Kawasaki disease associated with streptococcal infection within a family

Associations of infection burden with Kawasaki disease in a population-based setting during 30 years

OBJECTIVES

The objective of this study was to investigate the role of infections in the pathogenesis of Kawasaki disease.

METHODS

The investigation was a nationwide epidemiological case-control study, comprising all cases of Kawasaki disease diagnosed in Sweden 1987-2018. Controls were randomly sampled from the general population, matched on sex, age, and area of residency. Data on infections were obtained from the Swedish National Patient Register, which prospectively collects data on all Swedish residents. Infections were classified by organ system, infectious agent and by temporal proximity to Kawasaki disease diagnosis date. Prescription of antibiotics and infections in family members were also considered in separate analyses.

RESULTS

The study comprised n=1774 (61% male) cases and n=17 731 controls. Overall, a history of infections was associated with Kawasaki disease with an OR of 2.3 (95% CI 2.0 to 2.5). Respiratory, skin, urogenital and gastrointestinal tract infections were all associated with Kawasaki disease. Temporal stratification revealed a prominent clustering of infections during the weeks before a Kawasaki diagnosis, but also higher frequencies of infections several months preceding Kawasaki disease with OR ranging from 5.1 (95% CI 3.6 to 7.1) 15-28 days to 1.3 (95% CI 1.1 to 1.6) 181-365 days prior Kawasaki disease. A dose-response relationship was observed, with repeated infections associating with higher ORs of Kawasaki.

CONCLUSIONS

The findings suggest that infections are closely linked with Kawasaki disease, and with a wider temporal association than previously known. Further, the data imply that many different agents may induce the disease.

Kawasaki disease in siblings in close temporal proximity to each other-what are the implications?

Kawasaki disease (KD) is the commonest medium vessel vasculitis in children. The etiology of KD remains an enigma despite extensive research. Infections are considered to be one of the triggers for KD, especially in genetically susceptible hosts. KD occurring within a short time interval among siblings is an important clinical observation supporting this hypothesis. In addition, siblings of children with KD are at a higher risk of developing the disease as compared with other children. Screening for KD in febrile siblings, therefore, seems prudent. This would help initiate timely therapy and prevent complications. We briefly review 16 English language reports of KD in siblings diagnosed within 1 month of each other to highlight its etiological and therapeutic implications. Key Points • KD should be suspected in febrile children who have a sibling recently diagnosed with KD. • Etiological studies should also focus on siblings who develop KD in close temporal proximity.

Kawasaki disease shock syndrome: Unique and severe subtype of Kawasaki disease

BACKGROUND

Kawasaki disease shock syndrome (KDSS) is an uncommon presentation of Kawasaki disease (KD). KDSS has been associated with more severe markers of inflammation, coronary abnormalities and i.v. immunoglobulin (IVIG) resistance.

METHODS

A retrospective, descriptive study of children with KDSS in two hospitals was performed. Relevant articles about KD and shock were collected, and demographic data, clinical presentation, laboratory variables, echocardiogram findings, treatment and special features were analyzed when available. Twelve patients diagnosed with KDSS were retrospectively reviewed from two centers in Mexico, along with 91 additional cases from the literature.

RESULTS

Seventy-two patients presented with complete KD (69.9%), and 30.1% (31/103) had unusual KD manifestations. The most frequent diagnosis at the time of admission was toxic shock syndrome (TSS; n = 20). Sixteen of the 20 had coronary artery abnormalities. Overall, abnormalities in the coronary arteries were documented in 65% of the patients. The mortality rate was 6.8%.

CONCLUSION

The presence of coronary aneurysms was significantly and positively correlated with male gender, IVIG resistance, inotrope treatment, cardiac failure, abdominal pain and neurological symptoms. IVIG-resistant patients had higher neutrophil : lymphocyte ratio. Abdominal symptoms, hypoalbuminemia and elevated C-reactive protein were present in almost all of the patients. Multisystem involvement with atypical presentation in KDSS is frequent. An important differential diagnosis is TSS. Mechanical ventilation, gastrointestinal and neurological symptoms were associated with IVIG resistance and the presence of coronary aneurysms. The first line of treatment includes IVIG and pulse corticosteroids; in severe cases, infliximab, anakinra, cyclosporine or plasmapheresis are alternative treatment options.

Kawasaki disease in adults: Observations in France and literature review

OBJECTIVE

Kawasaki disease (KD) is a vasculitis that mostly occurs in young children and rarely in adults. We analyzed the characteristics of adult-onset KD (AKD) in France.

METHODS

We collected retrospective and prospective data for patients with a diagnosis of KD occurring after the age of 18 years. Cases were obtained via various French medical networks and identified from the international literature.

RESULTS

We included 43 patients of AKD at 26 institution from 1992 to 2015, with mean (SD) age 30 (11) years (range 18-68) and sex ratio (M/F) 1.2; 34 patients met the American Heart Association criteria and 9 were incomplete AKD. The median time to diagnosis was 13 days (interquartile range 8-21). The main symptoms were fever (100%), exanthema (98%), changes in the extremities (91%), conjunctivitis (77%), oral cavity changes (89%), cervical adenitis (55%) and cardiac abnormalities (45%). Overall, 35% of patients showed large-vessel vasculitis: coronary vasculitis (26%) and coronary aneurysm (19%). Treatment was mostly intravenous immunoglobulins (79%) and aspirin (81%). Four patients showed myocardial infarction due to coronary vasculitis, but none were treated with IVIg because of late diagnosis. After a median follow-up of 5 months (range 1-117), persistent aneurysm was noted in 9% of cases. Damage was significantly lower with early treatment than late or no treatment (p=0.01).

CONCLUSION

Given the high frequency of cardiac involvement and complications in this series of AKD, diagnosis and treatment should not be delayed, and early IVIg treatment seems to improve the outcome.

Possible involvement of infection with human coronavirus 229E, but not NL63, in Kawasaki disease

Although human coronavirus (HCoV)‐NL63 was once considered a possible causative agent of Kawasaki disease based on RT‐PCR analyses, subsequent studies could not confirm the result. In this study, this possibility was explored using serological tests. To evaluate the role of HCoV infection in patients with Kawasaki disease, immunofluorescence assays and virus neutralizing tests were performed. Paired serum samples were obtained from patients with Kawasaki disease who had not been treated with γ‐globulin. HCoV‐NL63 and two antigenically different isolates of HCoV‐229E (ATCC‐VR740 and a new isolate, Sendai‐H) were examined as controls. Immunofluorescence assays detected no difference in HCoV‐NL63 antibody positivity between the patients with Kawasaki disease and controls, whereas the rate of HCoV‐229E antibody positivity was higher in the patients with Kawasaki disease than that in controls. The neutralizing tests revealed no difference in seropositivity between the acute and recovery phases of patients with Kawasaki disease for the two HCoV‐229Es. However, the Kawasaki disease specimens obtained from patients in recovery phase displayed significantly higher positivity for Sendai‐H, but not for ATCC‐VR740, as compared to the controls. The serological test supported no involvement of HCoV‐NL63 but suggested the possible involvement of HCoV‐229E in the development of Kawasaki disease. J. Med. Virol. 86:2146–2153, 2014. © 2014 Wiley Periodicals, Inc.

Viral infections associated with Kawasaki disease

BACKGROUND/PURPOSE

Kawasaki disease (KD) is a disease of unknown cause. To investigate the infectious etiology of Kawasaki disease, we initiated a prospective case-control study to investigate possible links between common viral infections and Kawasaki disease.

METHODS

We enrolled 226 children with KD and 226 age- and sex-matched healthy children from February 2004 to March 2010. Throat and nasopharyngeal swabs were taken for both viral isolation and polymerase chain reaction (PCR) for various viruses.

RESULTS

The mean age of the 226 KD cases was 2.07 years, and the male to female ratio was 1.43 (133 boys to 93 girls). Their mean fever duration was 7.5 days with a mean peak temperature of 39.7°C. In addition to the typical symptoms of fever, neck lymphadenopathy, lip fissure and/or strawberry tongue, skin rash, nonpurulent bulbar conjunctivitis, palm/sole erythema, and induration followed by periungual desquamation, these KD cases also exhibited cough (69%), rhinorrhea (58%), and diarrhea (45%). Cases of KD had a significantly higher positive rate of viral isolation in comparison with the control group (7.5% vs. 2.2%, p = 0.02). Compared with the control group, cases of KD were more likely to have overall positive rates of viral PCR (50.4% vs. 16.4%, p < 0.001) and for various viruses including enterovirus (16.8% vs. 4.4%, p < 0.001), adenovirus (8.0% vs. 1.8%, p = 0.007), human rhinovirus (26.5% vs. 9.7%, p < 0.001), and coronavirus (7.1% vs. 0.9%, p = 0.003).

CONCLUSION

We found that some common respiratory viruses, such as adenoviruses, enteroviruses, rhinoviruses, and coronaviruses, were associated with KD cases.

Incomplete Kawasaki disease associated with complicated Streptococcus pyogenes pneumonia: A case report

A three-year-old boy presented with community-acquired pneumonia complicated by empyema. Streptococcus pyogenes (group A streptococcus) was identified on culture of the pleural fluid. The patient improved with antibiotic therapy and drainage of the empyema. During his convalescence, the patient developed persistent fever, lethargy and anorexia. His inflammatory markers were elevated, and repeat cultures were negative. Although the patient had none of the classical mucocutaneous features of Kawasaki disease, an echocardiogram was performed, which revealed coronary artery dilation. The patient was diagnosed with incomplete Kawasaki disease and treated with intravenous immunoglobulin and high-dose acetylsalicylic acid. The fever subsided within 48 h. To the authors' knowledge, the present report is the first report of Kawasaki disease associated with complicated S pyogenes pneumonia. It emphasizes the importance of considering incomplete Kawasaki disease among children with persistent fever, the role of echocardiography in diagnosis, and the potential link between Kawasaki disease and superantigen-producing organisms such as S pyogenes.

Kawasaki syndrome and concurrent Coxsackie virus B3 infection

We describe two previously healthy children who were hospitalized in the same period in different departments of our University with clinical signs of Kawasaki syndrome, which were treated with intravenous immunoglobulins and acetylsalicylic acid: in both cases, Coxsackie virus infection was concurrently demonstrated by enzyme-linked immunosorbent assay, and complement fixation test identified antibodies to serotype B3. In the acute phase, both patients presented hyperechogenic coronary arteries, but no cardiologic sequels in the mid term. The etiological relationship between Kawasaki syndrome and Coxsackie viruses is only hypothetical; however, the eventual identification of ad hoc environmental triggers is advisable in front of children with Kawasaki syndrome, with the aim of optimizing epidemiological surveillance and understanding the intimate biological events of this condition.

Recognition of kawasaki disease

Kawasaki disease is one of the most common vasculidities of childhood. It is the leading cause of acquired heart disease in children in the US.1 Although its course is typically self-limited, it is important that the clinician have a high degree of suspicion for its presence in light of its potential cardiac complications. It should be included in the differential diagnosis for any child with prolonged fever that is unresponsive to antibiotics. Diagnosis is often difficult in that the symptoms tend to present at different times. Usually a detailed medical history and multiple examinations (on different days) are needed to establish the diagnosis. Here, we present the case of a boy in whom a delayed diagnosis of Kawasaki disease was made after he had made multiple visits to pediatricians and also to the Emergency Department. In addition, the diagnostic criteria, differential diagnosis, treatment, and possible complications of Kawasaki disease are reviewed here.

The role of superantigens of group A Streptococcus and Staphylococcus aureus in Kawasaki disease

PURPOSE OF REVIEW

Since the first suggestion of a superantigen hypothesis for Kawasaki disease over a decade ago, debate on the aetiology remains inconclusive. This article reviews recent publications that address the role of superantigens of group A Streptococcus and Staphylococcus aureus in the pathogenesis of Kawasaki disease.

RECENT FINDINGS

Over the past few years, new superantigens produced by group A Streptococcus and S. aureus have been increasingly identified, bringing the total known number to more than 30. Several studies on T-cell Vbeta repertoires and seroloepidemiology have demonstrated evidence for the involvement of single or multiple superantigens produced by the two pathogens. The associated superantigens differed in those studies, including streptococcal pyrogenic toxins A and C, staphylococcal enterotoxins A-C, and toxic shock syndrome toxin 1. These disparate findings suggest that the inflammation of Kawasaki disease does not result from a single agent but rather a final common inflammatory pathway in genetically susceptible individuals after numerous infectious agents.

SUMMARY

Certain staphylococcal and streptococcal superantigens are suggested to be responsible for the development of Kawasaki disease. A better understanding of the precise role of the causative agents will lead to accurate diagnosis, more targeted therapy and an improvement of coronary outcomes.

Infections and Kawasaki disease: implications for coronary artery outcome

OBJECTIVE

We sought to determine the effect of coincident infection, at time of diagnosis of Kawasaki disease (KD), on treatment response and coronary artery outcome.

METHODS

A single-center, retrospective study of 129 consecutive patients diagnosed with typical KD between January 1997 and December 1998 was performed. Standardized clinical assessments, laboratory, microbiology, and imaging test results plus treatment regimens were reviewed. Coronary arteries were visualized by using echocardiography, and coronary artery lesions (CALs) were reported as body surface area-adjusted z scores. Infection-positive and -negative groups were identified, and clinical, laboratory, and treatment data were analyzed. The effect of infections and other outcome variables on CAL development was determined by multivariate regression analysis.

RESULTS

(1) Concurrent infections: 33% of children with typical KD had > or =1 confirmed infection at KD diagnosis. (2) Treatment response: the presence of infection did not alter the response to treatment with intravenous immunoglobulin, with resolution of fever in 83% of children after 1 dose of intravenous immunoglobulin together with aspirin administration regardless of presence or absence of infection. (3) Coronary outcome: in total, 31% of the patients developed CALs. Both the proven-infection and no-proven-infection groups had a similar CAL frequency. (4) Multivariate regression analysis: proven infection did not increase the risk of coronary artery involvement even after adjusting for other factors impacting on coronary artery outcomes.

CONCLUSIONS

Infections are common at diagnosis of KD. A broad spectrum of infectious agents was found. Infections at diagnosis of KD did not affect the patients' response to treatment and coronary artery outcome when compared with those patients without infections.

Epidemiologic features of Kawasaki disease in Taiwan, 1996-2002

OBJECTIVE

Kawasaki disease (KD) is the most common acquired heart disease in children worldwide. The incidence of KD varies among different countries, with Asian countries supposedly having higher incidences than Western countries. However, the incidence of KD in Taiwan has not been well investigated.

METHODS

Since the implementation of Taiwan's National Health Insurance (NHI) in 1995, NHI has covered health care for >96% its population. Using the NHI database from 1996 to 2002, we investigated epidemiologic features of KD (International Classification of Diseases, Ninth Revision, code 446.1), the rate of coronary artery aneurysm formation (International Classification of Diseases, Ninth Revision, code 414.11), and the change in incidence during the recent 7 years. We also compared the annual incidences in Taiwan with those reported by other countries.

RESULTS

During the 7-year study period, KD occurred most frequently in the summer and least frequently in winter. It is interesting that the highest peak occurred in the summer of 1998 at the same time that Taiwan's enterovirus 71 epidemic was occurring. Ninety-one percent of KD cases occurred in children who were <5 years old, and the male-to-female ratio was 1.70:1. Recurrence of KD was found in 1.3% (94 of 7305) of these children, and coronary artery aneurysm was found in 7.3% (536 of 7305). The annual incidence per 100,000 children was 146 in children <1 year old, 98 in 1-year-old children, 51 in 2-year-old children, 28 in 3-year-old children, 19 in 4-year-old children, and 5.3 in 5- to 9-year-old children; the incidence of KD decreased with increased age. The overall incidence was 66 cases per 100,000 children <5 years old from 1996 to 2002 with the annual incidence not differing significantly during the 7-year study period.

CONCLUSIONS

KD in Taiwan occurs more frequently in boys and in the summer months. During the 7-year study period, the annual KD incidence in Taiwan of 66/100000 in children <5 years old was the second highest in the world after Japan.

Kawasaki Syndrome in an Adult: Case Report and Review of the Literature in Adolescents and Adults

Kawasaki syndrome in adults is very rare, with fewer than 50 cases reported in the English-language literature. We describe the case of a physician with Kawasaki syndrome and summarize the clinical features and treatment of 11 patients in the literature since the last review in 1994. Our patient presented with high fever, conjunctivitis, and arthralgias, then developed progressive toxicity with oral lesions, cervical adenopathy, and desquamation of the fingers and toes. No exanthematous rash or coronary artery aneurysms were found. Recovery was rapid after therapy with aspirin and intravenous immunoglobulin (IVIg). The diagnosis of Kawasaki syndrome depends on clinical criteria and the exclusion of other diseases. This diagnosis can be challenging to make in an adult, particularly when it presents without all typical features. Kawasaki syndrome must be considered nonetheless in an adult with unexplained fever of more than 5 days duration, because early diagnosis and combination therapy with aspirin and IVIg can prevent the life-threatening complication of coronary artery aneurysms.

Kawasaki disease in Australia, 1993-95

AIM

To describe the epidemiology, management, and rate of cardiac sequelae of Kawasaki disease in Australia.

DESIGN

Cases were notified to the Australian Paediatric Surveillance Unit, an active national surveillance scheme, from May 1993 to June 1995.

RESULTS

139 cases of Kawasaki disease were confirmed. In 1994, the annual incidence was 3.7/100,000 children < 5 years old. Sixteen children were not admitted to hospital. Coronary artery abnormalities were reported in 35 (25%) children. Two patients were diagnosed at postmortem examination. Sixty six per cent of patients were diagnosed within 10 days of onset and 81% of these received intravenous gammaglobulin within 10 days. Forty five of the notified children did not fulfil the study criteria because of streptococcal infection or insufficient clinical criteria. One child with streptococcal infection had coronary artery dilatation.

CONCLUSION

Diagnosis of Kawasaki disease was delayed beyond 10 days in one third of patients, and almost 20% of children who could have received gammaglobulin within 10 days did not. The distinction between Kawasaki disease, streptococcal infection, and other possible diagnoses is problematic in some children.