P KZN AFEBRILE KD

 

Afebrile Kawasaki disease is not a benign form of the disease: Reply

Atsunori Yoshino

PDF

TOOLS

 

SHARE

I appreciate the letter to the Editor from Yamazaki‐Nakashimada et al.1 concerning our report.2 First, we thank Yamazaki‐Nakashimada et al. for highlighting our mistake. Our report was not the first report on afebrile Kawasaki disease (KD). We would like to express our sincere apologies to Pediatrics International and its readers for this oversight.

As Yamazaki‐Nakashimada et al. indicated, there were five previous articles on afebrile KD (Table 1).3-7 Four of the five patients had coronary artery (CA) dilatations. Of these four patients, and our patients who had CA dilatation, four of the six were ≤7 months of age. Five of the six patients were male.

Table 1. Previous reports of afebrile Kawasaki disease

	Patient age	Sex	CA dilatation	Time to treatment	No. clinical manifestations	BCG inoculation site	General condition	CRP (mg/dL)/WBC (/μL)/Hb (mg/dL)/Plt (×104/μL)	BT measurement method	Differential diagnosis
Hinze et al.3	3 months	M	+	2 weeks	4 +  rhinorrhea, irritability	NA	Poor feeding	15.8/17 400/8.9/112	Axillary	NA
Kato et al.4	2 years	M	+	15 days	2 +  arthralgia	NA	NA	4.1/11 500/NA/NA	NA	NA
Maresi et al.5	2 months	M	+	No treatment, deceased on 14th day	2 +  rhinorrhea, cough	NA	“Discreet”	NA/15370/NA/47.6	NA	NA
Pinches et al.6	3 months	M	+	NA	0	NA	Good	1.6/21300/9.0/102	NA	NA
Ulloa‐Gutierrez et al.7	5 years	F	–	No treatment	5	NA	“Acutely ill aspect”	10.2/NA/NA/70.8	NA	ASO, other infectious diseases

• ASO, anti‐streptolysin O antibody; BCG, bacillus Calmette–Guerin; BT, body temperature; CA, coronary artery; CRP, C‐reactive protein; Hb, hemoglobin; Plt, platelets; NA, not available; WBC, white blood cells.

These five previous reports were in English, and were retrievable using PubMed. Although there were a few other articles on afebrile KD, they were not available on Pubmed or were not in English, and only one patient had CA dilatation.1 Because the diagnosis of KD is based on clinical symptoms, the diagnosis of KD in patients without CA dilatation is more difficult than that in those with CA dilatation. KD cannot be diagnosed definitively if the patient does not have both fever and CA dilatation.

In contrast, if the patient has CA dilatation but does not have fever, we must include the following six diseases in the differential diagnosis, as described in our article: KD, chronic active Epstein–Barr virus infection, Yersinia pseudotuberculosis infection, systemic juvenile idiopathic arthritis, Takayasu disease, and juvenile polyarteritis nodosa.2 Regrettably, the five previously published articles did not describe this diagnostic process.

Moreover, only Hinze et al. reported the method of body temperature (BT) measurement.3 Furthermore, if there was a description, it was reported only as “axillary”. Because there is a report that described axillary BT measurement in KD is not so accurate8, we measured BT carefully and frequently, to confirm that our patients were afebrile.2

Nevertheless, I believe that most of the previously reported patients3-7 must have had KD. I also believe that there must be more undiagnosed patients who have KD without fever. This may include some cases of sudden death in infancy. As Yamazaki‐Nakashimada et al. noted in their letter, we must educate pediatricians about the existence of incomplete afebrile KD and accumulate data to facilitate accurate diagnosis.