Predictors of coronary artery lesions after intravenous γ-globulin treatment in Kawasaki disease

doi:10.1067/mpd.2000.107890

The Journal of Pediatrics

Volume 137, Issue 2, August 2000, Pages 177-180

https://doi.org/10.1067/mpd.2000.107890 Get rights and content

Abstract

Objective: We evaluated the efficacy of intravenous γ-globulin (IVGG) administration for children with Kawasaki disease to establish whether additional, more advanced therapy is needed in intractable cases. Study design: A total of 193 children with Kawasaki disease were studied retrospectively. Patients were admitted 3 to 7 days after the onset of the disease, and IVGG was administered. Laboratory measurements including white blood cell (WBC), neutrophil, and platelet counts and C-reactive protein (CRP) and albumin concentrations were determined before and 2 to 3 days after IVGG treatment. The progression of coronary artery lesions (CALs) was monitored by serial echocardiography until 30 days after treatment. Results: Of 193 children, 24 (12.2 %) had CALs including transient dilatation. In contrast to the other measurements, the WBC count increased in 21 of 24 (87.5%) children with CALs after IVGG therapy. The patients with increased neutrophil count and CRP concentration after IVGG therapy also had CAL formation at a high rate (78.3% and 66.7%, respectively). Among children with normal coronary arteries, elevations of the WBC and neutrophil counts and CRP concentration were observed after IVGG therapy in only 3, 6, and 8 patients, respectively (specificity: 98.2%, 97.0%, and 95.3%, respectively). Furthermore, multiple logistic regression indicated that these variables were useful predictors of CALs in KD. Conclusion: Though the introduction of IVGG therapy has improved the prognosis of Kawasaki disease, approximately 10% of patients still develop CALs. The need for more aggressive therapy in IVGG-resistant cases can be recognized early by increases in the WBC and neutrophil counts and serum CRP concentration after IVGG administration. (J Pediatr 2000;137:177-80)

Section snippets

Patients and methods

A total of 193 children with KD who were treated with IVGG at a secondary care facility, Fujisawa City Hospital, over 11 years were studied retrospectively, including 110 boys and 83 girls aged 3 months to 11 years. KD was defined as an acute febrile illness with high fever for at least 5 days that satisfied at least 4 of the following criteria: bilateral conjunctival injection, indurative edema of the hands and feet, acute nonpurulent cervical adenopathy, and polymorphous exanthema and

Results

The baseline characteristics in each group are presented in Table I. There were no significant differences between the groups.

Discussion

KD is an acute generalized vasculitis characterized by coronary artery changes 3 to 14 days after the onset. IVGG treatment is usually begun 3 to 8 days after the onset in most cases. Therefore it is important to determine the effectiveness of IVGG soon after therapy, especially in intractable cases, to allow consideration of more advanced therapy, such as additional IVGG, steroids, or plasma exchange.3, 4 However, no evaluation system currently exists to determine the effectiveness of IVGG

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Cited by (110)

Prediction of coronary artery lesions based on C-reactive protein levels in children with Kawasaki Disease: a retrospective cohort study
2023, Jornal de Pediatria
Since coronary artery lesions (CALs) are the most severe complication of Kawasaki disease (KD), clinically speaking, early prediction of CALs is crucial. The authors aimed to investigate the predictive value of C-reactive protein (CRP) in predicting CALs in KD patients.
KD patients were divided into the CALs group and the non-CALs group. The clinical and laboratory parameters were collected and compared. Multivariate logistic regression analysis was used to determine the independent risk factors of CALs. The receiver operating characteristic curve was applied to determine the optimal cut-off value.
851 KD patients who met the inclusion criteria were studied, including 206 in the CALs group and 645 in the non-CALs group. Children in the CALs group had significantly higher CRP levels than the non-CALs group (p < 0.05). Multivariable logistic regression analysis showed that incomplete KD, male, lower hemoglobin, and higher CRP were independent risk factors for predicting CAL (all p < 0.05). The optimal cut-off value of initial serum CRP for predicting CALs was 105.5 mg/L, with a sensitivity of 47.57% and a specificity of 69.61%. In addition, KD patients with high CRP (≥105.5 mg/L) had a higher occurrence of CALs than those with low CRP (<105.5 mg/L) (33% vs 19%, p < 0.001).
The incidence of CALs was significantly higher in patients with high CRP. CRP is an independent risk factor for CALs formation and may be useful for predicting CALs in KD patients.
Vasculitis in children: A diagnostic challenge
2022, Journal de Pediatrie et de Puericulture
Les vascularites primitives de l’enfant sont des maladies inflammatoires rares touchant les vaisseaux sanguins et pouvant se compliquer d’ischémie, voire de nécrose de certains organes. Elles constituent un véritable défi diagnostique et thérapeutique pour les pédiatres. À l’échelle mondiale, les vascularites les plus fréquentes de l’enfant sont la vascularite à IgA et la maladie de Kawasaki, mais dont les complications peuvent être sévères. Les autres vascularites de l’enfant, telles que la péri-artérite noueuse, l’artérite de Takayasu, les vascularites à ANCA, ou encore la maladie de Behçet, sont rares mais potentiellement graves. L’examen clinique minutieux et complet est une des clés du diagnostic. En effet, la précocité de la prise en charge thérapeutique est essentielle car le pronostic vital peut être engagé et le risque de séquelles à long terme conséquent. Un certain nombre de diagnostics différentiels doivent être évoqués, notamment en cas de début précoce avant l’âge de 1 an. Cet article propose un état des lieux des différentes vascularites de l’enfant et une démarche diagnostique clinique et paraclinique pour guider le clinicien.
Primary childhood vasculitis are a real diagnostic and therapeutic challenge for pediatricians. Some vasculitis are quite common, while others are much rarer compared to adults. Worldwide, the most common vasculitis in children are IgA vasculitis and Kawasaki disease, which are usually self-limited although children may develop severe complications. Other vasculitis in children, such as polyarteritis nodosa, Takayasu arteritis, ANCA vasculitis, and Behçet disease, are rare but may be life-threatening. A careful clinical examination is a key for diagnosis. Indeed, early treatment is essential, regarding the high risk of long-term damages. Differential diagnosis must be considered, especially in the case of early onset, before the age of 1 year. This article provides an overview of vasculitis main features in children, and may help the clinician to an early diagnosis.
Kawasaki Disease
2017, The Heart in Rheumatic, Autoimmune and Inflammatory Diseases: Pathophysiology, Clinical Aspects and Therapeutic Approaches
Kawasaki disease (KD) is a multisystem acute self-limited febrile vasculitic syndrome of unknown etiology that predominantly affects previously healthy infants and young children. The diagnosis is based on characteristic clinical features with supplemental laboratory and radiographic criteria. To date, there is not a single specific definitive diagnostic test for KD. Serious complications include coronary arteritis, coronary artery aneurysms, stenosis, and thrombosis, which may lead to myocardial infarction, and, very rarely, rupture of a coronary aneurysm. KD is seen worldwide and is the leading cause of acquired heart disease in children in most developed countries including the United States and Japan. Although the underlying etiology remains unknown, the predominant theory involves an infectious trigger leading to an overwhelming inflammatory response in a genetically susceptibile host manifesting as the classic clinical features. Timely treatment with intravenous immunoglobulin (IVIG) and aspirin generally leads to dramatic improvement in the clinical manifestations and markedly reduces the likelihood of coronary abnormalities.
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Citation Excerpt :
In incomplete forms of the disease, cardiological investigation with transthoracic echocardiography (TTE) may be required to investigate for signs of the disease (Boxed text 2) and to begin treatment [3,4]. Whilst these often present in the subacute phase (between the 10th and 25th day), coronary artery aneurysms may also be found in the late phase of the disease (between the 20th and 70th day) if a prior abnormality is present [5]. They usually affect the right coronary artery and proximal left anterior descending artery (LAD), main stem, more rarely the circumflex artery, and very rarely the distal coronary arterial segments (Fig. 4) [4].
Acquired coronary diseases include aneurysms, fistulae, dissections, and stenosis. Aneurysms may occur secondarily to Kawasaki disease, a childhood vasculitis, the prognosis of which depends on the coronary involvement, or they may be degenerative, infectious, inflammatory, or traumatic in origin. Fistulae develop between the coronary arterial system and a pulmonary or bronchial artery, or cardiac cavity. Dissections may occur spontaneously or may be post-traumatic. These coronary abnormalities may be found incidentally or may present as complications, infarction or rupture. The goals of this article are to understand acquired childhood and adult coronary diseases and their usual means of presentation, the ways of investigating them, and the principles of their treatment.
Kawasaki Disease
2015, Textbook of Pediatric Rheumatology
The use of neutrophil-lymphocyte ratio for the prediction of refractory disease and coronary artery lesions in patients with Kawasaki disease
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^☆: Reprint requests: Masaaki Mori, MD, Yokohama City University School of Medicine, 3-9 Fukuura, Yokohama 236-0004, Japan.

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Original ArticlesPredictors of coronary artery lesions after intravenous γ-globulin treatment in Kawasaki disease☆

Abstract

Section snippets

Patients and methods

Results

Discussion

Lancet

Lancet

J Am Coll Cardiol

J Pediatr

Am J Cardiol

A single intravenous infusion of gamma globulin as compared with four infusions in the treatment of acute Kawasaki syndrome

N Engl J Med

Original Articles
Predictors of coronary artery lesions after intravenous γ-globulin treatment in Kawasaki disease☆