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CARDIO CASE
REPORT:
KAWASAKI
DISEASE
ARROGANTE|CORREOS|JANER|QUITANGON
BARAIYA|PATEL
 OBJECTIVES

● Discuss and analyze the history and physical examination of the given case
● Understand the pathophysiology of Kawasaki disease
● Identify the clinical features, labs & diagnostic exam and principal criteria of
Kawasaki Disease
● Discuss the management and prognosis of Kawasaki disease
 TOPIC OUTLINE

1 2
Patient’s History & Differential
PE Diagnosis & Initial
Impression

3 4
Discussion - Management
Kawasaki Disease
 1
Patient’s
History & PE
 GENERAL DATA

AB, 1 yr old, Female, Roman Catholic from Daraga, Albay. Admitted

for the 1st time

Informant: Mother

Reliability: 95%

Date & Time of Admission: June 17 , 2021 at 10am

 CHIEF COMPLAINT

Fever for 7 days

 History of Present Illness

7 days PTA

Patient had fever and the recorded Tmax was 38.9 C. No cough, colds & other associated
symptoms noted. The patient was given paracetamol every 4h with unrecalled dose and with no
relief. No consult done.

6 days PTA

Still with fever and recorded Tmax 38.3 C, given paracetamol every 4h yet with no relief.
Now associated with palpable lymph node on the right lateral neck. No consult done.

5 days PTA

Still with fever at Tmax 38.5 C. Sought consult at a private MD and was given Co-
amoxiclav with unrecalled dose. After taking medications, patient developed rashes at the back.
Sought consult again at private MD and was given prednisone for rashes
 History of Present Illness
3 days PTA

Still with fever at Tmax 38.5 C, now associated with cough, colds,
conjunctivitis and erythema of lips. Sought consult at Tanchuling hospital and was
admitted. Medications given were cefuroxime, hydrocortisone, paracetamol and
cetirizine.

2 days PTA

Still persisted with fever at Tmax 38.4 C and above symptoms. Now
associated with bipedal edema.

Few hrs PTA

Patient was referred to our institution and admitted.

 Review of Systems

General: (-) change in appetite Respiratory: (-) Shortness of breath

(-) weight loss/gain (-) wheezing

Skin: (-) bleeding CVS: (-) cyanosis

EENT: (-) eye discharge (-) palpitations

(-) epistaxis Gastro: (-) nausea

(-) vomiting

(-) diarrhea

(-) hematemesis
 Review of Systems

GU: (-) dysuria Hema: (-) easy bruisability

(-) hematuria Neuro: (-) sleep problems

(-) crying when urination (-) personality/ behavioral change

Endocrine: (-) heat/cold intolerance

Musculoskeletal: (-) arthralgia (-) joint swelling

(-) myalgia (-) cold extremities

 Birth and Maternal History

Patient was born on June 13, 2020, delivered by NSD, full term at a local
hospital. She had a good cry and activity at birth with no meconium staining.
BW was 3.1 kg, length was 50 cm and pediatric aging was 38 weeks. She was
immediately room in after birth. No history of neonatal cyanosis or jaundice.
Newborn screening was done with normal results.

Mother is 30 yrs old G1P1 (1001), had no history of illness, alcohol intake,
bleeding nor exposure to teratogens during pregnancy. She had regular
prenatal consults at a lying in clinic with a total of 6 visits. She took ferrous
sulfate and Multivitamins.
 Nutritional (Feeding) History

Patient was exclusively breastfed until 6mos. At 6 mos, complementary

feeding was started with cerelac and rice porridge. Formula milk was also
given, Enfapro A+ 1:1 dilution.

At 12 mos, she was started on regular table food. She eats a variety of food
with preference for chicken, soup and fruits. Water intake is 4-6 glasses per
day.
 Immunization History

BCG & Hep B - at Birth

Pentavalent (Hep B, HiB, DPT) - 6-10-14 weeks

OPV - 6-10-14 weeks

PCV - 6-10-14 weeks

Influenza vacc - 6 mos

Measles vacc - 9 mos

 Growth and Developmental History
AGE GROSS MOTOR FINE MOTOR LANGUAGE PERSONAL/SOCIAL

2 mos Head bobs if held Hands unfisted Coos Social smile

sitting most of the time Alerts to voice Recognizes parent
& sounds

4 mos No head lag when Shakes rattle Orients to Laughs out loud
pulled to sit Mouths objects voice Enjoys looking
Rolls front to Reaching for around
back objects

6 mos Sits unsupported Transfers objects Babbles dada Recognizes

from 1 hand to strangers
other
 Growth and Developmental History

AGE GROSS MOTOR FINE MOTOR LANGUAGE PERSONAL/SOCIAL

9 mos Pulls herself up to Pincer grasp Say mama and Waves bye bye
stand dada but not Reciprocates gestures
Crawls specific Object permanence
Imitates sounds

12 mos Stands alone Puts blocks in a Knows 1-3 Follows one step
Walks few steps cup words command
alone
 Past Medical History Family History

(-) HTN
(-) Congenital anomalies
(-) BA
(-) Bronchial asthma
(-) CHD
(-) allergies
(-) DM
No previous hospitalizations and surgeries
(-) Arthritis

(-) Thyroid disorders

 Personal And Social History

Patient is the first child in the family. Her father works as a government
employee while her mother is a housewife.

They live in a one storey 2 bedroom house with adequate ventilation. Water
supply comes from local water district and distilled water is used for
drinking. Their toilet is flush type and garbage is collected in the barangay
twice a week.

No travel history outside bicol.

 Physical Examination
General Survey: Awake, Irritable, Not in Cardiorespiratory distress

V/S: ANTHROPOMETRICS
Length Weight Interpretation
BP: 100/60 mmHg
Length for 74 cm --- Normal
age (Median = 0)
CR: 130 bpm
Weight for --- 9 kg Normal
RR: 35 cpm age (Median = 0)

Temp: 37.7 C Weight for 74 cm 9 kg Normal

Length (Median = 0)
O2 sat: 99% at Room Air

HC- 45 cm MUAC - 16cm

Lenght for age: Median 0 Weight for age: Median 0
(NORMAL) (NORMAL)
Weight for Lt: Median 0 (NORMAL) Head Circumference for Age: Median
0 (NORMAL)
SKIN: no cyanosis, no jaundice, (+) nontender maculopapular rash, good skin turgor, warm to touch

HEAD: normocephalic, atraumatic, no lesions

EYES: symmetric eyes, Anicteric Sclerae, no sunken eyeballs, (+) bilateral nonexudative conjunctival
injection

EARS: well formed pinna, clear external auditory canals, intact tympanic membrane, no discharge, no
tenderness

NOSE: septum at midline, patent nares, pink mucosa, no discharge, no alar flaring

MOUTH: (+) erythematous cracked dry lips, (+) strawberry tongue, no pharhyngeal exudates, (-) cleft
lip and palate

NECK: trachea is in midline, (+) palpable cervical lymphadenopathy 2 cm nontender on the right lateral
neck
RESPIRATORY: symmetric chest expansion, no retractions, no use of accessory muscles, clear breath
sounds, no adventitious sounds

CARDIOVASCULAR: adynamic precordium, PMI is located in the 4th ICS left MCL, normal S1 with
normally split S2, no murmurs

ABDOMEN: flat, no lesions, normoactive bowel sounds, tympanitic on percussion, soft, non tender, no
palpable mass, no organomegaly

GENITALIA: no pubic hair, no discharge

EXTREMITIES: (+) erythematous hands and feet, (+) bipedal edema, (+) polymorphous rash on both
hands, (+) periungual desquamation on fingers and toes, no atrophy, full equal pulses, CRT<2secs
 Neurologic Exam
1. CRANIAL NERVES

I - Not Elicited

II - 2-3mm pupils equally reactive to light and accommodation

III, IV, VI - intact extraocular movements

V - reacts to stimulus applied to forehead, cheeks and mandible

VII - no facial asymmetry, able to smile

VIII - looks at the person calling for her attention

IX, X - able to swallow

XI - can turn head side to side

XII - able to stick her tongue out and move side to side
2. MOTOR

The patient was able to move all her extremities spontaneously through observation.

3. REFLEXES
 SALIENT FEATURES

Hx PE
● ● Patient is Irritable
1 yr old
● Weight 9kg, Lengtht 74cm
● Female
● Febrile at 37.7 C
● (+) 7-day history of remittent fever (Tmax: ● (+) 2cm nontender palpable cervical
38.9’C) lymphadenopathy
● (+) Cervical lymphadenopathy, right lateral ● (+) non tender maculopapular rash on the
neck back
● (+) rashes on back (after antibiotic intake) ● (+) bilateral conjunctival suffusion
● ● (+) erythematous oropharyngeal mucosa, red
(+) cough and colds
cracked lips, strawberry tongue
● (+) bilateral conjunctival injection ● (+) polymorphous rash on both hands
● (+) erythema on lips ● (+) bipedal edema
● (+) bipedal edema ● (+) periungual desquamation on fingers and
toes
2
Differential
Diagnosis & Initial
Impression
 RULE IN RULE OUT
Kawasaki disease (+) remittent fever Cannot be ruled out
(+) maculopapular rash on back
(+) Periungual desquamation
(+) Bilateral conjunctival injection
(+) Erythematous hand
(+) strawberry tongue
(+) Cervical lymphadenopathy, Right Lateral
neck
(+) bipedal edema
Measles (+) fever (-) Koplik spots
(+) cough (-) conjunctivitis
(+) colds (-) rash on face and hairline and behind
(+) Rash the ear
(+) Cervical lymphadenopathy (+) solitary unilateral cervical
lymphadenopathy
Steven johnson syndrome (+) fever (-)periorbital edema
(+) Rash (-)oral ulceration
(+) cervical lymphadenopathy
Sepsis (+) Fever (-)cyanosis
(+) cervical lymphadenopathy (-)pallor
(+)irritable
(+)conjunctiva
(+) bipedal edema
Rheumatic Fever (+)Fever (-)Joint pain
(+)Rash (-) most prevalence age 5-15years
WORKING IMPRESSION

Kawasaki Disease
 DIAGNOSTICS AND LABS

● leukocyte count is Elevated

● Normocytic, normochromic anemia is common.
● platelet count is generally normal in the 1st wk , 2nd and 3rd wk rapidly increases
● elevated ESR or CRP value
● Sterile pyuria, mild elevations of the hepatic transaminases
● hyperbilirubinemia
● cerebrospinal fluid pleocytosis may also be present
 Diagnostics

● WBC 17.5.
● RBC 30.0 (g/dl)
● HGB 10.5 (g/dl)
● PLT 450
● HCT 36
● NEUTROPHILS 3.5 %
● LYMPHOCYTES 7.0 %
 Radiology Findings
● Two-dimensional echocardiography is the most useful test to monitor for development of CAA.
● coronary artery dimensions, adjusted for BSA (z scores), may be increased in the 1st 5 wk after
presentation, and as previously noted, baseline z scores may offer prognostic information
regarding ultimate coronary artery dimensions.
● Aneurysms have been defined with use of absolute dimensions by the Japanese Ministry of Health
and are classified as:
● Small ≤4 mm internal diameter
● medium >4 to ≤8 mm
● giant >8 mm
● coronary dimension for BSA. The AHA z -score classification system is as follows:

No involvement : always <2

Dilation only : 2 to < 2.5

Small aneurysm : ≥2.5 to <5

Medium aneurysm: ≥5 to <10, and absolute dimension <8 mm

Large or giant aneurysm: ≥10, or absolute dimension ≥8 mm

 Echocardiography

● should be performed at diagnosis

● again after 1-2 wk of illness.
● If the results are normal, a repeat study should be performed 6-8 wk after onset of illness.
3
Kawasaki Disease
Systemic inflammatory disorder
manifesting as vasculitis
 Etiology
Cause remains unknown

Infectious Origin Genetic Role

● Young age-group ● Higher risk in Asian children
● Self-limited nature of acute ● Among siblings and children
of individuals w/ a history of
febrile illness
KD
● Clinical features
● Rare occurrence among <3
months old
Epidemiology

● Acute febrile illness of early childhood

● Most affected children are Asians & Pacific
Islanders
● More common in males
● Children <5 years old
 Pathology

Vasculitis that predominantly affects medium-size arteries

Arteritis is frequently observed in the coronary arteries

Leading cause of acquired heart disease in children in most developed countries

 3-Phase Arteriopathy of Kawasaki Disease

01 02 03

NECROTIZING
ARTERITIS
● 1st 2 weeks of illness
● Begins in the endothelium
& moves through the
coronary wall
● Saccular aneurysms
LUMINAL
SUBACUTE/CHRONI MYOFIBROBLAS
C VASCULITIS TIC
● May last weeks to years
PROLIFERATION
● Medial smooth muscle
● Driven by lymphocytes, cell-derived
plasma cells & eosinophils myofibroblastic process
● Results in fusiform ● Can cause progressive
aneurysms arterial stenosis
CLINICAL MANIFESTATIONS
CLINICAL COURSE
OTHER TYPES OF
KAWASAKI DISEASE
● INCOMPLETE TYPE – presence of fever of ≥5
days plus less than 4 of the clinical criteria AND
coronary artery dilatation on 2D echocardiography
● ATYPICAL - reserved for patients who may have
renal impairment or other symptoms not generally
seen in Kawasaki Disease
LABS AND DIAGNOSTICS
 4
Management
MANAGEMENT
 MANAGEMENT
IVIG-Resistant KD
● Persistent or recrudescent fever at least 36h and <7 days after completion of 1st IVIG infusion
● Occurs in approx. 15% of patients
 DOCTOR’S ORDER
JUNE 17, 2021 ➢ Admit patient to Pedia ward under Cardio service
➢ Secure consent for admission and management
1 yo ➢ Diet: DAT
Female
7-day history of fever ➢ IVF: D5IMB 500cc to run at 112-113 cc/h x 8h
(+) Cervical lymphadenopathy, right
lateral neck To follow: D5IMB 500cc to run at 55-56 cc/h x 16h
(+) rashes at back
➢ Diagnostics:
(+) cough and colds ❏ CBC with PC, BT ❏ Urinalysis
(+) conjunctivitis ❏ Na, K, Cl ❏ Chest x-ray AP/L
(+) erythema of lips ❏ ESR, CRP ❏ 2D-Echo
(+) erythema of hands and feet
(+) periungual desquamation ➢ Therapeutics:
(+) polymorphous rash on both ○ Normal Immunoglobulin (Human) 2.5g/50 ml 1.8g single infusion to run
hands for 10 hours at 4-5 cc/hr
(+) bipedal edema ○ Aspirin 180 mg PO every 6 hours until afebrile for 48 hours
(+) irritable, not in cardio-respiratory ➢ Monitor VS q4h and I&O q shift
distress ➢ WOF: hypotension, ↓ sensorium, desaturation, persistent vomiting
(-) murmur
➢ Refer accordingly
 COMPLICATIONS
TREATMENT
● Antithrombotic medication
● Aspirin (3-5 mg/kg/day)

● Coronary artery aneurysm Aneurysm

● Myocardial infarction ● Moderate size: dual-antiplatelet therapy
● Coronary artery stenosis ● Large-giant: anticoagulation w/ warfarin
● Inducible angina or low molecular -weight heparin is
● Sudden death added

Coronary Artery Stenosis & Inducible

Angina
● Coronary artery bypass grafting (CABG)
or catheter interventions
PROGNOSIS
Thank you!