We report a case of incomplete Kawasaki disease in a child who also tested positive for COVID-19. This case brings attention to the diverse presentation of coronavirus disease (COVID-19) disease in children.

A 5-year-old previously healthy African American male was admitted to the Pediatric inpatient floor with daily fever up to 39.4°C for 8 days. He had a history of rash, swelling (palms and soles), conjunctivitis, decreased appetite, diarrhea, dysuria, and abdominal pain. He had been treated with cefdinir for positive rapid streptococcal antigen test four days before, without clinical improvement. Physical examination showed dry, cracked, erythematous lips, non-exudative conjunctivitis, and bilateral shotty cervical lymphadenopathy but no rash. He had right scrotal edema and hydrocele suggestive of epididymo-orchitis on ultrasound. Clinically, he met the criteria for incomplete Kawasaki disease  (KD).

Initial laboratory workup was significant for leukocytosis (white blood cells 40,000/cumm), anemia (hemoglobin 8 g/dL), thrombocytopenia (platelet count 104,000/cumm), elevated inflammatory markers (ESR 72 mm, CRP 25.6 mg/dL, procalcitonin 27 ng/mL, ferritin 1030 ng/mL), hyponatremia (serum sodium 121 meq/L), pyuria, hypoalbuminemia (2 g/dL), elevated liver enzymes (ALT 55 U/L), elevated troponins (0.06 ng/mL)  and negative rapid influenza A/B antigens. Chest X-ray showed an enlarged cardiac silhouette (Fig. 1). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA was detected on RT-PCR from his nasopharyngeal swab. Echocardiogram showed a small global pericardial effusion but no ectasia, dilation, or aneurysm formation of coronary arteries (Fig. 2).

Fig.1 Chest radiograph showing enlarged cardiac silhouette.

Fig. 2 Apical four chamber view of a two dimensional echocardiogram of the patient showing a small global pericardial effusion. LA-Left Atrium; LV-Left ventricle; RA-Right atrium; RV-Right ventricle.

He was transferred to the pediatric intensive care unit because of hypotension. He received fluid boluses and intravenous immunoglobulin (IVIG) therapy was begun, which had to be discontinued because of recurring hypotension. He was briefly supported with high flow nasal cannula up to 10 liter for tachypnea and increased work of breathing, which was weaned-off. Once he was hemodynamically stable, IVIG infusion was resumed slowly at 5 grams over 10 hours (2-5 mL/minute) for 6 doses for a total dose of 30 grams (1.8 g/kg) [1]  with a different formulation,  after  pre-medicating with diphenhydramine and methylprednisolone (only for the first dose) and started on medium-dose aspirin (~39 g/kg/day).

The patient recovered on the pediatric floor with supportive therapy for COVID-19 [3] and was discharged after 6 days in the hospital. Hypotension with elevated inflammatory markers in patients with KD are the manifestations of KD shock syndrome (KDSS) [4]. Association between COVID-19 and KDSS [5]  has been speculated, but warrants further investigation.

Adverse effects to IVIG infusion commonly include hypotension and anaphylactic reactions. This can be treated with steroids and antihistamines as pre-medication. However, there is a weak recommendation regarding avoidance of steroids in patients with COVID-19, with some indirect evidence of disease worsening [2]. Readers need to be aware of co-occurrence of Kawasaki disease with COVID-19, and the associated management issues.

Contributors- ER-drafted the manuscript; RS-supervised ER and edited the manuscript; SS-helped with the echocardiographic images and their labeling; PG-conceived the idea of case report, supervised, edited and finalized the manuscript.

Funding: none; Competing interests: None stated.

REFERENCES

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2. COVID-19 Treatment Guidelines Panel. Coronavirus Diseases 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available from: https://www. covid19treatmentguidelines.nih.gov/. Accessed May 8, 2020.

3. Chiotos K, Hayes M, Kimberlin DW, Jones SB, James SH, Pinninti SG, et al. Multicenter Initial Guidance on Use of Antivirals for Children With COVID-19/SARS-CoV-2. J Pediatric Infect Dis Soc. 2020. Apr 22 [published online ahead of print]. Available from: https://academic-oup.com/jpids/advance-article/doi/10.1093/jpids/piaa045. Accessed May 8, 2020.

4. Kanegaye JT, Wilder MS, Molkara D,  Frazer JR, Pancheri J, Tremoulet AH, et al. Recognition of a Kawasaki disease shock syndrome. Pediatrics. 2009;123: e783-9.

5. Jones VG, Mills M, Suarez D, Hogan CA, Yeh D, Bradley Segal J, et al. COVID-19 and Kawasaki disease: Novel virus and novel case. Hosp Pediatr. 2020 Apr 7. https:// hosppeds.aappublications.org/content/early/2020/04/06/hpeds.2020-0123.long. Accessed May 8, 2020.