SIR 2004 Film Panel Case: Systemic Artery Aneurysms in Kawasaki Disease

Long-term results of large common iliac artery aneurysms caused by Kawasaki disease in four patients

Among Kawasaki disease patients with systemic artery aneurysms, the brachial and internal iliac arteries are the most commonly affected, and occlusions of both arteries are often found. However, the long-term fate of large common iliac artery aneurysms remains unknown, because their prevalence is very low. The long-term outcomes of common iliac artery aneurysms caused by Kawasaki disease in four patients (three females, one male) were investigated retrospectively based on their medical records and angiograms. Their ages ranged from 30 to 36 years-old. The onset age of Kawasaki disease ranged from 4 to 8 months, and the interval from the onset of Kawasaki disease to the latest angiogram ranged from 17 to 21 years. All patients had bilateral large coronary aneurysms and common iliac artery aneurysms with maximal diameters greater than 10 mm. Although all patients had multi-vessel coronary artery stenotic lesions and systemic artery aneurysms, they were asymptomatic. The three female patients underwent coronary artery bypass grafting, and the male patient underwent replacement of artificial vessels for large bilateral common iliac artery aneurysms at 3 years old of age. Over the long-term, common iliac artery aneurysms greater than 10 mm persisted as calcified aneurysms. However, they had no symptoms due to their common iliac artery aneurysms, and their ankle brachial pressure index was preserved, even if the stenosis of the common iliac artery developed as a late outcome, because the collateral arteries were well developed. The progression of stenosis of the common iliac artery after Kawasaki disease was slower.

Systemic Artery Aneurysms and Kawasaki Disease

BACKGROUND

Coronary artery aneurysms (CAAs) are a well-known complication of Kawasaki disease (KD), but there are no data on incidence or outcomes of systemic artery aneurysms (SAAs) in the current era.

METHODS

From April 1, 2016, to March 31, 2019, we screened for SAAs in 162 patients with KD at risk for SAAs with magnetic resonance angiography or peripheral angiography and analyzed incidence and early outcomes of SAAs.

RESULTS

Twenty-three patients had SAAs, demonstrating an incidence of 14.2% (23 of 162) in patients who were screened at 1 month after onset. The proportion of patients with SAAs was estimated to be 2% (23 of 1148) of all patients with KD. The median age at onset of KD with SAAs was 5 months. All patients with SAAs had CAAs, with z scores >8. Of patients with giant CAAs, 38.6% (17 of 44) had SAAs. A total of 129 SAAs occurred in 17 different named arteries. The most common sites for SAAs were the axillary (18.6%), common iliac (12.4%), and brachial (11.6%) arteries. During a median follow-up time of 6 months, 92.9% (79 of 85) of SAAs had some degree of regression, with 80% (68 of 85) of SAAs returning to normal. The overall regression rate was higher for medium to large SAAs than for medium to giant CAAs.

CONCLUSIONS

Although the incidence of SAAs may not be as dramatically reduced as we expected compared with previous data, SAAs have a high regression rate during short-term follow-up.

Kawasaki disease: characteristics, diagnosis, and unusual presentations

Introduction: Kawasaki disease (KD) is one of the commonest pediatric vasculitides and is associated with a significant risk of development of coronary artery abnormalities if left untreated. Areas covered: In this review, we have highlighted the incomplete and unusual presentations of KD and also emphasize the controversies pertaining to 2D echocardiography in KD. A PubMed search was performed regarding diagnosis and unusual presentations of KD. Expert opinion: Diagnosis of KD is essentially clinical and based on recognition of typical clinical features that may appear sequentially and all signs and symptoms may not be present at one point of time. There is no confirmatory laboratory test for diagnosis of this condition. Further complicating the picture is the fact that incomplete and atypical forms KD may be seen in up to 50% patients. Although 2D echocardiography continues to be the preferred imaging modality for cardiac assessment in patients with KD, it has its limitations.

Systemic arterial aneurysm complicated by thrombosis in an infant with resistant Kawasaki disease

Kawasaki disease (KD) is a systemic vasculitis commonly associated with coronary artery aneurysms. Small-sized and medium-sized systemic arterial aneurysms have also been described, particularly in infants and patients with resistant KD. This case illustrates the presentation of a systemic arterial aneurysm complicated by arterial thrombosis and successful interventional management in a young infant.

Characteristics and Fate of Systemic Artery Aneurysm after Kawasaki Disease

OBJECTIVE

To determine the long-term outcome of systemic artery aneurysms (SAAs) after Kawasaki disease (KD).

STUDY DESIGN

We investigated the characteristics and the fate of SAAs in 20 patients using medical records and angiograms. The age of onset of KD ranged from 1 month to 20 months. The interval from the onset of KD to the latest angiogram ranged from 16 months to 24 years. The regression rate of peripheral artery aneurysm and the frequency of stenotic lesions were analyzed by the Kaplan-Meier method in 11 patients who had undergone initial angiography within 4 months.

RESULTS

The mean duration of fever was 24 ± 12 days. All 20 patients had at least 1 symmetric pair of aneurysms in bilateral peripheral arteries, and 16 patients had multiple SAAs. The distributions of SAAs was as follows: brachial artery, 30; common iliac artery, 20; internal iliac artery, 21; abdominal aortic aneurysm, 7; and others, 29. The frequencies of regression of SAA and of the occurrence of stenotic lesions at 20 years after the onset of KD were 51% and 25%, respectively (n = 42). The diameter of all SAAs in the acute phase leading to stenotic lesions in the late period was >10 mm.

CONCLUSION

SAAs occurred symmetrically and were multiple in younger infants and those with severe acute vasculitis. The fate of SAAs resembles that of coronary artery aneurysms, and depends on the diameter during the acute phase. Larger SAAs can lead to stenotic lesions in the late period.

Magnetic Resonance Angiography Detection of Vascular Aneurysms in Patients With Kawasaki Disease and Coronary Artery Aneurysms

Kawasaki disease is a systemic panvasculitis that causes coronary artery aneurysms in approximately 15% to 25% of untreated patients. Systemic vascular aneurysms may also occur in medium-sized arteries throughout the body and may lead to increased morbidity and mortality in patients with Kawasaki disease. We report a case of diffuse systemic aneurysm formation in a 2-year-old patient with Kawasaki disease with coronary artery aneurysms. Full-body magnetic resonance angiography (MRA) imaging was utilized both in the acute phase and again prior to cardiac catheterization performed at 6 months from the acute illness. The initial MRA detected aneurysmal dilatation of the common and internal iliac arteries bilaterally in the acute phase. Subsequent MRA performed prior to cardiac catheterization 6 months later demonstrated resolution of the iliac artery lesions. Full-body MRA may be useful in screening for associated systemic vascular aneurysms in patients with Kawasaki disease and associated coronary artery aneurysms.

Giant coronary artery aneurysms in a Japanese octogenarian - The oldest case of Kawasaki Disease?

Kawasaki disease (KD) is a leading cause of non-atherosclerotic coronary artery aneurysms and, less commonly, peripheral artery aneurysms. We report an 81-year-old Japanese man from Hawaii with a history of an abdominal aortic aneurysm, bilateral iliac aneurysms, and an ambiguous right atrial cystic mass. The patient developed new-onset atrial fibrillation during lithotripsy. Angiography and magnetic resonance imaging revealed giant coronary artery aneurysms of the right coronary artery (RCA) and left anterior descending artery, and a thoracic aortic aneurysm. The RCA aneurysm was greater than 2 inches in diameter at the time of operation. Although we cannot confirm whether the patient had KD during childhood, this is the most likely diagnosis in the absence of a connective tissue disorder, systemic vasculitis, or atherosclerotic risk factors. This patient may represent the oldest case of KD, predating the earliest known case by more than 20 years. This case sheds light on the historical epidemiology of KD and its clinical course, especially regarding late vascular sequelae.

Late-appearing brachiocephalic aneurysm: an atypical vascular sequella of Kawasaki disease

Kawasaki disease (KD) is an acute vasculitis that can result in cardiovascular sequelae. One of the most serious consequences of KD is the development of arterial aneurysms that can lead to thrombosis and ischemia. Commonly, these lesions, occurring early in the course of KD, are found in the coronary arteries. However, this location is not exclusive. This report presents a case of KD with atypical findings of a late-appearing brachiocephalic artery aneurysm. The authors suggest that for patients with complicated KD, surveillance should include a careful vascular survey to discover aneurysms distant from the heart.

Chapter 11 Kawasaki Disease

Kawasaki disease (KD) is an acute febrile systemic vasculitis usually occurring in children younger than five years, and rarely reported in neonates and adults. This chapter discusses the epidemiology, etiology, pathogenesis, clinical manifestations, and treatments of KD. The etiology still remains unknown, although epidemiological and clinical features strongly suggest an infectious cause. Immunological abnormalities in the acute phase of the disease reflect activation of immune system and marked production of cytokines by activated cells. KD has some similarities to toxin-mediated diseases, both from a clinical and an immunological point of view. The role of one or more superantigens competent of stimulating large numbers of T cells produced by certain strains of Staphylococcus or Streptococcus is discussed in the chapter, in the context of the etiology of KD. Atypical cases are those with fever, acute surgical symptoms, or neurological manifestations as presenting signs. Medical history, physical examination, and laboratory tests including elevated white-blood cell (WBC) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and low hemoglobin, sodium and albumin levels may help to rule out illnesses mimicking KD. Oral or pulsed corticosteroids in children refractory to intravenous immunoglobulins (IVIG) are an alternative and safe treatment.