globulinemia D Syndrome: Two Diseases with Distinct Clinical, Serologic, and Genetic Features

Objective. To determine whether the 2 periodic febrile syndromes familial Mediterranean fever (FMF) and hyperimmunoglobulinemia D syndrome (HIDS) are distinct diseases. Methods. Clinical manifestations of the diseases were analyzed by physicians experienced with FMF and HIDS. Serum immunoglobulin (Ig) levels were studied in 70 patients with FMF using nephelometry or ELISA and compared with Ig levels in 50 patients with HIDS. Genetic linkage of HIDS with the chromosome 16 polymorphic locus RT70, currently used for refined localization of the FMF susceptibility gene (MEFV), was studied in 9 HIDS families (18 patients) using polymerase chain reaction amplification and gel electrophoresis. Results. The main clinical features distinguishing FMF from HIDS were lymph adenopathy, skin eruption, and symmetrical oligoarthritis in HIDS, and monoarthritis, peritonitis, and pleuritis in FMF Increased IgG levels were found in 12 patients with FMF (17%), IgAin 16 (23%), IgM in 9 (13%), and IgD in 9 (13%), significantly lower than the prevalence reported for HIDS. We found no evidence for genetic linkage between HIDS and the chromosome 16 marker RT70. Conclusion. HIDS and FMF are different entities, clinically, immuno logic ally, and genetically. (J Rheumatol 1997;24:1558-63) Key Indexing Terms: FAMILIAL MEDITERRANEAN FEVER HYPERIMMUNOGLOBULINEMIA D SYNDROME IgA IgD CHROMOSOME 16 MEFV Familial Mediterranean fever (FMF) is an autosomal reces­ sive disease characterized by recurrent episodes of febrile serositis, mostly peritonitis, arthritis, and pleuritis1. Although immunologic, serologic, and metabolic factors have been studied2"9, the pathogenesis of FMF is still not known. The recent mapping of the FMF susceptibility gene, designated MEFV, to chromosome 16p10, permits elucidaFrom the Heller Institute o f Medical Research, Sheba Medical Center, Tel-Hashomer, and Sackler Faculty o f Medicine, Tel-Aviv University', Tel-Aviv, Israel; Department o f Medicine and Laboratories of Clinical Chemistry, University Hospital S i Radboud, Nijmegen, The Netherlands; Department of Anatomy and Cell Biology, University o f Michigan, Ann Arbor, MI, USA; Arthritis and Rheumatism Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA. J.P.H. Drenth is a recipient o f a Dutch Organization of Science Fellowship for Clinical Investigators (KWO 900-716-065). A. Livnek, MD, Senior Physician, Sheba Medical Center (SMC), Senior Lecturert Sackler School o f Medicine (SSM); J.P.H, Drenth, MD , Resident, University Hospital St. Radboud (UHSR); I.S. Klasen, PhD, Head, Laboratories o f Clinical Chemistry, UHSR; P. Langevitz, MD, Head, Rheumatology Unit, SMC, Senior Lecturer, SSM; J. George, MD, Resident; SMC; D.A. Shelton, BS, Research Associate, University of Michigan (UM); D .L Gumucio, PhD, Associate Professor, UM; E. Pras, MD, Senior Physician, SMC; D .L Kastner, MD , PhD, National Institute of Arthritis and Musculoskeletal and Skin Diseases; M. Pras, MD, Head, Department of Medicine F, SMC, Professor o f Medicine, SSM; J.W.M. van der Me er, MD, Professor o f Internal Medicine, Head, Division of General Internal Medicine, UHSR. Address reprint requests to Dr. A. Livneh, Heller Institute o f Medical Research, Sheba Medical Center, Tel Hashomer 52621, Israel. Submitted July 3, 1996 revision accepted Jcinuaiy 20, 1997. tion of the molecular lesion underlying the disease by posi­ tional cloning. Hyperimmunoglobulinemia D syndrome (HIDS) is another autosomal recessive periodic febrile syndrome, characterized by febrile attacks of abdominal and joint pain11. While its resemblance to FMF is striking, there are suggestions that it is a clinically, serologically, and geneti­ cally distinct entity11”13. However, more data to support HIDS's uniqueness are required, as studies distinguishing the 2 diseases are limited and based on a small population of patients with FMFU. Moreover, progressive narrowing of the FMF candidate interval permits reexamination of genet­ ic linkage data on HIDS families. An earlier study12 used haplotype analysis with 4 markers from MEFV region of chromosome 16p, but the closest marker on the centromeric side of MEFV was roughly 10 cM from the gene. We took advantage o f a newly identified marker about 1 cM cen­ tromeric to MEFV to perform linkage studies in HIDS fam­ ilies. In addition, we established a collaborative study among our centers to compare the clinical and immunologi­ cal features of FMF and HIDS. MATERIALS AND METHODS Comparative analysis o f clinical manifestations. Representatives of the FMF clinic of Sheba Medical Center and the HIDS clinic at the University Hospital of Nijmegen and the HIDS study group who personally attend patients with the diseases met at Nijmegen to study the manifestations o f 1 1558 The Journal o f Rheumatology 1997; 24:8 the 2 diseases for similarities and differences by reviewing and discussing the clinical presentation of the diseases. The analysis was based on experi­ ence with 50 patients with HIDS treated by physicians of the hyper-IgD study group for the last 15 years, and about 4000 patients with FMF fol­ lowed over the last 40 years as part of an ongoing study in the FMF clinic. Clinical features of these patients have been reported1,11,14’15 and recently updated13,16. Determination and comparative analysis of immunoglobulin levels. Seventy consecutive patients with FMF, attending the FMF clinic for rou­ tine followup examination, donated 10 ml blood. All were following a con­ tinuous colchicine regimen. Before starting colchicine all had clinical man­ ifestations agreeing with the criteria for FM F1,17. At the time of blood dona­ tion, they were free of attacks. No patient had, in addition to FMF, a rec­ ognized acute or chronic allergic, inflammatory, or infectious condition leading to hyperglobulinemia. After clot formation, the serum was separat­ ed and kept at ~20°C until studied. IgD level was studied by ELISA as described1 Briefly, microtiter plates were coated with rabbit antihuman IgD antibody, and sera and stan­ dard solutions with known concentrations of IgD as reference were added. The presence of IgD was detected by addition of monoclonal IgG antihu­ man IgD followed by peroxidase conjugated, antimouse IgG and substrate. The absorbency was read using an ELISA reader and the level of IgD in sera was determined with reference to the standard solutions. Levels of the IgG, IgM, and IgA were studied using nephelometry (Cobas Fara, Roche Diagnostics, Basel, Switzerland). The immunoglobulin levels in 70 FMF and 50 HIDS sera were compared. Ig levels in HIDS sera were determined previously by the same laboratory, personnel, and methodology as in the current study and were reported as part of a large clinical and laboratory study of these patients13. Determination of the linkage between HIDS and RT70. DNA samples were obtained from members of 9 HIDS families, consisting of IS patients and 26 first degree relatives. Their pedigrees and genomic DNA preparation have been reported12. The diagnosis of HIDS was made according to pub­ lished criteria12. These families were genotyped for a newly described tetranucleotide-repeat marker derived from cosmid RT70, which is located within 1 cM of MEFV on chromosome 16p. Five alleles of this marker were identified in the general population19. RT70 polymerase chain reaction (PCR) primers were synthesized as follows: 5'-TCACTCTAGCTTGGGTGAAGG-3' and S'-CCTCTCCAGAGGACAACTGG-3'. The PCR reactions were carried out in a volume o f 10 jliI. The reaction mixture consisted of the pair of primers (0.1 pi of 150 ng/pl each), [32P] labeled primer [0.05 pi from a 15 pi reaction mix con­ taining 187.5 ng 5' primer, 7.5 pi gamma-[32P]-ATP (DuPont, Boston, MA, USA; 10 mCi/ml), 1.5 pi T4-polynucleotide kinase (Promega, Madison, W I5 USA; 10 U/pl), 10 x buffer and H ,0], genomic DNA (1-2 pi containing 25-50 ng), deoxynucleosides triphosphate (GeneAmp dNTPs, Perkin Elmer, Branchburg, NJ, USA; 2 pi of a mixture containing 2 pg/ml of each o f the 4 nucleosides), Taq polymerase (0.24 pi of 10 U/pl), 10 x buffer and H 20. The PCR program consisted of 30 cycles of 1 min denaturing at 94°C, 1 min annealing at 55°C, and 1 min extension at 72°C. The reaction was stopped with 7 pi loading/stop buffer (formamide, 0.1% xylene cyanol, 0 . \% bromophenol blue, and 2% 0.5 M EDTA). Electrophoresis of the PCR products was carried out in acrylamide sequencing gels at 1800 V for 3 h. The gel was dried and exposed to film, Lod scores defined as logarithm to the base 10 of the ratio of odds in favor o f linkage to the odds against linkage between RT70 and HIDS were cal­ culated using the LINKAGE programs, assuming a recessive model of HIDS inheritance and a gene frequency of 0.001. Statistical analysis. Statistical analysis was performed using the chisquared method or Student’s t test, indicated in Results. of FMF and HIDS is shown in Table 1. The 2 diseases appear to be distinct in most aspects, including the duration of the attack, the temperature curve, the organs involved and the nature of the involvement, the response to treatment, and the prognosis. A typical attack of FMF lasts 2 -4 days and is characterized by a temperature curve with a fast rise, plateau and abrupt fall, peritonitis, pleuritis or monoarthritis, possi­ bly erysipelas-like eruption, and virtually no other dermal manifestations or lymphadenopathy (rarely, if ever, in chil­ dren), On the other hand attacks of HIDS are marked by longer duration (around a week), gradual defervescence (lysis), common occurrence of lymphadenopathy and rash, and abdominal pain, which very infrequently develops into acute abdomen and symmetrical oligoarthritis or arthralgia. Amyloidosis, a life threatening manifestation of FMF, has not been noted in HIDS, and colchicine, while very effective in FMF, is less effective in HIDS. Additional dissimilarities exist, as outlined in Table 1, Serological analysis. Results of Ig analysis in patients with FMF are presented in Tables 2-4. As shown in Tables 2 and 3, abnormally elevated levels of Ig of at least one iso type were noted in 34 of 70 patients (49%). Sixteen patients (23% of all patients and 47% of patients with increased Ig levels) had elevated IgA. Elevated IgM levels were noted in 9 patients (13%), IgG in 12 (17%), and IgD in 9 (13%). In 10 patients, the increased IgA level was associated with a concomitant rise of IgG (5 patients), IgD (4 patients), or IgD plus IgM (one patient). As a group, however, patients with FMF exhibited normal Ig levels between the attacks (Table 4, mean values in FMF). All 9 patients with FMF (4 men and 5 women) who dis­ played elevated levels of IgD appeared to have classic FMF with attacks of peritonitis (9 patients), monoarthritis (7 patients), and pleuritis (3 patients), and had none of the spe­ cific HIDS clinical features delineated in the previous sec­ tion. All were colchicine responsive and did not have skin manifestations or lymphadenopathy. Compared to patients with HIDS, patients with FMF had significantly lower rates of elevated individual Ig levels (Table 3), and significantly lower mean IgA and IgD levels (Table 4). Therefore, in addition to differences in IgD, the prevalence of elevated Ig levels and mean IgA levels also differentiate the disease. Molecular analysis. A panel of 9 HIDS families was geno­ typed for the RT70 marker, which is about 1 cM centromeric to the FMF susceptibility gene on chromosome 16p. Lod scores between HIDS and RT70 are shown in Table 5. Total lod scores of < 2 were obtained up to recombination fre­ quency of 0.03, excluding HIDS from the interval within 3 cM of RT70. Moreover, haplotype analysis, using RT70 typ­ ings in conjunction with 4 other markers12, also rules out the placement of HIDS in the MEFV region of chromosome 16. RESULTS Clinical analysis. The comparison of clinical manifestations DISCUSSION Although FMF and HIDS share certain features, we Livneh, et al: FMF and HIDS 1559 Table I. FMF and HIDS are clinically distinct. Manifestation FMF HIDS Age of onset Usually before age 20 Childhood (70% before Duration of 1-4 days 1 st year of life) 3-7 days attack Fever Begins and ends abruptly. Sudden rise. Gradual The temperature curve is of decrease. Chills are common Abdominal continuous type. Chills are common Occur in most patients. Occurs in most patients; attacks Diffuse, or less frequently usually pain alone. localized. Peritoneal Acute abdomen (in irritation is the rule. < 10%). Diarrhea Diarrhea is not common (5%) very common (80%) Joint attacks Presents as monoarthritis Presents as symmetric of the large joints of oligoarthritis of lower extremities (75%). large joints of Poly arthralgia may lower extremities. occasionally accompany Arthralgia is very febrile attacks elsewhere. frequent. No chronic Chronic joints and joint disease found Thoracic spondyloarthropathy are rare (< 5% and < 1%, respectively) Pleuritis is common (25%), Not found attacks unilateral. Pericarditis is Rash rare (< 1%) Rare (< 5%). Only Very common (90%). erysipeloid. Those affected Types of rash: macular, experience only rare maculopapular, purpura. episodes during lifetime Pathology: vasculitis “Orchitis” Rare (< 5%), Unilateral, Not found Muscle pain Only in childhood and adolescence. Rare episodes during lifetime Short or prolonged episodes Rare Lymphadenopathy of febrile myalgia are uncommon. Afebrile muscle pain of lower extremities, usually provoked by exertion, is common (30%) Questionable in early Generalized and childhood cervical. Very common (> 90%) Splenomegaly In about 30% of patients In about 50% of patients Amyloidosis Develops in many untreated patients Not found Vasculitis Hypersensitivity, GN, Skin eruption Genetic origins, PAN are more common compared to population not affected by FMF Autosomal recessive. The Autosomal recessive. populations susceptibility gene is Chromosomal location is mapped to chromosome 16p. not known. Occurs in Sephardi Jews, Armenians, Arabs, and Turks Western Europeans WBC in attack Increased Increased ESR in attack Increased Increased Hematuria Common (5%), Present in 20% Synovial fluid Turbid, inflammatory; Turbid, inflammatory white cell count > 20 ,000 /jal Colchicine treatment Prevents attacks and amyloidosis Usually not effective WBC: white blood cells; ESR: erythrocyte sedimentation rate; GN: glomerulonephritis; PAN: polyarteritis