morning report 7/13/09. acute febrile vasculitic syndrome of early childhood affecting all blood...
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KAWASAKI DISEASEMorning Report 7/13/09
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Kawasaki Disease
Acute febrile vasculitic syndrome of early childhood
Affecting all blood vessels in the body but mostly medium and small vessels with a preferential involvement of the coronary arteries.
Exact etiology unknown but thought to be infectious in nature
Immune response thought to be oligoclonal or antigen driven
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Epidemiology
Race: Japanese > Blacks, Polynesians, Filipinos > Whites
Gender: Male:Female~ 3:2 Age:
90-95% <10years old Peak incident 18-24months
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Diagnosis
Presence of 5 or more days of fever + 4 or more of the 5 principle clinical features
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Peeling, Erythema, Edema of Hands and Feet
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Changes in Lips and Oral Cavity (Erythema, Stawberry Tongue)
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Polymorphous Exanthema
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Bilateral Bulbar Conjunctival Injection without Exudate
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Cervical Lymphadenopathy
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Other Clinical Findings
Arthritis/arthralgia Irritability Diarrhea, Vomiting, Abdominal Pain Hepatomegally, Jaundice Pleural Effusions, infiltrates Stiff Neck secondary to aseptic meningitis
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Incomplete or Atypical Kawasaki Disease
Children with unexplained fever for more than 5 days associated with 2-3 of the principle clinical features
More common in young infants May be supported by laboratory evidence
of systemic inflammation
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Differential Diagnosis
Viral Infections (Measles, adenovirus, enterovirus, EBV)
Scarlet Fever Staphylococcal scalded skin syndrome Bacterial cervical lymphadenitis Rocky Mountain Spotted Fever Leptospirosis
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Lab Studies
Moderate to high WBC count with left shift
Anemia Elevated ESR, CRP Thrombocytosis Mild-Moderate elevation in transaminases Sterile Pyuria
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Differential Diagnosis cont…
Toxic Shock Syndrome Drug Hypersensitivity Steven-Johnson syndrome Juvenile idiopathic arthritis Juvenile Polyarteritis Nodosa Mercury hypersensitivity reaction
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Cardiac Imaging
Echocardiogram is critical for the evaluation of all patients suspected of having KD. Baseline echo during acute stage to r/o coronary
artery aneurysms and evidence of myocarditis, valvulitis, or pericardial effusion
Echo should be repeated in 2nd-3rd week of illness and again 1 month after (or once all lab values normalize)
Prior to treatment 20-25% of patients had Cardiac involvement with mortality rate 0.1-2%
With IVIG risk reduced to 5%
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Treatment
Standard therapy is IVIG with Asprin During the acute phase of illness
IVIG (2gm/kg) and Asprin 80-100mg/kg /day
Continue high dose asprin until day 14 of illness if still afebrile Continue asprin 3-5mg/kg/day until no
evidence of coronary changes by 6-8 weeks
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~10% fail to respond to initial IVIG therapy (persistence of fever after 36hrs)
Retreatment with IVIG at same dose recommended
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Other Options
3rd dose IVIG Pulse Steroids (Methylprednisolone mg/kg
for 2-3 hours qday x3days) Infliximab (monoclonal ab against tumor
necrosis factor) Cyclophosphamide Methotrexate
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Long Term Follow Up
MI caused by thrombotis occlusion of abnormal coronary artery Is principle cause of death
Usually occurs within first year Children at high risk need frequent ECHO
evaluations Small solitary aneurysms-long term asprin
therapy Giant aneurysms or multiple complex
aneurysms-long term antiplatelet therapy and anticoagulation
Primary surgical management is coronary artery bypass graft