1. The patient is exhibiting signs and symptoms consistent with Kawasaki disease, including prolonged fever, oral ulcers, conjunctivitis, rash, lymphadenopathy, and extremity changes. 2. Kawasaki disease does occur in Egypt, with an estimated 280 cases diagnosed annually. 3. Treatment for Kawasaki disease involves intravenous immunoglobulin and aspirin to prevent coronary artery aneurysms, which develop in around 25% of untreated patients.

1. M.D Pediatrics
Ph.D Pediatric special need and nutrition
consultant Mansoura national Hospital
Insurance H Fever H and Egyptian liver H

2. •”‫منكم‬ ‫آمنوا‬ ‫الذين‬ ‫ا‬ ‫يرفع‬
.“‫درجات‬ ‫العلم‬ ‫أوتوا‬ ‫والذين‬
•”‫الذين‬ ‫يستوى‬ ‫هل‬ ‫قل‬
.“‫يعلمون‬ ‫ل‬ ‫والذين‬ ‫يعلمون‬

3. M.D Pediatrics
Ph.D Pediatric special need child health and nutrition
consultant Mansoura national Hospital Insurance H Fever
H and Egyptian liver H

4. male patient 13 years old from
Mehalet Damna ,he is the first
kid of the family and the older
brother of two healthy sisters

5.  The conditon stareted 1.5 months ago
when fever developed and increased
gradually .the child was feverish all the
day and fever was more at night but
without significant diurnal variations
and it was oscillating around 40º C . The
fever was altered temporarily by
antipyretics .

6. The family sought medical
advice and the child received a
lot of medications including
different classes of antibiotics
without any improvement.
Then the child was admitted to
hospital and was fully
investigated but yet
undiagnosed.

7.  One week later the child
developed oral ulcers which
markedly interfered with oral
feeding
 These ulcers were multiple and
persisted the whole duration of
illness.

8.  Also 2 days later the the child
developed simultaneous
events.
 There was edema , erythema ,
pain in the hands and feet.this
pain was associated with
limitation of movements.

9.  At the same time the patient
developed multiple neck
swellings bilaterally.
 These neck swellings were
variable in size the largest of
them was about lemon
size.They gradually
decreased in size

10.  One of the cervical lymph
nodes was excised and sent to
biopsy
 The child developed redness in
both eyes without marked
discharge which continued the
whole month.

11. Thre was no history of other
skin rash
There was no history suggestive
of bleeding tendency or
purpuric eruption .
No history of abdominal
distension
 No history of big joint affection

12.  No history of jaundice or
changes of the colour of urine or
stool
 No history of convulsions or
abnormal movements or limb
weakness.
 No history of disturbed
conscious level or increased
intracranial tension

13.  There is no history of dyspnea
or chest pain Or significant
chest symptoms
 There is no history of other
system affection

14.  There is no significant past
medical history or family history
as well

15.  General Examination
 The patient is fully conscious
well oriented for time place
and person , he is co-operative
and of average intelligence
 The patient has no special
decubitus

16.  The temperature during examination
was 39º C .
 Pulse was 145 BPM of average
volume , reglar , equal bilaterally with
intact peripheral pulsations and no
special character.
 Blood pressure 100/70 mmhg .
Respiratory rate 30.

17.  Head and Neck examination
revealed bilateral non purulent
conjuctival congestion ,
multiple mouth ulceration , red
strawberry tongue ,multiple
small lymph nodes the largest
of them 2 cm in diameter , the
lymph nodes are mobile ,non-
tender and firm in consistency.

19.  Neck veins are 3 cm above the
clavicle measured at the same
level to that of Angle of Louis
.Neck veins showed normal
pulsations with no inspiratory
filling.
 There was no goitre , complexion
abnormalities or any other
significant abnormality.

20.  UL examination revealed
bilateral distal skin peeling , no
arthritis , no clubbing, no sc
nodules , bilateral epitrochlear
lymphadenopathy 1.5 cm ,
firm and non tender. There
was no axillary lymph nodes.

21.  LL examination
revealed erythema
and skin peeling in
the sole of the foot
but no oedema ,
clubbing or
arthritis.

23.  Cardiac examination showed an
evident 3rd heart sound with
protodiastolic gallop but without
significant murmurs.
 A monocomponent pericardial
rub is heared

24.  Abdominal examination
revealed no abnormities apart
from mild tender hepatomegaly
( liver span 11 cm in MCL )
with rounded border and soft
consistency .
 Chest and neurological
examination were normal.

25.  Laboratory :
 ESR 70 mm in the 1st hour and 110 mm in
the 2nd hour
 CBC
 WBCs 8000/ cmm with normal differential
cont
 Hb 11gm/dl
 Platelets 485.000 / cmm

26.  CRP 18 mg / dl
 ASOT 100
 Normal liver and kiney
functions
 Urine analysis is free

27.  ANA and RF negative
 EBV Ig M negative
 CMV Ig M and Ig G –ve
 Widal test and blood culture
negative

28.  Bone marrow examination is
within normal
 Microscopic examination of the
lymph nodes showed only
reactive hyperplasia

29.  Normal CXR initially
 Normal initial pelviabdominal
ultrasound
 Echocardiography revealed
moderate pericardial effusion
 ECG is low voltage sinus
tachycardia t wave inversion in
antrolateral leads

31. What is Kawasaki disease?

32.  Kawasaki disease (KD) (ie,
Kawasaki syndrome [KS]) is a
febrile illness of childhood. It is
a self-limited acute vasculitic
syndrome of unknown
etiology, first described by
Tomisaku Kawasaki in 1967.

33.  The diagnosis of classic Kawasaki
disease (KD) requires fever of at
least 5 days duration and the
presence of 4 of the following :

34. 1-Changes in extremities (eg, erythema,
edema, desquamation): This may
limit movement and cause the child
to refuse to bear weight.
Desquamation of the fingers and
toes begins in the periungual region,
may involve the palms and soles

35. 2-Bilateral conjunctivitis (not
associated with exudates)
3- Polymorphous rash (not
vesicular)
4- Cervical lymphadenopathy
5- Changes in the lips and oral
cavity (eg, pharyngeal erythema,
dry/fissured or swollen lips,
strawberry tongue)

36.  Cardiac involvement is the
most important manifestation
of Kawasaki disease.
Myocarditis manifested by
tachycardia and decreased
ventricular function occurs in
at least 50% of patients.

37. Is Kawasaki disease present in
Egypt?

38.  It is estimated that at least 3,000
cases are diagnosed annually in the
United States. The incidence of
Kawasaki disease in Asian children
is substantially higher than in other
racial groups, but the illness occurs
worldwide in all ethnic groups.

39. Kawasaki disease in Northern
Africa (Extrapolated Statistics)
Country/Region
Extrapolated
Incidence
Population
Estimated Used
Egypt 280 76,117,4212
Libya 20 5,631,5852
Sudan 144 39,148,1622

40.  Pericarditis with a small
pericardial effusion is common
during the acute illness.
Coronary artery aneurysms
generally develop in up to 25%
of untreated patients during
the 2nd–3rd wk of illness.

41.  Patients with acute Kawasaki
disease should be treated with
intravenous immunoglobulin
(IVIG) and high-dose aspirin as
soon as possible after diagnosis

42. ACUTE STAGE
 Intravenous immunoglobulin 2
g/kg over 10–12hr with aspirin
80–100 mg/kg/24 hr divided
every 6 hr orally until 14th illness
day
CONVALESCENT STAGE
 Aspirin 3–5 mg/kg once daily
orally until 6–8 wk after illness
onset

43. LONG-TERM THERAPY FOR
THOSE WITH CORONARY
ABNORMALITIES
 Aspirin 3–5 mg/kg once daily
orally ± dipyridamole 4–6
mg/kg/24 hr divided in two or
three doses orally (most experts
add warfarin for those patients at
particularly high risk of
thrombosis)

44. ACUTE CORONARY THROMBOSIS
 Prompt fibrinolytic therapy with
tissue plasminogen activator,
streptokinase, or urokinase under
supervision of a pediatric
cardiologist

45.  IVIG also should be administered
to children presenting after the
10th day of illness (ie, children in
whom the diagnosis was missed
earlier) if they have either
persistent fever without other
explanation or aneurysms and
ongoing systemic inflammation,
as manifested by elevated ESR or
CRP

46.  Steroids
Although corticosteroids are the treatment
of choice in other forms of vasculitis, their
use has been limited in children with
Kawasaki disease
 Corticosteroids also have been used to treat
patients who have failed to respond to
initial therapy for Kawasaki disease

47.  Abciximab, a platelet glycoprotein IIb/IIIa
receptor inhibitor, has been used to treat
patients in the acute or subacute phase of
Kawasaki disease who have large coronary
aneurysms.
 A new class of agents that may play a role in
the treatment of patients with refractory
Kawasaki disease is monoclonal antibodies to
various proinflammatory cytokines.

48.  A humanized monoclonal antibody against
TNF-, infliximab, is being studied in a
clinical trial of treatment for children who
fail to become afebrile after initial IVIG
treatment.
 Cytotoxic agents like cyclophosphamide, in
conjunction with oral steroids, have been
suggested as useful for the treatment of
exceptional patients with particularly
refractory acute Kawasaki disease