Triggering through CD40 promotes interleukin-4-induced CD23 production and enhanced soluble CD23 release in atopic disease

The pathogenesis of atopic disease is closely linked to the overproduction of IgE. CD23 and CD40 are two cellular receptors involved in the regulation of IgE production and both receptors are elevated in atopic disease. We have examined the role of CD40 in the regulation of CD23 and soluble CD23 production in healthy and atopic donors. Triggering of the B cell CD40 receptor directly enhances interleukin (IL)-4-mediated up-regulation of CD23 at both the protein and the mRNA level. When atopic donors were studied, the synergistic effect of CD40 triggering on the IL-4-induced up-regulation of CD23 and soluble CD23 (sCD23) was enhanced and there was a relative skewing toward production of sCD23. These studies implicate the CD40 receptor in the hyperproduction of CD23 and sCD23 in atopic disease and suggest that abnormalities may exist in the cellular pathways leading to sCD23 production.

Nebulized IFN-gamma inhibits the development of secondary allergic responses in mice

The effects of nebulized IFN-gamma on primary and secondary IgE production and development of airway hyper-responsiveness (AHR) were investigated. BALB/c mice received primary exposure to aerosolized OVA daily for 10 days and developed anti-OVA IgE responses, immediate cutaneous reactivity to OVA, and altered airway function when assayed on day 12. After secondary exposure to OVA challenges on days 30 and 31, these mice developed an amplified IgE response, heightened cutaneous reactivity to OVA and AHR when measured on day 37. Administration of IFN-gamma for 13 days, beginning 3 days prior to and during primary OVA sensitization, resulted in a decrease in anti-OVA IgE, increases in serum anti-OVA IgG2a levels, a decrease in cutaneous reactivity to OVA, and normal airway function when assessed on day 12 after primary sensitization. This treatment also prevented the development of secondary anti-OVA IgE responses and altered airway responsiveness but did not induce a secondary rise in anti-OVA IgG2a in the serum measured on day 37. Treatment with IFN-gamma on days 26 to 30, well after primary responses were established but just prior to secondary OVA challenge, abolished the development of secondary anti-OVA IgE responses, resulted in an increase in anti-OVA IgG2a in the serum, and prevented the development of AHR. In vitro, CD4+ T cells obtained from OVA-sensitized mice treated with either "early" or "late" IFN-gamma inhibited IgE production. Delivery of IFN-gamma to the airways can prevent secondary allergen sensitization even after primary sensitization has been achieved and this effect is mediated by CD4+ T cells.

Nebulized IFN-gamma inhibits the development of secondary allergic responses in mice

The effects of nebulized IFN-gamma on primary and secondary IgE production and development of airway hyper-responsiveness (AHR) were investigated. BALB/c mice received primary exposure to aerosolized OVA daily for 10 days and developed anti-OVA IgE responses, immediate cutaneous reactivity to OVA, and altered airway function when assayed on day 12. After secondary exposure to OVA challenges on days 30 and 31, these mice developed an amplified IgE response, heightened cutaneous reactivity to OVA and AHR when measured on day 37. Administration of IFN-gamma for 13 days, beginning 3 days prior to and during primary OVA sensitization, resulted in a decrease in anti-OVA IgE, increases in serum anti-OVA IgG2a levels, a decrease in cutaneous reactivity to OVA, and normal airway function when assessed on day 12 after primary sensitization. This treatment also prevented the development of secondary anti-OVA IgE responses and altered airway responsiveness but did not induce a secondary rise in anti-OVA IgG2a in the serum measured on day 37. Treatment with IFN-gamma on days 26 to 30, well after primary responses were established but just prior to secondary OVA challenge, abolished the development of secondary anti-OVA IgE responses, resulted in an increase in anti-OVA IgG2a in the serum, and prevented the development of AHR. In vitro, CD4+ T cells obtained from OVA-sensitized mice treated with either "early" or "late" IFN-gamma inhibited IgE production. Delivery of IFN-gamma to the airways can prevent secondary allergen sensitization even after primary sensitization has been achieved and this effect is mediated by CD4+ T cells.

Immunoglobulin therapy in Kawasaki syndrome and RSV prophylaxis

Kawasaki syndrome and RSV infection are common illnesses that afflict infants and young children. Recent studies demonstrate that intravenous immunoglobulin (IVIG) treatment significantly reduces the clinical severity of these illnesses. The purpose of the current review will be initially to examine mechanisms of disease pathogenesis in KS and RSV infection. This will be followed by a discussion of the potential mechanisms by which IVIG acts in these two illnesses. In both KS and RSV prophylaxis, an important action by which IVIG may work is primarily through toxin or microbial neutralization resulting in the dampening or prevention of the inflammatory response. Other immunomodulatory actions of IVIG are likely to be operative in these diseases and will be an active area of future research.

Transesophageal echocardiography-guided approach to cardioversion of atrial fibrillation

In patients with atrial fibrillation, electrical cardioversion is often performed to relieve symptoms, to improve left ventricular function, and to decrease thromboembolic risks. However, cardioversion of atrial tachyarrhythmias is associated with an increased embolic risk, with an event rate of up to 5.6%. The American College of Chest Physicians recommend 3 weeks of systemic anticoagulation before elective cardioversion and 4 weeks of systemic anticoagulation afterwards. Expulsion of preexisting left atrial (LA) thrombi with resumption of sinus rhythm has traditionally been considered the mechanism for this increased embolic risk associated with cardioversion. The advent of transesophageal echocardiography (TEE) has allowed accurate detection of LA thrombus. Moreover, recent studies using TEE have identified a state of atrial "stunning" immediately after cardioversion, which is considered a thrombogenic milieu in which new thrombus formation and increased or de novo appearance of LA spontaneous echocardiographic contrast have been observed. Furthermore, embolic events have been reported after cardioversion despite exclusion of preexisting LA thrombus by TEE. These studies strongly suggest an alternative mechanism for embolism after cardioversion, ie, atrial stunning with worsened atrial appendage function and enhanced thrombogenesis. Recent studies have shown the safety of a TEE-guided anticoagulation approach in which exclusion of preexisting LA thrombus by TEE enables early cardioversion without the need for the standard 3 weeks of systemic anticoagulation. The importance of maintaining therapeutic anticoagulation has been further emphasized. Although preliminary observational studies of TEE-guided cardioversion are encouraging, there has been no prospective, randomized trial comparing the two strategies of anticoagulation management. The Assessement of Cardioversion Utilizing Transesophageal Echocardiography (ACUTE) pilot study randomized 126 patients from 10 sites and showed the feasibility and safety of the larger scale study. A larger multicenter, prospective randomized trial is now underway and is expected to randomize a total of 3,000 patients. The results of the ACUTE study will definitively establish the safest and the most cost-effective way to manage anticoagulation for elective cardioversion.

Integrated backscatter for quantification of left atrial spontaneous echo contrast

OBJECTIVES

This study was designed to develop a quantitative method of spontaneous echo contrast (SEC) assessment using integrated backscatter and to compare integrated backscatter SEC measurement with independent qualitative grades of SEC and clinical and echocardiographic predictors of thromboembolism.

BACKGROUND

Left atrial SEC refers to dynamic swirling smokelike echoes that are associated with low flow states and embolic events and have been graded qualitatively as mild or severe.

METHODS

We performed transesophageal echocardiography in 43 patients and acquired digital integrated backscatter image sequences of the interatrial septum to internally calibrate the left ventricular cavity and left atrial cavity under different gain settings. Patients were independently assessed as having no, mild or severe SEC. We compared intensity of integrated backscatter in the left atrial cavity relative to that in the left ventricular as well as to the independently assessed qualitative grades of SEC. Fourier analysis characterized the temporal variability of SEC. The integrated backscatter was compared with clinical and echocardiographic predictors of thromboembolism.

RESULTS

The left atrial cavity integrated backscatter intensity of the mild SEC subgroup was 4.7 dB higher than that from the left ventricular cavity, and the left atrial intensity of the severe SEC subgroup was 12.5 dB higher than that from the left ventricular cavity. The left atrial cavity integrated backscatter intensity correlated well with the qualitative grade. Fourier transforms of SEC integrated backscatter sequences revealed a characteristic dominant low frequency/high amplitude spectrum, distinctive from no SEC. There was a close relationship between integrated backscatter values and atrial fibrillation, left atrial size, left atrial appendage flow velocities and thrombus.

CONCLUSIONS

Integrated backscatter provides an objective quantitative measure of SEC that correlates well with qualitative grade and is closely associated with clinical and echocardiographic predictors of thromboembolism. The relationship between integrated backscatter measures and cardioembolic risk will be defined in future multicenter studies.

In vivo expression of IL-12 and IL-13 in atopic dermatitis

Previous studies in atopic dermatitis (AD) have shown that acute and chronic skin lesions are associated with a TH2-type profile of cytokine expression. IL-12 and IL-13 are recently described cytokines, which possess TH1-and TH2-like actions, respectively. We have used the technique of in situ hybridization to examine the expression of IL-12 and IL-13 messenger RNA in skin biopsy specimens of acute and chronic skin lesions and uninvolved skin from patients with AD. When compared with normal control skin, the acute and chronic skin lesions and unaffected skin from patients with AD had significantly greater numbers of cells that were positive for IL-13 mRNA (p < 0.05). Acute AD skin lesions expressed a higher number of positive cells than those observed in chronic AD skin lesions (p < 0.05) or psoriasis skin lesions (p < 0.05) There was a significant increase in the numbers of IL-12 mRNA-positive cells in chronic skin lesions compared with acute lesions and uninvolved skin from patients with AD (p < 0.05). These data demonstrate that acute AD skin lesions are associated with an increased expression of IL-13 mRNA. In contrast, the relative increase in IL-12 mRNA in chronic AD skin lesions suggests a possible role for IL-12-producing cells in modulating chronic inflammation.

Bacterial superantigens induce V beta-specific T cell receptor internalization

Staphylococcal enterotoxins can cause toxic shock syndrome and autoimmune diseases. Circulating T cells from these diseases have a very wide range of expression in particular T cell receptor (TCR) beta chain variable regions (V beta). One possibility for this wide range of TCR V beta expression is that during acute infection with organisms secreting superantigens (SAg) these potent molecules might modulate TCR expression. To test this hypothesis, we investigated the potential effects of SAg on TCR V beta cell surface expression. Peripheral blood mononuclear cells (PBMC) from healthy donors were incubated with staphylococcal SAg. Toxic shock syndrome toxin-1 (TSST-1) induced downregulation of V beta 2 expression, whereas staphylococcal enterotoxin (SE) B induced V beta 3-and V beta 12-specific downregulation. TSST-1 did not interfere with anti-V beta 2 mAb binding. Therefore, this downregulation was not due to steric hindrance of Ab binding by TSST-1. TSST-1 induced V beta 2 downregulation was time-, dose- and temperature-dependent. CD3 expression decreased in parallel with reduction of V beta expression. CD4 and CD8 expression were only slightly decreased. CD2, CD25 and HLA-DR expression were upregulated following TSST-1 stimulation of T cell lines. To investigate the fate of TCR after toxin stimulation, V beta 8+ Jurkat T cells were incubated with SEE which is known to stimulate V beta 8+ T cells, and analysed with fluoresence microscopy, and immunoprecipitation and Western blotting. After SEE stimulation, there was an increase in V beta 8 molecules found in the cytoplasm which correlated with loss of cell surface V beta 8 molecules, suggesting internalization of cell surface V beta 8 molecules was induced by SEE stimulation. Shedding of V beta 8 molecules into the culture supernatant was not detected. These data demonstrate that SAg mediated downregulation of TCR expression occurs primarily as the result of TCR internalization. This downregulation phenomenon may have physiological and pathological consequences in patients infected with Staphylococcus aureus.

Candida albicans induces selective expansion of human T lymphocytes expressing the T-cell receptor variable region V beta 5.1

Candida albicans is a common pathogen which can present major problems as an opportunistic skin pathogen in patients with immunodeficiency. The exact nature of the T cell responses to C. albicans is poorly understood. The purpose of this study was to determine whether C. albicans could stimulate the selective expansion of T lymphocytes expressing particular V beta gene segments. Human T lymphocytes stimulated in vitro with an extract of C. albicans were analyzed for T cell receptor V beta gene expression by using a quantitative PCR technique. We found that stimulation of peripheral blood mononuclear cells (PBMC) produced a selective increase in the expression of V beta 5.1 and 5.2 gene transcripts. Using cytofluorographic analysis with available anti-V beta monoclonal antibodies, we verified that there was a significant selective expansion (P = 0.035) of V beta 5.1 positive T lymphocytes in PBMC from six subjects stimulated in vitro with C. albicans. PCR analysis of V beta 5.1 expansion in 10 subjects showed increases in V beta 5.1 gene transcripts in 7/10 subjects. More importantly, analysis of the T cell infiltrate 48 h after intradermal injections with C. albicans also showed significant expression of V beta 5.1 in the infiltrates, along with the infiltration of V beta 8.1 + T cells. The selective expansion of V beta 5.1 bearing T lymphocytes in PBMC stimulated with C. albicans and in skin test reactions to C. albicans suggests that a restricted population of T cells react to C. albicans. Furthermore, our present data raise the provocative possibility that one or more antigens in C. albicans can act as a superantigen, producing selective expansion of a population of T lymphocytes bearing a particular V beta specificity.

Differential effects of staphylococcal toxic shock syndrome toxin-1 on B cell apoptosis

Superantigens, such as toxic shock syndrome toxin 1 (TSST-1), have been implicated in the pathogenesis of several autoimmune and allergic diseases associated with polyclonal B cell activation. In this report, we studied the in vitro effects of TSST-1 on B cell activation. We show herein that TSST-1 produced antagonistic effects on Ig synthesis by peripheral blood mononuclear cells (PBMC) from normal subjects, depending on the concentration used; Ig production was inhibited at 1000 pg/ml (P < 0.01) and enhanced at 1 and 0.01 pg/ml (P < 0.01) of toxin. Cultures of PBMC were then examined for morphologic features and DNA fragmentation characteristic for apoptosis. B cells exhibited a significantly higher (P < 0.01) incidence of apoptosis after stimulation with 1000 pg/ml of TSST-1 compared with 1 or 0.01 pg/ml of toxin or medium alone. Abundant expression of Fas, a cell surface protein that mediates apoptosis, was detected on B cells after stimulation with 1000 pg/ml of TSST-1 and was significantly higher on B cells undergoing apoptosis than on live cells (P = 0.01). Additionally, increased Fas expression and B cell death occurred at concentrations of TSST-1 inducing the production of high amounts of gamma interferon (IFN-gamma), and both events could be blocked by neutralizing anti-IFN-gamma antibody. These findings suggest that high concentrations of TSST-1 can induce IFN-gamma-dependent B cell apoptosis, whereas at low concentrations it stimulates Ig synthesis by PBMC from normal subjects. These findings support the concept that staphylococcal toxins have a role in B cell hyperactivity in autoimmunity and allergy.

Kawasaki syndrome: immunomodulatory benefit and potential toxin neutralization by intravenous immune globulin

Kawasaki Syndrome (KS) is an acute multi-system vasculitis of infancy and early childhood associated with the development of coronary artery abnormalities. The prevalence of cardiovascular abnormalities can be significantly reduced by treating patients during the first 10 days of illness with high-dose intravenous immune globulin (IVIG). Despite the widely held belief that KS is caused by an infectious agent, the aetiology of this illness remains controversial. Recent immunological and microbiological studies suggest a potential role for staphylococcal and streptococcal toxins (superantigens) in the pathogenesis of KS. Confirmation of these findings could result in more effective diagnostic and therapeutic approaches for the treatment of this common cause of acquired heart disease in children.

Cutaneous exposure to the superantigen staphylococcal enterotoxin B elicits a T-cell-dependent inflammatory response

We analyzed the impact of superantigens secreted by skin-colonizing Staphylococci on the skin and the associated lymphoid tissue following epicutaneous application and intracutaneous injection of small amounts of staphylococcal enterotoxin B (SEB). A single intracutaneous injection of 50 ng of SEB elicited a strong inflammatory response in the skin of BALB/c mice. Three to 6 h later, we observed langerhans cell activation, mast cell degranulation, vasodilation, upregulation of ICAM-1, and induction of VCAM-1 on dermal blood vessels, with vascular adhesion of granulocytes. by 12 to 24 h, cell infiltration of the dermis increased, reaching the epidermis. Among the infiltrating leukocytes, a substantial number of eosinophils was found. After 48 h, the infiltrate was dominated by mononuclear cells. The response to SEB was dose-dependent, and signs of inflammation slowly disappeared over 5 to 7 days. Although the induction of VCAM-1 on dermal blood vessels suggested a role for interleukin-1/tumor necrosis factor-alpha in this reaction, the activation of monocytes/macrophages was not able to substitute for lymphocytes, as severe combined immunodeficiency (SCID) mice (which are lymphocyte-deficient) did not mount an inflammatory skin response to intradermal injection of SEB. The fact that nude mice (T-cell-deficient) also did not mount an inflammatory response to SEB indicated the T-cell dependency of the response. The V beta specificity of the SEB effect was demonstrated by the fact that SJL/J mice, which lack V beta 8+ T cells (the major SEB-reactive T cell population in mice), exhibited much weaker responses. Deletion or tolerization of SEB-reactive V beta T cells was not observed after a single intradermal injection of such minute amounts of SEB.

Modulatory effects of staphylococcal superantigen TSST-1 on IgE synthesis in atopic dermatitis

Atopic dermatitis (AD) is a chronic skin disorder associated with elevated serum IgE and colonization of the skin by Staphylococi which secrete toxins with superantigenic activity. The present study examined the immunomodulatory effects of toxic shock syndrome toxin (TSST)-1, a prototypic superantigen, on IgE synthesis by interleukin (IL)-4-stimulated peripheral blood mononuclear cells (PBMC) from five patients with AD and five normal subjects. TSST-1 inhibited IL-4-induced IgE synthesis by AD and normal PBMC (P < 0.05). In contrast, IgG synthesis was not similarly affected (P > 0.30). Inhibition of IL-4-induced IgE production was associated with induction of interferon (IFN)-gamma synthesis by TSST-1 (P < 0.02). Normal PBMC synthesized significantly more (P < 0.005) IFN-gamma than AD PBMC. A neutralizing antibody to IFN-gamma reversed TSST-1-induced suppression of IgE synthesis by the normal PBMC (P < 0.03), but not the AD PBMC. In AD, but not normal, PBMC anti-IFN-alpha antibody reversed the suppression of IgE synthesis induced by TSST-1. These results demonstrate that TSST-1 uses different mechanisms for modulation of IgE synthesis in AD versus normal PBMC. Furthermore, the reversal of TSST-1-induced suppression of IgE synthesis in AD PBMC by anti-IFN-alpha, but not anti-IFN-gamma, is consistent with the concept that AD is associated with defective Th1 cell function and enhanced monocyte activity.

Upregulation of IgE synthesis by staphylococcal toxic shock syndrome toxin-1 in peripheral blood mononuclear cells from patients with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a chronic skin disease associated with increased IgE synthesis and colonization with Staphylococcus aureus secreting exotoxins, such as Toxic Shock Syndrome Toxin-1 (TSST-1).

OBJECTIVES

In this study, we were interested in determining the in vitro effects of TSST-1 on IgE synthesis in peripheral blood mononuclear cells from patients with AD.

METHODS

We stimulated peripheral blood mononuclear cells (PBMC) from AD patients with a wide range of TSST-1 concentrations and measured IgE synthesis by enzyme-linked immunosorbent assay (ELISA) after 14 days.

RESULTS

We show herein that TSST-1 produced antagonistic effects on IgE synthesis by PBMC from AD patients, depending on the concentration used: IgE synthesis was inhibited at 1000 pg/mL (P < 0.05) and enhanced at 0.01 pg/mL (P < 0.01) of toxin. TSST-1 was found to induce the production of much higher amounts of interferon-gamma (IFN gamma) at 1000 pg/mL than at 0.01 pg/mL of toxin (P = 0.0001). More importantly, immunoglobulin E (IgE) synthesis was enhanced by TSST-1 at 1 pg/mL in the presence of antibodies blocking IFN gamma activity. The other immunoglobulin (Ig) isotypes were also increased after TSST-1 stimulation suggesting that the enhanced IgE synthesis was secondary to a polyclonal B cell activation rather than an isotype switch. TSST-1-stimulated IgE synthesis was T cell-dependent because purified tonsil B cells were only able to synthesize increased amounts of IgE when small numbers of T cells were added to the cultures. Anti-HLA-DR and anti-LFA-1 monoclonal antibodies (MoAb) inhibited TSST-1-enhanced IgE synthesis, suggesting that the bridging of the T cell receptor (TCR) and major histocompatibility complex (MHC) class II on B cells was necessary for activation of B cell differentiation.

CONCLUSION

These data indicate that staphylococcal superantigens are able, at concentrations inducing low amounts of IFN gamma, to stimulate IgE synthesis by PBMC from AD patients, and suggest that staphylococcal toxins may contribute to elevated IgE synthesis in AD.

Evidence for superantigen involvement in cardiovascular injury due to Kawasaki syndrome

Kawasaki syndrome (KS), the major cause of acquired heart disease in children, is an acute multisystem vasculitis frequently associated with the development of myocarditis and coronary artery abnormalities. Despite the widely held belief that KS is an infectious disease, its etiology has remained elusive. Recently, we and others have reported the selective expansion of V beta 2+ T cells in the peripheral blood of most patients in the acute, but not in the convalescent, phase of KS. These data were consistent with the concept that this illness is triggered by a bacterial superantigen. We report here that a patient who died of acute KS had selective expansion of V beta 2+ T cells in her myocardium and coronary artery. Sequence analysis of TCR beta-chain genes of V beta 2+ T cells from the myocardium showed extensive junctional region diversity. These observations, along with the demonstration of V beta 2 expansion in both the CD4+ and CD8+ T cell subsets, support the concept that the activation of infiltrating V beta 2+ T cells are involved in the cardiovascular damage associated with KS.

Evidence for superantigen involvement in cardiovascular injury due to Kawasaki syndrome

Kawasaki syndrome (KS), the major cause of acquired heart disease in children, is an acute multisystem vasculitis frequently associated with the development of myocarditis and coronary artery abnormalities. Despite the widely held belief that KS is an infectious disease, its etiology has remained elusive. Recently, we and others have reported the selective expansion of V beta 2+ T cells in the peripheral blood of most patients in the acute, but not in the convalescent, phase of KS. These data were consistent with the concept that this illness is triggered by a bacterial superantigen. We report here that a patient who died of acute KS had selective expansion of V beta 2+ T cells in her myocardium and coronary artery. Sequence analysis of TCR beta-chain genes of V beta 2+ T cells from the myocardium showed extensive junctional region diversity. These observations, along with the demonstration of V beta 2 expansion in both the CD4+ and CD8+ T cell subsets, support the concept that the activation of infiltrating V beta 2+ T cells are involved in the cardiovascular damage associated with KS.

Evidence for a streptococcal superantigen-driven process in acute guttate psoriasis

Recent studies have suggested that T cells play a critical role in the pathogenesis of psoriasis. Guttate psoriasis is a well-defined form of psoriasis frequently associated with streptococcal throat infection. This study tested the hypothesis that T cells in acute guttate psoriasis skin lesions may be activated by streptococcal superantigens. Peripheral blood as well as lesional and perilesional skin biopsies were analyzed for T cell receptor V beta repertoire using monoclonal antibodies against 10 different V beta families. Skin biopsies from all patients with acute guttate psoriasis, but not skin biopsies from patients with acute atopic dermatitis or inflammatory skin lesions induced in normal subjects with sodium lauryl sulfate, demonstrated selective accumulation of V beta 2+ T cells (P < 0.05). The expansion of V beta 2+ T cells occurred in both the CD4+ and the CD8+ T cell subsets. Sequence analysis of T cell receptor beta chain genes of V beta 2-expressing T cells from skin biopsies of patients with guttate psoriasis showed extensive junctional region diversity that is more compatible with a superantigen rather than a conventional (nominal) antigen-driven T cell response. All streptococcal isolates from patients with guttate psoriasis secreted streptococcal pyrogenic exotoxin C, a superantigen known to stimulate marked V beta 2+ T cell expansion. These data support the concept that acute guttate psoriasis is associated with superantigenic stimulation of T cells triggered by streptococcal superantigen(s).

The potential role of bacterial superantigens in the pathogenesis of Kawasaki syndrome

Kawasaki syndrome is an acute multisystem vasculitis of infancy and early childhood associated with high fever, mucocutaneous inflammation, and the development of coronary artery abnormalities. Despite the widely held belief that Kawasaki syndrome is an infectious disease, investigations have failed to identify a causal organism. Previous studies have demonstrated that this illness is associated with marked activation of monocyte/macrophages and the selective expansion of V beta 2-, less so, of V beta 8.1/8.2-expressing T cells in the peripheral blood from Kawasaki syndrome patients during the acute phase of their illness. These immunologic features are characteristic of diseases that are caused by bacterial toxins which act as superantigens. Staphylococcal enterotoxins and streptococcal exotoxins are prototypic superantigens which stimulate large populations of T cells expressing particular T-cell receptor beta-chain variable (V beta) gene segments. Using the V beta 2+ T-cell expansion as an "immunologic footprint" for a superantigen, we have extended these observations to the identification and isolation of a novel clone of toxic shock syndrome toxin-1-producing Staphylococcus aureus in the majority of patients with Kawasaki syndrome and streptococcal pyrogenic exotoxin B/streptococcal pyrogenic exotoxin C-producing streptococci in a minority of Kawasaki syndrome patients. Toxic shock syndrome toxin-1, streptococcal pyrogenic exotoxin B, and streptococcal pyrogenic exotoxin C are known to stimulate V beta 2+ T cells. These observations support the hypothesis that the activation of V beta 2+ T cells during the acute phase of Kawasaki syndrome is caused by bacterial superantigen(s).

Molecular structure of staphylococcus and streptococcus superantigens

Staphylococcus aureus and streptococci, notably those belonging to group A, make up a large family of true exotoxins referred to as pyrogenic toxin superantigens. These toxins cause toxic shock-like syndromes and have been implicated in several allergic and autoimmune diseases. Included within this group of proteins are the staphylococcal enterotoxins, designated serotypes A, B, Cn, D, E, and G; two forms of toxic shock syndrome toxin-1 also made by Staphylococcus aureus; the group A streptococcal pyrogenic exotoxins, serotypes A, B, and C; and recently described toxins associated with groups B, C, F, and G streptococci. The nucleotide sequences of the genes for all of the toxins except those from the groups B, C, F, and G streptococcal strains have been sequenced. The sequencing studies indicate that staphylococcal enterotoxins B and C and streptococcal pyrogenic exotoxin A share highly significant sequence similarity; staphylococcal enterotoxins A, D, and E share highly significant sequence similarity; and toxic shock syndrome toxin-1 and streptococcal pyrogenic exotoxin B and C share little, if any, sequence similarity with any of the toxins. Despite the dissimilarities seen in primary amino acid sequence among some members of the toxin family, it was hypothesized that there was likely to be significant three-dimensional structure similarity among all the toxins. The three-dimensional structures of three of the pyrogenic toxin superantigens have been determined recently. The structural features of two of these, toxic shock syndrome toxin-1 and enterotoxin C3, are presented. Toxic shock syndrome-1 exists as a protein with two major domains, referred to as A and B. The molecule begins with a short N-terminal alpha-helix that then leads into a clawshaped structure in domain B that is made up of beta strands.

Superantigens in Kawasaki syndrome

Kawasaki syndrome (KS) is an acute multisystem vasculitis of infancy and early childhood associated with the development of myocarditis and coronary artery abnormalities. Despite the widely held belief that KS is caused by an infectious agent, there remains considerable controversy over its etiology. Recent immunologic and microbiologic studies suggest a potential role for staphylococcal and streptococcal toxins (superantigens) in the pathogenesis of KS. Confirmation of these findings could result in more effective diagnostic and therapeutic approaches to this common cause of acquired heart disease in children.

Quantification of mitral regurgitation by the proximal convergence method using transesophageal echocardiography. Clinical validation of a geometric correction for proximal flow constraint

BACKGROUND

Proximal flow convergence is a promising method to quantify mitral regurgitation but may overestimate flow when the flow field is constrained. This has not been investigated clinically, nor has a correction factor been validated.

METHODS AND RESULTS

Eighty-five patients were studied intraoperatively with transesophageal echocardiography and divided into two groups: central convergence (no constraining wall) and eccentric convergence (at least one constraining wall). Regurgitant stroke volume (RSV) and orifice area (ROA) were calculated by ROA = 2 pi r2 Va/Vp and RSV = ROA x VTIcw, where r and va are the radius and velocity of the aliasing contour and vp and VTIcw are the peak and integral of regurgitant velocity. In eccentric convergence patients, convergence angle (alpha) was measured from two-dimensional Doppler color flow maps, and ROA and RSV were corrected by multiplying by alpha/180. For reference, RSV was the difference between thermodilution and pulsed Doppler stroke volumes. In central convergence patients (n = 45), RSV (r = .95, delta = 2.5 +/- 10.8 mL) and ROA (r = .96, delta = 0.02 +/- 0.08 cm2) were accurately calculated, but significant overestimation was noted in the eccentric convergence patients (n = 40, delta RSV = 63.9 +/- 38.0 mL, delta ROA = 0.54 +/- 0.31 cm2), 68% of whom had leaflet prolapse or flail. delta RSV was correlated with alpha (r = -.69, P < .001). After correction by alpha/180, overestimation was largely eliminated (delta RSV = 15.5 +/- 19.3 mL and delta ROA = 0.14 +/- 0.14 cm2) with excellent correlation for the whole group (RSV, r = .91; ROA, r = .95).

CONCLUSIONS

A simple geometric correction factor largely eliminates overestimation caused by flow constraint with the proximal convergence method and should extend the clinical utility of this technique.