1. Good Morning 
Morning Report
July 2, 2013

2. Problem Characteristics
Semantic Qualifiers
Symptoms
Acute /subacute
Chronic
Localized
Diffuse
Single
Multiple
Static
Progressive
Constant
Intermittent
Single Episode
Recurrent
Abrupt
Gradual
Severe
Mild
Painful
Nonpainful
Bilious
Nonbilious
Sharp/Stabbing
Dull/Vague
Problem Characteristics
Ill-appearing/
Toxic
Well-appearing/
Non-toxic
Localized problem
Systemic problem
Acquired
Congenital
New problem
Recurrence of old problem
He has done research on transitions in care

3. Illness Script Predisposing Conditions Pathophysiological Insult
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 3

4. Differential Diagnosis**
What other diagnoses would you consider in a patient with suspected Kawasaki Disease?

5. 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

6. 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

7. 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?

8. Conjunctivitis** Bilateral bulbar injection No exudate Painless
Limbic sparing
Shortly after fever starts

9. Rash** Various forms Not bullous of vesicular
Nonspecific, diffuse with scattered macules & erythematous papules
Occasionally scarlatiniform, erythroderma, erythema multiforme,
uriticarial, or a fine micropustular eruption
Not bullous of vesicular
Often involves diaper area
Within 5d of fever

10. Adenopathy** Least common feature Anterior cervical triangle
Usually unilateral
> 1.5 cm
Firm, nontender
No overlying erythema

11. Strawberry Tongue** Changes of the lips and oral cavity
Cracked, red, swollen, bleeding lips
Diffuse erythema of oral mucosa
Oral ulcers and exudates are not seen

12. 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)

13. Clinical Manifestations**
“C R A S H”

14. 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
Chlamydia: Tachypnea, interstitial infiltrates, afebrile, not ill-appearing

15. Labs** What would your CBC look like?
Leukocytosis
Majority with WBC > 15,000
Predominance of immature and mature granulocytes
Anemia
Thrombocytosis…with platelet counts 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)

16. 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
Abscess: thick-walled cavity with air-fluid level, often follows aspiration, mouth organisms (strep and anaerobes +/- Staph and GNR), TB should be considered; needle aspiration for cx specimen is recommended; CT scan can provide more detail
Necrotizing PNA: rare complication of bacterial PNA in which liquefaction and necrosis of lung tissue is caused by toxins of highly virulent organisms; children appear VERY ill; tx consis of long course (4wks) of IV abx…typially vanc or clinda (for Strep, GAS, and staph)

17. 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

18. 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

19. Follow-Up

20. Atypical Kawasaki

21. No noon conference today!
Thanks 
No noon conference today!