Kawasaki disease: etiopathogenesis and novel treatment strategies

Thrombosis in vasculitis: An updated review of etiology, pathophysiology, and treatment

Introduction

Thromboembolic disease is a complication of many vasculitides. A common observation is that thromboembolic events coincide with the period of vasculitic disease, but the mechanism by which this occurs remains unclear. Inflammatory thrombosis is now recognized as a symptom of arteritis rheumatic, and vasculitides such as Behçet's syndrome (BS), and anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) or giant cell arteritis (GCA). This systematic review aimed to explain recent findings related to etiology, pathophysiology, and treatment methods for BS, AAV, and medium/large-vessel vasculitis.

Methods

A comprehensive literature search on English sources from PubMed, Scopus, MEDLINE, Science Direct, ProQuest, AIM, CINAHIL, and ELDIS databases was used to find the relevant articles and reports. The relevant papers (having full text) were obtained until June 2023. Two independent reviewers screened the titles and abstracts of the obtained articles, and a third arbitrator resolved disputes between the reviewers.

Results and conclusion

It is becoming increasingly clear that certain systemic inflammatory diseases, like vasculitis, are linked to a higher risk of both venous and arterial thrombosis. An increased incidence of thromboembolic disease in AAV has been noted, particularly during times of active disease. Growing evidence supports the use of immunosuppression in the management of venous thrombosis in vasculitis. These patients also have a higher risk of developing ischemic disease.

Coronary artery lesions in children with Kawasaki disease: status quo and nursing care

Aim

Coronary artery lesion (CAL) is a common yet serious complication in children with Kawasaki disease. The aim of the present study was to evaluate the influencing factors of CAL in children with Kawasaki disease, to provide reference for the clinical treatment and care of children with Kawasaki disease.

Design

A retrospective cohort study.

Methods

Children with Kawasaki disease treated in a tertiary hospital in China between 1 January 2021 and 31 December 2022 were selected. The characteristics and clinical data of children with Kawasaki disease were analyzed. Spearman's correlation analysis was conducted to evaluate the relationship between CAL and the characteristics of children with Kawasaki disease. A logistic regression analysis was used to analyze the influencing factors of CAL in children with Kawasaki disease.

Results

In total, 185 children with Kawasaki disease were included; the incidence of CAL in children with Kawasaki disease was 18.38%. Pearson's correlation analysis showed that gender (r = 0.504), age (r = 0.611), duration of fever ≥10 days (r = 0.579), hemoglobin (Hb) (r = 0.623), and C-reactive protein (CRP) (r = 0.558) were all correlated with the CAL in children with Kawasaki disease (all p < 0.05). Logistic regression analyses showed that male [odds ratio (OR) = 2.543, 95% confidence interval (CI): 1.801-3.077, p = 0.040], age ≤2 years (OR = 3.002, 95% CI: 2.744-3.641, p = 0.012), duration of fever ≥10 days (OR = 2.089, 95% CI: 1.624-2.515, p = 0.028), Hb ≤105 g/L (OR = 1.914, 95% CI: 1.431-2.406, p = 0.013), and CRP ≥100 mg/L (OR = 2.168, 95% CI: 1.893-2.531, p = 0.035) were the risk factors of CAL in children with Kawasaki disease (all p < 0.05).

Conclusions

The incidence of CAL in children with Kawasaki disease is high and there are many related risk factors. Clinical medical workers should take early warning and carry out interventions and nursing care according to these risk factors to improve the prognosis of children with Kawasaki disease.

Relationships between acute generalized eruptive pustulosis, age, sex, primary disease, and prescription medications: Further analysis of the Japanese Adverse Drug Event Report database

Background

Acute generalized eruptive pustulosis (AGEP) is a rare, but serious, drug-related adverse event. This study aimed to determine the relationships between AGEP and age, sex, primary disease, and prescription medications using a database of adverse drug events, namely, the Japanese Adverse Drug Event Report (JADER) database.

Methods

In this retrospective observational study, we analyzed AGEP reports extracted from the JADER database based on the preferred term for AGEP (code 10048799). We evaluated the effects of causative drugs, underlying diseases, age, and sex. The association between AGEP and prescription drugs was analyzed using the reporting odds ratio and adjusted for covariates using multiple logistic regression. Association rule mining was performed to evaluate the correlation between each combination of factors and AGEP.

Results

Between April 2004 and March 2023, 823,662 reports, including 869 reports on AGEP, were entered in the JADER database. The highest percentage of reports in each age group was in males aged <10 years, and clarithromycin was the most used drug in males aged <10 years. Nasopharyngitis was the most common reason for use, and Kawasaki disease was reported as a reason for use among males under 10 years of age, but not among females.

Conclusions

In boys aged <10 years, attention should be paid to the occurrence of AGEP when prescribing clarithromycin and treating Kawasaki disease.

Protective role of forsythoside B in Kawasaki disease-induced cardiac injury: Inhibition of pyroptosis via the SIRT1-NF-κB-p65 signaling pathway

Kawasaki disease (KD), an acute exanthematous febrile pediatric illness involving systemic non-specific inflammatory reactions in small- and medium-sized arteries, poses a significant risk of coronary artery and myocardial inflammatory injury. Developing new KD treatments with improved safety and fewer side-effects is highly desirable. Forsythoside B (FTS-B), extracted from the Forsythia suspensa plant, exerts anti-inflammatory activity by inhibiting NF-κB, which is regulated by SIRT1, the reduced expression of which is strongly associated with cardiovascular disease. However, it has yet to be established whether FTS-B influences KD-related inflammatory damage. In this study, we investigated the effects of FTS-B on inflammation in cellular and murine models of KD. Our findings revealed that KD is associated with cardiac dysfunction and inflammatory injury to myocardial and human coronary artery endothelial cells (HCAECs), resulting in a pyroptosis-feedback loop. Both cellular and KD models were characterized by reduced SIRT1 expression and increased NF-κB p65 expression. Contrastingly, the rates of pyroptosis in both murine model myocardial tissues and HCAECs were significantly alleviated in response to FTS-B treatment. Also in both models, we detected an increase of SIRT1 expression and a decrease in the expression of p65. Further examination of the protective mechanism of FTS-B using the SIRT1-specific inhibitor, EX 527, revealed that this inhibitor blocked the palliative effects of FTS-B on inflammatory injury-induced pyroptosis. These results highlight the potential utility of the SIRT1-NF-κB-p65 pathway as a therapeutic target for KD treatment and demonstrate that FTS-B can alleviate KD-induced cardiac and HCAEC inflammatory injury via inhibition of pyroptosis.

Identification of hub genes and pathogenesis in Kawasaki disease based on bioinformatics analysis

BACKGROUND

The aim of this study was to explore new biomarkers of Kawasaki disease (KD) and provide evidence for clinical diagnosis and treatment.

MATERIALS AND METHODS

Gene Expression Omnibus (GEO) datasets GSE68004 and GSE73461 were downloaded, and the differentially expressed genes (DGEs) were taken, along with DEGs enrichment analysis and protein interaction network. Finally, five algorithms in CytoHubba plug-in were applied to obtain hub genes.

RESULTS

In this study, 32 Co-DEGs were identified, and these genes mainly participated in neutrophil degranulation, neutrophil activation involved in immune response, and negative regulation of cytokine production involved in immune response; meanwhile, they were primarily enriched in starch and sucrose metabolism, fatty acid metabolism, autophagy and apoptosis, ferroptosis, and other pathways. Combined with the results of PPI and CytoHubba, 13 key genes were selected as follows: S100A12, HK3, HP, MMP9, MCEMP1, PYGL, ARG1, HIST2H2AA, ANXA3, HIST2H2AC, HIST2H2AA3, GYG1, DYSF.

CONCLUSIONS

These 13 key genes may mediate the occurrence and development of KD through various processes such as immune regulation, inflammatory response, glucose metabolism, autophagy, and apoptosis, which provide valuable references for the diagnosis and treatment of KD.

The impact of glucocorticoids therapy on cutaneous wounds in Kawasaki disease: A meta-analysis of randomized controlled trials

Kawasaki disease (KD) is one of the most challenging diseases that is defined as an acute vasculitis that affects the coronary arteries primarily in children. It causes complications if left untreated at early stages, ultimately leading to death. Corticosteroids have been recognized to treat and cause great impact on the patients with KD. Glucocorticoid is one of the main corticosteroids that are being used to treat KD and cutaneous wounds. However, ineffectiveness of a few glucocorticoids can limit the efficacy of this treatment. This study particularly aimed to elucidate the impact of glucocorticoids on cutaneous wounds in KD. To perform the meta-analysis, a comprehensive literature survey was conducted to unveil the studies and research conducted on Kawasaki patients that revealed different glucocorticoids in the form of specific interventions influencing KD. The literature was searched using numerous keywords, screened and data was extracted to perform the meta-analysis and then it was conducted using the metabin function of R package meta. A total of 2000 patients from both intervention and control groups were employed to carry out the meta-analysis to analyse and evaluate the impact of glucocorticoids on curing KD and cutaneous wounds in patients. The results disclosed that glucocorticoids along with other steroids, mainly IVIG (intravenous immunoglobulin), was an effective intervention to patients suffering from Kawasaki. The results depicted significant outcomes with the values (risk ratio [RR]: 1.08, 95% confidence interval [CI]: 0.58-2.00, p < 0.01) and enlightened the fact that adopting different glucocorticoids may significantly improve the efficacy of skin lesions along with KD. Hence, interventions of glucocorticoids must be utilized in the clinical practice to reduce the incidence of skin wounds and adverse effects caused due to KD.

Myocardial work is independent risk factor for coronary artery lesions in children with Kawasaki disease

BACKGROUND

The recognition ability of noninvasive echocardiographic myocardial work for coronary artery lesions (CAL) in children with Kawasaki disease (KD) has not been well characterized. This study aimed to determine whether impaired myocardial work is an independent risk factor for CAL in children with KD.

METHODS

Between December 2021 and April 2023, left ventricular (LV) myocardial work of 59 KD children was evaluated by myocardial work echocardiography, and their demographic, clinical and laboratory data were collected simultaneously. Multivariable logistic regression analysis was used to identify the independent risk factors for CAL.

RESULTS

Twenty-seven of 59 KD children had CAL according to the diagnostic criteria of echocardiography. There were significantly different heart rates, white blood cell count, LV ejection fraction, global work index (GWI), global work efficiency and global wasted work (GWW) between KD children with and without CAL ( P < 0.05). Multivariate logistic regression analysis identified that GWI [odds ratio (OR) = 0.985; P = 0.001], GWW (OR = 1.039; P = 0.019), erythrocyte sedimentation rate (ESR, OR = 1.051; P = 0.049) and C-reactive protein (CRP) (OR = 1.017; P = 0.044) were independent risk factors for CAL in children with KD. The area under receiver operating characteristic curve (AUC) of 0.847 for GWI was superior to that for GWW (AUC = 0.708), ESR (AUC = 0.645) and CRP (AUC = 0.626) to predict CAL in KD children ( P < 0.05). The optimal cutoff value of GWI was 1089 mmHg, with a sensitivity of 59.26% and a specificity of 96.87%.

CONCLUSION

GWI and GWW were independent risk factors for CAL in KD children with high discrimination ability.

Amino acids analysis reveals serum methionine contributes to diagnosis of the Kawasaki disease in mice and children

BACKGROUND

Kawasaki disease (KD) patients often lack early and definitive diagnosis due to insufficient clinical criteria, whereas biomarkers might accelerate the diagnostic process and treatment.

METHODS

The KD mouse models were established and thirteen amino acids were determined. A total of 551 serum samples were collected including KD patients (n = 134), HCs (n = 223) and KD patients after intravascular immunoglobulin therapy (IVIG, n = 194). A paired analysis of pre- and post-IVIG was employed in 10 KD patients.

RESULTS

The pathological alterations of the aorta, myocardial interstitium and coronary artery vessel were observed in KD mice; the serum levels of methionine in KD mice (n = 40) were markedly altered and negatively correlated with the C-reactive protein levels. Consistent with the mouse model, serum methionine were significantly decreased in KD children, with the relative variation ratio of KD with HCs above 30% and AUROC value of 0.845. Serum methionine were correlated with Z-Score and significantly restored to the normal ranges after KD patient IVIG treatment. Another case-control study with 10 KD patients with IVIG sensitivity and 20 healthy controls validated serum methionine as a biomarker for KD patients with AUROC of 0.86. Elevation of serum DNMT1 activities, but no differences of DNMT3a and DNMT3b, were observed in KD patients when comparing with those in the HCs.

CONCLUSIONS

Our study validated that serum methionine was a potential biomarker for KD, the alteration of which is associated with the activation of DNMT1 in KD patients.

Overview of Vasculitides in Adults

Vasculitis is characterized by the inflammation of blood vessels. Vasculitides refers to the different forms of vasculitis, often classified according to the size of the blood vessel that is involved. Vasculitis may occur as a primary process or secondary to many systemic diseases. This topic provides an overview of the clinical features, diagnosis, and classification of the different forms of vasculitides.

[Evidence-based guidelines for the diagnosis and treatment of Kawasaki disease in children in China (2023)]

Kawasaki disease (KD) is an acute self-limiting vasculitis, and it is the most common cause of acquired heart disease in children under 5 years old. One of the improvement goals in pediatric quality control work for the year 2023, as announced by the National Health Commission, is to reduce the incidence of cardiac events and KD-related mortality in children with KD. In order to standardize the diagnosis, treatment, and long-term management practices of KD in China, and effectively prevent and reduce the incidence of coronary artery lesions and long-term adverse effects, the guideline working group followed the principles and methods outlined by the World Health Organization and referenced existing evidence and experiences to develop the "Evidence-based guidelines for the diagnosis and treatment of Kawasaki disease in children in China (2023)". The guidelines address the clinical questions regarding the classification and definition of KD, diagnosis of different types of KD, treatment during the acute phase of KD, application of echocardiography in identifying complications of KD, and management of KD combined with macrophage activation syndrome. Based on the best evidence and expert consensus, 20 recommendations were formulated, aiming to provide guidance and decision-making basis for healthcare professionals in the diagnosis and treatment of KD in children.

Axillary artery aneurysms in pediatric patients: A narrative review

OBJECTIVES

Axillary artery aneurysms in children are rare and multifactorial. The presenting clinical picture can range from an incidental discovery to threatening symptoms, including loss of extremity function. With the present study we aim to give a comprehensive review of the existing literature focusing on the etiology and management of this rare but threatening pathology.

METHOD

A comprehensive review was made in a multi-staged manner. All identified studies have been categorized based on the type of lesions (true or false aneurysm) and their etiologies.

RESULTS

The treatments differ from the extension of the lesions and from the etiology.

CONCLUSIONS

Open surgery repair with great saphenous vein is still the best long-term approach, but even endovascular, embolization, or conservative management can be considered.

Platelet function in neonates and children

Platelets are major regulators of haemostasis and coagulation. The primary role of platelets in coagulation is to form a stable clot and stop bleeding. Studies of platelet phenotype and function in neonates and children have been restricted by the large volumes required for many common platelet function tests such as platelet aggregometry. Developmental changes in platelets have not been as well described as developmental changes in plasma coagulation proteins, and overall, platelet phenotype and function in neonates and children has been understudied when compared to adults. Recent developments in more sensitive platelet function testing methods requiring smaller blood volumes such as flow cytometry has enabled recent studies to further investigate platelet phenotype and function in neonates and children. In this review we will provide an overview of recent advances from the past five years in platelets in the context of developmental haemostasis, as well as the role of platelets in neonatal paediatric disease.

Dilemma in diagnosing incomplete Kawasaki disease in a resource limited setting

Introduction and importance

Kawasaki disease (KD) is an acute febrile systemic vasculitis that predominantly affects small to medium sized vessels and mostly occurs in children below 5 years of age. The morbidity and mortality mostly occur due to cardiac involvement.

Case presentation

The authors present a case of a 5-year-old male child from hilly region of Nepal who presented with fever for 7 days along with strawberry tongue and non-exudative conjunctivitis without rashes, extremity changes or lymphadenopathy. A suspicion of incomplete KD (IKD) was made. The notable investigation findings were increased erythrocyte sedimentation rate, C-reactive protein, leucocyte count and platelets. Echocardiography showed normal findings. Based on the clinical features and supplemental laboratory findings, a diagnosis of IKD was made. The patient improved after intravenous immunoglobulin and Aspirin.

Clinical discussion

The main learning objective that the authors get from this case is the challenges in the diagnosis of IKD in the resource limited setting like Nepal. Whether or not to start intravenous immunoglobulin is a dilemma for the physician in most of the cases of suspected IKD, due to the high cost and poor availability of intravenous immunoglobulin in this setting. Hence, the use of inflammatory markers, supplemental laboratory findings together with the few diagnostic criteria met by the patient helps in making a diagnosis and institute timely treatment with intravenous immunoglobulin and aspirin.

Conclusion

Diagnosis of KD in difficult in resource limited setting.

Cathelicidin (LL-37) causes expression of inflammatory factors in coronary artery endothelial cells of Kawasaki disease by activating TLR4-NF-κB-NLRP3 signaling

BACKGROUND

Kawasaki disease (KD) is a type of vasculitis with an unidentified etiology. Cathelicidin (LL-37) may be involved in the development of the KD process; therefore, further research to investigate the molecular mechanism of LL-37 involvement in KD is warranted.

METHODS

Enzyme-linked immunosorbent assay (ELISA) was used to detect the levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, NLRP3, and LL-37 in the sera of healthy subjects, children with KD, and children with pneumonia. Subsequently, human recombinant LL-37 or/and toll-like receptors 4 (TLR4)-specific inhibitor TAK-242 stimulated human coronary artery endothelial cells (HCAECs), CCK-8 was used to detect cell proliferation, flow cytometry to detect apoptosis, transmission electron microscopy to observe cytoskeletal changes, Transwell to measure cell migration ability, ELISA to detect inflammatory factor levels, Western blot analysis to analyze protein levels of toll-like receptors 4 (TLR4) and NF-κB p-65, and quantitative real-time polymerase chain reaction (qRT-PCR) to determine LL-37, NLRP3 mRNA levels.

RESULTS

In this study, we found that the level of LL-37 was highly expressed in the serum of children with KD, and after LL-37 stimulation, apoptosis was significantly increased in HCAECs, and the expression levels of TLR4, NLRP3 and inflammatory factors in cells were significantly enhanced. Intervention with the TLR4-specific inhibitor TAK-242 significantly alleviated the LL-37 effects on cellular inflammation, TLR4, NLRP3 promotion effect.

CONCLUSIONS

Our data suggest that LL-37 induces an inflammatory response in KD coronary endothelial cells via TLR4-NF-κB-NLRP3, providing a potential target for the treatment of KD.

Epstein-Barr virus downregulates the α7 nicotinic acetylcholine receptor of CD8+ T lymphocytes might associate with coronary artery lesions in Kawasaki disease patients

OBJECTIVES

Kawasaki disease (KD) is a systemic vasculitis that is caused by immunological dysregulation in children exposed to pathogens like Epstein-Barr virus (EBV). Myocardial ischemia or infarction due to coronary artery lesions (CALs) might be lethal. However, it is unclear how pathogens, immunomodulation, and CALs interact, particularly in KD patients co-infected with the most widespread virus, EBV.

METHODS

We investigated pathogen carriage and fundamental clinical data in 281 KD patients. Immunological differences between CALs and non-CALs in KD patients under different conditions were analyzed. Then, the effect of infection by different pathogens on the immune response was excluded, and most EBV co-infected KD patients were included to assess the incidence of CALs, the level of immune modulation, and regulatory mechanisms in different EBV infection states.

RESULTS

Our results showed multiple pathogenic infections occur in KD patients, with EBV being the most prevalent. The incidence of CALs in the EBV-DNA (+) acute infection group, EBV-DNA (-) acute infection group, and EBV latent infection group was 0 (0/6), 27.27% (3/11) and 41.67% (10/24), respectively. The two groups were younger and had increased IL-6 levels and B cells, decreasing CD8+ T cells than the EBV-DNA (+) acute infection group. Interestingly, the increased B cells were not associated with immunoglobulin release. Additionally, these patients down-regulated α7 nicotinic acetylcholine receptor (α7nAChR) and downstream molecule PI3K/AKT/mTOR while activating the NF-κB.

CONCLUSION

Patients with different EBV infection statuses exhibit different incidences of CALs. In acute EBV-DNA (-) infected and latent EBV-infected patients, the number of CD8+ T cells decreased and downregulated CD8+ T cells' α7nAChR and PI3K/AKT/mTOR, which may associate with CALs, while the expression of NF-κB and the pro-inflammatory factor IL-6 was upregulated by inhibiting the anti-inflammatory molecule α7nAChR.

Serum IL-41 might be a biomarker for IVIG resistance and coronary artery lesions in Kawasaki disease

BACKGROUND

This study aimed to evaluate serum IL-41 levels in IVIG resistance and CALs, and to elucidate the relationship between IL-41 and Kawasaki disease (KD)-related clinical parameters.

METHODS

93 children with KD were collected. Baseline clinical data were obtained by physical examination. Serum IL-41 levels were detected with an enzyme-linked immunosorbent assay. The correlations between IL-41 and the clinical parameter of KD were performed by Spearman correlation coefficient. Receiver operating characteristic curve analysis was performed to assess the predictive ability of IL-41 for IVIG resistance and CALs.

RESULTS

Serum IL-41 levels were significantly increased in the IVIG resistance group compared with the response group, and serum IL-41 levels in the CALs group were higher than those in the non-CALs group. Serum IL-41 levels were positively correlated with erythrocyte sedimentation rate, C-reactive protein and C-reactive protein/albumin ratio, but negatively correlated with albumin. Serum IL-41 levels was an independent risk factor for CALs, and total fever days and neutrophil-to-lymphocyte ratio (NLR) were independent predictors for IVIG resistance. The area under the curve (AUC) value for serum IL-41 to predict IVIG resistance was 0.73, yielding a sensitivity of 54.55% and a specificity of 81.71%. The AUC of serum IL-41 was 0.712, with a sensitivity of 63.16% and a specificity of 72.97% for predicting CALs. IL-41 was not inferior to NLR in predicting IVIG resistance (z = 0.282, p = 0.7783).

CONCLUSIONS

Serum IL-41 was increased in IVIG resistance and CALs. Serum IL-41 might be a new potential biomarker for IVIG resistance and CALs.

Novel Predictive Scoring System for Intravenous Immunoglobulin Resistance Helps Timely Intervention in Kawasaki Disease: The Chinese Experience

Background

Approximately 10%-20% of patients with Kawasaki disease (KD) are nonresponsive to intravenous immunoglobulin (IVIG) treatment, placing them at higher risk of developing coronary heart lesions. Early detection of nonresponsiveness is crucial to curtail this risk; however, the applicability of existing predictive scoring systems is limited to the Japanese population. Our study aimed to identify a predictive scoring system for IVIG resistance in KD specific to the Chinese population. We aimed to assess the utility of three commonly used risk-scoring systems in predicting IVIG resistance and compare them to the newly developed predictive scoring system.

Methods

A total of 895 patients with KD were enrolled in this retrospective review and divided into two groups: IVIG responders and nonresponders. Clinical and laboratory variables were compared between the two groups. Multivariable logistic regression models were used to construct a new scoring system. The utility of the existing and new scoring systems was assessed and compared using the area under the receiver operating characteristic curve.

Results

Albumin levels, percentage of neutrophils, and hemoglobin were independent predictors of resistance by logistic regression analysis. The new predictive scoring system was derived with improved sensitivity (60.5%) and specificity (87.8%). The area under the receiver operating characteristic curve was 0.818.

Conclusion

This study developed a novel risk-scoring system for predicting resistance to IVIG treatment in KD specific to the Chinese population. Although this new model requires further validation, it may be useful for improving prognostic outcomes and reducing the risk of complications associated with KD.

Identification of novel clusters of co-expressing cytokines in a diagnostic cytokine multiplex test

Introduction

Cytokines are mediators of the immune system that are essential for the maintenance, development and resolution of immune responses. Beneficial immune responses depend on complex, interdependent networks of signaling and regulatory events in which individual cytokines influence the production and release of others. Since disruptions in these signaling networks are associated with a wide spectrum of diseases, cytokines have gained considerable interest as diagnostic, prognostic and precision therapy-relevant biomarkers. However, currently individual cytokines testing has limited value because the wider immune response context is often overlooked. The aim of this study was to identify specific cytokine signaling patterns associated with different diseases.

Methods

Unbiased clustering analyses were performed on a clinical cytokine multiplex test using a cohort of human plasma specimens drawn from individuals with known or suspected diseases for which cytokine profiling was considered clinically indicated by the attending physician.

Results and discussion

Seven clusters of co-expressing cytokines were identified, representing common patterns of immune activation. Common expression profiles of the cytokine clusters and preliminary associations of these profiles with specific diseases or disease categories were also identified. These findings increase our understanding of the immune environments underlying the clinical presentations of patients of inflammatory, autoimmune and neoplastic diseases, which could then improve diagnoses and the identification of evidence-based treatment targets.

Diagnostic performances of D-dimer, prothrombin time, and red blood cell distribution width for coronary artery lesion in children with acute stage Kawasaki disease

Aim

To evaluate the performances of D-dimer, prothrombin time (PT), and red blood cell distribution width (RDW) for the diagnosis of coronary artery lesion (CAL) in acute stage Kawasaki disease (KD).

Methods

Between January 2018 and January 2021, a total of 102 children with acute stage KD were included in this retrospective study. Among them, 36 KD children with CAL were divided into the CAL group, and 66 KD children without CAL were divided into the NCAL group. Independent predictors of CAL in acute stage KD were identified by using univariate and multivariate logistic regression analysis. Spearman correlations were used to evaluate the association between CAL in acute stage KD and different indicators. The diagnostic performance of different indicators for CAL in acute stage KD was analyzed by the receiver operating characteristic (ROC) curve.

Results

Compared with the NCAL group, children in the CAL group had significantly higher white blood cell count, lymphocyte count, platelet count, D-dimer, and RDW levels, but lower PT levels (all p < 0.05). Logistic regression analysis revealed that D-dimer (OR = 1.0, 95% CI: 1.004-1.012, p < 0.001), PT (OR = 0.4, 95% CI: 0.2-0.8, p = 0.01), and RDW (OR = 7.0, 95% CI: 2.6-19.2, p < 0.001) were independent predictors of CAL in children with acute stage KD. CAL showed a positive correlation with D-dimer (r = 0.4, p < 0.001) and RDW (r = 0.5, p < 0.001), and had a negative association with PT (r = -0.2, p < 0.05). The ROC curve analysis showed that the combination of the three indicators had the highest diagnostic performance for CAL in acute stage KD with an area under the curve (AUC) of 0.922 (sensitivity, 86.1%; specificity, 89.4%), compared with D-dimer (AUC = 0.736), PT (AUC = 0.640), and RDW (AUC = 0.819) alone.

Conclusion

A combination of D-dimer, PT, and RDW may help predict CAL in children with acute stage KD.

Autoimmune Heart Disease: A Comprehensive Summary for Forensic Practice

Autoimmune heart disease is a non-random condition characterised by immune system-mediated aggression against cardiac tissue. Cardiac changes often exhibit nonspecific features and, if unrecognised, can result in fatal outcomes even among seemingly healthy young individuals. In the absence of reliable medical history, the primary challenge lies in differentiating between the various cardiopathies. Numerous immunohistochemical and genetic studies have endeavoured to characterise distinct types of cardiopathies, facilitating their differentiation during autopsy examinations. However, the presence of a standardised protocol that forensic pathologists can employ to guide their investigations would be beneficial. Hence, this summary aims to present the spectrum of autoimmune cardiopathies, including emerging insights such as SARS-CoV-2-induced cardiopathies, and proposes the utilisation of practical tools, such as blood markers, to aid forensic pathologists in their routine practice.

The role of CD180 in hematological malignancies and inflammatory disorders

Toll-like receptors play a significant role in the innate immune system and are also involved in the pathophysiology of many different diseases. Over the past 35 years, there have been a growing number of publications exploring the role of the orphan toll-like receptor, CD180. We therefore set out to provide a narrative review of the current evidence surrounding CD180 in both health and disease. We first explore the evidence surrounding the role of CD180 in physiology including its expression, function and signaling in antigen presenting cells (APCs) (dendritic cells, monocytes, and B cells). We particularly focus on the role of CD180 as a modulator of other TLRs including TLR2, TLR4, and TLR9. We then discuss the role of CD180 in inflammatory and autoimmune diseases, as well as in hematological malignancies of B cell origin, including chronic lymphocytic leukemia (CLL). Based on this evidence we produce a current model for CD180 in disease and explore the potential role for CD180 as both a prognostic biomarker and therapeutic target. Throughout, we highlight specific areas of research which should be addressed to further the understanding of CD180 biology and the translational potential of research into CD180 in various diseases.

Kawasaki Disease and Inborn Errors of Immunity: Exploring the Link and Implications

The exact etiopathogenesis of Kawasaki disease (KD), the most common childhood vasculitis, remains unknown; however, an aberrant immune response, possibly triggered by an infectious or environmental agent in genetically predisposed children, is believed to be the underlying pathogenetic mechanism. Patients with inborn errors of immunity (IEI) are predisposed to infections that trigger immune dysregulation due to an imbalance in various arms of the immune system. KD may develop as a complication in both primary and secondary immunodeficiencies. KD may occur either at disease presentation or have a later onset in IEIs. These include X-linked agammaglobulinemia (XLA), selective IgA deficiency, transient hypogammaglobulinemia of infancy; Wiskott-Aldrich syndrome (WAS), hyper IgE syndrome (HIES); chronic granulomatous disease (CGD), innate and intrinsic immunity defects, and autoinflammatory diseases, including PFAPA. Hitherto, the association between KD and IEI is confined to specific case reports and case series and, thus, requires extensive research for a comprehensive understanding of the underlying pathophysiological mechanisms. IEIs may serve as excellent disease models that would open new insights into the disease pathogenesis of children affected with KD. The current review highlights this critical association between KD and IEI supported by published literature.

Identification of key signaling pathways and hub genes related to immune infiltration in Kawasaki disease with resistance to intravenous immunoglobulin based on weighted gene co-expression network analysis

Background: Kawasaki disease (KD) is an acute vasculitis, that is, the leading cause of acquired heart disease in children, with approximately 10%-20% of patients with KD suffering intravenous immunoglobulin (IVIG) resistance. Although the underlying mechanism of this phenomenon remains unclear, recent studies have revealed that immune cell infiltration may associate with its occurrence. Methods: In this study, we downloaded the expression profiles from the GSE48498 and GSE16797 datasets in the Gene Expression Omnibus database, analyzed differentially expressed genes (DEGs), and intersected the DEGs with the immune-related genes downloaded from the ImmPort database to obtain differentially expressed immune-related genes (DEIGs). Then CIBERSORT algorithm was used to calculate the immune cell compositions, followed by the WGCNA analysis to identify the module genes associated with immune cell infiltration. Next, we took the intersection of the selected module genes and DEIGs, then performed GO and KEGG enrichment analysis. Moreover, ROC curve validation, Spearman analysis with immune cells, TF, and miRNA regulation network, and potential drug prediction were implemented for the finally obtained hub genes. Results: The CIBERSORT algorithm showed that neutrophil expression was significantly higher in IVIG-resistant patients compared to IVIG-responsive patients. Next, we got differentially expressed neutrophil-related genes by intersecting DEIGs with neutrophil-related module genes obtained by WGCNA, for further analysis. Enrichment analysis revealed that these genes were associated with immune pathways, such as cytokine-cytokine receptor interaction and neutrophil extracellular trap formation. Then we combined the PPI network in the STRING database with the MCODE plugin in Cytoscape and identified 6 hub genes (TLR8, AQP9, CXCR1, FPR2, HCK, and IL1R2), which had good diagnostic performance in IVIG resistance according to ROC analysis. Furthermore, Spearman's correlation analysis confirmed that these genes were closely related to neutrophils. Finally, TFs, miRNAs, and potential drugs targeting the hub genes were predicted, and TF-, miRNA-, and drug-gene networks were constructed. Conclusion: This study found that the 6 hub genes (TLR8, AQP9, CXCR1, FPR2, HCK, and IL1R2) were significantly associated with neutrophil cell infiltration, which played an important role in IVIG resistance. In a word, this work rendered potential diagnostic biomarkers and prospective therapeutic targets for IVIG-resistant patients.

Clinical characteristics and outcomes of children with Kawasaki disease combined with sepsis in the pediatric intensive care unit

Background

Kawasaki disease (KD) is a vascular inflammatory disease with unknown pathogenesis. There are few studies on KD combined with sepsis worldwide.

Purpose

To provide valuable data regarding clinical characteristics and outcomes related to pediatric patients with KD combined with sepsis in pediatric intensive care unit (PICU).

Methods

We retrospectively analyzed the clinical data of 44 pediatric patients admitted in PICU at Hunan Children's Hospital with KD combined with sepsis between January 2018 and July 2021.

Results

Of the 44 pediatric patients (mean age, 28.18 ± 24.28 months), 29 were males and 15 were female. We further divided the 44 patients into two groups: KD combined with severe sepsis (n=19) and KD combined with non-severe sepsis (n=25). There were no significant between-group differences in leukocyte, C-reactive protein, and erythrocyte sedimentation rate. Interleukin-6, interleukin-2, interleukin-4 and procalcitonin in KD with severe sepsis group were significantly higher than those in KD with non-severe sepsis group. And the percentage of suppressor T lymphocyte and natural killer cell in severe sepsis group were significantly higher than those in non-severe group, while the CD4⁺/CD8⁺ T lymphocyte ratio was significantly lower in KD with severe sepsis group than in KD with non-severe sepsis group. All 44 children survived and were successfully treated after intravenous immune globulin (IVIG) combined with antibiotics.

Conclusion

Children who develop with KD combined with sepsis have different degrees of inflammatory response and cellular immunosuppression, and the degree of inflammatory response and cellular immunosuppression is significantly correlated with the severity of the disease.

Interleukin-35 Enhances Regulatory T Cell Function by Potentially Suppressing Their Transdifferentiation into a T Helper 17-Like Phenotype in Kawasaki Disease

Interleukin-35 (IL-35) modulates immune cell activity in inflammation and autoimmune disorders. However, its specific effects on regulatory T cells (Tregs) in Kawasaki disease remain ambiguous. We enrolled 37 patients with Kawasaki disease and 20 healthy controls in this study. The percentages of CD4⁺CD25⁺CD127^dim/- Tregs and CD4⁺IL-17A⁺ T helper 17 (Th17) cells were determined via flow cytometry. Tregs were enriched and stimulated by recombinant IL-35. Immunosuppressive activity of Tregs was via co-culture with autologous CD4⁺CD25^- T cells. Purified Tregs were cultured for Th17 polarization, and the influence of IL-35 on Tregs transdifferentiation into a Th17-like phenotype was determined. The percentage of Tregs was elevated in patients with Kawasaki disease and positively correlated with C-reactive protein levels. There was no significant difference in the percentage of Th17 cells between the two groups. IL-35 stimulation increased the percentage of Tregs in both groups, but decreased the percentage of Tregs Th17 cells in affected patients. IL-35 enhanced the immunosuppressive activity of Tregs in both groups, resulting in decreased cellular proliferation and increased IL-35 subunit mRNA relative levels in co-culture system. IL-35 did not affect the immune checkpoint molecule expression in Tregs, but inhibited the transdifferentiation of Tregs into a Th17-like phenotype in affected patients, indicating by the down-regulations of C-C motif chemokine receptor-4/6 expression, retinoid-related orphan nuclear receptor γt mRNA levels, and IL-17 secretion. IL-35 contributes to the immunosuppressive function of Tregs by inhibiting the cellular proliferation and transdifferentiation of Tregs into a Th17-like phenotype, which may be a protective mechanism against Kawasaki disease.

When it doesn't run in the blood(vessels) - events involved in vascular disorders

In the current issue of the Biomedical Journal the underlying pathology of hemodynamic compromise in acute small subcortical infarction are elucidated. A follow-up study in patients with childhood Kawasaki disease is presented, as well as an insight into the gradually decreasing antigen expression in cases of acute myeloid leukemia. Furthermore this issue provides an exciting update concerning COVID-19 and the use of CRISPR-Cas, a review about computational approaches in the research of kidney stone formation, factors connected to central precocious puberty, and why a rock star of paleogenetics recently received a Nobel Prize. Additionally, this issue contains an article proposing the repurposing of the lung cancer drug Capmatinib, a study of how the gut microbiome develops in neonates, an impulse about the role of the transmembrane protein TMED3 in esophageal carcinoma, and the revelation about how competing endogenous RNA influences ischemic stroke. Lastly, genetic reasons for male infertility are discussed, as well as the relation between non-alcoholic fatty liver disease and chronic kidney disease.

"The Fever Is Still There!": Workup and Management of Prolonged Fever

Fever is one of the most common chief complaints that brings pediatric patients to seek medical care. Although fever is, in most cases, a physiologic response to a pathogen that has alerted the immune system, prolonged fever can be challenging to work up for the treating pediatrician. In addition to assessing causes of fever, pediatricians must also address the fears that many caregivers may have surrounding elevations in body temperature and provide education as to when fever becomes a concern. Fever can be classified by its duration as well as the presence or absence of associated symptoms. Fever without a source is defined as a fever that has been present for 1 week without a clear cause. Fever of unknown origin is a fever that has been present daily for 8 days or more without an apparent source. This article will walk through considerations for a clinician evaluating a pediatric patient with prolonged fever. [Pediatr Ann. 2023;52(4):e124-e126.].

Kawasaki disease: Surgical treatment

Kawasaki disease (KD) is a systemic vasculitis of small and medium arteries, preferably affecting coronary arteries. It is one of the most frequent causes of acquired heart disease in children. Despite being comprehensively studied, its etiopathogenesis is not totally explained. The surgical procedures usually become necessary during the late follow-up and may be coronary artery bypass grafting, cardiac defibrillator implantation with or without cardiac resynchronization therapy, or cardiac transplantation.

Serum levels of angiotensin-converting enzyme 2 in children with Kawasaki disease

Kawasaki disease (KD) has replaced rheumatic fever as the main cause of acquired heart disease in Japanese, American, and Chinese children. Polymorphisms in angiotensin-converting enzyme may be associated with susceptibility to KD, but the association of angiotensin-converting enzyme 2 (ACE2) with vascular endothelial injury in KD and the possibility for prognosis of vascular injury in KD by evaluating changes in serum ACE2 have not yet been assessed. Thus, this study aimed to investigate ACE2 levels in patients with KD to further explore the relationship between ACE2 and vascular injury in KD. Blood samples were collected from 49 children with KD before intravenous immunoglobulin treatment and 28 healthy children in the same period as the control group. Clinical data were collected from the patients and serum ACE2 levels of all participants were measured using an enzyme-linked immunosorbent assay. Serum ACE2 levels were significantly higher in the KD group than in the control group, and were negatively correlated with platelet levels in patients with KD. Serum ACE2 levels are related to the pathogenesis of KD and may be used as a potential serum marker for KD diagnosis.

Environmental Triggers for Vasculitis

Systemic vasculitides are autoimmune diseases characterized by vascular inflammation. Most types of vasculitis are thought to result from antigen exposure in genetically susceptible individuals, suggesting a likely role for environmental triggers in these conditions. Seasonal and geographic variations in incidence provide insight into the potential role of environmental exposures in these diseases. Many data support infectious triggers in some vasculitides, whereas other studies have identified noninfectious triggers, such as airborne pollutants, silica, smoking, and heavy metals. We review the known and suspected environmental triggers in giant cell arteritis, Takayasu arteritis, polyarteritis nodosa, Kawasaki disease, and antineutrophil cytoplasmic antibody-associated vasculitis.

MicroRNAs in Kawasaki disease: An update on diagnosis, therapy and monitoring

Kawasaki disease (KD) is an acute autoimmune vascular disease featured with a long stage of febrile. It predominantly afflicts children under 5 years old and causes an increased risk of cardiovascular combinations. The onset and progression of KD are impacted by many aspects, including genetic susceptibility, infection, and immunity. In recent years, many studies revealed that miRNAs, a novel class of small non-coding RNAs, may play an indispensable role in the development of KD via differential expression and participation in the central pathogenesis of KD comprise of the modulation of immunity, inflammatory response and vascular dysregulation. Although specific diagnose criteria remains unclear up to date, accumulating clinical evidence indicated that miRNAs, as small molecules, could serve as potential diagnostic biomarkers and exhibit extraordinary specificity and sensitivity. Besides, miRNAs have gained attention in affecting therapies for Kawasaki disease and providing new insights into personalized treatment. Through consanguineous coordination with classical therapies, miRNAs could overcome the inevitable drug-resistance and poor prognosis problem in a novel point of view. In this review, we systematically reviewed the existing literature and summarized those findings to analyze the latest mechanism to explore the role of miRNAs in the treatment of KD from basic and clinical aspects retrospectively. Our discussion helps to better understand the pathogenesis of KD and may offer profound inspiration on KD diagnosis, treatment, and prognosis.

Kawasaki Disease and Coronary Artery Involvement: A Narrative Review

Kawasaki disease is a systemic vasculitis with a risk of developing coronary artery lesions if left untreated. Kawasaki disease can be diagnosed clinically with classical symptoms (conjunctivitis, rash, lymphadenopathy, mucositis, edema of hands and feet), but predicting the risk of developing coronary artery aneurysm remains challenging. The coronary sequelae of Kawasaki disease have significant morbidity and mortality and are the second most common cause of acquired cardiac disease in children. Several genetic and immune factors are involved in the inflammation of coronary artery lesions in Kawasaki disease. Inositol trisphosphate 3-Kinase (ITPKC), Foxp3+, circular RNAs, mannose-binding lectin 2 (MBL2), complement factor H (CFH), kininogen 1 (KNG1), serpin family C member 1 (SERPINC1) and fibronectin 1 (FN1) are the essential genes identified in the pathogenesis of coronary artery lesions in Kawasaki disease. The addition of methylprednisolone to a combination of aspirin and intravenous immunoglobulins and biological agents like anakinra, etanercept, infliximab, and immunosuppressants like cyclosporine prevents the occurrence of coronary artery aneurysms in Kawasaki disease. Since the coronary artery lesions form the second most common cause of acquired cardiac disease in children and the incidence of myocardial infarction is a late complication, the risk stratification for coronary artery aneurysms and follow-up protocols for the prevention of cardiac thrombosis were proposed by the American Heart Association in 2017.

Exploring the Mechanism of Aspirin in the Treatment of Kawasaki Disease Based on Molecular Docking and Molecular Dynamics

Purpose

The research aims to investigate the mechanism of action of aspirin in the treatment of Kawasaki disease.

Methods

We predicted the targets of aspirin with the help of the Drugbank and PharmMapper databases, the target genes of Kawasaki disease were mined in the GeneCards and Disgenet databases, the intersection targets were processed in the Venny database, and the gene expression differences were observed in the GEO database. The Drugbank and PharmMapper databases were used to predict the target of aspirin, and the target genes of Kawasaki disease were explored in the GeneCards and Disgenet databases, and the Venny was used for intersection processing. We observed the gene expression differences in the GEO database. The disease-core gene target-drug network was established and molecular docking was used for verification. Molecular dynamics simulation verification was carried out to combine the active ingredient and the target with a stable combination. The supercomputer platform was used to measure and analyze the binding free energy, the number of hydrogen bonds, the stability of the protein target at the residue level, the radius of gyration, and the solvent accessible surface area.

Results

Aspirin had 294 gene targets, Kawasaki disease had 416 gene targets, 42 intersecting targets were obtained, we screened 13 core targets by PPI; In the GO analysis, we learned that the biological process of Kawasaki disease involved the positive regulation of chemokine biosynthesis and inflammatory response; pathway enrichment involved PI3K-AKT signaling pathway, tumor necrosis factor signaling pathway, etc. After molecular docking, the data showed that CTSG, ELANE, and FGF1 had the best binding degree to aspirin. Molecular dynamics was used to prove and analyze the binding stability of active ingredients and protein targets, and Aspirin/ELANE combination has the strongest binding energy.

Conclusion

In the treatment of Kawasaki disease, aspirin may regulate inflammatory response and vascular remodeling through CTSG, ELANE, and FGF1.

A decision tree model for predicting intravenous immunoglobulin resistance and coronary artery involvement in Kawasaki disease

Objectives

This study aims to develop a new algorithm for predicting intravenous immunoglobulin (IVIG) resistance and coronary artery involvement in Kawasaki disease (KD) through decision tree models.

Methods

Medical records of children hospitalized for KD were analysed retrospectively. We compared the clinical characteristics, and the laboratory data in the groups with IVIG resistance and coronary artery dilatations (CADs) in KD patients. The decision tree models were developed to predict IVIG resistance and CADs.

Results

A total 896 patients (511 males and 385 females; 1 month-12 years) were eligible. IVIG resistance was identified in 111 (12.3%) patients, and CADs were found in 156 (17.4%). Total bilirubin and nitrogen terminal- pro-brain natriuretic peptide (NT-proBNP) were significantly higher in IVIG resistant group than in IVIG responsive group (0.62 ± 0.8 mg/dL vs 1.38 ± 1.4 mg/dL and 1231 ± 2136 pg/mL vs 2425 ± 4459 mL, respectively, P < 0.01). Also, CADs were more developed in the resistant group (39/111; 14.9% vs. 117/785; 35.1%, P < 0.01). The decision tree for predicting IVIG resistance was classified based on total bilirubin (0.7 mg/mL, 1.46 mg/dL) and NT-proBNP (1561 pg/mL), consisting of two layers and four nodes, with 86.2% training accuracy and 90.5% evaluation accuracy. The Receiver Operating Characteristic (ROC) evaluated the predictive ability of the decision tree, and the area under the curve (AUC) (0.834; 95% confidence interval, 0.675–0.973; P < 0.05) showed relatively higher accuracy. The group with CADs had significantly higher total bilirubin and NT-proBNP levels than the control group (0.64 ± 0.82 mg/dL vs 1.04 ± 1.14 mg/dL and 1192 ± 2049 pg/mL vs 2268 ± 4136 pg/mL, respectively, P < 0.01). The decision trees for predicting CADs were classified into two nodes based on NT-proBNP (789 pg/mL) alone, with 83.5% training accuracy and 90.3% evaluation accuracy.

Conclusion

A new algorithm decision tree model presents for predicting IVIG resistance and CADs in KD, confirming the usefulness of NT-proBNP as a predictor of KD.

Unusual interventional treatment of a complex calcified coronary artery lesion in a child with Kawasaki disease: a case report

Background

Kawasaki disease (KD) is a medium vessel vasculitis occurring in children, as yet of undetermined aetiology. KD can lead to severe complications such as coronary artery aneurysms, thrombosis, and sudden death. Monitoring of coronary anomalies is an important issue in the early phase of the disease, and their follow-up is based on different imaging methods. The interventional treatment of these coronary anomalies, which is often complex, is a therapeutic challenge.

Case summary

We are reporting the case of a four-year-old child who presented KD which was complicated by coronary aneurysm of the proximal left anterior descending artery and ectasia of the right coronary artery (RCA). These lesions progressively calcified and resulted at the age of 13 in chronic occlusion of the RCA. After confirmation of myocardial viability and myocardial ischaemia, a complex angioplasty guided by intracoronary imaging was performed using rotational atherectomy, a cutting balloon, and a high pressure balloon. The control coronary angiography performed 1 year later revealed two false aneurysm on the RCA at the angioplasty site, which were successfully treated with a covered stent.

Discussion

This case report describes the challenges of treating coronary artery abnormalities such as calcified coronary lesions in children with KD. The coronary intervention of these lesions remains complex and may lead to coronary rupture. We highlight the advantage of using intracoronary imaging in the management of these calcified lesions for successful revascularization, and to assess the complications of percutaneous coronary intervention.

Immunological imbalance in microcephalic children with congenital Zika virus syndrome

Microcephalic children due congenital Zika virus syndrome (CZS) present neurological symptoms already well described. However, several other alterations can also be observed. Here, we aimed to evaluate the immune system of microcephaly CZS children. We showed that these patients have enlarged thymus, spleen and cervical lymph nodes, analysed by ultrasound and compared to the reference values for healthy children. In the periphery, they have an increase in eosinophil count and morphological alterations as hypersegmented neutrophils and atypical lymphocytes, even in the absence of urinary tract infections, parasitological infections or other current symptomatic infections. Microcephalic children due CZS also have high levels of IFN-γ, IL-2, IL-4, IL-5 and type I IFNs, compared to healthy controls. In addition, this population showed a deficient cellular immune memory as demonstrated by the low reactivity to the tuberculin skin test even though they had been vaccinated with BCG less than 2 years before the challenge with the PPD. Together, our data demonstrate for the first time that CZS can cause alterations in primary and secondary lymphoid organs and also alters the morphology and functionality of the immune system cells, which broadens the spectrum of CZS symptoms. This knowledge may assist the development of specific therapeutic and more efficient vaccination schemes for this population of patients.

Modulation of Reactive Oxygen Species Homeostasis as a Pleiotropic Effect of Commonly Used Drugs

Age-associated diseases represent a growing burden for global health systems in our aging society. Consequently, we urgently need innovative strategies to counteract these pathological disturbances. Overwhelming generation of reactive oxygen species (ROS) is associated with age-related damage, leading to cellular dysfunction and, ultimately, diseases. However, low-dose ROS act as crucial signaling molecules and inducers of a vaccination-like response to boost antioxidant defense mechanisms, known as mitohormesis. Consequently, modulation of ROS homeostasis by nutrition, exercise, or pharmacological interventions is critical in aging. Numerous nutrients and approved drugs exhibit pleiotropic effects on ROS homeostasis. In the current review, we provide an overview of drugs affecting ROS generation and ROS detoxification and evaluate the potential of these effects to counteract the development and progression of age-related diseases. In case of inflammation-related dysfunctions, cardiovascular- and neurodegenerative diseases, it might be essential to strengthen antioxidant defense mechanisms in advance by low ROS level rises to boost the individual ROS defense mechanisms. In contrast, induction of overwhelming ROS production might be helpful to fight pathogens and kill cancer cells. While we outline the potential of ROS manipulation to counteract age-related dysfunction and diseases, we also raise the question about the proper intervention time and dosage.

Etanercept with IVIg for acute Kawasaki disease: a long-term follow-up on the EATAK trial

BACKGROUND

The Etanercept as Adjunctive Treatment for Acute Kawasaki Disease, a phase-3 clinical trial, showed that etanercept reduced the prevalence of IVIg resistance in acute Kawasaki disease. In patients who presented with coronary artery involvement, it reduced the maximal size and short-term progression of coronary artery dilation. Following up with this patient group, we evaluated the potential long-term benefit of etanercept for coronary disease.

METHODS

Patients were followed for at least 1 year after the trial. The size of dilated arteries (z-score ≥ 2.5) was measured at each follow-up visit. The z-score and size change from baseline were evaluated at each visit and compared between patients who received etanercept versus placebo at the initial trial.

RESULTS

Forty patients who received etanercept (22) or placebo (18) in the Etanercept as Adjunctive Treatment for Acute Kawasaki Disease trial were included. All patients showed a persistent decrease in coronary artery size measurement: 23.3 versus 5.9% at the 6-month visit, 24 versus 13.1% at the 1-year visit, and 20.8 versus 19.3% at the ≥ 2-year visit for etanercept or placebo, respectively, with similar results for decrease in coronary artery z-scores. In a multivariate analysis, correcting for patients' growth, a greater size reduction for patients on the etanercept arm versus placebo was proved significant for the 6-month (p = 0.005) and the 1-year visits (p = 0.019) with a similar end outcome at the ≥ 2-year visit.

DISCUSSION

Primary adjunctive therapy with etanercept for children with acute Kawasaki disease does not change the end outcome of coronary artery disease but may promote earlier resolution of artery dilation.

Exploration of Potential Biomarker Genes and Pathways in Kawasaki Disease: An Integrated in-Silico Approach

Kawasaki disease (KD) is a common childhood systemic vasculitis with a special predilection for coronary arteries. Even after more than five decades of the initial description of the disease, the etiology of KD remains an enigma. This transcriptome data re-analysis study aimed to elucidate the underlying pathogenesis of KD using a bioinformatic approach to identify differentially expressed genes (DEGs) to delineate common pathways involved in KD. Array datasets from the Gene Expression Omnibus database were extracted and subjected to comparative meta-analysis for the identification of prominent DEGs. Fifteen hub genes with high connectivity were selected from these DEGs (IL1B, ITGAM, TLR2, CXCL8, SPI1, S100A12, MMP9, PRF1, TLR8, TREM1, CD44, UBB, FCER1G, IL7R, and FCGR1A). Of these 15 genes, five genes (CXCL8, FCGR1A, IL1B, TLR2, and TLR8) were found to be involved in neutrophil degranulation. To gain further insight into the molecular mechanism, a protein–protein network was established. Significantly enriched pathways based on the above-mentioned genes were mainly centered on biological regulation and signaling events. In addition, the pathway analysis also indicated that the majority of the DEGs in KD were enriched in systemic lupus erythematosus, suggesting a strong interplay between immunological and genetic factors in the pathogenesis of KD. These findings could significantly aid in identifying therapeutic targets and understanding KD biosignatures to design a biomarker panel for early diagnosis and severity of the disease.

[Association between duration of fever before treatment and intravenous immunoglobulin resistance in Kawasaki disease]

OBJECTIVES

To examine the association between duration of fever before intravenous immunoglobulin (IVIG) treatment and IVIG resistance in children with Kawasaki disease (KD).

METHODS

A retrospective analysis was performed on the medical data of 317 children with KD who were admitted from January 2018 to December 2020. According to the duration of fever before IVIG treatment, they were divided into two groups: short fever duration group (≤4 days) with 92 children and long fever duration group (>4 days) with 225 children. According to the presence or absence of IVIG resistance, each group was further divided into a drug-resistance group and a non-drug-resistance group. Baseline data and laboratory results were compared between groups. A multivariate logistic regression analysis was used to identify the influencing factors for IVIG resistance.

RESULTS

In the short fever duration group, 19 children (20.7%) had IVIG resistance and 5 children (5.4%) had coronary artery aneurysm, and in the long fever duration group, 22 children (9.8%) had IVIG resistance and 19 children (8.4%) had coronary artery aneurysm, suggesting that the short fever duration group had a significantly higher rate of IVIG resistance than the long fever duration group (P<0.05), while there was no significant difference in the incidence rate of coronary artery aneurysm between the two groups (P>0.05). In the short fever duration group, compared with the children without drug resistance, the children with drug resistance had a significantly lower level of blood sodium and significantly higher levels of procalcitonin, C-reactive protein, and N-terminal B-type natriuretic peptide before treatment (P<0.05). In the long fever duration group, the children with drug resistance had significantly lower levels of blood sodium and creatine kinase before treatment than those without drug resistance (P<0.05). The multivariate logistic regression analysis showed that a reduction in blood sodium level was associated with IVIG resistance in the long fever duration group (P<0.05).

CONCLUSIONS

IVIG resistance in children with KD varies with the duration of fever before treatment. A reduction in blood sodium is associated with IVIG resistance in KD children with a duration of fever of >4 days before treatment.

Cytokine Cascade in Kawasaki Disease Versus Kawasaki-Like Syndrome

Kawasaki disease (KD) is a medium vessel systemic vasculitis that predominantly occurs in children below five years of age. It is an acute febrile condition in which coronary artery aneurysms and myocarditis are the most common cardiovascular complications. It is most often characterized by hypercytoki-nemia. The etiopathogenesis of KD is not fully understood. The present review synthesizes the recent advances in the pathophysiology and treatment options of KD. According to different studies, the genetic, infections and autoimmunity factors play a major role in pathogenesis. Several susceptibility genes (e.g. caspase 3) and cytokines (e.g. IL-2, IL-4, IL-6, IL-10, IFN-γ and TNF-α) have been identified in KD. Patients with high cytokine levels are predisposed to KD shock syndrome. The importance of respiratory viruses in the pathogenesis of the disease is unclear. Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may induce in children and adults an abnormal systemic inflammatory response. This syndrome shares characteristics with KD. It has been called by many terms like MIS-C (Multisystem Inflammatory Syndrome in Children), PIMS-TS (pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2), hyperinflammatory shock syndrome, cytokine storm (cytokine release syndrome) or simply, Kawasaki-like syndrome. The cytokine’s role in the development of KD or Kawasaki-like syndrome being triggered by COVID-19 is controversial. The presences of the antiendothelial cell autoantibodies (AECAs) together with the newly developed hypothesis of immunothrombosis are considered potential pathogenic mechanisms for KD. In consequence, the diagnosis and treatment of KD and Kawasaki-like syndrome, one of the most common causes of acquired heart disease in developed countries, are challenging without a clearly defined protocol.

Red blood cell distribution width and tumor necrosis factor-α for the early prediction of coronary artery lesion in Kawasaki disease: a retrospective study

We aimed to identify novel risk factors for the early prediction of coronary artery lesion (CAL) in children with Kawasaki disease (KD). We retrospectively analyzed data from hospitalized children newly diagnosed with KD between January 1, 2018, and December 31, 2020, with the following inclusion criteria: (1) diagnosis of KD, (2) first onset of CAL after admission, (3) with complete clinical records. Demographic and laboratory data were collected and analyzed. The independent risk factors of KD combined with CAL were identified by multivariate logistic regression analysis, followed by receiver operating characteristic (ROC) curve analysis to calculate the efficacy of identified risk factors in predicting KD combined with CAL. Among 241 initially recruited patients, 226 were eligible to be included in the study. Based on echocardiographic indications of CAL, 104 patients (46%) were assigned to the CAL (KD-CAL) group and 122 (54%) patients were assigned to the non-CAL (KD-nCAL) group. The levels of red blood cell count, red blood cell distribution width (RDW), C-reactive protein, tumor necrosis factor-α (TNF-α), and interleukin-6 were significantly higher in the KD-CAL group than those in the KD-nCAL group (all p < 0.05). RDW and TNF-α were found as independent risk factors of CAL occurrence. The sensitivity and specificity of RDW, TNF-α, and RDW + TNF-α in predicting KD with CAL were 67.31% and 79.51%, 74.04% and 73.77%, and 79.81% and 80.33%, respectively.Conclusion: In conclusion, alterations in RDW and TNF-α levels can be used as novel biomarkers for early prediction of CAL in KD patients, although the differences in their absolute values were small and might not give any added value to echocardiography. What is Known: •Known risk factors of CAL in children with KD include male gender and delayed use of intravenous immune globulin. What is New: •Our current study identified that red blood cell distribution width (RDW) and tumor necrosis factor-α (TNF-α) are novel independent risk factors for predicting CAL combined with KD among patients. •The combination of these RDW and TNF-α together shows higher sensitivity and specificity than either one used alone.

Integrative treatment of herbal medicine with western medicine on coronary artery lesions in children with Kawasaki disease

BACKGROUND

Kawasaki disease (KD) is a major cause of coronary artery lesions (CALs) in children. Approximately 10% to 20% of children treated with intravenous immunoglobulin are intravenous immunoglobulin-resistant. This study evaluated the efficacy and safety of adding herbal medicine to conventional western medicines versus conventional western medicines alone for CALs in children with KD.

METHODS

This study searched 9 electronic databases until August 31, 2021. The inclusion criteria were the randomized controlled trials (RCTs) that assessed the CALs in children with KD and compared integrative treatment with conventional western treatments. Two authors searched independently for RCTs, including eligible articles that fulfilled the inclusion criteria, extracted data, and assessed the methodological quality using the Cochrane risk of bias tool. Meta-analysis was conducted using Cochrane Collaboration's Review Manager 5.4 software. The effect size was presented as the risk ratio (RR), and the fixed-effect models were used to pool the results.

RESULTS

The finally selected 12 studies included a total of 1030 KD patients. According to a meta-analysis, the integrative treatment showed better results than the conventional treatment in the CAL prevalence rate (RR = 2.00; 95% confidence interval [CI], 1.49-2.71; P < .00001), CAL recovery rate (RR = 1.27; 95% CI, 1.05-1.54; P = .02), and total effective rate (RR = 1.17; 95% CI, 1.11-1.23; P < .00001). Only 2 studies referred to the safety of the treatment. The asymmetrical funnel plot of the CAL prevalence rate indicated the possibility of potential publication bias.

CONCLUSIONS

This review found the integrative treatment to be more effective in reducing the CAL prevalence rate and increasing the CAL recovery rate and total effective rate in KD patients than conventional western treatment. However, additional well-designed RCTs will be needed further to compensate restrictions of insufficient trials on safety, methodological quality, and publication bias.

Kawasaki disease: lncRNA Slco4a1 regulates the progression of human umbilical vein endothelial cells by targeting the miR-335-5p/POU5F1 axis

BACKGROUND

Kawasaki disease (KD) is an autoimmune disease with systemic vasculitis as the main pathological change, and is most common in children under 5. The role of long non-coding RNAs (lncRNAs) in human diseases has been highlighted. LncRNA Slco4a1 was reported to promote cell growth and act as an oncogenic regulator in cancer. However, the role of lncRNA Slco4a1 in KD remains unclear. This study aimed to investigate the role and mechanism of lncRNA Slco4a1 in KD.

METHODS

Enzyme linked immunosorbent assay (ELISA), qRT-PCR, Western blot, and terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) staining were conducted to explore the function of lncRNA Slco4a1. The interaction between POU5F1 and miR-335-5p was analyzed by the RIP assay and dual luciferase assay.

RESULTS

LncRNA Slco4a1 was significantly upregulated in the serum of KD patients compared with healthy controls. LncRNA Slco4a1 was upregulated in human umbilical vein endothelial cells (HUVECs) stimulated with KD serum. LncRNA Slco4a1 overexpression could promote the expression of inflammatory factors and apoptosis in HUVECs. The number of inflammatory cells and the infiltration area of the coronary artery in KD rats were decreased after lncRNA Slco4a1 silencing. Furthermore, lncRNA Slco4a1 is a sponge of miR-335-5p and negatively regulated the expression of miR-335-5p. POU5F1 was the downstream target of miR-335-5p, and miR-335-5p overexpression could upregulate the expression of POU5F1. Additionally, miR-335-5p overexpression could inhibit the expression of inflammatory factors and apoptosis in HUVECs. We further investigated the effect of lncRNA Slco4a1 on the mitogen-activated protein kinase (MAPK) signaling pathway, and the results showed that lncRNA Slco4a1 could promote the activation of the MAPK signaling pathway.

CONCLUSIONS

Together, these results indicated that lncRNA Slco4a1 could regulate the progression of HUVECs in KD by targeting the miR-335-5p/POU5F1 axis, providing new insights for KD treatment.

Neurological manifestations of Kawasaki disease and multisystem inflammatory syndrome in children associated with COVID-19: A comparison of two different clinical entities

Kawasaki disease (KD) is one of the most frequent idiopathic vasculitis in children, affecting medium- and small-sized vessels. Multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 has recently emerged as a new systemic hyperinflammatory condition affecting children some weeks after an acute COVID-19 infection. KD and MIS-C share different aspects and differ in many others: patients affected by MIS-C are usually older, with prominent gastrointestinal manifestations, diffuse adenopathy, extensive conjunctivitis, myocardial damage, leukopenia, and thrombocytopenia at the laboratory exams. Both conditions can present neurological complications. The aim of this manuscript is to provide a narrative review of neurological involvement in KD and MIS-C. A comprehensive review literature has been performed, and the main clinical features have been analyzed, contributing to neurological differential diagnosis.

Comparison of Clinical Features and Inflammatory Markers between Kawasaki Disease Shock Syndrome and Kawasaki Disease without Shock: A Meta-Analysis

Since the shock is not a common symptom of KD, it is often misdiagnosed at the beginning of the pathogenesis of KDSS. The language searched was only Chinese and English. Data from the articles were screened and extracted for meta-analysis using Stata16.0 software. A total of 9 cohort studies, including 1231 patients, were included in this meta-analysis. The results of meta-analysis showed that the age of the children in the KDSS group was higher than that in the KD group without shock, and the difference was statistically significant (SMD = 1.15, 95% CI (0.52, 1.78), P < 0.05); the CRP content in the KDSS group was higher than that in the KD group without shock, and the difference was statistically significant (SMD = 1.99, 95% CI (0.72, 3.26), P < 0.05); the albumin content in the KDSS group was lower than that in the KD group without shock, and the difference was statistically significant (SMD = -1.26, 95% CI (-1.85,-0.67), P < 0.05); the AST content in the KDSS group was higher than that in the KD group without shock, and the difference was statistically significant (WMD = 25.95, 95% CI (15.14, 36.75), P < 0.05); the difference had statistical significance (RR = 3.50, 95% CI (2.30, 5.32), P < 0.05); meta-analysis results of type of KD, fever duration, WBC count, ESR, ALT, and other outcome measures showed that there was no significant difference between KDSS and KD without shock (P > 0.05). Compared with KD without shock, children with KDSS are older and have a higher incidence of coronary artery disease, serum CRP, and AST, but albumin is lower than KD without shock. According to these characteristics, it may be helpful for the early identification of KDSS.

Anterior segment involvement in Epstein-Barr virus: a review

The aim of this study is to describe the involvement of Epstein-Barr Virus (EBV) in the diseases of the ocular anterior segment. This is a narrative review designed using the PUBMED, SCOPE and Web of Science databases, searching for reported literature on findings in the anterior ocular segment related to EBV between 1990 and 2020. Epstein-Barr Virus (EBV) is implicated in the development of salmon-coloured conjunctival masses in the context of acute mononucleosis and lymphoproliferative disorders. Moreover, EBV can cause haemorrhagic conjunctivitis and its corneal implications appear as different types of keratitis patterns. The involvement of EBV in the pathogenesis of anterior segment inflammation is not well-defined. Current evidence regarding anterior segment disease caused by EBV infection has been proved by positive viral detection through polymerase chain reaction test in eyes with lymphoproliferative disorders known to be caused by EBV, as B- and NK/T-cell lymphoid tumours. Antiviral treatment (oral Aciclovir or Valaciclovir) in anterior segment disease caused by EBV remains controversial.

Carotid Intima-Media Thickness and Ankle-Brachial Index and Their Correlation with Coronary Artery Dilatation in Children with Kawasaki Disease

Objective

To investigate the correlation between carotid intima-media thickness (IMT), ankle-brachial index (ABI), and coronary artery dilatation (CAD) in children with Kawasaki disease (KD) and to evaluate the effectiveness of CAD.

Methods

A total of 68 children diagnosed with KD from January 2019 to January 2021 in our hospital were included. According to the results of cardiac color Doppler ultrasound, the children with KD were divided into a noncoronary artery dilation group (NCAD), with 41 children with KD who did not have coronary artery lesions, and a coronary artery dilation group (CAD), with 27 children with KD who had coronary artery dilation. 27 healthy children undergoing physical examination in our hospital at the same time were selected as the normal control group. Laboratory index of all subjects was measured individually. The carotid IMT, ABI, and coronary artery diameter of all subjects were measured and compared. Pearson correlation was used to analyze the correlation between carotid IMT, ABI, and the severity of coronary artery disease. The ROC curve was used to evaluate the efficacy of carotid IMT and ABI in predicting coronary artery disease.

Results

The ALB of children in the CAD group was lower than that in the NCAD group (P < 0.05). The IMT of carotid artery and the diameter of coronary artery in children of the CAD group and the NCAD group were higher than those of the normal control group, and the IMT of the CAD group was higher than that of the NCAD group. The ABI of children in the CAD group and the NCAD group was lower than that of the normal control group, and the ABI of children in the CAD group was lower than that of the NCAD group (P < 0.05). Correlation analysis showed that carotid artery IMT of children with KD was positively correlated with coronary artery diameter, while ABI was negatively correlated with coronary artery diameter. The AUC of carotid IMT for CAD in children with KD was 0.668 (95% CI: 0.538–0.797), that of ABI for CAD in children with KD was 0.646 (95% CI: 0.513–0.780), and that of the combination of carotid IMT and ABI for CAD was 0.874 (95% CI: 0.785–0.963).

Conclusion

The changes of carotid artery IMT and ABI in children with KD have a certain correlation with CAD, and the joint detection of carotid artery IMT and ABI can provide clinical reference value for predicting the degree of coronary artery disease in children with KD.