Relationship between ocular involvement and clinical manifestations, laboratory findings, and coronary artery dilatation in Kawasaki disease

Relationship between ocular manifestations, laboratory findings, echocardiographic findings, and intravenous immunoglobulin resistance in Kawasaki disease

BACKGROUND

This study investigates the incidence of ocular involvement in Kawasaki disease (KD) and evaluates the relationship between ocular manifestations, laboratory findings, echocardiographic findings, and intravenous immunoglobulin (IVIG) resistance.

METHODS

We conducted a cross-sectional study with 58 KD patients from June 2021 to March 2023. For all patients, a complete ophthalmologic examination and echocardiography were performed in the acute phase before starting the treatment. We analyzed the age, sex, mean of white blood cell (WBC) count, platelet count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), echocardiographic findings and IVIG responses for all patients and compared the group with ocular involvement with the group without involvement.

RESULTS

The incidence of bilateral acute conjunctivitis was 70.7%, while that of acute uveitis was 30%. Patients with uveitis had significantly higher rates of Coronary artery dilatation and IVIG resistance, as well as higher mean levels of WBC, platelet, and CRP compared to those without uveitis. (P < 0.05). Additionally, the age of patients with uveitis involvement was lower than those without involvement. No significant relationships existed between ESR, AST, or ALT values and uveitis (P > 0.05). Furthermore, no significant correlations existed between any examined items and acute bilateral conjunctivitis.

CONCLUSION

Uveitis in KD is significantly associated with coronary artery dilatation, IVIG resistance, higher WBC count, platelet count, and CRP level.

Bilateral Anterior Uveitis Following Paediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2 - Case Report and Focused Review

Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a systemic hyperinflammatory state described in children recently infected with SARS-CoV-2. Ophthalmologically, non-purulent conjunctival injection is the most common symptom, but cases of uveitis have been described. Here, we present a case of bilateral granulomatous anterior uveitis in a 10-year-old boy, 12 days after diagnosis of PIMS-TS. Symptoms resolved after a week of topical treatment and there was no relapse after six months. We carried out a focus review on uveitis in children with PIMS-TS and found eight studies. All in all, 21 children were reported with a median age of 11.5 years. Most of them had bilateral anterior inflammation, without synechiae nor hypertonia, which lasted five to seven days and responded well to the use of corticoids. This symptom is a potential predictor of a more severe disease and this link should be further explored.

French national diagnostic and care protocol for Kawasaki disease

Kawasaki disease (KD) is an acute vasculitis with a particular tropism for the coronary arteries. KD mainly affects male children between 6 months and 5 years of age. The diagnosis is clinical, based on the international American Heart Association criteria. It should be systematically considered in children with a fever, either of 5 days or more, or of 3 days if all other criteria are present. It is important to note that most children present with marked irritability and may have digestive signs. Although the biological inflammatory response is not specific, it is of great value for the diagnosis. Because of the difficulty of recognising incomplete or atypical forms of KD, and the need for urgent treatment, the child should be referred to a paediatric hospital as soon as the diagnosis is suspected. In the event of signs of heart failure (pallor, tachycardia, polypnea, sweating, hepatomegaly, unstable blood pressure), medical transfer to an intensive care unit (ICU) is essential. The standard treatment is an infusion of IVIG combined with aspirin (before 10 days of fever, and for a minimum of 6 weeks), which reduces the risk of coronary aneurysms. In case of coronary involvement, antiplatelet therapy can be maintained for life. In case of a giant aneurysm, anticoagulant treatment is added to the antiplatelet agent. The prognosis of KD is generally good and most children recover without sequelae. The prognosis in children with initial coronary involvement depends on the progression of the cardiac anomalies, which are monitored during careful specialised cardiological follow-up.

Systemic Vasculitis and Its Association with the Eye

Vasculitis is a group of diseases characterized by the inflammation of the blood vessel walls. They are classified according to the size of the main vessel involved: large vessel, medium vessel, and small vessel vasculitis. Ophthalmic manifestations are quite common in most of these diseases. Episcleritis and scleritis are the most prevalent manifestation of vasculitis. However, there are certain ocular features characteristic of specific vasculitis entities. Given the severity and potential life-threat of these diseases, knowledge of the ocular manifestations is mandatory for the ophthalmologists.

The role of Annexin A3 in coronary arterial lesions in children with Kawasaki disease

Kawasaki disease (KD) is an acute, self-limited vasculitis, and the etiology is still unclear. Coronary arterial lesions (CALs) are a major complication of KD. Excessive inflammation and immunologic abnormities are involved in the pathogenesis of KD and CALs. Annexin A3 (ANXA3) plays crucial roles in cell migration and differentiation, inflammation, cardiovascular and membrane metabolic diseases. The purpose of this study was to investigate the effect of ANXA3 on the pathogenesis of KD and CALs. There were 109 children with KD in the KD group [which was divided into two groups: 67 patients with CALs in the KD-CAL group, and 42 patients with noncoronary arterial lesions (NCALs) in the KD-NCAL group] and 58 healthy children in the control (HC) group. Clinical and laboratory data were retrospectively collected from all patients with KD. The serum concentration of ANXA3 was measured by enzyme-linked immunosorbent assays (ELISAs). Serum ANXA3 levels were higher in the KD group than in the HC group (P < 0.05). There was a higher concentration of serum ANXA3 in the KD-CAL group than in the KD-NCAL group (P < 0.05). Neutrophil cell counts and serum ANXA3 levels were higher in the KD group than in the HC group (P < 0.05) and quickly decreased when the patients were treated with IVIG after 7 days of illness. Platelet (PLT) counts and ANXA3 levels concurrently exhibited significant increases 7 days after onset. Furthermore, ANXA3 levels were positively correlated with lymphocyte and PLT counts in the KD and KD-CAL groups. ANXA3 may be involved in the pathogenesis of KD and CALs.

A Network of Serum Proteins Predict the Need for Systemic Immunomodulatory Therapy at Diagnosis in Noninfectious Uveitis

Purpose

Early identification of patients with noninfectious uveitis requiring steroid-sparing immunomodulatory therapy (IMT) is currently lacking in objective molecular biomarkers. We evaluated the proteomic signature of patients at the onset of disease and associated proteomic clusters with the need for IMT during the course of the disease.

Design

Multicenter cohort study.

Participants

Two hundred thirty treatment-free patients with active noninfectious uveitis.

Methods

We used aptamer-based proteomics (n = 1305 proteins) and a bioinformatic pipeline as a molecular stratification tool to define the serum protein network of a Dutch discovery cohort (n = 78) of patients and healthy control participants and independently validated our results in another Dutch cohort (n = 111) and a United States cohort (n = 67). Multivariate Cox analysis was used to assess the relationship between the protein network and IMT use.

Main Outcome Measures

Serum protein levels and use of IMT.

Results

Network-based analyses revealed a tightly coexpressed serum cluster (n = 85 proteins) whose concentration was consistently low in healthy control participants (n = 26), but varied among patients with noninfectious uveitis (n = 52). Patients with high levels of the serum cluster at disease onset showed a significantly increased need for IMT during follow-up, independent of anatomic location of uveitis (hazard ratio, 3.42; 95% confidence interval, 1.22–9.5; P = 0.019). The enrichment of neutrophil-associated proteins in the protein cluster led to our finding that the neutrophil count could serve as a clinical proxy for this proteomic signature (correlation: r = 0.57, P = 0.006). In an independent Dutch cohort (n = 111), we confirmed that patients with relatively high neutrophil count at diagnosis (> 5.2 × 10⁹/L) had a significantly increased chance of requiring IMT during follow-up (hazard ratio, 3.2; 95% confidence interval, 1.5–6.8; P = 0.002). We validated these findings in a third cohort of 67 United States patients.

Conclusions

A serum protein signature correlating with neutrophil levels was highly predictive for IMT use in noninfectious uveitis. We developed a routinely available tool that may serve as a novel objective biomarker to aid in clinical decision-making for noninfectious uveitis.

Initial anterior uveitis event associated with recent novel SARS-CoV-2 (COVID-19) infection in the setting of HLA-B27

Purpose

To describe an atypical ocular manifestation following SARS-CoV-2 infection.

Observations

A 27-year old previously healthy male with no past ocular history presented with pain, photophobia and red eye in his left eye (OS). His only notable mention on review of systems was a positive SARS-CoV-2 infection three weeks prior. Slit lamp examination demonstrated fine inferior keratic precipitates (KPs) in the inferior cornea and 3+ anterior chamber cells OS. There was no vitritis or chorioretinal lesions. The patient was diagnosed with his first event of acute anterior uveitis. Standard ocular inflammatory panel returned positive for HLA-B27. The postulated mechanism of initial anterior uveitis attack in the setting of COVID-19 infection was dysregulation of inflammatory cells and mediators in a patient with baseline elevated risk for ocular inflammation.

Conclusions and Importance

It is crucial to investigate patients for HLA-B27 following initial anterior uveitis event if infected by SARS-CoV-2, as patients with HLA-B27 are at baseline higher risk of ocular inflammatory dysregulation.

An Evaluation of Choroidal and Retinal Nerve Fiber Layer Thicknesses Using SD-OCT in Children with Childhood IgA Vasculitis

Background: We aimed to evaluate choroidal and retinal nerve fiber layer (RNFL) thicknesses in children undergoing the childhood IgA vasculitis (IgAV). Methods: Fifty-two patients with IgAV aged 1−6 years and 54 healthy children were included. Cases’ age, sex, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), RNFL thicknesses, and choroidal thickness values were recorded. Results: Median foveal center choroidal thickness was 374.0 µm (315.0 to 452.0 µm) in the IgAV group and 349.5 µm (285.0 to 442.0 µm) in the control group (p = 0.001). Median average RNFL thickness was 110.0 µm (91.0 to 134.0 µm) in the IgAV group and 104.0 µm (89.0 to 117.0 µm) in the control group (p < 0.001). Choroidal and RNFL thicknesses were significantly greater in all quadrants in the IgAV group than in the control group. No correlation was determined between ESR or CRP and foveal center choroidal and average RNFL thicknesses. Conclusions: Our findings show that choroidal and RNFL thicknesses increased significantly in children undergoing childhood IgA vasculitis compared to the healthy control group. These findings show that the choroid and RNFL are also affected by the inflammatory process in IgAV, which is a systemic vasculitis. We think that the choroidal and RNFL thicknesses can be used as a biomarker for childhood IgAV.

Choroidal involvement in systemic vasculitis: a systematic review

Systemic vasculitides are a large group of heterogeneous diseases characterized by inflammatory destruction of blood vessels targeting diverse organs and tissues including the eye. As the most vascularized layer of the eye, the choroid is expected to be affected in multiple systemic rheumatologic diseases with vascular involvement. While there are plenty of studies investigating retinal vascular involvement, choroidal vascular involvement in systemic vasculitides has not been investigated in isolation. However, choroidal manifestations including thickness changes, choroidal vasculitis and ischemia may be the earliest diagnostic features of systemic vasculitic diseases. Thus, multimodal imaging of the choroid may help early detection of choroidal involvement which may also have prognostic implications in these life-threatening diseases. This article aimed to review involvement of the choroid in systemic vasculitic diseases.