POS1294 EFFECT OF EMOTIONAL TRIGGERS ON THE FREQUENCY OF PFAPA ATTACKS - A MULTICENTER STUDY
Authors: Y. Levinsky, Y. Butbul, M. Gafner, M. Broide, S. Kagan, R. Tal, M. Natur, K. Kaidar, N. Dagan, G. Amarilyo, L. Harel
Journal: Annals of the Rheumatic Diseases (2021)

Background: The fact that mental state may serve as a trigger for attacks of periodic fever diseases is known in Familial Mediterranean fever (FMF). There is a lack of information regarding the role of emotional triggers for PFAPA attacks. Objectives: To examine whether emotional distress may trigger PFAPA attacks. Methods: Enrolled were patients with active PFAPA, from two Israeli medical centers. Researchers contacted their parents by phone in two occasions: a. within the two weeks of returning to school after the first COCID-19 lockdown; b. during the summer vacation (i.e., non-stressful period). Parents were asked regarding the occurrence of PFAPA attacks within the two weeks preceding the calls. The relative stress levels of the two periods were validated by an emotional distress scale questionnaire. Differences between occurrences of attacks during these two periods of time were recorded. Results: One-hundred and six pediatric patients enrolled in the study. Mean age was 7.37± 2.9. In the stressful period, 41 (38.7%) reported at least one attack during the preceding 2 weeks, compared to 24 (22.6%) in the non-stressful period (p = 0.017). Scores for the mean emotional distress questionnaire were higher in the stressful period compared to the non-stressful period (35.6± 8.1 vs. 32.1± 7.7, respectively, P = 0.047). Conclusion: This study shows that during a period of stress for children there were more PFAPA attacks compared to a relaxed period. These findings indicate that mental factors such as stress or excitement may be triggers for PFAPA attacks. Table 1. Attacks status during prior 2 weeks during stressful or non-stressful event Outcome First call (May 2020) Second call (August 2020) P-value Pediatric emotional distress score (PEDS), mean (±SD) 35.6 (±8.1) 32.1 (±7.7) 0.047 Any attacks during last 2 week, n (%) 41 (39.8%) 24 (24.2%) 0.017 Number of attacks 0.04 One, n (%) 27 (25.5%) 19 (17.9%) Two, n (%) 14 (13.2%) 5 (4.7%) References: [1]Marshall GS, Edwards KM, Butler J, Lawton AR. Syndrome of periodic fever, pharyngitis, and aphthous stomatitis. J Pediatr. 1987;110(1):43-46. doi:10.1016/S0022-3476(87)80285-8 [2]Feder HM, Salazar JC. A clinical review of 105 patients with PFAPA (a periodic fever syndrome). Acta Paediatr Int J Paediatr . 2010;99(2):178-184. doi:10.1111/j.1651-2227.2009.01554.x [3]Hall, J, Lindorff A. Children’s Transition to School: Relationships Between Preschool Attendance, Cortisol Patterns, and Effortful Control. The Educational and Developmental Psychologist. Educ Dev Psychol . 2017;34(1):1-18 [4]Stokes SJ, Saylor CF, Swenson CC, Daugherty TK. A comparison of children’s behaviors following three types of stressors. Child Psychiatry Hum Dev. 1995;26(2):113-123. doi:10.1007/BF02353235 [5]Førsvoll J, Kristoffersen EK, Øymar K. The immunology of the periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome; what can the tonsils reveal. A literature review. Int J Pediatr Otorhinolaryngol . 2020;130. doi:10.1016/j.ijporl.2019.109795 [6]Gidron Y, Berkovitch M, Press J. Psychosocial correlates of incidence of attacks in children with Familial Mediterranean Fever. J Behav Med . 2003;26(2):95-104. doi:10.1023/A:1023038504481 [7]Makay B, Emiroğlu N, Ünsal E. Depression and anxiety in children and adolescents with familial Mediterranean fever. Clin Rheumatol . 2010;29(4):375-379. doi:10.1007/s10067-009-1330-9 [8]Kraszewska-Głomba B, Matkowska-Kocjan A, Szenborn L. The Pathogenesis of Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome: A Review of Current Research. Mediators Inflamm 2015;2015:563876. doi:10.1155/2015/563876 Disclosure of Interests: None declared