1
|
Huang YN, Lin CY, Chi H, Chiu NC, Huang DTN, Chang L, Kung YH, Huang CY. Jaundice-predominant manifestation of Kawasaki disease in children. Front Pediatr 2024; 11:1281909. [PMID: 38264503 PMCID: PMC10803413 DOI: 10.3389/fped.2023.1281909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/15/2023] [Indexed: 01/25/2024] Open
Abstract
Background A jaundice-predominant presentation of Kawasaki disease (KD) is atypical. Methods A total of 12 children with KD with a predominant manifestation of jaundice at MacKay Children's Hospital were reviewed, along with 42 cases reported in the literature since 1990. Results The median age of the 12 patients was 1.85 years (range: 3 months-4 years), and 66.6% were male. All of the patients had elevated liver function at presentation, 50% had hydrops of the gallbladder, and almost 60% had gastrointestinal symptoms and signs. Complete KD was evident in 11 of the 12 patients (91.7%), and two patients (16.7%) had recurrent episodes. All of the patients received intravenous immunoglobulin (IVIG); however, one-third were refractory to treatment. Corticosteroids were used in five (41.7%) of the patients. Three (25%) of the patients had shock, and seven (58.3%) had coronary artery abnormalities, of whom one (8.3%) had persistent coronary artery aneurysm and the others recovered. A review of the 42 cases in the literature showed that the children with a jaundice-predominant presentation of KD had high rates of IVIG-refractory disease (25%), coronary artery abnormalities (25%), shock (13.2%), and corticosteroid treatment (24.2%). Conclusions Children with KD presenting with a jaundice-predominant manifestation are at a higher risk of IVIG-refractory disease, coronary artery abnormalities, and more recurrent episodes. Physicians should be aware of the risk of shock in this population.
Collapse
Affiliation(s)
- Ya-Ning Huang
- Department of Pediatrics, Hsinchu Municipal MacKay Children’s Hospital, Hsinchu, Taiwan
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Chien-Yu Lin
- Department of Pediatrics, Hsinchu Municipal MacKay Children’s Hospital, Hsinchu, Taiwan
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
- Department of Medicine, MacKay Medicine College, Taipei, Taiwan
| | - Hsin Chi
- Department of Medicine, MacKay Medicine College, Taipei, Taiwan
- Department of Pediatric Infectious Diseases, MacKay Children’s Hospital, Taipei, Taiwan
| | - Nan-Chang Chiu
- Department of Medicine, MacKay Medicine College, Taipei, Taiwan
- Department of Pediatric Infectious Diseases, MacKay Children’s Hospital, Taipei, Taiwan
| | - Daniel Tsung-Ning Huang
- Department of Medicine, MacKay Medicine College, Taipei, Taiwan
- Department of Pediatric Infectious Diseases, MacKay Children’s Hospital, Taipei, Taiwan
| | - Lung Chang
- Department of Medicine, MacKay Medicine College, Taipei, Taiwan
- Department of Pediatric Infectious Diseases, MacKay Children’s Hospital, Taipei, Taiwan
- Department of Pediatrics, Tamshui MacKay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hsin Kung
- Department of Pediatric Infectious Diseases, MacKay Children’s Hospital, Taipei, Taiwan
- Department of Pediatrics, Tamshui MacKay Memorial Hospital, Taipei, Taiwan
| | - Ching-Ying Huang
- Department of Medicine, MacKay Medicine College, Taipei, Taiwan
- Department of Pediatric Infectious Diseases, MacKay Children’s Hospital, Taipei, Taiwan
| |
Collapse
|
2
|
Kawasaki Disease with Hepatobiliary Manifestations. Medicina (B Aires) 2022; 58:medicina58121833. [PMID: 36557034 PMCID: PMC9781147 DOI: 10.3390/medicina58121833] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/09/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Background and Objectives: Kawasaki Disease (KD) incidence has been on the rise globally throughout the years, particularly in the Asia Pacific region. KD can be diagnosed based on several clinical criteria. Due to its systemic inflammatory nature, multi-organ involvement has been observed, making the diagnosis of KD more challenging. Notably, several studies have reported KD patients presenting with hepatobiliary abnormalities. Nonetheless, comprehensive data regarding the hepatobiliary manifestations of KD are limited in Malaysia, justifying a more in-depth study of the disease in this country. Thus, in this article, we aim to discuss KD patients in Malaysia with hepatobiliary manifestations. Materials and Methods: A total of six KD patients with hepatobiliary findings who presented at Hospital Canselor Tuanku Muhriz (HCTM) from 2004 to 2021 were selected and included. Variables including the initial presenting signs and symptoms, clinical progress, laboratory investigations such as liver function test (LFT), and ultrasound findings of hepatobiliary system were reviewed and analyzed. Results: Out of these six KD patients, there were two patients complicated with hepatitis and one patient with gallbladder hydrops. Different clinical features including jaundice (n = 3) and hepatomegaly (n = 4) were also observed. All patients received both aspirin and intravenous immunoglobulin (IVIG) as their first-line treatment and all of them responded well to IVIG. The majority of them (n = 5) had a complete recovery and did not have any cardiovascular and hepatobiliary sequelae. Conclusions: Despite KD mostly being diagnosed with the classical clinical criteria, patients with atypical presentations should always alert physicians of KD as one of the possible differential diagnoses. This study discovered that hepatobiliary manifestations in KD patients were not uncommon. More awareness on the epidemiology, diagnosis, and management of KD patients with hepatobiliary manifestations are required to allow for the initiation of prompt treatment, thus preventing further complications.
Collapse
|
3
|
Paglia P, Nazzaro L, De Anseris AGE, Lettieri M, Colantuono R, Rocco MC, Siano MA, Biffaro N, VAJRO P. Atypically Protracted Course of Liver Involvement in Kawasaki Disease. Case Report and Literature Review. Pediatr Rep 2021; 13:357-362. [PMID: 34287369 PMCID: PMC8293418 DOI: 10.3390/pediatric13030044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/26/2021] [Accepted: 06/29/2021] [Indexed: 12/18/2022] Open
Abstract
Hypertransaminasemia in patients with Kawasaki disease (KD) is reported to be transient. Here, we describe a child with an atypically protracted course of liver tests abnormalities and review the inherent literature. The patient was hospitalized at age 7-months for isolated hypertransaminasemia detected during a classical KD diagnosed 3 months before, and persistent since then. KD clinical evolution had been favorable, with rapid response to acetylsalicylic acid and intravenous immunoglobulins. Liver enzymes however remained persistently elevated with a fluctuating pattern (ALT > AST levels; peak of AST 186 IU/L and ALT 240 IU/L). During follow-up, the main causes of liver dysfunction had to be excluded through appropriate and extensive laboratory investigations. Transaminases values become steadily normal only 7 months after the acute presentation of KD. Conclusions: Our report shows that an atypically protracted courses of KD-related hypertransaminasemia above the previously reported temporal limits should be taken into account during the stepwise diagnostic approach to the patient's liver dysfunction. Insidious acetylsalycilic acid-hepatotoxicity warrants consideration in the differential diagnosis.
Collapse
Affiliation(s)
- Pamela Paglia
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
| | - Lucia Nazzaro
- Pediatrics Units of San Giovanni di Dio e Ruggi d’Aragona University Hospital, 84131 Salerno, Italy; (L.N.); (A.G.E.D.A.)
| | - Anna Giulia Elena De Anseris
- Pediatrics Units of San Giovanni di Dio e Ruggi d’Aragona University Hospital, 84131 Salerno, Italy; (L.N.); (A.G.E.D.A.)
| | - Milena Lettieri
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
- Department of Translational Medical Sciences, Section of Pediatrics, “Federico II” University, 80131 Naples, Italy
| | - Rossella Colantuono
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
| | - Maria Chiara Rocco
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
| | - Maria Anna Siano
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
| | - Nicola Biffaro
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
| | - Pietro VAJRO
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
- Pediatrics Units of San Giovanni di Dio e Ruggi d’Aragona University Hospital, 84131 Salerno, Italy; (L.N.); (A.G.E.D.A.)
- Correspondence: ; Tel.: +39-339-236-1008
| |
Collapse
|
4
|
Huang SW, Lin SC, Chen SY, Hsieh KS. Kawasaki Disease With Combined Cholestatic Hepatitis and Mycoplasma pneumoniae Infection: A Case Report and Literature Review. Front Pediatr 2021; 9:738215. [PMID: 35223706 PMCID: PMC8864216 DOI: 10.3389/fped.2021.738215] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
Kawasaki disease (KD), also called mucocutaneous lymph node syndrome, is a febrile multisystem vasculitis mainly affecting children younger than 5 years. KD typically manifests as skin lesions and in the lymph nodes and oral and conjunctival mucosa. It may induce coronary artery abnormalities, such as aneurysms, but gastrointestinal and hepatobiliary involvement are not common. We reviewed 32 cases of patients with a diagnosis of KD with hepatobiliary involvement between 2000 and 2021 and present the case of a 4-year-old girl who received a diagnosis of KD with combined cholestatic hepatitis and Mycoplasma pneumoniae infection. In the 33 cases reviewed, in addition to the classical clinical findings of KD, the most common clinical presentations were jaundice and abdominal pain. Moreover, abnormal laboratory results indicating hyperbilirubinemia, cholestasis, and hepatitis, among other conditions, were noted. Abdominal ultrasonography revealed abnormal findings in more than half children with KD with hepatobiliary involvement. Furthermore, cardiac involvement was noted in a high proportion of the patients. In particular, we noted the case of a 4-year-old girl with a rare presentation of 3-day fever combined with abdominal pain and jaundice. Her levels of aspartate aminotransferase, alanine aminotransferase, total bilirubin, direct bilirubin, alkaline phosphatase, and γ-glutamyl transpeptidase were 489 (15-50) U/L, 253 (5-45) U/L, 4.3 (<1.5) mg/dl, 2.4 (<0.2) mg/dl, 337 (134-315) U/L, and 145 (5-32) U/L, respectively. These results were indicative of cholestatic hepatitis. Furthermore, her serological test results for mycoplasma infection were positive. KD was diagnosed because the patient had high fever for more than 5 days and presented with lymphadenopathy on the left side of neck, a polymorphic skin rash, redness of oral mucosa with strawberry tongue, and nonpurulent conjunctival congestion. After intravenous immunoglobulin injection (IVIG) and acetylsalicylic acid administration, the fever subsided rapidly and clinical manifestations, such as jaundice and abdominal pain, were mitigated. The laboratory parameters gradually returned to within normal ranges. Echocardiography revealed no aneurysm. In conclusion, KD with cholestatic hepatitis should be considered when pediatric patients present with fever combined with abdominal pain and jaundice. Early treatment with IVIG and aspirin is recommended and can effectively relieve cholestatic hepatitis.
Collapse
Affiliation(s)
- Shen-Wen Huang
- Division of Allergy, Asthma, and Immunology, Department of Pediatrics, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Primary Care Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Chieh Lin
- Division of Allergy, Asthma, and Immunology, Department of Pediatrics, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shih-Yen Chen
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Pediatric Gastroenterology, Department of Pediatrics, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Kai-Sheng Hsieh
- Division of Pediatric Cardiology, Department of Pediatrics, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
5
|
Pratap K, Gardner LS, Gillis D, Newman M, Wainwright D, Prentice R. Hepatic predominant presentation of Kawasaki disease in adolescence case report and review of literature. BMC Gastroenterol 2020; 20:352. [PMID: 33109118 PMCID: PMC7590489 DOI: 10.1186/s12876-020-01461-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 09/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Kawasaki Disease (KD) is the most common paediatric vasculitis affecting small to medium arteries. Although the average age of diagnosis is 3.4 years with a well-defined clinical presentation, older patients with KD including adolescent and adult patients demonstrate a less classical presentation with prominent findings including hepatitis, cervical lymphadenopathy, and arthralgia. We describe a case of an adolescent presentation of Kawasaki Disease presenting with a predominantly cholestatic hepatic picture. CASE PRESENTATION We describe a case of KD in a 16-year-old Caucasian female with predominately hepatic disease that showed resistance to intravenous immunoglobulin (IVIG). The formal diagnosis of KD was made on her 8th day of symptoms. She displayed classical symptoms commencing with fever, followed by peripheral desquamation, strawberry tongue, cervical lymphadenopathy. She became clinically jaundiced with evidence of hepatic artery narrowing on ultrasound that resolved with treatment. Her disease was biphasic and required further IVIG for non-hepatic symptoms. She did not develop coronary aneurysms. CONCLUSION Significant hepatic dysfunction with clinical jaundice is rare in KD without associated gall bladder hydrops and tends to occur in older patients. We describe such a case and review the five described cases in the literature. Diagnostic delay is more common in adolescent patients and given that the prognosis of KD is closely correlated to diagnostic timing and provision of care, it is important to consider Kawasaki Disease in older demographics especially with undiagnosed hepatic disease.
Collapse
Affiliation(s)
- Krishan Pratap
- Department of Clinical Immunology and Allergy, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
| | - Logan S Gardner
- Department of Clinical Immunology and Allergy, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia.
- School of Medicine, University of Queensland, Brisbane, Australia.
| | - David Gillis
- Department of Clinical Immunology and Allergy, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia
| | | | - Dana Wainwright
- Department of Clinical Immunology and Allergy, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia
| | - Roger Prentice
- Department of Clinical Immunology and Allergy, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia
| |
Collapse
|
6
|
Roh DE, Kwon JE, Kim YH. Diagnosis and management of Kawasaki disease. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.7.374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Kawasaki disease, also known as mucocutaneous lymph node syndrome, is a common form of vasculitis in childhood. Among the recent trends in Kawasaki disease, it is notable that the prevalence rate is increasing, and the proportion of “incomplete” Kawasaki disease is also increasing. A delayed diagnosis with prolonged fever can cause complications, such as coronary artery aneurysm and decreased myocardial contractility. These complications might lead to significant morbidity and mortality. Kawasaki disease is diagnosed when the patient meets the principal criteria for clinical symptoms. Following the diagnostic criteria can prevent overdiagnosis but lead to missing of the incomplete form of the disease. Therefore, it is important to accurately understand Kawasaki disease. As the coronavirus disease 2019 (COVID-19) pandemic continues, concerns about a novel severe Kawasaki-like disease in children related to COVID-19 emerges. Indeed, there have been several reports of Kawasaki-like disease related to COVID-19 in children. Kawasaki disease is no longer rare and is often encountered at hospitals. This paper will provide useful and accurate information on Kawasaki disease.
Collapse
|
7
|
Bylund W, Zarow GJ, Ponce DM. Acute Jaundice in a Six-year-old: An Unusual Presentation of Atypical Kawasaki Disease. Clin Pract Cases Emerg Med 2020; 4:142-145. [PMID: 32426656 PMCID: PMC7219998 DOI: 10.5811/cpcem.2019.12.45180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/20/2019] [Accepted: 12/19/2019] [Indexed: 12/30/2022] Open
Abstract
Kawasaki disease (KD) is a rare vasculitis of childhood that is critical to recognize and treat due to associated morbidity and mortality. A six-year-old male presented to our emergency department (ED) afebrile but with reported recent fevers. Exam revealed jaundice and erythematous tongue with papules, and laboratory studies indicated a direct hyperbilirubinemia. Admitted for evaluation, he developed continuous fever, increasing maculopapular rash, and subsequent desquamation of hands and feet. He ultimately met criteria for incomplete KD, was treated with intravenous immunoglobulin, and avoided cardiac complications. This presentation of incomplete KD with hyperbilirubinemia is rare because the patient was afebrile at ED presentation.
Collapse
Affiliation(s)
- William Bylund
- Naval Hospital Okinawa, Department of Emergency Medicine, Okinawa, Japan
| | - Gregory J Zarow
- Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, Virginia.,The Emergency Statistician, Idyllwild, California
| | | |
Collapse
|