Clinical Presentation and Outcomes of Kawasaki Disease in Children from Latin America: A Multicenter Observational Study from the REKAMLATINA Network

OBJECTIVES

To describe the clinical presentation, management, and outcomes of Kawasaki disease (KD) in Latin America and to evaluate early prognostic indicators of coronary artery aneurysm (CAA).

STUDY DESIGN

An observational KD registry-based study was conducted in 64 participating pediatric centers across 19 Latin American countries retrospectively between January 1, 2009, and December 31, 2013, and prospectively from June 1, 2014, to May 31, 2017. Demographic and initial clinical and laboratory data were collected. Logistic regression incorporating clinical factors and maximum coronary artery z-score at initial presentation (between 10 days before and 5 days after intravenous immunoglobulin [IVIG]) was used to develop a prognostic model for CAA during follow-up (>5 days after IVIG).

RESULTS

Of 1853 patients with KD, delayed admission (>10 days after fever onset) occurred in 16%, 25% had incomplete KD, and 11% were resistant to IVIG. Among 671 subjects with reported coronary artery z-score during follow-up (median: 79 days; IQR: 36, 186), 21% had CAA, including 4% with giant aneurysms. A simple prognostic model utilizing only a maximum coronary artery z-score ≥2.5 at initial presentation was optimal to predict CAA during follow-up (area under the curve: 0.84; 95% CI: 0.80, 0.88).

CONCLUSION

From our Latin American population, coronary artery z-score ≥2.5 at initial presentation was the most important prognostic factor preceding CAA during follow-up. These results highlight the importance of early echocardiography during the initial presentation of KD.

Infliximab for intensification of primary therapy for patients with Kawasaki disease and coronary artery aneurysms at diagnosis

OBJECTIVE

Children with Kawasaki disease (KD) and an initial echocardiogram that demonstrates coronary artery aneurysms (CAAs, Z score ≥2.5) are at high risk for severe cardiovascular complications. We sought to determine if primary adjunctive infliximab treatment at a dose of either 5 or 10 mg/kg, compared with intravenous immunoglobulin (IVIG) alone, is associated with a greater likelihood of CAA regression in patients with KD with CAA at the time of diagnosis.

DESIGN AND SETTING

Single-centre observational study.

PATIENTS

Children with acute KD and Z score ≥2.5 at baseline.

INTERVENTIONS

Primary adjunctive infliximab (5 or 10 mg/kg) within 48 hours of initiating IVIG 2 g/kg.

MAIN OUTCOME MEASURES

Incidence of CAA regression to Zmax <2 within 2 months of disease onset.

RESULTS

Of the 168 patients with KD, 111 received IVIG alone and 57 received primary adjunctive infliximab therapy: 39 received 5 mg/kg and 18 received 10 mg/kg. Incidence of CAA regression to Zmax <2 within 2 months was statistically significant at 52%, 62% and 83% in the IVIG alone, IVIG+infliximab 5 mg/kg and IVIG+infliximab 10 mg/kg, respectively. The multivariable logistic regression model adjusting for age, sex, baseline Zmax and bilateral CAA at baseline showed that IVIG plus 10 mg/kg infliximab was significantly associated with a greater likelihood of CAA regression (adjusted OR: 4.45, 95% CI 1.17 to 16.89, p=0.028) compared with IVIG alone. The difference between IVIG+infliximab 5 mg/kg and IVIG alone was not significant.

CONCLUSIONS

Primary adjunctive high-dose 10 mg/kg infliximab treatment was associated with a greater likelihood of CAA regression in patients with CAA at the time of diagnosis.

Pediatric Thromboprophylaxis of Large Coronary Artery Aneurysm Using Rivaroxaban

Giant or large coronary artery aneurysms (CAA) are rare in children, most often secondary to Kawasaki disease, and anticoagulation is recommended to prevent thromboembolism. There are no published pediatric reports on the use of a direct oral anticoagulant for this indication. We describe the anticoagulation management of an 8-year-old boy with a dilated right CAA secondary to Kawasaki disease that has remained stable on rivaroxaban and aspirin, following bleeding complications on enoxaparin and challenges on warfarin. The use of rivaroxaban appears to be safe and effective in the prevention of thrombosis in a pediatric patient with CAA.

Cyclosporine for the treatment of multisystem inflammatory syndrome in children with coronary artery aneurysms

Multisystem inflammatory syndrome in children (MIS-C) is a newly described syndrome related to the COVID-19, resembling other known aetiologies, including Kawasaki disease. Cardiovascular involvement is common; left ventricle dysfunction and coronary artery aneurysm (CAA) are also observed. Many treatment guidelines recommend using intravenous immunoglobulin (IVIG) alone or with glucocorticoids as the first-line therapy. Biological agents, such as anakinra, are recommended for refractory cases, but the evidence is still accumulating. Moreover, the use of other treatment agents can be beneficial, especially when anakinra is unavailable. Here, we report the case of a 9-year-old girl who presented with MIS-C with CAAs. She received cyclosporine because two rounds of IVIG treatment were ineffective and the use of anakinra is not approved in Japan. Her cytokine profile showed that cyclosporine prevented exacerbation. The case highlights that cyclosporine therapy can be an option for the treatment of refractory MIS-C with CAA.

[Retrospective analysis of infliximab in the treatment of Kawasaki disease]

Objective: To investigate the efficacy and safety of infliximab (IFX) therapy for children with Kawasaki disease. Methods: Sixty-eight children with Kawasaki disease who received IFX therapy in Children's Hospital of Fudan University from January 2014 to April 2021 were enrolled. The indications for IFX administration, changes in laboratory parameters before and after IFX administration, response rate, drug adverse events and complications and outcomes of coronary artery aneurysms (CAA) were retrospectively analyzed. Comparisons between groups were performed with unpaired Student t test or Mann-Whitney U test or chi-square test. Results: Among 68 children with Kawasaki disease, 52 (76%) were males and 16 (24%) were females. The age of onset was 2.1 (0.5, 3.8) years. IFX was administered to: (1) 35 children (51%) with persistent fever who did not respond to intravenous immunoglobulin (IVIG) or steroids, 28 of the 35 children (80%) developed CAA before IFX therapy; (2) 32 children (47%) with continuous progression of CAA; (3) 1 child with persistent arthritis. In all cases, IFX was administered as an additional treatment (the time from the onset of illness to IFX therapy was 21 (15, 30) days) which consisted of second line therapy in 20 (29%), third line therapy in 20 (29%), and fourth (or more) line therapy in 28 (41%). C-reactive protein (8 (4, 15) vs. 16 (8, 43) mg/L, Z=-3.38, P=0.001), serum amyloid protein A (17 (10, 42) vs. 88 (11, 327) mg/L, Z=-2.36, P=0.018) and the percentage of neutrophils (0.39±0.20 vs. 0.49±0.21, t=2.63, P=0.010) decreased significantly after IFX administration. Fourteen children (21%) did not respond to IFX and received additional therapies mainly including steroids and cyclophosphamide. There was no significant difference in gender, age at IFX administration, time from the onset of illness to IFX administration, the maximum coronary Z value before IFX administration, and the incidence of systemic aneurysms between IFX-sensitive group and IFX-resistant group (all P>0.05). Infections occurred in 11 cases (16%) after IFX administration, including respiratory tract, digestive tract, urinary tract, skin and oral infections. One case had Calmette-Guérin bacillus-related adverse reactions 2 months after IFX administration. All of these adverse events were cured successfully. One child died of CAA rupture, 6 children were lost to follow up, the remaining 61 children were followed up for 6 (4, 15) months. No CAA occurred in 7 children before and after IFX treatment, while CAA occurred in 54 children before IFX treatment. CAA regressed in 23 (43%) children at the last follow-up, and the diameter of coronary artery recovered to normal in 10 children. Conclusion: IFX is an effective and safe therapeutic choice for children with Kawasaki disease who are refractory to IVIG or steroids therapy or with continuous progression of CAA.

Peripheral follicular cytotoxic T -like cells in Kawasaki disease with coronary artery aneurysms: A case report

INTRODUCTION

Kawasaki disease (KD) is the leading cause of acquired heart abnormalities during childhood. The infiltration of CD8+ T cells plays an essential role in the formation of coronary aneurysms. Follicular cytotoxic T (Tfc) cells are a newly defined subset of CD8+ T cells that express CXC-chemokine receptor 5. The role of Tfc cells in KD is unclear. However, in this report, we present 2 KD children with sustained coronary artery aneurysms (CAA), and we found that their peripheral C-X-C Chemokine Receptor 5+ T cells contained quite amounts of CD4 negative cells. Importantly, these cells have never been reported in KD.

PATIENTS CONCERNS

Case 1 was a 3-year-old boy with a complaint of continuous fever for 6 days and conjunctival injection for 3 days. Case 2 was a 6-month-old boy who was hospitalized because of persistent fever for 5 days, rashes and conjunctival injection for 1 day.

DIAGNOSIS

Case 1 was diagnosed with KD according to typical symptoms and signs including fever over 5 days, conjunctival injection, rashes, swelling cervical lymph nodes and a strawberry tongue. Case 2 had atypical symptoms including persistent fever for 5 days, rashes and conjunctival injection, and he was diagnosed with KD based on the echocardiographic findings.

INTERVENTION

Both the 2 patients received intravenous immunoglobulin and oral aspirin. Besides, case 1 was given the second infusion of intravenous immunoglobulin, intravenous prednisolone and low-molecular-weight heparin.

OUTCOMES

The CAA of case 1 did not regress until the 12th month after disease onset. The CAA of patient 2 began to regress at the third month after disease onset. During the months from disease onset to the recent follow-up, no cardiovascular events had occurred.

CONCLUSIONS

We speculate that Tfc cells may be associated with the formation of CAA. Further studies with larger sample size and functional analysis of these cells are needed.

Coronary Drug-Eluting Stent Infection Complicated by Coronary Artery Aneurysm and Purulent Pericarditis: Complete Resolution Without Surgery

Coronary stent infection is considered to be a rare but catastrophic complication of percutaneous coronary intervention. In this report, we present a 72-year-old man who developed a coronary stent infection complicated by coronary aneurysm and purulent pericarditis. Coronary artery aneurysm resolved over a period of 8 months following the successful management of infection with intensive antibiotic therapy alone. This case suggests that conservative therapy can be a therapeutic option in patients with high operative risks.

The peculiarities of Kawasaki disease at the extremes of age: Two case reports

RATIONALE

Extremes of age is an important risk factor for the development of coronary arteries aneurysms (CAAs) associated to Kawasaki disease (KD) along with male gender, prolonged fever and a delay in diagnosis or treatment.

PATIENT CONCERNS

We report two cases of KD in the extremes of age, a 5-month-old male infant and a 9-year-old child in order to underline the features of this disorder outside the typical age range of 1 to 4 years. The 5-month-old male was admitted in our clinic for generalized polymorphous exanthema and fever for approximately 7 days. The laboratory test pointed out leukocytosis and increased inflammatory biomarkers. The 9-year-old male child was admitted in our clinic for fever and submandibular adenopathy. The onset was approximately 5 days before the admission with a sudden development of unilateral, painless, submandibular lymphadenopathy for which the ENT specialist recommended antibiotics and nonsteroid anti-inflammatory drugs. In the 2nd day of admission, he presented severe desquamation of hands and soles.

DIAGNOSIS

Both cases were diagnosed with KD. The echocardiography showed no cardiac impairment in the infant, while in the older patient it revealed mild dilation of the left coronary artery.

INTERVENTIONS

Both patients received intravenously immunoglobulin and pulsed methylprednisolone.

OUTCOMES

The evolution was favorable in both cases, but in the infant, the C-reactive protein levels persisted mildly elevated for approximately 2 months after the diagnosis.

LESSONS

The peculiarities of KD in the extremes of age are related to a higher frequency of incomplete features and an increased incidence of coronary artery lesions resulting in a delay of the diagnosis, and subsequent poorer outcomes.

[Clinical effect and safety of clopidogrel combined with aspirin in antithrombotic therapy for children with Kawasaki disease complicated by small/medium-sized coronary artery aneurysms]

OBJECTIVE

To study the clinical effect and safety of clopidogrel combined with aspirin in antithrombotic therapy for children with Kawasaki disease (KD) complicated by coronary artery aneurysm (CAA).

METHODS

A total of 77 KD children who were diagnosed with multiple small/medium-sized CAAs by echocardiography between January 2013 and June 2018 were enrolled. They were randomly divided into observation group with 38 children (treated with clopidogrel and aspirin) and control group with 39 children (treated with low-molecular-weight heparin and aspirin). All children were followed up regularly, and the first 3 months of the course of the disease was the observation period. The children were observed in terms of the change of the coronary artery and the incidence of complications.

RESULTS

At month 3 of follow-up, among the children in the observation group, 6 had normal coronary artery, 11 had coronary artery retraction, 19 had stable coronary artery, and 2 progressed to giant coronary aneurysm; among the children in the control group, 7 had normal coronary artery, 12 had coronary artery retraction, 19 had stable coronary artery, and 1 progressed to giant coronary aneurysm; there was no significant difference in the change of the coronary artery between the two groups (P>0.05). There were 2 cases of epistaxis and 6 cases of skin ecchymosis in the observation group, and 1 case of epistaxis and 7 cases of petechiae and ecchymosis at the injection site in the control group, and no other serious bleeding events were observed in either group.

CONCLUSIONS

Clopidogrel combined with low-dose aspirin is safe and effective in antithrombotic therapy for children with KD complicated by CAA.

Kawasaki disease complicating bilateral facial nerve palsy and giant coronary artery aneurysms: A case report

RATIONALE

Kawasaki disease (KD), which is also known as mucocutaneous lymphnode syndrome, is a vasculitic disease and involves multi-system disorder with various clinical manifestations. KD is specific predilection for the coronary arteries and is the most common cause of childhood-acquired heart disease in developed countries. KD is rarely complicated by cranial nerve VII palsy.

PATIENT CONCERNS

This report described a 7-month-old infant who suffered from bilateral infranuclear facial nerve palsy (FNP) and multiple coronary artery aneurysms (CAAs) in parallel with KD. The patient had an intermittent fever for 18 days and had a medical history of bilateral conjunctival injection, strawberry tongue, reddened lips, and perianal excoriation. Physical examinations revealed fever (38.5°C), fingertips desquamation of the skin, and left cervical lymphadenopathies.

DIAGNOSIS

The diagnosis of KD is based on the presence of clinical features of persistent fever (≥5 days) together with polymorphous exanthema, cervical lymphadenopathy, non-purulent conjunctival injection, changes of the lips, oral cavity, and extremities. An echocardiogram has showed a beaded sample dilatation of all coronary arteries, in addition to aneurysms of the middle of the right coronary artery (6.2 mm in diameter; 14.5 Z score), and the left coronary artery (5.4 mm in diameter; 9.4 Z score). The physical examinations revealed incomplete closure of both eyes and bilateral drooping of the mouth, suggesting a bilateral infranuclear FNP.

INTERVENTIONS

The patient received intravenous immunoglobulin (IVIG) (2 g/kg) with high-dose aspirin according to the clinical guidelines.

OUTCOMES

Her fever finally resolved after 2 days' IVIG. All inflammatory indexes returned to normal or near-normal levels prior to discharge. However, the echocardiogram remained unchanged and the patient's facial nerve palsies had not recovered.

LESSONS

FNP in KD is uncommon. Yet, it may be a marker of disease progression. One should be aware of the diagnosis of KD when children suffer from high fever, FNP, and even with incomplete clinical features.

Management of coronary artery aneurysms using abciximab in children with Kawasaki disease

INTRODUCTION

There are limited data regarding the possible benefits of abciximab in children with Kawasaki disease (KD), who developed serious cardiac abnormalities non-responsive to standard treatment.

MATERIALS AND METHODS

We retrospectively identified children with KD who were treated with abciximab from 2007 to 2015. Data regarding clinical course, treatment, echocardiographic data and follow-up at 1 and 6months were retrieved.

RESULTS

During the study period, fifteen children were identified who were diagnosed with KD and were given abciximab. The median age at onset of symptoms was 11months (range: 2months-6years). The median day of disease at admission was 10days (range: 4-26days) and the median day of administration of abciximab was 17days (range: 9-40). Twelve children were diagnosed with complete and three with incomplete KD. Aneurysms were found in 8 children: 2 had ectatic coronary arteries and 5 presented with both ectasia and aneurysms. At 1month follow-up, echocardiographic findings showed regression in the size of aneurysms in 11 children, resolution of the aneurysms or ectasia of coronary arteries in 3 children, while one child who could not take aspirin because of G6PD deficiency died. After 6months of follow-up, echocardiographic findings showed resolution of coronary abnormalities in 12 (80%) children, whereas 2 children (13.3%) presented with significant regression of aneurysms.

CONCLUSIONS

Abciximab may have an important role in the management of severe cardiac complications of KD, although prospective randomized controlled studies are needed to fully evaluate its role.

ATYPICAL KAWASAKI DISEASE

INTRODUCTION

Kawasaki disease is an acute vasculitis which occurs primarily in children under the age of 5. The etiology of the disease is still unknown. Diagnostic criteria for Kawasaki disease are fever and at least four of the five additional clinical signs. Incomplete Kawasaki disease should be taken into consideration in case of all children with unexplained fever for more than 5 days, associated with 2 or 3 of the main clinical findings of Kawasaki disease. The diagnosis of incomplete Kawasaki disease is based on echocardiographic findings indicating the involvement of the coronary arteries. Cardiac complications, mostly coronary artery aneurysm, can occur in 20% to 25% of untreated patients and in 4% of treated patients. CASE REPORT. In this report we present a case of atypical Kawasaki disease in a 3.5-month-old infant. As soon as the diagnosis was made, the patient received high doses of intravenous immunoglobulin, with the initial introduction of ibuprofen, then aspirin with a good clinical response. Due to the presence of aneurysm of coronary arteries, further therapy involved aspirin and clopidogrel over the following 3 months, and then only aspirin for 2 years. There was a gradual regression of the changes in the coronary blood vessels to the normalization of the echocardiographic findings after 2 years.

CONCLUSION

Kawasaki disease is the second most common vasculitis of childhood, so it should be included in the differential diagnosis for any child with a prolonged unexplained fever. Atypical Kawasaki disease should be taken into consideration in cases when not all clinical criteria are present but coronary abnormalities are documented.

Giant right coronary artery aneurysm secondary to Kawasaki disease in child: a case report

Coronary artery aneurysm or ectasia was reported in approximately 15% to 25% of the affected children, particularly in the proximal end of the main blood vessel and the left anterior descending part. Rare patients have been reported with aneurysm in the distal end of the right coronary artery. In this case report, we present a rare case with aneurysm in the distal end of the right coronary artery. Multi-slice computed tomography was performed for the coronary angiography. Aspirin (10 mg/kg body weight per day) and gamma globulin (2 kg/kg body weight) was administrated via intravenous injection. The patient is currently in a healthy status with a 12-month follow up.

Anticoagulation in ischemic left ventricular aneurysm

OBJECTIVE

To evaluate the role of systemic anticoagulation using warfarin in patients with post-myocardial infarction left ventricular (LV) aneurysm formation with or without definite LV thrombus formation.

PATIENTS AND METHODS

This study included 648 patients with post-myocardial infarction LV aneurysm formation diagnosed retrospectively by 2-dimensional echocardiography from December 1, 1994, to February 29, 2012. Of these 648 patients, 106 patients received warfarin and 542 patients did not. We studied a composite of death, nonfatal myocardial infarction, cerebrovascular accident, and systemic embolization as the primary outcome and a composite of cerebrovascular accident and systemic embolization as the secondary outcome by using propensity score-adjusted multiple Cox proportional hazards regression analysis.

RESULTS

In patients with LV aneurysm, LV thrombus was observed in 89 patients (13.7%) and it was associated with a higher incidence of adverse secondary events (hazard ratio [HR], 3.63; 95% CI, 1.12-11.8; P=.03) in unadjusted analysis. However, in adjusted analysis, anticoagulation did not predict either a better or a worse outcome for primary outcomes (HR, 1.05; 95% CI, 0.67-1.64; P=.84) or for secondary outcomes (HR, 1.52; 95% CI, 0.670-3.46; P=.31). The benefit of anticoagulation was also not established in patients with LV thrombus (HR, 1.38; 95% CI, 0.32-5.97; P=.66).

CONCLUSION

In patients with ischemic LV aneurysms, oral anticoagulation therapy with warfarin may not be effective enough to reduce cardiac and cerebrovascular events including systemic embolism. Further studies are needed to confirm this finding.

[Fistula-producing giant coronary aneurysm in a 62-year-old woman]

Giant coronary aneurysms (GCA with a diameter > 20 mm) are rare with a prevalence < 0.02%. A 62-year-old woman with no history of ischaemic heart disease was admitted to hospital with acute chest pain. A coronary angiography revealed a left an-terior descendent-associated GCA. A cardiac computed tomo-g-raphy demonstrated a "snake-pit"-like fistula connecting the GCA and the pulmonary artery. Atherosclerosis, connective tissue dis-orders, and previous coronary intervention will predispose to GCA. No evidence-based treatment regimen exists, but coiling, excision or a conservative approach, as in this case, is possible strategies.

[Incomplete Kawasaki syndrome with a coronary artery aneurysm in an infant]

We report a four-month-old boy with incomplete Kawasaki syndrome. He developed a coronary artery aneurysm. Incomplete Kawasaki syndrome is rare in Denmark, and only reported in five patient cases in the past 25 years. It is difficult to diagnose Kawasaki disease; early diagnosis and treatment reduces the risk for cardiac sequel. In lack of diagnostic test, we recommend that the algorithm from the American Heart Association to diagnose incomplete Kawasaki is implemented in Denmark. The algorithm is based on classic clinical features, echocardiography and laboratory findings.

[Six Kawasaki disease patients with acute coronary artery thrombosis]

OBJECTIVE

To improve the awareness of acute coronary artery thrombosis in Kawasaki disease (KD).

METHOD

Six KD patients with acute coronary artery thrombosis (Jan. 2004 to Jan. 2013) were studied retrospectively. The basic information, clinical manifestations, laboratory data, echocardiography and electrocardiography (ECG), method and consequence of thrombolytic therapy were analyzed.

RESULT

The mean age of patients with coronary artery thrombosis (5 males and 1 female) was (17.2 ± 11.3) months.Five cases had thrombosis in left coronary artery (LCA), and four cases had thrombosis in aneurysm of left anterior descending artery (LAD). One case had thrombosis in both left and right coronary artery (RCA).One case died. Maximum thrombus was about 1.60 cm × 0.80 cm, locating in LAD. The diameter of LCA and RCA was (0.44 ± 0.07) cm and (0.45 ± 0.07) cm. Two patients showed abnormal ECG. Case 3 showed ST segment depression in lead V5. Case 6 showed myocardial infarction.In acute phase of KD, three patients received treatment with intravenous immunoglobin (IVIG), five patients were treated with aspirin.In sub-acute and convalescent phase of KD, all patients were treated with low-dose aspirin.Warfarin and dipyridamole were applied in 5 patients. All cases were treated with thrombolytic therapy using urokinase and/or heparin. After thrombolytic therapy, echocardiography showed thrombolysis in four cases and no change in one.One patient died of myocardial infarction.

CONCLUSION

Most of acute coronary thrombosis in KD occurred in LAD. KD patients with coronary artery thrombosis are at risk of sudden death due to myocardial infarction.

Chest pain in patients with undiagnosed Behçet's disease

Behçet's disease (BD) is a systemic inflammatory disease having a chronic and prolonged course with 4 major symptoms: oral and genital ulcerations, eye disease and cutaneous manifestations, as well as other multisystem involvements. Arterial involvement is a comparatively rare complication in BD and coronary lesions are extremely rare. We report here two cases of BD presenting as myocardial infarction (MI) with coronary artery aneurysm (CAA), with good improvement after immunosuppressive therapy.

Rapid progression of coronary aneurysm to stenosis in a patient with Kawasaki disease

In Kawasaki disease, coronary aneurysms typically regress slowly, although some may develop stenosis 1-2 decades after the acute illness. This is the first case report describing rapid progression of coronary aneurysm to stenosis within 14 weeks.

Spontaneous coronary artery dissection during cabergoline therapy

Although spontaneous coronary artery dissection is a rare cause of acute coronary syndrome, it should be considered during the evaluation of patients who have chest pain. Coronary vasospasm can lead to spontaneous dissection. The dopamine agonist cabergoline is known to cause digital vasospasm. Herein, we report a case of spontaneous right coronary artery dissection in a 43-year-old woman who was taking cabergoline as therapy for prolactinoma. To our knowledge, this is the first report of an apparent relationship between cabergoline therapy and spontaneous coronary artery dissection. The possible association of cabergoline with coronary artery spasm and dissection should be considered in patients who present with chest pain while taking this medication.

A huge coronary artery aneurysm in osteogenesis imperfecta: a case report

Osteogenesis imperfecta (OI) as an inherited connective tissue disorder can affect all tissues that contains type I collagen. Well-known cardiac complications of this disease such as aortic root dilatation, aortic regurgitation and mitral valve prolapse have been rarely reported in the literature. Coronary artery aneurysm is a rare cardiac complication in OI, as reported in a 19 year old female presenting with myocardial infarction and hypotension.

Takayasu arteritis with coronary aneurysms causing acute myocardial infarction in a young man

Takayasu arteritis is an inflammatory condition that involves the large cardiac vessels, predominantly the aorta and its main branches. It typically affects young women (age, ≤40 yr), most often Asians and Latin Americans. Herein, we describe a rare manifestation of Takayasu arteritis in a 19-year-old black Tunisian man who presented with acute inferior myocardial infarction and complete atrioventricular block after occlusion from a giant aneurysm in the right coronary artery. The coronary artery disease was associated with aneurysmal dilations in the carotid, vertebral, and right renal arteries. Medical therapy improved Thrombolysis in Myocardial Infarction flow in the area of the giant aneurysm from grade 1 to grade 3. Upon the diagnosis of Takayasu arteritis, intravenous methylprednisolone and oral prednisone therapy was started. After 10 days of hospitalization, the patient was discharged on a medical regimen. Renovascular hypertension due to renal artery stenosis was suspected, so he underwent successful percutaneous transluminal angioplasty of the inferior segmental artery of the right renal artery. During 12 months of close postprocedural monitoring, he experienced lower blood pressure, no chest pain, and no cardiovascular complications.This association of conditions has not been previously reported. Besides presenting this very rare combination of findings, we discuss the differential diagnosis of Takayasu arteritis in our patient.

Left main coronary artery aneurysm

Left main coronary aneurysm is extremely uncommon and its precise pathogenesis remains poorly understood. They are associated with serious complications and treatment is still the subject of disagreement. The authors present the case of a 42-year-old man admitted for a coronary syndrome, whose coronary angiogram revealed a large left main coronary aneurysm. The echocardiogram and multi-row detector CT angiography confirmed the abnormalities observed. No positive findings resulted from etiological evaluation. We decided to maintain the patient under oral anticoagulation and he remains clinically stable after two years of follow-up.

Multiple spontaneous coronary artery dissection associated with Trousseau's syndrome

Spontaneous coronary artery dissection (SCAD) remains a rare cause of acute coronary syndrome. SCAD has been observed in three groups of patients: those with coronary atherosclerosis, women in the peripartum period, and an idiopathic group. SCAD may also be associated with some other conditions. Herein, we present a 57 year-old man who developed SCAD concomitant with Trousseau's syndrome secondary to colon adenocarcinoma.

Spontaneous coronary artery dissection: case series and review

Spontaneous coronary artery dissection (SCAD) is a rare but important cause of acute coronary syndromes. SCAD can cause unstable angina, acute myocardial infarction, and sudden death. Predisposing factors include atherosclerosis, the peripartum period, and structural and inflammatory conditions affecting the arterial wall. The diagnosis of coronary dissection is usually made by coronary angiography. Prompt diagnosis and treatment of patients with dissection improves survival. Therapeutic options include medical therapy, percutaneous coronary intervention, and surgery. We present a series of patients with spontaneous coronary artery dissection at our institution. The etiology, pathogenesis, diagnosis, treatment, and prognosis of patients with coronary dissection are reviewed.

Postpartum spontaneous coronary artery dissection (SCAD) managed conservatively

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and has been described in young women during the peripartum period. Management of these patients has been controversial. A 35 year old Caucasian female, 11 days postcesarean section delivery presented with acute myocardial infarction. She underwent angiography within a few hours of presentation, which showed dissection of LAD. Repeat angiography six days later showed improvement of dissection. Patient showed clinical improvement on conservative treatment and no recurrence of symptoms over the past two years follow-up. There is no consensus on the treatment and our case is one of the cases managed successfully with conservative treatment.

Spontaneous healing of spontaneous coronary artery dissection: a case report

Spontaneous coronary artery dissection (SCAD) is an extremely rare cause of myocardial ischemia. It is more prevalent in young women, particularly in the peripartum period. We report a case of SCAD occurring in a 40-year-old non-pregnant woman who presented with acute coronary syndrome. Coronary angiography revealed dissection in the mid and distal portions of left anterior descending artery. She was treated with medical therapy and repeat coronary angiography at 2 months showed no signs of the previous dissection.

Idiopathic spontaneous coronary artery dissection presenting as acute myocardial infarction in a young boy

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction. It is more commonly seen in the younger age group particularly in women. We report a case of 14-year-old boy that presented with acute myocardial infarction (MI), with left ventricular (LV) dysfunction and was detected to have left main coronary artery dissection on coronary angiography. Myocardial perfusion imaging did not show any evidence of reversible ischemia. Patient was managed conservatively and was marginally improved. This case highlights one of the rare causes of myocardial infarction and the use of myocardial perfusion imaging in selecting treatment options for management of this rare entity.

[Prevention of thrombosis of coronary aneurysms in patients with a history of Kawasaki disease]

Patients with coronary artery aneurysms caused by Kawasaki disease are at increased risk of coronary thrombosis and ischemia. To prevent coronary thrombosis, long-term anti-thrombosis using anti-platelet drugs, such as aspirin, dipyridamole, ticlopidine, clopidogrel, and abciximab, with or without warfarin is recommended by official guidelines. In fact, aspirin or aspirin with warfarin are the most frequently administered regimen in these patients with coronary aneurysms. However, there has been paucity of data and no randomized controlled study to determine the efficacy of these drugs. This short article attempts to summarize the efficacy and safety of these drugs based on currently available literatures and our multi-institutional experience.

Successful management of an unruptured mycotic coronary aneurysm

Systemic complications of native-valve endocarditis include embolism, abscess formation and development of mycotic aneurysms. To date, only two cases of mycotic coronary aneurysm (MCA) detected by transesophageal echocardiography (TEE) have been reported since 1812. We describe the successful management of infectious mitral valve endocarditis complicated by a MCA involving the left circumflex artery initially detected by TEE. This report illustrates the importance of correlating findings between TEE and coronary angiography, as early detection and prompt management of these rare coronary aneurysms are of paramount importance.

Complete angiographic resolution of spontaneous coronary artery dissection associated with sleep deprivation

We describe a case of complete angiographic resolution of spontaneous coronary artery dissection associated sleep deprivation with a successful medical management. A 40-year-old woman presented to our emergency department with squeezing chest pain following 72 h sleep deprivation. Coronary angiography demonstrated longitudinal dissection of the middle part of the diagonal artery with TIMI III flow to the distal part of the vessel. The dissected vessel was small to intervene so we decided to treat it conservatively with antiplatelet agents and heparin. She remained free of chest pain during the hospitalization period and was discharged in good condition. We continued to treat her in the outpatient clinic with antiplatelet agents and the patient no longer complained of chest pain. At six months, coronary angiography demonstrated complete resolution of the previously dissected coronary artery.

Spontaneous coronary artery dissection and pulmonary thromboembolism: a case report

Spontaneous coronary artery dissection (SCAD) still is a rare cause of acute coronary syndrome. SCAD has been observed in three groups of patients: those with coronary atherosclerosis, peripartal women and idiopathic group. SCAD may be associated with some conditions. We report an unusual association: SCAD and pulmonary thromboembolism.

Case report: a very large dissection in the left anterior descending coronary artery of a 56-year-old man

Spontaneous coronary artery dissection (SCAD) is a rare condition that usually occurs in relatively young patients who are predominantly female. Seldom it could be a cause of acute myocardial ischemia leading to a sudden cardiac death. SCAD consists of intramural hematoma formation or, rarely, intimal tears that initiate and propagate the dissection in the vessel wall. In rare cases, the SCAD occurs in male patients. We report the case of a 56-year-old man with acute myocardial infarction who was successfully treated via systemic thrombolysis in a peripheral hospital. Associated conditions were thrombosis of right femoral artery in the past and high platelet count (800,000/mm3). After 1 month, elective coronary angiography revealed a very diffuse spiral dissection of the left anterior descending artery; hence, our choice of medical treatment consisted of double oral antiplatelet therapy (clopidogrel 75 mg plus aspirin 325 mg once daily). After a 2-year follow-up, there was absence of both angina and myocardial ischemia and there was a decrease in platelet count. Many strategies could be considered in patients with SCAD, such as PCI, bypass surgery, or conservative medical management. In general, the long-term prognosis of patients with SCAD is considered favorable if they survive the acute phase.

Successful surgical treatment of an infected right coronary artery aneurysm-to-right ventricle fistula after sirolimus-eluting stent implantation

The development of infected coronary aneurismal fistula following stenting seems exceedingly rare. A sirolimus-eluting stent (SES) was implanted in a 70-year-old male patient for acute coronary syndrome. His fever persisted despite treatment with adapted antibiotics. Coronary angiography and 16-multidetector row computed tomography demonstrated the huge right coronary aneurysm forming a fistula to the right ventricle. The aneurysm was excised by surgical treatment. Histopathological examination of the resected mass revealed leucocyte infiltration at the stent site, which lead to the diagnosis of mycotic aneurysm. SESs may play a potential role in locally blunting the innate response to bacterial agents.

Right coronary artery aneurysm

Coronary artery aneurysms, characterized by abnormal dilatations of a localized portion of the coronary artery, are an uncommon finding during angiography. We present a case where a giant right coronary aneurysm was detected during angiography, in a patient admitted with a inferior wall myocardial infarction.

Recurrent spontaneous coronary artery dissection with transient left ventricular systolic dysfunction

Spontaneous coronary artery dissection (SCAD) is a potentially life-threatening entity with a variety of clinical presentations. We report a patient who presented with chest pain and angiographic evidence of coronary dissection. Due to the rapid resolution of symptoms and benign-appearing nature of the dissection, no intervention was pursued and the patient was maintained on medical therapy. She represented 2 days later with substernal chest pain, dynamic EKG changes, positive cardiac biomarkers and a transient depression of her left ventricular function.

Additional value of computed tomography angiography in multiple coronary artery aneurysms--a case report

Though invasive coronary angiography is the gold standard for the diagnosis of coronary artery aneurysms, computed tomography angiography may be just as useful in providing details of their morphology, size, location and associated stenosis or ectasia. Besides, it has the advantage of being a non-invasive modality.We present a case in which an aneurysm, which was not identified by conventional angiography due to the presence of thrombus, was correctly identified by computed tomography angiography.

[Clinical analysis of 942 cases of Kawasaki disease]

OBJECTIVE

The study was designed to investigate the clinical characteristics and the effects of therapeutic proposal on Kawasaki disease (KD).

METHODS

Clinical features, diagnosis and treatment for totally 942 patients with KD hospitalized during Jan, 2000 to Dec, 2004 were reviewed. Clinical features of typical and incomplete KD were compared. Also, influential factors for KD resistant to intravenous immune globulin (IVIG) therapy were analyzed. Five hundred and ten cases were followed up for analyzing the prognosis of coronary artery lesion (CAL).

RESULTS

(1) 774 cases were diagnosed as typical KD, and 168 cases as incomplete KD. The incidence of infants with incomplete KD was higher than that of infants with typical KD (18.5% vs. 10.1%, P < 0.01). As compared with typical KD, the cases of incomplete KD had a long duration of fever before final diagnosis [(7.7 +/- 2.9) d vs. (7.0 +/- 2.4) d, P < 0.01], high hemoglobin level [Hb, (106.6 +/- 13.4) g/L vs. (103.5 +/- 12.3) g/L, P < 0.01], high hematocrit [Hct, (32.0 +/- 4.3)% vs. (31.0 +/- 4.0)%, P < 0.01], and high prevalence of CAL (23.8% vs. 16.8%, P < 0.05), respectively. The occurrence rate and emerging time of clinical manifestations in incomplete KD and in typical KD were presented, respectively: non-exudative conjunctivitis [occurrence rate, 64.9% vs. 93.5%; emerging time, (4.4 +/- 1.4) d vs. (4.0 +/- 1.6) d, respectively (P < 0.05 or P < 0.01)], erythema and cracking of lips [occurrence rate, 50.6% vs. 94.8%; emerging time, (4.9 +/- 1.4) d vs. (4.5 +/- 1.6) d, respectively (P < 0.05 or P < 0.01)], rash [occurrence rate, 35.1% vs. 87.7%; emerging time, (3.9 +/- 1.9) d vs. (3.4 +/- 1.7) d, respectively (P < 0.05 or P < 0.01)], erythema and edema of extremity [occurrence rate, 26.8% vs. 71.4%; emerging time, (6.7 +/- 1.5) d vs. (5.3 +/- 1.7) d, respectively (P < 0.01)], cervical lymphadenopathy [occurrence rate, 34.5% vs. 68.0%; emerging time, (4.3 +/- 2.5) d vs. (3.6 +/- 2.2) d, respectively (P < 0.05 or P < 0.01)], strawberry tongue [occurrence rate, 31.0% vs. 59.8%; emerging time, (5.6 +/- 2.2) d vs. (4.9 +/- 1.8) d, respectively (P < 0.05 or P < 0.01)], membranous desquamation of fingertips [occurrence rate, 34.5% vs. 56.3%; emerging time, (11.7 +/- 3.3) d vs. (10.3 +/- 2.7) d, respectively (P < 0.01)], and desquamation peri-anus [occurrence rate, 42.9% vs. 50.0%; emerging time, (6.7 +/- 2.7) d vs. (6.9 +/- 2.5) d, respectively (P > 0.05)]. Except for peri-anus desquamation, other clinical manifestations in incomplete KD were sporadical as compared to typical KD. (2) Six per cent (51/857) of cases were resistant to the IVIG therapy. As compared to the group responding to IVIG therapy, high prevalence of CAL (31.4% vs. 17.1%, P < 0.05), long fever duration [(10.6 +/- 3.9) d vs. (7.5 +/- 2.3) d, P < 0.01], low Hb level [(99.9 +/- 14.1) g/L vs. (104.3 +/- 12.4) g/L, P < 0.01], low Hct [(30.1 +/- 4.5)% vs. (31.2 +/- 4.0)%, P < 0.05], low platelet [PLT, (256.9 +/- 142.4) x 10(9)/L vs. (309.7 +/- 131.5) x 10(9)/L, P < 0.05], and low albumin level [ALB, (27.8 +/- 8.4) g/L vs. (33.5 +/- 6.7) g/L, P < 0.01] were found in the group resistant to IVIG therapy, respectively. (3) In patients who received IVIG 1 g/kg and 2 g/kg, the recovery rates from CAL were 83.1% and 89.7% (P > 0.05), respectively. The prevalence of CAL in those without CAL in acute and subacute stages was 0.9% and 3.5% (P > 0.05), respectively, during 2 year-follow-up period.

CONCLUSION

(1) Infants appeared to have more chances to suffer from incomplete KD. Incomplete KD had high prevalence of CAL. The peri-anus desquamation might be an important clue for early diagnosis of incomplete KD. (2) In acute stage, the influential factors for KD resistance to IVIG therapy included prolonged fever, non-elevated PLT, and persistent decrease in Hb, Hct and ALB levels. (3) Children receiving IVIG 1 g/kg and 2 g/kg had the similar effects on recovery and prevention from CAL within the first two years after KD onset.

Coronary Artery Dissection During Pregnancy Treated With Medical Therapy

Spontaneous coronary artery dissection is a rare etiology of myocardial infarction with a higher noted incidence in pregnancy. The recognition and proper treatment of this condition affects patient outcomes. We report the case of a coronary artery dissection during a twin pregnancy involving the left anterior descending artery. Successful treatment with medical management was possible once spontaneous reperfusion had been achieved.