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Epidemiology, clinical characteristics, and immediate outcome of Kawasaki disease: a population-based study from a tropical country

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A Correction to this article was published on 23 June 2021

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Data on Kawasaki disease from tropical countries are scarce. Hence, this population-based study aims to determine the epidemiology, clinical characteristics, and outcome of Kawasaki disease in children enrolled in the Kawasaki disease registry between 2006 and 2019 in Southern Malaysia. Diagnosis of Kawasaki disease was made using standard criteria. Primary outcome measure was a coronary artery aneurysm. Multivariable logistic regression was used to analyze the associated risk factors for coronary artery aneurysm. There were 661 Kawasaki disease, with 27% incomplete and 11% atypical presentations. Male-to-female ratio was 2:1, and median age of diagnosis was 1.4 years (interquartile range 9 to 32 months). Incidence in children of less than 5 years was 14.8 (95% confidence interval [CI]: 13.6 to 16.0) per 100,000 population, higher in males (19/100,000) and Chinese (22/100,000), with a gradual increase from 5.7/100,000 in 2006 to 19.6/100,000 in 2019, p < 0.001. Incidence in children between 5 and 9 years old was 1.3 (95% CI: 0.9 to 1.6) per 100,000 population and remained stable over time. There was a seasonal pattern with peak incidence during the rainy season. Out of 625 intravenous immunoglobulins (IVIG)-treated Kawasaki disease, 7.4% were resistant, and 9% had coronary artery aneurysms. Atypical presentation, male sex, late diagnosis, and IVIG resistance were independent risk factors for coronary artery aneurysms.

Conclusions: Despite the tropical climate, Kawasaki disease epidemiology is similar to non-tropic regions with seasonal patterns and a rising incidence. Atypical presentation, male sex, late diagnosis, and IVIG resistance were significantly associated with coronary artery aneurysms.

What is Known:

• Kawasaki disease predominantly occurs in males, children less than 5 years old, and the Asian population.

• Male sex, late diagnosis, incomplete Kawasaki disease, and IVIG resistance were associated with coronary artery aneurysms.

What is New:

• In multi-ethnic Asian countries such as Malaysia, ethnic Chinese have a higher prevalence of Kawasaki disease compared to other ethnicities.

• Kawasaki disease with atypical presentation can occur in both complete and incomplete Kawasaki disease and is significantly associated with a coronary artery aneurysm.

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Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Intravenous immunoglobulin


  1. Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, Shulman ST, Bolger AF, Ferrieri P, Baltimore RS, Wilson WR, Baddour LM, Levison ME, Pallasch TJ, Falace DA, Taubert KA, Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association (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 in the young, American Heart Association. Pediatrics 114:1708–1733

    Article  Google Scholar 

  2. Burns JC, Kushner HI, Bastian JF, Shike H, Shimizu C, Matsubara T, Turner CL (2000) Kawasaki disease: a brief history. Pediatrics 106:1–8

    Article  Google Scholar 

  3. McCrindle BW, Rowley AH, Newburger JW, Burns JC, Bolger AF, Gewitz M, Baker AL, Jackson MA, Takahashi M, Shah PB, Kobayashi T, Wu MH, Saji TT, Pahl E, American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Council on Epidemiology and Prevention (2017) Diagnosis, treatment, and long-term management of Kawasaki disease: a scientific statement for health professionals from the American Heart Association. Circulation 135:e927–e999

    Article  Google Scholar 

  4. Barone SR, Pontrelli LR, Krilov LR (2000) The differentiation of classic Kawasaki disease, atypical Kawasaki disease, and acute adenoviral infection: use of clinical features and a rapid direct fluorescent antigen test. Arch Pediatr Adolesc Med 154:453–456

    Article  CAS  Google Scholar 

  5. Manlhiot C, Christie E, McCrindle BW, Rosenberg H, Chahal N, Yeung RSM (2012) Complete and incomplete Kawasaki disease: two sides of the same coin. Eur J Pediatr 171:657–662

    Article  Google Scholar 

  6. Falcini F, Ozen S, Magni-Manzoni S, Candelli M, Ricci L, Martini G, Cuttica RJ, Oliveira S, Calabri GB, Zulian F, Pistorio A, la Torre F, Rigante D (2012) Discrimination between incomplete and atypical Kawasaki syndrome versus other febrile diseases in childhood: results from an international registry-based survey. Clin Exp Rheumatol 30:799–804

    PubMed  Google Scholar 

  7. Tulloh RMR, Mayon-White R, Harnden A, Ramanan AV, Tizard EJ, Shingadia D, Michie CA, Lynn RM, Levin M, Franklin OD, Craggs P, Davidson S, Stirzaker R, Danson M, Brogan PA (2019) Kawasaki disease: a prospective population survey in the UK and Ireland from 2013 to 2015. Arch Dis Child 104:640–646

    Article  Google Scholar 

  8. Sonobe T, Kiyosawa N, Tsuchiya K, Aso S, Imada Y, Imai Y, Yashiro M, Nakamura Y, Yanagawa H (2007) Prevalence of coronary artery abnormality in incomplete Kawasaki disease. Pediatr Int 49:421–426

    Article  Google Scholar 

  9. Xie L, Yan W, Huang M, Huang M, Chen S, Huang G, Liu F (2020) Epidemiologic features of Kawasaki disease in Shanghai from 2013 through 2017. J Epidemiol 30:429–435

    Article  Google Scholar 

  10. Fernandez-Cooke E, Tascón AB, Sánchez-Manubens 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 14:1–18

    Google Scholar 

  11. Manlhiot C, O’Shea S, Bernknopf B et al (2018) Epidemiology of Kawasaki disease in Canada 2004 to 2014: comparison of surveillance using administrative data vs periodic medical record review. Can J Cardiol 34:303–309

    Article  Google Scholar 

  12. Rowley AH (2011) Kawasaki disease: novel insights into etiology and genetic susceptibility. Annu Rev Med 62:69–77

    Article  CAS  Google Scholar 

  13. Burns JC, Herzog L, Fabri O et al (2013) Seasonality of Kawasaki disease: a global perspective. PLoS One 8:1–11

    Google Scholar 

  14. Onouchi Y (2018) The genetics of Kawasaki disease. Int J Rheum Dis 21:26–30

    Article  Google Scholar 

  15. Kwon YC, Kim JJ, Yun SW et al. (2017) Male-specific association of the FCGR2A His167Arg polymorphism with Kawasaki disease. PLoS One 12:1-11.

  16. Lin L, Wang SY, Yang SB, Xiao FC (2015) Association between the FCGR2A gene H131R polymorphism and risk of Kawasaki disease: a meta-analysis. Genet Mol Res 14:6256–6264

    Article  CAS  Google Scholar 

  17. Menikou S, Langford PR, Levin M (2019) Kawasaki disease: the role of immune complexes revisited. Front Immunol 10:1156

    Article  CAS  Google Scholar 

  18. Ueno K, Nomura Y, Morita Y, Eguchi T, Masuda K, Kawano Y (2015) Circulating platelet-neutrophil aggregates play a significant role in Kawasaki disease. Circ J 79:1349–1356

    Article  CAS  Google Scholar 

  19. Makino N, Nakamura Y, Yashiro M, Kosami K, Matsubara Y, Ae R, Aoyama Y, Yanagawa H (2019) Nationwide epidemiologic survey of Kawasaki disease in Japan, 2015–2016. Pediatr Int 61:397–403

    Article  Google Scholar 

  20. Ha S, Seo GH, Kim KY, Kim DS (2016) Epidemiologic study on kawasaki disease in Korea, 2007-2014: based on health insurance review & assessment service claims. J Korean Med Sci 31:1445–1449

    Article  CAS  Google Scholar 

  21. Huang YH, Lin KM, Ho SC, Yan JH, Lo MH, Kuo HC (2019) Increased incidence of Kawasaki disease in Taiwan in recent years: a 15 years nationwide population-based cohort study. Front Pediatr 7:121

    Article  Google Scholar 

  22. 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 29:483–488

    Article  Google Scholar 

  23. Mauro A, Fabi M, Da Frè M, Guastaroba P, Corinaldesi E, Calabri GB, Giani T, Simonini G, Rusconi F, Cimaz R (2016) Kawasaki disease: an epidemiological study in central Italy. Pediatr Rheumatol 14:1–6

    Article  Google Scholar 

  24. Durongpisitkul K, Sangtawesin C, Khongphatthanayopthin A, Panamonta M, Sopontammarak S, Sittiwangkul R, Pongpanich B (2006) Epidemiologic study of Kawasaki disease and cases resistant to IVIG therapy in Thailand. Asian Pac J Allergy Immunol 24:27–32

    PubMed  Google Scholar 

  25. Mohtar ZA, Yahaya AS, Ahmad F, Suri S, Halim MH (2014) Trends for daily rainfall in northern and southern region of Peninsular Malaysia. J Civ Eng Res 4:222–227

    Google Scholar 

  26. Suzuki T, Michihata N, Yoshikawa T, Hata T, Matsui H, Fushimi K, Yasunaga H (2020) High-dose versus low-dose intravenous immunoglobulin for treatment of children with Kawasaki disease weighing 25 kg or more. Eur J Pediatr 179(12):1901–1907

    Article  CAS  Google Scholar 

  27. Fu PP, Du ZD, Pan YS (2013) Novel predictors of intravenous immunoglobulin resistance in Chinese children with Kawasaki disease. Pediatr Infect Dis J 32:e319–e323

    Article  Google Scholar 

  28. Kim GB (2019) Reality of kawasaki disease epidemiology. Korean J Pediatr 62:292–296

    Article  Google Scholar 

  29. Singh S, Bhattad S (2016) Kawasaki disease incidence at Chandigarh, North India, during 2009–2014. Rheumatol Int 36:1391–1397

    Article  Google Scholar 

  30. Maccora I, Calabri GB, Favilli S, Brambilla A, Trapani S, Marrani E, Simonini G (2021) Long-term follow-up of coronary artery lesions in children in Kawasaki syndrome. Eur J Pediatr 180(1):271–275.

    Article  PubMed  Google Scholar 

  31. Li Y, Reeves RM, Wang X, Bassat Q, Brooks WA, Cohen C, Moore DP, Nunes M, Rath B, Campbell H, Nair H, Acacio S, Alonso WJ, Antonio M, Ayora Talavera G, Badarch D, Baillie VL, Barrera-Badillo G, Bigogo G, Broor S, Bruden D, Buchy P, Byass P, Chipeta J, Clara W, Dang DA, de Freitas Lázaro Emediato CC, de Jong M, Díaz-Quiñonez JA, Do LAH, Fasce RA, Feng L, Ferson MJ, Gentile A, Gessner BD, Goswami D, Goyet S, Grijalva CG, Halasa N, Hellferscee O, Hessong D, Homaira N, Jara J, Kahn K, Khuri-Bulos N, Kotloff KL, Lanata CF, Lopez O, Lopez Bolaños MR, Lucero MG, Lucion F, Lupisan SP, Madhi SA, Mekgoe O, Moraleda C, Moyes J, Mulholland K, Munywoki PK, Naby F, Nguyen TH, Nicol MP, Nokes DJ, Noyola DE, Onozuka D, Palani N, Poovorawan Y, Rahman M, Ramaekers K, Romero C, Schlaudecker EP, Schweiger B, Seidenberg P, Simoes EAF, Singleton R, Sistla S, Sturm-Ramirez K, Suntronwong N, Sutanto A, Tapia MD, Thamthitiwat S, Thongpan I, Tillekeratne G, Tinoco YO, Treurnicht FK, Turner C, Turner P, van Doorn R, van Ranst M, Visseaux B, Waicharoen S, Wang J, Yoshida LM, Zar HJ (2019) Global patterns in monthly activity of influenza virus, respiratory syncytial virus, parainfluenza virus, and metapneumovirus: a systematic analysis. Lancet Glob Health 7:e1031–e1045

    Article  Google Scholar 

  32. Saundankar J, Yim D, Itotoh B, Payne R, Maslin K, Jape G, Ramsay J, Kothari D, Cheng A, Burgner D (2014) The epidemiology and clinical features of kawasaki disease in Australia. Pediatrics 133:e1009–e1014

    Article  Google Scholar 

  33. Friedman KG, Gauvreau K, Hamaoka-Okamoto A et al (2016) Coronary artery aneurysms in Kawasaki disease: risk factors for progressive disease and adverse cardiac events in the US population. J Am Heart Assoc 5:e003289

    Article  Google Scholar 

  34. Yan F, Pan B, Sun H, Tian J, Li M (2019) Risk factors of coronary artery abnormality in children with kawasaki disease: a systematic review and meta-analysis. Front Pediatr 7:374

    Article  Google Scholar 

  35. Sudo D, Monobe Y, Yashiro M, Mieno MN, Uehara R, Tsuchiya K, Sonobe T, Nakamura Y (2012) Coronary artery lesions of incomplete Kawasaki disease: a nationwide survey in Japan. Eur J Pediatr 171:651–656

    Article  Google Scholar 

  36. Suzuki T, Kakimoto N, Tsuchihashi T, Suenaga T, Takeuchi T, Shibuta S, Kitano N, Suzuki H (2021) Z-score is a possible predictor of the risk of coronary artery lesion development in patients with Kawasaki disease in Japan. Eur J Pediatr (Mar 24).

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We would like to thank the Director-General of Health Malaysia for his permission to publish this article and Rasyidah Nizam for this manuscript’s graphics.

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Authors and Affiliations



MNMB contributed to the study conception and design, carried out the echocardiogram, wrote the first draft, performed data analysis and revised the manuscript. MHS contributed to the study conception and design, carried out the echocardiogram and performed data collection. FFH contributed in the study conception and  design, and performed data collection. HR contributed in the study design, data analysis, reviewed and revised the manuscript. EYA contributed in the study design, critically reviewed and revised the manuscript. NA contributed in the study design and critically reviewed the manuscript. All authors read and approved the final manuscript.

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Correspondence to Mohd Nizam Mat Bah.

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All procedures performed in studies involving human participants were following the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was registered with the National Malaysian Research Registry with the identification number NMRR-19-2549-50342. It was approved by the Ministry of Health Research and Ethics Committee.

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Malaysian Ministry of Health Research and Ethics Committee waived the written informed consent.

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The authors declare no competing interests.

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The original online version of this article was revised: The Ethical committee mentioned under Materials and methods has been updated.

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Mat Bah, M.N., Alias, E.Y., Razak, H. et al. Epidemiology, clinical characteristics, and immediate outcome of Kawasaki disease: a population-based study from a tropical country. Eur J Pediatr 180, 2599–2606 (2021).

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