Longstanding obliterative panarteritis in Kawasaki disease: lack of cyclosporin A effect

Kawasaki disease is a childhood vasculitis of medium-sized vessels, affecting the coronary arteries in particular. We have treated a therapy-resistant child who met all diagnostic criteria for Kawasaki disease. After the boy was given intravenous immunoglobulins and salicylates, as well as several courses of pulsed methylprednisolone, disease recurred and coronary artery lesions became progressively detectable. Cyclosporin A was started and seemed clinically effective. In contrast to the positive effect on inflammatory parameters, ie, C-reactive protein and white blood cell counts, a novel plasma marker for cytotoxicity (granzyme B) remained elevated. Coronary disease progressed to fatal obstruction and myocardial infarction. Echocardiography, electrocardiograms, and myocardial creatine phosphokinase did not predict impending death. At autopsy an obliterative panarteritis was observed resulting from massive fibrointimal proliferation, affecting the aorta and several large and medium-sized arteries. Immunophenotypic analysis of the inflammatory infiltrates in arteries revealed mainly granzyme-positive cytotoxic T cells and macrophages in the intima and media, as well as nodular aggregates of T cells, B cells, and plasma cells in the adventitia of affected arteries. These findings further endorse the role of specific cellular and humoral immunity in Kawasaki disease. Unremitting coronary arteritis and excessive smooth muscle hyperplasia resulted in coronary occlusion despite the use of cyclosporin A.     

Assay of locus-specific genetic load implicates rare Toll-like receptor 4 mutations in meningococcal susceptibility

As the central component of the human endotoxin sensor, Toll-like receptor 4 (TLR4) functions in the early detection and response to Gram-negative infection. We therefore examined a large collection of patients with meningococcal sepsis, comparing the frequency of rare TLR4 coding changes to those in an ethnically matched control population. TLR2 sequences were also acquired and compared. Total nucleotide variation at TLR4 and TLR2 loci was assayed by using a novel computational method. A total of 3.01 megabases of coding sequence was captured at these loci from white subjects with or without meningococcal disease. Authentic mutations were found and high-quality, bidirectional coverage was measured across the coding region by using mutationseeker, a program specifically designed to assay locus-specific genetic load. Using a method that obviates the confounding effect of linkage disequilibrium, we observed that rare heterozygous missense mutations of TLR4 contribute to the development of systemic meningococcal disease among white populations of the southern United Kingdom (P = 0.02; odds ratio 8.2). When results from all white populations were pooled, an overwhelmingly significant excess of such mutations was observed among individuals with disease (P = 2 x 10(-6); odds ratio 27.0). The common white TLR4 variant (TLR4B), synonymous TLR4 substitutions, and variant TLR2 alleles were not significantly over-represented among patients with systemic meningococcal infections. No single variant of TLR4 was significantly over-represented in the meningococcal population. Collectively, however, rare TLR4 coding variants were markedly over-represented. Sensing via TLR4 probably contributes to the early containment of meningococcal infection, and sensing defects create increased risk of disease.     

Effect of HLA-DR matching on acute rejection after clinical heart transplantation might be influenced by an IL-2 gene polymorphism

BACKGROUND: To examine whether genetic factors are involved in the development of acute rejection (AR), we investigated a (CA)m(CT)n repeat in the 3'-flanking region of the interleukin (IL)-2 gene. METHOD: We genotyped 290 heart transplant recipients with and without AR (International Society for Heart and Lung Transplantation criteria > or =3A) and 101 controls. RESULTS: The frequency of allele 135 of the repeat and its genotype distribution (carriers/noncarriers) were significantly associated with freedom from AR (P=0.03 and P=0.02, respectively). We also found interaction between allele 135 and HLA-DR matching. More carriers of allele 135 with no or one mismatch remained free from AR compared to patients without the allele (P=0.01). This was not found in the HLA-DR group with two mismatches. CONCLUSION: HLA-DR matching might only be effective in reducing AR after heart transplantation in recipients who carry allele 135 of the (CA)m(CT)n repeat in the 3'-flanking region of the IL-2 gene.     

Renal-selective delivery and angiotensin-converting enzyme inhibition by subcutaneously administered captopril-lysozyme.

In previous studies, we have demonstrated that the low molecular weight protein lysozyme can be used as a renal-selective drug carrier for delivery of the angiotensin-converting enzyme (ACE) inhibitor captopril. Typically, such macromolecular drug-targeting preparations are administered intravenously. In the present study, we investigated the fate of captopril-lysozyme following subcutaneous administration, a convenient route for long-term treatment. The absorption from the subcutaneous injection site and renal uptake of lysozyme were determined by gamma scintigraphy in rats. Bioavailability, renal accumulation, and stability of the captopril-lysozyme conjugate were evaluated by high performance liquid chromatography analysis and by ACE activity measurements. Lysozyme was absorbed gradually and completely from the subcutaneous injection site within 24 h and accumulated specifically in kidneys. After subcutaneous injection of the captopril-lysozyme conjugate, higher renal captopril levels and lower captopril-lysozyme levels in urine indicated the improved renal accumulation in comparison with intravenous administration of the conjugate, as well as its stability at the injection site. After both treatments, captopril-lysozyme conjugate effectuated renal ACE inhibition, whereas plasma ACE was not inhibited. In conclusion, our results demonstrate that we can use the subcutaneous route to administer drug delivery preparations like the captopril-lysozyme conjugate.     

The effectiveness of anxiety treatment on alcohol-dependent patients with a comorbid phobic disorder: a randomized controlled trial

OBJECTIVE: Evidence has emerged which indicates that the post-treatment relapse rate for alcohol-dependent patients with a comorbid anxiety disorder is higher than for alcohol-dependent patients without a comorbid anxiety disorder. The question raised by this evidence is whether the relapse rate in these dually diagnosed patients could be reduced if they were given additional treatment for the comorbid anxiety disorder. We attempted to answer this question by conducting a trial among patients with a double diagnosis of alcohol dependence and agoraphobia or social phobia. METHOD: We conducted a 32-week randomized controlled trial among 96 abstinent patients with a primary diagnosis of alcohol dependence and a comorbid anxiety disorder involving agoraphobia or social phobia. The patients were randomly assigned to an intensive psychosocial relapse-prevention program on its own (n = 49) or in combination with an anxiety treatment program comprising cognitive behavioral therapy (CBT) and optional pharmacotherapy consisting of an SSRI (n = 47). The primary outcome measure was the percentage of patients who suffered an alcohol relapse during a 32-week period. The secondary outcome measures were total abstinence, a reduction in the days of heavy drinking, and less severe anxiety symptoms. RESULTS: Although the additional therapy clearly reduced the anxiety symptoms, it had no significant effect on the alcohol relapse rates. CONCLUSION: Anxiety treatment for alcohol-dependent patients with a comorbid anxiety disorder can alleviate anxiety symptoms, but it has no significant effect on the outcome of alcohol treatment programs.     

Genetic analysis of physical activity in twins

BACKGROUND: The reduced contribution of physical activity (PA) to daily energy expenditure contributes to the increased prevalence of obesity. A genetic control of activity-induced energy expenditure (AEE) may contribute to a genetic susceptibility to obesity. OBJECTIVE: Our aim was to investigate the relative contribution of genetic and environmental factors to the variation and covariation in AEE and PA. DESIGN: Twelve monozygotic and 8 same-sex dizygotic (including 2 same-sex sibling pairs; age differences: 2 and 2.5 y) twin pairs aged between 18 and 39 y participated. AEE was measured in a respiration chamber for 24 h and with doubly labeled water in daily life for 2 wk. PA was recorded simultaneously with a triaxial accelerometer. Structural equation modeling was used to separate and quantify the observed variance into sex-adjusted additive genetic and common and unique environmental contributions. RESULTS: In the respiration chamber, common and unique environmental factors explained the variance in AEE and PA, and no genetic contribution was found. In daily life, genetic factors explained 72% of the variance in AEE and 78% of the variance in PA. Unique environmental factors explained the remaining variance. The same additive genetic factors explained 67% of the covariance in AEE and PA in daily life. CONCLUSIONS: In the present exploratory study that used gold standard measurements for AEE and PA but a limited sample size, genetic influence explained a large part of the variation in AEE and PA in daily life, whereas both AEE and PA were influenced by environment only within the confined area of the respiration chamber.     

Paired, quantitative measurements of hepatitis B virus DNA in saliva, urine and serum of chronic hepatitis B patients

OBJECTIVES: Despite an abundance of epidemiological evidence for horizontal transmission of hepatitis B virus (HBV), the transmission route remains to be fully elucidated. In a new approach, we evaluated quantitative HBV DNA content in serum, saliva and urine as a first step in exploring possible modes of horizontal transmission. METHODS: In an outpatient setting of an academic hospital, paired serum, saliva and urine samples were collected from 150 chronically infected HBV patients. A validated HBV DNA TaqMan assay was used to quantitatively measure HBV DNA. RESULTS: Mean log HBV DNA in serum was 5.8 (range, undetectable to 10.0 log HBV DNA) copies/ml, 50% of the patients had an HBV DNA above 10 copies/ml in serum. Mean log HBV DNA level in saliva was 3.2 (range, undetectable to 7.5) copies/ml, 15% had an HBV DNA above 10 copies/ml in saliva. Mean log HBV DNA level in urine was 2.6 (range, undetectable to 5.4) copies/ml and 1% had an HBV DNA above 10 copies/ml in urine. A high, non-linear correlation was shown between HBV DNA in serum and saliva (Spearman's rho 0.82) and between serum and urine (Spearman's rho 0.74). CONCLUSIONS: The significant amounts of HBV DNA found in saliva and urine in chronic HBV patients with high viraemia in serum may have implications for the understanding of hepatitis B epidemiology. The potential infectivity of these body fluids may provide an explanation for the 20% of cases of infection obtained through horizontal transmission for which the origin of infection is yet unknown.     

Development of a polymerase chain reaction for the detection of Anguillid herpesvirus DNA in eels based on the herpesvirus DNA polymerase gene

Anguillid herpesvirus (AnHV, also known as Herpesvirus anguillae or HVA) is found in both Japanese and European eels. Based on restriction enzyme analysis a small number of differences were found between AnHV isolated from Japanese eels and from European eels. The total genome size of both is about 245 kb, which is confirmed by alternating-field electrophoresis. Using a set of degenerate primers based on conserved regions within DNA-directed DNA polymerase coding regions, a 463 base pair fragment was isolated from both Japanese and European AnHV. Nucleotide sequence analysis showed that the cloned regions of both viruses have identical sequences. Based on this part of the DNA-polymerase sequence, primers were selected and used to develop a sensitive PCR to detect AnHV DNA in eel tissue samples. To avoid false negative results and to estimate the number of AnHV genome copies found in tissues, 100 copies of an internal control plasmid were added to the tissue samples. This semi-quantitative AnHV PCR can be used for both the European and Japanese isolates of AnHV, detects as few as 10 genome copies and is 100 times more sensitive than standard virus isolation.