Morning ReportJuly 16, 2012

Happy Monday!

SymptomsAcute /subacute Chronic

Localized DiffuseSingle MultipleStatic Progressive

Constant IntermittentSingle Episode Recurrent

Abrupt GradualSevere MildPainful NonpainfulBilious Nonbilious

Sharp/Stabbing Dull/Vague

Problem Characteristics

Ill-appearing/Toxic

Well-appearing/Non-toxic

Localized problem

Systemic problem

Acquired Congenital

New problem Recurrence of old problem

Semantic Qualifiers

Illness Script

Predisposing Conditions Age, gender, preceding events

(trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)

Pathophysiological Insult What is physically happening in

the body, organisms involved, etc.

Clinical Manifestations Signs and symptoms Labs and imaging

Differential Diagnosis**

Predisposing Conditions

Highest prevalence in Japan (10x that of US)

In the US Most common in Asians and Pacific Islanders Least common in caucasians

Age Median = 2yo 76% of cases in <5yo

Male:Female = 3:2Seasonal peaks in winter and springGenetic predisposition

Pathophysiology

Complete etiology is unknown, but features suggest an infectious source.

Generalized vasculitis Affects all blood vessels throughout the body Preferentially involves the coronary arteries

Process Initial neutrophil influx Large mononuclear cells w/lymphocytes and plasma

cells Active inflammation Progressive fibrosis and scar formation

Clinical Manifestations**

“C R A S H”

Conjunctivitis**Bilateral bulbar

injectionNo exudatePainlessLimbic sparingShortly after

fever starts

Rash**Various forms

Nonspecific, diffuse with scattered macules & erythematous papules

Occasionally scarlatiniform, erythroderma, erythema multiforme,

uriticarial, or a fine micropustular eruptionNot bullous of vesicularWithin 5d of feverOften involves diaper area

Adenopathy**

Least common feature

Anterior cervical triangle

Usually unilateral> 1.5 cm Firm, nontenderNo overlying

erythema

Strawberry Tongue**Changes of the lips and oral cavity

Strawberry tongue Cracked, red, swollen, bleeding lips Diffuse erythema of oral mucosa

Oral ulcers and exudates are not seen

Hands and Feet**Erythema of palms and solesFirm, sometimes painful induration of the hands

and feetLater desquamation that usually begins in

periungal region (2-3 weeks after fever onset)

Other**

Arthritis/arthralgias that involve multiple joints

Irritability***GI complaints

Diarrhea Vomiting Abdominal pain

Hepatomegaly and jaundiceAcalculous distension of gallbladder

Labs**

Leukocytosis Majority with WBC > 15,000 Predominance of immature and mature granulocytes

AnemiaThrombocytosis…with platelet counts 500-1000 x

103

Elevated ESR (>40 mm/hr) and CRP (>3mg/dL)Mild to moderate elevation of LFTsMild hyperbilirubinemiaSterile pyuriaAseptic meningitis (if CSF obtained)

Treatment**

High-dose aspirin (80-100mg/kg/day divided QID) during acute phase of illness 3-5mg/kg/day until no evidence of coronary changes by

6-8 weeks Continued aspirin therapy if coronary changes present

IVIG 2g/kg/dose (up to 2-3 doses depending on fever) Children treated with IVIG and ASA had faster

resolution of fever and fewer coronary abnormalities than those

treated with ASA alone

Refractory KD…treatment is controversial

Cardiac Complications**

Coronary artery aneurysm (identified on echo within 1-2mo of diagnosis) 20-25% of untreated patients; 5% of treated

patients Resolution within 1-2 years in approximately 50%

Myocardial infarction Principal cause of death Most occur within 1 year of disease onset but can

occur years later

MyocarditisValvulitisPericarditis with effusion

Echocardiogram**

Obtain on all patients with suspected Kawasaki At diagnosis Follow-up…usually at 2 weeks and 6 weeks after

diagnosis

Follow-Up

Thanks EVERY Content Spec!!

“Kawasaki Disease.” Pediatrics in Review. 2008, v29 (9), p308.

Noon conference = Feedback and Evaluations (Residents ONLY)