Kawasaki disease in Australia, 1993-95

Epidemiology of Kawasaki disease in Australia using two nationally complete datasets

AIM

The incidence of Kawasaki disease (KD) is reported to be increasing in some populations. We sought to describe long-term trends in the incidence and epidemiology of KD in Australia over 25 years.

METHODS

Two nationally complete administrative datasets relevant to KD in Australia were analysed and compared. The Australian Red Cross Lifeblood Supply Tracking Analysis Reporting System (STARS) recorded all doses of immunoglobulin (IVIG) approved in Australia between January 2007 and June 2016. The Australian Institute of Health and Welfare National Hospital Morbidity Database (NHMD) records all episodes of care in hospitals across Australia. Data relevant to KD were extracted an analysed, with comparisons made for the period of data overlap.

RESULTS

During the period of data overlap (2007-2015) the IVIG treatment rate in the 0- to 4-year age group (calculated from STARS) was 14.31 per 100 000 person-years (95% confidence interval 13.67-14.97). The hospitalisation rate in the same age group (calculated from the NHMD) was 14.99 per 100 000 person-years (95% confidence interval 14.33-15.66). Hospitalisation rates rose at an average rate of 3.54% annually over the 25 years to 2017 in the 0- to 4-year age group, almost exclusively in the 1- to 4-year age group.

CONCLUSIONS

There is evidence of increasing KD diagnosis in Australia. Similar trends have also been reported in Asia but not in North America or Europe. Increasing diagnosis may reflect a true increase in disease incidence, increasing recognition or overdiagnosis. Further research is needed to determine the cause for these trends.

What Lies Ahead for Young Hearts in the 21st Century - Is It Double Trouble of Acute Rheumatic Fever and Kawasaki Disease in Developing Countries?

Rheumatic heart disease (RHD), the principal long-term sequel of acute rheumatic fever (ARF), has been a major contributor to cardiac-related mortality in general population, especially in developing countries. With improvement in health and sanitation facilities across the globe, there has been almost a 50% reduction in mortality rate due to RHD over the last 25 years. However, recent estimates suggest that RHD still results in more than 300,000 deaths annually. In India alone, more than 100,000 deaths occur due to RHD every year (Watkins DA et al., N Engl J Med, 2017). Children and adolescents (aged below 15 years) constitute at least one-fourth of the total population in India. Besides, ARF is, for the most part, a pediatric disorder. The pediatric population, therefore, requires special consideration in developing countries to reduce the burden of RHD. In the developed world, Kawasaki disease (KD) has emerged as the most important cause of acquired heart disease in children. Mirroring global trends over the past two decades, India also has witnessed a surge in the number of cases of KD. Similarly, many regions across the globe classified as “high-risk” for ARF have witnessed an increasing trend in the incidence of KD. This translates to a double challenge faced by pediatric health care providers in improving cardiac outcomes of children affected with ARF or KD. We highlight this predicament by reviewing the incidence trends of ARF and KD over the last 50 years in ARF “high-risk” regions.

Kawasaki Disease in the Australian Population: An Australian Tertiary Hospital Experience

AIM

To describe the contemporary experience of Kawasaki Disease (KD) in a tertiary paediatric hospital.

METHODS

This was a retrospective analysis of admissions with suspected/confirmed KD to John Hunter Children's Hospital from 1 January 2015 to 31 December 2016, with follow-up. Patients were stratified into classical, incomplete, unlikely and uncertain KD cohorts based on the 2004 American Heart Association (AHA) guidelines.

RESULTS

Forty (40) patients had 45 admissions with suspected KD. Twenty-four (24) patients (60%) had complete and incomplete KD. Twenty-nine per cent (29%) (7/24) were not diagnosed at presentation. Thirty per cent (30%) (12/40) were incompletely assessed according to the AHA pathway. Seventy-one per cent (71%) of KD patients (17/24) were treated with aspirin and intravenous immunoglobulin. The incidence was 22-26 per 100,000 in children less than 5 years during the study period, higher compared to prior data.

CONCLUSION

The diagnosis of KD remains challenging, with some children not diagnosed at the time of initial presentation. The increase in KD incidence is hypothesis generating and requires further investigation.

Australian hospitalisations for Kawasaki disease, 1993-1994 to 2017-2018

AIM

To estimate and describe trends in hospitalisations for Kawasaki disease in Australia.

METHODS

Analysis of the National Hospital Morbidity Database for separations with a principal diagnosis of Kawasaki disease, 1993-1994 to 2017-2018. Limited to persons aged 0-19 years.

RESULTS

Over the period 1993-1994 to 2017-2018, there were 6368 hospitalisations for Kawasaki disease among people aged 0-19 years; 433 same-day (6.8%) and 5935 overnight (93.2%). Among overnight separations, 15.8% were for children under the age of 1 year and 58.7% for those aged 1-4 years; 60.3% were for males. The hospitalisations rate has increased from 5.2 per 100 000 population in 1993-1994 to 12.4 per 100 000 in 2017-2018. The ratio of male to female hospitalisations was 1.5:1.

CONCLUSIONS

Kawasaki disease is uncommon among Australia children, but its incidence is increasing. As there are no known preventable risk factors for the disease, prompt identification and treatment remain crucial to minimising the risk of cardiovascular sequelae.

Increased Kawasaki Disease Incidence Associated With Higher Precipitation and Lower Temperatures, Japan, 1991-2004

BACKGROUND

Kawasaki disease (KD) is an acute febrile vasculitis, which primarily affects children. The etiology of KD is unknown; while certain characteristics of the disease suggest an infectious origin, genetic or environmental factors may also be important. Seasonal patterns of KD incidence are well documented, but it is unclear whether these patterns are caused by changes in climate or by other unknown seasonal effects.

METHODS

The relationship between KD incidence and deviations from expected temperature and precipitation were analyzed using KD incidence data from Japanese nationwide epidemiologic surveys (1991-2004) and climate data from 136 weather stations of the Japan Meteorological Agency. Seven separate Poisson-distributed generalized linear regression models were run to examine the effects of temperature and precipitation on KD incidence in the same month as KD onset and the previous 1, 2, 3, 4, 5 and 6 months, controlling for geography as well as seasonal and long-term trends in KD incidence.

RESULTS

KD incidence was negatively associated with temperature in the previous 2, 3, 4 and 5 months and positively associated with precipitation in the previous 1 and 2 months. The model that best predicted variations in KD incidence used climate data from the previous 2 months. An increase in total monthly precipitation by 100 mm was associated with increased KD incidence (rate ratio [RR] 1.012, 95% confidence interval [CI]: 1.005-1.019), and an increase of monthly mean temperature by 1°C was associated with decreased KD incidence (RR 0.984, 95% CI: 0.978-0.990).

CONCLUSIONS

KD incidence was significantly affected by temperature and precipitation in previous months independent of other unknown seasonal factors. Climate data from the previous 2 months best predicted the variations in KD incidence. Although fairly minor, the effect of temperature and precipitation independent of season may provide additional clues to the etiology of KD.

Twelve Years of Kawasaki Disease in Portugal: Epidemiology in Hospitalized Children

BACKGROUND

Kawasaki disease (KD) is the leading cause of acquired heart disease in developed countries. Reported incidences vary worldwide but incidence of KD has not been established in Portugal.

AIM

The aims of the study were to describe the epidemiologic characteristics and estimate incidence rates of KD among hospitalized children in Portugal.

METHODS

This study was a descriptive, population-based study, which used hospital discharge records of patients <20 years of age diagnosed with KD from the Hospital Register database for 2000-2011. Incidence rates were calculated using the number of KD patients and corresponding National census data.

RESULTS

There were 533 hospitalizations of 470 patients with KD as the primary diagnosis in Portugal, 63 hospitalizations were transfers of patients between hospitals and there were no relapses. The mean age at admission was 2.8 years, with male predominance (male-to-female ratio: 1.6:1). Children <5 years and infants <1 year represented 83% and 23% of all the patients admitted, respectively. Mean annual incidence was 6.5 per 100,000 children <5 years, 4.5 per 100,000 infants <1 year and 7.8 per 100,000 infants 1-4 years. We found considerable differences between national territorial regions, with majority of cases in most dense regions. The mean length of hospital stay was 9 days, and the incidence peaked in spring (35%) and spring/winter (63%). Coronary aneurysms were reported in 8.5% of patients with a higher male-to-female ratio (3.4:1) and a lower mean age (1.93 years). Reported mortality was 0.4%.

CONCLUSIONS

This is the first large-scale epidemiologic study of KD in Portugal. The highest incidences occurred among male children 1-4 years of age and in spring/winter.

Transmission of acute infectious illness among cases of Kawasaki disease and their household members

BACKGROUND/PURPOSE

Kawasaki disease (KD) is a disease of unknown cause and the causative agent is most likely to be infectious in nature. To investigate the household transmission pattern of infectious illness and etiology, we thus initiated a prospective case and household study.

METHODS

We enrolled KD cases and their household members from February 2004 to September 2008. The KD cases and their household members accepted questionnaire-based interviews of the contact history, signs of infection, and symptoms to check whether clusters of infectious illness occurred.

RESULTS

A total of 142 KD cases and 561 household members were enrolled. Among the 142 KD cases, 136 cases (96%) were typical KD, and six (4%) were atypical KD. Of the 561 household members, 17% were siblings, 46% were parents, 18% were grandparents, and the others were cousins or babysitters. Prior to the onset of their KD illness, 66% (94/142) KD cases had contact with ill household members. On the same day of the onset of KD cases' illness, 4% (6/142) KD cases had household members with illness. After KD cases' disease onset, 70% (100/142) KD cases had at least one other family member with illness. Overall, 61% (343/561) of all the household members had acute infectious illness during KD cases' acute stage, and 92% (130/142) of the families had clusters of infectious illness.

CONCLUSION

A total of 66% KD cases had positive contact with ill household members prior to their disease onset and 92% of families had clusters of infectious illness, so KD is strongly associated with infections.

Clinical and epidemiological characteristics of kawasaki disease

Background:

Kawasaki disease (KD) is an acute multisystem vascular syndrome of unknown etiology that is the leading cause of acquired heart disease in children of developed counties.

Objectives:

We aimed to evaluate the epidemiological characteristics and clinical manifestations of KD in children residing in the southwest of Iran.

Patients and Methods:

In this retrospective study, we reviewed the medical records of all children with KD who had been admitted to the main children’s hospital of Ahvaz, southwest Iran, from March 2000 to March 2010. Data regarding clinical and epidemiological characteristics, management, and the outcome of disease for each patient were obtained. The patients were divided into cardiac and non-cardiac groups based on echocardiographic results.

Results:

In total, 104 patients with KD (66 boys and 38 girls) were enrolled in this study. The male to female ratio was 1.7:1. The mean ± SD age of the patients was 33.6 ± 24.2 months. Most (87.2%) cases were from urban areas. The disease occurred more frequently during winter and spring. Furthermore, 61.5% of the children had the criteria of classic KD, and 38.5% were labeled as incomplete KD. The mean ± SD of the duration of hospital stay was 6.9 ± 2.4 days. The mean time between illness and admission to the hospital was 6.47 ± 2.6 days. The most common sign was fever, followed by conjunctivitis and oral changes. In total, 20% of the patients had cardiac abnormalities. There was no significant statistical difference between the cardiac and non-cardiac groups according to age, sex, clinical manifestations, laboratory findings, and cessation of fever. The duration of hospital stay and the time between onset of illness and diagnosis were longer in the cardiac group. All patients received intravenous immunoglobulin and aspirin. Only one patient continued to have cardiac abnormalities after 6 months of follow-up.

Conclusions:

Kawasaki disease is not rare in southwest of Iran. The age, gender distribution and clinical findings are similar to that of other reports. Patients with cardiac abnormalities had delayed treatment and prolonged hospital stays.

The epidemiology and clinical features of Kawasaki disease in Australia

OBJECTIVES

The current Australian epidemiology of Kawasaki disease (KD) is poorly defined. Previous enhanced surveillance (1993-1995) estimated an incidence of 3.7/100,000 <5 years.

METHODS

We identified all patients hospitalized in Western Australia (current population ∼2.4 million) 1979 through 2009 with a discharge diagnosis of KD. We reviewed demographic, clinical, laboratory, and echocardiographic data from individual patient files and derived age-specific population estimates. KD diagnosis was made using standard criteria.

RESULTS

There were 353 KD cases, with incomplete KD in 34 (9.6%). Male to female ratio was 1.7:1 and median age was 3.8 years (interquartile range 12-60 months). Fifty (18.1%) patients were Asian. Mean annual incidence increased from 2.82 per 100,000 children aged <5 years (95% confidence interval, 1.93-3.99) in 1980 to 1989, to 7.96 (6.48-9.67) in 1990 to 1999, to 9.34 (7.72-11.20) in 2000 to 2009. The highest incidence was 15.7 in 2005. A total of 293 children (83%) received intravenous immunoglobulin and 331 (95.4%) aspirin. Of 282 children who completed echocardiographic studies, 47 (16.7%) had coronary artery (CA) ectasia/dilatation and 19 (6.8%) had CA aneurysms; male gender was significantly associated with CA abnormalities.

CONCLUSIONS

KD epidemiology in Western Australia mirrors that of other industrialized, predominantly European-Caucasian populations. The rising incidence likely reflects both improved ascertainment and a real increase in disease burden. The current Australian incidence is threefold higher than previously reported and similar to the United Kingdom. The CA outcomes, which include the pre-intravenous immunoglobulin era, are comparable to those reported elsewhere.

Viral infections associated with Kawasaki disease

BACKGROUND/PURPOSE

Kawasaki disease (KD) is a disease of unknown cause. To investigate the infectious etiology of Kawasaki disease, we initiated a prospective case-control study to investigate possible links between common viral infections and Kawasaki disease.

METHODS

We enrolled 226 children with KD and 226 age- and sex-matched healthy children from February 2004 to March 2010. Throat and nasopharyngeal swabs were taken for both viral isolation and polymerase chain reaction (PCR) for various viruses.

RESULTS

The mean age of the 226 KD cases was 2.07 years, and the male to female ratio was 1.43 (133 boys to 93 girls). Their mean fever duration was 7.5 days with a mean peak temperature of 39.7°C. In addition to the typical symptoms of fever, neck lymphadenopathy, lip fissure and/or strawberry tongue, skin rash, nonpurulent bulbar conjunctivitis, palm/sole erythema, and induration followed by periungual desquamation, these KD cases also exhibited cough (69%), rhinorrhea (58%), and diarrhea (45%). Cases of KD had a significantly higher positive rate of viral isolation in comparison with the control group (7.5% vs. 2.2%, p = 0.02). Compared with the control group, cases of KD were more likely to have overall positive rates of viral PCR (50.4% vs. 16.4%, p < 0.001) and for various viruses including enterovirus (16.8% vs. 4.4%, p < 0.001), adenovirus (8.0% vs. 1.8%, p = 0.007), human rhinovirus (26.5% vs. 9.7%, p < 0.001), and coronavirus (7.1% vs. 0.9%, p = 0.003).

CONCLUSION

We found that some common respiratory viruses, such as adenoviruses, enteroviruses, rhinoviruses, and coronaviruses, were associated with KD cases.

Update on Kawasaki disease: epidemiology, aetiology and pathogenesis

Kawasaki disease is an acute systemic vasculitis predominantly affecting young children. It is due to an abnormal host response to as yet unidentified infectious trigger(s). Kawasaki disease may cause coronary artery damage, long-term cardiovascular morbidity and occasionally mortality, especially if the diagnosis is missed or timely treatment is not given. This is the first of two updates on Kawasaki disease. Here we review recent advances in epidemiology, possible aetiologies, host susceptibility and pathogenesis of this fascinating condition.

Kawasaki disease in ghana: case reports from Korle Bu teaching hospital

Kawasaki disease, an acute febrile vasculitis, predominantly affects children under the age of 5 years and is thought to be a rare disease in the developing world. It has previously never been reported in Ghana. We report 3 cases from February, 2007 to February, 2008. This potentially serious disease has no definitive diagnostic test and it is not unusual for diagnosis to be delayed with serious consequences. Any child with irritability and persisting fever (>5 days) not responding to antipyretics and antibiotics, accompanied by a rash and non purulent conjunctivitis should be suspected to have Kawasaki disease.

Kawasaki disease

Kawasaki disease is a systemic vasculitis and the leading cause of acquired heart disease in North American and Japanese children. The epidemiology, cause, and clinical characteristics of this disease are reviewed. The diagnostic challenge of Kawasaki disease and its implications for coronary artery outcomes are discussed, as are the recommended treatment, ongoing treatment controversies, concerns associated with treatment resistance, and the importance of ongoing follow up.

Hospitalisation with infection, asthma and allergy in Kawasaki disease patients and their families: genealogical analysis using linked population data

BACKGROUND

Kawasaki disease results from an abnormal immunological response to one or more infectious triggers. We hypothesised that heritable differences in immune responses in Kawasaki disease-affected children and their families would result in different epidemiological patterns of other immune-related conditions. We investigated whether hospitalisation for infection and asthma/allergy were different in Kawasaki disease-affected children and their relatives.

METHODS/MAJOR FINDINGS

We used Western Australian population-linked health data from live births (1970-2006) to compare patterns of hospital admissions in Kawasaki disease cases, age- and sex-matched controls, and their relatives. There were 295 Kawasaki disease cases and 598 age- and sex-matched controls, with 1,636 and 3,780 relatives, respectively. Compared to controls, cases were more likely to have been admitted at least once with an infection (cases, 150 admissions (50.8%) vs controls, 210 admissions (35.1%); odds ratio (OR) = 1.9, 95% confidence interval (CI) 1.4-2.6, P = 7.2×10⁻⁶), and with asthma/allergy (cases, 49 admissions (16.6%) vs controls, 42 admissions (7.0%); OR = 2.6, 95% CI 1.7-4.2, P = 1.3×10⁻⁵). Cases also had more admissions per person with infection (cases, median 2 admissions, 95% CI 1-5, vs controls, median 1 admission, 95% CI 1-4, P = 1.09×10⁻⁵). The risk of admission with infection was higher in the first degree relatives of Kawasaki disease cases compared to those of controls, but the differences were not significant.

CONCLUSION

Differences in the immune phenotype of children who develop Kawasaki disease may influence the severity of other immune-related conditions, with some similar patterns observed in relatives. These data suggest the influence of shared heritable factors in these families.

Repeated systematic surveillance of Kawasaki disease in Ontario from 1995 to 2006

BACKGROUND

Rising incidences of Kawasaki disease (KD) have been reported worldwide. Reported herein are the results of 4 triennial KD surveillances conducted in Ontario.

METHODS

Between 1995 and 2006 all hospitals in Ontario were asked on 4 occasions to identify all patients with discharge diagnoses of KD and report incident cases.

RESULTS

The latest surveillance identified 697 new KD patients (100% response rate) for a total of 2378 KD patients through all 4 surveillances. Yearly incidence was 26.2/100,000 for <5 years old, 6.7/100,000 for 5-9 years old and 0.9/100,000 for 10-14 years old. KD incidence significantly increased from 1995 to 2006, although the increase seemed to plateau between the 3rd and 4th surveillance. There was an increase in the proportion of patients diagnosed with incomplete KD and a significant reduction in the rate of coronary artery abnormalities, possibly due to better disease recognition and treatment. Hospitals reporting <20 cases per surveillance were found to be more likely to report cases with incomplete KD. These patients were also less likely to be treated with i.v. immunoglobulin and aspirin but were more likely to be treated with antibiotics, suggesting uncertainties regarding diagnosis and management of KD patients in those centers.

CONCLUSIONS

The incidence of KD in Ontario is possibly one of the highest outside of Asia and has been rising since 1995. Although the most recent surveillance demonstrated improved cardiac outcomes, treatment delays or absence thereof continue to be a problem. Effective diagnosis and prompt treatment remain critical aspects of KD management.

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.

An evaluation of children with Kawasaki disease in Istanbul: a retrospective follow-up study

BACKGROUND

Kawasaki disease (KD) is an acute, self-limiting vasculitis of unknown etiology. The incidence of KD is increasing world wide. However, the epidemiological data for KD in Turkey has not been well described.

OBJECTIVE

To describe the demographic, clinical, and laboratory features of children with KD who were diagnosed and managed in the American Hospital, Istanbul, Turkey.

METHOD

Patients with KD were retrospectively identified from the hospital discharge records between 2002 and 2010. Atypical cases of KD were excluded. A standardized form was used to collect demographic data, clinical information, echocardiography and laboratory results.

RESULTS

Thirty-five patients with KD, with a mean age of 2.5 + 1.9 years, were identified. Eighty-five point seven per cent of patients were under 5 years of age. A seasonal pattern favouring the winter months was noticed. In addition to fever and bilateral conjunctival injection, changes in the oral cavity and lips were the most commonly detected clinical signs in our cases. Coronary artery abnormalities were detected in nine patients. The majority of our patients had started treatment with intravenous immunoglobulin in the first 10 days of the onset of fever, and only one patient required systemic steroids for intravenous immunoglobulin-resistant KD. The coronary artery abnormalities resolved in all nine patients within 8 months.

CONCLUSION

This study is the most comprehensive series of children from Turkey with KD included in Medline. As adult-onset ischemic heart disease may be due to KD in childhood, further prospective clinical investigations are needed to understand the epidemiology, management and long-term follow-up of the disease.

Incomplete, atypical kawasaki disease or evolving systemic juvenile idiopathic arthritis: a case report

Kawasaki disease is an acute febrile condition seen in children. However, it is also well recognized that some patients do not fulfill the classic diagnostic criteria for the diagnosis of kawasaki disease. The incomplete form of kawasaki disease is termed as ‘Incomplete KD’ or ‘Atypical KD’. We present a case of a 6 year old child with a history of prolonged fever, periorbital, oral and lip changes, changes in the extremities and an erythamatous, maculopapular rash. Based on the physical exam and her echocardiogram that showed right coronary artery dilatation, Intravenous immune globulin was administered in this patient. This patient was refractory to two doses of intravenous immune globulin and therefore was started on methylprednisolone, to which she responded dramatically. The diagnostic dilemma primarily arose when this child presented with joint pain a day after her discharge from the hospital and a positive laboratory workup. So, was this a case of incomplete Kawasaki refractory to intravenous immuno globulin therapy or systemic juvenile idiopathic arthritis? We suggest that physicians should be cognizant of the fact that they must individualize every patient’s management to the best of their knowledge and judgment, rather than merely going by the guidelines.

HLA-E gene polymorphism associated with susceptibility to Kawasaki disease and formation of coronary artery aneurysms

OBJECTIVE

Kawasaki disease (KD) is a pediatric systemic vasculitis of unknown cause for which a genetic influence is supposed. The purpose of this study was to identify possible genetic variants in the major histocompatibility complex (MHC) region that are associated with KD and the development of coronary artery aneurysms (CAAs) in a Taiwanese population.

METHODS

The 168 genetic variants covering the MHC locus were analyzed in an association study of a Taiwanese cohort of 93 KD patients and 680 unrelated healthy children matched for sex and age with the study patients.

RESULTS

Eleven single-nucleotide polymorphisms (SNPs) were associated with the occurrence of KD. The SNP located at the 3'-untranslated region of HLA-E (rs2844724) was highly associated (P < 1 x 10(-7)). In addition, the frequency of the C allele was higher in KD patients without CAAs than in controls (P < 0.001) due to a significantly increased frequency of the CC and CT genotypes. Plasma levels of soluble HLA-E were significantly higher in KD patients than in controls regardless of the presence of CAAs. Furthermore, there was a trend toward higher plasma levels of soluble HLA-E in KD patients with the CT and TT genotypes of the HLA-E gene polymorphism.

CONCLUSION

Our results suggest that the HLA-E gene polymorphism may play a role in the pathogenesis of KD.

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.

Failure to distinguish systemic-onset juvenile idiopathic arthritis from incomplete Kawasaki disease in an infant

In an infant, an initial diagnosis of incomplete Kawasaki disease was made according to the American Heart Association guidelines. However, the diagnosis of systemic-onset juvenile idiopathic arthritis was established later. Physicians need to recognize that systemic-onset juvenile idiopathic arthritis can be mistaken for incomplete Kawasaki disease, even when the guidelines are used.

Kawasaki syndrome in Denmark

OBJECTIVE

To describe the epidemiologic characteristics of Kawasaki syndrome (KS) and to estimate national KS incidence rates among children in Denmark.

METHODS

A retrospective population-based study using hospital discharge records with a KS diagnosis for children younger than 15 years selected from the Danish National Hospital Register for 1981-2004. Incidence rates were calculated using the number of KS patients and corresponding census data.

RESULTS

During 1981-2004, 360 children younger than 15 years were hospitalized with KS in Denmark, with 73% younger than 5 years. In this age group, the average annual incidence of KS gradually increased from 1981 to 1999 and thereafter stabilized at 4.5 to 5.0 per 100,000 person-years. The incidence was greater for boys than for girls (RR = 1.6, 95% CI = 1.2-2.0) and was highest among infants younger than 1 year (4.5), declining with increasing age (P = 0.03). However, the age-specific decline in incidence was only observed for boys, whereas the incidence for girls remained unchanged by age. The median length of hospital stay was 12 days, and the incidence peaked in the winter months.

CONCLUSIONS

Major epidemiologic characteristics identified among Danish childhood KS are consistent with those described in previous studies, such as highest incidence among young children and winter-seasonality. The KS incidence rate among children younger than 5 years in Denmark increased steadily during the early study period (coinciding with global recognition of KS) and seems to have stabilized from 1998-1999 onwards. Although the incidence among Danish children was lower than that reported for several other European countries, differences in methodology challenge definite comparisons.

Salicylate for the treatment of Kawasaki disease in children

BACKGROUND

Kawasaki disease is the most common cause of acquired heart disease in children in developed countries. The coronary arteries supplying the heart can be damaged in Kawasaki disease. The principal advantage of timely diagnosis is the potential to prevent this complication with early treatment. Salicylate (acetyl salicylate acid (ASA), aspirin) and intravenous immunoglobulin (IVIG) are widely used for this purpose. Salicylate is largely otherwise avoided in children because of concerns about serious side effects, particularly the risk of Reyes syndrome.

OBJECTIVES

The objective of this review was to evaluate the effectiveness of salicylate in treating and preventing cardiac consequences of Kawasaki disease in children.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Disease Group searched their trials register (last searched July 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 3, 2006). We searched MEDLINE (January 1966 to July 2006), EMBASE (January 1980 to July 2006), and CINAHL (1982 to July 2006), and reference list of articles. In addition we contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of salicylate to treat Kawasaki disease in children were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

We found one trial involving 102 children which was described as randomised, but it was not possible to confirm the method of treatment allocation. A second comparative study, possibly with a randomised treatment allocation, was also identified. The one randomised trial reported no association between the addition of ASA to IVIG treatment on the rate of coronary artery abnormalities at follow up, but with wide confidence limits. The second, possibly randomised trial did demonstrate a reduction in duration of fever with high dose ASA compared to low dose ASA, but was insufficiently powered to establish the effect on coronary artery abnormalities at follow up.

AUTHORS' CONCLUSIONS

Until good quality RCTs are carried out, there is insufficient evidence to indicate whether children with Kawasaki disease should continue to receive salicylate as part of their treatment regimen.

Kawasaki disease in New Zealand

AIM

To determine the epidemiology, management and outcome of Kawasaki disease (KD) in New Zealand.

DESIGN

Prospective audit using New Zealand Paediatric Surveillance Unit (NZPSU) Reports.

SETTING

Single country 2-year epidemiological study.

PATIENTS

All patients diagnosed with KD in New Zealand reported to the NZPSU from January 2001 to December 2002.

MAIN OUTCOME MEASURES

Incidence of KD; time to diagnosis; use of intravenous immunoglobulin; cardiac features and outcome.

RESULTS

Forty-nine new cases were identified. The annual incidence was 8.0 cases/100,000 children aged less than 5 years. Age at onset was less than 5 years in 86% of cases. Incidence was 4.6/100,000 for children of European origin, 9.6 for Maori, 12.2 for Pacific Islanders and 32.2 for children of East Asian origin. KD was diagnosed at a median of 6 days from onset of illness. 89% had fever and four or more diagnostic features. All patients had at least one echocardiogram: There was one small (2%) coronary artery aneurysm only; 13 (26%) had mild coronary artery dilatation. Thirty-five per cent did not have an echocardiogram performed four or more weeks from illness onset. 45 (92%) cases received intravenous immunoglobulin at median day six. There was one death due to occlusive coronary artery disease in a 3-month-old boy with atypical symptoms in whom KD was diagnosed at post-mortem.

CONCLUSIONS

The incidence of KD in New Zealand is defined with significantly variable risk according to ethnicity. Most patients received appropriate rapid diagnosis and treatment but there was considerable variation in practice in regard to number and timing of echocardiograms. There was a low coronary artery aneurysm rate (2%). Accelerated vaso-occlusive disease was responsible for the single fatality in an atypical case.

Epidemiologic pictures of Kawasaki disease in Shanghai from 1998 through 2002

BACKGROUND

Epidemiologic features of Kawasaki disease in China is still not clear.

METHODS

A questionnaire form and diagnostic guidelines for Kawasaki disease were sent to hospitals in Shanghai, which provided with pediatric medical care. All patients with Kawasaki disease diagnosed during January 1998 through December 2002 were recruited in this study.

RESULTS

A total of 768 patients with Kawasaki disease were reported. The incidence rates of Kawasaki disease for each year were 16.79 (1998), 25.65 (1999), 28.16 (2000), 28.05 (2001), and 36.76 (2002) per 100,000 children under 5 years of age. The male/female ratio was 1.83:1. The age at onset ranged from 1 month to 18.8 years (median: 1.8 years). The disease occurred more frequently in spring and summer. Fever was the most common clinical symptom, followed by oral changes, extremities desquamate, rash, conjunctive congestion, lymphadenopathy, extremities swelling, and crissum desquamate. Cardiac abnormalities were found in 24.3% of patients. The most common cardiac abnormality was coronary artery lesions including dilatation (68%) and aneurysm (10%). The case-fatality rate at acute stage of the disease was 0.26%. A second onset of the disease occurred in 1.82% of patients.

CONCLUSIONS

The incidence rate of Kawasaki disease in Shanghai is lower than that reported in Japan, but higher than those in western countries. The increasing trend in incidence, sex distribution and cardiac abnormalities are similar to those in previous reports. The seasonal distribution is similar to the report from Beijing and different from other reports.

Kawasaki disease: a decade of experience from North India

Kawasaki disease (KD) has not been frequently reported from developing countries, especially from India. In this series from a tertiary level center in North India, we report on the clinical features and management of patients with KD seen between January 1994 to November 2004. KD was diagnosed on the basis of standard diagnostic criteria. Investigations included work-up for other causes of fever along with chest X-rays, electrocardiograms, and 2-D echocardiography. Thallium scintigraphy and coronary angiography were performed in 20 and 3 cases, respectively. Sixty-nine children (49 boys and 20 girls) fulfilled the diagnostic criteria. Mean age at diagnosis was 4.9 +/- 3.0 years (range 0.3-14 years) and as many as 23 cases (33.3%) were above 5 years of age. Clustering was seen during the winter months. Extreme irritability, out of proportion to the degree of fever, was a characteristic feature. Redness of the lips and tongue was common but rash was seen only in 43 cases and lymphadenopathy in 47 cases. Thrombocytosis was present in 52.2% of the patients. Sixty-four patients received intravenous immunoglobulin. Cardiac abnormalities included extrasystoles in 1, coronary artery dilatation in 5, valvular regurgitation in 3, and perfusion defects on thallium scintigraphy in 4. There was no mortality. KD appears to occur at an older age in Indian children as compared to reports from Japan. Irritability is a characteristic clinical finding. Cardiac abnormalities are frequent during the acute stage but regress gradually. The disease needs to be considered in the differential diagnosis of all children with persistent unexplained fever.

Lack of association between infection with a novel human coronavirus (HCoV), HCoV-NH, and Kawasaki disease in Taiwan

We investigated whether infection with a novel human coronavirus (HCoV), called “New Haven coronavirus” (HCoV-NH)—which is similar to and likely represents the same species as another novel HCoV, HCoV-NL63—is associated with Kawasaki disease (KD) in Taiwan. Fifty-three patients with KD were enrolled in our study. Serum, peripheral-blood mononuclear cells, nasopharyngeal aspirates, throat swabs, and rectal swabs from these patients were assayed for HCoV-NL63 by real-time reverse-transcriptase (RT) polymerase chain reaction (PCR), and the throat swabs, nasopharyngeal aspirates, and rectal swabs were also assayed for HCoV-NH by RT-PCR. All PCR results were negative for both HCoV-NL63 and HCoV-NH; therefore, we did not find any association between HCoV-NH infection and KD in Taiwan

Kawasaki disease: what is the epidemiology telling us about the etiology?

Kawasaki disease (KD) is an important and common inflammatory vasculitis of early childhood with a striking predilection for the coronary arteries. It is the predominant cause of paediatric acquired heart disease in developed countries. Despite 40 years of research, the aetiology of KD remains unknown and consequently there is no diagnostic test and treatment is non-specific and sub-optimal. The consensus is that KD is due to one or more widely distributed infectious agent(s), which evoke an abnormal immunological response in genetically susceptible individuals. The epidemiology of KD has been extensively investigated in many populations and provides much of the supporting evidence for the consensus regarding etiology. These epidemiological data are reviewed here, in the context of the etiopathogenesis. It is suggested that these data provide additional clues regarding the cause of KD and may account for some of the continuing controversies in the field.

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

OBJECTIVE

To examine the patient characteristics, diagnostic criteria, treatment, complications and outcomes of Kawasaki disease (KD) in children diagnosed and treated in an Australian tertiary hospital setting and compare this to previously reported experience.

METHODS

Data were collected prospectively for 14 patients in 2002 and retrospectively for 31 patients in 2000 and 2001. Demographics, clinical features, laboratory features, treatment and outcome details were collected, analysed and compared to previous experience.

RESULTS

The median age at diagnosis was 2.77 years (0.28-8.84) and diagnosis was made after a mean 6.1 days of fever. Twenty-eight patients (62.2%) had classical KD and those with less than four criteria were younger than those with four or more criteria (P = 0.04). Patients were treated with intravenous immunoglobulin and aspirin. Twelve (26.7%) required re-treatment. Re-treatment was associated with treatment within 5 days of fever onset (P = 0.03). Twelve patients (27.3%) developed coronary artery abnormalities and the development of such abnormalities was associated with lower serum albumin at diagnosis (P = 0.008) and need for re-treatment (P = 0.03). There was no difference in coronary outcome between classical and incomplete presentations. Only two patients had coronary lesions at 12 months follow-up.

CONCLUSIONS

We found a trend towards earlier diagnosis and treatment of KD in the tertiary hospital setting, which may reflect heightened physician awareness of the disease. Our study confirms that children who present with incomplete disease are at risk of coronary artery abnormality. We recommend that clinicians continue to maintain high levels of suspicion, even in the absence of the complete clinical picture of KD, particularly in infants below 1 year of age.

Genetic variations in the receptor-ligand pair CCR5 and CCL3L1 are important determinants of susceptibility to Kawasaki disease

Kawasaki disease (KD) is an enigmatic, self-limited vasculitis of childhood that is complicated by development of coronary-artery aneurysms. The high incidence of KD in Asian versus European populations prompted a search for genetic polymorphisms that are differentially distributed among these populations and that influence KD susceptibility. Here, we demonstrate a striking, inverse relationship between the worldwide distribution of CCR5- Delta 32 allele and the incidence of KD. In 164 KD patient-parent trios, 4 CCR5 haplotypes including the CCR5- Delta 32 allele were differentially transmitted from heterozygous parents to affected children. However, the magnitude of the reduced risk of KD associated with the CCR5- Delta 32 allele and certain CCR5 haplotypes was significantly greater in individuals who also possessed a high copy number of the gene encoding CCL3L1, the most potent CCR5 ligand. These findings, derived from the largest genetic study of any systemic vasculitis, suggest a central role of CCR5-CCL3L1 gene-gene interactions in KD susceptibility and the importance of gene modifiers in infectious diseases.

The diagnosis and management of Kawasaki disease

Kawasaki disease (KD) is a systemic vasculitis of childhood with a predilection for the coronary arteries. It is the predominant cause of paediatric acquired heart disease in developed countries. The aetiology of KD remains unknown and consequently there is no diagnostic test. The diagnosis is made using a constellation of clinical criteria that in isolation have poor sensitivity and specificity. Early treatment prevents overt coronary artery damage in the majority of children. The long-term effects of childhood KD on later cardiovascular health remain unknown. A recent study showed that treatment of KD in Australia is suboptimal, with late diagnosis occurring in approximately half of the cases and an unacceptably high incidence of acute cardiac involvement. These guidelines highlight the difficulties in the diagnosis of KD and offer some clues that may assist early recognition of this important paediatric disease. They also detail current treatment recommendations and the evidence on which they are based. Increased awareness of the epidemiology and spectrum of the clinical presentation of KD is essential for early recognition and optimal management.

Epidemiologic features of Kawasaki disease in Taiwan, 1996-2002

OBJECTIVE

Kawasaki disease (KD) is the most common acquired heart disease in children worldwide. The incidence of KD varies among different countries, with Asian countries supposedly having higher incidences than Western countries. However, the incidence of KD in Taiwan has not been well investigated.

METHODS

Since the implementation of Taiwan's National Health Insurance (NHI) in 1995, NHI has covered health care for >96% its population. Using the NHI database from 1996 to 2002, we investigated epidemiologic features of KD (International Classification of Diseases, Ninth Revision, code 446.1), the rate of coronary artery aneurysm formation (International Classification of Diseases, Ninth Revision, code 414.11), and the change in incidence during the recent 7 years. We also compared the annual incidences in Taiwan with those reported by other countries.

RESULTS

During the 7-year study period, KD occurred most frequently in the summer and least frequently in winter. It is interesting that the highest peak occurred in the summer of 1998 at the same time that Taiwan's enterovirus 71 epidemic was occurring. Ninety-one percent of KD cases occurred in children who were <5 years old, and the male-to-female ratio was 1.70:1. Recurrence of KD was found in 1.3% (94 of 7305) of these children, and coronary artery aneurysm was found in 7.3% (536 of 7305). The annual incidence per 100,000 children was 146 in children <1 year old, 98 in 1-year-old children, 51 in 2-year-old children, 28 in 3-year-old children, 19 in 4-year-old children, and 5.3 in 5- to 9-year-old children; the incidence of KD decreased with increased age. The overall incidence was 66 cases per 100,000 children <5 years old from 1996 to 2002 with the annual incidence not differing significantly during the 7-year study period.

CONCLUSIONS

KD in Taiwan occurs more frequently in boys and in the summer months. During the 7-year study period, the annual KD incidence in Taiwan of 66/100000 in children <5 years old was the second highest in the world after Japan.

Kawasaki disease in the adult: a case report and review of the literature

Kawasaki disease, predominantly a disease of childhood, includes such symptoms as acute vasculitis, mucosal inflammation, rash, cervical adenopathy, and edema. Its most severe forms are associated with coronary artery aneurysms. We report a rare case of this disease in an asymptomatic adult and review its epidemiology, etiology, diagnosis, treatment, and prognosis.

Intravenous immunoglobulin for the treatment of Kawasaki disease in children

BACKGROUND

Kawasaki disease is the most common cause of acquired heart disease in children in developed countries. The coronary arteries supplying the heart can be damaged in Kawasaki disease. The principal advantage of timely diagnosis is the potential to prevent this complication with early treatment. Intravenous immunoglobulin (IVIG) is widely used for this purpose.

OBJECTIVES

The objective of this review was to evaluate the effectiveness of IVIG in treating, and preventing cardiac consequences, of Kawasaki disease in children.

SEARCH STRATEGY

Electronic searches of the Cochrane Peripheral Vascular Disease Group Specialised Register, CENTRAL, MEDLINE, EMBASE, and CINAHL were performed (last searched April 2003). We also searched references from relevant articles and contacted authors where necessary. In addition we contacted experts in the field for unpublished works.

SELECTION CRITERIA

Randomised controlled trials of intravenous immunoglobulin to treat Kawasaki disease were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Fifty-nine trials were identified in the initial search. On careful inspection only sixteen of these met all the inclusion criteria. Trials were data extracted and assessed for quality by at least two reviewers. Data were combined for meta-analysis using relative risk ratios for dichotomous data or weighted mean difference for continuous data. A random effects statistical model was used.

MAIN RESULTS

The meta-analysis of IVIG versus placebo, including all children, showed a significant decrease in new coronary artery abnormalities (CAAs) in favour of IVIG, at thirty days RR (95% CI) = 0.74 (0.61 to 0.90). No statistically significant difference was found thereafter. A subgroup analysis excluding children with CAAs at enrollment also found a significant reduction of new CAAs in children receiving IVIG RR (95%) = 0.67 (0.46 to 1.00). There was a trend towards benefit from IVIG at sixty days (p=0.06). Results of dose comparisons showed a decrease in the number of new CAAs with increased dose. The meta-analysis of 400 mg/kg/day for five days versus 2 gm/kg in a single dose showed statistically significant reduction in CAAs at thirty days RR (95%) = 4.47 (1.55 to 12.86). This comparison also showed a significant reduction in duration of fever with the higher dose. There was no statistically significant difference noted between different preparations of IVIG. There was no statistically significant difference of adverse effects in any group.

REVIEWER'S CONCLUSIONS

Children fulfilling the diagnostic criteria for Kawasaki disease should be treated with IVIG (2 gm/kg single dose) within 10 days of onset of symptoms.

Acute flaccid paralysis in Australian children

OBJECTIVES

To describe the epidemiology and causes of acute flaccid paralysis (AFP) in Australian children, and the clinical features of the two most common causes of AFP, Guillain-Barré syndrome and transverse myelitis.

METHODS

Monthly active surveillance for AFP was carried out through the Australian Paediatric Surveillance Unit, with AFP defined as 'acute onset of flaccid paralysis in one or more limbs or of bulbar paralysis in any child less than 15 years of age'.

RESULTS

Between March 1995 and December 1999, 143 cases of AFP were reported (approximately 0.8 per 100000 children < 15 years of age per annum). The age range was 2 months-14 years and 59% were boys. Out of these children, 137 (96%) were hospitalized and 47 required intensive care. No case of wild or vaccine-associated poliomyelitis was identified. The most common causes of AFP were Guillain-Barré syndrome in 67 (47%) and transverse myelitis in 27 (19%). Other diagnoses included acute disseminated encephalomyelitis, trauma, tick-bite paralysis and infantile botulism.

CONCLUSION

The participation of paediatricians in AFP surveillance contributed to the accreditation of Australia (along with the other 36 countries of the western Pacific region) as 'polio free' by the World Health Organization in October 2000. The surveillance also provided data on the frequency of AFP and identified Guillain-Barré syndrome and transverse myelitis as the most common diagnoses. In this large national series, many other conditions that may present as non-polio AFP were identified.

Epidemiologic picture of Kawasaki disease in Beijing from 1995 through 1999

OBJECTIVE

Kawasaki disease (KD) is supposed to be more common in the Asian race. The incidence in Japan is 10-fold higher than rates reported from western countries. This study sought to evaluate the epidemiologic picture of KD in Beijing and its suburbs.

METHOD

A questionnaire form and diagnostic guidelines for KD were sent to all hospitals with pediatric inpatient beds throughout Beijing and its suburbs. Pediatricians were asked to review the medical records and report all patients with KD diagnosed during the 5-year period from January, 1995, through December, 1999.

RESULTS

A total of 710 patients with KD were reported from 37 (95%) of 39 hospitals with pediatric inpatient beds. The incidences of KD for each year of the study were 18.2 (1995), 21.1 (1996), 18.6 (1997), 30.6 (1998) and 27.8 (1999) per 100,000 children <5 years of age. The male:female ratio was 1.7:1. The age at onset ranged from 1 month to 13.4 years (median, 2.3 years), with 85.2% <5 years old. The disease occurred more frequently in spring and summer and less frequently in autumn and early winter. Lymph node enlargement was the least common clinical sign, and its incidence decreased from 1995 to 1999. Cardiac abnormalities were found in 21.5% of patients and were more prevalent in patients diagnosed 10 days or longer after the onset. No patients died in the acute stage.

CONCLUSION

The incidence of KD in Beijing is lower than that reported in Japan, similar to the incidence in the United States and higher than in other western countries. The age and gender distribution and increasing trend in incidence are similar to those in previous reports, but seasonal distribution is unique.