Update on the treatment of Kawasaki disease in childhood

Decreased Serum Apolipoprotein CIII in the Acute Phase of Kawasaki Disease

Plasma exchange is an effective treatment for Kawasaki disease (KD), suggesting that plasma from patients with KD bears its causative agents. The aim of this study was to use mass spectrometry to identify candidate agents in patient sera. Serum samples were obtained from 17 KD patients. In six patients, samples were collected in each of three phases: the acute phase prior to acetylsalicylic acid (ASA) and intravenous immunoglobulin administration (Phase A1), the remission phase with ASA (Phase A2), and the remission phase without any medication (Phase A3). Sera from the remaining 11 patients were collected during Phases A1 and A2. The study also included two age- and gender-matched control groups, one with eight afebrile children and one with eight febrile children diagnosed with infectious disease. Patients in Phase A1 and febrile controls did not differ in body temperature, white blood cell counts, or C-reactive protein levels. Mass spectrometry analysis revealed that the intensity levels of m/z 9416, identified as apolipoprotein CIII (Apo CIII), were lower in Phase A1 samples compared with samples from patients in Phases A2 and A3, and from febrile controls (all comparisons, p < 0.01). Serum Apo CIII levels were also lower in Phase A1 samples compared with samples from Phase A2 patients and afebrile controls (both p < 0.01), but samples from patients in Phase A2 did not differ significantly from those of the afebrile controls (p = 0.55). This study demonstrated that serum Apo CIII level was decreased in the acute phase of KD.

Heart Disease in Children

The pediatric cardiology field has developed rapidly over the past few decades. More children than ever born with congenital heart disease (CHD) are growing into adulthood. Primary care providers play a key role in diagnosis, management, and referral of children with CHD because many common cardiac complaints (eg, feeding intolerance, cyanosis, chest pain, palpitations, and syncope) are first addressed in the primary care setting. The spectrum of heart disease in children ranges from common complaints to complex single-ventricle physiology, acute myocarditis, and heart transplantation. This article reviews the pathophysiology and management of the most frequent cardiac conditions encountered in primary care.

Update on the use of immunoglobulin in human disease: A review of evidence

Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.

Asymptomatic Kawasaki Disease in a 3-Month-Old Infant

Kawasaki disease (KD) is the leading cause of acquired heart disease in children in the United States. It is a systemic vasculitis characterized by diffuse inflammation of medium and small blood vessels. If untreated it can lead to myocardial infarction, ischemic heart disease, or sudden death. Early recognition and treatment decrease the incidence of coronary consequences, resulting in improved clinical outcomes. Incomplete KD is much less likely to fulfill major clinical diagnostic criteria. Infants <12 months of age are more likely to have an incomplete presentation, and children <6 months of age are more likely to develop cardiac complications. We present a case of a 3-month-old, previously healthy white boy who was noted to have a new transient cardiac murmur during a routine health assessment. He was completely asymptomatic, and physical examination was otherwise within normal limits. An echocardiogram was performed and showed abnormal dilation of several coronary arteries, consistent with the coronary ectasia associated with KD. Laboratory evaluation was significant for values suggestive of systemic inflammation. Based on these results, a presumed diagnosis of incomplete KD was made and treatment administered. Close surveillance was undertaken, and serial laboratory studies and imaging showed gradual resolution of inflammatory markers and cardiac ectasia. This unique case of incomplete KD without any of the physical signs normally associated with the disease emphasizes the spectrum of presentation and the possibility of missing a diagnosis of incomplete disease, reinforcing the need to remain vigilant.

Kawasaki disease

Kawasaki disease (KD) is the archetypal pediatric vasculitis, exemplifying the unique aspects and challenges of vascular inflammation in children. The condition is almost unheard of in adults, is closely associated with infections, and is self-limited, with fever resolving after an average of 12 days even without treatment. Yet KD is also a potentially fatal disease and the most common cause of acquired heart disease in the developed world. Unraveling of the developmental, immunologic, and genetic secrets of Kawasaki disease promises to improve our understanding of vasculitis in particular, and perhaps also to provide a window on the fundamental mysteries of inflammatory diseases in general.

Increased α1-antitrypsin levels in acute-phase Kawasaki disease as shown by SELDI-TOF MS analysis

Various agents have been suggested as causal or associated factors in the pathogenesis of Kawasaki disease (KD); however, the underlying factors of KD remain unknown. Plasma exchange is one of the most effective treatments for the acute phase of KD. This indicates that plasma may contain factors associated with the pathogenesis of KD. To search for proteins that may be involved in KD pathogenesis, we analyzed serum proteins with surface-enhanced laser desorption/ionization time of flight mass spectrometry (SELDI-TOF MS). Serum samples were obtained from 17 KD patients. Serum from six of the patients was collected during acute phase before acetylsalicylic acid (ASA) and intravenous immunoglobulin administration (phase A1), during remission with ASA (phase A2), and during remission without any medication (phase A3). Serum from the remaining 11 patients was collected for phases A1 and A2 only. There were two age- and sex-matched control groups comprising 8 afebrile healthy children (group B) and 8 febrile children with several infectious diseases (group C). There were no statistical differences in laboratory examination between phase A1 and group C except for albumin level, alanine aminotransferase, or sodium level. Serum samples were analyzed by SELDI-TOF MS after purification. We detected five peaks, i.e., those were specifically increased or decreased during phase A1, and identified 1 of these as α1-antitrypsin (α1-AT). α1-AT can inhibit neutrophil elastase activity. This elastase is thought to play a role in coronary artery damage. Our findings present an interesting starting point for further investigations into the pathophysiology of KD.

Pediatric vasculitis

Childhood vasculitis is a challenging and complex group of conditions that are multisystem in nature and often require integrated care from multiple subspecialties, including rheumatology, dermatology, cardiology, nephrology, neurology, and gastroenterology. Vasculitis is defined as the presence of inflammation in the blood vessel wall. The site of vessel involvement, size of the affected vessels, extent of vascular injury, and underlying pathology determine the disease phenotype and severity. This article explores the classification and general features of pediatric vasculitis, as well as the clinical presentation, diagnostic evaluation, and therapeutic options for the most common vasculitides.

The Molecular Biology and Treatment of Systemic Vasculitis in Children

Primary systemic vasculitides are rare in childhood but are associated with significant morbidity and mortality. The cause of the majority of vasculitides is unknown, although it is likely that a complex interaction between environmental factors, such as infections and inherited host responses, triggers the disease and determines the vasculitis phenotype. Several genetic polymorphisms in vasculitides have now been described, which may be relevant in terms of disease predisposition or development of disease complications. Treatment regimens continue to improve with the use of different immunosuppressive medications and newer therapeutic approaches such as biologic agents. This chapter reviews recent studies shedding light on the pathogenesis of vasculitis with emphasis on molecular biology where known, and summarizes current treatment strategies. We discuss new emerging challenges particularly with respect to the long-term cardiovascular morbidity for children with systemic vasculitis and emphasize the importance of future international multicenter collaborative studies to further increase and standardize the scientific base investigating and treating childhood vasculitis.

Vasculitis in children

Vasculitis is rare in children, and, apart from HSP and perhaps KD, most practicing pediatricians will never encounter a case. Nonetheless, progress in the diagnosis and treatment of these conditions has afforded most children with vasculitis a reasonably good prognosis. Accordingly, it is important to consider vasculitis as a potential cause of unexplained inflammation, perplexing rashes, or strange combinations of symptoms. Although evaluation and management of suspected vasculitis are difficult in the best of situations, they are impossible if the diagnosis is not considered.

Kawasaki disease: diagnosis, management and cardiac sequelae

Kawasaki disease (KD) is an acute self-limiting systemic vasculitis of unknown etiology and the most common cause of acquired coronary disease in children aged 6 months to 5 years. The inflammatory process results in coronary arteritis, aneurysmal lesions, arterial thrombotic occlusion or even sudden death. The diagnostic tests are unknown but treatment with immunoglobulin and aspirin is effective at reducing cardiac complications from 25 to 4.7% in the UK. Myocardial, endocardial or pericardial inflammation may occur acutely or many years later and abnormalities of myocardial blood flow may require ongoing medication, interventional catheterization or even cardiac surgery. There are several new drugs that may have important roles to play in managing KD in children and young adults.

Coronary artery dilation among patients presenting with systemic-onset juvenile idiopathic arthritis

OBJECTIVE

To evaluate coronary artery diameters among patients presenting with systemic-onset juvenile idiopathic arthritis (SoJIA).

METHODS

Fifty cases of SoJIA were reviewed. At the time of initial presentation with fever, 12 patients had echocardiograms that included a complete evaluation of the coronary arteries. A single reviewer measured the diameters of the left main, proximal left anterior descending, and proximal right coronary arteries. Body surface area-adjusted z scores were calculated with respect to a normative population.

RESULTS

Coronary artery dilation (z score: >2) was observed for 5 of the 12 patients with SoJIA who had echocardiograms performed at the time of presentation with fever. No patient developed a coronary artery aneurysm, and all of the coronary artery z scores normalized within 4 months. Only 2 of the 5 patients with coronary artery z scores of >2 fulfilled the clinical criteria for Kawasaki disease, the most commonly recognized cause of coronary artery dilation among children.

CONCLUSIONS

Children presenting with SoJIA may have coronary artery dilation similar to that observed for children with Kawasaki disease. These data suggest that the presence of coronary artery dilation on initial echocardiograms for patients with fever does not exclude the diagnosis of SoJIA.

Vasculitis in children

This article provides a general overview of vasculitis, situations in which the diagnosis should be considered, diagnostic methods, and therapeutic considerations. Details and treatments unique to specific vasculitides are also reviewed.

The diagnosis and management of Kawasaki disease

Kawasaki disease (KD) is a systemic vasculitis of childhood with a predilection for the coronary arteries. It is the predominant cause of paediatric acquired heart disease in developed countries. The aetiology of KD remains unknown and consequently there is no diagnostic test. The diagnosis is made using a constellation of clinical criteria that in isolation have poor sensitivity and specificity. Early treatment prevents overt coronary artery damage in the majority of children. The long-term effects of childhood KD on later cardiovascular health remain unknown. A recent study showed that treatment of KD in Australia is suboptimal, with late diagnosis occurring in approximately half of the cases and an unacceptably high incidence of acute cardiac involvement. These guidelines highlight the difficulties in the diagnosis of KD and offer some clues that may assist early recognition of this important paediatric disease. They also detail current treatment recommendations and the evidence on which they are based. Increased awareness of the epidemiology and spectrum of the clinical presentation of KD is essential for early recognition and optimal management.

Efficacy and safety of intravenous immunoglobulin for immune-mediated skin disease: current view

Intravenous immunoglobulins (IVIgs) exert a variety of immunomodulating activities and are, therefore, increasingly being used for the treatment of immune-mediated as well as autoimmune diseases. There is also accumulating evidence that high-dose IVIg (hdIVIg) is highly efficacious in the treatment of skin diseases, despite the lack of evidence from randomized, double-blind, placebo-controlled trials. A major advantage of hdIVIg in comparison with other commonly used immunomodulating therapeutic strategies is the excellent safety profile. Accordingly, IVIgs have been used successfully for the treatment of bullous autoimmune diseases such as pemphigus and bullous pemphigoid, dermatomyositis, scleroderma, cutaneous lupus erythematosus, toxic epidermal necrolysis, and erythema exudativum multiforme. In most cases, hdIVIg is effective only in combination with other immunomodulating strategies and allows for the reduction of adjuvants. Adverse effects of hdIVIg are generally mild and self-limiting. These include headache, myalgia, flush, fever, nausea or vomiting, chills, lower backache, changes in blood pressure, and tachycardia. To avoid infusion-related rigors, headaches, and other adverse events, pre-treatment with analgesics, NSAIDs, antihistamines, or low-dose intravenous corticosteroids may be beneficial. Controlled, double-blind, long-term clinical trials and a better understanding of the complex immunomodulating mechanism of IVIg are required to ultimately optimize dose, frequency, duration, and mode of IVIg administration.