A Multimodal Approach in the Diagnosis of Kawasaki Disease

Background. Kawasaki syndrome is a systemic vasculitis that mainly affects children under 5 years of age. Coronary aneurysms, which develop in 15–25% of untreated patients and can lead to myocardial infarction and sudden cardiac death, are particularly dangerous. The introduction of intravenous immunoglobulin reduced the incidence of this complication to 3–5%, however, 10% of patients show resistance to therapy. The growth of atypical forms and the appearance of multisystem inflammatory syndrome in children associated with COVID-19 increase the importance of accurate and timely diagnosis.

Objective: determining the role and place, studying the informative value of imaging methods in the diagnosis of Kawasaki syndrome and its complications in children.

Material and methods. For the period of 3 years from January 1, 2022, a retrospective analysis of the data of 16 patients with Kawasaki syndrome (mean age 3.5±1.8 years) was conducted. Echocardiography (EchoCG) was performed on a Philips EPIQ 7 ultrasound scanner using S5-1 (1–5 MHz) and S8-3 (3–8 MHz) sensors. The diameter of the coronary arteries and blood flow characteristics were evaluated. Computed tomography angiography (CTА) was carried out on a Canon Aquilion ONE 640-slice tomograph with bolus contrast agent injection and synchronization with electrocardiography. For suspected concomitant myocarditis, individual patients underwent heart magnetic resonance imaging (MRI) using a Siemens Aera 1.5 T device, which included obtaining T1and T2-weighted images, as well as assessing late contrast enhancement in myocardium after intravenous injection.

Results. EchoCG was performed in all 16 patients, CTА in 7, and heart MRI in 5. The proportion of patients with coronary aneurysms was 75% (12 out of 16). Combined lesion of several arteries was most often observed (58.3%). Dynamic follow-up after 6–12 months revealed a generally favorable prognosis: 27.3% of medium and 70% of small aneurysms remained without dynamics or regressed. However, 10% of small coronary aneurysms progressed, which underscored the need for careful, long-term monitoring of even small changes. The incidence of acute cardiac complications (acute coronary syndrome – 18.8%) in our cohort indicates a continuing risk of ischemic events. The differences in aneurysm sizes measured by CTА and EchoCG were not statistically significant (paired Student’s t-test: t(13)=1.09; p=0.297). At the same time, CTА revealed details critical for prognosis and tactics that were missed by EchoCG: an anomaly of the right coronary artery, mural thrombosis and calcification, as well as (in 1 case) the true extent of the lesion. Myocarditis was verified in 1 patient according to MRI data, namely, manifestations of left ventricular dilation and decreased contractile function, as well as edema signs by T2-tirm and late gadolinium enhancement, delayed accumulation of paramagnetic contrast agent of a characteristic non-coronary pattern.

Conclusion. EchoCG remains the method of choice in the acute period due to the early age of children. CTА is the most informative for assessing the distal sections of the coronary arteries and detecting complications (thrombosis, calcification, stenosis), while heart MRI is used to diagnose a combined inflammatory process. The optimal diagnostic strategy is aimed at detecting and dynamically monitoring the identified changes and should be based on a rational combination of these methods, taking into account the phase of the disease and age.

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