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Veres T, Amarilyo G, Abu Ahmad S, Abu Rumi M, Brik R, Hezkelo N, Ohana O, Levinsky Y, Chodick G, Butbul Aviel Y. Familial Periodic Fever, Aphthous Stomatitis, Pharyngitis and Adenitis Syndrome; Is It a Separate Disease? Front Pediatr 2021; 9:800656. [PMID: 35310141 PMCID: PMC8929572 DOI: 10.3389/fped.2021.800656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA) is the most common periodic fever syndrome in the pediatric population, yet its pathogenesis is unknown. PFAPA was believed to be sporadic but family clustering has been widely observed. OBJECTIVE To identify demographic and clinical differences between patients with PFAPA and a positive family history (FH+) as compared to those with no family history (FH-). METHODS In a database comprising demographic and clinical data of 273 pediatric PFAPA patients treated at two tertiary centers in Israel, 31 (14.3%) had FH+. Data from patients with FH+ were compared to data from those with FH-. Furthermore, family members (FMs) of those with FH+ were contacted via telephone for more demographic and clinical details. RESULTS The FH+ group as compared to the FH- group had more myalgia (56 vs. 19%, respectively, p = 0.001), headaches (32 vs. 2%, respectively, p = 0.016), and a higher carrier frequency of M694V mutation (54% vs. 25%, respectively, p = 0.05). Colchicine was seen to be a more beneficial treatment for the FH+ group as compared to the FH- group; however, with no statistical significance (p = 0.096). FMs displayed almost identical characteristics to patients in the FH+ group except for greater arthralgia during flares (64 vs. 23%, respectively, p = 0.008), and compared to the FH- group they had more oral aphthae (68 vs. 43%, respectively, p = 0.002), myalgia/arthralgia (64 vs. 19%/16%, respectively, p < 0.0001), and higher rates of FH of Familial Mediterranean fever (FMF) (45 vs.15%, respectively, p = 0.003). CONCLUSIONS Our findings suggest that patients with a FH+ likely experience a different subset of disease with higher frequency of family history of FMF, arthralgia, myalgia, and might have a better response to colchicine compared to FH-. Colchicine prophylaxis for PFAPA should be considered in FH+.
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Affiliation(s)
- Tamar Veres
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Amarilyo
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Sabreen Abu Ahmad
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Pediatrics B, Rambam Medical Center, Ruth Rappaport Children's Hospital, Haifa, Israel
| | - Maryam Abu Rumi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Riva Brik
- Department of Pediatrics B, Rambam Medical Center, Ruth Rappaport Children's Hospital, Haifa, Israel.,Pediatric Rheumatology Service, Rambam Medical Center, Ruth Rappaport Children's Hospital, Haifa, Israel
| | - Nofar Hezkelo
- Department of Medicine F-Recanati, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Orly Ohana
- Department of Pediatrics C, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Yoel Levinsky
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Gabriel Chodick
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Yonatan Butbul Aviel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Pediatrics B, Rambam Medical Center, Ruth Rappaport Children's Hospital, Haifa, Israel.,Pediatric Rheumatology Service, Rambam Medical Center, Ruth Rappaport Children's Hospital, Haifa, Israel
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Amarilyo G, Harel L, Abu Ahmad S, Abu Rumi M, Brik R, Hezkelo N, Bar-Yoseph R, Mei-Zahav M, Ohana O, Levinsky Y, Chodick G, Butbul-Aviel Y. Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis Syndrome - Is It Related to Ethnicity? An Israeli Multicenter Cohort Study. J Pediatr 2020; 227:268-273. [PMID: 32805260 DOI: 10.1016/j.jpeds.2020.08.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/22/2020] [Accepted: 08/12/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To evaluate the ethnic distribution of Israeli patients with the syndrome of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA). STUDY DESIGN The medical records of patients with PFAPA attending 2 pediatric tertiary medical centers in Israel from March 2014 to March 2019 were retrospectively reviewed. Patients with concomitant familial Mediterranean fever were excluded. Ethnicity was categorized as Mediterranean, non-Mediterranean, and multiethnic. Findings were compared with patients with asthma under treatment at the same medical centers during the same period. RESULTS The cohort included 303 patients with PFAPA and 475 with asthma. Among the patients with PFAPA, 178 (58.7%) were of Mediterranean descent (Sephardic Jews or Israeli Arabs), 96 (33.0%) were multiethnic, and 17 (5.8%) were of non-Mediterranean descent (all Ashkenazi Jews). Patients with PFAPA had a significantly higher likelihood of being of Mediterranean descent than the patients with asthma (58.7% vs 35.8%; P < .0001). The Mediterranean PFAPA subgroup had a significantly earlier disease onset than the non-Mediterranean subgroup (2.75 ± 1.7 vs 3.78 ± 1.9 years, P < .04) and were younger at disease diagnosis (4.77 ± 2.3 vs 6.27 ± 2.9 years, P < .04). CONCLUSIONS PFAPA was significantly more common in patients of Mediterranean than non-Mediterranean descent. Further studies are needed to determine the genetic background of these findings.
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Affiliation(s)
- Gil Amarilyo
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
| | - Liora Harel
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Sabreen Abu Ahmad
- Department of Pediatrics B, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Maryam Abu Rumi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Riva Brik
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Nofar Hezkelo
- Department of Medicine F-Recanati, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Ronen Bar-Yoseph
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Pediatric Pulmonary Institute, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Meir Mei-Zahav
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel; Pediatric Pulmonary Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orly Ohana
- Department of Pediatrics C, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Yoel Levinsky
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Gabriel Chodick
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel; Maccabi Institute for Research & Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Yonatan Butbul-Aviel
- Department of Pediatrics B, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
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Butbul Aviel Y, Harel L, Abu Rumi M, Brik R, Hezkelo N, Ohana O, Amarilyo G. Familial Mediterranean Fever Is Commonly Diagnosed in Children in Israel with Periodic Fever Aphthous Stomatitis, Pharyngitis, and Adenitis Syndrome. J Pediatr 2019; 204:270-274. [PMID: 30361059 DOI: 10.1016/j.jpeds.2018.08.080] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 08/06/2018] [Accepted: 08/30/2018] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To describe a cohort of pediatric patients diagnosed with periodic fever aphthous stomatitis, pharyngitis and adenitis (PFAPA) and familial Mediterranean fever (FMF) and compare them with children diagnosed solely with PFAPA (sPFAPA). STUDY DESIGN Clinical, laboratory, and genetic data of all pediatric patients diagnosed with sPFAPA or PFAPA/FMF were retrospectively collected from 2 primary Israeli medical referral centers and compared. RESULTS Of 270 patients with PFAPA, more than one-half were of Mediterranean ancestry. Among patients with PFAPA, 51 (18.9%) also were diagnosed with FMF (PFAPA/FMF). Genetic data on the 9 most common MEFV variants were available for 45 children (88%) in the PFAPA/FMF group. Two variants were found in 15 children (33.3 %), 1 variant was found 27 patients (60%), and 3 patients (6.6%) had no variants. Abdominal pain, myalgia, and arthralgia each were more commonly reported in the PFAPA/FMF group compared with the sPFAPA group (90% vs 49% [P < .0001]; 46% vs 23% [P = .02]; and 30% vs 17% [P = .049], respectively). Colchicine was more commonly prescribed for the PFAPA/FMF group compared with the sPFAPA group (82% vs 29%; P < .0001), but alleviation of PFAPA symptoms with colchicine was similar between groups (75% vs 63%; P = .23). CONCLUSION We show a strong association between 2 common autoinflammatory syndromes, PFAPA and FMF, in patients from Mediterranean ancestry. Clinicians should be aware that presentation of 1 disease may clinically evolve into another. The association between PFAPA and FMF poses the question similar pathogenesis and genetic influence of the MEFV gene on PFAPA.
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Affiliation(s)
- Yonatan Butbul Aviel
- Department of Pediatrics B, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel; Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Liora Harel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel; Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Maryam Abu Rumi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Riva Brik
- Department of Pediatrics B, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel; Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nofar Hezkelo
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Orli Ohana
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Gil Amarilyo
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel; Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
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Arane K, Mendelsohn K, Mimouni M, Mimouni F, Koren Y, Brik Simon D, Bahat H, Hanna Helou M, Mendelson A, Hezkelo N, Glatstein M, Berkun Y, Eisenstein E, Butbul YA, Brik R, Hashkes PJ, Uziel Y, Harel L, Amarilyo G. Japanese scoring systems to predict resistance to intravenous immunoglobulin in Kawasaki disease were unreliable for Caucasian Israeli children. Acta Paediatr 2018; 107:2179-2184. [PMID: 29797463 DOI: 10.1111/apa.14418] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/13/2018] [Accepted: 05/21/2018] [Indexed: 11/29/2022]
Abstract
AIM This study assessed the validity of using established Japanese risk scoring methods to predict intravenous immunoglobulin (IVIG) resistance to Kawasaki disease in Israeli children. METHODS We reviewed the medical records of 282 patients (70% male) with Kawasaki disease from six Israeli medical centres between 2004 and 2013. Their mean age was 2.5 years. The risk scores were calculated using the Kobayashi, Sano and Egami scoring methods and analysed to determine whether a higher risk score predicted IVIG resistance in this population. Factors that predicted a lack of response to the initial IVIG dose were identified. RESULTS We found that 18% did not respond to the first IVIG dose. The three scoring methods were unable to reliably predict IVIG resistance, with sensitivities of 23%-32% and specificities of 67%-87%. Calculating a predictive score that was specific for this population was also unsuccessful. The factors that predicted a lacked of response to the first IVIG dose included low albumin, elevated total bilirubin and ethnicity. CONCLUSION The established risk scoring methods created for Japanese populations with Kawasaki disease were not suitable for predicting IVIG resistance in Caucasian Israeli children, and we were unable to create a specific scoring method that was able to do this.
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Affiliation(s)
- Karen Arane
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Kerry Mendelsohn
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | | | | | - Yael Koren
- Tel Aviv Sourasky Medical Center; Tel Aviv Israel
| | - Dafna Brik Simon
- Schneider Children's Medical Center of Israel; Petach Tikva Israel
| | - Hilla Bahat
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Assaf Harofeh Medical Center; Zerifin Israel
| | | | | | - Nofar Hezkelo
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Miguel Glatstein
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Tel Aviv Sourasky Medical Center; Tel Aviv Israel
| | - Yackov Berkun
- Hadassah Hebrew University Medical Center; Jerusalem Israel
| | - Eli Eisenstein
- Hadassah Hebrew University Medical Center; Jerusalem Israel
| | | | - Riva Brik
- Rambam Health Care Campus; Haifa Israel
| | | | - Yosef Uziel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Meir Medical Center; Kfar Saba Israel
| | - Liora Harel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Schneider Children's Medical Center of Israel; Petach Tikva Israel
| | - Gil Amarilyo
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Schneider Children's Medical Center of Israel; Petach Tikva Israel
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Butbul-Aviel Y, Uziel Y, Hezkelo N, Brik R, Amarilyo G. Is palindromic rheumatism amongst children a benign disease? Pediatr Rheumatol Online J 2018; 16:12. [PMID: 29439723 PMCID: PMC5812218 DOI: 10.1186/s12969-018-0227-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/05/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Palindromic rheumatism is an idiopathic, periodic arthritis characterized by multiple, transient, recurring episodes. Palindromic rheumatism is well-characterized in adults, but has never been reported in pediatric populations. The aim of this study was to characterize the clinical features and outcomes of a series of pediatric patients with palindromic rheumatism. METHODS We defined clinical criteria for palindromic rheumatism and reviewed all clinical visits in three Pediatric Rheumatology centers in Israel from 2006through 2015, to identify patients with the disease. We collected retrospective clinical and laboratory data on patients who fulfilled the criteria, and reviewed their medical records in order to determine the proportion of patients who had developed juvenile idiopathic arthritis. RESULTS Overall, 10 patients were identified. Their mean age at diagnosis was 8.3 ± 4.5 years and the average follow-up was 3.8 ± 2.7 years. The mean duration of attacks was 12.2 ± 8.4 days. The most frequently involved joints were knees. Patients tested positive for rheumatoid factor in 20% of cases. One patient developed polyarticular juvenile idiopathic arthritis after three years of follow-up, six patients (60%) continued to have attacks at their last follow-up and only three children (30%) achieved long-term remission. CONCLUSIONS Progression to juvenile idiopathic arthritis is rare amongst children with palindromic rheumatism and most patients continued to have attacks at their last follow-up. Longer follow-up periods are required to predict the long-term outcomes of pediatric patients with palindromic rheumatism.
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Affiliation(s)
- Yonatan Butbul-Aviel
- 0000 0000 9950 8111grid.413731.3Department of Pediatrics B, Ruth Rappaport Children’s Hospital, Rambam Medical Center, Haifa, Israel ,0000 0000 9950 8111grid.413731.3Pediatric Rheumatology Service, Ruth Rappaport Children’s Hospital, Rambam Medical Center, Haifa, Israel ,0000000121102151grid.6451.6The Ruth and Bruce Rappaport Faculty of Medicine, The Technion - Israel Institute of Technology, Haifa, Israel
| | - Yosef Uziel
- 0000 0004 1937 0546grid.12136.37Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel ,0000 0001 0325 0791grid.415250.7Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar Saba, Israel
| | - Nofar Hezkelo
- 0000 0004 1937 0546grid.12136.37Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Riva Brik
- 0000 0000 9950 8111grid.413731.3Department of Pediatrics B, Ruth Rappaport Children’s Hospital, Rambam Medical Center, Haifa, Israel ,0000 0000 9950 8111grid.413731.3Pediatric Rheumatology Service, Ruth Rappaport Children’s Hospital, Rambam Medical Center, Haifa, Israel ,0000000121102151grid.6451.6The Ruth and Bruce Rappaport Faculty of Medicine, The Technion - Israel Institute of Technology, Haifa, Israel ,0000 0004 1937 0546grid.12136.37Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Gil Amarilyo
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel. .,Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, 14 Kaplan St., 4920235, Petach Tikva, Israel.
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Amarilyo G, Koren Y, Brik Simon D, Bar-Meir M, Bahat H, Helou MH, Mendelson A, Hezkelo N, Chodick G, Berkun Y, Eisenstein E, Butbul Aviel Y, Barkai G, Bolkier Y, Padeh S, Brik R, Hashkes PJ, Harel L, Uziel Y. High-dose aspirin for Kawasaki disease: outdated myth or effective aid? Clin Exp Rheumatol 2017; 35 Suppl 103:209-212. [PMID: 28079513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 10/10/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To compare the efficacy and safety of intravenous immunoglobulin (IVIG) plus high-dose aspirin (HDA) vs. IVIG plus low-dose aspirin (LDA) for the treatment of Kawasaki disease, with an emphasis on coronary artery outcomes. METHODS This study was a retrospective, medical record review of paediatric patients with Kawasaki disease comparing 6 centres that routinely used HAD for initial treatment and 2 that used LDA in 2004-2013. Treatment response and adverse events were compared. The primary outcome measure was the occurrence of coronary aneurysm at the subacute or convalescent stage. RESULTS The cohort included 358 patients, of whom 315 were initially treated with adjunctive HDA and 43 with LDA. There were no demographic differences between the groups. Coronary aneurysms occurred in 10% (20/196) of the HDA group and 4% (1/24) of the LDA group (p=0.34). Equivalence tests indicate it is unlikely that the risk of coronary aneurysm in LDA exceeds HDA by more than 3.5%. There were no significant between-group differences in the need for glucocorticoid pulse therapy or disease recurrence. Coronary ectasia rate and hospitalisation time were significantly greater in the HDA group. Adverse events were similar in the two groups. CONCLUSIONS We found no significant clinical benefit in using IVIG+HDA in Kawasaki disease compared to IVIG+LDA. The use of adjunctive HDA in this setting should be reconsidered.
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Affiliation(s)
- Gil Amarilyo
- Department of Paediatrics, Schneider Children's Medical Center of Israel, Petach Tikva; and Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Yael Koren
- Department of Paediatrics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dafna Brik Simon
- Department of Paediatrics, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Maskit Bar-Meir
- Department of Paediatrics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Hilla Bahat
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv; and Department of Paediatrics, Assaf Harofeh Medical Center, Zerifin, Israel
| | | | - Amir Mendelson
- Department of Paediatrics, Meir Medical Center, Kfar Saba, Israel
| | - Nofar Hezkelo
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Gabriel Chodick
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Yackov Berkun
- Department of Paediatrics, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Eli Eisenstein
- Department of Paediatrics, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Galia Barkai
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv; and Department of Paediatrics, Sheba Medical Center, Tel Hashomer, Israel
| | - Yoav Bolkier
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv; and Department of Paediatrics, Sheba Medical Center, Tel Hashomer, Israel
| | - Shai Padeh
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv; and Department of Paediatrics, Sheba Medical Center, Tel Hashomer, Israel
| | - Riva Brik
- Department of Paediatrics, Rambam Medical Center, Haifa, Israel
| | - Phillip J Hashkes
- Department of Paediatrics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Liora Harel
- Department of Paediatrics, Schneider Children's Medical Center of Israel, Petach Tikva; and Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Yosef Uziel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv; and Department of Paediatrics, Meir Medical Center, Kfar Saba, Israel.
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