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Good Morning . Morning Report July 2, 2013. Semantic Qualifiers. Illness Script. Predisposing Conditions Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) Pathophysiological Insult

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good morning

Good Morning 

Morning Report

July 2, 2013

illness script
Illness Script
  • Predisposing Conditions
    • Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)
  • Pathophysiological Insult
    • What is physically happening in the body, organisms involved, etc.
  • Clinical Manifestations
    • Signs and symptoms
    • Labs and imaging
differential diagnosis
Differential Diagnosis**
  • What other diagnoses would you consider in a patient with suspected Kawasaki Disease?
predisposing conditions
Predisposing Conditions
  • Which country has the highest prevalence of Kawasaki Disease?
    • Japan (10x that of US)
  • In the US, which ethnicity is most commonly affected? Least commonly?
    • Most common in Asians and Pacific Islanders
    • Least common in caucasians
  • Age
    • Median = 2yo
    • 76% of cases in <5yo
  • Male:Female = 3:2
  • Which seasons are you more likely to see patients present with KD?
    • Seasonal peaks in winter and spring
pathophysiology
Pathophysiology
  • Complete etiology is unknown, but features suggest an infectious source.
  • Generalized vasculitis
    • Affects all blood vessels throughout the body
    • Which specific vessels are affected in KD?
      • Preferentially involves the coronary arteries
  • Process
    • Initial neutrophil influx 
    • Large mononuclear cells w/lymphocytes and plasma cells 
    • Active inflammation 
    • Progressive fibrosis and scar formation
clinical manifestations
Clinical Manifestations
  • You are seeing a patient with multiple days of fever as well as a rash and some other non-focal symptoms. How many days of fever must be present before diagnosing a patient with KD?
  • What are the other 5 criteria used to diagnose KD?
c onjunctivitis
Conjunctivitis**
  • Bilateral bulbar injection
  • No exudate
  • Painless
  • Limbic sparing
  • Shortly after fever starts
r ash
Rash**
  • Various forms
    • Nonspecific, diffuse with scattered macules & erythematous papules
    • Occasionally scarlatiniform, erythroderma, erythemamultiforme,
    • uriticarial, or a fine micropustular eruption
  • Not bullous of vesicular
  • Often involves diaper area
  • Within 5d of fever
a denopathy
Adenopathy**
  • Least common feature
  • Anterior cervical triangle
  • Usually unilateral
  • > 1.5 cm
  • Firm, nontender
  • No overlying erythema
s trawberry tongue
Strawberry Tongue**
  • Changes of the lips and oral cavity
    • Strawberry tongue
    • Cracked, red, swollen, bleeding lips
    • Diffuse erythema of oral mucosa
  • Oral ulcers and exudates are not seen
h ands and feet
Hands and Feet**
  • Erythema of palms and soles
  • Firm, sometimes painful induration of the hands and feet
  • Later desquamation that usually begins in periungal region (2-3 weeks after fever onset)
other
Other**
  • Arthritis/arthralgias that involve multiple joints
  • In children, what behavioral complaint do parents often give?
    • Irritability***
  • GI complaints
    • Diarrhea
    • Vomiting
    • Abdominal pain
  • Hepatomegaly and jaundice
  • What abnormal finding may be seen on abdominal imaging (esp. RUQ)
    • Acalculous distension of gallbladder…hydrops of the gallbladder
slide15
Labs**
  • What would your CBC look like?
    • Leukocytosis
      • Majority with WBC > 15,000
      • Predominance of immature and mature granulocytes
    • Anemia
    • Thrombocytosis…with platelet counts 500-1000 x 103
  • Elevated ESR (>40 mm/hr) and CRP (>3mg/dL)
  • Mild to moderate elevation of LFTs
  • Mild hyperbilirubinemia
  • What abnormality could you see on the UA and urine culture?
    • Sterile pyuria…+WBC
    • Negative cultures
  • Aseptic meningitis (if CSF obtained)
treatment
Treatment**
  • High-dose aspirin (80-100mg/kg/day divided QID) during acute phase of illness 
    • 3-5mg/kg/day until no evidence of coronary changes by 6-8
    • weeks
    • Continued aspirin therapy if coronary changes present
  • IVIG
    • 2g/kg/dose (up to 2-3 doses depending on fever)
    • Children treated with IVIG and ASA had faster resolution of
    • fever and fewer coronary abnormalities than those treated
    • with ASA alone
  • Refractory KD…treatment is controversial
cardiac complications
Cardiac Complications**
  • Coronary artery aneurysm (identified on echo within 1-2mo of diagnosis)
    • 20-25% of untreated patients; 5% of treated patients
    • Resolution within 1-2 years in approximately 50%
  • Myocardial infarction
    • Principal cause of death
    • Most occur within 1 year of disease onset but can occur
    • years later
  • Myocarditis
  • Valvulitis
  • Pericarditis with effusion
echocardiogram
Echocardiogram**
  • When should you obtain an echo on patients with suspected Kawasaki disease?
    • Obtain on all patients with suspected Kawasaki
    • At diagnosis
    • Follow-up…usually at 2 weeks and 6 weeks after diagnosis
thanks
Thanks 
  • No noon conference today!