SCMR 22nd Annual Scientific Sessions
Description of Clinical Presentation: A 2 year old male presented with a 12 days febrile illness having been evaluated twice at an outside institution and diagnosed with viral illnesses. He was transferred to our institution for Kawasaki disease (KD) evaluation one week after fever defervescence. As part of his evaluation, he underwent a trans-thoracic echocardiogram (TTE) concerning for coronary aneurysm with thrombus in the left anterior descending coronary artery (LAD). Intravenous immunoglobulin and infliximab were administered as well as anticoagulation with aspirin and heparin. In addition, he was treated with a systemic tissue plasminogen activator (tPA) infusion but developed bleeding complications and was switched to heparin, clopidogrel, and aspirin. On hospital day 8, TTE showed no residual thrombus and a cardiac magnetic resonance imaging (CMR) study was performed to further delineate his coronary artery aneurysm, assess for residual thrombus and assess for any ischemic changes.
Diagnostic Techniques and Their Most Important Findings: A sedated transthoracic echocardiogram (TTE) diagnosed the key finding of giant right and left coronary artery aneurysms with a thrombus in the LAD (Figure 1A-C). The patient underwent a cardiac magnetic resonance imaging (CMR) evaluation including a post contrast 3D whole heart sequence after 12 days of treatment. The details of the scan include a slice thickness of 1 mm, repetition time of 367.7 ms, Echo time 1.38 ms and inversion time of 210 ms. The trigger time was 542 ms, flip angle of 18 degrees and field of view of 256. The important findings of the CMR study include a severely dilated right and left coronary artery system with the proximal RCA measuring 12 x 9 mm and the LAD measuring 10 x 10 mm with abrupt change in size more distally (Figure 1D and Figure 2), as well as resolution of the thrombus. Late gadolinium enhancement was negative suggesting no ischemia.
Learning Points from this Case: A 2 year old boy presented one week after 12 days of fever due to complete KD. Evaluation including CMR should be considered in unusual cases such as this to further delineate the coronary artery system as well as assess for ischemic changes. This case illustrates the importance of making a timely diagnosis of KD by highlighting the identification and treatment of a rare complication. The use of advanced imaging beyond TTE ws required to determine the extent of coronary involvement as well as rule out ischemic changes.