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Abstract

To the Editor: We read with interest the letter of Ulloa-Gutierrez et al reporting a 4-year-old boy with acute appendicitis as presenting sign of Kawasaki disease (KD). Since the publication of our study,1.Zulian F Falcini F Zancan L Martini G Secchieri S Luzzato C et al.Acute surgical abdomen as presenting manifestation of Kawasaki disease.J Pediatr. 2003; 142: 731-735Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar three more patients with acute abdominal symptoms as the presenting manifestation of KD have been referred to us for a second opinion. In Ulloa-Gutierrez's patient, as in the majority of the patients in our series, the sudden onset of fever, vomiting, and abdominal pain were the confounding features that induced the surgeons to perform laparotomy and partially delayed the diagnosis. However, in three of our patients whose diagnosis was made early, intravenous immunoglobulin treatment could not arrest the development of the abdominal complications or prevent the coronary involvement. This finding seems to confirm that the onset KD with abdominal symptoms represents the severe side of KD and the expression of a more aggressive disease. In the reported case, it would have been of some interest to obtain the histologic examination of appendix to show the presence of appendicular arteritis. Indeed it would have been useful to know if there was elevation of hepatic transaminase. In our opinion, a mild elevation of transaminases, unusual in classic appendicitis,2.Appendicitis.in: O'Neill Jr., J.A Rowe M.I Grosfeld J.L Pediatric surgery. 5th ed. Mosby, Inc, St Louis (MO)1998: 1369Google Scholar can represent a helpful variable to be considered in the differential diagnosis. Mesenteric adenitis could be a reasonable explanation for the abdominal symptoms in the reported case, but histologic examination in this case would not have helped in the differential diagnosis because the inflammatory picture is usually unspecific (personal observation). Mesenteric lymph node hyperplasia could represent the early response to an intestinal pathogen acting as trigger for the disease in these particular patients. In fact, as suggested by some authors, it is possible that in patients with acute abdominal symptoms, bacteria colonizing the small intestine mucosa may produce exotoxins acting as superantigens with subsequent Vβ2 T-cells clonal expansion.3.Yamashiro Y Nagata S Oguchi S Shimizu T Selective increase of Vβ2 T cells in small intestinal mucosa in Kawasaki disease.Pediatr Res. 1996; 39: 264-266Crossref PubMed Scopus (72) Google Scholar, 4.Yamashiro Y Nagata S Ohtsuka Y Oguchi S Shimizu T Microbiologic studies on the small intestine in Kawasaki disease.Pediatr Res. 1996; 39: 622-624Crossref PubMed Scopus (22) Google Scholar