松本 祐嗣

BACKGROUND: The immunosuppressant mizoribine (Miz) can reduce progression of childhood IgA nephropathy (IgAN). This study examined whether Miz affects CD163+ M2-type macrophages which are associated with kidney fibrosis in childhood IgAN. METHODS: A retrospective cohort of 90 children with IgAN were divided into groups treated with prednisolone (PSL) alone (P group; n = 42) or PSL plus Miz (PM group; n = 48) for a 2-year period. Normal human monocyte-derived macrophages were stimulated with dexamethasone (Dex), or Dex plus Miz, and analyzed by DNA microarray. RESULTS: Clinical and histological findings at first biopsy were equivalent between patients entering the P and PM groups. Both treatments improved proteinuria and haematuria, and maintained normal kidney function over the 2-year course. The P group exhibited increased mesangial matrix expansion, increased glomerular segmental or global sclerosis, and increased interstitial fibrosis at 2-year biopsy; however, the PM group showed no progression of kidney fibrosis. These protective effects were associated with reduced numbers of glomerular and interstitial CD163+ macrophages in the PM versus P group. In cultured human macrophages, Dex induced upregulation of cytokines and growth factors, which was prevented by Miz. Miz also inhibited Dex-induced expression of CD300E, an activating receptor which can prevent monocyte apoptosis. CD300e expression by CD163+ macrophages was evident in the P group, which was reduced by Miz treatment. CONCLUSION: Miz halted the progression of kidney fibrosis in PSL-treated pediatric IgAN. This was associated with reduced CD163+ and CD163+CD300e+ macrophage populations, plus in vitro findings that Miz can suppress steroid-induced macrophage expression of pro-fibrotic molecules. A higher resolution version of the Graphical abstract is available as Supplementary information.

Thrombotic microangiopathy (TMA) is a disease that causes organ damage due to microvascular hemolytic anemia, thrombocytopenia, and microvascular platelet thrombosis. Streptococcus pneumoniae-associated TMA (spTMA) is a rare complication of invasive pneumococcal infection. In addition, atypical hemolytic uremic syndrome (aHUS) is TMA associated with congenital or acquired dysregulation of complement activation. We report the case of a nine-month-old boy with refractory nephrotic syndrome complicated by spTMA in the setting of heterozygous complement factor-I (CFI) gene mutation and CFHR3-CFHR1 deletion. He repeatedly developed thrombocytopenia, anemia with schistocytes, hypocomplementemia, and abnormal coagulation triggered by infection, which manifested clinically with convulsions and an intraperitoneal hematoma. Eculizumab (a monoclonal humanized anti-C5 antibody) provided transient symptomatic benefit including improvement in thrombocytopenia; however, he developed unexplained cardiac arrest and was declared brain dead a few days later. In this report, we highlight the diagnostic challenges of this case and the causal relationship between spTMA and complement abnormalities and consider the contribution of heterozygous mutation of CFI and CFHR3-CFHR1 deletion.

Abstract Alport syndrome is a hereditary disorder characterized by renal impairment, hearing loss, and ocular symptoms and is caused by COL4A3, COL4A4, and COL4A5 mutations. Here, we report the case of 3-year-old boy with isolated hematuria detected in routine preventative urinary screening conducted in 3-year-old children. He carried a novel variant, NM_033380.3:c. 1032 + 1 G > A, which caused a splicing abnormality in COL4A5. He was diagnosed with X-linked Alport syndrome.

Maturity-onset diabetes of the young (MODY) is a form of diabetes mellitus characterized by autosomal dominant inheritance, early onset, and the absence of pancreatic autoimmune markers. MODY-causing mutations have been identified in 14 genes, and carboxyl ester lipase (CEL) has been implicated in MODY8. We report a Japanese patient with MODY who harbored a heterogeneous mutation in CEL exon 2 (NM_001807.4:c.146_147delCT; NP_001798.2:p.Ser49CysfsTer52). A 13-year-old girl experienced her first episode of diabetic ketoacidosis, during which her endogenous insulin secretion was poor. However, her insulin secretion had apparently recovered 2 months after the commencement of insulin treatment, and no further treatment was required for the following 2 years. Diabetic ketoacidosis recurred when the patient was 15 years old, when her insulin secretion was again poor. Since that time, the patient, who is now 18 years old, has been undergoing continuous insulin treatment. The large fluctuations in her insulin secretory capacity led us to suspect MODY. MODY8 patients that carry a mutation in the variable number of tandem repeats in the last exon of the CEL gene typically show pancreatic exocrine dysfunction. However, in the present case, which features premature termination, there is no involvement of exocrine dysfunction, potentially demonstrating a genotype-phenotype correlation.

BACKGROUND: Several immunosuppressants have been used to treat children with steroid-dependent nephrotic syndrome (SDNS). Mizoribine (MZR) is an immunosuppressant used to maintain remission in children with SDNS, although its effectiveness for treating SDNS remains controversial. Therefore, in this study, we assessed the clinical factors associated with children having SDNS who were successfully treated with MZR. METHODS: A total of 47 children with SDNS who underwent MZR treatment were retrospectively evaluated. Clinical features including pharmacokinetics after MZR administration were compared between MZR responders and non-responders. RESULTS: The comparison of the two groups revealed no significant differences in age, body weight (BW), daily dose of MZR per BW, serum concentration 2 h after administration (C2), peak serum concentration (Cmax), and area under the concentration curve 0-4 h after administration (AUC0-4). C2/(single dose/BW), Cmax/(single dose/BW), and AUC0-4/(single dose/BW) were significantly higher in the MZR responders than in the non-responders (all p < 0.01). Receiver operating characteristic analysis revealed that the cutoff values of C2 (single dose/kg), Cmax/(single dose/BW), and AUC0-4/(single dose/BW) were 0.55, 0.58, and 1.37, respectively. CONCLUSIONS: MZR is a useful immunosuppressant for treating frequent-relapse NS in children who are susceptible to the drug. The efficacy of MZR may be associated with not only serum concentrations defined by the dosage or absorption efficiency through MZR transporters, but also the susceptibility defined by the expression level and performance of MZR transporters on the target cells.

溶連菌感染後急性糸球体腎炎(PSAGN)は、A群β溶連菌感染症後に血尿、浮腫、高血圧を三主徴として発症する小児には比較的頻度の高い腎疾患であるが、時に乏尿によりはっきりした尿所見を認めずに浮腫や高血圧のみが前面になって発症する例があり、腎外症候性急性糸球体腎炎といわれる。今回、無熱性けいれんで発症した1例を経験したので報告する。症例は10歳男児。入院1週間前より腹痛、嘔吐、下痢といった胃腸炎症状を認めていた。入院前日より頭痛があり、入院当日に急激な意識レベルの低下、両側上肢の強直性けいれんを認め当院に搬送された。来院時の血液検査・髄液検査・頭部CTでは明らかな異常所見認めず、無熱性けいれんとして精査、加療目的に入院とした。第4病日頃より強い頭痛の訴えと血圧191/103mmHgと著明高値を認め、高血圧緊急症と診断した。同日に行った頭部MRI T2強調像、FLAIR像にて後頭葉に高信号域を認め可逆性後頭葉白質脳症(PRES)と診断した。血液検査では補体価の著減を認め、さらにASLO、ASKの著増、咽頭よりA群溶連菌迅速抗原陽性を認めたことより、PSAGNとこれに伴う二次性高血圧と診断した。高血圧症に対してニカルジピン塩酸塩持続静注等の緊急治療を行い諸症状は改善した。その後の全身状態は良好で第13病日に頭部MRI再検、PRESの所見は不明瞭化していることを確認し退院とした。PSAGNの中に、本例のように臨床的に高血圧のみが前面に出現する例があり、溶連菌感染症流行期に高血圧や浮腫を呈する症例の鑑別疾患として本症があることを考慮する必要があると考えられた。(著者抄録)

レニン・アンギオテンシン・アルドステロン(RAA)系抑制薬は各種腎疾患に対し腎保護目的で使用されることがあるが、腎機能障害や高K血症に留意する必要がある。本症例はAlport症候群と診断されている14歳の男子。蛋白尿と血尿が持続しリシノプリル、カンデサルタン、エプレレノンを内服し、腎機能はeGFR=80〜100ml/min/1.73m2程度で推移していた。今回、定期受診の2週間前からめまいや頭痛を時々訴えており、体重減少、低血圧を認めた。血液検査上、腎機能の悪化、高K血症、アシドーシスを認めた。RAA系抑制薬の副作用を考えエプレレノン、リシノプリルを中止したところ、高K血症やアシドーシスは改善した。腎機能は一旦改善傾向となったが病前まで回復せず、その後腎機能障害が進行し16歳時に末期腎不全に至った。本症例の原因としてRAA系抑制薬を3剤内服していたことに加え、原疾患による腎機能障害の進行、低蛋白血症による血管内脱水が考えられた。本症例のような進行性腎炎、高度蛋白尿に対しRAA系抑制薬を多剤内服している場合はRAA系抑制薬の副作用発現のリスクが高く、腎機能・電解質などの頻回のモニタリングや低血圧症状への注意が必要である。(著者抄録)

症例は9ヵ月男児。当院初診の約3ヵ月前に熱源不明の発熱で近医に入院治療を受け、その後2ヵ月間で約1.5kgの体重減少と活気不良を認めたため精査加療目的で当科紹介受診した。初診時、脱水兆候と無呼吸発作がみられ、血液検査で著明な電解質異常と代謝性アルカローシス、高レニン・高アルドステロン血症を認めた。入院後に直ちに電解質補正を実施し徐々に全身状態、検査値とも改善した。輸液中止後も電解質が正常であることを確認して退院とした。しかし退院1ヵ月後に誘因なく同様の活気不良、電解質異常と代謝性アルカローシスを生じ、再び入院治療を行った。Bartter症候群(BS)・Gitelman症候群(GS)など遺伝性塩類喪失性尿細管機能異常症を疑い遺伝子解析を行ったところCLCNKAにヘテロでの変異を認めたが、既存の病型分類には当てはまらずBS/GSは否定的と考えられた。一方、本例は発症の約3ヵ月前に熱源不明の発熱で入院治療を行った後から体重減少を認めており、腎盂腎炎や尿細管間質性腎炎などの感染症、もしくは薬剤性による間質性腎炎に伴う広汎な尿細管障害をきっかけとする慢性的な電解質異常や哺乳不良の結果、偽性BSを呈した可能性が考えられた。(著者抄録)

症例:12歳女児。重症新生児仮死による脳性麻痺、慢性腎不全の診断で重症心身障害児として外来管理を行なっていた。入院の3日前から頻回嘔吐、喘鳴が出現し徐々に増悪、経管栄養も困難となったため当院救急外来を受診した。発熱、喘鳴、ツルゴールの低下、10%の体重減少を認め、検査にて高Na血症および右上肺野の浸潤影を認めたことから、誤嚥性肺炎、高張性脱水の診断で入院となった。高張性脱水に対し、等張液を用いた輸液を開始したところ、脱水所見は改善したものの血清Na濃度は上昇を続けた。輸液を低張Na製剤に変更した後も血清Naが上昇するため、最終的に5%グルコース液にて1日水分量を最低100ml/kgとなるよう輸液量を維持したところ、数日で血清Na濃度は改善した。高Na血症下で慢性腎不全状態としては不相応に血清K濃度が低下する傾向があったことから、アルドステロン作用の関与を疑い追加検査を行ったところ、著明な高アルドステロン血症および抗利尿ホルモン(AVP)の高値を認めた。全身状態の改善後、自宅での充分な水分管理を続けたところ、約3ヵ月後には血漿アルドステロン値およびAVPの改善がみられ、電解質の異常は認められなかった。患児は胃食道逆流により日常的に嘔吐が認められ、慢性的な水分、栄養注入量の不足状態にあったことに加え、腎不全によるAVP反応性低下による希釈尿排泄が慢性的な脱水状態を生じ、アルドステロンの過剰分泌を来したものと考えられた。このようなNa排泄障害下でのNa含有製剤による輸液が容易に高Na血症を招いたと考えられた。本例のような特殊な背景がある患児に対して輸液を行う際には、基礎疾患とそれに伴う病態を十分に把握しておくことが重要と考えられた。(著者抄録)

症例は11歳の女児で、10歳5ヵ月時から四肢に緊満性水疱・滲出性紅斑が出現した。近医皮膚科で副腎皮質ステロイド内服薬・外用剤、抗菌薬などが投与されたが、皮膚症状の増悪と寛解を繰り返していた。11歳3ヵ月時から口腔内潰瘍を呈するようになり、再度副腎皮質ステロイド内服薬・外用剤、抗菌薬投与を行ったが潰瘍は残存していた。11歳5ヵ月時、発熱、下腿・手掌・足背に血疱が出現したため精査加療目的で入院となった。多形紅斑、アナフィラクトイド紫斑病、血管炎などを考慮し、初期治療としてプレドニゾロンの静脈内投与を開始した。その翌日には解熱し、皮疹も徐々に改善した。その後、口腔内潰瘍を血管炎の一症状ととらえ、先行する著明な好酸球増加と気管支喘息症状の既往からChurg-Strauss症候群(CSS)と診断した。経過中、皮疹は徐々に減少、消失したが、末梢神経症状は改善したものの完全に消失しなかった。

Background: Hemophagocytic lymphohistiocytosis (HLH) is a life threatening hematological disorder associated with severe systemic inflammation caused by an uncontrolled and ineffective immune response resulting in cytokine storm. Epstein-Barr virus (EBV) is the most common infectious agent in patients with the viral-associated HLH. Limited numbers of cases with cardiac complication have been demonstrated in other viral-associated HLH patients. Herein, we report a pediatric case of severe EBV-associated HLH with cardiac complications. Case presentation: A previously healthy 4-year-old Japanese female was admitted to a local hospital with a four day history of fever. Despite antibiotic treatment, her fever persisted to day 7 of the illness. Finally, the diagnosis of HLH was confirmed by fulfilling diagnostic criteria for HLH and pathological analysis of bone marrow aspiration. Real-time PCR detected a high copy number of EBV DNA in the peripheral blood mononuclear cells (PBMCs) at the time of hospital admission. During treatment according to HLH-2004 protocol, sudden cardiopulmonary arrest (CPA) occurred on day 30 of the illness and immediate resuscitation was successful. Acute myocarditis was considered the cause of the CPA. Although the treatment regimen was completed on day 88 of the illness, a remarkably high copy number of EBV DNA was still detected in her PBMCs. Based on our flow cytometric in situ hybridization analysis that revealed EBV infection of only B lymphocytes, we decided to administer rituximab to control the abnormal EBV infection. Afterwards the amount of EBV DNA decreased gradually to undetectable level on day 130 of the illness. Unfortunately, a coronary artery aneurysm was discovered at the left main coronary artery on day 180 of the illness. Finally, the patient was discharged from the hospital on day 203 of the illness without sequelae except for a coronary aneurysm. Conclusions: In this case report, EBV-HLH was complicated with cardiac symptoms such as myocarditis and coronary artery aneurysm. Although remarkably high copy number of EBV DNA was detected in PBMCs after completion of the HLH-2004 protocol, rituximab treatment resulted in a dramatic decrease of EBV DNA to undetectable levels. Rituximab treatment might have been beneficial for the patient's survival.

Severe pneumonia and leukocytosis are characteristic, frequently observed, clinical findings in pediatric patients with pandemic A/H1N1/2009 influenza virus infection. The aim of this study was to elucidate the role of cytokines and chemokines in complicating pneumonia and leukocytosis in patients with pandemic A/H1N1/2009 influenza virus infection. Forty-seven patients with pandemic A/H1N1/2009 influenza virus infection were enrolled in this study. Expression of interleukin (IL)-10 (P = 0.027) and IL-5 (P = 0.014) was significantly greater in patients with pneumonia than in those without pneumonia. Additionally, serum concentrations of interferon-? (P = 0.009), tumor necrosis factor-a (P = 0.01), IL-4 (P = 0.024), and IL-2 (P = 0.012) were significantly lower in pneumonia patients with neutrophilic leukocytosis than in those without neutrophilic leukocytosis. Of the five serum chemokine concentrations assessed, only IL-8 was significantly lower in pneumonia patients with neutrophilic leukocytosis than in those without leukocytosis (P = 0.001). These cytokines and chemokines may play important roles in the pathogenesis of childhood pneumonia associated with A/H1N1/2009 influenza virus infection.