KAWASAKI DISEASE

Carreon G., Carreon J., Casaul J.R., Coronado M.C., Corpuz D., Credo C., Danguilan M.C.,

De Gracia C.

AIM:

• Review the clinical presentations of Kawasaki disease, its progression, serious complications and management.

• Discuss the D/Dx of Kawasaki disease.

S>

• 14 m/o, M, from Antipolo City, Filipino, Catholic, born on May 21, 2010

• 1st admission at this institution (May 24, 2011)

CC:

• Request for transfer of service, T/C Kawasaki Disease

0 1 2 3 4 5 6 7 8 9

37

37.5

38

38.5

39

39.5

40

40.5

Temperature

irritabilitydiarrhea

rashes

unilateralcervicallymph-adenopathy

conjunctivalinjection

chills

swelling ofhands and feet

perinealdesquamation

dry, crackedlipsstrawberry

tongue

vomiting

Paracetamol Cefuroxime Aspirin IVIG,zinc sulfate

Day of Illness

1st DOI (5 days PTA) - 5/19/11

• (+) Fever (38.3-38.5 °C)• (+) Decreased appetite/activity• MEDs:Paracetamol drops (12 mkdose, 120mg/5mL,

5mL, q4h) –slight relief

0 1 2 3 4 5 6 7 8 9

37

37.5

38

38.5

39

39.5

40

40.5

Temperature

irritabilitydiarrhea

rashes

unilateralcervicallymph-adenopathy

conjunctivalinjection

chills

swelling ofhands and feet

perinealdesquamation

dry, crackedlipsstrawberry

tongue

vomiting

Paracetamol Cefuroxime Aspirin IVIG,zinc sulfate

Day of Illness

2nd DOI (4 days PTA) – 5/20/11

• (+) Fever (38.9)• LABs:CBC

U/A: light yellow, clear, s.g 1.010, (-) protein, (-) sugar, 0 RBC, 0-1 WBC, rare epithelial cells

CXR: 1° Complex TB infection

Hgb 11.5

Hct 0.377RBC 4.36

WBC 30

Neutrophils 72

Lymphocytes 19.6

Platelet 417

2nd DOI (4 days PTA) – 5/20/11

• MEDs:Paracetamol drops, 12 mkdoseCefuroxime, 105 mkd, 350 mg IV, q8hBudesoniodeSalbutamol

0 1 2 3 4 5 6 7 8 9

37

37.5

38

38.5

39

39.5

40

40.5

Temperature

irritabilitydiarrhea

rashes

unilateralcervicallymph-adenopathy

conjunctivalinjection

chills

swelling ofhands and feet

perinealdesquamation

dry, crackedlipsstrawberry

tongue

vomiting

Paracetamol Cefuroxime Aspirin IVIG,zinc sulfate

Day of Illness

3rd DOI (3 days PTA) – 5/21/11

• (+) Fever (40°C)• (+) Diarrhea (greenish, soft, 3-5 episodes)• (+) Maculopapular, pruritic rash

(hands>trunks>head>lower extremities)• LABs:Fecalysis: brown, soft, 0-2 pus, 0-1 RBC, moderate

bacteria• MEDs: same

0 1 2 3 4 5 6 7 8 9

37

37.5

38

38.5

39

39.5

40

40.5

Temperature

irritabilitydiarrhea

rashes

unilateralcervicallymph-adenopathy

conjunctivalinjection

chills

swelling ofhands and feet

perinealdesquamation

dry, crackedlipsstrawberry

tongue

vomiting

Paracetamol Cefuroxime Aspirin IVIG,zinc sulfate

Day of Illness

4th DOI (2 days PTA) – 5/22/11

• (+) Fever, rash, diarrhea (4-5 episodes)• (+) CLAD (R submandibular area, 2cm)• (+) bilateral, nonpurulent conjunctival

injections with perilimbal sparing

4th DOI (2 days PTA) – 5/22/11• LABs: CBC

ESR: 65 CRP: 48 U/A: dark yellow, sl. Turbid, s.g. 1.020, trace albumin, (-) sugar, pH 6, 2-4

pus, 0-1 RBC, few epithelial cells, few bacteria, few amorphous materials• MEDs: same

Hgb 10.2

Hct 31RBC 3.95

WBC 5

Neutrophils 57

Lymphocytes 43

Platelet 409

Primary Impression

• Kawasaki disease

5th DOI (1 day PTA) – 5/23/11

• Sx persisted• (+) stawberry tongue• MEDs: same

0 1 2 3 4 5 6 7 8 9

37

37.5

38

38.5

39

39.5

40

40.5

Temperature

irritabilitydiarrhea

rashes

unilateralcervicallymph-adenopathy

conjunctivalinjection

chills

swelling ofhands and feet

perinealdesquamation

dry, crackedlipsstrawberry

tongue

vomiting

Paracetamol Cefuroxime Aspirin IVIG,zinc sulfate

Day of Illness

6th DOI (DOA) – 5/24/11

• Sx persisted• (+) fever and chills (40.1°)• (+) perineal desquamation• (+) swelling of hands and feet• 37.2-39.6°C>123-180>26-45 + 4BM

6th DOI (DOA) – 5/24/11• LABs:• CBC

Re-reading of CXR (wet read) Pneumonia LU and both LLF Mild pulmonary hyperinflation

Hgb 96

Hct 27

RBC 3.6

WBC 23.9

Neutrophils 89

Lymphocytes 11

Platelet 571

6th DOI (DOA) – 5/24/11

*seen by a pediatric infectious disease specialist>> KAWASAKI DISEASE

• MEDs:Paracetamol, 12 mkdoseASA, 80 mkd (100mg/tab, 2 tabs, q6h)Cefuroxime, 100 mkd (250 mg IV, q6h)

0 1 2 3 4 5 6 7 8 9

37

37.5

38

38.5

39

39.5

40

40.5

Temperature

irritabilitydiarrhea

rashes

unilateralcervicallymph-adenopathy

conjunctivalinjection

chills

swelling ofhands and feet

perinealdesquamation

dry, crackedlipsstrawberry

tongue

vomiting

Paracetamol Cefuroxime Aspirin IVIG,zinc sulfate

Day of Illness

7th DOI (2nd HD) – 5/25/11

• (+) conjunctival injection• Improvement on the rash• Progression of perineal desquamation (upto

lower back)• (+) dry, cracked lips• 90-100/60>131-156>35-49>36.2-38.8 + 1 BM• MEDs: same

0 1 2 3 4 5 6 7 8 9

37

37.5

38

38.5

39

39.5

40

40.5

Temperature

irritabilitydiarrhea

rashes

unilateralcervicallymph-adenopathy

conjunctivalinjection

chills

swelling ofhands and feet

perinealdesquamation

dry, crackedlipsstrawberry

tongue

vomiting

Paracetamol Cefuroxime Aspirin IVIG,zinc sulfate

Day of Illness

8th DOI (3rd HD) – 5/26/11

• (-) conjunctival injection• Improvement on the rash• (+) perineal desquamation up to the lower

back• Improvement on strawberry tongue• (+) dry cracked lips

8th DOI (3rd HD) – 5/26/11

• LABs:2D-echo:

R coronary artery dilated (0.21 cm proximally, 0.18 cm distally)

L coronary artery dialted (0.22 cm proximally)Mild pulmonic and tricuspid regurgitationMild pulmonary HTN, pulmonary artery pressure at 51

mmHgSlight L ventricular hypertrophyFair L ventricular systolic fxn, EF 56 mmHgMinimal pericardial effusion noted posteriorly

8th DOI (3rd HD) – 5/26/11

• LABs:Re-reading of CXR (official result)

Sub-optimal for evaluation d/t motion artifacts. Repeat study suggested.

• MEDs:Paracetamol, 12 mkdCefuroxime, 100 mkdASA, 100 mkd IVIGZn sulfate drops, 5.5 mkd, 27.5mg/mL, 2mL, OD

0 1 2 3 4 5 6 7 8 9

37

37.5

38

38.5

39

39.5

40

40.5

Temperature

irritabilitydiarrhea

rashes

unilateralcervicallymph-adenopathy

conjunctivalinjection

chills

swelling ofhands and feet

perinealdesquamation

dry, crackedlipsstrawberry

tongue

vomiting

Paracetamol Cefuroxime Aspirin IVIG,zinc sulfate

Day of Illness