dk’s kd
TRANSCRIPT
DK’s KDby: Wiston E. Ilagan
This is a case of D.K, 5 months old, male, Filipino, Roman Catholic, presently residing at 336 Quilo-Quilo North P. Garcia, Batangas, who was admitted due to fever of 21 days.
Chief complaint
21 days PTA • Initially presented with fever (38 – 39 C) for 2 days • Paracetamol (10 mkdose), • Temporary relief of fever.
19 days PTA• Fever escalated (40 C) • Not relieved by Paracetamol. • Prompt consult at NL Villa Memorial Medical Center in
Lipa City Batangas.• Urinary Tract Infection based on urinalysis.• started with Ceftriaxone IV (123 mkdose)
History of Present Illness (Day 1 – Day 3)
17 days PTA• Defervescence• Ceftriaxone IV was shifted to Cefexime (6
mkday)• Discharged • In the afternoon of the same day, there was
reoccurrence of fever.
History of Present Illness (Day 4)
14 days PTA• Readmitted• Febrile (39.5 ), remittent • Cefixime discontinued• Shifted to Azithromycin• Irritable • ESR ( 48 mmol/hr) and CRP were requested which
showed increased values.• Given Hydrocortisone (5mkdose),
Diphenhydramine (1mkdose) and Ampicillin-Sulbactam (100 mkday)
History of Present Illness (Day 7)
13 DAYS PTA• ( + ) dry fissured lips, strawberry tongue , redness
of the bilateral eye and brawny edema of hands and feet
• More irritable that he can’t sleep.• Febrile (39 C). • Started on aspirin 80 mkD
History of Present Illness (Day 9)
11 days PTA• Given IVIG 2 g/kg. • Apparently well and disappearance of signs and
symptoms of KD • Deferevescence were noted, 48 hours after
administration. • Still on Azithromycin and developed loose stools. • Subsequently sent home on Aspirin tablet (80
mkday) and Azithromycin.
History of present illness (Day 11)
9 days PTA• Initially asymptomatic but developed fever
(39C) in the afternoon • 3 episodes of loose stools upon discharge
which • Prompted re-admission.• Referred to Pedia Intensivist• Looked up for alternative focus of
infection. • Blood, urine and stool C/S was done that
all eventually turned negative .
History of Present Illness (Day 12)
8 days PTA• Started on piperacillin-tazobactam 89 mkd.• Referred to a pediatric cardiologist.
History of Present Illness (Day 13)
7 days PTA• 2D echo was done: Dilated right coronary artery and
left coronary at 0.3 cm proximal and distal, minimal pericardial effusion
• Febrile (39 C).• Desquamating lesion on chest, abdomen and
extremities.• Erythematous rashes in the groin and buttocks area. • Started on methylprednisolone 255 IV • Aspirin was increased to 170 mg/tab 1 tab every 6
hours. • Stool and blood culture and sensitivity showed no
growth.
History of Present Illness ( Day 14)
6 days PTA• IV methylprednisolone was shifted to oral
methylprednisolone 8 mg BID.4 days PTA• Started on metronidazole. • Febrile (~38C).
History of Present Illness ( Day 15- Day 17)
3 days PTA• Febrile (39 C), • HAMA• discharged with home medications:
Paracetamol drops (10 mkdose), Metronidazole 125/ml, Methylprednisolone 8 mg tab BID, and ASA 8 mg 1 tab ½ tab OD.
2 days PTA• Febrile (38 C). • Paracetamol was given and was relieved.
History of Present Illness (Day 18 – Day 19)
1 day PTA• Afebrile, active, not irritable with decreasing
signs and symptoms of Kawasaki Disease. • His parents decided to bring him to Manila
for further evaluation.Few hours PTA .• Upon examination in the clinic, febrile
(38.4 C) • Admission
History of present Illness (Day 20-21)
No previous hospitalizations or surgeries. No known allergies to food or medications.
Past Medical History
Birth and Maternal history• Born to a 30-year old G2P1. • Denied any illnesses or exposure to
smoking/alcohol intake/radiation during her pregnancy.
• Term via normal spontaneous delivery• With no fetomaternal complications.
Paternal
HypertensionDiabetes mellitusLung carcinoma
Maternal
HypertensionDiabetes mellitusBreast carcinoma
Family history
Social smile at 1 month. Good head control; laughs loudly; and reaches for
objects Follows moving objects with eyes and takes bottle in
mouth = 4 months
Developmental History (5 months)
Nutritional History Breastfeeding until age of 2 with formula of
S-26, 1:1 dilution Consuming approximately 4 cm.
Lives in a well-lit, well-ventilated house with 3 other household members.
Water source for consumption is distilled water, not boiled. Garbage is collected daily.
Active and cheerful child and smiles to everyone
Personal and Social
Immunizations BCG, Hepa B, 1 dose of 5-in-1 (HiB/DPT/IPV)
vaccine, and 1 dose of 6-in-1 (HiB/IPV/DPT/HepaB) vaccine
• no weight lossGeneral
• No jaundice, no cyanosisSkin
• No swelling, discharge, tenderness, discharge epistaxis, discharge, mass
HEENT
Review of Systems
• No cough, colds, difficulty of breathingRESPIRATORY
• No cyanosisCardiovasular
• no hematemesis, constipation, hematocheziaGsstrointestinal
• No polyuria, hematuria, discharge, (+) erythematous rash in inguinal area
Genitourinary • No loss of consciousness, stiffening
of muscles, blank stare, drooling of saliva, muscle twitching
Neurology
Review of Systems
Physical ExaminationGeneral •awake, alert, not in cardiorespiratory distress
•Height: 70 cm Weight: 7.5 kg Length/Ht for age = O • Weight for Age = + 1
Vital Signs •Temperature = 36 C RR = 36 cpm HR = 142 bpm
Skin •(+) brownish desquamation on the chest and trunk
HEENT •normocephalic, pink palpebral conjunctiva, anicteric sclera, non sunken eyeball, no nasal discharge, (+) erythematous, dry lips and buccal mucosa, nonhyperemic posterior pharyngeal wall, tonsils not enlarged, (+) right palpable cervical lymphadenopathies = 1 cm
Chest/Lungs •symmetrical chest expansion, no retractions, clear and equal breath sounds, no wheezes/crackles
Cardiovascular •normal rate and regular rhythm, no murmurs
Physical Examination
Abdomen •globular, no visible pulsations, normoactive bowel sounds, soft, nontender
Genitourinary •(+) perineal erythema
Extremities •(+) erythematous palms and soles, no cyanosis, (+) edema dorsa of the hands and foot, pulses full and equal
KAWASAKI DISEASE S/P INTRAVENOUS IMMUNOGLOBULIN
Admitting Diagnosis / Working Impression
COURSE IN THE WARD
May 15 (Day 1) Vital signs
Skin:HEENTLungsHeart
Genitourinary Extremities
Course in the Ward
May 15, 2012
Day 1 afebrile3-4 episodes of pasty loose stools
Improved activityGood suck
less irritable 2D echo was done with the
follewing results:Advised for second round of IVIG
Discontinue MethylprednisoloneStart Dyprimadole 25 mg / tablet, prepare 6.25 mg papertab twice
a dayGive second dose of IVIG (2g/kg)
6 vials
May 16, 2012 (Day 2)
Vital signs
Skin:
HEENT
Lungs
Heart
Abdomen
Genitourinary
Extremities
May 16, 2012
Day 2 afebrile good suck
not irritableDecided to transfer to other
hospital for IVIG
Take home medications: Aspirin 100 mg / tablet # 10
(prepare 150 mg papertablet and give 1 papertablet every 6);
Dipyridamole 25 mg /tablet # 12 (prepare 6-25 mg paper tablet
two doses a day)
Salient Features 5 month old (+)Bilateral bulbar conjunctival injection,
nonpurulent (resolved) (+) Changes in the mucosa, dry fissured lips,
strawberry tongue (resolving) (+) Changes of the peripheral extremities, such as
edema and/or erythema of the hands or feet and periungual desquamation (resolving)
(+) Rash, primarily truncal; polymorphous but nonvesicular (resolving)
(+) Cervical adenopathy, lymphadenopathy (1 cm), uniateral right
1 2 3 4 5 6 7 8 9 10111213141516171819202135.5
3636.5
3737.5
3838.5
3939.5
4040.5
Se...
Fever for 21 days (high spiking, remittent, and unresponsive to antibiotics)
LABORATORY STUDIES
May 6 48 (<10 mmol/hr)
May 9 51 (<10 mmol/hr)
May 11 81 (<10 mmol/hr)
Erythrocyte Sedimentation Rate
Parameters MAY 6 MAY 9 MAY 11
MAY 14
NORMAL VALUES
WBC 19.8 23.8 22.3 5.6 5,000-10,000
Henoglobin 9 9.8 9.6 10 12-15
Hematocrit 28 30 30 30 37-45
Segmenters 54 47 50 53 55-65
Lymphocytes 32 36 31 43 26-35
Monocytes 8 17 14 --- 2-6
Eisonophiles 6 6 5 --- 2-4
Platelet 457,000
768,000
772,000
916,000
150,000-400,000
Complete Blood CountUNIT
Cu. Mm.
g/dl
Vol %
%
%
%
%
Cu. Mm.
Parameters MAY 12 MAY 14Color Light yellow YellowTurbidity Clear ClearGlucose Negative NegativeProtein Negative NegativepH 6.0 6.0Specific Gravity 1.020 1.020WBC 0-1 0-1RBC 0-1 0-1Casts None seen None seen
URINALYSIS and FECALYSIS
Parameters Result (May 5)Color yellowish brownConsistency Semi-formedWBC 0-1RBC 0-1Baxteria Few Parasites None
May 6 Blood C/S: no growth after 24 hours of
incubation May 8 Blood C/S: no growth after 2 days
May 7 There is haziness of the inner lung markings Impression: Consider Bronhitis. No consolidation
identified.
Laboratory studies
Normal abdominal sites Apex on the left Dilated right coronary artery and left
coronary at 0.3 cm proximal and distal Normal chamber sizes Minimal pericardial effusion Good left ventricular systolic function Left sided aortic arch
2D Echocardiography May 5
Intact interarterial / interventricular septae Normal cardiac valves and cardiac dimensions Dilated Left and Right Coronary artery. Left coronary
artery approximately 2.5 to 3.4 mm. The right coronary artery measures approximately 2.3 to 2.9 mm
There is saccular aneurysm at proximal coronary artery measuring 3.8 – 4.3 mm
Good left ventricular systolic function Small pericardial effusion No thrombus / vegetation seen Color flow Doppler study reveal tricuspid regurgitation
and pulmonic regurgitation
May 15 2D echo
DIFFERANTIAL DIAGNOSIS
Steven-Johnson Syndrome
Age = 5 mos, Prolonged fever, conjunctivitis, keratitis, target
lesions, erythema of oral mucosa, pseudomembrane formation
normal extremities, (-) CLADS, exudative conjunctivitis, vesiculr rash with crusting. associated with Herpes
Virus infection, athralgia
Streptococcal Scarlet fever
Fever = variable usually 10 days; strawberry tongue, flaky
desquamation, sandpaper rash, (+) CL, irritable
Normal eyes, pharyngitis, positive throat culture for Group A strep
Rapid clinical response to appropriate antibiotic therapy
Measles
High fever, rash , non-exudative conjunctivitis, lymphadenopathy,
desquamation severe cases.
Solitary enlarged lymphadenopathy, fever = 5 days only, Koplik spots and
morbiliform rash
Diagnostic Guidelines of Kawasaki Disease (MCLS: Infantile Acute Febrile Mucocutaneous Lymph Node Syndrome)
Pathophysiology of DiseasePredisposing factors:
Age-5 mosr old, Sex-Male, Race-Asian
Precipitating Factors:
Unknown yet linked with unknown etiologic agent and environmental factors
Entry of
KD AGENT
Autoimmune Response
Release of Chemical Mediators
Vasodilation and Cellular Permeabilty
Attraction of Phagocytes and WBC
Entry of antigen on lymphatic capillaries
S/S:
Redness, Swelling, Heat
Phagocytosis by neutrophils and macrophages (antigens are localized and inflammation happens
Increase pressure due to inflammation and entry
of antibodies
Entry of pathogens in the systemic circulation↓Regulation of toxins in the body↓Release of pyrogen↓Stimulation of the hypothalamus↓Increase or alteration of thermoregulation↓Increase in body temperature↓
Hyperthermia
Swelling of tissues↓Disruption of skin surfaces↓Skin desquamation and Rash↓Impaired skin integrity
Systemic blood vessels involvement (inflammation of small & medium size vessels)
If treated:
IVIG
GOOD PROGNOSIS Refractory symptoms
Give another round of IVIG
If not treated:
Complications developed
Pericarditis
Myocarditis
Cardiomegaly
Myocardial infarction
Heart failure
Ruptured coronary aneurysym
DEATH
Formerly known as mucocutaneous lymph node syndrome or infantile polyarteritis nodosa
Acute febrile vasculitis of childhood
First described by Dr. Tomisaku Kawasaki in Japan in 1967
Occurs worldwide with Asians at higher risk
Leading cause of acquired heart disease in children
WHAT IS KAWASAKI DISEASE?
Acute, multisystem, self-limited vasculitis• Small-medium vessels: panvasculitis• Age1: 0.5-5 years (90% of cases)Peak 9-24 months• Male: female = 1.3-1.7:1
• Incidence2-4: (per 100,000/yr of < 5 yrs old)–
◦ 360 for Japanese◦ 95 for Chinese◦ 77 for Hawaiians◦ 56 for Filipino◦ 7 for Caucasians
• Recurrence: 1.3-3%
Classical KDIncomplete KD
Atypical KD
Kawasaki Disease (KD)
Classical KD Fever > 5 days +
4/5 criteria of
• Bilateral conjunctival injection
• Changes in lips and oral cavity
• Cervical lymphadenopathy
• Polymorphous exanthem
• Changes in extremities
Exclusion of other diseases
Incomplete KD
Incomplete KD 15-20% of KD1 Age: <1 yr ESR > 40 mm/hr CRP > 3 mg/dL > 3/6 Supplemental
Criteria2 •Alb < 3 g/dL •Elevate ALT •Anemia for age •Plt after 7d >
450,000/mm3 •WBC > 15,000/mm3 •UA > 10 WBC/HPF
Atypical KD
Phases of KD
Subacute phase
Convalescent Phase
Thank you!