Chih-Lu Wang

The relationship of eosinophilia to intravenous immunoglobulin treatment failure in Kawasaki disease

To investigate the role of eosinophils in Kawasaki disease (KD) and the relationship to initial intravenous immunoglobulin (IVIG) treatment failure. A retrospective analysis of all children who were admitted and met the criteria of KD between 1999 and 2005. The patients were divided into IVIG‐responsive and IVIG‐resistant groups. A total of 185 patients were enrolled during the study period. A series of blood eosinophils and biochemistry studies were correlated to the effectiveness of IVIG. The neutrophils percentage before IVIG treatment (pre‐IVIG), leukocyte counts within 3 days after IVIG treatment (post‐IVIG), liver enzyme, albumin levels, and post‐IVIG eosinophils percentage were all significantly different between the two groups in univariate analysis. Under multivariate analysis with logistic regression, post‐IVIG eosinophilia [peripheral blood (PB) eosinophils ≥4%] had an inverse correlation to KD patients with IVIG‐resistance (p = 0.003). Also, pre‐IVIG hypoalbuminemia (albumin ≤3.0 g/dl) was positively correlated to IVIG‐resistance (p = 0.018). Further analysis showed that the PB eosinophils was markedly increased in the acute stage and returned to normal 3 weeks after IVIG treatment (p < 0.001). Eosinophil levels are highly elevated in the acute stage of KD both before and after the IVIG treatment. Post‐IVIG treatment eosinophilia has an inverse correlation to KD patients with IVIG‐resistance and may indicate IVIG‐responsive. This may be a valuable factor to survey for the necessity of a second dose IVIG treatment.

Serum albumin level predicts initial intravenous immunoglobulin treatment failure in Kawasaki disease

Objectives:  Kawasaki disease (KD) is a systemic vasculitis primarily affecting children who are <5 years old. Intravenous immunoglobulin (IVIG) is the standard therapy for KD. However, many patients with KD still show poor response to initial IVIG treatment. This study was conducted to investigate the risk factors for initial IVIG treatment failure in KD.

Association of lower eosinophil-related T helper 2 (Th2) cytokines with coronary artery lesions in Kawasaki disease.

Kawasaki disease (KD) is a systemic febrile vasculitis particular coronary artery involvement. Eosinophilia has been found in our and other studies in KD. This study further investigates whether eosinophil‐related T helper 2 (Th2) cytokines or the activation marker (eosinophil cationic protein – ECP) is involved in KD with coronary artery lesions (CAL). A total of 95 KD patients were enrolled for this study. Plasma samples were subjected to the measurement of interleukin (IL)‐4, IL‐5, and eotaxin by Luminex‐Bedalyte multiplex beadmates system and to the measurement of ECP by fluoroimmunoassay. Patients with KD had higher eosinophils than controls. Eosinophil‐related mediators: IL‐4, IL‐5, eotaxin, and ECP levels were also higher in KD patients than controls before intravenous immunoglobulin (IVIG) treatment. After IVIG treatment, ECP decreased but IL‐4, IL‐5, and eotaxin increased significantly. The higher the IL‐5 and eosinophil levels after IVIG treatment, the lower rate of CAL was found. Changes of eosinophils after IVIG treatment were positively correlated to changes of IL‐5 levels but not ECP levels. An increase of eosinophils and IL‐5, but not ECP levels after IVIG treatment, was inversely correlated with CAL formation in KD.

A unique plasma proteomic profiling with imbalanced fibrinogen cascade in patients with Kawasaki disease.

Kawasaki disease (KD) is the leading cause of acquired heart disease during childhood in the developed countries. The mechanism and biomarkers of KD remain to be determined. In this study, we sought to elucidate potential plasma proteomic markers in KD patients in comparison to that in febrile controls. Plasma samples from KD patients and febrile controls were subjected to two‐dimensional polyacrylamide gel electrophoresis analysis. Differential protein displays between KD patients and febrile controls were determined. Fibrinogen beta and gamma chains, alpha‐1‐antitrypsin (A1AT), CD5 antigen‐like precursor (CD5L), and clusterin were increased in KD patients, whereas immunoglobulin free light chains were decreased, as compared with controls. The differential protein displays were validated with enzyme‐linked immunosorbent assay tests. We found higher fibrinogen‐related proteins (fibrinogen, A1AT, clusterin, and CD5L), along with a lower level of the immunoglobulin free light chains that involve fibrin degradation in KD. Results from this study showing a unique proteomic profiling with abnormal fibrinogen cascade may afford a good biomarker of KD and a better strategy to prevent cardiovascular complications of KD by correcting abnormal fibrin deposition or degradation.

Coronary artery fistula associated with Kawasaki disease.

BACKGROUND The aim of this study was to investigate the rate, risks factors, and clinical impact of coronary artery fistula (CAF) in Kawasaki disease (KD). METHODS From February 1999 to December 2007, a total of 325 pediatric patients fulfilled the diagnostic criteria of KD and admitted for intravenous immunoglobulin treatment were enrolled in this study. Patients with and without CAF were designated as group 1 and group 2, respectively. Patients of group 1 were further subdivided as with and without coronary artery lesions (CALs). The clinical presentations, laboratory data, and outcomes were compared among the groups. RESULTS The mean age of the 325 patients was 21.1 months. Group 1 had 17 patients, and group 2 had 308 patients. The rate of CAF in KD was 5.3%. There were significant differences between group 1 and group 2 patients regarding age (11.8 +/- 1.8 vs 21.5 +/- 1.2 months, P = .01), the presence of CAL (64.7% vs 25%, P < .01), white blood cell counts (16.4 +/- 1.3 vs 13.5 +/- 0.3 x 10(3)/mm(3), P = .01), and platelet counts (432.1 +/- 39.1 vs 346.4 +/- 8.4 x 10(3)/mm(3), P = .02). Spontaneous closure of CAF was observed in 7 (41%) of the 17 patients during follow-up (mean 45 months). Group 1 patients without CAL had a more benign clinical course (total fever day 5.8 +/- 0.6 vs 8.6 +/- 0.8, P = .03) and higher spontaneous closure rate (5/6 vs 2/11, P = .035) than patients with CAL. CONCLUSIONS Patients of young age, CAL, high white blood cell counts, and high platelet counts have higher rate of CAF formation. Approximately 5% KD patients may associate with CAF, but most of them have good clinical outcome during follow-up.

Augmented TLR2 Expression on Monocytes in both Human Kawasaki Disease and a Mouse Model of Coronary Arteritis

Background Kawasaki disease (KD) of unknown immunopathogenesis is an acute febrile systemic vasculitis and the leading cause of acquired heart diseases in childhood. To search for a better strategy for the prevention and treatment of KD, this study compared and validated human KD immunopathogenesis in a mouse model of Lactobacillus casei cell wall extract (LCWE)-induced coronary arteritis. Methods Recruited subjects fulfilled the criteria of KD and were admitted for intravenous gamma globulin (IVIG) treatment at the Kaohsiung Chang Gung Memorial Hospital from 2001 to 2009. Blood samples from KD patients were collected before and after IVIG treatment, and cardiovascular abnormalities were examined by transthoracic echocardiography. Wild-type male BALB/c mice (4-week-old) were intraperitoneally injected with LCWE (1 mg/mL) to induce coronary arteritis. The induced immune response in mice was examined on days 1, 3, 7, and 14 post injections, and histopathology studies were performed on days 7 and 14. Results Both human KD patients and LCWE-treated mice developed coronary arteritis, myocarditis, valvulitis, and pericarditis, as well as elevated plasma levels of interleukin (IL)-2, IL-6, IL-10, monocyte chemoattractant protein (MCP)-1, and tumor necrosis factor (TNF)-α in acute phase. Most of these proinflammatory cytokines declined to normal levels in mice, whereas normal levels were achieved in patients only after IVIG treatment, with a few exceptions. Toll-like receptor (TLR)-2, but not TLR4 surface enhancement on circulating CD14+ monocytes, was augmented in KD patients before IVIG treatment and in LCWE-treated mice, which declined in patients after IVIG treatment. Conclusion This result suggests that that not only TLR2 augmentation on CD14+ monocytes might be an inflammatory marker for both human KD patients and LCWE-induced CAL mouse model but also this model is feasible for studying therapeutic strategies of coronary arteritis in human KD by modulating TLR2-mediated immune activation on CD14+ monocytes.

Identification of an association between genomic hypomethylation of FCGR2A and susceptibility to Kawasaki disease and intravenous immunoglobulin resistance by DNA methylation array.

Kawasaki disease (KD) is characterized by systemic vasculitis, and it is the most common acquired heart disease in children. However, the etiology and immunopathogenesis of KD are still unclear. A genome‐wide association study (GWAS) identified polymorphisms in CD40, BLK, and FCGR2A as the susceptibility genes for KD. No epigenetic array studies of KD have previously been published. This study was undertaken to investigate differences in DNA methylation in patients with KD as compared to controls.

Partial Protein-Hydrolyzed Infant Formula Decreased Food Sensitization but Not Allergic Diseases in a Prospective Birth Cohort Study

Background: Exposure to cow’s milk protein in early infancy could lead to increased rates of allergic diseases later in life. We investigated whether feeding a protein-hydrolyzed formula (HF) in the first 6 months of life decreased allergic diseases up to 36 months later. Methods: Newborns who had at least 1 first-degree family member with a history of atopy and could not breast-feed were enrolled. They were fed with HF or cow’s milk infant formula (CM) for at least 6 months via an open-label protocol and were monitored prospectively at 6, 18 and 36 months of age to assess allergy sensitization and allergic diseases. Results: A total of 1,002 infants were enrolled and 679 infants were consistently fed the same formula for the first 6 months of life (345 HF and 334 CM). The percentage of food sensitization (especially to milk protein) was significantly lower in the HF group than in the CM group at 36 months (12.7 vs. 23.4%, p = 0.048). There was no significant difference in the prevalence of aeroallergen sensitization between the groups. Occurrence of allergic diseases during the first 3 years of life was significantly correlated with aeroallergen sensitization, but not to food allergen sensitization, parental atopy or feeding types. Conclusions: Infants fed with HF during the first 6 months of life had a significantly lower percentage of sensitization to milk protein allergens, but not allergic diseases during the first 3 years of life. Avoidance of cow’s milk protein alone in infancy is not enough to decrease rates of allergic diseases.

Patient characteristics and intravenous immunoglobulin product may affect eosinophils in Kawasaki disease.

Editor Khan et al. showed that both patients phenotype and choice of intravenous immunoglobulin (IVIG) product may explain our finding of dynamic eosinophil changes in the acute stage of Kawasaki disease (KD) and the association with IVIG response (1). From the literature review, they found that polymorphisms in the platelet-activating factor acetylhydrolase (PAFAH) gene associated with IVIG resistance in KD and anti-sialic acid binding immunoglobulin-like lectin-8 (Siglec-8) autoantibodies in IVIG preparations can lead to spontaneous apoptosis of eosinophils. We agree that such eosinophilreducing factors should be considered before assuming that a low eosinophil count is an indicator of IVIG resistance. Further studies focusing on the relationships between PAF-AH genotype and eosinophils in different stage of KD and IVIG treatment response are needed to clarify the role of eosinophils in KD and IVIG treatment response. There are many factors that can affect the distribution of eosinophils in KD including genotype of the PAF-AH gene, IVIG product, disease course, aspirin, other prescribed medicines, etc. The naturally occurring anti-Siglec-8 autoantibodies in IVIG preparation may be an important factor that can influence eosinophil distribution in acute KD. If apoptosis were induced by anti-Siglec-8 autoantibodies of IVIG, we should observe a decrease, rather than an increase, in eosinophils after IVIG treatment. From our data, we showed a marked increase in eosinophils in the acute stage before IVIG treatment. After IVIG treatment, eosinophils were significantly increased and higher than that before IVIG treatment. Tsai et al. also showed that IVIG, prepared with beta-propiolactone, was most significantly associated with resistance, coronary artery aneurysm at convalescence, and giant aneurysm in KD (2). From 1999 to 2006, we have recorded four different brands of IVIG prescribed in different years for 75 KD patients. The absolute eosinophil counts after IVIG treatment in different brands were as follows: Bayer Gamimune N (295.5 ± 50.1/mm, n = 19), Do (443.7 ± 73.6/mm, n = 30), Biotest Intraglobin F (411.1 ± 76.3/mm, n = 20) and E-com (448.8 ± 101.1/mm, n = 6). There were no significant difference in absolute eosinophil counts between different brands of IVIG (p = 0.6, one-way anova by SPSS 12.0 for Windows XP; SPSS Inc., Chicago, IL, USA). Kawasaki et al. first observed that 11 of 50 KD patients (22%) had eosinophilia in peripheral blood (3). Terai et al. found accumulation of eosinophils in the coronary micro-vessel lesions and eosinophilia in peripheral blood and postulated the involvement of eosinophils in the pathogenesis of KD vasculitis (4). We have recently shown that eosinophils were significantly elevated in KD both before and after IVIG treatment, and eosinophilia after IVIG treatment had an inverse correlation to KD patients with IVIG resistance (1). Brosius et al. reported that the incidence of atopic dermatitis among children with KD was nine times greater than that of controls (5). Serum immunoglobulin E and interlukin-4 levels were also significantly higher in KD patients than in age-matched children (6). Patients with KD among these studies, including those not only without IVIG treatment but also those using different brands of IVIG in different countries, were toward an eosinophilia and Th2 regulation. The dynamic changes in eosinophils observed may be not affected primarily by IVIG product. Our previous results showed an inverse correlation of eosinophilia with the IVIG-resistant rate. Indeed, further investigation is needed to clarify the role of eosinophils through eosinophil Pediatr Allergy Immunol 2008: 19: 184–185

TARC/CCL17 gene polymorphisms and expression associated with susceptibility and coronary artery aneurysm formation in Kawasaki disease

Background:Kawasaki disease (KD) is a systemic vasculitis of unknown etiology. Thymus and activation-regulated chemokine/chemokine ligand 17 (TARC/CCL17) is one of the Th2 chemokines and has been suggested as a candidate gene for conferring susceptibility to Th2 associated with allergy diseases. This study examined the correlation between gene polymorphisms and plasma levels of TARC/CCL17 in patients with KD and the outcomes of KD.Methods:A total of 381 KD patients and 564 controls were subjected to determination of five tagging single-nucleotide polymorphisms of TARC/CCL17. In addition, plasma TARC/CCL17 levels were measured by enzyme-linked immunosorbent assay.Results:Polymorphisms of TARC/CCL17 were significantly different between normal children and patients with KD. A allele of rs4784805 has better intravenous immunoglobulin (IVIG) treatment response to KD. Furthermore, plasma TARC/CCL17 levels were higher in KD patients than that in controls before IVIG treatment. After IVIG treatment, plasma TARC/CCL17 levels decreased significantly.Conclusion:This study provides the first evidence supporting the association between TARC/CCL17 polymorphisms, susceptibility of KD, and IVIG responses in KD patients.