The multidisciplinary management strategy led to normalization of luminal diameters of bilateral giant coronary artery aneurysms after 9 months of treatment.
Case Report (n=1)
No
Does a multidisciplinary management strategy including alternative immunomodulation and precision anticoagulation improve outcomes in a pediatric patient with refractory Kawasaki disease, giant coronary artery aneurysms, and latent tuberculosis infection?
A multidisciplinary approach integrating alternative immunomodulation, strategic prophylaxis, and precision anticoagulation safely and effectively managed a pediatric patient with refractory Kawasaki disease, giant CAAs, and LTBI.
Background The management of refractory Kawasaki disease (KD) with giant coronary artery aneurysms (CAAs) complicated by latent tuberculosis infection (LTBI) represents a formidable “triple challenge”: it requires balancing aggressive inflammation control against the risk of tuberculosis reactivation, managing the extreme cardiovascular risk of giant CAAs driven by immune-coagulation crosstalk, and navigating the pharmacological hurdles of LTBI prophylaxis, namely rifampicin-induced warfarin resistance. Developing a safe, integrated strategy to concurrently address these inflammatory, cardiovascular, and infectious risks remains an urgent and unmet clinical need. Case presentation We report a 3.5-year-old boy with refractory KD and rapid-onset bilateral giant CAAs. Pre-biologic screening identified LTBI, strictly contraindicating guideline-recommended tumor necrosis factor-alpha (TNF-α) inhibitors. A multidisciplinary team (MDT) executed a sequential, pathophysiology-driven protocol: 1) Immunomodulation Prophylaxis: Systemic inflammation was controlled using methylprednisolone and a second IVIG dose, circumventing TNF-α blockade to ensure LTBI safety. Upon vasculitis remission and hepatic recovery, LTBI prophylaxis (isoniazid/rifampicin) was initiated. 2) Precision Anticoagulation: To overcome rifampicin-accelerated warfarin metabolism, we executed a rapid, percentage-based titration alongside a “prolonged low-molecular-weight heparin (LMWH) bridge”. A stable, conservative therapeutic INR (1.5–2.5) was achieved, requiring an exact 2.5-fold warfarin dose escalation. At the 9-month follow-up, the CAAs demonstrated luminal normalization, though necessitating lifelong surveillance for vascular pseudonormalization. Conclusion This case illustrates how an MDT-led, pharmacology-guided approach effectively resolves therapeutic conflicts in high-risk KD with biologic contraindications. By integrating alternative immunomodulation, strategic prophylaxis, and precision anticoagulation, this framework provides a practical clinical paradigm for managing intricate immune-coagulation-infection crosstalk.
Xue et al. (2026) conducted a case report in Refractory Kawasaki disease with giant coronary artery aneurysms and latent tuberculosis infection (n=1). Methylprednisolone and intravenous immunoglobulin (IVIG) followed by isoniazid/rifampicin prophylaxis and warfarin was evaluated on Normalization of luminal diameters of bilateral giant coronary artery aneurysms. The multidisciplinary management strategy led to normalization of luminal diameters of bilateral giant coronary artery aneurysms after 9 months of treatment.