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Comparison of Clinical Manifestation and Laboratory Findings between Adenoviral Infection with or without Kawasaki Disease

Yu Jin Kwak, Yi Kyung Kim, Ji Eun Ban, Sejung Sohn, Young Mi Hong
The Ewha Medical Journal 2018;41(3):45-52. Published online: July 31, 2018

Department of Pediatrics, Ewha Womans University College of Medicine, Seoul, Korea

Corresponding author Young Mi Hong Department of Pediatrics, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea Tel: 82-2-2650-2841, Fax: 82-2-2653-3718 E-mail: ymhong@ewha.ac.kr
• Received: March 27, 2018   • Revised: April 16, 2018   • Accepted: April 18, 2018

Copyright © 2018 Ewha Womans University School of Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Objectives
    Adenovirus infection, which has been known to mimic Kawasaki disease (KD), is one of the most frequent conditions observed during differential diagnosis when considering KD. Accordingly, it is essential to being able to differentiate between these two diseases. Therefore, we performed multiplex reverse transcriptase- polymerase chain reaction and tissue-Doppler echocardiography to distinguish between adenovirus patients and KD patients.
  • Methods
    A total of 113 adenoviral infection patients (female 48, male 65) diagnosed from January 2010 to June 2016 were evaluated. We divided adenoviral infection patients into two groups: group 1, which consisted of individuals diagnosed with KD according to the KD American Heart Association criteria (n=62, KD with adenovirus infection); and group 2, which comprised individuals only diagnosed with adenovirus infection (n=51). Laboratory data were obtained from each patient including N-terminal pro-brain natriuretic peptide. Echocardiographic measurements were compared between two groups. In addition, reverse transcriptase-polymerase chain reaction was performed using nasopharyngeal secretions to diagnose adenoviral infection.
  • Results
    Conjunctival injection, cervical lymphadenopathy, polymorphous skin rash, abnormalities of the lip or oral mucosa and abnormalities of extremities were significantly higher in group 1 than group 2. Moreover, group 1 had significantly higher C-reactive protein and alanine aminotransferase levels, as well as lower platelet counts and albumin levels than group 2. Coronary artery diameter was significantly greater in group 1 than group 2.
  • Conclusion
    In patients with adenoviral infection with unexplained prolonged fever, echocardiography and C-reactive protein can be used to differentiate KD with adenoviral infection from adenoviral infection alone.
  • Keywords: Mucocutaneous lymph node syndrome; Adenoviridae; Polymerase chain reaction; Echocardiography
Fig. 1.
Myocardial velocity by tissue Doppler imaging in Kawasaki disease patient. E’, early diastolic myocardial velocity; A’, late diastolic myocardial velocity; S’, systolic myocardial velocity.
emj-2018-41-3-45f1.jpg
Fig. 2.
Tei index by tissue Doppler imaging in Kawasaki disease patient. Tei index=(a-b)/b=(IVCT+IVRT)/LVET. IVCT, isovolumetric contraction time; IVRT, isovolumetric relaxation time; LVET, left ventricle ejection time.
emj-2018-41-3-45f2.jpg
Fig. 3.
Right coronary artery dilatation by echocardiography in Kawasaki disease patient.
emj-2018-41-3-45f3.jpg
Table 1.
Comparison of clinical characteristics between group 1 and group 2
Clinical characteristics Group 1 (n=62) Group 2 (n=51) P-value
Boys 37 (59.7) 28 (54.9) 0.609
Girls 25 (40.3) 23 (45.1) 0.703
Age (year) 4 (2–4) 3 (1–4) 0.045†
Fever duration (>5 days) 38 (61.3) 26 (51.0) 0.271
Conjunctival injection 39 (62.9) 16 (31.4) 0.001
Cervical lymphadenopathy 20 (32.3) 2 (3.9) <0.001
Polymorphous skin rash 22 (35.5) 1 (2.0) <0.001
Abnormalities of lip or oral mucosa 19 (30.6) 2 (3.9) <0.001
Abnormalities of extremities 8 (12.9) 1 (2.0) 0.039‡

Values are presented as number (%) or number (range).

†P value obtained from the Mann-Whitney test.

‡P value obtained from the Fisher’s exact test.

Group 1, KD with adenoviral infection; Group 2, adenoviral infection.

Table 2.
Comparison of laboratory data between two groups
Laboratory data Group 1 (n=62) Group 2 (n=51) P-value
Hb (g/dL) 11.4 (11.0–12.1) 11.8 (11.2–12.3) 0.116
WBC (/μL) 9,570 (7,417–12,677) 10,030 (7,500–12,440) 0.892
Neutrophil (%) 59.1 (49.9–65.7) 57.0 (46.5–67.0) 0.604
Platelet (x109/L) 230.0 (193.0–282.2) 257.0 (215.0–302.0) 0.044
ESR (mm/hr) 36.0 (26.0–49.5) 31.0 (18.5–41.0) 0.063
CRP (mg/dL) 5.65 (2.81–7.66) 2.52 (1.09–5.12) <0.001
AST (IU/L) 26.5 (17.5–32.3) 32.0 (28.0–35.0) <0.001
ALT (IU/L) 16.5 (13.0–29.3) 15.0 (12.0–18.0) 0.044
Total protein (g/dL) 6.5 (6.3–6.7) 6.5 (6.1–6.7) 0.858
Albumin (g/dL) 3.7 (3.6–3.9) 3.8 (3.7–4.0) 0.006
NT-pro BNP (pg/mL) 192.0 (82.5–316.5) 144.5 (144.0–220.0) 0.089

Values are expressed as the mean (range).

Group 1, KD with adenoviral infection; Group 2, adenoviral infection.

Hb, hemoglobin; WBC, white blood cell count; ESR, erythrocyte sedimentation rate; ALT, alanine aminotransferase; AST, aspartate aminotransferase; CRP, C-reactive protein; NT-proBNP, N-terminal pro-brain natriuretic peptide; RCA, right coronary artery.

Table 3.
Comparison of echocardiographic finding between two groups
Echo findings Group 1 (n=62) Group 2 (n=51) P value
RCA (mm) 2.30 (1.75–3.95) 1.70 (1.30–2.00) <0.001
LCA (mm) 1.80 (1.50–2.00) 1.60 (1.50–1.90) 0.067
EF (%) 69.45 (65.25–75.10) 71.55 (65.08–76.73) 0.392
FS (%) 38.15 (35.10–42.75) 39.60 (35.03–44.20) 0.423
TDI
 E’ (cm/sec) 1.80 (1.50–2.00) 9.73 (8.68–11.13) 0.020
 A’ (cm/sec) 69.45 (65.25–75.10) 4.56 (3.86–6.52) 0.805
 S’ (cm/sec) 38.15 (35.10–42.75) 5.47 (4.91–6.34) 0.066
Tei index 1.80 (1.50–2.00) 0.43 (0.38–0.47) 0.302
 IVCT (msec) 69.45 (65.25–75.10) 66.00 (54.00–79.00) 0.277
 IVRT (msec) 38.15 (35.10–42.75) 48.00 (41.00–58.00) 0.834
 LVET (msec) 1.80 (1.50–2.00) 277.00 (252.50–298.00) 0.696

Values are expressed as the mean (range).

Group 1, KD with adenoviral infection; Group 2, adenoviral infection.

RCA, right coronary artery; LCA, left coronary artery; EF, ejection fraction; FS, fractional shortening; TDI, tissue Doppler imaging; E', early diastolic myocardial velocity; A', late diastolic myocardial velocity; S', systolic myocardial velocity; IVCT, isovolumetric contraction time; IVRT, isovolumetric relaxation time; LVET, left ventricle ejection time.

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      Comparison of Clinical Manifestation and Laboratory Findings between Adenoviral Infection with or without Kawasaki Disease
      Ewha Med J. 2018;41(3):45-52.   Published online July 31, 2018
      DOI: https://doi.org/10.12771/emj.2018.41.3.45
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      Comparison of Clinical Manifestation and Laboratory Findings between Adenoviral Infection with or without Kawasaki Disease
      Ewha Med J. 2018;41(3):45-52.   Published online July 31, 2018
      DOI: https://doi.org/10.12771/emj.2018.41.3.45
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      Comparison of Clinical Manifestation and Laboratory Findings between Adenoviral Infection with or without Kawasaki Disease
      Image Image Image
      Fig. 1. Myocardial velocity by tissue Doppler imaging in Kawasaki disease patient. E’, early diastolic myocardial velocity; A’, late diastolic myocardial velocity; S’, systolic myocardial velocity.
      Fig. 2. Tei index by tissue Doppler imaging in Kawasaki disease patient. Tei index=(a-b)/b=(IVCT+IVRT)/LVET. IVCT, isovolumetric contraction time; IVRT, isovolumetric relaxation time; LVET, left ventricle ejection time.
      Fig. 3. Right coronary artery dilatation by echocardiography in Kawasaki disease patient.

      Fig. 1.

      Fig. 2.

      Fig. 3.

      Comparison of Clinical Manifestation and Laboratory Findings between Adenoviral Infection with or without Kawasaki Disease
      Clinical characteristics Group 1 (n=62) Group 2 (n=51) P-value
      Boys 37 (59.7) 28 (54.9) 0.609
      Girls 25 (40.3) 23 (45.1) 0.703
      Age (year) 4 (2–4) 3 (1–4) 0.045†
      Fever duration (>5 days) 38 (61.3) 26 (51.0) 0.271
      Conjunctival injection 39 (62.9) 16 (31.4) 0.001
      Cervical lymphadenopathy 20 (32.3) 2 (3.9) <0.001
      Polymorphous skin rash 22 (35.5) 1 (2.0) <0.001
      Abnormalities of lip or oral mucosa 19 (30.6) 2 (3.9) <0.001
      Abnormalities of extremities 8 (12.9) 1 (2.0) 0.039‡
      Laboratory data Group 1 (n=62) Group 2 (n=51) P-value
      Hb (g/dL) 11.4 (11.0–12.1) 11.8 (11.2–12.3) 0.116
      WBC (/μL) 9,570 (7,417–12,677) 10,030 (7,500–12,440) 0.892
      Neutrophil (%) 59.1 (49.9–65.7) 57.0 (46.5–67.0) 0.604
      Platelet (x109/L) 230.0 (193.0–282.2) 257.0 (215.0–302.0) 0.044
      ESR (mm/hr) 36.0 (26.0–49.5) 31.0 (18.5–41.0) 0.063
      CRP (mg/dL) 5.65 (2.81–7.66) 2.52 (1.09–5.12) <0.001
      AST (IU/L) 26.5 (17.5–32.3) 32.0 (28.0–35.0) <0.001
      ALT (IU/L) 16.5 (13.0–29.3) 15.0 (12.0–18.0) 0.044
      Total protein (g/dL) 6.5 (6.3–6.7) 6.5 (6.1–6.7) 0.858
      Albumin (g/dL) 3.7 (3.6–3.9) 3.8 (3.7–4.0) 0.006
      NT-pro BNP (pg/mL) 192.0 (82.5–316.5) 144.5 (144.0–220.0) 0.089
      Echo findings Group 1 (n=62) Group 2 (n=51) P value
      RCA (mm) 2.30 (1.75–3.95) 1.70 (1.30–2.00) <0.001
      LCA (mm) 1.80 (1.50–2.00) 1.60 (1.50–1.90) 0.067
      EF (%) 69.45 (65.25–75.10) 71.55 (65.08–76.73) 0.392
      FS (%) 38.15 (35.10–42.75) 39.60 (35.03–44.20) 0.423
      TDI
       E’ (cm/sec) 1.80 (1.50–2.00) 9.73 (8.68–11.13) 0.020
       A’ (cm/sec) 69.45 (65.25–75.10) 4.56 (3.86–6.52) 0.805
       S’ (cm/sec) 38.15 (35.10–42.75) 5.47 (4.91–6.34) 0.066
      Tei index 1.80 (1.50–2.00) 0.43 (0.38–0.47) 0.302
       IVCT (msec) 69.45 (65.25–75.10) 66.00 (54.00–79.00) 0.277
       IVRT (msec) 38.15 (35.10–42.75) 48.00 (41.00–58.00) 0.834
       LVET (msec) 1.80 (1.50–2.00) 277.00 (252.50–298.00) 0.696
      Table 1. Comparison of clinical characteristics between group 1 and group 2

      Values are presented as number (%) or number (range).

      P value obtained from the Mann-Whitney test.

      P value obtained from the Fisher’s exact test.

      Group 1, KD with adenoviral infection; Group 2, adenoviral infection.

      Table 2. Comparison of laboratory data between two groups

      Values are expressed as the mean (range).

      Group 1, KD with adenoviral infection; Group 2, adenoviral infection.

      Hb, hemoglobin; WBC, white blood cell count; ESR, erythrocyte sedimentation rate; ALT, alanine aminotransferase; AST, aspartate aminotransferase; CRP, C-reactive protein; NT-proBNP, N-terminal pro-brain natriuretic peptide; RCA, right coronary artery.

      Table 3. Comparison of echocardiographic finding between two groups

      Values are expressed as the mean (range).

      Group 1, KD with adenoviral infection; Group 2, adenoviral infection.

      RCA, right coronary artery; LCA, left coronary artery; EF, ejection fraction; FS, fractional shortening; TDI, tissue Doppler imaging; E', early diastolic myocardial velocity; A', late diastolic myocardial velocity; S', systolic myocardial velocity; IVCT, isovolumetric contraction time; IVRT, isovolumetric relaxation time; LVET, left ventricle ejection time.

      Table 1.

      Table 2.

      Table 3.

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