Infliximab treatment for refractory kawasaki disease Presented by Theerapan Songnuy, MD. April26, 2013

1. Theerapan Songnuy M.D.

2. Overview
 Kawasaki disease
 Standard Treatment
 Refractory Kawasaki Disease
 New Treatment : Infliximab
- Mechanism
- Efficacy
- Side effects
 Conclusion

3. Kawasaki Disease
 Acute febrile illness in children
 Classical symptoms:
- Persistent high fever
- Polymorphous rash
- Conjunctival congestion
- Lip cracking/ strawberry tongue
- Cervical lymphadenopathy
- Indurative edema of extremities

4. Inflammatory Process
 Inflammatory markers:
- TNF-alpha
- IL-2R
- IL-6
- etc.
Clin Immunol Immunopathol 1990; 56:29-36

6. Aim
 To examine the role of TNF-alpha in the
immune response leading to vascular
damage in the coronary arteritis mice model
of Kawasaki disease

7. Materials & Methods
 Mice :
- Wild-type C57BL/6, TNFRI-/- & TNFRII-/-
- From Charles River Lab & The Jackson
Lab
- Housed under pathogen-free condition at
U. of Toronto

8. Materials & Methods
 Lactobacillus casei cell wall extract
- MRS broth ( Difco, Detroit, MI)
- Cytoplasmic membrane disrupted by detergent lysis with 4%
sodium dodecyl sulfate for 1night at room temp.
- Washing cell wall-associated materials
- Incubated with DNase, RNase, trypsin to remove cytoplasmic
material
- Cell wall-materials were sonicated 2 hr by W-375 sonicator &
cooling by a dry ice-ethanol bath
- Centrifuged for 1 hr at 20,000 /min
- Suspended in phosphase buffed saline before use to induce
coronary arteritis

9. Materials & Methods
 Quantitative real time RT-PCR
- Mice 4-5 wk old were injected intra-peritoneally
with 0.5 ml PBS or 1 ml of LCWE
- After sacrificed, heart & spleen were processed
for RNA isolation
- cDNA was synthesized & amplified by real time
PCR
- Relative quantity of PCR products were
determined
(TNF-alpha) compared to GAPDH
- Also can be used for ICAM-1, VCAM-1, E-Selectin
et al

10. Materials & Methods
 Confocal immunomicroscopy
- Serial 6-um heart& spleen cryo-section, fixed in
acetone
- Incubation in PBS plus 0.1% saponin & 2% BSA
- Stained with purified rat antimouse TNF- alpha
mAb or isotype control
- Followed by biotinylated goat anti-rat IgG
- Mounted in DAKO anti-fade fluoresent mounting
medium
- View under a confocal microscope

11. Materials & Methods
 Cardiac histology & histological evaluation
- Tissue embedded in compound ( Tissue-
Tek)
snap-frozen in liquid nitrogen, stored at -80 c
- Coronary artery: 6-um-thick serial section of
left coronary artery
- Stained with H&E or elastin van Giesen
- Assess arteritis & elastin breakdown

12. Materials & Methods
 Treatment of mice with TNF antagonist
Etanerept
- After disease induced, Etanercept was
induced
IP at 8-10 mg/kg twice weekly
- Mice were sacrificed 28 & 42 d later
- Cardiac tissue prepared for histology

19. Conclusion
 TNF-alpha plays a key role of coronary artery damage in a
murine model
 After disease induction, TNF-alpha rose in the peripheral
immune system & localized at coronary artery
 Lead to lymphocyte recruitment
 Lead to elastin degradation, vessel wall damage, coronary
artery aneurysm
 Blocking TNF-alpha activity ( Etanercept & abolish signal
via TNFRI) result in decrease inflammation & elastin
breakdown

20. Standard Treatments
-If left untreated, coronary aneurysm 15-25%
-IVIG treatment reduced coronary complication to only
3-5 %

21. Refractory Kawasaki Disease
 Refractoriness to IVIG defined as:
- Persisting or re-emerging fever > 38
C
- Positive fractional changes of CRP
- Leukocytosis / increased neutrophils
After IVIG therapy for 48 hr

22. Therapy for IVIG-resistance
Kawasaki Disease
 Additional doses of IVIG
 Intravenous methyl prednisolone
 Oral corticosteroids
 Cyclophosphamide
 Cyclosporin
 Methotrexate
 Plasma exchange
 Infliximab, a tumor necrosis factor-alpha
blocker
Pediatrics 2004; 114: 1708-33.

23. Infliximab
( Tumor Necrotic Factor-alpha
Antagonist)

24. Paper infliximab

25. Aim
 To study the efficacy of infliximab for
suppressing the progression of
coronary artery lesions in cases of
refractory to extensive IVIG therapy

26. Materials & Methods
 Patients aged 2-10 years
 Fulfilled criteria diagnosis as Kawasaki
disease*
 Primarily treated with IVIG 2-4 g/kg

27. Materials & Methods
 Refractoriness to IVIG defined as:
- Persisting or re-emerging fever > 38
C
- Positive fractional changes of CRP
- Leukocytosis / increased neutrophils
After IVIG therapy for 48 hr :
Then infliximab would be started within
10 days of disease onset
J Rheumatol 2012;39:864-867

28. Materials & Methods
 Exclusion criteria:
- TB lung
- Recent therapy with corticosteroids or
biologic response modifiers
- Vaccination with BCG within 6 mo before
disease onset
- Low cardiac function
- Liver/renal dysfunction
J Rheumatol 2012;39:864-867

29. Infliximab Administration
 Dose : 5 mg/kg in 100 ml saline
 Route : intravenous
 In case of refractory to infliximab, plasma pheresis
was performed with 5% albumin for 3 consecutive da
Evaluation :
- At 48 hr. after infliximab (fever & inflammatory
markers )
-At 30 days ( intact coronary artery by echocardio-
graphy)
J Rheumatol 2012;39:864-867

32. Day after infliximab
J Rheumatol 2012;39:864-867

33. Day after infliximab
J Rheumatol 2012;39:864-867

34. J Rheumatol 2012;39:864-867

35. Results
 One patient showed coronary artery lesion at
30 d of follow up but complete regression 1 y
later
 No adverse reactions ( anaphylactoid
reaction, heart failure, or severe infectious)

37. Aim
 Efficacy and safety of infliximab
compared to re-treated IVIG for treating
IVIG-resistant Kawasaki disease
patients

38. Materials & Methods
 A two-center retrospective study
 From Jan 2000-March 2008
 Inclusion criteria:
- Fever > 4 d & 4 from 5 principal symptoms
- Fever > 4 d & < 4 from 5 principal symptoms
& coronary artery abnormality
- Received at least one re-treatment for
recurrent or persistent fever > 38 c beyond
36 h after completion of initial IVIG ( 2 g/k)

39.  Exclusion criteria
- Initial treatment at other centers
- Initial treatment with others than IVIG &
aspirin
- Re-treatment for coronary artery
changes
in the absence of fever
- First re-treatment > 10 d after initial
IVIG
or infliximab
Materials & Methods

40. Results
Primary
IVIG
Met
Inclusion
criteria
Re-treated
IVIG
Re-treated
Infliximab
Center 1
Boston
243 41 (17%) 41 0
Center 2
San Diego
398 65(16%) 45 20

41. J Pediatr 2011; 158: 644-9

42. (continued)

44. J Pediatr 2011; 158: 644-9

46. Conclusion
 Infliximab as the first re-treatment :
- Fewer days of fever
- Fewer length of stay
- Not improve coronary artery outcomes
- No adverse effects were noted
 Need a prospective trials for IVIG-resistance
Kawasaki disease patients

47. Thank You Very
Much