Pulmonary symptoms in Kawasaki disease

Clinical characteristics of Kawasaki disease with pulmonary radiographic abnormalities and its impact on the incidence of coronary artery lesions: a randomized retrospective cohort study

Objective

The aim of this study was to investigate the characteristics of Kawasaki disease (KD) in patients demonstrating pneumonia-like changes and pulmonary complications, as well as the subsequent impact on coronary artery lesions, by comparing them with those of KD patients with normal pulmonary imaging.

Method

From January 1, 2013 to October 1, 2022, this study included paediatric patients diagnosed with KD who were registered in the KD database at Yuying Children's Hospital affiliated with Wenzhou Medical University. Patients were divided into three distinct groups based on the presence and severity of abnormalities observed via lung imaging. We first compared the demographic and clinical characteristics across these groups. The imaging characteristics of KD patients with pneumonia-like changes and pulmonary complications were identified via chest radiography (x-ray) and chest computerized tomography (CT). Logistic regression models and stratified analyses were employed to further identify factors influencing coronary artery lesions (CALs).

Results

Among the 2,686 KD children admitted to our centre in recent years, 115 presented with pneumonia-like changes, 366 presented with pulmonary complications, and 495 presented with no evident abnormalities on chest radiographs. In KD patients with pneumonia-like changes, there were significant elevations in inflammatory markers including the C-reactive protein (CRP) (P = 0.011), white blood cell (WBC) (P = 0.027), NT-proBNP (P = 0.007), and D-dimer (D-D) (P = 0.002) levels. Imaging studies have frequently revealed bilateral lung infections, predominantly in the mid-lower lung fields. Bronchitis-related changes were the most common manifestation of pulmonary complications in KD patients. A significant difference was observed in the incidence of CALs among patients with pneumonia-like changes. After adjusting for confounding variables, patients with pneumonia-like changes had a greater likelihood of developing CALs, with an adjusted odds ratio (OR) of 1.94 [95% confidence interval (CI): 1.21, 3.11]. Similar findings were obtained through stratification and sensitivity analyses.

Conclusion

Patients diagnosed with KD who develop pneumonia-like changes and related pulmonary complications can be identified based on their clinical manifestations and imaging characteristics. Moreover, patients with KD and pneumonia-like changes had a significantly increased risk of developing CALs.

Unusual Manifestations of Kawasaki Disease in the COVID Era: A Case Series and Review of the Literature

Kawasaki disease (KD) is an acute medium-vessel vasculitis, mainly affecting infants older than six months and children under five years. It predisposes to the development of coronary artery aneurysms and constitutes the leading cause of acquired heart disease in children. Its diagnosis is based on clinical criteria, namely, fever lasting for ≥ five days together with at least four of the five principal clinical features of the disease. Occasionally, children with KD present with fever, but they fulfill only some of the five principal criteria, and this is described as incomplete KD. Furthermore, "atypical" KD is a term that is usually used for cases that appear with rather unusual clinical manifestations, which complicate clinical judgment and may delay diagnosis and treatment. In this case series, we present four cases of KD with rather unusual clinical features: a five-year-old boy with lobar pneumonia, a six-year-old girl with orange-brown chromonychia appearing on the 10th day of the disease, a 2.5-month-old infant with prolonged fever and urinary tract infection, and an 18-month-old infant with refractory KD and high suspicion of multisystem inflammatory syndrome in children (MIS-C). A literature review on the unusual manifestations of atypical KD was performed to identify clinical findings that must alert the clinician to consider this clinical entity.

Clinical Manifestations and Laboratory Findings of Kawasaki Disease: Beyond the Classic Diagnostic Features

Kawasaki disease (KD) has shown a marked increase in trend over the globe, especially within the last two decades. Kawasaki disease is often seen in the paediatric population below five years old, while it is rare for those who are beyond that age. Up to this date, no exact causes has been identified although KD was found more than half a century ago. The underlying pathogenesis of the disease is still unelucidated, and researchers are trying to unlock the mystery of KD. To further complicate the diagnosis and the prompt management, a specific biomarker for the diagnosis of KD is yet to be discovered, making it hard to differentiate between KD and other diseases with a similar presentation. Nonetheless, since its discovery, clinicians and scientists alike had known more about the different clinical aspects of typical KD. Thus, this article intends to revisit and review the various clinical manifestations and laboratory characteristics of KD in order to guide the diagnosis of KD.

Kawasaki disease associated pulmonary involvement in infants

OBJECTIVES

Kawasaki disease (KD) is an acute, self-limited multisystemic vasculitis of unknown cause. Pulmonary involvement has been reported in case reports and limited small case series, which is not commonly recognized, especially in younger patients <1 year. Here, we describe clinical and radiological features of infants with KD-associated pulmonary involvement (KD-PI).

METHODS

Infants with KD were retrospectively enrolled during the period January 2017 to December 2020 in Shenzhen Children's hospital. Patients with KD-PI were matched 1:1 based on current age and sex with KD patients without clinically apparent PI. Clinical data were collected from inpatient or outpatient medical records, including clinical manifestations, laboratory parameters, radiological findings, management, and prognosis.

RESULTS

Of 248 infant patients with KD, 34 presented with KD-PI. Of these, 22 had only subtle respiratory symptoms. Compared to KD controls, patients with KD-PI had significantly higher mean Kobayashi score (mean ± SD: 2.85 ± 1.94; p = .004), more had extremely high C-reactive protein (≥10 mg/dl: 11/34, 32.3%; p = .0115) and procalcitonin levels (˃1 ng/ml: 16/34, 47%; p = .039), and more were administered with adjuvant corticosteroids as initial therapy (38.2% vs. 2.9%; p = .0005). Abnormal chest radiological findings included peripheral consolidation (97.0%), localized pleural thickening (73.0%), lobular septal thickening (70.6%), ground-glass opacities (55.9%), linear opacities (35.3%), and pleural effusion (20.6%). No statistical difference was observed in the incidence of coronary artery abnormalities (CAAs) between two groups either in the acute phase or follow-up phase.

CONCLUSIONS

Higher use of adjuvant corticosteroids during initial therapy in our population may result in no difference in CAAs between the two groups despite higher levels of inflammation in KD-PI. Those results suggest that use of adjuvant corticosteroids may be beneficial in this population.

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.

Pulmonary presentation of Kawasaki disease-A diagnostic challenge

OBJECTIVES

Kawasaki disease (KD) is a multisystemic vasculitis with predominant mucocutaneous manifestations. Pulmonary involvement in KD is distinctly uncommon and is not commonly recognized. We describe our experience of managing children with KD wherein the initial presentation was predominantly pulmonary.

METHODS

Six hundred and two children have been diagnosed with KD during the period January 1993 to May 2017 in the Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh. Data were collected from inpatient records in Allergy Immunology Unit and follow-up files in the Pediatric Rheumatology Clinic.

RESULTS

Of 602 children, 11 (1.83%) had a predominant pulmonary presentation of KD. Mean age at diagnosis of KD was 2.5 years. Fever, cough and respiratory distress were the presenting complaints in all patients. First sign of KD was noted at a mean duration of 14.5 days from the onset of symptoms. Periungual desquamation was the most common clinical sign (72.7%). Persistent fever in spite of antimicrobials, thrombocytosis, and elevated erythrocyte sedimentation rate and C-reactive protein levels pointed toward a diagnosis of KD in our patients. Parenchymal consolidation was evident on chest X-ray in all patients, pleural effusion in six, empyema in three, and pneumothorax in two patients. Coronary artery abnormalities were evident in three patients. Intravenous immunoglobulin was given after a mean period of 22.4 days of onset of fever.

CONCLUSIONS

The diagnosis of KD is often delayed in children who have a predominantly pulmonary presentation. This can have adverse clinical consequences.

Comorbidity of Kawasaki disease and group a streptococcal pleural effusion in a healthy child: a case report

Background

Kawasaki disease is an acute self-limiting vasculitis that affects children. The most dreaded complication of Kawasaki disease reported in the literature over the years is coronary artery disease, which is considered as the main cause of acquired heart disease. However, pulmonary associations with Kawasaki disease have been overlooked. We present a rare, if not unique, case of Kawasaki disease associated with group A streptococcus pleural effusion in the English language literature. A search of the PubMed database was carried out, using a combination of the terms “Kawasaki disease”, “pneumonia”, and “group A streptococcus”. The majority of studies conducted in children with Kawasaki disease have concentrated on the coronary artery implications. Kawasaki disease is considered a self-limiting illness, but can have detrimental consequences if not diagnosed early. When there is a prolonged inflammatory reaction, with no infectious agent identified or remittent fever unresponsive to antibiotics, Kawasaki disease should be taken into consideration. Elevated Vβ2+ T cells compared with healthy controls suggest possible involvement of a superantigen in the etiology of Kawasaki disease, so it is wise that the health care provider concentrates not only on the cardiac consequences, but also on pulmonary associations.

Mycoplasma pneumoniae infection in patients with Kawasaki disease

Purpose

Kawasaki disease (KD) is the main cause of acquired heart disease in children. In addition to cardiovascular involvement, many complications have been recognized in KD. However, respiratory complications have been rarely reported. We investigated the differences in clinical characteristics, laboratory findings, radiography findings, and echocardiography findings of Mycoplasma pneumoniae infection and other types of pneumonia in KD patients.

Methods

Among 358 patients with KD, 54 developed concurrent pneumonia. Among the 54 patients, 12 (22.2%) with high titers of anti-M. pneumoniae antibody (AMA) (>1:640) were grouped in the M. pneumoniae group and 42 were included in the control group. Serum AMA was measured in each patient. Clinical laboratory findings and total duration of fever were analyzed.

Results

The duration of fever, serum hemoglobin, white blood cell count, platelet count, erythrocyte sedimentation rate, C-reactive protein level, albumin level, and the incidence of coronary arterial lesions showed no statistical difference in the 2 groups. Neutrophil count was significantly higher in the M. pneumoniae group than in the control group. Among various radiography findings observed in pneumonia, consolidation and pleural effusion were more frequent in the M. pneumoniae group than in the control group. On the other hand, parahilar peribronchial opacification, diffuse interstitial lesion, and normal findings prevailed in the control group.

Conclusion

KD patients can have concurrent infections, especially pulmonary symptoms. The cause of KD is likely to be associated with M. pneumoniae infection. Thus, immediate treatment of M. pneumoniae infection in KD patients is very important.

Lung parenchymal consolidation as an uncommon presentation and cause of delayed diagnosis in atypical Kawasaki syndrome

We report three patients who initially showed prolonged fever, lung parenchymal consolidation and laboratory findings of pneumonia, and secondarily presented a clinical picture ascribed to Kawasaki syndrome. Two of these children developed coronary artery dilations, which regressed upon echocardiography after 12 months. In the case of infants showing broncho-pulmonary abnormalities with slow resolution, active inflammatory parameters and high fever persistence, pediatricians should consider atypical Kawasaki syndrome as a possible alternative diagnosis.

Acute respiratory distress syndrome in a child with Kawasaki disease

This report presents a case of classic Kawasaki disease with progression to acute respiratory distress syndrome. The severity of the patient's pulmonary disease led clinicians to suspect toxic shock syndrome. Clinicians need to be aware that pulmonary manifestations of Kawasaki disease can include acute respiratory distress syndrome.