ABC | Volume 113, Nº6, December 2019

Original Article Reyna et al Coronary dilation in exanthematous illness Arq Bras Cardiol. 2019; 113(6):1114-1118 Table 1 – Demographic and clinical characteristics of patients with febrile exanthematous illness (FEI) and patients with Kawasaki disease (KD) Variable FEI (n = 22) KD (n = 12) p value Male (%) 59 75 0.02 Age, in months (mean) 41.3 18.1 0.05 Fever duration, in days (mean) 3.6 6.5 0.06 Maximum body temperature ( o C) 38.3 38.7 0.9 Exanthema 22(100) 12 (100) 1 Conjuntivitis 2(6.2) 12 (100) 0.03 Swollen lymph glands in the neck 0(0) 12 (100) -------- Swelling and redness in hands and bottoms of feet, n (%) 0(0) 12 (100) -------- Peeling skin n (%) 0(0) 12 (100) ----------- Swollen tongue n (%) 0(0) 12 (100) ----------- Time between diagnosis and echocardiography, in days (mean) 12 25.3 0.05 Coronary dilatation n (%) 6 (27.2) 4(33.3%) 0.4 Table 2 – Z scores of coronary arteries of subjects with febrile exanthematous illness and dilatation of at least one of the coronary branches Gender Age (Months) PRCA Z MRCA Z DRCA Z LMCA Z Circumflex Z LAD Z Diagnosis F 7 2 *1.7 1.9 *2.1 1.6 1.57 3 *4.1 2 *2.5 2.8 *4.9 SE F 27 2.4 *1.67 1.7 0.51 1.4 -0.1 2.2 0.49 1.6 0.29 1.5 -0.16 HFM disease M 84 3 *2.21 1.9 0.27 1.5 -0.53 3.3 *2.3 1.7 -0.16 1.6 -0.6 Scarlet fever M 120 3.4 *1.85 3 *1.7 2.3 0.47 3.5 1.48 2.6 0.94 2.5 0.74 Viral exanthem F 36 2.3 1.16 2 1.09 1.8 0.82 3.1 *2.6 2.1 1.4 2 1.07 HFM disease M 36 1.6 -0.57 1.2 -0.92 1 -1.34 2 -0.2 1.1 -1.16 1 *1.7 HFM disease Mean 51.6 2.45 0.93 1.95 0.24 1.6 0.15 2.85 0.59 1.85 0.26 1.9 0.26 xx *: Increased Z scores; F: Female; M: Male; PRCA: Proximal Right Coronary Artery; MRCA: Medial Right Coronary Artery; DRCA: Distal Right coronary artery; LMCA: Left main coronary artery; LAD: left anterior descending coronary artery; Z: Z values; SE: Sudden exanthema; HFM: Hand Food Mouth Pathogenesis of the dilation of coronary arteries in FEIs is not clear. However, it could be related with a greater myocardial demand for oxygen caused by fever and tachycardia. The consequent increase of coronary blood flow is produced through the compensatory dilation of the coronary arteries. Another potential dilation mechanismwould involve pathogenic proteins that bind to the endothelial cells, activating immune response pathways that produce cytokines and promote additional cellular damage. These findings make it clear that the etiology of coronary changes is not unique. There is a common pathophysiological mechanism that can cause temporary or permanent damage. Therefore, coronary changes should be carefully considered for the diagnosis of KD. An echocardiography should be performed in children diagnosed with FEI, and a timely prophylactic treatment should be considered. Moreover, these findings have implications that should be defined and discussed. Even though the number of subjects is low, the results are important and give rise to some questions: 1. Should an echocardiography be performed to all patients diagnosed with FEIs? 2. If coronary changes are detected, should gamma globulin be administered? 3. Do coronary changes in non-KD FEIs persist or are they reversible? Any affirmative answer would have an impact on public health and health economics. Maybe, many of the FEI cases primarily considered incompatible with KD should be reconsidered, and the number of the cases of atypical or incomplete KD would increase merely by the fact that the presence of coronary changes is determinant for the diagnosis of non-KD FEI. There is already a similar example in literature: patients without FEI criteria that were diagnosed with KD because of the coronary changes. 17,18 Limitations The main limitation of the study is its small sample size, but despite that, important differences were found. Moreover, it is noteworthy that in our country we do not have nomograms of the coronary arteries of Mexican children, which would allow a direct comparison and avoid the bias inherent to the use of nomograms from other regions. This study can encourage future studies to develop these nomograms with Mexican population. Also, the next step would be to perform a longitudinal study with follow-up of these subjects and assessment of the course of the diseases. 1116