Code STEMI! A unique case of Thrombosed coronary artery aneurysm in an adult patient with undiagnosed Kawasaki disease as a child.

Case Presentation: A 24-year-old man without significant past medical history presented to the hospital by EMS after a syncopal event at the gym while running on a treadmill. On admission, a routine syncope work-up was negative, including a normal basic metabolic panel, electrocardiogram, and telemetry monitoring. Given the patient’s unclear initial evaluation and concern for a cardiovascular etiology based on his acute and severe presentation, a formal exercise stress test was performed based on the 2017 ACC/AHA/HRS Syncope Guidelines. While in the non-invasive cardiology lab, the patient again collapsed with the electrocardiogram revealing ST elevations in the antero-septal leads. Emergent coronary angiography showed multiple thrombosed coronary artery aneurysms in the left anterior descending artery. The patient was referred to cardiothoracic surgery and underwent a single vessel CABG and had complete resolution of all symptoms.

Discussion: Kawasaki disease (also called mucocutaneous lymph node syndrome) is a vasculitis of unknown etiology that generally occurs in infancy and childhood. Coronary artery aneurysms occur as a sequela of the vasculitis in 20–25% of untreated children. This can lead to myocardial ischemia, infarction, and sudden death.Most commonly, the thrombosis of coronary aneurysms is seen in childhood, particularly in children who were not treated with IVIG after their initial diagnosed with Kawasaki’s disease. This patient denied a prior diagnosis of Kawasaki’s disease or having being treated with IVIG in the past.

A literature search was performed and did not reveal any prior case reports of adult manifestations or late cardiac complications of Kawasaki’s disease. This case will be the first reported case of an adult with Kawasaki disease related cardiac complication.

Conclusions: The diagnosis of late complications or missed pediatric diseases requires a high index of suspicion by adult hospitalists based on the patient’s history and clinical presentation. Increasingly, hospitalists are encountering traditionally pediatric diseases that are presenting with adult complications, such as PSGN, Cystic Fibrosis and, in this case, Kawasaki disease. A high clinical suspicion and a broad knowledge of pediatric diseases and their late complications will lead to early recognition and expedited diagnosis of rare and potentially fatal complications.