□ CASE REPORT □

A Japanese Patient with Familial Mediterranean Fever Associated with Compound Heterozygosity for Pyrin Variant E148Q/M694I

Akinori NAKAMURA, Masahide YAZAKI,Takahiko TOKUDA, Takeshi HATTORI* and Shu-ichi IKEDA

Abstract found among people of non-Ashkenazi Jewish, Arab, Armenian, and Turkish origin, and is quite rare in Japan. In Familial Mediterranean fever (FMF) is an inherited the majority of cases the inheritance of FMF is commonly in inflammatory disease occurring mainly in Mediterranean an autosomal recessive manner, but a pseudodominant or and Middle Eastern populations. FMF is caused by muta- dominant manner has been identified in a minority of cases tions in the MEFV that encodes pyrin/marenostrin. (3, 4). FMF is caused by in the Mediterranean Here, we report a Japanese female FMF patient with fever gene (MEFV)onchromosome 16p13.3 and approxi- heterozygosity for the compound pyrin E148Q/M694I mately 30 mutations have been reported to date. The gene showing recurrent fever, serositis or delay in skin wound encodes pyrin/marenostrin and the predominantly ex- healing. Her father and elder sister were heterozygous pressed in the cytoplasm of mature and for pyrin variant M694I alone and sometimes suffered , but its precise function remains unclear (2). from mild fever or delay in wound healing, but her Reactive AA frequently occurrs in the patients mother was heterozygous for pyrin variant E148Q alone with this disease and the prognosis is determined by the and had no symptoms. This suggested that the inheri- complication of AA amyloidosis (1, 2). In Japan, although tance of FMF occurred not only in an autosomal reces- 20 cases with FMF have been reported to date, only a few sive manner but also in an autosomal dominant manner cases were diagnosed by MEFV gene analysis (5–8). in this Japanese family, and the severity of the disease Here we first present a FMF patient associated with differed among the family members in relation to the mu- heterozygosity for compound pyrin variant E148Q/M694I in tation. In the treatment of FMF, colchicine, reserpine or Japan, and family members with heterozygosity for M694I prazosin hydrochloride have been reported to prevent alone suffered from less severe symptoms. the attacks, but, in our patient such drugs were ineffec- tive or caused side effects, and only the anti-allergic drug For editorial comment, see p 177. azelastine was of benefit in relieving the attacks. (Internal Medicine 44: 261–265, 2005) Case Report Key words: Familial Mediterranean fever, MEFV gene, pyrin/marenostrin, azelastine A 34-year-old Japanese female repeatedly suffed from fever, chest and abdominal pain, arthralgia or delay in skin wound healing since the age of 20. The symptoms used to occur one or more times a month, and were especially severe Introduction during menstruation. She had been diagnosed as having an unidentified form of infection in several different hospitals Familial Mediterranean fever (FMF) is an inherited dis- and had taken anti-inflammatory drugs or antibiotics, which ease characterized by periodic fever, polyserositis and ery- provided relief for a few days. At the age of 33 she became sipelas-like skin lesions (1, 2). FMF has been predominantly psychotic and attempted suicide with a large amount of tran-

From Third Department of Medicine, Shinshu University School of Medicine, Matsumoto and *Department of Neurology, Suwa Red Cross Hospital, Suwa Received for publication April 9, 2004; Accepted for publication October 10, 2004 Reprint requests should be addressed to Dr. Akinori Nakamura, Third Department of Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621

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Table 1. Laboratory Findings on Admission

Peripheral blood counts Biochemistry Serology WBC 7,600/l TP 7.4 g/dl CRP 5.44 mg/dl↑ Neu 68.6% Alb 4.6 g/dl SAA 144 g/ml↑ Ly 23.2% BUN 9 mg/dl IgG 996 mg/dl Mono 6.4% Cr 0.7 mg/dl IgA 166 mg/ml Eosino 1.5% T-bil 0.6 mg/dl IgM 120 mg/dl Baso 0.3% AST 16 U/l IgE 34 IU/ml RBC 494×104/l ALT 9 U/l IgD 2.1 mg/dl Hb 14.9 g/dl LDH 158 IU/l RA (–) Plt 20.0×104/l ALP 171 U/l ANA <×40 ESR 23 mm/h↑ -GTP 21 U/l Anti-DNA Ab (–) AMY 42 U/l C3 79 mg/dl HLA typing CK 44 U/l C4 15.8 mg/dl A locus A2, A24 Tchol 183 mg/dl CH-50 45.0 U/ml B locus B52, 56 TG 71 mg/dl P-ANCA (–) C locus Cw7 Na 143 mmol/l C-ANCA (–) DR locus DR2, DR11 K 3.8 mmol/l Anti-CBV IgM (–) Cl 105 mmol/l Aniti-CMV IgM (–) Urinalysis Glu 90 mg/dl Anti-Toxoplasma IgM (–) pH 6.5 Fe 77 g/dl Anti-Leptospira (–) SG 1.005 TIBC 369 g/dl Protein (–) UIBC 292 g/dl Tumor markers Glucose (–) Ferritin 64.5 ng/ml CEA 1.3 ng/ml Blood (–) ACE 11.1 U/l SCC 0.4 ng/ml

WBC: count, Neu: , Ly: lymphocyte, Mono: , Eosino: , Baso: basophil, RBC: red blood cell count, Hb: hemoglobin, Ht: hematocrit, Plt: platelets, ESR: erythrocyte sedimentation rate, TP: total protein, Alb: albumin, BUN: blood urea nitrogen, Cr: creatinine, T-bil: total bilirubin, AST: asparate aminotransferase, ALT: alanine aminotransferase, LDH: lactate dehydrogenase, ALP: alkaline phosphatase, AMY: amylase, CK: creatine kinase, Tcho: total cholesterol, TG: triglyceride, Glu: glucose, TIBC: total iron-binding ca- pacity, UIBC: unsaturated iron-binding capacity, ACE: angiotensin-converting enzyme, CRP: C-reactive protein, SAA: serum amyloid A protein, RF: rhematoid factor, ANA: anti-nuclear antibody, Anti-EBV IgM: anti-Epstein- Barr virus IgM, Anti-CMV IgM: anti-cytomegalovirus IgM, CEA: carcinoembryonic antigen, SCC: squamous cell carcinoma. quilizers, and was admitted to a nearby hospital. In hospital infections, autoimmune disorders including Béhçhet’s dis- she repeatedly had a fever with elevation of serum C-reactive ease, or malignancy. Considering that fever and serositis re- protein (CRP) (max: 16.9 mg/dl), but examinations did not currently appeared and her father and elder sister also reveal the cause and subsequently she was referred to our sometimes showed mild fever or delay in wound healing, the university hospital. Her body temperature was 37.3°C, blood most likely diagnosis was familial Mediterranean fever pressure 97/76 mmHg, and pulse rate 70 beats/min and regu- (FMF), although her parents were not consanguineous. To lar. The heart and lungs were normal. Tenderness was ob- perform a search in the MEFV gene, after obtaining served in the lower abdomen and some pigmented scars from informed consent, we extracted genomic DNA from periph- insect bites were present on the lower legs. She lacked eye eral lymphocytes of the patient and her family members by symptoms, oral stomatitis ulcers, lymphadenopathy, or the standard procedure. For PCR amplification of the gene arthropathy. The laboratory examinations revealed only an we used the nine primer sets, and PCR amplification was elevation of CRP (5.44 mg/dl), erythrocyte sedimentation performed as described in a previous report (9). Direct se- rate (23 mm/h) and serum amyloid A protein (144 g/ml; quencing for PCR products was carried out using an auto- normal <8 g/ml), but other laboratory investigations did not matic DNA sequencer Model 4000L, LI-COR in both disclose any specific abnormalities (Table 1). All bacterio- directions. Mutation search revealed a compound hetero- logic cultures of pharynx, blood, and urine were negative. zygosity for pyrin E148Q/M694I mutation in the patient Findings of cerebrospinal fluid and bone marrow aspiration (Fig. 1): these mutations have been reported previously (2). were not informative. X-ray films and computed tomography Her father and elder sister were hetrozygous for pyrin variant of both chest and abdomen, Ga scintigraphy, and echocardi- M694I alone and her mother was heterozygous for pyrin ography revealed no abnormal findings. Thus, the extensive E148Q alone, while her brother had no mutation in the gene investigation failed to reveal such causes of her disorder as (Fig. 2).

262 Internal Medicine Vol. 44, No. 3 (March 2005) A Japanese Case of FMF with the MEFV Gene Mutations



   



    

Figure 1. MEFV gene analysis in a healthy control and the patient. In the pa- tient, the G to C transition in codon 148 and the G to A in codon 694 convert a glutamic acid (E) to glutamine (Q) and methionine (M) to isoleucine (I), respec- tively.

Although her serum amyloid A protein level was very another treatment and focused on colchicine’s characteristic high (144 g/ml; normal < 8 g/ml), gastric and duodenal function: inhibition of neutrophil chemotactic activity (12). mucosal biopsies did not show any deposits of amyloid and We searched for another drug having a similar function and renal function was normal. Since colchicine has been estab- found that azelastine, which is an anti-allergic drug, also in- lished as effective in preventing attacks and subsequent de- hibits neutrophil chemotaxis (13). We have since been ad- velopment of amyloidosis (1, 2), 1mg daily was administered ministering 4–6 mg of azelastine to her daily and her attacks orally and her symptoms remitted for some time. However, of fever and polyserositis have decreased. one month later she suffered from severe abdominal pain and diarrhea due to side effects of the colchicine and the drug Discussion was discontinued. Reserpine (10) or prazosin hydrochloride (11) has been reported to be effective, but we could not give We presented a severe FMF patient associated with her either drug because of her psychosis and hypotension heterozygosity for the compound pyrin variant E148Q/ (systolic blood pressure <100 mmHg). Diclofenac sodium M694I. Interestingly, two family members, who were het- relieved her fever but not the pain, while pentazocine hydro- erozygous for pyrin M694I alone, also suffered from mild at- chloride or buprenorphine hydrochloride was useful for pain tacks of fever of unknown origin or delay in wound healing, relief but not for fever. Accordingly we needed to seek while her mother with heterozygosity for E148Q alone was

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to cause FMF, and some individuals even with homozygosity for pyrin E148Q might have no or very mild symptoms. In treating attacks of FMF, colchicine has been establish- ed to be effective in preventing them and in secondarily oc- curring amyloidosis, but side effects such as abdominal symptoms or bone marrow suppression are often encoun- tered. Reserpine (10) and prazosin hydrochloride (11) have also been reported to be useful and diclofenac sodium, pentazocine hydrochloride and buprenorphine hydrochloride have been used for pain relief and fever (2). Unfortunately the above drugs were either only partially effective in our pa- tient or could not be used at all. Accordingly we focused on colchicine’s characteristic function of inhibiting neutrophil Figure 2. Pedigree in the family and pyrin variants M694I and E148Q encoded by mutations in opposing MEFV alleles. Open chemotactic activity (12) and found that the anti-allergic boxes are asymptomatic family members irrespective of the drug azelastine also inhibits neutrophil chemotaxis (13). MEFV mutation. The black box is a FMF patient with com- Azelastine, like colchicine, successfully reduced the fre- pound dual allele MEFV mutations. Shaded boxes are sympto- quency and degree of the attacks in the present patient. It matic carriers with a single allele MEFV mutation. controls neutrophil function by inhibition of leukotriene B4 formation, arachidonic acid release and superoxide genera- tion (13). As in our case, when colchicine or other drugs can- asymptomatic. It has been reported that FMF patients with not be tolerated because of side effects or contraindications several pyrin M694 variants often show a severe phenotype in patients with FMF, azelastine should be considered. (2), that the methionine residue at position 694 makes a cru- In summary, we reported the first Japanese case of FMF cial contribution to pyrin’s function, and that a 50% comple- identified to be associated with compound heterozygosity for ment of normal pyrin activity may not prevent FMF pyrin variant E148Q/M694I. The FMF gene carriers with symptoms (3). Given these reports, it is not surprising that heterozygosity for pyrin variant M694I alone also experi- our FMF carriers associated with heterozygosity for pyrin enced milder or slight symptoms. Accordingly it is possible variant M694I alone showed some FMF symptoms, and a that such mild cases might often be overlooked and we pyrin variant M694I accompanied by variant E148Q in the should consider the possibility of FMF in the differential di- patient could cause the definite FMF phenotype. Recently it agnosis of recurrent fever or serositis of unknown origin. has been documented that an H478Y variant alone in a Spanish kindred produced a severe FMF phenotype with Acknowledgements: This study was supported by a grant from the amyloidosis (14). Thus the inheritance of FMF sometimes Intractable Disease Division, the Ministry of Health and Welfare, shows an autosomal dominant or pseudodominant pattern (3, Amyloidosis Research Committee of Japan. 4), and we first confirmed the presence of pseudodominant inheritance in a Japanese family. The pattern of inheritance References may depend on the location of the mutation in the MEFV gene. 1) Sohar E, Gafni J, Pras M, Heller H. Familial Mediterranean fever. A survey of 470 cases and review of the literature. Am J Med 43: 227– On the other hand, the role of pyrin E148Q as a mutation 253, 1967. in FMF has been controversial. It has been described that the 2) Drenth JP, van der Meer JW. Hereditary periodic fever. N Engl J Med allele frequency of pyrin E148Q in normal controls was rela- 345: 1748–1757, 2001. tively high, and some healthy individuals had a homozygous 3) Booth DR, Gillmore JD, Lachmann HJ. The genetic basis of autosomal pyrin E148Q, thus pyrin E148Q has been considered to be a dominant familial Mediterranean fever. QJM 93: 217–221, 2000. 4) Cazeneuve C, Sarkisian T, Pecheux C, et al. MEFV-gene analysis in normal variant (15, 16). However, it has also been reported Armenian patients with Familial Mediterranean fever: diagnostic value that the allele frequency of pyrin E148Q is significantly and unfavorable renal prognosis of the M694V homozygous genotype- higher among patients with AA amyloidosis and with un- genetic and therapeutic implications. Am J Hum Genet 65: 88–97, known chronic fever, and it might produce FMF when asso- 1999. ciated with certain other MEFV mutations (17). Taking this 5) Shinozaki K, Agematsu K, Yasui K, et al. Familial Mediterranean fever in 2 Japanese families. J Rheumatol 29: 1324–1325, 2002. report and the relationship between phenotype and genotype 6) Tomiyama N, Oshiro S, Higashiuesato Y, et al. End-stage renal disease in our family together, we speculate that heterozygosity for associated with familial Mediterranean fever. Intern Med 41: 221–224, pyrin E148Q alone might not reach the necessary threshold 2002. to cause FMF, that heterozygosity for pyrin M694I alone 7) Yoshida K, Kanaoka S, Kajimura M, et al. A Japanese case of familial might be slightly over the threshold, and that a compound Mediterranean fever with family history demonstrating a mutation in MEFV. Intern Med 42: 761–764, 2003. heterozygosity for E148Q and M694I might be enough to go 8) Kotone-Miyahara Y, Takaori-Kondo A, Fukunaga K, et al. E148Q/ beyond the threshold and produce the definite FMF pheno- M694I mutation in 3 Japanese patients with familial Mediterranean type. The pyrin E148Q mutation itself might be insufficient fever. Int J Hematrol 79: 235–237, 2004.

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9) Timmann C, Muntau B, Kuhne K, Gelhaus A, Horstmann RD. Two and colchicine resistance associated to the MEFV H478Y variant in a novel mutations R653H and E230K in the Mediterranean fever gene as- Spanish kindred: an unusual familial Mediterranean fever phenotype or sociated with disease. Mutat Res 479: 235–239, 2001. another MEFV-associated periodic inflammatory disorder? Am J Med 10) Hayashi A, Suzuki T, Shimizu A, Yamamura Y. Periodic fever sup- Genet 124: 67–73, 2004. pressed by reserpine. Lancet 1: 592, 1976. 15) Ben-Chetrit E, Lerer I, Malamud E, Domingo C, Abeliovich D. The 11) Kataoka H, Kumagai H, Hanai H. Treating familial Mediterranean E148Q mutation in the MEFV gene: is it a disease-causing mutation or fever with prazosin hydrochloride. Ann Intern Med 129: 424–425, sequence variant? Hum Mutat 15: 385–386, 2000. 1998. 16) Tchernitchko D, Legendre M, Cazeneuve C, Delahaye A, Niel F, 12) Molad Y. Update on colchicine and its mechanism of action. Curr Amselem S. The E148Q MEFV allele is not implicated in the develop- Rheumatol Rep 4: 252–256, 2002. ment of familial Mediterranean fever. Hum Mutat 22: 339–340, 2003. 13) Taniguchi K, Masuda Y, Takanaka K. Action sites of antiallergic drugs 17) Booth DR, Lachmann HJ, Gillmore JD, Booth SE, Hawkins PN. on neutrophils. Jpn J Pharmacol 52: 101–108, 1990. Prevalence and significance of the familial Mediterranean fever gene 14) Aldea A, Campistol JM, Arostegui JI, et al. A severe autosomal- mutation encoding pyrin Q148. Q J M 94: 527–531, 2001. dominant periodic inflammatory disorder with renal AA amyloidosis

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