A 3‐year‐old Hispanic male was hospitalized for fever and cervical lymphadenopathy. He was treated with antibiotics for suspected lymphadenitis but showed minimal improvement. He was eventually diagnosed with Kawasaki disease based on physical and laboratory findings, treated with intravenous immunoglobulin (IVIG) and discharged on aspirin therapy. His echocardiogram was normal prior to discharge. The patient was readmitted 8 months later with recurrence of fever and cervical lymphadenopathy associated with maculopapular rash, bilateral palmar erythema, and intermittent abdominal pain. The suspicion of Kawasaki disease was low given the recurrence rates are highest among children less than 3 years of age with coronary complications. His repeat echocardiogram showed normal coronary findings. Laboratory studies were significant for elevated liver enzymes, erythrocyte sedimentation rate (ESR), and C‐reactive protein (CRP). Blood cultures and viral antibody titers were negative. A CT scan of the neck showed prominent bilateral cervical lymphadenopathy with no abscesses, and chest x‐ray showed no hilar adenopathy. Cervical lymph node biopsy showed paracortical and follicular hyperplasia, several small subcapsular necrosis, as well as extracapsular inflammation. These morphologic changes were consistent with clinical impression of Kawasaki disease. Parallel to the findings on the lymph node biopsy, the patient developed fissured lips and bilateral desquamation of finger tips. Repeated laboratory studies showed persistently elevated ESR and CRP with thrombocytosis. The patient was diagnosed with recurrence of Kawasaki disease and treated successfully with IVIG.
Kawasaki disease is a febrile illness of childhood that involves inflammation in the walls of small and medium sized arteries. The peak age of incidence is between 13 and 24 months. Diagnostic criteria are based on signs and symptoms that include: fever for at least 5 days and the presence of at least 4 of the following 5 criteria: bilateral non purulent conjunctivitis; oral‐mucosal changes; edema and desquamation of the distal extremities; polymorphous rash; and cervical lymphadenopathy greater than 1.5 cm in diameter. Among the diagnostic criteria, cervical lymphadenopathy is the least common, presenting in about 50‐75% of patients. Isolated cervical adenopathy presenting as the first sign of Kawasaki disease usually results in a delayed diagnosis. Most are treated with antibiotics for suspected bacterial infection and sometimes undergo lymph node biopsy. It is not until later when patients demonstrate a poor response to antibiotics and other cardinal symptoms start to develop when Kawasaki disease is diagnosed. Once these patients receive IVIG, symptoms resolve.
It is important to keep Kawasaki disease in the differential diagnosis of cervical lymphadenopathy even when all criteria are not fulfilled. Although difficult, it is important to diagnosis Kawasaki disease in a timely manner, as this can reduce unnecessary procedures, cardiac sequelae, and antibiotic use.
To cite this abstract:Lee C, Addison J, Siam F. Recurrence of Kawasaki Disease. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 462. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/recurrence-of-kawasaki-disease/. Accessed April 5, 2020.