# Ultrasound Comparative Analysis of Coronary Arteries before and after Immune Blocking Therapy with Gamma Globulin in Children with Kawasaki Disease

Authors: Yi Yu; Jinhua Hu; Qun Xia; Juxia Huang; Yangmei Cheng; Fangling Wu; Yujing Liu; Jun Wang; Qiong Zhang
Journal: Evidence-Based Complementary and Alternative Medicine
 (2022)

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## Abstract

Objective. To investigate the ultrasound characteristics and clinical efficacy of coronary arteries before and after immune blocking therapy with gamma globulin in children with Kawasaki disease. Methods. A total of 64 children with Kawasaki disease who were treated in our hospital from January 2018 to October 2021 were selected. All the children were given immune blocking therapy with gamma globulin on the basis of conventional treatment. The disappearance time of related symptoms and signs (fever, mucosal congestion, cervical lymphadenopathy, and swelling of the hands and feet) in children were counted. The white blood cell count (WBC), platelet count (PLT), C-reactive protein (CRP), and procalcitonin (PCT) levels of the children before and after treatment were compared, and the characteristics of coronary echocardiography before and after treatment were observed for analysis and discussion, to carefully observe whether the coronary artery involvement of the children was improved. Results. The inner diameter of the left and right coronary arteries significantly decreased (P<0.05), and the levels of leukocytes, platelets, CRP, erythrocyte sedimentation rate, vascular endothelial growth factor (VEGF), and endostatin were significantly decreased compared with those before treatment, with a statistical difference (P<0.05). Conclusion. The effect of gamma globulin in the treatment of Kawasaki disease is remarkable, which can improve the blood indexes, VEGF, and endostatin levels in children, significantly reduce coronary dilatation, and reduce the incidence of coronary artery disease. Echocardiography is of high value in the examination of children with Kawasaki disease, which can accurately detect the size, location, and inner diameter of coronary artery lesions, and can effectively evaluate the treatment effect on children.


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## Body

## 1. Introduction

Kawasaki disease (KD) is a common acute fever disease in pediatrics [1]. The main pathological characteristics are systemic arteritis and arteriolitis, and the most serious harm is cardiovascular damage [2, 3]. It has been shown that the incidence is slightly higher in Asian children than in Europe and the United States and is common not only in children aged 6 months to 5 years but also in school-aged children and rarely in adults, with a male to female ratio of approximately 1.62 : 1 [4]. It is mainly manifested as coronary artery lesions, including coronary artery dilatation and coronary aneurysm, which is the most important factor affecting the prognosis of children. Clinical manifestations include rash, fever, rigid edema of the hands and feet, and ocular conjunctival congestion [5]. KD is a self-limiting disease. Although the prognosis is good, if the correct and effective treatment measures are not received in the early stage, it can affect the small and medium arteries of the whole body, easily induce coronary artery damage, and even induce myocardial infarction and sudden death in severe cases, which seriously threatens the safety and quality of life of children [6, 7].As an immunoglobulin, gamma globulin is mostly used for the treatment of infectious diseases clinically [8]. It can block the Fc receptors on the surface of platelets, mononuclear phagocytes, and vascular endothelial cells and reduce the vascular immune inflammatory response [9, 10]. Immunoglobulin contains various antibodies required by the body to enhance the immune function and prevent infection. It has been widely used in the clinical treatment of KD, and its clinical efficacy is certain, as it can rapidly reduce fever, eliminate acute symptoms, and reduce the incidence of coronary artery lesions [11, 12]. In this study, we observed the characteristics of coronary ultrasound before and after gamma globulin immunoblockade treatment in children with KD, which provides a clinical reference for gamma globulin treatment of KD to inhibit the aggravation of coronary artery damage.


## 2. Materials and Methods

### 2.1. Research Objects

A prospective analysis was performed on 64 children with KD who were treated in our hospital from January 2018 to October 2021. All the children were given gamma globulin immunosuppressive therapy on the basis of conventional treatment. There were 40 males and 24 females; the age ranged from 72 days to 15 years, with an average of (3.04 ± 0.34) years.


#### 2.1.1. Inclusion Criteria

The inclusion criteria were as follows: patients met the clinical diagnostic criteria for Kawasaki disease in the 2017 edition of “Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association” [13], patients did not received relevant treatment before admission, patients had complete clinical data and could cooperate with the whole process of treatment and examination, and patients with no history of hypersensitivity to gamma globulin drugs.


#### 2.1.2. Exclusion Criteria

The exclusion criteria were as follows: patients with congenital heart disease, patients with a history of aspirin or intravenous immunoglobulin therapy, and patients with mental system disease. The above studies were conducted with the informed consent of the families of the children and were approved by the ethics committee of our hospital.


### 2.2. Methods

After admission, all the children received the same routine treatment plan, such as atomization of phlegm, physical cooling, routine use of antibiotics, and nutritional support. On this basis, the treatment was treated by intravenous infusion of gamma globulin (manufacturing company: Guizhou Taibang Biological Products Co., Ltd., Chinese medicine Zhunzi: S20023034, specification: 50 mL: 2.5 g/piece), according to 2 g/kg single dose, intravenous infusion, slowly completed within 10–12 h; if the reaction is poor, the drug can be repeated once on the second day, repeat twice at most; aspirin (Shaanxi Yishengtang Pharmaceutical Co., Ltd., Chinese medicine Zhunzi: H61023268) was taken orally, once a day, 30–50 mg/kg each time. After 3 days of administration, if the child was antipyretic, the dosage was reduced to 4 mg/kg until the coronary artery lesions and erythrocyte sedimentation rate returned to normal.


### 2.3. Evaluation Indicators and Judgment Criteria

(1) Time to disappearance of symptoms and signs and length of hospital stay: during the whole treatment process, the time to disappearance of signs and symptoms, such as fever, mucosal congestion, cervical lymphadenopathy, and swelling of the hands and feet, and hospitalization time of the children were counted. (2) The levels of serum-related indexes were compared before and after treatment. First, 5.0 ml of peripheral venous blood was drawn and centrifuged at 3000 r/min for 5 min by the Beckman Microfuge 20 medical centrifuge. The upper serum was taken and stored in a refrigerator at −20°C. The Beckman Coulter dxh 600 blood routine tester was used to measure the blood routine-related indicators of the children before and after treatment for 2 weeks, including C-reactive protein (CRP), platelets, white blood cells, erythrocyte sedimentation rate, and other indicators. VEGF and endostatin were detected by ELISA. (3) The incidence of coronary artery disease (CAL) was detected by echocardiography. The diagnostic criteria of Kawasaki disease complicated with coronary artery disease are as follows: (i) coronary artery aneurysm (CAA), coronary artery dilation of different shapes, coronary artery diameter 4–7 mm; (ii) giant coronary artery aneurysm (GCAA), coronary artery diameter ≥ 8 mm; and (iii) Coronary artery dilatation, coronary artery ≥ 2.5 mm in younger than 3 years old, coronary artery ≥ 3.0 mm in ≥ 3 years old and < 9 years old, coronary artery ≥ 3.2 mm in ≥ 9 years old and < 14 years old, and 33.5 mm in those aged 14 and older.


### 2.4. Statistical Methods

SPSS 24.0 was used for the statistical analysis of the data. The measurement data were analyzed by thet-test of the opposite samples, represented by (x¯±s), and the enumeration data were represented by the chi-square test, which was represented by the percentage, and P<0.05 indicated that the difference was statistically significant.


## 2.1. Research Objects

A prospective analysis was performed on 64 children with KD who were treated in our hospital from January 2018 to October 2021. All the children were given gamma globulin immunosuppressive therapy on the basis of conventional treatment. There were 40 males and 24 females; the age ranged from 72 days to 15 years, with an average of (3.04 ± 0.34) years.


### 2.1.1. Inclusion Criteria

The inclusion criteria were as follows: patients met the clinical diagnostic criteria for Kawasaki disease in the 2017 edition of “Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association” [13], patients did not received relevant treatment before admission, patients had complete clinical data and could cooperate with the whole process of treatment and examination, and patients with no history of hypersensitivity to gamma globulin drugs.


### 2.1.2. Exclusion Criteria

The exclusion criteria were as follows: patients with congenital heart disease, patients with a history of aspirin or intravenous immunoglobulin therapy, and patients with mental system disease. The above studies were conducted with the informed consent of the families of the children and were approved by the ethics committee of our hospital.


## 2.1.1. Inclusion Criteria

The inclusion criteria were as follows: patients met the clinical diagnostic criteria for Kawasaki disease in the 2017 edition of “Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association” [13], patients did not received relevant treatment before admission, patients had complete clinical data and could cooperate with the whole process of treatment and examination, and patients with no history of hypersensitivity to gamma globulin drugs.


## 2.1.2. Exclusion Criteria

The exclusion criteria were as follows: patients with congenital heart disease, patients with a history of aspirin or intravenous immunoglobulin therapy, and patients with mental system disease. The above studies were conducted with the informed consent of the families of the children and were approved by the ethics committee of our hospital.


## 2.2. Methods

After admission, all the children received the same routine treatment plan, such as atomization of phlegm, physical cooling, routine use of antibiotics, and nutritional support. On this basis, the treatment was treated by intravenous infusion of gamma globulin (manufacturing company: Guizhou Taibang Biological Products Co., Ltd., Chinese medicine Zhunzi: S20023034, specification: 50 mL: 2.5 g/piece), according to 2 g/kg single dose, intravenous infusion, slowly completed within 10–12 h; if the reaction is poor, the drug can be repeated once on the second day, repeat twice at most; aspirin (Shaanxi Yishengtang Pharmaceutical Co., Ltd., Chinese medicine Zhunzi: H61023268) was taken orally, once a day, 30–50 mg/kg each time. After 3 days of administration, if the child was antipyretic, the dosage was reduced to 4 mg/kg until the coronary artery lesions and erythrocyte sedimentation rate returned to normal.


## 2.3. Evaluation Indicators and Judgment Criteria

(1) Time to disappearance of symptoms and signs and length of hospital stay: during the whole treatment process, the time to disappearance of signs and symptoms, such as fever, mucosal congestion, cervical lymphadenopathy, and swelling of the hands and feet, and hospitalization time of the children were counted. (2) The levels of serum-related indexes were compared before and after treatment. First, 5.0 ml of peripheral venous blood was drawn and centrifuged at 3000 r/min for 5 min by the Beckman Microfuge 20 medical centrifuge. The upper serum was taken and stored in a refrigerator at −20°C. The Beckman Coulter dxh 600 blood routine tester was used to measure the blood routine-related indicators of the children before and after treatment for 2 weeks, including C-reactive protein (CRP), platelets, white blood cells, erythrocyte sedimentation rate, and other indicators. VEGF and endostatin were detected by ELISA. (3) The incidence of coronary artery disease (CAL) was detected by echocardiography. The diagnostic criteria of Kawasaki disease complicated with coronary artery disease are as follows: (i) coronary artery aneurysm (CAA), coronary artery dilation of different shapes, coronary artery diameter 4–7 mm; (ii) giant coronary artery aneurysm (GCAA), coronary artery diameter ≥ 8 mm; and (iii) Coronary artery dilatation, coronary artery ≥ 2.5 mm in younger than 3 years old, coronary artery ≥ 3.0 mm in ≥ 3 years old and < 9 years old, coronary artery ≥ 3.2 mm in ≥ 9 years old and < 14 years old, and 33.5 mm in those aged 14 and older.


## 2.4. Statistical Methods

SPSS 24.0 was used for the statistical analysis of the data. The measurement data were analyzed by thet-test of the opposite samples, represented by (x¯±s), and the enumeration data were represented by the chi-square test, which was represented by the percentage, and P<0.05 indicated that the difference was statistically significant.


## 3. Results

### 3.1. Disappearance Time of Symptoms and Signs and Length of Hospital Stay

The time when the symptoms and signs disappeared and the length of hospital stay are given in Table1.Table 1
Disappearance time of symptoms and signs and length of hospital stay.
CasesAntipyretic timeCervical lymphadenopathy resolution timeMucous membrane hyperemia disappearance timeHand and foot swelling subsides timeHospital stay763.79 ± 0.516.81 ± 1.654.03 ± 0.774.19 ± 1.258.67 ± 0.76


### 3.2. Serum-Related Index Levels before and after Treatment in Children

Leukocyte level in the child after gamma globulin treatment was 8.24 ± 2.75 × 109/L compared to 17.14 ± 4.78 × 109/L before treatment. Platelet level in the child after gamma globulin treatment was 230.84 ± 54.81 × 109/L compared to 380.23 ± 109.73 × 109/L before treatment; CRP levels were 70.33 ± 8.66 mg/L before treatment and 70.33 ± 8.66 mg/L after treatment; ESR levels were 99.06 ± 10.24 mm/h before treatment and 99.06 ± 10.24 mm/h after treatment; the serum levels of the relevant indicators decreased in all children after gamma globulin treatment (P<0.001) (Table 2).Table 2
Comparison of serum-related indexes before and after treatment in children.
Leukocyte (×109/L)Platelets (×109/L)CRP (mg/L)ESR (mm/h)Before treatment17.14 ± 4.78380.23 ± 109.7370.33 ± 8.6699.06 ± 10.24After treatment8.24 ± 2.75230.84 ± 54.8120.15 ± 6.0532.41 ± 4.52t14.0710.61841.4151.91P< 0.001< 0.001< 0.001< 0.001


### 3.3. Comparison of VEGF and Endostatin Levels before and after Treatment in Children

After gamma globulin treatment, VEGF levels were 41.73 ± 6.31 pg/L and endothelial inhibitory hormone levels were 16.53 ± 1.47 ng/L. Before treatment, VEGF levels were 198.47 ± 17.36 pg/L and endothelial inhibitory hormone levels were 40.62 ± 2.13 ng/L.Before treatment, VEGF levels were 198.47 ± 17.36 pg/L and endothelial inhibitory hormone levels were 40.62 ± 2.13 ng/L. VEGF and endothelial inhibitory hormone levels decreased significantly after treatment in children (P<0.001). After gamma globulin treatment, VEGF and endostatin were significantly lower than those before treatment (Table 3).Table 3
Comparison of VEGF and endostatin levels before and after treatment in children.
VEGF (pg/L)Endostatin (ng/L)Before treatment198.47 ± 17.3640.62 ± 2.13After treatment41.73 ± 6.3116.53 ± 1.47t73.97681.148P< 0.001< 0.001


### 3.4. Changes of Coronary Artery Diameter in Children before and after Treatment

After gamma globulin treatment, the internal diameter of the left coronary artery was 2.70 ± 0.86 mm and that of the right coronary artery was 2.90 ± 0.35 mm. After treatment, the internal diameter of the left coronary artery was 4.30 ± 1.13 mm and that of the right coronary artery was 3.10 ± 1.02 mm. The coronary artery internal diameter of the children improved significantly after treatment (P<0.001) (Table 4) (Figure 1).Table 4
Changes of coronary artery diameter before and after treatment in children.
Inner diameter of the left coronary artery (mm)Inner diameter of the right coronary artery (mm)Before treatment4.30 ± 1.133.10 ± 1.02After treatment2.70 ± 0.862.90 ± 0.35t9.8231.263P< 0.001< 0.001Figure 1
Changes in the inner diameter of the left and right coronary arteries before and after treatment. (a) The ultrasound results of the left coronary artery and (b) the right coronary artery before treatment. (c) The ultrasound results of the left coronary artery and (d) the right coronary artery three months after gamma globulin immunoblocking therapy.
(a)(b)(c)(d)


## 3.1. Disappearance Time of Symptoms and Signs and Length of Hospital Stay

The time when the symptoms and signs disappeared and the length of hospital stay are given in Table1.Table 1
Disappearance time of symptoms and signs and length of hospital stay.
CasesAntipyretic timeCervical lymphadenopathy resolution timeMucous membrane hyperemia disappearance timeHand and foot swelling subsides timeHospital stay763.79 ± 0.516.81 ± 1.654.03 ± 0.774.19 ± 1.258.67 ± 0.76


## 3.2. Serum-Related Index Levels before and after Treatment in Children

Leukocyte level in the child after gamma globulin treatment was 8.24 ± 2.75 × 109/L compared to 17.14 ± 4.78 × 109/L before treatment. Platelet level in the child after gamma globulin treatment was 230.84 ± 54.81 × 109/L compared to 380.23 ± 109.73 × 109/L before treatment; CRP levels were 70.33 ± 8.66 mg/L before treatment and 70.33 ± 8.66 mg/L after treatment; ESR levels were 99.06 ± 10.24 mm/h before treatment and 99.06 ± 10.24 mm/h after treatment; the serum levels of the relevant indicators decreased in all children after gamma globulin treatment (P<0.001) (Table 2).Table 2
Comparison of serum-related indexes before and after treatment in children.
Leukocyte (×109/L)Platelets (×109/L)CRP (mg/L)ESR (mm/h)Before treatment17.14 ± 4.78380.23 ± 109.7370.33 ± 8.6699.06 ± 10.24After treatment8.24 ± 2.75230.84 ± 54.8120.15 ± 6.0532.41 ± 4.52t14.0710.61841.4151.91P< 0.001< 0.001< 0.001< 0.001


## 3.3. Comparison of VEGF and Endostatin Levels before and after Treatment in Children

After gamma globulin treatment, VEGF levels were 41.73 ± 6.31 pg/L and endothelial inhibitory hormone levels were 16.53 ± 1.47 ng/L. Before treatment, VEGF levels were 198.47 ± 17.36 pg/L and endothelial inhibitory hormone levels were 40.62 ± 2.13 ng/L.Before treatment, VEGF levels were 198.47 ± 17.36 pg/L and endothelial inhibitory hormone levels were 40.62 ± 2.13 ng/L. VEGF and endothelial inhibitory hormone levels decreased significantly after treatment in children (P<0.001). After gamma globulin treatment, VEGF and endostatin were significantly lower than those before treatment (Table 3).Table 3
Comparison of VEGF and endostatin levels before and after treatment in children.
VEGF (pg/L)Endostatin (ng/L)Before treatment198.47 ± 17.3640.62 ± 2.13After treatment41.73 ± 6.3116.53 ± 1.47t73.97681.148P< 0.001< 0.001


## 3.4. Changes of Coronary Artery Diameter in Children before and after Treatment

After gamma globulin treatment, the internal diameter of the left coronary artery was 2.70 ± 0.86 mm and that of the right coronary artery was 2.90 ± 0.35 mm. After treatment, the internal diameter of the left coronary artery was 4.30 ± 1.13 mm and that of the right coronary artery was 3.10 ± 1.02 mm. The coronary artery internal diameter of the children improved significantly after treatment (P<0.001) (Table 4) (Figure 1).Table 4
Changes of coronary artery diameter before and after treatment in children.
Inner diameter of the left coronary artery (mm)Inner diameter of the right coronary artery (mm)Before treatment4.30 ± 1.133.10 ± 1.02After treatment2.70 ± 0.862.90 ± 0.35t9.8231.263P< 0.001< 0.001Figure 1
Changes in the inner diameter of the left and right coronary arteries before and after treatment. (a) The ultrasound results of the left coronary artery and (b) the right coronary artery before treatment. (c) The ultrasound results of the left coronary artery and (d) the right coronary artery three months after gamma globulin immunoblocking therapy.
(a)(b)(c)(d)


## 4. Discussion

KD, also known as cutaneous mucosal lymph node syndrome, is an acute systemic vasculitis and a common autoimmune disease in pediatrics [14]. The incidence of KD is increasing year by year, often impairing cardiac function in children and leading to coronary heart disease, and is gradually attracting widespread medical attention [15]. Although the pathogenesis has not been elucidated, genetic studies have identified several susceptibility genes for KD and its sequelae in different ethnic groups, including FCGR2A and CD40 [16]. Recent studies have found [17] that KD may be induced by the entry of one or more pathogenic microorganisms into the organism and is a systemic vascular inflammatory disease characterized by immune activation or immune dysfunction. Gamma globulin contains multiple antibodies in serum of healthy individuals and is a passive immunotherapy [18, 19]. It has a neutralizing effect on autoantibodies, can relieve the effect of microbial toxins and vascular inflammation, reduce the level of inflammatory factors, promote the negative feedback of immune regulatory cells, improve cellular immunity and humoral disorders, and control the deterioration of symptoms. The application of high-dose gamma globulin in the acute phase can block all immune responses that cause vascular damage and reduce platelet aggregation, thereby reducing coronary artery damage to a certain extent, that is, reducing coronary artery dilatation. Reducing the rate of change and giving gamma globulin therapy to children with KD in a timely manner to prevent complications such as myocardial infarction and impaired coronary artery function in children with KD significantly improves the safety and health of children [20, 21].The results of this study showed that after the children received intravenous gamma globulin, the inner diameter of the left and right coronary arteries was significantly reduced (P<0.05), and the levels of white blood cells, platelets, CRP, ESR, VEGF, and endostatin were significantly decreased compared with those before treatment (P<0.05). The mechanism of action may be the more types and components of antibodies contained in gamma globulin, the more IVIG can inhibit the activity of FC receptors on lymphocytes, monocytes, macrophages, and other immune cell walls. (1) The more types and components of antibodies contained in gamma globulin, the more obvious the inhibitory effect of IVIG on the FC receptor activity of lymphocytes, mononuclear macrophages, and other immune cell walls, thus weakening the activation of a large number of immune cells, which can inhibit the inflammatory response, effectively relieve the toxic reactions in children, reduce the stimulation of inflammatory factors to the endovascular cortex, and reduce the occurrence of coronary artery lesions by improving the level of immune factors in children in the short term [22]; (2) activation of platelet-derived growth factors and their vascular pathways, reducing the degree of endothelial damage and thus the degree of vascular immune damage; (3) inhibition of B cell lymphocyte activity, resistance to toxin damage to children’s vascular cells, and competitive binding requiring relevant receptors on the vessel wall, leading to massive immune complex deposition; (4) reduction of platelet levels, reducing the risk of thrombosis, which can effectively improve coronary artery dilation and reduce damage to the coronary arteries, thus reducing the incidence of coronary artery disease.When gamma globulin preparations are injected, allergic-like reactions may occur, with side effects such as anaphylaxis in severe cases, which may be caused by the presence of traces of IgG aggregates in the preparations, which activate complement and cause basophils to release bioactive substances, such as histamine, or by the formation of immune complexes between antigens in the body and antibodies in the preparations during infection, which activate complement [23–25]. In addition to Western medicine, Kawasaki disease is classified in Chinese medicine as a warm and hot disease, and therefore, Chinese medicine treatment focuses on clearing heat and detoxifying toxins and promoting blood circulation [26]. Kawasaki disease is an external or warm-heat toxin that enters through the nose and mouth, manifesting itself as a transmigration process of the defense (wei), vital energy (qi), nutrient (ying), and blood (xue), with the lung and stomach being the main organs affected, and the liver and kidneys may be involved [27]. The treatment is based on clearing heat and detoxification, activating blood circulation and resolving blood stasis, paying attention to nourishing the stomach and nourishing fluid, and protecting the heart [26,2 8]. In the treatment of KD, Chinese medicine is mainly based on the differentiation of Wei-Qi and Ying-Blood. The treatment can be carried out with Yin Qiao San, Qing Ying Tang, or Bamboo Leaf and Gypsum Tang [28]. As blood stasis is always present in Chuan teratology, blood stasis activators such as Salvia miltiorrhiza and Radix Paeoniae should be used throughout the treatment to control the abnormal increase of platelets, reduce platelet aggregation, lower blood viscosity, prevent coronary aneurysm, and shorten the course of treatment [28, 29].


## 5. Conclusion

To sum up, gamma globulin has a significant effect in the treatment of KD, which can improve the levels of white blood cells, platelets, CRP, ESR, VEGF, and endostatin in children and helps to inhibit the inflammatory response and significantly reduce coronary artery dilation. Echocardiography is of high value in the examination of children with KD. It can accurately detect the size, location, and inner diameter of coronary artery lesions and can effectively evaluate the therapeutic effect on children.



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