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Indian Pediatr 2015;52: 345 |
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Kawasaki Disease in an Infant – Missed Clues
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Shambhawi Roy and *Aashima Dabas
Department of Pediatrics, University College of Medical
Sciences and GTB Hospital, New Delhi, India.
Email: *
[email protected]
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Patients who do not fulfil the criteria of classic Kawasaki disease are
diagnosed as ‘incomplete’ Kawasaki disease, a diagnosis that often is
based on echocardiographic findings of coronary artery abnormalities
[1]. Incomplete Kawasaki disease is more commonly diagnosed in young
infants than older children [2]. We discuss the case of an infant who
was diagnosed with Kawasaki disease in later part of his clinical
presentation.
A 40-day-old boy was referred from a peripheral
hospital in view of persistent fever for two weeks, despite intravenous
antibiotics. At admission, he was febrile and tachypneic. Examination
revealed hepatosplenomegaly without any skin changes. Blood
investigations showed hemoglobin 9.6 g/dL, leucocyte count 44,6×10 9/L,
platelet count 3.59×109/L,
and raised C-reactive protein (20mg/dL). Cerebrospinal fluid examination
revealed 90 lymphocytes with normal biochemistry. He was started on
intravenous meropenem and vancomycin awaiting blood culture report;
which was later sterile. The child was accepting breast feeds over next
2 days but fever persisted. On day 7 of admission, he developed features
of congestive heart failure (CHF) and was detected to be anemic (hemoglobin
6.2 g/dL). He recovered partly with blood transfusion but remained
febrile. Two days later, he developed features of cardiogenic shock and
was detected to have a systolic murmur at apex. Repeat blood counts were
similar and CRP was still raised. Electrocardiogram showed sinus
tachycardia. He was started on vasopressor and ventilatory support. In
view of persistent fever with acute cardiac event and elevated markers
of inflammation, a possibility of Incomplete Kawasaki disease was
suspected. A bedside echocardiography revealed dilated coronaries with
mitral regurgitation suggestive of Kawasaki disease. The baby was
started on intravenous immunoglobulins but died in next 24 hours due to
refractory shock.
Incomplete Kawasaki disease should be considered in
children with unexplained fever for more than 7 days duration
with laboratory evidence of systemic inflammation even in the absence of
principal features [1]. The diagnosis of incomplete KD in febrile
infants with rash and cerebrospinal pleocytosis is challenging as their
presentation closely mimics viral meningitis [3]. Acute congestive heart
failure is an extremely uncommon early manifestation of Kawasaki disease
[4]. The first manifestation of CHF which was attributed to anemia,
along with perisistent fever, were perhaps the early clues.
Currently echocardiography is recommended in all
cases with unexplained persistent fever and supplemental laboratory
criteria [1]. However, echocardiography is not often ordered in an
infant with unexplained persistent fever in settings where infections
are common. Possibly, an early echocardiography in our case could have
detected coronary changes. The delay in starting treatment accounted for
poor response of immunoglobulins, which has also been reported earlier
in incomplete Kawasaki disease [1,4].
We conclude that high index of suspicion for Kawasaki
disease should be kept in all infants and young children who present
with persistent fever with/without supporting features such as rash or
lymphadenopathy. Timely diagnosis and treatment may alter the course of
disease, and may prove lifesaving.
References
1. Newburger JW, Takahashi M, Gerber MA, Gewitz M,
Tani LY, Burns JC, 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. Pediatrics. 2004;114:1708-33.
2. Kitano N, Suzuki H, Takeuchi T, Suenaga T,
Kakimoto N, Shibuta S, et al. Epidemiologic features and
prognostic factors of coronary artery lesions associated with Kawasaki
disease based on a 13-year cohort of consecutive cases identified by
complete enumeration surveys in Wakayama, Japan. J Epidemiol.
2014;24:427-34.
3. Yeom JS, Woo HO, Park JS, Park ES, Seo J, Youn H.
Kawasaki disease in infants. Korean J Pediatr. 2013;56:377-82
4. Aggarwal P, Suri D, Narula N, Manojkumar R, Singh
S. Symptomatic myocarditis in Kawasaki Disease. Indian J Pediatr.
2012;79:813-4.
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