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Yellow Fever Vaccination and Kawasaki Disease

Schmöeller, Deonilson MD; Keiserman, Mauro W. MD; Staub, Henrique Luiz MSc, PhD; Velho, Flávio Petersen MD; de Fátima Grohe, Marily MD

The Pediatric Infectious Disease Journal: November 2009 - Volume 28 - Issue 11 - p 1037-1038
doi: 10.1097/INF.0b013e3181bbc571
Letters to the Editor
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Rheumatology Department (Schmöeller, Keiserman, Staub)

Cardiology Department (Velho)

Pediatrics Department; São Lucas Hospital; Pontifical Catholic University of Rio Grande do Sul (PUCRS); Porto Alegre, Brazil (de Fátima Grohe)

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To the Editors:

Kawasaki Disease (KD) is nowadays the main cause of acquired heart disease among children in North America and Japan.1 The role of vaccination as a trigger for KD is enigmatic. We herein describe an unusual case of KD following yellow fever vaccination.

The patient, a 12-year-old white boy living in a risk area for yellow fever, developed fever, fatigue, myalgia, and a diffuse rash, 20 days after yellow fever vaccination. After 2 weeks, the patient remained feverish. Conjuntivitis and cervical lymph node enlargement developed. Leukocytosis (17,000 cells/mm3), eosinophilia (1500 cells/mm3), and moderate anemia were present. The erythrocyte sedimentation rate was 112 mm in the first hour. Antinuclear antibodies and rheumatoid factors were absent. Tests for viral infections (cytomegalovirus, Epstein-Barr) and toxoplasmosis were negative. The echocardiogram revealed right (5 mm) and left (3.5 mm) dilated coronary lesions. KD was diagnosed, and the patient was treated with a 2 g/kg single dose of intravenous immunoglobulin plus acetyl-salicylic acid. After a week, he complained of intense arthralgia of the right knee and hip. Conjuntivitis reappeared. Low-dose prednisone (10mg daily) was started, with prompt clearing of the articular and ocular symptoms. One month later, a new echocardiogram showed partial improvement of coronary lesions (right coronary lumen 3.5 mm, left coronary lumen 2.8 mm). The current echocardiogram is normal. The patient has been asymptomatic on low-dose acetyl-salicylic acid.

KD is an autoimmune systemic disorder, and the immune response to previous vaccination is a matter of interest in patients with established KD. Reactions at a Bacillus Calmette-Guerin vaccination scar site during the course of KD have been reported by 3 groups of authors.2–4 Of note, KD was reported in a 35-day-old infant following immunization with hepatitis B vaccine.5 Eleven cases of KD following rotavirus vaccine (Rota Teq) were recently identified.6 To our knowledge, no cases of KD following yellow fever vaccination have been reported so far. The attenuated live virus vaccine for yellow fever has been available since 1937.7 Adverse viscerotropic and neurotropic events are very rare following immunization with yellow fever vaccine.8

Our patient was 12 years old, an unusual age for KD9; thus, an exogenous trigger such as vaccine might have contributed to KD occurrence by an immunocomplex mechanism. Although no cause-and-effect association between receiving a vaccine and the occurrence of KD is assumed, the issue is polemic. In our patient, KD appearance after yellow fever vaccination could have been only coincidental. Nevertheless, the possibility of triggering of KD by vaccines should not be neglected.

Deonilson Schmöeller, MD

Mauro W. Keiserman, MD

Henrique Luiz Staub, MSc, PhD

Rheumatology Department

Flávio Petersen Velho, MD

Cardiology Department

Marily de Fátima Grohe, MD

Pediatrics Department

São Lucas Hospital

Pontifical Catholic University of Rio Grande do Sul (PUCRS)

Porto Alegre, Brazil

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REFERENCES

1. Burns JC, Kushner HI, Bastian JF, et al. Kawasaki disease: a brief history. Pediatrics. 2000;106:E27.
2. Edelman K, Korvenranta H. Local skin redness and irritation five months after Bacillus Calmette Guerin (BCG) vaccination as a sign for Kawasaki's disease. Duodecim. 1996;112:698–700.
3. Kuniyuki S, Asada M. An ulcerated lesion at the BCG vaccination site during the course of Kawasaki disease. J Am Acad Dermatol. 1997;37:303–304.
4. Paranavithana S, Gunasekera DP. A case of Kawasaki disease with reaction at a DPT vaccination scar site. Ceylon Med J. 2003;48:62.
5. Miron D, Fink D, Hashkes PJ. Kawasaki disease in an infant following immunisation with hepatitis B vaccine. Clin Rheumatol. 2003;22:461–463.
6. Geier DA, King PG, Sykes LK, et al. RotaTeq vaccine adverse events and policy considerations. Med Sci Monit. 2008;14:9–16.
7. Brentjens MH, Yeung-Yue KA, Lee PC, et al. Vaccines for viral diseases with dermatologic manifestations. Dermatol Clin. 2003;21:349–369.
8. Receveur MC, Bruyand M, Pistone T, et al. Yellow fever vaccination: Update on rare and severe adverse effects. Med Mal Infect. In Press.
9. Tulloh RM, Wood LE. Coronary artery changes in patients with Kawasaki disease. Acta Paediatr Suppl. 2004;93:75–79.
© 2009 Lippincott Williams & Wilkins, Inc.