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Callinan, Laura S. MPH; Schonberger, Lawrence B. MD, MPH; Belay, Ermias D. MD; Vugia, Duc J. MD, MPH

The Pediatric Infectious Disease Journal: April 2013 - Volume 32 - Issue 4 - p 425
doi: 10.1097/INF.0b013e31827b190a
Letters to the Editor

Division of High-Consequences Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA

Infectious Diseases Branch, Division of Communicable Disease Control, California Department of Public Health, Richmond, CA

The authors have no funding or conflicts of interest to disclose.

We appreciate the comments of Dr. Islam1 regarding our analysis of Kawasaki disease (KD) patients in California. As Dr. Islam pointed out, there are several important factors that must be considered when making decisions regarding diagnosis and treatment of patients with suspected KD. Although several common infections mimic KD, many experts believe that experienced pediatricians can often make a KD diagnosis before the fifth day of fever.2,3 In our study, which was restricted to patients meeting the Centers for Disease Control and Prevention KD case or incomplete KD case definition, approximately one quarter of the patients were diagnosed and treated in this time frame. We found that treatment with intravenous immunoglobulin (IVIG) before the fifth day of illness may reduce the occurrence of coronary artery abnormalities among KD patients compared with treatment on or after the fifth day of illness. By including only patients who met the KD case definition, we attempted to capture only true KD patients, and therefore, we do not believe the true proportion of KD patients with coronary artery abnormalities treated before the fifth day of illness would be diluted. We were, however, unable to exclude patients treated after the tenth day of illness, which precluded assessing any additional benefit from treatment before the fifth day of illness compared with treatment between 5 and 9 days after KS onset. Demonstration of additional benefit of IVIG treatment before the fifth day of illness can be difficult because patients who are diagnosed and treated early may have more severe illness that is progressing more rapidly than patients treated later in the course of illness. Previous studies that have shown an increased risk of coronary artery abnormalities among patients treated with IVIG before the fifth day of illness should be interpreted with caution because the underlying severe illness may have been responsible for the increased risk. To reduce the risk of cardiac complications, patients should be treated as soon as the diagnosis of KS is made or strongly suspected. The Committee on Infectious Diseases of the American Academy of Pediatrics recommends that IVIG treatment should be started as soon as possible, when a KS diagnosis is made or there is strong suspicion of KS.4 As with any treatment, there are possible adverse reactions from IVIG administration. However, IVIG is generally considered safe and severe reactions are rare.5,6 The risk of adverse reactions from IVIG treatment must be weighed against the potential for serious complications of KS. We agree with Dr. Islam that treatment before the fifth day of fever should be given to patients who have a clear diagnosis of KD, but the challenge for clinicians is to promptly identify and treat patients with incomplete KS who are at risk of cardiac complications but exhibit fewer than 4 criteria required for KD diagnosis.7 In our study, 42 patients did not meet the KD case definition but developed coronary artery abnormalities and were classified as having incomplete KD. To identify and provide timely treatment for incomplete KD patients, physicians should use the guidance provided in the algorithm published by Newburger et al and endorsed by the American Academy of Pediatrics.4,6

Laura S. Callinan, MPH

Lawrence B. Schonberger, MD, MPH

Ermias D. Belay, MD

Division of High-Consequences Pathogens and Pathology

National Center for Emerging and Zoonotic Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, GA

Duc J. Vugia, MD, MPH

Infectious Diseases Branch

Division of Communicable Disease Control

California Department of Public Health

Richmond, CA

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1. Islam S. Diagnosis and Treatment of Suspected Kawasaki Syndrome before the Fifth Day of Illness. Pediatr Infect Dis J. 2012
2. Dajani AS, Taubert KA, Gerber MA, et al. Diagnosis and therapy of Kawasaki disease in children. Circulation. 1993;87:1776–1780
3. . Diagnostic guidelines for Kawasaki disease. Circulation. 2001;103:335–336
4. Larry KP ed.. Kawasaki disease. Red Book. 2012 American Academy of Pediatrics:454–460
5. Bonilla FA. Intravenous immunoglobulin: adverse reactions and management. J Allergy Clin Immunol. 2008;122:1238–1239
6. Newburger JW, Takahashi M, Gerber MA, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Pediatrics. 2004;114:1708–1733
7. Burns JC, Glodé MP. Kawasaki syndrome. Lancet. 2004;364:533–544
© 2013 Lippincott Williams & Wilkins, Inc.