Toshiaki Jibiki

Gene Expression Profiling of the Effect of High-Dose Intravenous Ig in Patients with Kawasaki Disease

Kawasaki disease (KD) is an acute vasculitis of infants and young children, preferentially affecting the coronary arteries. Intravenous infusion of high dose Ig (IVIG) effectively reduces systemic inflammation and prevents coronary artery lesions in KD. To investigate the mechanisms underlying the therapeutic effects of IVIG, we examined gene expression profiles of PBMC and purified monocytes obtained from acute patients before and after IVIG therapy. The results suggest that IVIG suppresses activated monocytes and macrophages by altering various functional aspects of the genes of KD patients. Among the 18 commonly decreased transcripts in both PBMC and purified monocytes, we selected six genes, FCGR1A, FCGR3A, CCR2, ADM, S100A9, and S100A12, and confirmed the microarray results by real-time RT-PCR. Moreover, the expressions of FcγRI and FcγRIII on monocytes were reduced after IVIG. Plasma S100A8/A9 heterocomplex, but not S100A9, levels were elevated in patients with acute KD compared with those in febrile controls. Furthermore, S100A8/A9 was rapidly down-regulated in response to IVIG therapy. Persistent elevation of S100A8/A9 after IVIG was found in patients who later developed coronary aneurysms. These results indicate that the effects of IVIG in KD may be mediated by suppression of an array of immune activation genes in monocytes, including those activating FcγRs and the S100A8/A9 heterocomplex.

Dramatic decrease of circulating levels of monocyte chemoattractant protein-1 in Kawasaki disease after gamma globulin treatment.

Kawasaki disease (KD) is a systemic vasculitis preferentially affecting coronary arteries. Extensive monocytes/macrophages infiltrate in the vascular lesions, implying the involvement of a chemotactic cytokine in their recruitment. We investigated the role of monocyte chemoattractant protein‐1 (MCP‐1, also termed monocyte chemotactic and activating factor) in KD. In the immunohistochemical studies using the cardiac tissues of patients with fatal KD, MCP‐1 but not interleukin (IL) ‐8 or macrophage inflammatory protein‐1α was localized at the extracellular matrix associated with mononuclear cellular infiltration. The sites of MCP‐1 expression correlated with the distribution of the acute inflammation, including early coronary vasculitis. In prospectively studied patients with KD, circulating levels of MCP‐1, IL‐8, tumor necrosis factor a (TNF‐α), and IL‐1α were elevated in 73, 77, 57, and 0% of samples before gamma globulin (GG) treatment (400 mg/kg × 5 days = total 2 g/kg), respectively, compared with respective control values. GG treatment correlated with a rapid decrease in the circulating levels of MCP‐1 (P = 0.001) but not IL‐8 (P = 0.19) or TNF‐α (P = 0.33). In the sensitive Western blotting, MCP‐1 bound to GG. Furthermore, GG inhibited the MCP‐1‐induced Ca2+ influx in a human monocytic cell line in vitro. These findings suggest a role of MCP‐1 in KD, and indicate that GG treatment may block MCP‐1 activity, thus alleviating KD vasculitis. J. Leukoc. Biol. 65: 566–572; 1999.

Influence of early repair of tetralogy of Fallot without an outflow patch on late arrhythmias and sudden death: a 27-year follow-up study following a uniform surgical approach

Pulmonary regurgitation and older age at the time of repair may have a large impact late after repair on subsequent mortality of patients with tetralogy of Fallot. We aimed to identify whether age at repair, and preservation of the pulmonary valve, had a favorable influence on morbidity and mortality. We also analyzed risk factors for late death subsequent to surgical repair. We identified 167 patients who, between 1965 and 1975, and at a mean age of 6 years, underwent total repair of tetralogy of Fallot by a single surgical team without use of an outflow patch. All patients were known to have survived for at least 30 days after repair, and late mortality was identified though the use of hospital records, interviews, and death certificates. The 29-year actuarial survival rate was 86%, with 24 late deaths. Of these deaths, seven occurred suddenly (4.2%). Morbidity was analyzed in 99 of the patients by means of a written questionnaire and telephone interview. It proved possible to analyze ventricular and valvar function in 50 of the patients. Survivors experienced no re-intervention, and 89% of them were in class I of the grading system of the New York Heart Association. We found evidence of 3 episodes of sustained ventricular tachycardia (3.0%), and two episodes of atrial tachycardia (2.0%). Of the 50 patients in whom serial examinations were available, 18 had pulmonary regurgitation of moderate degree or greater, and none had more than moderate tricuspid regurgitation, with a mean QRS duration of 148 ms and an ejection fraction for the left ventricle of 50%. Older age at repair (p = 0.03), and longer periods of cardiac arrest during repair (p = 0.02), were associated with late mortality. Although the mortality was similar to that observed in previous reports, our operative method might have a better effect in terms of late morbidity.

Elevated granulocyte colony-stimulating factor levels predict treatment failure in patients with Kawasaki disease

BACKGROUND Kawasaki disease (KD) is an acute vasculitis in young children, frequently associated with coronary artery aneurysms. The intravenous infusion of high-dose IgG (IVIG) effectively reduces the systemic inflammation and the incidence of coronary artery lesions, although the precise underlying mechanisms are unknown. OBJECTIVE We performed expression profiling of whole blood cells to investigate the mechanisms underlying the effect of IVIG and to identify biomarkers associated with unresponsiveness to IVIG. METHODS We compared the transcript abundance among pre-IVIG and post-IVIG patients and febrile control patients. Then we analyzed the mRNA levels and the protein levels among the different cohort of patients with KD who were either responsive or nonresponsive to the initial IVIG. RESULTS A total of 298 transcripts were overrepresented or underrepresented in the pre-IVIG patients compared with post-IVIG patients and febrile controls, of which 15 transcripts were differentially expressed in nonresponsive patients with KD compared with responsive patients before IVIG. The protein levels of polycythemia rubra vera 1, which was one of the most variably expressed transcripts in pre-IVIG patients, and the serum granulocyte colony-stimulating factor levels were significantly higher in nonresponsive patients than in responsive patients before the initial IVIG administration. CONCLUSION These findings suggest that the variable gene expression profiles were correlated to the responses of patients with KD to IVIG administration. Polycythemia rubra vera 1 and granulocyte colony-stimulating factor levels may be good biomarkers for predicting response to IVIG in patients with KD.

Alleviation of Myocardial Ischemia After Kawasaki Disease by Heparin and Exercise Therapy

Background—Heparin promotes angiogenesis. We evaluated the effects of combined treatment with heparin and exercise on myocardial ischemia in the chronic stage of Kawasaki disease. Methods and Results—This study was conducted in 7 patients (aged 6 to 19 years) who had a totally occluded coronary artery and stress-induced myocardial ischemia in the collateral-dependent areas. Twice-daily exercise using a bicycle ergometer was performed with increments of 0.5 W/kg every 3 minutes up to maximal exertion for 10 days. Heparin, which immediately increased circulating hepatocyte growth factor, was given intravenously 10 minutes before each exercise period. Newly developed myocardial infarction, ventricular tachyarrhythmia, anginal attack, or hemorrhagic complication was not observed in any patient. Dipyridamole-loading single photon emission computed tomography documented improved myocardial perfusion in the collateral-dependent areas and a significant reduction in total defect scores in all patients after the completion of 20 sessions (P =0.01). In control patients who did not receive the heparin-exercise therapy, however, stress defect scores remained unchanged (n=1) or increased (n=2) during follow-up. Computerized quantitative coronary angiography provided evidence that the heparin-exercise therapy increased the diameter of the occluded artery to which collaterals terminated (P =0.001) but not that of the reference artery with which collaterals were not connected (P =0.96). Conclusions—The findings suggest that a series of heparin and exercise treatments over 10 days may have a dramatic effect on the alleviation of myocardial ischemia in collateral-dependent regions. This may be a safe, noninvasive revascularization therapy for patients with coronary artery occlusion in the chronic stage of Kawasaki disease.

High concentrations of interleukin-8 and monocyte chemoattractant protein-1 in urine of patients with acute Kawasaki disease

We investigated urinary levels of interleukin-8 and monocyte chemoattractant protein-1 [1] in patients with acute Kawasaki disease. Kawasaki disease (KD) often presents with transient urinary abnormalities such as aseptic pyuria and proteinuria during the acute phase of illness [2, 3, 5]. Freshly voided urine samples from 19 KD patients, aged 2.9±1.6 years, were available during the febrile stage and the afebrile stage after treatment with 2 g/kg intravenous immune globulin over 5 days together with acetylsalicylic acid (30 mg/kg per day). For comparison, urine samples from seven patients aged 2.5±2.5 years, with congenital heart disease who did not show heart failure or urinary abnormalities were studied. During the febrile stage, 11 of 19 KD patients (58%) exhibited detectable levels of urinary interleukin-8 (IL-8) (840±855 pg/mg creatinine), whereas all controls had undetectable levels (Fig. 1a). Additionally, 7 of 19 KD patients (37%) exhibited urinary monocyte chemoattractant protein-1 (MCP-1) levels (1239±352 pg/mg creatinine) greater than 2 SD above mean control values (442±190 pg/mg creatinine) (Fig. 1b). Urinary levels of IL-8 and MCP-1 decreased significantly during the afebrile stage (P=0.01 and P=0.01, respectively) (Fig. 1a, T. Jibiki (&) Department of Paediatrics, Chiba Municipal Kaihin Hospital, 3-31-1 Isobe Mihama-ku, 261-0012 Chiba, Japan E-mail: t_jibiki@hotmail.com Tel.: +81-43-2777711 Fax: +81-43-2787482

Expression of tumor necrosis factor-α protein in the myocardium in fatal myocarditis

Abstract Background: Tumor necrosis factor (TNF)‐α is the most studied cytokine in the failing human heart and in experimental murine myocarditis. We have investigated the expression of TNF‐α in the myocardium in human myocarditis.

Intravenous immune globulin plus corticosteroids in refractory Kawasaki disease

Background:  The aim of the present study was to investigate the efficacy of i.v. immune globulin (IVIG) therapy combined with corticosteroids for additional treatment of acute Kawasaki disease (KD) unresponsive to initial IVIG treatment.

Acute scrotum in Kawasaki disease: Two case reports and a literature review

Acute scrotum is a rare complication of acute Kawasaki disease (KD), less well recognized than other disease manifestations. We describe the cases of two patients, aged 59 months and 19 months, with hydrocele testis in the acute phase of KD. Scrotal ultrasound and trans‐illumination were used in the diagnosis of hydrocele testis. One patient underwent eventual surgical intervention. We reviewed the literature for a better understanding of the pathogenesis of scrotal symptoms in acute KD and investigated the clinical importance of hydrocele testis. Careful further clinical observation may elucidate the true incidence of this extracardiac symptoms, thereby clarifying the diagnostic value of this possible complication in acute KD.

Myocarditis in a pediatric case of pandemic 2009H1N1 influenza.

We report a 6‐year‐old boy with no major disease history or allergic conditions initially presented with pneumonia, progressed to acute respiratory distress syndrome and acute myocarditis caused by pandemic 2009H1N1 influenza diagnosed with RT‐PCR testing, successfully managed with mechanical ventilation and percutaneous cardiopulmonary support system. Marked transient elevation of IgE in acute phase of the disease and the subsequent diagnosis of atopic asthma in our patient suggested a possible role of an underlying allergic condition in the clinicopathological process. Critically ill 2009H1N1‐infected patient with acute respiratory failure should carefully be physiologically monitored together with serial assessment of biomarkers aiming at a favorable cardiac outcome by giving the timely diagnosis and intervention.