Th17- and Treg-related cytokine and mRNA expression are associated with acute and resolving Kawasaki disease.

BACKGROUND: Kawasaki disease is a vasculitis most commonly afflicting children <5 years of age. Many autoimmune diseases are associated with up-regulation of T helper (Th) 17 cells, and down-regulation Treg cells. Few studies have examined the Th17/Treg expression in Kawasaki disease. METHODS: Blood samples were obtained from 186 children with Kawasaki disease at 24 h before IVIG therapy, followed by 3 days and 21 days after IVIG therapy. Thirty children with an acute febrile infectious disease and 30 healthy children were obtained as control. Plasma levels of Th17- and Treg-related cytokines including IL-6, IL-17A, IL-10, TGF-ß, and mRNA expression levels of RORγt and Foxp3 were tested. RESULTS: Patients with Kawasaki disease had higher levels of plasma IL-17A (25.35 ± 3.21 vs 7.78 ± 1.78 pg/ml, P < 0.001) and IL-6 (152.29 ± 21.94 vs 38.63 ± 12.40 pg/ml, P < 0.001) when compared to the febrile control group. IVIG resulted in a reduction in IL-6 and IL-17A at both 3 and 21 days after IVIG therapy. FoxP3 levels increased significantly 3 days after IVIG therapy (2.28 ± 0.34 vs 0.88 ± 0.14, P < 0.001). IVIG resistance was associated with higher levels of IL-10 and IL-17A. CONCLUSION: Kawasaki disease was associated with higher IL-17A and IL-6, a cytokine profile similar to other autoimmune diseases. IVIG therapy resulted in increased expression of Treg-related FoxP3. IVIG resistance was associated with higher levels of IL-10 and IL-17A. Our findings provide further evidence that Kawasaki disease is an autoimmune-like disease.

Effects of nifedipine on systemic hydraulic vascular load in patients with hypertension.

STUDY OBJECTIVE: The aim of the study was (1) to determine the difference in aortic input impedance and derived parameters between hypertensives and normotensives; and (2) to assess the acute effects of nifedipine on the aortic impedance, compliance, and resistance in patients with hypertension. DESIGN: A high fidelity multisensor catheter (Millar) was used to obtain the aortic pressure and flow signals for impedance analysis. The acute effects of nifedipine on the impedance parameters were evaluated at steady state before and after (10-30 min) a sublingual dose of 10 mg. PATIENTS: The patients included seven normotensive (mean blood pressure, 97 mm Hg) and nine hypertensive (mean blood pressure, 135 mm Hg), age matched, ethnic Chinese. Patients with clinical evidence of heart failure and valvular or congenital heart diseases were excluded. MEASUREMENTS AND MAIN RESULTS: Pulsatile aortic flow and pressure were measured by Millar catheter inserted into the ascending aorta. Cross sectional area of aorta was estimated by echocardiograms. Cardiac output was determined by Fick principle with an oximeter. These data were subjected to Fourier analysis for impedance spectra. In comparison with normotensives, hypertensives had increased peripheral vascular resistance R, at 2751(705) v 1651(363) dyne.s.cm-5; increased characteristic impedance Zc, at 193(64) v 122(27) dyne.s.cm-5; and increased first zero crossing frequency of impedance phase angle fo, at 4.8(0.9) v 3.4(0.7) Hz. Arterial compliances corresponding to peak systolic pressure Cs were lower, at 0.32(0.19) v 0.90(0.32) ml.mm Hg-1, as was mean pressure Cm, at 0.55(0.25) v 1.24(0.38) ml.mm Hg-1, and end diastolic pressure Cd, at 0.83(0.29) v 1.65(0.44) ml.mm Hg-1. Although the values of external ventricular hydraulic power were higher in hypertensive subjects, the difference was not statistically significant. Nifedipine administration in 7/9 hypertensives significantly reduced R, from 2806(721) to 2433(664) dyne.s.cm-5; mean aortic pressure Pm, from 138(22) to 112(12) mm Hg; total external ventricular power Wt, from 1452(306) to 1121(135) mW; and steady external power Ws, from 1251(310) to 939(119) mW; but did not reduce Zc, fo, Cs, Cm, Cd, and oscillatory external power Wo. CONCLUSIONS: The results indicate that (1) the stiffness of proximal aorta and vascular tone of peripheral arterioles are higher in hypertensives than in normotensives; (2) in hypertensive subjects, sublingual administration of nifedipine reduces the arterial pressure and peripheral arteriolar tone, but not the stiffness of proximal aorta; (3) the decrease in total external ventricular power in hypertensives treated with nifedipine results from a reduction in the steady, but not the oscillatory, component of hydraulic external ventricular power.

Long-term follow-up of valvotomy before 1968 for congenital aortic stenosis.

The clinical course of 59 patients who underwent valvotomy for aortic stenosis before 1968 was reviewed. All were older than 1 year at the time of operation. Mean follow-up period was 17.7 years. Forty-six patients are alive; 26 (57%) are 30 to 40 years and 6 (13%) are older. Actuarial analysis indicated that the probability of survival was 94% at 5 years and 77% at 22 years. Thirteen patients died, 7 suddenly. Among the latter, significant obstruction or regurgitation was present in the 4 who underwent catheterization 0.9 to 7.2 years before death, 2 of whom were symptomatic and 2 with progression of a strain pattern on electrocardiogram. Surgery was recommended but declined by the latter 2 patients. Reoperation was carried out in 21 patients (36%), 3 (12%) of whom died. Actuarial analysis revealed the probability of reoperation to increase from 2% at 5 years to 44% at 22 years. Bacterial endocarditis occurred on 4 occasions in 3 patients, 1 of whom died suddenly during treatment. The incidence of endocarditis was 3.8 episodes/1,000 patient-years. Actuarial analysis of serious events, defined as death, reoperation and endocarditis, with the most serious of these and each patient being represented only once, indicated the probability of being free of such an episode to be 92% at 5 years, decreasing to 39% at 22 years. These data emphasize the palliative nature of valvotomy and the meticulous follow-up so necessary in these patients.

Recognition of functional pulmonary atresia by color Doppler echocardiography.

Vigorous crying aids right ventricular ejection into the pulmonary artery. This phenomenon can differentiate functional pulmonary atresia from anatomic pulmonary atresia.

Quantitative analysis of end-tidal carbon dioxide during mechanical and spontaneous ventilation in infants and young children.

Capnography provides a substitute for monitoring of arterial carbon dioxide tension (PCO(2)). We performed a prospective study to evaluate a new application of capnography, using quantitative curve analysis in the pediatric ICU. Twenty-five infants and children admitted to the pediatric ICU after cardiovascular surgery for congenital heart diseases were included in the study. Capnographic curves were recorded during 3 phases of mechanical and spontaneous ventilation: phase 1, immediate postoperative period; phase 3, preextubation period; and phase 2, period between phases 1 and 3. Each recording included 17 sec of capnographic tracings from consecutive spontaneous and/or ventilator-driven breaths. Quantitative curve analysis was made to define parameters including peak value of exhaled PCO(2) (P), mean rate of rise of PCO(2) (R), and area under each capnographic curve (A). Qualitative inspection of the wave contour showed no obvious difference in phase 3 during spontaneous and mechanically assisted ventilator breaths. However, an obvious difference existed between spontaneous and mechanically assisted breaths in phase 2. For each parameter (P, R, and A), there was a significant difference in phases 2 and 3 from spontaneous breaths. However, there was no significant difference in phases 2 and 3 from ventilator-assisted breaths. We further calculated the ratio of parameters of spontaneous breaths (S) and ventilator-assisted breaths (V) in phase 2 and phase 3. The ratio of S/V for P, R, and A showed significant differences between phase 2 and phase 3. We conclude that quantitative analysis of exhaled end-tidal PCO(2) curves revealed significant changes of specific parameters during the transition from the ventilator-dependent state to the spontaneously breathing ventilator-independent state. This new approach provides a new way to estimate respiratory status in infants and children receiving ventilator therapy. Through quantitative capnographic curve analysis, if P, R, and A from spontaneous breaths approached those of ventilator-assisted breaths, patients have resumed reasonable pulmonary mechanics, and extubation may then be considered.

Texture features for classification of ultrasonic liver images.

The classification of ultrasonic liver images is studied, making use of the spatial gray-level dependence matrices, the Fourier power spectrum, the gray-level difference statistics, and the Laws texture energy measures. Features of these types are used to classify three sets of ultrasonic liver images-normal liver, hepatoma, and cirrhosis (30 samples each). The Bayes classifier and the Hotelling trace criterion are employed to evaluate the performance of these features. From the viewpoint of speed and accuracy of classification, it is found that these features do not perform well enough. Hence, a new texture feature set (multiresolution fractal features) based on multiple resolution imagery and the fractional Brownian motion model is proposed to detect diffuse liver diseases quickly and accurately. Fractal dimensions estimated at various resolutions of the image are gathered to form the feature vector. Texture information contained in the proposed feature vector is discussed. A real-time implementation of the algorithm produces about 90% correct classification for the three sets of ultrasonic liver images.

Cardiac troponin I: a reliable marker and early myocardial involvement with meningoencephalitis after fatal enterovirus-71 infection.

OBJECTIVES: A major outbreak of enterovirus 71 (EV71) in Taiwan in 1998 caused many severe cases and 78 deaths. Our purpose was to find reliable markers and early indicators of fatal EV71 central nervous system (CNS) infection. METHODS: From June 2000 to November 2001, 21 patients with hand foot mouth disease or herpangina with CNS infection were admitted to Kaohsiung Veterans General Hospital. All 21 had culture-confirmed EV71 infection or were EV71 IgM positive. Patients were divided into two groups: group I included the five fatalities at our institution and group II, the 16 surviving patients. RESULTS: Of the 21 infants and children with EV71 infection with CNS involvement, MR imaging studies were completed on 17, and 15 showed hyperintensity in the posterior portions of brain stem. All patients received intravenous immunoglobulin (IVIG) 1 g/day for two days and supportive care. Five patients rapidly deteriorated owing to irreversible hypotension and died. The other 16 patients recovered completely without sequel. In group I patients, the decrease of cardiac ejection function is significant and laboratory findings showed lower platelet count (P=0.0192). The mean of initial cTnI level for groups I and II was 10.6+/-11.6 and 0.48+/-0.55 ng/dl, respectively, higher in group I than in II (P=0.0019). CONCLUSION: We hypothesized that like patients with severe burns, those with severe EV-71 CNS meningoencephalitis have varying degrees of non-ischemic cardiac injury, manifesting as leakage of cTnI from myocytes into the circulation. EV-71 CNS meningoencephalitis likely to die with an early myocardial involvement evidenced by reduced ejection fraction and release of cTnI. We conclude that fatal EV71 CNS infection quickly leads to death due to severe encephalopathy associated with cardiomyopathy.

Mastoiditis: a disease often overlooked by pediatricians.

Although mastoiditis can be a life threatening disease, clinicians often overlook it because it is uncommon. We reviewed the presentation and management of all children younger than 15 years of age with the discharge diagnosis of mastoiditis in our hospital from January 1994 through December 1999. Nineteen patients that fulfilled the case definition were included. The most common clinical presentation in this series was fever. More specific findings, such as otorrhea, postauricular pain, swelling, and redness of mastoid could be found in less than half of these patients. Only two patients had characteristic physical findings, and mastoiditis was diagnosed in only three patients upon admission. Plain radiographic evidence of mastoiditis was usually not apparent early in the course. In this series, the majority of patients were diagnosed by computed tomography (CT) scans. The present study demonstrates that mastoiditis most commonly presents without a clearly diagnostic set of physical examination and laboratory findings. Mastoiditis should be considered in patients with otitis media or with fever of unknown origin (FUO). The empirical antibiotic treatment should cover organisms commonly found in acute otitis media (AOM), including Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.

The detection of ventricular dysfunction and carditis in children with Kawasaki disease using equilibrium multigated blood pooling ventriculography and 99Tcm-HMPAO-labelled WBC heart scans.

Thirty-seven children (11 girls, 26 boys; aged 2.8 +/- 2.2 years) with Kawasaki disease (KD) were included in the study. The biventricular functions were evaluated by equilibrium multigated blood pooling ventriculography (EMBPV) and the severity of carditis was decided by Tc-hexamethylpropyleneamine oxime (HMPAO) labelled white blood cell (WBC) heart scans (Tc-WBC). The results showed that 43% (16/37) of the KD cases with the severe carditis by Tc-WBC had the worst left ventricular ejection fraction (LVEF) (55.4 +/- 15.6%) and right ventricular ejection fraction (RVEF) (43.7 +/- 12.2%) by EMBPV; 24% (9/37) of the cases with the mild carditis had the best LVEF (63.5% +/- 8.2%) and RVEF (53.7% +/- 11.2%); the remaining 32% (12/37) had moderately severe carditis and biventricular function (LVEF: 58.2 +/- 17.2% and RVEF: 46.9 +/- 19.5%). Because Tc-WBC cannot only detect the severity of carditis but also predict impairment of ventricular function accurately, the choice of Tc-WBC should be preferable for KD-a common inflammatory cardiovascular disease in children.

99Tcm-HMPAO-labelled white blood cell scanning for the detection of carditis in the differentiation of rheumatic fever and inactive rheumatic heart disease in children.

Myocardial imaging with 99Tcm-hexamethylpropylene amineoxime (HMPAO)-labelled white blood cells (Tc-WBC) was used to detect carditis and differentiate rheumatic fever (RF) and inactive rheumatic heart disease (IRHD). Ten cases of RF and 15 cases of IRHD were studied, and the results revealed 60% (6/10) of the cases of RF with carditis, but none of the cases (0/15) of IRHD with carditis. There was significant difference (P less than 0.05, by Fisher's test) between RF and IRHD. In our preliminary conclusion, Tc-WBC heart scanning may be a noninvasive method for evaluating the existence of carditis in cases of RHD and in the differentiation of RF and IRHD.

Comparison of 99Tcm-HMPAO-labelled white blood cells and 67Ga citrate scans to detect myocarditis in the acute phase of Kawasaki disease.

Myocardial imaging with 99Tcm-HMPAO-labelled white blood cells (WBC) and 67Ga citrate was used to detect myocarditis in the acute phase of Kawasaki disease among 22 infants and children; 18 cases of myocarditis were detected by 99Tcm-HMPAO-labelled WBC heart scans, but only one case was detected by 67Ga citrate heart scans. In conclusion, 99Tcm-HMPAO-labelled WBC scanning provides a more sensitive method than 67Ga citrate scanning in the detection of myocarditis in Kawasaki disease.

Colon perforation in a patient with hyperimmunoglobulin E (Job's) syndrome.

A Taiwanese boy was diagnosed as having hyperimmunoglobulin E syndrome at the age of 4 years. At age 18 he was admitted to the hospital because of pneumonia in the left lower lobe. Abdominal pain developed 9 days later, and his condition progressed to peritonitis. Colon perforation, 10 cm distal to the ileocecal valve, was found. Double-barrel ileostomy was performed, and reanastomosis was done 1 1/2 months later. Afterward, he was fine, and he had no significant gastrointestinal problems after being discharged. To the author's knowledge, this is the first reported case of hyperimmunoglobulin E syndrome complicated by colon perforation.

A simple, noninvasive method to investigate vascular characteristics in children.

Palpation of pulses is an ancient clinical technique. In modern medical terms, arterial pulse analysis permits the evaluation of vascular characteristics, the important parameters for study of the properties of vessels. However, the various parameters used to describe the vascular characteristics have been conventionally deriving from expensive, invasive, and complicated methods and involving complex computations. The authors designed, therefore, a simple, noninvasive system to evaluate vascular characteristics. The system consisted of two units of pressure transducer for simultaneous recording of two peripheral arterial pulses, an analog signal processor, an A/D converter, and a personal computer. The vascular characteristics were analyzed by use of the Windkessel model and cross-correlation function. The analysis program was designed by members of this team. Through this system, systemic arterial compliance and pulse wave velocity can be obtained. Thirty-five children (11 normal children and 24 children with various stable, mild congenital heart diseases) were enrolled for data analysis. For these 35 children without hypertension or other clinically apparent arterial disease, the pulse wave velocity in the upper limb as between 3.7 and 16.8 m x sec-1, with a mean +/- standard deviation of 9.3 +/- 3.3 m x sec-1. The arterial compliance among the 11 normal children was between 0.72 and 1.72 mL x mmHg-1 x m-2 with a mean of 1.15 mL x mmHg-1 x m-2; both were consistent with the previously reported values obtained from complex methods. This system provides data comparable with those obtained from invasive methods. In the past, the arterial characteristics could not be extensively studied owing to the invasive nature of the conventional methods. This new, simple, convenient noninvasive system will thus provide a convenient method for clinical use in evaluating the vascular characteristics of patients, especially of children.

Percutaneous balloon valvuloplasty in severe pulmonary valvular stenosis.

Percutaneous balloon pulmonary valvuloplasty (PBPV) was achieved successfully in 20 of 22 patients with severe pulmonary valvular stenosis, aged two days to ten years (median four years and two months). The diameters of the balloon for PBPV were 88-125% (mean +/- SD = 109.5 +/- 10.0%) of the pulmonary valve annulus. PBPV failed in 2 patients because of the inability of the cardiac catheters to cross the stenotic valve. A significant reduction of right ventricle-pulmonary artery (RV-PA) pressure gradient occurred in all 20 patients (mean +/- SD = 72.1 +/- 10.3%). The mean RV-PA pressure gradient was reduced from 93.2 +/- 33.1 to 26.3 +/- 15.6 mmHg (P < 0.0001) and the mean right ventricular peak systolic pressure fell from 117.2 +/- 32.4 to 51.6 +/- 17.3 mmHg (P < 0.0001). Five (25%) of 20 patients had an infundibular gradient before PBPV. Two (10%) developed a new infundibular stenosis immediately after PBPV. Four (20%) presented with cyanosis, which disappeared after the successful PBPV. Two patients (10%) who showed a residual RV-PA pressure gradient of more than 40 mmHg had a significant infundibular obstruction initially. Two patients underwent recatheterization fifteen months after PBPV owing to a significant residual RV-PA pressure gradient and had no reductions in right ventricular pressure and RV-PA pressure gradient, but resolution of infundibular obstruction was noted in both. Repeat PBPV was successfully performed on these 2 patients. No significant complications were noted in any patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical repair of ventricular septal defect without ventriculotomy in the first 12 months of life.

Sixty-eight infants with clinical evidence of a large ventricular septal defect (VSD), refractory to conventional medical treatment, underwent surgical closure within the first 12 months of life from August 1987 to June 1991. There were 43 males and 25 females. The ages of the patients ranged from two to 12 months, with a mean age of 6.6 months. The mean body weight of the patients was 5.4 kg (range, 2.3-10 kg). Surgery was performed because of intractable heart failure in 27 infants (39.7%), failure to thrive in 40 (58.8%), repeated pneumonia in 43 (63.2%) and prolonged endotracheal intubation in nine (13.2%). There were 21 patients with a supracristal VSD (30.9%) and 47 patients with perimembranous VSD (69.1%). Nine patients (13.2%) had preoperative cardiac catheterization. Transatrial repair of perimembranous VSDs and transpulmonary repair of supracristal VSDs was used exclusively without ventriculotomy. Surgically induced heart blocks did not occur in any of the patients. Only two patients (2.9%) died during the early postoperative period. Diagnosis in most cases was confirmed by the present advanced integrated color Doppler echocardiographic technology which is widely used by pediatric cardiologists. There was no need to perform cardiac catheterization in most patients with VSDs. The morbidity and mortality were very low. We strongly suggest that for infants with a large VSD, primary repair should be the procedure of choice.

Evaluation of left ventricular function in Kawasaki disease using equilibrium multigated blood pooling ventriculography.

Twenty-eight children ranging in age from 1-6 years (11 girls, 17 boys) with Kawasaki disease and, for comparison, 30 normal children ranging in age from 1-8 years (8 girls, 22 boys) without any cardiovascular disease were included in this study. The left ventricular functions of the children were evaluated by equilibrium multigated blood pooling ventriculography (EMBPV), which was performed after in vivo labeling of red blood cells using 10 mCi Tc-99m pertechnetate. Scintigraphy was performed using a digital gamma camera with the aid of an electrocardiogram gate. The left ventricular functions were determined by Fourier analysis of the time-activity curve in the left ventricles. The parameters of the left ventricular functions included: 1) systolic phase--[a] ejection fraction (EF), [b] ejection time (ET), [c] peak ejection rate (PER), and [d] first 1/3 ejection rate mean (1/3ERM), and 2) diastolic phase--[a] peak filling rate (PFR), [b] fast filling fraction (FFF), [c] time to peak filling rate (TPFR), and [d] first 1/3 filling rate mean (1/3FRM). The results showed that no significant differences existed between the two groups in any parameter of the left ventricular function. The authors suggest that the left ventricular functions in children with Kawasaki disease are not apparently impaired. The results were proven by the presentation of the EMBPV in this study.

Equilibrium multigated blood pool ventriculography to evaluate the effects of high-dose gamma-globulin treatment for left ventricular functions in Kawasaki disease.

Twenty-one patients with acute state Kawasaki disease (15 boys, 6 girls; age range, 1-8 years) had equilibrium multigated blood pool ventriculography (EMBPV) before treatment. The symptoms and signs subsided after the administration of aspirin and the intravenous injection of high-dose (400 mg/kg per day x 5 days) gamma-globulin (IVGG) treatment. Then, a second EMBPV was arranged to evaluate the effects of the treatment on left ventricular functions. Left ventricular function was analyzed based on the following parameters: (systolic phase) ejection fraction, ejection time, peak ejection rate, first 1/3 ejection rate mean; and (diastolic phase) peak filling rate, fast filling fraction, time to peak filling rate, first 1/3 filling rate mean. The results showed that there were no significant differences in the parameters of left ventricular function before and after treatment (P > 0.05, paired Student's t-tests).

Labeled WBC cardiac imaging and two-dimensional echocardiography to evaluate high-dose gamma globulin treatment in Kawasaki disease.

Twenty-eight children (5 girls, 23 boys; age, 20.3 +/- 16.2 months) with Kawasaki disease (KD) were included in this study. The children were treated with aspirin plus intravenous injection of gamma globulin (IVGG). Both Tc-99m HMPAO labeled WBC heart imaging (Tc-WBC) and two-dimensional echocardiograms (2D-Echo) were used to evaluate the effects of IVGG on the most common cardiac presentations--carditis and dilated coronary arteries--in KD. After IVGG therapy, the results showed that 32.1% (9/28) carditis patients had improved; 39.3% (11/28) of patients had no significant change; 28.6% (8/28) of patients had severe changes, and there was no significant difference among the three groups by the evidences of Tc-WBC. Dilated coronary arteries (CA) became smaller in 32.1% (9/28) of patients; 53.6% (15/28) of patients had no definite change; 14.3% (4/28) of patients had dilated LCA that became larger; and borderline difference existed among the three groups, proved by 2D-Echo. Between the Tc-WBC and 2D-Echo, 35.7% (10/28) of patients had similar changes, and 64% (18/28) of patients showed incongruous changes; and there was little difference. In conclusion, Tc-WBC and 2D-Echo provide strong evidence of the existence of carditis and dilated coronary arteries in certain patients, even after IVGG treatment. The improvements of carditis and dilated coronary arteries were not correlated with each other after IVGG therapy.

Tc-99m HMPAO WBC imaging to detect carditis and to evaluate the results of high-dose gamma globulin treatment in Kawasaki disease.

Eighteen patients with Kawasaki disease and suspected carditis (11 boys, 7 girls, mean age 18 months) in acute stages underwent Tc-99m HMPAO WBC imaging of the heart. Signs and symptoms subsided after conventional aspirin therapy and the intravenous injection of high-dose (400 mg/kg per day for 5 days) gamma-globulin treatments. Tc-99m HMPAO WBC imaging of the heart was arranged a second time to evaluate the effects of the treatments for carditis. The results showed that a significant difference existed in the severity of carditis before and after the treatments (P less than 0.001, by signed rank test), 39% (7/18) with significant improvement in severity of carditis, 50% (9/18) without definite change. However, 11% (2/18) became more severely ill after the treatments. Tc-99m HMPAO WBC imaging may be useful in detecting carditis in Kawasaki disease and in evaluating the effects of aspirin plus the newly recommended gamma-globulin for the treatment of carditis in Kawasaki disease.

Tc-99m HMPAO labeled WBC scan for the detection of myocarditis in different phases of Kawasaki disease.

Myocardial imaging with Tc-99m HMPAO WBC was used to detect myocarditis of Kawasaki disease in 103 infants and children (66 boys and 37 girls, mean age 3 years and 4 months). The clinical course of Kawasaki disease may be divided into three phases, from the onset of illness onset until all clinical symptoms and signs have disappeared. Twenty-four hour myocardial imaging was performed in anterior, LAO, and left lateral views. The grading system was as follows: score 0 less than bone uptake; 1 = bone uptake; 2 greater than bone uptake; and 3 greater than or equal to liver uptake. If the score was greater than or equal to 2, significant myocarditis was considered. The appearing ratio of myocarditis was 57% (13/23) in the first phase; 65% (15/23) in the second phase; 54% (31/57) in the third phase. No significant difference was demonstrated among the three groups of patients (P greater than 0.1, by Chi-square test). In conclusion, an occult myocarditis may continue in all three phases of Kawasaki disease, even if the clinical symptoms and signs had improved by the evidence of Tc-99m HMPAO labeled WBC scan to avoid advanced cardiac complication.