Wang Wang
Liyan Zhu2†
Zhiheng Liu
Haitao Lv
Guanghui Qian- 1Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
- 2Department of Experimental Center, Medical College of Soochow University, Suzhou, China
- 3Department of Cardiology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
Kawasaki disease (KD) is a systematic vasculitis that is often complicated by coronary artery lesions and is a leading cause of acquired heart disease in developed countries. Previous studies have suggested that genetic susceptibility, together with an inducing infectious agent, could be involved in KD pathogenesis; however, the precise causative agent of this disease remains unknown. Moreover, there are still debates concerning whether KD is an infectious disease or an autoimmune disease, although many studies have begun to show that various pathogens functioning as critical inducers could activate different kinds of immune cells, consequently leading to the dysfunction of endothelial cells and systematic vasculitis. Here in this review, we attempt to summarize all the available evidence concerning pathogen infections associated with KD pathogenesis. We also discuss the related mechanisms, present a future perspective, and identify the open questions that remain to be investigated, thereby providing a comprehensive description of pathogen infections and their correlations with the host immune system in leading to KD.
1 Introduction
Pathogen infectious diseases have posed a great challenge to human health worldwide (Baldari et al., 2023). Currently, various pathogens have been suggested as critical triggers in inducing systematic vasculitis in children with Kawasaki disease (KD), which is a leading cause of acquired heart disease in developed countries (McCrindle et al., 2017). High-dose intravenous immunoglobulin (IVIG) infusion and aspirin can subdue KD symptoms and partially reduce the occurrence of coronary artery lesions (CALs); however, approximately 10%–20% of affected children develop recrudescent or persistent fever even after IVIG infusion, and those patients have a higher risk of CAL (Li et al., 2018; Nadig et al., 2023). Critically, if this disease is not untreated in a timely manner, sudden death may occur due to coronary artery aneurysms (Shulman and Rowley, 2015; McCrindle et al., 2017; Sosa et al., 2019). Although genetic background (Chang et al., 2014), urban industrialization, environmental factors (Chang et al., 2020; Corinaldesi et al., 2020), and regional winds together with large-scale atmospheric circulation (Rodo et al., 2011, 2014), have been suggested to correlate with KD, these theories fail to explain the seasonal epidemics of this illness, and also fail to explain why Kawasaki disease does not broadly recur. Nevertheless, an increasing number of epidemiological and clinical data all point to KD having an infectious etiology. For example, epidemiological data from multiple centers worldwide demonstrate that KD has a significant seasonal epidemic (Valtuille et al., 2023), frequent occurrence, and low recurrence characteristics in young children (Nakamura et al., 2008, 2012; Burns et al., 2013; Lin et al., 2015; Ozeki et al., 2017, 2018; Kido et al., 2019; Kim et al., 2020; Xie et al., 2020). Notably, several studies have shown that both the immune repertoire (Kuo et al., 2019) and the heterogeneous host immune response including the autoantibody responses in KD children resemble those observed in patients with bacterial or viral infections (Lindquist and Hicar, 2019; Jackson et al., 2021; Ghosh et al., 2022), lending further support of an infectious disease cause of KD.
Additionally, serum KD-specific molecules which were mostly derived from biofilms possessed molecular structures common to MAMPs (microbe-associated molecular pattern) from Bacillus cereus, B. subtilis, Yersinia pseudotuberculosis (Y. pstb), and Staphylococcus aureus (Kusuda et al., 2014), implicating a possible relationship between MAMPs and the etiological mechanism of KD vasculitis. Recently, at least 14 types of viruses have been suggested to correlate with KD based on serological and polymerase chain reaction (PCR) analysis of clinical samples (Principi et al., 2013). However, another study showed that at least 15 types of viruses were related to KD because the isolation rates of various viruses in KD patients were significantly higher than those in the control group (Huang et al., 2015; Jackson et al., 2021). Viral infections can cause vascular damage either through direct invasion of the vascular endothelium or provoking a rapid cell-damaging event (Hara et al., 2021). This in turn results in a larger release of proinflammatory cellular components from damaged endothelial cells, pyroptosis, or proinflammatory cell death (Mohandas et al., 2023), hence making various kinds of innate immune cells infiltrate the coronary arteries of KD subjects (Kuijpers et al., 1999; Takahashi et al., 2010a). These data thus suggest that different kinds of microbes are implicated in the pathogenesis of KD, but which microbes are the key inducers and the underlying mechanisms remain unclear. In this review, to better understand the comprehensive profiles between microbial infection and KD pathogenesis, we summarized the major features of our current understanding with respect to various pathogens related to KD. We also discuss the state of this field in KD with respect to the relationship and/or mechanisms concerning the abnormal immune response triggered by various infectious agents, and the open questions that remain to be investigated.
2 Involvement of pathogens during KD pathogenesis
2.1 Viral infection and KD
2.1.1 DNA viruses
Several DNA viruses, including Epstein–Barr virus (EBV), human adenovirus, human parvovirus B19, torque teno virus, herpes family virus, varicella zoster virus, bocaparvo virus, and cytomegalovirus have been identified to be associated with KD pathogenesis.
2.1.1.1 Human adenovirus
Adenovirus type 2 was first isolated from a patient with fatal Kawasaki disease (Embil et al., 1985), while another case report showed that human adenovirus infection can be found in monozygotic twin boys who developed KD (Fukuda et al., 2017). Among the adenovirus-infected cohort, the overall incidence of KD was 5.29 times higher than that of the non-adenovirus-infected control subjects (adjusted HR 5.29, 95% CI: 2.48–11.3), as shown by a population-based cohort study (Huang et al., 2020), suggesting a correlation between adenovirus infection and KD pathogenesis. Notably, there are also studies showing a lack of association between adenovirus infection and KD, suggesting that more intense research is needed to explore the relationships between adenovirus infections and KD (Okano et al., 1990; Shike et al., 2005).
2.1.1.2 Human parvovirus B19
Human parvovirus B19 (HPV-B19) is a single-stranded DNA virus that may have a pathogenic role in the development of KD with other predisposing factors because it can cause symptoms resembling those observed in KD patients (Nigro et al., 1994; Holm et al., 1995). Importantly, HPV-B19 infection should be considered in the differential diagnosis of KD patients who show atypical clinical symptoms during the erythema infectiosum epidemic stage (Oura et al., 2022).
2.1.1.3 Torque teno virus
The torque teno virus (TTV), which is a single-stranded circular DNA virus, was first found in the lymph node of a KD patient (Katano et al., 2012). For instance, a high viral load of torque teno virus 7 (TTV7) was identified in KD patients (Thissen et al., 2018; Spezia et al., 2023a), and the viral load of TTV positively correlated with the level of total bilirubin and aspartate aminotransferase in KD patients (Spezia et al., 2023b), suggesting that TTV might play a critical role in the pathophysiology of patients with KD.
2.1.1.4 Herpes simplex virus
Herpes simplex virus (HSV) consists of multiple subtypes (Rowley et al., 2011), and its family members, including EBV, HHV-6 and varicella-zoster, were all found to be involved in KD. For instance, a previous study showed that the DNA sequence of EBV can be detected in KD patients (Kikuta et al., 1988), and there are many cases of KD-like lesions, specifically coronary artery aneurysms (CAAs), that were suggested to be caused by EBV infection (Kikuta et al., 1993; Rosenfeld et al., 2020; Xiao et al., 2020). However, EBV might not be the direct causative agent of KD, as shown by another study (Kikuta et al., 1990). Notably, a case of Kawasaki disease triggered by EBV virus infection was found to be complicated with familial Mediterranean fever (Maggio et al., 2019). Moreover, the prevalence of EBV in KD children was significantly lower during the early stage (van Stijn et al., 2020), and deoxyuridine 5′-triphosphate nucleotide hydrolase (dUTPase), a pathogen nonstructural protein encoded by EBV, can stimulate monocyte-derived macrophages through Toll-like receptor 2-dependent signaling transduction (Ariza et al., 2009), suggesting that DUTPase could be used as a potential target for drug development against EBV infection and KD treatment.
In addition to EBV, certain KD patients also have concomitant varicella zoster virus or coxsackievirus A4 infection (Turkay et al., 2006; Toprak et al., 2015). Given that the features of HHV6-infected patients resemble those symptoms observed in KD children (Kakisaka et al., 2012; Alramadhan et al., 2020), HHV-6B was thus suggested to be a critical mediator during the pathogenesis of KD, and HHV-6B infection was also suggested to be responsible for the increased number of KD patients during the SARS-CoV-2 pandemic (Dursun and Temiz, 2020).
2.1.1.5 Bocavirus
Human bocavirus (HboV) is a single-stranded DNA etiologic agent that has been suggested as a cause of acute respiratory tract infection in children (Schildgen et al., 2008). This virus was first identified in nasopharyngeal, serum or stool samples, and was thus suggested to play a pathogenic role in some cases of Kawasaki disease (Catalano-Pons et al., 2007). Late, this work was verified by the results from another group showing that HboV can indeed be detected in nasopharyngeal secretions of KD patients, demonstrating a coincidental or possible etiological association between HboV infection and KD pathogenesis (Santos et al., 2011). Furthermore, a significant correlation between HboV infection and KD incidence was identified based on epidemiological data (Kim et al., 2014; Lim et al., 2021), whereas some investigators have proposed that there is little correlation between HboV infection and KD based on the serological test (Lehmann et al., 2009). Cytomegalovirus was also suggested to be involved in the development of atypical KD and coronary aneurysms (Catalano-Pons et al., 2005; Guc et al., 2008). Taken together, more intense researches is needed to elucidate the precise mechanism concerning DNA viruses associated with KD pathogenesis.
2.1.2 RNA viruses associated with KD
Apart from the DNA viruses mentioned above, a total of nine types of RNA viruses have been suggested to correlate with KD pathogenesis, including coxsackie virus, enterovirus, human coronavirus NL63 (HCoV-NL63), influenza virus, measles virus, SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2), feline virus, influenza A virus H1N1 and human immunodeficiency virus, as discussed below.
2.1.2.1 Coxsackie virus
The coxsackie virus, which belongs to enteroviruses of small RNA viridine, has been identified as the main cause of viral myocarditis in humans since 1955 (Dalldorf, 1955). Both coxsackie virus B3 (CVB3) and coxsackie virus A4 were identified to correlate with KD (Rigante et al., 2012; Ueda et al., 2015), and this type of virus can induce neonatal symptoms similar to viral myocarditis observed in KD (Verma et al., 2009).
2.1.2.2 Enterovirus
It has been demonstrated that the KD incidence in the enterovirus (EV)-infected cohort was significantly higher than that in the non-EV-infected cohort (Weng et al., 2018), thereby indicating a high correlation between EV infection and KD. In addition, a decreased incidence of severe enterovirus infection cases is simultaneously correlated with decreased KD hospitalizations during the SARS-CoV-2 epidemic (Guo et al., 2022), thus suggesting that enterovirus might function as a critical mediator during the pathogenesis of KD.
2.1.2.3 HCoV-NL63 virus
Although HCoV-NL63 was once identified in several KD patients (Dominguez et al., 2006), most data later do not support an association between HCoV-NL63 infection and KD (Baker et al., 2006; Chang et al., 2006; Lehmann et al., 2009). In fact, only 1 (2%) of 48 patients with KD was found to be positive for HCoV-NL63/NH (Shimizu et al., 2005), although HCoV-229E was also suggested to be involved in KD (Lehmann et al., 2009; Shirato et al., 2014).
2.1.2.4 Influenza virus
Influenza viruses have been revealed to positively correlate with the monthly KD incidence (Kim et al., 2014). For instance, influenza A H1N1/09 virus has been shown to be associated with the pathogenesis of KD by several groups (Joshi et al., 2011; Wang et al., 2019; Banday et al., 2021). Additionally, Parainfluenza type 3 virus (PIV-3) was also found to correlate with KD (Schnaar and Bell, 1982; Karron et al., 1993), suggesting that influenza virus infection has etiological importance in the development of KD. However, given that concomitant influenza infection affects the clinical manifestations of KD and impacts the laboratory test results of the disease (Huang et al., 2015), it remains to be determined regarding influenza infection and KD pathogenesis.
2.1.2.5 Measles virus
The measles virus (MeV), which is an enveloped RNA virus, frequently causes acute febrile illness accompanied by a rash (Takemoto et al., 2022). This virus can be isolated from KD children, and the symptoms caused by MeV infection partially resemble those observed in KD patients (Whitby et al., 1991; Kuijpers et al., 2000).
2.1.2.6 SARS-CoV-2
The RNA respiratory virus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) can induce multisystem inflammatory syndrome in children (also called MIS-C), including multifocal endovascular dermatitis, thrombosis, and systemic thrombotic microangiopathy, which resemble certain features observed in KD (Ackermann et al., 2020; Consiglio et al., 2020; Loomba et al., 2020; Bukulmez, 2021; Cherqaoui et al., 2021; Sancho-Shimizu et al., 2021; Sokolovsky et al., 2021; Zhang et al., 2021).
Moreover, SARS-CoV-2 can be detected in certain KD patients, and a host of SARS-CoV-2-positive patients exhibit KD-like syndrome (Consiglio et al., 2020; Jones et al., 2020; Toubiana et al., 2020; Sharma et al., 2021). However, although high titers of anti-SARS-CoV-2 antibodies have been detected both in KD and multisystem inflammatory syndrome patients (Kabeerdoss et al., 2021), the two diseases are different because of the differential T-cell subsets, interleukin (IL)-17A, and biomarkers associated with arterial damage (Consiglio et al., 2020). On the other hand, global studies have reported that the incidence of KD declined during the COVID-19 pandemic, suggesting a potential KD pathogenesis involving transmission among children (Ae et al., 2022). However, several earlier studies showed that the KD incidence has increased during the pandemic (Ouldali et al., 2020; Roe, 2020; Stower, 2020; Viner and Whittaker, 2020), supporting the hypothesis that KD might be caused by an unknown RNA virus that may function as the main trigger in inducing abnormal immune responses in genetically susceptible individuals.
2.1.2.7 Other types of RNA viruses
In addition to the RNA viruses mentioned above, several other types of RNA viruses were also found to be involved in KD. For example, both a novel feline virus (Moynahan, 1987) and the influenza A virus (Wang et al., 2019) were suggested to be related to KD symptoms. Notably, HIV patients also show symptoms similar to those observed in KD patients (Johnson et al., 2016). The intracytoplasmic inclusion bodies induced by viruses can be isolated from KD patients, suggesting that the infectious etiologic agent of KD might be associated with an unknown novel RNA virus (Rowley et al., 2011). In addition, dengue virus was also identified in the serum of certain KD patients in southern Thailand, and mosquitoes were hypothesized to work with the dengue virus to spread the KD pathogen, thus inducing cell proliferation and morphological changes in endothelial cells and coronary arteritis lesions in KD patients (Sopontammarak et al., 2008). Moreover, regions with the highest reported arboviral infections in Venezuela simultaneously have the highest incidence of KD (Paniz-Mondolfi et al., 2020), demonstrating the critical roles of viral infections in mediating the pathogenesis of KD.
2.2 Bacterial infection associated with KD
Regarding bacterial infection, the superantigens produced by gut bacteria may be involved in the onset of KD. Until recently, there were five Streptococcus spp. (S. pneumonia, pseudopneumoniae, oralis, gordonii, and sanguinis) were found to increase during the acute phase in KD patients based on metagenomic sequencing, indicating that Streptococci are involved in the pathogenesis of KD disease (Kinumaki et al., 2015). Furthermore, the stool of KD patients contains higher numbers of gram-positive bacteria, including Streptococcus, Staphylococcus, Eubacterium, and Peptostreptococcus genera, Hsp60-producing gram-negative bacteria, and a lower number of lactobacilli, when compared with those from healthy control children (Yamashiro et al., 1996; Takeshita et al., 2002; Nagata et al., 2009). Specifically, three pathogens, S. pyogenes (Leahy et al., 2012), S. mitis Nm-65 (Tabata et al., 2021), and S. sanguis (Tsurumizu et al., 1991), have been identified in the pleural fluid, tooth surface or blood of KD patients. Additionally, serum IgM antibodies against superantigens of S. aureus and S. pyogenes have been identified in KD patients (Matsubara et al., 2006), and these two pathogens together can produce 19 different superantigens (Llewelyn and Cohen, 2002). Mechanistically, S. aureus isolated from the rectum or pharynx of KD patients can secrete toxic shock syndrome toxin 1 (TSST-1) and staphylococcal protein A, which in turn stimulate Vβ2+ lymphocyte amplification and are thus involved in the abnormal immune responses of KD patients (Leung et al., 1993; Wann et al., 1999; Leung et al., 2002).
Regarding Yersinia pseudotuberculosis (Konishi et al., 1997), the Propionibacterium acnes strain and its products cytopathogenic proteins (CPPs; Kato et al., 1983; Tomita et al., 1987) can all be isolated from KD patients, suggesting a causative role of bacterial infection in mediating the pathogenesis of KD. Moreover, several recent studies suggest that Y. pstb infection is closely related to KD pathogenesis (Kato et al., 2019; Kamura et al., 2020; Miyata et al., 2022; Ohnishi et al., 2022), and the antibody titers of Y. pstb were significantly elevated in both Chinese and Japanese KD patients (Chou et al., 2005; Tahara et al., 2006). In contrast, a recent study showed that the positive rate of Y. pstb infection is much lower in KD patients (Horinouchi et al., 2015; Hayashi et al., 2023), but when the population is exposed to a higher risk of Y. pstb infection, the incidence of KD is much higher (Vincent et al., 2007).
2.3 Mycoplasma pneumoniae and Chlamydia pneumoniae hypothesis related to KD
In addition to the microbes mentioned above, M. pneumoniae infection was identified in an important proportion of KD patients (Umezawa et al., 1989; Ebrahim et al., 2011; Lee et al., 2011; Tang et al., 2016; Wang et al., 2021; Huang et al., 2022). For instance, the M. pneumoniae infection-positive rate in KD patients was significantly higher than that in non-KD patients during the SARS-CoV-2 epidemic (Ding et al., 2021), and certain KD patients were found to be coinfected with M. pneumoniae and Epstein–Barr virus (Huang et al., 2012).
Additionally, the positive rate of serum Chlamydia pneumoniae IgM antibody in KD children was significantly higher than that in the control group (Numazaki and Chiba, 1996); however, another study showed that the link between C. pneumoniae infection and KD pathogenesis or coronary artery lesions remains to be clarified (Chua et al., 2000; Strigl et al., 2000), suggesting that more intense research is needed to confirm the correlations between M. pneumoniae or C. pneumoniae infection and KD pathogenesis.
2.4 Rickettsia infection and KD
Rickettsia-like organisms were also found in biopsies of the skin and lymph nodes of KD patients (Tasaka and Hamashima, 1978). However, in most cases, only Coxiella burnetiid but not Rickettsia conorii, R. typhi, Coxiella burnetii or Ehrlichia phagocytophila was suggested to cause KD-like symptoms in young children (Kafetzis et al., 2001), suggesting its specific causative roles in KD pathogenesis.
2.5 Pathogen infection evidenced from experimental studies with a murine model
Given that the fungus Candida albicans can be isolated from KD patients, and its extract, the Candida albicans water soluble fraction (CAWS) intraperitoneally injected in mice could induce symptoms resembling those observed in KD patients (Murata, 1979; Martinez et al., 2012; Yoshikane et al., 2015; Stock et al., 2016; Noval Rivas and Arditi, 2020). Furthermore, β-glucan, which is the major component of CAWS, is also increased in KD patients (Ishibashi et al., 2014). Mechanistically, the mannoprotein-β-glucan complex of C. albicans can affect the functions of leukocytes, endothelial cells, and platelets in vitro (Kurihara et al., 2003). The systematic vasculitis induced by CAWS in mice can be alleviated after administration of human immunoglobulin or etanercept (Takahashi et al., 2010b; Ohashi et al., 2013). Together, these findings imply that infectious agents might play critical roles in triggering this disease.
Another major KD-like murine coronary arteritis model involves induction by L. casei cell wall extract (LCWE), which is widely used to mimic systematic vasculitis in KD patients (Lehman et al., 1988; Abe et al., 2020). In the LCWE-induced mouse model, the TLR2 and ILβ-dependent signaling pathways were suggested to play important roles during its pathogenesis (Rosenkranz et al., 2005; Lee et al., 2012; Matundan et al., 2019). Additionally, the dectin-1/Syk signaling pathway in macrophages (Lin et al., 2013) and the Notch4 signaling pathway in endothelial progenitor cells are also involved in LCWE-induced coronary artery disease, thereby contributing to the development of KD pathogenesis (Wang et al., 2016). Moreover, LCWE was likewise suggested to function as immunogenic for proinflammatory T helper (Th) 1, Th17, and CD8+ T cells and inducible regulatory T cells (iTreg) (Noval Rivas et al., 2017; Hsieh et al., 2021). Taken together, the systematic vasculitis induced by CAWS or LCWE in mice resembles pathological features observed in KD patients, demonstrating the causative roles of etiological agent infection and related PAMP/MAMP signaling activation in inducing KD vasculitis (Table 1).
Table 1. Microbial etiology demonstrated as critical triggers of Kawasaki disease.
3 Summary and perspective
Taken together, various pathogens identified in KD were all suggested to be the critical triggers in causing systematic vasculitis, and these pathogens were demonstrated to work independently or synergistically to potentiate abnormal immune responses by inducing pyroptosis and/or proinflammatory cell death, hence leading to systematic vasculitis in KD (Figure 1). However, whether these pathogens are direct causes or merely the accompanying pathogens after KD induction remains elusive. Additionally, the causative agent of KD remains ambiguous, and several questions remain to be clarified. First, those pathogens suggested to be involved in the pathogenesis of KD largely rely on PCR and serological methods using a relatively small sample size. Second, the differences in timing of obtaining the blood sample and constraints of the study design used to measure pathogens in KD patients by different investigators could make pathogen identification inconsistent. Third, whether KD is caused by a single pathogen or is the combined result of more than one agent remains to be investigated. Consequently, the relationship between pathogen infection and KD vasculitis is far more complex than currently appreciated. Caution should be exercised in the clinic when considering the possible agents merely based on the symptom similarities between KD and other infectious diseases. Importantly, given that the recognition of the infectious origin of KD is a critical prerequisite to understanding its pathogenetic mechanism, more intense research using artificial intelligence, metagenomic sequencing and culturing specific pathogens isolated from KD patients from multiple centers and then verifying each of them in animal models could help uncover the underlying mechanisms of pathogen infections involved and thus facilitate the development of novel intervention strategies for Kawasaki disease.
Figure 1. Schematic illustrating the pathogenic mechanisms of KD. The superantigens (SAgs) hypothesis and different infectious agents produce pathogen/microbe-associated molecular patterns (PAMPs/MAMPs) were all proposed to be involved in KD pathogenesis. SAgs non-specifically activate T cells and/or B cells. PAMPs/MAMPs also stimulate immune cells [e.g., macrophages (Mφ), dendritic cells (DCs), monocytes (MCs)] and endothelial cells (ECs) through cellular pattern recognition receptors (PRRs; e.g., TLRs, NOD1, and Dectin-1/-2). Additionally, PAMPs/MAMPs can activate the complement lectin pathway through soluble PRRs (e.g., ficolin-1 and mannose binding lectin-2). Activated complement pathways can induce inflammatory vascular damage through recruitment of innate inflammatory cells and direct injury to ECs. This cross-talk among different cells augments the production of proinflammatory cytokines/chemokines and reactive oxygen/nitrogen species (ROS/NOS), hence leading to a systemic inflammatory reaction in KD.
Author contributions
WW: Writing – original draft, Data curation. LZ: Conceptualization, Funding acquisition, Investigation, Writing – original draft. XL: Writing – original draft, Data curation, Project administration. ZL: Data curation, Resources, Writing – original draft. HL: Conceptualization, Investigation, Supervision, Writing – review & editing. GQ: Conceptualization, Funding acquisition, Writing – review & editing.
Funding
The author(s) declare financial support was received for the research, authorship, and/or publication of this article. Work in our lab was funded by the National Natural Science Foundation of China (grant number nos. 82171797, 81971477, 82371806, 81870365, 82070512, and 82270529), the Jiangsu Provincial Social Development Project (grant number SBE2021750252), and the Gusu Health Talent Program (grant number GSWS2020038).
Acknowledgments
The authors thank the editor and reviewers for their constructive comments and suggestions on the paper. We apologize to colleagues in the field whose work could not be cited owing to space limitations.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The reviewer YD declared a shared affiliation with the authors to the handling editor at the time of review.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Abbreviations
BCG, Bacillus Calmette-Guérin; CAA, Coronary artery aneurysm; CAWS, Candida albicans water soluble fraction; DAMP, Damaged-associated molecular patterns; ELISA, Enzyme-linked immunosorbent assay; KD, Kawasaki disease; LCWE, Lactobacillus casei cell wall extract; MAMP, Microbe associated molecular pattern; PAMP, Pathogen associated molecular pattern; PCR, Polymerase chain reaction; PRR, Pattern recognition receptor; SEB, Staphylococcal enterotoxin B; SEC, Staphylococcal enterotoxin C; SPE, Streptococcal pyrogenic exotoxins; TCR, T-cell receptor; TSS, Toxic shock syndrome; TSST-1, Toxic shock syndrome toxin-1.
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Keywords: bacteria, fungi, Kawasaki disease, vasculitis, virus
Citation: Wang W, Zhu L, Li X, Liu Z, Lv H and Qian G (2023) Emerging evidence of microbial infection in causing systematic immune vasculitis in Kawasaki disease. Front. Microbiol. 14:1313838. doi: 10.3389/fmicb.2023.1313838
Edited by:
Svetlana Khaiboullina, University of Nevada, Reno, United StatesReviewed by:
Yueyue Ding, Children's Hospital of Suzhou University, ChinaToshiro Hara, Fukuoka Children’s Hospital, Japan
Tao Li, Hubei University of Medicine, China
Copyright © 2023 Wang, Zhu, Li, Liu, Lv and Qian. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Haitao Lv, haitaosz@163.com; Guanghui Qian, ghqian@suda.edu.cn
†These authors have contributed equally to this work