CR-20
Common Complaint with an Uncommon Diagnosis: From Trauma to Kawasaki Disease
Patel A
NSU-KPCOM, Davie, Florida, United states
Introduction: Kawasaki disease (KD) is a vasculitis that affects the coronary arteries, veins, and capillaries of young children. 20 per 100,000 children younger than five years of age develop Kawasaki disease; Asians and Pacific Islanders have the highest incidence (30 per 100,000) while Caucasians have the lowest incidence (12/100,000). The cause of KD is unknown. However several theories exist, including immunologic responses, infectious etiology, demographics, and genetic makeup [1].
Case presentation: We present a case of a 3-year old British Caucasian female with a history of repaired Tetralogy of Fallot who initially presented to the ER with a fever of 38.7 degrees Celsius. Patient had recent history of neck trauma on two separate occasions where the neck was forcibly flexed forward. Both traumas occurred within a week of her fever. She was seen in the ER for a total of 3 visits.
During the initial ER visit, patient was febrile with a heart rate of 163 beats per minute, respiratory rate of 26 breaths per minute, blood pressure of 98/66mmHg, and O2 saturation of 99%. No loss of consciousness, nausea, emesis, cough, diarrhea, or rash. Rapid strep test and urine analysis were negative. She was discharged the same day with Tylenol and Motrin and was told to follow up with PCP. Next day, patient presented to the ER with neck pain and decreased appetite. She developed a lower lip blister and her neck was tender to palpation but no swelling or lymphadenopathy. Laboratory studies revealed elevated CRP and WBC. Patient was requested to return the next day for reevaluation. The following day, patient presented with complaints of a headache. WBC count decreased, but CRP remained elevated. Throat culture was negative. Neck ultrasound showed mild prominent lymph nodes. Patient was febrile and cervical lymph nodes appeared enlarged and erythematous. Patient was given IV Rocephin and Clindamycin and was admitted to the hospital.
Upon admission, IV antibiotics were continued, and viral studies were negative. Wound culture of left neck showed no organisms. Over her course of stay in the hospital, patient developed bilateral conjunctivitis and generalized rash that was consistent with KD. Echocardiogram showed normal coronary arteries. She was given IVIG and high-dose aspirin. After IVIG course, patient became afebrile and returned to her normal baseline with a decreased CRP of 9.7. She was discharged with high-dose aspirin for 2 more days and then switched to low dose aspirin.
Discussion: The unusual course of events beginning with trauma to the patient’s head and neck, followed by a viral illness and fevers, culminating with KD prompts us to question the cause of KD. Although etiology of KD is unknown, this case may provide insight that certain factors such as congenital malformations (i.e. TOF) and trauma put children at a greater risk for KD and must be considered in the evaluation of young children presenting to the ER with routine complaints.
References:
1) Holman RC, Belay ED, Christensen KY, et al. Hospitalizations for Kawasaki syndrome among children in the United States, 1997-2007. Pediatr Infect Dis J 2010; 29:483.
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