RASH AND BURN: A CASE

MANAGEMENT OF KAWASAKI
DISEASE
Ron Christian Neil T. Rodriguez, MD
1st Year Pediatric Resident
Mary Johnston Hospital
 GENERAL DATA
• 2/M
• Roman Catholic
• Lives in Tondo, Manila
• Admitted on February 5, 2020
CHIEF COMPLAINT:
FEVER AND RASH
 •Intermittent fever (Tmax 38.7 C)
•No rash, vomiting, diarrhea, constipation
3 DAYS •Self medicated with Paracetamol; No consults done
PTA

•Persistence of high grade fever, still without any

2 DAYS accompanying symptoms
PTA
 • Still with persistent fever
• (+) Bilateral conjunctival injection; clear, watery eye discharge; small, unilateral,
movable, non-tender, lymph node approx. 2 cm at the right submandibular area
• (+) 1 episode of soft, non-foul smelling, greenish stools
1 DAY PTA • Consulted with private Pediatrician and was prescribed Erceflora, Pedialyte,
Cetirizine and Zinc; Advised admission

• Persistence of symptoms now with appearance of generalized maculopapular

rash starting on the back, progressing towards the trunk, hands, legs, and feet
• (+) Erythema of the hands and feet
FEW • Sought consult with AMD
HOURS PTA

ADMISSION
 REVIEW OF SYSTEMS
• General: (-) Body Malaise, (+) Fever, (-) Anorexia
• Skin: (+) Rashes, (+) Pruritus
• HEENT : (+) Conjunctivitis, (-) Blurred vision, (-) Epistaxis, (-) Nasal/Aural
discharge
• Respiratory: (-) Cough, (-) Colds
• Cardiac: (-) Palpitations, (-) Chest Pain, (-) Murmur
• Gastro: (-) Vomiting, (-) Constipation
 REVIEW OF SYSTEMS
• Genitourinary: (-) Dysuria, (-) Hematuria
• Musculoskeletal: (-) Joint pains, (-) Fracture, (-) Trauma
• Neurologic: (-) Numbness, (-) Weakness (-) Seizure
• Extremities: (+) Erythema of limbs, (-) Edema, (-) Cyanosis
 PAST MEDICAL HISTORY
• No previous hospitalizations
• No previous surgical operations
• No known allergies
 PERSONAL, SOCIAL AND
DEVELOPMENTAL HISTORY
• Patient currently eats a well balanced diet composed of rice, meat,
vegetables, occasional fruits, and milk and water
• Has not yet entered daycare
• Currently lives with his parents in a well ventilated home, with no pets nor
exposure to smoke.
• Development is at par with age
IMMUNIZATION HISTORY
 FAMILY HISTORY
• No family history of:
• Atopy
• Asthma
• Heart disease
• Kawasaki Disease
• Family denies neither exposure to persons with symptoms of COVID-19 nor
travel to places with cases of COVID-19
 PHYSICAL EXAMINATION
• Awake, alert, irritable, ill looking, well hydrated, well nourished, carried
• Weight: 16 kg
• PR: 132 RR: 30 Temp: 38.3 C
• Pink palpebral conjunctiva, hyperemic sclera, no eye discharges
• Nasal septum midline, minimal clear nasal discharge
• No tragal tenderness, no aural discharge
• Dry, cracked hyperemic lips, moist oral mucosa, no oral ulcers, no dental
caries, hyperemic tongue and pharynx, non-hyperemic, non-enlarged tonsils
• Small, palpable, movable, non-tender, solitary lymphadenopathy at the right
submandibular area approx. 1.5 cm in diameter
 PHYSICAL EXAMINATION
• Adynamic precordium, normal rate and rhythm, no murmurs
• No retractions, symmetric chest expansion, clear breath sounds
• Flat abdomen, no visible masses, normoactive bowel sounds, non-tender,
soft
• Pulses full and equal, CRT < 2 secs, erythematous hands and feet
• Multiple, erythematous maculopapular rashes at the back, trunk, arms
• No nuchal rigidity elicited. Other neurologic examination cannot be done at
time of admission as patient was highly irritable
 SALIENT FEATURES
• 2y/M • Irritable
• CC: Fever and rash • Temp: 38.3 C
• 5 day history of fever, unresponsive • Hyperemic sclera
to antipyretics • Dry cracked lips, hyperemic tongue
• Occasional diarrhea and pharynx
• Bilateral conjunctivitis • Small palpable, movable,
• Irritability nontender, unilateral lymph node
approx. 1.5 cm in diameter
• Presence of small, unilateral lymph
node enlargement at • Erythematous hands and feet
submandibular area • Maculopapular rashes
INITIAL IMPRESSION:
Acute lymphadenitis; Non-specific viral exanthem, rule out
dengue fever
 DIFFERENTIAL DIAGNOSIS
Patient Adenovirus Rubeola/Measles Scarlet Fever Kawasaki Disease

2y/Male (+) Exudative (+) Fever School age children 4 mos to 5 years old
CC: Fever and rash pharyngitis (+) Cough, coryza (+) Fever Male>Female
(+) Fever (+) Exudavtive (+) Conjunctivitis (+) Goose-like rashes (+) Fever >/= 5 days
(+) Diarrhea conjunctivitis (+) Koplik spots with sandpaper-like (+) Conjunctivitis
(+) Irritable (+) Maculopapular texture often affecting (+) Generalized
(+) Hyperemic sclera rashes starting at the the , sparing the face maculopapular rashes
(+) Dry cracked lips, hairline and spreads and head (+) Unilateral
hyperemic tongue downwards (+) Circumoral pallor lymphadenopathy
and pharynx (-) Lymphadenopathy (+) Strawberry tongue (+) Strawberry-like
(+) Small palpable, (+) Cervical tongue with dry lips
movable, nontender, lymphadenopathy (+) Hand and feet
unilateral lymph node Responds to antibiotic erythema
approx. 1.5 cm in therapy within 24 to 48
diameter hours
(+) Erythematous Ocular findings are
hands and feet rare
(+) Maculopapular
rashes starting at back
 COURSE IN THE WARDS – DAY 1
(DAY OF ADMISSION)
S O A P
• Fourth day of illness • High-grade fever Acute lymphadenitis; • Admit to Isolation
• Irritable • Bilateral Non-specific viral Room (Rm 202)
• Decreased conjunctivitis exanthem, rule out • PNSS
appetite • Dry, cracked, dengue fever • CBC with platelet
• No cough/colds hyperemic lips • Urinalysis
• Minimal diarrhea • Hyperemic tongue • Degnue NS1 Ag
• Generalized pruritus • Unilateral cervical • Fecalysis
lymphadenopathy • Paracetamol drops
• Erythematous ( mkd)
hands and feet • Probiotics
• Multiple, (Erceflora)
erythematous • Zinc sulfate drops
maculopapular
rashes at the back,
trunk, and arms
ON ADMISSION
 LAB RESULTS (FEB 4, 2020)
2/4/2020 • Urinalysis: Yellow, hazy, pH 6, SG
Hemoglobin 13.1 1.030, (-) Protein, (-) Glucose, Pus 0-
Hematocrit 38.4
2/hpf, RBC 1-2/hpf, Bacteria rare
WBC 26.18 • Fecalysis: Brown, loose consistency,
no parasites seen, bacteria plenty,
Segmenters 73
WBC 1-2/hpf
Lymphocytes 17
• Dengue NS1Ag: Negative
Monocytes 10
Basophil 0
Eosinophil 0
Platelet 300
 COURSE IN THE WARDS – DAY 1
(DAY OF ADMISSION)
S O A P
• Fourth day of illness • High-grade fever Acute lymphadenitis; • Admit to Isolation
• Irritable • Bilateral Non-specific viral Room (Rm 202)
• Decreased conjunctivitis exanthem • PNSS
appetite • Dry, cracked, • Paracetamol drops
• No cough/colds hyperemic lips ( mkd)
• Minimal diarrhea • Hyperemic tongue • Probiotics
• Generalized pruritus • Unilateral cervical (Erceflora)
lymphadenopathy • Zinc sulfate drops
• Erythematous • IV Ampicillin ( mkd)
hands and feet
• Multiple,
erythematous
maculopapular
rashes at the back,
trunk, and arms
 COURSE IN THE WARDS – DAY 2
S O A P
• Fifth day of illness • High-grade fever Acute lymphadenitis; • PNSS  D5 IMB
• Irritable • Minimal bilateral Non-specific viral • Paracetamol drops
• Fair appetite conjunctivitis exanthema ( mkd)
• No cough/colds • Dry, cracked, • Probiotics
• Minimal diarrhea hyperemic lips (Erceflora)
• Generalized pruritus • Hyperemic tongue • Zinc sulfate drops
• Unilateral cervical • IV Ampicillin (Day 1;
lymphadenopathy mkd)
• Erythematous
hands and feet
• Multiple,
erythematous
maculopapular
rashes at the back,
trunk, and arms
 COURSE IN THE WARDS – DAY 3
S O A P
• Sixth day of illness • High-grade fever Acute lymphadenitis; • D5 IMB
• Irritable • Dry, cracked, Non-specific viral • Repeat CBC
• Fair appetite hyperemic lips exanthema; t/c • ESR, CRP, ASO Titer
• No cough/colds • Hyperemic tongue Kawasaki Disease • Chest X-ray
• No diarrhea • Unilateral cervical • Paracetamol drops
• Generalized pruritus lymphadenopathy ( mkd)
• Reduced erythema • Probiotics
of hands and feet (Erceflora)
• Multiple, • Zinc sulfate drops
erythematous • IV Ampicillin (Day 1;
maculopapular mkd)
rashes at the back,
trunk, and arms
 LAB RESULTS (FEB 7, 2020)
2/4/2020 2/7/2020 • ASO Titer: < 20 IU/mL
Hemoglobin 13.1 11.9
• CRP: 187.3 mg/L
Hematocrit 38.4 34.1
• ESR: 68 mm/hr
WBC 26.18 12.05
• Chest X-ray: Hilar adenopathies,
Segmenters 73 79 Koch’s etiology not ruled out
Lymphocytes 17 15
Monocytes 10 6
Basophil 0 0
Eosinophil 0 0
Platelet 300 278
LAB RESULTS (FEB 7, 2020)
 COURSE IN THE WARDS – DAY 3
S O A P
• Sixth day of illness • High-grade fever Kawasaki Disease • D5 IMB
• Irritable • Dry, cracked, • Paracetamol drops
• Fair appetite hyperemic lips ( mkd)
• No cough/colds • Hyperemic tongue • Probiotics
• No diarrhea • Unilateral cervical (Erceflora)
• Generalized pruritus lymphadenopathy • Zinc sulfate drops
• Reduced erythema • Referral to Pediatric
of hands and feet Cardiology
• Multiple, • For 2D Echo
erythematous • For IVIG therapy
maculopapular • Aspirin (90 mkday)
rashes at the back, • D/C IV Ampicillin
trunk, and arms
 COURSE IN THE WARDS – DAY 4
S O A P
• Seventh day of • High-grade fever Kawasaki Disease • D5 IMB
illness • Dry, cracked, • 2D Echo (done
• Irritable hyperemic lips outside of hospital)
• Fair appetite • Hyperemic tongue • Admit to PICU for
• No cough/colds • Unilateral cervical IVIG therapy
• No diarrhea lymphadenopathy • IVIG therapy (2 g/kg;
• Generalized pruritus • Reduced erythema 4 test doses given 30
mins each for 2
of hands and feet
hours; remaining
• Multiple,
given at 41.2 cc/hr
erythematous for 10 hours)
maculopapular • Aspirin (90 mkday)
rashes at the back, • Paracetamol drops (
trunk, and arms mkd)
• Probiotics (Erceflora)
• Zinc sulfate drops
 LAB RESULTS – FEB 8, 2020
• 2D Echo: Situs solitus, cardiac apex to the left, atrioventricular and
ventriculoarterial concordance, normal chamber sizes, intact interatrial
septum, intact interventricular septum, normal coronary artery sizes, good
left and right ventricular systolic function, left-sided aortic arch, no patent
ductus arteriosus, no coarctation of the aorta
 COURSE IN THE WARDS – DAY 5
S O A P
• Eighth day of illness • Cracked, Kawasaki Disease s/p • Transferred to regular
• First day afebrile hyperemic lips IVIG therapy ward
• Slightly irritable • Non-hyperemic • D5 IMB
• Fair appetite tongue • Aspirin (90 mkday)
• No cough/colds • Unilateral cervical • Paracetamol drops (
• No diarrhea lymphadenopathy mkd)
• Minimal pruritus • Improving rashes at • Probiotics (Erceflora)
• Zinc sulfate drops
the back, trunk,
and arms
 COURSE IN THE WARDS – DAY 6
S O A P
• Ninth day of illness • Cracked, Kawasaki Disease s/p • Transferred to regular
• Second day hyperemic lips IVIG therapy ward
afebrile • Non-hyperemic • D5 IMB
• Slightly irritable tongue • Aspirin (MD)
• Improved appetite • Unilateral cervical • Paracetamol drops (
• No cough/colds lymphadenopathy mkd)
• No diarrhea • Decreased rashes • Probiotics (Erceflora)
• Zinc sulfate drops
• Minimal pruritus at the back, trunk,
• For discharge
and arms
tomorrow
 COURSE IN THE WARDS – DAY 7
S O A P
• Tenth day of illness • Improved lips Kawasaki Disease s/p • Discharge
• Third day afebrile • Non-hyperemic IVIG therapy • For repeat 2D Echo
• Slightly irritable tongue after 6 weeks (April
• Improved appetite • Unilateral cervical 2020)
• No cough/colds lymphadenopathy
• No diarrhea • Decreased rashes
• No pruritus at the back, trunk,
and arms
ON DISCHARGE
FINAL DIAGNOSIS
KAWASAKI DISEASE
 KAWASAKI DISEASE
• Also known as mucocutaneous lymph node syndrome and infantile
polyarteritis nodosa
• Manifests as vasculitis with predilection to the coronary arteries
• If not treated, may lead to coronary artery abnormalities (CAA)
• Leading cause of acquired heart disease in children in developed countries
• Etiology is currently unknown
 EPIDEMIOLOGY
• Disease seen in early childhood affecting mostly children age 5 and below
• Boys > Girls
• Those with Asian descent are more at risk to have the disease
• ITKPC gene, a T-cell regulator, has been found to be significantly associated with
increased susceptibility to the disease and more severe forms of Kawasaki
disease
• In the Philippines, according to the PPS registry, from January 1, 2020 to May
30, 2020, there have been 98 cases of Kawasaki disease
 PATHOLOGY OF KAWASAKI
DISEASE
• Predominantly affects the medium
sized arteries, often the coronary
arteries
• 3-phase process to arteriopathy
• 1st phase: neutrophilic necrotizing
arteritis within the first 2 weeks of
illness, beginning in the endothelium,
which can give rise to saccular
aneuryms
• 2nd phase: subacute/chronic vasculitis
driven by lymphocytes, plasma cells
and eosinophils, which may last for
weeks to years, and results to fusiform
aneurysms
• 3rd phase: progressive stenosis of the
artery
 PATHOLOGY OF KAWASAKI
DISEASE
• Tumor necrosis factor α (TNF α)  pleiotropic cytokine critical in the
regulation of immune cells and plays a critical role in inflammation
• Produced by activated T cells and macrophages, and binds to 2 receptors:
TNFR1 and TNFR2
• Binding to these receptors results to nuclear translocation of transcription factors
resulting to increased expression of gene products including cell proliferation,
expression of leukocyte recruitment molecules, production of pro-inflammatory
cytokines, production of acute-phase reactants, increased expression of
proteases including matrix metalloproteinases (MMPs)
PATHOLOGY OF KAWASAKI
DISEASE
 CLINICAL MANIFESTATIONS
• Patients present with high grade, remitting fever of at least 5 days
duration, which is often unresponsive to antipyretics
• Aside from fever, there are 5 principal symptoms of Kawasaki disease:
• Bilateral nonexudative conjunctival injection with limbal sparing
• Erythema of the oral and pharyngeal mucosa with strawberry tongue, and red
cracked lips
• Edema and erythema of the hands and feet
• Rash of various forms
• Nonsuppurative cervical lymphadenopathy, usually unilateral with node size >
1.5 cm
• The five symptoms do not have to occur concurrently
 CLINICAL MANIFESTATIONS
• Mnemonic: “CRASH and Burn”
• Conjunctivitis
• Rash
• Adenopathy
• Strawberry tongue
• Hands and feet erythema
• High fever (Burn)
 ATYPICAL KAWASAKI DISEASE
• Incomplete Kawasaki Disease
• Patients have persistent fever of at least 5 days but less than 4 out of the 5
characteristic symptoms
• To diagnose a patient with atypical Kawasaki Disease, findings of coronary
artery abnormalities in 2D Echo or angiography can help in solidifying the
diagnosis
 OTHER MANIFESTATIONS OF
KAWASAKI DISEASE
• Commonly occur within the 10 days of illness
• Vomiting, diarrhea, or abdominal pain are found in >60% of patients
• At least 1 respiratory symptom such as rhinorrhea or cough occurs in 35%
• Irritability
• Arthritis – 2nd or 3rd week of illness, affecting the small or large joints and may
persist for weeks
• Features not consistent with Kawasaki Disease: exudative conjunctivitis,
exudative pharyngitis, generalized lymphadenopathy, discrete oral lesions,
splenomegaly, bullous, petechial, or vesicular rashes
 OTHER MANIFESTATION OF
KAWASAKI DISEASE
• Node-first KD  Kawasaki disease initially presenting as fever and
lymphadenopathy
• Often confused for bacterial or viral cervical lymphadenopathy or lymphadenitis
• Persistence of high-fever, lack of response to antibiotics, and subsequent
development of other symptoms of Kawasaki Disease
• Patients tend to be older (at least 4 years old), have more febrile days, and has
higher CRP levels
• May also present with retropharyngeal and peritonsillar inflammation in CT scans
 CARDIAC INVOLVEMENT
• Most important manifestation of Kawasaki Disease, usually manifesting as
myocarditis
• Tachycardia disproportionate to fever and diminished left ventricular function
• KD Shock Syndrome  cardiogenic shock secondary to greatly diminished
left ventricular function; patients have higher risk of coronary artery dilation
• Pericarditis with small pericardial effusion
• Mitral regurgitation of at least mild severity seen in 2D Echo in 10-25% of
patients but diminishes over time
• Coronary artery aneurysms occur in the 2nd or 3rd week of illness of untreated
patients
 CARDIAC INVOLVEMENT
• Majority of mortalities of Kawasaki Disease occur in patients with giant or
large coronary artery aneurysms, defined by AHA as a z-score (internal
diameter) of >/= 10 or absolute dimension >/= 8 mm
• Associated with greatest risk of developing thrombosis, stenosis, angina, or
myocardial infarction
• Rupture of a giant aneurysm is a rare complication that occurs during the 1st
month of illness onset and may present as hemopereicardium with
tamponade
• Other arteries affected include the axillary, popliteal, and iliac but always
occurs on the setting of a giant aneurysm
CARDIAC INVOLVEMENT
 DIAGNOSING KAWASAKI DISEASE
• Diagnosis is based on the presence of clinical signs and symptoms. Initially
patients may be diagnosed as cervical lymphadenitis prior to Kawasaki
disease
• Diagnosis should be done within 10 days of illness (ideally within 7 days) to
improve coronary artery outcomes
• Establishing the diagnosis with prompt treatment is essential
• Recommendation: Any infant age </= 6 months with fever of >/= 7 days
without explanation should undergo echocardiography to assess the
coronary arteries
• Atypical Kawasaki Disease can be diagnosed depending on both clinical
and laboratory findings
DIAGNOSING ATYPICAL
KAWASAKI DISEASE
 LABORATORY AND RADIOLOGIC
FINDINGS
• No diagnostic test can be used to diagnose Kawasaki disease
• Patients with KD often show the following laboratory findings:
• Leukocytosis with neutrophil predominance
• Normal platelet count in the 1st week but increases in the 2nd to 3rd week
• Elevated ESR
• Elevated CRP
• If platelet, ESR and CRP are all normal within 7 days of illness, KD is unlikely
• 2D Echocardiography is the most useful test to monitor for coronary artery
aneurysms
 2D ECHOCARDIOGRAPHY IN
KAWASAKI DISEASE
• Means of monitoring coronary artery aneurysms in patients suspected or
diagnosed with Kawasaki Disease
• Monitors z-scores of coronary arteries, as well as ventricular function
• Baseline z-scores can offer prognostic information regarding ultimate coronary
artery dimensions
• As defined by the Ministry of Health in Japan, aneurysms are defined based
on the absolute dimensions:
• Small (</= 4mm internal diameter)
• Medium (>4 mm to </= 8mm internal diameter)
• Giant (> 8 mm internal diameter)
 2D ECHOCARDIOGRAPHY IN
KAWASAKI DISEASE
• Z-score classification according to the AHA:
• No involvement: always <2
• Dilation only: 2 to <2.5; or if initially <2, a decrease in z score during follow-up ≥1
• 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 must be done at diagnosis and after 1-2 weeks of illness. If
normal, a repeat must be done by 6-8 weeks after onset of illness
• Abnormal findings or recurrence of symptoms will require more
echocardiography
2D ECHOCARDIOGRAPHY IN
KAWASAKI DISEASE
 TREATMENT OF KAWASAKI DISEASE
• Gold standard of treatment is the single dose infusion of 2 g/kg IVIg,
administered within 10 to 12 hours within 10 days of symptom onset,
accompanied with moderate (30-50 mkday divided every 6 hours) to high
(80-100 mkday divided every 6 hours) dose aspirin until patient is afebrile
• Aspirin is lowered to antiplatelet doses (3-5 mkday single dose) if the patient
becomes afebrile for 48 hours
• Continued for 6-8 weeks after onset of illness onset and is discontinued in
patients who have normal echocardiography findings
• If with CAA, aspirin treatment is continued until normal echocardiography are
recorded
• NSAIDs must NOT be given during the treatment with aspirin as these can
block its action
 TREATMENT OF KAWASAKI DISEASE
• For long-term therapy patients with coronary arteries, the following are often
prescribed:
• Aspirin 3-5 mkday once daily orally
• Clopidogrel 1 mkday (max 75 mg/day)
• Most experts add warfarin or LMW heparin for patients with high risk of thrombosis
• For those with acute coronary thrombosis, prompt fibrinolytic therapy with
tissue plasminogen activator (tPA) or other thrombolytic agent is given under
supervision from a pediatric cardiologist
 TREATMENT OF KAWASAKI DISEASE
• Corticosteroids can be given concurrent with IVIg therapy, with prednisolone
given at 2 mg/kg
• Single pulse dose IV methylprednisolone as lone treatment, however, did not
improve coronary outcomes
 TREATMENT OF KAWASAKI DISEASE
• Refractory Kawasaki disease (or IVIg resistant)  persistent or recrudescent
fever 36 hours after completion of initial IVIg infusion; occurs in 15% of
patients
• Most common treatment options for refractory Kawasaki disease includes 2nd
dose of IVIg infusion, tapering course of corticosteroids, and/or infliximab, a
chimeric monoclonal anti-TNF a (5 mg/kg for 2 hours)
• Cyclosporine or cyclophosphamide may be added for patients with severely
affected patients with enlarging coronary aneurysms
TREATMENT OF KAWASAKI DISEASE
 COMPLICATIONS OF KAWASAKI
DISEASE
• Myocardial infarction, angina, and sudden death are the complications of
untreated Kawasaki disease. Hence, anti-thrombotic therapy are the
cornerstone of therapy for these patients
• Patients may develop coronary artery stenosis and inducible ischemia,
which can be resolved with coronary artery bypass grafting (CABG) or
catheter interventions
• Reye syndrome  may occur to patients who are on salicylate or aspirin
therapy and contracts viral disease; often results to encephalopathy and
fulminant hepatitis which can be fatal if not treated
• Recommended that patients on aspirin therapy must receive annual influenza
vaccination, with first dose given 11 months after initial IVIg infusion, as IVIg may
interfere with immune response to live-virus vaccines
 PROGNOSIS OF KAWASAKI
DISEASE
• Most dreaded complication of Kawasaki disease is the development of
coronary artery aneurysms
• Prognosis is good should appropriate and timely intervention be given, with
risk of coronary aneurysm development < 5%
• Predictors of poor outcome:
• Young age
• Male gender
• Persistent fever
• Poor response to IVIG
• Laboratory abnormalities (Neutrophilia, thrombocytopenia, transaminitis,
hyponatremia, hypoalbuminemia, elevated BNP, and elevated CRP)
 PROGNOSIS OF KAWASAKI
DISEASE
• Recurrence of Kawasaki disease is relatively low, at 2%, with chances of
recurrence seen during the 1st year of illness onset
• For children who had Kawasaki disease, was treated, and have normal
echocardiography, there is an unclear association as to a higher risk to
develop atherosclerotic disease upon reaching adulthood
• Counseling with regards to a heart-healthy diet, adequate exercise, tobacco
avoidance, and intermittent lipid monitoring should be given to patients who
have recovered from Kawasaki disease
 COVID-19 AND KAWASAKI
DISEASE
• Between April 2020 to May 2020, there have been multiple reports of children
developing symptoms similar to Kawasaki disease in Europe and United
States
• These cases have been called “Pediatric Multisystem Inflammatory
Syndrome” (PMIS)
• At time of discovery, pediatric patients were noted to have similar, yet
milder, symptoms of COVID-19 as compared to adults, but also would
require hospitalization and intensive care
 COVID-19 AND KAWASAKI
DISEASE
• A key finding of PMIS is evidence of severe inflammation, which is similar to
Kawasaki Disease and like Kawasaki Disease, children with PMIS also have
high fevers and can present with red eyes, and rash. Severe abdominal pain
and diarrhea may also be one of the complaints of patients with PMIS
• However, PMIS patients tend to be older than typical Kawasaki Disease
patients. Some of their blood tests, including markers of inflammation, are
more abnormal than patients with Kawasaki disease.
• As of today, there is still no registered amount of Pediatric patients who have
PMIS in the Philippines
 COVID-19 AND KAWASAKI
DISEASE
• WHO has set a preliminary case definition of PMIS:
• Children and adolescents 0–19 years of age with fever > 3 days AND two of the
following:
• Rash or bilateral non-purulent conjunctivitis or mucocutaneous inflammation signs (oral, hands
or feet).
• Hypotension or shock.
• Features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities (including
ECHO findings or elevated Troponin/NT-proBNP),
• Evidence of coagulopathy (by PT, PTT, elevated d-Dimers).
• Acute gastrointestinal problems (diarrhoea, vomiting, or abdominal pain).
• AND Elevated markers of inflammation such as ESR, C-reactive protein, or procalcitonin.
• AND No other obvious microbial cause of inflammation, including bacterial sepsis,
staphylococcal or streptococcal shock syndromes.
• AND Evidence of COVID-19 (RT-PCR, antigen test or serology positive), or likely contact
with patients with COVID-19.
THANK YOU