# 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

## TL;DR

A 3.5-year-old boy with severe Kawasaki disease and latent tuberculosis was successfully managed using a multidisciplinary approach balancing inflammation, anticoagulation, and infection control.

## Contribution

A novel, multidisciplinary framework for managing refractory Kawasaki disease with giant aneurysms and latent tuberculosis is proposed.

## Key findings

- A sequential treatment protocol using methylprednisolone and IVIG safely controlled inflammation without reactivating tuberculosis.
- Precision anticoagulation with warfarin dose escalation and LMWH bridging achieved stable INR despite rifampicin interference.
- The case demonstrates successful management of complex immune-coagulation-infection interactions in a high-risk pediatric patient.

## Abstract

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.

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.

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.