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What was the research about?

Kawasaki disease is a rare childhood illness that inflames blood vessels. Symptoms include high fever; rash; and swollen tongue, hands, and feet. The disease can sometimes cause a dangerous bulge, called an aneurysm, in the blood vessels that supply the heart.

Most children recover from Kawasaki disease after treatment with intravenous immunoglobulin, or IVIG. But in 10 to 20 percent of children, fever persists or returns, which doctors call resistant Kawasaki disease. These children have a high risk of aneurysm.

In this study, the research team looked at the safety and effectiveness of two treatments for children with resistant Kawasaki disease:

• A second dose of IVIG
• A medicine called infliximab

What were the results?

Infliximab was safe and effective for children with resistant Kawasaki disease. Compared with children who received a second dose of IVIG, children who received infliximab:

• Were less likely to have fever after treatment.
• Had shorter hospital stays.
• Had fewer side effects and serious adverse events such as anemia. The research team defined a serious adverse event as one that resulted in a hospital stay, disability, or even death.

The two treatments didn’t differ in:

• Heart scores that measure if a child has an aneurysm.
• Lab tests that measure inflammation.

Who was in the study?

The study included 103 children ages 4 weeks to 17 years with resistant Kawasaki disease. All received care at one of 30 health centers across the United States. Among children, 58 percent were White, 18 percent were Black or African American, 11 percent were Asian, 8 percent were more than one race, and less than 4 percent were unknown or other races. The average age was 2, and 57 percent were boys.

What did the research team do?

The research team assigned children by chance to receive either a second dose of IVIG or infliximab. All children had received a first dose of IVIG and had a fever that persisted or returned within 36 hours. Children who still had a fever seven days later took the other treatment.

Parents completed surveys about their child’s symptoms four times on the first day of treatment and then once daily for two weeks. Children had an echocardiogram when they started the study and two weeks after leaving the hospital. An echocardiogram uses sound waves to take pictures of the heart.

People who had Kawasaki disease as children, and parents of children with Kawasaki disease, gave input on the study.

What were the limits of the study?

Doctors across health centers may have interpreted echocardiogram results differently. Also, the study didn’t enroll children who already had aneurysms from Kawasaki disease. Results may differ for these patients.

Future research could look at the best dose of infliximab for children with resistant Kawasaki disease. Studies could also include children with heart damage from Kawasaki disease.

How can people use the results?

Doctors and parents can use these results when considering treatment for children with resistant Kawasaki disease.

Objective

To compare the effectiveness of infliximab versus a second dose of intravenous immunoglobulin (IVIG) in resolving fever among children with IVIG-resistant Kawasaki disease.

Study Design

Kawasaki disease is a rare, systemic vasculitis of unknown etiology that affects infants and children and can damage the coronary arteries. Children with Kawasaki disease have symptoms such as fever, rash, swollen hands and feet, oral mucosal changes, and swollen lymph nodes. IVIG-resistant Kawasaki disease occurs when fever persists or returns within 36 hours of receiving an initial dose of IVIG.

This randomized controlled trial compared the effectiveness of infliximab versus IVIG in resolving fever; improving coronary artery measurement that indicates risk of an aneurysm; and reducing inflammation, adverse events, and hospitalization among children with IVIG-resistant Kawasaki disease.

Researchers randomly assigned children with IVIG-resistant Kawasaki disease to receive either infliximab or a second dose of IVIG. Children whose fever did not resolve within seven days after receiving their assigned medication switched to the other study medicine.

The study included 103 children with IVIG-resistant Kawasaki disease treated at one of 30 health centers across the United States. Of these children, 58% were White, 18% were Black or African American, 11% were Asian, 8% were multiple races, and less than 4% were unknown race or other races. The average age was 2, and 57% were male.

Parents completed questionnaires about children’s symptoms four times within the first 24 hours after their children started treatment, and then recorded symptoms and temperatures once daily for two weeks. Children had an echocardiogram at baseline and two weeks after hospital discharge.

People who had Kawasaki disease as children and parents of children with Kawasaki disease provided input on the study.

Results

Compared with children who received a second dose of IVIG, children who received infliximab:

• Were more likely to achieve resolution of fever (odds ratio=3.12; 95% confidence interval: 1.36, 7.52)
• Had fewer days in the hospital after treatment (mean days=3.2 versus 4.5; p<0.001)
• Experienced fewer adverse events (45 versus 65; p=0.029) and serious adverse events (15 versus 36; p<0.001)

Median coronary artery z-scores and laboratory measures of inflammation did not differ significantly between the two treatments.

Limitations

Because the study did not use a central laboratory to read the echocardiograms, health centers may have interpreted the results differently. The study did not enroll children who already had aneurysms from Kawasaki disease at baseline. Results may differ for these patients.

Conclusions and Relevance

In this study, compared with a second dose of IVIG, infliximab was a safe and effective treatment for children with IVIG-resistant Kawasaki disease.

Future Research Needs

Future research could evaluate the optimal dose of infliximab for children with IVIG-resistant Kawasaki disease. Studies could also compare treatment options for children with heart damage from Kawasaki disease.