VAIL, Colo. — Patients with severe Kawasaki disease can present in shock.
This was the thrust of two recent studies of severe Kawasaki disease conducted in Denver and San Diego. In both studies, patients with Kawasaki disease who were ill enough to be admitted to the ICU were less likely to have an admitting diagnosis of Kawasaki disease than were less severely ill patients admitted to the wards, Dr. Marsha Anderson said at a conference on pediatric infectious diseases sponsored by the Children's Hospital, Denver.
Severe Kawasaki disease presenting with shock was often mistaken for septic or toxic shock. As a result, ICU patients with Kawasaki disease were treated with intravenous immunoglobulin (IVIG)—the first-line therapy—a median of 2 days later than were Kawasaki disease patients on the general wards.
“I think we have to consider Kawasaki disease in our differential diagnosis in patients who present in shock,” said Dr. Anderson of the University of Colorado, Denver.
In the Denver study, on which she was a coauthor, patients with severe Kawasaki disease as defined by ICU admission constituted 3.3% of a consecutive series of 423 Kawasaki disease patients (Pediatrics 2008;122:e786–90).
In San Diego, severe Kawasaki disease was defined as systolic hypotension unresponsive to fluids, with resultant ICU admission. Severely affected patients accounted for 7% of 187 consecutive Kawasaki disease patients (Pediatrics 2009;123:e783–9).
In both studies, patients with severe disease were significantly more likely to be female, with low platelet counts and high levels of C-reactive protein and band counts. In San Diego, patients with severe Kawasaki disease had significantly lower hemoglobin levels than did less ill patients; however, in Denver this wasn't the case. On the other hand, in Denver (but not San Diego) severely affected patients had lower serum albumin levels than did those on the wards. In both studies, patients with severe Kawasaki disease were more likely to have IVIG resistance and to require a second dose of IVIG or a second-line therapy. This was the case for 64% of ICU patients in Denver, compared with 5% on the wards. Similarly, 46% of severely affected patients in San Diego were IVIG resistant, as were 18% of those on the wards.
Coronary artery abnormalities, mitral regurgitation, and left ventricular systolic dysfunction were significantly more common in patients with severe Kawasaki disease than in controls in the San Diego study.
In Denver, there was a strong trend for more coronary artery abnormalities in the ICU patients, but it didn't quite achieve statistical significance.
Severe Kawasaki often was mistaken for septic or toxic shock, which delayed the correct treatment.
Source Dr. Anderson