Effect of emotional stress on the frequency of PFAPA attacks - a multicenter study during the COVID-19 pandemic period

יואל לוינסקי ^2,6 Mor Broide ^3,6 Shelly Kagan ^2,6 Michal Gafner ^2,6 Rotem Tal ^1,6 Muhammad Natur ^1,6 Kfir Kedar ^1,6 Neta Dagan ^1,6 Yoni Butbul ^4,5 Gil Amarylio ^1,6 Liora Harel ^1,6

¹Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, ישראל
²Department of Pediatrics B, Schneider Children's Medical Center of Israel, ישראל
³Department of Pediatrics A, Schneider Children's Medical Center of Israel, ישראל
⁴Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel, ישראל
⁵The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, ישראל
⁶Sackler Faculty of Medicine, Tel Aviv University, ישראל

Objective – There is scarce information regarding triggers of PFAPA attacks. The objectives of this study were to examine whether emotional stress triggers PFAPA episodes.

Study design - Patients aged 3-16 years who were diagnosed with PFAPA by a pediatric rheumatologist from two Israeli centers were enrolled. Researchers contacted their parents by phone in two occasions: a. within the two weeks of returning to school after the COCID-19 lockdown; b. during the summer vacation. Parents were asked regarding the occurrence of PFAPA attacks within the two weeks preceding the calls. In addition, parents were asked an open-ended question regarding possible triggers to the attacks and to fulfill the pediatric emotional distress scale questionnaire in the two occasions.

Results – One hundred and six pediatric patient were enrolled in the study. Their average age was 7.37± 3.8. In the first phone call (corresponding to the period of return to school) 41 (38.7%) reported on any attacks in the last two weeks compared to only 24 (22.6%) in the second call (p = 0.017). The mean emotional distress questionnaire was higher in the first period compared to the second period (35.6± 8.1 versus 32.1± 7.7, respectively, P = 0.047). In addition, emotional trigger was the most common trigger reported by the parents (45, 42.5%)

Conclusion - This study shows that during a period of stress there were more PFAPA attacks compared to a relaxed period. These findings indicate that mental factors such as stress or excitement may be triggers for PFAPA attacks.