Evaluation of the Temporal Association between Kawasaki Disease and Viral Infections in South Korea

Evaluation of the Association Between Coronary Artery Aneurysms and Concomitant Infection in Patients With Kawasaki Disease

We analyzed the relationship between recovery from coronary artery aneurysms (CAAs) and concurrent infections in patients with Kawasaki disease (KD). The estimated median time of aneurysm persistence between patients with and without infections was compared using Kaplan-Meier survival analyses. Risk factors associated with persistent CAAs at 2 years were identified using multivariable analyses. Co-infection was confirmed in 20.5% (106/518) of patients diagnosed with KD. No significant differences regarding treatment or coronary artery outcome were identified between patients with and without infections. The estimated median time of aneurysm persistence was higher in the co-infected group (9 vs. 6 months). A maximum Z-score ≥ 4.00 at 1 month had 78% sensitivity and 83% specificity in predicting CAAs without recovery within 1 year of onset, whereas the predictability was higher within 2 years of onset, with a Z-score ≥ 4.88 (sensitivity, 92%; specificity, 91%). Concomitant infections did not affect the response to treatment or coronary artery outcomes in patients with KD.

Association between long-term PM2.5 exposure and risk of Kawasaki disease in children: A nationwide longitudinal cohort study

BACKGROUND

Based on previous studies suggesting air pollution as a potential risk factor for Kawasaki Disease (KD), we examined the association of long-term exposure to childhood fine particulate matter (PM2.5) with the risk of KD.

METHODS

We used National Health Insurance Service-National Sample Cohort data from 2002 to 2019, which included beneficiaries aged 0 years at enrollment and followed-up until the onset of KD or age 5 years. The onset of KD was defined as the first hospital visit record with a primary diagnostic code of M30.3, based on the 10th revision of the International Classification of Diseases, and with an intravenous immunoglobulin (IVIG) prescription. We assigned PM2.5 concentrations to 226 districts, based on mean annual predictions from a machine learning-based ensemble prediction model. We performed Cox proportional-hazards modeling with time-varying exposures and confounders.

RESULTS

We identified 134,634 individuals aged five or less at enrollment and, of these, 1220 individuals who had a KD onset and an IVIG prescription during study period. The average annual concentration of PM2.5 exposed to the entire cohort was 28.2 μg/m³ (Standard Deviation 2.9). For each 5 μg/m³ increase in annual PM2.5 concentration, the hazard ratio of KD was 1.21 (95% CI 1.05-1.39).

CONCLUSIONS

In this nationwide, population-based, cohort study, long-term childhood exposure to PM2.5 was associated with an increased incidence of KD in children. The study highlights plausible mechanisms for the association between PM2.5 and KD, but further studies are needed to confirm our findings.

Emerging evidence of microbial infection in causing systematic immune vasculitis in Kawasaki disease

Kawasaki disease (KD) is a systematic vasculitis that is often complicated by coronary artery lesions and is a leading cause of acquired heart disease in developed countries. Previous studies have suggested that genetic susceptibility, together with an inducing infectious agent, could be involved in KD pathogenesis; however, the precise causative agent of this disease remains unknown. Moreover, there are still debates concerning whether KD is an infectious disease or an autoimmune disease, although many studies have begun to show that various pathogens functioning as critical inducers could activate different kinds of immune cells, consequently leading to the dysfunction of endothelial cells and systematic vasculitis. Here in this review, we attempt to summarize all the available evidence concerning pathogen infections associated with KD pathogenesis. We also discuss the related mechanisms, present a future perspective, and identify the open questions that remain to be investigated, thereby providing a comprehensive description of pathogen infections and their correlations with the host immune system in leading to KD.

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.

T Cell Receptor Sequences Amplified during Severe COVID-19 and Multisystem Inflammatory Syndrome in Children Mimic SARS-CoV-2, Its Bacterial Co-Infections and Host Autoantigens

Published hypervariable region V-beta T cell receptor (TCR) sequences were collected from people with severe COVID-19 characterized by having various autoimmune complications, including blood coagulopathies and cardiac autoimmunity, as well as from patients diagnosed with the Kawasaki disease (KD)-like multisystem inflammatory syndrome in children (MIS-C). These were compared with comparable published v-beta TCR sequences from people diagnosed with KD and from healthy individuals. Since TCR V-beta sequences are supposed to be complementary to antigens that induce clonal expansion, it was surprising that only a quarter of the TCR sequences derived from severe COVID-19 and MIS-C patients mimicked SARS-CoV-2 proteins. Thirty percent of the KD-derived TCR mimicked coronaviruses other than SARS-CoV-2. In contrast, only three percent of the TCR sequences from healthy individuals and those diagnosed with autoimmune myocarditis displayed similarities to any coronavirus. In each disease, significant increases were found in the amount of TCRs from healthy individuals mimicking specific bacterial co-infections (especially Enterococcus faecium, Staphylococcal and Streptococcal antigens) and host autoantigens targeted by autoimmune diseases (especially myosin, collagen, phospholipid-associated proteins, and blood coagulation proteins). Theoretical explanations for these surprising observations and implications to unravel the causes of autoimmune diseases are explored.

Temporal Correlation Between Kawasaki Disease and Infectious Diseases in South Korea

IMPORTANCE

Infections are proposed to be triggering factors for Kawasaki disease (KD), although its etiological factors remain unknown. Recent reports have indicated a 4- to 6-week lag between SARS-CoV-2 infection and multisystem inflammatory syndrome in children with a similar presentation to that of KD.

OBJECTIVE

To investigate the temporal correlation between KD and viral infections, focusing on respiratory viruses.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among individuals aged 0 to 19 years diagnosed with KD between January 2010 and September 2020 from the Korean National Health Insurance Service. Data on infectious disease outbreaks from 2016 to 2019 were collected from the Korea Disease Control and Prevention Agency, Korean Influenza and Respiratory Virus Monitoring System, Korea Enteroviruses Surveillance System, and the Enteric Pathogens Active Surveillance Network in South Korea. Data were analyzed from December 2020 to October 2021.

MAIN OUTCOMES AND MEASURES

National databases for infectious diseases were used for a time-series analysis of the correlation between viral infections and KD. The temporal correlation between infectious disease outbreaks and KD outbreaks was evaluated using the Granger causality test (G-test), which is a useful tool to estimate correlations between 2 time series of diseases based on time lags.

RESULTS

Overall, 53 424 individuals with KD were identified, including 22 510 (42.1%) females and 30 914 (57.9%) males and 44 276 individuals (82.9%) younger than 5 years. Intravenous immunoglobulin-resistant KD was identified in 9042 individuals (16.9%), and coronary artery abnormalities were identified in 384 individuals (0.7%). Of 14 infectious diseases included in the analyses, rhinovirus infection outbreaks were identified as significantly correlated at 1 to 3 months before KD outbreaks in South Korea (r = 0.3; 1 month: P < .001; 2 months: P < .001; 3 months: P < .001). Outbreaks of respiratory syncytial virus infection were identified as significantly correlated with KD outbreaks by 2 months (r = 0.5; 2 months: P < .001). Additionally, varicella outbreaks were identified as significantly correlated at 2 and 3 months before KD outbreaks (r = 0.7; 2 months: P < .001; 3 months: P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study with a time series analysis of children and youth in South Korea with KD, respiratory infections caused by rhinovirus and respiratory syncytial virus and varicella outbreaks were significantly correlated with KD at 1 to 3 months before KD outbreaks.

Number of Kawasaki Disease Admissions Is Associated with Number of Domestic COVID-19 and Severe Enterovirus Case Numbers in Taiwan

Background: Non-pharmaceutical interventions (NPIs) introduced in response to the COVID-19 pandemic, including mask-wearing and social distancing, have changed the prevalence of circulating viruses in the community. Since viral infections represent a potential triggering factor for the development of Kawasaki disease (KD), we examined the relationship between KD admission rates and the number of COVID-19, severe influenza, and severe enterovirus infections both before and after the COVID-19 pandemic. Methods: We conducted a retrospective study using data obtained from the Chang Gung Research Database (including seven Taiwanese hospitals and more than 10,000 beds) and the Centers for Disease Control in Taiwan from January 2018 to December 2020. We recorded the number of KD admissions, as well as COVID-19, severe influenza, and severe enterovirus infections. Results: The numbers of KD admissions, severe enterovirus infections, and severe influenza infections were significantly lower from April to September 2020. The number of KD hospitalizations was positively correlated with the number of domestic COVID-19 cases (p = 0.001). A decrease in KD admission numbers was positively correlated with a decrease in severe enterovirus case numbers (p = 0.007). Conclusion: Our findings provide further evidence that viral infections may be an important trigger factor in the development of KD. Therefore, NPIs may not only prevent transmissible viral infections in children, but also decrease the risk of KD.

Spatiotemporal clusters of Kawasaki disease in South Korea from 2008 to 2017: A municipal-level ecological study

INTRODUCTION

As the etiology of Kawasaki disease (KD) remains unknown, identifying spatiotemporal clusters with proper stratification of KD could provide further evidence for investigating the triggers of KD. However, spatiotemporal distributions of KD with sex stratification have never been reported. Therefore, we aimed to analyze the spatiotemporal patterns of KD by sex in South Korea.

METHODS

We extracted epidemiologic week (Epiweek)-based KD cases in patients <5 years of age (ICD-10-CM code: M303) from 2008 to 2017 national health insurance service data at the 250 municipal level. To determine whether spatial autocorrelation and persistent municipal-level clusters exist, year- and sex-stratified global Moran's I statistics, Getis-Ord Gi* statistics, and emerging hotspot analysis on KD incidence were conducted.

RESULTS

A total of 72,510 KD cases were reported between 2008 and 2017 (male-to-female ratio = 1.40:1). Incidence has increased since 2008, with the highest incidence in 2016 (396.8 per 100,000 population). KD had seasonality of winter and summer but different by sex. Positive spatial autocorrelation was consistently reported in every stratum, with the 2011-2014 period having the strongest index value (total sex I = 0.286, p < 0.001; male I = 0.242, p < 0.001; female I = 0.213, p < 0.001). Hot spots were consistently detected in the northern parts, and cold spots were in the southern part for 9 years in both sexes. The emerging hot spot analysis showed new, consecutive, and sporadic hot spots on the northwestern and eastern coasts and new and sporadic cold spots in the southwestern part. However, the distribution and proportion of hot or cold spot types differed according to sex.

DISCUSSION

The spatiotemporal features of KD had limits to concluding that only infectious triggers result in KD occurrence. Therefore, our findings support the notion that KD is a syndrome with multiple factors, including infectious, genetic, and environmental factors, that are associated with sex differences.

The possible association between epidemics of hand-foot-and-mouth disease and responsiveness to immunoglobulin therapy in Kawasaki disease

BACKGROUND

Enterovirus causing hand-foot-mouth disease (HFMD) has been reported to be associated with the development of Kawasaki disease (KD), whereas the involvement of enterovirus in the clinical course of KD is uncertain. The aim of this study is to investigate the association between the clinical course of KD and HFMD epidemics.

METHODS

This study included 108 patients who developed KD during HFMD epidemic seasons (July and August) from 2010 to 2014 and who were initially treated with high-dose intravenous immunoglobulin (IVIG). A mean of ≥5.0 HFMD patients reported weekly from each sentinel medical facility was considered to represent a large HFMD epidemic. We compared the clinical characteristics of KD patients in summers of years with and without large HFMD epidemics.

RESULTS

Large HFMD epidemics occurred in 2011 and 2013. The number of KD patients in summer was the highest in 2011. The proportion of patients with resistance to the IVIG therapy in summers of years with the large epidemics (14%) was significantly lower than that in summers of other years (31%, P = 0.030), whereas the proportion of patients with coronary artery abnormalities did not differ to a statistically significant extent. The development of KD during large HFMD epidemics was significantly associated with a lower risk of resistance to the IVIG therapy (incidence rate ratio 0.92, P = 0.049).

CONCLUSION

Patients developing KD during large HFMD epidemic may have good responsiveness to IVIG. It is important to identify microbes from KD patients to predict responsiveness to IVIG therapy.

Rheumatological complications of Covid 19

Introduction

COVID-19 has caused unprecedented hardships in the 21st century with more than 150 million infections. Various immunological phenomena have been described during the course of the infection, and this infection has also triggered autoimmunity. Rheumatological illnesses have been described following resolution of the acute infection; hence we sought to conduct a review of the rheumatological complications of COVID-19.

Methods

We conducted a literature search for articles relating to sequelae of COVID-19 from Jan 2020 to 30th April 2021.

Results

We found a number of reports of inflammatory arthritis after SARS-CoV-2 infection. SLE and renal disease have been described, and vasculitis also appears to be a common complication. Rhabdomyolysis and myositis has also been reported in a number of patients. We also found some evidence of large vessel vasculitis in ‘long COVID’ patients.

Conclusions

This review highlights a number of important complications such as inflammatory arthritis, lupus-like disease, myostis and vasculitis following SARS-CoV-2 infection.

The Blood Gene Expression Signature for Kawasaki Disease in Children Identified with Advanced Feature Selection Methods

Kawasaki disease (KD) is an acute vasculitis, accompanied by coronary artery aneurysm, coronary artery dilatation, arrhythmia, and other serious cardiovascular diseases. So far, the etiology of KD is unclear; it is necessary to study the molecular mechanism and related factors of KD. In this study, we analyzed the expression profiles of 75 DB (identifying bacteria), 122 DV (identifying virus), 71 HC (healthy control), and 311 KD (Kawasaki disease) samples. 332 key genes related to KD and pathogen infections were identified using a combination of advanced feature selection methods: (1) Boruta, (2) Monte-Carlo Feature Selection (MCFS), and (3) Incremental Feature Selection (IFS). The number of signature genes was narrowed down step by step. Subsequently, their functions were revealed by KEGG and GO enrichment analyses. Our results provided clues of potential molecular mechanisms of KD and were helpful for KD detection and treatment.

Arterial Thrombosis in Coronavirus Disease 2019 Patients: A Rapid Systematic Review

BACKGROUND

Emerging evidence suggests that severe form of coronavirus disease 2019 (COVID-19) is mediated, in part, by a hypercoagulable state characterized by micro- and macro-vascular thrombotic angiopathy. Although venous thrombotic events in COVID-19 patients have been well described, data on arterial thrombosis (AT) in these patients is still limited. We, therefore, conducted a rapid systematic review of current scientific literature to identify and consolidate evidence of AT in COVID-19 patients.

METHODS

A systematic search of literature was conducted between November 1, 2019, and June 9, 2020, on PubMed and China National Knowledge Infrastructure to identify potentially eligible studies.

RESULTS

A total of 27 studies (5 cohort, 5 case series, and 17 case reports) describing arterial thrombotic events in 90 COVID-19 patients were included. The pooled incidence of AT in severe/critically ill intensive care unit-admitted COVID-19 patients across the 5 cohort studies was 4.4% (95% confidence interval 2.8-6.4). Most of the patients were male, elderly, and had comorbidities. AT was symptomatic in >95% of these patients and involved multiple arteries in approximately 18% of patients. The anatomical distribution of arterial thrombotic events was wide, occurring in limb arteries (39%), cerebral arteries (24%), great vessels (aorta, common iliac, common carotid, and brachiocephalic trunk; 19%), coronary arteries (9%), and superior mesenteric artery (8%). The mortality rate in these patients is approximately 20%.

CONCLUSIONS

AT occurs in approximately 4% of critically ill COVID-19 patients. It often presents symptomatically and can affect multiple arteries. Further investigation of the underlying mechanism of AT in COVID-19 would be needed to clarify possible therapeutic targets.

The landscape of extrapulmonary manifestations of human parainfluenza viruses: A systematic narrative review

Human parainfluenza virus (HPIV) infection is associated with every kind of respiratory tract illnesses, including the common cold, laryngotracheobronchitis (i.e. croup), tracheobronchitis, bronchiolitis, and pneumonia, in both children and adults. Although HPIVs are common respiratory pathogens, there are increasing reports about extrapulmonary manifestations of HPIVs infection. Each of the HPIVs could produce infection of other organs (central nervous system, heart, myocardium, etc.) in all age groups who are either immunocompetent or immunocompromised. This review aimed at summarizing the available data on clinical manifestations of HPIV infection outside the respiratory tract from 1961 to 2020. The findings support the possibility of extrapulmonary infections that were thought to be due to rare host genetic or immunologic defects in infected patients. These findings highlight the fact that extrapulmonary dissemination of HPIV can occur, but the association is not clearly demonstrated. Our data support the hypothesis that HPIV infection is one of the possible causes of these alterations and may even be the direct cause in some cases.

COVID-19 and multisystem inflammatory syndrome in children and adolescents

As severe acute respiratory syndrome coronavirus 2 continues to spread worldwide, there have been increasing reports from Europe, North America, Asia, and Latin America describing children and adolescents with COVID-19-associated multisystem inflammatory conditions. However, the association between multisystem inflammatory syndrome in children and COVID-19 is still unknown. We review the epidemiology, causes, clinical features, and current treatment protocols for multisystem inflammatory syndrome in children and adolescents associated with COVID-19. We also discuss the possible underlying pathophysiological mechanisms for COVID-19-induced inflammatory processes, which can lead to organ damage in paediatric patients who are severely ill. These insights provide evidence for the need to develop a clear case definition and treatment protocol for this new condition and also shed light on future therapeutic interventions and the potential for vaccine development. TRANSLATIONS: For the French, Chinese, Arabic, Spanish and Russian translations of the abstract see Supplementary Materials section.

An Outbreak of Kawasaki-like Disease in children during SARS-CoV- 2 Epidemic: No Surprise?

Background and aim:

Kawasaki disease is an acute systemic febrile illness of unknown aetiology, which usually affects children under 5 years of age. It is well known that Kawasaki disease is one of the most common causes of acquired heart diseases in children in the developed countries. Many studies, have suggested that heterogeneous infectious agents, such as common viruses, may trigger Kawasaki disease in young children with genetic background. Nowadays we are facing a pandemic caused by a Novel Coronavirus named SARS-CoV-2. Consequently, it could be possible that once exposed to this new coronavirus, some children, genetically predisposed, may mount an exaggerated inflammatory response which clinically manifests as Kawasaki Disease.

Methods:

from January to May 2020 a systematic search was performed on Pubmed for the following search terms: “COVID-19”, “children”, “SARS-CoV-2”, “complications”, “Kawasaki disease”, “cytokine storm”.

Results:

Usually, infants and children present milder symptoms of SARS-CoV-2 disease with a better outcome than adults. At variance, some children may be genetically disposed to a more robust inflammatory response to SARS-CoV-2, similar to Kawasaki disease. In fact, Kawasaki disease is the result of an abnormal immune response, in susceptible children, to an external trigger such as an infection. Thus, according to the pathogenesis of Kawasaki disease, paediatricians may expect an increase in cases of Kawasaki disease during the COVID-19 pandemic. (www.actabiomedica.it)

Are the cutaneous manifestations during or due to SARS-CoV-2 infection/COVID-19 frequent or not? Revision of possible pathophysiologic mechanisms

BACKGROUND

SARS-Cov-2 is a single-stranded RNA virus, a Betacoronavirus, composed of 16 non-structural proteins, with specific roles in replication of coronaviruses. The pathogenesis of COVID-19 is not yet fully understood. The virus and host factors interplay among distinct outcomes of infected patients.

METHODS

Using MeSH (Medical Subject Headings) in PubMed, authors searched for articles cotaining information on COVID-19 and the skin.

RESULTS

The pathophysiology of the disease is multifactorial: association with innate immune response, hypercoagulability state, lung tissue damage, neurological and/or gastrointestinal tract involvement, monocytic/macrophage activation syndrome, culminating in exaggerated cytokine secretion, called "cytokine storm", which leads to worsening and death. These systemic conditions may be associated with cutaneous lesions, that have polymorphic aspects, where at histopathological level show involvement in different skin changes. These lesions may be associated with multisystemic manifestations that could occur due to angiotensin-converting enzyme 2 receptor and transmembrane serine protease action, allowing the pulmonary infection and possibly skin manifestation. Several reports in literature show cutaneous lesions similar to chilblain, urticarial eruptions, diffuse or disseminated erythema, livedo racemosa, blue toe syndrome, retiform purpura, vesicle trunk, purpuric exanthema or exanthema with clinical aspects of symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) and others.

CONCLUSIONS

This review describes the complexity of Covid-19, pathophysiological and clinical aspects, dermatological finding and other dermatological conditions associated with SARS-CoV-2 infection or COVID-19.

Is it Kawasaki shock syndrome, Kawasaki-like disease or pediatric inflammatory multisystem disease? The importance of semantic in the era of COVID-19 pandemic

A few weeks after the peak of the global 2019 novel coronavirus disease pandemic, cases of shock, multisystem inflammation and severe myocarditis have occurred in children and adolescents, generating some concerns and above all many questions. An almost immediate association raised with shock syndrome related to Kawasaki disease (KD). However, in light of bo/th experience and literature have taught us about severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection, and what already known on the epidemiology of KD, we suggest here the hypothesis of a new 'post-viral' systemic inflammatory disease related to excessive adaptive immune response rather than a form of KD caused by SARS-COV-2. We discuss analogies and differences between the two forms.

Emergence of Kawasaki disease related to SARS-CoV-2 infection in an epicentre of the French COVID-19 epidemic: a time-series analysis

Background

Kawasaki disease is an acute febrile systemic childhood vasculitis, which is suspected to be triggered by respiratory viral infections. We aimed to examine whether the ongoing COVID-19 epidemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with an increase in the incidence of Kawasaki disease.

Methods

We did a quasi-experimental interrupted time series analysis over the past 15 years in a tertiary paediatric centre in the Paris region, a French epicentre of the COVID-19 outbreak. The main outcome was the number of Kawasaki disease cases over time, estimated by quasi-Poisson regression. In the same centre, we recorded the number of hospital admissions from the emergency department (2005–2020) and the results of nasopharyngeal multiplex PCR to identify respiratory pathogens (2017–2020). These data were compared with daily hospital admissions due to confirmed COVID-19 in the same region, recorded by Public Health France.

Findings

Between Dec 1, 2005, and May 20, 2020, we included 230 patients with Kawasaki disease. The median number of Kawasaki disease hospitalisations estimated by the quasi-Poisson model was 1·2 per month (IQR 1·1–1·3). In April, 2020, we identified a rapid increase of Kawasaki disease that was related to SARS-CoV-2 (six cases per month; 497% increase [95% CI 72–1082]; p=0·0011), starting 2 weeks after the peak of the COVID-19 epidemic. SARS-CoV-2 was the only virus circulating intensely during this period, and was found in eight (80%) of ten patients with Kawasaki disease since April 15 (SARS-CoV-2-positive PCR or serology). A second peak of hospital admissions due to Kawasaki disease was observed in December, 2009 (six cases per month; 365% increase ([31–719]; p=0.0053), concomitant with the influenza A H1N1 pandemic.

Interpretation

Our study further suggests that viral respiratory infections, including SAR-CoV-2, could be triggers for Kawasaki disease and indicates the potential timing of an increase in incidence of the disease in COVID-19 epidemics. Health-care providers should be prepared to manage an influx of patients with severe Kawasaki disease, particularly in countries where the peak of COVID-19 has recently been reached.

Funding

French National Research Agency.

Advances in the relationship between coronavirus infection and cardiovascular diseases

The outbreak of coronavirus disease 2019 (COVID-19) has once again aroused people's concern about coronavirus. Seven human coronaviruses (HCoVs) have been discovered so far, including HCoV-229E, HCoV-NL63, HCoV-OC43, HCoV-HKU115, severe acute respiratory syndrome coronavirus, Middle East respiratory syndrome coronavirus and severe acute respiratory syndrome coronavirus 2. Existing studies show that the cardiovascular disease increased the incidence and severity of coronavirus infection. At the same time, myocardial injury caused by coronavirus infection is one of the main factors contributing to poor prognosis. In this review, the recent clinical findings about the relationship between coronaviruses and cardiovascular diseases and the underlying pathophysiological mechanisms are discussed. This review aimed to provide assistance for the prevention and treatment of COVID-19.

Unleashing the mysterious link between COVID-19 and a famous childhood vasculitis: Kawasaki disease

Background

Coronavirus disease 2019 (COVID-19) emerged as a small outbreak in Wuhan rapidly progressing into the deadliest pandemic since the Spanish flu of 1918. The disease was deemed trivial in children, until the reporting, few days ago, of an emerging pediatric multi-inflammatory syndrome mimicking Kawasaki disease (KD).

Main body

This report reveals that coronaviridae were implicated in induction of several post-infectious vasculitides, namely, KD, AHEI, and HSP. This occurs in genetically susceptible individuals to vascular inflammation. Shared genetic susceptibilities between KD and CoV include genes encoding for CD 40, HLAB-15:03, and ACE. This leads to augmented inflammation with hypersecretion of cytokines especially IL-6.

Conclusion

The revealed relationships between KD and CoV can help to predict the risk of KD in COVID-19 patients through screening levels of upregulated cytokines. It might also signify that classic treatment of KD with IVIG might need to be replaced with anti-cytokine therapy in COVID-19 patients.

Adenovirus infection and subsequent risk of Kawasaki disease: A population-based cohort study

BACKGROUND

The relationship between adenovirus infection and Kawasaki disease (KD) is unclear. The purpose of this study was to determine the relationship between adenovirus infection and KD using a cohort study in Taiwan.

METHODS

We used Taiwan National Health Insurance data (from 2000 to 2008) to conduct a population-based cohort study, analyzing children that was under 18 years of age. In total, 5280 children had adenovirus infection, and 5280 children without adenovirus infection were matched and followed up. Subsequent KD was the major outcome event. The Cox proportional hazards model was used to estimate the hazard ratio (HR) with 95% confidence intervals (CIs) of developing KD associated with adenovirus infection.

RESULTS

There was a significantly higher cumulative incidence of KD in the adenovirus-infected cohort than that in the control cohort (log-rank test, p < 0.001). In the adenovirus-infected cohort, overall incidence of KD was 5.29 times higher than that of the control cohort (adjusted HR 5.29, 95% CI: 2.48-11.3). Increased KD risk was associated with previous adenovirus infection in children aged 3-5 years, in female patients, in those with a low urbanization level, and in those with allergies.

CONCLUSION

An association between previous adenovirus infection and KD was identified in Taiwanese children, but other potential risk factors were not fully analyzed. The relationship between infection and KD requires further study.

Reality of Kawasaki disease epidemiology

Epidemiologic studies of Kawasaki disease (KD) have shown a new pattern or change of its occurrence suggestive of its pathophysiology or risk factors from the first patient with KD reported in 1961. The incidence of KD in Northeast Asian countries including Japan, South Korea, China, and Taiwan is 10–30 times higher than that in the United States and Europe. Knowing the true epidemiology of KD in each country and the availability of publications of KD epidemiology also could benefit general health care providers and general population. This would enable the early detection and treatment of KD, ultimately reducing the incidence of coronary artery complications and mortality. Therefore, efforts to investigate the true epidemiology of KD should be continued in every country using a questionnaire survey, National Health Insurance system data, or combined methods depending on each country’s medical environment to ensure high-quality care of patients with KD.

Update on association between Kawasaki disease and infection

The relationship between infection and Kawasaki disease (KD) remains unclear. Infection has long been considered a key predisposing factor for KD. Bacterial and viral agents may be related to the onset of KD because of superantigen and cytokine production. Various bacterial and viral infections have been reported to be associated with KD, but the actual mechanism remains unknown. The higher association between KD and enterovirus has been well documented by using Taiwan National Health Insurance Research Database. However, no evidence has been obtained that various bacterial and viral infections induce KD. Comprehensive research, including infectious agents, should be conducted to elucidate the pathogenesis of KD.

Profile of resistance to IVIG treatment in patients with Kawasaki disease and concomitant infection

INTRODUCTION

Kawasaki disease (KD) can be associated with concomitant viral or bacterial infections. Children with persistent or recurrent fever 36 hours after the end of intravenous immunoglobulin (IVIG) are considered to be resistant to treatment and are at increased risk for coronary complications. Although concomitant infection does not affect coronary outcome, it is unknown how it influences the response to IVIG treatment.

METHODOLOGY

Retrospective cohort study between 2008 and 2016 in a tertiary pediatric university hospital, including 154 children, of which 59 (38%) had concomitant infection.

RESULTS

Children with concomitant infection were more likely to have fever 48 hours after initial IVIG treatment (36% vs 20%, p = 0.05) and to be treated with a second dose (33% vs 18%, p = 0.04). Children with infection had higher C-reactive protein at the time of diagnosis (148 vs 112 mg/L, p = 0.04), and 48 hours after IVIG administration (111 vs 59 mg/L, p = 0.003). Nevertheless, there was no statistically significant difference in the prevalence of coronary complications (Z-score > 2.5) between children with and without concomitant infection (36% vs 39%, p = 0.68).

CONCLUSION

Children with KD and concomitant infection are more likely to have persistent fever and elevated inflammatory markers after treatment. This association increases the likelihood of receiving a second dose of IVIG but not the risk of coronary complication. Accordingly, prospective studies to distinguish true IVIG resistance from infection induced persistent fever is warranted.

Enterovirus Infection and Subsequent Risk of Kawasaki Disease: A Population-based Cohort Study

BACKGROUND

The relationship of enterovirus (EV) infection and Kawasaki disease (KD) is still unclear. The purpose of this study was to conduct a population-based cohort study to determine the relationship between KD and EV infection in Taiwan.

METHODS

A population-based cohort study was conducted to analyze the children file (age < 18 years) of the Taiwan National Health Insurance program between 2000 and 2008. In total, 285,636 children with EV infection and 285,636 children without EV infection were included and followed up. The subsequent KD was the major outcome event.

RESULTS

The cumulative incidence of KD was significantly higher in the EV-infected cohort than in the non-EV-infected cohort (log-rank test, P < 0.001). The overall incidence of KD was 56% higher in the EV-infected cohort than in the non-EV-infected cohort, with an adjusted hazard ratio of 1.56 (95% confidence interval: 1.44-1.69). Stratified analysis showed higher KD risk associated with previous EV infection in children 3-5 years old, in girls, in children living in less urbanization levels, in children with parental low-income occupation, and in children with allergic diseases.

CONCLUSIONS

There is a higher association between KD and previous EV infection in Taiwanese children, especially in those 3-5 years old, with female sex, with less urbanization level, with low-income parental occupation, and with allergy.

Epidemiology and Clinical Features of Kawasaki Disease in South Korea, 2012-2014

BACKGROUND

To reveal the recent epidemiologic features of Kawasaki disease (KD) in South Korea based on data from a nationwide survey.

METHODS

We collected data between 2012 and 2014 regarding the incidence, symptoms and signs, treatment trends and coronary complications associated with acute KD by sending questionnaires to 97 hospitals with pediatric residency programs as well as 19 community hospitals without residency training.

RESULTS

We received full and partial data from 97 and 13 hospitals, respectively (response rate: 94.8%). A total of 14,916 cases of KD were reported by these 110 hospitals (4588 in 2012, 5183 in 2013 and 5145 in 2014). The male-to-female ratio was 1.4:1, and the median age at diagnosis was 29 months. The incidence of KD per 100,000 children younger than 5 years of age were 170.9, 194.9 and 194.7 in 2012, 2013 and 2014, respectively. The recurrence rate was 4.7%. KD occurred more frequently during summer (especially June and July) and winter (December and January) seasons. Intravenous immunoglobulin was administered to 95.4% of the patients, and the nonresponder rate for the first intravenous immunoglobulin was 11.8%. Coronary aneurysm occurred in 1.7% of the patients, and giant aneurysm developed in 19 patients (0.16%) during the 3 years. One patient had myocardial infarction and 1 patient died of suspected coronary aneurysm rupture.

CONCLUSIONS

The incidence of KD in South Korea increased to 194.7 per 100,000 children younger than 5 years in 2014; meanwhile, the coronary aneurysm rate decreased to 1.7%.

Use of corticosteroids during acute phase of Kawasaki disease

In spite of initial intravenous immunoglobulin (IVIG) treatment, a significant number of patients are unresponsive to it and are at a higher risk for coronary artery lesions. Corticosteroids have been used as a secondary drug or used in combination with IVIG. Three options of using corticosteroids for the treatment of patients during the acute phase of Kawasaki disease, have been considered. The first is their use exclusively for patients unresponsive to IVIG treatment. The second is their use in combination with IVIG as the routine first line therapy for all patients. The last is the use in the combination as the first line therapy for selected patients at a high risk being unresponsive to initial IVIG. However, it is uncertain that the corticosteroids as the second line treatment are better than the additional IVIG in patients unresponsive to initial IVIG. The combination of corticosteroids and IVIG as the routine first line therapy also have not enough evidences. The last option of using corticosteroids - the combination of corticosteroids and IVIG in patients at high risk of unresponsiveness, is a properly reasonable treatment strategy. However, there have been no globally standardized predictive models for the unresponsiveness to initial IVIG treatment. Therefore, future investigations to determine the best predictive model are necessary.

Cardiac Function in Kawasaki Disease Patients with Respiratory Symptoms

Background and Objectives

Respiratory symptoms are often observed in children with Kawasaki disease (KD) during the acute phase. The association of respiratory viruses in children with KD was investigated using multiplex reverse transcriptase-polymerase chain reaction (RT-PCR) and tissue Doppler echocardiography.

Subjects and Methods

138 KD patients were included from January 2010 to June 2013. We compared 3 groups (group 1: n=94, KD without respiratory symptoms; group 2: n=44, KD with respiratory symptoms; and group 3: n=50, febrile patients with respiratory symptoms). Laboratory data were obtained from each patient including N-terminal pro-brain natriuretic peptide (NT-proBNP). Echocardiographic measurements were compared between group 1 and group 2. RT-PCR was performed using nasopharyngeal secretion to screen for the presence of 14 viruses in groups 2 and 3.

Results

The incidence of KD with respiratory symptoms was 31.8%. The duration of fever was significantly longer, and coronary artery diameter was larger in group 2 than in group 1. Tei index was significantly higher and coronary artery diameter larger in group 2 than group 1. Coronary artery diameter, C-reactive protein levels, platelet count, alanine aminotransferase levels, and NT-pro BNP levels were significantly higher and albumin levels lower in group 2 compared with group 3.

Conclusion

NT-pro BNP was a valuable diagnostic tool in differentiating KD from other febrile viral respiratory infections. Some viruses were more frequently observed in KD patients than in febrile controls. Tei index using tissue Doppler imaging was increased in KD patients with respiratory symptoms.