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Gorelik M, Lee Y, Abe M, Andrews T, Davis L, Patterson J, Chen S, Crother TR, Aune GJ, Noval Rivas M, Arditi M. IL-1 receptor antagonist, anakinra, prevents myocardial dysfunction in a mouse model of Kawasaki disease vasculitis and myocarditis. Clin Exp Immunol 2019; 198:101-110. [PMID: 31099056 PMCID: PMC6718290 DOI: 10.1111/cei.13314] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2019] [Indexed: 12/11/2022] Open
Abstract
Kawasaki disease (KD) vasculitis is an acute febrile illness of childhood characterized by systemic vasculitis of unknown origin, and is the most common cause of acquired heart disease among children in the United States. While histological evidence of myocarditis can be found in all patients with acute KD, only a minority of patients are clinically symptomatic and a subset demonstrate echocardiographic evidence of impaired myocardial function, as well as increased left ventricular mass, presumed to be due to myocardial edema and inflammation. Up to a third of KD patients fail to respond to first-line therapy with intravenous immunoglobulin (IVIG), and the use of interleukin (IL)-1 receptor antagonist (IL-1Ra, anakinra) is currently being investigated as an alternative therapeutic approach to treat IVIG-resistant patients. In this study, we sought to investigate the effect of IL-1Ra on myocardial dysfunction and its relation to myocarditis development during KD vasculitis. We used the Lactobacillus casei cell-wall extract (LCWE)-induced murine model of KD vasculitis and investigated the effect of IL-1Ra pretreatment on myocardial dysfunction during KD vasculitis by performing histological, magnetic resonance imaging (MRI) and echocardiographic evaluations. IL-1Ra pretreatment significantly reduced KD-induced myocardial inflammation and N-terminal pro B-type natriuretic peptide (NT-proBNP) release. Both MRI and echocardiographic studies on LCWE-injected KD mice demonstrated that IL-1Ra pretreatment results in an improved ejection fraction and a normalized left ventricular function. These findings further support the potential beneficial effects of IL-1Ra therapy in preventing the cardiovascular complications in acute KD patients, including the myocarditis and myocardial dysfunction associated with acute KD.
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Affiliation(s)
- M Gorelik
- Department of Virology and Immunology, Texas Biomedical Research Institute, San Antonio, TX, USA.,Pediatric Rheumatology, Baylor College of Medicine, Houston, TX, USA
| | - Y Lee
- Division of Pediatric Infectious Diseases and Immunology, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - M Abe
- Division of Pediatric Infectious Diseases and Immunology, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - T Andrews
- Division of Pediatric Hematology and Oncology, University of Texas Health Science Center, San Antonio, TX, USA
| | - L Davis
- Division of Pediatric Hematology and Oncology, University of Texas Health Science Center, San Antonio, TX, USA
| | - J Patterson
- Department of Virology and Immunology, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - S Chen
- Division of Pediatric Infectious Diseases and Immunology, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - T R Crother
- Division of Pediatric Infectious Diseases and Immunology, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - G J Aune
- Division of Pediatric Hematology and Oncology, University of Texas Health Science Center, San Antonio, TX, USA
| | - M Noval Rivas
- Division of Pediatric Infectious Diseases and Immunology, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - M Arditi
- Division of Pediatric Infectious Diseases and Immunology, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Pilania RK, Bhattarai D, Singh S. Controversies in diagnosis and management of Kawasaki disease. World J Clin Pediatr 2018; 7:27-35. [PMID: 29456929 PMCID: PMC5803562 DOI: 10.5409/wjcp.v7.i1.27] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/13/2017] [Accepted: 12/28/2017] [Indexed: 02/06/2023] Open
Abstract
Kawasaki disease (KD) is a common medium vessel systemic vasculitis that usually occurs in small children. It has a predilection for the coronary arteries, but other medium sized arteries can also be involved. The etiology of this disorder remains a mystery. Though typical presentation of KD is quite characteristic, it may also present as incomplete or atypical disease in which case the diagnosis can be very challenging. As both incomplete and atypical forms of KD can be associated with serious coronary artery complications, the pediatrician can ill afford to miss these diagnoses. The American Heart Association has enunciated consensus guidelines to facilitate the clinical diagnosis and treatment of this condition. However, there are still several issues that remain controversial. Intravenous immunoglobulin remains the cornerstone of management but several other treatment modalities, especially glucocorticoids, are increasingly finding favour. We review here some of the contemporary issues, and the controversies thereon, pertaining to management of KD.
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Affiliation(s)
- Rakesh Kumar Pilania
- Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Dharmagat Bhattarai
- Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Surjit Singh
- Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
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Mărginean CO, Meliț LE, Gozar L, Mărginean CD, Mărginean MO. Incomplete Refractory Kawasaki Disease in an Infant-A Case Report and a Review of the Literature. Front Pediatr 2018; 6:210. [PMID: 30101141 PMCID: PMC6074057 DOI: 10.3389/fped.2018.00210] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 07/09/2018] [Indexed: 12/23/2022] Open
Abstract
Kawasaki disease (KD) is a febrile vasculitis, which is commonly defined by fever and at least four specific clinical symptoms. Incomplete KD is defined by suggestive echocardiographic findings with an incomplete clinical picture. Refractory KD is diagnosed in patients resistant to intravenous immunoglobulin (IVIG). We report the case of a 6-month-old male infant admitted to our clinic for persistent fever and onset of a generalized polymorphous rash, accompanied by high fever, rhinorrhea, and cough for the past 7 days. The laboratory tests, on the day of admission, revealed leukocytosis with neutrophilia, anemia, thrombocytosis, hypernatremia, hypoalbuminemia, elevated C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Echocardiography showed dilation of the left anterior descending coronary artery (LAD). Based on all these findings, we established the diagnosis of KD, and we initiated IVIG and intravenous pulsed methylprednisolone, with an initial favorable outcome. However, the symptoms reappeared, and we administered a second higher single dose of IVIG, but without any clinical improvement. Moreover, the laboratory parameters and echocardiographic findings worsened. We reinitiated a longer course of intravenous methylprednisolone in a smaller dose, which had a favorable impact on the clinical, laboratory, and echocardiographic parameters. Multiple uncertainties exist related to the management of refractory KD despite the wide spectrum of therapeutic options that have been proposed. Our case demonstrates that in patients refractory to aggressive initial therapy, low or moderate doses of steroid given daily may be helpful.
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Affiliation(s)
- Cristina O Mărginean
- Department of Pediatrics, University of Medicine and Pharmacy TîrguMures, Târgu Mures, Romania
| | - Lorena E Meliț
- Department of Pediatrics, University of Medicine and Pharmacy TîrguMures, Târgu Mures, Romania
| | - Liliana Gozar
- Department of Pediatric Cardiology, University of Medicine and Pharmacy TîrguMures, Târgu Mures, Romania
| | - Cristian Dan Mărginean
- Department of Pediatrics, University of Medicine and Pharmacy TîrguMures, Târgu Mures, Romania
| | - Maria O Mărginean
- Department of Pediatrics, University of Medicine and Pharmacy TîrguMures, Târgu Mures, Romania
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