Two Cases of Super-Giant Coronary Aneurysms after Kawasaki Disease
A 4-year-old boy was admitted to a nearby hospital because of fever. He showed conjunctival injection, enlargement of cervical lymph nodes, and edema and erythema of the hands and feet. Under the diagnosis of KD, he was given 2 g/kg of IVIG and high-dose aspirin. Because his fever did not subside, additional IVIG (2 g/kg) was given on the 6th day. On the 8th day, 1 mg/kg∙day of oral prednisolone was started; the fever subsided 2 days later. He was discharged with oral prednisolone (0.5 mg/kg∙day) on the 11th day, and prednisolone was discontinued on the 29th day.\nOn the 32nd day of illness, echocardiography at the outpatient department showed multiple giant CAAs. Cardiac CT also revealed a giant, bead-shaped, fusiform aneurysm in multiple coronary arteries; the diameter of the RCA, left main coronary artery (LMCA), and LAD was 22.3 mm, 7.9 mm, and 16.8 mm, respectively. CT scan revealed multiple thrombi in the LCX, RCA, and LAD, as well as multifocal stenosis in the LCX. Oral warfarin, aspirin, and amlodipine were started, and the patient was transferred to our hospital on the 41st day of illness. On admission, he denied any symptoms. His vital signs were as follows: blood pressure, 99/70 mm Hg; pulse rate, 109 beats/min; respiratory rate, 24 breaths/min; temperature, 36.7℃. His fingertips were desquamated.\nWe added oral carvedilol (0.28 mg/kg∙day) to decrease his blood pressure and heart rate. On the 44th day, repeated cardiac CT was performed to determine whether an emergency operation was necessary; the largest diameter of the proximal RCA, LMCA, and LAD was 23 mm, 7 mm, and 14 mm, respectively. Multiple thrombi were observed in the LAD and RCA, while the thrombus in the proximal LAD lesion had decreased (). Because no significant change had occurred since the previous cardiac CT, we continued the medical treatment. The thrombus in the RCA had nearly disappeared on the 53rd day. On the 67th day of illness, the thrombus in the LAD looked organized, and the diameter of the coronary arteries did not change on follow-up echocardiography. He was discharged with warfarin, aspirin, amlodipine, and carvedilol (1.3 mg/kg∙day).\nOn the 109th day of illness, a large thrombus on the RCA had developed, and cardiac enzyme was elevated at a routine check-up visit after a dental procedure. Before the dental procedure, warfarin was replaced by subcutaneous enoxaparine. He underwent emergent coronary angiography and intracoronary urokinase (4000 IU/kg) infusion (), but there was little effect. We added clopidogrel (1.1 mg/kg∙day) and maintained intravenous heparin for 8 days. He was subsequently discharged without any symptoms and further complications. At the last follow-up visit (9 months after the onset of KD), the patient was doing well without any symptoms.