Kawasaki disease: Initial treatment and prognosis
- Robert Sundel, MD
Robert Sundel, MD
- Section Editor — Pediatric Rheumatology
- Associate Professor of Pediatrics
- Harvard Medical School
- Section Editors
- Marisa Klein-Gitelman, MD, MPH
Marisa Klein-Gitelman, MD, MPH
- Section Editor — Pediatric Rheumatology
- Chief, Division of Rheumatology
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Professor of Pediatrics
- Northwestern University Feinberg School of Medicine
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
Kawasaki disease (KD), formerly called mucocutaneous lymph node syndrome, is one of the most common vasculitides of childhood . It is typically a self-limited condition with fever and manifestations of acute inflammation lasting for an average of 12 days without therapy. However, cardiovascular complications may develop, particularly coronary artery (CA) aneurysms. These, in turn, can lead to coronary occlusion and cardiac ischemia, and result in significant morbidity or even mortality. (See "Cardiovascular sequelae of Kawasaki disease".)
The frequency of CA aneurysm development and associated morbidity and mortality have dramatically decreased as a result of intravenous immune globulin (IVIG) therapy. This therapy is effective for preventing CA abnormalities, but the benefits in children who have already developed CA aneurysms are more equivocal. Thus, expeditious diagnosis and timely treatment are critical to achieve the optimal clinical outcome. The initial treatment of KD is discussed in this review. The clinical manifestations, diagnosis, cardiovascular sequelae, and treatment of refractory KD are reviewed elsewhere. (See "Refractory Kawasaki disease" and "Kawasaki disease: Clinical features and diagnosis" and "Cardiovascular sequelae of Kawasaki disease".)
Theoretically, it should be possible to stratify therapy for Kawasaki disease (KD) according to disease severity defined by the likelihood of developing coronary artery (CA) aneurysms. Many risk scores have been proposed, but none are validated across different populations [2,3]. Since no criteria have been developed that can reliably identify children most at risk for severe disease at the time of initial presentation, all children diagnosed with KD or incomplete KD are treated at the time of diagnosis . Studies are ongoing to determine whether patients with risk factors for failing to respond to intravenous immune globulin (IVIG) treatment would benefit from more aggressive initial therapy for KD. (See "Refractory Kawasaki disease", section on 'Risk factors'.)
In 2004, guidelines by the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) were developed for the treatment of patients who fulfill the diagnostic criteria for Kawasaki disease (KD) (table 1) and for those who do not (so-called incomplete KD) (algorithm 1) [4,5]. The recommended initial therapy includes intravenous immune globulin (IVIG, 2 g/kg) administered as a single infusion over 8 to 12 hours and aspirin (initial dose of 80 to 100 mg/kg daily divided into four doses). Patients are usually observed for 24 hours (minimum 12 hours) following completion of initial therapy to confirm resolution of fever. Additional agents are used only for children who fail to respond to standard therapy. (See "Kawasaki disease: Clinical features and diagnosis" and "Incomplete (atypical) Kawasaki disease" and 'Refractory KD' below.)
A retrospective review of 195 patients with KD treated at four centers in the United States from 1981 to 2006 showed that application of the 2004 AHA/AAP guidelines resulted in the administration of IVIG therapy in almost all affected children (97 percent) .
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- INITIAL THERAPY
- Intravenous immune globulin
- - Efficacy and dosing
- - Administration
- - Timing of therapy
- - Type of IVIG
- - Adverse effects
- ADJUVANT THERAPIES
- - Disease stratification
- TNF inhibition
- Other therapies
- REFRACTORY KD
- Long-term morbidity
- Monitoring for fever
- Cardiac evaluations
- Physical activity
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS