Kawasaki syndrome: association with the application of rug shampoo

The etiologies of Kawasaki disease

Kawasaki disease (KD) is a systemic vasculitis that affects young children and can result in coronary artery aneurysms. The etiology is currently unknown, but new clues from the epidemiology of KD in Japan, the country of highest incidence, are beginning to shed light on what may trigger this acute inflammatory condition. Additional clues from the global changes in KD incidence during the COVID-19 pandemic, coupled with a new birth cohort study from Japan, point to the potential role of person-to-person transmission of an infectious agent. However, the rising incidence of KD in Japan, with coherent waves across the entire country, points to an increasing intensity of exposure that cannot be explained by person-to-person spread. This Review discusses new and historical observations that guide us toward a better understanding of KD etiology and explores hypotheses and interpretations that can provide direction for future investigations. Once the etiology of KD is determined, accurate diagnostic tests will become available, and new, less expensive, and more effective targeted therapies will likely be possible. Clearly, solving the mystery of the etiologies of KD remains a priority for pediatric research.

Exposures associated with the onset of Kawasaki disease in infancy from the Japan Environment and Children's Study

Kawasaki disease (KD) is an acute systemic vasculitis that mainly affects infants and young children. The etiology of KD has been discussed for several decades; however, no reproducible risk factors have yet been proven. We used the Japan Environment and Children’s Study data to explore the association between the causal effects of exposure during the fetal and neonatal periods and KD onset. The Japan Environment and Children’s Study, a nationwide birth cohort study, has followed approximately 100,000 children since 2011. We obtained data on exposures and outcomes from the first trimester to 12 months after birth. Finally, we included 90,486 children who were followed for 12 months. Among them, 343 children developed KD. Multivariate logistic regression revealed that insufficient intake of folic acid during pregnancy (odds ratio [OR], 1.37; 95% CI 1.08–1.74), maternal thyroid disease during pregnancy (OR, 2.03; 95% CI 1.04–3.94), and presence of siblings (OR, 1.33; 95% CI 1.06–1.67) were associated with KD onset in infancy. In this study, we identified three exposures as risk factors for KD. Further well-designed studies are needed to confirm a causal relationship between these exposures and KD onset.

Multisystem inflammatory syndrome in children: Is there a linkage to Kawasaki disease?

Since 1967, researches have hunted for an etiology for Kawasaki Disease (KD). Meanwhile, the 2019 Coronavirus Disease (COVID-19) pandemic has produced a strange new illness termed multisystem inflammatory syndrome in children (MIS-C) and raised hopes that a cause for KD may be identified. This current review paper discusses KD and its potential connection to pediatric COVID-19 and MIS-C illness.

Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association

BACKGROUND

Kawasaki disease is an acute vasculitis of childhood that leads to coronary artery aneurysms in ≈25% of untreated cases. It has been reported worldwide and is the leading cause of acquired heart disease in children in developed countries.

METHODS AND RESULTS

To revise the previous American Heart Association guidelines, a multidisciplinary writing group of experts was convened to review and appraise available evidence and practice-based opinion, as well as to provide updated recommendations for diagnosis, treatment of the acute illness, and long-term management. Although the cause remains unknown, discussion sections highlight new insights into the epidemiology, genetics, pathogenesis, pathology, natural history, and long-term outcomes. Prompt diagnosis is essential, and an updated algorithm defines supplemental information to be used to assist the diagnosis when classic clinical criteria are incomplete. Although intravenous immune globulin is the mainstay of initial treatment, the role for additional primary therapy in selected patients is discussed. Approximately 10% to 20% of patients do not respond to initial intravenous immune globulin, and recommendations for additional therapies are provided. Careful initial management of evolving coronary artery abnormalities is essential, necessitating an increased frequency of assessments and escalation of thromboprophylaxis. Risk stratification for long-term management is based primarily on maximal coronary artery luminal dimensions, normalized as Z scores, and is calibrated to both past and current involvement. Patients with aneurysms require life-long and uninterrupted cardiology follow-up.

CONCLUSIONS

These recommendations provide updated and best evidence-based guidance to healthcare providers who diagnose and manage Kawasaki disease, but clinical decision making should be individualized to specific patient circumstances.

Kawasaki disease: novel insights into etiology and genetic susceptibility

Kawasaki disease (KD) is a vasculitis of young childhood that particularly affects the coronary arteries. Molecular analysis of the oligoclonal IgA response in acute KD led to production of synthetic KD antibodies. These antibodies identify intracytoplasmic inclusion bodies in acute KD tissues. Light and electron microscopic studies indicate that the inclusion bodies are consistent with aggregates of viral proteins and RNA. Advances in molecular genetic analysis and completion of the Human Genome Project have sparked a worldwide effort to identify genes associated with KD. A polymorphism of one such gene, ITPKC, a negative regulator of T cell activation, confers susceptibility to KD in Japanese populations and increases the risk of developing coronary artery abnormalities in both Japanese and U.S. children. Identification of the etiologic agent and of genes conferring KD susceptibility are the best means of improving diagnosis and therapy and enabling prevention of this important disorder of childhood.

Kawasaki disease: aetiopathogenesis and therapeutic utility of intravenous immunoglobulin

Kawasaki disease (KD) is an acute febrile childhood vasculitis, associated with the development of coronary artery abnormalities in 25–30% of untreated patients. The aetiopathogenesis is not well known but it is accepted that an undefined infectious trigger in genetically predisposed individuals results in the disease. KD is characterized by an endothelial cell injury, which could be due to abnormal cytokine production and to generation of cytotoxic antibodies against the endothelial cells. Intravenous immunoglobulin IVIG is an effective treatment in preventing the occurrence of coronary artery abnormalities in KD. Several mechanisms may explain the anti-inflammatory effects of IVIG in this disease. They include modification of the cytokine balance, and alteration on both the differentiation and the function of monocytes/macrophages, neutrophils and lymphocytes.

Searching for the cause of Kawasaki disease--cytoplasmic inclusion bodies provide new insight

Although Kawasaki disease (KD) is the most common cause of acquired heart disease in children in the developed world, its aetiology remains unknown. In this Opinion, Anne Rowley and colleagues discuss evidence, including recently identified cytoplasmic inclusion bodies, which suggests that KD is caused by an infectious agent.

Kawasaki disease (KD) has emerged as the most common cause of acquired heart disease in children in the developed world. The cause of KD remains unknown, although an as-yet unidentified infectious agent might be responsible. By determining the causative agent, we can improve diagnosis, therapy and prevention of KD. Recently, identification of an antigen-driven IgA response that was directed at cytoplasmic inclusion bodies in KD tissues has provided new insights that could unlock the mysteries of KD.

Delayed diagnosis of Kawasaki syndrome: an analysis of the problem

OBJECTIVE

Most pediatric providers in Colorado are familiar with Kawasaki syndrome (KS). However, in a recent outbreak, 30% of cases were diagnosed after illness day 10. We hypothesized that these children saw providers who were not familiar with KS, were given antibiotics for other diagnoses that delayed identification, had access-to-care issues, or presented atypically.

METHODS

A retrospective chart review of 106 consecutive KS cases seen at the Children's Hospital in Denver during 1994-2000 was conducted.

RESULTS

Twenty-five of 106 children (23.6%) were diagnosed after day 10 of illness (delayed-diagnosis group [DDG]), and these 25 cases were compared with 81 cases diagnosed on or before day 10 (early-diagnosis group [EDG]). There were no differences between patients in the DDG and EDG in age, gender, number of visits, specialty of the primary care physician, time to the first medical visit, number of antibiotics received, coronary artery abnormalities, white blood cell count, or erythrocyte sedimentation rate. Patients in the DDG had significantly more days of fever, rash, red eyes, and oral changes. A platelet count of >450000/mm3 occurred more often in the DDG (56%) than the EDG (30%). After additional analysis, patients in the EDG had close clustering of symptom onset in the first few days of illness, but patients in the DDG had onset of symptoms scattered over 9 days. Patients in the DDG were 2.8 times more likely to have coronary artery aneurysms than patients in the EDG (DDG: 24%; EDG: 8.6%).

CONCLUSIONS

Diagnosis after the 10th day of illness was not linked to type of medical provider, number of antibiotics received, or number of physician visits. Patients in the DDG exhibited the typical features of KS, but the onset of their symptoms was dispersed over time as opposed to the close clustering of symptoms in the EDG. Because coronary artery aneurysms occurred significantly more often in the patients in the DDG, more education is needed to teach health care providers to have a high index of suspicion for KS in young children presenting with fever/rash illnesses.

Kawasaki syndrome

Kawasaki syndrome is an acute, self-limited vasculitis that occurs in children of all ages and presents a challenge for the clinician: the disorder can be difficult to recognise; there is no diagnostic laboratory test; there is an extremely effective therapy; and there is a 25% chance of serious cardiovascular damage if the treatment is not given early in the course of the disease. This review includes discussion of the history of the syndrome, the diagnostic challenges, epidemiology, aetiology, pathology, immunopathogenesis, therapy, genetic influences, and the long-term cardiovascular sequelae.

[Systemic necrotizing vasculitides: classifications and therapeutic strategies]

OBJECTIVES

The knowledge of systemic necrotizing vasculitides improved since new classifications have been established along with a better understanding of pathogenesis of the diseases. The major vasculitides are described herein.

CURRENT KNOWLEDGE AND KEY POINTS

Pathogenesis plays now a major role for classifying diseases and influences the diagnostic strategies. The prospective therapeutic trials established by French and European groups are largely based on our better knowledge of the diseases.

FUTURE PROSPECTS AND PROJECTS

Despite the good results obtained with and demonstrated in prospective trials, the vasculitides remain severe and deserve new studies testing new drugs but also strategies based on prognostic factors and scores which should play a major role in treatments decision.

Investigation of Kawasaki syndrome risk factors in Colorado

Risk factors for Kawasaki syndrome (KS) were evaluated through a case-control study during an investigation of a KS cluster in Denver, CO. KS was associated with a humidifier in the child's room (odds ratio, 7.3; 95% confidence interval, 1.8 to 29.3) and possibly with an antecedent respiratory illness. The use of humidifiers should be further investigated as part of future studies of KS.

Legionella-like and other amoebal pathogens as agents of community-acquired pneumonia

We tested serum specimens from three groups of patients with pneumonia by indirect immunofluorescence against Legionella-like amoebal pathogens (LLAPs) 1-7, 9, 10, 12, 13; Parachlamydia acanthamoeba strains BN 9 and Hall's coccus; and Afipia felis. We found that LLAPs play a role (albeit an infrequent one) in community-acquired pneumonia, usually as a co-pathogen but sometimes as the sole identified pathogen.

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 syndrome

Kawasaki syndrome is a fascinating worldwide illness of young children. This acute self-limited vasculitis has become the most common cause of acquired heart disease in children in the United States and Japan. KS causes significant coronary artery disease that may lead to myocardial infarction and sudden death. Clinical and epidemiologic features of KS support an infectious cause, but the etiology remains unknown. Clearly, additional research on the cause of KS and its pathogenesis is needed urgently to allow for improved diagnosis; more specific therapy; and, ultimately, prevention of the disorder.

Kawasaki syndrome

Kawasaki syndrome (KS) is an acute, sometimes fatal vasculitis of young children. KS has replaced acute rheumatic fever as the most common cause of acquired heart disease in children in the United States. The illness is manifested by prolonged fever, conjunctival injection, enanthem, exanthem, erythema and swelling of the hands and feet, and cervical adenopathy. These acute features of illness are self-limiting, but coronary artery abnormalities occur in 20% of untreated patients. The etiology of the illness is unknown, but its clinical and epidemiologic features are most consistent with an infectious cause. Common cardiovascular manifestations of the illness include myocarditis, pericardial effusion, and coronary artery aneurysm formation. Treatment with intravenous gamma globulin (IVGG) and aspirin within the first 10 days of illness reduces the prevalence of coronary artery abnormalities from 20% in those treated with aspirin alone to 4%. Patients who develop coronary artery aneurysms, particularly those who develop giant coronary artery aneurysms, may suffer myocardial infarction secondary to thrombosis or stenosis in the abnormal vessel. Additional research to determine the cause of KS is urgently needed to allow for improved diagnosis, more specific therapy, and prevention of the disorder.

Passive surveillance for Kawasaki disease in San Diego County

BACKGROUND

Kawasaki disease (KD) is the most common cause of acquired heart disease in children in the United States. Epidemiologic surveillance is conducted to monitor baseline incidence of the disease and to identify epidemics. The aim of this study was to evaluate a passive surveillance system for reporting cases of KD in San Diego County to the local, state and national health authorities.

METHODS

We performed a retrospective review of a 2-year period to identify the number of patients who met criteria of the Centers for Disease Control and Prevention for diagnosis of KD and who were successfully reported to the county, state and national databases.

RESULTS

The total number of KD patients for 1994 and 1995 was determined by retrospective review of medical record discharge diagnosis codes. Of the 28 San Diego County residents diagnosed with KD in 1994, 24 (86%) met CDC criteria and 15 (63%) of these eligible patients were reported to the county and state health authorities. Of the 41 residents in 1995, 34 (83%) met CDC criteria and 22 (65%) were reported to the above agencies. No patient in either 1994 or 1995 was reported by local or state health authorities to the CDC.

CONCLUSION

Passive surveillance for KD in San Diego County resulted in the reporting of approximately two-thirds of the eligible patients at the county and state levels but completely failed to report any documented cases to the CDC. Implementation of a sentinel hospital reporting system should be considered as a preferred alternative to national passive surveillance in the effort to track total numbers of patients and to follow disease trends over time.

Compliance assessed by the Medication Event Monitoring System

The accurate assessment of patient compliance is especially crucial in evaluating the efficacy of a new treatment. Because of the problems associated with parenteral desferrioxamine, the development of a safe, effective, and convenient iron chelator is of high priority. The high morbidity and mortality associated with iron overload requires careful evaluation of the ability of any new agent to promote long term effective iron chelation. Patients' compliance with an orally available chelating agent, 1,2,-dimethyl-3-hydroxypyrid-4-one (L1), that has been demonstrated to induce in vivo iron excretion equivalent to that of desferrioxamine during supervised short term administration, was examined. Compliance was assessed in seven patients by patient interview, by daily diaries reviewed monthly with each patient, and with the use of the Medication Event Monitoring System (MEMS) standard pill bottles with microprocessors in the cap that record the timing and frequency of bottle openings. L1 was dispensed in MEMS containers to the patients, who, unaware of their significance, recorded compliance using a daily diary. Overall compliance rate (% of prescribed doses taken) measured by MEMS was 88.7 +/- 6.8%. When 'doubling of doses' was accounted for, significantly poorer compliance with L1 was noted by MEMS (91.7 +/- 7.4%) than by patients' diaries (95.7 +/- 5.2%). There was no significant difference in patient compliance recorded between the first and last 30 day period of drug administration. MEMS can eliminate the confounding variable of erratic patient compliance in the evaluation of a new drug's efficacy. As MEMS cannot distinguish a missed dose from one doubled at the next bottle opening, the use of patient diaries is a useful adjunct to the accurate assessment of compliance and should be combined with the use of MEMS.

Clinical and epidemiologic characteristics of patients referred for evaluation of possible Kawasaki disease. United States Multicenter Kawasaki Disease Study Group

STUDY OBJECTIVES

(1) To determine those diseases that most often mimic Kawasaki disease (KD) in the United States. (2) To examine the physical findings and laboratory studies that influenced experienced clinicians to exclude the diagnosis of KD. (3) To compare epidemiologic features of patients with KD and patients referred for evaluation of possible KD in whom alternative diagnoses were established.

DESIGN

Case comparison study.

SETTING

Seven pediatric tertiary care centers.

PATIENTS

Consecutive sample of 280 patients with KD and 42 comparison patients examined within the first 14 days after onset of fever.

MEASUREMENTS AND MAIN RESULTS

(1) Infectious diseases, particularly measles and group A beta-hemolytic streptococcal infection, most closely mimicked KD and accounted for 35 (83%) of 42 patients in the comparison group. (2) The standard diagnostic clinical criteria for KD were fulfilled in 18 (46%) of 39 patients in whom other diagnoses were established. (3) Patients with KD were significantly less likely to have exudative conjunctivitis or pharyngitis, generalized adenopathy, and discrete intraoral lesions, and more likely to have a perineal distribution of their rash. The patients with KD were also more likely to have anemia and elevated erythrocyte sedimentation rate; leukocyte count less than 10 X 10(3)/mm3 and platelet count less than 200 X 10(3)/mm3 were significantly less prevalent in patients with KD. (4) Residence within 200 yards of a body of water was more common among KD patients.

CONCLUSIONS

(1) Measles and streptococcal infection should be excluded in patients examined for possible KD. (2) Laboratory studies that may be useful in discriminating patients with KD from those with alternative diagnoses include hemoglobin concentration, erythrocyte sedimentation rate, and serum alanine aminotransferase activity. (3) Residence near a body of water may be a risk factor for the development of KD.

Kawasaki disease and its diagnosis

Mucocutaneous lymph node syndrome, or Kawasaki disease, is a febrile, exanthematous disease of children that has potentially fatal complications. The most important complication is the development of aneurysms in the coronary arteries, which may thrombose or occasionally, rupture and cause severe morbidity or death. Criteria for the diagnosis of Kawasaki disease have been developed that may help the clinician make the diagnosis and prevent complications. The major criteria include fever, skin eruption, ocular changes, oral changes, changes in the extremities, and lymphadenopathy. Prognosis may be evaluated by the clinical picture and cardiac work-up with echocardiogram.

Kawasaki disease in a 4-year-old boy

A 4-year-old boy experienced sudden fever, followed by a rash on the trunk and extremities and erythema of the pharynx. Five days later, the fever remained and erythema appeared on the oropharynx, tongue, and lips. The skin of the palms and soles became erythematous and indurated, and both conjunctivae became injected. Desquamation of the skin occurred on both thumbs and one finger, and an anterior cervical lymph node was found to be enlarged. The patient was diagnosed as having Kawasaki disease, and treatment with aspirin was started. The desquamation progressed to involve the entire surface of the palms and soles, and then symptoms resolved. Twenty years after recognition of Kawasaki disease, this enigmatic illness continues to defy attempts to understand its etiology and pathogenesis. Most experts agree that the cause is either an environmental toxin or an infectious agent, but other possible causative agents may need to be proposed and investigated.

Kawasaki syndrome

Kawasaki's syndrome is an acute, largely self-limited multisystem vasculitis of childhood with prominent rheumatic complaints, involving both the heart and the joints. Although the etiologic agent has not been discovered, the evidence appears overwhelming that a microbial agent is the responsible trigger for this multisystem disease. Immunologically mediated phenomena appear to be important in the development of the significant complications of KS carditis, coronary vasculitis, and arthritis. Although truly effective therapy is not yet available, there is an exciting possibility that immunologic treatment may have beneficial effect. More effective preventive and therapeutic methods will become available when the elusive agent is discovered.

Kawasaki disease: a pathology survey in western Europe

There is an increasing awareness that Kawasaki disease does occur outside Japan, but reliable data regarding the incidence of the disease in western Europe are lacking. Such information may be important, not only providing insight into the incidence but also indicating whether or not the pathology is comparable to that reported from Japan. For these reasons a survey has been initiated among pediatric pathologists in western Europe with the use of a questionnaire. The results show that the experience with Kawasaki disease of pediatric pathologists in western Europe is extremely limited. Only 25 cases have been reported. One may infer from these data that the incidence of Kawasaki disease in western Europe is far below that in Japan. The pathology encountered appears to be the same as that reported from Japan and the United States. This finding in particular may be important for further epidemiological studies regarding etiology and pathogenesis of Kawasaki disease.

Kawasaki disease: a report of 26 patients

Twenty-six patients suffering from Kawasaki Disease (24 from the U.K. and two from the Netherlands) were reported and their details documented on a questionnaire returned by members of the British Society for the Study of Infection between 1981 and 1983. Seventeen of the children (65.4%) were presumed British extraction. The male:female ratio was 1.6:1.0 and their mean age 3.38 years. No seasonal variation was noted. The clinical and laboratory findings are detailed. Little evidence of infection was discovered. Two patients, both British, died of myocardial infarction (7.7%). Four of the 24 survivors had evidence of coronary artery abnormalities making a total of six (23.1%) of the total series of 26 patients to have coronary artery disease demonstrated. Of the three patients (11.5%) given corticosteroids, two died. The significance of these findings is briefly discussed.

Variant strain of Propionibacterium acnes: a clue to the aetiology of Kawasaki disease

By means of anaerobic culture for 3-4 weeks a variant strain of Propionibacterium acnes was isolated from one lymph-node biopsy specimen, and from blood samples of five of twenty-three patients with early Kawasaki disease, but from only one of fifteen blood samples from patients after 8 days' illness. No anaerobe was isolated from sixty age-matched controls with various disorders, but the same bacillus with the same serotype was isolated from house-dust mites from six patients' homes. Patients had significantly higher serum agglutination titres to these strains than controls. The antigen moiety of P acnes was found in the patients' circulating immune complexes. Inoculation of animals caused various inflammatory lesions, particularly in the reticuloendothelial system, and coronary arteritis, myocarditis, and endocarditis in one of them, suggesting that the bacillus is pathogenic. The culture filtrate of this strain showed toxicity in tissue culture. This variant strain of P acnes may have a causative role in Kawasaki disease and house-dust mites a role as vectors.

Staphylococcal scalded skin syndrome, toxic shock syndrome, and Kawasaki disease

Three dramatic clinical syndromes have been compared and contrasted. Of these, staphylococcal scalded syndrome is most readily recognized and least likely to have a morbid or fatal outcome. It is easy to confuse toxic shock syndrome and Kawasaki disease. Since the case fatality rate is significant in both of these diseases, and the management so different, proper recognition of the disease by its external features is critical.