eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Kawasaki Disease: Follow-up

Author: Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Coauthor(s): Elena L Jones, MD, Clinical Assistant Professor of Dermatology, College of Physicians and Surgeons of Columbia University; Clinic Chief, Department of Dermatology, St Luke's-Roosevelt Hospital Center
Contributor Information and Disclosures

Updated: Oct 20, 2009

Follow-up

Further Inpatient Care

  • Admit patients with Kawasaki disease (KD) to the hospital, administer intravenous immunoglobulin (IVIG), and observe them until their fever is controlled.
  • Carefully monitor cardiovascular performance.
  • Once the fever resolves, clinically significant congestive heart failure (CHF) or myocardial dysfunction is unlikely.

Further Outpatient Care

  • Reevaluate all patients within 1 week of hospital discharge.
  • Schedule the patient for repeat echocardiography 21-28 days after the onset of fever.
  • If baseline echocardiographic studies and those obtained at 3-4 weeks do not depict any evidence of coronary aneurysms, further echocardiography is usually unnecessary.
  • Patients with no cardiac changes on echocardiography at any stage do not require activity restrictions or medications beyond 3 months after the initial illness.
  • Ensure that a patient with coronary artery aneurysms (CAAs) or other cardiac abnormalities receives further care, as dictated by a cardiologist.

Inpatient & Outpatient Medications

  • The mainstays of inpatient therapy include aspirin (100 mg/kg/d) and IVIG (400 mg/kg/d in 2-h infusions for 4 consecutive days).
  • IVIG therapy can be administered alternatively as a 2-g/kg dose infused over 8-12 hours as a single dose.
  • Aspirin (3-10 mg/kg/d divided 2-4 times daily) is continued until the fever, platelet levels, and erythrocyte sedimentation rate (ESR) return to the reference range.

Transfer

  • Transfer patients with suspected Kawasaki disease to a facility that has skilled clinicians and a pediatric or adult cardiologist to evaluate the echocardiogram.
  • IVIG must be available for prompt administration.

Complications

  • Cardiovascular
    • Clinically significant heart failure or myocardial dysfunction (unlikely to occur once fever is resolved)
    • Diffuse coronary artery ectasia and aneurysm formation, giant aneurysm (internal luminal diameter >8 mm)
    • Myocardial infarction (MI)
    • Myocarditis (common but rarely causes CHF)
    • Valvulitis, usually mitral (only occurs in 1% of patients and rarely requires valve replacement)
    • Pericarditis with small pericardial effusions (occurs in 25% of patients with acute illness)
    • Systemic arterial aneurysms
    • Rupture of CAA with hemopericardium
  • Other complications
    • Extreme irritability, especially in younger infants
    • Aseptic meningitis
    • Arthritis
    • Mild hepatic dysfunction, jaundice (rare)
    • Gallbladder hydrops (diagnosed using ultrasonography, usually resolves without surgical intervention)
    • Diarrhea
    • Pneumonitis
    • Otitis media
    • Erythema and induration at the site of bacille Calmette-Guérin (BCG) inoculation (reported in Japan)
    • Peripheral extremity gangrene (extremely rare)
    • Bowel ischemia and necrosis

Prognosis

  • With prompt treatment, the prognosis is good.
  • The current mortality rate is 0.1-2%.

Patient Education

  • The fact that most cases resolve must be communicated to the patient and family. The fact that Kawasaki disease can be fatal must also be communicated.
  • Educate patients about the possibility of recurrence.
    • The recurrence rate is 4% in Japan but is less than 1% in North America.
    • Emphasize the need for continued care if cardiac problems are present because Kawasaki disease is a potentially fatal illness.
    • Advise the patient's family that aspirin therapy must be continued until discontinued by the physician.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnosis atypical cases of Kawasaki disease (KD) is a pitfall.
  • Failure to make a diagnosis before the 10th day of illness so that intravenous immunoglobulin (IVIG) can be administered to help prevent coronary artery aneurysms (CAAs) is a pitfall. If the diagnosis is suspected but cannot be confirmed, refer the patient to a center with experience in treating illness in a timely manner.
  • Various infectious foci can mimic Kawasaki disease, including retropharyngeal abscess or cellulitis, peritonsillar abscess, orbital cellulitis, cervical lymphadenitis or deep neck infection, retropharyngeal phlegmon, and preseptal cellulitis.
  • Kawasaki disease mimics measles and group A beta-hemolytic streptococcal infection; therefore, making a wrong diagnosis may lead to inappropriate treatment.
  • When considering the rare diagnosis of mastoiditis, evaluate for other entities in the differential diagnosis before performing surgical intervention. However, if the patient is unstable or a threatened complication of mastoiditis is apparent, immediate mastoidectomy is required.
 


More on Kawasaki Disease

Overview: Kawasaki Disease
Differential Diagnoses & Workup: Kawasaki Disease
Treatment & Medication: Kawasaki Disease
Follow-up: Kawasaki Disease
Multimedia: Kawasaki Disease
References
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Further Reading

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Keywords

Kawasaki disease, KD, Kawasaki syndrome, Kawasaki's disease, KS, Kawasaki's syndrome, mucocutaneous lymph node syndrome, infantile periarteritis nodosa, myocarditis, pericarditis, pericardial effusion, mitral insufficiency, aortic insufficiency, dysrhythmias, arthritis

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Contributor Information and Disclosures

Author

Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Optigenex Consulting fee Independent contractor

Coauthor(s)

Elena L Jones, MD, Clinical Assistant Professor of Dermatology, College of Physicians and Surgeons of Columbia University; Clinic Chief, Department of Dermatology, St Luke's-Roosevelt Hospital Center
Disclosure: Nothing to disclose.

Medical Editor

Rosemary Johann-Liang, MD, Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration
Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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