Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Surviving Pollen Season: Tips from Dr. Ed Brooks, Plus Periodic Fevers

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Surviving Pollen Season: Tips from Dr. Ed Brooks, Plus Periodic Fevers · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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  I'm Holly Wayment, and this is Pediatrics Now, cases, updates,
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  and discussions for the busy pediatric practitioner.
• 0:07
  Thanks so much for joining us today, and remember to click on the link in this
• 0:12
  podcast for free credit that may include CME, MOC, or ethics credit,
• 0:17
  depending on our topic or podcast.
• 0:20
  Today, here back on the show is Dr. Ed Brooks. He's the Division Chief for Allergy,
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  Immunology, and Infectious Disease at the University of Texas Health Science
• 0:31
  Center and University Health.
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  Dr. Brooks, thank you so much for being back here on the show.
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  So first, as all of us know, we are in the heart of pollen season.
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  Can you give us a quick wrap-up of what is the best practice right now?
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  It's the tree season, the tree pollen. So Mountain of Cedar,
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  of course, is in the winter in January, and now all the other trees are ganging up on it.
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  So every other tree is pollinating during March and April.
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  Obviously, the dominant species in San Antonio is oak, but there's plenty of
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  others to make you miserable.
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  Tree pollen pollinates at nighttime.
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  And so the highest pollen counts are typically in the morning.
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  People with tree pollen allergy will wake up, feel fine, and then go outside and be miserable.
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  So be prepared. And it's okay to wear a mask in the morning as your child's
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  getting on the school bus.
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  So if he has bad pollen allergy.
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  And as I used to tell my son, you can rinse your eyes out at the water fountain,
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  try to get the pollen out of your eyes.
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  Medication-wise, for itching and sneezing, the antihispins are very good.
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  For some kids, that's all they need, but the most effective medications are the nasal steroids.
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  At least once a day, they should be using nasal steroids.
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  And ideally, you administer it prior to exposure to what you're allergic to.
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  So if you're tree pollen allergic, then first thing in the morning before you go outside.
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  If it's severe, you can use it several times a day.
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  I usually tell my patients at least two or three times a day if it's bad.
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  And once they get it under control, they can back off to the once a day.
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  Most kids don't like nasal sprays, but it's the most effective.
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  A lot of people do it the other way around, where just taking the nasal steroids as needed,
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  rather as staying ahead of it and staying on top of it and taking Porten or
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  Zyrtec, taking that every day.
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  But it's really what you're saying, flip it, right?
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  Yeah. Yeah, that's exactly what I tell my patients to flip it.
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  Because I hear that often.
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  I'd say, if you're going to use something all the time, then use the nasal spray,
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  and then add the anti-hyp spree, you have severe itching and sneezing.
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  Is there any concern for stunting growth if it's used too much?
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  Not really. It's a tiny amount, and since it's applied directly to the nose,
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  you get very little systemic absorption, and newer formulated corticosteroids like fluticasone,
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  memetasone, budesonide have a high first pass effect in the liver.
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  So they tend to be degraded very rapidly and have less systemic side effects.
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  Should the nasal steroids, should you always use that before bed and then it's
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  in your nasal passage all night or any advice there?
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  Again, it depends on what your allergens are and when you have your symptoms.
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  A lot of people have dust mite allergy, and that lives in the bed.
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  So yes, if you have that allergy, you should take it at that time so that the
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  idea is that you administer prior to exposure to your allergy so you can prevent the symptoms.
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  It's harder to treat once you have a lot of allergic inflammation.
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  For tree pollen allergy, as I said, I usually recommend first thing in the morning
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  because that's when the pollens tend to be highest.
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  My son is, I believe, the first at UT Health to be getting the allergy prevention
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  drops, and he's getting some relief from that.
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  I know it's only been a few months, but so far, so good.
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  Yeah, we do offer that, and it's non-FTA approved. so insurance won't pay for it.
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  We've tried to price it more reasonably to cover our extract costs.
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  The trick with the sublingual immunotherapy, there's tablets that are commercial tablets.
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  The insurance often will pay most of it, and you'd have a copay.
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  And those have undergone clinical trials, and they are effective.
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  The rule of thumb with the sublingual therapy is that you have to use about
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  10 times as much extract as compared to the subcutaneous immunotherapy or allergy shots.
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  So it's important that we formulate it on a very high dose.
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  And it's amazing how those can be done at home, but it does take several years, correct?
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  Well, we normally notice both in our allergy shock patients as well as the sublingual
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  patients, you start to get some improvement within three months.
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  And again, it depends on the dose you're able to get up to.
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  But most people will get near complete relief after six months and up to a year.
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  The long-term therapy is more to have long-term durability of the immunotherapy.
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  Often people will stop early and the allergies tend to come right back within a few months.
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  But if we treat them, our recommendations are for four years.
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  We find that children respond fairly quickly within usually two years and we may be able to stop.
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  And young adults, three years, and then older adults, four years.
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  And some retirees may go longer because, as I say, the immune system just doesn't want to change.
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  So it's harder. The older we are, the harder it is to steer that ship away from
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  what it's been reacting to your whole life.
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  I've heard that when someone's elderly, then the allergies can get a little better.
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  Some people, their allergies do get better.
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  And it's not the rule. The rule is allergies don't tend to leave. But...
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  Particularly if you think about what we're doing with immunotherapy,
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  we're giving you what you're allergic to, and we have to give very high doses
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  to get the immune system to basically realize that this is normal,
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  that you don't need to react against it.
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  There's more sophisticated explanation
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  as to what goes on, but that's the way I like to think about it.
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  And long-term therapy, again,
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  is to induce immune tolerance so that the immune system, the memory cells and
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  what we call the T-regulatory cells now continue to suppress the response.
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  And your son had good results, correct? Right.
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  I did the sublingual drop with him as well.
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  And to Mount Cedar and Cat, now he has a cat.
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  And he doesn't have, he did, you know, as many teenagers, it did not complete
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  therapy when he got a lot better. slacked off despite my protest.
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  We think medicine here and there, but it's much better than what it was.
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  Going back to what you were saying about some people, the allergies go away.
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  There's one study of people that had a lot of cats that have cat allergies.
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  When they studied their immune system, it looks as if they were on shots.
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  So if you're exposed to a high level of what you're allergic to,
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  theoretically, it's sort of like getting allergy shots.
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  But in general, that is not the case.
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  Beekeepers who get stung all the time have the same phenomenon and able to maintain
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  their long-term tolerance.
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  Wow. Most people, yeah, because the seasons are
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  discreet and they don't get continual exposure
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  and why people with dust mite allergy don't get
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  tolerance is a good would be a good
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  question we don't know how much dust mite
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  you would need to get some tolerance but it is possible that people will develop
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  tolerance naturally most of us do right most of us don't have allergy and but
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  we'll have an immune response to the pollens and dog dandruff, et cetera.
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  And some people even have a positive allergy test but not have any symptoms.
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  And that's because there's other immune mechanisms such as you call them blocking
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  antibodies of an IgG class that tend to block,
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  the allergen from even binding to a MAP cell or to the IgE.
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  So the symptoms are critical to make the diagnosis.
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  An allergy test is an imperfect tool that you can have a positive test and not be allergic.
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  And sometimes we get negative tests and people say, oh, yeah,
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  when I get around a cat, I sneeze my head off.
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  But then when we test them, it comes out negative.
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  There may be some scientific explanations for some of these variations,
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  but the key is the history is the most important.
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  If you sneeze, you're on cats, and you're almost certainly allergic to cats.
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  And if you sneeze and get watery, itchy eyes, in January, it's almost always
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  mountain seer, although we do have some winter grasses that can interfere.
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  In the springtime, you see, I'm miserable in March and April.
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  It's one of the other 50 species of trees that it's around, and that's where
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  the testing really comes in helpful.
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  We know which tree pollen it is.
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  Our other seasons don't help us very much.
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  The fall, although it's classic for ragweed and hay fever, unfortunately,
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  it's also the cold and flu season.
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  So the school starts, so it's very confusing whether people are having colds
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  or if it's their allergy symptoms.
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  And again, the testing can be very helpful. I know with my son who has pollen
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  allergies, he's the only of my three children, he's the only one where we didn't
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  have a dog going in and out of the house when he was a baby.
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  The hygiene hypothesis, what we refer to the theory, has to do with our microbiome.
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  And there's been lots of research on the microbiome, but allergic disease was
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  one of the earliest research projects that identified.
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  Alterations in the microbiome, and the most consistent finding was that there
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  was a less diversity of the microbiome.
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  And other studies that show specific taxa that are dominant in the microbiome,
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  but the diversity is the most critical one.
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  Epidemiologic studies have shown that children who are raised with dogs from
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  early life have less allergy, and children who are in daycare have less allergy.
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  And again, the theory being that they're exposed to more microorganisms and
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  infections that tend to help shape the immune system.
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  And if you live in a bubble and don't get infections or not around pets,
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  the natural tendency of the immune system is towards this, you say,
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  T helper type 2 or allergic immune system.
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  And I know how it is as a mom, especially with a baby, to feel like you have
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  to disinfectant wipes on everything or going to the grocery store on those carts or all of that.
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  And I know we all, like you talked about, we're too clean though.
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  It's not good for the allergies.
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  Right, right. You know, it's a double-edged sword. You don't want to get bad infections.
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  And at the same time, if a child is not exposed to the natural environment,
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  then there is a tendency to develop allergic disease.
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  And there's another facet to our hygiene hypothesis.
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  And this is a really hot topic now in allergy research.
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  And the catch word is barrier function. What that implies is that the skin,
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  the mucous membranes, and a lot of the genetics that have been applied to these
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  studies suggest that people with allergies have a less barrier function.
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  And so the tight junctions in the epithelium and the lining of the mouth amongst
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  the gut and the skin is more permeable.
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  And that soaps and other chemicals can break that barrier function down.
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  Particularly, you know, it's evident in eczema. and kids who were scrubbed with
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  soap frequently, and you can scrub yourself into eczema.
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  You know, there's a psychiatric condition, compulsive hand washing,
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  which people will develop eczema.
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  So just using these harsh detergents, it breaks down the barrier function and
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  people tend to develop eczema.
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  And there's chemicals, soaps, and emulsifiers all over the place.
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  I like to quote a scientist, famous Swiss scientist,
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  who took a clean dish out of the dishwasher and they rinsed them off and then
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  take that liquid and put it into epithelial cell cultures and demonstrates damage
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  to the cells so that soaps are not benign.
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  Now, we have a pretty good, most of us have pretty good barrier function and we resist that. Yeah.
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  Suggests that all of these agents have a subtle effect on our barrier function.
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  And so it's not just that we're not getting exposed to microorganisms,
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  it appears that some of the things we're using to sterilize the environment, particularly soaps,
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  enhance the process of permeability in the epithelium, which allows entry of
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  allergens and sensitization.
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  Thus, preceding the initial event for developing allergic disease.
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  So I've been sort of on the soapbox lately about telling people,
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  don't use baby wipes that have detergent in them. Just water. Water's fine.
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  Same with cleaning your floor. The babies are crawling around on the floor and
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  you're using Mr. Clean, a harsh cleaner.
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  And so if you do use a harsh cleaner, you should remove the soap with water.
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  I think it's in general, Well, this obsession with germs is just that, an obsession.
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  And the things that cause human disease usually come from other humans, viral infections.
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  Tuberculosis and things like that i guess
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  we could say it's your not soap box no soap box that less can be more when it
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  comes to soap and even are you saying even if you don't have a baby in the home
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  it's better to mop the floor just with water when possible i think so yeah and let's,
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  I don't know very many people that get ill from their house germs, if you will.
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  The majority of the germs are germs that we provide or their pet does and it
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  turns out these germs may be beneficial.
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  I'm not sure we're cleaning. We're cleaning to get the dirt up,
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  but then at the same time, I think we're obsessed with risk of germs on our floors.
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  I think it's a bigger risk if we walk around all day with our shoes on.
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  And Americans don't take their shoes off when they go in the house.
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  So they carry all the whatever they've dragged into the house.
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  It's usually not germs. It's chemicals out in our environment,
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  on our streets, on our sidewalks.
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  Well, we're taking our shoes off now since our last podcast.
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  And you informed me of that. It's not perfect, but I'm trying that at home.
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  And I think it's a lot better when you think about
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  all the chemicals it's just sounds and your
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  socks clean the floor you're right
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  and there's not commercials for the there's so many commercials for the cleaning
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  products that make them look so enticing you have to find a way to make money
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  to make commercials so dr books do you want to say anything about pollen allergies
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  before we move on And one question I had is,
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  is it during the heart of pollen season, is it good to wash sheets every night
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  and shower right when you get home and right in the morning?
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  Is that excessive? I think washing the sheets is probably unnecessary.
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  Taking a quick rinse at night is a good idea because the pollens stick to your
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  hair, your clothes, everything.
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  So you just bring in the enemy into your bedroom with you. Right.
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  Eventually, you know, you can bring the pollens. We'll make it indoors,
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  stores, windows and things.
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  So people ask me about the air fresheners, or the air filters.
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  And they did a lot of studies on this. This was reviewed in the expert panel.
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  And air filters are not recommended. They don't seem to have a clinical impact.
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  So I get that question a lot. It's actually a benefit to some plans.
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  I've gotten that question about, oh, should I get an air purifier?
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  Yeah. The only two situations in which I would recommend it is why don't you have a cat.
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  Cat dander is very buoyant.
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  You can kick your cat out of your bedroom, but the dander will eventually make
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  it in there and it may be beneficial because their dander is very buoyant, very pervasive.
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  The other situation is if you've got a water intrusion problem or mold problem
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  in the house, and if you've got mold spores flying around, then air filter may be beneficial.
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  A third situation is when you're cleaning the house, when you're vacuuming,
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  because what you do is kick all the dust up in the air.
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  So an air filter may help after you've cleaned to get some of that dust out of the air.
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  And the reason, rationale behind why they don't seem to work.
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  Usually, most scientists think, well, most of the, even the pollens,
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  they don't float in the indoor environment. They need a little wind.
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  And the dust particles are very heavy. So most allergens are sort of heavy.
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  And unless you are blowing fans around, people tell me, oh, yeah,
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  it's worse when I have the fan on in the room.
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  Most allergens are on the floor or on the pillow, on the cat,
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  on the dog. so you get most of your exposure when you disturb the air.
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  Not that they don't work. They do remove allergens from the air,
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  but it just don't seem to have a clinical effect when they've studied it.
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  Well, this is all such great advice. I know pediatricians are seeing a lot of
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  kids right now who are coughing and sneezing, sniffling, and parents are dealing
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  with that as well, kids who have it.
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  So this is so insightful as we're right in pollen season.
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  Again, thank you for being on Pediatrics Now.
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  I'm talking to Dr. Ed Brooks, Division Chief for Allergy, Immunology,
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  Rheumatology, and Infectious Disease at the University of Texas Health Science
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  Center and University Health. We'll be right back.
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  Pediatrics now is brought to you by the department of pediatrics at the university
• 21:37
  of texas health science center and by cpan no call too small i'm back with dr
• 21:44
  ed brooks thank you again for being back on the show. My pleasure.
• 21:51
  So we're talking about periodic fevers. Can you just give us a refresher?
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  What exactly is a periodic fever?
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  The periodic fevers that we
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  deal with in rheumatology are what we call auto-inflammatory conditions.
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  And they mimic other febrile illnesses.
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  And of course, when a child has fever, recurrent fever, we need to distinguish
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  that from infectious disease, of course.
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  And there are several auto-inflammatory diseases that have fever as a dominant feature.
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  One of those, the most common pediatricians most likely to encounter is the
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  acronym PFAPA, which stands for periodic fever,
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  aphtostopatitis, pharyngitis, and apnopathy.
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  And is a great mimicker of strep pheringitis, which is often screened for in these children.
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  And it may be positive. Some kids are colonized where they may actually have
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  concurrent strep pheringitis.
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  But some of the clinical features are very similar.
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  In contrast to other upper respiratory infections, they do not have congestion,
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  coughs, other respiratory symptoms.
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  And so if they have isolated just sore throat, even have the white membranes on the throat.
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  Cervical adenopathy. They get pancreasores or aftostopatitis.
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  And some of these kids also will get abdominal pains and some will get joint
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  pains. And some will have just a few of these features.
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  But the one thing that really distinguishes these kids from infectious disease
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  or other rheumatologic conditions is the regularity with the periodic nature of it.
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  And they occur very regularly. The classic is every four weeks.
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  It can vary from every three to five weeks, every single month.
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  I've had parents tell me, I put it on my calendar with it.
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  No, we can't travel that day because he's going to have a fever and they can
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  get very high fevers, 105.
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  Sometimes they get lower fevers and they feel terrible.
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  The episode snaps from three to five days. And then in between,
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  this is really important.
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  They're perfectly fine. They do great until they get their next fever.
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  Wow, it sounds terrible. And it often has been misdiagnosed as strep pharyngitis
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  or respiratory infections.
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  And the hard part is it often presents in the first few years of life.
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  And if they're at daycare or in pre-K They're also getting infectious illnesses
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  on top of this So it can be very confusing Yes,
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  how do you keep track of one virus starting, another infection ending?
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  Right It's tricky, it's tricky.
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  So in that context, it's maybe harder to tell.
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  But then after a year of this, and it's continuing to have these characteristic features, then.
• 25:25
  But the periodic nature. And so when they come in with that story,
• 25:29
  honestly, there's only one thing it can be.
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  There's really no other medical condition that acts this way.
• 25:37
  You know, leukemias have recurrent fevers. It's usually daily.
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  And obviously infectious disease can have certain patterns.
• 25:45
  And again, it's not like something that goes away for a month and then comes back.
• 25:48
  Nothing really does this. So in some respects, it's an easier diagnosis for
• 25:54
  us to make if it's clean like that.
• 25:58
  And there's unfortunately no specific laboratory testing that can tell you what it is.
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  There is one condition called hyper-IGD syndrome, and we will measure an IGD
• 26:12
  level to see if it's elevated, but that's about the only test other than negative
• 26:17
  testing. So they get strep tested or negative.
• 26:19
  Recurrent strep pharyngitis, again, it's usually not that regular.
• 26:23
  PFAPA stands for periodic fever, aphthysstomatitis, pharyngitis,
• 26:31
  and adenopathy, and it's usually cervical adenopathy.
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  And the characteristic feature is they have regular fevers every three to five
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  weeks, and the episodes last about three to five days,
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  where they have these very high fevers, they're miserable, they're sore throat,
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  sometimes they can't even drink or eat, and then after it goes away,
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  it goes away completely and they're perfectly fine without any treatment. Wow.
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  A lot of kids can get by with just antipyretics like Motrin and Tylenol if they
• 27:09
  have mild symptoms or they respond to that.
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  The one treatment that we use almost as a therapeutic intervention is corticosteroids.
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  So we'll put them on prednisone one per kilo on days one, two,
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  and sometimes three days, and it will completely abort the episode.
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  And so that's almost diagnostic of the condition as well.
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  One of the downsides of that, other than being exposed to corticosteroids every
• 27:39
  month, is that the episodes may come back sooner.
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  So I had a patient recently that they took the corticosteroids and they would
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  keep taking it each episode and they would be like every two weeks.
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  And so that's one of the downsides. I have some patients that it's all they
• 27:57
  do, and they give one or two days of prednisone, and they're fine with that.
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  There's some less successful therapies.
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  Cimetidine was used in this condition, and it seemed to work.
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  And a small percentage of patients responded to that therapy.
• 28:19
  Some patients will respond to tonsillectomy. So if they do have enlarged tonsils,
• 28:25
  that's sometimes a consideration.
• 28:28
  It is surgery, but sometimes it's successful.
• 28:32
  The other medications we use, one is colchicine, which is an old medicine for gout.
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  And that's usually successful.
• 28:42
  At least. And then there's some biologic medicines, one's anakinra,
• 28:46
  which is an anti-IL-1 alpha antagonist, and then some of the TNF blocking agents.
• 28:55
  Now, the disease that this mimics is called Mediterranean fever.
• 29:04
  And Mediterranean fever has exactly the same characteristics.
• 29:09
  The main difference is Mediterranean fever, we know the gene.
• 29:12
  It's in all of the defects in the autoinflammatory disease.
• 29:17
  The majority of them are in what we call the inflammasome of the cell.
• 29:21
  So they have a dominant mutation in one of those genes.
• 29:27
  And Mediterranean fever will last through childhood and into adulthood and can
• 29:33
  have some long-term complications such as amyloidosis in the kidneys.
• 29:39
  The non-familial form, what we call the PFAPA.
• 29:46
  Usually disappears by the age of eight or nine and doesn't come back.
• 29:51
  We don't know the genetics about that specific, the most common form of it.
• 29:57
  As I said, it doesn't run in families, just sporadic.
• 30:00
  And so that part of it is still a bit of a mystery.
• 30:04
  I'm reading the National Institutes, according to the National Institutes of
• 30:08
  Health, periodic fever in children, the cause is unknown. Is that still the case?
• 30:14
  Right. The most common form that we call PFAPA is unknown.
• 30:20
  We don't know the genetics behind it. And like I said, it doesn't run in families.
• 30:25
  And so as soon as we get a history that there are other family members that
• 30:29
  have the same thing, we'll do genetic testing. and particularly,
• 30:34
  you know, the Mediterranean fever.
• 30:37
  But there's a whole host of these autoinflammatory conditions that have different
• 30:42
  features and often are mimicked by other autoimmune conditions.
• 30:50
  Like if they have a prominent feature of arthritis, then they may ultimately develop arthritis.
• 30:59
  We've seen that in some of our patients that seem to start out with a classic
• 31:04
  PFAP or periodic fever, and then over time start having more chronic joint pains.
• 31:11
  And the distinction between those two entities, they're usually what we call seronegative.
• 31:16
  The juvenile idiopathic arthritis, or JIA, we categorize into seropositive and seronegative.
• 31:24
  Seropositive means they have a positive rheumatoid factor, a positive ANA,
• 31:28
  and those are the two main screening tests that we use in juvenile arthritis.
• 31:33
  About 10 to 20% of them don't have any positive autoantibodies,
• 31:38
  and such as psoriatic arthritis will develop arthritis.
• 31:43
  So if a child has psoriasis or has a first-degree family member with psoriasis,
• 31:48
  and there are certain patterns to the type of arthritis, to the joints that
• 31:52
  are involved, then what we may label them as psoriatic arthritis.
• 31:58
  And systemic onset juvenile arthritis often presents initially with.
• 32:06
  Fevers lasting for weeks to months, high-spiking fevers, and sometimes even
• 32:12
  before they develop arthritis.
• 32:14
  But again, those are often daily fevers as opposed to the monthly fevers we see in PFAPA.
• 32:23
  Well, with the periodic fevers, it sounds like it's just a big diagnostic challenge.
• 32:32
  Well, with the PFAP of the most common form, it's usually, as I said,
• 32:38
  nothing else acts this way.
• 32:39
  And then, of course, we'll do a trial of prednisone.
• 32:43
  And if it completely aborts the episode, that almost proves it.
• 32:48
  Because nothing else will respond like that.
• 32:51
  And typically, like in juvenile arthritis, the arthritis comes and it doesn't
• 32:57
  go away. It doesn't disappear for a month and then come back.
• 33:01
  That's not typical at all.
• 33:03
  But as I said, sometimes we've seen some patients that sort of evolve down the
• 33:09
  road as they get older into just chronic joint pains.
• 33:13
  And again, those are very tricky to understand.
• 33:17
  Because usually, again, as I said, the PFAP disappears by the age of eight.
• 33:22
  So when do you know when it's time to see an expert, a rheumatologist?
• 33:29
  When do you refer?
• 33:31
  Well, I think a lot of families, if they're having these episodes of high fever,
• 33:37
  then they want to see a specialist to make sure there's not something else going on.
• 33:43
  However, I think if the pediatrician does a little bit of reading and CME on
• 33:51
  the PFAPA, I think they can do just fine with it.
• 33:54
  If they're not responding to simple antipyretics like Motrin and Tylenol.
• 34:01
  And I think it's probably a good time to see the rheumatologist because we're
• 34:06
  familiar with some of the other medications that might be beneficial and some
• 34:12
  of the other treatments like tonsillectomy, et cetera,
• 34:14
  and the odds that those are those different things are going to help.
• 34:18
  And I think it helps to explain to families that, well, I usually start them
• 34:23
  on cimetidine, but only 10% of the children are going to respond.
• 34:28
  And then I might move to colchicine.
• 34:32
  And the dosing on colchicine can be a little tricky and it can cause some side
• 34:36
  effects that we have to be careful about because once they get side effects,
• 34:40
  a lot of families are not willing to take it anymore.
• 34:43
  And then, of course, if nothing's working to advance that and when to do genetic
• 34:48
  testing to interpret the genetic testing, I think those things.
• 34:52
  But the most simplest forms of it where they have the regular fevers every four
• 34:58
  weeks with pharyngitis and maybe canker sores and the adenopathy.
• 35:04
  And you put them on, say, one per kilo of prednisone on day one of the next fever.
• 35:11
  And if it aborts it, I think you can feel fairly confident of what they're dealing with.
• 35:16
  Be treated in the clinic, in the office.
• 35:19
  Yeah. So I think, and probably a lot of kids are managed that way.
• 35:23
  And I think the pediatricians are getting more savvy. I mean,
• 35:27
  we didn't know much about this until about 20 years ago.
• 35:31
  Obviously, Mediterranean fever has been around for a long time,
• 35:35
  so it's been well recognized.
• 35:38
  But the PFAPA, I guess it was around.
• 35:42
  I just don't recall when I was in training, et cetera, anybody talking about it.
• 35:47
  We learned about Mediterranean fever, but the PFAPA, and I don't know if it's
• 35:53
  increased in prevalence.
• 35:54
  I think it has and we've been seeing a lot more cases either it has or people
• 35:59
  recognize that maybe this is that not just recurrent infections I think there
• 36:04
  was a tendency again because of the,
• 36:07
  concomitant upper respiratory infections and strep pharyngitis that.
• 36:14
  Be misdiagnosed or just, oh, it's probably a little cold or fever and it'll pass.
• 36:20
  And most of the kids are fairly mild.
• 36:24
  But when they have the full-blown syndrome, then I think now pediatricians are
• 36:31
  beginning to recognize it.
• 36:33
  And thanks to your education that you're giving us all today.
• 36:38
  It's very helpful. Ed, Dr.
• 36:41
  Brooks, do you recommend if the child is not miserable, the fever isn't high,
• 36:47
  is it better to not give the medicine for the fever, the antipyretics,
• 36:53
  or what is your advice there? Or just go ahead and do it?
• 36:56
  Yeah, it's not going to change the course of it. That's the funny thing.
• 37:01
  These things are going to do what they're going to do.
• 37:04
  And like many things, we use medications so we feel better while we're sick.
• 37:10
  And if they're short, last only two days, and the child's not too miserable,
• 37:16
  I think it's fine to ride it out, so to speak.
• 37:20
  So either approach is fine.
• 37:23
  There's no long-term damage that's going to occur.
• 37:28
  The other reason to refer is if it's familial, if there's other members of the
• 37:34
  family that have similar symptoms.
• 37:36
  And then we need to do some genetic investigation to find out if they are a
• 37:42
  case of the Mediterranean fever.
• 37:45
  And of course, to rule out cancer, when would you refer there?
• 37:51
  Again, you know, So cancer doesn't act this way.
• 37:57
  And if there's additional symptoms or persistent fatigue, persistent low-grade fevers,
• 38:06
  you know, pediatricians can do simple blood counts and chemistry panels to see
• 38:13
  if there's any abnormalities.
• 38:16
  Wrong to refer if you suspect leukemia, but there are certain characteristics
• 38:22
  that you want to look for and leukemia come on suddenly and it can,
• 38:26
  it can be a little bit indolent as well.
• 38:29
  And they can have sort of low grade fevers.
• 38:32
  So, but it doesn't really act like this. Then really, you know,
• 38:37
  high fevers for three days and then disappears in there. And those kids have full energy.
• 38:42
  They're absolutely, they're completely back to normal.
• 38:45
  There's no lingering symptoms whatsoever. So I think that would,
• 38:49
  it's kind of rules against a chronic process like leukemia.
• 38:54
  And what about with schools? Because if you have a fever at school, you're sent home.
• 38:59
  Right. I have a standard 504 letter, you know, where I will send home and tell
• 39:07
  them they're not contagious.
• 39:08
  They don't need to be sent home. Now, the kids, if their fever is high,
• 39:12
  they're not able to attend school. They feel miserable.
• 39:18
  But if it's controlled with antipyretics or prednisone or some of the other
• 39:23
  therapies, they shouldn't have a whole lot of fever.
• 39:27
  But I send that letter to let them know they have this condition.
• 39:30
  And about every month, they may have an episode of fever.
• 39:34
  And it could be a real problem because they're missing school for two or three
• 39:38
  days every month. it could be a real problem.
• 39:41
  And we know like the fever is the body doing its finest work,
• 39:45
  but then in this case, it's just there and we don't know why.
• 39:49
  Yeah, the body's screwing up. It's really not fighting anything.
• 39:53
  And it's an outpouring of inflammatory mediators, which basically comes from
• 40:00
  what we call the inflammasome and the endpoint producing IL-1.
• 40:06
  And that turns on the fever mechanism and the hypothalamus.
• 40:12
  Where the fever comes from. So it's coming from other cells in the body and
• 40:17
  then the fever is turned on in the hypothalamus and fascinating disease.
• 40:24
  And could it be a harbinger for something bad to come for all of us as parents
• 40:31
  and pediatricians just worrying about what does this mean?
• 40:35
  Right. Now that's kind of a yes, no answer. If, if it's the classic form of
• 40:40
  PFAPA, no, there's, in fact, it's going to go way on. It's going to do its thing.
• 40:46
  It's going to go way on its own and you have nothing to worry about.
• 40:50
  Some, as I mentioned, some of the kids present initially like a PFAPA and then,
• 40:57
  you know, particularly if they have prominent features of arthritis,
• 41:01
  and then later they seem to develop what we're labeling them as juvenile arthritis
• 41:09
  because then the fevers go away and then they're left with nothing but arthritis.
• 41:13
  And it's kind of a chicken and the egg thing. Did the fever episodes sort of
• 41:18
  induce the inflammatory arthritis?
• 41:21
  Because we don't think it's an autoimmune condition, but autoinflammatory.
• 41:28
  And that's really not well described in the literature.
• 41:33
  So it usually doesn't turn into something else down the road.
• 41:39
  Well, that's good news. Yeah. Do we know, is this becoming more common?
• 41:45
  I have not read anything that tells me the prevalence is higher.
• 41:50
  But my personal, and it's either we're getting more referrals or my personal
• 41:56
  impression that I'm seeing more patients with it.
• 42:00
  So it may be better awareness in the pediatric referral networks, or it may be increasing.
• 42:08
  I think we'll find out.
• 42:11
  When it is time to refer, rheumatology or any other type of specialty would you recommend?
• 42:17
  Yeah, rheumatology is the main one that deals with this.
• 42:22
  Now, as an immunologist, if someone identifies themselves as an immunologist,
• 42:27
  I think they can also manage these patients.
• 42:30
  But most people who go through the training, allergy and immunology,
• 42:34
  practice dominantly allergic disease.
• 42:38
  And they will know about these diseases.
• 42:41
  I can't say on an individual basis whether 100% of allergists will be aware
• 42:48
  of how to fully manage these. I think it's in the realm of rheumatology.
• 42:52
  And now that we have a board, I trained before there was a board certification
• 42:56
  for pediatric rheumatology, but I trained in rheumatology.
• 43:00
  And now there's a lot more pediatric rheumatologists that I think we can refer to.
• 43:07
  Although in San Antonio, there is a shortage. We're trying to recruit more.
• 43:12
  That is a tough one. And of course, you see patients at our UT clinic in the
• 43:19
  medical center in a building called Westgate, and then also patients at University Hospital. Correct.
• 43:28
  Music.
• 43:36
  Of juvenile arthritis and what they can do, what they can look for to see if
• 43:43
  the child really is having juvenile arthritis.
• 43:46
  Probably the pediatricians are getting a bucket load of people that just hurt,
• 43:51
  kids that just hurt. That's so tough.
• 43:56
  Distinguishing between JIA and fibromyalgia, I think would be helpful.
• 44:03
  How do you evaluate a child that hurts all the time?
• 44:06
  Juvenile idiopathic arthritis, and even the muscle diseases that can give you
• 44:14
  muscle pain and weakness.
• 44:16
  We call it dermatomyositis.
• 44:18
  So those are all sort of have overlapping initial presenting symptoms.
• 44:25
  That's coming up next week. What to do for the patient, the child who hurts all the time.
• 44:32
  Is it growing pains? Is it joint pain?
• 44:36
  Is something else. Is it all immune condition? A lot of these things get written off as growing pains.
• 44:44
  And it's interesting that growing pains is associated with fibromyalgia.
• 44:49
  Before we wrap up, do you want to mention anything? I like to talk about having
• 44:54
  a life outside of medicine, anything interesting you're reading,
• 44:56
  watching, doing in your spare time.
• 45:00
  It's the final four. That's the final four here in San Antonio.
• 45:06
  The lady longhorns are in the final four
• 45:09
  go horns my alma mater and my
• 45:12
  daughters my oldest daughter is there now that's that's what i'm obsessed with
• 45:17
  right now dr ed brooks thank you so much for talking again today on pediatrics
• 45:23
  now and coming up next week we'll talk about what to do for that patient, that child who hurts.
• 45:31
  Thank you, Holly. You're getting good at this. Oh, thank you.