Diagnosis of Kawasaki disease

A computational workflow for the detection of candidate diagnostic biomarkers of Kawasaki disease using time-series gene expression data

Unlike autoimmune diseases, there is no known constitutive and disease-defining biomarker for systemic autoinflammatory diseases (SAIDs). Kawasaki disease (KD) is one of the "undiagnosed" types of SAIDs whose pathogenic mechanism and gene mutation still remain unknown. To address this issue, we have developed a sequential computational workflow which clusters KD patients with similar gene expression profiles across the three different KD phases (Acute, Subacute and Convalescent) and utilizes the resulting clustermap to detect prominent genes that can be used as diagnostic biomarkers for KD. Self-Organizing Maps (SOMs) were employed to cluster patients with similar gene expressions across the three phases through inter-phase and intra-phase clustering. Then, false discovery rate (FDR)-based feature selection was applied to detect genes that significantly deviate across the per-phase clusters. Our results revealed five genes as candidate biomarkers for KD diagnosis, namely, the HLA-DQB1, HLA-DRA, ZBTB48, TNFRSF13C, and CASD1. To our knowledge, these five genes are reported for the first time in the literature. The impact of the discovered genes for KD diagnosis against the known ones was demonstrated by training boosting ensembles (AdaBoost and XGBoost) for KD classification on common platform and cross-platform datasets. The classifiers which were trained on the proposed genes from the common platform data yielded an average increase by 4.40% in accuracy, 5.52% in sensitivity, and 3.57% in specificity than the known genes in the Acute and Subacute phases, followed by a notable increase by 2.30% in accuracy, 2.20% in sensitivity, and 4.70% in specificity in the cross-platform analysis.

Correct identification of incomplete Kawasaki disease

Incomplete Kawasaki disease (IKD) is characterized by a longer fever time, younger age of onset, and higher incidence of coronary artery disease compared with complete Kawasaki disease. Kawasaki disease is often difficult to diagnose early because of its incomplete clinical symptoms. This issue could delay treatment and harm the health of the child. This article reviews the clinical characteristics and pathogenesis of IKD to help clinicians understand the symptoms of IKD, make the correct diagnosis, and provide timely treatment.

Future Challenges of Covid-19 and Oral Manifestations in Daily Dental Practice: A Literature Review

OBJECTIVE

Some patients reportedly present with oral manifestations of coronavirus disease 2019 (Covid-19). It is unknown if this is due to the virus itself or a side effect of treatment; however, severe acute respiratory syndrome coronavirus 2 has been shown to have a predilection for angiotensin-converting enzyme receptors that are present in the respiratory tract, oral mucosa, tongue, and salivary glands, causing alterations in taste and smell. Therefore, the objective of this review was to present the future challenges of Covid-19 and oral manifestations in daily dental practice through a literature review.

MATERIALS AND METHODS

Scientific evidence in the databases Scopus and PubMed was searched using the Boolean operators. Articles published in Spanish and English between January and December 2020 were included.

RESULTS

Of the 89 articles found in Scopus, 69 were of the open access type and 20 were in the "others" category; only 22 scientific articles were found in PubMed.

CONCLUSION

It is important to take into account these clinical manifestations such as loss of taste and smell in order to detect the disease. Good oral hygiene is also recommended as a preventive measure to reduce viral load, which considerably reduces the probability of infecting other people who are in contact with the infected patient.

Observation on the clinical effect of high-dose Intravenous Immunoglobulin combined with low-dose prednisone acetate in the treatment of patients with Kawasaki Disease

Objective:

To evaluate the clinical effect of high-dose intravenous immunoglobulin (HDIVIG) single dose and pulse therapy combined with small-dose prednisone acetate in the treatment of patients with Kawasaki disease (KD).

Methods:

Eighty patients with KD from Baoding Children’s Hospital, China, were randomly divided into two groups: the experimental group and the control group, each with 40 cases. Patients in the experimental group were treated with HDIVIG single dose, pulse therapy combined with low-dose prednisone acetate, while patients in the control group were treated with conventional-dose immunoglobulin. Patients in both groups were treated with aspirin orally, and given symptomatic treatment including anti-inflammatory, nutritional support, correction of water and electrolyte disturbance and acid-base balance. Peripheral venous blood samples were drawn from all patients at the time of admission, Day-1, Day-7 and Day-14 after treatment, and in the basic state of getting up in the morning, and then the levels of tumor necrosis factor (TNF-a), C-reactive protein (CRP), interleukin-6 (IL-6) and other inflammatory factors were detected by enzyme-linked immunosorbent assay (ELISA). The time of body temperature falling to normal, lymph node swelling recovery, hands and feet swelling, mucosal hyperemia regression after treatment in the two groups was recorded, and the treatment effect of the two groups was comprehensively evaluated.

Results:

After treatment, the levels of inflammatory factors such as TNF-a, CRP, IL-6 in the experimental group were significantly lower than those in the control group, with a statistically significant difference (P<0.05). In addition, the time of body temperature falling to normal, lymph node swelling recovery, hands and feet swelling, and mucosal hyperemia regression in the experimental group was significantly shorter than that in the control group (p=0.00). The effective rate of the experimental group was 95% and that of the control group was 80%, with a statistically significant difference (p=0.04).

Conclusion:

HDIVIG single dose, pulse therapy combined with small-dose prednisone acetate has a favourable therapeutic effect in the treatment of patients with KD, by which the inflammatory factors can be significantly improved, clinical symptoms and weight can be quickly ameliorated, and therapeutic effect can be enhanced.

The importance of heart and brain imaging in children and adolescents with Multisystem Inflammatory Syndrome in Children (MIS-C)

Multisystem Inflammatory Syndrome in Children (MIS-C) recently reported in a minority of children affected by SARS-CoV-2, mimics Kawasaki disease (KD), a medium vessel vasculitis of unknown cause. In contrast to acute COVID-19 infection, which is usually mild in children, 68% of patients with MIS-C will need intensive care unit. Myocarditis and coronary artery ectasia/aneurysm are included between the main cardiovascular complications in MIS-C. Therefore, close clinical assessment is need it both at diagnosis and during follow-up. Echocardiography is the cornerstone modality for myocardial function and coronary artery evaluation in the acute phase. Cardiovascular magnetic resonance (CMR) detects diffuse myocardial inflammation including oedema/fibrosis, myocardial perfusion and coronary arteries anatomy during the convalescence and in adolescents, where echocardiography may provide inadequate images. Brain involvement in MIS-C is less frequent compared to cardiovascular disease. However, it is not unusual and should be monitored by clinical evaluation and brain magnetic resonance (MRI), as we still do not know its effect in brain development. Brain MRI in MIS-C shows T2-hyperintense lesions associated with restricted diffusion and bilateral thalamic lesions. To conclude, MIS-C is a multisystem disease affecting many vital organs, such as heart and brain. Clinical awareness, application of innovative, high technology imaging modalities and advanced treatment protocols including supportive and anti-inflammatory medication will help physicians to prevent the dreadful complications of MIS-C.

Outcome of Children Admitted With SARS-CoV-2 Infection: Experiences From a Pediatric Public Hospital

OBJECTIVE

To study clinical characteristics and outcome of children with admitted to a paediatric hospital in Mumbai, India.

METHODS

Review of medical records of 969 children admitted between 19 March and 7 August, 2020, to assess the clinico-demographic characteristics, disease severity and factors predicting outcome in COVID-19 children. Variables were compared between children who were previously healthy (Group I) and those with co-morbidity (Group II).

RESULTS

123 (71 boys) children with median (IQR) age of 3 (0.7- 6) years were admitted, of which 47 (38%) had co-morbidities. 39 (32 %) children required intensive care and 14 (11.4%) died. Male sex, respiratory manifestation, oxygen saturation <94%; at admission, mechanical ventilation, inotrope, hospital stay of <10 days were independent predictors of mortality. Oxygen saturation <94% at admission (OR 35.9, 95% CI 1.5-856) and hospital stay <10 days (OR 9.1, 95% CI 1.04-99.1) were significant.

CONCLUSION

COVID-19 in children with co-morbidities causes severe disease. Association of mortality with oxygen saturation by pulse oximeter <94% on admission, and hospital stay <10 days, needs further evaluation.

Characteristics of Children With Kawasaki Disease-Like Signs in COVID-19 Pandemic: A Systematic Review

Recent studies have shown that several children diagnosed with COVID-19 have developed Kawasaki Disease (KD)-like symptoms. This systematic review aims to assess the demographic, laboratory, and clinical characteristics of children with KD-like syndrome during the COVID-19 pandemic and evaluate efficacy of treatments and patients' outcome. A comprehensive search was carried out systematically through PubMed, Scopus, and Web of Science (WoS), medRxiv, and bioRxiv by two reviewers independently for all studies or preprints data on the demographic, laboratory, and clinical characteristics of children with K.D-like signs during the COVID-19 outbreak. Overall, 378 studies were identified by the systematic search, of which 25 studies were included in the study. The included studies involved 599 patients in total. Thirteen studies (52%) were case reports or case series, and the rest (48%) were cohort studies. In 19 studies, patients were diagnosed with Multisystem inflammatory syndrome in children (MIS-C). In 16 studies COVID-19 was diagnosed in all patients based on their polymerase chain reaction result, serological findings, and computed tomography results. Higher C-reactive protein and erythrocyte sedimentation rate level were the most prevalent laboratory findings. In most studies, patients had leucopenia with marked lymphopenia, hypoalbuminemia, and increased ferritin, as well as hyponatremia. Abnormal echocardiography and respiratory outcomes were the most common clinical outcomes. In 11 studies, all patients required intensive care unit admission. Findings of the present systematic review show that the incidence of KD-like syndrome in the COVID-19 pandemic increased significantly. Moreover, this study offers new insights in the KD-like syndrome pathogenesis and clinical spectrum during COVID-19 pandemic.

Potential link between SARS-CoV-2 and Kawasaki disease: importance of dentists for the diagnosis

Kawasaki disease (KD) is a vasculitis with predilection for coronary arteries. Due to a lack of reliable confirmatory laboratory tests, the diagnosis of KD is based on a characteristic pattern of clinical findings that appear in a typical temporal sequence. The diagnostic criteria have been periodically modified and the American Heart Association has proposed the most recent guidelines for its diagnosis. However, patients may have incomplete or atypical forms of KD and diagnosis can often be difficult. Because oropharyngeal manifestations are a common and important feature for diagnosing KD and recent studies have hypothesized a possible association between KD and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in this review we highlight the importance of dentists in the diagnosis of KD and its potential association with SARS-CoV-2.

Diagnostic significance of circulating miRNAs in Kawasaki disease in China: Current evidence based on a meta-analysis

BACKGROUND

There is no golden standard for the diagnosis of Kawasaki disease (KD), the most common cause of acquired heart disease in children in many countries. In recent years, many studies have focused on the relationship between microRNAs (miRNAs) and KD. Thus, we perform this meta-analysis to understand the role of circulating miRNAs as a biomarker to detect KD.

METHODS

We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure through March 10, 2019. Meta-disc 1.4 and STATA 15.1 (Stata Corporation, College Station, TX) were used to conduct the meta-analysis.

RESULTS

Six eligible articles were included in this meta-analysis. The overall performance of total mixed miRNAs detection was: pooled sensitivity, 0.7 (95% confidence interval, 0.66-0.74); pooled specificity, 0.87 (95% confidence interval, 0.83-0.90); and area under the summary receiver operating characteristic curves value (SROC), 0.8302. The meta-regression analysis indicated that the specimen types, the composition of the control group, and types of the reference miRNA were not responsible for the existing heterogeneities. The subgroup analysis showed that SROC of the plasma group (0.8890) was more significant than the serum group (0.7204), and SROC of the non-healthy control group (0.9622) was more significant than the healthy control group (0.8096).

CONCLUSIONS

: This is the first meta-analysis show that miRNAs may be used as novel biomarkers for detecting KD, especially for distinguishing KD from other febrile diseases. More studies are needed in the future to clarify the association between KD and miRNAs.

PROSPERO REGISTRATION NUMBER

CRD42019129976.

Cerebrospinal fluid changes and clinical features of aseptic meningitis in patients with Kawasaki disease

OBJECTIVE

To assess the distinguishing features of aseptic meningitis (AM) in patients with Kawasaki disease (KD) compared with bacterial meningitis (BM) patients.

METHODS

Thirty-eight patients with KD and 126 patients with BM were retrospectively investigated. The following clinical manifestations and laboratory parameters were compared between the two groups: duration of fever before lumbar puncture, conjunctival injection, oral cavity changes, rash, cervical lymphadenopathy and extremity changes, vomiting, front fontanel bulging, neck stiffness, leukocyte number, hemoglobin level, platelet number, C-reactive protein level, cerebrospinal fluid (CSF) content, liver enzyme level, and urinalysis.

RESULTS

Vomiting and neck stiffness were more prevalent in patients with BM. KD patients with AM showed elevated blood leukocyte numbers and C-reactive protein levels in the early febrile stage. CSF glucose was significantly lower in patients with BM compared with KD patients with AM. Receiver operating characteristic curve analysis showed that the optimal cutoff value of CSF glucose for discrimination of BM and AM/KD was 2.945 mmol/L, with a sensitivity of 84.2% and a specificity of 71.4%.

CONCLUSIONS

Detailed investigations of clinical manifestation and laboratory parameters are necessary to distinguish AM and BM in patients with KD. Decreased CSF glucose is a potential indicator of BM.

Outcome of Children Admitted With SARS-CoV-2 Infection: Experiences From a Pediatric Public Hospital

Objective

To study clinical characteristics and outcome of children with admitted to a paediatric hospital in Mumbai, India.

Method

Review of medical records of 969 children admitted between 19 March and 7 August, 2020, to assess the clinico-demographic characteristics, disease severity and factors predicting outcome in COVID-19 children. Variables were compared between children who were previously healthy (Group I) and those with co-morbidity (Group II).

Results

123 (71 boys) children with median (IQR) age of 3 (0.7–6) years were admitted, of which 47 (38%) had co-morbidities. 39 (32 %) children required intensive care and 14 (11.4%) died. Male sex, respiratory manifestation, oxygen saturation <94% at admission, mechanical ventilation, inotrope, hospital stay of <10 days were independent predictors of mortality. Oxygen saturation <94% at admission (OR 35.9, 95% CI 1.5–856) and hospital stay <10 days (OR 9.1, 95% CI 1.04–99.1) were significant.

Conclusion

COVID-19 in children with co-morbidities causes severe disease. Association of mortality with oxygen saturation by pulse oximeter <94% on admission, and hospital stay <10 days, needs further evaluation.

Kawasaki Disease With Combined Cholestatic Hepatitis and Mycoplasma pneumoniae Infection: A Case Report and Literature Review

Kawasaki disease (KD), also called mucocutaneous lymph node syndrome, is a febrile multisystem vasculitis mainly affecting children younger than 5 years. KD typically manifests as skin lesions and in the lymph nodes and oral and conjunctival mucosa. It may induce coronary artery abnormalities, such as aneurysms, but gastrointestinal and hepatobiliary involvement are not common. We reviewed 32 cases of patients with a diagnosis of KD with hepatobiliary involvement between 2000 and 2021 and present the case of a 4-year-old girl who received a diagnosis of KD with combined cholestatic hepatitis and Mycoplasma pneumoniae infection. In the 33 cases reviewed, in addition to the classical clinical findings of KD, the most common clinical presentations were jaundice and abdominal pain. Moreover, abnormal laboratory results indicating hyperbilirubinemia, cholestasis, and hepatitis, among other conditions, were noted. Abdominal ultrasonography revealed abnormal findings in more than half children with KD with hepatobiliary involvement. Furthermore, cardiac involvement was noted in a high proportion of the patients. In particular, we noted the case of a 4-year-old girl with a rare presentation of 3-day fever combined with abdominal pain and jaundice. Her levels of aspartate aminotransferase, alanine aminotransferase, total bilirubin, direct bilirubin, alkaline phosphatase, and γ-glutamyl transpeptidase were 489 (15-50) U/L, 253 (5-45) U/L, 4.3 (<1.5) mg/dl, 2.4 (<0.2) mg/dl, 337 (134-315) U/L, and 145 (5-32) U/L, respectively. These results were indicative of cholestatic hepatitis. Furthermore, her serological test results for mycoplasma infection were positive. KD was diagnosed because the patient had high fever for more than 5 days and presented with lymphadenopathy on the left side of neck, a polymorphic skin rash, redness of oral mucosa with strawberry tongue, and nonpurulent conjunctival congestion. After intravenous immunoglobulin injection (IVIG) and acetylsalicylic acid administration, the fever subsided rapidly and clinical manifestations, such as jaundice and abdominal pain, were mitigated. The laboratory parameters gradually returned to within normal ranges. Echocardiography revealed no aneurysm. In conclusion, KD with cholestatic hepatitis should be considered when pediatric patients present with fever combined with abdominal pain and jaundice. Early treatment with IVIG and aspirin is recommended and can effectively relieve cholestatic hepatitis.

Value of serial echocardiography in diagnosing Kawasaki's disease

Kawasaki disease (KD) is an acute vasculitis predominantly affecting the small arteries of young children. Up to 25% of untreated patients suffer from coronary artery (CA) complications. Early diagnosis and treatment is mandatory in incomplete KD to reduce the risk of coronary involvement. Between 2002 and 2018, 124 patients have been diagnosed suffering from KD at the University Children's Hospital Regensburg (KUNO). We assessed luminal diameters of both CAs normalized as Z-scores by 2D-echocardiography. A total of 94 patients were analyzed. Of them, 31 (33%) were affected by an incomplete form of KD. In 24 children (26%), serial echocardiography was necessary in order to confirm diagnosis. Mean Z-scores for the left main coronary artery (LMCA), right main coronary artery (RMCA), and left anterior descending artery increased significantly between the initial (LMCA 0.79z, RMCA 0.15z, LAD 0.49z) and second (LMCA 1.69z, RMCA 0.99z, LAD 1.69z) examination (p < 0.05).Conclusion:To confirm diagnosis of KD, it might not be necessary to detect dilation or aneurysms. Our observation suggests that patients suspected having KD should be monitored with serial echocardiography in order to detect a possible enlargement of the CA diameters, even if Z-scores are within the normal range. What is Known: • Kawasaki disease (KD) is an acute vasculitis predominantly affecting the small arteries of young children. Up to 25% of untreated patients suffer from coronary artery (CA) complications. • Due to less classic clinical criteria in patients with incomplete KD, the risk for CA pathology is even higher. What is New: • A significant progression of patients' CA Z-scores in serial echocardiographic measurements may be helpful to ensure diagnosis of KD early even if Z-scores are within the normal range. • Twenty-seven patients (90%) with incomplete KD could be diagnosed within 10 days of fever, early enough to prevent significantly higher rates of CA aneurysm.

Kawasaki or Kawasaki-like disease? A debate on COVID-19 infection in children

Kawasaki disease (KD) is an inflammatory syndrome which is generally observed among children. Considering the significant number of COVID-19-positive children presenting with the manifestations of typical/atypical KD, it has been mentioned as a possible complication of COVID-19 infection among the children. However, many of the reported cases do not completely fill the clinical diagnostic criteria, which has made some researchers use the term "Kawasaki-like disease" instead of KD for this state. The current manuscript aims to review the key studies in the field, address the ongoing conflict, and indicate the objective requirements of the further studies.

Oral manifestations of COVID-2019-related multisystem inflammatory syndrome in children: a review of 47 pediatric patients

Background

Although much is still unknown about the full effects of COVID-19, literature from the early stages of the COVID-19 pandemic (spring and summer 2020) supports a postviral immunologic reaction resulting in a multisystem inflammatory syndrome in children (MIS-C). The purpose of this study was to report the rates of documented oral and oropharyngeal manifestations among these patients and to determine the association of these findings with other MIS-C symptoms.

Methods

The authors conducted a retrospective review of pediatric patients with COVID-19 who were admitted to the Morgan Stanley Children’s Hospital of NewYork-Presbyterian. Patients fulfilling the Centers for Disease Control and Prevention criteria for MIS-C were included in this study. The documented signs, symptoms, and laboratory values were collected and compared with the presence of oral or oropharyngeal findings.

Results

The mean (standard deviation) age of MIS-C patients was 9.0 (5.0) years (range, 1.3-20.0 years), and there was no obvious sex difference (51.1% male, 48.9% female). With respect to oral findings, 23 patients (48.9%) had red or swollen lips, whereas only 5 (10.6%) had a strawberry tongue. Oral or oropharyngeal findings were associated significantly with the presence of systemic rash (P = .04) and conjunctivitis (P = .02).

Conclusions

The presence of oral or oropharyngeal changes may be an early indicator of MIS-C and should be considered suggestive of MIS-C in the setting of COVID-19 infection.

Practical Implications

Dental care providers may play an integral role both in the early detection of oral manifestations of MIS-C and in the identification of oral lesions in hospitalized patients with confirmed MIS-C.

Severe COVID-19, multisystem inflammatory syndrome in children, and Kawasaki disease: immunological mechanisms, clinical manifestations and management

Multisystem inflammatory syndrome (MIS-C) is a pediatric hyperinflammation disorder caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). It has now been reported from several countries the world over. Some of the clinical manifestations of MIS-C mimic Kawasaki disease (KD) shock syndrome. MIS-C develops 4–6 weeks following SARS-CoV-2 infection, and is presumably initiated by adaptive immune response. Though it has multisystem involvement, it is the cardiovascular manifestations that are most prominent. High titres of anti-SARS-CoV-2 antibodies are seen in these patients. As this is a new disease entity, its immunopathogenesis is not fully elucidated. Whether it has some overlap with KD is still unclear. Current treatment guidelines recommend use of intravenous immunoglobulin and high-dose corticosteroids as first-line treatment. Mortality rates of MIS-C are lower compared to adult forms of severe COVID-19 disease.

Kawasaki Disease and Multisystem Inflammatory Syndrome in Children with COVID-19

Since December 2019, the world has been exposed to a novel virus from the coronaviruses family, named coronavirus disease 2019 (COVID-19), which has affected the life of millions people around the world. This global pandemic causes a wide spectrum of clinical manifestation in children, adults, and elderly. One side of the spectrum in children is being asymptomatic and the other side is severe inflammatory symptoms. In this article, we describe the clinical manifestations, genetic background, and immune response of children with COVID-19, who are presented with severe multisystem inflammatory syndrome (MIS).

Current pharmacological intervention and development of targeting IVIG resistance in Kawasaki disease

Kawasaki disease is an acute childhood self-limited vasculitis, causing the swelling or inflammation of medium-sized arteries, eventually leading to cardiovascular problems such as coronary artery aneurysms. Acetylsalicylic acid combined with intravenous immunoglobulin (IVIG) is the standard treatment of Kawasaki disease (KD). However, a rising number of IVIG resistant cases were reported with severe disease complications such as the KD Shock Syndrome or KD-Macrophage activation syndrome. Recent reports have depicted the overlapped number of children with SARS-CoV-2 and KD, which was called multisystem inflammatory syndrome. Simultaneously, the incidence rate of KD-like diseases are increased after the outbreak of COVID-19, suggesting the virus may be associated with KD. New intervention is important to overcome the problem of IVIG treatment resistance. This review aims to introduce the current pharmacological intervention and possible resistance genes for the discovery of new drug for IVIG resistant KD.

Kawasaki Disease and COVID-19

The recent passing away of Dr. Tomisaku Kawasaki, who first described what is now known as Kawasaki Disease (KD), and recent reports of a multisystem inflammatory disease in children associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (MIS-C), makes a review on KD and MIS-C timely. Kawasaki Disease is a systemic vasculitis with predilection for coronary arteries occurring mostly in early childhood. The main features are high fever, extensive skin rash, cheilitis with red, cracking, bleeding lips and strawberry tongue, conjunctivitis, erythema and induration of hands and feet, subsiding with periungual peeling, cervical lymphadenopathy, and coronary artery dilation/aneurysms. Treatment consists of intravenous (IV) immunoglobulin (Ig) plus acetylsalicylic acid. MIS-C is considered a cytokine storm with high fever, inflammation, multi-organ dysfunction, that shares features with KD, toxic shock, and macrophage activation syndrome. Many children require admission to paediatric intensive care units for circulatory support. Bacterial sepsis, staphylococcal toxic shock syndrome, and enterovirus-causing myocarditis should be excluded. Treatment is not standardized and includes IVIg, IV methylprednisolone and IL-6 and IL-1 inhibitors.

The emerging spectrum of cardiopulmonary pathology of the coronavirus disease 2019 (COVID-19): Report of 3 autopsies from Houston, Texas, and review of autopsy findings from other United States cities

This paper collates the pathological findings from initial published autopsy reports on 23 patients with coronavirus disease 2019 (COVID-19) from 5 centers in the United States of America, including 3 cases from Houston, Texas. Findings confirm that COVID-19 is a systemic disease with major involvement of the lungs and heart. Acute COVID-19 pneumonia has features of a distinctive acute interstitial pneumonia with a diffuse alveolar damage component, coupled with microvascular involvement with intra- and extravascular fibrin deposition and intravascular trapping of neutrophils, and, frequently, with formation of microthombi in arterioles. Major pulmonary thromboemboli with pulmonary infarcts and/or hemorrhage occurred in 5 of the 23 patients. Two of the Houston cases had interstitial pneumonia with diffuse alveolar damage pattern. One of the Houston cases had multiple bilateral segmental pulmonary thromboemboli with infarcts and hemorrhages coupled with, in nonhemorrhagic areas, a distinctive interstitial lymphocytic pneumonitis with intra-alveolar fibrin deposits and no hyaline membranes, possibly representing a transition form to acute fibrinous and organizing pneumonia. Multifocal acute injury of cardiac myocytes was frequently observed. Lymphocytic myocarditis was reported in 1 case. In addition to major pulmonary pathology, the 3 Houston cases had evidence of lymphocytic pericarditis, multifocal acute injury of cardiomyocytes without inflammatory cellular infiltrates, depletion of splenic white pulp, focal hepatocellular degeneration and rare glomerular capillary thrombosis. Each had evidence of chronic cardiac disease: hypertensive left ventricular hypertrophy (420 g heart), dilated cardiomyopathy (1070 g heart), and hypertrophic cardiomyopathy (670 g heart). All 3 subjects were obese (BMIs of 33.8, 51.65, and 35.2 Kg/m2). Overall, the autopsy findings support the concept that the pathogenesis of severe COVID-19 disease involves direct viral-induced injury of multiple organs, including heart and lungs, coupled with the consequences of a procoagulant state with coagulopathy.

Involvement of p53, p21, and Caspase-3 in Apoptosis of Coronary Artery Smooth Muscle Cells in a Kawasaki Vasculitis Mouse Model

Background

Overexpression of p53, p21, and caspase-3 promotes apoptosis of vascular smooth muscle cells. However, the mechanisms that lead to apoptosis of coronary artery smooth muscle cells (CASMCs) is unclear in Kawasaki disease (KD). This study investigated involvement of p53, p21, and caspase-3 in the apoptosis of CASMCs from a Kawasaki vasculitis mouse model.

Material/Methods

The Kawasaki vasculitis mouse model with coronary artery lesions was generated via administration of Lactobacillus casei cell wall extract. In 2 groups of mice (healthy control and KD vasculitis mice), the levels of p53, p21, and caspase-3 protein in the root of the coronary artery were evaluated via immunohistochemistry. Receiver operating characteristic curves were plotted for determination of area under the curve, 95% confidence interval, sensitivity, specificity, and cutoff values for the ability of p53, p21, and caspase-3 expression to predict CASMC apoptosis and coronary artery lesion formation in KD vasculitis mice.

Results

Compared with healthy mice, KD vasculitis mice had a significantly higher apoptosis index and upregulated p53, p21, and caspase-3 expression. Also, the immunoreactive score for caspase-3 was positively correlated with the immunoreactivity scores for p53 and p21. The optimal cutoff values for p53, p21, and caspase-3 expression for predicting the presence of coronary artery lesions were 4.15, 4.18, and 4.22, respectively.

Conclusions

Upregulated levels of p53, p21, and caspase-3 promoted apoptosis of CASMCs in KD vasculitis mice. Thus, the levels of p53, p21, and caspase-3 may serve as valuable predictors of coronary artery lesion formation in KD.

Three Cases of Pediatric Multisystem Inflammatory Syndrome Associated with COVID-19 Due to SARS-CoV-2

BACKGROUND Coronavirus disease 2019 (COVID-19) infection commonly presents as fever, cough, and shortness of breath in adults. Children are thought to have milder respiratory symptoms and to recover more quickly. We describe a new presentation of COVID-19 infection in children consisting of multisystem inflammation with decreased left ventricular function and evidence of lung disease. CASE REPORT Three children presented with fever, conjunctivitis, dry and cracked lips, rash, and/or cervical lymphadenopathy for at least 5 days. Two of these children required mechanical ventilation, and 1 of the 2 needed extracorporeal membrane oxygenation (ECMO) to support cardiorespiratory function. All of these children had moderate to severe hyponatremia and lymphopenia, which is usually seen in COVID-19. They were treated with intravenous immunoglobulin and high-dose aspirin. All of the children recovered. CONCLUSIONS Early recognition of children with multisystem inflammation is important because they are at increased risk for deterioration. Treatment with intravenous immunoglobulin and aspirin was used because this regimen has been shown to be beneficial in vasculitis of Kawasaki disease. The development of shock due to cardiac involvement may require ECMO.

Our Evolving Understanding of Kawasaki Disease Pathogenesis: Role of the Gut Microbiota

Kawasaki disease (KD) was first described by Dr. Tomisaku Kawasaki in 1967. The etiology of KD has been studied comprehensively but remains largely unknown. The disease seems to result from the interplay of genetic and environmental susceptibility factors with infectious triggers, followed by a subsequent abnormal immune response characterized by increased levels of inflammatory cytokines and chemokines during the acute phase. Evidence has mounted to suggest that an imbalance between T helper 17 cells (Th17s) and regulatory T cells (Tregs) is associated with aberrant immune responses in KD. Recent advances in culture-independent techniques for detection and identification of intestinal commensal bacteria enabled the discovery that Th17 and Treg differentiation are regulated by short chain fatty acids (SCFAs), in particular butyrate, produced by the gut microbiota. This finding provided a mechanistic link between dysbiosis, defined as changes in the composition of the gut microbiota, and various inflammatory diseases. On this basis, we propose that dysbiosis, with reduced production of SCFAs leading to imbalances of Th17s/Tregs, could be involved in the etiology of KD. A pilot study supported this hypothesis, as only fecal concentrations of butyrate were significantly reduced in KD patients among SCFAs. This evolving perspective prompted us to undertake metagenomic analyses of bacterial DNA from the feces of KD patients who were antibiotic-naïve at diagnosis. Simultaneous measurements of Th17s/Tregs in peripheral blood and SCFA concentrations in feces would provide valuable information regarding the association between dysbiosis and dysregulated immune responses in KD.

Diagnosis and management of Kawasaki disease

Kawasaki disease, also known as mucocutaneous lymph node syndrome, is a common form of vasculitis in childhood. Among the recent trends in Kawasaki disease, it is notable that the prevalence rate is increasing, and the proportion of “incomplete” Kawasaki disease is also increasing. A delayed diagnosis with prolonged fever can cause complications, such as coronary artery aneurysm and decreased myocardial contractility. These complications might lead to significant morbidity and mortality. Kawasaki disease is diagnosed when the patient meets the principal criteria for clinical symptoms. Following the diagnostic criteria can prevent overdiagnosis but lead to missing of the incomplete form of the disease. Therefore, it is important to accurately understand Kawasaki disease. As the coronavirus disease 2019 (COVID-19) pandemic continues, concerns about a novel severe Kawasaki-like disease in children related to COVID-19 emerges. Indeed, there have been several reports of Kawasaki-like disease related to COVID-19 in children. Kawasaki disease is no longer rare and is often encountered at hospitals. This paper will provide useful and accurate information on Kawasaki disease.

Clinico-laboratory profile of Kawasaki disease with arthritis in children

Kawasaki disease (KD) is associated with several musculoskeletal manifestations. Although arthritis has been reported to occur in 2.3-31% of children with KD, there is paucity of detailed studies on the subject. We report our experience on arthritis in children with KD. Data were collated from a review of records of patients diagnosed with KD and arthritis during the period January 1994-June 2019. Eight hundred sixty-five children (male:female 29:11) were diagnosed with KD during this period-of these, 40 (4.6%) had arthritis. Median day of diagnosis of KD was 17 days. Twenty-nine (72.5%), 8 (20%), and 3 (8.6%) children developed arthritis in acute, subacute, and convalescent phases of KD, respectively. Oligoarticular involvement was observed in 32 (80%) children and among these, 7 (20%) had monoarthritis. Predominant joints involved were knee (74.3%), ankle (40%), and hip (28.6%). Thirty-two children (80%) were treated with non-steroidal anti-inflammatory drugs (NSAIDs). Median duration of arthritis was 10 days (range, 2-180 days) with uneventful recovery in all cases. Three (7.5%) children had coronary artery ectasia which regressed on follow-up.Conclusion: Arthritis in KD is usually non-erosive, self-limiting, and responds well to a short course of NSAIDs.What is Known:• Arthritis has been reported to occur in 2.3-31% of children with KD.• Arthritis in KD is usually oligoarticular, non-erosive, and responds well to short course of non-steroidal anti-inflammatory drugs.What is New:• Children with KD and arthritis do not appear to be at increased risk of development of coronary artery abnormalities.• Arthritis in children with KD can result in diagnostic confusion, and diagnosis of KD may get delayed.

N-terminal pro-brain natriuretic peptide as a biomarker for predicting coronary artery lesion of Kawasaki disease

Coronary artery lesion (CAL) caused by Kawasaki disease (KD) is currently the most common acquired heart disease in children in many countries. Nevertheless, there is no single useful marker existing for predicting CAL of KD. Recently, many reports have noted that N-terminal pro-brain natriuretic peptide (NT-proBNP) can be utilized as a biomarker to predict CAL. Thus, we perform a meta-analysis to ascertain the diagnostic value of NT-proBNP in detecting CAL of KD in the acute phase. PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and China National Knowledge Infrastructure were searched to detect relevant publications. Finally, eight eligible studies were included. The overall diagnostic sensitivity and specificity were 0.84 (95% confidence interval [CI]: 0.78-0.89) and 0.71 (95% CI: 0.68-0.75), respectively. The area under the summary receiver operating characteristic curves value (SROC) curve was 0.8582 ± 0.0531. Moreover, the overall sensitivity and specificity across five studies adopted the threshold of approximately 900 ng/L were 0.82 (95% CI: 0.73-0.89) and 0.72 (95% CI: 0.68-0.76), respectively. SROC was 0.8868 ± 0.0486. This meta-analysis would be the first one to describe the role of NT-proBNP in detecting CAL of KD. We register this study with PROSPERO (CRD42019130083).

Utility of color Doppler echocardiography combined with clinical markers in diagnosis and prediction of prognosis of coronary artery lesions in Kawasaki disease

The utility of color Doppler echocardiography in the diagnosis and follow-up of Kawasaki disease (KD) with coronary artery lesions (CAL) was analyzed, and the clinical parameters associated with the disease were examined. The general data, the color Doppler echocardiography data and the biochemical indexes from 102 children with KD were analyzed. The patients were divided into a CAL group and a non-coronary artery lesion (NCAL) group based on the presence or absence of CAL. The risk factors for CAL in KD were screened by univariate and multivariate analyses. Among the 102 cases, CAL complications were identified in 47 cases (46.08%). Compared with the NCAL group, the CAL group showed significantly higher incidences of fever duration, increased levels of N-terminal pro B-type natriuretic peptide (NT-proBNP), cardiac troponin I (cTnI), C-reactive protein (CRP), intravenous immunoglobulin resistance, erythrocyte sedimentation rate (ESR), platelets, alanine aminotransferase and aspartate aminotransferase, and significantly lower serum albumin levels (P<0.05). According to the multivariate analysis, fever duration [odds ratio (OR)=2.014], NT-proBNP (OR=3.004), cTnI level (OR=2.638), ESR (OR=1.461) and CRP elevation (OR=1.094) were predictors of CAL in KD. During convalescence, the left and right coronary artery diameters in the CAL group significantly decreased (P<0.05). Color Doppler echocardiography can observe the condition of coronary artery disease in patients with KD in real time and predicts its outcomes, which may be helpful for early diagnosis and long-term follow-up. Fever duration, cTnI, NT-proBNP and ESR levels were correlated with coronary artery diameter, of which the comprehensive use may be more accurate in determining the occurrence of CAL in KD.

Gastrointestinal hemorrhage before anticoagulant therapy in Kawasaki disease: a case report

Background

Kawasaki disease (KD) is an acute febrile multisystem vasculitis and has been recognized to be the most common cause of acquired heart disease in children. Owing to its propensity to involve vessels throughout the entire body, KD often mimics other disease processes. The diagnosis might be delayed if other prominent symptoms appear before the characteristic clinical features of KD. Although gastrointestinal symptoms including vomiting, diarrhea, and abdominal pain are not uncommon in KD patients, KD with gastrointestinal bleeding is quite rare.

Case presentation

A previously healthy 4-year-old boy initially presented with abdominal pain, followed by fever, rash, and gastrointestinal hemorrhage, eventually diagnosed as complete KD. The patient recovered smoothly after appropriate management and no subsequent complications occurred in the following months.

Conclusion

The diagnosis of KD should be considered in children presenting with abdominal symptoms and fever without definable cause. Pediatricians should be aware of the risk of gastrointestinal bleeding in patients with KD, especially in those with prominent abdominal symptoms.

Cardiovascular Involvement in Kawasaki Disease Is Much More Than Mere Coronary Arteritis

Kawasaki disease (KD) is now a common cause of acquired heart disease in children. Coronary artery involvement is the most serious complication in children with KD. Several non-coronary complications have now been identified in this condition but these are often overlooked. Myocarditis is an integral component of KD and may be more common than coronary artery abnormalities. Pericardial involvement and valvular abnormalities have also been observed in patients with KD. KD shock syndrome is now being increasingly recognized and may be difficult to differentiate clinically from toxic shock syndrome. Endothelial dysfunction has been reported both during acute stage and also on follow-up. This may be a potentially modifiable cardiovascular risk factor.

Kawasaki Disease in Children Older Than 10 Years: A Clinical Experience From Northwest India

Background: Kawasaki disease (KD) is predominantly seen in young children (<5 years). Diagnosis of KD is often delayed in older children and adolescents, leading to a higher risk of coronary artery abnormalities (CAAs). There is a paucity of literature on KD in older children. Methods: Data were collated from a review of records of patients diagnosed with KD who were aged ≥10 years at the time of diagnosis, during the period from January 1994 to June 2019. Results: Eight hundred and sixty five patients were diagnosed with KD during this period. Of these, 46 (5.3%; 26 boys and 20 girls) were aged 10 years or older at the time of diagnosis. The median age at diagnosis was 11 years (range of 10-30 years). The median interval between the of fever and the diagnosis of KD was 12 days (range of 4-30 days). Eight patients (17.4%) presented with hypotensive shock. Coronary artery abnormalities (CAAs) were seen in six patients (13.04%), and three patients had myocarditis. Patients with CAAs were found to have significantly higher median platelet counts and higher median C-reactive protein levels. First-line treatment included intravenous immunoglobulin. Adjunctive therapy was given in five patients (infliximab in four patients and steroids in one patient). The median time between the onset of fever and the administration of IVIg was 13.5 days (range of 6-2). The total duration of follow up is 2,014.5 patient-months. Conclusion: Diagnosis of KD in children older than 10 years is usually delayed, and these patients are thus at a higher risk of CAAs.

The rs1051931 G>A Polymorphism in the PLA2G7 Gene Confers Resistance to Immunoglobulin Therapy in Kawasaki Disease in a Southern Chinese Population

Background: Kawasaki disease (KD) is a common cardiovascular disease in infants and young children, with fever, rash, and conjunctivitis as the main clinical manifestations, which can lead to the occurrence of coronary aneurysms. Intravenous immunoglobulin (IVIG) is the preferred treatment for KD patients, but 10-20% of patients are resistant to IVIG. Lipoprotein-associated phospholipase A 2 (Lp-PLA2) is a potential therapeutic target for coronary atherosclerotic heart disease, and the polymorphism of Phospholipase A2 Group VII (PLA2G7) is closely related to the activity of Lp-PLA2, of which rs1051931 is the strongest. Therefore, the rs1051931 polymorphism may be a predictor of IVIG resistance in KD patients. Methods: A total of 760 KD cases, including 148 IVIG-resistant patients and 612 IVIG-responsive patients, were genotyped for rs1051931 in PLA2G7, we compared the effects of rs1051931 on IVIG treatment in KD patients by odds ratios (OR) and 95% confidence interval (CI). Results: The homozygous mutation AA may be a protective factor for IVIG resistance in KD patients (adjusted OR = 3.47, 95% CI = 1.14-10.57, P = 0.0284) and is more evident in patients with KD aged <60 months (adjusted OR = 3.68, 95% CI = 1.10-12.28, P = 0.0399). Conclusions: The PLA2G7 rs1051931 G>A polymorphism may be suitable as a biomarker for the diagnosis or prognosis of IVIG resistance in KD in a southern Chinese population.

CT Coronary Angiography Studies After a Mean Follow-up of 3.8 Years in Children With Kawasaki Disease and Spontaneous Defervescence

Background: There is paucity of literature on follow-up of children with Kawasaki disease (KD) who have spontaneous defervescence during the acute stage and do not receive intravenous immunoglobulin. We report herein the role of computed tomography coronary angiography (CTCA) as an imaging modality in such situations. Methods: This prospective observational study was carried out during the period January 2016-June 2017. Children underwent CTCA on 128-slice Dual Source CT (DSCT) scanner (Somatom Definition Flash, Siemens; Germany), and 2D-echocardiography on the same day. Results: Mean age at time of diagnosis was 6.52 ± 3.13 years; range 2-14 years. Mean age at time of study was 11.03 ± 5.10 years; range 3.75-23.30 years. Mean interval between diagnosis of KD and time of present study was 3.84 ± 2.27 years. None of the patients showed any coronary artery abnormalities on either 2D-echocardiography or CTCA. While assessment of proximal segments of left main coronary artery, proximal right coronary artery, and left anterior descending artery was comparable on both 2D-echocardiography and CTCA, left circumflex artery, and distal right coronary artery could be clearly visualized only on CTCA. Conclusion: In our experience, patients with KD who have spontaneous defervescence during the acute stage and do not receive IVIg may not have significant long-term coronary sequelae. CTCA is a useful imaging modality for delineation of coronary artery in patients with KD on long term follow-up especially in older children with thick chest walls and poor acoustic windows.

Unusual Presentation Of Kawasaki Disease With Gastrointestinal And Renal Manifestations

Diagnosis of Kawasaki disease (KD) is based on well-established clinical criteria. In incomplete or atypical KD, the diagnosis is challenging, because of the paucity of clinical signs or because of the presence of clinical manifestations that generally are not seen in KD. We describe the case of a 3-year-old female patient with persistent high fever, vomiting, watery diarrhea, metabolic acidosis and severe hypopotassemia. On the fourth day of fever, bilateral conjunctivitis, mucous and extremity changes were registered. Urine changes as glycosuria and proteinuria were also noticed. Echocardiography revealed ectasia of the left anterior descending coronary artery, and diagnosis of KD was established. The treatment consisted of intravenous immunoglobulin (IVIG) and oral aspirin. Recurrence of disease was recorded on the 23rd day of the disease, with favorable evolution after the second dose of IVIG was infused.

Kawasaki disease: characteristics, diagnosis, and unusual presentations

Introduction: Kawasaki disease (KD) is one of the commonest pediatric vasculitides and is associated with a significant risk of development of coronary artery abnormalities if left untreated. Areas covered: In this review, we have highlighted the incomplete and unusual presentations of KD and also emphasize the controversies pertaining to 2D echocardiography in KD. A PubMed search was performed regarding diagnosis and unusual presentations of KD. Expert opinion: Diagnosis of KD is essentially clinical and based on recognition of typical clinical features that may appear sequentially and all signs and symptoms may not be present at one point of time. There is no confirmatory laboratory test for diagnosis of this condition. Further complicating the picture is the fact that incomplete and atypical forms KD may be seen in up to 50% patients. Although 2D echocardiography continues to be the preferred imaging modality for cardiac assessment in patients with KD, it has its limitations.

Significance of Differential Characteristics in Infantile Kawasaki Disease

BACKGROUND AND OBJECTIVES

Immunological variability in Kawasaki disease (KD) shows age-specific differences; however, specific differences in laboratory values have not been compared between infants and non-infants with KD. We compared age-adjusted Z-values (Z) of white and red blood cells in infants with KD with those in non-infants with KD.

METHODS

This study retrospectively investigated 192 infants and 667 non-infants recruited between 2003 and 2015 at the Korea University Hospital. Laboratory values for infants with KD and non-infants with KD were analyzed and age-unadjusted raw values (R) and age-adjusted Z for blood cells counts were determined.

RESULTS

Z in infants with KD during pre-intravenous immunoglobulin (IVIG), post-IVIG, and chronic phases showed increased lymphopenia and eosinophilia, low neutrophil:lymphocyte and neutrophil:eosinophil ratios, worse anemia, increased thrombocytosis, and reduced erythrocyte sedimentation rates compared with those in non-infants with KD. The optimal cut-off value for pre-IVIG Z-hemoglobin for prediction of KD in all patients was <-0.01 (area under the curve [AUC], 0.914; sensitivity/specificity, 0.999/0.886; p=0.04). The optimal cut-off value for pre-IVIG C-reactive protein (CRP) for prediction of KD in infants compared to that in febrile control infants was >40 mg/L (AUC, 0.811; sensitivity/specificity, 0.712/0.700; p=0.04).

CONCLUSIONS

Laboratory characteristics enable differentiation between infants and non-infants with KD and contribute to a better understanding of changes in blood cell counts. Infants with incomplete KD can be more easily differentiated from infants with simple febrile illness using pre-IVIG Z-hemoglobin and pre-IVIG CRP values.

Comprehensive analyses of DNA methylation and gene expression profiles of Kawasaki disease

OBJECTIVE

Kawasaki disease (KD) is a childhood febrile vasculitis with unknown etiology. Epigenetic regulation in the gene expression dynamics has become increasingly important in KD. Thus, we performed an integrated analysis of DNA methylation and gene expression data to identify novel molecular mechanisms and key functional genes in KD.

METHODS

DNA methylation (GSE84624) and gene expression (GSE68004) datasets were downloaded from Gene Expression Omnibus. Methylated-differentially expressed genes (mDEGs) were documented as the overlapping genes between the differentially methylated genes (DMGs) in GSE84624 and differentially expressed genes (DEGs) in GSE68004. Functional enrichment analyses of the mDEGs were conducted using DAVID database. Protein-protein interaction (PPI) network was then constructed to obtain the hub genes involved in KD using STRING database.

RESULTS

A total of 1389 DMGs and 1362 DEGs were screened out between KD and control samples. Overlapping of them resulted in four hypermethylated/downregulated and 187 hypomethylated/upregulated genes. These mDEGs were mainly enriched in inflammation response, innate immune response, and blood coagulation, and signaling pathways such as platelet activation, osteoclast differentiation, and chemokine signaling pathway. PPI network analyses identified MAPK14 and PHLPP1 as the hub genes involved in KD, which could distinguish KD from other common pediatric febrile diseases. In addition, the methylation and expression levels of MAPK14 and PHLPP1 were validated in other independent datasets.

CONCLUSION

This study provides an integrated view of interactions among DNA methylation and gene expression in patients with KD. MAPK14 and PHLPP1 are the key genes influenced by methylation and may serve as candidate biomarkers for KD.

Utilization of Coronary Artery to Aorta for the Early Detection of Kawasaki Disease

Timely diagnosis of coronary involvement is paramount in Kawasaki disease (KD) as it can be associated with long-term morbidity. However, echocardiographic measurements of coronary artery dilation in KD are inconsistent and not proficient for all abnormal arteries. The purpose of this study was to investigate more valuable indices and determine their sensitivity and specificity for early diagnosis of coronary involvement in KD. We performed this retrospective study in 218 children. All patients underwent laboratory and echocardiographic evaluations upon admission. We measured the size of the left main coronary artery (LMA), left anterior descending coronary artery (LAD), right coronary artery (RCA), and aorta (Ao), and calculated the LMA/Ao, LAD/Ao, and RCA/Ao ratios. We also calculated the cut-off values of each index using receiver operating characteristic curves. LMA, LAD, and RCA measurements did not correlate with white blood cell count, platelet count, erythrocyte sedimentation rate, C-reactive protein level, or brain natriuretic peptide level. The LMA measurement was associated with hemoglobin, hematocrit, and iron saturation. LAD/Ao was correlated with white blood cell and platelet counts (P < 0.05), whereas RCA/Ao was correlated with ferritin level (P < 0.05). The cut-off value of LMA/Ao was 0.2, with a sensitivity of 85% and specificity of 70%. Individual coronary artery/Ao ratios might provide helpful insight for detection of coronary abnormality in KD in the acute phase. Further investigation is essential to clarify prompt early diagnosis of coronary involvement in KD.

Biomarkers for Kawasaki Disease: Clinical Utility and the Challenges Ahead

Kawasaki disease (KD) has replaced acute rheumatic fever as the most common cause of acquired heart disease in children in the developed world and is increasingly being recognized from several developing countries. It is a systemic vasculitis with a predilection for coronary arteries. The diagnosis is based on a constellation of clinical findings that appear in a temporal sequence. Quite understandably, this can become a problem in situations wherein the clinical features are not typical. In such situations, it can be very difficult, if not impossible, to arrive at a diagnosis. Several biomarkers have been recognized in children with acute KD but none of these has reasonably high sensitivity and specificity in predicting the course of the illness. A line up of inflammatory, proteomic, gene expression and micro-RNA based biomarkers has been studied in association with KD. The commonly used inflammatory markers e.g. erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and total leucocyte counts (TLC) lack specificity for KD. Proteomic studies are based on the identification of specific proteins in serum, plasma and urine by gel electrophoresis. A host of genetic studies have identified genes associated with KD and some of these genes can predict the course and coronary outcomes in the affected individuals. Most of these tests are in the early stages of their development and some of these can predict the course, propensity to develop coronary artery sequelae, intravenous immunoglobulin (IVIg) resistance and the severity of the illness in a patient. Development of clinical criteria based on these tests will improve our diagnostic acumen and aid in early identification and prevention of cardiovascular complications.

Pitfalls in the diagnosis and management of Kawasaki disease: An update for the pediatric dermatologist

Kawasaki disease is easily diagnosed when it presents in its complete form, but because not all characteristic symptoms are always present at the same time, and the diagnosis of incomplete and atypical Kawasaki disease is often challenging, a delay in diagnosis or misdiagnosis often occurs. We present the diagnostic approach to Kawasaki disease with common pitfalls and explain how to avoid them. We also describe current practice and new trends in treatment.

Differential diagnoses of diaper dermatitis

Diaper dermatitis is the most common contact eczema present in early childhood. The main cause is an irritant reaction to urine and feces, which is facilitated by the occlusive conditions under the diaper, leading to hyperhydration of the stratum corneum (diaper dermatitis). In addition, diaper pressure and friction can increase the risk of skin inflammation, which also opens the skin up to other irritant agents, allergens, and infectious agents, such as candida albicans. However, a variety of diseases are associated with inflammation of the skin in the diaper region, therefore the term "diaper dermatitis" is merely descriptive and does not reflect anything about the etiopathogenesis. The term diaper dermatitis refers only to an inflammation in the diapering area and should not be automatically equated with reactions to diapers. Making the correct diagnosis requires a thorough examination of the skin in its entirety and a detailed report of the patient's medical and family history. Once a specific pattern is identified, a precise diagnosis, and an appropriate therapy, can be determined.