ST-segment elevation myocardial infarction in Kawasaki disease: A case report and review of literature

Abstract

Background: Kawasaki disease (KD) is an acute self-limiting febrile vasculitis that occurs during childhood and can cause coronary artery aneurysm (CAA). CAAs are associated with a high rate of adverse cardiovascular events.

Case summary: A Korean 35-year-old man with a 30-year history of KD presented to the emergency room with chest pain. Emergent coronary angiography was performed as ST-segment elevation in the inferior leads was observed on the electrocardiogram. An aneurysm of the left circumflex (LCX) coronary artery was found with massive thrombi within. A drug-eluting 4.5 mm 23 mm-sized stent was inserted into the occluded area without complications. The maximal diameter of the LCX was 6.0 mm with a Z score of 4.7, suggestive of a small aneurysm considering his age, sex, and body surface area. We further present a case series of 19 patients with KD, including the current patient, presenting with acute coronary syndrome (ACS). Notably, none of the cases showed Z scores; only five patients (26%) had been regularly followed up by a physician, and only one patient (5.3%) was being treated with antithrombotic therapy before ACS occurred.

Conclusion: For KD presenting with ACS, regular follow up and medical therapy may be crucial for improved outcomes.

Keywords: Acute coronary syndrome; Case report; Coronary angiography; Kawasaki disease; Percutaneous coronary intervention; ST elevation myocardial infarction.

Figure 1

Electrocardiogram and coronary angiography. A: Initial electrocardiogram in the emergency room. Sinus rhythm with ST-segment elevation in leads II, III and aVF; B: Coronary angiography revealed total occlusion of the distal left circumflex, shown as red arrowheads, and the obtuse marginal arteries with severely enlarged vessels and sluggish flow in the 15° right anterior oblique and 25° caudal projection, presented as yellow arrowheads; C: Aneurysmal dilatation in the proximal segment of the right coronary artery was observed in the 30° left anterior oblique projection. LAD: Left anterior descending; RCA: Right coronary artery; OM: Obtuse marginal; LCX: Left circumflex.

Figure 2

Coronary angiographic images and Intravascular ultrasound during percutaneous coronary intervention and follow-up coronary computerized tomography. A: Images and Intravascular ultrasound (IVUS) showed a diameter of 6.0 mm with hazy material filling the distal left circumflex (LCX), suggestive of thrombosis; B: Fluoroscopy showed a thrombolysis in myocardial infarction 2 flow to the distal LCX with massive thrombi; C: A drug-eluting stent was successfully inserted into the culprit lesion without a no-reflow phenomenon; D: We were not able to further advance the IVUS catheter into the obtuse marginal due to resistance and/or angulation; E and F: Coronary computerized tomography performed one year later showed good patency at the LCX stent area and ectatic aneurysm in all coronary arteries. IVUS: Images and Intravascular ultrasound; LCX: Left circumflex; PCI: Percutaneous coronary intervention.

Figure 3

A summary of expert consensus of Kawasaki disease imaging surveillance and management.