Kawasaki Disease in India, Lessons Learnt Over the Last 20 Years

Over the last 20 years, Kawasaki disease is being increasingly recognized in India and it may soon replace acute rheumatic fever to become the commonest cause of acquired heart disease amongst children. However, the vast majority of children with Kawasaki disease in India are still not being diagnosed. Diagnosis of Kawasaki disease is based on a constellation of clinical findings which have a typical temporal sequence. All pediatricians must we familiar with the nuances involved in arriving at a diagnosis of Kawasaki disease. With early diagnosis and prompt treatment, the risk of coronary artery abnormalities can be significantly reduced.

Kawasaki disease incidence at Chandigarh, North India, during 2009-2014

The aim of this study was to estimate incidence of Kawasaki disease (KD) in Chandigarh, North India, during 2009-2014. Diagnosis of KD was based on American Heart Association guidelines. Records of all children diagnosed with KD below 15 years at a large tertiary care referral centre from North India for paediatric immunology were analysed from January 2009 to December 2014. Children residing in Chandigarh were identified. Incidence rates were calculated based on population of Chandigarh in National Census 2011. Methodology was similar to our previously reported study from 1994 to 2008. Incidence of KD in children below 5 was also computed. A total of 258 children were diagnosed to have KD. Of these, 54 (43 boys, 11 girls) resided in Chandigarh. Coronary artery abnormalities on echocardiography were noted in 6. Incidence rate varied between 1.11 (in 2012) and 4.71/100,000 children below 15 (in 2009). In children below 5, incidence rate varied between 1.0 (in 2012) and 9.1/100,000 (in 2009). Peak incidence of KD was in third year of life. There was clustering of cases in February, April, June and October with a nadir in July. While the overall number of KD cases has increased, the 2009-2014 Chandigarh incidence is comparable to our previous figures. Our study is based on hospitalized children with KD and may be missing patients diagnosed elsewhere but that number is likely to be small. Further, patients in whom the diagnosis has never been made would also be missed. Median age at diagnosis has reduced as compared to our previous study. This is probably a reflection of increased awareness about KD amongst paediatricians and physicians in the region as a result of which the proportion of infants and young children diagnosed to have KD has shown a significant increase. Seasonal pattern of occurrence of KD is consistent with our previous observation.

[Refractory Kawasaki disease with coronary aneurysms treated with infliximab]

The classic treatment of Kawasaki disease with immunoglobulin and acetyl salicylic acid obtains a good response in 90% of patients, decreasing the risk of coronary involvement. However, in patients that do not respond to immunoglobulin, it is not clear which therapy should be used: other doses of immunoglobulin, corticosteroids or infliximab. Infliximab is becoming an important second line treatment for Kawasaki refractory to immunoglobulin, although there are few studies and clinical reports with this drug. We present a 5 months-old infant with refractory Kawasaki disease who developed coronary aneurysms despite two immunoglobulin doses and three intravenous pulses-doses of corticosteroids. The infant was finally treated with a single dose of infliximab with good clinical progress.