Notes:

Mucous membranes

- Mucous membranes produce mucus to trap microbes so that they cannot spread to the
body, mucous membranes in the body may differ in structure but all have epithelial cells
over a deep layer of connective tissue.

Sebum – Unsaturated fatty acids known as sebum provide a protective film on the skin and inhibits
bacterial growth

Epithelium forms continuous sheets of cells that line internal surfaces and cover the external
surface of the body. It is a selective barrier that protects tissues
Connective Tissue – tissue that supports, protects, and gives structure to other tissues and
organs in the body
SKIN

- its primary function is to provide protection, heat regulation, secretion, excretion,

sensation and absorption.

EXCRETION/SECRETION

 Eccrine glands are the major sweat glands of the human body, found in virtually all
skin. They produce a clear, odorless substance consisting primarily of water and NaCl
 Sebum – Unsaturated fatty acids known as sebum provide a protective film on the skin
and inhibits growth
 Note that the odor from sweat is due to bacterial activity on the secretions of the
apocrine glands
 Apocrine sweat glands are inactive until they are stimulated by hormonal changes in
puberty. Apocrine sweat glands are mainly thought to function as olfactory pheromones,
chemicals important in attracting a potential mate. The stimulus for the secretion of
apocrine sweat glands is adrenaline, which is a hormone carried in the blood.

Epidermis - is the outermost layer of the skin, it creates our skin stone and provide water proof
barriers

- Sebaceous glands - are microscopic glands in the skin that secrete an oily/waxy
matter, called sebum, to lubricate and waterproof the skin and hair
 - stratum corneum is the outer layer of the skin (epidermis). It serves as the primary
barrier between the body and the environment.
- Stratum granulosum - These granules contain lipids, help form a waterproof barrier
that functions to prevent fluid loss from the body
- Stratum spinosum – a spiny-shaped cells, partly responsible for the skin's strength and
flexibility.
- Keratinocytes - are the primary type of cell found in the epidermis, preserve against
microbial, viral, fungal and parasitic invasion; to protect against UV radiation; and to
minimize heat, solute and water loss.
- basal layer is the innermost layer of the epidermis, and contains small round cells
called basal cells continually divide, and new cells constantly push older ones up toward
the surface of the skin, where they are eventually shed. ... The basal cell layer contains
cells called melanocytes.
-

Dermis - is the middle layer of the skin, it is composed of collagen fibers, sweat glands,
sebaceous glands, arrector pili muscles,

- The hairs on the skin lie flat and prevent heat from being trapped by the layer of still air
between the hairs. This is caused by tiny muscles under the surface of the skin, called
arrector pili muscles.

Hypodermis - it is composed of adipose tissue, that function as an insulation, padding

and a storage for reserved energy and also hypodermis contains blood, nerves and
lymph vessels.

- Fat associated with our skin does help insulate our body and therefore
increases body temperature as a result.

ABSORPTION - Due to the absorptive capabilities of skin, the cells comprising the outermost
0.25–0.40 mm of the skin can be supplied by external oxygen rather than via the underlying
capillary network. Additionally certain medications can be administered through the skin.
Lymph nodes

- serve as filters and provide specialized tissues where foreign antigens can be

trapped and exposed to cells of the immune system for destruction
- Usually found near junctions of major lymphatic vessels, commonly in the neck,
armpits and groins.
- serve as a center for the production of PHAGOCYTES

BLOOD VESSELS

- The wall of the blood vessels consists three layers, Tunica intima, Tunica media
and Tunica externa.
- The inner layer (tunica intima) is the thinnest layer formed from a single
continuous layer of endothelial cells and supported by a subendothelial layer of
connective tissue and supportive cells
 The internal elastic lamina or internal elastic lamella is a layer of elastic tissue that
forms the outermost part of the tunica intima of blood vessels.
- The tunica media is consist of smooth muscle cells, elastic and connective
tissues arranged circularly around the vessel
- Tunica externa composed entirely of connective fibers and surrounded by an
external elastic lamina which functions to support vessels with surrounding
tissues.

CORONARY ARTERY

- Coronary is important for delivering blood to the heart, if any of the of these
arteries are affected by diseases it could lead to complications due to decreased
flow of oxygen going to the heart and it might lead to heart attack or even death

Physical Assessment

- Occurrence of erythema, fissuring, bleeding, and/or crusting of the lips and

involvement of the mucous membranes causes strawberry tongue and
conjunctivitis.
 - Erythema is redness of the skin or mucous membranes, caused by hyperemia
(increased blood flow)
- Erythema of the hands and feet particularly on the palms and soles sometimes
accompanied by firm and painful induration of the hands or feet that can impede
ambulation. Within 2-3 weeks after the onset of fever
- Induration: Localized hardening of soft tissue of the body. The area becomes firm, but
not as hard as bone
- Maculopapular rash is made of both flat and raised skin lesions.
- Desquamation of the fingers and toes begins and usually in the periungual
region, 1-2 months after the onset of fever, Beau's lines may become apparent.
- Periungual. : situated or occurring around a fingernail or toenail.
- ACUTE UNILATERAL LYMPHADENOPATHY - to the localized swollen lymph node(s)
on one side of the neck and is usually associated with bacterial infections
- Fever
- polymorphous exanthem, extremity changes, mucosal changes involving the lips and
oral cavity, bilateral bulbar conjunctival injection, and unilateral cervical
lymphadenopathy

ETIOLOGY

- GENETIC According to Tina K Sosa, siblings of affected children have a 10-20

times higher probability of developing KD than the general population.
- ASIAN In international statistics, KD is most common in Japan, Taiwan and
Korea. The highest incidence of KD is reported in Japan with a frequency of 10-
20 times higher than western countries.
- Dr. Tomisaku Kawasaki

- AGE >5yrs - Children’s immune system is still developing at this age so their
immune response in not quite stable putting them risk for developing infections
caused by bacteria, viruses, fungi, and parasites.
- SEX – According to statistics, majority of cases are males with a male-to-female
ratio of 1.5
 - Seasonal Variations - There are reports that It varies by geographical area. In
japan the occurrence of the case increases during January and the summer
months of June and July, winter and spring months
- Environmental - Infection triggers an inflammatory response, and part of the
response is attacking the endothelial cells in the blood vessels.

-  Multiple organisms of bacterial and viral origin have are under suspicion as a cause, but
to date, no single agent has been identified as the leading cause.  However, there has been
evidence showing over 40% of children diagnosed with KD have tested positive for viral
respiratory pathogens.

-
Symptomatology

1. Conjunctivitis - In Kawasaki disease, small blood vessels are inflamed including

the small blood vessels in the conjunctiva and this causes the eye to become
reddish
2. Rash - Due to inflamed blood vessels, it’ll become erythematous causing
redness to the skin or rash
- Erythema is redness of the skin or mucous membranes, caused by hyperemia
(increased blood flow)
3. Lymphadenopathy - Due to inflammation, there is an increase release of
inflammatory cells as a response to inflammation causing lymph nodes to swell
4. Strawberry tongue - Mucosal involvement is part of Kawasaki disease as blood
vessels are inflamed, tongue is also affected
5. Erythema on hands and feet - In Kawasaki disease, walls in blood vessels are
inflamed, as a response there will be an increased blood flow causing erythema
and might develop to desquamation, Erythema is redness of the skin or mucous
membranes, caused by hyperemia (increased blood flow)
6. FEVER >5 days Fever is a result of the body’s immune response to fight an
infection. In KD, etiology is still unknown. Fever inhibits bacterial growth and increase
the rate of tissue repair when an infection is present in the body
These inflammatory cells work by picking up foreign substances that arise from
infections then creat an inflammatory response, these inflammatory response involves
misdirecting the attack from the infection and temporarily attacking the medium sized
vessels

The immune response from these lymphocytes involves cellular proliferation, which can cause
the nodes to enlarge (reactive lymphadenopathy)

Neutrophils are rapidly recruited to lymph nodes in response to a range of stimuli. This

recruitment can occur via lymphatic vessels.

Cytokines are produced by a broad range of cells, including immune cells like macrophages, B
lymphocytes, T lymphocytes and mast cells, as well as endothelial cells, fibroblasts, and
various stromal cells

CYTOKINES  IL-1, IL-6 and TNFFEVER

- a group of cytokines that cause fever responses, in addition to resetting the

thermostat in the hypothalamus, these cytokines mobilize energy via fat
and protein breakdown to allow for increased body temp. 
- This group also causes the number of circulating neutrophils to increase
- They also cause dendritic cells to begin migrating to the spleen and lymph
nodes

- These cytokines are also referred to as proinflammatory -when local levels

are high, they can cause increased vascular permeability and promote the
adhesion of neutrophils to the vascular endothelium of the area.
The inflammatory response increases the amount of blood flow to the site of injury to
get more nutrients and white blood cells to an area in need. To increase blood flow to the
area, the blood vessels get wider (dilate).

ERYTHEMA - dilated capillaries in the hand, which draw more blood to the surface

1. Erythema is redness of the skin or mucous membranes, caused by hyperemia

(increased blood flow)

Perivascular - tissues surrounding a blood vessel

Conjunctivitis

- The conjunctiva is a loose connective tissue that covers the surface of the eyeball

- When small blood vessels in the conjunctiva become inflamed, they're more visible.

Strawberry tongue

- Lingual Artery -  a major blood vessel that supplies blood to the tongue and the
floor of the mouth
- The lingual artery splits into three named branches, and each branch supplies
blood to a different area of the tongue and mouth

- Dorsal Lingual Arteries

 These two or three small blood vessels are located at the back of the tongue.
They supply blood to the tongue's mucous membrane

- Sublingual Artery
 This branch passes forward through the tongue and supplies the muscles that
make up the floor of the mouth,
 - Deep Lingual Artery
 This branch is the end section of the tongue's artery. It's located on the
underside of the tongue, close to the lingual frenulum — the small piece of
tissue that attaches the tongue to the floor of the mouth.

LIPS - The arteries and veins are connected through a series of blood vessels called

the capillaries. These red-colored blood filled capillaries are close to the thin skin on
your lips, so your lips appear red

POLYMORPHOUS RASH - a rash caused by sun exposure in people who have

developed sensitivity to sunlight. The rash usually appears as red, tiny bumps or slightly
raised patches of skin

IF TREATED

“Considerations before confirming KD, changes in laboratory data such as

thrombocytosis, leukocytosis, elevated ESR (erythrocyte sedimentation rate) and CRP (C-
reactive protein), elevated liver enzymes and mild anemia. The changes in these infectious and
inflammatory markers required a thorough investigation into possible causes for the child’s
symptoms including viral infections, scarlet fever, staphylococcal scalded skin syndrome,
juvenile rheumatoid arthritis or Rocky Mountain spotted fever.

Streptococcal pharyngiti -> Scarlet fever = rash, strawberry tongue, swelling of lymph nodes

CBC  anemia, increased wbc, platelet

C-reactive protein test is a protein made by the liver that is sent to the bloodstream in response to
inflammation

High CRP levels can also indicate that there's inflammation in the arteries

Echocardiogram – can show pericardial effusion, coronary aneurysms

Microscopic urinalysis

Mononuclear leukocytes include lymphocytes, monocytes, macrophages, and dendritic cells.

This group is involved in both innate and adaptive immune system function.
Electrocardiogram (ECG/EKG)

IVIG

- it helps to calm down the immune system and reduces inflammation

- Ivig deactivates antibodies that causes the inflammation

Aspirin inhibit cyclooxygenase; prevents platelet aggregation = giving aspirin to kids go result
to reye syndrome (encephalopathy, liver injury) so we take the risk and monitor the child.

Prednisolone

Methylprednisolone IV - Suppression of inflammation and modification of the normal immune response.

Monitor pain - Monitor pain level and child’s response to analgesia.

Cardiac monitoring and assessment - Take vital signs as directed by conditions; assess
for signs of mycocarditis (tachycardia, gallop rhythm, chest pain); and monitor for heart
failure
Monitor I&O.- Closely monitor intake and output, and monitor hydration status by
checking skin turgor, weight, urinary output, specific gravity, and presence of tears.
Plan periods of rest and activities - Allow the child periods of uninterrupted rest;
encourage the child to move about freely under supervision; provide soft toys and quiet
play and encourage use of hands and fingers; and provide quiet, peaceful environment
with diversional activities.
PROVIDE ORAL CARE Offer cool liquids (ice chips and ice pops); progress to soft,
bland foods; and give mouth care every 1 to 4 hours with special mouth swabs; use soft
toothbrush only after healing has occurred.
Platelets - are tiny blood cells that help your body form clots to stop bleeding. If one of your
blood vessels gets damaged, it sends out signals to the platelets. The platelets then rush to
the site of damage. they form a plug (clot) to fix the damage.
Proinflammatory(Cytokines) -when local levels are high, they can cause increased
vascular permeability and promote the adhesion of neutrophils to the vascular
endothelium of the area. Severe damage to the vessel, causing increase in
platelet resulting to chance of having blood clot formation remains (thrombus)
blocking the flow of blood, depriving tissues of normal blood flow and oxygen. = ischemia.
Collagen fibers It helps strengthen and provide elasticity to blood vessels
Aneurysm - Over the next few weeks to months, the active inflammatory cells are replaced by
fibroblasts and monocytes, and fibrous connective tissue begins to form within the vessel wall.
The intima proliferates and thickens; the vessel wall eventually becomes narrowed or occluded
owing to stenosis or a thrombus.

Irritability is a feeling of agitation. ... Babies and young children are often reported to feel
irritable, especially when they're tired or sick. For example, children often become fussy when
they have ear infections or stomach aches. Adults can also feel irritable for a variety of reasons

Aseptic meningitis is the inflammation of the meninges,

Anterior uveitis is an inflammation of the middle layer of the eye. This middle layer includes the
iris (colored part of the eye) and adjacent tissue, known as the ciliary body.

Otitis media is a group of inflammatory diseases of the middle ear.

Myocarditis is an inflammation of the heart muscle

Pericarditis refers to inflammation of the pericardium,

Pneumonitis is a general term that refers to inflammation of lung tissue

Orchitis (or-KIE-tis) is an inflammation of one or both testicles

Meatitis. This means redness at the opening of the penis. It may have a sore or scab on it.
Passing urine is painful

Vulvitis is the inflammation of the soft skin on the outside of the female genitalia

Urethritis is inflammation of the urethra

Desquamation - It is associated with healing from damage to the skin from either internal
cause.
Over the next few weeks to months, the active inflammatory cells are replaced by
fibroblasts and monocytes, and fibrous connective tissue begins to form within
the vessel wall.

STAGE 2

Platelets - If one of your blood vessels gets damaged, it sends out signals to the platelets.
The platelets then rush to the site of damage. they form a plug (clot) to fix the damage.

Over the next few weeks to months, the active inflammatory cells are replaced by
fibroblasts and monocytes, and fibrous connective tissue begins to form within
the vessel wall.
Fibroblasts from the surrounding connective tissues replace the collagen and extracellular
material lost by the injury.

MONOCYTE In healing wounds, circulating monocytes also enter the tissue and instead of

becoming macrophages, can differentiate into fibroblast-like cells called fibrocytes.

Fibrous connective tissue, which is composed of parallel bundles of collagen fibers

- Collagen fibers It helps strengthen and provide elasticity to blood vessels

Fibrin – deposited in the blood vessel wall as part of the healing process and could make the
vessel stiffer, less elastic and stretchy.

- In case aneurysm doesn’t develop. Fibrin makes the blood vessels wall thicker which
reduces the diameter of the blood vessel and reduced blood flow to the heart (ischemic)

STAGE 3

Self-limited disease – a disease that will resolve on its own

Beau's lines are indentations that run across the nails

Kawasaki disease is a self-limited disease meaning it will recover through time even
without treatment, however there is a study that 2% of patients with KD died after their
recovery and approximately 25% chance of developing Coronary artery aneurism that
may contribute to myocardial infarction and even death.
PHAGOCYTES - Phagocytic cells ingest and destroy microbes that pass into body tissues

CHEMOTAXIS: Chemically stimulated movement of phagocytes to a site of damage