Long-term prognosis of patients with Kawasaki disease: at risk for future atherosclerosis?

Candesartan Attenuates Vasculitis in a Mouse Model of Kawasaki Disease Induced by Candida albicans Water-Soluble Fraction

BACKGROUND

The standard treatment for Kawasaki disease is immunoglobulin therapy, but the high frequency of coronary sequelae in immunoglobulin-refractory cases indicates a need for further improvement in treatment.

METHODS

Kawasaki disease-like vasculitis was induced in 5-week-old DBA/2 mice by intraperitoneal administration of 0.5 mg Candida albicans water-soluble fraction (CAWS) daily for 5 days followed by daily administration of candesartan, an angiotensin receptor blocker. The vasculitis suppression effect was confirmed histologically and serologically in mice sacrificed at 28 days after the start of candesartan.

RESULTS

The area of inflammatory cell infiltration at the aortic root was 2.4±1.4% in the Control group, 18.1±1.9% in the CAWS group, and 7.1±2.3%, 5.8±1.4%, 7.6±2.4%, and 7.9±5.0% in the CAWS+candesartan 0.125-mg/kg, 0.25-mg/kg, 0.5-mg/kg, and 1.0-mg/kg groups, respectively (p=0.0200, p=0.0122, p=0.0122, and p=0.0200 vs. CAWS, respectively). The low-dose candesartan group also showed significantly reduced inflammatory cell infiltration. A similar trend was confirmed by immunostaining of macrophages and TGFβ receptors. Measurement of the inflammatory cytokines IL-1β, IL-6, and TNF-α confirmed the anti-vasculitis effect of candesartan.

CONCLUSIONS

Candesartan inhibited vasculitis even at clinical doses used in children, making it a strong future candidate as an additional treatment for immunoglobulin-refractory Kawasaki disease.

The Predictive Values of MMP-9, PLTs, ESR, and CRP Levels in Kawasaki Disease with Cardiovascular Injury

Objective

To explore the levels of matrix metalloproteinase-9 (MMP-9), platelets (PLTs), C reactive protein (CRP), and erythrocyte sedimentation rate (ESR) and their predictive values in Kawasaki disease (KD) with cardiovascular injury.

Methods

128 children were diagnosed with KD in the Lanzhou University Second Hospital. 75 patients had coronary artery lesion (CAL), while 53 patients did not. The levels of MMP-9, PLTs, and CRP and ESR in the two groups were determined. The area under the curve (AUC) of the receiver-operating characteristic (ROC) curve and the Youden index (YI) were used to evaluate the efficacy of MMP-9, PLTs, ESR, and CRP for predicting CALs in KD.

Results

The mean age of the patients was 2.7 ± 2.03 years (range, 2 months to 11 years). There were 87 boys (67.97%) and 41 girls (32.03%). In contrast to the NCAL group, the CAL group had obviously higher levels of MMP-9, PLTs, and CRP and an obviously higher ESR (P < 0.05). MMP-9 showed a linear positive correlation with ESR (P < 0.05) and CRP (P < 0.05). The AUC of the combined detection of the four indicators was 0.877, the sensitivity was 85.07% and the specificity was 78.95%.

Conclusion

MMP-9, PLTs, ESR, and CRP are important indicators for a CAL in KD. The efficacy of the combined detection of MMP-9, PLTs, ESR and CRP is better than that of any single indicator for predicting a CAL in KD.

Kawasaki Disease: Pathology, Risks, and Management

Kawasaki disease (KD), first reported as an acute febrile mucocutaneous lymph node syndrome, is a self-limiting vasculitis of unknown etiology. The most important aspect of KD is the prevention of coronary artery lesion (CAL) because myocardial ischemia or infarction due to CAL might be lethal. In addition to the CAL, patients with KD develop systemic vasculitis, which indicates the presence of vascular endothelial damage. Studies assessing pulse wave velocity or percentage change in flow-mediated dilatation have shown that aortic stiffness is increased in patients with KD history. In contrast, the cardio-ankle vascular index, a novel parameter not affected by blood pressure, has not demonstrated increased aortic stiffness in patients with KD. Although many studies using various parameters have suggested a risk of atherosclerosis in patients with a history of KD, a few others have reported no significant differences between KD patients and controls. Therefore, it will be necessary to thoroughly understand the characteristics of each parameter, before evaluating the results of those studies, to understand systemic vascular dysfunction in these populations, and to manage their vascular health. Although it is controversial whether the risk of atherosclerosis in patients with KD is higher, those with CAL are thought to be at a high risk of atherosclerosis. Therefore, appropriate treatment to prevent CAL in the acute phase and subsequent regular follow-up is important. Here, we review the pathology, risk, and management of vascular disorders, especially systemic vascular disorders, in patients with KD history.

Hydrogen Gas Inhalation Regressed Coronary Artery Aneurysm in Kawasaki Disease-Case Report and Article Review

Kawasaki disease (KD) is a systemic vasculitis that primarily affects children under the age of 5 years old and is among the most common acquired heart disease in developed countries, particularly in Asia. No effective treatment is currently available for aneurysm formation in KD. In this report, we showed a KD patient with an aneurysm over the right coronary artery with a size of 6.08 mm in diameter and 35 mm in length, which completely regressed to within normal range after hydrogen inhalation within 4 months after disease onset. This 10-year-old KD patient was diagnosed on the 12th day of disease onset with incomplete presentation of KD symptoms. Intravenous immunoglobulin was prescribed after KD diagnosis was confirmed by the formation of a coronary artery aneurysm. Once discharged from the hospital, the family used hydrogen inhalation (77% hydrogen and 23% oxygen) at home with nasal cannula 1 h per day. The aneurysm was found to be completely regressed at the 4-month follow-up (day 138 of the illness). The follow-up laboratory data showed complete blood cell count, differential count, electrolytes, liver enzyme, and renal function to all be within normal range. This is the first study to report an aneurysm from KD with regression under supplementary therapy with hydrogen gas inhalation and no other complications. Therefore, hydrogen gas inhalation may be an alternative anti-free radical or anti-oxidant therapy for KD, but further study is still required.

Profile of Urinary Cytokines in Kawasaki Disease: Non-Invasive Markers

This cohort study aimed to investigate urinary cytokines expression to help identify a less invasive method of cytokine detection for Kawasaki disease (KD). Patients with confirmed KD were recruited. Patients with fever or urinary tract infection (UTI) were enrolled as control groups. Urinary samples were collected before and 3 days after intravenous immunoglobulin (IVIG) treatment. The levels of cytokines were detected by MILLPLEX^® MAP human multiplex assay. All cytokines, i.e., epidermal growth factor (EGF), interferon (IFN)-γ, interleukin (IL)-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-9, IL-10, IL-13, IL-17A, IL-33, interferon-gamma-induced protein (IP)-10, macrophage inflammatory protein (MIP)-1β, tumor necrosis factor (TNF)-α, and vascular endothelial growth factor (VEGF) except monocyte chemoattractant protein (MCP)-1 were significantly higher in the KD group, compared with the fever-control (FC) group, whereas the expressions of IFN-γ, IL-1β, IL-6, IL-8, IL-17A, IL-33, MCP-1, MIP-1β, and TNF-α were significantly lower in the urine of KD patients, as compared with the UTI group. The expressions of EGF, IFN-γ, IL-8, IL-13, and IL-17A were higher in the urine of KD patients than in the FC group, whereas the level of IL-1β was lower in KD than in the UTI group after age adjustment by logistic regression. Levels of IL-6, IL-8, IL-13, IP-10, and MCP-1 were significantly higher in the pre-IVIG urine of KD patients than in the post-IVIG treatment group. Additionally, urine IL-4 and blood C-reactive protein were higher in the KD group with coronary artery lesion (CAL) than in the non-CAL group. Results of this study provide a new view of urinary cytokine expression in the disease progress of KD, which may help clinicians to predict and prevent morbidity early and non-invasively.

An Update on Cardiovascular Risk Factors After Kawasaki Disease

First described in Japan 50 years ago, Kawasaki disease is a worldwide multisystem disease. It is an acute self-limited vasculitis of unknown etiology that can lead to coronary artery lesions, such as dilatation, aneurysms, and stenosis in children. It is one of the common causes of acquired heart disease among children in developed countries. The coronary aneurysm is a severe complication in the acute stage, possibly leading to stenotic lesions or myocardial ischemia. More concerns have centered on endothelial damage and the early onset of atherosclerosis in patients with KD. Although the coronary artery aneurysm is small or degenerated, the vascular structure does not return to normal, vascular endothelial dysfunction and remodeling continue. Most patients diagnosed with coronary artery sequelae are at risk of long-term complications. There are still many unknown aspects regarding the long-term prognosis of patients. Concerns have centered on the early onset of atherosclerosis in patients with KD. There is still no consensus on the relationship between Kawasaki disease and atherosclerosis. This study aimed to evaluate if patients with a history of KD were at risk of accelerated atherosclerosis.

Effective infliximab therapy for the early regression of coronary artery aneurysm in Kawasaki disease

BACKGROUND

There is limited information available regarding the role of infliximab (IFX) following the acute phase of Kawasaki disease (KD). We aimed to evaluate whether IFX is associated with coronary artery aneurysm (CAA) regression.

METHODS

Between 2005 and 2016, we identified 971 consecutive patients with KD from 3 tertiary institutions, and 49 (5%) with CAAs were enrolled in our study. Patients were divided into 2 groups: 27 who received IFX and 22 who did not. The persistence rate of CAAs was compared between the groups.

RESULTS

Age, sex, and duration of the febrile period did not significantly differ between the groups. The maximum value of C-reactive protein was higher in the IFX- than in the non-IFX group. The maximum z-score of CAAs did not differ between the groups. The 2-, 4- and 6-year cumulative persistence rate of CAA was 24%, 24% and 24% in IFX-group, whereas 67%, 52% and 33% in non-IFX group, respectively (P = 0.03). The median duration of CAA regression was 1.1 vs. 4.6 years. Among those who developed medium- or large-sized CAAs, the 2-, 4- and 6-year cumulative persistence rate of CAA was 33%, 33% and 33% in IFX group, whereas 77%, 51% and 48% in non-IFX group, respectively (P = 0.047). Multivariate logistic regression analysis indicated that the maximum z-score (hazard ratio 0.72, p < 0.001) and response to IFX (hazard ratio 4.56, p = 0.017) were independently related to regression.

CONCLUSION

IFX therapy was observed to be effective for the early improvement of CAAs in patients with intravenous immunoglobulin-resistant KD.

Long-term outcome of coronary artery dilatation in Kawasaki disease

Background

Kawasaki disease (KD) is an acute systemic vasculitis syndrome with a high incidence of coronary aneurysms in untreated children. The majority of aneurysms resulting from KD are known to regress with time.

Aims

This study aimed to determine the course and outcome of coronary artery dilatation in patients with KD and ascertain whether there are any differences in the outcomes in the different branches.

Setting and Design

This is a retrospective cohort study of patients diagnosed with KD with midterm follow-up data.

Methods

Serial echocardiography was performed in all KD patients with coronary dilatation for 1-10½ years. The Kaplan-Meier curve was used for statistical analysis.

Results

There were 154 patients with coronary dilatation studied. The frequency of coronary dilatation in acute phase was 33.3% and decreased to 7.9% 6-8 weeks later. Each patient could have dilatations at more than one branch, so the total number of dilatations was 245. The median time needed for regression was 2.6 months (mean: 10.5 months) while the median of follow-up duration was 41 months (mean: 23 months). Small- and medium-sized dilatations had more favorable outcomes compared to the giant ones. Location of dilatation did not influence the outcome.

Conclusions

The majority (77.4%) of small- and medium-sized dilatations regress within 2 years, but giant aneurysms tend to persist. The outcome of coronary dilatation is determined by the diameter and not by the location. Regression rate is faster in smaller dilatations. Left main coronary artery is the most frequent location for dilatation.

Pulse Wave Velocity in Kawasaki Disease

Kawasaki disease (KD) is an acute childhood febrile disease of unknown etiology. It exhibits not only coronary artery aneurysms in some cases but also systemic vasculitis. Whether KD is associated with accelerated atherosclerosis remains debatable. The measurement of pulse wave velocity (PWV) is useful as a simple, noninvasive measurement of arterial stiffness, an atherosclerotic manifestation. We herein present a systematic review of clinical studies that focused on PWV in patients with KD. A PubMed-based search identified 8 eligible studies published until June 2015. The PWV of patients with KD, regardless of antecedent coronary artery lesions, was high relative to controls, even though their blood pressure appeared to be similar. Although definitive conclusions cannot be made with the limited information, patients with KD may be at risk of systemic atherosclerosis in association with arterial stiffness. Further research, including longitudinal and outcome studies, is needed to determine the clinical significance of a potential increase in PWV in patients with KD.

A meta-analysis of re-treatment for intravenous immunoglobulin-resistant Kawasaki disease

OBJECTIVE

To determine the optimal drug therapy for intravenous immunoglobulin-resistant Kawasaki disease.

METHODS

Studies regarding drug therapy for intravenous immunoglobulin-resistant Kawasaki disease were selected from medical electronic databases including PubMed, Medline, Elsevier, and Springer Link. The effectiveness in terms of temperature recovery and coronary artery damage was compared between a second intravenous immunoglobulin treatment and glucocorticosteroid treatment for children with intravenous immunoglobulin-resistant Kawasaki disease using meta-analysis with Review Manager 5.3 software. Indices to evaluate the effects were body temperature, biomarker levels, and coronary artery lesions detected by echocardiography. Results are reported as relative risks or odds ratio with a 95% confidence interval and p<0.05.

RESULTS

Meta-analysis included 52 patients in the second intravenous immunoglobulin treatment group and 75 patients in the glucocorticosteroid treatment control group from four studies that met our inclusion criteria. Temperatures of patients who received glucocorticosteroid treatment were effectively controlled compared with those who received a second intravenous immunoglobulin treatment (relative risk=0.73, 95% confidence interval: 0.58-0.92, p=0.007). There were no differences, however, in the incidence of coronary artery lesions between the two groups (odds ratio=1.55, 95% confidence interval: 0.57-4.20, p=0.39).

CONCLUSIONS

Glucocorticosteroids are more effective in controlling body temperature compared with intravenous immunoglobulin re-treatment in intravenous immunoglobulin-resistant Kawasaki disease children; however, glucocorticosteroids and intravenous immunoglobulin re-treatment showed no difference in the prevention of coronary artery lesions.

Persistence of endothelial cell damage late after Kawasaki disease in patients without coronary artery complications

Background:

Recent studies proposed an increased risk of atherosclerosis in patients with a history of Kawasaki disease. This study aimed to investigate the persistence of vascular injury after an acute phase of the Kawasaki disease.

Materials and Methods:

We determined the number of circulating endothelial cells (CEC) in the peripheral blood of 13 patients with a history of Kawasaki disease within four to ten years, in comparison with 13 healthy relative controls. The CECs were counted as CD146+/CD34 + cells by the standard flow cytometry technique, and the independent t-test was employed to compare the mean number of CECs in the two groups.

Results:

The mean number of CECs was significantly higher in patients than in controls (12 ± 3.03 vs. 2.38 ± 0.87, respectively, P < 0.001).

Conclusion:

This study elucidates the persistence of vascular injury late after Kawasaki disease. This finding suggests that prolonged administration of vascular anti-inflammatory agents might be beneficial for preventing atherosclerosis in the subsequent years, in these patients.

Lipoprotein particle concentrations in children and adults following Kawasaki disease

OBJECTIVE

To test the hypothesis that children and adults with a history of Kawasaki disease (KD) are more likely to have abnormal lipoprotein particle profiles that could place them at increased risk for developing atherosclerosis later in life.

STUDY DESIGN

Fasting serum samples were obtained from 192 children and 63 adults with history of KD and 90 age-similar healthy controls. Lipoprotein particle concentrations and sizes were measured by nuclear magnetic resonance spectroscopy (LipoScience Inc, Raleigh, North Carolina), and serum was assayed for total cholesterol (TC), triglycerides, and high-density lipoprotein (HDL) cholesterol (HDL-C). Low-density lipoprotein (LDL) cholesterol was estimated using the Friedewald formula. Data were analyzed in a least-square means model, with adjustment for age and sex and with the use of Holm correction for multiple comparisons.

RESULTS

Compared with respective control groups, both adult and pediatric subjects with KD had significantly lower mean very low-density lipoprotein-chylomicron particles, intermediate-density lipoproteins, triglycerides, and TC concentrations. Pediatric subjects with KD had significantly lower LDL particle and LDL cholesterol concentrations and lower mean TC/HDL-C ratio (P < .001). In contrast, the adult subjects with KD had significantly lower HDL particle, small HDL particle, and HDL-C concentrations (P < .001), but HDL-C was within normal range.

CONCLUSIONS

Nuclear magnetic resonance lipoprotein particle analysis suggests that pediatric and adult subjects with KD, regardless of their aneurysm status, are no more likely than age-similar, healthy controls to have lipid patterns associated with increased risk of atherosclerosis.

Developments in large and midsize vasculitis

Childhood vasculitis is a complex and fascinating area in pediatric rheumatology that has experienced an unprecedented surge in research, leading to new knowledge over the past several years. Vasculitis is defined as the presence of inflammatory cell infiltration in blood vessel walls, usually with multisystemic involvement. The most frequent forms of vasculitis in childhood are the small-size vasculitides, of which Henoch-Schoenlein Purpura and other leucocytoclastic vasculitis are the best examples, followed by Kawasaki disease, a midsize vasculitis, and Takayasu arteritis, a large-size vasculitis, both of which are topics in this article.

Kawasaki Disease: A Clinician's Update

Aims. Kawasaki disease is an acute systemic vasculitis and is the most common cause of acquired heart disease in children in the developed world. This review aims to synthesise recent insights into the disease and provide an update for clinicians on diagnostic and treatment practices. Methods. We conducted a review of the literature exploring epidemiology, aetiology, diagnosis, and management of Kawasaki disease. We searched MEDLINE, Medline In-Process, Embase, Google Scholar, and reference lists of relevant articles. Conclusions. Kawasaki disease is a febrile vasculitis which progresses to coronary artery abnormalities in 25% of untreated patients. The disease is believed to result from a genetically susceptible individual's exposure to an environmental trigger. Incidence is rising worldwide, and varies widely across countries and within different ethnic groups. Diagnosis is based on the presence of fever in addition to four out of five other clinical criteria, but it is complicated by the quarter of the Kawasaki disease patients with "incomplete" presentation. Treatment with intravenous immunoglobulin within ten days of fever onset improves clinical outcomes and reduces the incidence of coronary artery dilation to less than 5%. Given its severe morbidity and potential mortality, Kawasaki disease should be considered as a potential diagnosis in cases of prolonged paediatric fever.

Mortality among Japanese with a history of Kawasaki disease: results at the end of 2009

BACKGROUND

The long-term outcomes of Kawasaki disease (KD) are unknown.

METHODS

Fifty-two collaborating hospitals collected data on all patients who had received a new definite diagnosis of KD between July 1982 and December 1992. Patients were followed until December 31, 2009 or death. Standardized mortality ratios (SMRs) were calculated based on Japanese vital statistics data.

RESULTS

Of the 6576 patients enrolled, 46 (35 males and 11 females) died (SMR: 1.00; 95% CI: 0.73-1.34). Among persons without cardiac sequelae, SMRs were not high after the acute phase of KD (SMR: 0.65; 95% CI: 0.41-0.96). Among persons with cardiac sequelae, 13 males and 1 female died during the observation period (SMR: 1.86; 95% CI: 1.02-3.13).

CONCLUSIONS

In this cohort, the mortality rate among Japanese with cardiac sequelae due to KD was significantly higher than that of the general population. In contrast, the rates for males and females without sequelae were not elevated.

Anti-platelet agents in pediatric cardiac practice

Pediatric patients with a variety of congenital and acquired cardiac conditions receive antithrombotic therapy. Many of the indications are empirical, and have either not been proven in controlled studies or are extrapolated from adult studies. This article reviews the current available literature regarding the use of anti-platelet drugs in the pediatric cardiac population.

A meta-analysis of the biomarkers associated with coronary artery lesions secondary to Kawasaki disease in Chinese children

The biomarkers associated with coronary artery lesions (CAL) secondary to Kawasaki disease (KD) in Chinese children were investigated by using Meta-analysis. We searched documents published from January 1997 to December 2009 from medical electronic databases. According to inclusion and exclusion criteria, eligible full-text papers were identified. We conducted a comprehensive quantitative analysis by using Stata10.0 statistical software package to assess the heterogeneity among the documents, calculated the summary effect and analyze publication bias and sensitivity. A total of 92 documents and 16 biomarkers were identified. All documents were case-control studies, and included 2398 patients in CAL group and 5932 patients in non-CAL (NCAL) group. The Meta-analysis showed that the levels of platelet count, platelet hematocrit (PCT), neutrophils count, platelet distribution width (PDW), mean platelet volume (MPV), erythrocyte sedimentation rate (ESR), cardiac troponin I (cTnI), and endothelin-1 (ET-1) in CAL group were significantly higher than those in NCAL group, and serum albumin (Alb) and hemoglobin (Hb) levels were significantly lower in CAL group (all P<0.05). White blood cell (WBC) count, serum sodium, matrix metalloproteinase 9 (MMP-9), total cholesterol (TC), hematocrit (HCT) and CD3+T lymphocytes percentage had no statistically significant difference between the two groups. In conclusion, our results indicated that the 10 biomarkers including platelet count, neutrophils count, PCT, PDW, MPV, ESR, cTnI, ET-1, Alb and Hb were associated with CAL, and may be involved in the pathogenesis of CAL. The biomarkers of WBC count, serum sodium, MMP-9, TC, HCT, and CD3+T lymphocytes percentage bore no relationship with the development of CAL among Chinese children with KD.

Multiple mirror-image peripheral arterial aneurysms in Kawasaki disease

We present the case of a 5-year-old boy diagnosed with Kawasaki disease at 10 months of age who developed fusiform aneurysms of the coronary arteries as well as a previously undescribed pattern of mirror-image peripheral arterial aneurysms. These aneurysms were diagnosed on conventional angiography of the aortoiliac circulation and the bilateral upper extremity circulation.

The functions of endothelial progenitor cells were significantly improved after treatment with intravenous immunoglobulin and aspirin in children with Kawasaki disease

We sought to determine the effects of treatment with intravenous immunoglobulin (IVIG) and aspirin on the functions of endothelial progenitor cells (EPCs) in patients with Kawasaki disease (KD) as well as its relationship with concentrations of tumor necrosis factor-α (TNF-α) and high-sensitivity C-reactive protein (hs-CRP). Ten KD patients in the acute phase of their disease were recruited. We investigated EPC functions in children with KD before and after treatment with IVIG and aspirin. In vitro assays were used to measure the functions, including proliferation, adhesion, and migration activities, of EPCs. Plasma levels of TNF-α and hs-CRP were also assessed. All of the data were assessed before and at 7 days after treatment initiation. EPC functions after 7 days of treatment with IVIG and aspirin were significantly improved than they were before treatment with IVIG and aspirin. Treatment with IVIG and aspirin significantly decreased TNF-α and hs-CRP concentrations. There was a significant linear regression relationship between decreased plasma TNF-α levels, hs-CRP levels, and increased functions of circulating EPCs. The results of our study indicate that the functions of circulating EPCs improved after treatment with IVIG and aspirin, which may be related to decreased concentrations of TNF-α and hs-CRP.

The T helper type 17/regulatory T cell imbalance in patients with acute Kawasaki disease

The study is designed to investigate the changes and roles of T helper type 17/regulatory T cells (Th17/T(reg) ) in the immunological pathogenesis of Kawasaki disease (KD). In addition, we explore the alteration and significance of Th17 cells in patients with intravenous immune globulin-resistant KD. Real-time polymerase chain reaction (PCR) was used to evaluate the mRNA levels of interleukin (IL)-17A/F, retinoic acid-related orphan receptor (ROR)-γt and forkhead box P3 (FoxP3) in CD4-positive cells. The proportions of Th17 cells and CD4(+) CD25(+) FoxP3(high) T(regs) were analysed by flow cytometry. Plasma cytokine [IL-17A, IL-6, IL-23 and transforming growth factor (TGF)-β] concentrations were measured by sandwich enzyme-linked immunosorbent assay. Our data demonstrate that Th17 proportions and expression levels of cytokines (IL-17, IL-6 and IL-23) and transcription factors (IL-17A/F, ROR-γt) were up-regulated significantly, while T(reg) proportions and expression levels of T(reg ) transcription factor (FoxP3) were down-regulated significantly in children with acute KD (P<0·01). Compared with the sensitive group, the Th17 proportions were up-regulated significantly during the acute phase in immune globulin-resistant KD (P < 0·01). The plasma IL-17A, IL-6 and IL-23 concentrations in patients with KD were significantly higher compared with the concentrations in normal controls (NC) and infectious disease (ID). Plasma TGF-β concentrations were markedly lower in the KD group than the NC and ID groups (P < 0·05). These results suggest that Th17/T(reg) cells imbalance exists in the patients with KD. Th17/T cells imbalance may be important factors causing disturbed immunological function and resulting in immunoglobulin-resistant KD.

Kawasaki disease preceding haemophagocytic lymphohistiocytosis: challenges for developing world practitioners

Kawasaki disease (KD) is a recognised precipitant of haemophagocytic lymphohistiocytosis (HLH). Although KD has been previously described in the developing world, there are no reported cases of KD preceding HLH. We report a case of a child with a persistent rash and unremitting fever consistent with the diagnosis of KD, who was found to have HLH, after intravenous gamma globulin failed to produce a clinical response. The diagnosis was made using the revised diagnostic criteria for HLH from the Histiocyte Society (1994). She fulfilled six of the eight clinical and laboratory criteria needed to make the diagnosis.

Affects of "age at diagnosis" on coronary artery lesions in patients with incomplete kawasaki disease

Background and Objectives

Diagnosis of Kawasaki disease (KD) is based on 5 clinical features. Incomplete KD (IKD), which has fewer features, is more common in infants and older children, in whom the rate of coronary artery aneurysms is paradoxically higher. We conducted this study to evaluate risk factors associated with age-at-diagnosis on coronary arterial lesions (CAL) in patients with IKD.

Subjects and Methods

Retrospective data from 396 patients with KD in a single center were collected from January 2003 to July 2007. Patients were grouped according to their age at diagnosis; Group A (<1 year of age), Group B (1≤age<5 years of age), and Group C (≥5 years of age).

Results

Among a total of 396 patients with KD, 87 (22.0%) were in Group A, 246 (62.1%) in Group B, and 63 (15.9%) in Group C. In groups A and C, lag times for starting intravenous immunoglobulin (IVIG) were longer than in Group B. There were no differences in the incidence of IKD, late CAL, or rates of IVIG retreatment among the three groups. Among 174 patients with IKD, there were no age-related differences in late CAL incidence or IVIG retreatment. Compared with typical KD, duration of fever and lag times to start IVIG were longer, and the rate of IVIG retreatment was higher in IKD, but there was no difference in the risk of CAL between typical KD and IKD.

Conclusion

In the management of KD, especially the incomplete type, age-associated factors appear not to be significant for predicting the development of CAL.

Myocardial ischemia in Wegener's granulomatosis: coronary atherosclerosis versus vasculitis

Wegener's granulomatosis (WG) is one of the most common small- and medium-sized necrotizing vasculitides that mainly affects the upper and lower respiratory tract and the kidneys. Cardiac manifestations in WG are relatively rare, and their role and place among different causes of mortality remain largely unknown. Substantially increased number of reports describing involvement of all structures of the heart, which underlie conduction disturbances, valvular disease, ischemic heart disease and other potentially serious conditions, underscores importance of comprehensive cardiovascular investigations and monitoring of patients with WG. The majority of previous reports and our current observation distinguish coronary vasculitis and thrombosis as a cause of myocardial ischemia and cardiovascular co-morbidities in WG. It seems plausible that inflammatory processes in this disease, like in some other systemic vasculitidies, do not predispose to accelerated atherogenesis. However, characteristic small- and medium-sized vasculitis still can manifest as myocardial ischemia and infarction. We overview diverse cardiac manifestations and present our own rare case of angina in the oligosymptomatic debut of WG. Importantly, in this case, coronarography failed to reveal atherosclerotic disease or thrombotic occlusion. However, magnetic resonance imaging (MRI) with adenosine test revealed subendocardial ischemia. As a result of immunosuppressive therapy with a steroid and cyclophosphamide, myocardial ischemia disappeared.

Myocardial Ischemia in Wegener’s Granulomatosis: Coronary Atherosclerosis Versus Vasculitis

Wegener’s granulomatosis (WG) is one of the most common small- and medium-sized necrotizing vasculitides that mainly affects the upper and lower respiratory tract and the kidneys. Cardiac manifestations in WG are relatively rare, and their role and place among different causes of mortality remain largely unknown. Substantially increased number of reports describing involvement of all structures of the heart, which underlie conduction disturbances, valvular disease, ischemic heart disease and other potentially serious conditions, underscores importance of comprehensive cardiovascular investigations and monitoring of patients with WG. The majority of previous reports and our current observation distinguish coronary vasculitis and thrombosis as a cause of myocardial ischemia and cardiovascular co-morbidities in WG. It seems plausible that inflammatory processes in this disease, like in some other systemic vasculitidies, do not predispose to accelerated atherogenesis. However, characteristic small- and medium-sized vasculitis still can manifest as myocardial ischemia and infarction. We overview diverse cardiac manifestations and present our own rare case of angina in the oligosymptomatic debut of WG. Importantly, in this case, coronarography failed to reveal atherosclerotic disease or thrombotic occlusion. However, magnetic resonance imaging (MRI) with adenosine test revealed subendocardial ischemia. As a result of immunosuppressive therapy with a steroid and cyclophosphamide, myocardial ischemia disappeared.

Oxidative stress and defective platelet apoptosis in naïve patients with Kawasaki disease

Kawasaki disease (KD) is a rare and often undiagnosed disease, at least in the western countries. It is characterized by an inflammatory acute febrile vasculitis of medium sized arteries with a propensity to damage the coronary arteries. It normally occurs in the early childhood and the diagnosis is based on clinical symptoms. During the progression of the disease thrombocytosis is usually detected. This can exert a pathogenetic role in the cardiovascular complications occurring in KD. In the present work peripheral blood plasma and platelets from twelve naïve patients with KD were analyzed in order to detect possible pathogenetic determinants or progression markers. Morphological, biochemical and flow cytometrical methods have been used. With respect to age-matched healthy donors, we found an increase of platelet activation markers, i.e. degranulation, phosphatidylserine (PS) externalization and leukocyte-red cell-platelet aggregates. Some significant alterations that could represent suitable diagnostic determinants have also been detected in patient plasma: (i) decreased antioxidant power, (ii) decreased levels of asymmetric dymethylarginine (ADMA), a naturally occurring chemical interfering with the production of nitric oxide, and (iii) increased levels of soluble P-Selectin and soluble annexin V. Since PS externalizing platelets are known to exert a pro-coagulant activity, our data suggest the hypothesis that increased risk of vascular complications in KD could depend on platelet stimulation and defective apoptosis probably related to nitrosative stress.