Mizoribine provides effective treatment of sequential histological change of arteritis and reduction of inflammatory cytokines and chemokines in an animal model of Kawasaki disease

The incidence of panvasculitis in the coronary arteries and aortic root was 100% in the control group. The incidence of panvasculitis in the MZR group decreased to 50%. Moreover, the scope and severity of the inflammation of those sites were significantly reduced in the MZR group as well as the IgG group. On the other hand, increased cytokines and chemokines, such as IL-1α, TNF-α, KC, MIP-1α, GM-CSF, and IL-13, in the nontreatment group were significantly suppressed by treatment with MZR, but the MCP-1 level increased. In addition, IL-1α, TNF-α, IL-10, IL-13, and MIP-1α were suppressed by treatment in the IgG group.

BACKGROUND

Intravenous immunoglobulin (IVIg) treatment results in an effective response from patients with acute-phase Kawasaki disease (KD), but 16.5% of them remain nonresponsive to IVIg. To address this therapeutic challenge, we tried a new therapeutic drug, mizoribine (MZR), in a mouse model of KD, which we have established using injections of Candida albicans water-soluble fractions (CAWS).

METHODS

CAWS (4 mg/mouse) were injected intraperitoneally into C57BL/6N mice for 5 consecutive days. MZR or IgG was administered for 5 days. After 4 weeks, the mice were sacrificed and autopsied, the hearts were fixed in 10% neutral formalin, and plasma was taken to measure cytokines and chemokines using the Bio-Plex system.

RESULTS

The incidence of panvasculitis in the coronary arteries and aortic root was 100% in the control group. The incidence of panvasculitis in the MZR group decreased to 50%. Moreover, the scope and severity of the inflammation of those sites were significantly reduced in the MZR group as well as the IgG group. On the other hand, increased cytokines and chemokines, such as IL-1α TNF-α, KC, MIP-1α, GM-CSF, and IL-13, in the nontreatment group were significantly suppressed by treatment with MZR, but the MCP-1 level increased. In addition, IL-1α, TNF-α, IL-10, IL-13, and MIP-1α were suppressed by treatment in the IgG group.

CONCLUSION

MZR treatment suppressed not only the incidence, range, and degree of vasculitis, but also inflammatory cytokines and chemokines in the plasma of the KD vasculitis model mice, suggesting that MZR may be useful for treatment of KD.

Clinical characteristics of aseptic meningitis induced by intravenous immunoglobulin in patients with Kawasaki disease

BACKGROUND

Aseptic meningitis is a serious adverse reaction to intravenous immunoglobulin (IVIG) therapy. We studied the clinical characteristics of patients with acute Kawasaki disease (KD) who developed IVIG-induced aseptic meningitis.

METHODS

A retrospective analysis of the medical records of patients with KD who developed aseptic meningitis after IVIG treatment was performed.

RESULTS

During the 10-year period from 2000 through 2009, among a total of 384 patients with Kawasaki disease, 4 (3 females and 1 male; age range, 19-120 months) developed aseptic meningitis after IVIG. All 4 developed aseptic meningitis within 48 hours (range, 25-40 hours) of initiation of IVIG. The analyses of cerebrospinal fluid (CSF) revealed elevated white blood cell counts (22-1,248/μL) in all 4 patients; a predominance of polynuclear cells (65%-89%) was noted in 3. The CSF protein level was elevated in only 1 patient (59 mg/dL), and the glucose levels were normal in all 4 patients. Two patients were treated with intravenous methylprednisolone; the other 2 children were observed carefully without any special therapy. All patients recovered without neurological complications.

CONCLUSIONS

In our patients with Kawasaki disease, aseptic meningitis induced by IVIG occurred within 48 hours after initiation of IVIG, resolved within a few days, and resulted in no neurological complications, even in patients who did not receive medical treatment.

Advanced Ceramics Sintering Using High-Power Millimeter-Wave Radiation

The results of ceramics sintering experiments using high-power millimeter-wave radiation are reported. Sintering of silicon nitride with 5%Al2O3 and 5%Y2O3 was performed in a multi-mode applicator using a 10-kW 28-GHz gyrotron in CW operation. It was found that the silicon nitride samples sintered with 28 GHz radiation at 1650'C for 30 min reached to as high as theoretical density (TD), while the conventionally sintered samples at 1700°C for 60 min resulted in the density as low as 90% TD. Focusing experiments of millimeter-wave radiation from the high-power pulsed 60-GHz gyrotron have been performed using a quasi-optical antenna system (two-dimensional ellipso-parabolic focusing antenna system) to demonstrate the feasibility of the power density of as high as 100 kW/cm2. Typical heating characteristics using the focused beam were made clear for this system. It was found that the densification of yttria-stabilized zirconia (ZrO2-8mol%Y2O3) samples to as high as 97% TD was obtained from the sintering with focused 60 GHz beam in pulse operation with a 10-ms pulse duration at a 0.5Hz repetition. The densification temperature for the zirconia could be lowered by 200°C than that expected conventionally.

A phase III, multicenter, collaborative, open-label clinical trial of sildenafil in Japanese patients with pulmonary arterial hypertension

BACKGROUND

There is evidence that phosphodiesterase type-5 is effective for the treatment of pulmonary arterial hypertension (PAH).

METHODS AND RESULTS

A phase III, multicenter, open-label clinical trial of sildenafil 20mg t.i.d. was conducted in 21 Japanese patients with PAH to examine its efficacy, safety, and pharmacokinetics. The present trial consisted of a screening period and 12-week treatment. Patients who were enrolled in the present trial increased their 6-min walking distance of administration increased at week 12 by 84.2m from baseline. Hemodynamic parameters (eg, mean pulmonary artery pressure and pulmonary vascular resistance), Borg dyspnea scores, and plasma brain natriuretic peptide concentrations also improved compared to baseline. Most patients improved or sustained WHO functional class. Seven subjects, who were examined for the pharmacokinetics of sildefanil, showed relatively large interindividual variations in the C(max), AUC(0-8), C(ss,av), and C(trough) of the drug. Any serious adverse events, severe adverse events, and deaths were not observed. Most of events of undeniable causality were mild or moderate in severity. Sildefanil was well tolerated by the subjects.

CONCLUSIONS

Sildenafil 20mg t.i.d. was effective and safe for Japanese patients with PAH.

A 3-year-old girl with Graves' disease with hypoglycemia following transient adrenal hyporesponsiveness

A 3-year-old girl with Graves' disease developed a generalized convulsion as a result of hypoglycemia (25 mg/dL). At the time of the hypoglycemic seizure, her plasma adrenocorticotropin (ACTH) level (1460 pg/mL) was extremely high, but her serum cortisol level (28.4 microg/dL) was relatively low given the severe stress. The cortisol-releasing hormone (CRH) provocation test done after thyroid function had improved revealed normal ACTH and cortisol responses. Since there was no other cause of hypoglycemia, such as hyperinsulinemia, long-term starvation, suddenly advanced emaciation, or prolonged fasting, it was suspected that the transient adrenal hyporesponsiveness was the main cause of hypoglycemia.

[Heart and lung transplantation in children--current status and perspectives]

In fact, pediatric organ donation and transplantation give a significant benefit to diseased children and their parents. During recent 3 years, the number of reported pediatric heart transplantation (HT) has remaining unchanged at -450/year, and the number of lung transplantation (LT) was reported around 90/year in the registry of ISHLT. The prognosis is not so different from that of adults, fifty % in LT and 75% in HT at 5 years. Dilated cardiomyopathy in HT and pulmonary arterial hypertension in LT are the most common diseases of indications. Important issues for all pediatricians include availability, and access to donor organ. The warm heart with gift of life or organ donation surely cure children suffered from intractable heart and lung diseases.

Standard method for ultrasound imaging of coronary artery in children

The Child Coronary Arterial Diameter Reference Study Group of the Japan Kawasaki Disease Society recommends ultrasound imaging as the standard method for measuring the diameter of the coronary artery in children. The patient is examined in a supine or right decubitus position by using a sector probe (≥ 5 MHz). The coronary arterial diameter measured at the minimum gain setting is the distance between the internal echo edge and the internal echo edge. The diameter is measured during the early diastolic phase at the end of the T wave. The left main coronary artery and the proximal right coronary artery are approached from the precordial short axis at the level of the aortic valve. The proximal and mid-right coronary arteries are observed on the atrioventricular groove, anterior to the tricuspid valve ring. The right coronary artery of the acute margin of the heart runs along the right side of the tricuspid valve ring. The distal right coronary artery is observed on the posterior atrioventricular groove, and the posterior descending branch of the right coronary artery is observed on the posterior interventricular groove. The right coronary artery is also well observed from the right sternal border in the right decubitus position. Proximal and mid-anterior descending arteries are observed on the anterior interventricular groove. The proximal left circumflex coronary artery is observed in the atrioventricular groove, anterior to the mitral valve ring.

Nationwide survey of severe respiratory syncytial virus infection in children who do not meet indications for palivizumab in Japan

In Japan, palivizumab, a humanized monoclonal antibody specific for respiratory syncytial virus (RSV), has been available since 2002. However, its use is limited to children at risk of severe RSV infection, with specific criteria that have been validated in large-scale clinical studies. The Pharmaceutical Committee of the Japan Pediatric Society established a committee to conduct a nationwide questionnaire survey to determine which diseases place children at risk of severe RSV infection and require preventive measures. A questionnaire sent to 613 medical institutions, including major pediatric hospitals and general hospitals with pediatric services, received 272 responses (44.4%). In total, 1,115 children not meeting current indications for palivizumab therapy were hospitalized for severe RSV infection, 16 (1.4%) of whom died; this suggests that palivizumab therapy should be considered for children with severe immunodeficiency or those at risk of nosocomial RSV infection in whom prevention of RSV infection by standard control measures appears difficult.

Common variants in CASP3 confer susceptibility to Kawasaki disease

Kawasaki disease (KD; OMIM 611775) is an acute vasculitis syndrome which predominantly affects small- and medium-sized arteries of infants and children. Epidemiological data suggest that host genetics underlie the disease pathogenesis. Here we report that multiple variants in the caspase-3 gene (CASP3) that are in linkage disequilibrium confer susceptibility to KD in both Japanese and US subjects of European ancestry. We found that a G to A substitution of one commonly associated SNP located in the 5' untranslated region of CASP3 (rs72689236; P = 4.2 x 10(-8) in the Japanese and P = 3.7 x 10(-3) in the European Americans) abolished binding of nuclear factor of activated T cells to the DNA sequence surrounding the SNP. Our findings suggest that altered CASP3 expression in immune effecter cells influences susceptibility to KD.

Autoimmune thyroid disease in children and adolescents with idiopathic pulmonary arterial hypertension

BACKGROUND

Previous studies have reported a high prevalence of autoimmune thyroid disease (AITD) in adult patients with pulmonary arterial hypertension (PAH). The aim of this retrospective study was to determine the prevalence of AITD in children and adolescents with idiopathic PAH (IPAH).

METHODS AND RESULTS

The study group included 16 patients who had been diagnosed as having idiopathic PAH when they were younger than 15 years old; all were younger than 20 years of age. Thyroid function and antithyroid antibody levels were examined regularly at 6-12-month intervals and when there were clinical signs of thyroid dysfunction. In total, 7 patients (44%) had AITD; 2 patients developed Graves' disease, 2 developed silent thyroiditis, and 3 had antithyroid antibodies with euthyroidism. The duration after PAH onset and the prostacyclin (PGI(2)) treatment period were significantly longer in patients with AITD (7.6+/-2.1 and 7.4+/-2.3 years, respectively) than in patients without AITD (5.0+/-1.1 and 4.8+/-1.2 years, respectively; P<0.01 and P<0.05).

CONCLUSIONS

The prevalence of AITD is high in children and adolescents with IPAH, so evaluation of thyroid function is important to prevent deterioration of right heart failure.

Genetic analysis in children with transient thyroid dysfunction or subclinical hypothyroidism detected on neonatal screening

About 30% of children with elevated TSH levels during neonatal screening have a transient form of disorder. On the other hand, it has been reported that subclinical hypothyroidism persists in late childhood in about 30% of children found to be false-positive during neonatal screening. The aim of this study was to determine whether transient thyroid dysfunction and subclinical hypothyroidism detected during neonatal screening are influenced by genetic background. The TSH receptor (TSHR), thyroid peroxidase (TPO) and dual oxidase 2 (DUOX2) genes, for which it has been reported that heterozygous defects cause neonatal transient thyroid dysfunction, were analyzed. Nine children with transient thyroid dysfunction or subclinical hypothyroidism detected during neonatal screening were studied. One child was heterozygous for a TSHR gene mutation (R450H), and another child was heterozygous for a TPO gene mutation (P883S). No children with mutation of the DUOX2 gene were identified. Genetic background may contribute to development of transient thyroid dysfunction and subclinical hypothyroidism detected during neonatal screening.

Clinicopathological characteristics of ganglioneuroma and ganglioneuroblastoma: a report from the CCG and COG

BACKGROUND

The International Neuroblastoma Pathology Classification (INPC) was the first to clearly define prognostic subgroups in ganglioneuroma (GN) and ganglioneuroblastoma (GNB).

PROCEDURE

Histopathology and tumor resectability of 552 GN/GNB cases from the Children's Cancer Group (CCG) and Children's Oncology Group (COG) neuroblastoma studies were reviewed. The results were analyzed along with clinical information and biological data of the cases.

RESULTS

According to the INPC, 300 tumors were classified into the Favorable Histology (FH) group and 252 were into the Unfavorable Histology (UH) group. Tumors in the FH group included 43 ganglioneuroma-maturing (GN-M), 198 ganglioneuroblastoma-intermixed (GNB-I), and 59 ganglioneuroblastoma-nodular, favorable subset (GNB-N-FS), and were often (91%) resected completely by single or multiple surgical procedures. Patients with the FH tumors had an excellent prognosis with no tumor-related deaths. The UH group included ganglioneuroblastoma-nodular, unfavorable subset (GNB-N-US) tumors. Patients with the UH tumors had a high incidence (53%) of distant metastasis at the time of diagnosis, and their prognosis significantly depended on clinical stage (5-year EFS: 80.1% for non-stage 4 patients; 16.7% for stage 4 patients): Complete primary tumor resection was not beneficial to those GNB-N-US patients, regardless of whether metastasis was present or not. MYCN amplification was detected in four tumors in the FH group and six tumors in the UH group. The majority (160/191, 84%) of GN-M and GNB-I tumors had a diploid pattern determined by flow cytometry.

CONCLUSIONS

Stringent application of the INPC along with clinical staging was critical for prognostic evaluation of the patients with this group of tumors.

Infliximab reduces the cytokine-mediated inflammation but does not suppress cellular infiltration of the vessel wall in refractory Kawasaki disease

The aim of our study was to evaluate the efficacy of infliximab for the treatment of patients with refractory Kawasaki disease (KD) and investigate the dynamic changes of cytokines during infliximab treatment. We have performed a study of cytokine and proinflammatory molecule levels in 43 KD patients including 18 responders to IVIG, 14 nonresponders, and 11 patients treated with infliximab. We determined serum levels of soluble TNF receptor I (sTNFR I) and IL-6, as well as VEGF, damage associated molecular pattern (DAMP) molecules; myeloid-related protein (MRP)8/MRP14 and S100A12 sequentially. In eight patients, fever subsided immediately upon infliximab treatment. Four patients, who started infliximab after 12 d of illness, developed coronary artery lesions. Each of the cytokines was elevated before infliximab treatment in all patients. Although serum levels of proinflammatory cytokines decreased dramatically after infliximab treatment, DAMP molecules and VEGF and markers of local tissue damage were not suppressed. In contrast, in IVIG responders all cytokines decreased markedly after IVIG treatment. We show that infliximab is one of the adoptive therapies in refractory KD patients. Different behaviors of proinflammatory cytokines and DAMP molecules and VEGF after infliximab treatment suggest that infliximab is effective for suppression of cytokine-mediated inflammation, but could not completely block local vasculitis.

[Pulmonary arterial hypertension in pediatric age]

Pulmonary arterial hypertension (PAH) is serious and a progressive disease with relatively poor prognosis if not identified and treated early in children. In pediatric age group, the transition of the pulmonary circulation from fetal life to neonatal period plays a pivotal role to maintain the pulmonary vascular resistance to be low. In children with iPAH, acute drug response to vasodilator is more prominent than that in adult. But, prognosis is relatively poor. Recently, phosphodiesterase (PDE) 5 inhibitor (sildenafil, Viagra) and endothelin receptor antagonist (bosentan, Tracleer) in addition to prostacyclin used as a combination therapy can be used for this age population. The 5-year survival has been improved to > 80%. In this chapter, we focus on pathophysiological aspects and treatment strategy of idiopathic PAH, familial PAH, and PAH in the neonate (ex. PPHN).

[Analysis of genetic mutation and modifier genes in pulmonary arterial hypertension]

Mutations of the bone morphogenetic protein receptor II gene (BMPR2) have been reported in patients with pulmonary arterial hypertension (PAH). In hereditary hemorrhagic telangiectasia (HHT) patients with PAH, missense mutations of the activin receptor-like kinase 1 gene (ALK1) located in the serine-threonine kinase domain. Recently, the mutations of ALK1 in the serine-threonine kinase domain were observed in PAH patients. ALK1 mutations play a critical role in PAH without HHT as well as in PAH with HHT. Because only 10-20% carriers with BMPR2 mutations develop PAH, the existence of environmental factors or modifier genes as 5-HTT(serotonin transporter) and ACE (angiotensin converting enzyme) is highly probable.

Implications of mutations of activin receptor-like kinase 1 gene (ALK1) in addition to bone morphogenetic protein receptor II gene (BMPR2) in children with pulmonary arterial hypertension

BACKGROUND

Mutations of the bone morphogenetic protein receptor II gene (BMPR2), and 1 mutation of the activin receptor-like kinase 1 gene (ALK1) have been reported in patients with pulmonary arterial hypertension (PAH).

METHODS AND RESULTS

A genomic study of ALK1 and BMPR2 was conducted in 21 PAH probands under 16 years of age to study the relationship between the clinical features of the patients and these genes. In all 4 familial aggregates of PAH, 3 ALK1 or 1 BMPR2 mutations were identified. Among 17 probands aged between 4 and 14 years with idiopathic PAH, 2 ALK1 mutations (2/17: 11.8%) and 3 BMPR2 mutations (3/17: 17.6%; 5 mutations in total: 5/17: 29.4%) were found.

CONCLUSION

Each proband with the ALK1 mutation developed PAH, as did the probands with the BMPR2 mutation. Hence, it is proposed that ALK1 plays as notable a role as BMPR2 in the etiology of PAH. Furthermore, asymptomatic carriers with the ALK1 mutation within the serine - threonine kinase domain are at risk of developing PAH and hereditary hemorrhagic telangiectasia, so close follow-up is recommended for those individuals.

[Clinical utility of ulinastatin, urinary protease inhibitor in acute Kawasaki disease]

Ulinastatin, a trypsin inhibitor, is useful as a first-line or a second-line treatment regimen including alternative therapy for IVIG-resistant or IVIG nonresponder Kawasaki disease (KD) patients. Mechanisms involving protections against tissue organs and endthelial cell and anti-inflammatory effects by ulinastatin, are dependent on the inhibition of PMN-derived elastase, tumor necrosis factor alpha (TNFalpha), and other proinflammatory cytokines/interleukins(IL-1, IL-6, IL-8). Ulinastatin also suppresses the activation of PMN cells, macrophages, and platelets. Although almost no statistical data related to the definitive effect in acute stage of KD, ulinastatin have shown possible effects, but not always, in a part of KD patients. The indications of clinical use include shock and pancreatitis. Off-label uses of ulinastatin have been reported in hematological, hepatic, renal, OB/Gy diseases and cardiovascular diseases including vasculitis syndromes. The efficacy of ulinastatin in aKD remained to be investigated.