Hakaru Tasaki

Ulinastatin, an Elastase Inhibitor, Inhibits the Increased mRNA Expression of Prostaglandin H2 Synthase-Type 2 in Kawasaki Disease

Kawasaki disease is an inflammatory disease of unknown cause that causes panvasculitis, including coronary arteritis. Polymorphonucleocytosis in the early stage of the illness suggests the implication of neutrophils in the pathogenesis of the disease. In the acute phase of Kawasaki disease, mRNA expression of prostaglandin H2 synthase (PHS)-2, as determined by reverse transcription-polymerase chain reaction, was markedly enhanced, and thromboxane A2 (TXA2)-synthesizing activity was increased in polymorphonuclear leukocytes (PMNL). This up-regulation of PHS-2 was suppressed by ulinastatin (a neutrophil-elastase inhibitor) treatment. Lipopolysaccharide-induced enhancement of PHS-2 mRNA was also inhibited by therapeutic doses of ulinastatin in vitro by use of PMNL from healthy volunteers. Thus, ulinastatin inhibits arachidonate PHS metabolism by inhibiting new induction of PHS-2 at the mRNA level, which is a novel pharmacologic action of this substance. Ulinastatin treatment is possibly an additional therapeutic approach to Kawasaki disease.

A polymorphism in the promoter of the CD14 gene (CD14/-159) is associated with the development of coronary artery lesions in patients with Kawasaki disease

OBJECTIVE To investigate whether a polymorphism in the CD14 gene is associated with Kawasaki disease (KD). STUDY DESIGN We extracted DNA from the whole blood of 69 control children and 67 patients with KD. We determined a polymorphism in the CD14 gene at position -159 upstream from the major transcription site (CD14/-159) by restriction fragment assay. We then investigated the association between CD14/-159 and the onset of KD and development of coronary artery lesion (CAL). RESULTS The genomic and allelic frequencies of the polymorphism were not different between normal children and KD patients. The KD patients with TT genotypes at CD14/-159 had more CAL complications than those with CT and CC (OR, 4.05; 95% CI, 1.34-12.22). The frequencies of the T allele was significantly higher than that of the C allele in KD patients with CAL (OR, 2.20; 95% CI, 1.23-3.94). Their data were confirmed in the patients whether the patients were treated with intravenous gamma-globulin. KD patients with TT genotypes had significantly higher levels of C-reactive protein and vascular endothelial growth factor, which had previously been reported as risk factors for CAL, than those with CC genotypes. CONCLUSION These results indicate that the T allele and TT genotype at CD14/-159 are risk factors for CAL in KD, and that the development of CAL in KD may be related to the magnitude of CD14 toll-like receptor response.

Inhibition of Leukotriene Synthesis by Azelastine

BACKGROUND Azelastine, oxatomide, and ketotifen are used for patients with allergic diseases. These drugs inhibit the release of chemical mediators including the leukotrienes; however, the mechanism involved is unclear. OBJECTIVE To clarify the mechanism of inhibition, we investigated the effects of three drugs on the function of phospholipase A2, 5-lipoxygenase, leukotriene C4 synthase, and leukotriene A4 hydrolase, which are all catabolic enzymes involved in synthesizing leukotriene C4 and leukotriene B4 in rat basophilic leukemia (RBL)-1 cells. METHODS AND RESULTS The production of leukotriene C4 and leukotriene B4 was measured by high performance liquid chromatography (HPLC). All three drugs inhibited the production of leukotriene C4 and leukotriene B4 when cells were stimulated with A23187. All three drugs also inhibited the A23187-stimulated release of 3H-arachidonic acid from membrane phospholipids. Azelastine inhibited the production of leukotriene C4, but not leukotriene B4, when either arachidonic acid or leukotriene A4 free acid was used as the substrate in our cell free system. Oxatomide and ketotifen did not inhibit the synthesis of either leukotriene C4 or leukotriene B4 in the same cell free study. CONCLUSION Results indicated that oxatomide and ketotifen inhibit the production of leukotriene C4 and leukotriene B4 by inhibiting phospholipase A2 activity, whereas, azelastine inhibits the leukotriene C4 production by inhibiting phospholipase A2 and leukotriene C4 synthase.

Inhibition of Leukotriene Synthesis by Honokiol in Rat Basophilic Leukemia Cells

The effects of honokiol, a diphenyl compound extracted from a Chinese herbal medicine, on leukotriene (LT) synthesis were evaluated in rat basophilic leukemia (RBL) cells. The production of LTC4 and LTB4 stimulated by the Ca2+ ionophore A23187 was measured in RBL-1 cells by high-performance liquid chromatography. Honokiol inhibited the production of LTC4 and LTB4 stimulated by A23187 in RBL-1 cells. Honokiol did not inhibit either phospholipase A2 activity, measured by the release of 3H-arachidonic acid (AA), or LTC4 synthase and LTA4 hydrolase activities, measured with LTA4-free acid as substrate. The synthesis of LTC4 and LTB4 from AA in RBL-1 cell lysates in the presence of Ca2+ was inhibited by honokiol. These results indicate that honokiol blocks LT synthesis by inhibiting 5-lipoxygenase activity. Honokiol also inhibited immunoglobulin E-mediated production of these LTs in RBL-2H3 cells, which was measured by a specific radioimmunoassay (RIA). These results suggest that honokiol may exhibit antiallergic actions by inhibiting LT synthesis in immediate-type hyperreactivity.

Facial palsy in Kawasaki disease: report of two cases and a review

A case of facial palsy was reported initially in 1974 by Murayama [8] as one of the neurological manifestations in Kawasaki disease. Thereafter, an additional nine case have been documented in Japan. This facial palsy, in the revised “Diagnostic Guideline of Kawasaki Disease” released in 1984, has been added recently as one of the neurological signs and symptoms of Kawasaki disease. This is a report on two cases of Kawasaki disease showing facial palsy with indurative oedema during their clinical course, and also a clinical review of the ten previously reported cases of facial palsy complicating Kawasaki disease.

Recurrent reversible rhabdomyolysis associated with hyperthermia and status epilepticus

A 6‐year‐old boy developed rhabdomyolysis following hyperthermia and status epilepticus with a diagnosis of severe myoclonic epilepsy of infancy. At 2 and 3 years of age, he had similar episodes. Each time he recovered completely in 3‐4 weeks with conservative management, in spite of renal insufficiency and marked liver dysfunction. Several cases of recurrent myoglobinuria after intense exercise or generalized tonic‐clonic convulsions were reported to have genetic errors of carbohydrate or lipid metabolism of muscle. In our patient, however, the activity of these enzymes was found to be normal. This indicates that status epilepticus may cause recurrent rhabdomyolysis in subjects with normal glycolytic and lipolytic enzyme activity. Myoglobinuria, rhabdomyolysis, severe myoclonic epilepsy of infancy, status epilepticus

CONTINUOUS SUBCUTANEOUS INSULIN INJECTION FOR SELF-CARE OF YOUNG PATIENTS WITH INSULIN-DEPENDENT DIABETES MELLITUS

Continuous subcutaneous insulin injection was used for the self‐care of five patients aged 10–18 years with insulin‐dependent diabetes mellitus. After an introduction to the concept and procedures for continuous subcutaneous injection, the patients soon became familiar with self‐care using an insulin pump at home and at school. Three months later, the control of blood glucose improved with smaller doses of insulin in four cases and milder hypoglycemia was observed compared to when using multiple injections. Significantly decreased variations and lowered means of early morning blood glucose values were observed and seemed to explain the reason for better glycemic control. Buffered regular insulin continuously injected by pumps brought a more stable nocturnal blood glucose level compared to isophane insulin injected at bedtime, the absorption of which seemed to vary considerably. On the contrary, unbuffered regular insulin injected by pumps brought frequent nocturnal hypoglycemia, sudden worsening of glycemic control and skin infections and thus, was deemed inadequate for continuous subcutaneous injection.

Extensive white matter involvement in hemorrhagic shock and encephalopathy syndrome

Reported is a case of hemorrhagic shock and encephalopathy syndrome (HSE) with extensive white matter involvement. A three year old, previously healthy boy was presented with an acute onset of fever, loss of consciousness and convulsions. He had disseminated intravascular coagulation, metabolic acidosis, non‐ketotic hypoglycemia and hepatorenal dysfunction. The computed tomography (CT) scan of his head on the second day of illness demonstrated symmetric, extensive low‐density areas in the cerebral and cerebellar white matter. The child died on the 13th hospital day. A post‐mortem histopathological examination of the liver revealed centrilobular necrosis and infiltration of fatty acid droplets. The concentrations of serum 2′,5′‐oligoadenylate synthetase and urinary neopterin were markedly elevated, indicating excessively activated cell‐mediated immunity. This overproduction of inflammatory cytokines might play an important role in the pathogenesis of the brain lesion as well as in other clinical and laboratory manifestations. The patient had a decreased serum level of α1‐antitrypsin, which may have been associated with the development of uncontrolled inflammation and coagulation disorder.

Studies on the Effect of Long‐Term Use of Low Dose Aspirin in Kawasaki Disease

The inhibitory action of long‐term low dose aspirin (1–2 mg/kg/day for over 10 months) on the cyclooxygenase pathway in platelets and vascular endothe‐lium was evaluated in 10 patients with Kawasaki disease. The results were compared with those obtained after taking aspirin at 5–10 mg/kg/day during the acute phase of the illness. Platelet aggregations induced by adenosinedi‐phosphate (ADP), epinephrine and collagen were inhibited by aspirin doses of 1–2 and 5–10 mg/kg/day, when compared with those of controls (p < 0.05). Platelet synthesis of thromboxane B2 (TXB2) under doses of 1–2 and 5–10 mg/kg/day was 0.57 ± 0.07 and 0.72 ± 0.09 ng/ml platelet‐rich plasma (PRP) /105 platelets, respectively (p > 0.1). These values were significantly lower than those of the control group (22.88± 3.42 ng/ml PRP/105 platelets) (p < 0.05). No differences were found in platelet aggregation and TXB2 productivity between the two aspirin doses. Levels of 6 keto‐prostaglandin F1α (6k‐PGF1α) in platelet‐poor plasma (PPP) did not differ significantly in these 3 sets of data. The results indicate that long‐term administration of low dose aspirin (1–2 mg/kg/day) inhibits platelet aggregation by inhibiting synthesis of thromboxane A2 (TXA2), without interfering with prostacyclin production probably in the endothelium of blood vessels.

Continuous subcutaneous insulin injection for a case of mitochondrial cytopathy with diabetes mellitus requiring a large amount of insulin

A female patient, 15-years-old, was admitted to our ward with proteinuria and glycosuria. At birth, she had been delivered by cesarian section after 40 weeks gestation, due to her mother’s weakened uterine contractions. Her birth weight was 3950 g. From age 11 onwards, her annual school urinary examinations had revealed proteinuria and, at age 15, glycosuria. She had had irregular menstrual periods since her menarche at age 12. Upon presentation in our ward, her physical examination revealed a short stature (height, 145.7 cm; mean – 2.3 SD), a weight of 44.2 kg (body mass index, 20.8), a borderline low mentality and a heart murmur. No complications from her diabetes mellitus and no hearing defects were found. Her fasting blood glucose was 9.2 mmol/L and her insulin was 23.5 μU/mL as assayed by a counting immunoassay kit provided by Sysmex Co. Ltd, Kobe, Japan (normal range, 4–20 μU/mL). Two hours after oral administration of 75 g glucose, her blood glucose rose to 13.9 mmol/L and her insulin to 61.7 μU/mL. Her glycated hemoglobin (HbA1c; (determined by enzyme immunoassay using a DCA-2000; Bayer-Sankyo Co. Ltd, Tokyo, Japan) was 9.1% and no ketonuria was detected. Although her daily urinary excretion of protein reached 0.8 g, her concentration of serum albumin was normal and histological examination of a biopsied kidney showed only minimal change. Blood lactate was within the normal range at 1.34 mmol/L (12.1 mg/dL), but in the cerebrospinal fluid was as high as 3.46 mmol/L (31.1 mg/dL). Ultrasonographic examination revealed hypertrophic cardiomyopathy and presence of a mildly fatty liver. The fatty liver was ameliorated after therapy was begun for diabetes mellitus. Histological examination of a biopsy of her left triceps muscle, performed according to a previously reported method,1,5 revealed ragged-red fibers. DNA complementary to the mitochondrial DNA was made from both peripheral lymphocytes and the biopsied muscle using a polymerase chain reaction and was then analyzed with restriction enzymes according to previously reported procedures.6,7 Both of the samples were positive for an adenine to guanine mutation at the 3243rd nucleotide of the mitochondrial gene for leucine tRNA with a UUR codon. This mutation is thought to be specific for the mitochondrial encephalomyopathy–lactic acidosis–and stroke-like symptoms (MELAS) type of mitochondrial cytopathy.6 Although the mother of the patient told us that she had non-insulin-dependent diabetes mellitus and that the elder brother of the patient was healthy, both family members refused to undergo laboratory examinations. The clinical course of the patient is shown in Fig. 1. Administration of a small amount of isophane insulin, 0.3 U/kg per day for 6 months, lowered her HbA1c to 6.9% and insulin was then replaced with oral hypoglycemic agents. Her glycemic control was satisfactory for the following 2 years, but at 17 years of age she suddenly became hyperglycemic, although she had not lapsed in either her diet or exercise therapy. Twice daily isophen insulin injections at doses of 0.5–0.7 U/kg were resumed and resulted in good Pediatrics International (1999) 41, 97–100