Adult Summary Report

Secondary Findings in Adult Subjects

Non-diagnostic, excludes newborn screening & prenatal testing/screening

• Status (Adult): Passed (Consensus scoring is Complete)
• Curation Status (Adult): Released 1.0.1
• GENE/GENE PANEL: MEFV
• Condition: Familial Mediterranean Fever (AD)
• Mode(s) of Inheritance: Autosomal Dominant

Actionability Assertion

• MEFV ⇔ 134610: Assertion Pending

Actionability Rationale

This topic was initially scored prior to development of the process for making actionability assertions. The Actionability Working Group decided to defer making an assertion until after the topic could be reviewed through the update process.

Final Consensus Scores

Outcome / Intervention Pair	Severity	Likelihood	Effectiveness	Nature of the Intervention	Total Score
Recurrent serositis / Colchicine	1	0D	3C	2	6DC
Amyloidosis / Colchicine	1	0D	3C	2	6DC
Joint problems / Colchicine	1	0D	3C	2	6DC

1. What is the nature of the threat to health for an individual carrying a deleterious allele?

Prevalence of the Genetic Condition

Familial Mediterranean Fever (FMF) predominantly affects populations living in the southeastern Mediterranean region. Populations having a high prevalence (1/200-1/1000) include non-Ashkenazi Jews, Armenians, Turks, and Arabs. FMF is also seen in many other countries, although in much lower numbers. However, the proportion of cases attributed to a single MEFV pathogenic variant is unknown. [1, 2, 3, 4]

Clinical Features

FMF is an autoinflammatory fever syndrome characterized by recurrent short episodes of inflammation and serositis including fever, peritonitis, synovitis, pleuritic, and, rarely, pericarditis and meningitis. Attacks can vary in frequency (as often as once a week or every few years), typically last 1-4 days, and resolve spontaneously. Mild symptoms (myalgia, headache, nausea, dyspnea, arthralgia, low back pain, asthenia and anxiety) precede attacks and last about 17 hours in approximately 50% of patients. Attacks manifest as fever, diffuse or localized abdominal pain, constipation or diarrhea, arthralgias (in large joints), arthritis (in upper/lower limb/knee joints) chest pain caused by pleuritis and/or pericarditis, and skin eruption. Joint attacks can result in severe damage to the joint and permanent deformity may require joint replacement. The main long-term complication is amyloid A (AA) amyloidosis, which is common in untreated individuals, can lead to renal failure, and has a poor prognosis. Untreated individuals with FMF, especially those with multiple attacks and/or amyloidosis, are at higher risk for infertility.
Heterozygotes are typically asymptomatic, though some manifest a spectrum of findings from classic to mild FMF. Clinical features in individuals with a single pathogenic MEFV mutation are typically milder and the attacks shorter and less frequent than patients with two MEFV mutations. Most patients have an incomplete abdominal attack as the major criterion of the disease. Patients manifest mainly fever and abdominal symptoms. [1, 3, 4]

Natural History

Younger children with a single pathogenic variant and symptoms of recurrent autoinflammatory disorder have a milder disease course compared to individuals with biallelic pathogenic variations, with no major differences in presenting signs. However, clinical signs have been reported to completely disappear at puberty in some cases, indicating that a single pathogenic variant may not necessarily predict lifelong illness. [4]

2. How effective are interventions for preventing harm?

Patient Management

To establish the extent of disease and needs in an individual diagnosed with FMF, the following evaluations are recommended:
• Physical examination to assess joint problems
• Urinalysis for the presence of protein. If proteinuria is found, further evaluation is required, including 24-hour urinary protein assay and renal function tests, and also, if indicated, rectal biopsy for the presence of amyloid.
• Medical genetics consultation. (Tier 4) [4]

The presence of a single MEFV pathogenic variant together with clinical symptoms is sufficient to warrant the initiation of a trial of colchicine. Therefore, manifesting heterozygotes should be treated. However, since the natural history and outcome for persons with FMF who are heterozygous for a single MEFV pathogenic variant are unknown, there is no recommendation of lifelong treatment with colchicine for this group. A report of clinical diagnosed FMF patients with a single MEFV variation indicated that 21 of 25 (84%) either completely or partially responded to colchicine therapy. A second report of 94 heterozygous patients with recurrent fever indicated that 82% required colchicine treatment, which was effective in over 90%. (Tier 3) [4]

Surveillance

No recommendations specific to surveillance in heterozygous patients were identified. The following recommendations are made generally about FMF patients.
All individuals with FMF, including those not currently being treated, those being treated with colchicine, and those receiving medication other than colchicine should undergo an annual physical examination, a urine spot test for protein, and an evaluation for hematuria. (Tier 3) [4]

Monitoring of acute-phase reactants (ESR and fibrinogen levels) at regular intervals during attack-free periods is recommended, particularly in those with the M694V variant. (Tier 3) [4]

Circumstances to Avoid

A single report has suggested that cisplatin worsens symptoms of FMF. (Tier 3) [4]

Cyclosporin appears to adversely affect renal transplant graft survival in individuals with FMF. It has also been reported to trigger FMF attacks, which responded well to colchicine in a previously asymptomatic individual with myelodysplastic syndrome who was heterozygous for the MEFV pathogenic variant M694I. (Tier 3) [4]

3. What is the chance that this threat will materialize?

Mode of Inheritance

Autosomal Dominant
FMF is usually inherited in an autosomal recessive manner, although recent studies have suggested that some heterozygotes manifest a spectrum of findings from classic to mild FMF. [4]

Prevalence of Genetic Variants

No information on the frequency of MEFV mutations in the general population was identified.
The pathogenic variant A2080G is found in more than 90% of affected Jewish persons of North African origin. (Tier 4) [4]

About 85% of patients of Mediterranean origin that meet clinical criteria have a mutation in both copies of the MEFV gene, with only one mutation identified in about 20% of affected cases. (Tier 3) [2]

Penetrance

Information on the penetrance among patients who have a single pathogenic MEFV variant was not identified.

Relative Risk

Information on relative risk was not identified.

Expressivity

Symptoms and severity vary among affected individuals, even among members of the same family suggesting that manifestations are also influenced by other genes and/or environmental factors. (Tier 4) [4]

4. What is the Nature of the Intervention?

Nature of Intervention

Colchicine toxicity is a serious complication that should be given adequate consideration and be prevented. Colchicine is an alkaloid with a narrow therapeutic range. High concentrations may cause serious toxicity that can be life threatening. Complications of cholchicine use occasionally include myopathy and toxic epidermal necrolysis-like reaction. Colchicine treatment may induce oligospermia/azoospermia. Other identified interventions include blood and urine tests, associated with low burden and risk. [4, 5]

5. Would the underlying risk or condition escape detection prior to harm in the setting of recommended care?

Chance to Escape Clinical Detection

Symptoms associated with FMF (e.g., fever, pain) are not specific and may not direct the correct diagnosis.

Date of Search: 05.23.2016

Reference List

1. Giancane G, Ter Haar NM, Wulffraat N, Vastert SJ, Barron K, Hentgen V, Kallinich T, Ozdogan H, Anton J, Brogan P, Cantarini L, Frenkel J, Galeotti C, Gattorno M, Grateau G, Hofer M, Kone-Paut I, Kuemmerle-Deschner J, Lachmann HJ, Simon A, Demirkaya E, Feldman B, Uziel Y, Ozen S. Evidence-based recommendations for genetic diagnosis of familial Mediterranean fever. Ann Rheum Dis. (2015) 74(4):635-41.

2. Witsch-Baumgartner M, Touitou I. Clinical utility gene card for: prototypic hereditary recurrent fever syndromes (monogenic autoinflammatory syndromes). Eur J Hum Genet. (2015) 23(8).

3. Familial Mediterranean fever. Orphanet encyclopedia, http://www.orpha.net/consor/cgi-bin/OC_Exp.php?lng=en&Expert=342

4. M Shohat. Familial Mediterranean Fever. 2000 Aug 08 [Updated 2016 Dec 15]. In: RA Pagon, MP Adam, HH Ardinger, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2024. Available from: http://www.ncbi.nlm.nih.gov/books/NBK1227

5. Ozen S, Demirkaya E, Erer B, Livneh A, Ben-Chetrit E, Giancane G, Ozdogan H, Abu I, Gattorno M, Hawkins PN, Yuce S, Kallinich T, Bilginer Y, Kastner D, Carmona L. EULAR recommendations for the management of familial Mediterranean fever. Ann Rheum Dis. (2016) 75(4):644-51.