In our study, 460 cases of patients who were admitted to Motahari Hospital of Urmia between 2009 and 2019 with an initial diagnosis of Kawasaki disease were initially examined. Of these, patients who met Kawasaki diagnostic criteria entered the final review and the remaining cases were excluded from the study according to the exclusion criteria. Finally, out of 460 cases, 241 patients were included in the final analysis (Table 1, 2).
Age
In our study, the mean age was 34.86 ± 25.6 months with a minimum age of 2 and a maximum of 132 months. The mean age was 32.62 ± 24.97 months in patients who responded well to treatment and 38.75 ± 26.35 months in patients who did not respond well to IVIG treatment. In age analysis, age had no significant relationship with response to disease treatment (p-value = 0.192).
Gender
The number of male patients compared to female patients in our study was 137 to 104 with a relative prevalence of 56.8–43.2%, respectively. This rate was 85 to 52 in patients who responded well to treatment and 67 to 36 in patients who did not respond well to IVIG treatment, respectively. Statistical analysis showed that the response rate to treatment based on gender in these patients in our study was not significantly different (p-value = 0.8).
Conjunctivitis
Among the 241 patients in the study, the presence of conjunctivitis was reported to be positive in 130 (53.9%) patients with a relative prevalence of. While 110 patients (46.1%), had no symptoms of conjunctivitis during hospitalization.
Mucosal Membranes Changes
In this study, we examined changes in mucous membranes including hyperemia or erythema of the throat, dry and cracked lips, lip hyperemia, and strawberry tongue from patients' histories. The results showed that 195 patients (80.9%) had one of the above symptoms in the history and clinical examinations while 46 patients (19.1%) did not have any of the above symptoms.
Changes in Extremes
This criterion included one or more changes in the extremities, including peripheral erythema, peripheral edema, scaling around the nails, and pervasive scaling. According to our results, only 58 patients (24.1%), had one or more of these symptoms, and 183 patients (75.9%), did not have these symptoms.
Polymorphic rash and erythema of the hands and feet
Polymorphic rashes mainly on the trunk were examined in this study. Of the patients in the study, 117 patients (48.5%) had this rash, while 124 patients (51.5%), were without this symptom. Erythema in the hands or feet was present in 48 patients (19.9%) but 193 patients (80.1%) did not have this symptom.
Lymphadenopathy
Cervical lymphadenopathy with a diameter of more than 1.5 cm was defined as the presence of lymphadenopathy in the disease criteria in this study. In this case, 66 patients (27.4%) had cervical lymphadenopathy, while 175 patients (72.6%) had not cervical lymphadenopathy.
Neutrophils to lymphocytes ratio
In the present study, the mean ratio of neutrophils to lymphocytes in patients who responded to appropriate treatment was 3.06 ± 2.89, while in patients who did not respond appropriately to treatment, this ratio was 4 ± 3.51. This ratio was not significantly related to the response to IVIG treatment in Kawasaki patients (p-value = 0.058).
Blood neutrophil and lymphocyte count
The mean number of neutrophils and lymphocytes in our patients was 6286 ± 1708 and 3150 ± 2983 per mm3, respectively. None of these cells had a significant relationship with the response to IVIG treatment in Kawasaki patients (neutrophil p-value = 0.27, lymphocyte p-value = 0.14).
C-Reactive Protein
The acute phase reactant CRP was quantitatively investigated in the present study. The mean CRP of patients was 27.65 ± 41.90 mg/L. This rate was 40.79 ± 26.33 mg/L in patients with the appropriate response to treatment and 43.84 ± 29.88 mg/L in patients with resistance to treatment. Analysis of the results showed that there was no significant difference in CRP level with response to IVIG treatment in Kawasaki patients (p-value = 0.16).
Blood leukocytes
The mean number of leukocytes in patients with an appropriate response to treatment was 14266 ± 6291 per mm3 and in patients who were resistant to treatment was 13450 ± 4443 per mm3. This rate was significantly different in the responsive to with resistant to IVIG treatment in Kawasaki patients. The number of blood leukocytes in patients who responded to appropriate treatment was significantly higher than patients who were resistant to IVIG treatment(p-value = 0.013).
Hypoalbuminemia
In the present study, hypoalbuminemia was defined as less than 3 g/dl, in which 13 patients (5.4%), had albumin below 3 and 228 patients (94.6%), had albumin equal to or above 3 g/dL. Data analysis did not show a significant relationship between hypoalbuminemia and response to treatment in the present study (p-value = 0.18).
Alanine transaminase
The level of blood ALT enzyme in patients was adjusted according to the age of patients and was divided into two states, normal and normal in which 46 patients (19.1%) had elevated ALT enzyme, while 195 patients (80.9%) had normal ALT enzyme levels. Data analysis showed that there was no significant relationship between response to treatment and increase in ALT enzyme (p-value = 0.15).
Anemia
After adjusting the hemoglobin level based on the age of the patients and determining the presence or absence of anemia, the results showed that 182 patients, (75.5%) have had anemia and 59 patients (24.5%) had normal hemoglobin. Data analysis did not show a significant difference between the presence of anemia and response to treatment in the present study (p-value = 0.15).
Thrombocytosis
Platelets above or equal to 450,000 per mm3 were considered thrombocytosis in the present study, and 91 patients (37.8%), had thrombocytosis, while 150 patients (62.2%), had platelets below 450,000. Data analysis did not show a significant difference between the presence of thrombocytosis and response to treatment in the present study (p-value = 0.53).
Pyuria
The presence of leukocytes above 10 per HPF[1] in the urine of patients was considered as the presence of pyuria in the present study. 73 patients (30.3%) of patients had pyuria but 168 patients (69.7%) of patients without pyuria. Data analysis showed that there is a significant difference between pyuria and response to treatment, so that in patients with leukocytes less than 10 or 10 per urine HPF, the response to treatment was significantly higher than patients with urinary leukocytes per HPF more than 10 (p-value = 0.01).
Echocardiographic criteria
Echocardiographic criteria studied in the present study included LAD or RCA coronary artery transparency with a Z-score between 2 and 2.5, no reduction in vascular diameter, decreased left ventricular function, mitral valve insufficiency and pericardial effusion. There were two criteria of decreased left ventricular function and vascular transparency, each in only 3 patients, which was equivalent to 1.2% of patients, while in 98.8 patients, these echocardiographic criteria were not reported. No reduction in vascular diameter was present in 16 patients, equivalent to 2.9% of patients, while this criterion was reported negatively in 224 patients, equivalent to 93.3% of patients. Mitral valve insufficiency of any severity was positive in 6 patients (2.5% of patients) and finally only 1 patient (0.4% of patients) had pericardial effusion.
Kawasaki diagnostic criteria
Among the patient records in the present study, 128 patients met Kawasaki main criteria, 109 patients did not meet the diagnostic criteria and had 2 or 3 main criteria along with 3 complementary criteria with fever for more than 5 days and 4 patients They had echocardiographic criteria for the disease. The relative frequency of these patients was 53.11%, 45.22% and 1.67%, respectively.
Resistance and response to treatment
Response to treatment in the present study was defined as cessation of fever up to 24 hours after the start of IVIG treatment with no recurrence, and resistance to treatment was defined as persistent fever in patients after 24 hours despite initiation of IVIG administration. However, 153 patients (63.5%) showed appropriate response and 88 patients (36.5%) showed resistance to treatment.
The interval between the start of treatment and the onset of symptoms
The mean time interval between the start of treatment and the onset of symptoms in the studied patients was 3.86 3. 6.86 days. This criterion also had no significant relationship with response to treatment with response to IVIG treatment in Kawasaki patients (p-value = 0.11).
Footnote:
[1] High power field of urine analysis by microscope