Kawasaki disease: pathophysiology, clinical manifestations, and management

Kawasaki disease: patients' transition journey and recommendations for adult care

BACKGROUND

Children who develop coronary artery aneurysms after Kawasaki disease are at risk for cardiovascular morbidity, requiring health care transition and lifelong follow-up with an adult specialist. Follow-up losses after health care transition have been reported but without outcome and patient experience evaluation.

OBJECTIVE

The Theoretical Domains Framework underpinned our aim to explore the required self-care behaviours and experiences of young adults' post-health care transition.

METHODS

A qualitative description approach was used for virtual, 1:1 interviews with 11 participants, recruited after health care transition from a regional cardiac centre in Ontario. Directed content analysis was employed.

RESULTS

Health, psychosocial, and lifestyle challenges were compounded by a sense of loss. Six themes emerged within the Theoretical Domains Framework categories. Participants offered novel health care transition programme recommendations.

CONCLUSIONS

The realities of health care transition involve multiple, overlapping stressors for young adults with Kawasaki disease and coronary artery aneurysms. Our findings will inform a renewed health care transition programme and will include outcome evaluation.

Jaundice-predominant manifestation of Kawasaki disease in children

Background

A jaundice-predominant presentation of Kawasaki disease (KD) is atypical.

Methods

A total of 12 children with KD with a predominant manifestation of jaundice at MacKay Children's Hospital were reviewed, along with 42 cases reported in the literature since 1990.

Results

The median age of the 12 patients was 1.85 years (range: 3 months-4 years), and 66.6% were male. All of the patients had elevated liver function at presentation, 50% had hydrops of the gallbladder, and almost 60% had gastrointestinal symptoms and signs. Complete KD was evident in 11 of the 12 patients (91.7%), and two patients (16.7%) had recurrent episodes. All of the patients received intravenous immunoglobulin (IVIG); however, one-third were refractory to treatment. Corticosteroids were used in five (41.7%) of the patients. Three (25%) of the patients had shock, and seven (58.3%) had coronary artery abnormalities, of whom one (8.3%) had persistent coronary artery aneurysm and the others recovered. A review of the 42 cases in the literature showed that the children with a jaundice-predominant presentation of KD had high rates of IVIG-refractory disease (25%), coronary artery abnormalities (25%), shock (13.2%), and corticosteroid treatment (24.2%).

Conclusions

Children with KD presenting with a jaundice-predominant manifestation are at a higher risk of IVIG-refractory disease, coronary artery abnormalities, and more recurrent episodes. Physicians should be aware of the risk of shock in this population.

Long-term effect of SARS-CoV-2 infection on cardiovascular outcomes and all-cause mortality

Since the very beginning of the coronavirus disease 2019 (COVID-19) pandemic in early 2020, it was evident that patients with cardiovascular disease (CVD) were at an increased risk of developing severe illness, and complications spanning cerebrovascular disorders, dysrhythmias, acute coronary syndrome, ischemic and non-ischemic heart disease, pericarditis, myocarditis, heart failure, thromboembolic disease, stroke, and death. Underlying these was excessive systemic inflammation and coagulopathy due to SARS-COV-2 infection, the effects of which also continued long-term as evidenced by post-COVID-19 cardiovascular complications. The acute and chronic cardiovascular effects of COVID-19 occurred even among those who were not hospitalized and had no previous CVD or those with mild symptoms. This comprehensive review summarizes the current understanding of molecular mechanisms triggered by the SARS-CoV-2 virus on various cells that express the angiotensin-converting enzyme 2, leading to endothelial dysfunction, inflammation, myocarditis, impaired coagulation, myocardial infarction, arrhythmia and a multisystem inflammatory syndrome in children or Kawasaki-like disease.

Evaluation of left ventricular myocardial stratified strain in patients with Kawasaki disease using two-dimensional speckle tracking imaging

Kawasaki disease (KD) is an acute autoimmune self-limited disease of unknown etiology. We aimed to evaluate the left ventricular myocardial stratified strains in children with KD in different stages using two-dimensional speckle tracking imaging, and to find the index that can early predict myocardial function injury in children with KD. A total of 73 children with KD were divided into acute, convalescent, and chronic stages according to the disease course. All children had no coronary artery damage. Further, 64 normal children were selected as the control group. The longitudinal and circumferential strain peaks of each myocardium were recorded, and the left ventricular global longitudinal strain (LVGLS), global circumferential strain (LVGCS), and transmural gradient between endocardium and epicardium (ΔGLS, ΔGCS) were calculated. Compared with the control group, LVGLS, GLS-Endo, GLS-Mid, GLS-Epi, and ΔGLS decreased in acute KD; LVGLS, GLS-Endo, GLS-Mid, GLS-Epi, ΔGLS, LVGCS, GCS-Mid, and GCS-Epi decreased in the convalescent stage; and only GLS-Endo was lower in children with chronic KD (P < 0.05). ROC curve was used to calculate the stratified strain parameters so as to predict left ventricular systolic function in children with acute KD; the area under the LVGLS curve was the largest (AUC = 0.953, P < 0.001). When the cutoff value of LVGLS was −19.89%, the sensitivity and specificity were 95.8% and 83.2%, respectively.

Kawasaki disease in Colombia: A systematic review and contrast with multisystem inflammatory syndrome in children associated with COVID-19

Introduction

Materials and methods

Results

Conclusions

Role of Superantigens In Various Childhood Inflamatory Diseases

----:: Super antigens (Sags) are some part of virus or bacteria proteins which stimulate T cells and antigen-presenting cells leading to systemic immune repose and inflammation. ---SAgs might have possible role in in various inflammatory childhood diseases (eg Kawasaki disease, atopic dermatitis, and chronic rhinosinusitis). ----Worldwide studies had done to determine the role of staphylococcal SAgs (TSST-1 ) in various inflammatory diseases. The SAgs (TSST-1) not only induce sepsis and septic shock (even in negative blood culture for S.aureus) ,but also might have significant role in various childhood inflammatory diseases ( eg KD, OMS, Polyp, dermatitis, psoriasis ) . In proven SAgs induced inflammatory diseases, inhibition the cell-destructive process by SAgs suppressants might be helpful. ----In toxic shock or sepsis like presentation even in cases with negative blood cultures immediate use pf anti staphylococcal drugs is required. ---Occasionaly, clinical presentation of some human viruses (eg coronavirus and adenovirus) mimic KD. ----- In addition ,coinfection with adenovirus, coronavirus, and para-influenza virus type 3 were observed with KD. -- Bacterial Sags induced increasement of acute-phase reactants and number of white blood cell, and neutrophil counts In developed KD. ----Multisystem inflammatory syndrome in children (MISC) and KS observed during the recent COVID-19 pandemia. This study summarized the relation between viral and bacterial SAgs and childhood inflammatory diseases.

eQTL Highlights the Potential Role of Negative Control of Innate Immunity in Kawasaki Disease

Purpose

Kawasaki disease (KD) is an acute systemic vasculitis mainly found in the medium-sized arteries, especially the coronary arteries. Immune system is involved in the pathogenesis of acute KD in children, but the functional differences in the immune system between healthy children and KD patients remain unclear.

Patients and Methods

A total of 190 KD patients and 119 healthy controls were recruited for the next-generation sequencing of 512 targeted genes from 4 immune-related pathways. Subsequently, the peripheral blood mononuclear cells (PBMCs) were isolated. RNA sequencing of the LPS treated PBMCs from additional 20 KD patients and 20 healthy controls was used to examine the differentially expressed genes (DEGs). Then, an expression quantitative trait locus (eQTL) analysis combined with previously analyzed RNA data were used to examine the DEGs. Finally, the serum levels of 13 cytokines were detected before and after LPS treatment in 40 samples to confirm the findings from eQTL analysis.

Results

A total of 319 significant eQTL were found, and both eQTL analysis and RNA sequencing showed some DEGs were involved in the connective tissue disorders and inflammatory diseases. DEGs that function to negatively regulate immunity were closely related to the pathogenesis of KD. In addition, the serum levels of IL-10 (an inflammatory and immunosuppressive factor) and SCD25 (an important immunosuppressant) reduced significantly in the KD patients.

Conclusion

Our study shows the expression of factors responsible for the negative control of innate immunity is altered, which plays an important role in the etiology of KD.

Verification of "Japanese Scoring Systems" to Predict IVIG Resistance and Identification of Predictors for IVIG Resistance in Thai Children with Kawasaki Disease

The objective of this study was to assess the validity of using the Kobayashi, Sano and Egami scoring systems to predict the intravenous immunoglobulin (IVIG) resistance of Kawasaki disease (KD) and to identify the predictors of IVIG resistance in our Thai population. A retrospective study involving 130 KD patients who were admitted between January 2005 and April 2018 was performed. We found that 17 (13%) KD patients did not respond to the first IVIG dose. The three scoring systems have good specificity (80.8%, 74% and 92.1%, respectively) but low sensitivity (0%, 33.3% and 22.2%, respectively). Multivariate analysis suggested that a body temperature greater than 40.2 °C (odds ratio of 3.80, P value = 0.03), a neutrophil percentage greater than 74% (odds ratio of 3.82, P value = 0.03) and serum albumin less than 3 g/L (odds ratio of 5.09, P value = 0.01) were predictors of IVIG resistance. Our study cannot conclude that the three Japanese scoring systems are not suitable for predicting IVIG resistance in the Thai population due to study limitations. However, a high-grade fever (≥ 40.2 °C), neutrophil predominance ≥ 74% and hypoalbuminemia (serum albumin level < 3 g/L) were predictors of IVIG resistance in Thai KD patients.

Seasonal Trends of Viral Prevalence and Incidence of Kawasaki Disease: A Korea Public Health Data Analysis

Kawasaki disease (KD) is a systemic vasculitis that occurs mainly in children under 5 years of age and is often accompanied by coronary artery lesions. The cause of the disease remains undetermined, but it is estimated to result from viral or bacterial infections. Certain studies have shown infection as a leading cause of KD. The purpose of this study was to investigate the relationship between KD incidence and viral infections in different pediatric age groups, using the Health Insurance Review and Assessment (HIRA) Open Access Big Data Platform, to confirm seasonal trends by analyzing monthly patterns. We investigated the HIRA data of KD patients (M30.3) who were treated with intravenous immunoglobulin from 2015 to 2018. Weekly virus positive detection rate data (PDR) for this period was obtained from the Korea Disease Control and Prevention Agency for human adenovirus (HAdV), human parainfluenza virus (HPIV), human respiratory syncytial virus (HRSV), influenza virus (IFV), human coronavirus (HCoV), human rhinovirus (HRV), human bocavirus (HBoV), human metapneumovirus (HMPV), rotavirus, norovirus, and astrovirus. We then analyzed the weekly/monthly virus PDR and its association with KD incidence, including monthly incidence patterns, and seasonal trends. Seasonal trend analysis of the virus PDR was performed using the time series analysis method through ARIMA (Autoregressive Integrated Moving Average). Correlations between KD incidence and PDR at 1- and 2-month intervals were analyzed using the Granger test. A total of 16,740 patients were diagnosed with KD during the study period, mainly young children, with a male-to-female ratio of 1.35. Specifically, 15,635 (93%) patients were under 5 years of age, with an incidence rate of 172.4/100,000 person-years. Annually, the cumulative number of cases per month was the highest in January, with an average of 469 cases, and was the lowest in September, with an average of 291 cases, although most were diagnosed with KD in winter (29.3%). Granger tests showed that PDR for HRSV, rotavirus, and norovirus were related with KD incidence by 1 month, while PDR for HRSV, HRV, rotavirus, and norovirus by 2 months. This study found that detection rates of respiratory and enteric viruses preceded KD by 1–2 months. Further research is needed to confirm the association between these viruses and KD.

Identification of Key Genes and Underlying Mechanisms in Acute Kawasaki Disease Based on Bioinformatics Analysis

Background

Kawasaki disease (KD) is a systemic vasculitis that predominantly occurs in children, but the pathogenesis of KD remains unclear. Here, we explored key genes and underlying mechanisms potentially involved in KD using bioinformatic analyses.

Material/Methods

The shared differentially expressed genes (DEGs) in KD compared to control samples were identified using the microarray data from the Gene Expression Omnibus Series (GSE) 18606, GSE68004, and GSE73461. Analyses of the functional annotation, protein-protein interaction (PPI) network, microRNA-target DEGs regulatory network, and immune cell infiltration were performed. The expression of hub genes before and after intravenous immunoglobulin (IVIG) treatment in KD was further verified using GSE16797.

Results

A total of 195 shared DEGs (164 upregulated and 31 downregulated genes) were identified between KD and healthy controls. These shared DEGs were mainly enriched in immune and inflammatory responses. Ten upregulated hub genes (ITGAX, SPI1, LILRB2, MMP9, S100A12, C3AR1, RETN, MAPK14, TLR5, MYD88) and the most significant module were identified in the PPI network. There were 309 regulatory relationships detected within 70 predicted microRNAs and 193 target DEGs. The immune cell infiltration analysis showed that monocytes, neutrophils, activated mast cells, and activated natural killer cells had relatively high proportions and were significantly more infiltrated in KD samples. Six hub genes of ITGAX, LILRB2, C3AR1, MAPK14, TLR5, and MYD88 were markedly downregulated after IVIG treatment for KD.

Conclusions

Our study identified the candidate genes and associated molecules that may be related to the KD process, and provided new insights into potential mechanisms and therapeutic targets for KD.

Post-COVID-19 Outbreak of Severe Kawasaki-like Multisystem Inflammatory Syndrome in Children

With the continuation of the second wave of a novel coronavirus disease (COVID-19), which is likely to be even more devastating, there are several associated health problems. COVID-19 is usually mild and non-fatal in children. However, in rare cases, children could severely be affected, and clinical manifestations may differ from adults. A multisystem inflammatory syndrome in children (MIS-C) is a rare but serious complication associated with COVID-19, initiated by an overactive immune response in kids that usually hits weeks after exposure to the COVID-19. MIS-C is a disorder in which inflammation could occur in different parts of the body. The disease puts pressure on the heart, as blood vessels leading towards the heart get inflamed and incapable of carrying adequate blood, hence producing cardiac complications in children hospitalised with MIS-C. The problem seems to be associated with COVID-19 in children; however, the association between MIS-C and COVID-19 is still unidentified. There is very little understanding of what triggers the MIS-C, which necessitates a rigorous mapping of the disease and associated risk elements for better disease management and navigating through this crisis.

Five immune-gene-signatures participate in the development and pathogenesis of Kawasaki disease

Objective

To screen for immune genes that play a major role in Kawasaki disease and to investigate the pathogenesis of Kawasaki disease through bioinformatics analysis.

Methods

Kawasaki disease‐related datasets GSE18606, GSE68004, and GSE73461 were downloaded from the Gene Expression Omnibus database. Three microarrays were integrated and standardized to include 173 Kawasaki disease samples and 101 normal samples. The samples were analyzed using CIBERSORT to obtain the infiltration of 22 immune cells and analyze the differential immune cells in the samples and correlations. The distribution of the samples was analyzed using principal component analysis (PCA). Immune‐related genes were downloaded, extracted from the screened samples and analyzed for differential analysis (different expression genes [DEG]) and weighted gene co‐expression network analysis (WGCNA). We constructed coexpression networks, and used the cytohobbe tool in Cytoscape to analyze the coexpression networks and select the immune genes that played a key role in them.

Results

Immune cell infiltration analysis showed that B cells naive, T cells CD8, natural killer (NK) cells activated, and so forth were highly expressed in normal samples. T cells CD4 memory activated, monocytes, neutrophils, and so forth were highly expressed in Kawasaki disease samples. PCA results showed a significant difference in the distribution of normal and Kawasaki disease samples. From the screened samples, 97 upregulated and 103 downregulated immune‐related genes were extracted. WGCNA analysis of DEG yielded 10 gene modules, of which the three most relevant to Kawasaki disease were red, yellow, and gray modules. They were associated with cytokine regulation, T‐cell activation, presentation of T‐cell receptor signaling pathways, and NK cell‐mediated cytotoxicity. CXCL8, CCL5, CCR7, CXCR3, and CCR1 were identified as key genes by constructing a coexpression network.

Conclusion

Our study shows that we can distinguish normal samples from Kawasaki disease samples based on the infiltration of immune cells, and that CXCL8, CCL5, CCR7, CXCR3, and CCR1 may play important roles in the development of Kawasaki disease.

Determination of the Relationship Between Kobayashi, Sano, and Egami Criteria and Prevalence of Intravenous Immunoglobulin Resistance and Coronary Artery Aneurysm in Iranian Children with Kawasaki Disease

Introduction

Kawasaki disease (KD) is a systemic vasculitis that occurs mostly in children under five years old. Kawasaki affects the middle-size arteries, especially the coronary arteries. Therefore, without adequate treatment, it may cause coronary artery aneurysm in 25% of patients. The purpose of this study was to investigate the relationship between Kobayashi, Sano, and Egami criterions with coronary artery aneurysm in KD patients during the last ten years and to identify risk factors in patients with intravenous immunoglobulin (IVIG)-resistant and coronary artery aneurysms.

Methodology

Medical records of 363 Kawasaki patients referred during 2008–2017 were reviewed. Patients’ demographic data and Kobayashi, Sano, and Egami scores of each patient were calculated. Based on echocardiographic findings, cases of coronary artery aneurysm were determined. Sensitivity, specificity, positive and negative predictive value, and the accuracy of each criterion were determined to predicting IVIG resistance and detect coronary artery aneurysm.

Results

There was a slight relationship between IVIG-resistance in Kawasaki children and its prediction based on the Kobayashi risk score, but no relationship was found between the Egami and Sano criteria. Sixty-three patients (17.4%) had coronary artery lesions (CALs) on time of diagnosis. There were no statistically significant differences between gender and mean age of children with and without CALs. Also, there was no significant relationship between coronary artery aneurysm in Kawasaki children and its prediction based on the above three risk factors. The area under the ROC-curve of all three risk measures of Kobayashi, Egami, and Sano indicated that all three criteria were not useful in predicting CALs.

Conclusion

Despite the low accuracy of the three above criteria to predictive of patients with IVIG resistance, it seems that the variables of age, duration of fever, and C-reactive protein (CRP) are more useful than other variables and may be utilized to evaluate patients by establishing a more appropriate cut-off point.

Adjuvant herbal therapy for targeting susceptibility genes to Kawasaki disease: An overview of epidemiology, pathogenesis, diagnosis and pharmacological treatment of Kawasaki disease

BACKGROUND

Kawasaki disease (KD) is a self-limiting acute systemic vasculitis occur mainly in infants and young children under 5 years old. Although the use of acetylsalicylic acid (AAS) in combination with intravenous immunoglobulin (IVIG) remains the standard therapy to KD, the etiology, genetic susceptibility genes and pathogenic factors of KD are still un-elucidated.

PURPOSE

Current obstacles in the treatment of KD include the lack of standard clinical and genetic markers for early diagnosis, possible severe side effect of AAS (Reye's syndrome), and the refractory KD cases with resistance to IVIG therapy, therefore, this review has focused on introducing the current advances in the identification of genetic susceptibility genes, environmental factors, diagnostic markers and adjuvant pharmacological intervention for KD.

RESULTS

With an overall update in the development of KD from different aspects, our current bioinformatics data has suggested CASP3, CD40 and TLR4 as the possible pathogenic factors or diagnostic markers of KD. Besides, a list of herbal medicines which may work as the adjunct therapy for KD via targeting different proposed molecular targets of KD have also been summarized.

CONCLUSION

With the aid of modern pharmacological research and technology, it is anticipated that novel therapeutic remedies, especially active herbal chemicals targeting precise clinical markers of KD could be developed for accurate diagnosis and treatment of the disease.

Evaluation of left ventricular function in immunoglobulin-resistant children with Kawasaki disease: a two-dimensional speckle tracking echocardiography study

Background

Kawasaki disease (KD) patients who are unresponsive to intravenous immune globulin (IVIG) have a high occurrence of coronary artery lesions (CALs). The characteristics of left ventricular (LV) function alternation in IVIG‐resistant patients are not well‐described.

Hypothesis

Two‐dimensional speckle tracking echocardiography (STE) is a useful technique that can accurately detect myocardium subclinical dysfunction in resistant patients and may assist in differentiating patients with KD at a higher risk of IVIG resistance.

Methods

A consecutive sample of 50 IVIG‐resistant patients (25 males, 2.2 ± 0.9 years), 50 IVIG‐responsive patients (27 males, 2.2 ± 0.7 years) and 50 normal subjects (27 males, 2.1 ± 0.9 years) were analyzed using STE, and receiver operating characteristic curve (ROC) analysis was utilized to determine the threshold values of STE parameters associated with IVIG resistance.

Results

Compared with normal children, IVIG‐resistant patients had lower global longitudinal strain (GLS) (15.82 ± 3.32 vs 20.01 ± 2.98, P = 0.000) and lower global circumferential strain (GCS) (16.65 ± 3.12 vs 20.11 ± 2.86, P = 0.042). Both GLS and GCS in IVIG‐resistant patients were significantly lower than in IVIG‐responsive patients (15.82 ± 3.32 vs 19.95 ± 3.01, 16.65 ± 3.12 vs 19.01 ± 3.00, P = .000, .030, respectively). ROC analysis demonstrated that the absolute values of GLS < 16.8% and GCS < 15.9% were optimal predictors of IVIG unresponsiveness (area under the curve = 0.78, 0.75; sensitivity = 0.83, 0.79; specificity = 0.69, 0.65, respectively).

Conclusion

IVIG‐resistant patients presented with more severe LV systolic dysfunction compared with IVIG‐responsive patients, which may be the result of myocarditis rather than CALs. STE may be a helpful diagnostic tool that provides supportive criteria to detect KD patients at a higher risk of IVIG resistance.

[Pyrexia and hemoptysis for eight days in a school-age child]

A girl was diagnosed with intravenous immunoglobulin (IVIG)-resistant Kawasaki disease (KD) due to pyrexia and hemoptysis for eight days. The girl was a school-age child with major clinical manifestations of pyrexia, skin rash, enlargement of bilateral cervical lymph nodes, conjunctival hyperaemia, red and cracked lips and strawberry-like tongue, followed by swelling of both hands and feet. Laboratory examination showed significant increases in white blood cell count, platelet count, C-reactive protein, erythrocyte sedimentation rate and liver enzymes, a significant reduction in albumin, and the presence of aseptic pyuria. After the first course of IVIG treatment, the girl still had recurrent pyrexia, with hemoptysis on day 2 after admission, and lung CT showed uneven luminance and patchy shadow. The symptoms were quickly alleviated after the second course of IVIG treatment combined with methylprednisolone and aspirin treatment. KD is a febrile disease characterized by multiple systemic vasculitis in childhood and can involve various organ systems such as the heart, lungs, kidneys and the nervous system. Therefore, it is necessary to carefully monitor and recognize the rare symptoms of KD, and early recognition of pulmonary complications of KD can avoid delay in diagnosis, prevent the development of more serious complications, and help with early treatment and disease recovery.

Early childhood exposure to maternal smoking and Kawasaki Disease: A longitudinal survey in Japan

Kawasaki disease is the leading cause of acquired childhood heart disease in most developed countries, but the etiology of the disease is unknown. An aberrant immune response to some environmental triggers may play a role and involuntary exposure to tobacco smoke can alter immune functions. We thus prospectively examined the association between early childhood exposure to maternal smoking and the incidence of Kawasaki disease. We used a large, nationwide population-based longitudinal survey ongoing since 2010 and restricted participants to a total of 38,444 children for whom information on maternal smoking was available. Maternal smoking status was ascertained at 6months of age, and responses to questions about hospital admission for Kawasaki disease between the ages of 6 and 30months were used as outcome. We conducted binomial log-linear regression analyses adjusting for children's, parental, and residential factors with children of non-smoking mothers as our reference group. Maternal smoking increased the risk of admission, in particular for the period between 6 and 18months of age, in a dose-dependent manner. Compared with children of non-smoking mothers, the children of mothers who smoked had a risk ratio of 1.83 (95% confidence interval: 1.06, 3.35) for hospital admissions between 6 and 30months of age and a risk ratio of 2.69 (95% confidence interval: 1.56, 4.64) for hospital admissions between 6 and 18months of age. Early childhood exposure to maternal smoking may increase the risk of Kawasaki disease hospitalizations in childhood.

Atypical coronary artery aneurysms due to Kawasaki disease in Noonan syndrome with a novel PTPN11 mutation

We report a 3-year-old boy with giant and atypical coronary artery aneurysms in the acute phase of Kawasaki disease, despite appropriate therapeutic intervention, in Noonan syndrome with a novel heterozygous PTPN11 mutation, c. 907 G&gt;A (p.Asp303Asn). We hypothesised that this PTPN11 mutation might affect both hyperinflammation caused by Kawasaki disease and vascular fragility in the coronary artery, resulting in coronary artery aneurysms.

Incomplete Kawasaki disease in the 2-month-old infant: A case report

RATIONALE

The diagnosis of Kawasaki disease (KD) is difficult and is often delayed for children whose age falls outside the typical age range of 6 months to 5 years, especially for those with incomplete KD (IKD) or atypical features.

PATIENT CONCERNS

A 2-month-20-day-old girl presented to our hospital with a chief complaint of intermittent fever for 1 day and 1 episode of seizure, with poor feeding and swelling of feet.

DIAGNOSIS

Until the appearance of red cracked lips, a diagnosis of IKD was considered. A rise in periungual desquamation of the hands confirmed the diagnosis.

INTERVENTIONS

Intravenous immunoglobulins were administered and aspirin and dipyridamole were used orally.

OUTCOME

The temperature, C-reactive protein, and erythrocyte sedimentation rate returned to normal level and there was no coronary artery lesion.

LESSONS

This case highlights that the diagnosis of IKD should be considered in children whose primary presentation is fever and neurologic features, lacking principal clinical findings, particularly those <6 months of age.

Melatonin: A hypothesis for Kawasaki disease treatment

Kawasaki disease (KD) is the most common cause of acquired heart disease with unknown etiology among children in developed countries. Acute inflammation of the vasculature, genetic susceptibility and immunopathogenesis based on a transmittable and infectious origin, are the pathologic events involved in the early inflammatory etiology and progression of this disease. However, the exact causes of KD remain unknown. Current proposed recommendations include three therapy lines; firstly, an initial standard therapy with intravenous immunoglobulin (IVIG) followed by aspirin. Secondly, in cases of high risk of coronary lesions, the adjunctive therapy with corticosteroid is commonly considered. Thirdly, in KD patients refractory to the previous therapies, tumor necrosis factor (TNF-α) antagonists are being used to modulate pro-inflammatory cytokines. In view of this status quo, our starting hypothesis is that the ubiquitous and non-toxic neurohormone melatonin could be of critical importance in developing novel adjuvant therapies against KD, as it occurs with a plethora of other diseases. Considering its pleiotropic properties, particularly its antiinflammatory and immunoregulatory capacities, melatonin should be of great therapeutic interest for helping to control the main pathologic features of KD patients. In addition, this multifunctional indole has a safe pharmacological profile, enhancing the therapeutic activity of several drugs and reducing their possible side effects. Consequently, melatonińs actions to manage KD need to be tested in further clinical studies.

Giant coronary artery aneurysms in a 12-week-old infant with incomplete Kawasaki disease

Kawasaki disease (KD) is an acute inflammatory vasculitis that occurs worldwide and disproportionately affects male children, most commonly between the ages of 6 months and 5 years. KD can present with only a few features and thus be difficult to diagnose, particularly in the youngest and oldest patients. We describe a 12-week-old Caucasian female infant who presented with rash and fever but no other features of KD, who developed giant coronary artery aneurysms. Considering how common is the presentation of a febrile infant with a rash, this case highlights the importance of considering KD early in the differential diagnosis for any infant with unexplained fever. Furthermore, it emphasises how echocardiography can help in the investigation of a febrile child with no clear source of infection.

The Roles of Genetic Factors in Kawasaki Disease: A Systematic Review and Meta-analysis of Genetic Association Studies

This systematic review and meta-analysis aimed to better elucidate the roles of genetic factors in Kawasaki disease (KD), and determine the potential genetic biomarkers of KD. The systematic literature search of PubMed, Medline, Embase, Web of Science and CNKI identified 164 eligible studies. The qualitative synthesis revealed that 62 genes may be correlated with the susceptibility to KD, and 47 genes may be associated with the incidence of coronary artery lesions (CALs) in KD. A total of 53 polymorphisms in 34 genes were investigated in further quantitative synthesis. Of these, 23 gene polymorphisms were found to be significantly correlated with KD susceptibility, and 10 gene polymorphisms were found to be significantly associated with the incidence of CALs in KD. In conclusion, our findings indicate that gene polymorphisms of ACE, BLK, CASP3, CD40, FCGR2A, FGβ, HLA-E, IL1A, IL6, ITPKC, LTA, MPO, PD1, SMAD3, CCL17 and TNF may affect KD susceptibility. Besides, genetic variations in BTNL2, CASP3, FCGR2A, FGF23, FGβ, GRIN3A, HLA-E, IL10, ITPKC and TGFBR2 may serve as biomarkers of CALs in KD.

Intrauterine and Early Postnatal Exposure to Particulate Air Pollution and Kawasaki Disease: A Nationwide Longitudinal Survey in Japan

OBJECTIVES

To examine the effects of prenatal and postnatal exposure to particulate matter on Kawasaki disease (KD) occurrence, using data from a nationwide population-based longitudinal survey in Japan that began in 2010.

STUDY DESIGN

Prenatal and postnatal suspended particulate matter concentrations were obtained at municipality level and assigned to participants based on their municipality of birth. We analyzed data from 30 367 participants with data on either exposure period. We used hospital admission for KD from 6 to 30 months of age as the main outcome of interest. We conducted a multilevel logistic regression analysis, adjusting for individual and municipality-level variables.

RESULTS

Children who were exposed to higher levels of suspended particulate matter, in particular during pregnancy, were more likely to be hospitalized for KD. The ORs for ≥25 µg/m³ exposure compared with <20 µg/m³ exposure were 1.59 (95% CI 1.06, 2.38) for prenatal exposure and 1.41 (0.82, 2.41) for postnatal exposure. Prenatal exposure during mid-to-late gestation seemed to be more relevant for the increased risk.

CONCLUSIONS

Early life exposure to particulate air pollution, in particular during pregnancy, is associated with an increased risk of KD hospital admission in early childhood in a nationally representative sample in Japan.

Clinical Outcomes of Low-Dose Methotrexate Therapy as a Second-Line Drug for Intravenous Immunoglobulin-Resistant Kawasaki Disease

PURPOSE

Intravenous immunoglobulin (IVIG) is the standard treatment for Kawasaki disease (KD). However, there is still no standard treatment for IVIG-resistant KD. This study aimed to evaluate the efficacy of low-dose methotrexate (MTX) as a treatment for IVIG-resistant KD.

MATERIALS AND METHODS

We retrospectively analyzed 10-year data for patients with IVIG-resistant KD who were administered MTX at Severance Children's Hospital.

RESULTS

The subjects included 75 patients with KD aged 5 months to 9.2 years who had been administered MTX. Their maximum body temperatures decreased significantly within 24 h of therapy. The patients' C-reactive protein levels were significantly lower 1 week after administering the first dose of MTX than those before treatment. No adverse effect for MTX was observed.

CONCLUSION

MTX treatment of IVIG-resistant KD resulted in rapid defervescence, improvement of clinical symptoms, and normalization of acute-phase reactants in all patients. Thus, MTX could be a candidate treatment for IVIG-resistant KD.

Myocardial Perfusion Reserve Index in Children With Kawasaki Disease

BACKGROUND

Coronary artery lesions in patients with Kawasaki disease (KD) can impair myocardial perfusion, yet evaluation of perfusion defects by cardiac magnetic resonance (MR) in children is often qualitative.

PURPOSE

In this study we aimed to use a quantitative method of myocardial perfusion using stress cardiac MR-derived myocardial perfusion reserve index (MPRI) in children with KD and compare MPRI with ventricular mechanical performance evaluated by cardiac MR strain analysis.

STUDY TYPE

This study was a retrospective review.

SUBJECTS

Twenty-one children with a diagnosis of KD who underwent stress perfusion cardiac MR were compared with nine controls.

FIELD STRENGTH/SEQUENCE

First-pass perfusion imaging using a T₁ -weighted gradient echo sequence was performed at rest and stress after administration of adenosine with 1.5T or 3T magnets.

ASSESSMENT

The MPRI was calculated as the ratio of maximum slope of myocardial enhancement during stress compared to rest and was evaluated with the American Heart Association 17 segment model.

STATISTICAL TESTS

Demographic and clinical characteristics among KD patients and controls were compared using Student's t-test for normally distributed continuous variables, Wilcoxon-rank sum test for nonnormally distributed variables, and χ² for categorical variables.

RESULTS

There was a significant decrease in MPRI in Segment 7 (1.53 vs. 2.23, P = 0.0058) in KD patients compared with controls. The reduction in MPRI in Segment 12 approached statistical significance (1.58 vs. 2.31, P = 0.0636). Three patients who underwent serial studies had decreased MPRI longitudinally. No differences were seen in circumferential or radial strain.

DATA CONCLUSION

MPRI shows impaired myocardial perfusion in patients with KD. MPRI can change over time, suggestive of progressive coronary artery changes, which may precede fibrosis and mechanical decline. MPRI can assess segmental and global perfusion defects in patients with KD and should be a part of routine cardiac MR evaluation in KD.

LEVEL OF EVIDENCE

3 Technical Efficacy Stage 3 J. Magn. Reson. Imaging 2017.

Kawasaki Disease With Coronary Artery Aneurysms: Psychosocial Impact on Parents and Children

INTRODUCTION

For those living with Kawasaki disease and coronary artery aneurysms, little is known about the psychosocial burden faced by parents and their children.

METHODS

Exploratory, descriptive, mixed-methods design examining survey and interview data about health-related uncertainty, intrusiveness, and self-efficacy.

RESULTS

Parents' uncertainty was associated with missed diagnosis, higher income, and maternal education. Higher uncertainty scores among children were associated with absence of chest pain and lower number of echocardiograms. High intrusiveness scores among parents were associated with previous cardiac catheterization, use of anticoagulants, lower parent education and income, and missed diagnosis. High intrusiveness scores among children were associated with high paternal education. Children's total self-efficacy scores increased with chest pain and larger aneurysm size. Qualitative analysis showed two central themes: Psychosocial Struggle and Cautious Optimism.

DISCUSSION

Negative illness impact is associated with a more intense medical experience and psychosocial limitations. Timely assessment and support are warranted to meet parents' and children's needs.

Atypical desquamation in a 2.5-year-old boy with Kawasaki disease: A case report

Kawasaki disease (KD) is a vasculitis that mostly affects children under 5 years of age. This article presents a 2.5-year-old boy who presented with 6 days of fever, generalized maculopapular rash, bilateral non-exudative conjunctivitis, cracked lips, right cervical lymphadenopathy, erythematous extremities, and perianal desquamation. Laboratory studies showed leukocytosis and sterile pyuria. Because diagnosis of KD was proved, oral acetylsalicylic acid with the anti-inflammatory dose and intravenous immunoglobulin were started for him. On the seventh day of admission time, he developed desquamation and erythema on the site of his right cervical lymphadenopathy as well as periungual scaling. About three weeks after starting the treatment, scaling of the cervical lymphadenopathy and periungual area stopped. Echocardiography was performed for him three times: at the time of diagnosis, four weeks, and 6 months later and revealed normal coronary arteries. We report this sign, desquamation on the site of cervical lymphadenopathy, as a new finding.

Getting warmer

The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient's case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant.

Kawasaki disease: etiopathogenesis and novel treatment strategies

INTRODUCTION

Kawasaki disease is an acute febrile systemic vasculitis that predominantly occurs in children below five years of age. Its etiopathogenesis is still not clear, but it is thought to be a complex interplay of genetic factors, infections and immunity. Areas covered: This review article discusses in detail Kawasaki disease, with particular emphasis on the recent updates on its pathogenesis and upcoming alternate treatment options. Though self-limiting in many cases, it can lead to severe complications like coronary artery aneurysms and thrombo-embolic occlusions, and hence requires early diagnosis and urgent attention to avoid them. Intravenous immunoglobulin (IVIG) with or without aspirin has remained the sole treatment option for these cases, but 10-15% cases develop resistance to this treatment. Expert commentary: There is a need to develop additional treatment strategies for children with Kawasaki disease. Targeting different steps of pathogenesis could provide us with alternate therapeutic options.

Breastfeeding and Risk of Kawasaki Disease: A Nationwide Longitudinal Survey in Japan

BACKGROUND AND OBJECTIVES

Kawasaki disease (KD) is the most common cause of childhood-acquired heart disease in developed countries. However, the etiology of KD is not known. Aberrant immune responses are considered to play key roles in disease initiation and breastfeeding can mature immune system in infants. We thus examined the association between breastfeeding and the development of KD.

METHODS

We used a nationwide population-based longitudinal survey ongoing since 2010 and restricted participants to a total of 37 630 children who had data on their feeding during infancy. Infant feeding practice was queried at 6 to 7 months of age, and responses to questions about hospital admission for KD during the period from 6 to 30 months of age were used as outcome. We conducted logistic regression analyses controlling for child and maternal factors with formula feeding without colostrum as our reference group.

RESULTS

A total of 232 hospital admissions were observed. Children who were breastfed exclusively or partially were less likely to be hospitalized for KD compared with those who were formula fed without colostrum; odds ratios for hospitalization were 0.26 (95% confidence interval: 0.12-0.55) for exclusive breastfeeding and 0.27 (95% confidence interval: 0.13-0.55) for partial breastfeeding. Although the risk reduction was not statistically significant, feeding colostrum only also provided a protective effect.

CONCLUSIONS

We observed protective effects of breastfeeding on the development of KD during the period from 6 to 30 months of age in a nationwide, population-based, longitudinal survey in Japan, the country in which KD is most common.

[Coronary artery aneurysms probably due to Kawasaki's disease]

We report the case of a young adult admitted to the Abidjan Heart Institute for coronary angiography to explore unstable angina. Coronary angiography showed multiple aneurysms which suggested sequelae of misdiagnosed Kawasaki disease.

Overview of Pharmacological Treatment Options for Pediatric Patients with Refractory Kawasaki Disease

Kawasaki disease is an autoimmune disease found predominantly in children under the age of 5 years. Its incidence is higher in those who live in Asian countries or are of Asian descent. Kawasaki disease is characterized as an acute inflammation of the vasculature bed affecting mainly the skin, eyes, lymph nodes, and mucosal layers. Although the disease is usually self-limiting, patients may develop cardiac abnormalities that can lead to death. The exact cause of the disease is unknown; however, researchers hypothesize that an infectious agent is responsible for causing Kawasaki disease. Initial treatment options with intravenous immune globulin and aspirin are sufficient to cure most patients who acquire this disease. Unfortunately, in up to one-quarter of patients, the disease will be refractory to initial therapy and will require further management with corticosteroid, immunomodulatory, or cytotoxic agents. The lack of randomized, controlled trials makes treatment of refractory disease difficult to manage. Until larger randomized, controlled trials are published to give more guidance on therapy for this stage of disease, clinicians should use the data available from observational studies and case reports in conjunction with their clinical expertise to make treatment decisions.

Kawasaki disease in a 9-year old girl presenting with febrile cholestasis: case report and review of literature

Kawasaki disease is a systemic vasculitis that develops during childhood, especially in those younger than 5 years. Gastrointestinal involvement does not belong to the classic diagnostic criteria. We reported here, a 9-year old girl who presented with febrile cholestasis, and developed a medium right coronary artery aneurysm despite intravenous immunoglobulin administration on the 9th day of fever. Hepatobiliary ultrasonographic evaluation revealed normal findings. Seroimmunologic markers of cholestasis were negative. Her clinical feature was ameliorated shortly after a second dose of intravenous immunoglobulin administration. We consider that a high index of suspicion of Kawasaki disease could prevent delayed diagnosis and complications.

Kawasaki disease in children: Epidemiology, clinical symptoms and diagnostics of 231 cases in 10 years

The present study was a retrospective analysis of the dynamic changes and clinical characteristics of 231 cases of Kawasaki disease (KD) in pediatric patients admitted to the People's Hospital of Inner Mongolia between January 2003 and December 2012. A total of 37.23% of the cases occurred in the first 5 years, compared with 62.77% in the latter 5 years. The age distribution ranged from 3 months to 10 years, with a peak age of <1 year. The male-to-female ratio was 2.12:1, and the reoccurrence rate was 1.3%. Among the patient cohort, 7.8% were Mongolian children. The most common clinical symptom was fever (87.6%), while perianal skin peeling was the most rare (14.1%). With regard to the analyzed biomarkers, 90.4% of patients had abnormal platelet (PLT) counts; the next highest abnormality rates were associated with erythrocyte sedimentation rate (ESR) (74.46%) and white blood cell (WBC) counts (59.74%), followed by levels of C-reactive protein (CRP) (57.58%), creatinine kinase-MB (40.26%) and hemoglobin (Hb) (38.53%). In conclusion, the present study has found that approximately two-thirds of cases of KD over a 10-year period occurred in the latter 5 years. Changes in a number of experimental indicators, including PLT, ESR and WBC, could be used in the diagnosis of the condition and to reflect the success of the clinical treatment.

Clinical and experimental study of Castleman disease in children

BACKGROUND

Castleman disease (CD) is a rare lymphoproliferative disease that is often underdiagnosed or misdiagnosed, especially in children. For this reason, we describe the clinical manifestations, diagnosis and treatment of CD in 11 children.

PROCEDURE

A retrospective study was performed to analyze the clinical features of 11 children with CD in a single institution from January 2001 to December 2012. All had computed tomography (CT) and lymph node resection for pathology diagnosis.

RESULTS

The average age of patients was 9.67 ± 4.26 years (range 1.3-15.5 years) including eight males (72.73%) and three females (27.27%). All but two (18.18%) had multicentric Castleman disease (MCD). Human immunodeficiency virus (HIV) or human herpes virus 8 (HHV8) infected cells were not detected in all patients. All patients were misdiagnosed in outside hospitals without tissue examination. Only in one case, the preoperative CT scan suggested CD. After treatment, 10 out of 11 children with CD in our study were disease free in the follow-up period ranging from 12 to 136 months (average 65.1 ± 10.21 months).

CONCLUSION

CD in children is rare, and is frequently misdiagnosed clinically. Our study shows that surgical resection is very effective in the treatment of unicentric Castleman disease (UCD). The rare UCD patient and all MCD patients treated with the modified NHLBFM-90 protocol had good prognosis.