Coronary Aneurysm and Myocardial Infarction in Young Adult Secondary to Undiagnosed Childhood Kawasaki Disease

Kawasaki Disease is the leading cause of acquired heart disease in children. In a previous study Safi et al. demonstrated a case of undiagnosed childhood Kawasaki disease presenting as silent myocardial infarction during adolescence in 16 years old boy. The present case is a 25 years old young adult with a giant saccular coronary aneurysm who had suspicious childhood Kawasaki disease history. Myocardial infarction is a complication of coronary artery aneurysm. The majority of infarcts occurs in the first 6 months of the disease but may present later in life as our case.


Case
A 25-year-old male patient was admitted to our hospital with a history of substernal burning prolonged to 4 -5 hours and atypical chest pain.On admission, his blood pressure was 110/60 mmHg, and heart rate was 85 beat/min.There was no abnormal physical sign on systemic examination.His electrocardiogram showed ST elevation and biphasic T waves in the pre cordial V1-V6 leads.ECG showed development of negative T waves in leads D1 and a VL.The patient had electrocardiographic evidence of sub acute anterior wall myocardial infarction.In patient's past medical history, it was revealed that the patient had a presence of fever more than five days, cervical lymphadenopathy and various skin rashes at age between five and ten years.All clinical manifestations had resolved by 4 weeks without any specific treatment.There was no risk factor in patient's family history of coronary artery disease (Figure 1).After the implementation of balloon angioplasty, a giant saccular coronary aneurysm was also found.The aneurysm of the middle segment of the D1 was repaired with two stent-grafts.The circumflex coronary artery was also aneurysmal.After coronary intervention, patient's symptoms improved and patient observed in coronary intensive care unit for 7 days.Patient was discharged with long-term anti platelet and β-adrenoceptor blocker therapy and close follow up (Figures 3 and 4).

Discussion
Kawasaki disease is an acute systemic vasculitis, which is a febrile multisystem disease.It is the leading cause of acquired heart disease in children [1].The most severe squelae of Kawasaki disease are cardiac complications like coronary artery aneurysms [2].Coronary artery aneurysms or ectasia can be found in 15% to 25% of untreated children usually several weeks after symptom onset [3].Therefore Kawasaki disease may cause myocardial infarction, ischemic heart disease, or sudden death [3][4][5].In young children and adolescents, reasons of myocardial infarction are Takayasu's Arteritis, Marfan syndrome, Systemic Lupus Erythematosus, Behçet's Disease, and Kawasaki Disease [6].
Safi et al. [7] demonstrated a case of undiagnosed childhood Kawasaki disease presenting as silent myocardial infarction during adolescence in 16 years old boy.The present case is a 25 years old young adult with a giant saccular coronary aneurysm.In our case, the coronary artery aneurysm was presumably secondary to Kawasaki disease.At age between five and ten years, the patient had a history compatible with Kawasaki disease symptoms.The patient was asymptomatic between history compatible with Kawasaki disease and present illness.Myocardial infarction is a complication of coronary artery aneurysm.The majority of infarcts occurs in the first 6 months of the disease but may present later in life as our case [2].
The disease appears worldwide in young children but mainly in Japan, Asia, and the United States [8].Cervical lymphadenopathy, fever for at least five days, a generalized rash, conjunctivitis, red palms and soles, indurative edema with subsequent skin desquamation, and changes in the oral mucosa are the clinical presentations of Kawasaki disease [9].The presence of four symptoms along with coronary artery aneurysms is diagnostic.The case fatality rate secondary to coronary artery aneurysm is 0.5% to 2.8% [8].The prognosis of the disease is generally good and normally, full recovery can be obtained [10].Aneurysms developed children need close follow-up and may need long-term anticoagulation therapy [8].Children in whom aneurysms develop might result with thrombus formation and myocardial infarction.It occurs most often in the first year after the illness, with rare occurrence  later in life [7].All children with Kawasaki Disease should have echocardiography performed four to six weeks after disease onset.It is necessary to follow-up with a pediatric cardiologist who the patients with coronary artery abnormalities.Patients with giant coronary artery aneurysms require prolonged anti coagulation therapy [11].
In an article about Kawasaki disease after pediatric coronary bypass surgery, they found an excellent long-term prognosis, with a 25-year survival rate of 95%.In this study, they followed 114 children ranging in age from one year to 19 years [12].

Conclusion
Kawasaki disease primarily affects children younger than 5 years but rarely presents as a myocardial infarction in adolescents and young adults.Echocardiography and angiography confirm the cardiac complications and vasculitis [8].
The purpose of the present paper is to help the clinician recognize the long-term complication of Kawasaki Disease in young adults with the symptoms of acute coronary syndrome.

Figure 1 :
Figure 1: ST elevation and biphasic T waves in the precordial V1-V6 leads, Negative T waves in leadD1, aVL.

Figure 2 :Figure 3 :Figure 4
Figure 2: Total occlusion of the first diagonal branch (D1) of the left anterior descending (LAD) coronary