Skip to main content
SpringerLink
Log in

Immune Dysregulation in the Tonsillar Microenvironment of Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA) Syndrome

Journal of Clinical Immunology volume 40, pages 179–190 (2020)Cite this article

Abstract

Periodic Fever, Aphthous stomatitis, Pharyngitis and Adenitis (PFAPA) syndrome is an inflammatory disorder of childhood classically characterized by recurrent fevers, pharyngitis, stomatitis, cervical adenitis, and leukocytosis. While the mechanism is unclear, previous studies have shown that tonsillectomy can be a therapeutic option with improvement in quality of life in many patients with PFAPA, but the mechanisms behind surgical success remain unknown. In addition, long-term clinical follow-up is lacking. In our tertiary care center cohort, 62 patients with PFAPA syndrome had complete resolution of symptoms after surgery (95.3%). Flow cytometric evaluation demonstrates an inflammatory cell population, distinct from patients with infectious pharyngitis, with increased numbers of CD8+ T cells (5.9% vs. 3.8%, p < 0.01), CD19+ B cells (51% vs. 35%, p < 0.05), and CD19+CD20+CD27+CD38-memory B cells (14% vs. 7.7%, p < 0.01). Cells are primed at baseline with increased percentage of IL-1β positive cells compared to control tonsil-derived cells, which require exogenous LPS stimulation. Gene expression analysis demonstrates a fivefold upregulation in IL1RN and TNF expression in whole tonsil compared to control tonsils, with persistent activation of the NF-κB signaling pathway, and differential microbial signatures, even in the afebrile period. Our data indicates that PFAPA patient tonsils have localized, persistent inflammation, in the absence of clinical symptoms, which may explain the success of tonsillectomy as an effective surgical treatment option. The differential expression of several genes and microbial signatures suggests the potential for a diagnostic biomarker for PFAPA syndrome.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Abbreviations

CpG-ODN:

CpG-oligodeoxynucleotide

FBS:

Fetal bovine serum

GAPDH:

Glyceraldehyde 3-phosphate dehydrogenase

HRP:

Horseradish peroxidase

IFN:

Interferon

IKK:

Inhibitor of kappa B kinase

IL-1:

Interleukin-1

IL-1Ra:

Interleukin-1 receptor antagonist (protein)

IL1RN:

Interleukin-1 receptor antagonist (gene)

LPS:

Lipopolysaccharide

NF-κB:

Nuclear factor kappa-light-chain enhancer of activated B cells

NK:

Natural killer

OSA:

Obstructive sleep apnea

PFAPA:

Periodic fever, aphthous stomatitis, pharyngitis, and adenitis

PSG:

Penicillin-streptomycin-glutamine

PVDF:

Polyvinylidene fluoride

RP:

Recurrent pharyngitis

RT-qPCR:

Reverse transcription quantitative polymerase chain reaction

SEM:

Standard error of mean

TLR:

Toll-like receptor

TNF:

Tumor necrosis factor

References

  1. Feder HM Jr, Bialecki CA. Periodic fever associated with aphthous stomatitis, pharyngitis and cervical adenitis. Pediatr Infect Dis J. 1989;8(3):186–7.

    PubMed  Google Scholar 

  2. Feder HM, Salazar JC. A clinical review of 105 patients with PFAPA (a periodic fever syndrome). Acta Paediatr. 2010;99(2):178–84.

    CAS  PubMed  Google Scholar 

  3. Lierl M. Periodic fever syndromes: a diagnostic challenge for the allergist. Allergy. 2007;62(12):1349–58.

    Article  CAS  PubMed  Google Scholar 

  4. Marshall GS, Edwards KM, Butler J, Lawton AR. Syndrome of periodic fever, pharyngitis, and aphthous stomatitis. J Pediatr. 1987;110(1):43–6.

    Article  CAS  PubMed  Google Scholar 

  5. Padeh S, Brezniak N, Zemer D, Pras E, Livneh A, Langevitz P, et al. Periodic fever, aphthous stomatitis, pharyngitis, and adenopathy syndrome: clinical characteristics and outcome. J Pediatr. 1999;135(1):98–101.

    Article  CAS  PubMed  Google Scholar 

  6. Stojanov S, Hoffmann F, Kery A, Renner ED, Hartl D, Lohse P, et al. Cytokine profile in PFAPA syndrome suggests continuous inflammation and reduced anti-inflammatory response. Eur Cytokine Netw. 2006;17(2):90–7.

    CAS  PubMed  Google Scholar 

  7. Stojanov S, Lapidus S, Chitkara P, Feder H, Salazar JC, Fleisher TA, et al. Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) is a disorder of innate immunity and Th1 activation responsive to IL-1 blockade. Proc Natl Acad Sci U S A. 2011;108(17):7148–53.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Valenzuela PM, Araya A, Perez CI, Maul X, Serrano C, Beltran C, et al. Profile of inflammatory mediators in tonsils of patients with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. Clin Rheumatol. 2013;32(12):1743–9. https://doi.org/10.1007/s10067-013-2334-z.

    Article  PubMed  Google Scholar 

  9. Forsvoll J, Oymar K. The role of tonsillectomy in the periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome; a literature review. BMC Ear Nose Throat Disord. 2018;18:3. https://doi.org/10.1186/s12901-017-0049-5.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Thomas KT, Feder HM Jr, Lawton AR, Edwards KM. Periodic fever syndrome in children. J Pediatr. 1999;135(1):15–21.

    Article  CAS  PubMed  Google Scholar 

  11. Shaw LP, Bassam H, Barnes CP, Walker AS, Klein N, Balloux F. Modelling microbiome recovery after antibiotics using a stability landscape framework. ISME J. 2019;13(7):1845–56. https://doi.org/10.1038/s41396-019-0392-1.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Caporaso JG, Kuczynski J, Stombaugh J, Bittinger K, Bushman FD, Costello EK, et al. QIIME allows analysis of high-throughput community sequencing data. Nat Methods. 2010;7(5):335–6. https://doi.org/10.1038/nmeth.f.303.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Amir A, McDonald D, Navas-Molina JA, Kopylova E, Morton JT, Zech Xu Z et al. Deblur rapidly resolves single-nucleotide community sequence patterns. mSystems. 2017;2(2). https://doi.org/10.1128/mSystems.00191-16.

  14. McMurdie PJ, Holmes S. phyloseq: an R package for reproducible interactive analysis and graphics of microbiome census data. PloS One. 2013;8(4):e61217. https://doi.org/10.1371/journal.pone.0061217.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. McDonald D, Clemente JC, Kuczynski J, Rideout JR, Stombaugh J, Wendel D, et al. The biological observation matrix (BIOM) format or: how I learned to stop worrying and love the ome-ome. Gigascience. 2012;1(1):7. https://doi.org/10.1186/2047-217X-1-7.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lozupone C, Hamady M, Knight R. UniFrac--an online tool for comparing microbial community diversity in a phylogenetic context. BMC Bioinformatics. 2006;7:371. https://doi.org/10.1186/1471-2105-7-371.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Beals EW. Bray-Curtis ordination: an effective strategy for analysis of multivariate ecological data. Adv Ecol Res. 1984;14:1–55.

    Article  Google Scholar 

  18. Anderson MJ. Permutational multivariate analysis of variance (PERMANOVA). In: Balakrishnan TCN, Everitt B, Piegorsch W, Ruggeri F, Teugels JL (eds). Wiley StatsRef: Statistics Reference Online; 2017.

  19. Mandal S, Van Treuren W, White RA, Eggesbo M, Knight R, Peddada SD. Analysis of composition of microbiomes: a novel method for studying microbial composition. Microb Ecol Health Dis. 2015;26:27663. https://doi.org/10.3402/mehd.v26.27663.

    Article  PubMed  Google Scholar 

  20. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2019. https://www.r-project.org/.

  21. Tasher D, Somekh E, Dalal I. PFAPA syndrome: new clinical aspects disclosed. Arch Dis Child. 2006;91(12):981–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Renko M, Salo E, Putto-Laurila A, Saxen H, Mattila PS, Luotonen J, et al. A randomized, controlled trial of tonsillectomy in periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. J Pediatr. 2007;151(3):289–92.

    Article  CAS  PubMed  Google Scholar 

  23. Svensson A, Patzi Churqui M, Schluter K, Lind L, Eriksson K. Maturation-dependent expression of AIM2 in human B-cells. PLoS One. 2017;12(8):e0183268. https://doi.org/10.1371/journal.pone.0183268.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Atkinson TP, Centor RM, Xiao L, Wang F, Cui X, Van Der Pol W, et al. Analysis of the tonsillar microbiome in young adults with sore throat reveals a high relative abundance of Fusobacterium necrophorum with low diversity. PLoS One. 2018;13(1):e0189423. https://doi.org/10.1371/journal.pone.0189423.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Jensen A, Fago-Olsen H, Sorensen CH, Kilian M. Molecular mapping to species level of the tonsillar crypt microbiota associated with health and recurrent tonsillitis. PLoS One. 2013;8(2):e56418. https://doi.org/10.1371/journal.pone.0056418.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Perez-Lorenzo R, Zambrano-Zaragoza JF, Saul A, Jimenez-Zamudio L, Reyes-Maldonado E, Garcia-Latorre E. Autoantibodies to autologous skin in guttate and plaque forms of psoriasis and cross-reaction of skin antigens with streptococcal antigens. Int J Dermatol. 1998;37(7):524–31.

    Article  CAS  PubMed  Google Scholar 

  27. Costalonga M, Herzberg MC. The oral microbiome and the immunobiology of periodontal disease and caries. Immunol Lett. 2014;162(2 Pt A):22–38. https://doi.org/10.1016/j.imlet.2014.08.017.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Garavello W, Romagnoli M, Gaini RM. Effectiveness of adenotonsillectomy in PFAPA syndrome: a randomized study. J Pediatr. 2009;155(2):250–3.

    Article  PubMed  Google Scholar 

  29. Kolly L, Busso N, von Scheven-Gete A, Bagnoud N, Moix I, Holzinger D, et al. Periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis syndrome is linked to dysregulated monocyte IL-1beta production. J Allergy Clin Immunol. 2013;131(6):1635–43. https://doi.org/10.1016/j.jaci.2012.07.043.

    Article  CAS  PubMed  Google Scholar 

  30. Dan JM, Havenar-Daughton C, Kendric K, Al-Kolla R, Kaushik K, Rosales SL et al. Recurrent group A Streptococcus tonsillitis is an immunosusceptibility disease involving antibody deficiency and aberrant TFH cells. Sci Transl Med. 2019;11(478). https://doi.org/10.1126/scitranslmed.aau3776.

  31. Dytrych P, Krol P, Kotrova M, Kuzilkova D, Hubacek P, Krol L, et al. Polyclonal, newly derived T cells with low expression of inhibitory molecule PD-1 in tonsils define the phenotype of lymphocytes in children with periodic fever, aphtous stomatitis, pharyngitis and adenitis (PFAPA) syndrome. Mol Immunol. 2015;65(1):139–47. https://doi.org/10.1016/j.molimm.2015.01.004.

    Article  CAS  PubMed  Google Scholar 

  32. Manthiram K, Correa H, Boyd K, Roland J, Edwards K. Unique histologic features of tonsils from patients with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. Clin Rheumatol. 2018;37(5):1309–17. https://doi.org/10.1007/s10067-017-3773-8.

    Article  PubMed  Google Scholar 

  33. Berlucchi M, Meini A, Plebani A, Bonvini MG, Lombardi D, Nicolai P. Update on treatment of Marshall's syndrome (PFAPA syndrome): report of five cases with review of the literature. Ann Otol Rhinol Laryngol. 2003;112(4):365–9.

    Article  PubMed  Google Scholar 

  34. Feder HM Jr. Cimetidine treatment for periodic fever associated with aphthous stomatitis, pharyngitis and cervical adenitis. Pediatr Infect Dis J. 1992;11(4):318–21.

    Article  PubMed  Google Scholar 

  35. Lierl MB. Efficacy of montelukast for treatment of periodic fever with aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA). J Allergy Clin Immunol. 2008;121(2 (Suppl 1)):S228. https://doi.org/10.1016/j.jaci.2007.12.899.

    Article  Google Scholar 

  36. Takahara M. Clinical outcome of tonsillectomy for palmoplantar pustulosis and etiological relationship between palmoplantar pustulosis and tonsils. Adv Otorhinolaryngol. 2011;72:86–8. https://doi.org/10.1159/000324618.

    Article  PubMed  Google Scholar 

  37. Ueda S, Takahara M, Tohtani T, Yoshizaki T, Kishibe K, Harabuchi Y. Up-regulation of ss1 integrin on tonsillar T cells and its induction by in vitro stimulation with alpha-streptococci in patients with pustulosis Palmaris et Plantaris. J Clin Immunol. 2010;30(6):861–71. https://doi.org/10.1007/s10875-010-9451-0.

    Article  PubMed  Google Scholar 

  38. Wu W, Debbaneh M, Moslehi H, Koo J, Liao W. Tonsillectomy as a treatment for psoriasis: a review. J Dermatolog Treat. 2014;25(6):482–6. https://doi.org/10.3109/09546634.2013.848258.

    Article  PubMed  Google Scholar 

  39. Muto M, Manfroi B, Suzuki H, Joh K, Nagai M, Wakai S, et al. Toll-like receptor 9 stimulation induces aberrant expression of a proliferation-inducing ligand by tonsillar germinal center B cells in IgA nephropathy. J Am Soc Nephrol. 2017;28(4):1227–38. https://doi.org/10.1681/ASN.2016050496.

    Article  CAS  PubMed  Google Scholar 

  40. Tanimoto Y, Fukuyama S, Tanaka N, Ohori J, Tanimoto Y, Kurono Y. Presence of keratin-specific antibody-forming cells in palatine tonsils of patients with pustulosis palmaris et plantaris (PPP) and its correlation with prognosis after tonsillectomy. Acta Otolaryngol. 2014;134(1):79–87. https://doi.org/10.3109/00016489.2013.831477.

    Article  CAS  PubMed  Google Scholar 

  41. Muto M, Ohmura A, Hamamoto Y, Konishi Y, Shiozawa S, Youn JI, et al. Generalized pustular psoriasis: strategy for identification of psoriasis susceptibility gene. Arch Dermatol Res. 2003;295(Suppl 1):S60–2. https://doi.org/10.1007/s00403-002-0373-4.

    Article  PubMed  Google Scholar 

  42. Marrakchi S, Guigue P, Renshaw BR, Puel A, Pei XY, Fraitag S, et al. Interleukin-36-receptor antagonist deficiency and generalized pustular psoriasis. N Engl J Med. 2011;365(7):620–8. https://doi.org/10.1056/NEJMoa1013068.

    Article  CAS  PubMed  Google Scholar 

  43. Cheung MS, Theodoropoulou K, Lugrin J, Martinon F, Busso N, Hofer M. Periodic fever with aphthous stomatitis, pharyngitis, and cervical adenitis syndrome is associated with a CARD8 variant unable to bind the NLRP3 Inflammasome. J Immunol. 2017;198(5):2063–9. https://doi.org/10.4049/jimmunol.1600760.

    Article  CAS  PubMed  Google Scholar 

  44. Sangiorgi E, Azzara A, Molinario C, Pietrobono R, Rigante D, Verrecchia E, et al. Rare missense variants in the ALPK1 gene may predispose to periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome. Eur J Hum Genet. 2019;27:1361–8. https://doi.org/10.1038/s41431-019-0421-6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. St John MA, Li Y, Zhou X, Denny P, Ho CM, Montemagno C, et al. Interleukin 6 and interleukin 8 as potential biomarkers for oral cavity and oropharyngeal squamous cell carcinoma. Arch Otolaryngol Head Neck Surg. 2004;130(8):929–35. https://doi.org/10.1001/archotol.130.8.929.

    Article  PubMed  Google Scholar 

  46. La Fratta I, Tatangelo R, Campagna G, Rizzuto A, Franceschelli S, Ferrone A, et al. The plasmatic and salivary levels of IL-1beta, IL-18 and IL-6 are associated to emotional difference during stress in young male. Sci Rep. 2018;8(1):3031. https://doi.org/10.1038/s41598-018-21474-y.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Riis JL, Granger DA, DiPietro JA, Bandeen-Roche K, Johnson SB. Salivary cytokines as a minimally-invasive measure of immune functioning in young children: correlates of individual differences and sensitivity to laboratory stress. Dev Psychobiol. 2015;57(2):153–67. https://doi.org/10.1002/dev.21271.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

The authors would like to acknowledge Dr. Hal M. Hoffman (University of California, San Diego) for helpful discussion, and the patients and families who participated.

Funding

This work was supported by National Institutes of Health 1K08HD075830-01A1 (L.B.), Thrasher Research Fund (L.B.), The Hartwell Foundation (L.B), and A.P. Giannini (L.B.).

Author information

Author notes

  1. Irene Luu and Anukriti Sharma contributed equally to this work.

Authors and Affiliations

  1. Department of Pediatrics, Division of Allergy, Immunology and Kawasaki Disease, University of California San Diego, La Jolla, CA, USA

    Irene Luu, Marisela Guaderrama, Michelle Peru & Lori Broderick

  2. Department of Pediatrics and Scripps Institution of Oceanography, University of California San Diego, La Jolla, CA, USA

    Anukriti Sharma & Jack A. Gilbert

  3. Rady Children’s Foundation, Rady Children’s Hospital, San Diego, San Diego, CA, 92123, USA

    Javan Nation, Nathan Page, Daniela Carvalho, Anthony Magit, Wen Jiang, Shelby Leuin, Morgan Bliss, Marcella Bothwell, Matthew Brigger, Donald Kearns, Seth Pransky & Lori Broderick

  4. Department of Surgery, Division of Otolaryngology, University of California San Diego, La Jolla, CA, USA

    Javan Nation, Nathan Page, Daniela Carvalho, Anthony Magit, Wen Jiang, Shelby Leuin, Morgan Bliss, Marcella Bothwell, Matthew Brigger, Donald Kearns & Seth Pransky

  5. Department of Pathology, University of California San Diego, La Jolla, CA, 92093, USA

    Robert Newbury

Authors
  1. Irene Luu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anukriti Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marisela Guaderrama
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michelle Peru
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Javan Nation
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Nathan Page
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Daniela Carvalho
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Anthony Magit
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Wen Jiang
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Shelby Leuin
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Morgan Bliss
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Marcella Bothwell
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Matthew Brigger
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Donald Kearns
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Robert Newbury
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Seth Pransky
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Jack A. Gilbert
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. Lori Broderick
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception, design, and execution. Patient recruitment and securing of clinical material were performed by Javan Nation, Nathan Page, Daniela Carvalho, Anthony Magit, Wen Jiang, Shelby Leuin, Morgan Bliss, Marcella Bothwell, Matthew Brigger, Donald Kearns, Robert Newbury, Seth Pransky, and Lori Broderick. Ex vivo and in vitro experiments were performed by Lori Broderick, Irene Luu, and Marisela Guaderrama. Data collection and analysis were performed by Lori Broderick, Irene Luu, and Michelle Peru. Microbiome analysis was performed by Anukriti Sharma and Jack Gilbert. The first draft of the manuscript was written by Lori Broderick and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Lori Broderick.

Ethics declarations

Conflict of Interest

L.B. is a speaker for Novartis, Inc., and has an ongoing research collaboration with Regeneron, Inc. The other authors declare no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the UCSD Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Dr. Pransky is now affiliated with Pediatric Specialty Partners, La Jolla, CA

Electronic supplementary material

ESM 1

(DOCX 113 kb)

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Luu, I., Sharma, A., Guaderrama, M. et al. Immune Dysregulation in the Tonsillar Microenvironment of Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA) Syndrome. J Clin Immunol 40, 179–190 (2020). https://doi.org/10.1007/s10875-019-00724-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10875-019-00724-2

Keywords

search

Navigation