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��ࡱ�>��	wz����v��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	��ybjbj$$	4�F|F|�o�����������)))����====��$=�" ������&&&R"T"T"T"T"T"T"$%��'>x"-)�"&��x"����s�"����H�8�)�h ���R"�������� Y����=��T �"0�"��'���'��')��&(����t<&&&x"x"�&&&�"�������������������������������������������������������������������������'&&&&&&&&&�	�:	Whether echocardiographic detection of 
small pericardial effusion
 is supporting in diagnosing Kawasaki Disease 






Yuthapong Budharaksa, M.D.

Pongsak Khowsathit, M.D.
Alisa Limsuwan, M.D.

Division of Pediatric Cardiology
Ramathibodi Hospital, Mahidol University
Bangkok, Thailand


Correspondence and reprint requests: Alisa Limsuwan, MD,
Division of Pediatric Cardiology, Ramathibodi Hospital, Rama VI Road, Bangkok 10400, Thailand
Tet+662 201 1685, Fax + 662 201 1850
E-mail:alimsuwan@yahoo.com





Abstract
In pediatric patients, small pericardial effusion commonly occurs in various conditions. This finding has been used as a supplemental criterion for Kawasaki disease (KD) diagnosis. We investigate whether the detection of small pericardial effusion has limited value in diagnosis of KD.�Method: A prospective echocardiogram study was performed in two groups young children, specifically children in Group 1 were recruited from the well child clinic while Group 2 was KD patients. The echocardiogram was obtained to define pericardial effusion during systole and diastole.� �Result: Eighty-seven children (mean age�2.2 years, male: 63%) were enrolled in this study. Group 1 comprised 64 children, 24 children had a mild upper respiratory tract infection (URI).While 23 children were in Group 2, 11 of them had incomplete KD. Pericardial effusion detected during systole was visualized in 40.6 % of Group 1 and 43.5% of Group 2 (p=0.81). In Group 1, 66.7% of children with URI were found to have pericardial effusion during systole compared to 25% in the normal healthy children (p=0.001). The rate of detected small pericardial effusion during systole in URI children was similar to KD group (63.6%, p=1.00).�In contrary, the detection of pericardial effusion throughout cardiac cycle including diastolic phase was found only in 13% of Group 2 whereas none in Group 1 (p =0.02). Conclusion: �Defining small pericardial effusion only during systole is quite accustomed among young children. The pericardial effusion detected during diastole is quite uncommon but is a more explicit finding in children with KD.�
Keywords: pericardial effusion, Kawasaki disease, children, respiratory tract infection, echocardiogram


Kawasaki disease is systemic vasculitis with prominent cardiovascular manifestation. During the acute phase, the pericardium, myocardium, endocardium, valves and coronary arteries all may be involved. Since the introduction of the latest American Heart Association (AHA) guideline for KD diagnosis algorithm, the prevalence of KD�s diagnosis is amplified ADDIN EN.CITE <EndNote><Cite><Author>Newburger</Author><Year>2004</Year><RecNum>1</RecNum><record><rec-number>1</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Newburger, J. W.</author><author>Takahashi, M.</author><author>Gerber, M. A.</author><author>Gewitz, M. H.</author><author>Tani, L. Y.</author><author>Burns, J. C.</author><author>Shulman, S. T.</author><author>Bolger, A. F.</author><author>Ferrieri, P.</author><author>Baltimore, R. S.</author><author>Wilson, W. R.</author><author>Baddour, L. M.</author><author>Levison, M. E.</author><author>Pallasch, T. J.</author><author>Falace, D. A.</author><author>Taubert, K. A.</author></authors></contributors><titles><title>Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association</title><secondary-title>Pediatrics</secondary-title></titles><pages>1708-33</pages><volume>114</volume><number>6</number><keywords><keyword>Algorithms</keyword><keyword>Anti-Inflammatory Agents, Non-Steroidal/therapeutic use</keyword><keyword>Aspirin/therapeutic use</keyword><keyword>Child</keyword><keyword>Coronary Aneurysm/etiology/ultrasonography</keyword><keyword>Coronary Angiography</keyword><keyword>Coronary Thrombosis/drug therapy/etiology/prevention &amp; control</keyword><keyword>Echocardiography</keyword><keyword>Fever/etiology</keyword><keyword>Heart Diseases/diagnosis/etiology/prevention &amp; control</keyword><keyword>Humans</keyword><keyword>Immunoglobulins, Intravenous/therapeutic use</keyword><keyword>Mucocutaneous Lymph Node Syndrome/*diagnosis/*drug therapy/etiology</keyword><keyword>Risk Assessment</keyword><keyword>Steroids/therapeutic use</keyword></keywords><dates><year>2004</year><pub-dates><date>Dec</date></pub-dates></dates><accession-num>15574639</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=15574639 </url></related-urls></urls></record></Cite></EndNote>(1). In this algorithm, the use of laboratory and echocardiographic findings as supplemental criteria are contributed to the increased rate of KD diagnosis, predominantly in children with absence of complete clinical signs. Pericardial effusion is considered to be an echocardiographic feather of KD due to possible reflection of the inflammatory pericardium ADDIN EN.CITE <EndNote><Cite><Author>Newburger</Author><Year>2004</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Newburger, J. W.</author><author>Takahashi, M.</author><author>Gerber, M. A.</author><author>Gewitz, M. H.</author><author>Tani, L. Y.</author><author>Burns, J. C.</author><author>Shulman, S. T.</author><author>Bolger, A. F.</author><author>Ferrieri, P.</author><author>Baltimore, R. S.</author><author>Wilson, W. R.</author><author>Baddour, L. M.</author><author>Levison, M. E.</author><author>Pallasch, T. J.</author><author>Falace, D. A.</author><author>Taubert, K. A.</author></authors></contributors><titles><title>Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association</title><secondary-title>Circulation</secondary-title></titles><pages>2747-71</pages><volume>110</volume><number>17</number><keywords><keyword>Algorithms</keyword><keyword>Anti-Inflammatory Agents, Non-Steroidal/therapeutic use</keyword><keyword>Aspirin/therapeutic use</keyword><keyword>Child</keyword><keyword>Coronary Aneurysm/etiology/ultrasonography</keyword><keyword>Coronary Angiography</keyword><keyword>Coronary Thrombosis/drug therapy/etiology/prevention &amp; control</keyword><keyword>Echocardiography</keyword><keyword>Fever/etiology</keyword><keyword>Heart Diseases/diagnosis/etiology/prevention &amp; control</keyword><keyword>Humans</keyword><keyword>Immunoglobulins, Intravenous/therapeutic use</keyword><keyword>Mucocutaneous Lymph Node Syndrome/*diagnosis/*drug therapy/etiology</keyword><keyword>Risk Assessment</keyword><keyword>Steroids/therapeutic use</keyword></keywords><dates><year>2004</year><pub-dates><date>Oct 26</date></pub-dates></dates><accession-num>15505111</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=15505111 </url></related-urls></urls></record></Cite></EndNote>(2). Nevertheless,  small  pericardial effusion can be visualized and detected by echocardiogram in various conditions, including the normal amount of pericardial fluid as small as 15 ml in adults  ADDIN EN.CITE <EndNote><Cite><Author>Jacobs</Author><Year>1978</Year><RecNum>3</RecNum><record><rec-number>3</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jacobs, W. R.</author><author>Talano, J. V.</author><author>Loeb, H. S.</author></authors></contributors><titles><title>Echocardiographic interpretation of pericardial effusion</title><secondary-title>Arch Intern Med</secondary-title></titles><pages>622-5</pages><volume>138</volume><number>4</number><keywords><keyword>*Echocardiography</keyword><keyword>Humans</keyword><keyword>Pericardial Effusion/*diagnosis</keyword></keywords><dates><year>1978</year><pub-dates><date>Apr</date></pub-dates></dates><accession-num>637645</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=637645 </url></related-urls></urls></record></Cite></EndNote>(3). Therefore, we conducted this study to evaluate whether the use of echocardiographic detection of small pericardial effusion may have some limitation in assisting diagnosis of incomplete KD. Our primary objective of this study was to determine the usefulness of pericardial effusion in distinguishing children with KD from the control group. Our secondary objective was to characterize the echocardiographic pericardial effusion in children with KD.
Methods
We conducted a prospective cohort study to evaluate echocardiographic finding of pericardial effusion in children 5 years of age or under with KD and control group from January to December 2008. The protocol was approved by the Institutional Ethics Committee; written informed consent was obtained by their legal guardians. 
Population
 	The control group or Group 1 comprised 64 children with 40 being healthy and 24 having afebrile upper respiratory tract infection (URI). Twenty-three children were diagnosed with KD and admitted to our hospital. Each patient met the established criteria for KD or incomplete KD (partial clinical criteria with the presence of coronary abnormality detected by echocardiogram). In this KD group or Group 2, twelve patients were diagnosed with complete KD whereas 11 patients incomplete KD. Each was treated with intravenous immunoglobulin and high dose aspirin. 
After enrollment, history and physical examination including body weight, height and blood pressure were measured in all individuals.
Ultrasound studies
Echocardiogram was performed in all cases with a Phillips iE33 device equipped with 8 and 12 MHz linear array probe. Standard echocardiogram for structural and function was obtained prior to the evaluation of pericardial effusion. Conventional techniques were used to delineate the epicardial and pericardial reflection in parasternal long and short axis, apical 4 chamber, subcostal long and short axis views. The existing of small pericardial effusion was defined as the presence of an echolucent posterior pericardial space during 5 cardiac cycles including systole and diastole phase  ADDIN EN.CITE <EndNote><Cite><Author>Horowitz</Author><Year>1974</Year><RecNum>4</RecNum><record><rec-number>4</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Horowitz, M. S.</author><author>Schultz, C. S.</author><author>Stinson, E. B.</author><author>Harrison, D. C.</author><author>Popp, R. L.</author></authors></contributors><titles><title>Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion</title><secondary-title>Circulation</secondary-title></titles><pages>239-47</pages><volume>50</volume><number>2</number><keywords><keyword>*Echocardiography</keyword><keyword>Humans</keyword><keyword>Pericardial Effusion/*diagnosis</keyword></keywords><dates><year>1974</year><pub-dates><date>Aug</date></pub-dates></dates><accession-num>4846631</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=4846631 </url></related-urls></urls></record></Cite></EndNote>(4).
The M-mode echocardiogram was obtained in parasternal short axis view providing nonmoving chest wall to posterior pericardium. Pericardial effusion was defined as the echo-free space between the epicardium and pericardium. The effusion size was defined as the maximum perpendicular distance between the epicardial and the pericardial at papillary muscle level during 5 cardiac cycles including systole and diastole phase  ADDIN EN.CITE <EndNote><Cite><Author>Horowitz</Author><Year>1974</Year><RecNum>4</RecNum><record><rec-number>4</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Horowitz, M. S.</author><author>Schultz, C. S.</author><author>Stinson, E. B.</author><author>Harrison, D. C.</author><author>Popp, R. L.</author></authors></contributors><titles><title>Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion</title><secondary-title>Circulation</secondary-title></titles><pages>239-47</pages><volume>50</volume><number>2</number><keywords><keyword>*Echocardiography</keyword><keyword>Humans</keyword><keyword>Pericardial Effusion/*diagnosis</keyword></keywords><dates><year>1974</year><pub-dates><date>Aug</date></pub-dates></dates><accession-num>4846631</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=4846631 </url></related-urls></urls></record></Cite></EndNote>(4).
Statistics
Data are presented as mean �SD.  The difference in variables between 2 groups of patients and controls were compared using Student�s t test and Pearson correlation test where appropriate. A P-value of < 0.05 was considered statistically significant. All statistical analyses were performed using the Statistical Package for the Social Sciences version 12 (SPSS Inc., Chicago, IL, USA).


Results
Baselines demographic of 87 children (55 boys) enrolled in the study with the mean age 26.4�18.6 months were presented in Table 1. Twenty-three children diagnosed with Kawasaki disease (Group 2) were predominantly male (19 of 23 children) and heavier with larger body surface area in comparison with the control (Group 1) (p<0.05).  
 Pericardial effusion detected by echocardiogram during only systole was visualized in both group of children particularly 40.6 % of Group 1 and 43.5% of Group 2 (p=0.81). In contrast the detection of pericardial effusion throughout cardiac cycle including �diastole� was found in 13% of KD whereas none in Group 1 (p =0.02). Therefore identification of pericardial effusion in �diastole� usually reflects pericardial effusion detected throughout cardiac cycle.
Among children being diagnosed with KD, the visualization of diastolic pericardial effusion had no statistic significant difference between complete KD (CKD) and incomplete KD (IKD). 
In control group, 66.7% of children with URI were found to have pericardial effusion during only systole compared to 25% in the normal healthy children (p=0.001). Whereas the incident of pericardial effusion during systole in children with URI was similar between the group of children with CKD group (66.7% versus 63.6%, p=1.00).� While the detection of diastolic pericardial effusion is unique in KD since these finding is not detected in non-KD neither the children with URI nor healthy youngsters (Table 2).
Discussion
The echocardiogram remains the leading tool to evaluate the pericardial effusion. In the presence of small pericardial effusion, separation of the epicardial and pericardial echo-reflection detected posterior to the left ventricle by M-mode may occur only in systole. With an increased amount of pericardial fluid, the detection of pericardial effusion could also be visualized in diastolic phase. Therefore detection of pericardial effusion usually indicated the persistence of pericardial fluid throughout cardiac cycle. In adult study, more than 15 ml of pericardial fluid was always found when a posterior echo-free space persisted throughout the cardiac cycle or diastolic pericardial effusion  ADDIN EN.CITE <EndNote><Cite><Author>Horowitz</Author><Year>1974</Year><RecNum>4</RecNum><record><rec-number>4</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Horowitz, M. S.</author><author>Schultz, C. S.</author><author>Stinson, E. B.</author><author>Harrison, D. C.</author><author>Popp, R. L.</author></authors></contributors><titles><title>Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion</title><secondary-title>Circulation</secondary-title></titles><pages>239-47</pages><volume>50</volume><number>2</number><keywords><keyword>*Echocardiography</keyword><keyword>Humans</keyword><keyword>Pericardial Effusion/*diagnosis</keyword></keywords><dates><year>1974</year><pub-dates><date>Aug</date></pub-dates></dates><accession-num>4846631</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=4846631 </url></related-urls></urls></record></Cite></EndNote>(4). However, little is known regarding the echocardiographic detection of small pericardial effusion in pediatric population which is considered to have less pericardial fluid than the adult  ADDIN EN.CITE <EndNote><Cite><Author>Holt</Author><Year>1970</Year><RecNum>5</RecNum><record><rec-number>5</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Holt, J. P.</author></authors></contributors><titles><title>The normal pericardium</title><secondary-title>Am J Cardiol</secondary-title></titles><pages>455-65</pages><volume>26</volume><number>5</number><keywords><keyword>Amphibians</keyword><keyword>Animals</keyword><keyword>Atrial Function</keyword><keyword>Blood Pressure</keyword><keyword>Cattle</keyword><keyword>Dogs</keyword><keyword>Elasticity</keyword><keyword>Fishes</keyword><keyword>Haplorhini</keyword><keyword>Horses</keyword><keyword>Humans</keyword><keyword>Mammals</keyword><keyword>Organ Size</keyword><keyword>Pericardial Effusion</keyword><keyword>*Pericardium/anatomy &amp; histology/blood supply/innervation/physiology</keyword><keyword>Pressure</keyword><keyword>Rabbits</keyword><keyword>Sheep</keyword><keyword>Swine</keyword><keyword>Ventricular Function</keyword></keywords><dates><year>1970</year><pub-dates><date>Nov</date></pub-dates></dates><accession-num>4991283</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=4991283 </url></related-urls></urls></record></Cite></EndNote>(5).
In our study, we demonstrated the detection of small pericardial effusion by echocardiogram in a one fourth of the normal asymptomatic healthy children during cardiac systole. The detection of systolic pericardial effusion is much more common occurrence in children with URI (66.7%) and KD (63.6%). The possible explanation of pericardial effusion visualized by echocardiogram in children with viral URI is an increase of the normal physiologic pericardial fluid due to pericardial reaction or subclinical pericarditis ADDIN EN.CITE <EndNote><Cite><Author>Imazio</Author><Year>2008</Year><RecNum>7</RecNum><record><rec-number>7</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Imazio, M.</author><author>Trinchero, R.</author></authors></contributors><auth-address>Cardiology Department, Maria Vittoria Hospital, Via Cibrario 72, 10141 Torino, Italy. massimo_imazio@yahoo.it</auth-address><titles><title>Myopericarditis: Etiology, management, and prognosis</title><secondary-title>Int J Cardiol</secondary-title></titles><periodical><full-title>Int J Cardiol</full-title></periodical><pages>17-26</pages><volume>127</volume><number>1</number><keywords><keyword>Acute Disease</keyword><keyword>Anti-Inflammatory Agents, Non-Steroidal/therapeutic use</keyword><keyword>Echocardiography</keyword><keyword>Electrocardiography</keyword><keyword>Humans</keyword><keyword>Ibuprofen/therapeutic use</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Myocarditis/diagnosis/*drug therapy/*etiology</keyword><keyword>Pericarditis/diagnosis/*drug therapy/*etiology</keyword><keyword>Prognosis</keyword></keywords><dates><year>2008</year><pub-dates><date>Jun 23</date></pub-dates></dates><accession-num>18221804</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18221804 </url></related-urls></urls></record></Cite></EndNote>(6). This finding of the small pericardial effusion visualized by echocardiogram usually has no clinical implication in terms of having an impact either on hemodynamic status or cardiac function.
In KD, clinical signs and finding are the fundamental criteria for diagnosis. The supplemental criteria were used in assisting the diagnosis of young children with the incomplete clinical criteria. The echocardiographic finding was considered positive when the right coronary artery (RCA) or the left anterior descending coronary artery (LAD) s diameter z-score wase"2.5 or the coronary arteries met the Japanese Ministry of Health criteria for aneurysm. Pericardial effusion finding is also considered to be a minor supplemental criteria is assisting in KD diagnosis since it is needed in at least 2 other positive features, including perivascular brightness, lack of tapering, decreased left ventricular function, mitral regurgitation, or the z-score for diameter of LAD or RCA of 2.0 to 2.5 ADDIN EN.CITE <EndNote><Cite><Author>Newburger</Author><Year>2004</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Newburger, J. W.</author><author>Takahashi, M.</author><author>Gerber, M. A.</author><author>Gewitz, M. H.</author><author>Tani, L. Y.</author><author>Burns, J. C.</author><author>Shulman, S. T.</author><author>Bolger, A. F.</author><author>Ferrieri, P.</author><author>Baltimore, R. S.</author><author>Wilson, W. R.</author><author>Baddour, L. M.</author><author>Levison, M. E.</author><author>Pallasch, T. J.</author><author>Falace, D. A.</author><author>Taubert, K. A.</author></authors></contributors><titles><title>Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association</title><secondary-title>Circulation</secondary-title></titles><pages>2747-71</pages><volume>110</volume><number>17</number><keywords><keyword>Algorithms</keyword><keyword>Anti-Inflammatory Agents, Non-Steroidal/therapeutic use</keyword><keyword>Aspirin/therapeutic use</keyword><keyword>Child</keyword><keyword>Coronary Aneurysm/etiology/ultrasonography</keyword><keyword>Coronary Angiography</keyword><keyword>Coronary Thrombosis/drug therapy/etiology/prevention &amp; control</keyword><keyword>Echocardiography</keyword><keyword>Fever/etiology</keyword><keyword>Heart Diseases/diagnosis/etiology/prevention &amp; control</keyword><keyword>Humans</keyword><keyword>Immunoglobulins, Intravenous/therapeutic use</keyword><keyword>Mucocutaneous Lymph Node Syndrome/*diagnosis/*drug therapy/etiology</keyword><keyword>Risk Assessment</keyword><keyword>Steroids/therapeutic use</keyword></keywords><dates><year>2004</year><pub-dates><date>Oct 26</date></pub-dates></dates><accession-num>15505111</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=15505111 </url></related-urls></urls></record></Cite></EndNote>(2). 
Previous report indicated approximately one third of KD patients were found to have pericardial effusion during acute phase ADDIN EN.CITE <EndNote><Cite><Year>1987</Year><RecNum>6</RecNum><record><rec-number>6</rec-number><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Guidelines for treatment and management of cardiovascular sequelae in Kawasaki disease. Subcommittee of Cardiovascular Sequelae, Subcommittee of Surgical Treatment, Kawasaki Disease Research Committee</title><secondary-title>Heart Vessels</secondary-title></titles><pages>50-4</pages><volume>3</volume><number>1</number><keywords><keyword>Aneurysm/etiology/therapy</keyword><keyword>Cardiovascular Diseases/*etiology/surgery/therapy</keyword><keyword>Coronary Aneurysm/etiology/therapy</keyword><keyword>Coronary Disease/etiology/therapy</keyword><keyword>Heart Valve Diseases/etiology/therapy</keyword><keyword>Humans</keyword><keyword>Mucocutaneous Lymph Node Syndrome/*complications</keyword><keyword>Myocardial Infarction/etiology/therapy</keyword><keyword>Myocarditis/etiology/therapy</keyword><keyword>Pericarditis/etiology/therapy</keyword></keywords><dates><year>1987</year></dates><accession-num>3624163</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3624163 </url></related-urls></urls></record></Cite></EndNote>(7). In our study demonstrated that one fourth of the normal asymptomatic healthy children in contrary to almost two third of children with common cold and KD were found to have small pericardial effusion during systole. Therefore our finding suggested that echocardiographic detection of only �systolic� pericardial effusion is not a pathognomonic finding in KD. 
Since the introduction of the AHA guideline for KD diagnosis algorithm, detection of small pericardial effusion could be used as a supplemental criterion for incomplete KD diagnosis. Therefore, it is important to define the characteristic of pericardial effusion in patients with KD in comparison with the other common illness in children to prevent the overuse of echocardiogram criteria to over diagnosed KD.
Our finding of small pericardial effusion visualized throughout cardiac cycle particularly in diastolic phase could only be identified in KD group. Therefore we would like to emphasize that small pericardial effusion detected by echocardiogram throughout cardiac cycle including diastolic phase is considered to be pathological pericardial fluid. The echocardiogram screening in children suspected of KD should be scanned both in M-mode and 2-D echocardiogram. The report of pericardial effusion detection should be specified cardiac cycle timing.
There are several limitations in our study. Firstly, the small number of young children participated in this study which has the impact on the power of statistical analysis between the groups of young children. Secondly, the quantitative amount of pericardial effusion could not be obtained due to technical difficulty since the young participants are barely cooperated with the examination. The accurate quantification of pericardial effusion in children could possibly be obtained if the children cooperated with the examination. Sedation is an option but we considered unjustifiable given their young ages. 
 Conclusion 
Defining small amount of the pericardial effusion during systole is quite common in young children. This systole pericardial effusion is similarly detected in healthy young children with URI and KD. Therefore, detection of systolic pericardial effusion should not be used as a criterion in diagnosing IKD. In contrast, visualization of diastolic pericardial effusion is quite a distinctive pathological finding in children with KD.












Reference
 ADDIN EN.REFLIST 1.	Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, et al. (2004) Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Pediatrics. 114(6):1708-33.
2.	Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, et al. (2004) Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 110(17):2747-71.
3.	Jacobs WR, Talano JV, Loeb HS.(1978) Echocardiographic interpretation of pericardial effusion. Arch Intern Med. 138(4):622-5.
4.	Horowitz MS, Schultz CS, Stinson EB, Harrison DC, Popp RL. (1974) Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation. 50(2):239-47.
5.	Holt JP. (1970) The normal pericardium. Am J Cardiol.26(5):455-65.
6.	Imazio M, Trinchero R.(2008)  Myopericarditis: Etiology, management, and prognosis. Int J Cardiol.  23;127(1):17-26.
7.	(1987) Guidelines for treatment and management of cardiovascular sequelae in Kawasaki disease. Subcommittee of Cardiovascular Sequelae, Subcommittee of Surgical Treatment, Kawasaki Disease Research Committee. Heart Vessels.3(1):50-4. 



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