Discrimination of Kawasaki disease with concomitant adenoviral detection differentiating from isolated adenoviral infection

Subsequent development of Kawasaki disease following acute human adenovirus infection among siblings

We report a middle-childhood girl presented with high-grade fever and headache for 4 days. Following this, the child developed mucocutaneous symptoms. She had a notable family history of autoimmune disease. Tests revealed increased inflammatory markers. On the sixth day of illness, a two-dimensonal echocardiogram showed an enlarged coronary artery, diagnosed as incomplete Kawasaki disease (KD) and treated with IVIG and aspirin.Within a week, her younger sibling, an early-childhood girl presented with features of viral prodrome, developed mucocutaneous lesions and subcutaneous oedema of limbs. Her investigations also showed elevated inflammatory markers and echocardiographic changes, diagnosed as incomplete KD.The subsequent development of KD in siblings, both showing initial viral symptoms and a family history of autoimmune disease, led to the suspicion of a potential viral trigger. This was confirmed through viral PCR studies for human adenovirus (type 3). These cases highlight an unusual occurrence of KD developing in siblings following acute adenoviral infection.

Calculating the fraction of Kawasaki disease potentially attributable to seasonal pathogens: a time series analysis

Background

Kawasaki disease is an acute, febrile, systemic vasculitis of children that primarily affects medium-sized blood vessels with a tropism for the coronary arteries. Although the etiological factors remain unknown, infections have been suggested as the trigger of Kawasaki disease. We sought to calculate the fraction of Kawasaki disease potentially attributable to seasonal infections.

Methods

This cohort study used a population-based time series analysis from the French hospitalisation database (Programme de Médicalisation des Systèmes d'Information), which includes all inpatients admitted to any public or private hospital in France. We included all children aged 0-17 years hospitalised for Kawasaki disease in France over 13 years. The monthly incidence of Kawasaki disease per 10,000 children over time was analysed by a quasi-Poisson regression model. The model accounted for seasonality by using harmonic terms (a pair of sines and cosines with 12-month periods). The circulation of eight common seasonal pathogens (adenovirus, influenza, metapneumovirus, Mycoplasma pneumoniae, norovirus, rhinovirus, rotavirus, respiratory syncytial virus, and Streptococcus pneumonia) over the same period was included in the model to analyse the fraction of Kawasaki disease potentially attributable to each pathogen. Infections were identified on the basis of polymerase chain reaction or rapid antigen testing in hospital laboratories.

Findings

Between Jan 1, 2007, and Dec 31, 2019, we included 10,337 children with Kawasaki disease and 442,762 children with the selected infectious diseases. In the Kawasaki disease cohort, the median age [IQR] was 2 [0-4] years, 6164 [59.6%] were boys. Adenovirus infection was potentially responsible for 24.4% [21.5-27.8] (p < 0.001) of Kawasaki diseases, Norovirus for 6.7% [1.3-11.2] (p = 0.002), and RSV 4.6% [1.2-7.8] (p = 0.022). Sensitivity analyses found similar results.

Interpretation

This cohort study of data from a comprehensive national hospitalisation database indicated that approximately 35% of Kawasaki diseases was potentially attributable to seasonal infections.

Funding

None.

Viral Coinfections in Kawasaki Disease: A Meta-analysis

CONTEXT

Viral infections are suspected triggers in Kawasaki disease (KD); however, a specific viral trigger has not been identified.

OBJECTIVES

In children with KD, to identify (1) overall prevalence of viral infections; (2) prevalence of specific viruses; and (3) whether viral positivity was associated with coronary artery aneurysms (CAAs) or refractoriness to intravenous immunoglobin (IVIG).

DATA SOURCES

We searched Embase, Medline, and Cochrane databases and gray literature.

STUDY SELECTION

Eligible studies were conducted between 1999 and 2019, and included children diagnosed with KD who underwent viral testing.

DATA EXTRACTION

Two investigators independently reviewed full-text articles to confirm eligibility, extract data, appraise for bias, and assess evidence quality for outcomes using the Grading of Recommendations Assessment Development and Evaluation criteria. We defined viral positivity as number of children with a positive viral test divided by total tested. Secondary outcomes were CAA (z score ≥2.5) and IVIG refractoriness (fever ≥36 hours after IVIG).

RESULTS

Of 3189 unique articles identified, 54 full-text articles were reviewed, and 18 observational studies were included. Viral positivity weighted mean prevalence was 30% (95% confidence interval [CI], 14-51) and varied from 5% to 66%, with significant between-study heterogeneity. Individual virus positivity was highest for rhinovirus (19%), adenovirus (10%), and coronavirus (7%). Odds of CAA (odds ratio, 1.08; 95% CI, 0.75-1.56) or IVIG refractoriness (odds ratio, 0.88; 95% CI, 0.58-1.35) did not differ on the basis of viral status.

LIMITATIONS

Low or very low evidence quality.

CONCLUSIONS

Viral infection was common with KD but without a predominant virus. Viral positivity was not associated with CAAs or IVIG refractoriness.

The Differential Diagnosis of Sterile Pyuria in Pediatric Patients: A Review

Sterile pyuria is a common finding in pediatric patients. Literature describing the diagnoses as well as clinical characteristics of children with sterile pyuria is lacking. This review was performed to establish an evidence-based approach to the differential diagnosis by way of an extensive literature search. The definition of pyuria is inconsistent. The various causes of pediatric sterile pyuria identified were classified as either Infectious or Non-Infectious. Sub-categories of Infectious causes include: Viral Infection, Bacterial Infection, Other Infections (tuberculosis, fungal, parasitic), Sexually Transmitted Infections, Recent Antibiotic Therapy. Non-Infectious causes include: Systemic Disease, Renal Disease, Drug Related, Inflammation adjacent to Genitourinary Tract. Clinicians that encounter pediatric patients with sterile pyuria and persistent symptoms should consider the substantial differential diagnosis described in this study.

Kawasaki Disease Complicated by Salmonella oranienburg Coinfection

Kawasaki disease is a medium vessel vasculitis with a multisystem presentation affecting 9-20 per 100,000 children under 5 years of age in the United States. Salmonella coinfection has not been previously described. We present a 12-month-old vaccinated male with Kawasaki disease in the setting of Salmonella bacteremia. Initial intervention for the Kawasaki disease with IVIG was ineffective, prompting adjunctive therapy with anakinra, with eventual full recovery. Concurrent Kawasaki disease and bacteremia may confound diagnosis and necessitate nontraditional treatment approaches.

Coronary Artery Dilation in Children with Febrile Exanthematous Illness without Criteria for Kawasaki Disease

Background

Coronary dilatation is the most important complication of Kawasaki disease (KD) and, in addition to some clinical characteristics, is common to KD and febrile exanthematous illnesses (FEIs).

Objective

To assess whether children with FEI, who do not meet the criteria for KD, have changes in coronary arteries dimensions.

Methods

Echocardiography was performed within the first two weeks of the disease in patients < 10 years with fever and exanthema without other KD criteria. To make a comparison with KD patients, we reviewed the echocardiograms and medical records of patients with a diagnosis of KD of the last five years. Coronary ectasia was assessed using Z scores of coronary arteries. The means of the dimensions of the coronary arteries were compared with a z test and a level of significance of 0.05 was adopted.

Results

A total of 34 patients were included, 22 (64.7%) with FEI, and 12(35.2%) with a diagnosis of KD. Using the Z scores of coronary artery, a dilation of any of the coronary artery branches was observed in six (27.2%) patients with FEI.

Conclusions

An important percentage of patients with FEI has coronary artery dilation.