• Pediatric Diseases
  • Child’s Abnormal Cardiac Rhythm
  • Congenital Atresia of the Esophagus
  • Congenital Cardiac Disorder
  • Congenital Metabolic Disorder
  • Kawasaki Disease
  • Inguinal Hernia, Hydrocele Testicle/Nook Edema, Umbilical Hernia
  • Short Stature
  • Cord Hernia
  • Baby Autoimmune Neutropenia
  • Blood Disease (1), mother-child immunity comes to an issue- Hemolytic Anemia of Newborn
  • Blood Disease (2), mother-child immunity comes to an issue- Neonatal Hemochromatosis (GALD)
  • Blood Disease (3), mother-child immunity comes to an issue – Neonatal Allogeneic Immune Thrombocytopenia (NAIT)

Pediatric Diseases：Kawasaki Disease

• Risk factor for cardiac infarct development.
• Numbers of patient is ever increasing.
• Triggered by excess immune reaction?
• Clinical condition of Kawasaki disease.
• Diagnose with five matches from major symptom.
• Disease which requires the differentiation.
• Acute Phase Treatment.
• Trial for stratified treatment using the IVIG Refractory Case Prediction Score.
• Revised edition of Acute Phase Treatment Guideline
• Consider for prognosis in accordance with internal diameter of hepatic artery.
• Hepatic Artery pathological lesion and long-term prognosis among anamnestic patient of the matured Kawasaki Disease

Risk factor for cardiac infarct development.

Kawasaki Disease is an acute febrile illness which appears more commonly among infants. It is Vasculitis syndrome which middle to small size inflammation of muscular artery is its primary pathological lesions. In case of no treatment has conducted, Coronary artery lesion (CAL) is combined on coronary artery with 25 to 30% ratio. And this pathological change becomes a risk factor for cardiac infarct due to the formation of blood clot. Therefore, it becomes important to extinct the severe inflammation reaction by prompt acute phase treatment, and to inhibit the development of blood vessel pathological change. Original article is reported by Tomitaro Kawasaki in 1967, then half century has been passed but still it remains to be identified.

Kawasaki Disease, when no treatment, Coronary Artery lesion is combined at 1 out of 3 to 4 people

Numbers of patient is ever increasing.

National survey for Kawasaki Disease is conducting approximately every 2 years since 1970. Since national fad is recognized in 1979, 1982 and 1986, annual numbers of patients is transitioned around 5,000, but shows increasing tendency from latter half of 1990. Annual numbers of patients are raised above 10,000 in 2005, and ever increasing since then.

In recent 23rd National Survey for Kawasaki Disease, numbers of patients in 2014 shows the record-high 15,979. Also, disease prevalence shows 302.5 per 100k of 0 to 4 years old infants in 2013, and 308.0 in 2014. It breaks the record-high number every year. Although the numbers of children are decreasing due to the declining birth rate, absolute number itself is increasing every year since 1990s. Thus, accumulated numbers of patients exceed 300,000.

Kawasaki Disease is mainly affected with infants, its disease prevalence is 66.2% under age 3, 88.2% under age 5, and peak prevalence period is in late infancy (6 to 11 months). According to the latest national survey, approximately 92% patients get an acute phase medical treatment using immune globulin. Acute phase cardiac lesion is seen with 9.3% and such insult remains as after effect on and after 30 sick days at 2.8% ratio. The ratio of sibling case where brother-sister are affected is 1.5%, 0.89% for either one of parents with a history of Kawasaki Disease, and 3.5% for recurrent case.

Triggered by excess immune reaction?

Various theories are discussed as the cause of Kawasaki Disease, but it is still unknown. In the past, the thought which some kind of infection disease is backgrounded is commonly spread around, but recently the thought becomes as main stream that pathogenic microbe like fungus, virus or rickettsia may break into the body triggers the excess immune reaction (natural immunity), then certain disease state, which appears out with any one of these microbes, are hidden in the body.

• Infection Factor

From the facts such as, three epidemic period exists in the past, and frequency of occurrence of Kawasaki Disease decreases in September to November period where both bacteria and virus decrease, involvement of infection factor is considered. Bacteria, Virus, rickettsia, chlamydia, fungus are considered as the cause of disease. Up until now, bacterial broth test, virus separation, analysis using serum antibody titer are energetically conducted, but no reproducible results are obtained. Research (Metagenome analysis) from gene analysis view point using next generation sequencer is to be conducted since 2009, so that cyclopaedically virus research, like cyclopaedically mapping of nucleic acid sequence, and selecting microbe which is related to pathological condition, are proceeded.

• Genetic Factor

It is suggested that genetic factor contributes to this disease since disease prevalence in Japan is 10 to 20 times higher than the one in European countries, and occurrence frequency amongst sibling cases and Japanese (Japanese descent) are high. Until now, by means of Genome Wide Approach which searches disease susceptibility gene from every genome, Kawasaki disease susceptibility gene (ITPKC, CASP3) is identified. Also, by means of genome-wide association study (GWAS), B lymphoid tyrosine kinase (BLK), human leukocyte antigen (HLA), CD40, FCGR2A are reported as Kawasaki disease susceptibility gene. From the result of these gene analysis, although sufficient verification has not yet been gained to explain development of Kawasaki Disease, but the polytypic combination of ITPKC and CASP3 gene is significantly related to treatment-resistance or CAL Complication risk. Application usage for tailor-made treatment is therefore expected in the future.

Clinical condition of Kawasaki disease.

Clinical condition in acute phase of Kawasaki Disease is characterized in excess activation of innate immune system, and it is combined with the increase of inflammatory cytokine and chemokine. Then it is considered that these factors set up derivation of fever, increase of acute protein production or neutrophil in blood, and inflammation of blood vessel.

Currently, fundamental research using various kind of experimental animal and Research using Kawasaki Disease specific iPS cell, are energetically conducting. Therefore, detail of onset factor of Kawasaki Disease, clarification of clinical condition, and furthermore mechanism of vascular sequelae, are gradually going to be apparent.

Diagnose with five matches from major symptom.

There is no specific diagnostic method observed from examination findings for the diagnostic of Kawasaki Disease. It is done in accordance with the guideline for Kawasaki Disease (5th Revision by Kawasaki Disease Research Group of Ministry of Health, Labor and Welfare)

Kawasaki Disease (MCLS, Mucocutaneous Lymph Node Syndrome)

Kawasaki Disease is an acute febrile illness with unknown cause which appears more commonly amongst infants and characterized with entire body inflammation of blood vessel.

Mucocutaneous Lymph Node Syndrome combined with specific desquamation of the fingers and toes: clinical observation of 50 own experiments case.
(Tomisaku Kawasaki Allergy 1967,16,178)

Diagnose as Kawasaki Disease when 5 symptoms or more are associated out of below listed 6 major symptoms.

• a.a. Fever continued more than 5 days (the case which fever has reduced in 5 days by treatment is included)
• b.Bilateral eye conjunctival bloodshot
• c.Lip/Mouth observation: Flushing of the lip, Strawberry tongue, Diffuse redness of oropharyngeal mucosa
• d.Unshaped exanthema
• e.Changes on distal portion of the extremities: (acute phase) Hard swelling of limbs, erythematous patch of palm and sole or tip of finger and toe
                             (Recovery phase) Membrane-like desquamation
• f.Non-infected Cervical lymph node swelling in acute phase

When only 4 symptoms are recognized out of above 6 major symptoms, but when coronary fistula (i.e. enlargement) is identified by 2D echocardiography or cardiac angiography during the course and other disease is excluded, it is diagnosed as Kawasaki Disease.

There exists 15 to 20% “Kawasaki Disease aborted type” where symptom does not fulfill a criterion of Guideline for Diagnosis and is considered as Kawasaki Disease because of the denial of other disease thus considered as Kawasaki Disease. Aborted type does ever mean a mild case, and likely associated with cardiac complication, it is recommended to start treatment next to no time.

Disease which requires the differentiation

1. a.Yersinia Infection
There is a case where similar symptom of Kawasaki Disease appears in Yersinia pseudotuberculosis (Yp) infection, and 10% among them fulfill the diagnosis criterion. Also, there is cases where coronary artery aneurysm/dilatation.
2. b.Canker Rash
Rose pink punctate rash, then later diffuse erythema is observed. There is a case showing strawberry tongue. Rash may be withdrawn in approximately 1 week, then later abrasion or desquamation will be seen for few weeks.
3. c.Adenoviral Infection
Conjunctival congestion by fever onset, inflammation of pharynx and conjunctivitis are three major symptoms in pharyngoconjunctival fever.
4. d.Juvenile Idiopathic Arthritis
Systemic arthritis is defined as arthritis which is associated with fever of a remittent type continues more than 2 weeks, and with one or more following symptoms, (1) Transient and non-stationary erythema, (2) Generalized lymph node enlargement, (3) Hepatic or spleen enlargement, (4) Inflammation of a serous membrane.
5. f.Others
Repetition is not so high, but there is a case which is arising secondary in immediately after other disease so that relativity is strongly suspected. Especially, EB Virus infection, measles, influenza, yersinia infection, staphylococcic infection, hemolytic streptococcal infection and mycoplasma infection are subject to be distinguished.

Even though only 4 symptoms are recognized from above 6 major symptoms, when coronary aneurysm (including so called enlargement) is distinguished and other disease are excluded, then it is diagnosed as Kawasaki Disease.

Acute Phase Treatment.

Immunoglobulin Super Mass (IVIG) single dose is the most reliable anti-inflammatory therapy at this moment and decline of fever is gained in 80% of the cases. On the contrary, there exists IVIG refractory case with 10 to 20%. In this IVIG refractory case, coronary artery disorder is associated with 7 times higher rate, with comparison of IVIG reaction case.

Trial for stratified treatment using the IVIG Refractory Case Prediction Score.

With using IVIG Refractory Case Prediction Score developed in 2006, randomized controlled study is carried out for the purpose of stratified treatment for severe Kawasaki Disease patients. In 2012, it is reported one after the other that IVIG+ Steroid early phase combined administration has significantly reduced the repetition of coronary artery lesion complication.

Revised edition of Acute Phase Treatment Guideline

New guideline is reported in 2012. Its general outline is as follows.

• ①Initial phase treatment
Set out to shorten the duration of fever or early weakening of inflammation marker before Penangites on coronary artery has completed histologically, i.e. treatment is successful before 8 – 9 diseased days. Stratify IVIG refractory prediction case by risk score, and it can be considered that the combination administration of Prednisolone (PDL) or Intravenous Methylprednisolompal (IVMP) in addition to first treatment IVIG 2g/kg administration.
• ②Selection of treatment for initial phase treatment refractory case
For initial phase treatment refractory case, additional administration of IVIG, IVMP, Infliximab (IFX), Ulinastatin, Cyclosporine A, Plasma Exchange (plasma pheresis, PE) are selected depend on the symptom. Recent research says, IVIG administration 91.5%, Steroid administration 30.0%, IFX 4.3%, immune suppressor 3.7%, and PE 2.2% are used. As to the usage of Steroid for the case where coronary artery has already started to expand, there is a case where steroid usage is already included so that it is necessary to judge its application in careful manner.

Consider for prognosis in accordance with internal diameter of hepatic artery.

Prognostic factors in Kawasaki Disease are expansion of coronary artery or coronary artery aneurysm. Up to now, prognosis is considered as follows.

• (1) As for no coronary artery pathological abnormality, or regressed case in early phase: At this moment, it is considered as almost no matter as far as coronary artery pathological abnormality concern.
• (2) Maximum internal diameter of coronary artery is less than 4mm (tubercle or enlargement): repetition where coronary artery pathological abnormality is remained are seldom from the review of endovascular ultrasonography.
• (3) From more than 4mm to 8mm diameter (medium bump): For medium bump, it is recommended to watch and wait pursuant to mega bump.
• (4) More than 8mm (mega bump): It is considered that complete regression will not occur for this category. Selective coronary arteriography is necessary, and also necessary to be careful about the advancement of obstructing lesion.

Hepatic Artery pathological lesion and long-term prognosis among anamnestic patient of the matured Kawasaki Disease

Recently, by the examination of angioscopy, intravascular echo, vascular function test, or vascular echo, probability is indicated that Kawasaki disease inflammation of blood vessel may turn into the risk factor for arterial sclerosis.

Also, from National Research by Japan Kawasaki Disease Society, and collaborative research with Japanese Circulation Society (Japan Cardiovascular Society), it is clearly articulated that the onset of coronary artery event (acute cardiac infarction, acute coronary syndromes) which do not directly relate to coronary artery aneurysm or stenotic lesion, have seen amongst adult case. Just 50 years had passed since Kawasaki Disease reported, it is considered as necessary to study further in long term bases.

Especially, for not only anamnestic patient with coronary artery sequelae but also adult patients without having echocardiographic examination, opinion indicates that long term prognosis is necessary to be kept in mind. Under these circumstances, necessity of further ongoing inquest is pointed out regarding the prognosis or management of patient in remote phase.