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Morning ReportJuly 2, 2013
Good Morning
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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
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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
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Differential Diagnosis**
What other diagnoses would you consider in a patient with suspected Kawasaki Disease?
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Predisposing ConditionsWhich country has the highest prevalence of Kawasaki
Disease? Japan (10x that of US)
In the US, which ethnicity is most commonly affected? Least commonly? Most common in Asians and Pacific Islanders Least common in caucasians
Age Median = 2yo 76% of cases in <5yo
Male:Female = 3:2Which seasons are you more likely to see patients
present with KD? Seasonal peaks in winter and spring
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Pathophysiology
Complete etiology is unknown, but features suggest an infectious source.
Generalized vasculitis Affects all blood vessels throughout the body Which specific vessels are affected in KD?
Preferentially involves the coronary arteriesProcess
Initial neutrophil influx Large mononuclear cells w/lymphocytes and plasma
cells Active inflammation Progressive fibrosis and scar formation
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Clinical Manifestations
You are seeing a patient with multiple days of fever as well as a rash and some other non-focal symptoms. How many days of fever must be present before diagnosing a patient with KD?
What are the other 5 criteria used to diagnose KD?
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Conjunctivitis**Bilateral bulbar
injectionNo exudatePainlessLimbic sparingShortly after
fever starts
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Rash**Various forms
Nonspecific, diffuse with scattered macules & erythematous papules
Occasionally scarlatiniform, erythroderma, erythema multiforme,
uriticarial, or a fine micropustular eruptionNot bullous of vesicularOften involves diaper areaWithin 5d of fever
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Adenopathy**
Least common feature
Anterior cervical triangle
Usually unilateral> 1.5 cm Firm, nontenderNo overlying
erythema
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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
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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)
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Clinical Manifestations**
“C R A S H”
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Other**
Arthritis/arthralgias that involve multiple jointsIn children, what behavioral complaint do parents
often give? Irritability***
GI complaints Diarrhea Vomiting Abdominal pain
Hepatomegaly and jaundiceWhat abnormal finding may be seen on abdominal
imaging (esp. RUQ) Acalculous distension of gallbladder…hydrops of the
gallbladder
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Labs**What would your CBC look like?
Leukocytosis Majority with WBC > 15,000 Predominance of immature and mature granulocytes
Anemia Thrombocytosis…with platelet counts 500-1000 x 103
Elevated ESR (>40 mm/hr) and CRP (>3mg/dL)Mild to moderate elevation of LFTsMild hyperbilirubinemiaWhat abnormality could you see on the UA and urine
culture? Sterile pyuria…+WBC Negative cultures
Aseptic meningitis (if CSF obtained)
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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
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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
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Echocardiogram**
When should you obtain an echo on patients with suspected Kawasaki disease? Obtain on all patients with suspected Kawasaki At diagnosis Follow-up…usually at 2 weeks and 6 weeks after
diagnosis
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Follow-Up
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Atypical Kawasaki
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Thanks
No noon conference today!