Influenza A (H1N1) pdm09 virus infection in a patient with incomplete Kawasaki disease: A case report

Kawasaki Disease and Respiratory Viruses: Ecological Spatiotemporal Analysis

Background

Kawasaki disease is an uncommon vasculitis affecting young children. Its etiology is not completely understood, although infections have been frequently postulated as the triggers. Respiratory viruses, specifically, have often been implicated as causative agents for Kawasaki disease presentations.

Objective

We aimed to conduct an ecological spatiotemporal analysis to determine whether Kawasaki disease incidence was related to community respiratory virus circulation in a shared region and population, and to describe viral associations before and during the COVID-19 pandemic.

Methods

We obtained independent statewide data sets of hospital admissions of Kawasaki disease and respiratory multiplex polymerase chain reaction tests performed at two large hospital networks in Victoria, Australia, from July 2011 to November 2021. We studied spatiotemporal relationships by negative binomial regression analysis of the monthly incidence of Kawasaki disease and the rate of positive respiratory polymerase chain reaction tests in different regions of Victoria. Peak viral seasons (95th percentile incidence) were compared to median viral circulation (50th percentile incidence) to calculate peak season increased rate ratios.

Results

While no seasonal trend in Kawasaki disease incidence was identified throughout the study period, we found a 1.52 (99% CI 1.27-1.82) and a 1.43 (99% CI 1.17-1.73) increased rate ratio of Kawasaki disease presentations in association with human metapneumovirus and respiratory syncytial virus circulation, respectively, before the COVID-19 pandemic. No respiratory viral associations with Kawasaki disease were observed during the COVID-19 pandemic.

Conclusions

Our large ecological analysis demonstrates novel spatiotemporal relationships between human metapneumovirus and respiratory syncytial virus circulation with Kawasaki disease. The disappearance of these associations in the COVID-19 pandemic may reflect the reduced circulation of non-SARS-CoV-2 viruses during this period, supporting the prepandemic associations identified in this study. The roles of human metapneumovirus and respiratory syncytial virus in Kawasaki disease etiology warrant further investigation.

Emerging evidence of microbial infection in causing systematic immune vasculitis in Kawasaki disease

Kawasaki disease (KD) is a systematic vasculitis that is often complicated by coronary artery lesions and is a leading cause of acquired heart disease in developed countries. Previous studies have suggested that genetic susceptibility, together with an inducing infectious agent, could be involved in KD pathogenesis; however, the precise causative agent of this disease remains unknown. Moreover, there are still debates concerning whether KD is an infectious disease or an autoimmune disease, although many studies have begun to show that various pathogens functioning as critical inducers could activate different kinds of immune cells, consequently leading to the dysfunction of endothelial cells and systematic vasculitis. Here in this review, we attempt to summarize all the available evidence concerning pathogen infections associated with KD pathogenesis. We also discuss the related mechanisms, present a future perspective, and identify the open questions that remain to be investigated, thereby providing a comprehensive description of pathogen infections and their correlations with the host immune system in leading to KD.

Pneumonia in the presentation of Kawasaki disease: The syndrome or a sequence of two diseases?

Two cases of Kawasaki disease (KD) presented as persistent lung consolidation associated with Group A Streptococcus and Influenza A co-infection, which resolved following intravenous immunoglobulin. Thus, pediatricians should consider the diagnosis of KD in the presence of pneumonia that is nonresponsive to antibiotic therapy with prolonged fever and inflammatory reactions.

Profile of Children with Kawasaki Disease Associated with Tropical Infections

OBJECTIVE

To describe various infectious triggers for Kawasaki disease (KD) in India.

METHODS

A series of 10 children with diagnosed infections who developed KD during their course of illness has been presented. They were diagnosed by the American Heart Association (AHA) 2017 guidelines. Echocardiography was done to check for coronary artery dilation. Treatment was instituted as per standard protocol.

RESULTS

Kawasaki disease was diagnosed in 8 boys and 2 girls, aged 1 mo to 11 y. These children were being treated for dengue, chikungunya, SARS-CoV-2, hepatitis A, tuberculosis, brucellosis, disseminated staphylococcal sepsis, scrub typhus, and enteric fever.

CONCLUSIONS

Kawasaki disease has been associated with infectious triggers. It should be considered in febrile patients with mucocutaneous involvement or in nonresponsive sepsis, despite adequate therapy.

Kawasaki disease and influenza-new lessons from old associations

Kawasaki disease (KD), an enigmatic medium vessel vasculitis, presents as an acute febrile illness predominantly affecting young children. KD appears to be a hyper-inflammatory response elicited by environmental or infectious agents (including respiratory viruses) in genetically predisposed individuals. Numerous reports from the current era of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic have described the occurrence of KD/KD-like illness in close temporal proximity to SARS-CoV-2 infection or exposure. Notably, KD has been reported in association with H1N1-pdm09 virus that caused the previous pandemic a decade ago. Non-H1N1 influenza infections as well as influenza vaccination have also been reported to trigger KD. Herein, we report a case of H1N1-pdm09 influenza who developed KD. We review the published literature on influenza infection or vaccination triggering KD. This may help in a better understanding of the KD/KD-like illness associated with SARS-CoV-2. Besides, we also evaluate the safety of aspirin in influenza-triggered KD as aspirin administration in children with influenza is associated with the risk of development of Reye syndrome.

The Blood Gene Expression Signature for Kawasaki Disease in Children Identified with Advanced Feature Selection Methods

Kawasaki disease (KD) is an acute vasculitis, accompanied by coronary artery aneurysm, coronary artery dilatation, arrhythmia, and other serious cardiovascular diseases. So far, the etiology of KD is unclear; it is necessary to study the molecular mechanism and related factors of KD. In this study, we analyzed the expression profiles of 75 DB (identifying bacteria), 122 DV (identifying virus), 71 HC (healthy control), and 311 KD (Kawasaki disease) samples. 332 key genes related to KD and pathogen infections were identified using a combination of advanced feature selection methods: (1) Boruta, (2) Monte-Carlo Feature Selection (MCFS), and (3) Incremental Feature Selection (IFS). The number of signature genes was narrowed down step by step. Subsequently, their functions were revealed by KEGG and GO enrichment analyses. Our results provided clues of potential molecular mechanisms of KD and were helpful for KD detection and treatment.

Evaluating Postoperative Outcomes of Patients Undergoing Elective Procedures in an Ambulatory Surgery Center During the COVID-19 Pandemic

BACKGROUND

Despite the rapid increase in the number of publications pertaining to COVID-19, there is a lack of data examining patient outcomes following elective procedures performed during this pandemic.

OBJECTIVES

The purpose of this investigation was to examine the postoperative outcomes of patients who underwent elective procedures in an ambulatory surgery center during the COVID-19 pandemic, and to share the preoperative screening and patient selection protocol implemented in our center.

METHODS

Elective procedures performed in an ambulatory surgery center between March 1, 2020 and April 16, 2020 were retrospectively reviewed. The primary outcomes were occurrence of COVID-19-related postoperative complications. These complications include pneumonia, stroke, myocardial infarction, and clotting disorders. The predictive variables analyzed in this study were age, American Society of Anesthesiologists score, specialty conducting the procedure, operating time, and the type of plastic and reconstructive surgery procedure being performed.

RESULTS

A total of 300 consecutive electives cases were included in the study. The most common procedures were pain management (43.0%), gastrointestinal (26.0%), aesthetic (14.0%), orthopedic (10.3%), reconstructive (4.0%), otorhinolaryngology (2.0%), and gynecology (0.67%). The median age of the cohort was 54.6 years (range, 1-90 years) and the median procedure time was 47 minutes (range, 11-304 minutes). COVID-19-related symptoms or complications following the procedures were not observed in any of the patients or in the healthcare care personnel.

CONCLUSIONS

In this cohort of 300 elective cases, we found no patients with COVID-19-related symptoms postoperatively. This suggests that with proper preoperative screening and patient selection, elective procedures can be safely performed in an ambulatory surgery center during this pandemic.

LEVEL OF EVIDENCE: 4

COVID-19 in clinical practice: A narrative synthesis

The coronavirus disease 2019 (COVID-19) was first reported in the city of Wuhan, China. The disease rapidly spread to the rest of China, to Southern-East Asia, then to Europe, America, and on to the rest of the world. COVID-19 is associated with a betacoronavirus named SARS-CoV-2. The virus penetrates the organism through the respiratory tract, conveyed by contaminated droplets. The main cell receptor targeted is the surface-bound ACE-2. As of the 26th July 2020, 15,200,000 COVID-19 cases and 650,000 deaths were reported worldwide. The mortality rate is estimated between 1.3 and 18.3%. The reproductive rate without any public health intervention is estimated around 4-5.1 in France. Most hospitalized patients for COVID-19 present respiratory symptoms, which in some cases is associated with fever. Up to 86% of admissions to ICU are related to acute respiratory failure. To date, no anti-viral therapy has proven its efficacy considering randomized trials. Only immunomodulatory treatments such as corticosteroids have shown to cause significant improvement in patient outcome.

Kawasaki and COVID-19 disease in children: a systematic review

OBJECTIVE

To present scientific evidence based on a systematic literature review (PRISMA) evaluating the association of Kawasaki Disease (DK) and COVID-19 in children.

METHODS

For the selection of studies, a combination based on the Medical Subject Heading Terms (MeSH) was used. The Medline (Pubmed), LILACS, SciELO, COCHRANE, and BIREME databases were used. The search period for the articles comprised the last 10 years (2010 to 2020).

RESULTS

840 articles with potential for inclusion were retrieved, one of which met the inclusion criteria and the guiding question that consisted of evaluating the association of Kawasaki disease and COVID-19 in children.

CONCLUSION

A significant increase in the incidence of Kawasaki-type diseases after the onset of the epidemic has been reported, suggesting an association between the COVID-19 epidemic and the high incidence of a severe form of KD. However, further studies are needed to conduct an investigation of the association between these two diseases.

COVID-19 and Hyperinflammatory Syndrome in Children: Kawasaki Disease with Macrophage Activation Syndrome in Disguise?

A hyperinflammatory syndrome has been described in times of COVID-19 in children. In the setting of uncertainty due to a new virus, the so-called hyperinflammatory syndrome has been coined as a novel entity by some and is being referred to as pediatric inflammatory multisystem syndrome (PIMS). However, the characteristics of the syndrome resemble those of Kawasaki disease (KD), an inflammatory syndrome in children that can lead to coronary artery abnormalities due to a subsequent vasculitis. Furthermore, Kawasaki disease may occasionally trigger macrophage activation syndrome (MAS), a condition in which there is uncontrolled activation and proliferation of macrophages and other cell types, and could lead to multiorgan system dysfunction. This study provides a review of the data regarding COVID-19, Kawasaki disease, and macrophage activation syndrome to demonstrate the similarities and differences between the inflammatory syndrome seen with COVID-19 and KD. In addition, a framework for diagnosis and evaluation is provided that focuses on the pathway previously established for KD and MAS. The authors believe that based on current knowledge, KD treatment delays may carry deleterious effects in the near future for children with COVID-19-related Kawasaki disease.

Novel coronavirus infection and Kawasaki disease

There is a global problem of increment of the number of children with clinical features that mimic Kawasaki Disease (KD) during the ongoing Coronavirus Disease 2019 (COVID-19) pandemic. The disease was first reported by Tomisaku Kawasaki, a Japanese pediatrician, in a four-year-old child with a rash and fever at the Red Cross Hospital in Tokyo in January 1961. Now Kawasaki disease is recognized worldwide. The complexity of symptoms was defined as an «acute febrile mucocutaneous lymphnode syndrome". At the moment, it is still unclear whether the coronavirus itself can lead to development of mucocutaneous lymph node syndrome. However, it is believed that COVID-19 virus infection worsens the course of Kawasaki disease, and in some cases, children affected by SARS-V-2 may develop a disease that has a clinical picture similar to Kawasaki disease.

COVID-19 and Kawasaki syndrome: should we really be surprised?

A hyperinflammatory response to COVID-19 is being described in children. While this presents, and responds to management, similar to that of Kawasaki Disease it is being coined a new entity. But is it really? We explore how this phenomenon may be Kawasaki Disease with a new trigger.

Kawasaki Disease as the Immune-Mediated Echo of a Viral Infection

Although the etiology of Kawasaki disease (KD) remains elusive, the available evidence indicates that the primum movens may be a dysregulated immune response to various microbial agents, leading to cytokine cascade and endothelial cell activation in patients with KD. Documented infections by different viruses in many individual cases have been largely reported and are discussed herein, but attempts to demonstrate their causative role in the distinctive KD scenario and KD epidemiological features have been disappointing. To date, no definite link has been irrefutably found between a single infection and KD.