Case Report
Kawasaki's Disease in Remission With Cardiac Involvement: Intrasacular Thrombus in a Giant Aneurism of Both Coronary Arteries. Case Report
Enfermedad de Kawasaki en fase de convalecencia con afección cardiaca: trombo intra-sacular en aneurisma gigante de ambas coronarias. Reporte de un caso
Karla Mendiola Ramíreza,
, Jorge Omar Osorio Díazb, María del Rocío Maldonado Velázquezc, Enrique Faugier Fuentesd
Corresponding author
a Second Year Pediatrics Resident, Hospital Infantil de México, Mexico City, Mexico
b Second Year Pediatric Cardiology Resident, Hospital Infantil de México, Mexico City, Mexico
c Chief of Servicio de Reumatología Pediátrica, Hospital Infantil de México, Mexico City, Mexico
d Attending Physician Reumatología Pediátrica, Hospital Infantil de México, Mexico City, Mexico
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Case report" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1354 "Ancho" => 3250 "Tamanyo" => 263625 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">a) Electrocardiograma que muestra ritmo sinusal, FC 125, a P +30°, eje QRS +60°, PR 0,12, Qtc 0,40, Ondas Q en DII, aVF y V6. b) Ecocardiograma en el que se aprecia aneurisma de la coronaria derecha de 0,1 cm<span class="elsevierStyleSup">2</span>; coronaria izquierda descendente anterior de 6,8 mm; origen de ambas coronarias de 3 mm; FE del 61%.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Karla Mendiola Ramírez, Jorge Omar Osorio Díaz, María del Rocío Maldonado Velázquez, Enrique Faugier Fuentes" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Karla" "apellidos" => "Mendiola Ramírez" ] 1 => array:2 [ "nombre" => "Jorge Omar" "apellidos" => "Osorio Díaz" ] 2 => array:2 [ "nombre" => "María del Rocío" "apellidos" => "Maldonado Velázquez" ] 3 => array:2 [ "nombre" => "Enrique" "apellidos" => "Faugier Fuentes" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173574311000025" "doi" => "10.1016/j.reumae.2010.11.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574311000025?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X10002391?idApp=UINPBA00004M" "url" => "/1699258X/0000000700000005/v1_201305061900/S1699258X10002391/v1_201305061900/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173574311000074" "issn" => "21735743" "doi" => "10.1016/j.reumae.2010.12.003" "estado" => "S300" "fechaPublicacion" => "2011-09-01" "aid" => "300" "copyright" => "Elsevier España, S.L." 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Reporte de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1354 "Ancho" => 3250 "Tamanyo" => 264967 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">(a) Electrocardiogram showing sinus rhythm, HR 125, a <span class="elsevierStyleItalic">P</span> +30°, QRS axis +60°, PR 0.12, cQt 0.40, Q waves on DII, aVF, and V6. (b) Echocardiogram showing aneurism of the right coronary of 0.1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>; left anterior descending coronary of 6.8<span class="elsevierStyleHsp" style=""></span>mm; origin of both coronaries of 3<span class="elsevierStyleHsp" style=""></span>mm; EF 61%.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Kawasaki's disease (KD) is of relevance in the pediatric practice because it is the most common systemic vasculitis of unknown origin and the first cause of acquired cardiac disease in young patients.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The inflammatory process has a predilection for coronary arteries, leading to the formation of aneurisms, thrombus and stenosis. Aneurisms and coronary ectasia are detected in 15%–25% of patients with KD who do not receive treatment and are the main cause of myocardial infarction, ischemia and sudden death.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The peak of mortality in KD occurs between days 15 and 45, after the resolution of fever; during this time there is vasculitis in the coronary arteries, platelet elevation and a state of hypercoagulability.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The American Heart Association (AHA) has published guidelines for the stratification of coronary risk; it divides the disease in 5 groups according to the size of the aneurisms.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Risk factors associated to the formation of coronary aneurisms (CA) are: age under 1 year or over 5, delay in the diagnosis and treatment of disease, an increase of inflammatory markers (ESR, CrP, procalcitonin) after the administration of gammaglobulin, leukocytosis over 30×10<span class="elsevierStyleSup">9</span>/l, thrombocytopenia, an increase in liver enzymes and low albumin levels.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment with gammaglobulin before day 10 of disease and aspirin reduces the risk of cardiac complications from 4.7% to 25%. Its objective is to inhibit the production of pro-inflammatory cytokines, metalloproteinases, TNF-α and platelet aggregation, reduction in the formation of CA and early identification of vaso-occlusive cardiovascular risk factors may help reduce severe cardiac disease.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Timely diagnosis and treatment, identification of risk factors and close follow-up of patients may help prevent fatal cardiovascular complications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Presentation</span><p id="par0040" class="elsevierStylePara elsevierViewall">The patient is a 4-year-old male who was previously healthy. One month prior to his hospitalization he presented upper respiratory tract infection and difficult to treat fever, managed with antipyretics and antibiotics, without a good response.</p><p id="par0045" class="elsevierStylePara elsevierViewall">KD diagnosis was established in a private hospital based on: (1) difficult to control fever lasting more than 5 days; (2) non-suppurative bilateral conjunctivitis; (3) changes in oral mucosa (raspberry tongue); (4) erythema polymorphus and (5) cervical lymphadenopathy. He presented desquamation of the site of BCG vaccine application. On day 8, an echocardiogram was performed showing a healthy heart, the right coronary measuring 1.8<span class="elsevierStyleHsp" style=""></span>mm and the left one measuring 2.6<span class="elsevierStyleHsp" style=""></span>mm; there were no aneurisms. Laboratory tests showed: Hb 9.3<span class="elsevierStyleHsp" style=""></span>g/dl (NR 12–15.5<span class="elsevierStyleHsp" style=""></span>g/dl), Hto 28% (NR 36%–47%), platelets 197,000 (NR 150<span class="elsevierStyleHsp" style=""></span>000–450<span class="elsevierStyleHsp" style=""></span>000), leukocytes 14<span class="elsevierStyleHsp" style=""></span>300 (NR 6000–10<span class="elsevierStyleHsp" style=""></span>000). Harada Score: points. On day 8, the patient was treated with intravenous gammaglobulin at a dose of 2<span class="elsevierStyleHsp" style=""></span>g/kg/dose and aspirin 100<span class="elsevierStyleHsp" style=""></span>mg/kg/day for days. He was discharged without any further treatment due to improvement.</p><p id="par0050" class="elsevierStylePara elsevierViewall">From day 12 to day 35 of the disease he presented no fever nor received medical treatment or attention.</p><p id="par0055" class="elsevierStylePara elsevierViewall">He came to our hospital on day 36 of the disease with a 9-h episode of vomiting, abdominal pain, cyanosis, somnolence and shallow respirations. He presented cardiac arrest, metabolic acidosis and shock; after resuscitation for 5<span class="elsevierStyleHsp" style=""></span>min he achieved sinus rhythm.</p><p id="par0060" class="elsevierStylePara elsevierViewall">He was hospitalized. An electrocardiogram showed sinus rhythm, heart rate (HR) of 136; <span class="elsevierStyleItalic">P</span> axis +45°; QRS axis +80°; PR: 0.11; cQt: 0.36; ST depression on V6; Q wave on DI, DII, aVL and aVR; and left ventricle hypertrophy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). A chest X-ray showed <span class="elsevierStyleItalic">Situs solitus</span>; levocardia; ICT 0.62; normal pulmonary flow. The echocardiogram showed a mild pericardial effusion on the free wall of the left ventricle, subendocardial ischemia, dyskinesia of the lateral wall of the left ventricle, and paradoxical septal movement. The left coronary measured 2.8<span class="elsevierStyleHsp" style=""></span>mm; circumflex 2.3<span class="elsevierStyleHsp" style=""></span>mm, with a fusiform aneurism of 5.8<span class="elsevierStyleHsp" style=""></span>mm; anterior descending 1.7<span class="elsevierStyleHsp" style=""></span>mm with fusiform aneurisms measuring 7.5, 8.1, and 11<span class="elsevierStyleHsp" style=""></span>mm. The right coronary artery measured 2.4<span class="elsevierStyleHsp" style=""></span>mm, with a saccular aneurism measuring 7.5<span class="elsevierStyleHsp" style=""></span>mm and an intrasaccular thrombus 0.5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>. Systolic function showed an ejection fraction of 55%, FA 27%, normal mitral EA and a Tie index of 0.26 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Laboratory results showed: Hb 7.6<span class="elsevierStyleHsp" style=""></span>g/dl (NR 12–15.5<span class="elsevierStyleHsp" style=""></span>g/dl), Hto 23% (NR 36%–47%), platelets 379<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span> (NR 150<span class="elsevierStyleHsp" style=""></span>000–450<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span>), leukocytes 7900/mm<span class="elsevierStyleSup">3</span> (NR 6000–10<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span>), albumin 3.1<span class="elsevierStyleHsp" style=""></span>g/dl (NR 3.5–5<span class="elsevierStyleHsp" style=""></span>g/dl), TGO 367 UI/l (NR 15–50<span class="elsevierStyleHsp" style=""></span>UI/l), TGP 107<span class="elsevierStyleHsp" style=""></span>UI/l (NR 10–40<span class="elsevierStyleHsp" style=""></span>UI/l), DHL 321<span class="elsevierStyleHsp" style=""></span>UI/l (NR 110–295<span class="elsevierStyleHsp" style=""></span>UI/l), procalcitonin 2.44<span class="elsevierStyleHsp" style=""></span>ng/dl (NR 2.0<span class="elsevierStyleHsp" style=""></span>ng/dl), ESR 40<span class="elsevierStyleHsp" style=""></span>mm/h (NR 0–10<span class="elsevierStyleHsp" style=""></span>mm/h), CRP 5.5<span class="elsevierStyleHsp" style=""></span>mg/l (VR 0–0.300<span class="elsevierStyleHsp" style=""></span>mg/l). Urinalysis presented albuminuria, hemoglobinuria, erythrocyturia 10–12/field, abundant leukocytes, granular casts 0–2/field, epithelial cells 2–3/field. Cardiac enzymes, 12<span class="elsevierStyleHsp" style=""></span>h after admission: AP 195<span class="elsevierStyleHsp" style=""></span>UI/l (NR 150–420<span class="elsevierStyleHsp" style=""></span>UI/l), DHL 1190<span class="elsevierStyleHsp" style=""></span>UI/l (NR 110–295<span class="elsevierStyleHsp" style=""></span>UI/l), CPK Mb 5.173<span class="elsevierStyleHsp" style=""></span>UI/l (NR 0–25<span class="elsevierStyleHsp" style=""></span>UI/l), TGP 352<span class="elsevierStyleHsp" style=""></span>UI/l (NR 10–40<span class="elsevierStyleHsp" style=""></span>UI/l), TGO 269<span class="elsevierStyleHsp" style=""></span>UI/l (NR 15–50<span class="elsevierStyleHsp" style=""></span>UI/l). Lipid profile: cholesterol 159<span class="elsevierStyleHsp" style=""></span>mg/dl (NR 150–200<span class="elsevierStyleHsp" style=""></span>mg/dl) and triglycerides 233<span class="elsevierStyleHsp" style=""></span>mg/dl (NR 30–86<span class="elsevierStyleHsp" style=""></span>mg/dl).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Treatment with dobutamine and levosimendan was started, as well as assisted mechanical ventilation. The patient underwent a transfusion once and thrombolysis was carried out with recombinant plasminogen activator and heparin, suspended after bleeding through the ventilation type, and low molecular weight heparin (enoxaparin) was prescribed as well as antiplatelet therapy (aspirin). He was managed in the ICU for 10 days, vasoactive drugs for 4 days and mechanical ventilation for 6 days.</p><p id="par0075" class="elsevierStylePara elsevierViewall">On day 50 of hospitalization he underwent a myocardial thalium-201 perfusion SPECT; there was no evidence of necrosis. No stress test with dipyridamole was found due to the age of the patient. He was stratified as AHA V due to the obstruction of the coronary artery, treated with low molecular weight heparin and later received warfarin and aspirin.</p><p id="par0080" class="elsevierStylePara elsevierViewall">On day 55 an electrocardiogram showed sinus rhythm, HR 125, aP +30°, QRS axis +60°, PR 0.12, cQt 0.40, Q waves on DII, aVF and V6 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a). The echocardiogram showed minimal pericardial effusion, no paradoxical movement or dyskinesia; there is a reduction in the size of the intrasaccular thrombus in the right coronary aneurism of 0.1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>, fusiform aneurism of the left descending anterior coronary of 6.8<span class="elsevierStyleHsp" style=""></span>mm, origin of both coronaries of 3<span class="elsevierStyleHsp" style=""></span>mm; EF 61% (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b). Laboratory data showed Hb 11.2<span class="elsevierStyleHsp" style=""></span>g/dl (NR 12–15.5<span class="elsevierStyleHsp" style=""></span>g/dl), Hto 33.8% (NR 36%–47%), platelets 461<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span> (NR 150<span class="elsevierStyleHsp" style=""></span>000–450<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span>), leukocytes 8100/mm<span class="elsevierStyleSup">3</span> (NR 6000–10<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span>). BUN 8<span class="elsevierStyleHsp" style=""></span>mg/dl (NR 5.0–18<span class="elsevierStyleHsp" style=""></span>mg/dl), uric acid 2.9<span class="elsevierStyleHsp" style=""></span>mg/dl (NR 2.4–6.4<span class="elsevierStyleHsp" style=""></span>mg/dl), creatinine 0.2<span class="elsevierStyleHsp" style=""></span>mg/dl (NR 0.2–0.4<span class="elsevierStyleHsp" style=""></span>mg/dl), DB 0.08<span class="elsevierStyleHsp" style=""></span>mg/dl (NR 0.2<span class="elsevierStyleHsp" style=""></span>mg/dl), IB 0.28<span class="elsevierStyleHsp" style=""></span>mg/dl (NR 0.2<span class="elsevierStyleHsp" style=""></span>mg/dl), TB 0.36<span class="elsevierStyleHsp" style=""></span>mg/dl (NR 0.2–1.0<span class="elsevierStyleHsp" style=""></span>mg/dl), proteins 7.2<span class="elsevierStyleHsp" style=""></span>g/dl (NR 4.2–7.4<span class="elsevierStyleHsp" style=""></span>g/dl), albumin 3.8<span class="elsevierStyleHsp" style=""></span>g/dl (NR 3.5–5.0<span class="elsevierStyleHsp" style=""></span>g/dl), TGO 38<span class="elsevierStyleHsp" style=""></span>UI/l (NR 15–50<span class="elsevierStyleHsp" style=""></span>UI/l), TGP 62<span class="elsevierStyleHsp" style=""></span>UI/l (NR 10–40<span class="elsevierStyleHsp" style=""></span>UI/l), LDH 321<span class="elsevierStyleHsp" style=""></span>UI/l (NR 110–295<span class="elsevierStyleHsp" style=""></span>UI/l), urinalysis: granular casts 0–1/field, erythrocyturia 7–9/field, leukocytes 3–5/field, bacterias++, epithelial cells 2–4/field, negative nitrites. Urine culture was negative.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The patient is currently asymptomatic and under surveillance by Rheumatology and Cardiology. The echocardiogram after 4 months of the onset of KD showed: right coronary of 3.6<span class="elsevierStyleHsp" style=""></span>mm, with an intrasaccular thrombus of 0.1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>, left coronary of 2.5<span class="elsevierStyleHsp" style=""></span>mm, anterior descending of 5.37<span class="elsevierStyleHsp" style=""></span>mm, ectasia of the long circumflex of 2.5<span class="elsevierStyleHsp" style=""></span>mm, treatment with warfarin 0.1<span class="elsevierStyleHsp" style=""></span>mg/kg/day and aspirin 3<span class="elsevierStyleHsp" style=""></span>mg/kg/day.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">We have presented the case of a patient with KD who had CA and intrasaccular thrombus, surviving a myocardial infarction and showing a progressive reduction of the CA and thrombus. No adequate follow-up was carried out and was initially discharged, mainly because of lack of knowledge regarding the disease.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Our patient presented several poor prognosis markers and high risk for the development of cardiac complications, which could have been avoided with periodic evaluation in an outpatient clinic.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Heaton et al. described the only fatal cases of KD in patients 6 months and 4 years of age; autopsy reports describe the presence of CA, as well as intrasaccular thrombi. Initial echocardiographic studies showed an absence of CA and the initial treatment was with gammaglobulin and aspirin; the development of CA was detected between days 15 and 50 of the convalescence phase.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Some risk factors for the early formation of CA have been identified: age under year or over 5, delay in diagnosis and treatment of the disease, an increase in inflammatory markers (ESR, CRP and procalcitonin) after therapy with gammaglobulin, leukocytosis over 30<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/l, thrombocytopenia (platelets under 100<span class="elsevierStyleHsp" style=""></span>000), an increase in liver enzyme levels and low levels of albumin.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Myocardial infarction in children with KD is one of the main causes of sudden death, with a mortality rate of 22%. Signs and symptoms are non-specific or present uncontrolled crying, vomiting, diarrhea, dyspnea, chest pain, abdominal pain, vascular collapse and shock. Electrocardiographically, the patients present ST segment elevation, Q waves, and T wave inversion. Echocardiographically he presents dyskinesia or hypokynesia, effusions, valvulopathy and paradoxical septal movement. Laboratory tests show an elevation of CPK, MB fraction (maximum peak in the first 24<span class="elsevierStyleHsp" style=""></span>h, normalized after 48–96<span class="elsevierStyleHsp" style=""></span>h), elevation of troponin I, elevation of muscle enzymes (aminotransferases). The start of fibrinolytic therapy during the first hours improves patient prognosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Treatment of KD before day 10 reduces cardiac complications in 4.7% to 25%. 15% of patients will not respond to the first dose of gammaglobulin, requiring a second dose. Intravenous steroid therapy as a second line therapy in combination has shown usefulness in the reduction of coronary risk and aneurism formation.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Recent studies have shown that the combination of warfarin and aspirin in patients with a high cardiovascular risk reduces the risk of myocardial infarction in 5%–33%.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Diagnosis and treatment with gammaglobulin before day 10 of KD can prevent fatal cardiovascular complications.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres125516" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec112809" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres125515" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec112808" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Presentation" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of Interest" ] 8 => array:2 [ "identificador" => "xack38093" "titulo" => "Acknowledgement" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-06-17" "fechaAceptado" => "2010-11-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec112809" "palabras" => array:3 [ 0 => "Kawasaki disease" 1 => "Coronary artery aneurisms" 2 => "Myocardial infarction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec112808" "palabras" => array:3 [ 0 => "Enfermedad de Kawasaki" 1 => "Aneurisma de arterias coronarias" 2 => "Infarto de miocardio" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Kawasaki disease is of relevance in pediatric practice because it is a systemic vasculitis of unknown origin and the most common cause of acquired heart disease in young patients. Its main complication is the formation of a coronary aneurism in 25% of the patients, unless they receive timely medical treatment.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 4-month-old male child with Kawasaki's disease, who received treatment with gammaglobulin and acetyl-salicylic acid, in which the initial echocardiogram showed aneurisms. Admitted to our hospital with cardiogenic shock, we documented, by echocardiography, the presence of coronary aneurisms with intrasaccular thrombus and acute myocardial infarction. He received fibrinolytic therapy, with an adequate response: the size of aneurisms decreased, as did the intrasaccular thrombus. Currently the patient is asymptomatic and receiving treatment with warfarin and acetylsalicylic acid.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The diagnosis and treatment, as well as identification of risk factors can prevent fatal complications at the cardiovascular level. The treatment in the first 10 days of illness with gammaglobulin and acetyl-salicylic acid reduced cardiac complications from 4.7% to 25%.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La enfermedad de Kawasaki es de relevancia en la práctica pediátrica debido a que es la vasculitis sistémica de origen desconocido más común y la primera causa de cardiopatía adquirida en pacientes jóvenes. Su complicación principal es cardiaca, ya que el 25% de los pacientes sufre la formación de aneurismas coronarios si no reciben de manera oportuna tratamiento médico.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Reportamos el caso de un niño de 4 meses de edad, con enfermedad de Kawasaki, que recibe tratamiento con gammaglobulina y ácido acetilsalicílico. El ecocardiograma inicial no presenta ectasias o aneurismas. Ingresa en nuestro hospital con datos de choque cardiogénico, se documenta por ecocardiografía aneurismas coronarios, con trombo intra-sacular e infarto agudo al miocardio. Recibe terapia fibrinolítica, con respuesta adecuada: disminución del tamaño de los aneurismas y del trombo intra-sacular. Actualmente el paciente se encuentra asintomático y en vigilancia en la consulta externa, recibe tratamiento con warfarina y ácido acetilsalicílico.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El diagnóstico y el tratamiento oportuno, así como la identificación de factores de riesgo, pueden evitar complicaciones fatales a nivel cardiovascular. El tratamiento en los primeros 10 días de la enfermedad con gammaglobulina y ácido acetilsalicílico reduce del 4.7% al 25% de las complicaciones cardiacas.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Mendiola Ramírez K, et al. Enfermedad de Kawasaki en fase de convalecencia con afección cardiaca: trombo intra-sacular en aneurisma gigante de ambas coronarias. Reporte de un caso. Reumatol Clin. 2011. <span class="elsevierStyleInterRef" href="doi:10.1016/j.reuma.2010.11.003">doi:10.1016/j.reuma.2010.11.003</span>.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1222 "Ancho" => 3250 "Tamanyo" => 233502 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">(a) Electrocardiogram showing sinus rhythm, HR 136, <span class="elsevierStyleItalic">P</span> axis +45°, QRS axis +80°, PR 0.11, cQt 0.36, ST depression in V6, Q wave on DI, DII, aVL, and aVR, left ventricular hypertrophy. (b) Echocardiogram reflecting right coronary of 2.4<span class="elsevierStyleHsp" style=""></span>mm, with a saccular aneurism of 7.5<span class="elsevierStyleHsp" style=""></span>mm with intrasaccular thrombus of 0.5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1354 "Ancho" => 3250 "Tamanyo" => 264967 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">(a) Electrocardiogram showing sinus rhythm, HR 125, a <span class="elsevierStyleItalic">P</span> +30°, QRS axis +60°, PR 0.12, cQt 0.40, Q waves on DII, aVF, and V6. (b) Echocardiogram showing aneurism of the right coronary of 0.1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>; left anterior descending coronary of 6.8<span class="elsevierStyleHsp" style=""></span>mm; origin of both coronaries of 3<span class="elsevierStyleHsp" style=""></span>mm; EF 61%.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis, treatment and long term management of Kawasaki disease: a statement for Health Professionals from the Comite on Rheumatic Fever, Endocarditis and Kawasaki Disease. Council on cardiovascular disease in the young, American Heart Association" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.W. Newburger" 1 => "M. Takahashi" 2 => "M.H. Gerber Mewitz" 3 => "L.L.Y. Tani" 4 => "S.T. Shulman" 5 => "A.F. Bolge" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/01.CIR.0000145143.19711.78" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2004" "volumen" => "110" "paginaInicial" => "2747" "paginaFinal" => "2771" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15505111" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Increased detection rate of Kawasaki Disease using new diagnostic algorithm, including early use of echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Thérese" 1 => "F. Dubos" 2 => "V. Hue" 3 => "F. Godart" 4 => "C. Francart" 5 => "P. Vicent" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jpeds.2009.04.058" "Revista" => array:6 [ "tituloSerie" => "J Pediatr" "fecha" => "2009" "volumen" => "155" "paginaInicial" => "695" "paginaFinal" => "699" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19595368" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "When children with Kawasaki Disease grow up. Myocardial and vascular complications in adulthood" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.B. Gordon" 1 => "A.M. Kahn" 2 => "J. Burns" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2009.04.102" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2009" "volumen" => "54" "paginaInicial" => "1911" "paginaFinal" => "1920" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19909870" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Kawasaki disease in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L.E. Wood" 1 => "R.M.R. Tulloh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/hrt.2008.143669" "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2009" "volumen" => "95" "paginaInicial" => "787" "paginaFinal" => "792" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18697808" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fatal Kawasaki disease caused by early occlusive coronary artery disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Heaton" 1 => "N. Wilson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dis Child" "fecha" => "2002" "volumen" => "87" "paginaInicial" => "145" "paginaFinal" => "146" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12138067" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Significant relationship between serum high sensitivity C-reactive protein, high density lipoprotein cholesterol levels and children with Kawasaki Disease and coronary artery lesion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Y.O. Chen" 1 => "T. Yu-Fang" 2 => "L. Chen-Liang" 3 => "C. Yee-Hsuan" 4 => "H. Kai-Sheng" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0929-6646(09)60395-8" "Revista" => array:6 [ "tituloSerie" => "J Formos Med Assoc" "fecha" => "2009" "volumen" => "108" "paginaInicial" => "719" "paginaFinal" => "724" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19773210" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Corticoesteroid therapy for primary treatment of Kawasaki disease, weight of evidence: a meta-analysis and systematic review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Ganesh" 1 => "G. Seth" 2 => "T. Ponniah" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cardiovasc J Afr" "fecha" => "2009" "volumen" => "20" "paginaInicial" => "233" "paginaFinal" => "236" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19701534" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multicenter and retrospective case study of warfarin and aspirin combination therapy in patients with giant coronary aneurysms caused by Kawasaki disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. Suda" 1 => "Y. Kudo" 2 => "T. Higaki" 3 => "Y. Nomura" 4 => "M. Miura" 5 => "M. Matsumura" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circ J" "fecha" => "2009" "volumen" => "73" "paginaInicial" => "1319" "paginaFinal" => "1323" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19436123" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "identificador" => "xack38093" "titulo" => "Acknowledgement" "texto" => "<p id="par0135" class="elsevierStylePara elsevierViewall">The authors wish to thank Dr. Abraham Galicia Reyes, cardiologist and electro physiologist, for sharing his expertise on these types of patients.</p>" ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000000700000005/v1_201305061627/S2173574311000025/v1_201305061627/en/main.assets" "Apartado" => array:4 [ "identificador" => "17376" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000000700000005/v1_201305061627/S2173574311000025/v1_201305061627/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574311000025?idApp=UINPBA00004M" ]
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| 2021 September | 52 | 51 | 103 |
| 2021 August | 32 | 42 | 74 |
| 2021 July | 35 | 37 | 72 |
| 2021 June | 43 | 39 | 82 |
| 2021 May | 61 | 47 | 108 |
| 2021 April | 102 | 97 | 199 |
| 2021 March | 121 | 38 | 159 |
| 2021 February | 68 | 32 | 100 |
| 2021 January | 59 | 29 | 88 |
| 2020 December | 49 | 31 | 80 |
| 2020 November | 43 | 20 | 63 |
| 2020 October | 17 | 20 | 37 |
| 2020 September | 46 | 31 | 77 |
| 2020 August | 29 | 24 | 53 |
| 2020 July | 25 | 35 | 60 |
| 2020 June | 43 | 33 | 76 |
| 2020 May | 40 | 15 | 55 |
| 2020 April | 25 | 16 | 41 |
| 2020 March | 26 | 8 | 34 |
| 2020 February | 1 | 0 | 1 |
| 2020 January | 4 | 0 | 4 |
| 2019 September | 6 | 0 | 6 |
| 2019 June | 2 | 0 | 2 |
| 2019 March | 2 | 0 | 2 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 4 | 1 | 5 |
| 2018 April | 96 | 13 | 109 |
| 2018 March | 130 | 16 | 146 |
| 2018 February | 88 | 5 | 93 |
| 2018 January | 46 | 3 | 49 |
| 2017 December | 96 | 4 | 100 |
| 2017 November | 45 | 7 | 52 |
| 2017 October | 30 | 7 | 37 |
| 2017 September | 50 | 5 | 55 |
| 2017 August | 53 | 14 | 67 |
| 2017 July | 50 | 10 | 60 |
| 2017 June | 63 | 10 | 73 |
| 2017 May | 64 | 11 | 75 |
| 2017 April | 50 | 9 | 59 |
| 2017 March | 43 | 6 | 49 |
| 2017 February | 29 | 15 | 44 |
| 2017 January | 33 | 6 | 39 |
| 2016 December | 73 | 19 | 92 |
| 2016 November | 60 | 8 | 68 |
| 2016 October | 86 | 15 | 101 |
| 2016 September | 105 | 18 | 123 |
| 2016 August | 79 | 3 | 82 |
| 2016 July | 45 | 13 | 58 |
| 2016 June | 2 | 0 | 2 |
| 2016 May | 1 | 0 | 1 |
| 2016 April | 1 | 0 | 1 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 September | 1 | 19 | 20 |
| 2015 August | 3 | 0 | 3 |
| 2015 July | 26 | 5 | 31 |
| 2015 June | 29 | 12 | 41 |
| 2015 May | 52 | 7 | 59 |
| 2015 April | 24 | 7 | 31 |
| 2015 March | 38 | 5 | 43 |
| 2015 February | 37 | 11 | 48 |
| 2015 January | 29 | 9 | 38 |
| 2014 December | 41 | 9 | 50 |
| 2014 November | 39 | 9 | 48 |
| 2014 October | 52 | 8 | 60 |
| 2014 September | 39 | 4 | 43 |
| 2014 August | 40 | 6 | 46 |
| 2014 July | 47 | 15 | 62 |
| 2014 June | 60 | 10 | 70 |
| 2014 May | 64 | 10 | 74 |
| 2014 April | 55 | 8 | 63 |
| 2014 March | 62 | 15 | 77 |
| 2014 February | 47 | 12 | 59 |
| 2014 January | 52 | 12 | 64 |
| 2013 December | 39 | 7 | 46 |
| 2013 November | 48 | 8 | 56 |
| 2013 October | 44 | 9 | 53 |
| 2013 September | 38 | 10 | 48 |
| 2013 August | 48 | 12 | 60 |
| 2013 July | 52 | 11 | 63 |
| 2013 June | 48 | 3 | 51 |
| 2013 May | 30 | 9 | 39 |
| 2013 April | 32 | 14 | 46 |
| 2013 March | 35 | 11 | 46 |
| 2013 February | 43 | 13 | 56 |
| 2013 January | 33 | 22 | 55 |
| 2012 December | 32 | 19 | 51 |
| 2012 November | 19 | 21 | 40 |
| 2012 October | 15 | 8 | 23 |
| 2012 September | 10 | 4 | 14 |
| 2012 July | 1 | 0 | 1 |
| 2012 June | 4 | 0 | 4 |
| 2012 May | 3 | 0 | 3 |
| 2012 April | 9 | 0 | 9 |
| 2012 March | 6 | 0 | 6 |
| 2012 February | 8 | 0 | 8 |
| 2012 January | 2 | 0 | 2 |
| 2011 December | 16 | 0 | 16 |
| 2011 November | 13 | 0 | 13 |
| 2011 October | 11 | 0 | 11 |
Show all
