Kawasaki syndrome in the United States 1976 to 1980

Linear ubiquitination improves NFAT1 protein stability and facilitates NFAT1 signalling in Kawasaki disease

NFAT1 is known for its roles in T cell development and activation. So far, the phosphorylation of NFAT1 has been extensively studied, but the other post-translational modifications of NFAT1 remain largely unknown. In this study, we reported that NFAT1 is a linearly ubiquitinated substrate of linear ubiquitin chain assembly complex (LUBAC). LUBAC promoted NFAT1 linear ubiquitination, which in turn inhibited K48-linked polyubiquitination of NFAT1 and therefore increased NFAT1 protein stability. Interestingly, the linear ubiquitination levels of NFAT1 in patients with the Kawasaki disease were upregulated. Further studies demonstrated that the patients with the Kawasaki disease had increased mRNA levels of HOIL-1L. These findings revealed a linearly ubiquitinated substrate of LUBAC and an important biological function of NFAT1 linear ubiquitination in the Kawasaki disease and therefore may provide a novel strategy for the treatment of the Kawasaki disease.

Seasonality and geographical distribution of Kawasaki disease among Black children in the Southeast United States

Introduction

Kawasaki Disease (KD) is a leading cause of pediatric acquired heart disease in the United States, affecting up to 7,000 children annually. Seasonal variation, an epidemiological characteristic of KD, has previously been reported predominantly among Asian children; however, little is known about the epidemiology and seasonality of KD of Black children within the U.S.

Methods

Electronic medical records were abstracted from 529 hospitalized KD patients admitted to a single tertiary center in Alabama between 2005 and 2019. Medical charts were reviewed to confirm KD diagnosis following American Heart Association criteria. Cases were stratified by the month of diagnosis date to assess seasonality, and statewide distribution of incidence is reported at county level using geographical spatial analysis. Comparisons were performed between Black patients and White patients with KD.

Results

The average number of KD cases per year was 35. Approximately, 60% were males and 44% were White children (N = 234), 45% were Black children (N = 240) and 11% were other races (N = 55). Black children were younger than White children at KD admission (median age 32 vs. 41 months respectively, p = 0.02). Overall, the highest rates of cases occurred between January and April. When stratifying by race, cases started to rise in December among White children with the highest rates between February and April with a peak in March. Among Black children cases were high during the winter season (January-April) with a peak in April. Similarly high rates also occurred in June, July and November. There were no differences in geographical distribution of cases by race.

Conclusion

KD incidence among White children in Alabama follows a seasonal cycle similar to other regions in the U.S. However, sustained incidence and additional peaks outside of the usual KD seasonality were seen among Black children with KD. Further studies are needed to investigate differential triggers between races.

Outcomes of laparotomy in preterm infants with extremely low operative weight (< 1000 g)

PURPOSE

Most studies on outcomes of surgery in extremely premature neonates include cases based on birth weight irrespective of weight at the time of surgery. Reported figures may not accurately reflect what is truly experienced in babies with smaller weight at the time of surgery. This study sought to document the outcomes of laparotomy in preterms at extremely low operative (ELOW) of < 1000 g.

METHODS

Preterm infants weighing < 1000 g at the time of laparotomy were identified from a prospectively collected database. Data were collected over 12 years (Sept 2007-Mar 2020). Primary outcome investigated was in-hospital mortality. Other outcomes including long-term morbidities are reported.

RESULTS

79 ELOW infants were included. Median gestational age was 25 weeks (23-29 weeks) and median birth weight 680 g (382-986 g). The median weight at laparotomy was 755 g (380-993 g) at a median age of 11 days of life (1-38 days). The commonest diagnoses at laparotomy included: necrotising enterocolitis 44 (56%), spontaneous intestinal perforation 20 (25%) and meconium obstruction of prematurity 5 (6%). The median predicted mortality using CRIB II scoring system was 35%. 21 (27%) in-hospital mortality was recorded. Babies who died had significantly lower operative weight (610 vs 767 g p = 0.0303) compared to those who survived despite no significant difference in birth weight. 30% had one or more surgical complications. 50% had no recorded morbidity at 2-year assessment while 19% had severe impairment.

CONCLUSION

73% of preterm infants that underwent laparotomy at < 1000 g survived to discharge and 50% of survivors had no long-term morbidity. Association between mortality and lower operative weight at laparotomy is shown. This study provides a focused data on the ELOW category of patients which could more accurately guide counselling and management decisions.

Anti-inflammatory Treatment of Kawasaki Disease: Comparison of Current Guidelines and Perspectives

Kawasaki disease (KD), an acute, generalized vasculitis, is associated with an increased risk of coronary heart disease and is the most common cause of acquired heart disease in childhood. The incidence of KD is increasing worldwide. There are numerous international treatment guidelines. Our study aims to perform the first one so far comparison of them. While the gold standard therapy remains still the same (intravenous immunoglobulins and aspirin), there is currently a lack of evidence for choosing optimal treatment for high-risk patients and refractory KD. In this review, we also discuss the treatment of complications of KD and Kawasaki-like phenotypes, present an anti-inflammatory treatment in the light of new scientific data, and present novel potential therapeutic targets for KD.

Multisystem inflammatory syndrome in children and Kawasaki disease: a critical comparison

Children and adolescents infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are predominantly asymptomatic or have mild symptoms compared with the more severe coronavirus disease 2019 (COVID-19) described in adults. However, SARS-CoV-2 is also associated with a widely reported but poorly understood paediatric systemic vasculitis. This multisystem inflammatory syndrome in children (MIS-C) has features that overlap with myocarditis, toxic-shock syndrome and Kawasaki disease. Current evidence indicates that MIS-C is the result of an exaggerated innate and adaptive immune response, characterized by a cytokine storm, and that it is triggered by prior SARS-CoV-2 exposure. Epidemiological, clinical and immunological differences classify MIS-C as being distinct from Kawasaki disease. Differences include the age range, and the geographical and ethnic distribution of patients. MIS-C is associated with prominent gastrointestinal and cardiovascular system involvement, admission to intensive care unit, neutrophilia, lymphopenia, high levels of IFNγ and low counts of naive CD4⁺ T cells, with a high proportion of activated memory T cells. Further investigation of MIS-C will continue to enhance our understanding of similar conditions associated with a cytokine storm.

[Clinical features of children with recurrent Kawasaki disease: a Meta analysis]

OBJECTIVE

To study the clinical features of children with recurrent Kawasaki disease (KD).

METHODS

PubMed, Web of Science, Embase, CNKI, Wanfang Med Online, and Weipu Data were searched for case-control studies on the clinical features of initial and recurrent KD. The articles were screened according to the inclusion and exclusion criteria. RevMan 5.3 software was used to perform the Meta analysis. Effect models were selected based on the results of heterogeneity test, and then pooled OR or weighted mean difference (WMD), and their 95% CI were calculated.

RESULTS

A total of 9 case-control studies were included, with 12 059 children with KD in total, among whom 206 children had recurrent KD (127 boys/61.7%; 79 girls/38.3%). The results of the Meta analysis showed that compared with the initial KD onset, the children with recurrent KD had a shorter duration of fever (WMD=-1.81, 95%CI:-2.99 to -0.64) and a lower proportion of children with swelling of the hands and feet (OR=0.46, 95%CI:0.26 to 0.80). There was no significant difference in the incidence rate of coronary artery lesions between recurrent KD and initial KD (OR=1.34, 95%CI:0.84 to 2.14).

CONCLUSIONS

Current evidence shows that children with recurrent KD tend to have a shorter duration of fever and a lower incidence of swelling of the hands and feet. KD recurrence is more common in boys. Current evidence does not show an increased risk of developing coronary artery lesions in children with recurrent KD.

Kawasaki Disease: an Update

PURPOSE OF REVIEW

Provide the most recent updates on the epidemiology, pathogenesis, and treatment advances in Kawasaki disease.

RECENT FINDINGS

Treatment advances in complex, IVIG-refractory cases of Kawasaki disease. Multisystem inflammatory syndrome, a newly reported inflammatory condition with Kawasaki-like features and an association with the 2019 Coronavirus (COVID-19). Kawasaki disease (KD) is a rare systemic inflammatory disease that predominately affects children less than 5 years of age. Pathogenesis of KD remains unknown; the leading theory is that an unknown stimulus triggers an immune-mediated inflammatory cascade in a genetically susceptible child. Classic KD is a clinical diagnosis based on set criteria and excluding other similar clinical entities. Patients who do not fulfill complete diagnostic criteria for KD are often referred to as atypical (or incomplete) KD. The most feared complication of KD is coronary artery abnormality development, and patients with atypical KD are also at risk. Administration of intravenous immunoglobulin (IVIG) and aspirin has greatly reduced the incidence of coronary lesions in affected children. Several other immune-modulating therapies have recently been utilized in complex or refractory cases.

Increased Kawasaki Disease Incidence Associated With Higher Precipitation and Lower Temperatures, Japan, 1991-2004

BACKGROUND

Kawasaki disease (KD) is an acute febrile vasculitis, which primarily affects children. The etiology of KD is unknown; while certain characteristics of the disease suggest an infectious origin, genetic or environmental factors may also be important. Seasonal patterns of KD incidence are well documented, but it is unclear whether these patterns are caused by changes in climate or by other unknown seasonal effects.

METHODS

The relationship between KD incidence and deviations from expected temperature and precipitation were analyzed using KD incidence data from Japanese nationwide epidemiologic surveys (1991-2004) and climate data from 136 weather stations of the Japan Meteorological Agency. Seven separate Poisson-distributed generalized linear regression models were run to examine the effects of temperature and precipitation on KD incidence in the same month as KD onset and the previous 1, 2, 3, 4, 5 and 6 months, controlling for geography as well as seasonal and long-term trends in KD incidence.

RESULTS

KD incidence was negatively associated with temperature in the previous 2, 3, 4 and 5 months and positively associated with precipitation in the previous 1 and 2 months. The model that best predicted variations in KD incidence used climate data from the previous 2 months. An increase in total monthly precipitation by 100 mm was associated with increased KD incidence (rate ratio [RR] 1.012, 95% confidence interval [CI]: 1.005-1.019), and an increase of monthly mean temperature by 1°C was associated with decreased KD incidence (RR 0.984, 95% CI: 0.978-0.990).

CONCLUSIONS

KD incidence was significantly affected by temperature and precipitation in previous months independent of other unknown seasonal factors. Climate data from the previous 2 months best predicted the variations in KD incidence. Although fairly minor, the effect of temperature and precipitation independent of season may provide additional clues to the etiology of KD.

The genetics of Kawasaki disease

Kawasaki disease (KD) is a complex disorder which affects genetically susceptible infants and children. Several susceptibility genes (e.g., ITPKC, CASP3, CD40 and ORAI) and chromosomal regions have been identified through genome-wide association and genome-wide linkage studies to have association with KD. Knowledge of susceptibility genes involved in the pathogenesis of KD may provide new insights into diagnosis and treatment of this condition. However, there is much that we still do not know about the genetic basis of KD.

Twelve Years of Kawasaki Disease in Portugal: Epidemiology in Hospitalized Children

BACKGROUND

Kawasaki disease (KD) is the leading cause of acquired heart disease in developed countries. Reported incidences vary worldwide but incidence of KD has not been established in Portugal.

AIM

The aims of the study were to describe the epidemiologic characteristics and estimate incidence rates of KD among hospitalized children in Portugal.

METHODS

This study was a descriptive, population-based study, which used hospital discharge records of patients <20 years of age diagnosed with KD from the Hospital Register database for 2000-2011. Incidence rates were calculated using the number of KD patients and corresponding National census data.

RESULTS

There were 533 hospitalizations of 470 patients with KD as the primary diagnosis in Portugal, 63 hospitalizations were transfers of patients between hospitals and there were no relapses. The mean age at admission was 2.8 years, with male predominance (male-to-female ratio: 1.6:1). Children <5 years and infants <1 year represented 83% and 23% of all the patients admitted, respectively. Mean annual incidence was 6.5 per 100,000 children <5 years, 4.5 per 100,000 infants <1 year and 7.8 per 100,000 infants 1-4 years. We found considerable differences between national territorial regions, with majority of cases in most dense regions. The mean length of hospital stay was 9 days, and the incidence peaked in spring (35%) and spring/winter (63%). Coronary aneurysms were reported in 8.5% of patients with a higher male-to-female ratio (3.4:1) and a lower mean age (1.93 years). Reported mortality was 0.4%.

CONCLUSIONS

This is the first large-scale epidemiologic study of KD in Portugal. The highest incidences occurred among male children 1-4 years of age and in spring/winter.

Kawasaki syndrome and factors associated with coronary artery abnormalities in California

BACKGROUND

Kawasaki syndrome (KS) occurs in children <18 years of age and is the leading cause of acquired heart disease among children in the United States. Understanding the epidemiology of KS and factors associated with coronary artery abnormalities (CAA) may lead to timely diagnosis and treatment of KS and could limit CAA.

METHODS

Epidemiologic characteristics, including risk factors for the development of CAA, among KS and incomplete KS patients <18 years of age with onset during 2000-2009 reported by the California Department of Public Health to the Centers for Disease Control and Prevention's national KS surveillance system were analyzed.

RESULTS

A total of 2056 KS and incomplete KS patients <18 years of age were reported during 2000-2009. The median age of patients was 2 years; 60% of patients were male. Of 1818 patients with race information reported, 56% were white and 28% were Asian/Pacific Islander. Ninety-eight percent of patients received intravenous immunoglobulin. Of 1843 patients with information on cardiac complications, 89 (5%) had coronary artery aneurysms and 341 (19%) had CAA. Characteristics associated with the occurrence of CAA in KS patients were male sex, Asian/Pacific Islander race, age <1 year or 9-17 years, and not receiving intravenous immunoglobulin treatment before the fifth day of illness.

CONCLUSIONS

This study suggests that intravenous immunoglobulin treatment before the fifth day of illness may reduce CAA among KS patients. Timely diagnosis and treatment of KS continue to be important in reducing the occurrence of cardiac complications.

Rate, associated factors and outcomes of recurrence of Kawasaki disease in Ontario, Canada

BACKGROUND

Previous studies on recurrence of Kawasaki disease (KD) have mostly been limited to Japan, which has an incidence of KD 8-10-fold higher than North America. The aim of the present study was to determine the rate of KD recurrence for patients in Ontario, to identify factors potentially associated with increased odds of recurrence, and to compare the clinical course and outcomes of index and recurrent KD episodes.

METHODS

Review was undertaken of all patients with recurrence of KD identified in Ontario, Canada, from 1995 to 2006. All patients with recurrence of KD (defined as at least three clinical signs of KD in addition to fever ≥ 5 days), presenting ≥ 14 days after the return to baseline from the index episode were included.

RESULTS

A total of 1010 patients were followed for 5786 patient-years. During this period a total of 17 recurrent episodes in 16 patients were identified at a median of 1.5 years after the initial episode (2 weeks-5 years). Rate of recurrence of KD was 2.9 episodes/1000 patient-years, which is higher than the expected annual incidence of KD in the same age group (26.2/100,000 per year). No factors associated with increased risk of recurrence were identified, perhaps due to the small number of events. Clinical course and outcomes of the index and recurrent KD episodes were similar.

CONCLUSIONS

A previous history of KD should increase the index of suspicion for future episodes of KD to allow for rapid recognition, treatment and to achieve optimal outcomes.

Hospitalizations for Kawasaki syndrome among children in the United States, 1997-2007

BACKGROUND

The present study describes the rate and trends of childhood hospitalizations with Kawasaki syndrome (KS) in the United States.

METHODS

Retrospective analysis of hospitalizations with KS among children <18 years of age in the United States using the Kids' Inpatient Database (1997, 2000, 2003, and 2006) and the Nationwide Inpatient Sample (1998-2007).

RESULTS

The KS-associated hospitalization rate for children <5 years of age was 20.8 (95% CI: 18.5-23.1) per 100,000 children in 2006. Annual rates remained constant during the study period, except for a peak in 2005. In 2006, 76.8% (SE = 0.9%) of an estimated 5523 (SE = 289) KS-associated hospitalizations among children <18 years of age were <5 years of age. The mean age for all children at hospitalization was 3.0 years (SE <0.1); 25.7 months (SE = 0.3) for children <5 years of age, and 24.8 months (SE = 0.4) and 27.1 months (SE = 0.5) for boys and girls, respectively. The rate for boys was higher than that for girls (24.2 [95% CI: 21.3-27.1] and 16.8 [95% CI: 14.7-18.9], respectively). The rate for Asian/Pacific Islander children (30.3 [95% CI: 20.2-40.4]) was the highest among the racial groups.

CONCLUSIONS

The national KS-associated annual hospitalization rate for children <5 years of age from 1997 to 2007 was relatively stable and was similar to previously published rates, except for an increase in 2005. Most hospitalizations were in children <3 years of age with few hospitalizations during the first 2 months of age. Children of Asian/Pacific Islander descent had the highest hospitalization rate.

Early but prolonged gallbladder hydrops in a 7-month-old girl with Kawasaki syndrome: Report of a case

Kawasaki syndrome (KS) is a self-limiting childhood disease. Gallbladder hydrops is an uncommon manifestation of this syndrome, found rarely in infants. We report the case of a 7-month-old girl with KS manifesting as gallbladder hydrops, which resolved spontaneously during follow-up. To our knowledge, this represents the youngest such case ever reported. We discuss the clinical characteristics, radiological features, and outcome of gallbladder hydrops in KS during infancy to help understand this rare complication.

Kawasaki disease: what is the epidemiology telling us about the etiology?

Kawasaki disease (KD) is an important and common inflammatory vasculitis of early childhood with a striking predilection for the coronary arteries. It is the predominant cause of paediatric acquired heart disease in developed countries. Despite 40 years of research, the aetiology of KD remains unknown and consequently there is no diagnostic test and treatment is non-specific and sub-optimal. The consensus is that KD is due to one or more widely distributed infectious agent(s), which evoke an abnormal immunological response in genetically susceptible individuals. The epidemiology of KD has been extensively investigated in many populations and provides much of the supporting evidence for the consensus regarding etiology. These epidemiological data are reviewed here, in the context of the etiopathogenesis. It is suggested that these data provide additional clues regarding the cause of KD and may account for some of the continuing controversies in the field.

Adult Kawasaki disease: report of two cases and literature review

OBJECTIVES

To describe 2 cases of adult Kawasaki Disease (KD) and to review the medical literature to better define the epidemiological, clinical, laboratory, histopathological, cardiovascular, and therapeutic aspects of adult KD compared with pediatric KD.

METHODS

Report of 2 cases, and review of the literature using a Medline search from 1967 to June 2003.

RESULTS

Including our 2 cases, there are 57 reports of adult KD, 74% among patients aged 18 to 30 years. Nine cases of KD associated with human immunodeficiency virus (HIV) infection were described, suggesting that an immunocompromised state may predispose to this syndrome. The incidence of specific diagnostic criteria was roughly similar in adults and in children. However, cheilitis, meningitis, and thrombocytosis were observed in a larger percentage of children, while arthralgia, adenopathy, and liver function abnormality were more common in adults. Although adult KD often was diagnosed after the acute phase, when a significant beneficial effect from gammaglobulin infusion could not be expected, this treatment did appear to shorten the course of the disease. Coronary aneurysms were less frequent in adults than in children. Prognosis was more favorable in adults, with less cardiovascular complications and no deaths.

CONCLUSIONS

Adult KD is a rare condition, which may go unrecognized. Other known disease processes with similar clinical presentations such as hypersensitivity drug reaction and toxic shock syndrome must be ruled out. For adult KD, exclusion criteria such as absence of hypotension, visceral impairment, staphylococcal infection, and any drug able to induce a drug hypersensitivity reaction are suggestive of the diagnosis, in the presence of the inclusion criteria, rash, conjunctival effusion, oropharynx changes, extremity changes, or adenopathy.

Kawasaki syndrome in Hawaii

OBJECTIVE

To describe the incidence and epidemiology of Kawasaki syndrome (KS) in Hawaii.

METHODS

Retrospective analysis of the State Inpatient Database for Hawaii residents hospitalized with KS during 1996 through 2001.

RESULTS

During 1996 through 2001, 267 persons younger than 18 years of age living in Hawaii were hospitalized with KS; 226 (84.6%) were younger than 5 years of age. The average annual incidence for KS was 45.2 per 100,000 children younger than 5 years of age. The incidence was higher for children younger than 1 year of age than for those 1-4 years of age (74.3 and 37.5 per 100,000). The KS incidence for Asian and Pacific Islander children and for White children was 70.9 and 35.3 per 100,000, respectively. Incidence was highest among Japanese American children living in Hawaii (197.7 per 100,000). Honolulu County had the most KS patients (85.0%) and the highest incidence (53.1 per 100,000) among Hawaii counties. For children younger than 5 years of age hospitalized with KS, the median length of stay was 2 days, and the median hospital charge was $9379.

CONCLUSION

During 1996 through 2001, the annual incidence rate for KS among children younger than 5 years of age in Hawaii was the highest in the United States. The incidence among Japanese American children in Hawaii was higher than that among other racial groups in the state and when compared with children living in Japan.

Seasonality and temporal clustering of Kawasaki syndrome

BACKGROUND

The distribution of a syndrome in space and time may suggest clues to its etiology. The cause of Kawasaki syndrome, a systemic vasculitis of infants and children, is unknown, but an infectious etiology is suspected.

METHODS

Seasonality and clustering of Kawasaki syndrome cases were studied in Japanese children with Kawasaki syndrome reported in nationwide surveys in Japan. Excluding the years that contained the 3 major nationwide epidemics, 84,829 cases during a 14-year period (1987-2000) were analyzed. To assess seasonality, we calculated mean monthly incidence during the study period for eastern and western Japan and for each of the 47 prefectures. To assess clustering, we compared the number of cases per day (daily incidence) with a simulated distribution (Monte Carlo analysis).

RESULTS

Marked spatial and temporal patterns were noted in both the seasonality and deviations from the average number of Kawasaki syndrome cases in Japan. Seasonality was bimodal with peaks in January and June/July and a nadir in October. This pattern was consistent throughout Japan and during the entire 14-year period. Some years produced very high or low numbers of cases, but the overall variability was consistent throughout the entire country. Temporal clustering of Kawasaki syndrome cases was detected with nationwide outbreaks.

CONCLUSIONS

Kawasaki syndrome has a pronounced seasonality in Japan that is consistent throughout the length of the Japanese archipelago. Temporal clustering of cases combined with marked seasonality suggests an environmental trigger for this clinical syndrome.

Épidémiologie de la maladie de Kawasaki en Guadeloupe

OBJECTIVE

To study the incidence of Kawasaki disease in the population of the French West Indies.

METHODS

Fifty-six children where enrolled between January 1, 1995 and December 31, 2000), in this retrospective study in Guadeloupe (French West Indies), according to the diagnostic criteria of the American Heart Association.

RESULTS

There were 31 boys and 25 girls. Their mean age at the time of diagnosis was 26.5 +/- 22 months. The mean incidence was 25.4/100 000 children aged under 5, per year. Cardiac involvement was noted in 17.8% of the cases during the first 3 months, with good outcome in all the children followed-up.

CONCLUSION

The incidence of Kawasaki disease in Guadeloupe is high. The absence of epidemiological, clinical or biological predictive criteria of cardiac involvement should prompt the early use of immunoglobulins, notably in atypical presentations of the disease.

Kawasaki syndrome hospitalizations in Ireland, 1996 through 2000

OBJECTIVE

To describe the epidemiologic characteristics and estimate the incidence of Kawasaki syndrome (KS) among children in Ireland.

METHODS

Hospital discharge records with a KS diagnosis among patients <18 years of age were examined using Ireland's Hospital In-Patient Enquiry database for 1996 through 2000.

RESULTS

During the study period 265 hospitalizations associated with KS among children <18 years of age were recorded in Ireland. Of those, 194 (73%) occurred among children <5 years of age. The median age of patients at admission was 2 years. The average annual KS hospitalization rate for children <5 years of age was 15.2 per 100 000 children, and among that group the hospitalization rate was higher for infants <1 year of age than for children 1 to 4 years of age (19.7 and 16.0 per 100 000 children, respectively). Most KS hospitalizations occurred among children <5 years of age and among boys. The highest monthly number of hospitalizations occurred during the months of November through January. No deaths associated with KS were reported among hospitalized children.

CONCLUSION

Hospital discharge data provide useful information on the epidemiology of KS in Ireland. The hospitalization rate for KS in Ireland is similar to rates in the United States and may be higher than those in other European countries, although the European studies differ in methodologies and time periods.

Kawasaki syndrome hospitalizations in the United States, 1997 and 2000

OBJECTIVE

To estimate the incidence and describe the epidemiologic characteristics of Kawasaki syndrome (KS) among children in the United States.

METHODS

Hospital discharge records with a KS diagnosis among patients <18 years of age were obtained from the 1997 and 2000 Kids' Inpatient Database and weighted to estimate the number and rate of KS-associated hospitalizations for the United States.

RESULTS

In 2000, approximately 4248 hospitalizations associated with KS occurred in the United States, and the median age of patients at admission was 2 years. Children <5 years of age accounted for 3277 of these KS hospitalizations (77%) and had a KS hospitalization rate of 17.1 per 100,000 children. This rate was similar to the 1997 rate of 17.6 per 100,000 children. The KS hospitalization rate was significantly higher for infants <1 year of age than for children 1 to 4 years of age (19.8 and 16.4 per 100,000 children, respectively). The rate of KS hospitalizations among children aged <5 years was highest among Asian and Pacific Islander children and was followed by the rate for black children (39.0 and 19.7 per 100,000 children, respectively). No deaths associated with KS were reported among hospitalized children. The median charge for a KS hospitalization was 7779 dollars (mean 10,725 dollars) and the total annual charges for KS hospitalizations in 2000 were approximately 35 million dollars among children <5 years of age.

CONCLUSIONS

Among children <5 years of age, the annual KS-associated hospitalization rates were similar for 1997 and 2000. The epidemiologic characteristics and hospitalization rates for KS at a national level were consistent with those reported from earlier studies, suggesting that the incidence for KS has not markedly changed in the United States during the past decade.

School-aged children with Kawasaki disease: high incidence of cervical lymphadenopathy and coronary artery involvement

OBJECTIVE

We describe 10 school-aged children with Kawasaki disease (KD) with a high incidence of cervical lymphadenopathy and coronary abnormality.

METHODS

Based on a database of 1002 children with KD in Chang Gung Children's Hospital from January 1983 to March 2001, 10 (1%) school-aged patients (five boys, five girls) who met the diagnostic criteria of KD were included for analysis.

RESULTS

Cervical lymphadenopathy was noted in all (100%) of these patients. Unilateral neck mass mimicking acute suppurative infections not responding to antibiotic therapy was the initial presentation in nine (90%) of the 10 patients. The mean interval between disease onset and diagnosis was 9.9 +/- 3.3 days (range, 6-15 days). Seven (70%) of these patients responded to one course of high-dose intravenous immunoglobulin (IVIG) therapy (2 g/kg) and oral aspirin (80-100 mg/kg per day), two (20%) required a second course of IVIG, and one (10%) responded to high-dose aspirin treatment only. Coronary artery abnormality (dilatation or aneurysm) was documented by echocardiography in seven (70%) patients (four boys, three girls). In six patients, the coronary artery abnormalities resolved in 1 year, while one patient had persistent right coronary artery aneurysm, which necessitated continued anticoagulant and low-dose aspirin therapy.

CONCLUSION

The incidence of school-aged children among patients with KD is about 1% in our hospital. These patients are notable for the high incidence of initial manifestations of unilateral neck mass and coronary artery involvement. This disease should be listed as the differential diagnosis in school-aged children presenting with fever and neck mass that do not respond to antibiotic therapy.

Epidemiologic characteristics of children hospitalized for Kawasaki disease in California

OBJECTIVE

To evaluate the epidemiologic pattern of Kawasaki disease (KD) in California.

METHODS

Statewide hospital discharge data from California from 1995 through 1999 were used. Children 0 through 17 years old who had a discharge diagnosis of KD (by ICD9-CM code 446.1) were identified. Precipitation and temperature data of climate divisions of the state were used to determine their possible association with incidences of KD. Multiple regression analysis was performed to evaluate factors related to the KD incidence of the counties.

RESULTS

There were 2,325 patients admitted to 194 California hospitals during the 5-year study period. The male-to-female ratio was 1.62. Median age was 30 months; peak incidence by year of age was in the second year of life. Overall annual incidence was 15.3 cases per 100,000 children <5 years old and 3.2 cases per 100,000 children 5 through 9 years old. Compared with 1995 and 1996, the incidence for children <5 years old increased by 30% in 1997 and 1998 (P < 0.01). In contrast the incidence for children 5 through 9 years old remained relatively unchanged. Asians had the highest incidence of 35.3 cases per 100,000 children <5 years old, followed by blacks (24.6) and whites (14.7) (P < 0.01). The number of cases peaked in March and had its nadir in September. In a multiple regression analysis, no association was found between KD incidence and temperature or precipitation. KD incidence was not related to average family size, proportion of Asians in the population, population density or whether the county is in northern or southern California. There was no in hospital death. The median length of hospital stay was 2 days.

CONCLUSIONS

The incidence of Kawasaki disease in patients <5 years old increased in 1997 and 1998. Asians had the highest KD incidence compared with other races. Peak incidence was in March, and the lowest incidence was in September. KD incidence was not associated with temperature, precipitation, family size or population density.

Hospitalizations for Kawasaki disease among children in the United States, 1988-1997

OBJECTIVE

To evaluate the epidemiologic pattern of Kawasaki disease (KD) in the United States over 10 years.

METHODS

The National Inpatient Sample, a stratified national sample of >900 hospitals in 22 states of the United States, was used. Data on hospital discharges from 1988-1997 were analyzed. Patients <18 years of age with a discharge diagnosis of KD were identified.

RESULTS

There were 6442 patients with KD admitted to 651 hospitals. Median age at hospital admission was 2 years. Peak incidence by year of age was 1 year old. Children <2 years old accounted for 36.6% of all cases; <5 years old, 75.6%; and <10 years old, 95.6%. The age distribution seems to be wider than reported from Japan. The incidence for children <5 years old was 8.1 per 100 000 people in 1988, and increased to 18.5 in 1997. There were 3905 males (60.6%) and 2537 females (39.4%), for a male-to-female ratio of 1.54. The incidences were higher in winter and spring (December to May) and dropped to a nadir between July and September. No apparent change in seasonal pattern was noted over 10 years. The South census region showed a seasonal change 2 to 3 months ahead of other regions. The overall in-hospital mortality rate was 0.17%. The mortality rate in children > or =10 years (1.4%) was significantly higher in than children <10 years (0.11%).

CONCLUSIONS

KD affects mainly children under 5 years of age, with a peak incidence in children 1 to 2 years of age. The incidence of KD was rising over the study period. There is a male predominance. Although KD occurs year-round, the lowest incidence is seen from July through September. Such seasonal variation did not change over the 10 years. Seasonal pattern may vary in different geographic regions. Mortality from KD is rare, although children > or =10 years are at higher risk.

Pharmacological therapy for patients with Kawasaki disease

Kawasaki disease is a systemic vasculitis of unknown aetiology that has been reported worldwide since its initial description in Japanese children. The most significant sequelae of acute Kawasaki disease are related to the inflammation of small to medium sized arteries and, in particular, the development of coronary artery aneurysms. Because the aetiology is unknown, pharmacological therapy is nonspecific and directed towards modulation of the inflammatory response and inhibition of platelet activation with the aim of preventing coronary artery aneurysms. In the US, the recommended treatment for Kawasaki disease in the acute phase is a single, high dose of intravenous gammaglobulin (2 g/kg) and high dose aspirin (80 to 100 mg/kg/day). Use of this regimen has resulted in a significant decrease in the incidence of coronary artery abnormalities. Although the American Heart Association currently recommends high dose aspirin, moderate doses are used in Japan and the optimal dose of aspirin is not known. There has been renewed interest in the use of corticosteroids in the treatment of acute Kawasaki disease: however, their precise role remains unclear. Newer antiplatelet agents have also shown some promise in the treatment of patients with coronary artery aneurysms. Long term pharmacological therapy consists primarily of anticoagulation in patients with persistent coronary artery abnormalities. In this review, current recommendations for pharmacological therapy in Kawasaki disease are reviewed and some of the controversies in management of this disease, including management of patients who do not respond to initial therapy and the role of corticosteroids in the acute setting, are outlined.

Kawasaki disease--Indian perspective

Kawasaki disease is a syndrome of unknown etiology affecting children below 5 years of age and is a leading cause of acquired heart disease in many developed countries. Incidence of this disease in India is extremely low as evidenced by the meagre case reports. Complications due to this disease in Indian patients are still rarer. Here we report two cases of Kawasaki disease both of whom had a benign course. A comparison of this disease in Indian and Western literature shows that the incidence of cardiac complications in the Indian patients is about 10% while in the west it is reported at around 30%. This paucity of complications in the Indian patients may be the reason of poor reporting of this disease in our country.

Kawasaki-like syndromes associated with human immunodeficiency virus infection

Kawasaki disease is an acute febrile vasculitic syndrome of early childhood. It is very rarely seen in adults. Among the adult patients with Kawasaki disease who have been described, a disproportionate number are infected with human immunodeficiency virus (HIV). This suggests that the immunocompromised state may predispose individuals to this syndrome. We report our experience with 2 HIV-positive patients who presented with Kawasaki-like syndromes and review the published literature on HIV-positive patients with similar syndromes.

Relationship of climate, ethnicity and socioeconomic status to Kawasaki disease in San Diego County, 1994 through 1998

BACKGROUND

Kawasaki disease (KD) is the most common cause of acquired heart disease in children in the United States. By monitoring trends in patient numbers and demographics during a 5-year period, we were able to explore the relationship between climate, ethnicity, socioeconomic status and susceptibility to KD.

METHODS

We conducted active surveillance for all patients hospitalized with KD in San Diego County from 1994 through 1998. Data on seasonal variation in monthly rainfall and temperature were obtained from the US Meteorological Service. Patient sex, age, date of admission and self-reported ethnicity were identified from patient medical records. Socioeconomic status was assessed on the basis of insurance status among patients hospitalized at a single institution.

RESULTS

During the 5-year period there were 169 cases of KD in San Diego County. The overall annual incidence of KD in children < 5 years of age ranged from 8.0 to 15.4/100 000. KD incidence was inversely associated with average monthly temperature (r = -0.47, P < 0.001) and positively associated with average monthly precipitation (r = -0.52, P < 0.001). Asian/Pacific Islanders < 5 years of age were 2.7 times as likely and Hispanics were one-third as likely to be hospitalized for KD than children from all other ethnic groups combined. Children with private or military insurance in all ethnic groups were more likely to have a diagnosis of KD than children with government assistance or no insurance. After controlling for insurance status, only Asian/Pacific Islanders remained at increased risk (rate ratio, 2.14) for KD relative to all other ethnic groups combined.

CONCLUSION

KD is a common childhood vasculitis of unknown etiology. The skewed ethnic distribution and seasonality are consistent with the hypothesis that KD is an infectious disease that is influenced by environmental and genetic factors.

Kawasaki disease in older children and adolescents

Features of 28 patients older than 8 years of age with acute Kawasaki disease were reviewed. Observations included a predominance of male patients and white patients, delays in diagnosis of acute Kawasaki disease, presence of additional signs and symptoms, and a substantial incidence of coronary artery abnormalities (21%) including mild transient changes.

[Pathology of large vessel vasculitides]

INTRODUCTION

Vasculitides can be classified according to the size of the involved vessels. The pathological patterns of large vessel vasculitides are presented here.

CURRENT KNOWLEDGE AND KEY POINTS

They concern Buerger's disease, temporal arteritis, Takayasu's disease, Behçet's disease, infectious arteritides, rheumatologic and miscellaneous diseases. Buerger's disease is a thrombotic arteriopathy with no arterial wall involvement. Temporal arteritis and Takayasu's disease belong to the group of giant cell arteritides. In temporal arteritis, the inflammation is prominent in the internal part of the media and is aggressive for the arterial wall. In Takayasu's disease, the external part of the media is prominently involved. The fibrous thickening of the arterial wall with stenosis is characteristic. Behçet's disease can involve the large arteries with a risk of arterial rupture. Infectious arteritides are not unfrequent in vascular surgery and in previous arterial lesions. Rheumatologic diseases can result in aortitis with aortic incompetence.

FUTURE PROSPECTS AND PROJECTS

These diseases have pathological characteristics which contribute to diagnosis. However, a clearcut classification of vasculitides will come from the precise knowledge of their etiology.

Kawasaki syndrome among American Indian and Alaska Native children, 1980 through 1995

BACKGROUND

Kawasaki syndrome (KS) is a leading cause of acquired heart disease among US children, but the epidemiologic features of KS among American Indian and Alaska Native (AI/AN) children have not been described.

METHODS

We examined Indian Health Service computerized records of hospital discharges for AI/AN children <18 years of age with KS during 1980 through 1995.

RESULTS

During 1980 through 1995, 85 AI/AN children were reported with a hospitalization for KS; 10 of the children had an additional KS hospitalization record within 5 months. The average annual KS hospitalization rate for children <5 years of age, based on first KS hospitalization only, was 4.3 cases per 100000 children; the rate for children age <1 year (n = 21) was 8.6 per 100000 and for children ages 1 to 4 years was 3.6 per 100000. The annual rates for children < 5 years of age ranged from 0 to 8.5 per 100000 children. KS hospitalizations for children peaked in January and February; 50.6% of the children were hospitalized during January through April. The overall median length of hospital stay was 4 days (range, 1 to 29 days); the median duration decreased from 8 days from 1980 through 1982 to 4 days from 1993 through 1995.

CONCLUSIONS

The overall annual hospitalization rate of KS among AI/AN children <5 years of age was slightly lower than rates for several majority white populations in the United States. (4.6 to 15.2 cases per 100000) and much lower than rates for blacks and Asians/Pacific Islanders.

Recurrent Kawasaki disease

Kawasaki disease (mucocutaneous lymph node syndrome) is a disease of unknown aetiology characterised by vasculitis which may affect the coronary arteries. Young children are most commonly affected although the disease has been described in adults. We report a case of recurrent Kawasaki disease which presented to an oral medicine clinic, where early recognition prompted appropriate management.

Kawasaki disease and the T-cell antigen receptor

We investigated the evidence for an infectious etiology of Kawasaki disease (KD), an acute vasculitis of unknown etiology, by assessing the effects of KD on the T cell antigen receptor variable beta region families (V beta). Using 3-color flow cytometry, we studied KD patients pre- and post-intravenous gamma globulin (IVIG) therapy and at > 40 days post therapy, additionally comparing them to matched pediatric control patients (PCC) and their own healthy parents (one parent/KD child). Of all the V beta families examined, only V beta 2 exhibited statistically significant differences, between the pre- and post-IVIG samples and preIVIG and parent samples. No associations were found between V beta 2 findings and T cell memory, activation, or adhesion markers. For 2 KD patients, 4 parents, and 1 PCC participant, > 15% of resting CD8+ lymphocytes and > 15% of blastic CD8+ lymphocytes expressed a single V beta family, which varied by individual, without similar expansions in the CD4+ cell populations. One of the participants with this abnormality was the only one with significant cardiac abnormalities. For all participants with the V beta abnormality, other T-cell abnormalities were extensive and involved both CD4+ and CD8+ cells. We suggest that V beta 2 changes do occur in KD, as previously reported. However, these may not be involved in disease pathogenesis. Other V beta changes also occur. Those occurring in parents may reflect asymptomatic reinfection with an infectious agent causing KD. Further, some KD patients may have restricted cytotoxic T-cell responses to that as yet unidentified agent; this restricted response may be associated with more severe cardiac involvement.

Kawasaki disease: clustering in infants and pre-school children in Kuwait

We report five children who presented within a 2-month period and who all fulfilled at least four of the five criteria essential for the diagnosis of Kawasaki disease. They were three girls and two boys aged between 5 months and 3 years. Two of them had atypical presentations; one mimicked infectious mononucleosis and the other had severe abdominal pain and was later found to have hydrops of the gall bladder. Although treatment was started within the 1st 10 days of the illness, echocardiographic changes were found in three cases: one had myocarditis and the other two showed in the coronary arteries. The occurrence of five cases in such as short period of time is similar to the clusterings of Kawasaki disease reported in Japan and the USA, and strongly suggests the presence of a causative infectious agent.

A case-control study of recurrent Kawasaki disease using the database of the nationwide surveys in Japan

In spite of many reports of recurrent Kawasaki disease, little information about the risk factors associated with recurrence is available. We conducted a case-control study on 150 cases of recurrent Kawasaki disease and 1173 pair-matched controls selected from the database of nationwide surveys of the same disease in Japan. Items observed were: sex, age, use of intravenous gamma globulin, and cardiac sequelae at the first episode. Sex and cardiac sequelae did not affect the risk of recurrence. One- to 2-year-old children were more likely to be affected again than infants (odds ratio [OR] = 1.42; 95% confidence interval [CI], 0.94-2.13), and children who were 3 years of age or older were less likely to experience a recurrence than infants (OR = 0.59; 95% CI, 0.34-1.02). Intravenous gamma globulin therapy at the first episode increased the risk for recurrence of Kawasaki disease within 12 months (OR = 2.66, 95% CI, 1.06-6.66). However, it did not affect recurrences 12 months after the first episode (OR = 1.02; 95% CI, 0.53-1.97).

CONCLUSION

Patients with Kawasaki disease treated with intravenous gamma globulin are 2.66 times as likely to be affected by the disease again within 12 months as those treated without intravenous gamma globulin.

Evidence for a superantigen mediated process in Kawasaki disease

The clinical, pathological, and immunological similarities between Kawasaki disease and the staphylococcal and streptococcal toxic shock syndromes suggest that a superantigen toxin may be involved in the pathogenesis of the disease. The V beta repertoire of peripheral blood mononuclear cells from 21 children with Kawasaki disease, 28 children with other illnesses, and 22 healthy controls were examined using monoclonal antibodies to V beta 2, 5, 8, 12, and 19. The mean percentage of V beta 2 expressing T cells in the patients with Kawasaki disease was increased when compared with healthy controls or children with other illnesses. The mean percentages of V beta 5, 8, 12, and 19 expressing T cells were also increased in the patients with Kawasaki disease compared with healthy controls, but were not increased when compared with children with other illnesses. The selective use of V beta 2 supports the hypothesis that a superantigen is involved in the pathogenesis of Kawasaki disease.

Surgical presentation of Kawasaki disease (mucocutaneous lymph node syndrome)

Five patients with Kawasaki disease (mucocutaneous lymph node syndrome) are reported whose varied presentations included acute abdominal pain, peripheral arterial aneurysms, digital gangrene and sterile pyuria and whose presenting pathology ranged from hydrops of the gallbladder to enteric pseudo-obstruction. As the complications of the disease can usually be managed without resort to surgery, which is associated with a mortality rate of up to 25 per cent, the recognition of Kawasaki disease will prevent hazardous and unnecessary laparotomy.

Mucocutaneous lymph node syndrome (Kawasaki disease)

Mucocutaneous lymph node syndrome has rarely been reported in the dental literature despite the orofacial features characteristic of the disease. A case is reported in which the cardinal signs were present: erythema of the oral mucosa, cervical lymphadenopathy, conjunctivitis, pyrexia, and desquamation of the skin of the hands and feet. In addition, hydrops of the gallbladder and cardiac disorder were also found. The patient may first seek treatment by the dental practitioner, by whom the diagnosis may be made. Attention is drawn to the possibility of cardiac abnormalities that may influence dental treatment.

Hydrops of the gallbladder associated with Kawasaki syndrome

Hydrops of the gallbladder is recognized as a major component of the abdominal crisis occurring in children with Kawasaki syndrome. Sixteen patients with hydrops of the gallbladder secondary to Kawasaki syndrome have been diagnosed and treated at the Childrens Hospital of Los Angeles. One patient was treated by cholecystectomy and 15 nonoperatively without untoward sequelae. Nonoperative management with serial ultrasonic evaluation and close clinical monitoring is a safe method of treatment for this entity. Pathologic and clinical data are presented and discussed. Review of diagnosis and treatment of 41 reported cases of hydrops of the gallbladder in Kawasaki syndrome from the English language literature is also presented.