Open Access

Familial Mediterranean fever is no longer a rare disease in Japan

  • Kiyoshi Migita1, 2Email author,
  • Yasumori Izumi2,
  • Yuka Jiuchi2,
  • Nozomi Iwanaga2,
  • Chieko Kawahara1,
  • Kazunaga Agematsu3,
  • Akihiro Yachie4,
  • Junya Masumoto5,
  • Keita Fujikawa6,
  • Satoshi Yamasaki7,
  • Tadashi Nakamura8,
  • Yoshifumi Ubara9,
  • Tomohiro Koga10,
  • Yoshikazu Nakashima10,
  • Toshimasa Shimizu10,
  • Masataka Umeda10,
  • Fumiaki Nonaka11,
  • Michio Yasunami12,
  • Katsumi Eguchi13,
  • Koh-ichiro Yoshiura14 and
  • Atsushi Kawakami10
Arthritis Research & Therapy201618:175

https://doi.org/10.1186/s13075-016-1071-5

Received: 15 April 2016

Accepted: 4 July 2016

Published: 30 July 2016

Abstract

Background

The aim of this study was to evaluate the clinical manifestations and prevalence of familial Mediterranean fever (FMF) in Japanese patients with unexplained fever and rheumatic manifestations.

Methods

We enrolled 601 patients with unexplained fever or suspected FMF throughout Japan between 2009 and 2015. Patients were divided into three groups according to Tel Hashomer criteria: sure FMF, probable FMF, and non-FMF patients, including definitive rheumatic diseases. Mutation detection in exons 1, 2, 3, and 10 of the FMF gene MEFV was performed by direct sequencing.

Results

A total of 192 patients (31.9 %) were diagnosed with FMF according to FMF diagnostic criteria. These could be divided into sure FMF (56.3 %, n = 108) and probable FMF (43.7 %, n = 84) patients. Fever, abdominal symptoms, and thoracic symptoms were significantly more common in FMF than non-FMF patients. Among FMF patients, 26 (13.5 %) had concomitant rheumatic diseases. Most FMF patients (94.3 %, 181/192) carried at least one MEFV mutation. Allele frequencies of M694I (13.5 % vs 0 %) and E148Q (39.1 % vs 24.8 %) mutations were significantly higher in FMF compared with healthy subjects. Allele frequencies of common MEFV mutations in FMF patients were M694I (13.5 %), P369S (8.6 %), R408Q (8.1 %), G304R (2.9 %), R202Q (4.4 %), E148Q (39.1 %), L110P (11.7 %), and E84K (3.1 %). Patients with a sure FMF phenotype had a higher frequency of MEFV exon 10 mutation (M694I) and a lower frequency of MEFV exon 3 mutations (P369S, R408Q) compared with those with a probable FMF phenotype.

Conclusion

The high prevalence of FMF in Japanese patients with unexplained fever was confirmed in the present study. FMF should be suspected in cases of unexplained fever or non-specific rheumatic manifestations, and mutational analysis of MEFV could be useful to predict the clinical phenotypes of FMF in Japan.

Keywords

Familial Mediterranean fever MEFV gene Rheumatic manifestations

Background

Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterized by short, recurrent bouts of fever [1]. The recurrent episodes of fever and systemic inflammation, which last a few days and commonly appear during pre-adolescence, are accompanied by peritonitis, arthritis, pleurisy, and skin manifestations [2]. FMF diagnosis is difficult because of the lack of specific clinical signs. It is prevalent in Mediterranean and Middle Eastern populations [3], where clinical diagnosis has been prompt, but non-Mediterranean FMF patients have also been reported [4]. Although considered a rare disease, it is possible that its diagnosis has been delayed in some countries such as Japan [5].

Molecular genetic diagnostic testing is often used to provide some information on FMF diagnosis [6]. However, a crucial issue for genetic counseling is that some patients presenting with manifestations of sure FMF are heterozygotes of MEFV variants [7]. The identification of double MEFV mutations in patients with FMF symptoms confirms the disease analysis, but it is not uncommon for no mutated alleles or only a single mutated allele to be detected, even in Mediterranean FMF patients [8]. Moreover, in Japanese FMF patients, MEFV exon 10 mutations are usually associated with sure disease phenotypes, even in heterozygous carriage [9]. A high proportion of asymptomatic carriers of MEFV exon 2 or 3 variants is also observed [10, 11].

This observational study was performed to determine the actual prevalence of FMF in Japanese patients with unexplained fever and to elucidate its clinical characteristics. We also analyzed the implications of these MEFV variants on the clinical picture of Japanese patients with unexplained fever or non-specific rheumatic manifestations.

Methods

Design, setting, patients, and measurements

The study was conducted at the Clinical Research Center of Nagasaki Medical Center, Japan. Patients with unexplained fever were recruited consecutively from those treated and followed up in the rheumatology department of participating hospitals. Unexplained fever was defined as a temperature above 38 °C that lasts for 3 weeks including recurrent episodes of fever without diagnosis after standardized history-taking, physical examination, and obligatory investigation. These subjects included the newly diagnosed FMF patients in the previously performed multi-centric survey for FMF [12]. The study comprised 601 patients (216 males, 385 females, mean age 44.3 ± 20.2 years). On the basis of Tel Hashomer criteria [13], patients were divided into three groups: sure FMF—certain clinical diagnosis in the presence of two major criteria or one major and two minor criteria; probable FMF—clinical diagnosis considered probable in the presence of one major and one minor criterion or two minor criteria; and non-FMF—clinical diagnosis considered unlikely in the presence of only one minor and no major criteria. Clinical manifestations of FMF, including characteristics of febrile episodes (duration and frequency), and the presence of serositis (chest or abdominal pain), arthritis, myalgia, and erysipelas-like rash was documented. Demographic data (including gender, consanguinity of parents, familial history, and age of onset of inflammation signs) and main clinical data (including fever, thoracic, abdominal, articular, cutaneous signs, duration and frequency of episodes, presence of amyloidosis, and response to colchicine) were recorded by the doctor using a standard form. Response to colchicine was defined as complete, incomplete, or absent.

Mutational analysis

Blood samples (2 ml) were collected from all subjects. Genomic DNA was extracted from whole blood using the Wizard® Genomic DNA Purification Kit (Promega, USA). Mutational analysis was performed by direct DNA sequencing. Polymerase chain reaction (PCR) amplification was performed for each MEFV exon, as described previously [9]. A total of 27 PCR products per patient were purified using ExoSAP-IT (GE Healthcare Japan, Tokyo, Japan) and sequenced directly using specific primers and BigDye Terminator v1.1 (Applied Biosystems, Tokyo, Japan). The control group for MEFV genotyping consisted of 105 gender-matched Japanese healthy subjects (44 men and 61 women). The mean ± SD age was 44.2 ± 11.5 years.

Statistical analyses

Data were analyzed using SPSS software (SPSS Inc., Chicago, IL, USA). Results were expressed as the mean ± standard deviation (SD) for continuous variables. For quantitative data, the Mann–Whitney U rank-sum test compared two independent groups. Comparisons for categorical variables were evaluated using the chi-square test (or Fisher’s exact test when appropriate). Adjustment for multiple comparisons was performed using the Bonferroni method. Pc values were calculated by multiplying the p value by the number of alleles tested.

Results

Patient demographic data

Ten patients were excluded from the study (Fig. 1). The main reasons for exclusion were the absence of periodic fever syndrome (drug fever, infections, and neoplastic diseases). At the time of analysis, the mean patient age was 44.3 ± 20.2 years (range 0–94 years) and the mean age of the onset of symptoms was 36.3 ± 19.7 years (range 1–94 years). The main clinical characteristics of the 601 patients were as follows: 385 patients were female (64.1 %), fever was observed in 482 (80.2 %), abdominal symptoms in 163 (27.1 %), thoracic signs in 75 (12.5 %), arthritis signs in 345 (57.4 %), and amyloidosis in 22 (3.7 %). On the basis of Tel Hashomer criteria, 192 patients (31.9 %) were diagnosed with FMF, of whom 108 had typical FMF (56.3 %) and 84 had incomplete FMF (43.7 %). The remaining 409 patients (68.1 %) were classified as non-FMF patients, including two patients with suspected tumor necrosis factor receptor associated periodic syndrome (TRAPS) and two patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome (PFAPA) (Fig. 1). As shown in Fig. 1, among non-FMF patients, 118 patients had established rheumatic diseases (rheumatoid arthritis, n = 35; systemic lupus erythematosus, n = 19; Behçet's disease, n = 17; gout, n = 12; inflammatory myopathies, n = 7; mixed connective-tissue disease, n = 4; psoriatic arthritis, n = 4; remitting seronegative symmetrical synovitis with pitting edema, n = 3; Henoch-Schonlein purpura, n = 3; vasculitis syndrome, n = 3; SAPHO syndrome, n = 2; palindromic rheumatism, n = 2; Sjögren's syndrome, n = 2; Reiter's syndrome, n = 1; Crowned dens syndrome, n = 1; relapsing polychondritis, n = 1; spondylarthritis, n = 1; systemic sclerosis, n = 1). Additionally, among non-FMF patients, 68 patients were finally diagnosed as having rheumatic diseases (Behçet's disease, n = 11; rheumatoid arthritis, n = 9; inflammatory myopathies, n = 7; vasculitis syndrome, n = 7; Sjögren's syndrome, n = 6; systemic lupus erythematosus, n = 6; palindromic rheumatism, n = 5; mixed connective-tissue disease, n = 4; gout, n = 3; CREST syndrome, n = 2; ankylosing spondylitis, n = 2; adult onset Still's disease, n = 1; Caplan's syndrome, n = 1; IgG4-related disease, n = 1; SAPHO syndrome, n = 1; psoriatic arthritis, n = 1; eosinophilic fasciitis, n = 1). Among the remaining non-FMF patients, 37 patients were finally diagnosed with non-rheumatic diseases (amyloidosis, n = 5; myelodysplastic syndromes, n = 4; Castleman's disease, n = 4; undifferentiated arthritis, n = 3; viral infection, n = 3; Sweet's disease, n = 2; Kikuchi's disease, n = 2; hemophagocytic syndrome, n = 2; chronic thyroiditis, n = 2; idiopathic thrombocytopenic purpura, n = 1; alcoholic hepatitis, n = 1; Wilson's disease, n = 1; cryoglobulinemia, n = 1; Crohn's disease, n = 1; recurrent stomatitis, n = 1; malignant lymphoma, n = 1; reactive lymphadenitis, n = 1; non-tuberculous mycobacterial disease, n = 1; interstitial nephritis, n = 1).
Fig. 1

Flow diagram of patient enrollment

FMF patients had a shorter duration of febrile attack and higher frequencies of abdominal or thoracic symptoms and family history of periodic fever (Table 1). Colchicine was administered to 300 patients (sure FMF, 86.1 %; probable FMF, 95.2 %; non-FMF patients, 31.1 %), and the response was higher in patients with typical FMF (97.8 %) compared with those in the other groups (non-FMF, 64.6 %). The response rates for colchicine treatment were not significantly different between subgroups of FMF classified by MEFV mutations (Table 2).
Table 1

Comparisons of clinical features of between FMF and non-FMF

 

FMF

Non-FMF

 
 

n = 192

n = 409

p

Male/female

83/109

133/276

0.011

Age at onset (years), mean ± SD

30.4 ± 39.4

39.4 ± 20.3

<0.0001

Fever

184 (95.8 %)

298 (72.9 %)

<0.0001

Frequencies of febrile attack (per month), mean ± SD

1.06 ± 0.92

0.97 ± 1.11

0.020

Duration of fever attack (days), mean ± SD

3.7 ± 4.0

6.7 ± 8.4

0.001

Abdominal pain

77 (40.1 %)

86 (21.0 %)

<0.0001

Thoracic pain

51 (26.6 %)

24 (5.9 %)

<0.0001

Arthritis

108 (56.3 %)

237 (57.9 %)

0.695

Erysipelas-like erythema

34 (17.7 %)

43 (10.5 %)

0.014

AA amyloidosis

7 (3.6 %)

15 (3.7 %)

0.989

Family history of periodic fever

39 (20.3 %)

25 (6.1 %)

<0.0001

Rheumatic diseases

26 (13.5 %)

186 (45.5 %)

<0.0001

Values are shown as n (%) unless otherwise indicated. AA amyloid A, FMF familial Mediterranean fever

Table 2

Clinical response to colchicine in FMF patients

Subgroups

Response rate

p

Sure

vs

Probable

91/93 (97.8 %)

74/80 (92.5 %)

0.095

(0.82 ± 0.40)*

 

(0.84 ± 0.54)*

   

MEFV mutations (+)

vs

MEFV mutations (–)

154/162 (95.1 %)

11/11 (100 %)

0.585

M694I (+)

vs

M694I (–)

36/37 (97.3 %)

129/136 (94.9 %)

0.459

E148Q (+)

vs

E148Q (–)

109/115 (94.8 %)

56/58 (96.6 %)

0.461

Rheumatic diseases (+)

vs

Rheumatic diseases (–)

23/23 (100 %)

142/150 (94.7 %)

0.311

*Mean dose of colchicine, mg/day. FMF familial Mediterranean fever

Clinical manifestations in FMF patients

As shown in Table 3, short durations of fever, and thoracic and abdominal symptoms were more frequently observed in sure FMF patients (2.2 ± 0.8 days) compared with probable FMF patients (6.2 ± 5.5 days). Conversely, arthritis was more frequently observed in probable FMF patients compared with sure FMF patients. Among FMF patients, 7 (3.6 %) had biopsy-proven amyloid A (AA) amyloidosis (sure FMF, n = 6; probable FMF, n = 1). Among non-FMF patients, 15 patients had AA amyloidosis and primary diseases were rheumatoid arthritis (n = 10) and Crohn's disease (n = 1), whereas primary diseases were not identified in four patients. The allele frequencies of MEFV mutations between AA amyloidosis patients with or without FMF are shown in Table 4. Only the allelic frequency of M694I was significantly higher in FMF patients with AA amyloidosis.
Table 3

Comparisons of clinical features of patients with different FMF phenotypes

 

Sure FMF

Probable FMF

 
 

n = 108

n = 84

p

Male/female

51/57

32/52

0.205

Age at onset (years), mean ± SD

30.5 ± 17.4

30.3 ± 16.6

0.939

Fever

108 (100 %)

76 (90.5 %)

0.001

Frequencies of febrile attack (per month), mean ± SD

1.11 ± 0.93

0.98 ± 0.90

0.309

Duration of fever attack (days), mean ± SD

2.2 ± 0.8

6.2 ± 5.5

<0.0001

Abdominal pain

54 (50.0 %)

23 (27.4 %)

0.002

Thoracic pain

33 (30.6 %)

18 (21.4 %)

0.155

Arthritis

53 (49.1 %)

55 (65.5 %)

0.023

Erysipelas-like erythema

15 (13.9 %)

19 (22.6 %)

0.116

AA amyloidosis

6 (5.6 %)

1 (1.2 %)

0.110

Family history of periodic fever

26 (24.1 %)

13 (15.5 %)

0.142

Rheumatic diseases

14 (13.0 %)

12 (14.3 %)

0.790

Values are shown as n (%) unless otherwise indicated. AA amyloid A, FMF familial Mediterranean fever

Table 4

Allelic frequencies of MEFV mutations of AA amyloidosis patients with or without FMF

  

AA amyloidosis

 
  

FMF

Non-FMF

 
  

2n = 14

2n = 30

p

Exon10

M694I

8 (57.1 %)

0

<0.0001

Exon3

R408Q

1 (7.1 %)

0

0.318

 

P369S

1 (7.1 %)

0

0.318

Exon2

G304R

0

1 (3.3 %)

0.682

 

R202Q

1 (7.1 %)

0

0.318

 

E148Q

5 (35.7 %)

5 (16.7 %)

0.1540

 

L110P

3 (21.4 %)

2 (6.7 %)

0.175

Exon1

E84K

0

1 (3.3 %)

0.682

Values are shown as n (%). Primary diseases of amyloid A (AA) amyloidosis in non-familial Mediterranean fever (FMF) were rheumatoid arthritis (n = 10) and Crohn's disease (n = 1)

For the sure FMF patients, 13.0 % (14/108) had concomitant rheumatic diseases (rheumatoid arthritis, n = 6; Sjögren's syndrome, n = 3; dermatomyositis complex, n = 2; Behçet's disease, n = 1; adult onset Still's disease, n = 1; Kawasaki disease, n = 1). In the probable FMF patients, 14.3 % (12/84) had concomitant rheumatic diseases (systemic lupus erythematosus, n = 4; Sjögren's syndrome, n = 3; rheumatoid arthritis, n = 2; Behçet's disease, n = 1; palindromic rheumatism, n = 1; polymyositis, n = 1).

FMF patients with rheumatic diseases had a higher frequency of arthritis episodes and an elderly onset of FMF. Conversely, FMF patients without rheumatic diseases had a higher frequency of abdominal pain and family history of FMF (Table 5). No significant difference was observed in the allele frequencies in MEFV mutations between FMF patients with or without rheumatic diseases (Table 6).
Table 5

Comparisons of clinical features of patients with or without accompanying rheumatic diseases

 

FMF

 
 

Rheumatic diseases (+)

Rheumatic diseases (–)

 
 

n = 26

n = 166

p

Male/female

4/22

79/87

0.002

Age at onset (years), mean ± SD

39.3 ± 15.8

29.0 ± 16.8

0.006

Fever

24 (92.3 %)

160 (96.4 %)

0.296

Frequencies of febrile attack (per month), mean ± SD

1.01 ± 0.59

1.06 ± 0.96

0.523

Duration of fever attack (days), mean ± SD

3.0 ± 2.2

3.8 ± 4.1

0.359

Abdominal pain

3 (11.5 %)

74 (44.6 %)

0.001

Thoracic pain

4 (15.4 %)

47 (28.3 %)

0.165

Arthritis

21 (80.8 %)

87 (52.4 %)

0.007

Erysipelas-like erythema

3 (11.5 %)

31 (18.7 %)

0.281

AA amyloidosis

0

7 (4.2 %)

0.355

Family history of periodic fever

1 (3.8 %)

38 (22.9 %)

0.025

Values are shown as n (%) unless otherwise indicated. AA amyloid A, FMF familial Mediterranean fever

Table 6

Comparisons of allelic frequencies of MEFV mutations of FMF patients with or without accompanying rheumatic diseases

  

FMF

  
  

Rheumatic diseases (+)

Rheumatic diseases (–)

  
  

2n = 52

2n = 332

p

pc

Exon10

M694I

4 (7.7 %) [1/26 (3.8 %)]

48 (14.5 %) [4/166 (2.4 %)]

0.185

2.7738

 

P751L

0

1 (0.3 %)

0.865

12.9687

 

G632S

0

1 (0.3 %)

0.865

12.9687

Exon3

R410H

0

1 (0.3 %)

0.865

12.9687

 

R408Q

8 (15.4 %) [2/26 (7.7 %)]

23 (6.9 %) [0/166 (0 %)]

0.043

0.6419

 

P369S

8 (15.4 %) [2/26 (7.7 %)]

25 (7.5 %) [0/166 (0 %)]

0.060

0.9050

 

R354Q

0

1 (0.3 %)

0.865

12.9687

Exon2

G304R

3 (5.8 %) [0/26 (0 %)]

8 (2.4 %) [1/166 (0.6 %)]

0.176

2.6382

 

E225K

0

1 (0.3 %)

0.865

12.9687

 

R202Q

3 (5.8 %)

14 (4.2 %)

0.411

6.1680

 

E148Q

23 (44.2 %) [4/26 (15.4 %)]

127 (38.3 %) [19/166 (11.4 %)]

0.411

6.1702

 

P115R

0

0

  
 

L110P

8 (15.4 %) [0/26 (0 %)]

37 (11.1 %) [1/166 (0.6 %)]

0.377

5.6513

Exon1

E84K

1 (1.9 %)

11 (3.3 %)

0.500

7.4946

 

R80H

0

0

  

Values are shown as n (%) [% of homozygote]. FMF familial Mediterranean fever, pc corrected p value

Allele frequencies of MEFV mutations in FMF and healthy subjects

Distributions of MEFV genotypes in the FMF and non-FMF groups are shown in Table 7. Table 8 shows the allelic frequencies of MEFV mutations in the FMF and non-FMF groups. Most FMF patients (94.3 %, 181/192) carried at least one MEFV mutation. Significant differences were observed between FMF patients and healthy subjects regarding the allelic frequencies of mutations in MEFV exon 2 (E148Q, 39.1 % vs 24.8 %, respectively) and exon 10 (M694I, 13.5 % vs 0 %, respectively). However, there were no significant differences between FMF patients and healthy subjects regarding the allelic frequencies of other mutations (Table 9).
Table 7

MEFV genotypes in FMF or non-FMF patients

 

FMF

Non-FMF

 

Sure

Probable

Newly-diagnosed rheumatic diseases

Established rheumatic diseases

Others

 

n = 108

n = 84

n = 68

n = 118

n = 223

M694I/M694I

5 (4.6 %)

0

0

0

0

M694I/P751L

1 (0.9 %)

0

0

0

0

M694I/E148Q/E148Q

1 (0.9 %)

0

0

0

0

M694I/L110P/E148Q

8 (7.4 %)

0

0

0

0

M694I/E148Q

22 (20.4 %)

0

0

0

0

M694I/normal

10 (9.3 %)

0

0

0

0

G632/E148Q

0

1 (1.2 %)

0

0

0

R354Q/normal

0

1 (1.2 %)

0

0

0

P369S/R408Q

2 (1.9 %)

8 (9.5 %)

2 (2.9 %)

2 (1.7 %)

16 (7.2 %)

G304R/G304R

0

1 (1.2 %)

0

0

0

G304R/P369S/R408Q

0

0

0

0

1 (0.5 %)

G304R/normal

1 (0.9 %)

5 (6.0 %)

1 (1.5 %)

6 (5.1 %)

8 (3.6 %)

R202Q/R202Q

0

0

0

0

1 (0.5 %)

R202Q/P369S/R408Q

1 (0.9 %)

0

0

2 (1.7 %)

0

R202Q/normal

5 (4.6 %)

4 (4.8 %)

4 (5.9 %)

3 (2.5 %)

11 (4.9 %)

E225K/P369S/R408Q

0

1 (1.2 %)

0

0

0

E148Q/E148Q

3 (2.8 %)

4 (4.8 %)

2 (2.9 %)

4 (3.4 %)

2 (0.9 %)

E148Q/G304R/P369S/R408Q

1 (0.9 %)

0

1 (1.5 %)

0

0

E148Q/R202Q/P369S/R408Q

0

2 (2.4 %)

0

0

0

E148Q/R202Q

2 (1.9 %)

0

0

1 (0.9 %)

2 (0.9 %)

E148Q/E148Q/P369S/P369S/R408Q/R408Q

0

1 (1.2 %)

0

0

0

E148Q/E148Q/P369S/R408Q

1 (0.9 %)

2 (2.4 %)

0

0

2 (0.9 %)

E148Q/P369S/P369S/R408Q/R408Q

0

1 (1.2 %)

0

0

1 (0.5 %)

E148Q/P369S/R408Q

3 (2.8 %)

5 (6.0 %)

0

3 (2.5 %)

7 (3.1 %)

E148Q/P369S

0

1 (1.2 %)

0

0

1 (0.5 %)

E148Q/normal

15 (13.9 %)

16 (19.0 %)

10 (14.7 %)

26 (22.0 %)

44 (19.7 %)

P115R/normal

0

0

1 (1.5 %)

1 (0.9 %)

0

L110P/E148Q/E148Q/P369S/R408Q

0

1 (1.2 %)

0

1 (0.9 %)

1 (0.5 %)

L110P/E148Q/E148Q/P369S

0

0

0

1 (0.9 %)

0

L110P/E148Q/R202Q/P369S/R408Q

0

0

0

0

1 (0.5 %)

L110P/E148Q/P369S/R408Q

0

0

1 (1.5 %)

1 (0.9 %)

2 (0.9 %)

L110P/E148Q/P369S

0

1 (1.2 %)

0

0

3 (1.4 %)

L110P/E148Q/G304R

0

1 (1.2 %)

0

0

1 (0.5 %)

L110P/E148Q/R202Q

1 (0.9 %)

2 (2.4 %)

0

0

0

L110P/L110P/E148Q/E148Q

0

0

0

0

1 (0.5 %)

L110P/E148Q/E148Q

3 (2.8 %)

7 (8.3 %)

1 (1.5 %)

1 (0.9 %)

5 (2.2 %)

L110P/L110P/E148Q

1 (0.9 %)

0

0

0

0

L110P/E148Q

13 (12.0 %)

5 (6.0 %)

6 (8.8 %)

13 (11.0 %)

21 (9.4 %)

E84K/L110P/E148Q

0

1 (1.2 %)

0

1 (0.9 %)

0

E84K/G304R

0

1 (1.2 %)

0

0

0

E84K/E148Q

0

2 (2.4 %)

0

0

1 (0.5 %)

E84K/R410H

1 (0.9 %)

0

0

0

1 (0.5 %)

E84K/normal

3 (2.8 %)

4 (4.8 %)

1 (1.5 %)

1 (0.9 %)

6 (2.7 %)

R80H/normal

0

0

0

0

1 (0.5 %)

Normal

5 (4.6 %)

6 (7.1 %)

38 (55.9 %)

51 (43.2 %)

83 (37.2 %)

Values are shown as n (%). FMF familial Mediterranean fever

Table 8

Allele frequencies of MEFV mutations in FMF and non-FMF patients

  

FMF

Non-FMF

 
  

Sure

Probable

Newly-diagnosed rheumatic diseases

Established rheumatic diseases

Others

Healthy subjects

  

2n = 216

2n = 168

2n = 136

2n = 236

2n = 446

2n = 210

Exon10

M694I

52 (24.1 %)

0

0

0

0

0

 

P751L

1 (0.5 %)

0

0

0

0

0

 

G632S

0

1 (0.6 %)

0

0

0

0

Exon3

R410H

1 (0.5 %)

0

0

0

1 (0.2 %)

0

 

R408Q

8 (3.7 %)

23 (13.7 %)

4 (2.9 %)

9 (3.8 %)

32 (7.2 %)

12 (5.7 %)

 

P369S

8 (3.7 %)

25 (14.9 %)

4 (2.9 %)

10 (4.2 %)

36 (8.1 %)

13 (6.2 %)

 

R354Q

0

1 (0.6 %)

0

0

0

0

Exon2

G304R

2 (0.9 %)

9 (5.4 %)

3 (1.8 %)

6 (2.4 %)

10 (2.2 %)

6 (2.9 %)

 

E225K

0

1 (0.6 %)

0

0

0

0

 

R202Q

9 (4.2 %)

8 (4.8 %)

4 (2.9 %)

6 (2.5 %)

16 (3.6 %)

6 (2.9 %)

 

E148Q

82 (38.0 %)

68 (40.5 %)

24 (17.6 %)

59 (25.0 %)

106 (23.8 %)

52 (24.8 %)

 

P115R

0

0

1 (0.7 %)

1 (0.4 %)

0

0

 

L110P

27 (12.5 %)

18 (10.7 %)

8 (5.9 %)

18 (7.6 %)

36 (8.1 %)

15 (7.1 %)

Exon1

E84K

4 (1.9 %)

8 (4.8 %)

1 (0.7 %)

2 (0.8 %)

8 (1.8 %)

2 (1.0 %)

 

R80H

0

0

0

0

1 (0.2 %)

0

Values are shown as n (%). FMF familial Mediterranean fever

Table 9

Comparisons of allelic frequencies of MEFV mutations between FMF and healthy subjects

  

FMF

Healthy subjects

  
  

2n = 384

2n = 210

p

pc

Exon10

M694I

52 (13.5 %)

0

<0.0001

<0.0001

 

P751L

1 (0.3 %)

0

0.646

9.6970

 

G632S

1 (0.3 %)

0

0.646

9.6970

Exon3

R410H

1 (0.3 %)

0

0.646

9.6970

 

R408Q

31 (8.1 %)

12 (5.7 %)

0.289

4.3336

 

P369S

33 (8.6 %)

13 (6.2 %)

0.295

4.4222

 

R354Q

1 (0.3 %)

0

0.646

9.6970

Exon2

G304R

11 (2.9 %)

6 (2.9 %)

0.996

14.9378

 

E225K

1 (0.3 %)

0

0.646

9.6970

 

R202Q

17 (4.4 %)

6 (2.9 %)

0.343

5.1459

 

E148Q

150 (39.1 %)

52 (24.8 %)

0.0004

0.0065

 

P115R

0

0

  
 

L110P

45 (11.7 %)

15 (7.1 %)

0.077

1.1527

Exon1

E84K

12 (3.1 %)

2 (1.0 %)

0.077

1.1610

 

R80H

0

0

  

Values are shown as n (%). FMF familial Mediterranean fever, pc corrected p value

MEFV mutations in FMF patients

Table 10 shows the allelic frequencies of MEFV mutations according to the FMF disease phenotype. Among FMF patients, the allelic frequencies of the MEFV exon 10 mutation (M694I) were significantly higher in sure FMF patients compared with probable FMF patients, while the allelic frequencies of the MEFV exon 3 mutations (P369S, R408Q) were significantly lower in sure FMF patients compared with probable FMF patients. No significant difference was seen in the allele frequencies of other MEFV mutations between FMF patients with or without rheumatic disease.
Table 10

Comparisons of allelic frequencies of MEFV mutations of patients with sure FMF and probable FMF

  

Sure FMF

Probable FMF

  
  

2n = 216

2n = 168

p

pc

Exon10

M694I

52 (24.1 %)

0

<0.0001

<0.0001

 

P751L

1 (0.5 %)

0

0.563

8.4375

 

G632S

0

1 (0.6 %)

0.438

6.5625

Exon3

R410H

1 (0.5 %)

0

0.563

8.4375

 

R408Q

8 (3.7 %)

23 (13.7 %)

0.0004

0.0055

 

P369S

8 (3.7 %)

25 (14.9 %)

0.0001

0.0016

 

R354Q

0

1 (0.6 %)

0.438

6.5625

Exon2

G304R

2 (0.9 %)

9 (5.4 %)

0.011

0.1641

 

E225K

0

1 (0.6 %)

0.438

6.5625

 

R202Q

9 (4.2 %)

8 (4.8 %)

0.778

11.6771

 

E148Q

82 (38.0 %)

68 (40.5 %)

0.617

9.2482

 

P115R

0

0

  
 

L110P

27 (12.5 %)

18 (10.7 %)

0.589

8.8411

Exon1

E84K

4 (1.9 %)

8 (4.8 %)

0.104

1.5597

 

R80H

0

0

  

Values are shown as n (%). FMF familial Mediterranean fever, pc corrected p value

Influence of MEFV mutation number on clinical phenotype

Although FMF is considered an autosomal recessive disease, the presence of only a single mutation can often be associated with the occurrence of FMF. We analyzed the differences in clinical manifestations according to the number of MEFV mutations. FMF patients with two or more than two MEFV mutations had AA amyloidosis and family history of periodic fever more frequently compared with those with a single or no MEFV mutations (Table 11).
Table 11

Clinical features of FMF patients with different numbers of MEFV mutations

 

No. of MEFV mutations

 

Clinical manifestations

≥2

0 or 1

 
 

n = 117

n = 75

p

Male/female

52/65

31/44

0.671

Age at onset (years), mean ± SD

28.3 ± 15.2

33.7 ± 19.2

0.097

Fever

113 (96.6 %)

71 (94.7 %)

0.383

Frequencies of febrile attack (per month), mean ± SD

1.11 ± 0.97

0.97 ± 0.83

0.438

Duration of fever attack (days), mean ± SD

3.1 ± 2.1

4.6 ± 5.6

0.201

Abdominal pain

51 (43.6 %)

26 (34.7 %)

0.218

Thoracic pain

36 (30.8 %)

15 (20.0 %)

0.099

Arthritis

69 (59.0 %)

39 (52.0 %)

0.342

Erysipelas-like erythema

17 (14.5 %)

17 (22.7 %)

0.150

AA amyloidosis

7 (6.0 %)

0

0.029

Family history of periodic fever

31 (26.5 %)

8 (10.7 %)

0.008

Rheumatic diseases

18 (15.4 %)

8 (10.7 %)

0.351

Values are shown as n (%) unless otherwise indicated. AA amyloid A, FMF familial Mediterranean fever

Discussion

This is a multicentric study into the prevalence of FMF patients in Japan. FMF was diagnosed in a high number of Japanese patients with unexplained fever or rheumatic manifestations. Based on our findings, we propose that FMF should be considered as a differential diagnosis for patients with unexplained rheumatic symptoms, even in the Japanese population. Other forms of recurrent hereditary fever, such as TRAPS, appear to be rarer than FMF, although genetic analysis for these diseases was not routinely performed.

The clinical diagnosis of FMF is not easy [3]. It has mainly been based on clinical signs, although MEFV genetic analysis is useful in Japan [14]. It is conceivable that the reported delay in diagnosis may result from the low awareness of FMF in Japan because of its misconceived rarity. The detection of MEFV mutations with high penetrance may help achieve a precise FMF diagnosis [15]. However, the observation of many heterozygous patients in whom a second allele was excluded [7, 16], especially in non-Mediterranean countries such as Japan, suggests the involvement of other genetic or environmental FMF susceptibility factors in disease susceptibility [17, 18]. Additionally, MEFV variants with low penetrance could be associated with clinical features that resemble FMF [10, 11].

It is evident that the use of the genetic approach to FMF diagnosis in patients with atypical clinical presentations has not been fully addressed. Of note, we identified significant differences in the allele frequencies of MEFV variants (M694I and E148Q) between FMF and non-FMF patients in the present study. The diagnostic value of MEFV exon 10 mutations has previously been established [19]; however, MEFV exon 2 or 3 polymorphisms were not thought to affect FMF occurrence [20, 21]. The E148Q variant has been established as a polymorphism, but some studies suggest that it is related to some clinical manifestations of rheumatic diseases [22]. In our study, the prevalence of this MEFV variant was increased in FMF patients compared with health subjects.

Our Japanese FMF patients had some notable clinical and genetic characteristics. The prevalence of MEFV exon 10 mutations and MEFV homozygous mutations was lower compared with those in Western countries [23]. Contrary to the concept that FMF is caused by recessive loss-of-function mutations, it is more likely that MEFV mutations cause FMF by a gain-of-function model [24]. It is conceivable that these genetic features contribute to the increased proportion of patients with probable FMF. Additionally, a genotype–phenotype relationship between the MEFV exon 10 mutation and the sure FMF phenotype was confirmed. Although clinical judgments still remain crucial in FMF diagnosis, our data show that a molecular approach to FMF diagnosis enables confirmation of typical FMF cases or genotype–phenotype correlations.

In the present study, we defined a minor subgroup carrying MEFV variants in whom a definitive diagnosis of FMF was made in addition to pre-existing established rheumatic diseases. These patients had periodic fever, serositis, or synovitis that was not explained by the activities of primary rheumatic diseases. Furthermore, these clinical manifestations were silenced by colchicine in the majority of patients. These findings suggest that an overlap between FMF and established rheumatic diseases is not unusual. It is well known that rheumatic diseases including lupus often cause acute serositis. When FMF patients with these rheumatic diseases showed laboratory data suggestive of active primary rheumatic diseases, such as hypocomplementemia or high titer of anti-ds-DNA antibody, these manifestations seem to be caused by FMF-related serositis [25]. Additionally, steroids have no beneficial effects in FMF attacks. A response to adequate colchicine therapy could confirm FMF [26], whereas steroid use has a benefit in some autoinflammatory diseases, including AOSD [27]. These findings may provide valuable information on differential diagnosis for FMF and rheumatic diseases.

Conflicting evidence exists as to whether single MEFV mutations are associated with the occurrence of other inflammatory diseases [28]. MEFV has previously been shown to be an independent modifier of the clinical manifestations of rheumatoid arthritis. Rabinovich et al. found that rheumatoid arthritis patients carrying MEFV mutations developed more severe disease than those with multiple mutations [22], while Ayaz et al. reported that juvenile idiopathic arthritis patients harboring MEFV mutations presented with the polyarticular course with detective arthritis [29]. These findings suggest that MEFV mutations or polymorphisms, even in one allele, associate with atypical clinical manifestations or subclinical inflammation not attributable to the primary rheumatic disease. It is tempting to speculate that, after the development of rheumatic diseases, the presence of an MEFV mutation modulates the clinical phenotype or contributes to the occurrence of FMF. No consensus has yet been demonstrated to classify the E148Q variant as pathogenic or non-pathogenic [30]. This sequence variant was described as a disease-causing mutation with low penetrance [31]. On the other hand, 50 % of E148Q homozygotes are asymptomatic and there is high prevalence of this variant in the Japanese population contrasting with a low FMF prevalence. E148Q is insufficient to trigger FMF but may act as a disease modifier [32]. In our study, Japanese FMF patients have a higher prevalence of E148Q compared to healthy subjects. Although the allele frequency of the E148Q variant is high in the Japanese population, these data may suggest that some Japanese patients with low-penetrance E148Q mutation may develop FMF in combination with unknown environmental or other genetic factors.

Our present study has a number of limitations. One of the main limitations of our study may be its hospital-based nature. The prevalence of symptomatic or FMF-suspicious individuals may be higher in those patients attending hospital regularly. Also, we did not evaluate disease severity, and there was insufficient follow-up of the long-term disease course, including the response to colchicine treatment. Although participating hospitals were encouraged to update patient files, these measures are not complete. The regular screening for AA amyloidosis was not performed in some institutes, which may alter the incidence of AA amyloidosis in our subjects. The mean age of onset of FMF patients in this study was 28.4 years, which seems to be relatively older compared to the previous Japanese investigations. A significant number of enrolments of adult patients with FMF may contribute to the more elderly onset of FMF in this study.

Conclusions

Our data showed a high prevalence of FMF as well as MEFV mutations in Japanese patients with unexplained fever. We suggest that a significant number of FMF cases were included in Japanese patients with unexplained fever. Mutational analysis of MEFV should be considered in cases of unexplained fever or non-specific rheumatic manifestations, even in Japan.

Abbreviations

AA, amyloid A; FMF, familial Mediterranean fever; MEFV, MEditerranean FeVer gene; SAPHO, Synovitis Acne Pustulosis Hyperostosis Osteitis

Declarations

Funding

The study was supported by the Practical Research Project for Rare/Intractable Diseases from the Japan Agency for Medical Research and Development, AMED.

Authors’ contributions

MY carried out the molecular genetic studies and drafted the manuscript. KM and KY analyzed the genetic data and revised the manuscript. AY and JM analyzed the clinical data and drafted the manuscript. YI, KA, KE, and AK participated in the design of the study and drafted the manuscript. YJ performed the statistical analysis and helped to revise the manuscript. NI conceived of the study, and participated in its design and coordination, and helped to draft the manuscript. CK, KF, SY, TN, YU, TK, YN, TS, MU, and FN collected the clinical data and revised the manuscript. All authors read and approved the final manuscript.

Authors’ information

The author is Director of Clinical Research Center, NHO Nagasaki Medical Center. KM is professor of Department of Rheumatology, Fukushima Medical University.

Competing interests

The authors declare that they have no competing interests.

Ethical approval and consent to participate

Ethical approval for this study (No. 21003) was provided by the Ethics Committee of Nagasaki Medical Center and written informed consent was obtained from each individual.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Rheumatology, Fukushima Medical University School of Medicine
(2)
Clinical Research Center, NHO Nagasaki Medical Center
(3)
Department of Infectious Immunology, Shinshu University Graduate School of Medicine
(4)
Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University
(5)
Department of Pathology, Ehime University Proteo-Science Center and Graduate School of Medicine
(6)
Department of Rheumatology, Japan Community Health care Organization, Isahaya General Hospital
(7)
Department of Rheumatology, Hiroshima University Hospital
(8)
Department of Rheumatology, Kumamoto Shinto General Hospital
(9)
Department of Rheumatology, Toranomon Hospital
(10)
Department of Immunology and Rheumatology, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University
(11)
Departments of Rheumatology, Sasebo City General Hospital
(12)
Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University
(13)
Sasebo Chuo Hospital
(14)
Department of Human Genetics, Atomic Bomb Disease Institute, Nagasaki University

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Copyright

© The Author(s). 2016

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