Volume 4, Case 4
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaiʻi John A. Burns School of Medicine
A 12-year old male Asian tourist visiting your town comes to the emergency department with a chief complaint of coughing and fever. They do not speak English well. From what you can tell, his sister has a cold and he has a past history of "Kawasaki".
Exam VS: T38.2 (oral), P110, R32, BP 110/70, oxygen saturation in room air 98%. He is alert and active. He is not toxic. He has an occasional moist cough. Eyes clear. Oral mucosa clear and moist. Nasal congestion with thick yellow-green mucus. TM's normal. Neck supple. Heart regular, no murmurs. Lungs clear to auscultation. Abdomen non-tender. No CVA tenderness. Color and perfusion are good.
A chest radiograph is ordered to rule out pneumonia. The exam findings are not very suggestive of pneumonia, but the history is unclear because of the language problem.
View chest radiograph.
PA and lateral views of the chest are shown here. You must enlarge the image to appreciate the findings here. The heart size is normal. There are no pulmonary infiltrates. There are several spherical calcifications with central lucencies overlying the heart measuring up to 1.8 cm in size. There are at least four of these clearly visible on the lateral view overlying the heart and possibly two more. The PA view shows one of these clearly adjacent to the right inferior heart border.
A translator is arranged on a three-way telephone translation access line so that more history can be obtained. His parents indicate that he had a severe case of Kawasaki disease when he was two years old. (10 years ago). During his hospitalization, he developed heart failure. After his hospitalization, he had to take heart medicines and aspirin at home. He sees a heart specialist at home who examines him twice a year. He last had a chest radiograph one-year ago. His parents give you the name and phone number of his cardiologist.
With the translator still on the line, a phone call to his cardiologist across several time zones is successful. The cardiologist confirms his past history of Kawasaki disease. The child developed severe coronary aneurysms and congestive heart failure at age 2 years. IV gamma globulin therapy that is used today to reduce the likelihood of developing coronary aneurysms, was not in use at the time of his initial illness 10 years ago. He is now followed periodically. He no longer requires medications for congestive heart failure. You describe the spherical pearl-like calcifications on his chest radiograph. The cardiologist indicates that this is nothing new since these have been visible on his chest radiographs for many years now. These represent calcifications of his coronary aneurysms.
Some the clinical manifestations of Kawasaki disease are described in Case 1 of Volume 3, Myocardial Failure in a 2-Month Old. Coronary aneurysms are a known complication of Kawasaki disease. Acutely, coronary aneurysms may thrombose resulting in coronary insufficiency. Myocarditis may also develop resulting in cardiogenic congestive heart failure and/or shock. Cardiogenic shock in young children may present with vomiting. While vomiting is often assumed to be due to viral gastrointestinal infections, a careful assessment of perfusion parameters and cardiac auscultation should prompt the physician to consider cardiac conditions. Myocarditis may often present with muffled heart tones. Thus, it is important to ascertain the integrity of the heart tones in children presenting with vomiting or other symptoms suggestive of congestive heart failure.
During the years following the acute phase of Kawasaki disease, small aneurysms will usually resolve without complications. Others may evolve resulting in coronary vessel stenosis subjecting such patients to an increased risk of myocardial ischemia and infarction in later life. Large coronary calcifications such as the ones seen on this patient's chest radiograph are unusual. This case is useful to appreciate the magnitude of coronary vessel damage in some children with Kawasaki disease. Thus, children or teenagers with a past history of Kawasaki disease presenting with chest pain suggestive of ischemia should be treated as a rule out myocardial infarction since their degree of coronary vessel disease may be severe.
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