Nontypical presentation of a common disease: a case report

Background Kawasaki disease is an idiopathic medium-sized vasculitis that occurs primarily in infants and children younger than 5 years of age. Atypical Kawasaki disease applies to patients who do not fulfill the complete criteria of fever of 5 days or more with at least four of five features: bilateral conjunctival injection, changes in the lips and oral cavity, cervical lymphadenopathy, extremity changes, and polymorphous rash. Acute kidney injury is defined as a sudden decline in kidney function within hours, including structural injuries and loss of function. Acute kidney injury is extremely common in hospitalized pediatric patients. However, it is rarely documented in Kawasaki disease. Acute kidney injury is underestimated in Kawasaki disease due to the lack of a clear definition of age-specific normal serum creatinine levels and routine renal functions. This report describes a case who presented with clinical features suggestive of atypical Kawasaki disease and developed acute kidney injury. Case presentation A 2-year-old Saudi girl had a history of high-grade fever for 5 days, moderate dehydration, dry cracked lips, poor appetite, and generalized erythematous rash; therefore, she was diagnosed to have incomplete Kawasaki disease. Laboratory investigations revealed normochromic normocytic anemia, leukocytosis, thrombocytosis, high inflammatory markers, and acute kidney injury stage III. An echocardiogram showed a 4-mm dilatation on the left main coronary artery and a 3-mm dilatation on the right. A renal biopsy was not performed to identify the cause of the injury as it showed improvements after the start of the specific therapy for Kawasaki disease; intravenous immune globulin at a dose of 2 g/kg, aspirin at a high dosage of 80 mg/kg/day, and prednisolone at 2 mg/kg. In addition to the acute kidney injury management, normal saline boluses were followed by furosemide at a 2 mg/kg dose. Her urine output increased, and her renal functions normalized. She was discharged in good condition after 10 days. Conclusions It is valuable to check renal function tests in a confirmed case of Kawasaki disease to reduce the negative consequences of late acute kidney injury discovery. Early detection and intervention make a substantial difference in acute kidney injury management.

Affinché non MIS-Cappi il caso: la sindrome infiammatoria multisistemica SARS-CoV-2-correlata

Background - Covid-19 is less frequent and milder in children than in adults. However, cases of multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (MIS-C) have been reported in children, whose phenotype resembles atypical Kawasaki disease. Objectives - The paper describes incidence as well as clinical, laboratoristic and radiological findings of MIS-C. Materials and methods - In the Paediatric Infectious Disease Centre of Palermo (Italy), a targeted surveillance for MIS-C from March 2020 to January 2021 was conducted. Case definition included WHO, UK and US criteria. Results - The paper reports the cases of 9 patients with MIS-C out of which 8 (88%) were hospitalized after September 2020. 44% were male and their median age was 6.5 years. Organ-system involvement included gastrointestinal (66%), cardiovascular (66%), mucocutaneous (88%), reticuloendothelial (77%) and respiratory (55%) systems. C-reactive protein (CRP), procalcitonin, D-dimer and pro-B-type natriuretic peptide levels (pro-BNP) were high in all patients. Chest radiography showed bilateral ground glass-opacities (55%) and pleural effusions (44%). Abdominal imaging findings included small-volume ascites (55%) and mesenteric lymphadenopathy (22%). Echocardiogram showed transient valves regurgitation (55%). In all the patients, the left ventricular ejection fraction was normal and coronary-artery aneurysms were not documented. They were treated with immunomodulating therapies. All patients neither received intensive care nor died. Conclusions - MIS-C represents a new systemic inflammatory syndrome with a phenotype resembling Kawasaki disease. MIS-C remains a rare condition, in which gastrointestinal and mucocutaneous involvement is predominant, nevertheless cardiovascular involvement must be investigated. MIS-C could be suspected even if SARS-CoV-2 exposure precedes the onset of the symptoms by more than 6 weeks. In most cases, a good prognosis might be expected.

Atypical Kawasaki disease in an early infant, a diagnostic challenge: Case report

A 4.5-month-old girl presented to us with continuous fever for 10 days and loose stools for 2 days. She received short courses of multiple oral antibiotics during this period however, was not relieved. Initial investigations were suggestive of urinary tract infection for which broad spectrum antibiotics were started. However, fever persisted even after 72 h of antibiotics. Blood counts showed persistently high total leukocyte count and increasing platelet count, along with high C-reactive protein. Consequently, a diagnosis of Kawasaki disease (KD) was suspected, which was supported by echocardiographic findings. After she received intravenous immunoglobulins, her fever subsided and lab parameters showed significant improvement. This case highlights an unusual presentation of KD in an uncommonly young age group without much clinical pointers except for persistent fever.

Multisystem inflammatory syndrome in Indian adolescents associated with SARS-CoV-2 infection: a case report

Background Adolescents with coronavirus disease 2019 (COVID-19) associated multisystem inflammatory syndrome (MIS) can present with shock and myocardial injury and mimic Kawasaki disease. Case presentation We describe 4 previously well adolescents (age 13–14 years), presenting with clinical features of MIS in children (MIS-C). All patients had nearly similar clinical presentation. Hematological investigations revealed elevated inflammatory markers, anemia, thrombocytopenia, and decreased neutrophil:lymphocyte ratio. All patients were negative on real-time polymerase chain reaction against severe acute respiratory syndrome coronavirus 2, but had elevated immunoglobulin G titers. Two patients had atypical Kawasaki disease. Three patients had severe disease with hypotensive shock and required intensive care with fluids and inotropes. Two patients required non-invasive respiratory support for dyspnea and one patient had biventricular dysfunction. All received empiric antibiotics, low-molecular weight heparin, steroids, and intravenous immunoglobulin. One patient succumbed, while others recovered well. Conclusions MIS-C may be a late presentation in adolescent with COVID-19. Individualized treatment with empiric antibiotics, immunomodulation, and thromboprophylaxis can result in significantly better outcome.

Atypical Kawasaki Disease in an Adolescent with Multivisceral Involvement

Kawasaki disease (KD) is a vasculitis mostly seen in children aged less than 5 years. It can involve different organs and tissues. Its diagnosis is based on the clinical criteria of the American Heart Association (AHA). We report a case of a Moroccan adolescent with an atypical presentation of KD initially treated as typhoid fever. Gastrointestinal, renal, and pulmonary signs were the main clinical findings that made the diagnosis of KD challenging and delayed. The consequence was a severe cardiac damage with myocarditis and coronary artery dilation. KD is uncommon in adolescents, and it is important to recognize the atypical forms and the different presentations of KD in order to prevent the delay of diagnosis and treatment, and hence the cardiac complications.

A 3 Month Old Child with Atypical Kawasaki Disease

Background: Kawasaki Disease (KD) is an autoimmune vasculitis of unknown etiology that occurs predominantly in infants and young children with special predilection to coronary arteries. Case Presentation: We report the case of a 3-month-old child with an atypical form of KD, characterized by prolonged fever and non- specific symptoms, who developed an aneurysm of the left anterior descending coronary artery. Conclusion: This case report underlines the challenges in recognizing atypical forms of the illness in young infants with minor features, who are at higher risk of long term cardiac complications. Bangladesh Journal of Medical Science Vol.20(3) 2021 p.665-668

Atypical Kawasaki Disease in a Two-Year-Old Girl with Initial Presentation of Acute Diarrhea

Kawasaki Disease is a spectrum of idiopathic, self-limited fever disease affecting childrenunder 5 years old. This disorder can be challenging to be diagnosed by a pediatrician since thereis no specific diagnostic laboratory test. One atypical Kawasaki Disease case presented withgastrointestinal symptoms, a two-year-old girl was hospitalized with fever, accompanied by non-hemorrhagic diarrhea three days before admission. Physical examination revealed unilateralcervical lymph enlargement and mild-moderate dehydration. Initial laboratory examinationresult showed thrombocytosis, leukocytosis (shift to the left), and normal routine fecal analysis.The patient was initially diagnosed with acute diarrhea with mild-moderate dehydration. She wastreated with a rehydration regimen and antibiotic, but her fever persisted. On the third day ofhospitalization, she fulfilled 3 of the classic Kawasaki Disease criteria (conjunctivitis, crackedlips with strawberry tongue, and lymphadenopathy). Further blood work resulted in increased C-reactive protein 43.35 mg/L and ESR 72 mm/hour, while chest X-ray and electrocardiographwere within normal limit. This patient was proceed to Hasan Sadikin General Hospital for furtherexamination and therapy. Atypical Kawasaki Disease can be a puzzling diagnosis due to itsuncommon presentations. Clinicians should importantly keep it in mind as a differential diagnosisin patients with prolonged fever. Keywords: atypical Kawasaki disease; diarrhea; prolonged fever