DEPARTMENT OF HEALTH & HUMAN SERVICES. Centers for Disease Control
and Prevention (CDC). Atlanta, Georgia 30333. Kawasaki Syndrome Case ...
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333
CDC CASE#
Kawasaki Syndrome Case Report Form Approved Please fill in the blank or check the answer for each question Reset Section 1-8 Radio Buttons OMB 0920-0009
(1-4)
– PATIENT INFORMATION/DEMOGRAPHICS –
Residence: City:
Patient's Initials: (First, Middle, Last)
Age at Onset:
(8-10)
2. Race:
1. Ethnicity: (25)
■ Not Hispanic/Latino 1 ■Hispanic/Latino
0
9
(13-14)
(15-16)
(mm/dd/yyyy)
__ __ __ ____ __ __ __
(11-12)
(17-24)
3. Sex:
(26)
3 ■ Asian ■ White 2 ■ Black or African American
Unk
(Mo.)
State: _________________ ___ ___
County: ________________ ___ ___ ___
(5-7)
Date of Birth:
(Yrs)
Native Hawaiian or Other Pacific Islander
4
1
5
6
■ American Indian/Alaska Native
■ Other Unk
9
(27)
1
Male
2
■ Female
9
■ Unk
– CLINICAL OUTCOMES –
4. Date of Onset of Symptoms:
5. Was the patient hospitalized? (36)
__ __ __ ____ __ __ __ (mm/dd/yyyy)
0
(28--35)
7. Outcome: 1 2
3
Unk
9
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
■ Dead
■ NO
■ Alive with sequelae (specify): _______________________________
NO
0
1
YES
9
(37-38)
IF YES, list onset date of prior Kawasaki Syndrome episode:
■ Unk
__ __ __ ____ __ __ __ (mm/dd/yyyy) (41-48)
– SIGNS, SYMPTOMS, AND DIAGNOSTIC CRITERIA –
9. The criteria for a case are: 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:
1) bilateral conjunctival injection, 2) oral changes, 3) peripheral extremity changes, 4) rash,
No
Reset Section 9 Radio Buttons
Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
Yes
■
9
No
(49)
Date of fever onset : __ __ __ ____ __ __ __ (mm/dd/yyyy) (50-57)
Number of days febrile: ___ ___ (58-59) 0
1
1. Bilateral conjunctival injection . . . . . . . . . . . . . . . .
0
1
If the fever disappears due to intravenous gamma globulin (IVGG) therapy before the fifth day of illness, a fever of 5 days . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5) and cervical lymphadenopathy (at least one lymph node >1.5 cm in diameter).
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)
9
(60)
4. Rash
.......................................
0
1
9
(64)
9
(61)
5. Cervical lymphadenopathy >1.5 cm diameter . . . . . . . . .
0
1
9
(65)
– 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)
______ (72-73)
(74-81)
B. ECHO
0
(82)
1
(83)
2
(84)
3
(85)
4
(86)
9
(87)
______
__ __ __ ____ __ __ __
(88-89)
(90-97)
C. ANGIOGRAM
0
(98)
1
(99)
2
(100)
3
(101)
4
(102)
9
(103)
______
__ __ __ ____ __ __ __
(104-105)
(106-113)
COMPLICATIONS Check or list whether complications were associated with this illness. Reset Section 11-13 Radio Buttons 11. CARDIAC No Yes Unknown 12. NONCARDIAC Specify (114) Coronary artery aneurysms diameter of aneurysm: ______mm 0 1 9 Arthralgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (115) Other aneurysms (specify): __________________________ 0 1 9 Aseptic meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (116) Coronary artery dilatation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 9 Gall bladder hydrops . . . . . . . . . . . . . . . . . . . . . . . . . . . . (117) Aortic regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 9 Hearing loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (118) Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 9 Hepatitis or hepatomegaly . . . . . . . . . . . . . . . . . . . . . . . . (119) Congestive heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 9 Iritis or uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (120) Mitral regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 9 Meatitis or sterile pyuria . . . . . . . . . . . . . . . . . . . . . . . . . (121) Myocardial infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 9 Myalgia or myositis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (122) Myocardial ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 9 Myocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pericarditis or pericardial effusion . . . . . . . . . . . . . . . . . . . . . .
0
1
9
(123)
0
1
9
(124)
TREATMENT:
13. WAS INTRAVENOUS GAMMA GLOBULIN (IVGG) GIVEN? . . . . . . . . . . . . . . . .
Other (specify): _______________________________ REPORTED BY:
■ NO 1 ■ YES 9 ■ UNK (135)
0
Name:
__ __ __ ____ __ __ __ (mm/dd/yyyy)
______________________________________
______________________________________
(136-1 143)
IF YES, was IVGG started before the fifth day of illness while the patient was still febrile?
0
■ NO 1 ■ YES 9 ■ UNK (144)
Phone No.____________________________ Date:
Yes
Unknown
1
9
(125)
0
1
9
(126)
0
1
9
(127)
0
1
9
(128)
0
1
9
(129)
0
1
9
(130)
0
1
9
(131)
0
1
9
(132)
0
1
9
(133)
0
1
9
(134)
PLEASE MAIL COMPLETED FORM TO:
Address: ______________________________________ IF YES, date of first IVGG treatment:
No 0
__ __ __ ____ __ __ __ (mm/dd/yyyy)
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 (E), June 2003 (CDC Adobe Acrobat 9.4, S508 Electronic Version, October 2011)
Kawasaki Syndrome Case Report
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