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Indian Pediatr 2017;54: 51-52 |
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Dengue Fever Triggering Kawasaki Disease
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Ekta Agarwal, Dheeraj Shah and Piyush Gupta
From the Department of Pediatrics, University College
of Medical Sciences, Dilshad Garden, Delhi, India.
Correspondence to: Dr Piyush Gupta, Block R6A,
Dilshad Garden, Delhi 110 095, India. [email protected]
Received: May 17, 2016;
Initial review: July 01, 2016;
Accepted: October 10, 2016.
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Background: Several bacterial and viral
infections are listed as triggering factors for Kawasaki disease;
association with dengue fever is rare. Case characteristics: A
5-year-old girl who presented with fever that was confirmed to be dengue
fever, and subsequently improved, except that the fever persisted. She
fulfilled diagnostic criteria for Kawasaki disease on day 7 of fever.
Outcome: Child responded satisfactorily to intravenous
immunoglobulin administration. Message: Kawasaki disease should
be kept as one of the probabilities in a case of dengue if fever
persists beyond the expected duration.
Keywords: Dengue virus, Lymphadenopathy, Mucosal inflammation,
Rash, Thrombocytopenia.
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T
he exact etiology of Kawasaki disease is not
known; infection is hypothesized to play a major triggering role in
genetically predisposed individuals. Multiple infectious agents have
been implicated, including viruses, bacteria, rickettsiae and toxins
[1]. The association of Kawasaki disease with dengue fever is rare, and
is a diagnostic challenge, as clinical features of the two diseases may
overlap. We report a child with serologically confirmed dengue
fever who subsequently developed Kawasaki disease.
Case Report
A 5-year-old girl was admitted to our hospital with
high grade fever for 3 days along with vomiting and decreased oral
acceptance. She had tachycardia (pulse 110/min), respiratory rate of
32/min and a normal blood pressure (90/60 mmHg). Physical examination
revealed erythematous macular rashes over whole body, petechiae on
extremities, and tender hepatomegaly. The hematocrit was elevated (41%),
and there was associated thrombocytopenia (platelet count 67 × 10 9/L).
Chest radiograph showed right-sided pleural effusion. A clinical
diagnosis of Dengue fever with warning signs was made, as per WHO
definition [2]. Etiology was confirmed by a positive NS1 antigen, and
positive dengue IgM and IgG serology. The child was managed as per
standard treatment guidelines [2]. She improved gradually over next
three days. Vomiting subsided, appetite improved and vitals were
maintained. There were no respiratory or abdominal symptoms. The
platelets count improved to 140×109/L
and hematocrit normalized. However, she continued to have spikes of
fever, touching 39ºC or more.
On day 7 of fever, she developed extreme irritability
and a diffuse polymorphic rash; examination revealed conjunctival
redness, strawberry tongue, and mucositis. Two tender lymph nodes were
palpable in the left anterior cervical triangle measuring approx 1.5 cm
each. Tonsils were not enlarged and systemic examination was normal. She
was investigated for co-existing infections including malaria, enteric
fever, hepatitis, urinary tract infection, pneumonia, liver abscess and
tuberculosis. Blood counts were normal and peripheral smear revealed no
abnormal cells or parasites. She had negative serology for typhoid fever
and viral hepatitis; SGPT was mildly raised (68 IU/L). ESR was 65 mm in
the 1 st hour. The chest X-ray
was normal and tuberculin test revealed no induration after 48 hours.
Cultures of blood, urine, and throat were sterile. Ultrasonography of
abdomen revealed mildly enlarged liver with slight hypo-echogenicity.
During the period of investigations, she continued to be irritable and
had high grade fever. Additionally, she developed tender erythema of
palms and soles with mild edema of hands. We suspected Kawasaki disease
in view of persistent fever, extremity changes, rash, conjunctival
congestion, oral mucosal involvement, and unilateral cervical
lymphadenopathy, along with a negative work-up for common infections.
ECG and echocardiography were normal.
We treated her with intravenous immunoglobulins
(IVIG) (1 g/kg for 2 days) and high dose oral aspirin (40 mg/kg/day).
Child showed significant improvement in the next 48 hours with the
resolution of fever and rash. There was a marked improvement in
conjunctival redness and irritability. Oral mucosa and tongue slowly
regained normal texture and color. Aspirin was reduced to 5 mg/kg/day on
day 14 of illness. At discharge, all signs of active inflammation had
disappeared. A repeat echocardiography at 12 weeks follow-up was also
normal, and the child had no clinical evidence of any residual
disease/complication.
Discussion
This child presented with fever during an outbreak of
dengue fever in the city. We had several reasons, besides fever, to
suspect dengue fever in the index case. These included presence of
characteristic rash, evidence of mucocutaneous bleeds, thrombocytopenia
and capillary leak (suggested by pleural effusion). The diagnosis was
established by positive dengue serology.
Recovery from dengue is characterized by symptomatic
improvement (fever abets, vomiting and pain abdomen subsides, and most
importantly the appetite returns), associated with improvement in
platelet count. Our child had all the features of recovery except that
the fever persisted. This may happen in a child having co-existing
malaria, enteric fever, viral hepatitis, or urinary tract disorders. We
also initially explored these diagnoses. Diagnosis of Kawasaki disease
was clinical as suggested by persistence of fever and fulfilment of the
other criteria such as mucosal and peripheral involvement typical of the
disease. Prompt recovery following intravenous immunoglobulin also lend
credit to the diagnosis.
The association of dengue fever with Kawasaki disease
is rarely reported. We found only four reports of this association
[3-6]. These children were aged between 26 months to 10 years. Of these,
three had coronary artery involvement.Kawasaki disease in the present
case may have been triggered by dengue fever. On the other hand, a
chance association with dengue fever can not be excluded. Sopontamark,
et al. [7], conducted a study on sera of 65 cases diagnosed as
Kawasaki disease, collected over 4 years. Of these, 9 (18.7%) patients
had proven dengue infection, on the basis of serological titers. None of
these; however, had clinical manifestations of dengue fever. These
findings were reported to be significant and the possibility of dengue
fever as a trigger for Kawasaki disease by altering the immune response
in susceptible host during the acute phase .
Despite India being endemic for dengue fever, there
has been only one previous report of Kawasaki disease with dengue fever
from our country [6]. We are reporting this case to enlighten our
colleagues on a possible association between the two illnesses and to
consider Kawasaki disease in a child with dengue fever whose fever is
not responding.
Contributors: PG: conceptualized the report. The
case was managed by EA, DS and PG. Literature review was carried by EA
and PG. EA wrote the draft manuscript which was edited by DS and PG. All
three authors have seen and approved the manuscript.
Funding: None. Competing interests: None
stated.
References
1. Principi N, Rigante D, Esposito S. The role of
infection in Kawasaki syndrome. J Infect. 2013;67:1-10.
2. National Guidelines for Clinical Management of
Dengue Fever. Available from:
www.nvbdcp.gov.in/Dengue-Guidelines.htm. Accessed May 16, 2016.
3. Sopontammarak S, Pruekprasert P. Concomitant
dengue hemorrhagic fever with Kawasaki disease. Southeast Asian J Trop
Med Public Health. 2000;31:190-2.
4. Tourneux P, DuWllot D, Boussemart T, Belloy M.
Kawasaki disease and dengue: a fortuitous association? Arch Pediatr.
2002;9:218.
5. Mekmullica J, Pancharoen C, Deerojanawong J,
Lertsapcharoen P. Concomitant dengue infection and Kawasaki disease in
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6. Singh S, Jat KR, Suri D, Ratho RK. Dengue fever
and Kawasaki disease: a clinical dilemma. Rheumatol Int. 2009;29:717-9.
7. Sopontammarak S, Promphan W, Roymanee S, Phetpisan
S. Positive serology for dengue viral infection in pediatric patients
With Kawasaki disease in Southern Thailand. Circ J.
2008;72:1492-4
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