of the autoinflammatory bone diseases is unknown except for a few extremely rare monogenic diseases.

Challenging the opinion that SAPHO syndrome is associated with low intracellular ROS production in neutrophils

Background SAPHO syndrome, characterized by synovitis, acne, pustulosis, hyperostosis, and osteitis, belongs to the autoinflammatory bone disorders, in which dysregulation of innate immunity typically causes inflammation in sterile bone. The mechanisms underlying SAPHO syndrome are unknown, but neutrophil activation is suggested as part of disease pathophysiology. Previously, a patient with SAPHO syndrome-like phenotype was shown to lack production of intracellular NADPH-oxidase-derived reactive oxygen species (ROS) in response to phorbol myristate acetate (PMA; Ferguson et al, Arthritis and Rheumatism, 2008). In absence of phagosome-formation, such ROS are produced in intracellular granules, and are suggested to be part of regulatory signaling associated with hyperinflammatory disease.