Microbiologic studies on the small intestine in Kawasaki disease

The intestinal microbiota contributes to the development of immune-mediated cardiovascular inflammation and vasculitis in mice

Alterations in the intestinal microbiota contribute to the pathogenesis of various cardiovascular disorders, but how they affect the development of Kawasaki disease (KD), an acute pediatric vasculitis, remains unclear. We report that depleting the gut microbiota reduces the development of cardiovascular inflammation in a murine model mimicking KD vasculitis. The development of cardiovascular lesions was associated with alterations in the intestinal microbiota composition and, notably, a decreased abundance of Akkermansia muciniphila and Faecalibacterium prausnitzii. Oral supplementation with either of these live or pasteurized individual bacteria, or with short-chain fatty acids (SCFAs) produced by them, attenuated cardiovascular inflammation. Treatment with Amuc_1100, the TLR-2 signaling outer membrane protein from A. muciniphila , also decreased the severity of vascular inflammation. This study reveals an underappreciated gut microbiota-cardiovascular inflammation axis in KD vasculitis pathogenesis and identifies specific intestinal commensals that regulate vasculitis in mice by producing metabolites or via extracellular proteins acting on gut barrier function.

IN BRIEF

It remains unclear whether changes in the intestinal microbiota composition are involved in the development of cardiovascular lesions associated with Kawasaki disease (KD), an immune-mediated vasculitis. Jena et al. observe alterations in the intestinal microbiota composition of mice developing vasculitis, characterized by reduced A. muciniphila and F. prausnitzii . Oral supplementation with either of these bacteria, live or pasteurized, or with bacteria-produced short-chain fatty acids (SCFAs) or Amuc_1100, the TLR-2 signaling outer membrane protein of A. muciniphila , was sufficient to alleviate the development of cardiovascular lesions in mice by promoting intestinal barrier function.

HIGHLIGHTS

Absence or depletion of the microbiota decreases the severity of vasculitis in a murine model mimicking KD vasculitis. Supplementation of B. wadsworthia and B. fragilis promotes murine KD vasculitis. Decreased abundances of F. prausnitzii and A. muciniphila are associated with the development of cardiovascular lesions in mice. Supplementation with either live or pasteurized A. muciniphila and F. prausnitzii, or the TLR-2 signaling Amuc_1100, reduces the severity of vasculitis by promoting gut barrier function.

Emerging evidence of microbial infection in causing systematic immune vasculitis in Kawasaki disease

Kawasaki disease (KD) is a systematic vasculitis that is often complicated by coronary artery lesions and is a leading cause of acquired heart disease in developed countries. Previous studies have suggested that genetic susceptibility, together with an inducing infectious agent, could be involved in KD pathogenesis; however, the precise causative agent of this disease remains unknown. Moreover, there are still debates concerning whether KD is an infectious disease or an autoimmune disease, although many studies have begun to show that various pathogens functioning as critical inducers could activate different kinds of immune cells, consequently leading to the dysfunction of endothelial cells and systematic vasculitis. Here in this review, we attempt to summarize all the available evidence concerning pathogen infections associated with KD pathogenesis. We also discuss the related mechanisms, present a future perspective, and identify the open questions that remain to be investigated, thereby providing a comprehensive description of pathogen infections and their correlations with the host immune system in leading to KD.

Clinical characteristics of patients with recurrent Kawasaki disease: a nationwide cohort study of 19 456 patients with minimum 3-year follow up

OBJECTIVE

To identify the clinical characteristics of patients with recurrent Kawasaki disease (KD).

DESIGN

A nationwide, population-based, cohort study using the Korean National Health Insurance claims database between 2013 and 2016.

PATIENTS

A total of 19 456 patients under the age of 5 years who were diagnosed with initial episode of KD were included. A minimum follow-up period of 3 years was mandatory for inclusion.

MAIN OUTCOME MEASURES

The epidemiological and clinical profiles were compared between KD patients with and without recurrence.

RESULTS

The overall recurrence rate of KD was 3.84% (n=748), and the median interval to recurrence was 498 days (IQR: 257-860 days). Approximately 70% of all recurrences occurred within 2 years of the initial diagnosis. The annual proportions of recurrence were 40%, 28%, 18%, 8% and 4% from the first to the fifth year following the initial episode, respectively. Recurrence rates were significantly higher in patients aged <1 year than in those aged 4-5 years (4.65% vs 2.22%) and those who showed resistance to an initial dose of intravenous immunoglobulin (IVIG) (10.00% vs 3.18%). Allergic comorbidities and coronary artery complications at the initial episode were not associated with increased rates of recurrence.

CONCLUSIONS

We clearly identified the annual recurrence rates and their intervals from the initial episode according to the various factors identified, including young age and resistance to initial IVIG. Our results, based on a nationwide cohort, can be used as reference for follow-up management in patients with KD and in future studies.

Effect of Entamoeba histolytica infection on gut microbial diversity and composition in diarrheal patients from New Delhi

During amoebiasis, colonization of the gut by Entamoeba histolytica can lead to alterations of the host microbiota. In this study, we have compared the gut microbiota of patients of amoebiasis with healthy controls using 16S rRNA gene variable regions, (V1-V3) and (V3-V5), of the bacterial genome. From this 16S rRNA gene amplicon data, one paired-end and two single-end datasets were selected and compared by the number of OTUs obtained, sequence count, and diversity analysis. Our results showed that the V1-V3-paired-end dataset gave the maximum number of OTUs in comparison to the two single-end datasets studied. The amoebiasis samples showed a significant drop in richness in the alpha diversity measurements and lower intra group similarity compared to the healthy controls. Bacteria of genus Prevotella, Sutterella, and Collinsella were more abundant in healthy controls whereas Escherichia, Klebsiella, and Ruminococcus were more abundant in the E. histolytica-positive patients. All the healthy controls harbored bacteria belonging to Faecalibacterium, Prevotella, Ruminococcus, Subdoligranulum, and Escherichia genera while all the E. histolytica-positive patient samples contained genus Enterobacter. The compositional changes in the gut microbiome observed in our study indicated a higher prevalence of pathogenic bacteria along with a depletion of beneficial bacteria in E. histolytica-infected individuals when compared with healthy controls. These results underline the interplay between E. histolytica and the human gut microbiome, giving important inputs for future studies and treatments.

Landscape of intestinal microbiota in patients with IgA nephropathy, IgA vasculitis and Kawasaki disease

Objective

To explore the common differential flora of IgAN, Kawasaki disease and IgA vasculitis by screening and analyzing the differential intestinal flora between the three disease groups of IgAN, Kawasaki disease and IgA vasculitis and their healthy controls.

Methods

Papers on 16srRNA sequencing-related intestinal flora of IgAN, Kawasaki disease and IgA vasculitis were searched in databases, the literature was systematically collated and analysed, the original data was download from the relevant databases, and then the operational taxonomic unit and species classification analysis were performed. Besides, Alpha diversity analysis and Beta diversity analysis were performed to screen for IgAN, Kawasaki disease and I1gA vasculitis groups and finally compare the common intestinal differential flora among the three groups.

Results

Among the common differential flora screened, Lachnospiracea_incertae_sedis was lower in both the IgAN and Kawasaki disease groups than in the respective healthy controls; Coprococcus was low in the IgAN group but high in the IgA vasculitis group. Fusicatenibacter was lower in both the Kawasaki disease and IgA vasculitis groups than in their respective healthy controls, and Intestinibacter was low in the Kawasaki disease group, but its expression was high in the IgA vasculitis group.

Conclusion

The dysbiosis of the intestinal flora in the three groups of patients with IgAN, Kawasaki disease and IgA vasculitis, its effect on the immunity of the organism and its role in the development of each disease group remain unclear, and the presence of their common differential flora may further provide new ideas for the association of the pathogenesis of the three diseases.

Analysis of multiple organ involvement in Kawasaki disease

This study aimed to explore the incidence and clinical characteristics of multiple complications in children with Kawasaki disease (KD). All patients were diagnosed in our hospital between January 2016 and December 2020. A total of 640 cases were included, 43 patients had coronary artery aneurysm, 51 patients had coronary artery dilation, and 546 patients had no coronary artery damage. The patients were divided into three subgroups based on age: < 1 year old, 1-5 years old, and > 5 years old. The multiple complications of all the KD children and the correlation between extracardiac complications and cardiovascular complications were analyzed. Among the 640 KD children, most were 1-5 years old (415/640, 64.8%). Children < 1 year old (31.6%) and > 5 years old (28.3%) were more likely to have cardiovascular complications. The incidence of respiratory complications was highest in 1-5 year olds (57.1%). Involvement of the digestive and the hematological systems gradually decreased with age, whereas involvement of the nervous system, the urinary system, and the joints gradually increased with age. The incidence of cardiovascular injury with extracardiac complications (22.3%) was higher than that without extracardiac complications (16.3%), although the difference was not statistically significant (p > 0.05).Conclusions: KD can be complicated by multiple-organ injury but there was no significant relationship between the occurrence of extracardiac complications and cardiovascular complications. What is Known: • Cardiovascular disease is generally believed to be the most common and serious complication of Kawasaki disease (KD). • Over recent years, we have found that extracardiovascular complications of KD are more common than generally supposed and, because they have some effect on prognosis, we believe that more attention should be paid to these complications. What is New: • There was no significant relationship between the occurrence of extracardiac complications and cardiovascular complications.

Multisystem inflammatory syndrome in children and Kawasaki disease: a critical comparison

Children and adolescents infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are predominantly asymptomatic or have mild symptoms compared with the more severe coronavirus disease 2019 (COVID-19) described in adults. However, SARS-CoV-2 is also associated with a widely reported but poorly understood paediatric systemic vasculitis. This multisystem inflammatory syndrome in children (MIS-C) has features that overlap with myocarditis, toxic-shock syndrome and Kawasaki disease. Current evidence indicates that MIS-C is the result of an exaggerated innate and adaptive immune response, characterized by a cytokine storm, and that it is triggered by prior SARS-CoV-2 exposure. Epidemiological, clinical and immunological differences classify MIS-C as being distinct from Kawasaki disease. Differences include the age range, and the geographical and ethnic distribution of patients. MIS-C is associated with prominent gastrointestinal and cardiovascular system involvement, admission to intensive care unit, neutrophilia, lymphopenia, high levels of IFNγ and low counts of naive CD4⁺ T cells, with a high proportion of activated memory T cells. Further investigation of MIS-C will continue to enhance our understanding of similar conditions associated with a cytokine storm.

Kawasaki disease presenting after intussusception: a case report

INTRODUCTION

Kawasaki disease is a common vasculitis of unknown etiology that occurs mainly in preschool children. It manifests as a self-limited acute febrile illness with other features including extremity changes, cervical lymphadenopathy, oropharyngeal changes, truncal rash, and conjunctivitis. Intestinal involvement is not uncommon, with abdominal pain and vomiting being the most frequently reported symptoms. Intussusception has been described as a manifestation or complication of this disease, but few reports exist in literature.

CASE PRESENTATION

A 7-month-old boy of Asian origin who presented with vomiting and passage of bloody mucoid stool was diagnosed with intussusception that was successfully reduced during emergency laparotomy. The baby was discharged home post-surgery following clinical improvement. He was readmitted on the fourth postoperative day with fever, irritability, and diarrhea. He was investigated and treated for presumed intraabdominal sepsis with multiple antibiotics with no improvement. He gradually developed the mucocutaneous features of Kawasaki disease and was treated with intravenous immunoglobulin and aspirin with good outcome.

CONCLUSION

Intussusception and Kawasaki disease both commonly occur in children less than 2 years old. It is important to include Kawasaki disease as a differential diagnosis in children of this age who present with an acute febrile illness and gastrointestinal symptoms. A common underlying pathologic process could be contributing to both conditions.

Altered gut microbiota correlated with systemic inflammation in children with Kawasaki disease

Kawasaki disease (KD) is a multi-systemic vasculitis of unknown etiology that occurs mainly in children, and the disturbance of gut microbiota is generally believed to cause a hyperimmune reaction triggering KD. The aim of the study was to investigate the alterations in the fecal microbiota and assess its relationship with systemic inflammation. Totally 30 KD children were enrolled and followed up for 6 months, with another group of 30 age- and sex-matched healthy children as controls. Phylotype profiles of fecal microbial communities were analyzed using 16S rRNA gene sequencing. Serum inflammatory markers were detected by flow cytometer. We showed that KD children exhibited a significant reduction in fecal microbial diversity in the acute phase compared with the healthy controls. Enterococcus, Acinetobacter, Helicobacter, Lactococcus, Staphylococcus and Butyricimonas in acute KD children were significantly higher than the healthy children. Levels of systemic inflammation biomarkers, including IL-2, IL-4, IL-6, IL-10, TNF-α, and INF-γ, were significantly elevated in the acute KD children. Altered microbiota genera Enterococcus and Helicobacter abundances were shown to be correlated positively with IL-6, which were never previously reported in KD. This study suggested that gut microbiota alteration is closely associated with systemic inflammation, which provides a new perspective on the etiology and pathogenesis of KD.

Previous antibiotic use and the development of Kawasaki disease: a matched pair case-control study

BACKGROUND

Kawasaki disease (KD) is an acute febrile illness with systemic vasculitides, mostly affecting infants and young children. The etiology of KD is still unclear; however, altered gut microbiota have been recently implicated as a contributing factor for the development of vasculitis.

METHODS

We conducted an age- and gender-matched case-control study on 50 patients and 200 control subjects to search for potential factors leading to intestinal dysbiosis associated with KD. Data were analyzed using conditional multivariable logistic regression.

RESULTS

Previous antibiotic administration was associated with the patients who developed KD (odds ratio [OR] 11.7, 95% confidence interval [CI] 4.7-29.1, P < 0.0001), but not other variables, including breastfeeding and group nursery. In subgroup analyses, cesarean birth was indicated as an associated factor in addition to previous antibiotic administration in infants under 12 months of age (OR: 8.0, 95% CI: 1.8-34.4, P = 0.005), but not in older children.

CONCLUSIONS

The association between previous antibiotic administration and the onset of KD was demonstrated. Antibiotics may contribute to the development of KD by affecting the intestinal microbiota in infants and young children.

Kawasaki disease: pathophysiology and insights from mouse models

Kawasaki disease is an acute febrile illness and systemic vasculitis of unknown aetiology that predominantly afflicts young children, causes coronary artery aneurysms and can result in long-term cardiovascular sequelae. Kawasaki disease is the leading cause of acquired heart disease among children in the USA. Coronary artery aneurysms develop in some untreated children with Kawasaki disease, leading to ischaemic heart disease and myocardial infarction. Although intravenous immunoglobulin (IVIG) treatment reduces the risk of development of coronary artery aneurysms, some children have IVIG-resistant Kawasaki disease and are at increased risk of developing coronary artery damage. In addition, the lack of specific diagnostic tests and biomarkers for Kawasaki disease make early diagnosis and treatment challenging. The use of experimental mouse models of Kawasaki disease vasculitis has considerably improved our understanding of the pathology of the disease and helped characterize the cellular and molecular immune mechanisms contributing to cardiovascular complications, in turn leading to the development of innovative therapeutic approaches. Here, we outline the pathophysiology of Kawasaki disease and summarize and discuss the progress gained from experimental mouse models and their potential therapeutic translation to human disease.

This Review outlines the pathophysiology of Kawasaki disease and discusses the progress gained from experimental mouse models and their potential therapeutic translation to human disease.

Kawasaki disease is a childhood systemic vasculitis leading to the development of coronary artery aneurysms; it is the leading cause of acquired heart disease in children in developed countries.

The cause of Kawasaki disease is unknown, although it is suspected to be triggered by an unidentified infectious pathogen in genetically predisposed children.

Kawasaki disease might not be a normal immune response to an unusual environmental stimulus, but rather a genetically determined unusual and uncontrolled immune response to a common stimulus.

Although the aetiological agent in humans is unknown, mouse models of Kawasaki disease vasculitis demonstrate similar pathological features and have substantially accelerated discoveries in the field.

Genetic and transcriptomic analysis of blood samples from patients with Kawasaki disease and experimental evidence generated using mouse models have demonstrated the critical role of IL-1β in the pathogenesis of this disease and the therapeutic potential of targeting this pathway (currently under investigation in clinical trials).

Implications of hepatic dysfunction in Kawasaki disease: Time-related changes in aspartate aminotransferase, alanine aminotransferase, total bilirubin, and C-reactive protein levels

IMPORTANCE

The cause of the hepatic dysfunction that commonly accompanies Kawasaki disease (KD) remains unclear.

OBJECTIVE

We tried to clarify the cause of the hepatic dysfunction.

METHODS

A total of 381 consecutive patients with acute KD, who had undergone inpatient treatment with intravenous immunoglobulin until the 7th day of illness, were divided into a group of 199 patients with an alanine aminotransferase (ALT) level ≥ 40 IU/L on admission (group I), a group of 52 patients with an ALT level ≥ 40 IU/L at some point after admission (group II), and a group of 130 patients with ALT levels consistently < 40 IU/L throughout hospitalization (group III). Aspartate aminotransferase (AST), ALT, total bilirubin (T-Bil), and C-reactive protein (CRP) levels were analyzed over time, and time-courses were compared.

RESULTS

In the initial stage of illness, in group I, AST, ALT, T-Bil peaked on days 1-3, and AST tended to improve significantly on the 4th day (P < 0.001). T-Bil improved on day 5 (P < 0.01), and ALT improved significantly on day 6 (P < 0.001). CRP increased every day up to day 6 (P < 0.001). In group II, AST and ALT increased after admission, and thereafter CRP increased, then decreased. The frequency of use of aspirin and aspirin doses did not differ significantly in the three groups.

INTERPRETATION

Recovery from liver dysfunction occurred in the initial stage of illness in group I-within the period of CRP exacerbation, which is an indicator of systemic inflammation.

Causes of Kawasaki Disease-From Past to Present

Kawasaki disease (KD) is a multisystem vasculitis that primarily affects the coronary arteries of young children. The causes of KD remain a mystery. It is suspected that some sort of infectious agent is involved because KD has epidemicity and seasonality. That said, the incidence of the disease is high among Japanese people, so it can be speculated that the hosts may have some sort of genetic characteristic that leaves them susceptible to KD. Various theories regarding the etiology have been asserted, such as the infectious vasculitis theory, autoantigen theory, superantigen theory, and RNA virus theory; however, none of them have been able to overcome this epidemicity. Taking into consideration the knowledge gained from previous reports, the best scenario explaining the pathogenesis is "individuals with certain genetic backgrounds are affected by microorganisms which trigger KD." In this article, the pathogenesis of KD is discussed with a focus on the microorganisms mentioned above, along with the previous and current hypotheses as well as my own opinion.

The Gut Microbiota-Host Partnership as a Potential Driver of Kawasaki Syndrome

Kawasaki syndrome (KS) is a necrotizing vasculitis of small- and medium-sized vessels mostly affecting children under 5 years of age; a host of clinical and epidemiological data supports the notion that KS might result from an infectious disease. However, many efforts have failed to identify a potentially universal trigger of KS. The contribution of the intestinal microbial community-called the "microbiota"-to KS has been evaluated by an increasing number of studies, though limited to small cohorts of patients. Differences in the microbiota composition were found in children with KS, both its acute and non-acute phase, with abnormal colonization by Streptococcus species in the intestinal tract and a wider presence of Gram-positive cocci in jejunal biopsies. In particular, a higher number of Gram-positive cocci (of the genera Streptococcus and Staphylococcus), Eubacterium, Peptostreptococcus, and HSP60-producing Gram-negative microbes have been found in the stools of KS children, and their effects on the antigenic repertoire of specific T cells and Vβ2 T cell expansion have been assessed. Conversely, Lactobacilli were lacking in most children with KS compared with other febrile illnesses and healthy controls. All studies available to date have confirmed that an imbalance in the gut microbiota might indirectly interfere with the normal function of innate and adaptive immunity, and that variable microbiota interactions with environmental factors, mainly infectious agents, might selectively drive the development of KS in genetically susceptible children. Further investigations of the intestinal microflora in larger cohorts of KS patients will provide clues to disentangle the pathogenesis of this disease and probably indicate disease-modifying agents or more rational KS-specific therapies.

Intestinal Involvement in Kawasaki Disease

OBJECTIVES

To describe a case of Kawasaki disease with intestinal involvement and to analyze other published reports to define clinical characteristics, diagnostic issues, and therapeutic approaches of gastrointestinal involvement in Kawasaki disease.

STUDY DESIGN

A computerized search without language restriction was conducted using PubMed and SCOPUS. An article was considered eligible for inclusion in the systematic review if it reported data on patient(s) with intestinal involvement in Kawasaki disease. Our case was also included in the analysis.

RESULTS

Thirty-three articles reporting 48 cases of Kawasaki disease with intestinal involvement were considered. Fever, abdominal pain, and vomiting were the most frequent symptoms observed and typical Kawasaki disease signs and symptoms appeared after intestinal complaints in all cases. Plain radiographs, ultrasonography, and computed tomography showed pseudo-obstruction as the most frequent sign of gastrointestinal involvement; 25 patients underwent surgery. Cardiac involvement was documented in 21 cases. All but three patients received medical treatment with immunoglobulin intravenous or aspirin. The outcome was good in 28 patients; 7 patients showed persistence of coronary artery abnormalities; 1 patient developed cyanosis, and later, left hand and forefoot gangrene; 3 patients died.

CONCLUSIONS

The diagnosis and treatment of Kawasaki disease might be delayed if intestinal symptoms appear before the characteristic clinical features of Kawasaki disease, thus, increasing the risk of cardiac complications. Furthermore, patients may undergo unnecessary invasive procedures. Pediatricians and pediatric surgeons, therefore, should consider Kawasaki disease among diagnoses in children with fever, abdominal symptoms, and radiologic findings of pseudo-obstruction.

Clostridium difficile colitis complicating Kawasaki disease in children: Two case reports

Clostridium difficile infection is increasingly diagnosed in children with a wide clinical spectrum ranging from asymptomatic carriage to fulminant colitis. Symptomatic patients typically present with diarrhea, with or without blood, fever, and abdominal pain. Kawasaki disease, a vasculitis of unknown etiology, occurs primarily in young children. Establishing the diagnosis of Kawasaki disease can be challenging given the lack of a confirmatory diagnostic test or pathognomonic features as well as the appearance of symptoms over time rather than simultaneously. In addition, commonly occurring nonspecific associated symptoms, such as diarrhea and abdominal pain, may confound the clinical presentation. We present two cases of children with Kawasaki disease presenting with fever and Clostridium difficile colitis to illustrate the importance of keeping a high index of suspicion for Kawasaki disease.

Kawasaki disease-specific molecules in the sera are linked to microbe-associated molecular patterns in the biofilms

Background

Kawasaki disease (KD) is a systemic vasculitis of unknown etiology. The innate immune system is involved in its pathophysiology at the acute phase. We have recently established a novel murine model of KD coronary arteritis by oral administration of a synthetic microbe-associated molecular pattern (MAMP). On the hypothesis that specific MAMPs exist in KD sera, we have searched them to identify KD-specific molecules and to assess the pathogenesis.

Methods

We performed liquid chromatography-mass spectrometry (LC-MS) analysis of fractionated serum samples from 117 patients with KD and 106 controls. Microbiological and LC-MS evaluation of biofilm samples were also performed.

Results

KD samples elicited proinflammatory cytokine responses from human coronary artery endothelial cells (HCAECs). By LC-MS analysis of KD serum samples collected at 3 different periods, we detected a variety of KD-specific molecules in the lipophilic fractions that showed distinct m/z and MS/MS fragmentation patterns in each cluster. Serum KD-specific molecules showed m/z and MS/MS fragmentation patterns almost identical to those of MAMPs obtained from the biofilms formed in vitro (common MAMPs from Bacillus cereus, Yersinia pseudotuberculosis and Staphylococcus aureus) at the 1^st study period, and from the biofilms formed in vivo (common MAMPs from Bacillus cereus, Bacillus subtilis/Bacillus cereus/Yersinia pseudotuberculosis and Staphylococcus aureus) at the 2^nd and 3^rd periods. The biofilm extracts from Bacillus cereus, Bacillus subtilis, Yersinia pseudotuberculosis and Staphylococcus aureus also induced proinflammatory cytokines by HCAECs. By the experiments with IgG affinity chromatography, some of these serum KD-specific molecules bound to IgG.

Conclusions

We herein conclude that serum KD-specific molecules were mostly derived from biofilms and possessed molecular structures common to MAMPs from Bacillus cereus, Bacillus subtilis, Yersinia pseudotuberculosis and Staphylococcus aureus. Discovery of these KD-specific molecules might offer novel insight into the diagnosis and management of KD as well as its pathogenesis.

Heat shock proteins and superantigenic properties of bacteria from the gastrointestinal tract of patients with Kawasaki disease

We previously suggested that gut bacteria may be involved in the onset of Kawasaki disease (KD). In this study, we evaluated the production of heat shock proteins (hsps) and superantigens (sAgs) by microorganisms isolated from the jejunal mucosa of 19 children with KD in the acute phase and from 15 age-matched control children. We identified 13 strains of Gram-negative microbes from patients with KD; these microbes produced large amounts of hsp60 and induced pro-inflammatory cytokine production by peripheral blood mononuclear cells. The Gram-negative microbes also elicited endogenous hsp60 production, leading to the secretion of anti-inflammatory intereukin-10 (IL-10). We also identified 18 strains of Gram-positive cocci that had superantigenic properties and which induced the expansion of Vβ2 T cells in vitro. All bacteria identified in this study were antibiotic resistant. These data suggest that sAg and hsps produced by gut bacteria might be involved in KD.

A case of Kawasaki disease with colonic edema

Kawasaki disease (KD) is recognized as a systemic vasculitis affecting multi-organ with inflammatory changes. The commonest and most serious complication of KD is coronary artery aneurysm, but KD may cause other organic complications beside cardiac problems. Gastrointestinal tract also present complications of KD in which, for example, hepatic dysfunction, pancreatitis, intussusception, colonic obstruction, intestinal pseudo-obstruction, and bowel edema are included. Among them, colonal wall edema is left unknown in the incidence, and it has been reported even if rare. In this report, we describe a case of KD with colonal wall edema, occurred in 5-yr-old boy who complained of severe abdominal pain and vomiting.

The surgical manifestations of the intestinal tract in Kawasaki disease

Kawasaki disease (KD) is an inflammatory condition of unknown etiology. It involves mainly the skin, mucous membranes, lymph nodes, and myocardium. It may involve the gastrointestinal tract; however, it rarely presents as a surgical abdomen. We present a case of a young child with suspected small bowel obstruction who was subsequently diagnosed with KD. We review the surgical presentations of the intestinal tract in KD.

Acute surgical abdomen as presenting manifestation of Kawasaki disease

Ten children (4.6%) among a cohort of 219 with Kawasaki disease (KD) had their onset with severe abdominal complaints. Incomplete KD presentation at the time of acute abdomen was present in nine of 10 patients. Acute abdominal pain and distension, vomiting, hepatomegaly, and jaundice were the most common symptoms at onset. Hematemesis was present in one; toxic shock syndrome requiring care in the intensive care unit occurred in four. Five patients had laparotomy, three had percutaneous transhepatic biliary drainage, and one had a gastrointestinal endoscopy. Postoperative diagnosis was gallbladder hydrops with cholestasis in five, paralytic ileus in three, appendicular vasculitis in one, and hemorrhagic duodenitis in one. All patients completely recovered, but 50% developed coronary aneurysms despite early intravenous gammaglobulin treatment. Acute surgical abdomen can be the presenting manifestation of KD. In older children with fever, rash, and acute abdominal pain or hematemesis, KD should be considered in the differential diagnosis.