One year in review: Kawasaki disease

Relationship between serum plasminogen activator and D-dimer levels and the severity of Kawasaki disease in children as well as their predictive value for coronary artery lesion

OBJECTIVE

To evaluate the relationships between serum plasminogen activator (PA) and D-dimer levels, the severity of Kawasaki disease (KD) in children, and their ability to predict coronary artery lesions (CAL).

METHODS

This retrospective study analyzed the clinical data of 102 children diagnosed with KD at the Affiliated Hospital of Jiangnan University from January 2020 to September 2023. The cohort was divided into two groups: 31 children with CAL in the CAL group and 71 without it in the non-CAL group. The study assessed the incidence of CAL and investigated the correlations between serum PA and D-dimer levels and various inflammatory markers (white blood cell (WBC) count, platelet count, and erythrocyte sedimentation rate (ESR)). Receiver operating characteristic (ROC) curves were used to evaluate the predictive value of these biomarkers for CAL.

RESULTS

CAL was present in 30.04% of the children. Pearson correlation analysis revealed that serum PA levels were inversely correlated with WBC count (P = 0.0187), platelet count (P = 0.0116), and ESR (P = 0.0041), while D-dimer levels were positively correlated with these markers (P < 0.001). A negative correlation between PA and D-dimer levels was also observed (P < 0.001). The combined use of PA and D-dimer levels to predict CAL achieved an area under the curve of 0.871.

CONCLUSION

Serum PA levels were negatively associated with the severity of KD, whereas D-dimer levels were positively associated. Together, these markers showed significant predictive value for CAL, highlighting their utility in assessing disease severity and guiding management in children with KD.

Development of an immunoinflammatory indicator-related dynamic nomogram based on machine learning for the prediction of intravenous immunoglobulin-resistant Kawasaki disease patients

BACKGROUND

Approximately 10-20% of Kawasaki disease (KD) patients suffer from intravenous immunoglobulin (IVIG) resistance, placing them at higher risk of developing coronary artery aneurysms. Therefore, we aimed to construct an IVIG resistance prediction tool for children with KD in Shanghai, China.

METHODS

Retrospective analysis was conducted on data from 1271 patients diagnosed with KD and the patients were randomly divided into a training set and a validation set in a 2:1 ratio. Machine learning algorithms were employed to identify important predictors associated with IVIG resistance and to build a predictive model. The best-performing model was used to construct a dynamic nomogram. Moreover, receiver operating characteristic curves, calibration plots, and decision-curve analysis were utilized to measure the discriminatory power, accuracy, and clinical utility of the nomogram.

RESULTS

Six variables were identified as important predictors, including C-reactive protein, neutrophil ratio, procalcitonin, CD3 ratio, CD19 count, and IgM level. A dynamic nomogram constructed with these factors was available at https://hktk.shinyapps.io/dynnomapp/. The nomogram demonstrated good diagnostic performance in the training and validation sets (area under the receiver operating characteristic curve = 0.816 and 0.800, respectively). Moreover, the calibration curves and decision curves analysis indicated that the nomogram showed good consistency between predicted and actual outcomes and had good clinical benefits.

CONCLUSION

A web-based dynamic nomogram for IVIG resistance was constructed with good predictive performance, which can be used as a practical approach for early screening to assist physicians in personalizing the treatment of KD patients in Shanghai.

French national diagnostic and care protocol for Kawasaki disease

Kawasaki disease (KD) is an acute vasculitis with a particular tropism for the coronary arteries. KD mainly affects male children between 6 months and 5 years of age. The diagnosis is clinical, based on the international American Heart Association criteria. It should be systematically considered in children with a fever, either of 5 days or more, or of 3 days if all other criteria are present. It is important to note that most children present with marked irritability and may have digestive signs. Although the biological inflammatory response is not specific, it is of great value for the diagnosis. Because of the difficulty of recognising incomplete or atypical forms of KD, and the need for urgent treatment, the child should be referred to a paediatric hospital as soon as the diagnosis is suspected. In the event of signs of heart failure (pallor, tachycardia, polypnea, sweating, hepatomegaly, unstable blood pressure), medical transfer to an intensive care unit (ICU) is essential. The standard treatment is an infusion of IVIG combined with aspirin (before 10 days of fever, and for a minimum of 6 weeks), which reduces the risk of coronary aneurysms. In case of coronary involvement, antiplatelet therapy can be maintained for life. In case of a giant aneurysm, anticoagulant treatment is added to the antiplatelet agent. The prognosis of KD is generally good and most children recover without sequelae. The prognosis in children with initial coronary involvement depends on the progression of the cardiac anomalies, which are monitored during careful specialised cardiological follow-up.

Is Kawasaki Disease Caused by a Respiratory Virus?

BACKGROUND

Kawasaki disease is characterized by high fever, rash, cervical lymphadenopathy, conjunctival injection, oral mucous membrane changes and swelling of the extremities followed by skin sloughing. Despite >50 years of study, no bacterial, viral or other infectious agent has been consistently associated with the illness. The lockdown and social distancing for COVID-19 in March 2020 led to a marked decrease in respiratory virus circulation. This provided an "experiment of nature" to determine whether Kawasaki disease would decline in parallel.

METHODS

Discharge ICD-10 diagnosis codes were obtained from the Vizient Clinical Data Base for Kawasaki disease and respiratory viruses, and analyzed for the age group < 5 years. Weekly respiratory virus positivity data were also obtained from BioFire Diagnostics.

RESULTS

Common enveloped respiratory viruses declined precipitously from April 2020 through March 2021 to levels at or below historical seasonal minimum levels. Kawasaki Disease declined about 40% compared with 2018-2019, which is distinctly different from the pattern seen for the enveloped respiratory viruses. Strong seasonality was seen for Kawasaki disease as far back as 2010, and correlated most closely with respiratory syncytial virus, human metapneumovirus and less so with influenza virus suggesting there is a baseline level of Kawasaki disease activity that is heightened during yearly respiratory virus activity but that remains at a certain level even in the near total absence of respiratory viruses.

CONCLUSIONS

The striking decrease in enveloped respiratory viruses after lockdown and social distancing was not paralleled by a comparable decrease in Kawasaki disease incidence, suggesting a different epidemiology.

Kawasaki disease complicated with shock syndrome, macrophage activation syndrome, and acute abdomen in children: Two case reports

Background

Kawasaki disease (KD) is an acute systemic vasculitis that can involve multiple organs. Few reports have been published about KD patients presenting with multiple complications such as acute abdomen, KD shock syndrome (KDSS), and macrophage activation syndrome (MAS).

Case Description

We present the cases of two males (9 and 12 years old) diagnosed with KD accompanied by rare manifestations. Case 1 is a 9-year-old male treated for acute appendicitis, KDSS, and MAS. Case 2 is a 12-year-old male who presented with KDSS, MAS, and an ileal perforation. They were treated with intravenous immunoglobulin, aspirin, high-dose corticosteroids, vasoactive drugs, and symptomatic treatment, with good outcomes.

Conclusions

Clinicians should be aware of the possibility of KD in the presence of fever and unusual manifestations, such as severe inflammatory indicators and acute abdomen that is nonresponsive to antibiotic therapy. Meanwhile, KD-related unusual complications should be recognized, such as KDSS and MAS.

Molecular mechanisms of endothelial dysfunction in Kawasaki-disease-associated vasculitis

Kawasaki disease (KD) is an acute, inflammation mediated vasculitis, mainly affecting in children under five, which is consider as the most common coronary artery disease in children. The injuries of coronary arteries would result in dilation or thrombus formation, bringing great threaten to patients. Endothelium, located in the inner surface of coronary artery, serves as the interface between the circulating inflammatory cells and vascular media or adventitia, which is the first target of inflammatory attacks during early stage of KD. A series of studies have determined vascular endothelial cells damages and dysfunction in KD patients. However, current therapeutic strategy is still challenging. So that it is critical to underline the mechanisms of endothelium injuries. In this review, the role of endothelial cells in the pathogenesis of KD and the therapeutic methods for endothelial cells were systematically described.

Cytokine Cascade in Kawasaki Disease Versus Kawasaki-Like Syndrome

Kawasaki disease (KD) is a medium vessel systemic vasculitis that predominantly occurs in children below five years of age. It is an acute febrile condition in which coronary artery aneurysms and myocarditis are the most common cardiovascular complications. It is most often characterized by hypercytoki-nemia. The etiopathogenesis of KD is not fully understood. The present review synthesizes the recent advances in the pathophysiology and treatment options of KD. According to different studies, the genetic, infections and autoimmunity factors play a major role in pathogenesis. Several susceptibility genes (e.g. caspase 3) and cytokines (e.g. IL-2, IL-4, IL-6, IL-10, IFN-γ and TNF-α) have been identified in KD. Patients with high cytokine levels are predisposed to KD shock syndrome. The importance of respiratory viruses in the pathogenesis of the disease is unclear. Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may induce in children and adults an abnormal systemic inflammatory response. This syndrome shares characteristics with KD. It has been called by many terms like MIS-C (Multisystem Inflammatory Syndrome in Children), PIMS-TS (pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2), hyperinflammatory shock syndrome, cytokine storm (cytokine release syndrome) or simply, Kawasaki-like syndrome. The cytokine’s role in the development of KD or Kawasaki-like syndrome being triggered by COVID-19 is controversial. The presences of the antiendothelial cell autoantibodies (AECAs) together with the newly developed hypothesis of immunothrombosis are considered potential pathogenic mechanisms for KD. In consequence, the diagnosis and treatment of KD and Kawasaki-like syndrome, one of the most common causes of acquired heart disease in developed countries, are challenging without a clearly defined protocol.

Overexpressed Neuropilin-1 in Endothelial Cells Promotes Endothelial Permeability through Interaction with ANGPTL4 and VEGF in Kawasaki Disease

Disrupted endothelial permeability plays a crucial role in the vasculitis pathogenesis of Kawasaki disease (KD), which leads to pathological vascular leak and facilitates inflammatory cell infiltration in vascular lesions; however, the mechanisms involved in the development of endothelial barrier dysfunction during KD vasculitis are still largely unclear. Here, we found that sera from patients with KD can induce endothelial cell (EC) hyperpermeability compared to sera from healthy controls. We observed that serum vascular endothelial growth factor (VEGF) levels were increased in KD patients and sera from KD patients upregulated the expression of VEGF receptor 2 (VEGFR2) and neuropilin-1 (NRP1) in human coronary artery endothelial cells (HCAECs). Intriguingly, compared with silence of VEGFR2 in HCAECs, NRP1 silence resulted in a marked decrease in EC permeability. Furthermore, soluble NRP1 (sNRP1) remarkably reduced the stimulation of EC permeability by sera from KD patients compared with bevacizumab treatment. Importantly, we showed that besides VEGF, angiopoietin-like-4 (ANGPTL4), a NRP1-binding vasoactive factor, was also increased in KD and contributed to the EC permeability in KD conditions. In addition, levels of both ANGPTL4 and VEGF were inversely correlated with albumin levels in the serum of KD patients. Collectively, the data demonstrated that overexpressed NRP1, along with upregulated VEGFR2, in HCAECs treated with KD sera promotes endothelial permeability via interaction with the increased ANGPTL4 and VEGF in KD. Neutralization of hyperpermeability factors by sNRP1 may be a novel therapeutic strategy for KD vasculitis.

Predictive value of brachial artery flow-mediated dilation on coronary artery abnormality in acute stage of Kawasaki disease

Coronary artery abnormalities (CAAs) are a severe complication of Kawasaki disease (KD) that may lead to cardiovascular events. Given the evidence that brachial artery flow-mediated dilation (FMD) decreases in children after the onset of KD, we hypothesized that it could be an early marker of CAA development in the acute stage and investigated its relationship with variation in the coronary artery diameter. A total of 326 sex- and age-matched children were enrolled, including 120 with KD, 109 febrile children and 97 healthy controls. In this study, FMD was significantly decreased in the KD group compared with the febrile and healthy groups. FMD was lower in the CAA group than in the no coronary artery abnormality group. The comparison of FMD showed an obvious difference among the CAA subgroups. The FMD in the coronary aneurysm (CA) group showed a strong negative correlation with the pretreatment maximum coronary artery Z-score (preZmax). While preZmax was 2.5, the receiver operating characteristic curve indicated an optimal cutoff point of 3.44% for FMD. FMD ≤ 3.44% could be considered as a signal of coronary lesions in acute stage of KD.

Kawasaki disease for the paediatric dermatologist: skin manifestations and new insights into the pathophysiology

Early diagnosis of Kawasaki disease (KD) is critical to allow prompt initiation of treatment and avoid cardiac complications. All children with KD have fever accompanied by clinical signs, with four of the five classic criteria for complete KD being mucocutaneous, thus creating an important role for dermatologists. Moreover, dermatologists must be familiar with other dermatological findings that are not included in the American Heart Association classification criteria but can support the diagnosis, particularly in incomplete forms of the disease. We review the skin manifestations described for KD and perform an overview of pathophysiological advances and new treatments.

Epidemiology of Kawasaki Disease in Europe

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.