[Expression of Nod-like receptor protein 3 inflammasome in peripheral blood mononuclear cells of children with Kawasaki disease in the acute stage]

OBJECTIVE

To study the association of Nod-like receptor protein 3 (NLRP3) inflammasome with inflammatory response in the acute stage and coronary artery lesion (CAL) in children with Kawasaki disease (KD).

METHODS

A total of 42 children with KD who were hospitalized from January to October 2017 were enrolled as the KD group, among whom 9 had CAL (CAL group) and 33 had no CAL (NCAL group). Fifteen age- and gender-matched children with pneumonia and pyrexia were enrolled as the pneumonia-pyrexia group. Fifteen healthy children were enrolled as the healthy control group. Real-time PCR was used to measure the mRNA expression of NLRP3 inflammasome (NLRP3, ASC and caspase-1) in peripheral blood mononuclear cells. The Spearman rank correlation test was used to investigate the correlation of NLRP3 mRNA expression with serum levels of C-reactive protein, erythrocyte sedimentation rate, interleukin-6, interleukin-1β, procalcitonin, albumin and prealbumin.

RESULTS

The KD group had significantly higher mRNA expression of NLRP3, ASC and caspase-1 in the acute stage than the pneumonia-pyrexia and healthy control groups (P<0.05). The CAL group had significantly higher mRNA expression of NLRP3 than the NCAL group (P<0.05). NLRP3 mRNA expression was correlated with C-reactive protein, interleukin-6, interleukin-1β, and prealbumin levels in children with KD in the acute stage (r_s=0.449, 0.376, 0.427, and -0.416 respectively; P<0.05).

CONCLUSIONS

NLRP3 inflammasome may participate in inflammatory response in the acute stage and the development of CAL in children with KD.

[Pyrexia and hemoptysis for eight days in a school-age child]

A girl was diagnosed with intravenous immunoglobulin (IVIG)-resistant Kawasaki disease (KD) due to pyrexia and hemoptysis for eight days. The girl was a school-age child with major clinical manifestations of pyrexia, skin rash, enlargement of bilateral cervical lymph nodes, conjunctival hyperaemia, red and cracked lips and strawberry-like tongue, followed by swelling of both hands and feet. Laboratory examination showed significant increases in white blood cell count, platelet count, C-reactive protein, erythrocyte sedimentation rate and liver enzymes, a significant reduction in albumin, and the presence of aseptic pyuria. After the first course of IVIG treatment, the girl still had recurrent pyrexia, with hemoptysis on day 2 after admission, and lung CT showed uneven luminance and patchy shadow. The symptoms were quickly alleviated after the second course of IVIG treatment combined with methylprednisolone and aspirin treatment. KD is a febrile disease characterized by multiple systemic vasculitis in childhood and can involve various organ systems such as the heart, lungs, kidneys and the nervous system. Therefore, it is necessary to carefully monitor and recognize the rare symptoms of KD, and early recognition of pulmonary complications of KD can avoid delay in diagnosis, prevent the development of more serious complications, and help with early treatment and disease recovery.

[Clinical features of children with Kawasaki disease aged over 5 years]

OBJECTIVE

To study the clinical and laboratory features of children with Kawasaki disease (KD) aged >5 years.

METHODS

A retrospective analysis was performed for the clinical data of 250 elderly children (aged >5 years) who were diagnosed with KD or incomplete KD (divided into 5-9 years and >9 years groups) and 266 KD children aged 1-5 years. Clinical and laboratory features were compared between groups.

RESULTS

The >9 years group had the lowest incidence rates of hand and foot swelling and fingertip or perianal desquamation (P<0.05). The 5-9 years group had the highest incidence rate of neck lymph node enlargement (P<0.05). The >9 years group had the longest course of fever (P<0.05). There were no significant differences among the three groups in the incidence rates of rash, bulbar conjunctival hyperaemia and the change in lips, the proportion of children with incomplete KD, and the proportion of children with no response to intravenous immunoglobulin (IVIG). The >9 years group had the lowest platelet count and albumin (P<0.05). The 5-9 years group had the highest percentage of neutrophils (P<0.05). There were no significant differences among the three groups in white blood cell count, C-reactive protein, erythrocyte sedimentation rate, and alanine aminotransferase (P>0.05). As for the degree of CAL, the 1-5 years group had the highest incidence of mild coronary dilation, and the >9 years group had the highest incidence rate of moderate coronary aneurysm (P<0.05). There was no significant difference in the incidence rate of large coronary aneurysm among the three groups (P>0.05).

CONCLUSIONS

KD children aged >5 years have atypical clinical manifestations, with a high incidence rate of neck lymph node enlargement, a high percentage of neutrophils, and a low level of albumin and platelet. The risk of moderate coronary aneurysm increases with age.

Getting warmer

The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient's case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant.

Endothelial microparticles induce vascular endothelial cell injury in children with Kawasaki disease

OBJECTIVE

To explore the role of microparticles produced by endothelial cells in the injury of vascular endothelial cells.

MATERIALS AND METHODS

We stimulated human umbilical vein endothelial cells (HUVEC) with TNF-α in vitro, analyzed the change of cellular morphology, and measured EMP level in the supernatant with a flow cytometer. Then, we evaluated the corresponding clinical indicators and the role of EMP in endothelial injury.

RESULTS

The endothelial cellular morphology underwent significant changes, and a large number of microparticles were secreted. In turn, these microparticles blocked cell cycle and induced apoptosis.

CONCLUSIONS

The microparticles produced by endothelial cells play an important role in the injury of vascular endothelial cells.

Recurrent Kawasaki disease

BACKGROUND

Recurrent Kawasaki disease is rare.

CASE CHARACTERISTICS

An eight-month old infant had classic Kawasaki disease with transient coronary artery dilatation.

OBSERVATIONS

Recurrence of incomplete Kawasaki disease after two years of initial diagnosis.

OUTCOME

The index episode of Kawasaki disease was resistant to single infusion of immunoglobulin, while repeat episode responded within 24 hours of institution of therapy.

MESSAGE

Early recognition of recurrent Kawasaki disease requires a high index of suspicion.

[A retrospective analysis of 602 Kawasaki disease cases with electronic data capture system]

OBJECTIVE

To explore the value of electronic data capture (EDC) system in large-sample size studies on Kawasaki disease (KD).

METHOD

The clinical data of 602 KD cases from 2007 to 2012 admitted to Shanghai Children's Hospital with EDC system connected with hospital information system (HIS) were retrospectively analyzed. Age, gender, acute symptoms, laboratory results, echocardiography, therapy were collected. The differences in parameters were compared between KD with and without coronary artery lesion (CAL). Furthermore, the difference between intravenous immunoglobulin (IVIG) resistant group and sensitive group were compared. Multi-factor logistic regression analyses were used to analyze the risk factors. The sensitivity and specificity of IVIG resistance parameters were detected with receiver operating characteristic curve (ROC) analysis.

RESULT

The male to female ratio of KD cases was 1.85: 1. The median age of KD cases was 2.0 years (one month to 11.7 years old); 20.1% cases (121/602) exhibited CAL. Compared with KD without CAL (n = 481), the incidence of bright red cracked lips (71.1% vs. 88.6%, P = 0.001), peeling of the skin of the toes (28.1% vs. 41.6%, P = 0.021) and perianal skin peeling (29.8% vs. 38.9%, P = 0.031) were statistically lower in KD with CAL (n = 121). The incidence of CAL in KD IVIG resistant group was significantly higher than KD IVIG sensitive group (34.6% (9/26) vs.21.3% (112/525), P = 0.05 ). Male ratio (80.8% vs. 63.4%, P = 0.05), time of IVIG ( (6 ± 2) vs. (8 ± 5) d, P = 0.009), erythrocyte sedimentation rate(ESR) ( (81 ± 2) vs. (66 ± 30) mm/1 h, P = 0.014), C-reactive protein ((107 ± 51) vs. (87 ± 52) mg/L, P = 0.017), blood platelet ( (599 ± 178) vs. (489 ± 182) ×10(9)/L, P = 0.003), hemoglobin ( (96 ± 13) vs. (102 ± 19) g/L, P = 0.032) and albumin ((34 ± 6) vs. (37 ± 6) g/L, P = 0.020) were significantly different between IVIG resistant group and sensitive group. Logistic regression analysis showed that alanine aminotransferase (ALT) ≥ 80 U/L was the independent risk factor of IVIG resistance (P = 0.012). C-reactive protein = 104 mg/L (sensitivity 61.5%, specificity 62.7%), ESR = 106 mm/1 h (sensitivity 26.9%, specificity 93.6%) and blood platelet = 187×10(9)/L (sensitivity 76.9%, specificity 53.1%) of KD in acute phase were predictive for IVIG resistance with receiver operate characteristic curve analysis.

CONCLUSION

EDC system can acquire KD clinical data quickly and accurately. It is helpful for multicenter retrospective analysis of KD.

Risk factors for coronary artery lesions in Kawasaki disease

AIM

To identify the risk factors associated with the development of coronary artery lesions (CAL) in pediatric patients with Kawasaki Disease (KD).

METHODS

A retrospective chart review of the medical records of pediatric patients diagnosed with KD who were admitted to King Abdulaziz University Hospital, Jeddah, Saudi Arabia between January 2001 and December 2011 was performed. Odd ratio (OR) with 95 % Confidence interval (CI) was measured for each risk factor for CAL. Data were presented as frequencies (percentages). A P-value less than 0.05 was considered statistically significant.

RESULTS

A total of 44 patients were included in the study. Males were predominant, 27 (61.4%). The mean age of the patients was 26.7 months (range 1.5-108 months). Typical KD was recorded in 23 patients (52.3%), while coronary artery lesions were found in 26 (59.1%) patients. Coronary artery lesion was more common among patients with atypical KD, males, patients presented with history of fever more than 5 days, and intravenous immunoglobulins (IVIG) infusion after 10 days of start of fever (OR 4.2, 95% CI 1.1-15.3; p =0.01, OR 5.2, 95% CI 1.4-19.5; p =0.01, OR 5.4, 95% CI 1.5-20.1; p =0.01, OR 5.6, 95% CI 1.4-21.9; p =0.6, respectively).

CONCLUSION

Atypical Kawasaki disease should be considered in children and early administration of IVIG reduces the frequency of coronary artery lesions.