Possible Kawasaki>

[remg041]

My 8 y/o had an extremely swollen lymph node on his neck and a fever of 100.4. and slight rash, mostly on his trunk.  It was a Sat. night. A sono was neg. for an abscess.   Mono spot was neg.  WBC 10.6K, platelets 343K.   Sed rate was 34.  They prescribed Amoxicillin and said it was likely strep. Saw our ped.  on Mon.  He thought it was likely viral (no growth yet reported after 24 hrs on cultures) but to finish Amox since we were already into it in case further culture showed growth.    On Wed., fever was persisting, mostly low grade.   I think the highest we recorded was 102.8 one time.     He said to d/c amoxicillin and call him Fri. or Sat. if fever persists.  That night, my son complained of severe itchiness and rash looked almost like hives on his feet, and redness on legs.   I gave him Benadryl and it improved a bit.  Next Sat we returned to dr.   His lips were dry and chapped.   Dr. mentioned atypical Kawasaki as a remote possibility.   Wasn't sure if he was a little dehydrated.  We went for labwork.
His last fever was 4am Sunday. Mon. afternoon recd lab results.    I don't have a copy, but I know the high sensitivity c-reactive protein was 17 and the sed rate 69.   There were white cells in the urine.   His platelets were within normal limits.   The fever had been gone for more than 24 hours.     We were advised to see a pediatric cardiologist for an echo, which we did Tues and it was normal.

The cardiologist said while he can't rule out Kawasaki, he didn't think there was enough evidence to treat it, esp. since by that point we were on the 11th day, and he had been w/out fever.

We are repeating labs later this week and repeating echo in 3 wks.

Chapped lips were not red or puffy, no strawberry tongue, no swelling hands/feet, no peeling skin.   Is this typical for an atypical case?    Or too atypical to even be atypical?? Everything I've read sounds like he should've had more of the signs/symptoms, but the blood test results still concern me.

[Marie M Gleason, M.D.]

Atypical Kawasaki disease is mostly a term used when infants less than a year of age present with persistent fevers without the other classic criteria for Kawasaki.  It is not the norm to see "atypical" Kawasaki in older children.  usually they have the more complete forms, although all of the signs need not be present at the same time.  Kawasaki is a diagnosis of exclusion.  If your child is already afebrile by the 11th day of illness, and feeling well, with resolution of all symptoms, and the echocardiogram interpreted by a pediatric cardiologist is not suggestive of carditis, then it is difficult to invoke the diagnosis of Kawasaki disease. Giving intravenous immunoglobulin is usually not indicated.  I think the plan to follow the labs closely and repeat the echo in 3 weeks sounds like a reasonable plan.  If the sedimentation rate and CRP are continuing to rise, then the doctors may need to think about the diagnosis more seriously.  Also watch for peeling of the hands and feet.

[remg041]

Dear Dr. Gleason,

Hope you will get this reply.    This originally started 11/20.   His last fever was 11/28.

Follow up blood work done on 12/11 shows C-RP 0.6 and ESR 21.    We do not notice the swollen glands any longer.

In the last week, we have noticed peeling of the toes and now the hands as well.   His eyes are slightly pink in the evenings but seem clear in the mornings.   Not really red eyes, just noticeably more pink than his siblings.

Although I realize that the peeling hands and toes, as well as bloodshot eyes, are signs consistent with Kawasaki Disease, does the fact that they have occured so much later than the fever mean anything?

Our follow up echo is Wednesday.   Even if it is clear, it is my understanding that coronary artery involvement can appear much lighter.  

In light of the recent signs creeping up, what would be the recommended follow up schedule (if any) for echo, assuming it is clear this week?    

Thank you again for your help.

[remg041]

Thank you very much for your prompt reply.    I feel much more at ease now.   While I realize that it is no substitution for an actual examination, and we still have some uncertainty without having a diagnosis, I am greatly reassured by your explaination.