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Si X, Hou C, Wang H, Yan W, Tang Y, Hu X, Ni J, Sun L, Lv H, Xu QQ. Comparison of six Z-score formulas based on echocardiography for coronary artery lesions in Kawasaki disease. Int J Cardiol 2024; 409:132102. [PMID: 38685457 DOI: 10.1016/j.ijcard.2024.132102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 04/21/2024] [Accepted: 04/24/2024] [Indexed: 05/02/2024]
Abstract
GOAL Kawasaki disease (KD) patients are at risk of developing the serious complication of coronary artery dilation (CAD). To diagnose CAD caused by KD, various Z-Score formulas are used worldwide. This paper aims to evaluate the differences and inclusiveness among the six most commonly used Z-Score formulas in diagnosing CAD in Suzhou, China. Additionally, the study seeks to compare the differences in CAD diagnosis among different high-risk factor groups. By doing so, this research provides a valuable reference for accurately diagnosing CAD in KD patients. METHOD This paper presents a retrospective analysis of 1509 patients diagnosed with KD at the Children's Hospital of Soochow University between January 2018 and December 2020. We collected the patients' clinical and echocardiographic data and used six Z-Score formulas (Kobayashi et al., de Zorzi et al., Kurotobi et al., McCrindle et al., Olivieri et al., and Dallaire et al.) to diagnose the degree of CAD in different segments. We then compared the diagnostic differences and inclusiveness of these formulas, especially the diagnostic differences in medium to giant CAA. To achieve this, we divided the patients into groups based on their age (≤12 months, 13-30 months, and > 30 months) and fever duration (≤5 days, 6-7 days, 8-9 days, and ≥ 10 days). Using the McNemar test and the Kappa test, we compared the differences and the consistencies of CDA diagnosis among the six Z-Score formulas. Moreover, we used the Friedman test and Chi-square segmentation formula to compare the differences in age and number of fever duration between groups and to compare each Z-Score formula pair within the group. RESULTS Except for the LMCA segment, where there were no statistically significant differences between de Zorzi formula and McCrindle formula, the Z-score formulas showed statistically significant differences in the degree of CAD diagnosis across all other segments. Inclusiveness assessment revealed that Kobayashi formula and Dallaire formula showed significantly higher rates of dilatation (6.58% and 5.32%), or of small aneurysms (6.52% and 4.52%) compared to other formulas (1.0%-1.73%). Medium aneurysms were also more likely to be identified with Kobayashi and Dallaire formulas (0.8% and 0.8%) compared to the remaining formulas (0.13-0.40%). There are significant differences in the diagnoses of medium to giant CAA made by these six formulas in LAD and RCA. The longer the duration of fever and the younger the age, the higher the diagnosis rates of CAD and CAA. There were no statistically significant differences between de Zorzi formula and McCrindle formula, de Zorzi formula and Oliveri formula, and Kurotobi formula and Dallaire formula within the four groups based on the duration of fever. Similarly, there were no statistically significant differences between Kobayashi formula and Dallaire formula, and between de Zorzi formula and Oliveri formula in the age groups of ≤12 months and 13-30 months. CONCLUSION There are diagnostic differences among these six Z-score formulas, considering the aforementioned statistics. Kobayashi formula and Dallaire formula are more inclusive, and less likely to under-diagnose significant CAD. They perform evenly for dilatation only, for small aneurysms and the median size aneurysms, and that is for segments of LMCA, LAD and RCA. In addition, McCrindle formula joins the "inclusive" pack for LAD and RCA in the matter of CAD. The younger the age of the patients and the longer the duration of fever, the higher the diagnosis rates of CAD and CAA. Furthermore, the younger the age of the patients and the shorter the duration of fever, the greater the differences between the various formulas.
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Affiliation(s)
- Xueying Si
- Children's Hospital of Soochow University, Suzhou 215000, China
| | - Cui Hou
- Children's Hospital of Soochow University, Suzhou 215000, China
| | - Hui Wang
- Children's Hospital of Soochow University, Suzhou 215000, China
| | - Wenying Yan
- School of Biology & Basic Medical Sciences, Soochow University, Suzhou 215000, China
| | - Yunjia Tang
- Children's Hospital of Soochow University, Suzhou 215000, China
| | - Xinlu Hu
- Children's Hospital of Soochow University, Suzhou 215000, China
| | - Juncheng Ni
- Children's Hospital of Soochow University, Suzhou 215000, China
| | - Ling Sun
- Children's Hospital of Soochow University, Suzhou 215000, China
| | - Haitao Lv
- Children's Hospital of Soochow University, Suzhou 215000, China
| | - Qiu-Qin Xu
- Children's Hospital of Soochow University, Suzhou 215000, China.
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Yu JJ, Choi HJ, Cho HJ, Kim SH, Cheon EJ, Kim GB, Eun LY, Jung SY, Jun HO, Woo HO, Park SA, Yoon S, Ko H, Ban JE, Choi JW, Song MS, Han JW. Newly Developed Sex-Specific Z Score Model for Coronary Artery Diameter in a Pediatric Population. J Korean Med Sci 2024; 39:e144. [PMID: 38685889 PMCID: PMC11058341 DOI: 10.3346/jkms.2024.39.e144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/01/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND This study aimed to generate a Z score calculation model for coronary artery diameter of normal children and adolescents to be adopted as the standard calculation method with consensus in clinical practice. METHODS This study was a retrospective, multicenter study that collected data from multiple institutions across South Korea. Data were analyzed to determine the model that best fit the relationship between the diameter of coronary arteries and independent demographic parameters. Linear, power, logarithmic, exponential, and square root polynomial models were tested for best fit. RESULTS Data of 2,030 subjects were collected from 16 institutions. Separate calculation models for each sex were developed because the impact of demographic variables on the diameter of coronary arteries differs according to sex. The final model was the polynomial formula with an exponential relationship between the diameter of coronary arteries and body surface area using the DuBois formula. CONCLUSION A new coronary artery diameter Z score model was developed and is anticipated to be applicable in clinical practice. The new model will help establish a consensus-based Z score model.
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Affiliation(s)
- Jeong Jin Yu
- Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea.
| | - Hee Joung Choi
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Hwa Jin Cho
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Sung Hye Kim
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Eun Jung Cheon
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Gi Beom Kim
- Department of Pediatrics, College of Medicine, Seoul National University, Seoul, Korea
| | - Lucy Youngmin Eun
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Se Yong Jung
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ok Jun
- Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyang-Ok Woo
- Department of Pediatrics, Institute of Medical Science, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Sin-Ae Park
- Department of Pediatrics, Presbyterian Medical Center, Jeonju, Korea
| | - Soyoung Yoon
- Department of Pediatrics, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Hoon Ko
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Ji-Eun Ban
- Department of Pediatrics, Ewha Womans University Medical Center, Seoul, Korea
| | - Jong-Woon Choi
- Department of Pediatrics, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Min Seob Song
- Department of Pediatrics, Inje University Paik Hospital, Busan, Korea
| | - Ji Whan Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Yang Y, Wang L, Yang Y, Wu X, Xu L, Bi C. Z-score regression model for coronary artery diameter in healthy Chinese Han children. Acta Radiol 2023; 64:798-805. [PMID: 35306860 DOI: 10.1177/02841851221085685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary artery distension and aneurysm are complications of Kawasaki disease in children. PURPOSE To develop a Z-score regression model for coronary artery diameter in children that could be used as reference. MATERIAL AND METHODS This retrospective analysis included children with normal heart structure between March 2013 and April 2017. Body surface area (BSA) was calculated. The diameters of the right coronary, left main coronary, left anterior descending, and circumflex arteries were measured by echocardiography. Pearson correlation analysis was used to establish linear, exponential, logarithmic, power, and square root regression models. RESULTS The analysis included 509 children (280 boys) aged 1 day to 15.2 years. Coronary artery diameters were significantly correlated with age, height, body mass, BSA, and BSA (r = 0.663-0.826; P < 0.05), with a stronger correlation for BSA than BSA (P < 0.05). The adjusted determination coefficients (Ra2) were higher for the exponential and square root models than for the other models (P < 0.05). The random error term variance was constant for the exponential model (P > 0.05), and processing with the weighted least-square methods eliminated heteroscedasticity in the other models. The Z-scores were normally distributed for the exponential and square root models (P > 0.05). CONCLUSION Overall, the square root model was the optimal equation for the calculation of coronary artery Z-score in Chinese Han children. This model could be used to facilitate the diagnosis of coronary artery distension in children with suspected Kawasaki disease.
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Affiliation(s)
- Yanzhang Yang
- Department of Pediatrics, 117872Hebei General Hospital, Shijiazhuang, Hebei, PR China
| | - Li Wang
- Department of Pediatrics, Shijiazhuang Fifth Hospital, Shijiazhuang, Hebei, PR China
| | - Yanfang Yang
- Department of Medical Imaging, Gaocheng Integrated Traditional Chinese and Western Medicine Hospital, Shijiazhuang, Hebei, PR China
| | - Xiaojing Wu
- Department of Pediatrics, 117872Hebei General Hospital, Shijiazhuang, Hebei, PR China
| | - Lijin Xu
- Department of Pediatrics, 117872Hebei General Hospital, Shijiazhuang, Hebei, PR China
| | - Changbo Bi
- Department of Pediatrics, 117872Hebei General Hospital, Shijiazhuang, Hebei, PR China
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Differences in Sensitivity Between the Japanese and Z Score Criteria for Detecting Coronary Artery Abnormalities Resulting from Kawasaki Disease. Pediatr Cardiol 2023; 44:153-160. [PMID: 36121493 DOI: 10.1007/s00246-022-03008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/12/2022] [Indexed: 01/24/2023]
Abstract
No studies have assessed differences between the Japanese and Z score criteria in the echocardiographic detection sensitivity of coronary artery (CA) abnormalities using large-scale data containing samples from multiple facilities engaged in daily clinical practices of Kawasaki disease (KD). We analyzed data from the 25th Japanese nationwide KD survey, which identified 30,415 patients from 1357 hospitals throughout Japan during 2017-2018. Hospitals were classified according to their use of Z score criteria. We assessed differences in hospital and patient background factors and compared the prevalence of CA abnormalities among groups using the Z score criteria. Multivariable logistic regression analyses were performed to evaluate differences in the detection sensitivity for CA abnormalities. The Z score criteria were more likely to be utilized in larger hospitals with more pediatricians and cardiologists. Even after controlling for potential confounders, detection sensitivities by the Z score criteria were significantly higher than by the Japanese criteria in patients with CA dilatations (adjusted odds ratio (95% confidence interval) 1.77 (1.56-2.01)) and aneurysms (1.62 (1.17-2.24)). No significant difference was found in patients with giant CA aneurysms. Compared with the Japanese criteria, the Z score criteria were significantly more sensitive for detecting patients with CA dilatations regardless of age, and for those with CA aneurysms only in patients aged ≤ 1 year. Our results indicate that differences in the detection sensitivity for CA abnormalities between the Z score and the Japanese criteria were dependent on the CA size and patient age.
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Gan Y, Feng Y, Zhou X, Li H, Wang G, Aini M, Shu J, Tu D. Serum levels of angiotensin-converting enzyme 2 in children with Kawasaki disease. Clin Exp Med 2022:10.1007/s10238-022-00933-x. [PMID: 36344782 PMCID: PMC10390598 DOI: 10.1007/s10238-022-00933-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
AbstractKawasaki disease (KD) has replaced rheumatic fever as the main cause of acquired heart disease in Japanese, American, and Chinese children. Polymorphisms in angiotensin-converting enzyme may be associated with susceptibility to KD, but the association of angiotensin-converting enzyme 2 (ACE2) with vascular endothelial injury in KD and the possibility for prognosis of vascular injury in KD by evaluating changes in serum ACE2 have not yet been assessed. Thus, this study aimed to investigate ACE2 levels in patients with KD to further explore the relationship between ACE2 and vascular injury in KD. Blood samples were collected from 49 children with KD before intravenous immunoglobulin treatment and 28 healthy children in the same period as the control group. Clinical data were collected from the patients and serum ACE2 levels of all participants were measured using an enzyme-linked immunosorbent assay. Serum ACE2 levels were significantly higher in the KD group than in the control group, and were negatively correlated with platelet levels in patients with KD. Serum ACE2 levels are related to the pathogenesis of KD and may be used as a potential serum marker for KD diagnosis.
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Kim SH. Diagnosis of coronary artery abnormalities in Kawasaki disease: recent guidelines and z score systems. Clin Exp Pediatr 2022; 65:430-438. [PMID: 34922423 PMCID: PMC9441617 DOI: 10.3345/cep.2021.01459] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/25/2021] [Indexed: 11/27/2022] Open
Abstract
Kawasaki disease, an acute systemic vasculitis affecting children, is the leading cause of acquired heart disease in developed countries. This vasculitis has a predilection for the coronary artery, and coronary artery abnormalities are the main criteria for its diagnosis. The diagnosis of coronary abnormalities has historically been based on dichotomous criteria, but recent guidelines have accepted the body surface area-adjusted z score system to define coronary abnormalities and classify coronary artery aneurysms. Z score systems have improved risk classifications of coronary aneurysms and improved correlations with clinical prognosis. However, the discrepancy of calculated z scores according to the formula has been noticed in the application of the z score system, which is possibly related to the diagnosis of coronary artery abnormalities. This variability was greater in larger coronary aneurysm dimensions. A careful choice of the z score formula and its consistent use is needed in clinical applications.
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Affiliation(s)
- Sung Hye Kim
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Abstract
BACKGROUND Coronary artery aneurysms are well-described in Kawasaki disease and the Multisystem Inflammatory Syndrome in Children and are graded using Z scores. Three Z score systems (Boston, Montreal, and DC) are widely used in North America. The recent Pediatric Heart Network Z score system is derived from the largest diverse sample to-date. The impact of Z score system on the rate of coronary dilation and management was assessed in a large real-world dataset. METHODS Using a combined dataset of patients with acute Kawasaki disease from the Children's Hospital at Montefiore and the National Heart, Lung, and Blood Institute Kawasaki Disease Study, coronary Z scores and the rate of coronary lesions (Z ≥ 2.0) and aneurysms (Z ≥ 2.5) were determined using four Z score systems. Agreement among Z scores and the effect on Kawasaki management were assessed. RESULTS Of 333 patients analysed, 136 were from Montefiore and 197 from the Kawasaki Disease Study. Age, sex, body surface area, and rate of coronary lesions did not differ between the samples. Among the four Z score systems, the rate of acute coronary lesions varied from 24 to 55%. The mean left anterior descending Z scores from Pediatric Heart Network and Boston had a large uniform discrepancy of 1.3. Differences in Z scores among the four systems may change anticoagulation management in up to 22% of a Kawasaki population. CONCLUSIONS Choice of Z score system alone may impact Kawasaki disease diagnosis and management. Further research is necessary to determine the ideal coronary Z score system.
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Santimahakullert K, Vijarnsorn C, Wongswadiwat Y, Chanthong P, Khrongsrattha S, Panamonta M, Chan-on P, Durongpisitkul K, Chungsomprasong P, Kanjanauthai S, Soongswang J. A retrospective cohort study of major adverse cardiac events in children affected by Kawasaki disease with coronary artery aneurysms in Thailand. PLoS One 2022; 17:e0263060. [PMID: 35085339 PMCID: PMC8794099 DOI: 10.1371/journal.pone.0263060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 01/12/2022] [Indexed: 11/18/2022] Open
Abstract
Kawasaki disease (KD) is a common form of vasculitis in children that can be complicated by coronary artery aneurysms (CAAs). Data of long-term outcomes and major adverse cardiac events (MACE) in children with CAAs following KD in developing country are limited. Our aims were to determine the rates of MACE and identify risk factors associated with MACE in children with KD and CAAs in Thailand. We performed a retrospective analysis of data from 170 children diagnosed with KD and CAAs in two tertiary hospitals between 1994 and 2019. During a median (range) follow-up of 5.4 years (22 days to 23 years), 19 patients (11.2%) experienced MACE, that included 12 coronary artery bypass grafting, 2 percutaneous coronary intervention and 5 children with evidence of myocardial ischemia and coronary occlusion. Coronary interventions were performed at a median time of 4 years (0.01 to 9.5 years) after KD diagnosis. Forty-nine patients (28.8%) had giant CAAs. No MACE was reported in children with small CAAs. Independent risks of MACE were from the absence of intravenous immunoglobulin treatment (HR 7.22; 95% CI 2.21 to 23.59; p = 0.001), the presence of giant aneurysms (HR 13.59; 95% CI 2.43 to 76.09; p = 0.003), and CAAs that involved bilateral branches of coronary arteries (HR 6.19; 95% CI 1.24 to 30.92; p = 0.026). Among children with giant CAAs, the intervention-free rate was 93.8%, 78.7% and 52.2%, at 1, 5 and 10 years, respectively. Of note, 81% of the small CAAs regressed to a normal size, and for medium CAAs, 50% regressed to normal size. Overall, ~10% of children with CAAs following KD experienced MACE in this cohort. Timely IVIG treatment in children with KD following symptom onset will reduce the risk of MACE. Cautious surveillance to identify cardiac complications should be recommended for children once medium or giant CAAs develop. Trial registration:TCTR20190125004.
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Affiliation(s)
- Kanokvalee Santimahakullert
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chodchanok Vijarnsorn
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- * E-mail:
| | - Yuttapong Wongswadiwat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Prakul Chanthong
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sappaya Khrongsrattha
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Manat Panamonta
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Paradorn Chan-on
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Kritvikrom Durongpisitkul
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Paweena Chungsomprasong
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Supaluck Kanjanauthai
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jarupim Soongswang
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Dallaire F. Z Score Disease or Coronary Artery Disease: The (Missing) Link between Statistics and Anatomy in Kawasaki Disease. J Am Soc Echocardiogr 2021; 34:673-675. [PMID: 33845157 DOI: 10.1016/j.echo.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 04/04/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Frédéric Dallaire
- Department of Pediatrics, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada.
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Abstract
Aim of the review: To review major epidemiological aspects of Kawasaki disease (KD) in Europe, describing demographic characteristics, revising its incidence along with time trends and geographic variations, and describing migration studies to provide clues about its etiology. Recent findings: The annual incidence of KD in Europe is about 10-15 per 100,000 children under 5 years old and seems to be relatively stable over time and space. Demographic characteristics are in line with those in other countries of the world, with a higher incidence in children from Asia and possibly North African origin. All studies performed across Europe found a coherent seasonal distribution of KD onset peaking from winter to early spring. This seasonal distribution was consistent over the years and suggests a climate-related environmental trigger. The occurrence of peaks during pandemics, microbiological findings and a possible link with southerly winds support the hypothesis of an airborne infectious agent. Neither other airborne agents such as pollutants or pollens nor urbanization and industrialization seem to have major effect on the etiology. Conclusion: Discrepancies in KD incidence rates across studies were due more to methodological differences, variation in definitions and awareness of the disease than a real increase in incidence. Genetic predisposition is undeniable in KD, but environmental factors seem to play a pivotal role. Several lines of evidence support a non-exclusive airborne infectious agent with a protective immune response by the host as a key factor in inducing the inflammatory cascade responsible for symptoms and complications.
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Affiliation(s)
- Maryam Piram
- Department of Pediatrics, Research Centre of the Sainte Justine University Hospital, Sainte Justine University Hospital, University of Montreal, Montreal, QC, Canada.,Centre for Epidemiology and Population Health (CESP), University Paris-Saclay, Le Kremlin Bicêtre, France
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