Coronary magnetic resonance imaging: current state-of-the-art

Adult Kawasaki's disease with myocarditis, splenomegaly, and highly elevated serum ferritin levels

Kawasaki's disease is a disease of unknown cause. The characteristic clinical features of Kawasaki's disease are fever ≥ 102°F for ≥ 5 days accompanied by a bilateral bulbar conjunctivitis/conjunctival suffusion, erythematous rash, cervical adenopathy, pharyngeal erythema, and swelling of the dorsum of the hands/feet. Kawasaki's disease primarily affects children and is rare in adults. In children, Kawasaki's disease is more likely to be associated with aseptic meningitis, coronary artery aneurysms, and thrombocytosis. In adult Kawasaki's disease, unilateral cervical adenopathy, arthritis, conjunctival suffusion/conjunctivitis, and elevated serum transaminases (serum glutamic oxaloacetic transaminase [SGOT]/serum glutamate pyruvate transaminase [SGPT]) are more likely. Kawasaki's disease in adults may be mimicked by other acute infections with fever and rash, that is, group A streptococcal scarlet fever, toxic shock syndrome (TSS), and Rocky Mountain Spotted Fever (RMSF). Because there are no specific tests for Kawasaki's disease, diagnosis is based on clinical criteria and the syndromic approach. In addition to rash and fever, scarlet fever is characterized by circumoral pallor, oropharyngeal edema, Pastia's lines, and peripheral eosinophilia, but not conjunctival suffusion, splenomegaly, swelling of the dorsum of the hands/feet, thrombocytosis, or an elevated SGOT/SGPT. In TSS, in addition to rash and fever, there is conjunctival suffusion, oropharyngeal erythema, and edema of the dorsum of the hands/feet, an elevated SGOT/SGPT, and thrombocytopenia. Patients with TSS do not have cervical adenopathy or splenomegaly. RMSF presents with fever and a maculopapular rash that becomes petechial, first appearing on the wrists/ankles after 3 to 5 days. RMSF is accompanied by a prominent headache, periorbital edema, conjunctival suffusion, splenomegaly, thrombocytopenia, an elevated SGOT/SGPT, swelling of the dorsum of the hands/feet, but not oropharyngeal erythema.

We present a case of adult Kawasaki's disease with myocarditis and splenomegaly. The patient's myocarditis rapidly resolved, and he did not develop coronary artery aneurysms. In addition to splenomegaly, this case of adult Kawasaki's disease is remarkable because the patient had highly elevated serum ferritin levels of 944-1303 ng/mL; (normal < 189 ng/mL). To the best of our knowledge, this is the first report of adult Kawasaki's disease with highly elevated serum ferritin levels. This is also the first report of splenomegaly in adult Kawasaki's disease. We conclude that Kawasaki's disease should be considered in the differential diagnosis in adult patients with rash/fever for ≥ 5 days with conjunctival suffusion, cervical adenopathy, swelling of the dorsum of the hands/feet, thrombocytosis and otherwise unexplained highly elevated ferritin levels.

Value of magnetic resonance imaging, angiography, and fractional flow reserve to evaluate the left main coronary artery after direct surgical angioplasty

BACKGROUND

Direct surgical angioplasty of the left main coronary artery is aimed to restore a more physiologic blood flow through the left main coronary artery compared with conventional bypass surgery and allows subsequent percutaneous coronary interventions of more distal coronary lesions. Some data on anatomic evaluation with coronary angiography and magnetic resonance imaging (MRI) are known, and we conducted a study to report the physiologic evaluation.

METHODS

Coronary angiography, MRI, and fractional flow reserve measurements were performed in 18 patients 8 years after direct surgical angioplasty of the left main coronary artery.

RESULTS

At coronary angiography and MRI, a dilated funnel-shaped left main coronary artery was seen in all 18 patients, but both methods failed to demonstrate a flow-limiting lesion in the distal left main coronary artery in 1 patient. The functional severity was shown by fractional flow reserve measurement, and subsequently, this patient underwent repeated bypass grafting surgery.

CONCLUSIONS

After long-term follow-up, 17 of 18 patients had an excellent result of direct surgical angioplasty of the left main coronary artery. MRI is a safe and noninvasive way to visualize the left main coronary artery after direct surgical angioplasty, but quantitative assessment of a lesion is not reliable. Fractional flow reserve measurements are mandatory to evaluate the hemodynamic properties of the left main coronary artery after direct surgical angioplasty.

Giant coronary artery aneurysm secondary to Kawasaki disease: diagnosis in an adult by multi-detector row CT coronary angiography

We present the case of an adult female patient with a giant coronary artery aneurysm secondary to Kawasaki disease diagnosed for the first time, as far as the authors are aware, on multi-detector row computed tomography (MDCT). The long-term complications relate to the persistence of these aneurysms with giant coronary aneurysms having the lowest regression rate, the highest risk of stenosis and strongest association with myocardial infarction. MDCT coronary angiography represents an ideal, alternative non-invasive imaging modality for the diagnosis and follow-up of the coronary arterial complications of Kawasaki disease, thereby avoiding invasive coronary imaging, and its use in the management algorithm should be considered. We also aim to contribute to the expanding clinical role of MDCT coronary imaging.