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Kawasaki disease may be confused with toxic shock syndrome or septic shock
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Misdiagnosis of Kawasaki disease is common in the intensive care unit, emphasizing the need for physicians to remain aware of the full range of clinical symptoms associated with the disease.
“Physicians need to consider Kawasaki disease in the differential diagnosis of any patient who presents with an illness that looks like toxic shock syndrome or septic shock, because it is often difficult to distinguish between the two,” Samuel R. Dominguez, MD, PhD, assistant professor of pediatric infectious diseases at the University of Colorado, Denver School of Medicine, told Infectious Diseases in Children. “Furthermore, despite the common belief to the contrary, patients with Kawasaki disease can present with hypotension and shock.”
Data from a study conducted by Dominguez and colleagues from the University of Colorado and the Children’s Hospital in Aurora, Colo. indicated the following common characteristics among 14 pediatric patients admitted to the ICU who were discharged with a diagnosis of Kawasaki disease compared with patients with Kawasaki disease who were not admitted to the ICU:
- Initial diagnoses were most commonly toxic shock or septic shock.
- 92.8% met criteria for complete Kawasaki disease before treatment.
- These patients were more likely to be female.
- ICU patients had higher band counts, lower platelet counts, lower albumin levels and higher C-reactive protein values than their non-ICU counterparts.
- IV immunoglobulin treatment was delayed more often in these patients.
- These patients were more likely to have IV Ig–refractory disease, requiring second doses of IV Ig, infliximab (Remicade, Centocor) or steroids.
The researchers gathered data from chart reviews for 423 children discharged from the hospital between January 1995 and December 2007. “This is the first case control study of patients with Kawasaki disease who required admission to a pediatric ICU, and it adds to the already expanding spectrum of disease presentation and severity of Kawasaki disease,” Dominguez said.
Further studies need to be conducted to determine the association between patients with Kawasaki disease who are admitted to the ICU and their likelihood of developing more severe coronary artery disease. Additionally, Dominguez emphasized the need for more funding to determine the cause of Kawasaki disease as well as to develop a diagnostic test for patients. – by Nicole Blazek
Other groups, including our own in Chicago, have observed similar subgroups of Kawasaki disease patients, but the Denver investigators are the first to characterize them well. It remains to be seen if additional similar series of patients confirm these features as distinguishing them from more routine patients with the disease.
To the extent that IVIG is often used as adjunctive therapy for streptococcal toxic shock syndrome, it is sometimes administered relatively early, even if Kawasaki disease is not being considered. This nice series serves to remind that occasional patients with Kawasaki disease may present with particularly severe manifestations and that the disease should be in the differential diagnosis as early as possible. Questions remain concerning the precise mechanism of hypotension, possibly related to the near-universal myocarditis present in Kawasaki disease, and the long-term cardiac consequences in these patients.
– Stanford T. Shulman, MD
Infectious Diseases in Children Editorial Board member
For more information:
- Dominguez SR, Friedman K, Seewald R, et al. Kawasaki disease in a pediatric intensive care unit: a case-control study. Pediatrics. 2008;doi:10.1542/peds.2008-1275.