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)
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