Patent Application
20190302113
Aspect of the invention related to diagnosing, treating, for studying and treating HIV Kawasaki-like syndrome (KLS) and Kawasaki disease.
Adult Kawasaki-like Syndrome (KLS) seen in HIV+ individuals is a dramatic vasculitis with fevers, conjunctivitis, rash, changes of the oropharynx, and erythematous/painful hands and feet, usually without the sentinel lymph node more commonly seen in pediatric Kawasaki Disease. The adult and pediatric syndromes share an unusual histopathology of IgA+ plasma cells within inflamed arterial walls. The distinctive clinical presentation and pathognomonic histopathology suggest a shared inciting etiology and atypical inflammatory response in HIV KLS and KD patients.
Pediatric Kawasaki Disease (KD) is diagnosed clinically based on a constellation of signs and physical exam findings including a fever ≥5 days plus at least four of the following five physical findings: non-exudative conjunctivitis, rash, changes of the oropharynx, erythema and/or painful swelling of the hands and feet, and a sentinel lymph node (>1 cm and tender). Kawasaki Disease is typically seen in children >6 months <5 years of age. Epidemiology of the disease includes periodic outbreaks suggestive of a ubiquitous infectious etiology, with an atypical presentation in a subset of individuals who come to medical attention as having Kawasaki Disease. KD inflammation has predilection for coronary arteries, with serious sequelae including development of coronary artery aneurysms and residual long term risk for Increased cardiovascular morbidity and mortality. In children, therapy with IVIG reduces morbidity and mortality from Kawasaki disease by decreasing the proportion of patients with coronary artery aneurysm formation from 20% to 3%-4%. Diagnosis of KD by clinical criteria is problematic as children presenting with partial syndromes (fever plus 3 or fewer physical findings) may not receive IVIG and aspirin therapy, but can develop coronary artery aneurysms and sudden death.
Kawasaki Disease is extremely rare in adults. In the 1980s cases of an adult febrile syndrome that resembled pediatric Kawasaki Disease came to medical attention. The majority of the adults affected were noted to be HIV\ most with advanced disease and low CD4 counts. HIV+ individuals with Kawasaki-like syndrome (KLS), also known as Kawasaki Disease-like syndrome (KDLS), commonly experience a gastrointestinal disturbance with diarrhea and/or abdominal pain followed within several weeks by development of the protean manifestations of the syndrome including fevers, conjunctivitis, rash, changes of the oropharynx (strawberry tongue, fissures, cheilitis), painful erythema +/− swelling of the hands and feet, usually without a sentinel lymph node. HIV KLS patients respond to IVIG and aspirin, and therefore have been treated similar to pediatric KD patients (reviewed in (1)). Based on very limited evaluations, no HIV KLS patient has been documented to have developed coronary artery aneurysms; however cases of coronary artery aneurysm formation have been documented in HIV negative adults with KD.
Kawasaki Disease is the only vasculitis syndrome that includes infiltration of vessel walls with IgA+ plasma cells. Henoch-Scholein Purpura is an IgA-associated vasculitis that includes IgA deposition without infiltration by IgA+ plasma cells. The coronary arteries of children with fatal Kawasaki disease show mixed inflammatory cells with a prominent population of IgA+ plasma cells. KD autopsies have shown that the IgA plasma cell infiltration includes multiple vascular and non-vascular tissues throughout the body (2). The IgA plasma cell finding has led to the hypothesis that Kawasaki Disease in an infectious agent that originally invades through the respiratory tract or gut, as IgA plasma cell ontogeny and immunoglobulin class switching occur predominantly in mucosal tissues. A conjunctival biopsy of an HIV+ patient with KLS showed IgA+ plasma cells infiltrating arterial walls. That critical finding linked HIV KLS with pediatric Kawasaki Disease at the level of histopathology (3). The same study showed markedly elevated sTNFRII levels in serum during the acute phase of HIV KLS, suggesting a major role for TNFα in KLS pathophysiology as serum levels of soluble TNF receptors are regulated by TNFα.
Understanding the pathophysiology of HIV KLS may improve therapeutic interventions and contribute toward development of a practicable diagnostic test that would at least partially alleviate current dependence on a constellation of clinical signs and physical findings combined with extensive diagnostic testing to rule out other etiologies. Development of a reliable KLS/KD diagnostic test is important as individuals who present with incomplete Kawasaki syndromes may not receive IVIG therapy and can go on to develop the vascular sequelae. A reliable diagnostic test would also shorten hospitalizations and curtail an expensive diagnostic evaluation to rule out other etiologies. Fortuitous presentation of two acute cases of HIV KLS, one severe and one typical, allowed us to investigate KLS inflammation in the acute and convalescent phase. Interesting results of those investigations are presented here.
Some aspects of the invention include diagnostic methods based on the unique pathophysiology of KLS/KD, comprising the steps of; quantifying human proteins in a serum sample from a patient, the proteins selected from of the group consisting of: IL-6, IL-13, sTNFRII, CCL1 (I-309), CCL2 (MCP-I), and CxCL11 (I-TAC), wherein the patient exhibits at least one symptom of Kawasaki disease or KLS; measuring the level of plasma cell recruiting chemokine CxCL11 and/or “Th2” biomarkers IL-13 & CCL1 (singly or in combination) and/or vascular inflammation marker CCL2 isolated from the sample; and tagging the sample as being from a patient positive or preliminarily positive for KD or HIV KLS if the level of plasma cell recruiting chemokine CxCL11 and/or “Th2” biomarkers IL-13 and CCL1 (singly or in combination) and/or vascular inflammation marker CCL2 isolated from the sample is 2 or more Standard Deviations higher than are the levels of these proteins in serum of a similar patient, wherein the similar patient is asymptomatic for KLS and KD.
Some embodiments for diagnosing KD or HIV KLS, further including the step of: validating that the patient is positive for KD or HIV KLS by determining if the levels of sTNRII and/or IL-6 isolated from the patients' sample is 2 or more Standard Deviations higher than the levels of these proteins isolated from the serum of a similar patient, wherein the similar patient is asymptomatic for KLS and KD. In some embodiments the isolations steps include the use of a Multiplex ELISA. In some embodiments the isolation step includes the use of a strip testing technology. In still other embodiments the isolation step includes the use of mass spectroscopy identification technique.
Some aspects of the invention include a method of treating a patent for KD or HIV KLS treatment method, comprising the steps of: administering a therapeutically effective dose of at least one compound that interferes with the interactions of at least one receptor ligand pairs selected from the group consisting of: CxCL11-CCR3, CCL1-CCR8, and CCL2-CCR2 wherein the patient is afflicted with KS or HIV KLS. In some embodiments the compound is at least one antibody that binds to at least one of protein selected from the group consisting of: CxCL11, CCR3, CCL1, CCR8, CCL2, and CCR2.
A first embodiment includes, methods for treating a patient based on the unique pathophysiology of KLS/KD, comprising the steps of: quantifying at least one human protein in a serum sample from a patient, wherein the protein is selected from the group consisting of: IL-6, IL-13, sTNFRII, CCL1 (I-309), CCL2 (MCP-I), and CxCL11 (I-TAC), wherein the patient exhibits at least one symptom of Kawasaki disease or KLS; measuring the level of “plasma cell recruiting” chemokine CxCL11 and/or “Th2” biomarkers IL-13 & CCL1 (singly or in combination) and/or “vascular inflammation marker” CCL2 in the serum sample; and tagging the sample as being from a patient positive or preliminarily positive for KD or HIV KLS if the level of “plasma cell recruiting” chemokine CxCL11 and/or “Th2” biomarkers IL-13 and CCL1 (singly or in combination) and/or “vascular inflammation marker” CCL2 isolated from the sample is 2 or more Standard Deviations higher than are the levels of these proteins in the serum of a similar patient, wherein the similar patient is asymptomatic for KLS and KD.
A second embodiment includes methods according to the first embodiment, further including the step of: validating that the patient is positive for KD or HIV KLS by confirming that the levels of sTNRII and/or IL-6 quantified in the patients' sample is 2 or more Standard Deviations higher than the levels of these proteins isolated from the serum of a similar patient, wherein the similar patient is asymptomatic for KLS and KD.
A third embodiment includes methods according to the first and the second embodiments, wherein the quantifying and/or measuring steps include the use of a Multiplex ELISA.
A fourth embodiment includes the methods according to first and the second embodiments, wherein the quantifying and/or measuring steps include the use of a strip testing technology.
A fifth embodiment includes the methods according to first and the second embodiments wherein the quantifying and/or measuring steps include the use of a mass spectroscopy identification technique.
A sixth embodiment includes treatment methods, comprising the steps of: administering a therapeutically effective dose of at least one compound that interferes with the interactions of at least one receptor ligand pair selected from the group consisting of: CxCL11-CCR3, CCL1-CCR8, and CCL2-CCR2 wherein the patient is afflicted with KD or HIV KLS.
A seventh embodiment includes treatment methods according to the sixth embodiment, wherein the compound is at least one antibody that binds to at least one protein selected from the group consisting of: CxCL11, CCR3, CCL1, CCR8, CCL2, and CCR2.
An eighth embodiment includes systems for treating a patient, comprising: a human serum sampling handling device; at least one protein probe that selectively binds at least protein selected from the group consisting of: IL-6, IL-13, sTNFRII, CCL1 (I-309), CCL2 (MCP-I), and CxCL11 (I-TAC); a detector that monitors the at least one probe and records a signal from the probe that is proportional to the level of at least protein in the serum sample, where the at least one protein is selected from the group consisting of; IL-6, IL-13, sTNFRII, CCL1 (I-309), CCL2 (MCP-I), and CxCL11 (I-TAC) and wherein the detector produces a signal that is proportional to the level of the at least one protein selected from the group consisting of; IL-6, IL-13, sTNFRII, CCL1 (I-309), CCL2 (MCP-I), and CxCL11 (I-TAC); a central processing unit, wherein the central processing unit is configured to receive the signal from the detector and to access a matrix of values for the levels of at least one protein selected from the group consigning of IL-6, IL-13, sTNFRII, CCL1 (I-309), CCL2 (MCP-I), and CxCL11 (I-TAC), determined in patients that are both diagnosed with and diagnosed without Kawasaki Disease or KLS, wherein the central processing unit compares the levels of the at least one protein quantified in the serum sample and in the matrix and produces an output; and a user interface that receives the output from the central processing unit and displays a readable image of the comparison of the levels of protein in the serum sample and the values in the matrix.
A ninth embodiment includes systems according to the eighth embodiment, wherein the sample handling device is selected from the group consisting of: single well plates, multi-well plates, tubes, vials, syringe bodies, and aspirators.
A tenth embodiment includes systems according to the eighth and ninth embodiments, wherein the protein probe includes at least one antibody that has been raised to at least of the proteins selected from the group consisting of: IL-6, IL-13, sTNFRII, CCL1 (I-309), CCL2 (MCP-I), and CxCL11 (I-TAC).
An eleventh embodiment includes systems from the eighth through the tenth embodiments, wherein the protein probe comprises a Multiplex ELISA.
A twelfth embodiment includes systems from the eighth through the eleventh embodiments, wherein the detector records a change in at least one signal generated by the interaction between proteins in the serum sample the protein probe, wherein the signal is selected from the group consisting of: luminescence, fluorescence, conductivity, chemiluminescence, and radiation.
A thirteenth embodiment includes systems from the eighth through the twelfth embodiments, wherein the central processing unit is a digital computer.
A fourteenth embodiment includes systems from the eighth through the thirteenth embodiments, wherein the user interface is selected from the group consisting of: a monitor and a printer.
A fifteenth embodiment includes systems from the eighth through the fourteenth embodiments, wherein the central processing unit is configured to produce an output that includes flagging a difference in the level of at least one protein selected from the group consisting of; IL-6, IL-13, sTNFRII, CCL1 (I-309), CCL2 (MCP-I), and CxCL11 (I-TAC), of at least I standard deviation measured between said proteins in the serum sample and the values for said proteins stored in the matrix for individuals that have not been diagnosed with Kawasaki disease or KLS.
A sixteenth embodiment includes systems from the eighth through the fifteenth embodiments, wherein the central processing unit is configured to produce an output that includes flagging a difference in the level of at least one protein selected from the group consisting of: IL-6, IL-13, sTNFRII, CCL1 (I-309), CCL2 (MCP-1), and CxCL11 (I-TAC), of at least 2 standard deviations measured between said proteins in the serum sample and the values for said proteins stored in the matrix for individuals that have not been diagnosed with Kawasaki disease or KLS.
A seventeenth embodiment includes systems from the eighth through the sixteenth embodiments, wherein the central processing unit is further configured to receive at least one additional input, wherein the at least one additional input includes the presence of a least one gross physical manifestation of Kawasaki disease or KLS in the patient from which the serum sample was obtained.
An eighteenth embodiment includes systems from the eighth through the seventeenth embodiments, wherein the central processing unit is further configured to produce an output that notes the existence of the existence of the at least one gross physical manifestation of Kawasaki disease or KLS and transmits the note to the user interface.
For the purposes of promoting an understanding of the principles of the novel technology, reference will now be made to the preferred embodiments thereof, and specific language will be used to describe the same. It will nevertheless be understood that no limitation of the scope of the novel technology is thereby intended, such alterations, modifications, and further applications of the principles of the novel technology being contemplated as would normally occur to one skilled in the art to which the novel technology relates are within the scope of this disclosure and the claims.
As used herein, unless explicitly stated otherwise or clearly implied otherwise, the term ‘about’ refers to a range of values plus or minus 10 percent, e.g., about 1.0 encompasses values from 0.9 to 1.1.
As used herein, unless explicitly stated otherwise or clearly implied otherwise, the term ‘method of treating’ includes such as providing therapeutic levels of specific compounds to a patient, diagnosing disease or abnormality in a patient, and/or providing medical advice to a patient.
As used herein, unless explicitly stated otherwise or clearly implied otherwise, the terms ‘therapeutically effective dose,’ ‘therapeutically effective amounts,’ and the like, refers to a portion of a compound that has a net positive effect on the health and well-being of a human or other animal. Therapeutic effects may include an improvement in longevity, quality of life and the like these effects also may also include a reduced susceptibility to developing disease or deteriorating health or well-being. The effects may be immediate realized after a single dose and/or treatment or they may be cumulative realized after a series of doses and/or treatments.
Patient 1 was a 23 year old South American male with a history of IVDA/cocaine/marijuana use residing in the US for one year who was admitted from the emergency room with two days of fevers, rash, strawberry tongue, and conjunctivitis preceded by several months of low grade diarrhea, progressing to include NN and abdominal pain during the week preceding admission. On admission his main complaints were fevers, rash and weakness. His admitting vitals were: Temp 101.9° F., HR 142, BP 68/47, RR 16, pulse oximetry 100% on RA. His basic labs showed: WBC 5.0, Hct 41, Plt 83, Na 128, Bicarb 20, K 2.5, Cl 90, BUN 42, Scr 3.9, AST 167, ALT 71; CXR was unremarkable. His admitting diagnoses were fever/diarrhea/dehydration, and he was treated empirically with vancomycin, ceftriaxone and clindamycin for presumed group A strep or mild toxic shock. Patient's BP, HR, electrolytes and Ser normalized with hydration and associated hemoconcentration resolved revealing an underlying anemia and hypoalbuminemia, but the fevers persisted in spite of antibiotic therapy. He was screened for HIV and viral hepatitis and found to be HIV+ with an absolute CD4 count of 3 and viral load of 180,000 copies per ml, and to be chronically infected with Hepatitis C virus (HCV). Over the ensuing week the patient remained normotensive and febrile while undergoing an extensive diagnostic evaluation. Toward the end of the 1st week of hospitalization he was clinically deteriorating with worsening fevers up to 103.9° F. and episodes of hypotension responsive to fluid resuscitation. There were multiple adjustments to his antibiotic therapy during the first week including courses of first & fourth generation cephalosporins, vancomycin, trimethoprim/sulfamethoxazole, and addition of amphotericin B without improvement of his clinical status. On the eighth day of hospitalization he was transferred to the ICU, and semi-electively intubated for ongoing fevers, respiratory rate of 40, and impending vascular collapse. Photos of patient's physical findings at time of ICU transfer are shown in
The patient's hypotension rapidly responded to the IVIG infusion plus steroids, including coming off pressor support within 24 h of completing IVIG and resolution of fevers. He made rapid and steady improvement, however four days after IVIG therapy he had recurrent fevers to 101.5° F. while still on methylprednisolone. On hospital day 17, eight days after IVIG#1, the patient was having fevers to 103.6° F. on prednisone plus vanc/cefepime, but he was otherwise doing well. On hospital day 18, nine days after IVIG#1, antibiotics were discontinued and the patient received a second dose of IVIG (IVIG#2). Patient's fevers improved slightly to <102° F. after IVIG#2, but did not resolve during the following week. Steroids were tapered off and on day 6, status post IVIG#2 (hospital day 24) the patient was having high grade fevers (103.3° F.) while on scheduled acetaminophen and ibuprofen therapies. The patient's platelet count was now 285 and the possibility of aspirin (ASA) therapy was revisited. ASA 650 mg po qid was started and the patient defervesced within 24 h. The inpatient medical service was uncomfortable with the high dose ASA therapy and the patient was switched to 50 mg prednisone+165 mg ASA daily. He had fine desquamation of the skin of the distal fingers and toes, and around the eyes. He sloughed all the epithelium from his tongue. Remarkably he suffered no other residual end organ damage and was discharged to home on day 11 s/p IVIG#2 (hospital day 29) on a regimen of 165 mg ASA daily, a 2 week prednisone taper, and bactrim/azithromycin prophylaxis for PCP/MAC. A summary of his diagnostic evaluation is included in Table 1.
The patient had follow-up outpatient clinic visits one, five, and thirteen weeks after hospital discharge. He started protease inhibitor-based cART with eventual immune reconstitution (CD4 293; HIV vl<50 copies/ml two years later). He had a negative cardiac stress thallium study 6 months after discharge from the hospital and went off aspirin therapy. With the patient's permission, serum collected immediately prior to the first dose of IVIG during his hospitalization and convalescent serum collected at a clinic visit 13 weeks post discharge were stored at −80° C. for possible future investigation of KLS. The patient did not have a KLS recurrence during the next 5 years, and was lost to follow up when he returned to his native country.
Patient 2 was a 31 year old African American male recently diagnosed with HIV, CD4 count of 19, an HIV viral load of 139,000 copies per ml, with a pre-existing idiopathic eosinophilia who was admitted from the ER with ten days of fever (102.7° F.), myalgias, mild abdominal pain with occasional diarrhea, headaches, and painful swelling of the hands and feet beginning roughly coincident with initiation of 1st cART regimen (tenofovir/emtricitabine/ritonavir-lopinavir). He was not on PCP prophylaxis as the CD4 count was pending at time of previous clinic visit, and he had a questionable history of a sulfa drug allergy. His past medical history was remarkable for secondary syphilis 1 year earlier treated with IM benzathine PCN. His vital signs on admission were: Temp 103.7° F., HR 90, BP 110/63, RR 16. His physical exam was remarkable for non-exudative conjunctivitis, mild thrush, non-tender cervical lymphadenopathy all <1 cm, impressive painful swelling of the hands and feet, an erythematous rash somewhat difficult to appreciate due to dark skin pigment. Basic admission labs were unremarkable: WBC 10.0, HCT 35, Plts 382, Alk Phos 91, ALT 32, Alb 3.6, and Ser 1.1. The admitting medicine team did not initiate antibiotic therapy; the patient's cART was held, an infection workup was initiated, and ophthalmology, infectious diseases and rheumatology consults were requested. The working diagnoses were drug reaction versus Chlamydia-associated reactive arthritis. The ID consultant evaluating the patient was suspicious that the patient had KLS and pursued additional input within the Infectious Diseases division. On day 5 of the patient's hospitalization he remained febrile to 103° F., available diagnostic testing was negative (including Chlamydia urine ligase chain reaction), and on the basis of clinical criteria he received 2 gm/kg IVIG plus ASA 325 mg po qid. After completing the IVIG infusion he had no further fevers, felt remarkably better, and was discharged from the hospital the following day, resuming prior cART plus ASA 325 mg bid, azithromycin MAC prophylaxis, and fluconazole for thrush. A G6PD was pending at discharge with plans to initiate dapsone PCP prophylaxis during outpatient follow up. His diagnostic evaluation is included in Table 1.
He returned to the ID clinic 2 and 5 weeks after discharge for follow up care and was doing well on both visits. He had significant periungual desquamation of the hands on the 2 week follow up visit. With the patient's permission, serum collected immediately prior to the first dose of IVIG during his hospitalization and convalescent serum collected at his clinic visit 5 weeks post discharge were stored at −80° C. for possible future investigation of KLS.
Advances in multiplex ELISA technology offered new opportunities to investigate KLS using the acute and convalescent serum stored at −80° C. Multiplex ELISA makes it possible to determine levels of multiple analytes using a small volume of patient serum. A protocol was approved by the Indiana University Institutional Review Board to do a case control study with the frozen KLS patient sera, leftover pretreatment serum from an unrelated endovascular function study of HIV subjects with CD4 counts >350 not taking cART, and serum from an HIV negative control subject. The single HIV negative normal serum was included to preliminarily identify analytes that may be abnormally low in HIV+ individuals (e.g. IL-1ra;
The data was analyzed as individual comparisons of patient 1 and patient 2 acute and convalescent values to the combined analyte data from the three asymptomatic HIV+ control subjects with a Student's T-test to determine statistical significance within this small clinical cohort. The serum results from the HIV negative control “normal serum” were not included in the statistical analysis. For within-the-study statistical comparisons, p values of <0.05 are considered statistically significant and are indicated by *; p values <0.01 are indicated by **. Correction for multiple comparisons were not performed because all analytes in the panel had previously been reported to be elevated in KLS or KD, or were logically linked with KLS pathogenesis (CCL1, IL-13, and CxCL11).
The results of the multiplex ELISA testing can be grouped into three functional categories. In the first category are analytes that were not elevated in the KLS patients compared to asymptomatic HIV+ control subjects. This category includes IL-17 and CCLS (Rantes) (data not shown); and IL-10 that was below the limit of detection (<0.4 pg/ml) in the two KLS patients, the three HIV control subjects, and the HIV negative serum.
In the second category are analytes uniquely related to the severity of KLS. Referring now to
Referring now to
Because HIV Kawasaki-like syndrome is a relatively rare disease the opportunity to study its pathophysiology is limited. Published investigations to date generally support the proposition that HIV KLS is the same disease as pediatric KD; occurring in adults likely made susceptible by immune dysfunction caused by advanced HIV disease (3). The clinical presentation of HIV KLS is similar to that of KD except that HIV patients do not typically have a sentinel lymph node and have lower ESR/CRP values than seen in pediatric KD patients. In HIV KLS patients the typical clinical presentation includes >5 days of fever, macular rash, conjunctivitis, painful swelling/erythema of the hands and feet, and changes of the oropharynx. Changes of the oropharynx fall on a spectrum of severity and can be complicated by co-morbidities such as thrush. Similarly, the rash can be subtle in individuals with dark skin pigments. Curiously, at least half of HIV individuals with KLS have mild abdominal pain with some degree of diarrhea preceding development of the protean manifestations of the syndrome. In this report, both KLS patients had an abdominal pain/diarrheal prodrome. Neither patient had a sentinel lymph node. Both patients had changes of the oropharynx, but that assessment was somewhat complicated in patient 2 because of co-existent thrush. A dark skin pigment made the rash in patient 2 a subtle physical finding. Because HIV KLS patients rarely, if ever, have a sentinel lymph node, there is risk that HIV KLS goes undiagnosed because affected individuals have less than the four physical findings required to make a formal HIV KLS diagnosis. Pending development of a diagnostic test for KD/KLS, HIV+ individuals with fevers >5 days, non-exudative conjunctivitis, changes in the peripheral extremities and no other source of fever should have HIV KLS considered as a possible etiology of their illness.
Patient 1 in this report was hospitalized with an ongoing febrile illness for >1 week before KLS was diagnosed and treated. This unintentional observation of the natural course of KLS in a patient with advanced HIV/AIDS offers new insights into KLS. Untreated KLS is potentially a fatal disease in HIV/AIDS. At the point that the IVIG infusion was started, Patient 1 required maximal fluid and pressor support to maintain his blood pressure. It is likely that he would have expired absent IVIG therapy as he was adrenally sufficient (random cortisol >20) and receiving hydrocortisone when his vascular tone collapsed with an echocardiogram that showed normal cardiac contractility. Because the patient was already on hydrocortisone when he developed severe hypotension, it seems unlikely that addition of methylprednisolone at the time of IVIG therapy was responsible for reversing the shock state. A previous investigation of HIV KLS noted recurrent fevers after an initial IVIG infusion, leading to retreatment with IVIG, plasmaphoresis, and thalidomide. In at least some patients, IVIG appears to reverse the protean manifestations of KLS but not the fever. The clinical course of Patient 1 highlights a role for aspirin in the treatment of HIV KLS. Fevers in Patient 1 did not break until aspirin therapy was initiated after the second IVIG infusion. It is possible that the second WIG infusion would not have been necessary had he been able to take aspirin therapy with the first WIG infusion. Based on the experience of patients 1 and 2 in this report, it appears that 325-650 mg aspirin po qid may be sufficient to achieve remission of the fevers, and that a drop down dose of 325 mg po bid is sufficient to sustain remission of fevers in the ˜1-2 week window of time immediately following IVIG treatment. The conventional dose of 80 mg/kg (3-4 full size aspirin tablets four times daily for an average size adult) does not appear to be necessary, and is viewed unfavorably by many adult medical practitioners. In children, low dose ASA (3-5 mg/kg daily) after IVIG appears to be sufficient therapy. Even though no coronary artery aneurysms have been documented in HIV KLS patients, possibly because most diagnosed cases get treated with IVIG and few have angiography, that outcome and KLS septic shock (this report) are likely preventable with IVIG treatment, and IVIG probably should be administered beyond the recommended 10 day febrile window used in pediatrics. Early diagnosis and treatment of KLS with IVIG and aspirin are important for maximizing patient well-being and limiting medical expenditures on prolonged hospitalizations for fevers of unknown origin. Based on lack of a convenient modality for assessing coronary artery pathology in adults (transthoracic echocardiography is not adequate to visualize adult coronary arteries), after the initial 2 weeks of ASA therapy it seems reasonable to continue HIV KLS patients on low dose ASA (81-165 mg daily) until a follow up cardiac stress test 6-12 months out from the acute illness rules out ischemic complications. Limited pediatric KD data suggest that negative myocardial perfusion cardiac stress testing has a reasonable negative predictive value for future cardiac events.
The hemodynamic collapse in patient 1 was due to loss of vascular tone as described with pediatric Kawasaki Disease Septic Shock (KDSS); this case was likely the adult HIV KLS equivalent of KDSS. Multiplex ELISA definition of the cytokine milieu in Patient 1 supports loss of vascular tone and increased capillary permeability (CXR had increased interstitial markings) due to a cytokine storm that included high levels of TNFα and IL-6, coupled with an ineffective elevation of counter inflammatory cytokines IL-10 and IL-1ra. Relative level of IL-10 (14 pg/ml) was low in the septic state, and the high level of IL-1ra may not have been of much benefit as surprisingly the serum level of IL-10 in both KLS patients was <0.4 pg/ml (see Table 3). TNFα appears to be a central cytokine in KLS as sTNFRII was markedly elevated in both KLS patients, even when TNFα was not directly measurable in the serum (Patient 2). Elevated sTNFRII has previously been reported in a HIV+ patient with a Kawasaki Disease like illness. The two additional HIV KLS patients in this report with elevated sTNFRII in the acute phase reinforce the hypothesis that TNFα is a critical cytokine in the pathophysiology of KLS as soluble TNF receptors levels in serum are regulated by TNFα. In one pediatric KD report, patients with the highest serum TNF-α serum levels had an increased risk of coronary aneurysm formation, and TNFRI has previously be reported to be elevated in pediatric patients with KD.
HIV KLS appears to be pauci-interferon vasculitis, but whether the same is true in pediatric KD is less clear. Pediatric KD studies found low to undetectable serum levels of type 1 and type II interferons, and a decreased frequency of intracellular IFN-γ+ circulating T lymphocytes in acute pediatric KD. In this report, Patient 2 with typical KLS had elevated levels of IFN-α (46 pg/ml) while IFN-γ was below the limit of detection (<10 pg/ml). In patient 1 during KLS septic shock, IFN-α was undetectable and IFN-γ was elevated (27 pg/ml). The serum IFN-γ level in normal serum is undetectable and during acute viral illnesses (Influenza, RSV, Adenovirus, Dengue fever) has been reported to run in the 8-30 pg/ml range; serum IFN-α levels in children with influenza has a reported mean value of 602+/−95 pg/ml. A more informative global readout of interferon biology is likely CxCL10, a chemokine up regulated by type 1 and 2 interferons. Serum levels of CxCL10 have been reported to be up regulated by two groups studying acute pediatric KD patients (see Table 2); in this report CxCL10 was not remarkably elevated in either KLS patient in the acute phase of KLS.
As reported herein elevated levels of the Th2 cytokine IL-13 and the Th2 chemokine CCL1 (I-309) isolated from the serum of both adult HIV KLS patients in the acute phase that, in the convalescent phase, returned to levels found in asymptomatic HIV+ controls. In pediatric KD, others have documented excess serum IL-4 (median acute KD 17 pg/ml versus 7.6 pg/ml healthy controls) and minimally elevated levels of IFN-γ (median in acute KD 0.6 units/ml versus healthy control 0.4 units/ml). Patients with advanced HIV appear to drift away from Th1 responses toward Th2 responses, with progressive loss of CD4 T cell frequency/production of IL-2 & IFN-γ with relative preservation of CD4 T cell IL-4 frequency/production, though not all studies support this Th1 to Th2 shift with HIV progression. Functional evidence in support of a Th2 shift with HIV progression includes development of a pathogen-independent eosinophilia (Th2 cytokine IL-5) in some patients with declining CD4 T cell counts; idiopathic eosinophilia was a pre-existing condition in Patient 2 of this report. These data support a KLS model in which a ubiquitous infectious agent acquired either through re-exposure or reactivation triggers a pathologic Th2 response in HIV+ individuals due to HIV-related diminution in Th1IFN-γ/IL-2 responses caused by progression of HIV disease (
Referring now to
In general, the cytokine milieu in the HIV KLS patient with a typical presentation (patient 2) was consistent with that previously reported in pediatric KD including elevations in CCL2 (MCP-I), IL-6, and M-CSF, TNFα related biology (TNFRII) (see Table 3). The differences between typical KLS and pediatric KD were the less-than-significant elevations in osteoprotegrin and IL-10, and lack of an IL-1β and IL-17 response. It is problematic to emphasize comparisons based on non-standardized testing; for example the reported IL-1β levels are based on a radioimmunoassay of 6 KD patients with 5 healthy controls in 1988. Elevations in CCL2, IL-6, and TNF-α biology (TNF-α, sTNFR1) have been reported in two or more KD studies. Elevations of CCL2, IL-6, and TNFRII in the two KLS patients in this report, along with the previous demonstration of IgA+ infiltration of vessel walls on conjunctival bx during acute HIV KLS support a similar pathophysiology and likely inciting agent in KLS and KD. The IgA antibody response in pediatric KD is oligoclonal, and IgA monoclonal antibodies reverse-engineered from KD patients recognize RNA-containing cytoplasmic inclusions in KD patient tissues. It has previously been postulated that the ontogeny of KD IgA plasma cells includes original expansion in the pulmonary or gastrointestinal mucosa. Without being bound by theory of hypothesis, it is noted that these results fit nicely with the theory that HIV KLS patients commonly having an abdominal pain/diarrhea prodrome before developing the protean manifestations of KLS, and the RNA-containing cytoplasmic inclusions with the possibility of a latent “infection”.
The cytokine milieu in KLS patients during the acute vasculitis strongly corroborates the known findings of inflammation within vascular walls including IgA+ plasma cells. CCL2 (MCP-1), a chemokine made by vascular smooth muscle cells and endothelium, is dramatically elevated in KLS. CCL2 is a well-established biomarker for atherosclerosis, an inflammatory condition within arterial walls. CCL1 (I-309), an endothelial and smooth muscle chemokine, recruits Th2 T lymphocytes via chemokine receptor 8 (CCR8), supports KLS being a Th2-type vasculitis. The Th2 conclusion is further supported by readily measurable levels of the Th2 cytokine IL-13 in both KLS patients in this report, in the absence or near absence of IFN-γ (a Th1 cytokine) and CxCL10 (regulated by IFN-γ). More interesting, CxCL11, a cytokine that recruits plasma cells via chemokine receptor CxCR3, was markedly elevated in both KLS patients, while levels in asymptomatic HIV control subjects and the “normal serum” approximated 0. In human peripheral blood, majorities of IgA+ memory B cells and IgA+ antibody secreting cells (ASC, i.e. plasma cells) are CxCR3 positive. In humans elevated CxCL11 is a biomarker associated with aortic aneurysm formation, and its receptor CxCR3 is required for aneurysm formation in a mouse model. CxCR3 inhibitors are being developed and have entered early human clinical trials. Based on limited data, it appears that the KD/KLS pathognomonic finding of IgA plasma cell infiltration of arterial walls is reflected in the blood in the form of the plasma cell recruiting chemokine CxCL11. The KLS serum cytokine data in this report support a pathologic role for Th2 type inflammation and CxCL11 in recruitment of plasma cells during the acute phase of KLS. The intimate relationship between the serum and inflamed vascular wall raises the possibility of a diagnostic test for KLS and KD based on serum analytes; perhaps a combination of elevated CxCL11, CCL1, CCL2, IL-6, IL-13 and TNFRII, or possibly as simple as elevated CCL1 (Th2 inflammation) and CxCL11 (plasma cell recruitment) in the right clinical setting.
Erhlichea per
Chlamydia/GC LCR
‡conflicting data based on bioassays;
§published data in units/ml without conversion factor;
†published data in arbitrary units mRNA in peripheral blood mononuclear cells (PBMC).
While the novel technology has been illustrated and described in detail in the figures, tables, and foregoing description, the same is to be considered as illustrative and not restrictive in character, it being understood that only the preferred embodiments have been shown and described and that all changes and modifications that come within the spirit of the novel technology are desired to be protected. As well, while the novel technology was illustrated using specific examples, theoretical arguments, accounts, and illustrations, these illustrations and the accompanying discussion should by no means be interpreted as limiting the technology. All patents, patent applications, and references to texts, scientific treatises, publications, and the like referenced in this application are incorporated herein by reference in their entirety.
The present application is related to, claims the priority benefit of, and is a U.S. continuation patent application of U.S. Nonprovisional patent application Ser. No. 14/427,576, filed Mar. 11, 2015, which is related to, claims the priority benefit of, and is a 35 U.S.C. 371 national stage application of International Patent Application Serial No. PCT/US2013/059529 to Johnson, filed Sep. 12, 2013, which is related to and claims the priority benefit of U.S. Provisional Patent Application Ser. No. 61/700,105 filed Sep. 12, 2012. The entire contents of each of the aforementioned priority applications are hereby expressly incorporated herein by reference in their entireties into this disclosure.
| Number | Date | Country | |
|---|---|---|---|
| 61700105 | Sep 2012 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 14427576 | Mar 2015 | US |
| Child | 16375283 | US |
