Persistent elevation of aspartate aminotransferase in a child after incomplete Kawasaki disease: a case report and literature review

Abstract

Background Interpretation of abnormalities in liver function tests, especially in asymptomatic children, is a common problem faced by clinicians. Isolated elevation of aspartate aminotransferase may further puzzle physicians. Macro-aspartate aminotransferase (AST) results from complexes AST produces with other plasma components, such as immunoglobulin. To our knowledge, this is the first report on a case of macro-AST-associated incomplete Kawasaki disease (KD). It is to make physicians aware of this benign condition and help to prevent extensive, unnecessary investigations and invasive workups. Case presentation A 16-month old boy with a 7-day history of fever was admitted to our pediatric ward for pyrexia workup. After complete investigations, KD was confirmed by a pediatric rheumatologist. During his admission and serial follow-up tests, an isolated AST elevation was noted. Comprehensive tests were performed and using the polyethylene glycol (PEG) precipitation method, macro-AST was confirmed. The patient has been followed up for 3 years, and so far, the benign nature of this condition has been confirmed. Conclusion Clinicians should consider testing for macro-AST when elevated AST is the only abnormal lab finding. Although an uncommon finding, macro-AST may be seen in both children and adults. There are many reasons for this phenomenon, including resolved acute hepatitis or in some cases, inflammatory bowel disease, hepatic malignancy, monoclonal gammapathy, celiac disease, or KD; however, it may be observed in asymptomatic healthy children as well. Using the PEG precipitation method, a definitive diagnosis can be made. In none of these conditions does macro-AST have any prognostic significance. An appreciation of macro-AST may prevent the need for more invasive investigations to which patients may be unnecessarily subjected. It is important to recognize this condition as benign and assure patients that no specific treatment is required.

Incomplete Kawasaki Disease in a Preschooler: A Literature Review and Report

“…A diminished ability to display a febrile response may be present in some infants, further contributing to the difficulty of diagnosing KD in this age group. Salgado et al, Singh et al, and Pilania et al all expressed similar concerns 12,19,20 . We believe that the role of fever and the duration required to fulfill the criteria (especially in infants) need to be redefined in the future.…”

Persistently high serum aspartate aminotransferase level in an asymptomatic young patient

“…Almost all of the cases were diagnosed by PEG precipitation (Table 3). 2,3,[13][14][15][16][17][18][19] There are many different methods for detecting macro-AST, including GFC, UF, PEG precipitation test, and stored refrigeration at 4°C. 3,6 The final diagnosis of macro-AST was confirmed by the PEG precipitation test.…”

Atypically Protracted Course of Liver Involvement in Kawasaki Disease. Case Report and Literature Review

“…In spite of these premises, it is worth of note that ASA frequency of use and doses (ranging 10–30 mg/kg/day) are reported having been not significantly different in 381 KD patients (mean age 25.3 months) divided in three groups allocated into children with ALT level ≥40 IU/L on admission, ≥40 IU/L at some point after admission, or ALT levels consistently <40 IU/L throughout hospitalization [ 9 ]. Still, these authors considered an arbitrary upper normal value of transaminases, which is not appropriate during the first year of life.…”