LAUSR

I appreciate the letter to the Editor from Yamazaki-Nakashimada et al. concerning our report. First, we thank YamazakiNakashimada et al. for highlighting our mistake. Our report was not the first report on afebrile Kawasaki disease (KD). We would like to express our sincere apologies to Pediatrics International and its readers for this oversight. As Yamazaki-Nakashimada et al. indicated, there were five previous articles on afebrile KD (Table 1). Four of the five patients had coronary artery (CA) dilatations. Of these four patients, and our patients who had CA dilatation, four of the six were ≤7 months of age. Five of the six patients were male. These five previous reports were in English, and were retrievable using PubMed. Although there were a few other articles on afebrile KD, they were not available on Pubmed or were not in English, and only one patient had CA dilatation. Because the diagnosis of KD is based on clinical symptoms, the diagnosis of KD in patients without CA dilatation is more difficult than that in those with CA dilatation. KD cannot be diagnosed definitively if the patient does not have both fever and CA dilatation. In contrast, if the patient has CA dilatation but does not have fever, we must include the following six diseases in the differential diagnosis, as described in our article: KD, chronic active Epstein–Barr virus infection, Yersinia pseudotuberculosis infection, systemic juvenile idiopathic arthritis, Takayasu disease, and juvenile polyarteritis nodosa. Regrettably, the five previously published articles did not describe this diagnostic process. Moreover, only Hinze et al. reported the method of body temperature (BT) measurement. Furthermore, if there was a description, it was reported only as “axillary”. Because there is a report that described axillary BT measurement in KD is not so accurate, we measured BT carefully and frequently, to confirm that our patients were afebrile. Nevertheless, I believe that most of the previously reported patients must have had KD. I also believe that there must be more undiagnosed patients who have KD without fever. This may include some cases of sudden death in infancy. As Yamazaki-Nakashimada et al. noted in their letter, we must educate pediatricians about the existence of incomplete afebrile KD and accumulate data to facilitate accurate diagnosis.