My first clinical experience with Kawasaki disease (or mucocutaneous lymph node syndrome as it was called then) was as a senior resident in 1979 alongside my consultant and mentor, Dr. Stanford T. Shulman (Editor Emeritus of Pediatric Annals). After Dr. Shulman, an international expert on Kawasaki disease, helped me establish the diagnosis, I learned that the management included aspirin therapy and, in some cases, corticosteroids. In this issue of the journal, guest editor Dr. Deirdre De Ranieri, a pediatric rheumatologist, has organized her colleagues (as well as a special appearance by Dr. Shulman) to present articles on the clinical utility of intravenous immunoglobulin (IVIG) in a variety of diseases in the pediatric patient.
When clinicians are treating patients who receive IVIG, the challenge of whether to refer them and their families to a subspecialist often surfaces. Even if the primary care clinician has extensive experience with IVIG, a knowledgeable group of nurses, pharmacists, and a skilled unit overall, it is still necessary, as detailed in the articles, to also formally consult a pediatric infectious disease specialist, an immunologist, a rheumatologist, a hematologist, a gastroenterologist, a neurologist, and even a dermatologist to provide wide-ranging care for these patients.
Each patient will also need ongoing follow-up checks to properly manage IVIG infusions that are required for chronic disease treatment. For Kawasaki disease, clinical responses to infusions must also be documented, with close attention to cardiac ultrasounds, coronary abnormalities, and aneurysm development. The long-term role of each medical provider may be defined on a case-by-case basis. I've also felt and have taught students that being actively involved in the decision-making process allows for additional learning and understanding of what is required to manage chronic disease. Having that knowledge allows everyone involved (primary care physicians and subspecialists) in the patient's care to make evidence-based clinical decisions, as well as to effectively communicate with the family.