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Indian Pediatr 2011;48: 808-809 |
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Kawasaki Disease in Association with Urinary
Tract Infection |
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Entesar H Husain†‡ and #Maryam
Al-Rashid
From the †Department of Pediatrics, Faculty of Medicine;
‡Department of Pediatrics, Mubarak Al-Kabeer Hospital;
#Department of Pediatrics, Amiri Hospital; Kuwait.
Correspondence to: Dr Entesar H Husain, Department of Pediatrics, Faculty of Medicine,
P.O. Box
24923, Safat, Kuwait 13110.
Email: [email protected]
Received: March 03, 2010;
Initial review: April 06, 2010;
Accepted: July 26, 2010.
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We report a 2-month-old infant with E. coli urinary tract
infection, who did not respond to antibiotic therapy. She later
developed clinical features fulfilling criteria of Kawasaki disease (KD),
and was treated with intravenous immunolglobulin and aspirin. KD
should be considered in the differential diagnosis in patients who
present with infection and do not respond to antibiotic therapy.
Key words: Kawasaki disease, Urinary tract infection.
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K
awasaki disease (KD) is an acute febrile
vasculitis of childhood characterized by the following clinical
features; bilateral non-exudative conjunctivitis, erythema of the
lips and oral mucosa, changes in the extremities, rash and cervical
lymphadenopathy. Sterile pyuria has been seen in 10-50% of patients
with KD in the acute phase [1]. Recently, some reports have shown
the association of KD with urinary tract infection (UTI) [1,2].
We report an infant with KD with UTI in whom the
clinical manifestations of KD evolved later.
Case Report
A previously healthy 2 ½ -month old infant,
presented with a 2-day-history of a febrile illness associated with
maculopapular rash and nasal congestion. She also had a history of
irritability and decreased feeding for one day prior to admission.
On examination, she was unwell and irritable. Her temperature was
39.5ºC, heart rate 145/minute and respiratory rate 35 per minute.
The cardiovascular, respiratory and abdominal examination was within
normal. She had severe nasal block and tearing of the right eye but
no conjunctivitis. A generalized maculopapular rash was noted over
the face, extremities and trunk. The Initial investigations showed
hemoglobin 84 g/L, platelets 388×10 9
/L, and white blood cell count 10.3×109
/L (60% neutrophils, 32% lymphocytes, 7%
monocytes, 1% eosinophils). The C-reactive protein was 57 mg/L and
liver function tests were normal. Urinalysis showed WBC 6-8 cells /HPF
and urine nitrite positive; urine culture grew 105
CFU/mL
of E.coli. She received treatment with
intravenous cefotaxime (150 mg/kg/day). On the fourth day of
admission, the child was still irritable, with decreased oral
feeding and febrile at 39ºC; swelling of both hands and feet was
noted with accentuated erythema. She had also developed cracked lips
with bleeding and bilateral conjunctivitis. The baby was diagnosed
to have KD based on the presence of the clinical features and was
started on intravenous immunoglobulin 2 g/kg, and aspirin 100
mg/kg/day. The fever subsided after 48 hours and there was a marked
improvement of the irritability and feeding pattern. Cefotaxime was
continued for treatment of the UTI. Subsequently on the 9th day of
the illness, she developed peeling of the skin overlying the tips of
her fingers and toes. Echocardiography, done during hospitalization
and follow up, was normal. Follow up blood counts on the 10th day of
admission showed increasing platelets counts to 722×109/L.
An ultrasound scan revealed normal kidneys and a voiding
cyctourethrogram four weeks after discharge excluded vesicoureteric
reflux.
Discussion
KD is a systemic vasculitis, which may be
associated with abnormal urinary findings such as sterile pyuria,
mild proteinuria and microscopic hematuria. Sterile pyuria has been
reported to occur in 10-50% of children during the acute phase [1].
It was well known that pyuria in KD originate from the urethra [3],
but a recent study showed that the white blood cells in the urine in
patients with KD might originate from the urethra or the kidney or
both [4]. In most of the described series, sterile pyuria is found
more commonly in infants than in older children [5].
In addition to the current case, there are two
cases in the literature of children diagnosed with a documented UTI
who subsequently had KD [1,2]. It is unclear if the vasculitis is
provoking the infection or the gram negative organisms precipitating
UTI are able to produce superantigens similar to staphylococcal and
streptococcal antigens that have been suggested to be responsible
for the development of KD. From the cases described, UTI seems to be
more common in infants with incomplete features of KD. It is
difficult to conclude from the limited number of cases if infants
with underlying vesicoureteric reflux are more likely to present
with UTI when presenting with KD. The likelihood of developing
coronary aneurysms increases in children who had UTI due to
misdiagnosis and the delay in administering IVIG [2].
In conclusion, it is unclear if UTI is a cause of
KD in some infants or this observation is only coincidental.
Laboratory evidence of infection in a patient does not always rule
out KD. KD should be one of the differential diagnoses in patients
who are suspected of having UTI and do not respond to antibiotic
therapy.
Contributors: Both authors were involved in
all aspects of patient management and manuscript preparation.
Funding: None.
Competing interests: None stated.
References
1. Shiono N, Koga Y, Ito H, Egawa K, Ono S, Itami
N. Really sterile pyuria with Kawasaki disease. Pediatr Nephrol.
2004;19:124.
2. Wu CY, Hsieh KS, Chiou YH, Wang RS, Huang IF,
Lee WY, et al. Prolonged fever and pyuria: a urinary tract
infection presentation of incomplete Kawasaki disease. Acta Paediatr.
2005;3:375-7.
3. Melish ME, Hicks RM, Larson EJ. Mucocutaneous
lymph node syndrome in the United States. Am J Dis Child.
1976;130:599-607.
4. Watanabe T, Abe Y, Sato S, Uehara Y, Ikeno K,
Abe T. Sterile pyuria in patients with Kawasaki diseases originates
from both the urethra and kidney. Pediatr Nephrol. 2007;7:987-91.
5. Wirojanan J, Sopontammarak S, Vachvanichsanong
P. Sterile pyuria in Kawasaki disease. Pediatr Nephrol. 2004;19:363.
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