Kawasaki syndrome: where are the answers?

Therapeutic down-modulators of staphylococcal superantigen-induced inflammation and toxic shock

Staphylococcal enterotoxin B (SEB) and related superantigenic toxins are potent stimulators of the immune system and cause a variety of diseases in humans, ranging from food poisoning to toxic shock. These toxins bind directly to major histocompatibility complex (MHC) class II molecules on antigen-presenting cells and specific Vβ regions of T-cell receptors (TCR), resulting in hyperactivation of both monocytes/macrophages and T lymphocytes. Activated host cells produce massive amounts of proinflammatory cytokines and chemokines, activating inflammation and coagulation, causing clinical symptoms that include fever, hypotension, and shock. This review summarizes the in vitro and in vivo effects of staphylococcal superantigens, the role of pivotal mediators induced by these toxins in the pathogenic mechanisms of tissue injury, and the therapeutic agents to mitigate the toxic effects of superantigens.

Enfermedad de kawasaki

La enfermedad de Kawasaki es una vasculitis sistémica de etiología desconocida que afecta principalmente a niños menores de 5 años. Es actualmente la primera causa de cardiopatía adquirida en la infancia en los países desarrollados, lo que la convierte en una enfermedad de suma trascendencia en el momento actual. No se conoce su etiología, aunque existen fuertes sospechas de que sea infecciosa. El diagnóstico se realiza por criterios clínicos de fiebre persistente de al menos 5 días de duración y 4 de 5 criterios clínicos: cambios en extremidades, exantemas polimorfos, inyección conjuntival no exudativa, cambios en los labios y la mucosa oral y adenopatías > 1,5 cm, habitualmente unilateral. La complicación más frecuente es la dilatación y los aneurismas de las arterias coronarias, la cual ocurre en el 20-25% de los niños no tratados. El tratamiento estándar de la enfermedad es con gammaglobulina intravenosa en dosis de 2 g/kg, antes de los 10 días del comienzo de la enfermedad, más ácido acetilsalicílico oral en dosis antiinflamatorias. El riesgo de lesión coronaria en los niños tratados es del 3-5%.

A 15-year review of children with Kawasaki's Syndrome having general anesthesia or deep sedation

BACKGROUND

Children with Kawasaki's syndrome (KS), also known as Kawasaki's disease or 'mucocutaneous lymph node syndrome', have approximately 20-25% incidence of developing coronary artery aneurysms (CAA), stenosis or obliteration if not appropriately diagnosed and treated. In addition some children have myocarditis, pericardial effusions and/or cardiac arrhythmias during the acute phase of KS. Even with current treatment protocols, 2-4% will still be at risk of coronary artery pathology and the long-term implications regarding future coronary artery disease are unknown. Many of these children present for surgical or diagnostic procedures requiring general anesthesia or deep sedation. Only sporadic case reports have been published on the anesthetic experiences of such patients.

METHODS

With Institutional Review approval, we reviewed the medical records of all children with discharge diagnosis of KS from 1985 to 2000 for those receiving general anesthesia or deep sedation. Data abstracted from the medical records included information on any surgical procedures performed any time after onset of KS symptoms, type of anesthetic, perioperative monitoring and presence or absence of operative or perioperative complications.

RESULTS

A total of 178 children with KS were identified of whom 47 (26.4%) received either general anesthesia (34) or deep sedation (13). There were no deaths; one child developed congestive heart failure in the immediate postoperative period associated with KS myocarditis. Five (15%) of those having general anesthesia initially were either not diagnosed as having KS or had no preoperative cardiac evaluations. None of the children having general anesthesia had ST segment analysis, invasive monitoring or troponin measurements perioperatively.

CONCLUSIONS

The high incidence of serious myocardial complications attributable to KS reported in the pediatric literature is rarely noted in the anesthesia literature. We feel there is a potential for more serious perioperative complications among KS children, although we can only speculate why complications are not more frequently encountered. Anesthetists involved in pediatric services are encouraged to consider KS in their diagnosis of children presenting with febrile illnesses with rashes and to consider the possibility of KS myocardial compromise if they encounter unexpected deterioration perioperatively. Preoperative ultrasound examination and perioperative monitoring (e.g. ST segment analysis and troponin measurements) for myocardial compromise are encouraged if KS is suspected.

The history of pediatric rheumatology

The care and study of children with rheumatic diseases began slowly in the 19th century, with the most attention centered on rheumatic fever. Other rheumatic diseases of children received little attention until the 1940s. Rheumatic diseases taken together remain a significant cause of chronic illness in children throughout the world. A number of other conditions that masquerade as rheumatic diseases in children also demand recognition and management. Although ultimate causes and cures of childhood rheumatic diseases remain elusive, advances in therapy have improved the outlook for affected children, and advances in biomedical research are adding to our basic understanding of the disease process involved. Pediatric rheumatology has become a well-organized, although underpopulated, specialty that enhances recognition and care of affected children and contributes to basic research knowledge in infectious disease, immunology, and genetics. This review focuses most prominently on the early history of pediatric rheumatology and its development as a specialty. The recent burgeoning of new biomedical science and new means of treatment will be better told in the historical perspective of years to come.

The epidemiology of Kawasaki disease in an urban hospital: does African American race protect against coronary artery aneurysms?

The etiology and pathogenesis of Kawasaki disease (KD) is largely unknown. Certain demographic factors and laboratory findings are predictive of the development of coronary artery (CA) aneurysms. The objectives of this study were to determine the epidemiology of KD patients in an urban hospital and determine risk factors associated with their development of CA abnormalities. A longitudinal case series of KD patients admitted to Children's National Medical Center from 1990 to 2002 was examined. Age, sex, ethnic background, duration of fever prior to diagnosis, address, month diagnosed, and CA abnormalities (ectasia or aneurysms) on echocardiography were recorded. Median household income was obtained from the U.S. Census Bureau Web site. The Student t-test, logistic regression analyses, and the Kruskal-Wallis test were used, with significance assumed at p < 0.05. A total of 302 patients were evaluated. CA abnormalties were found in 27 patients (9%), with aneurysms identified in 13 patients (4%). Age was 2.9 +/- 2.4 years (range, 2 months to 14 years). A total of 51 patients (16%) were < or =1 year and 35 patients (12%) were > or =5 years. Ethnic distribution was 54% (164) African American, 24% (72) Caucasian, 9% (29) Asian/Pacific Islander, 8% (23) Hispanic, and 5% (14) Middle Eastern. Only 2/164 (1.2%) African Americans developed CA aneurysms. Neighborhood median income of the cohort was $45,400 +/- $21,200 ($52,200 +/-$25,800 for patients with aneurysms). A total of 28% of cases clustered between December and January. Cases doubled annually in 1999-2001 compared to 1990-1998 (39 vs 19). Multivariate logistic regression found age between 1 and 5 years [p = 0.045; odds ratio, 0.31; 95% confidence interval (CI), 0.10-0.97] and African American race (p = 0.014; odds ratio, 0.15; 95% CI, 0.03-0.68) to be independently protective against CA aneurysms. Duration of fever prior to diagnosis, considered in 210 patients, was different between patients with and without aneurysms (11 +/- 5.3 vs 6.5 +/- 3.8 days, respectively, p = 0.0007). Multivariate logistic regression found fever longer than 5 days to be the only predictive factor associated with the development of aneurysms and any abnormality. African Americans had a shorter duration of fever than the rest of the cohort (6.03 vs 7.31 days), (p = 0.0087). The epidemiology of KD at our hospital is similar to that at other centers except for the predominance of African Americans with a shorter duration of fever prior to diagnosis and a decreased incidence of CA aneurysms compared to other ethnicities. The protective nature of African American ethnicity against the development of CA aneurysms raises speculation about the role of genetics and its interaction with immunity in the pathogenesis of KD.

Diagnosis, treatment and outcome of Kawasaki disease in an Australian tertiary setting: a review of three years experience

OBJECTIVE

To examine the patient characteristics, diagnostic criteria, treatment, complications and outcomes of Kawasaki disease (KD) in children diagnosed and treated in an Australian tertiary hospital setting and compare this to previously reported experience.

METHODS

Data were collected prospectively for 14 patients in 2002 and retrospectively for 31 patients in 2000 and 2001. Demographics, clinical features, laboratory features, treatment and outcome details were collected, analysed and compared to previous experience.

RESULTS

The median age at diagnosis was 2.77 years (0.28-8.84) and diagnosis was made after a mean 6.1 days of fever. Twenty-eight patients (62.2%) had classical KD and those with less than four criteria were younger than those with four or more criteria (P = 0.04). Patients were treated with intravenous immunoglobulin and aspirin. Twelve (26.7%) required re-treatment. Re-treatment was associated with treatment within 5 days of fever onset (P = 0.03). Twelve patients (27.3%) developed coronary artery abnormalities and the development of such abnormalities was associated with lower serum albumin at diagnosis (P = 0.008) and need for re-treatment (P = 0.03). There was no difference in coronary outcome between classical and incomplete presentations. Only two patients had coronary lesions at 12 months follow-up.

CONCLUSIONS

We found a trend towards earlier diagnosis and treatment of KD in the tertiary hospital setting, which may reflect heightened physician awareness of the disease. Our study confirms that children who present with incomplete disease are at risk of coronary artery abnormality. We recommend that clinicians continue to maintain high levels of suspicion, even in the absence of the complete clinical picture of KD, particularly in infants below 1 year of age.

Kawasaki disease: a decade of experience from North India

Kawasaki disease (KD) has not been frequently reported from developing countries, especially from India. In this series from a tertiary level center in North India, we report on the clinical features and management of patients with KD seen between January 1994 to November 2004. KD was diagnosed on the basis of standard diagnostic criteria. Investigations included work-up for other causes of fever along with chest X-rays, electrocardiograms, and 2-D echocardiography. Thallium scintigraphy and coronary angiography were performed in 20 and 3 cases, respectively. Sixty-nine children (49 boys and 20 girls) fulfilled the diagnostic criteria. Mean age at diagnosis was 4.9 +/- 3.0 years (range 0.3-14 years) and as many as 23 cases (33.3%) were above 5 years of age. Clustering was seen during the winter months. Extreme irritability, out of proportion to the degree of fever, was a characteristic feature. Redness of the lips and tongue was common but rash was seen only in 43 cases and lymphadenopathy in 47 cases. Thrombocytosis was present in 52.2% of the patients. Sixty-four patients received intravenous immunoglobulin. Cardiac abnormalities included extrasystoles in 1, coronary artery dilatation in 5, valvular regurgitation in 3, and perfusion defects on thallium scintigraphy in 4. There was no mortality. KD appears to occur at an older age in Indian children as compared to reports from Japan. Irritability is a characteristic clinical finding. Cardiac abnormalities are frequent during the acute stage but regress gradually. The disease needs to be considered in the differential diagnosis of all children with persistent unexplained fever.