3-year-old girl • fever • cervical lymphadenopathy • leukocytosis • Dx?

,; ,

doi:doi: 10.12788/jfp.0352

Case Reports

3-year-old girl • fever • cervical lymphadenopathy • leukocytosis • Dx?

J Fam Pract. 2022 March;71(2):88-90 | doi: 10.12788/jfp.0352

PDF Download

References

1. McCrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a scientific statement for health professionals from the American Heart Association. Circulation. 2017;135:e927-e999. doi: 10.1161/CIR.0000000000000484

2. Holman RC, Belay ED, Christensen KY, et al. Hospitalizations for Kawasaki syndrome among children in the United States, 1997-2007. Pediatr Infect Dis. 2010;29:483-488. doi: 10.1097/INF.0b013e3181cf8705

3. Tashiro N, Matsubara T, Uchida M, et al. Ultrasonographic evaluation of cervical lymph nodes in Kawasaki disease. Pediatrics. 2002;109:e77. doi: 10.1542/peds.109.5.e77

4. Chen CJ, Huang FC, Taio MM, et al. Sonographic gallbladder abnormality is associated with intravenous immunoglobulin resistance in Kawasaki disease. Scientific World J. 2012;2012:485758. doi: 10.1100/2012/485758

5. Dominguez SR, Anderson MS, El-Adawy M, et al. Preventing coronary artery abnormalities: a need for earlier diagnosis and treatment of Kawasaki disease. Pediatr Infect Dis J. 2012;31:1217-1220. doi: 10.1097/INF.0b013e318266bcf9

6. Kuo HC. Preventing coronary artery lesions in Kawasaki disease. Biomed J. 2017;40:141-146. doi: 10.1016/j.bj.2017.04.002

7. Chen S, Dong Y, Yin Y, et al. Intravenous immunoglobulin plus corticosteroid to prevent coronary artery abnormalities in Kawasaki disease: a meta-analysis. Heart. 2013;99:76-82. doi: 10.1136/heartjnl-2012-302126

8. Chantasiriwan N, Silvilairat S, Makonkawkeyoon K, et al. Predictors of intravenous immunoglobulin resistance and coronary artery aneurysm in patients with Kawasaki disease, Paediatr Int Child Health. 2018;38:209-212. doi: 10.1080/20469047.2018.1471381

9. Son MBF, Gauvreau K, Tremoulet AH, et al. Risk model development and validation for prediction of coronary artery aneurysms in Kawasaki disease in a North American population. J Am Heart Assoc. 2019;8:e011319. doi: 10.1161/JAHA.118.011319

10. de La Harpe M, di Bernardo S, Hofer M, et al. Thirty years of Kawasaki disease: a single-center study at the University Hospital of Lausanne. Front Pediatr. 2019;7:11. doi: 10.3389/fped.2019.00011

11. Newburger JW, Takahashi M, Gerber MA, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 2004;110:2747-2771. doi: 10.1161/01.CIR.0000145143.19711.78

Laboratory findings suggesting Kawasaki disease include a WBC count ≥ 15,000/mcL, normocytic, normochromic anemia, platelets ≥ 450,000/mcL after 7 days of illness, sterile pyuria (≥ 10 WBCs/high-power field), serum alanine aminotransferase level > 50 U/L, and serum albumin ≤ 3 g/dL.

Cardiac abnormalities are not included in the diagnostic criteria for Kawasaki disease but provide evidence in cases of incomplete Kawasaki disease if ≥ 4 criteria are not met and there is strong clinical suspicion.¹ Incomplete Kawasaki disease should be considered in a patient with a CRP level ≥ 3 mg/dL and/or ESR ≥ 40 mm/h, ≥ 3 supplemental laboratory criteria, or a positive echocardiogram.¹

Ultrasound imaging may reveal cervical lymph nodes resembling a “cluster of grapes.”³ The case patient’s imaging showed a “chain of enlarged lymph nodes.” She likely had gallbladder “hydrops” due to its increased longitudinal and horizontal diameter and lack of other anatomic changes.⁴

Prompt treatment is essential

Treatment for complete and incomplete Kawasaki disease is a single high dose of intravenous immunoglobulin (IVIG) along with aspirin. Patients meeting criteria should be treated as soon as the diagnosis is established.⁵ A single high dose of IVIG (2 g/kg), administered over 10 to 12 hours, should be initiated within 5 to 10 days of disease onset. Administering IVIG in the acute phase of Kawasaki disease reduces the prevalence of coronary artery abnormalities.⁶ Corticosteroids may be used as adjunctive therapy for patients with high risk of IVIG resistance.^1,7-9

Our patient was not deemed to be at high risk for IVIG resistance (Non-Japanese patient, age at fever onset > 6 months, absence of coronary artery aneurysm⁹) and was administered IVIG on Day 4. She was also given moderate-dose aspirin, then later transitioned to low-dose aspirin. The patient’s fevers improved, she was less irritable, and she had periods of playfulness. Physical exam then showed erythematous and cracked lips with peeling skin.

Continue to: The patient was discharged...