Cardiac arrest as initial presentation of Kawasaki disease with giant coronary aneurysms: A case report and review of literature

Table 1 Clinical and laboratory characteristics at from disease onset to discharge

	Clinical status	Laboratory findings	Imaging	Interventions
Local hospital	Cardiac arrest, CPR for 45 minutes and return of spontaneous circulation, pink frothy sputum, GCS 4 points	WBC: 20.5 × 109/L, AST: 385 IU/L, ALT: 175 IU/L, hs-cTnI: 2.3 ng/mL	Echocardiography: Coronary artery aneurysm (LMCA: 4.8 mm, LAD: 8 mm, RCA: 7.5 mm), RCA thrombus; chest X-ray: Acute pulmonary edema	CPR, intubation, vasopressors (adrenaline, noradrenaline)
Emergency Department	GCS 4 points, shock status, VIS 210, CRT > 3 seconds	pH = 7.14, serum lactate > 13.3 mmol/L, troponin I > 50 μg/L, serum ferritin > 1676 μg/L, INR = 8.03	ECG: ST depression in leads-DI, aVL. Echocardiography: Giant coronary artery aneurysm (LMCA diameter = 1.6 mm, LAD: 7.5 mm, RCA diameter = 8.1 mm), thrombus in RCA	Mechanical ventilation, IVIG (2 g/kg), vasopressors, intravenous antibiotic (cefepime) and heparin
Before CRRT and TPE	Shock status, respiratory failure, GCS 4 points, acute kidney injury	AST: 3670 IU/L, ALT: 1029 IU/L, serum ferritin > 1676 μg/L, INR = 8.03	Echocardiography: Giant coronary artery aneurysm, EF 55%-60%	Vasopressors, IVIG, methylprednisolone 10 mg/kg/day, CRRT, anti-cerebral edema therapy (NaCl 3%)
After CRRT and TPE	Hemodynamic stability (VIS 47)	AST: 222 IU/L, ALT: 32 IU/L, serum ferritin: 1784 μg/L, INR = 1.32	Chest X-ray: Improvement in pulmonary injury; echocardiography: Coronary artery aneurysm, absence of thrombus	Combined CRRT and TPE, intravenous heparin and corticosteroids
At PICU discharge	Alert (GCS 14 points), extubation and enteral feeding	AST: 54 IU/L, ALT: 75 IU/L, serum ferritin: 776 μg/L	Echocardiography: Coronary artery aneurysm, EF 62%; brain magnetic resonance imaging: Normal findings	Aspirin, ceasing vasopressors, transferred to the Cardiology Unit for further sustained therapies

CPR: Cardiopulmonary resuscitation; WBC: White blood cell; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; LMCA: Left main coronary artery; LAD: Left anterior descending artery; RCA: Right coronary artery; GCS: Glasgow Coma Scale; VIS: Vasoactive-inotropic score; INR: International normalized ratio; ECG: Echocardiography; IVIG: Intravenous immunoglobin; CRRT: Continuous renal replacement therapy; TPE: Therapeutic plasma exchange; EF: Ejection fraction; PICU: Pediatric intensive care unit.

Table 2 A summary of published clinical cases of Kawasaki patients complicated sudden cardiac arrest

Ref.	Clinical features	Interventions	Patients’ outcomes
Maresi et al[20], 2001	A 2-month-old male infant diagnosed of rhinitis and coughing without fever for a week before admission, presented with conjunctival hyperemia and allergic exanthema on the chest and arms. Laboratory findings: Leukocytosis (WBC: 15.37 × 109/L), elevated CRP; and thrombocytosis (476 × 109/L)	Ceftriaxone	The patient died suddenly on the 7th day of hospitalization. Autopsy findings: Cause of death (cardiac tamponade); underlying cause (rupture of an inflamed aneurysm in the LAD coronary artery)
Imai et al[21], 2006	A 5-year-old Japanese male, diagnosed of KD on the 5th day since disease onset. Laboratory findings: WBC 29.4 × 109/L; CRP 16.61 mg/dL; platelet 324 × 109/L. Echocardiography (on the day 12 since disease onset): A giant LAD artery aneurysm (diameter = 18 mm)	CPR, IVIG, aspirin, propranolol, nifedipine, and warfarin	On the 13th day of illness, cardiac arrest developed abruptly and the patient died one hour later
Ashrafi et al[22], 2007	A 4-month-old Caucasian male, recurring fever for three weeks, maculopapular rash, edema of upper extremities, erythema of oral mucosa and conjunctival injection. Laboratory findings: Leukocytosis and thrombocytosis	IVIG, aspirin	The infant suddenly developed spasmodic movements, followed by shallow breathing and cardiac arrest. Autopsy findings: Cause of death (prominent aneurysmal dilatation involving, LAD, circumflex artery, posterior descending artery, right coronary artery)
	A 9-year-old Caucasian girl, developed KD with coronary artery involvement and revealed an immunodeficiency of unknown etiology, steatohepatitis, and interstitial pneumonitis		The patient developed gastrointestinal bleeding and cardiac arrest
Pucci et al[23], 2008	A 3-month-old female infant, with 8-day history of intermittent fever, presented with oral and lip fissures and a diffuse maculopapular eruption. Laboratory tests: WBC 29 × 109/L; thrombocytemia 771 × 109/L; CRP 142 mg/L. Echocardiogram: Two small aneurysms (diameter = 3.5 mm) at the origin of the RCA, proximal dilatation in the LAD and circumflex coronary (LCx) arteries	IVIG, aspirin, corticosteroids and heparin	The patient experienced sudden cardiac arrest and died on the seventh day of treatment. Cause of death: Occlusive coronary thrombosis with a giant aneurysm
Pucci et al[24], 2012	A 3-month-old male experienced intermittent fever for 6 days, skin rash, conjunctivitis, respiratory symptoms, and remitting enteritis, was diagnosed with bronchiolitis and hospitalized on day 17 after disease onset. Laboratory tests: WBC 13.2 × 109/L, platelet count 921 × 109/L, CRP 90 mg/dL	Betamethasone	The child suddenly died at home. Autopsy findings: Cause of death (giant aneurysm of the RCA with subocclusive thrombosis)
Dionne et al[25], 2015	A 3-month-old infant was initially diagnosed with a urinary tract infection. Twelve days later, he presented with persistent fever, vomiting, conjunctivitis and discharged with a diagnosis of viral gastroenteritis. Being febrile for 21 days, he was admitted to the emergency due to shock. Laboratory tests: WBC 30 × 109/L, platelet count 494 × 109/L, CRP 200 mg/L, increased cardiac enzyme-troponin I 59.0 μg/L. Echocardiogram: LVEF of 14% with diffuse coronary artery dilatation	IVIG, aspirin, heparin, inotropes, recombinant tissue plasminogen activator therapy, methylprednisolone, infliximab, cyclophosphamide and anakinra	The patient died in-hospital. Cause of death: Multi-vessel obstruction and aneurysms
Argo et al[26], 2016	A 7-month-old infant, apparently well-nourished and without fever or exanthem was admitted to the emergency unit. Laboratory tests: Significantly increased platelet count (651 × 109/L), cardiac enzyme troponin-T 196 ng/mL		He died two hours after being admitted to the hospital. Autopsy findings: Cause of death (aneurysmatic and thrombotic in RCA)
Yajima et al[27], 2016	A 5-month-old male was hospitalized for suppuration at the injection site following BCG vaccination at 1.5 months of age. He presented with fever (38 °C) for 7 consecutive days, bilateral edema of the inferior limbs and polymorphous exanthemas on his thoracoabdominal regions. Laboratory tests: WBC 10.9 × 109/L, platelet count 534 × 109/L, CRP 4.78 mg/dL	Antibiotics	Four days after discharge, he refused breastfeeding and died suddenly after readmission. Autopsy findings: Cause of death myocardial infarction was due to thrombus emboli in the coronary arteries
Zhang et al[28], 2018	A 5-year-old male admitted with fever (38.5 °C) for 3 days, bilateral conjunctival congestion, erythematous lips, diffuse erythema in the face, neck, and torso, swelling and pain below the right earlobe. He was initially diagnosed with mumps and suspected scarlet fever. Laboratory tests: Procalcitonin 0.71 ng/mL, CRP 51.05 mg/mL, and interleukin 6 = 15.03 pg/mL	Ribavirin, intravenous cefixime	The patient died on day 8 after hospitalization. Autopsy findings: Cause of death (pericardial tamponade due to a rupture of inflamed aneurysm of the LAD)
Salzillo et al[29], 2025	A 6-year-old male presented with high fever and bilateral lymphadenopathy, was initially diagnosed with classic-type Hodgkin lymphoma. Two weeks later he was readmitted because of mild precordial chest pain, a rapidly progressive cardiac failure, unresponsive to inotropic support. Echocardiography: LVEF of 30%, dramatically increased cardiac enzyme-troponin and NT-pro-BNP	CPR	The child died at 24 hours after admission due to acute heart failure. Autopsy findings: A huge aneurysm filled with large organized thrombi of the RCA and left coronary artery

WBC: White blood cell; CRP: C-reactive protein; LAD: Left anterior descending coronary artery; KD: Kawasaki disease; CPR: Cardiopulmonary resuscitation; IVIG: Intravenous immunoglobulin; RCA: Right coronary artery; LCx: Left circumflex artery; LVEF: Left ventricular ejection fraction.