KAWASAKI DISEASE

Reactivation of BCG inoculation site in a child with febrile exanthema of 3 days duration: an early indicator of incomplete Kawasaki disease

The aetiology of febrile exanthems in children is often difficult to distinguish clinically. A diagnosis of Kawasaki disease (KD) should be considered in infants with exanthematous fever. More perplexing is the increasing incidence of an atypical form of KD. Pathogenesis of KD remains unclear even though an aberrant response of the immune system to an unidentified pathogen is often hypothesised. A 30-fold increase in the incidence of KD in Italy during the SARS-CoV-2 pandemic suggests an immune response to a viral trigger. We report an infant clinically diagnosed with high probability as incomplete KD, who presented with reactivation of the BCG injection site even though fever with rash was only less than 3 days duration. Echocardiography confirmed coronary artery abnormalities and prompt treatment with intravenous immunoglobulin facilitated rapid recovery. Physicians should consider a diagnosis of KD if BCG site reactivation is noted in children presenting with febrile exanthema.

Kawasaki disease in infants less than one year of age: an Italian cohort from a single center

Background and aims

Few data are currently available for Kawasaki disease (KD) below 12 months especially in Caucasians. This study aims to analyze clinical and laboratory features of KD among an Italian cohort of infants.

Methods

A retrospective chart review of KD children aged less than 1 year at time of disease onset between January 2008–December 2017 was performed. Clinical data, laboratory parameters, instrumental findings, treatment and outcome were collected in a customized database.

Results

Among 113 KD patients, 32 (28.3%) were younger than 1 year. Nineteen patients aged below 6 months, and three below 3 months. The median age was 5.7 ± 2.7 months. The mean time to diagnosis was 7 ± 3 days and was longer in the incomplete forms (8 ± 4 vs 6 ± 1 days). Conjunctival injection was present in 26 patients (81.2%); rash in 25 (78.1%); extremity changes in 18 (56.2%); mucosal changes in 13 (40.6%,) and lymphadenopathy only in 7 (21.8%). Mucosal changes were the least common features in incomplete forms (18.2%). Twenty-two patients (68.7%) had incomplete KD. Nineteen (59.4%) had cardiac involvement, of whom 13 (59.0%) had incomplete form. ESR, PCR and platelet values were higher in complete KD; especially, ESR resulted significantly higher in complete forms (80 ± 25.7 mm/h vs 50 ± 28.6 mm/h; p = 0.01). Conversely, AST level was statistically significant higher in patients with incomplete forms (95.4 ± 132.7 UI/L vs 29.8 ± 13.2 UI/L; p = 0.03). All patients received IVIG. Response was reported in 26/32 patients; 6 cases needed a second dose of IVIG and one required a dose of anakinra.

Conclusion

In our cohort, incomplete disease was commonly found, resulting in delayed diagnoses and poor cardiac prognosis. Infants with incomplete KD seem to have a more severe disease and a greater predilection for coronary involvement than those with complete KD. AST was significantly higher in incomplete forms, thus AST levels might be a new finding in incomplete forms’ diagnosis. Eventually, we highlight a higher resistance to IVIG treatment. To our knowledge this is the first study involving an Italian cohort of patients with KD below 12 months.

An infant presenting with Kawasaki disease following immunization for influenza: A case report

Kawasaki disease (KD) is a childhood vascular disorder of unknown etiology. Concerns have recently been raised regarding vaccinations as a potential risk factor for KD. In addition, various forms of vasculitis have been reported as adverse events following administration after various vaccines. Patients exhibiting post vaccination KD have previously been described; however, thus far, to the best of our knowledge, only one patient exhibiting post influenza vaccination KD has been reported in Japan. The present study describes a case of KD 24 h after immunization with influenza in an infant (age, 18 months) following 6 days of high fever, a body rash that had persisted for 2 days and nonsuppurative bilateral conjunctivitis. To the best of the authors' knowledge, this is the first reported case in Korea and the present study reviews various recent studies regarding vasculitis following vaccination and the causal association between them.

Kawasaki disease in infants below 6 months: a clinical conundrum?

AIM

Kawasaki disease (KD) is a medium vessel vasculitis of childhood. In infancy KD is often characterized by incomplete and atypical forms. There is paucity of literature on KD in children below 6 months and there are no data from any developing country. This study defines the profile of children with KD below 6 months at our centre.

METHODS

During January 1994 to March 2015, 460 children were diagnosed with KD and 17 (3.6%) were below 6 months. Diagnosis was based on American Heart Association (AHA) criteria. All children were treated with intravenous immunoglobulin and aspirin; three also received infliximab.

RESULTS

Mucosal changes were present in 11 patients (64%); extremity changes in 11 (64%); rash in nine (53%); conjunctival injection in eight (47%); and cervical lymphadenopathy in three (17%). Irritability was noted in 15 patients (88%); four (23%) had respiratory symptoms; and two (11%) had bacille Calmette-Guérin scar reactivation. Fifteen (88%) had incomplete KD. Twelve patients were diagnosed beyond day 10 of illness. Thrombocytopenia was seen in four. Coronary artery abnormalities were present in six (35%) patients. Two children died from disease-related complications - one of these had giant coronary artery aneurysms.

CONCLUSION

Our data show that incomplete forms of KD are commonly seen in children below 6 months of age, thereby resulting in delayed diagnoses. Pediatricians need to have a high index of suspicion of KD when dealing with a young infant with unexplained fever beyond 5 days. The AHA criteria appear to be inadequate for diagnosing KD in infants below 6 months.

Pediatric vasculitis: recognizing multisystemic manifestations at body imaging

Pediatric vasculitides are multisystem diseases that can be diagnostic challenges because of variable clinical manifestations. The clinical manifestation is determined by the size of the affected vessels, organs involved, extent of vascular injury, and underlying pathologic characteristics. Henoch-Schönlein purpura and Kawasaki disease are the two most common subtypes of pediatric vasculitis. Diagnosis of pediatric vasculitis can be difficult, and the outcome can be serious or fatal in the absence of timely intervention. Imaging plays a central role in establishing the diagnosis of vasculitis involving large- and medium-sized vessels, visualizing its vascular and extravascular manifestations, and monitoring the disease course and response to treatment. Although imaging cannot depict the vessel changes of small-vessel vasculitis directly, it can be used to detect tissue damage resulting from vessel inflammation. This article discusses the classification and clinical features of the major pediatric vasculitides. The imaging approach to and nonneurologic findings of major pediatric vasculitis subtypes are reviewed for the pediatric body imager.

Recent Advances in Kawasaki Disease - Proceedings of the 3rd Kawasaki Disease Summit, Chandigarh, 2014

Kawasaki disease (KD) is the most common cause of acquired heart disease in children in Japan, North America and Europe. It is now being increasingly recognized from the developing countries as well. If not diagnosed and treated in time, KD can result in coronary artery abnormalities in approximately 15-25% cases. The long-term consequences of these abnormalities may manifest in adults as myocardial ischemia and congestive heart failure. Intravenous immunoglobulin (IVIg) remains the drug of choice for treatment of KD, but several new agents like infliximab, cyclosporine, glucocorticoids and statins are now being increasingly used in these patients. While echocardiography has been the preferred imaging modality hitherto, CT coronary angiography has emerged as an exciting new supplementary option and provides an entirely new dimension to this disease. The incidence of KD has shown a progressive increase in several countries and it is likely that this disease would impact public health programmes in the near future even in the developing countries.

Aortic stiffness studies in children with Kawasaki disease: preliminary results from a follow-up study from North India

Kawasaki disease (KD) is an acute medium vessel vasculitis seen in children. Coronary artery abnormalities are the most notable long-term complications. Intravenous immunoglobulin therapy has led to significant reduction in incidence of coronary aneurysms. However, higher risk of cardiovascular disease has been noted even in those children who have never been reported to develop coronary artery aneurysms during the subacute phase. Noninvasive estimation of this cardiovascular risk is useful in initiating timely preventive strategies. Arterial stiffness has been shown to be an independent predictor of cardiovascular events in general population. This study was aimed at measuring abdominal aorta stiffness in a cohort of children with KD from North India. Thirty children diagnosed to have KD at least 5 years prior to enrollment were evaluated by echocardiography for cardiac and abdominal aorta studies. Electrocardiographs were done in all patients for QT dispersion. There was a noticeable trend toward lower aortic strain, higher pressure strain elastic modulus and normalized pressure strain elastic modulus in children in the study group, though this difference did not reach statistical significance. Mean corrected QT dispersion was significantly higher in cases compared with controls. On cardiac evaluation, none of the subjects had any residual coronary artery involvement. A trend toward lower distensibility and higher stiffness of abdominal aorta was seen in cases compared with controls, though it was not found to be statistically significant. This could be a predictor of premature atherosclerosis in long term. Significantly higher QT dispersion was seen in cases compared with controls. More multicentric studies with larger sample size and longer follow-up periods are needed to clarify this issue.

Carotid intima-media thickness in children with Kawasaki disease

Kawasaki disease (KD) is an acute medium vessel vasculitis seen in children. The most significant long-term complication is related to coronary artery abnormalities. Use of intravenous immunoglobulins, however, has led to significant reduction in incidence of coronary aneurysms. What is more alarming is the fact that higher risk of cardiovascular disease is seen in even those children who do not have coronary artery aneurysms during subacute phase. Various factors like abnormal lipid profiles, abnormal vessel wall reactivity and endothelial dysfunction have been implicated for this. Carotid intima-media thickness (cIMT) has been used as a surrogate marker for atherosclerosis. This study was planned to evaluate cIMT in children with KD. Twenty-seven children with diagnosis of KD at least 1 year prior to enrolment were evaluated for cIMT at enrolment and then after 3 months. Fasting lipid profile was done for all patients. Mean cIMT was significantly higher in children with KD compared to controls. In lipid profiles, undesirable HDL-C and triglyceride levels were seen in 2 and 3 children, respectively. Undesirable and borderline LDL-C levels were seen in 1 and 2 patients, respectively. Undesirable and borderline total cholesterol levels were seen in 1 and 3 patients, respectively. Higher cIMTs were seen in our cohort of KD patients. Proatherogenic abnormalities in lipid profile were seen in a few patients. Both abnormalities may predict a higher risk of atherosclerosis in future. The results of this study need to be replicated on a larger study sample and over longer follow-up periods.