Two Cases of Super-Giant Coronary Aneurysms after Kawasaki Disease
A 31-month-old girl presenting with a fever was admitted to a nearby hospital. She showed bilateral conjunctival injection, swelling of the hands and feet, enlargement of the cervical lymph nodes, and a polymorphous rash. Because she was considered to have KD, IVIG (2 g/kg) and high-dose aspirin were given to her on the 5th day of illness. Because the fever persisted, she received additional IVIG (2 g/kg) on the 7th day. Intravenous methylprednisolone was infused on the 9th day because of persistent fever. Echocardiography showed a mildly enlarged coronary artery. The fever dropped on the 16th day, and she was discharged with oral methylprednisolone (2 mg/kg∙day) and low-dose aspirin (5 mg/kg∙day).\nAt the outpatient department on the 25th day of illness, her echocardiography revealed that the right coronary artery (RCA) was severely dilated up to 16 mm in diameter. She was transferred to our hospital. On admission, her vital signs were as follows: blood pressure, 120/60 mm Hg; pulse rate, 140 beats/min; respiratory rate, 24 breaths/min; temperature, 37.6℃. Her great toe tip and sole were desquamated. Her platelet count was 648000/uL; erythrocyte sedimentation rate, 72 mm/h; and serum C-reactive protein, 0.42 mg/dL. Her serum creatine kinase-MB was normal. However, her serum troponin I level was higher than normal at 0.58 ng/mL. The echocardiography showed giant CAA and thrombus formation in the left anterior descending artery (LAD), RCA, and left circumflex artery (LCX). The maximal diameter of the RCA, LAD, and LCX was 16 mm, 9.9 mm, and 7.5 mm, respectively. The flow through coronary artery was intact ().\nShe was transferred to the intensive care unit because she was at a high risk of aneurysmal rupture or myocardial infarction. She was intubated and deeply sedated with midazolam, ketamine, and vecuronium, and was also given continuous intravenous esmolol and nicardipine. For preventing further thrombus formation, intravenous heparin was infused continually, and oral methylprednisolone was tapered off on schedule. After stabilization of her heart rate and blood pressure, we added oral atenolol (2 mg/kg∙day) and amlodipine (0.1 mg/kg∙day) to stop the intravenous esmolol and nicardipine and replaced the intravenous heparin with warfarin. On the 46th day of illness, she returned to the general ward. Despite the adequate dose of aspirin and warfarin, echocardiography on the 57th day showed that the thrombi had reappeared in the RCA. Therefore, we added clopidogrel (0.75 mg/day) to her medication.\nShe underwent cardiac computed tomography (CT), which revealed aneurysmal dilatation of coronary arteries. The maximal diameter of the proximal LAD, LCX, and RCA was 10.8 mm, 7.4 mm, and 18 mm, respectively. She was discharged with oral aspirin, warfarin, clopidogrel, atenolol, and amlodipine on the 68th day. On the 9th month of illness, she underwent cardiac CT and echocardiography. The size of the CAAs had not increased, while the thrombus in the RCA had disappeared (). At the last follow-up visit, which was 10 months after the onset of KD, the patient was doing well without any symptoms.