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Kuroda K, Stottlemyre M. Acute Appendicitis Associated With Kawasaki Disease: Case Report and Review of the Literature. Cureus 2021; 13:e18997. [PMID: 34853740 PMCID: PMC8608400 DOI: 10.7759/cureus.18997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 12/12/2022] Open
Abstract
Acute appendicitis is a rare complication of Kawasaki disease in the setting of the absence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We experienced a rare case of acute appendicitis associated with Kawasaki disease. The patient is a six-year-old male who was brought to the emergency department by his mother with a pruritic rash, nausea, vomiting, and abdominal pain. Given fever, tenderness in the right lower quadrant on physical examination, leukocytosis with bandemia, and a non-compressible and dilated appendix on ultrasound, he was diagnosed with acute appendicitis and was treated with a laparoscopic appendectomy. He developed persistent fevers after surgery with new lip swelling, mucositis, and bilateral conjunctival injection. Kawasaki disease was suspected and intravenous gammaglobulin and aspirin were administrated. He made a full recovery. This case suggests that careful examination is needed for accurate diagnosis, especially in patients with postoperative persistent fever without signs of intra-abdominal complications. We performed a PubMed literature search and reviewed eight cases of appendicitis associated with Kawasaki disease. Of note, this case was seen in 2018 before the SARS-CoV-2 pandemic and the description of multisystem inflammatory syndrome in children (MIS-C).
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Affiliation(s)
- Kaku Kuroda
- Family Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA.,Pediatrics, United States Naval Hospital Okinawa, Ginowan, JPN
| | - Morgan Stottlemyre
- Pediatrics, Washington University School of Medicine, St. Louis, USA.,Pediatrics, United States Naval Hospital Okinawa, Ginowan, JPN
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2
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Porritt RA, Paschold L, Noval Rivas M, Hongying Cheng M, Yonker LM, Chandnani H, Lopez M, Simnica D, Schultheiß C, Santiskulvong C, Van Eyk J, Fasano A, Bahar I, Binder M, Arditi M. Identification of a unique TCR repertoire, consistent with a superantigen selection process in Children with Multi-system Inflammatory Syndrome. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2020:2020.11.09.372169. [PMID: 33200133 PMCID: PMC7668738 DOI: 10.1101/2020.11.09.372169] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Multisystem Inflammatory Syndrome in Children (MIS-C), a hyperinflammatory syndrome associated with SARS-CoV-2 infection, shares many clinical features with toxic shock syndrome, which is triggered by bacterial superantigens. The superantigen specificity for binding different Vβ-chains results in Vβ-skewing, whereby T cells with specific Vβ-chains and diverse antigen specificity are overrepresented in the TCR repertoire. Here, we characterized the TCR repertoire of MIS-C patients and found a profound expansion of TCR Βeta Variable gene (TRBV)11-2. Furthermore, TRBV11-2 skewing was remarkably correlated with MIS-C severity and serum cytokine levels. Further analysis of TRBJ gene usage and CDR3 length distribution of MIS-C expanding TRBV11-2 clones revealed extensive junctional diversity, indicating a superantigen-mediated selection process for TRBV expansion. In silico modelling indicates that polyacidic residues in TCR Vβ11-2 engage in strong interactions with the superantigen-like motif of SARS-CoV-2 spike glycoprotein. Overall, our data indicate that the immune response in MIS-C is consistent with superantigenic activation.
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Affiliation(s)
- Rebecca A Porritt
- Departments of Pediatrics, Division of Infectious Diseases and Immunology, Infectious and Immunologic Diseases Research Center (IIDRC) and Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lisa Paschold
- Department of Internal Medicine IV, Oncology/Hematology, Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Magali Noval Rivas
- Departments of Pediatrics, Division of Infectious Diseases and Immunology, Infectious and Immunologic Diseases Research Center (IIDRC) and Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mary Hongying Cheng
- Department of Computational and Systems Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Lael M Yonker
- Mucosal Immunology and Biology Research Center and Department of Pediatrics, Boston, Massachusetts General Hospital, MA, USA
| | - Harsha Chandnani
- Department of Pediatrics, Loma Linda University Hospital, CA, USA
| | - Merrick Lopez
- Department of Pediatrics, Loma Linda University Hospital, CA, USA
| | - Donjete Simnica
- Department of Internal Medicine IV, Oncology/Hematology, Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Christoph Schultheiß
- Department of Internal Medicine IV, Oncology/Hematology, Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | | | - Jennifer Van Eyk
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alessio Fasano
- Mucosal Immunology and Biology Research Center and Department of Pediatrics, Boston, Massachusetts General Hospital, MA, USA
| | - Ivet Bahar
- Department of Computational and Systems Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Mascha Binder
- Department of Internal Medicine IV, Oncology/Hematology, Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Moshe Arditi
- Departments of Pediatrics, Division of Infectious Diseases and Immunology, Infectious and Immunologic Diseases Research Center (IIDRC) and Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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3
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Leung DYM, Schlievert PM. Kawasaki syndrome: role of superantigens revisited. FEBS J 2020; 288:1771-1777. [PMID: 32770775 PMCID: PMC7436680 DOI: 10.1111/febs.15512] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/18/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022]
Abstract
Kawasaki syndrome (KS) is an acute vasculitis in children complicated by the development of heart disease. Despite its description over 50 years ago, the etiology of coronary artery disease in KS is unknown. High dose intravenous immunoglobulin is the most effective approach to reduce cardiovascular complications. It remains unclear why patients with KS develop coronary artery aneurysms. A subset of patients is resistant to immunoglobulin therapy. Given the heterogeneity of clinical features, variability of history, and therapeutic response, KS may be a cluster of phenotypes triggered by multiple infectious agents and influenced by various environmental, genetic, and immunologic responses. The cause of KS is unknown, and a diagnostic test remains lacking. A better understanding of mechanisms leading to acute KS would contribute to a more precision medicine approach for this complex disease. In the current viewpoint, we make the case for microbial superantigens as important causes of KS.
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Affiliation(s)
- Donald Y M Leung
- Division of Allergy/Immunology, Department of Pediatrics, National Jewish Health, Denver, CO, USA
| | - Patrick M Schlievert
- Department of Microbiology and Immunology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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4
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Abstract
Kawasaki disease (KD) is a multisystem vasculitis that primarily affects the coronary arteries of young children. The causes of KD remain a mystery. It is suspected that some sort of infectious agent is involved because KD has epidemicity and seasonality. That said, the incidence of the disease is high among Japanese people, so it can be speculated that the hosts may have some sort of genetic characteristic that leaves them susceptible to KD. Various theories regarding the etiology have been asserted, such as the infectious vasculitis theory, autoantigen theory, superantigen theory, and RNA virus theory; however, none of them have been able to overcome this epidemicity. Taking into consideration the knowledge gained from previous reports, the best scenario explaining the pathogenesis is "individuals with certain genetic backgrounds are affected by microorganisms which trigger KD." In this article, the pathogenesis of KD is discussed with a focus on the microorganisms mentioned above, along with the previous and current hypotheses as well as my own opinion.
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Affiliation(s)
- Satoru Nagata
- Departments of Pediatrics, Tokyo Women's Medical University, Tokyo, Japan
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5
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Fabi M, Corinaldesi E, Pierantoni L, Mazzoni E, Landini C, Bigucci B, Ancora G, Malaigia L, Bodnar T, Di Fazzio G, Lami F, Valletta E, Cicero C, Biasucci G, Iughetti L, Marchetti F, Sogno Valin P, Amarri S, Brusa S, Sprocati M, Maggiore G, Dormi A, Lanzoni P, Donti A, Lanari M. Gastrointestinal presentation of Kawasaki disease: A red flag for severe disease? PLoS One 2018; 13:e0202658. [PMID: 30180185 PMCID: PMC6122791 DOI: 10.1371/journal.pone.0202658] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 08/07/2018] [Indexed: 12/22/2022] Open
Abstract
Background Kawasaki disease (KD) is a febrile systemic vasculitis of unknown etiology and the main cause of acquired heart disease among children in the developed world. To date, abdominal involvement at presentation is not recognized as a risk factor for a more severe form of the disease. Objective To evaluate whether presenting abdominal manifestations identify a group at major risk for Intravenous immunoglobulin (IVIG)-resistance and coronary lesions. Methods Retrospective study of KD patients diagnosed between 2000 and 2015 in 13 pediatric units in Italy. Patients were divided into 2 groups according to the presence or absence of abdominal manifestations at onset. We compared their demographic and clinical data, IVIG-responsiveness, coronary ectasia/aneurysms, laboratory findings from the acute and subacute phases. Results 302 patients (181 boys) were enrolled: 106 patients with, and 196 patients without presenting abdominal features. Seasonality was different between the groups (p = 0.034). Patients with abdominal manifestations were younger (p = 0.006) and more frequently underwent delayed treatment (p = 0.014). In the acute phase, patients with abdominal presentation had higher platelet counts (PLT) (p = 0.042) and lower albuminemia (p = 0.009), while, in the subacute phase, they had higher white blood cell counts (WBC) and PLT (p = 0.002 and p < 0.005, respectively) and lower red blood cell counts (RBC) and hemoglobin (Hb) (p = 0.031 and p 0.009). Moreover, the above mentioned group was more likely to be IVIG-resistant (p < 0.005) and have coronary aneurysms (p = 0.007). In the multivariate analysis, presenting abdominal manifestations, age younger than 6 months, IVIG- resistance, delayed treatment and albumin concentration in the acute phase were independent risk factors for coronary aneurysms (respectively p<0.005, <0.005, = 0.005 and 0.009). Conclusions This is the first multicenter report demonstrating that presenting gastrointestinal features in KD identify patients at higher risk for IVIG-resistance and for the development of coronary aneurysms in a predominantly Caucasian population. Clinical trial registration 8/20014/O/OssN.
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Affiliation(s)
- Marianna Fabi
- Pediatric Cardiology and Adult Congenital Unit, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
- * E-mail:
| | | | - Luca Pierantoni
- Department of Pediatrics, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Elisa Mazzoni
- Department of Pediatrics, Maggiore Hospital, Bologna, Italy
| | - Chiara Landini
- Department of Pediatrics, Maggiore Hospital, Bologna, Italy
| | | | - Gina Ancora
- Department of Pediatrics, Infermi Hospital, Rimini, Italy
| | - Laura Malaigia
- Department of Pediatrics, Bufalini Hospital, Cesena, Italy
| | - Tetyana Bodnar
- Department of Pediatrics, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Giorgia Di Fazzio
- Department of Pediatrics, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Francesca Lami
- Department of Pediatric, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Enrico Valletta
- Department of Pediatrics, G.B.Morgagni–L. Pierantoni Hospital, AUSL della Romagna, Forlì, Italy
| | - Cristina Cicero
- Department of Pediatrics, Guglielmo da Saliceto Hospital, AUSL, Piacenza, Italy
| | - Giacomo Biasucci
- Department of Pediatrics, Guglielmo da Saliceto Hospital, AUSL, Piacenza, Italy
| | - Lorenzo Iughetti
- Department of Pediatric, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Federico Marchetti
- Department of Pediatrics, Santa Maria delle Croci Hospital, AUSL della Romagna, Ravenna, Italy
| | - Paola Sogno Valin
- Department of Pediatrics, Santa Maria della Scaletta Hospital, Imola, Italy
| | - Sergio Amarri
- Department of Pediatrics, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Sandra Brusa
- Department of Pediatrics, Santa Maria della Scaletta Hospital, Imola, Italy
| | - Monica Sprocati
- Department of Pediatrics, Arcispedale Sant’Anna, Ferrara, Italy
| | | | - Ada Dormi
- Department of Medical and Surgical Sciences DIMEC, University of Bologna, Bologna, Italy
| | - Paolo Lanzoni
- Department of Pediatrics, Ramazzini Hospital, Carpi, Italy
| | - Andrea Donti
- Pediatric Cardiology and Adult Congenital Unit, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Marcello Lanari
- Department of Pediatrics, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
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Streptococcal superantigens: categorization and clinical associations. Trends Mol Med 2013; 20:48-62. [PMID: 24210845 DOI: 10.1016/j.molmed.2013.10.004] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 10/01/2013] [Accepted: 10/08/2013] [Indexed: 01/01/2023]
Abstract
Superantigens are key virulence factors in the immunopathogenesis of invasive disease caused by group A streptococcus. These protein exotoxins have also been associated with severe group C and group G streptococcal infections. A number of novel streptococcal superantigens have recently been described with some resulting confusion in their classification. In addition to clarifying the nomenclature of streptococcal superantigens and proposing guidelines for their categorization, this review summarizes the evidence supporting their involvement in various clinical diseases including acute rheumatic fever.
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8
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Principi N, Rigante D, Esposito S. The role of infection in Kawasaki syndrome. J Infect 2013; 67:1-10. [PMID: 23603251 PMCID: PMC7132405 DOI: 10.1016/j.jinf.2013.04.004] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/04/2013] [Accepted: 04/05/2013] [Indexed: 01/12/2023]
Abstract
Objectives To analyse the evidence suggesting a possible infectious origin of Kawasaki syndrome (KS). Methods PubMed was searched for all of the studies published over the last 15 years using the key words “Kawasaki syndrome” or “mucocutaneous lymph node syndrome” and “infectious disease” or “genetics” or “vasculitis” or “pathogenesis”. Results Various levels of evidence support the hypothesis that KS is a complex disease triggered by an infection due to one or more pathogens. Viruses or bacteria may be the primum movens, although no specific infectious agent can be considered definitely etiological. A number of genetic polymorphisms have been identified in subjects with KS, but none of them can currently be considered a real marker of susceptibility. Conclusions Various data suggest that KS is intimately related to infectious diseases and that its clinical expression is influenced by predisposing genetic backgrounds, but our knowledge of the infectious agent(s) involved and the genetic characteristics of susceptible children remains only partial. Further studies are needed to address the many still open questions concerning the disease.
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Affiliation(s)
- Nicola Principi
- Pediatric Clinic 1, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milan, Italy
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9
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Blankier S, McCrindle BW, Ito S, Yeung RSM. The role of atorvastatin in regulating the immune response leading to vascular damage in a model of Kawasaki disease. Clin Exp Immunol 2011; 164:193-201. [PMID: 21361911 PMCID: PMC3087911 DOI: 10.1111/j.1365-2249.2011.04331.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2011] [Indexed: 02/06/2023] Open
Abstract
Superantigens have been implicated in a number of diseases including Kawasaki disease (KD), a multi-system vasculitis resulting in coronary artery aneurysms. We have characterized a murine disease model in which coronary arteritis is induced by a novel superantigen found in Lactobacillus casei cell wall extract (LCWE). Using this animal model of KD, we have identified three pathogenic steps leading to coronary artery aneurysm formation. These steps include T cell activation and proliferation, production of the proinflammatory cytokine tumour necrosis factor (TNF)-α and up-regulation of matrix metalloproteinase 9 (MMP-9), an elastolytic protease. In addition to their cholesterol-lowering effects, 3-hydroxy-3-methylglutaryl (HMG) coenzyme A (CoA) reductase inhibitors (statins) have pleotropic immunomodulatory properties. Thus, we examined the effect of atorvastatin in modulating each of these three critical pathogenic processes leading to aneurysm formation in the disease model. Atorvastatin inhibited lymphocyte proliferation in response to superantigen stimulation in a dose-dependent manner. This inhibition was also observed for production of soluble mediators of inflammation including interleukin (IL)-2 and TNF-α. The inhibitory effect on proliferation was rescued completely by mevalonic acid, confirming that the mechanism responsible for this inhibitory activity on immune activation was inhibition of HMG-CoA reductase. Similarly, TNF-α-induced MMP-9 production was reduced in a dose-dependent manner in response to atorvastatin. Inhibition of extracellular-regulated kinase (ERK) phosphorylation appears to be the mechanism responsible for inhibition of MMP-9 production. In conclusion, atorvastatin is able to inhibit critical steps known to be important in the development of coronary aneurysms, suggesting that statins may have therapeutic benefit in patients with KD.
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Affiliation(s)
- S Blankier
- Cell Biology Program, The Hospital for Sick Children Research Institute, Toronto, Canada
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10
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Macias ES, Pereira FA, Rietkerk W, Safai B. Superantigens in dermatology. J Am Acad Dermatol 2011; 64:455-72; quiz 473-4. [DOI: 10.1016/j.jaad.2010.03.044] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 02/18/2010] [Accepted: 03/03/2010] [Indexed: 12/15/2022]
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12
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The systemic and pulmonary immune response to staphylococcal enterotoxins. Toxins (Basel) 2010; 2:1898-912. [PMID: 22069664 PMCID: PMC3153275 DOI: 10.3390/toxins2071898] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 07/12/2010] [Indexed: 11/21/2022] Open
Abstract
In response to environmental cues the human pathogen Staphylococcus aureus synthesizes and releases proteinaceous enterotoxins. These enterotoxins are natural etiologic entities of severe food poisoning, toxic shock syndrome, and acute diseases. Staphylococcal enterotoxins are currently listed as Category B Bioterrorism Agents by the Center for Disease Control and Prevention. They are associated with respiratory illnesses, and may contribute to exacerbation of pulmonary disease. This likely stems from the ability of Staphylococcal enterotoxins to elicit powerful episodes of T cell stimulation resulting in release of pro-inflammatory cytokines. Here, we discuss the role of the immune system and potential mechanisms of disease initiation and progression.
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Nagata S, Yamashiro Y, Ohtsuka Y, Shimizu T, Sakurai Y, Misawa S, Ito T. Heat shock proteins and superantigenic properties of bacteria from the gastrointestinal tract of patients with Kawasaki disease. Immunology 2010; 128:511-20. [PMID: 19950419 PMCID: PMC2792135 DOI: 10.1111/j.1365-2567.2009.03135.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We previously suggested that gut bacteria may be involved in the onset of Kawasaki disease (KD). In this study, we evaluated the production of heat shock proteins (hsps) and superantigens (sAgs) by microorganisms isolated from the jejunal mucosa of 19 children with KD in the acute phase and from 15 age-matched control children. We identified 13 strains of Gram-negative microbes from patients with KD; these microbes produced large amounts of hsp60 and induced pro-inflammatory cytokine production by peripheral blood mononuclear cells. The Gram-negative microbes also elicited endogenous hsp60 production, leading to the secretion of anti-inflammatory intereukin-10 (IL-10). We also identified 18 strains of Gram-positive cocci that had superantigenic properties and which induced the expansion of Vβ2 T cells in vitro. All bacteria identified in this study were antibiotic resistant. These data suggest that sAg and hsps produced by gut bacteria might be involved in KD.
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Affiliation(s)
- Satoru Nagata
- Department of Pediatrics, Juntendo University School of Medicine, Tokyo, Japan.
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14
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Suenaga T, Suzuki H, Shibuta S, Takeuchi T, Yoshikawa N. Detection of multiple superantigen genes in stools of patients with Kawasaki disease. J Pediatr 2009; 155:266-70. [PMID: 19446844 DOI: 10.1016/j.jpeds.2009.03.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 01/21/2009] [Accepted: 03/06/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To investigate whether superantigens (SAgs) are involved in the development of Kawasaki disease (KD) by examining SAg genes in the stool of patients with KD. STUDY DESIGN Stool specimens were obtained from 60 patients with KD and 62 age-matched children (36 children with acute illness and 26 healthy children). Total DNA was extracted from these stool samples. Using polymerase chain reaction, we examined genes of 5 SAgs: streptococcal pyrogenic exotoxin-A (SPE-A), SPE-C, SPE-G, SPE-J, and toxic shock syndrome toxin-1. RESULTS At least 1 of the 5 SAg genes was detected in 42 (70%) specimens from patients with KD, 14 (38.9%) from the febrile group, and 7 (26.9%) from the healthy group. The detection rate between subjects with and without KD was of at least 1 of the 5 SAg genes (P < .001), and more than 2 SAg genes were significantly different (P = .002). CONCLUSIONS SAg may be involved in the development of KD; data suggest that multiple SAgs may trigger KD.
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Affiliation(s)
- Tomohiro Suenaga
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
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15
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Other Allergic Skin Disorders. PEDIATRIC ALLERGY, ASTHMA AND IMMUNOLOGY 2008. [PMCID: PMC7119998 DOI: 10.1007/978-3-540-33395-1_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In this chapter we discuss allergic skin disorders other than atopic dermatitis (AD): the urticaria-angioedema syndrome, allergic contact dermatitis (ACD), protein contact dermatitis (PCD), phytodermatitis, allergic photodermatitis and allergic vasculitis.
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Brogan PA, Shah V, Clarke LA, Dillon MJ, Klein N. T cell activation profiles in Kawasaki syndrome. Clin Exp Immunol 2007; 151:267-74. [PMID: 18070150 DOI: 10.1111/j.1365-2249.2007.03567.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Superantigens (SAgs) are potent stimulators of T cells bearing specific Vbeta T cell receptors (TCR) and may play a role in the pathogenesis of Kawasaki syndrome (KS), although despite 15 years of intense study this area remains controversial. Because SAgs can cause Vbeta restricted T cell activation in the absence of Vbeta skewing the aims of this study were to describe a flow cytometric protocol to study both CD4 and CD8 Vbeta repertoires, and CD69 expression across the CD4 and CD8 Vbeta repertoire in children with KS. Sixteen children with KS were studied. There was no significant increase in overall peripheral blood CD4 or CD8 T cell activation as determined by CD69 expression. However, Vbeta restricted CD4 and/or CD8 activation was observed in eight of 11 (72%) of the KS patients, a finding not observed in healthy controls. Thirteen of 16 (81%) of the KS patients had evidence of either Vbeta skewing (particularly CD4 Vbeta2 and Vbeta5.1) and/or Vbeta restricted activation. Three patients had Vbeta restricted activation in the absence of skewing. We suggest that these preliminary observations highlight the many layers of complexity when considering T cell activation in KS, which could explain some of the conflicting studies regarding peripheral blood T cell activation and Vbeta skewing. It is likely that in order to move forward with this debate a combination of detailed microbiological, immunological and molecular techniques applied to individual patients will be required ultimately to prove or refute the SAg hypothesis of KS.
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Affiliation(s)
- P A Brogan
- Department of Rheumatology, Institute of Child Health and Great Ormond St Hospital for Children, London, UK.
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Loizon S, Boeuf P, Tetteh JKA, Goka B, Obeng-Adjei G, Kurtzhals JAL, Rogier C, Akanmori BD, Mercereau-Puijalon O, Hviid L, Behr C. Vβ profiles in African children with acute cerebral or uncomplicated malaria: very focused changes among a remarkable global stability. Microbes Infect 2007; 9:1252-9. [PMID: 17890120 DOI: 10.1016/j.micinf.2007.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 04/30/2007] [Accepted: 05/14/2007] [Indexed: 11/18/2022]
Abstract
T cells are thought to play a critical role in cerebral malaria pathogenesis. However, available evidences are restricted to rodent models in which V beta specific T cell expansion has been associated with neurological syndrome suggesting involvement of superantigens or dominant antigens. Using flow cytometry, we studied the peripheral V beta T cell repertoire of Ghanaian children with cerebral malaria, uncomplicated malaria and asymptomatic control children, to look for either expansion or deletion of specific V beta associated with cerebral malaria. At admission, the general pattern of the repertoire of the patients was very similar, with no major distortion compared to the control group a part a significant increase of the frequency of the V beta 21.3 subset correlating with disease severity and attributed to the CD4 subset. During convalescence very limited fluctuations were observed including a significant decrease of the V beta 21.3 subset and increase of the V beta 20 subset, a subset not detected at admission. The remarkable stability of the V beta repertoire observed in acute malaria either cerebral or uncomplicated argues against the idea that cerebral malaria would result from a T cell-mediated inflammatory shock syndrome driven by some dominant super-antigenic activity(ies). The significance of the reproducible increase of the CD4+V beta 21.3T cell subset deserves further investigations.
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Affiliation(s)
- Séverine Loizon
- Unité d'Immunologie Moléculaire des Parasites, CNRS URA 2581, Département de Parasitologie, Institut Pasteur, 25 rue du Dr Roux, 75724 Paris cedex 15, France
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Matsubara K, Fukaya T. The role of superantigens of group A Streptococcus and Staphylococcus aureus in Kawasaki disease. Curr Opin Infect Dis 2007; 20:298-303. [PMID: 17471041 DOI: 10.1097/qco.0b013e3280964d8c] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Since the first suggestion of a superantigen hypothesis for Kawasaki disease over a decade ago, debate on the aetiology remains inconclusive. This article reviews recent publications that address the role of superantigens of group A Streptococcus and Staphylococcus aureus in the pathogenesis of Kawasaki disease. RECENT FINDINGS Over the past few years, new superantigens produced by group A Streptococcus and S. aureus have been increasingly identified, bringing the total known number to more than 30. Several studies on T-cell Vbeta repertoires and seroloepidemiology have demonstrated evidence for the involvement of single or multiple superantigens produced by the two pathogens. The associated superantigens differed in those studies, including streptococcal pyrogenic toxins A and C, staphylococcal enterotoxins A-C, and toxic shock syndrome toxin 1. These disparate findings suggest that the inflammation of Kawasaki disease does not result from a single agent but rather a final common inflammatory pathway in genetically susceptible individuals after numerous infectious agents. SUMMARY Certain staphylococcal and streptococcal superantigens are suggested to be responsible for the development of Kawasaki disease. A better understanding of the precise role of the causative agents will lead to accurate diagnosis, more targeted therapy and an improvement of coronary outcomes.
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Brogan PA. What's new in the aetiopathogenesis of vasculitis? Pediatr Nephrol 2007; 22:1083-94. [PMID: 17357785 PMCID: PMC7087892 DOI: 10.1007/s00467-007-0450-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Revised: 01/05/2007] [Accepted: 01/08/2007] [Indexed: 11/30/2022]
Abstract
The cause of the majority of childhood vasculitides is unknown although it is likely that a complex interaction between environmental factors and inherited host responses trigger the disease and determine the vasculitis phenotype. Epidemiological clues continue to implicate infectious triggers in Kawasaki syndrome (KS) and Henoch Schonlein purpura (HSP). Several genetic polymorphisms have now been described in KS and HSP which predispose to disease or predict disease severity. Anti-neutrophil cytoplasmic antibodies (ANCA) are now known to be directly involved in the pathogenesis of vascular injury in ANCA-associated vasculitides, although why some individuals develop ANCA in the first instance is not yet understood. Endothelial injury and repair are active areas of research in vasculitis. It is now possible to track endothelial injury non-invasively in children with vasculitis using surrogate markers of endothelial injury. The vasculogenic pathways involved in vascular repair following vasculitis, including endothelial progenitor cells, are beginning to be studied. It is anticipated that an improved understanding of the aetiopathogenesis of vasculitis in the young will ultimately shape future novel diagnostic and therapeutic approaches and will help us predict which children may develop premature arteriosclerosis in later life.
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Affiliation(s)
- Paul A Brogan
- Department of Rheumatology, Institute of Child Health, Level 6, 30 Guilford St., London, WC1N 1EH, UK.
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Fulton DR, Newburger JW. Kawasaki Disease. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50051-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Kawasaki disease (KD) is an inflammatory condition of unknown etiology. It involves mainly the skin, mucous membranes, lymph nodes, and myocardium. It may involve the gastrointestinal tract; however, it rarely presents as a surgical abdomen. We present a case of a young child with suspected small bowel obstruction who was subsequently diagnosed with KD. We review the surgical presentations of the intestinal tract in KD.
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Affiliation(s)
- Liat Yaniv
- Department of Pediatrics, Faculty of Medicine, Bnai Zion Medical Center, Technion, Haifa, Israel
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Horita N, Yokota SI, Fuse S, Takamuro M, Tomita H, Sato K, Fujii N, Tsutsumi H. The throat flora and its mitogenic activity in patients with Kawasaki disease. Microbiol Immunol 2005; 48:899-903. [PMID: 15557749 DOI: 10.1111/j.1348-0421.2004.tb03609.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The etiology of Kawasaki disease (KD) remains unknown, although some infectious organism has been suggested as the cause. Recent studies suggest that some bacterial toxins with superantigen activity are involved in its pathogenesis, but no specific bacterial toxin has yet been identified. Throat swabs for bacterial culture were obtained from 21 patients with KD and 20 with other febrile illnesses as controls. Mitogenic activity in culture supernatants obtained from individual bacterial strains was measured by lymphocyte proliferation assay. Sixty-one bacterial strains were isolated from KD patients, and 62 strains from control patients. There was no apparent difference in bacterial species in the throat flora between KD patients and febrile controls. Moreover, total and individual mitogenic activity of strains from KD patients was no greater than that of strains from febrile controls. The bacterial superantigen activity of throat flora may not play a major role in the pathogenesis of KD.
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Affiliation(s)
- Norihisa Horita
- Department of Pediatrics, Sapporo Medical University School of Medicine, USA.
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Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, Shulman ST, Bolger AF, Ferrieri P, Baltimore RS, Wilson WR, Baddour LM, Levison ME, Pallasch TJ, Falace DA, Taubert KA. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Pediatrics 2004; 114:1708-33. [PMID: 15574639 DOI: 10.1542/peds.2004-2182] [Citation(s) in RCA: 869] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Kawasaki disease is an acute self-limited vasculitis of childhood that is characterized by fever, bilateral nonexudative conjunctivitis, erythema of the lips and oral mucosa, changes in the extremities, rash, and cervical lymphadenopathy. Coronary artery aneurysms or ectasia develop in approximately 15% to 25% of untreated children and may lead to ischemic heart disease or sudden death. METHODS AND RESULTS A multidisciplinary committee of experts was convened to revise the American Heart Association recommendations for diagnosis, treatment, and long-term management of Kawasaki disease. The writing group proposes a new algorithm to aid clinicians in deciding which children with fever for > or =5 days and < or =4 classic criteria should undergo echocardiography [correction], receive intravenous gamma globulin (IVIG) treatment, or both for Kawasaki disease. The writing group reviews the available data regarding the initial treatment for children with acute Kawasaki disease, as well for those who have persistent or recrudescent fever despite initial therapy with IVIG, including IVIG retreatment and treatment with corticosteroids, tumor necrosis factor-alpha antagonists, and abciximab. Long-term management of patients with Kawasaki disease is tailored to the degree of coronary involvement; recommendations regarding antiplatelet and anticoagulant therapy, physical activity, follow-up assessment, and the appropriate diagnostic procedures to evaluate cardiac disease are classified according to risk strata. CONCLUSIONS Recommendations for the initial evaluation, treatment in the acute phase, and long-term management of patients with Kawasaki disease are intended to assist physicians in understanding the range of acceptable approaches for caring for patients with Kawasaki disease. The ultimate decisions for case management must be made by physicians in light of the particular conditions presented by individual patients.
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Abstract
PURPOSE OF REVIEW Kawasaki disease is an acute, self-limited vasculitis of childhood characterized by fever, bilateral nonexudative conjunctivitis, erythema of the lips and oral mucosa, changes in the extremities, rash, and cervical lymphadenopathy. Coronary artery aneurysms or ectasia develop in approximately 15 to 25% of untreated children with the disease and may lead to myocardial infarction, sudden death, or ischemic heart disease. RECENT FINDINGS In the United States, Kawasaki disease has now surpassed acute rheumatic fever as the leading cause of acquired heart disease in children. The cause of Kawasaki disease remains unknown, but fortunately intravenous immune globulin therapy has proved to be effective at reducing the prevalence of coronary aneurysms in most children treated in the acute phase. Therapy for Kawasaki disease resistant to intravenous immune globulin therapy is an area of research and controversy. The long-term treatment of children with Kawasaki disease is dependent on coronary artery status. SUMMARY This review covers key data on the etiology, pathogenesis, treatment, and long-term outcomes of Kawasaki disease, highlighting recent publications.
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Affiliation(s)
- Jane W Newburger
- Department of Cardiology at Children's Hospital, Boston, Massachusetts 02115, USA.
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Curtis N. Kawasaki disease and toxic shock syndrome--at last the etiology is clear? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2004; 549:191-200. [PMID: 15250533 DOI: 10.1007/978-1-4419-8993-2_26] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
A decade after the superantigen hypothesis for KD was first suggested, it has still not been either proven or refuted conclusively. Although initial optimism for the hypothesis was quashed by a series of published papers apparently refuting the idea, in the last few years there have been a number of good studies providing evidence in support of the superantigen hypothesis. Whether this renewed enthusiasm is justified will hopefully become clear in the near future. Ultimately, accurate diagnosis, more targeted treatment, and preventative strategies depend on the unraveling of the immunopathogenesis of this disease.
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Affiliation(s)
- Nigel Curtis
- University of Melbourne Department of Pediatrics, Royal Children's Hospital, Parkville, Australia
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Gupta-Malhotra M, Viteri-Jackson A, Thomas W, Zabriskie JB. Antibodies to highly conserved peptide sequence of staphylococcal and streptococcal superantigens in Kawasaki disease. Exp Mol Pathol 2004; 76:117-21. [PMID: 15010289 DOI: 10.1016/j.yexmp.2003.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2003] [Indexed: 10/26/2022]
Abstract
Superantigen-mediated disease such as toxic shock syndrome is seen in patients who have a weak antibody response to the antigen toxic shock syndrome toxin 1 (TSST-1). We hypothesized that there may be deficiency in antibody production to staphylococcal and streptococcal toxins in Kawasaki disease (KD) children. A peptide was constructed from the homologous portion of the staphylococcal enterotoxins (SE) and streptococcal pyrogenic enterotoxins (SPE), and antibodies to the peptide were made. The anti-peptide antibody immunoblotted several of the SE toxins and SPE toxins. Presence of the peptide antibodies was investigated via ELISA in the sera of acute KD (n = 30), convalescent KD (n = 12), control adults (n = 10), and children (n = 19). The mean anti-peptide antibodies were indistinguishable between control children and KD before treatment with immunoglobulin (P = 0.7) but rose significantly after therapy (P < 0.01). The adults had significantly higher antibodies than the KD, both acute and late (P < 0.0001) and the control children (P < 0.0001). Thus, KD patients do not have a defective serological response against toxins such as SPE/SE/TSST-1. Normal children have significantly lower antitoxin antibody levels to the toxins compared to the adults.
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Affiliation(s)
- Monesha Gupta-Malhotra
- Division of Pediatric Cardiology, New York Presbyterian Hospital, Cornell University, New York, NY 10021, USA.
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Brogan PA, Shah V, Klein N, Dillon MJ. Vbeta-restricted T cell adherence to endothelial cells: a mechanism for superantigen-dependent vascular injury. ACTA ACUST UNITED AC 2004; 50:589-97. [PMID: 14872503 DOI: 10.1002/art.20021] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To investigate the potential for endothelial cells to operate as superantigen-presenting cells for T cells and the potential for such an interaction to cause endothelial cell activation and injury. METHODS Class II major histocompatibility complex (MHC)-positive human umbilical vein endothelial cells (HUVECs) were cocultured for 4 hours with purified T cells and the superantigens staphylococcal enterotoxin B (SEB) or toxic shock syndrome toxin 1 (TSST-1). After staining with fluorescence-conjugated monoclonal antibodies, flow cytometric analysis was performed on the HUVECs and T cells to examine V(beta)-restricted T cell adherence to the endothelial cell monolayer, V(beta)-restricted T cell activation (CD69 up-regulation), surface expression of endothelial cell activation markers, and generation of endothelial microparticles (EMPs). RESULTS Coculture of purified T cells with class II MHC-positive HUVECs and either TSST-1 or SEB resulted in V(beta)-restricted CD69 up-regulation by CD4 and CD8 cells (V(beta)2 activation for TSST-1; V(beta)3, V(beta)5.1, and V(beta)12 activation for SEB). Additionally, there was CD4 and CD8 T cell V(beta)-restricted adherence to the HUVEC monolayer at 4 hours. Expression of intercellular adhesion molecule 1, E-selectin, and vascular cell adhesion molecule 1 was up-regulated on the class II MHC-positive HUVECs following exposure to superantigen in the presence of T cells, and there was increased EMP release from activated HUVECs, which occurred earlier and was of greater magnitude than that observed in response to tumor necrosis factor alpha. CONCLUSION Class II MHC-positive endothelial cells operate as competent superantigen-presenting cells for CD4 and CD8 lymphocytes in vitro. Dual signaling between endothelial cells and T cells results in V(beta)-restricted activation and adherence to endothelial monolayers and endothelial cell activation and release of EMPs expressing inducible cell adhesion molecules. It is proposed that this mechanism could account in part for the vascular injury associated with superantigen-mediated diseases including Kawasaki disease.
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MESH Headings
- Antigen-Presenting Cells/drug effects
- Antigen-Presenting Cells/immunology
- Antigens, CD/metabolism
- Antigens, Differentiation, T-Lymphocyte/metabolism
- Bacterial Toxins
- Biomarkers
- Cell Adhesion/immunology
- Cell Membrane/metabolism
- Cells, Cultured
- Coculture Techniques
- Endothelium, Vascular/drug effects
- Endothelium, Vascular/immunology
- Endothelium, Vascular/pathology
- Enterotoxins/immunology
- Enterotoxins/pharmacology
- Humans
- Lectins, C-Type
- Lymphocyte Activation
- Particle Size
- Receptors, Antigen, T-Cell, alpha-beta/immunology
- Superantigens/immunology
- Superantigens/pharmacology
- T-Lymphocytes/drug effects
- T-Lymphocytes/immunology
- Umbilical Veins/cytology
- Up-Regulation
- Vasculitis/immunology
- Vasculitis/pathology
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Nomura Y, Masuda K, Yoshinaga M, Takei S, Miyata K. Possible relationship between streptococcal pyrogenic exotoxin A and Kawasaki syndrome in patients older than six months of age. Pediatr Infect Dis J 2003; 22:794-8. [PMID: 14506370 DOI: 10.1097/01.inf.0000083824.15218.de] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We previously investigated antibody titers against four kinds of superantigens [streptococcal pyrogenic exotoxin A (SPEA), streptococcal pyrogenic exotoxin C, toxic shock syndrome toxin-1 and staphylococcal enterotoxin B] in patients with Kawasaki syndrome (KS) younger than 6 months of age and reported a relationship between toxic shock syndrome toxin-1 and KS patients. In this study we have investigated antibody titers in KS patients older than 6 months of age. METHODS Serum of 81 patients with KS older than 6 months of age, before intravenous gamma-globulin therapy, and 88 normal age-matched children were used in this study. The IgG antibody titers against four kinds of superantigens were measured with an enzyme-linked immunosorbent assay. RESULTS The KS patients showed significantly elevated mean SPEA titer (P = 0.006) and significantly higher incidence of high SPEA (P = 0.0024) compared with the controls. The SPEA titer in KS patients showed a significant positive correlation with the number of days from onset of illness (P = 0.0002). CONCLUSIONS The elevated antibody titer against superantigens of KS patients older than 6 months of age was different from that of KS patients younger than 6 months of age. Our results suggest that KS patients' exposure to SPEA occurred a few weeks before the onset of KS. SPEA may be one of the possible etiologic agents of KS among patients older than 6 months of age in Kagoshima, Japan.
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Affiliation(s)
- Yuichi Nomura
- Department of Pediatrics, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City 890-8520, Japan.
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30
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Affiliation(s)
- H Cody Meissner
- Division of Pediatric Infectious Diseases, New England Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA.
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Zulian F, Falcini F, Zancan L, Martini G, Secchieri S, Luzzatto C, Zacchello F. Acute surgical abdomen as presenting manifestation of Kawasaki disease. J Pediatr 2003; 142:731-5. [PMID: 12838207 DOI: 10.1067/mpd.2003.232] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ten children (4.6%) among a cohort of 219 with Kawasaki disease (KD) had their onset with severe abdominal complaints. Incomplete KD presentation at the time of acute abdomen was present in nine of 10 patients. Acute abdominal pain and distension, vomiting, hepatomegaly, and jaundice were the most common symptoms at onset. Hematemesis was present in one; toxic shock syndrome requiring care in the intensive care unit occurred in four. Five patients had laparotomy, three had percutaneous transhepatic biliary drainage, and one had a gastrointestinal endoscopy. Postoperative diagnosis was gallbladder hydrops with cholestasis in five, paralytic ileus in three, appendicular vasculitis in one, and hemorrhagic duodenitis in one. All patients completely recovered, but 50% developed coronary aneurysms despite early intravenous gammaglobulin treatment. Acute surgical abdomen can be the presenting manifestation of KD. In older children with fever, rash, and acute abdominal pain or hematemesis, KD should be considered in the differential diagnosis.
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Popa ER, Stegeman CA, Bos NA, Kallenberg CGM, Tervaert JWC. Staphylococcal superantigens and T cell expansions in Wegener's granulomatosis. Clin Exp Immunol 2003; 132:496-504. [PMID: 12780698 PMCID: PMC1808727 DOI: 10.1046/j.1365-2249.2003.02157.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In Wegener's granulomatosis (WG), a form of autoimmune systemic vasculitis, chronic carriage of Staphylococcus aureus constitutes a risk factor for the development of exacerbations. Circulating T cells in this disease are persistently activated, suggesting the presence of a chronic stimulus. A causal link between chronic carriage of S. aureus and chronic T cell activation in WG is conceivable, because S. aureus produces superantigens (SAg), which are potent T cell stimulators. Superantigenic stimulation of T cells results in expansion of T cell subsets expressing SAg-binding T cell receptor V-beta (Vbeta) chains. In the present study we hypothesized that in WG the presence of staphylococcal SAg is accompanied by expansion of SAg-reacting T cell subsets. We tested our hypothesis in a cross-sectional and a longitudinal study in which the association between seven staphylococcal SAg genes [typed by poplymerase chain reaction (PCR)], eight SAg-binding Vbeta chains and four SAg-non-binding Vbeta chains (assessed by flow-cytometry) was assessed. Both studies showed that T cell expansions were present at a significantly higher rate in WG patients than in healthy individuals, but were not associated with the presence of either S. aureus or its SAg. Moreover, T cell expansions were generally of small extent, and did not appear simultaneously in both CD4 and CD8 subsets. We conclude that in WG S. aureus effects its supposed pathogenic function by a mechanism other than superantigenic T cell activation.
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Affiliation(s)
- E R Popa
- Department of Clinical Immunology, University Hospital, Groningen, The Netherlands.
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33
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Abstract
Superantigens (SAgs) are potent stimulators of T cells bearing specific Vbeta T cell receptors (TCR) and may play a role in the aetiopathogenesis of systemic vasculitis, although this remains contentious. To investigate the possible aetiological role of SAgs, this study examined peripheral blood T cell Vbeta repertoires in children with systemic vasculitis. FACS analysis of 17 different peripheral blood T cell Vbeta families was performed in 20 healthy control children, 27 disease control children with nonvasculitic inflammatory disease, 25 children with primary systemic vasculitis, six patients with Kawasaki disease (KD) and six patients with Henoch-Schönlein purpura (HSP). There was a significantly increased variance of CD4 Vbeta12 and Vbeta17, and CD8 Vbeta1 in the primary systemic vasculitis group compared to control and disease controls. Moreover, 80% of the primary systemic vasculitis children had one or more CD4 Vbeta expansions or deletions, compared with 30% of controls (P < 0.002), and 37% of the disease controls (P < 0.002). In the KD group, the mean percentage of CD4 Vbeta2 T cells was higher than in controls or disease controls. In the HSP group, there was no consistent skewing of the T cell Vbeta repertoire. We have observed changes in the T cell Vbeta repertoire in children with vasculitis over and above those observed in disease controls. While these data provide impetus for further research into this contentious field, they do not resolve unequivocally the question of the role of SAgs in childhood vasculitic syndromes.
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Affiliation(s)
- P A Brogan
- Department of Nephrourology, Institute of Child Health, 30 Guilford St, London, UK, WC1N 1EH.
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Leung DYM, Meissner HC, Shulman ST, Mason WH, Gerber MA, Glode MP, Myones BL, Wheeler JG, Ruthazer R, Schlievert PM. Prevalence of superantigen-secreting bacteria in patients with Kawasaki disease. J Pediatr 2002; 140:742-6. [PMID: 12072880 DOI: 10.1067/mpd.2002.123664] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To assess the prevalence of superantigen secreting bacteria in children with acute Kawasaki disease (KD) relative to control patients. STUDY DESIGN Bacterial cultures were obtained in a blinded fashion from the throat, rectum, and groin of 45 patients with untreated acute KD and 37 febrile control patients from 6 centers in the United States. Cultures were processed for the presence of superantigen-producing bacteria at a central laboratory. RESULTS Staphylococci or streptococci that produced superantigens (TSST-1, SEB, SEC, SPEB, SPEC) were isolated from 25 of 45 patients with KD (56%) as compared with 13 of 37 (35%) control patients (P =.078). Because SEB- and SEC-producing Staphylococcus aureus have not been associated with KD and because they do not induce a Vbeta2+ T-lymphocyte response, we analyzed the difference between groups relative to superantigens TSST-1 or SPEB/SPEC production. TSST-1 secreting S aureus or SPEB/SPEC producing group A streptococci were isolated from 20 of 45 (44%) patients with KD compared with 7 of 37 (19%) control patients (P =.019). CONCLUSIONS The overall isolation rates of superantigen (TSST-1, SPEB, SPEC, SEB, SEC) producing bacteria between patients with KD and febrile control patients were not statistically significant. However, future studies should further examine the potential role of Vbeta2-stimulatory superantigens (TSST-1 and SPEB/SPEC) in KD.
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Affiliation(s)
- Donald Y M Leung
- Department of Pediatrics, The National Jewish Medical and Research Center and University of Colorado Health Sciences Center, Denver, USA
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35
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Affiliation(s)
- H C Meissner
- Department of Pediatrics, New England Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA.
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36
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Abstract
Kawasaki disease is a leading cause of acquired heart disease in children in the USA. An acute vasculitis of unknown etiology, it occurs predominantly in infancy and early childhood, and more rarely in teenagers. Coronary artery aneurysms or ectasia develop in approximately 15-25% of children with the disease. Treatment with intravenous gamma globulin, 2 g per kg, in the acute phase reduces this risk three- to fivefold. Angiographic resolution occurs in approximately one-half of aneurysmal arterial segments, but these show persistent histologic and functional abnormalities. The remainder continue to be aneurysmal, often with development of progressive stenosis or occlusion. The worst prognosis occurs in children with so-called 'giant aneurysms', i.e. those with a maximum diameter greater than 8 mm, because thrombosis is promoted both by sluggish blood flow within the massively dilated vascular space and by the frequent development of stenotic lesions. Serial stress tests with myocardial imaging are mandatory in the management of patients with Kawasaki disease and significant coronary artery disease to determine the need for coronary angiography and transcatheter interventions or coronary bypass surgery. Continued long-term surveillance in patients with and without detected coronary abnormalities is necessary to determine the natural history of Kawasaki disease.
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Affiliation(s)
- J W Newburger
- Department of Cardiology, Children's Hospital, Boston, MA 02115, USA
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Wann ER, Fehringer AP, Ezepchuk YV, Schlievert PM, Bina P, Reiser RF, Höök MM, Leung DY. Staphylococcus aureus isolates from patients with Kawasaki disease express high levels of protein A. Infect Immun 1999; 67:4737-43. [PMID: 10456925 PMCID: PMC96803 DOI: 10.1128/iai.67.9.4737-4743.1999] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/1999] [Accepted: 06/30/1999] [Indexed: 01/28/2023] Open
Abstract
Kawasaki disease (KD) is an acute vasculitis of young children that can be complicated by coronary artery abnormalities. Recent findings suggest that a superantigen(s) may play an important role in stimulating the immune activation associated with the disease, although the origin of this superantigen(s) is unclear. Staphylococcus aureus, isolated from the rectum or pharynx of patients with KD, secretes toxic shock syndrome toxin 1 (TSST-1). The KD isolates express low levels of other exoproteins compared to isolates from patients with toxic shock syndrome (TSS). Thus, it was previously suggested that the KD isolates may be defective in the global regulatory locus agr (for accessory gene regulator), which positively regulates these factors (D. Y. M. Leung et al., Lancet 342:1385-1388, 1993). Here we describe another characteristic of KD isolates. When considered collectively, the KD isolates were found to express higher levels of staphylococcal protein A than the TSS isolates, another characteristic of an agr-defective phenotype. This correlated with a higher level of spa mRNA in these isolates. In contrast, the KD and TSS isolates expressed comparable levels of TSST-1, consistent with previous findings (D. Y. M. Leung et al., Lancet 342:1385-1388, 1993). Analysis of RNAIII transcript levels and nucleotide sequence analysis of the RNAIII-coding region suggested that the KD isolates are not defective in RNAIII, the effector molecule of the agr regulatory system. However, induction of RNAIII transcription in the KD isolates did not result in a dramatic decrease in the amount of spa mRNA, as has been reported for other strains (F. Vandenesch, J. Kornblum, and R. P. Novick, J. Bacteriol. 173:6313-6320, 1991).
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Affiliation(s)
- E R Wann
- Albert A. Alkek Institute of Biosciences and Technology, Texas A & M University Health Science Center, Houston, Texas 77030-3303, USA
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38
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Leung DY, Hauk P, Strickland I, Travers JB, Norris DA. The role of superantigens in human diseases: therapeutic implications for the treatment of skin diseases. Br J Dermatol 1998; 139 Suppl 53:17-29. [PMID: 9990409 DOI: 10.1046/j.1365-2133.1998.1390s3017.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Although it is well established that immune mechanisms contribute to the pathogenesis of chronic inflammatory skin diseases such as atopic dermatitis (AD) and psoriasis, the actual events that trigger the immunological pathways resulting in these skin diseases are not well understood. Colonization and infection with Staphylococcus aureus and streptococci has been reported to exacerbate AD and psoriasis. Recent studies demonstrating that bacterial toxins can act as superantigens provide mechanism(s) by which S. aureus and streptococci could mediate an inflammatory skin lesion that consists predominantly of activated T-cells and monocytes. This review will explore the diverse mechanisms by which bacterial superantigens can induce skin inflammation following systemic or local infection. These observations provide a new direction for the development of novel approaches for the treatment of skin inflammation.
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Affiliation(s)
- D Y Leung
- Department of Paediatrics, National Jewish Medical and Research Center, Denver, CO 80206, USA
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39
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Mancia L, Wahlström J, Schiller B, Chini L, Elinder G, D'Argenio P, Gigliotti D, Wigzell H, Rossi P, Grunewald J. Characterization of the T-cell receptor V-beta repertoire in Kawasaki disease. Scand J Immunol 1998; 48:443-9. [PMID: 9790317 DOI: 10.1046/j.1365-3083.1998.00415.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Kawasaki disease (KD) is a paediatric multisystem necrotizing vasculitis constituting the most frequent cause of acquired heart disease in childhood. Conflicting data have been reported regarding expanded T-cell populations using particular T-cell receptor (TCR) beta-chain variable (BV) gene segments, suggesting either a superantigen- or a conventional antigen-mediated immune response in this disease. In order to further investigate the role of T lymphocytes, cells were stained with an extensive panel of 21 different TCRBV specific monoclonal antibodies (MoAbs) covering almost 70% of all T-cells. Flow cytometry was employed to analyse the expression of the TCRBV repertoire in the CD4+ and CD8+ subsets separately, and of activation markers, in freshly isolated peripheral blood lymphocytes of 25 Kawasaki disease patients during the acute and convalescent phases of the disease. No abnormal usage of any TCRBV family was found, neither acutely nor during convalescence, compared with a control group of healthy children. However, a significant increase in interleukin-2 receptor (IL-2R)-expressing T lymphocytes restricted to the CD4+ subset was observed in KD patients. Our data confirm a strong immune activation in KD that might be of importance in the pathogenesis of the disease.
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Affiliation(s)
- L Mancia
- Microbiology and Tumorbiology Center, Karolinska Institute, Stockholm, Sweden
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40
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Leung DY, Schlievert PM, Meissner HC. The immunopathogenesis and management of Kawasaki syndrome. ARTHRITIS AND RHEUMATISM 1998; 41:1538-47. [PMID: 9751085 DOI: 10.1002/1529-0131(199809)41:9<1538::aid-art3>3.0.co;2-m] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- D Y Leung
- The National Jewish Medical and Research Center, and University of Colorado Health Sciences, Center, Denver 80206, USA
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41
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Masuda K, Takei S, Nomura Y, Imanaka H, Sameshima K, Yoshinaga M. Transient low T cell response to streptococcal pyrogenic exotoxin-C in patients with Kawasaki disease. Pediatr Res 1998; 44:27-31. [PMID: 9667366 DOI: 10.1203/00006450-199807000-00004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Superantigens (SAs) are known to induce transient anergy followed by T cell activation. Recent reports have suggested that SAs are involved in the pathogenesis of Kawasaki disease (KD). In the present study, we investigated the peripheral T cell response to SAs by measuring proliferation and IL-2 production to determine whether the T cell anergy is induced by SAs in patients with KD. T cells were obtained from 45 Japanese patients with KD in different stages of the disease and were stimulated by streptococcal pyrogenic exotoxin (SPE)-A, SPE-C, and toxic shock syndrome toxin-1 (TSST-1). T cells from patients with KD in the acute or convalescent stage up to 2 mo showed significantly lower proliferation and IL-2 production than did T cells from healthy control subjects stimulated by SPE-C, but not SPE-A or TSST-1. The T cell response to SPE-C normalized within 1 y. The low T cell response to SPE-C in the acute stage correlated with a peak platelet count and the C-reactive protein-positive period. These findings suggest that the transient low T cell response to SPE-C in patients with KD may have been related to SA-induced anergy or disappearance of SPE-C-responding cells from the circulation. The present results suggested that SPE-C may be involved in the pathogenesis of KD.
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Affiliation(s)
- K Masuda
- Department of Pediatrics, Faculty of Medicine, Kagoshima University, Kagoshima City, Sakuragaoka, Japan
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42
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The possible role of bacterial superantigens in the pathogenesis of autoimmune disorders. ACTA ACUST UNITED AC 1998. [DOI: 10.1016/s0167-5699(98)80009-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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43
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Jason J, Montana E, Donald JF, Seidman M, Inge KL, Campbell R. Kawasaki disease and the T-cell antigen receptor. Hum Immunol 1998; 59:29-38. [PMID: 9544237 DOI: 10.1016/s0198-8859(97)00233-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We investigated the evidence for an infectious etiology of Kawasaki disease (KD), an acute vasculitis of unknown etiology, by assessing the effects of KD on the T cell antigen receptor variable beta region families (V beta). Using 3-color flow cytometry, we studied KD patients pre- and post-intravenous gamma globulin (IVIG) therapy and at > 40 days post therapy, additionally comparing them to matched pediatric control patients (PCC) and their own healthy parents (one parent/KD child). Of all the V beta families examined, only V beta 2 exhibited statistically significant differences, between the pre- and post-IVIG samples and preIVIG and parent samples. No associations were found between V beta 2 findings and T cell memory, activation, or adhesion markers. For 2 KD patients, 4 parents, and 1 PCC participant, > 15% of resting CD8+ lymphocytes and > 15% of blastic CD8+ lymphocytes expressed a single V beta family, which varied by individual, without similar expansions in the CD4+ cell populations. One of the participants with this abnormality was the only one with significant cardiac abnormalities. For all participants with the V beta abnormality, other T-cell abnormalities were extensive and involved both CD4+ and CD8+ cells. We suggest that V beta 2 changes do occur in KD, as previously reported. However, these may not be involved in disease pathogenesis. Other V beta changes also occur. Those occurring in parents may reflect asymptomatic reinfection with an infectious agent causing KD. Further, some KD patients may have restricted cytotoxic T-cell responses to that as yet unidentified agent; this restricted response may be associated with more severe cardiac involvement.
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Affiliation(s)
- J Jason
- Department of Health and Human Services, Public Health Service, Atlanta, GA, USA
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Jason J, Gregg L, Han A, Hu A, Inge KL, Eick A, Tham I, Campbell R. Immunoregulatory changes in Kawasaki disease. CLINICAL IMMUNOLOGY AND IMMUNOPATHOLOGY 1997; 84:296-306. [PMID: 9281389 DOI: 10.1006/clin.1997.4376] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Kawasaki disease (KD) is an acute vasculitis of unknown etiology, occurring in young children and treated with intravenous gamma globulin (IVIG) to prevent significant cardiac morbidity and mortality. We studied KD patients pre- and post-IVIG therapy and at >40 days posttherapy, additionally comparing them with matched pediatric control patients and parents. Using three-color flow cytometry, we examined immune changes in KD, especially previously unassessed markers of T-lymphocyte activation, memory, and adhesion. The percentage of cells positive for CD19, CD25, CD38, and CD71 was significantly lower during convalescence compared with pre-IVIG (medians: CD19, 18% vs 26%, P = 0.0004; CD25, 6% vs 9% for CD3(+) cells, P = 0.0074; CD38, 78% vs 89% for CD8(+) cells, P = 0.0015; CD71, 1% vs 6% for CD4(+) cells, P = 0.0024). The proportion of CD3(+) cells increased (medians: CD3, 66% vs 45%, P < 0.0001). Values for all parameters varied greatly pre- and post-IVIG, but not in a consistent direction. The sole patient with cardiac abnormalities had the greatest pre-/post-IVIG variability. These changes support the involvement of T-lymphocytes in the acute KD vasculitic process. They also suggest that T-lymphocytes involved in endothelial damage during acute KD may be subsequently removed or eliminated from the peripheral blood.
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MESH Headings
- Antigens, CD/analysis
- Antigens, CD19/analysis
- Antigens, Differentiation, B-Lymphocyte/analysis
- Biomarkers/blood
- Blast Crisis/immunology
- Blast Crisis/pathology
- CD4-Positive T-Lymphocytes/chemistry
- CD4-Positive T-Lymphocytes/immunology
- Child
- Child, Preschool
- Female
- Humans
- Immunoglobulins, Intravenous/pharmacology
- Infant
- Integrin beta1/analysis
- Male
- Mucocutaneous Lymph Node Syndrome/immunology
- Receptors, Antigen, T-Cell/analysis
- Receptors, Interleukin-2/analysis
- Receptors, Transferrin
- T-Lymphocytes/chemistry
- T-Lymphocytes/immunology
- Time Factors
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Affiliation(s)
- J Jason
- Division of HIV, Sexually Transmitted Diseases, Tuberculosis Laboratory Research,National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, 30333, USA
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Leung DY, Sullivan KE, Brown-Whitehorn TF, Fehringer AP, Allen S, Finkel TH, Washington RL, Makida R, Schlievert PM. Association of toxic shock syndrome toxin-secreting and exfoliative toxin-secreting Staphylococcus aureus with Kawasaki syndrome complicated by coronary artery disease. Pediatr Res 1997; 42:268-72. [PMID: 9284264 DOI: 10.1203/00006450-199709000-00004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Kawasaki syndrome (KS) has been reported to be associated with selective expansion of Vbeta2+ T cells and either staphylococcal toxic shock syndrome toxin-1 or streptococcal pyrogenic exotoxin C in uncomplicated cases. However, there have been no previous studies on the role of superantigens in KS associated with coronary artery disease, the major complication of this illness. The present study characterized bacteria isolated from three acute KS patients who developed coronary artery disease. Staphylococcus aureus secreting either TSST-1 (n = 3) or exfoliative toxin A (n = 1), both known to stimulate expansion of Vbeta2+ T cells, were isolated from all three patients. The percent Vbeta2+ T cells was determined in three patients with coronary artery disease. On presentation, one patient demonstrated reduction, whereas the other two showed expansion, of Vbeta2+ T cells. Repeat analyses of the latter two children showed their percent Vbeta2+ T cells to decrease toward normal. These observations suggest that coronary artery disease in KS may result from superantigenic stimulation of Vbeta2+ T cells. This is also the first demonstration of an association of staphylococcal exfoliative toxin with acute KS. The observation that three different bacterial toxins associated with KS are potent activators of Vbeta2+ T cells suggests an important role for this T cell subset in the pathogenesis of this autoimmune disease.
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Affiliation(s)
- D Y Leung
- Division of Pediatric Allergy-Immunology, The National Jewish Medical and Research Center, Denver, Colorado 80206, USA
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Bertotto A, Spinozzi F, Vagliasindi C, Radicioni M, De Rosa O, Vaccaro R. Tuberculin skin test reactivity in Kawasaki disease. Pediatr Res 1997; 41:560-2. [PMID: 9098860 DOI: 10.1203/00006450-199704000-00017] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A strongly positive tuberculin skin reaction (> 1.5 cm2) was observed during the acute phase of the illness in 11 children with Kawasaki disease (KD), but not in control pediatric patients with other febrile infections (41 patients) or diseases similar to KD (9 patients). The cutaneous sensitivity to intermediate strength [5 tuberculin units (TU)] purified protein derivative (PPD) inoculation had completely disappeared by the second monthly checkup. Peripheral blood T lymphocytes from KD subjects proliferated vigorously and produced significant amounts of IL-2 in response to the stimulation elicited by 0.05 TU/mL of PPD. In contrast, the proliferative response of, and IL-2 release by, control T cells was within background values. Mounting laboratory evidence suggests that heat shock proteins (HSP) may be involved in the pathogenesis of KD. Our clinical and experimental data may, therefore, have been due to immunologic cross-reactivity between mycobacterial derived HSP65 and its human homologue HPS63 (self P1 antigen). Despite the low number of patients investigated, our findings suggest that the tuberculin skin test and its in vitro correlates (T cell mitogenesis and IL-2 production) could provide simple and reliable diagnostic tools for identifying atypical forms of KD, or vice versa, in subjects not vaccinated against tuberculosis.
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Affiliation(s)
- A Bertotto
- Department of Pediatrics, Perugia University Medical School, Italy
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