Epidemiology of Kawasaki disease in infants 3 months of age and younger

Acalculous Cholecystitis From Kawasaki Disease in a Three-Month-Old Girl: A Rare Sign at an Uncommon Age

We report a case of a previously healthy three-month-old girl who presented with acute fever, watery diarrhea, and right upper abdominal guarding. Abdominal ultrasonography findings were compatible with acute acalculous cholecystitis. Initially, antibiotics were administered for a total of eight days without improvement. Hence, atypical Kawasaki disease (KD) was suspected despite the absence of classical disease manifestations and her uncommon age. The diagnosis was made using alternative diagnostic criteria and echocardiography. After KD was diagnosed, high-dose intravenous immunoglobulin G and aspirin were administered on day 9 of disease onset. Her clinical condition significantly improved within 24 hours, and she recovered well without complications during the 1.5 years of follow-up.

Kawasaki disease in Malaysia: Biochemical profile, characterization, diagnosis and treatment

Introduction

Kawasaki disease (KD) is an acute idiopathic systemic vasculitis with a self- limiting course that predominantly affects children under 5 years old, particularly in the East Asian countries. Nevertheless, to date, the data on KD in Malaysia are limited. This study aimed to evaluate the epidemiology, clinical features, treatment, and outcomes of KD among the pediatric patients admitted to Hospital Canselor Tunku Muhriz (HCTM), Kuala Lumpur, Malaysia.

Method

A retrospective cohort study of 66,500 pediatric patients presented at HCTM from the year 2004 to 2021 was conducted.

Results

62 KD cases out of 66,500 pediatric admissions were reported, with a male-to-female ratio of 1.58 to 1. Majority of KD patients (95.0%) were younger than 5 years old. Prior infection was reported in 5 KD patients (8.1%). Apart from the classical features, manifestations of various organ systems including cardiovascular (16.1%), gastrointestinal (43.5%), neurological (1.61%), musculoskeletal (1.61%), and genitourinary (17.7%) systems were observed. There was a significant association between sterile pyuria and coronary artery aneurysm (CAA) (p < 0.05). Interestingly, abnormal liver parameters (p < 0.05) and incomplete KD (p < 0.05) were significantly related to IVIG resistance.

Discussion

The presence of family history, immunological disorder, and previous infection in our KD patients suggested that there is a possibility of genetic, immunological, and infectious roles in the pathophysiology of KD. IVIG resistance is more likely to occur in KD patients with hepatic dysfunction or incomplete KD presentation. These findings highlighted the significant contribution of laboratory parameters to the prognosis of KD, prompting more in-depth research on the KD scoring systems and their relevance in this country.

Bacille Calmette-Guérin Site Reactivation of Kawasaki Disease in Infants under 3 Months of Age: Relation with Diagnosis and Prognosis

Diagnosis of Kawasaki disease in infants under 3 months of age is challenging. This study aimed to confirm the diagnostic efficacy of BCGitis in patients with Kawasaki disease aged <3 months. Overall, 473 children were enrolled; they were grouped by age into group 1 (≤3 months, n = 19) and group 2 (>3 months, n = 454). Data, including clinical features and laboratory results, were analyzed and compared between the groups. In group 1, 89% of patients showed Bacille Calmette-Guérin site reactivation. In group 1, total duration of fever and fever duration before initial treatment were significantly shorter than in group 2 (p = 0.001). The incidences of conjunctival injection, changes in extremities (erythema and edema), and cervical lymphadenopathy were significantly lower (p = 0.006, p = 0.040, and p < 0.001, respectively), and desquamation was higher in group 1 (p = 0.004). The incidences of incomplete Kawasaki disease, coronary artery complications, and resistance to intravenous immunoglobulin did not differ between the groups. Kawasaki disease should be suspected in infants aged <3 months with unexplained fever and BCGitis, even if the principal clinical symptoms are not fully presented. BCGitis in infantile Kawasaki disease is a useful sign and can help in the diagnosis of Kawasaki disease.

Effects of immunoglobulin plus prednisolone in reducing coronary artery lesions in patients with Kawasaki disease: study protocol for a phase III multicenter, open-label, blinded-endpoints randomized controlled trial

Background

Kawasaki disease (KD) is an acute systemic vasculitis of unclear etiology that mainly affects infants and young children. Strategies to reduce the incidence and severity of coronary artery lesions (CALs), the determinant factor in the long-term prognosis of KD, are currently a focus of studies on KD. Corticosteroids, preferred in the treatment of the majority of vasculitides, are controversial in the treatment of acute KD. In this trial, we will evaluate whether the addition of prednisolone to standard intravenous immunoglobulin (IVIG) plus aspirin therapy can reduce the occurrence of CAL in Chinese patients with KD.

Methods

This is a multicenter, prospective, open-label, randomized controlled trial, which is expected to be conducted in more than 20 hospitals in China and aims to assess the efficacy and safety of IVIG + prednisolone treatment versus standard treatment. Patients with KD who fulfill the inclusion and exclusion criteria will be recruited and randomized (1:1) to receive either a large dose of IVIG (2 g/kg over 12–24 h with a maximum dose of 60 g) + aspirin 30 mg/kg/d or IVIG (2 g/kg over 12–24 h) + aspirin 30 mg/kg/d + prednisolone (2 mg/kg/d with a maximum dose of 60 mg tapered over 15 days after normalization of C-reactive protein concentration). The primary outcome will be the occurrence of CAL at 1 month of illness. The follow-up duration for each participant will be set as 1 year. Patients and treating physicians will be unmasked to group allocation.

Discussion

This will be the first multicenter randomized controlled trial to evaluate the efficacy of IVIG + aspirin + prednisolone in Chinese pediatric patients with KD, which may provide high-level evidence for improving the initial treatment for acute KD.

Trial registration

ClinicalTrials.govNCT04078568. Registered on 16 August 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05807-3.

Characteristics and trends in diagnosis of Kawasaki disease outside the usual age range

OBJECTIVE

To explore the trends in diagnosis of Kawasaki disease (KD) and determine the characteristics for patients outside the usual age range of 6 months to 4 years.

METHOD

A retrospective review of patients with KD identified in four epidemiological surveys spanning 20 years (1998-2017) in Shanghai was performed.

RESULTS

A total of 8416 patients were included. All in all, 223 (2.6%) were aged 0 to 2 months, 639 (7.6%) were 3 to 5 months, 6556 (77.9%) were 6 months to 4 years, 915 (10.9%) were 5 to 9 years, and 83 (1.0%) were ≥ 10 years. The use of intravenous immunoglobulin increased in all extreme age groups, and delayed treatment rates decreased in all patients except in those aged 0 to 2 months and ≥ 10 years. The number of patients outside the usual age increased over time, but the proportion of these patients did not change significantly. They had more incomplete KD and coronary artery aneurysms (CAA), while those aged 0 to 2 months and ≥ 10 years had more delayed diagnoses in their respective age groups. The incidence of CAA was similar in younger and older children, but the former group had more cases of incomplete KD and abnormal laboratory parameters, while the latter group had longer duration of fever and was more difficult to diagnose promptly.

CONCLUSIONS

The proportion of KD outside the usual age range did not increase over time. Older and younger children have different clinical and laboratory characteristics. Key Points • The number of patients outside the usual age increased over time, but the proportion of these patients did not increase. • Patients aged 0 to 2 months and ≥ 10 years had more delayed diagnoses in their respective age groups. • Younger children had more cases of incomplete KD and abnormal laboratory parameters, while older children had longer duration of fever and were more difficult to diagnose promptly.

Neonatal Kawasaki disease with multiple arterial aneurysms: a case report

BACKGROUND

Kawasaki disease (KD) is a medium vessel vasculitis that typically occurs in children aged between 6 months and 5 years. It is extraordinarily rare in the neonatal period. KD-related systemic artery aneurysms (SAAs) have never been reported in neonates.

CASE PRESENTATION

A male infant was transferred to our institution for persistent high-grade fever lasting 16 days. Symptoms started at day 14 of life, and he was admitted to a children's hospital on the second day of fever. Physical examination at the time found no signs suggestive of KD. The only laboratory parameters which were of significance were values suggestive of systemic inflammation. However, his fever persisted and inflammatory markers continued to rise despite 2 weeks of antibiotic therapy. KD as a noninfectious cause of fever was considered when he came to our institution, and echocardiographic findings of left and right medium coronary artery aneurysms (CAAs) confirmed our suspicions. Full-body magnetic resonance angiography also revealed bilateral axillary artery aneurysms. Administration of intravenous gamma globulin resulted in rapid improvement. His fever resolved on the next day and CAAs and SAAs regressed to normal at 6 months and 3 months after diagnosis, respectively.

CONCLUSION

This unique case of incomplete KD highlights the importance of considering KD in neonates with unexplained prolonged fever and reinforces the need to remain vigilant for SAAs in KD.

Kawasaki Disease in Infants in the First 3 Months of Age in a Mexican Population: A Cautionary Tale

Background: Kawasaki disease (KD) is an acute febrile illness that largely affects young children before 5 years of age. Younger children with KD are reported to have a higher prevalence of coronary artery abnormalities. Little is known about infants in the first 3 months of age diagnosed with KD. Methods: A retrospective study was conducted at the National Institute of Pediatrics in Mexico City from 1995 to 2019. Clinical features, laboratory results and cardiac outcomes were recorded. Infants in the first 3 months of age were compared with older patients. Wilcoxon-Mann-Whitney analysis was performed for continuous variables and Fisher's exact test for categorical variables. Results: Six hundred and eighty-eight cases of KD were included in this study. Fourteen cases were diagnosed in the first three months of age. Heart failure and KD shock-syndrome was found in five cases (35.7%). Giant coronary artery aneurysms were found in six cases in the younger group (42.9%). Conclusions: Diagnosis of KD in children younger than 3 months of age is rare. In most cases, an incomplete presentation contributed to a delay diagnosis, treatment, and complications. Younger patients with KD have an increased risk of presenting cardiac complications, including giant coronary artery aneurysms, shock, and death.

Association between the miRNA-149 rs2292832 T>C polymorphism and Kawasaki disease susceptibility in a southern Chinese population

Background

Kawasaki disease (KD), which is characterized by vasculitis, is prone to occur in patients under 5 years of age, has an ambiguous etiology, and displays coronary artery lesions as the chief complication. Previous studies have linked miRNA‐149 to cancers, and rs2292832 T>C is related to allergic diseases and inflammatory bowel disease, which both show immune system disorders and coronary artery disease. Therefore, we performed a study concentrating on the association between the miRNA‐149 rs2292832 T>C polymorphism and KD susceptibility.

Methods

The subjects enrolled were 532 children with KD and 623 controls. We used TaqMan real‐time PCR to obtain the genotypes of the rs2292832 T>C polymorphism.

Results

Ultimately, no significant association was found between the miRNA‐149 rs2292832 T>C polymorphism and KD susceptibility, even in stratification analysis.

Conclusion

Our results indicated that in southern Chinese patients, the miRNA‐149 rs2292832 T>C polymorphism did not affect KD susceptibility, which needs to be further confirmed.

Kawasaki disease in infants less than one year of age: an Italian cohort from a single center

Background and aims

Few data are currently available for Kawasaki disease (KD) below 12 months especially in Caucasians. This study aims to analyze clinical and laboratory features of KD among an Italian cohort of infants.

Methods

A retrospective chart review of KD children aged less than 1 year at time of disease onset between January 2008–December 2017 was performed. Clinical data, laboratory parameters, instrumental findings, treatment and outcome were collected in a customized database.

Results

Among 113 KD patients, 32 (28.3%) were younger than 1 year. Nineteen patients aged below 6 months, and three below 3 months. The median age was 5.7 ± 2.7 months. The mean time to diagnosis was 7 ± 3 days and was longer in the incomplete forms (8 ± 4 vs 6 ± 1 days). Conjunctival injection was present in 26 patients (81.2%); rash in 25 (78.1%); extremity changes in 18 (56.2%); mucosal changes in 13 (40.6%,) and lymphadenopathy only in 7 (21.8%). Mucosal changes were the least common features in incomplete forms (18.2%). Twenty-two patients (68.7%) had incomplete KD. Nineteen (59.4%) had cardiac involvement, of whom 13 (59.0%) had incomplete form. ESR, PCR and platelet values were higher in complete KD; especially, ESR resulted significantly higher in complete forms (80 ± 25.7 mm/h vs 50 ± 28.6 mm/h; p = 0.01). Conversely, AST level was statistically significant higher in patients with incomplete forms (95.4 ± 132.7 UI/L vs 29.8 ± 13.2 UI/L; p = 0.03). All patients received IVIG. Response was reported in 26/32 patients; 6 cases needed a second dose of IVIG and one required a dose of anakinra.

Conclusion

In our cohort, incomplete disease was commonly found, resulting in delayed diagnoses and poor cardiac prognosis. Infants with incomplete KD seem to have a more severe disease and a greater predilection for coronary involvement than those with complete KD. AST was significantly higher in incomplete forms, thus AST levels might be a new finding in incomplete forms’ diagnosis. Eventually, we highlight a higher resistance to IVIG treatment. To our knowledge this is the first study involving an Italian cohort of patients with KD below 12 months.

Clinical features and mid-term follow-up in infants younger than 3 months with Kawasaki disease in a Chinese population

AIM

To explore the clinical features and mid-term follow-up of Kawasaki disease (KD) in infants younger than 3 months of age in a Chinese population.

METHODS

We performed a retrospective analysis of clinical signs, laboratory data, echocardiography results and outcomes for patients with KD diagnosed at our hospital from January 2009 to December 2013. A total of 1150 children were diagnosed with KD, and 200 KD patients were enrolled in this study. Group 1 included 40 children younger than 3 months of age. We randomly selected a control group as Group 2 included 160 children older than 3 months of age who fulfilled diagnostic criteria for KD and maintained follow-up for more than 1 year.

RESULTS

There was a significant difference in clinical manifestations between the two groups, except respiratory infection. Group 1 was more likely to have incomplete presentation (P < 0.001). There were no significant differences in laboratory data except for white blood cell counts between the two groups. Coronary artery abnormalities were significantly different between the two groups (P < 0.001). At a mean follow-up of 18 months (range 12-48 months), all patients with coronary artery abnormalities, except for giant coronary aneurysms, returned to normal in terms of diameter as assessed by echocardiography.

CONCLUSIONS

Infants younger than 3 months of age with KD often present with incomplete criteria, and diagnosis may be delayed. In addition, there may be a higher risk of developing coronary artery abnormalities. All patients except those with giant coronary aneurysms recovered well without complications at mid-term follow-up.

A 3-month-old infant with atypical Kawasaki disease

We report a 3-month-old girl who presented with high-grade fever for 3 days. Her initial physical examination was normal. Investigation showed abnormal white cells in her urine. She was diagnosed with a urinary tract infection and received an antibiotic for 1 day. After that, she developed a generalised maculopapular rash over her body. An adverse drug reaction from the antibiotic was suspected, and the patient was referred to our hospital. On admission, she still had fever and was irritable. She was diagnosed with sepsis and given another broad-spectrum antibiotic for 2 days. However, her fever still persisted. An additional thorough physical examination showed redness of her BCG inoculation scar. Consequently, a diagnosis of Kawasaki disease (KD) was made. After she received intravenous immunoglobulin, her fever diminished straight away. This case highlights an unusual manifestation of KD in an uncommonly young age group.

Treatment Options for Resistant Kawasaki Disease

"Resistant" Kawasaki disease is defined by the American Heart Association as failure to respond within 36 h following the first dose of intravenous immunoglobulin. The optimal management of resistant Kawasaki disease remains uncertain, the outcomes are potentially serious, and the cost of some treatments is considerable. We review the current evidence to guide treatment of resistant Kawasaki disease. Given the relative rarity, there are few trial data, and studies tend to be small and methodologically heterogeneous, making interpretation difficult and limiting generalisability. The literature on resistant Kawasaki disease should be interpreted with reference to current expert consensus guidelines.

Clinical Characteristics of Kawasaki Disease in Infants Younger than Six Months: A Single-Center Study

BACKGROUND AND OBJECTIVES

Kawasaki disease (KD) is the leading cause of acquired heart disease, which predominantly occurs in children under the age of 5 years. However, there are fewer cases of KD in infants younger than 6 months, which makes it difficult to diagnose. We investigated the clinical manifestations of KD in this age group and compared them with those in the older age group.

SUBJECTS AND METHODS

We retrospectively reviewed the medical records of 239 patients with KD admitted to the Hallym Sacred Heart Hospital from January 2013 to June 2015. The data were categorized into 2 groups by age: Group A (≤6 months, n=26) and Group B (>6 months, n=213).

RESULTS

Group A had a longer hospitalization period than Group B (6.69 vs. 5.19 days, p=0.002). Group A had fewer clinical manifestations upon admission, due to which there was a higher incidence of incomplete KD (1.88 vs. 3.54 of the diagnostic criteria, p<0.05; and 19.2% vs. 4.2% incomplete KD incidence, p=0.002). The rate of cardiac complications was higher in Group A (30.8% vs. 11.7%, p=0.011).

CONCLUSION

The rate of cardiac complications of the patients younger than 6 months was significantly higher than that of the older patients. Therefore, infants younger than 6 months with unexplained fever for more than 5 days should be suspected as having KD, even if the principal clinical features are not fully presented. Echocardiography must be appropriately used for diagnosis of KD in suspected patients.

Study protocol for a phase III multicentre, randomised, open-label, blinded-end point trial to evaluate the efficacy and safety of immunoglobulin plus cyclosporin A in patients with severe Kawasaki disease (KAICA Trial)

INTRODUCTION

Kawasaki disease (KD) is an acute, self-limited vasculitis of unknown aetiology that predominantly affects infants and young children. We hypothesise that cyclosporin A (CsA) may be effective in treating KD by regulating the Ca(2+)/NFAT signalling pathway. This trial compares the current standard therapy of intravenous immunoglobulin (IVIG) and the combined IVIG+CsA therapy in paediatric patients with severe KD.

METHODS AND ANALYSIS

This trial is a phase III, multicentre, randomised, open-label, blinded-end point trial that evaluates the efficacy and safety of IVIG+CsA therapy. Patients with severe KD who satisfy the eligibility criteria are randomised (1:1) to receive either CsA (5 mg/kg/day for 5 days; Neoral) plus high-dose IVIG (2 g/kg for 24 h and aspirin 30 mg/kg/day), or high-dose IVIG alone (2 g/kg for 24 h and aspirin 30 mg/kg/day). The primary end point is the frequency of occurrence of coronary artery abnormalities during the trial period. An independent end point review committee will be in charge of the trial assessment.

ETHICS AND DISSEMINATION

The protocol was approved by the Institutional Review Board of each institution. The trial was notified and registered at the Pharmaceutical and Medical Devices Agency, in Japan. The trial is currently on-going and is scheduled to finish in April 2017. The findings will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

JMA-IIA00174; Pre-results.

Neonatal Kawasaki disease: case report and data from nationwide survey in Japan

Kawasaki disease (KD) is a systemic vasculitis that develops during childhood, with a peak incidence from 6 to 23 months of age. KD also affects younger children, including neonates. We herein describe the case of a 22-day-old patient with incomplete KD. Some characteristics of neonatal KD are also presented with a review of nationwide surveys of KD in Japan involving approximately 130,000 patients during a 12-year period. The surveys identified 23 neonatal cases, accounting for 1/5,500 of patients of all ages with KD. We found that the characteristics of neonatal KD are likely to be incompatible with the classic criteria for KD and that the incidence of coronary disorders in neonatal patients was not statistically higher than that in older patients. These findings are very similar to those of previous reports of neonatal KD.

CONCLUSION

Neonatal KD is rare and often presents with only a few features of KD. In addition, both neonatal and older patients with KD are at risk of coronary disorders. These characteristics present a challenge to pediatricians in the diagnosis and treatment of febrile neonates.

Clinical characteristics and serum N-terminal pro-brain natriuretic peptide as a diagnostic marker of Kawasaki disease in infants younger than 3 months of age

PURPOSE

The incidence of Kawasaki disease (KD) is rare in young infants (less than 3 months of age), who present with only a few symptoms that fulfill the clinical diagnostic criteria. The diagnosis for KD can therefore be delayed, leading to a high risk of cardiac complications. We examined the clinical characteristics and measured the serum levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels of these patients for assessing its value in the early detection of KD.

METHODS

We retrospectively reviewed the data of young infants diagnosed with KD from 2004 to 2012. The control group included 20 hospitalized febrile patients. Laboratory data, including NT-proBNP were obtained for each patient in both groups.

RESULTS

Incomplete KD was observed in 21/24 patients (87.5%). The mean fever duration on admission was 1.36±1.0 days in the KD group. Common symptoms included erythema at the site of Bacille Calmette-Guerin inoculation (70.8%), skin rash (50.0%), changes of oropharyngeal mucosa (29.1%), and cervical lymphadenopathy (20.8%). The mean number of major diagnostic criteria fulfilled was 2.8±1.4. Five KD patients (20.8%) had only one symptom matching these criteria. The incidence of coronary artery complications was 12.5%. The mean serum NT-proBNP level in the acute phase, in the KD and control groups, were 4,159±3,714 pg/mL and 957±902 pg/mL, respectively, which decreased significantly in the convalescent phase.

CONCLUSION

Incomplete KD was observed in 87.5% patients. Serum NT-proBNP might be a valuable biomarker for the early detection of KD in febrile infants aged <3 months.

Epidemiologic features and prognostic factors of coronary artery lesions associated with Kawasaki disease based on a 13-year cohort of consecutive cases identified by complete enumeration surveys in Wakayama, Japan

Background

To clarify the contribution of patient age to the development of coronary artery lesions (CALs) associated with Kawasaki disease (KD), epidemiologic features and prognostic factors were investigated using hospital-based complete enumeration surveys in a specific area.

Methods

Consecutive KD cases identified between October 1999 and September 2012 in Wakayama Prefecture, Japan, were analyzed. The primary outcome measure was the presence/absence of CALs (giant aneurysm, mid- or small-sized aneurysm, and dilatation) on echocardiography 1 month after disease onset. Demographics and medical treatment factors were compared between the patients with and without CALs. Odds ratios (ORs) and 95% confidence intervals (CIs) of explanatory variables (age, gender, and factors related to high-dose intravenous immunoglobulin treatment) for the development of CALs were determined.

Results

The median age of the 1415 patients (796 males, 619 females) was 25 months after excluding 2 children of foreign residents; 2.2% of the patients had a past history of KD, and 1.8% showed incomplete presentation. CALs were observed in 3.3% (4.0% of males, 2.3% of females; P = 0.080). The ORs of CALs among patients <11 months old (3.0, 95% CI 1.4–6.6) and those >48 months old (3.1, 95% CI 1.5–6.6) were significantly higher than values in 11- to 48-month-olds.

Conclusions

The effect of patient age on the development of CALs was found to be U-shaped, with the bottom at ages 11 to 48 months. This finding was based on a 13-year cohort of consecutive KD cases in a specific area with little selection bias and is consistent with previously reported results.

Kawasaki disease in infants

Kawasaki disease (KD) is an acute febrile illness that is the predominant cause of pediatric acquired heart disease in infants and young children. Because the diagnosis of KD depends on clinical manifestations, incomplete cases are difficult to diagnose, especially in infants younger than 1 year. Incomplete clinical manifestations in infants are related with the development of KD-associated coronary artery abnormalities. Because the diagnosis of infantile KD is difficult and complications are numerous, early suspicion and evaluation are necessary.

Concurrent adrenal neuroblastoma and kawasaki disease: a report of a rare case

Kawasaki disease (KD) is a systemic vasculitis of unknown etiology and a leading cause of acquired heart disease. It is assumed that there is an activation of the immune system by an infectious trigger in a genetically susceptible host. Neuroblastoma is the most common extracranial solid tumor in young children. It mainly originates from primordial neural crest cells that generate the adrenal medulla and sympathetic ganglia. A diagnosis of concurrent KD and neuroblastoma in a living child has been made in only one previous report. We report the second case and review the literature.