Kawasaki disease for dermatologists

Cutaneous signs of selected cardiovascular disorders: A narrative review

Cardiovascular diseases are the leading cause of mortality and morbidity globally. Clinicians must know cutaneous signs of cardiovascular disease, including petechiae, macules, purpura, lentigines, and rashes. Although cutaneous manifestations of diseases like infectious endocarditis and acute rheumatic fever are well established, there is an indispensable need to evaluate other important cardiovascular diseases accompanied by cutaneous signs. Moreover, discussing the latest management strategies in this regard is equally imperative. This review discusses distinctive skin findings that help narrow the diagnosis of cardiovascular diseases and recommendations on appropriate treatment.

[Clinical details in the diagnosis of Kawasaki disease]

Kawasaki disease (KD) is one of the leading causes of acquired heart diseases in children aged under 5 years. The clinical manifestations of KD include fever, changes in the extremities, rash or redness at the site of bacille Calmette-Guérin vaccination, bilateral bulbar conjunctival hyperemia, changes in lips and mouth, nonsuppurative cervical lymphadenopathy, and other systemic manifestations. There are difficulties in the diagnosis of KD due to its asynchronous clinical manifestations. With reference to the latest case reports and research advances in KD, this article summarizes the clinical details in the diagnosis of KD, so as to improve the level of clinical diagnosis of KD.

A Sri Lankan infant with immunoglobulin resistant incomplete Kawasaki disease with a vesicular psoriasiform rash, hypertension and late onset small joint arthritis: a case report

Background

Kawasaki disease (KD) is a medium and small vessel vasculitis which usually has a good response to immunoglobulin therapy (IVIG). We present a case of incomplete KD with IVIG resistance associated with an unusual combination of vesicular guttate-psoriasiform rash, hypertension and late onset small joint arthritis.

Case presentation

A four-month-old male infant from Sri Lanka presented with high fever, conjunctival redness, pedal oedema and skin rash. He was found to have hypertension since admission with a high white cell count and high inflammatory markers. There was poor response to intravenous antibiotics and subsequent 2D echocardiogram revealed coronary artery aneurysms suggestive of KD. In the third week of illness he developed a vesiculo-papular rash involving face, trunk and limbs – which on biopsy revealed features of guttate psoriasis.

Fever spikes continued and the coronary arteries showed progressive dilatation despite timely intravenous immunoglobulin administered on day 6 and methylprednisolone administered on day 10-13. Therapeutic response by means of reduction of fever was seen only after initiation of intravenous infliximab on day 28 of illness for which the fever responded within 24 hours. He developed a small joint arthritis of hands and feet on day 40 of illness which responded only after initiating methotrexate therapy. The hypertension persisted for 4 months after the onset of the illness before complete resolution.

Conclusion

This case report depicts an unusual presentation of KD with a vesicular guttate-psoriasiform eruption, hypertension and late onset small joint arthritis. It highlights that clinicians should be aware of the fact that KD could present with such atypical manifestations and could develop unusual complications.

Clinical Manifestations and Laboratory Findings of Kawasaki Disease: Beyond the Classic Diagnostic Features

Kawasaki disease (KD) has shown a marked increase in trend over the globe, especially within the last two decades. Kawasaki disease is often seen in the paediatric population below five years old, while it is rare for those who are beyond that age. Up to this date, no exact causes has been identified although KD was found more than half a century ago. The underlying pathogenesis of the disease is still unelucidated, and researchers are trying to unlock the mystery of KD. To further complicate the diagnosis and the prompt management, a specific biomarker for the diagnosis of KD is yet to be discovered, making it hard to differentiate between KD and other diseases with a similar presentation. Nonetheless, since its discovery, clinicians and scientists alike had known more about the different clinical aspects of typical KD. Thus, this article intends to revisit and review the various clinical manifestations and laboratory characteristics of KD in order to guide the diagnosis of KD.

Cutaneous manifestations of acute kidney injury

Acute kidney injury (AKI) is a common medical problem with a multitude of aetiologies. Prompt diagnosis and management is key in the prevention of complications. Cutaneous signs can often give diagnostic clues of underlying systemic diseases causing AKI.

This review summarises cutaneous findings of diseases causing AKI in adults. Knowledge of such cutaneous signs could lead to earlier diagnosis of underlying kidney disease and facilitate management strategies in a timely manner.

Acute interstitial nephritis, polyarteritis nodosa, Kawasaki's disease, granulomatosis with polyangiitis (previously Wegener's granulomatosis), microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis (previously Churg-Strauss syndrome), Henoch-Schonlein purpura, cryoglobulinaemia, Sjogren's Syndrome, systemic sclerosis, nephrogenic systemic fibrosis, dermatomyositis, systemic lupus erythematosus, amyloidosis, and cholesterol embolisation syndrome were highlighted as diseases causing AKI with cutaneous manifestations.

Staphylococcal Scalded Skin Syndrome and Bullous Impetigo

Staphylococcal scalded skin syndrome (SSSS) and bullous impetigo are infections caused by Staphylococcus aureus. The pathogenesis of both conditions centers around exotoxin mediated cleavage of desmoglein-1, which results in intraepidermal desquamation. Bullous impetigo is due to the local release of these toxins and thus, often presents with localized skin findings, whereas SSSS is from the systemic spread of these toxins, resulting in a more generalized rash and severe presentation. Both conditions are treated with antibiotics that target S. aureus. These conditions can sometimes be confused with other conditions that result in superficial blistering; the distinguishing features are outlined below.

Association of TNF-α rs1800629, CASP3 rs72689236 and FCGR2A rs1801274 Polymorphisms with Susceptibility to Kawasaki Disease: A Comprehensive Meta-Analysis

Kawasaki Disease (KD) is a multifactorial condition at the junction of infectious diseases, immunology, rheumatology, and cardiology. The aim of this study is to derive a more precise estimation of the association of TNF-α rs1800629, CASP3 rs72689236 and FCGR2A rs1801274 polymorphisms with risk of KD. Methods: PubMed, EMBASE, CNKI databases were searched to identify all relevant studies. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using CMA 2.2 software. Results: A total of 25 studies including eleven studies on TNF-α rs1800629, five studies on CASP3 rs72689236 and nine studies on FCGR2A rs1801274 were selected. Overall, pooled data revealed that CASP3 rs72689236 and FCGR2A rs1801274 polymorphisms were significantly associated with an increased risk of KD. However, there was no significant association between TNF-α rs1800629 and KD. Conclusions: This meta-analysis suggested that CASPS rs72689236 and FCGR2A rs1801274 polymorphisms may modulate individual susceptibility to KD.

Multisystem Inflammatory Syndrome in Children Associated with COVID-19: A Review with an Emphasis on Mucocutaneous and Kawasaki Disease-Like Findings

BACKGROUND

COronaVIrus Disease 2019 (COVID-19) affects children with less severe symptoms than adults. However, severe COVID-19 paediatric cases are increasingly reported, including patients with Kawasaki disease (KD) or a multisystem inflammatory syndrome (MIS-C) that can present with features resembling KD.

SUMMARY

MIS-C is an emerging severe paediatric syndrome associated with COVID-19 that can show overlapping features of KD, KD shock syndrome, and toxic shock syndrome. MIS-C might be an inflammatory disease distinct from KD resulting from an exaggerated immune response. A high prevalence of mucocutaneous manifestations - in addition to gastrointestinal and cardiovascular involvements - was found in MIS-C. The most frequent mucocutaneous findings were conjunctivitis and rash, often described as macular and/or papular or polymorphous. In this article, we present a brief overview of MIS-C with an emphasis on mucocutaneous findings and the relationship with KD.

Multisystem Inflammatory Syndrome in a Child with Scrub Typhus and Macrophage Activation Syndrome

Clinical and laboratory parameters of multisystem inflammatory syndrome in children (MIS-C) mimic Kawasaki disease (KD). KD has been described in association with dengue, scrub typhus and leptospirosis. However, MIS-C with concomitant infection has rarely been reported in literature. A 14-year-old-girl presented with fever and rash with history of redness of eyes, lips and tongue. Investigations showed anemia, lymphopenia, thrombocytosis with elevated erythrocyte sedimentation rate, C-reactive protein, pro-brain natriuretic peptide, Interleukin-6, ferritin and d-dimer. Scrub typhus immunoglobulin M was positive. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG) level was also elevated. A diagnosis of MIS-C with concomitant scrub typhus was proffered. Child received azithromycin, intravenous immunoglobulin and methylprednisolone. After an afebrile period of 2.5 days, child developed unremitting fever and rash. Repeat investigations showed anemia, worsening lymphopenia, thrombocytopenia, transaminitis, hypertriglyceridemia, hyperferritinemia and hypofibrinogenemia which were consistent with a diagnosis of macrophage activation syndrome (MAS). KD, MIS-C and MAS represent three distinct phenotypes of hyperinflammation seen in children during coronavirus disease pandemic. Several tropical infections may mimic or coexist with MIS-C which can be a diagnostic challenge for the treating physician. Identification of coexistence or differentiation between the two conditions is important in countries with high incidence of tropical infections to guide appropriate investigations and treatment.

Incomplete Kawasaki disease complicated with acute abdomen: A case report

BACKGROUND

Kawasaki disease (KD) is an acute systemic vasculitis characterized by unknown etiology.

CASE SUMMARY

A 4.5-year-old boy developed an acute abdomen during the onset of incomplete KD. He still had persistent abdominal pain after undergoing exploratory laparotomy and appendectomy. Ultrasound examination at early onset revealed a giant coronary artery aneurysm. The patient developed a myocardial infarction and heart failure accompanied by respiratory and cardiac arrest. He underwent coronary artery revascularization and coronary artery bypass graft using an autologous internal mammary artery. After the operation, the cardiac output increased, and the symptoms of heart failure resolved. Follow-up evaluation at 1 mo after operation showed that the patient's cardiac function had restored to New York Heart Association standard Grade I heart failure, and normal growth was obtained.

CONCLUSION

Coronary artery revascularization and coronary artery bypass graft is an effective method for treating myocardial ischemia in children with KD complicated with giant coronary artery aneurysm . Nevertheless, some issues still need specific attention.

Incomplete Kawasaki disease complicated with acute abdomen: A case report

BACKGROUND

Kawasaki disease (KD) is an acute systemic vasculitis characterized by unknown etiology.

CASE SUMMARY

A 4.5-year-old boy developed an acute abdomen during the onset of incomplete KD. He still had persistent abdominal pain after undergoing exploratory laparotomy and appendectomy. Ultrasound examination at early onset revealed a giant coronary artery aneurysm. The patient developed a myocardial infarction and heart failure accompanied by respiratory and cardiac arrest. He underwent coronary artery revascularization and coronary artery bypass graft using an autologous internal mammary artery. After the operation, the cardiac output increased, and the symptoms of heart failure resolved. Follow-up evaluation at 1 mo after operation showed that the patient's cardiac function had restored to New York Heart Association standard Grade I heart failure, and normal growth was obtained.

CONCLUSION

Coronary artery revascularization and coronary artery bypass graft is an effective method for treating myocardial ischemia in children with KD complicated with giant coronary artery aneurysm . Nevertheless, some issues still need specific attention.

Multi-System Inflammatory Syndrome in a Child Mimicking Kawasaki Disease

There have been recent reports of children presenting with severe multi-system hyperinflammatory syndrome resembling Kawasaki disease (KD) during current COVID-19 pandemic. Exact pathophysiology is unknown, however, most of the children have multi-organ dysfunction and respiratory system involvement is less common compared to adults. These patients have certain characteristic laboratory parameters different from those seen in children with KD. However, only limited literature is available at present for identification and management of such patients. We report a young girl who presented with fever, rash and other manifestations mimicking classic KD and fulfilling the case definitions for pediatric multi-system inflammatory syndrome. She had lymphopenia, thrombocytopenia and hyponatremia in the absence of macrophage activation syndrome, similar to that seen in patients reported from UK and Italy. Clinical manifestations resolved and laboratory parameters improved with intravenous immunoglobulin and corticosteroids. Early recognition is important to administer immunomodulatory therapy which may be life saving for these patients.

Kawasaki disease in siblings and a review of drug treatment

We have managed two anonymized siblings with Kawasaki disease (KD). The occurrence of KD in the elder brother alerted us to the occurrence of incomplete KD in the younger brother. Both siblings were treated with intravenous immunoglobulin and a high dose of dipyridamole with resolution of the coronary artery aneurysm. Dipyridamole was used instead of aspirin because both siblings were glucose-6-phosphate dehydrogenase deficient for which aspirin was contraindicated. To prevent damage to the coronary arteries, treatment should be started as soon as the diagnosis is made. There have been a lot of advances in medical therapy in recent years, which are reviewed together with conventional proven therapy for KD. Early diagnosis and prompt treatment are important to achieve optimal treatment outcome in KD. Family history of KD among siblings enables clinicians for an earlier diagnosis so as to prevent the disease complications particularly in patients with incomplete features.

Vasculitis

Vasculitis, characterized by inflammation and necrosis, manifests a wide spectrum of presentation by involving a vasculature of various sizes and locations. A definitive diagnosis of vasculitis invariably requires histologic confirmation since there are no diagnostic clinical, imaging, or laboratory findings. The most widely adopted vasculitis classification is the Chapel Hill Consensus Conference (CHCC) nomenclature of systemic vasculitis which integrated clinical symptoms, histopathologic features, and laboratory findings. This classification accounts for the size of the involved vessels. This chapter outlines the clinical and histologic features of the small-vessel vasculitis including the immune complex vasculitis and antineutrophil cytoplasmic antibody-associated vasculitis; medium-vessel vasculitis such as polyarteritis nodosa and Kawasaki disease; large-vessel vasculitis, namely, giant cell arteritis and Takayasu arteritis; variable-vessel vasculitis such as Behcet disease and Cogan syndrome; and vasculitis associated with systemic diseases including rheumatoid arthritis, lupus vasculitis, and sarcoid vasculitis. Vasculitis can also be secondary to drugs, infection, underlying systemic disease, or trauma. Therefore, a diagnosis of vasculitis cannot be based on histologic ground alone. Clinical pathologic correlation is necessary.

A rare cutaneous manifestation of Kawasaki disease

Kawasaki disease (KD) is the second common vasculitis in childhood following Henoch-Schönlein purpura. The common skin manifestations in KD are polymorphic exanthema, epidermal desquamation, erythema of the palms and soles and edema over the extremities. Skin erythema at the Bacille-Calmette-Guérin (BCG) vaccination site has been reported frequently in patients with KD. Skin ulceration after BCG vaccination in a context of KD was also reported but not as a part of the disease manifestation. We report a 14-month-old child who presented with clinical criteria for KD and developed left forearm ulcer that did not respond to antimicrobial therapy but responded well to immunomodulatory therapy.

Controversies in diagnosis and management of Kawasaki disease

Kawasaki disease (KD) is a common medium vessel systemic vasculitis that usually occurs in small children. It has a predilection for the coronary arteries, but other medium sized arteries can also be involved. The etiology of this disorder remains a mystery. Though typical presentation of KD is quite characteristic, it may also present as incomplete or atypical disease in which case the diagnosis can be very challenging. As both incomplete and atypical forms of KD can be associated with serious coronary artery complications, the pediatrician can ill afford to miss these diagnoses. The American Heart Association has enunciated consensus guidelines to facilitate the clinical diagnosis and treatment of this condition. However, there are still several issues that remain controversial. Intravenous immunoglobulin remains the cornerstone of management but several other treatment modalities, especially glucocorticoids, are increasingly finding favour. We review here some of the contemporary issues, and the controversies thereon, pertaining to management of KD.

Pulmonary presentation of Kawasaki disease-A diagnostic challenge

OBJECTIVES

Kawasaki disease (KD) is a multisystemic vasculitis with predominant mucocutaneous manifestations. Pulmonary involvement in KD is distinctly uncommon and is not commonly recognized. We describe our experience of managing children with KD wherein the initial presentation was predominantly pulmonary.

METHODS

Six hundred and two children have been diagnosed with KD during the period January 1993 to May 2017 in the Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh. Data were collected from inpatient records in Allergy Immunology Unit and follow-up files in the Pediatric Rheumatology Clinic.

RESULTS

Of 602 children, 11 (1.83%) had a predominant pulmonary presentation of KD. Mean age at diagnosis of KD was 2.5 years. Fever, cough and respiratory distress were the presenting complaints in all patients. First sign of KD was noted at a mean duration of 14.5 days from the onset of symptoms. Periungual desquamation was the most common clinical sign (72.7%). Persistent fever in spite of antimicrobials, thrombocytosis, and elevated erythrocyte sedimentation rate and C-reactive protein levels pointed toward a diagnosis of KD in our patients. Parenchymal consolidation was evident on chest X-ray in all patients, pleural effusion in six, empyema in three, and pneumothorax in two patients. Coronary artery abnormalities were evident in three patients. Intravenous immunoglobulin was given after a mean period of 22.4 days of onset of fever.

CONCLUSIONS

The diagnosis of KD is often delayed in children who have a predominantly pulmonary presentation. This can have adverse clinical consequences.