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Kawasaki disease (KD) is a systemic vasculitis affecting infants and children; it manifests as fever and signs of mucocutaneous inflammation. Intravenous immunoglobulin (IVIG) treatment effectively attenuates the fever and systemic inflammation. However, 10–20% patients are unresponsive to IVIG. To identify genetic variants influencing IVIG non-response in KD, a genome-wide association study (GWAS) and a replication study were performed using a total of 148 IVIG non-responders and 845 IVIG-responders in a Korean population. rs28662 in the sterile alpha motif domain-containing protein 9-like (SAMD9L) locus showed the most significant result in the joint analysis of GWAS and replication samples (odds ratio (OR) = 3.47, P = 1.39 × 10−5). The same SNP in the SAMD9L locus was tested in the Japanese population, and it revealed a more significant association in a meta-analysis with Japanese data (OR = 4.30, P = 5.30 × 10−6). These results provide new insights into the mechanism of IVIG response in KD.

Background and Objectives We investigated the status of infliximab use in intravenous immunoglobulin (IVIG)-resistant Kawasaki disease (KD) patients and the incidence of coronary artery aneurysms (CAAs) according to treatment regimens. Methods Between March 2010 and February 2017, 16 hospitals participated in this study. A total of 102 (32.3±19.9 months, 72 males) who received infliximab at any time after first IVIG treatment failure were enrolled. Data were retrospectively collected using a questionnaire. Results Subjects were divided into two groups according to the timing of infliximab administration. Early treatment (group 1) had shorter fever duration (10.5±4.4 days) until infliximab infusion than that in late treatment (group 2) (16.4±4.5 days; p5). Overall response rate to infliximab was 89/102 (87.3%) and the incidence of significant CAA was lower in group 1 than in group 2 (1/42 [2.4%] vs. 17/60 [28.3%], p

Background and objectives Patients with Kawasaki disease (KD) are clinically heterogeneous because its diagnosis is based solely on clinical observation and there are no definitive biomarkers. We dissected the clinical heterogeneity of KD patients using the KD-associated genetic variants. Methods We performed a genetic association analysis in several KD subgroups categorized by clinical characteristics using the KD-associated variants of the B lymphoid tyrosine kinase (BLK; rs6993775) and Fc gamma receptor II a (FCGR2A; rs1801274) in a large number of case (n=1,011) and control (n=4,533) samples. Results BLK and FCGR2A were very significantly associated with KD in Korean KD patients (odds ratio [OR],1.48; p=4.63×10⁻¹¹ for BLK, and OR, 1.26; p=1.42×10⁻⁴ for FCGR2A). However, in KD subgroup analysis, we found that neither BLK nor FCGR2A were associated with either incomplete Kawasaki disease (iKD) type patients or those older than 5 years of age (p>0.2), suggesting that patients with iKD or those older than 5 years of age are a unique subgroup of KD. In genetic association analysis after excluding iKD patients and those older than 5 years old, we found that BLK was associated with all KD subgroups, whereas FCGR2A was specifically associated with male KD patients younger than 1 year of age (OR, 2.22; p=2.35×10⁻⁵). Conclusions KD is a clinically and genetically heterogeneous disease. These findings will provide new insights into the clinical and genetic heterogeneity of KD.

Kawasaki disease (KD) is an acute febrile vasculitis predominately affecting infants and children. The dominant incidence age of KD is from 6 months to 5 years of age, and the incidence is unusual in those younger than 6 months and older than 5 years of age. We tried to identify genetic variants specifically associated with KD in patients younger than 6 months or older than 5 years of age. We performed an age-stratified genome-wide association study using the Illumina HumanOmni1-Quad BeadChip data (296 cases vs. 1,000 controls) and a replication study (1,360 cases vs. 3,553 controls) in the Korean population. Among 26 candidate single nucleotide polymorphisms (SNPs) tested in replication study, only a rare nonsynonymous SNP (rs4365796: c.1106C＞T, p.Thr369Met) in the lymphoid enhancer binding factor 1 (LEF1) gene was very significantly associated with KD in patients younger than 6 months of age (odds ratio [OR], 3.07; pcombined = 1.10 × 10-5), whereas no association of the same SNP was observed in any other age group of KD patients. The same SNP (rs4365796) in the LEF1 gene showed the same direction of risk effect in Japanese KD patients younger than 6 months of age, although the effect was not statistically significant (OR, 1.42; p = 0.397). This result indicates that the LEF1 gene may play an important role as a susceptibility gene specifically affecting KD patients younger than 6 months of age.

Purpose To differentiate adenoviral pharyngoconjunctival fever (PCF) from acute Kawasaki disease (KD) using laboratory tests before results of virus-real time polymerase chain reaction and ophthalmologic examination are obtained. Methods Baseline patient characteristics and laboratory measurements were compared between 40 patients with adenovirus infection and 123 patients with KD. Results The patients with adenovirus infection were generally older than those with KD (median: 3.9 years vs. 2 years, P=0.000). White blood cell and, platelet count, and aspartate aminotransferase, alanine aminotransferase, and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels showed significant differences between the 2 groups, but the C-reactive protein (CRP) levels did not (6.8±3.0 mg/dL vs. 8.3±5.8 mg/dL, P=0.126). In the adenovirus infection group, the CRP levels were

Kawasaki disease (KD) is a self-limited systemic vasculitis of an unknown pathogenesis mainly affecting children

Background In recent days, the prevalence of childhood metabolic syndrome (MS) has increased substantially due to the increasing rate of childhood obesity on a global scale. The aims of this study were to detect the important parameters and provide the screening system to prevent cardiovascular disease in adolescents with MS. Methods Ninety one male adolescents were divided into two groups based on the presence or absence of MS. Anthropometric measurement and laboratory study were studied. Intimal medial thickness and pulse wave velocity were estimated. Left ventricular mass index (LVMI), ejection fraction, myocardial velocity, strain and strain rate were measured by tissue Doppler imaging and strain rate imaging. Results The prevalence of MS was 7.7%. Weight, body mass index (BMI), waist circumference (WC), glucose, insulin, homeostasis model assessment of insulin resistance, triglyceride and LVMI were significantly increased in the MS group. High density lipoprotein-cholesterol (HDL-C), peak early diastolic myocardial velocity (e'), systolic myocardial velocity (s') and global longitudinal strain were significantly lower in the MS group. In univariant analysis, LVMI was significantly correlated with BMI, WC, fat %, fat mass, systolic blood pressure, alanine aminotransferase, total cholesterol (TC) and low density lipoprotein-cholesterol. e' was significantly correlated with BMI, fat %, fat mass, and HDL-C. Global circumferential strain had significant correlation with glucose and TC. Basal anterolateral strain rate was significantly correlated with weight, BMI, WC, fat %, and fat mass. Conclusion LVMI, strain and strain rate are practical and accurate parameters for assessment of left ventricular function in adolescents with MS.

Kawasaki disease (KD) is a systemic vasculitis affecting infants and children; it manifests as fever and signs of mucocutaneous inflammation. Intravenous immunoglobulin (IVIG) treatment effectively attenuates the fever and systemic inflammation. However, 10-20% patients are unresponsive to IVIG. To identify genetic variants influencing IVIG non-response in KD, a genome-wide association study (GWAS) and a replication study were performed using a total of 148 IVIG non-responders and 845 IVIG-responders in a Korean population. rs28662 in the sterile alpha motif domain-containing protein 9-like (SAMD9L) locus showed the most significant result in the joint analysis of GWAS and replication samples (odds ratio (OR) = 3.47, P = 1.39 × 10

Kawasaki disease (KD), a systemic vasculitis of infants and children, manifests as fever and mucocutaneous inflammation. Although its etiology is largely unknown, the epidemiological data suggest that genetic factors are important in KD susceptibility. To identify genetic variants influencing KD susceptibility, we performed a genome-wide association study (GWAS) and replication study using a total of 915 children with KD and 4553 controls in the Korean population. Six single-nucleotide polymorphisms (SNPs) in three loci were associated significantly with KD susceptibility (P

Kawasaki disease (KD) is an acute systemic vasculitis that can potentially cause coronary artery aneurysms in some children. KD occurs approximately 1.5 times more frequently in males than in females. To identify sex-specific genetic variants that are involved in KD pathogenesis in children, we performed a sex-stratified genome-wide association study (GWAS), using the Illumina HumanOmni1-Quad BeadChip data (249 cases and 1,000 controls) and a replication study for the 34 sex-specific candidate SNPs in an independent sample set (671 cases and 3,553 controls). Male-specific associations were detected in three common variants: rs1801274 in FCGR2A [odds ratio (OR) = 1.40, P = 9.31 × 10−5], rs12516652 in SEMA6A (OR = 1.87, P = 3.12 × 10−4), and rs5771303 near IL17REL (OR = 1.57, P = 2.53 × 10−5). The male-specific association of FCGR2A, but not SEMA6A and IL17REL, was also replicated in a Japanese population (OR = 1.74, P = 1.04 × 10−4 in males vs. OR = 1.22, P = 0.191 in females). In a meta-analysis with 1,461 cases and 5,302 controls, a very strong association of KD with the nonsynonymous SNP rs1801274 (p.His167Arg, previously assigned as p.His131Arg) in FCGR2A was confirmed in males (OR = 1.48, P = 1.43 × 10−7), but not in the females (OR = 1.17, P = 0.055). The present study demonstrates that p.His167Arg, a KD-associated FCGR2A variant, acts as a susceptibility gene in males only. Overall, the gender differences associated with FCGR2A in KD provide a new insight into KD susceptibility.

Kawasaki disease (KD) is the most common cause of acquired heart disease in children. Intravenous immunoglobulin (IVIG) is the standard therapy for KD, but more than 10% of KD patients do not respond to IVIG and are at high risk for the development of coronary artery lesions (CALs). To identify clinical and genetic risk factors associated with CAL development and IVIG nonresponsiveness, this study analyzed the clinical data for 478 Korean KD patients. Multivariate logistic regression analysis showed that incomplete KD, IVIG nonresponse, fever duration of 7 days or longer, and the CC/AC genotypes of the rs7604693 single nucleotide polymorphism (SNP) in the PELI1 gene were significantly associated with the development of CALs, with odds ratios (ORs) ranging from 2.06 to 3.04. The risk of CAL formation was synergistically increased by the addition of individual risk factors, particularly the genetic variant in the PELI1 gene. Multivariate analysis also showed that a serum albumin level of 3.6 g/dl or lower was significantly associated with nonresponsiveness to IVIG [OR, 2.76; 95% confidence interval (CI), 1.34-5.68; P = 0.006]. Conclusively, incomplete KD, IVIG nonresponsiveness, long febrile days, and the rs7604693 genetic variant in the PELI1 gene are major risk factors for the development of CALs, whereas low serum albumin concentration is an independent risk factor for IVIG nonresponsiveness.

Kawasaki disease is a systemic vasculitis of unknown etiology, with clinical observations suggesting a substantial genetic contribution to disease susceptibility. We conducted a genome-wide association study and replication analysis in 2,173 individuals with Kawasaki disease and 9,383 controls from five independent sample collections. Two loci exceeded the formal threshold for genome-wide significance. The first locus is a functional polymorphism in the IgG receptor gene FCGR2A (encoding an H131R substitution) (rs1801274; P = 7.35 × 10(-11), odds ratio (OR) = 1.32), with the A allele (coding for histadine) conferring elevated disease risk. The second locus is at 19q13, (P = 2.51 × 10(-9), OR = 1.42 for the rs2233152 SNP near MIA and RAB4B; P = 1.68 × 10(-12), OR = 1.52 for rs28493229 in ITPKC), which confirms previous findings(1). The involvement of the FCGR2A locus may have implications for understanding immune activation in Kawasaki disease pathogenesis and the mechanism of response to intravenous immunoglobulin, the only proven therapy for this disease.

Background and Objectives: We sought to determine parameters to guide the decision of retreatment in patients with Kawasaki disease (KD) who remained febrile after initial intravenous immunoglobulin (IVIG). Subjects and Methods: A total of 129 children with KD were studied prospectively. Patients were treated with IVIG 2 to 9 days after the onset of disease. Laboratory measures, such as white blood cell (WBC), percentage of neutrophils, C-reactive protein (CRP), and N-terminal pro-brain natriuretic peptide (NT-proBNP), were determined before and 48 to 72 hours after IVIG treatment. Patients were classified into IVIG-responsive and IVIG-resistant groups, based on the response to IVIG. Results: Of a total of 129 patients, 107 patients (83%) completely responded to a single IVIG therapy and only 22 patients (17%) required retreatment: 14 had persistent fever and 8 had recrudescent fever. There was no significant difference between the groups in age, gender distri bution, and duration of fever to IVIG initiation, but coronary artery lesions developed significantly more often in the resis tant group than in the responsive group (31.8% vs. 2.8%, p=0.000). Compared with pre-IVIG data, post-IVIG levels of WBC, percentage of neutrophils, CRP, and NT-proBNP decreased to within the normal range in the responsive group, whereas they remained high in the resistant group. Multivariate logistic regression indicated that neutrophil counts, CRP, and NT-proBNP were independent parameters of retreatment. Conclusion: Additional therapy at an early stage of the disease should be administered for febrile patients who have high values of CRP, NT-proBNP, and/or neutrophil counts after IVIG therapy. (Ko

It is difficult to predict the prognosis or clinical course of secondary hemophagocytic lymphohistiocytosis (HLH) due to the various underlying causes. The authors analyzed the clinical and laboratory findings and outcomes in patients with HLH who had initially been diagnosed with Kawasaki disease (KD), and evaluated the clinical significance of each factor. Among the 21 patients with HLH, 5 had initially been diagnosed with KD and 16 had other etiologies. A comparative analysis was performed for fever duration, presence of cytopenia, serum ferritin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), triglyceride, fibrinogen, hyponatremia, reactivation, and survival rate in those HLH patients associated with KD (group I) and other causes (group II). In patients in group I, a higher level of reactivation (20%), a lower survival rate (P = .001), higher AST (P = .031) and ferritin (P = .005), and frequent hyponatremia (P = .000) were found compared to patients in group II. Interestingly, patients in group I was older than the average of age of most KD patients. A high index of suspicion on the progression from KD to HLH would be mandatory when the KD patients show elevated AST and ferritin and the presence of hyponatremia, and especially so if the patient is of older age.

PurposeKawasaki disease (KD) is the main cause of acquired heart disease in children. In addition to cardiovascular involvement, many complications have been recognized in KD. However, respiratory complications have been rarely reported. We investigated the differences in clinical characteristics, laboratory findings, radiography findings, and echocardiography findings of Mycoplasma pneumoniae infection and other types of pneumonia in KD patients.MethodsAmong 358 patients with KD, 54 developed concurrent pneumonia. Among the 54 patients, 12 (22.2%) with high titers of anti-M. pneumoniae antibody (AMA) (>1:640) were grouped in the M. pneumoniae group and 42 were included in the control group. Serum AMA was measured in each patient. Clinical laboratory findings and total duration of fever were analyzed.ResultsThe duration of fever, serum hemoglobin, white blood cell count, platelet count, erythrocyte sedimentation rate, C-reactive protein level, albumin level, and the incidence of coronary arterial lesions showed no statistical difference in the 2 groups. Neutrophil count was significantly higher in the M. pneumoniae group than in the control group. Among various radiography findings observed in pneumonia, consolidation and pleural effusion were more frequent in the M. pneumoniae group than in the control group. On the other hand, parahilar peribronchial opacification, diffuse interstitial lesion, and normal findings prevailed in the control group.ConclusionKD patients can have concurrent infections, especially pulmonary symptoms. The cause of KD is likely to be associated with M. pneumoniae infection. Thus, immediate treatment of M. pneumoniae infection in KD patients is very important.

Background: Idiopathic cardiomyopathies (CMPs) are an important heterogeneous group of diseases. With the advance of therapeutic strategies, epidemiologic data on CMP have become very important, but only a few have been reported in Asian children. We conducted a retrospective epidemiologic study of primary CMP in Korean children. Methods and Results: Using a multicenter survey, we studied primary CMP among Korean children from January 1998 to December 2006 based on classification (2006) of CMP by the American Heart Association. A total of 277 primary CMP patients were reported from 17 cardiovascular centers. The average annual occurrence of new cases of primary CMP was 0.28 per 100,000 Korean children younger than 15 years of age (95% confidence interval (CI) 0.24-0.31). Dilated CMP (DCMP) was 66.43%, hypertrophic CMP (HCMP) 23.47%, restrictive CMP (RCMP) 6.50% and others 3.61%. The point prevalence of primary CMP at the end of the study was estimated as 2.11/100,000 (95%CI 1.83-2.43), DCMP 1.39/100,000, HCMP 0.51/100,000, RCMP 0.16/100,000 and others 0.04/100,000. Survival rates over 9 years were 69.8% in DCMP, 90.3% in HCMP, and 47.2% in RCMP. Conclusions: Recent point prevalence of childhood primary CMP in Korea was estimated as 2.11/100,000. Further epidemiologic study with a nationwide survey is necessary. (Circ J 2011; 75: 2228-2234)

Purpose : Adiponectin is an endogenous modulator of vascular remodeling that suppresses vascular inflammation. However, the role of adiponectin in Kawasaki disease (KD) has not been elucidated. The purpose of this study is to investigate the correlation between serum adiponectin level and several parameters, such as interleukin (IL)-6, tumor necrosis factor (TNF)-α, lipid profile, and C reactive protein (CRP), and to clarify the association between adiponectin and cardiac function. Methods : Twenty-two KD patients (22 patients in acute phase and 20 patients in subacute phase) were enrolled in the study group. The control group consisted of 31 subjects (13 febrile patients and 18 healthy children). Both groups underwent blood sampling and tissue Doppler imaging (TDI). Results : CRP was significantly increased in the KD group compared with the control group. There were no significant differences in serum TNF-α, IL-6, and adiponectin levels between groups. However, a negative correlation was found between adiponectin level and CRP level or platelet count. Systolic myocardial velocity and A myocardial velocity measured by TDI were decreased significantly in the acute KD group compared with the subacute KD group and control group. Positive correlations were found between adiponectin level and systolic myocardial velocity or A myocardial velocity. Conclusion : In acute KD patients, low adiponectin level was related to severe inflammatory reactions and decreased left ventricular functions. (Korean J Pediatr 2010;53:41-47)

Forty-three patients with Kawasaki disease who were resistant to initial intravenous immunoglobulin (IVIG) were randomized to receive either a second dose of IVIG (n = 32) or an infliximab (n = 11). With IVIG retreatment 21 patients (65.6%) responded, and with infliximab 10 patients (90.9%) responded. The infliximab group had shorter duration of fever and fewer days of hospitalization. Coronary artery outcomes and adverse events were similar.

Multidetector row computed tomography (MDCT) coronary angiography was performed using a 16-slice MDCT scanner in three children with coronary aneurysms due to Kawasaki disease. Patients were given a beta-blocker. Following contrast injection, all data were acquired during a 20-second breathhold. Results were compared with those of conventional coronary angiography performed previously. MDCT provided clear visualization of coronary artery aneurysms, with coronary calcifications but which had not yet progressed to stenotic lesions. Because MDCT allows noninvasive detection and exclusion of coronary obstructions, it may be able to replace repeat conventional angiography as a follow-up study for children with coronary artery disease.

Myocardial contractility and afterload are important factors for adequate circulation. To noninvasively assess changes in inotropy and afterload, ascending aortic blood flow was measured by continuous-wave Doppler echocardiography before and after the administration of an inotrope and a vasodilator in eight open chest dogs. Data were collected in the baseline, at three different doses of epinephrine (0.1, 0.5, and 1 microg/kg/min) and nitroprusside (1, 4, and 8 microg/kg/min) administration, and after a simultaneous infusion of both drugs in various combinations. Epinephrine infusion caused increases in peak velocity (PV), mean acceleration (MA), velocity time integral (VTI), and minute distance without a significant change in afterload. Acceleration time (AT) and ejection time (ET) showed a slight tendency to decrease with an increase in inotropy, but with no significance. Nitroprusside infusion produced dose-dependent decreases in blood pressure and index of systemic vascular resistance (ISVR), which was associated with increases in PV, MA, and minute distance, and with a decrease in AT. The combined infusion of nitroprusside and epinephrine, unless ISVR was elevated, produced synergistic effects on PV, MA, VTI, and minute distance. However, these Doppler parameters tended to diminish with an elevation in afterload. ISVR obtained during nitroprusside infusion had a better correlation with both PV and MA than with VTI or the Doppler time intervals. Our study suggests that Doppler measurement of aortic blood flow velocity and acceleration can be used for the noninvasive assessment of changes in inotropy and afterload.

The diagnostic accuracy of echocardiography alone and the safety of cardiac surgery using this diagnostic approach were retrospectively assessed in 111 children operated for congenital heart defects (CHD) during a 3.5-yr period ending in October 2001. Preoperative diagnosis was compared with the intraoperative findings obtained by surgical inspection. Perioperative death was defined as death within 30 days postoperatively. Of the patients, 70% were operated on in infancy. Seventy-six percent (84 of 111) underwent surgery after echocardiographic diagnosis alone. A high percentage of patients with patent ductus arteriosus (100%), partial atrioventricular canal (100%), coarctation of the aorta (89%), ventricular septal defect (86%), atrial septal defect (85%), and total anomalous pulmonary venous connection (75%) was operated without prior catheterization. Diagnostic errors occurred in 2.4% (2 of 84) of patients with echocardiography only and in 7.4% of patients with catheterization. No error in either group was related to surgical morbidity or mortality. There were five (6.0%) perioperative deaths in the echocardiography group and two (7.4%) in the catheterization group, with no difference in the mortality between the groups. In conclusion, many patients with CHD can be accurately diagnosed by echocardiography alone, and can safely undergo surgery without catheterization, not increasing the overall risk.

Objectives: Spontaneously hypertensive rats (SHR) are frequently used as rat models of essential hypertension. The mechanism for the development of hypertension is complicated and it is unknown. The renin-angiotensin system (RAS) plays a key role in the control of blood pressure. Microarrays are a powerful tool for studying genetics. The purpose of this study was to investigate changes of gene expression in the heart tissues of SHR after losartan treatment to provide basic data that is useful in the early diagnosis of hypertension and gene treatment. Methods: Rats were divided into three groups: the control (C) group; the hypertension (H) group (SHR), and the losartan (L) group; treated with losartan (10 mg/kg/day) in SHR. Rats were sacrificed at week 5 and microarray analysis was performed. Results: 102 gene expressions including the genes associated with cell proliferation such as Raf1, Uchl1, Btla, Spock1 were increased. The other 139 gene expressions, including the genes related to the regulation of metabolism such as TFIID, Auf1, Bmp, Hub, Taf51 showed decreases in gene expression. A total of 31 genes were differentially expressed in the L group compared to the H group. Of these, 16 genes including the genes associated with macromolecule metabolism such as MGC105766, Ppp1r1a, Rpl3l showed increased expression. The other 15 genes including the genes associated with primary metabolism such as Mcpt4, Ngn3, Tdo, Ak2 Hyal2 showed decreased expressions.

목적: 가와사끼병에서 C-반응 단백질(CRP)과 적혈구 침강속도(ESR)의 불일치 및 정맥내 면역글로불 린(IVIG) 치료 후의 변화를 보고자 하였다. 방법: 총 123명의 가와사끼병 환자의 의무기록를 후향적으로 분석하였다. 염증성 지표들을 IVIG 치료 전과 치료 후 48-72시간에 검사하였다. 불일치는 CRP ≥10 mg/dL와 ESR

We report a fetus with an unusual combination of a narrow ductus arteriosus (DA) and foramen ovale. A pregnant mother was referred at 26 weeks of gestation for fetal pericardial effusion. Fetal echocardiography showed pericardial effusion, right atrial enlargement, right ventricular hypertrophy, and tricuspid regurgitation. The DA looked tortuous with S-shaped kinking. The atrial septum primum bulged into the left atrium. Color Doppler did not show any flow across the atrial septum. Cesarean section was performed at 31 weeks of gestation. Admission to intensive care was required after delivery, but the infant gradually improved and was discharged home without any sequela.

Purpose Tumor necrosis factor (TNF)-α is thought to contribute to pulmonary hypertension. We aimed to investigate the effect of infliximab (TNF-α antagonist) treatment on pathologic findings and gene expression in a monocrotaline-induced pulmonary hypertension rat model. Methods Six-week-old male Sprague-Dawley rats were allocated to 3 groups: control (C), single subcutaneous injection of normal saline (0.1 mL/kg); monocrotaline (M), single subcutaneous injection of monocrotaline (60 mg/kg); and monocrotaline + infliximab (M+I), single subcutaneous injection of monocrotaline plus single subcutaneous injection of infliximab (5 mg/kg). The rats were sacrificed after 1, 5, 7, 14, or 28 days. We examined changes in pathology and gene expression levels of TNF-α, endothelin-1 (ET-1), endothelin receptor A (ERA), endothelial nitric oxide synthase (eNOS), matrix metalloproteinase (MMP)2, and tissue inhibitor of matrix metalloproteinase (TIMP). Results The increase in medial wall thickness of the pulmonary arteriole in the M+I group was significantly lower than that in the M group on day 7 after infliximab treatment (P

BACKGROUND The study objective was to examine the vascular wall changes caused by balloon dilation of coarctation of the aorta (CoA) acutely and at short-term follow-up using intravascular ultrasound imaging. Intravascular ultrasound has been valuable in assessing the vessel wall changes in coronary and peripheral arteries after balloon dilation, often with more detail than angiography. METHODS AND RESULTS Intravascular ultrasound imaging, using 4.8F, 20-MHz or 6.2F, 12.5-MHz catheters on either Diasonics or HP scanners, was performed in 17 patients during balloon angioplasty for native (n = 12) and recurrent (n = 5) CoAs. Nine patients were also studied at the time of follow-up cardiac catheterization 28.1 +/- 18.0 months after angioplasty. Immediately after dilation, the mean pressure gradient across the CoA decreased from 42.9 +/- 16.4 to 9.0 +/- 5.4 mm Hg (P < .001) and the mean diameter of the coarcted segment increased from 4.4 +/- 1.9 to 7.9 +/- 2.4 mm (P < .001). An intimal tear or flap was noted by ultrasound in 12 of the 12 native CoAs and 4 of the 5 recoarctations. In contrast, only 6 of the native CoAs and 2 of the recoarctations had an intimal flap or dissection detected by angiography. At follow-up, the residual pressure gradient did not significantly change from that measured immediately after dilation, but the CoA diameter increased from 7.8 +/- 1.5 to 9.9 +/- 2.3 mm (P < .01). No aneurysms were detected. Four of the 9 patients showed ultrasonic and angiographic evidence of healing and remodeling with diminution in size or disappearance of the intimal tears. CONCLUSIONS There is a high incidence of intimal tears and dissections immediately after balloon angioplasty for native and recurrent CoAs. Intravascular ultrasound is more sensitive than angiography in detecting the vascular wall changes. Even significant intimal tears are not necessarily associated with aneurysm formation, and many decrease in size or disappear at short-term follow-up.

Idiopathic cardiomyopathies (CMPs) are an important heterogeneous group of diseases. With the advance of therapeutic strategies, epidemiologic data on CMP have become very important, but only a few have been reported in Asian children. We conducted a retrospective epidemiologic study of primary CMP in Korean children.Using a multicenter survey, we studied primary CMP among Korean children from January 1998 to December 2006 based on classification (2006) of CMP by the American Heart Association. A total of 277 primary CMP patients were reported from 17 cardiovascular centers. The average annual occurrence of new cases of primary CMP was 0.28 per 100,000 Korean children younger than 15 years of age (95% confidence interval (CI) 0.24-0.31). Dilated CMP (DCMP) was 66.43%, hypertrophic CMP (HCMP) 23.47%, restrictive CMP (RCMP) 6.50% and others 3.61%. The point prevalence of primary CMP at the end of the study was estimated as 2.11/100,000 (95%CI 1.83-2.43), DCMP 1.39/100,000, HCMP 0.51/100,000, RCMP 0.16/100,000 and others 0.04/100,000. Survival rates over 9 years were 69.8% in DCMP, 90.3% in HCMP, and 47.2% in RCMP.Recent point prevalence of childhood primary CMP in Korea was estimated as 2.11/100,000. Further epidemiologic study with a nationwide survey is necessary.

A case is presented of vascular ring caused by right aortic arch with mirror-image branching and left ductus arteriosus. In this case, the descending aorta was located right of the tracheoesophagus and the left ductus arteriosus connected to the descending aorta far below the arch, producing compression of the esophagus only. Through median sternotomy, the ligation and division of the ductus was performed with concomitant repair of ventricular septal defect.

Background and Objectives: At birth, the fetal circulation must immediately adapt to extrauterine life. Our goal was to evaluate perinatal changes in the size of the aorta (Ao) and pulmonary artery (PA), and to investigate factors influencing these changes. Subjects and Methods: Aortic and PA diameters were measured by echocardiography in 50 healthy term babies one day before and 4 to 5 days after birth. Results: Compared with prenatal measurements, the Ao increased (from 7.4±0.6 mm to 8.4±0.6 mm, p

The fate of coronary artery aneurysms (CAAs) caused by Kawasaki disease depends mainly on their initial size and shape. Small to medium-sized CAAs are known to regress to normal size or decrease in size, with a good outcome. A patient with Kawasaki disease is reported who had a medium-sized CAA prematurely occluded with thrombi during regression, resulting in myocardial ischemia. This event was probably due to simultaneous use of aspirin and ibuprofen. Thus, the concomitant use of ibuprofen should be avoided when aspirin is given as an antiplatelet agent because ibuprofen blocks the platelet inhibition induced by aspirin.

Double-outlet left ventricle (DOLV) is conventionally repaired with an extracardiac conduit when pulmonary stenosis is present. We report a case of surgical repair for DOLV with severe pulmonary stenosis where the right ventricular outflow tract was established using a vascular graft patch anteriorly after constructing the posterior wall with autologous tissue. This approach provides excellent hemodynamic repair without the use of an extracardiac conduit and has the major advantage of growth potential.

Polymorphism of angiotensin converting enzyme (ACE) gene is reported to be associated with ischemic heart disease, hypertrophic cardiomyopathy, and idiopathic dilated cardiomyopathy. In this study, we investigated the relationship between Kawasaki disease and insertion/deletion polymorphism of ACE gene. Fifty five Kawasaki disease patients and 43 healthy children were enrolled. ACE genotype was evaluated from each of the subjects' DNA fragments through polymerase chain reaction (PCR). Frequencies of ACE genotypes (DD, ID, II) were 12.7%, 60.0%, 27.3% in Kawasaki group, and 41.9%, 30.2%, 27.9% in control group respectively, indicating low rate of DD and high rate of ID genotype among Kawasaki patients (p

Purpose The incidence of Kawasaki disease (KD) is rare in young infants (less than 3 months of age), who present with only a few symptoms that fulfill the clinical diagnostic criteria. The diagnosis for KD can therefore be delayed, leading to a high risk of cardiac complications. We examined the clinical characteristics and measured the serum levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels of these patients for assessing its value in the early detection of KD. Methods We retrospectively reviewed the data of young infants diagnosed with KD from 2004 to 2012. The control group included 20 hospitalized febrile patients. Laboratory data, including NT-proBNP were obtained for each patient in both groups. Results Incomplete KD was observed in 21/24 patients (87.5%). The mean fever duration on admission was 1.36±1.0 days in the KD group. Common symptoms included erythema at the site of Bacille Calmette-Guerin inoculation (70.8%), skin rash (50.0%), changes of oropharyngeal mucosa (29.1%), and cervical lymphadenopathy (20.8%). The mean number of major diagnostic criteria fulfilled was 2.8±1.4. Five KD patients (20.8%) had only one symptom matching these criteria. The incidence of coronary artery complications was 12.5%. The mean serum NT-proBNP level in the acute phase, in the KD and control groups, were 4,159±3,714 pg/mL and 957±902 pg/mL, respectively, which decreased significantly in the convalescent phase. Conclusion Incomplete KD was observed in 87.5% patients. Serum NT-proBNP might be a valuable biomarker for the early detection of KD in febrile infants aged

The right ventricle may be divided into two or more compartments by various structures in various ways. Rarely, the apical trabecular component may be sequestered from the rest of the right ventricle. We report 4 cases with different underlying lesions that share a common pathology of apical sequestration of the right ventricle resulting in diverse hemodynamic consequences. Case 1 had pulmonary valve stenosis. The apical sequestration of the right ventricle resulted in no significant hemodynamic consequence. Case 2 had multiple defects in the muscular ventricular septum. The volume of left-to-right shunt seemed to be reduced because of the commitment of some of the defects to the sequestered cavity. Case 3 had a large defect in the trabecular septum. As the defect involved the whole septum that was related to the sequestered right ventricular apex, the left ventricle together with the sequestered right ventricle formed a boot-shaped chamber. Hemodynamically, the muscular shelf was an interventricular septum. Case 4 had a coronary artery fistula to an isolated cavity that occupied the apical region of the right ventricle. The pathology was similar to the case that was reported as a five-chambered heart. The abnormal cavity was, in fact, the sequestered right ventricular apex.

Objectives: The etiology for Kawasaki disease (KD) remains unknown, but several studies have suggested the involvement of immune dysregulation and genetic factors. The purpose of this study is to compare gene expressions before and after an infusion of intravenous immunoglobulin (IVIG) in KD patients. Methods: Blood was obtained from both acute and sub-acute phases of 4 patients with KD and febrile control children. Blood was collected in PAXgene blood RNA tubes and RNA was extracted using a PAXgene blood RNA isolation kit. Labeled RNAs were analyzed using Roche NimbleGen human whole genome 12-plex array. Results: KD patients prior to IVIG injection showed more than a two-fold increase in the expression of 88 genes and more than a two-fold decrease in the expression of 98 genes compared to the control group. They also showed more than two-fold increase in the expression of 226 genes and more than a two-fold decrease in 117 genes in KD patients after IVIG treatment compared to the patients before IVIG injection. Through microarray evaluation, the expressions of genes involved in proliferation, translation, inflammatory response, immune response, cell adhesion, cell migration, cell differentiation, apoptosis, cell growth, transport, cell cycle, transcription, signal transduction and metastasis were observed. Conclusion: Changes in gene expressions in pediatric patients with KD before and after IVIG were observed via microarray evaluation. (Ewha Med J 2013;36(1):35-42)

Background and Objectives We sought to determine whether high-dose aspirin is necessary for the acute therapy of Kawasaki disease (KD) in the intravenous immunoglobulin (IVIG) era. Subjects and Methods Two groups of KD patients treated during the different periods were included. Study group (n=51, treated with IVIG without concomitant use of aspirin in the acute phase) was compared with control group (n=129, treated with IVIG plus high-dose aspirin) with regard to the response to IVIG, duration of fever after IVIG completion, time to C-reactive protein (CRP)

Fulminant myocarditis is characterized by the rapid development of life-threatening congestive heart failure. Intravenous immunoglobulin (IVIG), by modulating the immune response, may be used for the treatment of acute myocarditis. We report two children with fulminant myocarditis successfully treated with a 10-h infusion of high-dose IVIG. In those cases, a dramatic clinical improvement was achieved, with both cardiac enzymes and myocardial function normalized within 1-2 weeks after treatment.

Seven patients underwent attempted low pressure balloon dilation of stenotic conduits or homografts from right ventricle to pulmonary artery (n = 5), in the aortic valve position (n = 1), or from right atrium to left pulmonary artery (n = 1). In the right ventricle to pulmonary artery group, mean gradient reduction was only 17%. At follow-up, two patients underwent surgical conduit replacement, one had a stent implanted at cardiac catheterization, the other two are awaiting surgical intervention. The patient with a homograft in the aortic valve position had a good initial result but restenosed within 1 year and underwent a pulmonary autograft operation. The patient with the Fontan homograft stenosis had transient obstruction relief but subsequently required stent implantation. Low-pressure balloon dilation of conduits or homografts is only partially and transiently successful. Whether stent implantation will offer better long-term results remains to be determined.

Purpose Kawasaki disease (KD) is the main cause of acquired heart disease in children. In addition to cardiovascular involvement, many complications have been recognized in KD. However, respiratory complications have been rarely reported. We investigated the differences in clinical characteristics, laboratory findings, radiography findings, and echocardiography findings of Mycoplasma pneumoniae infection and other types of pneumonia in KD patients. Methods Among 358 patients with KD, 54 developed concurrent pneumonia. Among the 54 patients, 12 (22.2%) with high titers of anti-M. pneumoniae antibody (AMA) (>1:640) were grouped in the M. pneumoniae group and 42 were included in the control group. Serum AMA was measured in each patient. Clinical laboratory findings and total duration of fever were analyzed. Results The duration of fever, serum hemoglobin, white blood cell count, platelet count, erythrocyte sedimentation rate, C-reactive protein level, albumin level, and the incidence of coronary arterial lesions showed no statistical difference in the 2 groups. Neutrophil count was significantly higher in the M. pneumoniae group than in the control group. Among various radiography findings observed in pneumonia, consolidation and pleural effusion were more frequent in the M. pneumoniae group than in the control group. On the other hand, parahilar peribronchial opacification, diffuse interstitial lesion, and normal findings prevailed in the control group. Conclusion KD patients can have concurrent infections, especially pulmonary symptoms. The cause of KD is likely to be associated with M. pneumoniae infection. Thus, immediate treatment of M. pneumoniae infection in KD patients is very important.

Background and Objectives This was a multicenter study to evaluate the usefulness of the tumor necrosis factor-alpha (TNF-α) blocker infliximab for treatment of Korean pediatric patients with refractory Kawasaki disease (KD). Subjects and Methods Data from 16 patients throughout Korea who were diagnosed with refractory KD and received infliximab were collected retrospectively. Results Complete response to therapy with cessation of fever occurred in 13 of 16 patients. C-reactive protein (CRP) concentrations decreased following infliximab infusion in all 14 patients in whom it was measured before and after treatment. There were no infusion reactions or complications associated with infliximab except in 1 case with acute hepatitis occurring during treatment followed by calculous cholecystitis 4 months later. Fifteen patients had coronary artery (CA) abnormalities before infliximab therapy. Three had transient mild dilatation and 9 had CA aneurysms, with subsequent normalization in 4 patients, persistent mild dilatation in 3, persistent aneurysm in 2, and there were 3 cases (2 with CA aneurysm, 1 with mild CA dilatation) without follow-up echocardiography. Conclusion The results of this study suggest that infliximab may be useful in the treatment of refractory KD, and it appears that there is no significant further progression of CA lesions developing after infliximab treatment. Multicenter trials with larger numbers of patients and long-term follow-up are necessary to assess the clinical efficacy and safety of infliximab in refractory KD.

Background and Objectives The pathogenesis of hyponatremia (serum sodium

Purpose : We investigated the relationship between thyroid hormone and serum tumor necrosis factor (TNF), interleukin (IL-6) and N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) in patients with Kawasaki disease (KD). Methods : Serum levels of thyroid hormone, TNF, IL-6, and NT-proBNP were measured in 52 KD patients in the acute and subacute phase and 10 patients with acute febrile illness (control group). TNF and IL-6 were determined by sandwich enzyme-linked immunosorbent assay (ELISA). Echocardiography was performed to detect coronary artery lesions (CAL) in KD patients. Results : Low T3 syndrome occurred in 63.5% of KD patients. T3 in the acute phase of KD was lower than that in the control. In KD patients, T3 was lowered in the acute phase and elevated in the subacute phase, whereas TNF, IL-6 and NT-proBNP were elevated in the acute phase and decreased in the subacute phase. NT-proBNP, and IL-6 were higher in patients with low T3 than in those with normal T3. In addition, T3 inversely correlated with IL-6 and NT-proBNP. Of the 4 patients with CAL, 3 had very low T3. Compared with intravenous immunoglobulin (IVIG)-responsive patients, IVIG-resistant patients had lower T3 and higher IL-6 and NT-proBNP. Conclusion : T3 decreases in the acute phase of KD and normalizes in the subacute phase without thyroid hormone replacement. Low T3 may be partially induced by IL-6 rather than TNF, and is strongly associated with high NT-proBNP. T3 in KD may be used for the differential diagnosis, monitoring the activity of the disease, and predicting the severity of inflammation.

Purpose : Indomethacin is widely used for the prophylaxis and treatment of patent ductus arteriosus (PDA); however, it is associated with side effects such as renal failure, intraventricular hemorrhage, and gastrointestinal bleeding. Intravenous ibuprofen has been shown to be as effective as indomethacin in prompting PDA closure. If treatment with oral ibuprofen is as effective as indomethacin, it would have the advantages of greater availability, simpler administration, and lower cost. We conducted this study to compare the efficacy and side effects of indomethacin with those of oral ibuprofen, vis- a-vis on the pharmacological closure of PDA. Methods : As a randomized double-blind study, 34 preterm infants with respiratory distress syndrome and hemodynamically significant PDA were treated with either intravenous indomethacin or oral ibuprofen. Echocardiography was performed by one cardiologist who was blind to the treatment that any given infant received. The rate of ductal closure, the need for additional drug treatment or surgical ligation, clinical outcome, and the side effects of drug treatment were compared. Results : Ductal closure occurred in 16 of 18 patients (88.9%) from the indomethacin group and in 14 of 16 patients (87.5%) from the ibuprofen group (P>0.05). Three patients in the indomethacin group and four in the ibuprofen group required a second drug treatment (P>0.05). Three patients (i.e., one patient in the indomethacin group and two in the ibuprofen group) underwent surgical ligation (P>0.05). Between the two groups, there was no significant difference vis- a-vis in side effects or clinical outcome. Conclusion : Compared to indomethacin, oral ibuprofen has the advantages of simpler administration and lower cost, while being as effective; in addition, there are no differences between the two drug treatments with regards to side effects or clinical outcomes. Therefore, the widespread use of oral ibuprofen should be considered in treating PDA in preterm infants. (Korean J Pediatr 2008;51:956-963)

Purpose : Despite the seriousness of bacterial meningitis in children, there is little information on the incidence, causative organisms, mortality rate and age distribution. We studied the frequency by age group and causal pathogens, and clinical characteristics in children with bacterial meningitis in the private sector in Korea. Methods : The medical records containing the data on bacterial meningitis patients under 18 years of age confirmed by cerebrospinal fluid (CSF) findings were retrospectively analyzed from September, 1993 to August, 2006 at Ewha Womans University Mokdong Hospital. Results : Eighty-one cases of bacterial meningitis were observed. Overall the most common organism was Streptococcus agalactiae (group B streptococcus, GBS) (30 cases, 37.0%) followed by Haemophilus influenzae (22 cases, 27.2%), Streptococcus pneumoniae (12 cases, 14.8%), Escherichia coli (3 cases, 3.7%), Neisseria meningitidis (1 case, 1.2%) and others (13 cases, 16.0%). In neonates and young infants under 2 months, the most common organism was GBS. In children between 3 months, and 5 years, the most common organism was H. influenzae. S. pneumoniae was the most common organism in children over 5 years of age. Thirty-one patients (38.3%) had complications. Of all ages, the mortality rate of bacterial meningitis markedly decreased compared with the previously reported rate. Conclusion : In neonates, GBS meningitis was most common. The frequency of H. influenzae meningitis decreased after the introduction of H. influenzae type b vaccination. A strategy for the prevention of GBS meningitis in neonates should be established. The influence of the pneumococcal conjugate vaccine on S. pneumoniae meningitis should be studied.

= Abstract = A group of patients with Kawasaki disease (KD) initially present with cervical lymphadenitis or deep neck infection. These unusual KD presentations lead to unnecessary antibiotic therapy or surgical intervention, thereby delaying intravenous immu noglobulin treatment and increasing the risk of coronary artery damage. We present four KD patients whose initial presenta tions mimicked a retropharyngeal abscess. Nonsuppurative cervical lymphadenitis or suspected neck abscess unresponsive to intravenous antibiotics could signal the possibility of KD. (Korean J Pediatr 2008;51:1023-1027)

Foreign body aspiration (FBA) is a common accident in young children. Undiagnosed and retained foreign bodies may result in severe early and late complications such as asphyxia, pneumonia, atelectasis and bronchiectasis. Moreover, because it can mimic bronchiolitis, croup or asthma, an accurate history and a high index of suspicion are of paramount importance for early diagnosis. With our experience on bronchial FBA initially misdiagnosed as acute bronchiolitis, we emphasize that a minute radiological finding should not be neglected and a repeat chest radiograph may be helpful when the initial study shows normal findings. Multidetector computed tomography is a very useful noninvasive diagnostic modality for FBA.

목 적 : 학동기 아동에서의 가와사끼병은 드물게 나타나며 대부분 불완전한 양상을 보이므로 진단이 늦어지고 심혈관계 합병증의 발생이 증가한다. 본 연구에서는 이들의 임상 특징을 조사하여 이 연령군에서 가와사끼병의 조기 진단에 도움이 되고자 하였다. 방 법 : 1995년 6월부터 2006년 5월까지 가와사끼병으로 입원하...