Abstract
Kawasaki disease (KD) is the commonest medium vessel vasculitis in children. The etiology of KD remains an enigma despite extensive research. Infections are considered to be one of the triggers for KD, especially in genetically susceptible hosts. KD occurring within a short time interval among siblings is an important clinical observation supporting this hypothesis. In addition, siblings of children with KD are at a higher risk of developing the disease as compared with other children. Screening for KD in febrile siblings, therefore, seems prudent. This would help initiate timely therapy and prevent complications. We briefly review 16 English language reports of KD in siblings diagnosed within 1 month of each other to highlight its etiological and therapeutic implications.
Key Points • KD should be suspected in febrile children who have a sibling recently diagnosed with KD. • Etiological studies should also focus on siblings who develop KD in close temporal proximity. |
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
Kawasaki disease (KD) is one of the commonest childhood vasculitides and usually occurs in children below 5. Recognition of the characteristic signs and symptoms is crucial as the diagnosis remains essentially clinical. However, in cases with incomplete KD, certain laboratory parameters and echocardiographic assessment of coronary arteries may facilitate the diagnosis [1]. KD has lately generated enormous interest among physicians, scientists, and even the lay public due to its association with the novel coronavirus pandemic (SARS-CoV-2/COVID-19) [2]. This is reflected in the increasing number of publications that are emerging from around the globe linking KD to an infectious trigger. As a unique coincidence, Dr. Tomisaku Kawasaki, the legendary Japanese pediatrician after whom the disease is eponymously named, passed away recently [3].
Despite intense research efforts spanning over many decades, the exact etiology remains unknown. The etiological hypotheses include a KD-specific RNA virus, superantigen-mediated illness, and tropospheric winds transporting infectious or toxic agents. Environmental triggers, especially infections, are believed to trigger the disease in genetically susceptible individuals [4]. An important clinical observation that supports this hypothesis is the occurrence of KD in siblings who have disease onset in close temporal proximity to each other. Another clinical observation favoring this hypothesis is the older sibling often presenting with KD first—probably a reflection of greater likelihood of exposure to an infectious trigger. Despite an increased risk of developing KD, siblings of index cases may not be diagnosed due to atypical or incomplete presentations. Incomplete or “atypical” KD patients seem to be at a higher risk of developing coronary artery abnormalities (CAAs) which may be partly due to delays in diagnosis [5].
In this manuscript, we have reviewed the published literature on siblings with KD who developed the disease in close temporal proximity to each other. This may help in answering the long-standing question regarding the exact etiology of KD.
Search strategy
There have been only a few case reports and retrospective studies that have described the occurrence of KD in siblings within a short time period. Two authors (AZB, DB) independently performed a literature search using PubMed/Medline and Google scholar databases. The keywords included in the search were “Kawasaki disease” and “sibling,” “Kawasaki disease” and “twin,” and “Kawasaki disease” and “family.” The term “Mucocutaneous lymph node syndrome” was also used in place of “Kawasaki disease” for literature search and used in combination with sibling, twin, and family for performing a detailed literature search. All articles describing KD in siblings (irrespective of the time frame) were selected for full-text reading. English language articles describing the occurrence of KD in siblings within a month of each other were selected for our non-systematic review (Table 1). English language reports describing cases published in other languages were also included in the review. References of retrieved articles were also cross-checked. Reports where interval between the onset of KD in sibling pairs was not specified were excluded from this review. We were unable to retrieve the abstract and full text of one article reporting simultaneous KD in a twin pair (Table 1, S. No. 17) [22].
Clinical presentation of Kawasaki disease
Kawasaki disease presents with a unique symptom complex of fever accompanied by (a) non-exudative conjunctival injection, (b) polymorphous rash, (c) unilateral cervical lymphadenopathy, (d) changes in lips or oral mucosa, and (e) extremity changes [23]. This characteristic symptom complex is included in the American Heart Association (AHA) clinical criteria for diagnosis of KD, with “complete” or “typical” KD patients fulfilling at least 4 of the abovementioned clinical features in addition to fever. Patients presenting with fever and only 2 or 3 classical manifestations are labeled as “incomplete” KD. Despite being so-called “incomplete” KD, coronary artery involvement may, in fact, be higher in these patients [24]. Unless detected early and treated promptly, the long-term consequences in patients with incomplete KD can be grave [25]. Incomplete KD was recognized even in the first published manuscript on KD [26].
Etiology of KD—a brief overview
Infections have come a long way as the probable cause eliciting an aberrant immune response leading to KD in genetically predisposed individuals. In-depth studies of autopsy specimens have implicated a specific RNA virus in causation of KD [27]. Several other infectious triggers that have been implicated include streptococci, staphylococci [28], Yersinia [29], and a number of viruses [30].
Epidemiological studies on KD have also revealed a striking association with the pattern of tropospheric winds, which have been hypothesized to transport Candida spp. and trigger KD through mechanisms that are not clearly understood [31,32,33]. In fact, Candida albicans water-soluble fraction has been shown to result in a KD-like illness in murine models [34].
Analysis of sibling pairs with KD is useful as it helps to reflect on these individual etiologies. The fact that the prevalence of KD is higher in some ethnic groups (e.g., Asians) led to the identification of genes attributed to increased susceptibility to the disease. Among these, single-nucleotide polymorphisms in CD40L, inositol 1, 4, 5-trisphosphate 3-kinase C (ITPKC), and several interleukin genes have been extensively studied [35]. Shimizu et al. also reported the association of transforming growth factor (TGF)-beta 2 (TGFB2), TGF-beta receptor 2 (TGFBR2), and SMAD3 polymorphisms with KD and the development of coronary artery lesions [36]. A linkage study by Onouchi et al. identified 10 chromosomal loci in siblings with KD which had positive linkage signals. Among these, 12q24 region had the most significant association [37]. However, these results need to be replicated from other geographical regions.
How common is KD in siblings?
The occurrence of KD in siblings was first reported by Tominaga et al. in 1977. They described 51 sibling cases, two-thirds of whom had an interval of < 1 week between onset of disease [38, 39]. The first English language report of KD presenting simultaneously in siblings appeared in 1978 [6]. Detailed epidemiological studies conducted in Japan and Korea usually describe a sibling incidence rate of KD of about 2% and 0.2% respectively [10, 11, 40,41,42]. Though these studies reported siblings with KD, the exact interval between disease onsets has not been clearly reported, and thus, these studies were not included in the present review.
Clinical features unique to KD in siblings
Irrespective of the time duration between disease onset, siblings appear to be at a significantly higher risk of developing KD [11]. Siblings may have incomplete KD or atypical KD [17] which may go unnoticed, and these children may go on to develop coronary artery abnormalities despite normal initial echocardiography [18, 19, 21]. There are several reports of incomplete KD in siblings (Table 1). Fever of any duration in siblings of KD, especially presenting within a short time interval after the index case, should alert the treating physician to a possibility of KD. These children should be actively screened for KD by a targeted history and detailed physical examination including subtle clinical pointers like perianal peeling, BCG site reactivation, and chromonychia. Other investigations that are helpful in these circumstances include assays of N-terminal pro-brain natriuretic peptide (NT-proBNP) assay and a detailed echocardiography. This would ensure timely treatment and decrease the risk of developing CAAs. In addition, these children need to be carefully followed up as CAAs may not be evident on initial echocardiography (Table 1). Data on coronary artery status were available for 13 sibling pairs only. Index patients developed CAAs in 3 pairs (3/13, 23%), and the sibling developed CAAs in 4 pairs (4/13, 31%). Additionally, only aortic root dilatation developed in the sibling in one pair (1/13, 8%).
KD in siblings—guide to etiology?
In addition to implications in disease management mentioned above, the study of KD in siblings provides a valuable opportunity to analyze the etiology of KD. This is because the siblings are likely to have similar genetic backgrounds and exposure to environmental risk factors. Analysis of tropospheric winds transporting infectious or toxic agents in relation to the occurrence of KD reveals a probable incubation period of 6–48 h, thereby reflecting a host response to the antigen or toxin rather than an infection per se [32]. In such circumstances, KD would probably occur simultaneously in siblings. Such instances have also been reported in the literature. It has been noted that the older sibling often presents first with KD and there is a time lag in disease onset in siblings with KD. This could be a result of the older sibling getting infected at school/daycare and passing on the putative infectious agent to the younger sibling at home. The time lag would then be explained by the incubation period seen in infectious diseases. Many patients with “infection triggered” KD have a proven infection. This holds true even for sibling pairs (Table 1). Some of these “infection triggered” KD cases may be mediated through superantigens or heat shock proteins rather than through the infectious agent directly [28]. Of more than 200 sibling pairs reviewed, a specific infectious trigger was documented in only 3 pairs which included streptococcus, adenovirus, and parvovirus. In one pair, throat swab showed growth of Haemophilus influenzae. However, its role in directly triggering the disease was conjectural. When siblings of a patient with KD develop a febrile illness in close temporal proximity, the attending pediatrician should be alert to the possibility of an infection that may also trigger KD [13].
Conclusion
KD needs to be suspected strongly in febrile siblings of children recently diagnosed to have KD. Studies on the etiopathogenesis of KD need to put a greater emphasis on sibling pairs who develop KD in close temporal proximity to each other. Detailed genome-wide association studies need to be conducted in such situations. Recently, KD has been reported in association with novel coronavirus (SARS-CoV-2/COVID-19) infection in children [43]. It may be prudent to look for signs of KD in siblings of patients with COVID-19 who develop a febrile illness.
Data availability
Relevant data included in Table 1.
Abbreviations
- ↑:
-
increase in
- AHA:
-
American Heart Association
- ALT:
-
alanine aminotransferase
- ASO:
-
anti-streptolysin O
- CAAs:
-
coronary artery abnormalities
- CRP:
-
C-reactive protein
- DNase B:
-
deoxyribonuclease B
- ESR:
-
erythrocyte sedimentation rate
- ITPKC:
-
inositol 1, 4, 5-trisphosphate 3-kinase C
- IVIg:
-
intravenous immunoglobulin
- KD:
-
Kawasaki disease
- KDSS:
-
KD shock syndrome
- LCA:
-
left coronary artery
- LCX:
-
left circumflex artery
- ND:
-
not documented
- RCA:
-
right coronary artery
- S. No.:
-
serial number
- TGF:
-
transforming growth factor
- TGFB2:
-
transforming growth factor-beta 2
- TGFBR2:
-
TGF-beta receptor 2
References
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(17):e927–e999
Verdoni L, Mazza A, Gervasoni A, Martelli L, Ruggeri M, Ciuffreda M, Bonanomi E, D'Antiga L (2020) An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet 395(10239):1771–1778
Genzlinger N (2020) Dr. Tomisaku Kawasaki, who pinpointed a mysterious disease, dies at 95. The New York Times. https://nyti.ms/2YMDEX8. Accessed 7 July 2020
Nakamura A, Ikeda K, Hamaoka K (2019) Aetiological significance of infectious stimuli in Kawasaki disease. Front Pediatr 7:244
Ha KS, Jang G, Lee J, Lee K, Hong Y, Son C, Lee JW (2013) Incomplete clinical manifestation as a risk factor for coronary artery abnormalities in Kawasaki disease: a meta-analysis. Eur J Pediatr 172(3):343–349
Lyen KR, Brook CG (1978) Mucocutaneous lymph node syndrome in two siblings. Br Med J 1(6121):1187
Elamin AM (1979) Kawasaki disease in two African siblings. Trop Dr 9(4):153–154
Fink HW (1984) Kawasaki syndrome in twins. Pediatr Infect Dis 3(4):372–373
Harada F, Sada M, Kamiya T, Yanase Y, Kawasaki T, Sasazuki T (1986) Genetic analysis of Kawasaki syndrome. Am J Hum Genet 39(4):537–539
Yanagawa H, Nakamura Y, Yashiro M, Fujita Y, Nagai M, Kawasaki T, Aso S, Imada Y, Shigematsu I (1988) A nationwide incidence survey of Kawasaki disease in 1985-1986 in Japan. J Infect Dis 158(6):1296–1301
Fujita Y, Nakamura Y, Sakata K, Hara N, Kobayashi M, Nagai M, Yanagawa H, Kawasaki T (1989) Kawasaki disease in families. Pediatrics 84(4):666–669
Elamin A (1993) Kawasaki disease in a Sudanese family. Ann Trop Paediatr 13(3):263–268
Anderson DG, Warner G, Barlow E (1995) Kawasaki disease associated with streptococcal infection within a family. J Paediatr Child Health 31(4):355–357
Kaneko K, Unno A, Takagi M, Maruyama T, Obinata K (1995) Kawasaki disease in dizygotic twins. Eur J Pediatr 154(10):868
Dergun M, Kao A, Hauger SB, Newburger JW, Burns JC (2005) Familial occurrence of Kawasaki syndrome in North America. Arch Pediatr Adolesc Med 159(9):876–881
Türel Ö, Bornaun H, Hatipoglu N, Öztarhan K (2011) Kawasaki disease in dizygotic twins in Turkey. J Rheumatol 38(8):1812–1813
Kottek A, Shimizu C, Burns JC (2011) Kawasaki disease in monozygotic twins. Pediatr Infect Dis J 30(12):1114–1146
Zhang X, Sun J, Zhai S, Yang S (2013) Kawasaki disease in two sets of monozygotic twins: is the etiology genetic or environmental? Pak J Med Sci 29(1):227–230
Fukuda S, Ito S, Fujiwara M, Abe J, Hanaoka N, Fujimoto T, Katsumori H (2017) Simultaneous development of Kawasaki disease following acute human adenovirus infection in monozygotic twins: a case report. Pediatr Rheumatol Online J 15(1):39
Maggio MC, Cimaz R, Alaimo A, Comparato C, Di Lisi D, Corsello G (2019) Kawasaki disease triggered by parvovirus infection: an atypical case report of two siblings. J Med Case Rep 13(1):104
Namita U, Saddiq MH, Ahamed Z (2019) Simultaneous development of Kawasaki disease in identical twins: a case report. J Fam Med Prim Care 8(4):1481–1482
Fink HW (1985) Simultaneous Kawasaki disease in identical twins: case report. Va Med 112(4):248–251
Kawasaki T (2006) Kawasaki disease. Proc Jpn Acad Ser B Phys Biol Sci 82(2):59–71
Shivalingam G, Prashanth GP, Hebbal K, Aguiar R (2017) Clinical presentation and cardiovascular outcome in complete versus incomplete Kawasaki disease. Indian Pediatr 54(10):844–847
Behmadi M, Alizadeh B, Malek A (2019) Comparison of clinical symptoms and cardiac lesions in children with typical and atypical Kawasaki disease. Med Sci Basel Switz 7(4):63
Burns JC (2002) Commentary: translation of Dr. Tomisaku Kawasaki’s original report of fifty patients in 1967. Pediatr Infect Dis J 21(11):993–995
Rowley AH, Baker SC, Shulman ST, Rand KH, Tretiakova MS, Perlman EJ, Garcia FL, Tajuddin NF, Fox LM, Huang JH, Ralphe JC, Takahashi K, Flatow J, Lin S, Kalelkar MB, Soriano B, Orenstein JM (2011) Ultrastructural, immunofluorescence, and RNA evidence support the hypothesis of a “new” virus associated with Kawasaki disease. J Infect Dis 203:1021–1030
Matsubara K, Fukaya T, Miwa K, Shibayama N, Nigami H, Harigaya H, Nozaki H, Hirata T, Baba K, Suzuki T, Ishiguro A (2006) Development of serum IgM antibodies against superantigens of Staphylococcus aureus and Streptococcus pyogenes in Kawasaki disease. Clin Exp Immunol 143(3):427–434
Vincent P, Salo E, Skurnik M, Fukushima H, Simonet M (2007) Similarities of Kawasaki disease and Yersinia pseudotuberculosis infection epidemiology. Pediatr Infect Dis J 26:629–631
Turnier JL, Anderson MS, Heizer HR, Jone PN, Glodé MP, Dominguez SR (2015) Concurrent respiratory viruses and Kawasaki disease. Pediatrics 136(3):e609–e614
Rodó X, Ballester J, Cayan D, Melish ME, Nakamura Y, Uehara R, Burns JC (2011) Association of Kawasaki disease with tropospheric wind patterns. Sci Rep 1:152
Rodó X, Curcoll R, Robinson M, Ballester J, Burns JC, Cayan DR et al (2014) Tropospheric winds from northeastern China carry the etiologic agent of Kawasaki disease from its source to Japan. Proc Natl Acad Sci U S A 111(22):7952–7957
El-Askary H, LaHaye N, Linstead E, Sprigg WA, Yacoub M (2017) Remote sensing observation of annual dust cycles and possible causality of Kawasaki disease outbreaks in Japan. Glob Cardiol Sci Pract 2017(3):e201722
Sato W, Ishibashi KI, Yamanaka D, Adachi Y, Ohno N (2017) Effects of natural and chemically defined nutrients on Candida albicans water-soluble fraction (CAWS) vasculitis in mice. Med Mycol J 58(2):E47–E62
Kuo HC, Chang WC (2011) Genetic polymorphisms in Kawasaki disease. Acta Pharmacol Sin 32(10):1193–1198
Shimizu C, Jain S, Davila S, Hibberd ML, Lin KO, Molkara D, Frazer JR, Sun S, Baker AL, Newburger JW, Rowley AH, Shulman ST, Davila S, Burgner D, Breunis WB, Kuijpers TW, Wright VJ, Levin M, Eleftherohorinou H, Coin L, Popper SJ, Relman DA, Fury W, Lin C, Mellis S, Tremoulet AH, Burns JC (2011) Transforming growth factor-beta signalling pathway in patients with Kawasaki disease. Circ Cardiovasc Genet 4:16–25
Onouchi Y (2009) Molecular genetics of Kawasaki disease. Pediatr Res 65(5):46R–54R
Tominaga M, Ohshima K, Yanagawa H (1977) Epidemiological study of family occurrence of MCLS. Pediatr Jpn:1859–1863 (in Japanese)
Yanagawa H, Shigematsu I (1983) Epidemiological features of Kawasaki disease in Japan. Acta Paediatr Jpn 25(2):94–107
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(4):397–403
Park YW, Han JW, Park IS, Kim CH, Yun YS, Cha SH et al (2005) Epidemiologic picture of Kawasaki disease in Korea, 2000-2002. Pediatr Int 47(4):382–387
Park YW, Han JW, Hong YM, Ma JS, Cha SH, Kwon TC, Lee SB, Kim CH, Lee JS, Kim CH (2011) Epidemiological features of Kawasaki disease in Korea, 2006-2008. Pediatr Int 53(1):36–39
Viner RM, Whittaker E (2020) Kawasaki-like disease: emerging complication during the COVID-19 pandemic. Lancet 395(10239):1741–1743
Author information
Authors and Affiliations
Contributions
AZB: Inception of idea, writing of initial draft of manuscript, editing and revision of manuscript at all stages of its production, and review of literature.
DB: Writing of initial draft of the manuscript, contributed to editing of manuscript, and review of literature.
VP: Editing of manuscript and critical revision of the manuscript at all stages of production and final approval.
SS: Contributed to editing of manuscript, revision of the manuscript and its final approval.
Corresponding author
Ethics declarations
Disclosures
None.
Ethical approval and informed consent
As this manuscript pertains only to a review, specific ethics approval is not mandated.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Banday, A.Z., Bhattacharya, D., Pandiarajan, V. et al. Kawasaki disease in siblings in close temporal proximity to each other—what are the implications?. Clin Rheumatol 40, 849–855 (2021). https://doi.org/10.1007/s10067-020-05328-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10067-020-05328-5