ArticleFrontiers in immunology2026
Multidisciplinary management of refractory Kawasaki disease with bilateral giant coronary artery aneurysms and latent tuberculosis infection: a case report focusing on immune-coagulation-infection crosstalk.
Article in Frontiers in immunology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
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.
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