ABC | Volume 113, Nº6, December 2019

Original Article Reyna et al Coronary dilation in exanthematous illness Arq Bras Cardiol. 2019; 113(6):1114-1118 of two hospitals belonging to the Health Services of Petróleos Mexicanos in Mexico. The parents signed an informed consent to participate in the study. The American Heart Association (AHA) criteria 10 were applied to all cases to confirm that the KD diagnostic criteria were not met, including cases that could be considered atypical or incomplete. All the patients underwent an echocardiogram within the first two weeks of the disease using a Vivid 7 General Electric® device. Patients who had a fever ≥ 38°C, which had lasted for at least one day, and exanthema were considered. Subjects with previous known diseases, such as arterial hypertension, family history of cardiopathy, congenital cardiopathy, children with weight above the 95th percentile or below the 5th percentile according to their age, or who had been using steroids during at least one month before the disease were not included. To establish a comparison with KD patients, we reviewed the echocardiograms and the medical electronic records of patients with a diagnosis of KD detected by the Pediatric Cardiology Service during the last five years. 11 Those who met the AHA criteria for KD were included in the analysis, and the children were then selected by convenience sampling. Assessment of the coronary arteries Echocardiography was performed according to that described by Muniz et al. 12 Coronary ectasia (CE) was defined as a dilation of the coronary artery > 1.5-fold in diameter, evidenced by an echocardiogram, when compared to the adjacent normal segments of the same arteries according to coronary artery Z scores. 11 The mean Z score for each coronary artery segment was 0, with a SD of 1. Statistical analysis Comparison of the means of the dimensions of the coronary arteries was performed with a z test, using a one-tailed analysis with a 95% confidence interval. Demographic and clinical characteristics were analyzed using an unpaired Student’s t-test or a Fisher’s exact test, depending on the type of variable, with a difference of p < 0.05. No adjustments were performed in the analysis, since the intention of the study is exploratory. The analysis of the results was done through the Stata program version 13. Ethics The study was approved by the Research and Ethics Committees at both hospitals. Informed consent signed was signed by the parents of the children included in the study. Results We included a total of 34 patients: 22 (64.7%) had a diagnosis of non-KD FEI; 11 of them (50%) were diagnosed as viral exanthema, the most common were hand-foot-and-mouth disease (n = 5; 22.7%) and exanthema subitem (n = 4; 18.1%); there was also one case of scarlet fever and one of Gianotti-Crosti syndrome. The remaining 12 patients were diagnosed with KD. Distribution by sex was as follows: in the FEI group, 13 (59%) patients were male and nine (40.9%) were female; in the KD group, nine (75%) patients were male and three (25%) were female. In terms of age, in the FEI group, the mean age was 41.3 months (range: 7 to 120 months), and in the KD group, the mean age was 18.1 months (range: 6 to 36 months). Other demographic and clinical variables are described in Table 1. Kawasaki disease criteria Regarding the diagnostic criteria for KD in our sample, we found that the average duration of fever was 3.6 ± 2 days, only six subjects (27.2%) met the fever duration criterion of ≥ 5 days. The average of body temperature peak was 38.3°C. Exanthema was present in all subjects, since it was one of the inclusion criteria in the study. One of them had conjunctival hyperemia; none of them had edema, desquamation of foot, hand or tongue, or swollen ganglia. The comparison with the KD patients is shown in Table 1, which shows a higher frequency of some clinical problems in children with KD, swollen lymph glands in the neck, swelling and redness in hands and bottoms of feet, peeling skin and swollen tongue. No difference was found in these percentages compared with those of patients with coronary dilation. Assessment of coronary arteries in subjects with FEI Measurements of the left main coronary artery (LMCA), proximal right coronary artery (PRCA), medial right coronary artery (MRCA), distal right coronary artery (DRCA), circumflex, left anterior descending coronary artery (LAD) were available in 22 patients with FEI. The PRCA showed the largest dilation (mean Z score = 0.45 ± 0.63, p < 0.005), followed by the LMCA (mean Z score = 0.14 ± 1.0, p < 0.05) (Table 2). According to the coronary artery Z-scores, six (27.2%) patients diagnosedwith FEI showed dilation in at least one of the coronary branches. Comparison between the groups are shown in Table 3. Discussion Previous publications have reported cases of increase in the dimensions of the coronary arteries among subjects with diseases such as polyarteritis nodosa, periodontal disease, Mediterranean spotted fever caused by Rickettsia , murine typhus, and even rheumatic fever. Furthermore, it has been shown that the dimensions of the coronary arteries of children with prolonged fever, who do not meet the criteria for KD, are larger than those of healthy subjects, but smaller than those of children suffering from KD. 12-15 These findings are in accordance with our study. We found a high percentage of subjects with FEI and coronary dilation, but the dimensions of their coronary arteries was smaller than those of subjects diagnosed with KD. It is known that coronary abnormalities are present in 20% of the cases diagnosed with KD. 16 In our study, the percentage of coronary dilation among subjects with non-Kawasaki FEI was 26% using the Z score. This implies that coronary changes are more common in FEIs than in KD. It also suggests that it is likely that many of the cases diagnosed as atypical or incomplete KD (based on the presence of coronary alteration) could be, in fact, another FEI. 1115