Difficulty in diagnosing refractory Kawasaki disease under the «mask» of hemoblastosis: a clinical case from the experience of a hematologist





Kawasaki disease, leukaemic reaction, coronary artery aneurysms, children


Kawasaki disease (KD) is an acute systemic vasculitis that is the most common cause of acquired heart disease in children under 5 years of age with hyperthermia. Diagnosis of KD is a clinical challenge, given the wide range of clinical manifestations and similarities with many viral and bacterial diseases.

Purpose - to describe a clinical case of refractory КD in a three-month-old girl with an emphasis on the importance of echocardiography and coronary angiography for the final verification of the disease, urgent initiation of treatment with minimal suspicion of КD.

Clinical case. The article reports on a three-month-old patient with a difficult diagnosis of refractory form of КD. The disease debuted with hyperthermia, enterocolitis, obstructive bronchitis, and hepatoliver syndrome. The manifestations of skin exanthema were initially considered as an allergic dermatitis to the use of a cephalosporin antibiotic. Multisystemic inflammatory syndrome associated with SARS-CoV-2 infection was suspected. After the use of immunosuppressive therapy with mega-doses of dexamethasone and intravenous human immunoglobulin 2 g/kg/day for 3 days, clinical improvement was achieved. Subsequently, the haemogram showed an increase in neutrophilic hyperleukocytosis to the appearance of blast cells, hyperthrombocytosis and severe anaemia. A differentiation was made between a leukemic reaction, the debut of myeloproliferative disease, juvenile myelomonocytic leukaemia. Against the background of a rapid decrease in the number of leukocytes, the girl developed hyperthermia, migratory intermittent maculopapular rash, and foots edema. Laboratory findings included thrombocytosis and an increase in acute-phase parameters. Echocardiography revealed left ventricular dilation, a small amount of excess fluid in the pericardium, dilatation of the left coronary artery evenly to the bifurcation. Computed tomography revealed giant coronary artery aneurysms, which gave grounds to diagnose KD.

The study was performed in accordance with the principles of the Declaration of Helsinki. Informed consent of the parents of child was obtained for the study.

No conflict of interests was declared by the authors.

Author Biographies

O.I. Dorosh, СNCE of LRC «Western Ukrainian Specialized Pediatric Medical Centre», Lviv

Danylo Halytsky Lviv National Medical University, Ukraine

V.P. Yevtukh, Danylo Halytsky Lviv National Medical University

Center for Medical Innovations NOVO, Lviv, Ukraine


Ae R, Abrams JY, Maddox RA, Schonberger LB, Nakamura Y, Shindo A et al. (2020). Platelet count variation and risk for coronary artery abnormalities in Kawasaki disease. Pediatr Infect Dis J. 39(3): 197-203. https://doi.org/10.1097/INF.0000000000002563; PMid:31851145

Agarwal S, Agrawal DK. (2017). Kawasaki disease: etiopathogenesis and novel treatment strategies. Expert Rev Clin Immunol. 13(3): 247-258. https://doi.org/10.1080/1744666X.2017.1232165; PMid:27590181 PMCid:PMC5542821

Anderson MS, Todd JK, Glode MP. (2005). Delayed diagnosis of Kawasaki syndrome: an analysis of the problem. Pediatrics. 115: e428-e33. https://doi.org/10.1542/peds.2004-1824; PMid:15805345

Bajolle F, Meritet JF, Rozenberg F, Chalumeau M, Bonnet D, Gendrel D et al. (2014). Markers of a recent bocavirus infection in children with Kawasaki disease: "A year prospective study". Pathol Biol. 62(6): 365-368. https://doi.org/10.1016/j.patbio.2014.06.002; PMid:25193448

Baker AL, Lu M, Minich LL, Atz AM, Klein GL, Korsin R et al. (2009). Associated symptoms in the ten days before diagnosis of Kawasaki disease. J Pediatr. 154: 592-595. https://doi.org/10.1016/j.jpeds.2008.10.006; PMid:19038400 PMCid:PMC2745188

Bar-Meir M, Kalisky I, Schwartz A, Somekh E, Tasher D. (2018). Prediction of resistance to intravenous immunoglobulin in children with Kawasaki disease. J Pediatric Infect Dis Soc. 7(1): 25-29. https://doi.org/10.1093/jpids/piw075; PMid:28062554

Burns JC, Capparelli EV, Brown JA, Newburger JW, Glode MP, US/Canadian Kawasaki Syndrome Study Group. (1998). Intravenous gamma-globulin treatment and retreatment in Kawasaki disease. Pediatr Infect Dis J. 17(12): 1144-1148. https://doi.org/10.1097/00006454-199812000-00009; PMid:9877364

Burns JC, Cayan DR, Tong G, Bainto EV, Turner CL, Shike H et al. (2005). Seasonality and temporal clustering of Kawasaki syndrome. Epidemiology. 16(2): 220-225. https://doi.org/10.1097/01.ede.0000152901.06689.d4; PMid:15703537 PMCid:PMC2894624

Chahal N, Somji Z, Manlhiot C et al. (2012). Rate, associated factors and outcomes of recurrence of Kawasaki disease in Ontario, Canada. Pediatr Int. 54(3): 383-387. https://doi.org/10.1111/j.1442-200X.2012.03628.x; PMid:22631567

Chang A, Delmerico AM, Hicar MD. (2019). Spatiotemporal analysis and epidemiology of Kawasaki disease in Western New York: a sixteen Year Review of cases presenting to a Single Tertiary Care Center. Pediatr Infect Dis J. 38(6): 582-588. https://doi.org/10.1097/INF.0000000000002239; PMid:30418354

Chang LY, Lu CY, Shao PL, Lee PI, Lin MT, Fan TY et al. (2014). Viral infections associated with Kawasaki disease. J Formos Med Assoc. 113(3): 148-154. URL: http://www.ncbi.nlm.nih.gov/pubmed/24495555. https://doi.org/10.1016/j.jfma.2013.12.008; PMid:24495555 PMCid:PMC7125523

Chen CJ, Huang FC, Tiao MM, Huang YH, Lin LY, Yu HR et al. (2012). Sonographic gallbladder abnormality is associated with intravenous immunoglobulin resistance in Kawasaki disease, The Scientific World Journal: 485758. https://doi.org/10.1100/2012/485758; PMid:22792043 PMCid:PMC3385618

Chen JJ, Ma XJ, Liu F, Yan WL, Huang MR, Huang M et al. (2016). Epidemiologic features of Kawasaki disease in Shanghai from 2008 through 2012. Pediatr Infect Dis J. 35(1): 7-12. https://doi.org/10.1097/INF.0000000000000914; PMid:26372452

Chen X, Gao L, Zhen Z, Wang Y, Na J, Yu W et al. (2022). Risk factors and predictive models for intravenous immunoglobulin resistance in children with recurrent Kawasaki disease. J Inflamm Res. 15: 2877-2889. eCollection 2022. https://doi.org/10.2147/JIR.S360802; PMid:35571506 PMCid:PMC9091694

Dionne A, Dahdah N. (2018). Myocarditis and Kawasaki disease. Int J Rheum Dis. 21(1): 45-49. Epub 2017 Nov 3. https://doi.org/10.1111/1756-185X.13219; PMid:29105303

Dominguez SR, Anderson MS, El-Adawy M, Glode MP. (2012). Preventing coronary artery abnormalities: a need for earlier diagnosis and treatment of Kawasaki disease. Pediatr Infect Dis J. 31: 1217-1220. https://doi.org/10.1097/INF.0b013e318266bcf9; PMid:22760536

Du S, Mansmann U, Geisler BP, Li Y, Hornung R. (2022). A diagnostic model for Kawasaki disease based on immune cell characterization from blood samples. Front Pediatr. 9: 769937. eCollection 2021. https://doi.org/10.3389/fped.2021.769937; PMid:35071130 PMCid:PMC8767645

Edraki MR, Mohammadi H, Mehdizadegan N, Ghorashi M, Amoozgar H, Borzouee M et al. (2020). Japanese Kawasaki disease scoring systems: are they applicable to the Iranian population? Arch Iran Med. 23(1): 31-36.

Eladawy M, Dominguez SR, Anderson MS, Glod MP. (2013). Kawasaki disease presenting to the pediatric gastroenterologist: a diagnostic challenge. J Pediatr Gastroenterol Nutr. 56: 297-299. https://doi.org/10.1097/MPG.0b013e3182794432; PMid:23085893

Eleftheriou D, Levin M, Shingadia D, Tulloh R, Klein NJ, Brogan PA. (2014). Manag Kawasaki Dis. Arch Dis Child. 99(1): 74-83. https://doi.org/10.1136/archdischild-2012-302841; PMid:24162006 PMCid:PMC3888612

Fabi M, Corinaldesi E, Pierantoni L, Mazzoni E, Landini C, Bigucci B et al. (2018). Gastrointestinal presentation of Kawasaki disease: A red flag for severe disease? PLoS One. 13(9): e0202658. eCollection 2018. https://doi.org/10.1371/journal.pone.0202658; PMid:30180185 PMCid:PMC6122791

Fernandez-Cooke E, Barrios Tascón A, Sánchez-Manubens J, Antón J, Grasa Lozano CD, Aracil Santos J et al. (2019). Epidemiological and clinical features of Kawasaki disease in Spain over 5 years and risk factors for aneurysm development. (2011-2016): KAWA-RACE study group. PLoS One. 14(5): e0215665. eCollection 2019. https://doi.org/10.1371/journal.pone.0215665; PMid:31107862 PMCid:PMC6527399

Fischer TK, Holman RC, Yorita K, Belay ED, Melbye M, Koch A. (2007). Kawasaki syndrome in Denmark. Pediatr Infect Dis J. 26(5): 411-415. https://doi.org/10.1097/01.inf.0000259964.47941.00; PMid:17468651

Fuller MG. (2019). Kawasaki Disease in Infancy. Adv Emerg Nurs J. 41(3): 222-228. https://doi.org/10.1097/TME.0000000000000253; PMid:31356247

Giannouli G, Tzoumaka-Bakoula C, Kopsidas I, Papadogeorgu P, Chrousos GP, Michos A et al. (2013). Epidemiology and risk factors for coronary artery abnormalities in children with complete and incomplete Kawasaki disease during a 10-year period. Pediatr Cardiol. 34: 1476-1481. https://doi.org/10.1007/s00246-013-0673-9; PMid:23463134

Godfred-Cato S, Abrams JY, Balachandran N, Jaggi P, Jones K, Rostad CA et al. (2022). Distinguishing multisystem inflammatory syndrome in children from COVID-19, Kawasaki disease and toxic shock syndrome. Pediatr Infect Dis J. 41(4): 315-323. https://doi.org/10.1097/INF.0000000000003449; PMid:35093995 PMCid:PMC8919949

Gradoux E, Di Bernardo S, Bressieux-Degueldre S, Mivelaz Y, Boulos Ksontini T, Prsa M, Sekarski N. (2022). Epidemiology of Kawasaki disease in children in Switzerland: a national prospective cohort study. Swiss Med Wkly. 152: w30171. eCollection 2022 May 23. https://doi.org/10.4414/SMW.2022.w30171; PMid:35748748

Guo MM, Tsai IH, Kuo HC. (2021). Effect of breastfeeding for 6 months on disease outcomes in patients with Kawasaki disease. PLoS One. 16(12): e0261156. eCollection 2021. https://doi.org/10.1371/journal.pone.0261156; PMid:34932591 PMCid:PMC8691627

Han SB, Lee SY. (2018). Differentiating Kawasaki disease from urinary tract infection in febrile children with pyuria and C-reactive protein elevation. Ital J Pediatr. 44(1): 137. https://doi.org/10.1186/s13052-018-0585-7; PMid:30454066 PMCid:PMC6245823

Holman RC, Belay ED, Christensen KY, Folkema AM, Steiner CA, Schonberger LB. (2010). Hospitalizations for Kawasaki syndrome among children in the United States, 1997-2007. Pediatr Infect Dis J. 29(6): 483-488. https://doi.org/10.1097/INF.0b013e3181cf8705; PMid:20104198

Huang GY, Ma XJ, Huang M, Chen SB, Huang MR, Gui YH et al. (2006). Epidemiologic pictures of Kawasaki disease in Shanghai from 1998 through 2002. J Epidemiol. 16(1): 9-14. https://doi.org/10.2188/jea.16.9; PMid:16369103 PMCid:PMC7560545

Huang WC, Huang LM, Chang IS, Chang LY, Chiang BL, Chen PJ et al. (2009). Epidemiologic features of Kawasaki disease in Taiwan, 2003-2006. Pediatrics. 123(3): e401-e405. https://doi.org/10.1542/peds.2008-2187; PMid:19237439

Ikeda K, Suzuki T, Morikawa A et al. (2013). Efficacy of intravenous immunoglobulin combined with prednisolone following resistance to initial intravenous immunoglobulin treatment of acute Kawasaki disease. J Pediatr. 163(2): 521-526. https://doi.org/10.1016/j.jpeds.2013.01.022; PMid:23485027

Jakob A, Whelan J, Kordecki M, Berner R, Stiller B, Arnold R et al. (2016). Kawasaki Disease in Germany. Pediatr Infect Dis J. 35(2): 129-134. https://doi.org/10.1097/INF.0000000000000953; PMid:26465100

Jindal AK, Pilania RK, Prithvi A, Guleria S, Singh S. (2019). Kawasaki disease: characteristics, diagnosis, and unusual presentations. Expert Rev Clin Immunol. 15(10): 1089-1104. https://doi.org/10.1080/1744666X.2019.1659726; PMid:31456443

Jones VG, Mills M, Suarez D. (2020). COVID-19 and Kawasaki disease: novel virus and novel case. Hosp Pediatr. 10(6): 537-540. https://doi.org/10.1542/hpeds.2020-0123; PMid:32265235

Kido S, Ae R, Kosami K et al. (2019). Seasonality of i.v. immunoglobulin responsiveness in Kawasaki disease. Pediatr Int. 61(6): 539-543. https://doi.org/10.1111/ped.13863; PMid:30980447

Kim DS. (2006). Kawasaki disease. Yonsei Med J. 47(6): 759-772. https://doi.org/10.3349/ymj.2006.47.6.759; PMid:17191303 PMCid:PMC2687814

Kim GB. (2019). Reality of Kawasaki disease epidemiology. Kor J Pediatr. 62(8): 292-296. https://doi.org/10.3345/kjp.2019.00157; PMid:31319643 PMCid:PMC6702118

Kim KY, Kim DS. (2016). Recent advances in Kawasaki disease. Yonsei Med J. 57(1): 15-21. https://doi.org/10.3349/ymj.2016.57.1.15; PMid:26632378 PMCid:PMC4696947

Lee KY, Han JW, Lee JS. (2007). Kawasaki disease may be a hyperimmune reaction of genetically susceptible children to variants of normal environmental flora. Med Hypotheses. 69(3): 642-651. https://doi.org/10.1016/j.mehy.2006.12.051; PMid:17337130 PMCid:PMC7117004

Lee MN, Cha JH, Ahn HM, Yoo JH, Kim HS, Sohn S et al. (2011). Mycoplasma pneumoniae infection in patients with Kawasaki disease. Korean J Pediatr. 54(3): 123-127. https://doi.org/10.3345/kjp.2011.54.3.123; PMid:21738542 PMCid:PMC3120998

Lin MT, Wu MH. (2017). The global epidemiology of Kawasaki disease: review and future perspectives. Glob Cardiol Sci Pract. e201720. https://doi.org/10.21542/gcsp.2017.20; PMid:29564341 PMCid:PMC5856963

Liu FF, Liu HH, Qiu Z, Wang JJ, Samadli S, Wu Y et al. (2020). Clinical observation of noncoronary cardiac abnormalities in Chinese children with Kawasaki disease. Eur J Clin Investig. 50(4): e13210. https://doi.org/10.1111/eci.13210; PMid:32061097

Liu X, Wang L, Zhou K, Shao S, Hua Y, Wu M et al. (2021). Predictive value of C-reactive protein to albumin ratio as a biomarker for initial and repeated intravenous immunoglobulin resistance in a large cohort of Kawasaki disease patients: a prospective cohort study. Pediatr Rheumatol Online J. 19(1): 24. https://doi.org/10.1186/s12969-021-00517-1; PMid:33712036 PMCid:PMC7953655

Luca NJ, Yeung RS. (2012). Epidemiology and management of Kawasaki disease. Drugs. 72(8): 1029-1038. https://doi.org/10.2165/11631440-000000000-00000; PMid:22621692

Maddox RA, Holman RC, Uehara R et al. (2015). Recurrent Kawasaki disease: USA and Japan. Pediatr Int. 57(6): 1116-1120. https://doi.org/10.1111/ped.12733; PMid:26096590 PMCid:PMC4676732

Makino N, Nakamura Y, Yashiro M, Sano T, Ae R, Kosami K et al. (2018). Epidemiological observations of Kawasaki disease in Japan, 2013-2014. Pediatr Int. 60(6): 581-517. https://doi.org/10.1111/ped.13544; PMid:29498791

Marrani E, Burns JC, Cimaz R. (2018). How should we classify Kawasaki disease? Front Immunol. 9: 2974. eCollection 2018. https://doi.org/10.3389/fimmu.2018.02974; PMid:30619331 PMCid:PMC6302019

Masuda H, Kobayashi T, Hachiya A, Nakashima Y, Shimizu H, Nozawa T et al. (2018). Infliximab for the treatment of refractory Kawasaki disease: a nationwide survey in Japan. J Pediatr. 195: 115-120.e3. https://doi.org/10.1016/j.jpeds.2017.10.013; PMid:29224935

Matsubara T, Ichiyama T, Furukawa S. (2005). Immunological profile of peripheral blood lymphocytes and monocytes/macrophages in Kawasaki disease. Clin Exp Immunol. 141(3): 381-387. https://doi.org/10.1111/j.1365-2249.2005.02821.x; PMid:16045726 PMCid:PMC1809464

McCrindle BW, Li JS, Minich LL, Colan SD, Atz Am, Takahashi M et al. (2007). Coronary artery involvement in children with Kawasaki disease: risk factors from analysis of serial normalized measurements. Circulation. 116: 174-179. https://doi.org/10.1161/CIRCULATIONAHA.107.690875; PMid:17576863

McCrindle BW, Rowley AH, Newburger JW, Burns JC, Bolger AF, Gewitz M et al. (2017). Diagnosis, treatment, and long-term management of Kawasaki disease: a scientific statement for health professionals from the American Heart Association. Circulation. 135: e927-e99. https://doi.org/10.1161/CIR.0000000000000484; PMid:28356445

Meier JD, Grimmer JF. (2014). Evaluation and management of neck masses in children. Am Fam Physician. 89(5): 353-358. PMID: 24695506.

Miendje Deyi Y, Goubau P, Bodéus M. (2000). False-positive IgM antibody tests for cytomegalovirus in patients with acute Epstein-Barr virus infection. Eur J Clin Microbiol Infect Dis. 19(7): 557-560. https://doi.org/10.1007/s100960000317; PMid:10968331

Ming L, Cao HL, Li Q, Yu G. (2021). Red Blood Cell Distribution Width as a Predictive Marker for Coronary Artery Lesions in Patients with Kawasaki Disease. Pediatr Cardiol. 42(7): 1496-1503. https://doi.org/10.1007/s00246-021-02633-x; PMid:34036412 PMCid:PMC8463334

Minich LL, Sleeper LA, Atz AM, McCrindle BW, Lu M, Colan SD et al. (2007). Delayed diagnosis of Kawasaki disease: what are the risk factors? Pediatrics. 120: e1434-e1440. https://doi.org/10.1542/peds.2007-0815; PMid:18025079

Nakamura Y. (2018). Kawasaki disease: epidemiology and the lessons from it. Int J Rheum Dis. 21(1): 16-19. https://doi.org/10.1111/1756-185X.13211; PMid:29115029

Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC et al. (2004). Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the committee on rheumatic fever, endocarditis, and Kawasaki disease. Council on cardiovascular disease of the young, Am Heart Assoc. Pediatrics. 114: 1708-1733. https://doi.org/10.1542/peds.2004-2182; PMid:15574639

Ng YM, Sung RY, So LY. (2005). Kawasaki disease in Hong Kong, 1994 to 2000. Hong Kong Med J. 11(5): 331-335.

Niu MM, Jiang Q, Ruan JW, Liu HH, Chen WX, Qiu Z et al. (2021). Clinical implications of procalcitonin in Kawasaki disease: a useful candidate for differentiating from sepsis and evaluating IVIG responsiveness. Clin Exp Med. 21(4): 633-643. https://doi.org/10.1007/s10238-021-00709-9; PMid:33839960 PMCid:PMC8036161

Öner T, Yılmazer MM, Güven B, Devrim I, Cilengiroğlu ÖV, Demirpençe S et al. (2012). An observational study on peripheral blood eosinophilia in incomplete Kawasaki disease. Anadolu Kardiyol Derg. 12(2): 160-164. https://doi.org/10.5152/akd.2012.042

Onouchi Y. (2018). The genetics of Kawasaki disease. Int J Rheum Dis. 21(1): 26-30. https://doi.org/10.1111/1756-185X.13218; PMid:29152908

Perrin L, Letierce A, Guitton C, Tran TA, Lambert V, Kon-Paut I et al. (2009). Comparative study of complete versus incomplete Kawasaki disease in 59 pediatric patients. Joint Bone Spine. 76: 481-485. https://doi.org/10.1016/j.jbspin.2008.11.015; PMid:19811939

Raeeskarami SR, Tahghighi F, Ziaee Bigdeli AH, Assari R, Ziaee V, Aghighi Y, Sadeghi P. (2018). Role of Kobayashi risk scoring for determining refractory Kawasaki disease. J Compr Pediatr. 9(4): e67116. https://doi.org/10.5812/compreped.67116

Riancho-Zarrabeitia L, Rasilla D, Royé D, Fdez-Arroyabe P, Santurtún A. (2018). Kawasaki disease in Spanish paediatric population and synoptic weather types: an observational study. Rheumatol Int. 38(7): 1259-1266. https://doi.org/10.1007/s00296-018-4066-5; PMid:29846788

Riphagen S, Gomez X, Gonzalez-Martinez C. (2020). Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 395(10237): 1607-1608. https://doi.org/10.1016/S0140-6736(20)31094-1; PMid:32386565

Sadeghi P, Izadi A, Mojtahedi SY, Khedmat L, Jafari M, Afshin A et al. (2021). A 10-year cross-sectional retrospective study on Kawasaki disease in Iranian children: incidence, clinical manifestations, complications, and treatment patterns. BMC Infect Dis. 21(1): 368. https://doi.org/10.1186/s12879-021-06046-2; PMid:33874899 PMCid:PMC8056507

Saffar MJ, Reshidighader F. (2005). Kawasaki disease in East Mazandaran, Islamic Republic of Iran, 1997-2002. East Mediterr Health J. 11(1-2): 28-35.

Sakurai Y. (2019). Autoimmune aspects of Kawasaki disease. J Investig Allergol Clin Immunol. 29(4): 251-261. https://doi.org/10.18176/jiaci.0300; PMid:30183655

Sánchez-Manubens J, Antón J, Bou R, Iglesias E, Calzada-Hernandez J. (2016). Incidence, epidemiology and clinical features of Kawasaki disease in Catalonia, Spain. Clin Exp Rheumatol. 34: S139-S144.

Singh S, Jindal AK, Pilania RK. (2018). Diagnosis of Kawasaki disease. Int J Rheum Dis. 21(1): 36-44. https://doi.org/10.1111/1756-185X.13224; PMid:29131549 PMCid:PMC7159575

Son MBF, Gauvreau K, Ma L, Baker AL, Sundel RP, Fulton DR et al. (2009). Treatment of Kawasaki disease: analysis of 27 US Pediatric Hospitals from 2001 to 2006. Pediatrics. 124(1): 1-8. https://doi.org/10.1542/peds.2008-0730; PMid:19564276

Sonobe T, Kiyosawa N, Tsuchiya K, Aso S, Imada Y, Imai Y et al. (2007). Prevalence of coronary artery abnormality in incomplete Kawasaki disease. Pediatr Int. 49: 421-426. https://doi.org/10.1111/j.1442-200X.2007.02396.x; PMid:17587261

Sonoda K, Mori M, Hokosaki T, Yokota S. (2014). Infliximab plus plasma exchange rescue therapy in kawasaki disease. J Pediatr. 164(5): 1128-1132. https://doi.org/10.1016/j.jpeds.2014.01.020; PMid:24560183

Sudo D, Makino N, Nakamura Y. (2020). Recurrent Kawasaki disease and cardiac complications: nationwide surveys in Japan. Arch Dis Child. 105(9): 848-852. https://doi.org/10.1136/archdischild-2019-317238; PMid:32107252

Suzuki H, Terai M, Hamada H, Honda T, Suenaga T, Takeuchi T et al. (2011). Cyclosporin a treatment for Kawasaki disease refractory to initial and additional intravenous immunoglobulin. Pediatr Infect Dis J. 30(10): 871-876. https://doi.org/10.1097/INF.0b013e318220c3cf; PMid:21587094

Tacke CE, Breunis WB, Pereira RR, Breur JM, Kuipers IM, Kuijpers TW. (2014). Five years of Kawasaki disease in the Netherlands: a national surveillance study. Pediatr Infect Dis J. 33(8): 793-797. https://doi.org/10.1097/INF.0000000000000271; PMid:24463809

Takahashi K, Oharaseki T, Yokouchi Y. (2014). Update on etio and immunopathogenesis of Kawasaki disease. Curr Opin Rheumatol. 26(1): 31-36. URL: http://www.ncbi.nlm.nih.gov/pubmed/24247115. https://doi.org/10.1097/BOR.0000000000000010; PMid:24247115

Tirelli F, Marrani E, Giani T, Cimaz R. (2020). One year in review: Kawasaki disease. Curr Opin Rheumatol. 32(1): 15-20. https://doi.org/10.1097/BOR.0000000000000671; PMid:31599798

To KK, Chua GT, Kwok KL, Wong JS, Au DCY, Lam YY et al. (2020). False-positive SARS-CoV-2 serology in 3 children with Kawasaki disease. Diagn Microbiol Infect Dis. 98(3): 115141. https://doi.org/10.1016/j.diagmicrobio.2020.115141; PMid:32795776 PMCid:PMC7366972

Toubiana J, Poirault C, Corsia A. (2020). Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study. BMJ. 369: m2094. https://doi.org/10.1136/bmj.m2094; PMid:32493739 PMCid:PMC7500538

Tremoulet AH, Jain S, Jaggi P, Jimenezfernandez S, Pancheri J, Sun X et al. (2014). Infliximab for intensification of primary therapy for Kawasaki disease: a phase 3 randomised, double-blind, placebo-controlled trial. Lancet. 383(9930): 1731-1738. https://doi.org/10.1016/S0140-6736(13)62298-9; PMid:24572997

Tremoulet AH, Pancoast P, Franco A, Bujold M, Shimizu C, Onouchi Y et al. (2012). Calcineurin inhibitor treatment of intravenous immunoglobulin-resistant Kawasaki disease. J Pediatr. 161(3): 506-512. https://doi.org/10.1016/j.jpeds.2012.02.048; PMid:22484354 PMCid:PMC3613150

Tsai CM, Chu CH, Liu X, Weng KP, Liu SF, Huang YH, Kuo HC. (2021). A novel score system of blood tests for differentiating Kawasaki disease from febrile children. PLoS One. 16(1): e0244721. eCollection 2021. https://doi.org/10.1371/journal.pone.0244721; PMid:33481812 PMCid:PMC7822339

Tsuda E, Hashimoto S. (2021). Time course of coronary artery aneurysms in Kawasaki disease. J Pediatr. 230: 133-139.e2. https://doi.org/10.1016/j.jpeds.2020.12.004; PMid:33301786

Turnier JL, Anderson MS, Heizer HR, Jone PN, Glodé MP, Dominguez SR. (2015). Concurrent respiratory viruses and Kawasaki disease. Pediatrics. 136(3): e609-e614. https://doi.org/10.1542/peds.2015-0950; PMid:26304824

Uehara R, Belay ED, Maddox RA, Holman RC, Nakamura Y, Yashiro M et al. (2008). Analysis of potential risk factors associated with nonresponse to initial intravenous immunoglobulin treatment among Kawasaki disease patients in Japan. Pediatr Infect Dis J. 27(2): 155-160. https://doi.org/10.1097/INF.0b013e31815922b5; PMid:18174868

Uehara R, Belay ED. (2012). Epidemiology of Kawasaki disease in Asia, Europe, and the United States. J Epidemiol. 22(2): 79-85. https://doi.org/10.2188/jea.JE20110131; PMid:22307434 PMCid:PMC3798585

Usta Guc B, Cengiz N, Yildirim SV, Uslu Y. (2008). Cytomegalovirus infection in a patient with atypical Kawasaki disease. Rheumatol Int. 28(4): 387-389. https://doi.org/10.1007/s00296-007-0440-4; PMid:17717671 PMCid:PMC7079931

Valota M, Thienemann F, Misselwitz B. (2019). False-positive serologies for acute hepatitis A and autoimmune hepatitis in a patient with acute Epstein-Barr virus infection. BMJ Case Rep. 12(5): e228356. https://doi.org/10.1136/bcr-2018-228356; PMid:31079040 PMCid:PMC6536262

Van Anh KY, Shah S, Tremoulet AH. (2020). Hemolysis from intravenous immunoglobulin in obese patients with Kawasaki disease. Front Pediatr. 8: 146. eCollection 2020. https://doi.org/10.3389/fped.2020.00146; PMid:32318529 PMCid:PMC7146618

Verdoni L, Mazza A, Gervasoni A et al. (2020). An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet. 395(10239): 1771-1778. https://doi.org/10.1016/S0140-6736(20)31103-X; PMid:32410760

Viner RM, Whittaker E. (2020). Kawasaki-like disease: emerging complication during the COVID-19 pandemic. Lancet. 395(10239): 1741-1743. https://doi.org/10.1016/S0140-6736(20)31129-6; PMid:32410759

Wang L, Zhang S, Ma J, Ni J, Wang J, Li X et al. (2021). Kawasaki disease - management strategies given symptoms overlap to COVID-19: a review. JNMA J Nepal Med Assoc. 59(236): 417-424. https://doi.org/10.31729/jnma.5698; PMid:34508537 PMCid:PMC8369595

Warfarin (Rx). URL: https://reference.medscape.com/drug/coumadin-jantoven-warfarin-342182?src=mbl_msp_android&ref=share.

Xie T, Wang Y, Fu S, Wang W, Xie C, Zhang Y, Gong F. (2017). Predictors for intravenous immunoglobulin resistance and coronary artery lesions in Kawasaki disease. Pediatr Rheumatol Online J. 15(1): 17. https://doi.org/10.1186/s12969-017-0149-1; PMid:28320400 PMCid:PMC5359815

Yang HM, Du ZD, Fu PP. (2013). Clinical features of recurrent Kawasaki disease and its risk factors. Eur J Pediatr. 172(12): 1641-1647. https://doi.org/10.1007/s00431-013-2101-9; PMid:23887608

Yi DY, Kim JY, Choi EY, Choi JY, Yang HR. (2014). Hepatobiliary risk factors for clinical outcome of Kawasaki disease in children. BMC Pediatrics. 14: 51. https://doi.org/10.1186/1471-2431-14-51; PMid:24548331 PMCid:PMC3938642

Yoon KL. (2015). Update of genetic susceptibility in patients with Kawasaki disease. Korean J Pediatr. 58(3): 84-88. https://doi.org/10.3345/kjp.2015.58.3.84; PMid:25861330 PMCid:PMC4388975

Zhang X, Ya-Wang Shao, Ya-Lan Zhang, Yi Liu. (2021). Serum Lp-PLA2 Level Predicting Coronary Artery Lesions in Children with Kawasaki Disease. Heart Surg Forum. 24(4): E611-E618. https://doi.org/10.1532/hsf.3833; PMid:34473042