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

CC: Request for transfer of service, T/C Kawasaki Disease

irritability diarrhea rashes unilateral cervical lymph- adenopathy conjunctival injection chills swelling of hands and feet perineal desquamatio n dry, cracked lips strawberry tongue vomiting ParacetamolCefuroxime AspirinIVIG, zinc sulfate Day of Illness

1 st DOI (5 days PTA) - 5/19/11 (+) Fever ( °C) (+) Decreased appetite/activity MEDs:  Paracetamol drops (12 mkdose, 120mg/5mL, 5mL, q4h) –slight relief

irritability diarrhea rashes unilateral cervical lymph- adenopathy conjunctival injection chills swelling of hands and feet perineal desquamatio n dry, cracked lips strawberry tongue vomiting ParacetamolCefuroxime AspirinIVIG, zinc sulfate Day of Illness

2 nd 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 Hgb11.5 Hct0.377 RBC4.36 WBC30 Neutrophils72 Lymphocytes19.6 Platelet417

2 nd DOI (4 days PTA) – 5/20/11 MEDs:  Paracetamol drops, 12 mkdose  Cefuroxime, 105 mkd, 350 mg IV, q8h  Budesoniode  Salbutamol

irritability diarrhea rashes unilateral cervical lymph- adenopathy conjunctival injection chills swelling of hands and feet perineal desquamatio n dry, cracked lips strawberry tongue vomiting ParacetamolCefuroxime AspirinIVIG, zinc sulfate Day of Illness

3 rd 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

irritability diarrhea rashes unilateral cervical lymph- adenopathy conjunctival injection chills swelling of hands and feet perineal desquamatio n dry, cracked lips strawberry tongue vomiting ParacetamolCefuroxime AspirinIVIG, zinc sulfate Day of Illness

4 th 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

4 th DOI (2 days PTA) – 5/22/11 LABs:  CBC  ESR: 65  CRP: 48  U/A: dark yellow, sl. Turbid, s.g , trace albumin, (-) sugar, pH 6, 2-4 pus, 0-1 RBC, few epithelial cells, few bacteria, few amorphous materials MEDs: same Hgb10.2 Hct31 RBC3.95 WBC5 Neutrophils57 Lymphocytes43 Platelet409

Primary Impression Kawasaki disease

5 th DOI (1 day PTA) – 5/23/11 Sx persisted (+) stawberry tongue MEDs: same

irritability diarrhea rashes unilateral cervical lymph- adenopathy conjunctival injection chills swelling of hands and feet perineal desquamatio n dry, cracked lips strawberry tongue vomiting ParacetamolCefuroxime AspirinIVIG, zinc sulfate Day of Illness

6 th DOI (DOA) – 5/24/11 Sx persisted (+) fever and chills (40.1°) (+) perineal desquamation (+) swelling of hands and feet °C> > BM

6 th DOI (DOA) – 5/24/11 LABs: CBC  Re-reading of CXR (wet read) Pneumonia LU and both LLF Mild pulmonary hyperinflation Hgb96 Hct27 RBC3.6 WBC23.9 Neutrophils89 Lymphocytes11 Platelet571

6 th DOI (DOA) – 5/24/11 *seen by a pediatric infectious disease specialist>> KAWASAKI DISEASE MEDs:  Paracetamol, 12 mkdose  ASA, 80 mkd (100mg/tab, 2 tabs, q6h)  Cefuroxime, 100 mkd (250 mg IV, q6h)

irritability diarrhea rashes unilateral cervical lymph- adenopathy conjunctival injection chills swelling of hands and feet perineal desquamatio n dry, cracked lips strawberry tongue vomiting ParacetamolCefuroxime AspirinIVIG, zinc sulfate Day of Illness

7 th DOI (2 nd HD) – 5/25/11 (+) conjunctival injection Improvement on the rash Progression of perineal desquamation (upto lower back) (+) dry, cracked lips /60> >35-49> BM MEDs: same

irritability diarrhea rashes unilateral cervical lymph- adenopathy conjunctival injection chills swelling of hands and feet perineal desquamatio n dry, cracked lips strawberry tongue vomiting ParacetamolCefuroxime AspirinIVIG, zinc sulfate Day of Illness

8 th DOI (3 rd HD) – 5/26/11 (-) conjunctival injection Improvement on the rash (+) perineal desquamation up to the lower back Improvement on strawberry tongue (+) dry cracked lips

8 th DOI (3 rd 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 regurgitation Mild pulmonary HTN, pulmonary artery pressure at 51 mmHg Slight L ventricular hypertrophy Fair L ventricular systolic fxn, EF 56 mmHg Minimal pericardial effusion noted posteriorly

8 th DOI (3 rd 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 mkd  Cefuroxime, 100 mkd  ASA, 100 mkd  IVIG  Zn sulfate drops, 5.5 mkd, 27.5mg/mL, 2mL, OD

irritability diarrhea rashes unilateral cervical lymph- adenopathy conjunctival injection chills swelling of hands and feet perineal desquamatio n dry, cracked lips strawberry tongue vomiting ParacetamolCefuroxime AspirinIVIG, zinc sulfate Day of Illness