Form 0920-0009 Kawasaki Syndrome form

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333

CDC CASE#

Kawasaki Syndrome Case Report

Form Approved
OMB 0920-0009

Please fill in the blank or check the answer for each question

(1-4)

– PATIENT INFORMATION/DEMOGRAPHICS –

Residence:
City:

Patient's Initials:
(First, Middle, Last)

Age at Onset:

County: ________________ ___ ___ ___

(5-7)

1. Ethnicity: (25)

■ Not Hispanic/Latino
1 ■ Hispanic/Latino

9

0

■ Unk

(mm/dd/yyyy)

(Mo.)

(13-14)

(15-16)

State: _________________ ___ ___

(8-10)

2. Race:

Date of Birth:

(Yrs)

__ __ /__ __/__ __ __ __

(11-12)

(17-18)

■ Native Hawaiian or Other Pacific Islander
5 ■ American Indian/Alaska Native

3 ■ Asian
■ White
2 ■ Black or African American

4

1

(19-20)

3. Sex:

(26)

6
9

■ Other
■ Unk

1
2

(21-24)

(27)

■ Male 9 ■ Unk
■ Female

– CLINICAL OUTCOMES –

4. Date of Onset
of Symptoms:

__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(28-29)

7. Outcome:
1
2

5. Was the patient
hospitalized? (36)

(30-31)

0

(32-35)

■ NO

1

■ YES

9

6. If YES, number of
days hospitalized:

■ Unk

8. DOES THE PATIENT HAVE RECURRENT
KAWASAKI SYNDROME? (40)

(39)

■ Alive, no known sequelae
9 ■ Unk
■ Dead 3 ■ Alive with sequelae (specify): _______________________________

0

■ NO

1

■ YES

9

■ Unk

(37-38)

IF YES, list onset date of prior
Kawasaki Syndrome episode:
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(41-42)

(43-44)

(45-48)

– SIGNS,SYMPTOMS, AND DIAGNOSTIC CRITERIA –

9. The criteria for a case are:

1) bilateral conjunctival injection,
2) oral changes,
3) peripheral extremity changes,
4) rash,

Fever >5 days unresponsive to antibiotics, and at least four
of the five following physical findings with no other more
reasonable explanation for the observed clinical findings:

No
Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0

Yes

■

1

(52-53)

9

No

■ (49)

(54-57)

Number of days febrile: ___ ___ (58-59)
Fever >5 days . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Bilateral conjunctival injection . . . . . . . . . . . . . . . .

■
0■

■
1■

0

If the fever disappears due to intravenous gamma globulin (IVGG) therapy before the
fifth day of illness, a fever of <5 days duration fulfills fever criterion for case definition.

Unknown

■

Date of fever onset : __ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(50-51)

5) and cervical lymphadenopathy (at least one lymph node >1.5 cm in diameter).

■ (60)
9 ■ (61)

1

9

Yes

Unknown

2. Oral mucosal changes (erythema of lips or oropharynx, . .
strawberry tongue, or drying or fissuring of the lips)

0

■

1

■

9

■ (62)

3. Peripheral extremity changes (edema, erythema, . . . . . . .
or generalized or periungual desquamation)

0

■

1

■

9

■ (63)

4. Rash

0

.......................................

5. Cervical lymphadenopathy >1.5 cm diameter . . . . . . . . .

■
0■

■
1■

■ (64)
9 ■ (65)

1

9

– CARDIAC STUDIES –

10.

Check the results for each study
type (A-C), and list the number of
weeks after illness onset that the
study was done. If multiple studies
were done, report the results that
showed coronary artery aneurysm
or dilatation for the first time.

Normal
Results

Not done

Coronary
Artery
Aneurysms

Coronary
Artery
Dilatation

Other
Abnormalities

Unknown
Results

# Wks after
illness
onset

Date of first test
showing coronary artery
aneurysm or dilatation
__ __ /__ __/__ __ __ __

(mm/dd/yyyy)

A. EKG

0

■ (66)

1

■ (67)

2

■ (68)

3

■ (69)

4

■ (70)

9

■ (71)

______

B. ECHO

0

■ (82)

1

■ (83)

2

■ (84)

3

■ (85)

4

■ (86)

9

■ (87)

______

C. ANGIOGRAM

0

■ (98)

1

■ (99)

2

■ (100)

3

■ (101)

4

■ (102)

9

■ (103)

______

(72-73)

(74-75)
(90-91)

(88-89)
(104-105)

■
0■
0

■
1■
1

■ (123)
9 ■ (124)

TREATMENT:

13. WAS INTRAVENOUS GAMMA
GLOBULIN (IVGG) GIVEN? . . . . . . . . . . . . . . . .

REPORTED BY:
0

■ NO 1 ■ YES 9 ■ UNK (135)

Name:

______________________________________

Address: ______________________________________
IF YES, date of first IVGG treatment:

__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(136-137) (138-139)

IF YES, was IVGG started before the fifth day
of illness while the patient was still febrile?

0

______________________________________

(140-143)

■ NO 1 ■ YES 9 ■ UNK (144)

Phone No. (
Date:

) ____________________________

__ __ /__ __/__ __ __ __ (mm/dd/yyyy)

(92-93)

(106-107) (108-109)

Other (specify): _______________________________

9

(78-81)
(94-97)

__ __ /__ __/__ __ __ __

COMPLICATIONS Check or list whether complications were associated with this illness.
11. CARDIAC
No
Yes Unknown 12. NONCARDIAC
Specify
Coronary artery aneurysms diameter of aneurysm: ______mm 0 ■ 1 ■ 9 ■ (114)
Arthralgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other aneurysms (specify): __________________________ 0 ■ 1 ■ 9 ■ (115)
Aseptic meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Coronary artery dilatation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 ■ 1 ■ 9 ■ (116)
Gall bladder hydrops . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Aortic regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 ■ 1 ■ 9 ■ (117)
Hearing loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 ■ 1 ■ 9 ■ (118)
Hepatitis or hepatomegaly . . . . . . . . . . . . . . . . . . . . . . . .
Congestive heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 ■ 1 ■ 9 ■ (119)
Iritis or uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mitral regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 ■ 1 ■ 9 ■ (120)
Meatitis or sterile pyuria . . . . . . . . . . . . . . . . . . . . . . . . .
Myocardial infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 ■ 1 ■ 9 ■ (121)
Myalgia or myositis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Myocardial ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 ■ 1 ■ 9 ■ (122)
Myocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pericarditis or pericardial effusion . . . . . . . . . . . . . . . . . . . . . .

(76-77)

__ __ /__ __/__ __ __ __

No

■
0■
0■
0■
0■
0■
0■
0■
0■
0■
0

Yes

■
1■
1■
1■
1■
1■
1■
1■
1■
1■
1

(110-113)

Unknown

■
■
9■
9■
9■
9■
9■
9■
9■
9■
9

(125)

9

(126)
(127)
(128)
(129)
(130)
(131)
(132)
(133)
(134)

PLEASE MAIL COMPLETED FORM TO:
Kawasaki Syndrome Surveillance

Division of High-Consequence
Pathogens and Pathology
Mailstop A-30
Centers for Disease Control
and Prevention
Atlanta, GA 30333

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0009).

CDC 55.54 Rev. 06/2003

Kawasaki Syndrome Case Report