Diagnosis, treatment and outcome of Kawasaki disease in an Australian tertiary setting: a review of three years experience

Kawasaki Disease: A Clinician's Update

Aims. Kawasaki disease is an acute systemic vasculitis and is the most common cause of acquired heart disease in children in the developed world. This review aims to synthesise recent insights into the disease and provide an update for clinicians on diagnostic and treatment practices. Methods. We conducted a review of the literature exploring epidemiology, aetiology, diagnosis, and management of Kawasaki disease. We searched MEDLINE, Medline In-Process, Embase, Google Scholar, and reference lists of relevant articles. Conclusions. Kawasaki disease is a febrile vasculitis which progresses to coronary artery abnormalities in 25% of untreated patients. The disease is believed to result from a genetically susceptible individual's exposure to an environmental trigger. Incidence is rising worldwide, and varies widely across countries and within different ethnic groups. Diagnosis is based on the presence of fever in addition to four out of five other clinical criteria, but it is complicated by the quarter of the Kawasaki disease patients with "incomplete" presentation. Treatment with intravenous immunoglobulin within ten days of fever onset improves clinical outcomes and reduces the incidence of coronary artery dilation to less than 5%. Given its severe morbidity and potential mortality, Kawasaki disease should be considered as a potential diagnosis in cases of prolonged paediatric fever.

Incomplete clinical manifestation as a risk factor for coronary artery abnormalities in Kawasaki disease: a meta-analysis

Incomplete Kawasaki disease (KD) comprises a large proportion of the total number of cases. Although it has the potential of delaying diagnosis, it is not conclusive whether an incomplete presentation is a risk factor for coronary artery abnormalities (CAAs). We performed a meta-analysis to establish the risk of CAA in 20 studies including 4,504 cases and 32,519 controls, and the risk of giant aneurysm in two studies including 5,390 cases and 37,648 controls. The pooled results indicated that incomplete KD was associated with an increased risk of CAA [odds ratio (OR) = 1.447, 95 % confidence interval (CI) = 1.158-1.808, p = 0.001]. Subgroup analyses demonstrated higher associations in patients younger than 12 months (OR = 2.023, 95 % CI = 1.252-3.271, p = 0.004), Asians and Indians (OR = 1.57, 95 % CI = 1.234-1.999, p < 0.001 and OR = 7.088, 95 % CI = 1.640-30.631, p = 0.009, respectively). Subgroup analysis according to the period of patient enrollment before and after 2004 showed increased association of incomplete KD with CAA only among studies with patients enrolled after 2004 (OR = 1.969, 95 % CI = 1.240-3.127, p = 0.004). In conclusion, incomplete KD seems to be associated with an increased risk of CAA, and this is more prominent in patients younger than 12 months, Asians and Indians.

Clinical and epidemiological characteristics of children with Kawasaki disease in Turkey

BACKGROUND

Kawasaki disease (KD) is the leading cause of acquired heart disease in childhood in the developed countries. The objective of this study is to describe the clinical and epidemiological characteristics of children with KD in Turkey.

METHODS

The medical records of 24 patients treated for KD between January 1994 and June 2009 at Ankara University Medical School, Turkey were reviewed.

RESULTS

The male-to-female ratio was 1.4 : 1. The median age at diagnosis was 2 years (range: 6.5 months to 11 years). Conjunctivitis and changes in the lips and oral cavity were seen in 21/24 (87.5%), cervical lymphadenopathy 17/24 (70.8%), polymorphous rash 16/24 (66.7%) and peripheral changes in 12/24 (50%). Coronary artery abnormality (CAA) was observed in 8/24 (33.3%) cases. CAA was seen in both the complete and incomplete groups with similar frequency (31.3% vs. 37.5%, respectively).

CONCLUSIONS

KD must be kept in mind in the differential diagnosis of infants with prolonged fever.

Giant coronary artery aneurysms in Kawasaki disease--the need for coronary artery bypass

The incidence of coronary artery involvement has fallen markedly following early gammaglobulin infusions in Kawasaki disease. Nevertheless such involvement may still occur and if giant coronary aneurysms develop they are more likely to lead to myocardial ischaemia. Two subjects are described who developed giant aneurysms, one of whom was subjected to successful coronary artery bypass following the detection of myocardial ischaemia on a nuclear perfusion scan 5 years following his acute episode. The other is being followed to detect the first signs of any ischaemia. While all patients who develop coronary artery aneurysms following Kawasaki disease require diligent long-term review, that is especially important in the few with giant aneurysms. Early detection of significant coronary artery stenosis and its successful treatment may prevent myocardial infarction in childhood and adolescence with all its long-term consequences.

Kawasaki disease may be a hyperimmune reaction of genetically susceptible children to variants of normal environmental flora

Kawasaki disease (KD) is an acute febrile systemic vasculitis of unknown etiology that occurs predominantly in children <5 years of age. For the etiopathogenesis of KD, there is no agreement even as to whether KD is an infectious disease or an immune-mediated disease. The epidemiologic characteristics of KD, including the strict predilection of age in all ethnic groups and the gradually increased incidence after the KD emergence, suggest that KD is affected by the immune maturation in early childhood that may be determined by genetic factors, and KD is also affected by the changed environmental circumstances such as improved public hygiene.

We postulated that the pathogenesis of KD is a hyperimmune reaction in genetically susceptible children to the variants of normal flora, which are induced by the environmental factors. Using this hypothesis, we might partly explain the clinical and epidemiological characteristics of KD. We expect that this hypothesis may help to determine the causative agents for KD in the near future.

Features of Kawasaki disease at the extremes of age

AIM

The diagnosis of Kawasaki disease (KD) in those outside the typical age range (6 months-4 years) is often delayed, potentially worsening prognosis. The features of KD in children<or=6 months and >or=5 years were compared with those presenting within the more typical age distribution.

METHODS

Korean children with complete diagnostic criteria for KD were grouped according to their age at presentation: Group A (<or=6 months), Group B (7 months-4 years) and Group C (>or=5 years). The clinical features, laboratory findings and outcome in each group were compared.

RESULTS

Of 136 children presenting to a single centre between 1999 and 2003, 10 children were in Group A, 114 in Group B and 12 in Group C. The mean total fever duration was 8 days in Group C and 6.2 days in Group A (P=0.03). All children in Group C had cervical lymphadenopathy, compared with 50% of Group A and 64% of Group B (P=0.01). Coronary artery lesions were commoner in older children (Group C, 42%) compared with Group B (17%, P=0.05). All children had an equivalent leukocytosis, but Group C had significantly higher neutrophil counts (P=0.001). Group A had significantly lower mean haemoglobin (P=0.003) and total protein (P=0.002) at presentation and a more marked thrombocytosis 1 week after intravenous immunoglobulin therapy (P<0.05).

CONCLUSION

The clinical and laboratory phenotype of KD varies with age. Older children may have a more marked inflammatory response and worse outcome. Younger children who are treated appropriately may not have a chance to higher risk of coronary artery lesions.