Exam 3: Kawasaki Case Study

Question 1

Kawasaki

Answer 1

Mucocutaneous lymph node syndrome

An acute onset of a generalized systemic inflammation,
which results in a vasculitis of medium-sized arteries of
the body. Notably, it attacks the coronary arteries,
responsible for delivering oxygen-rich blood to the
heart, often resulting in high risk for aneurysm.

Question 2

Kawasaki Facts (7)

Answer 2

1. Leading cause of acquired heart disease in children in the United States
2. 90% of patients affected are than girls
3. Highest reported rates are during the winter and spring
4. Highest rates of occurrence in children with Asian ancestry (NOT exclusive)!
5. Generally self-limiting over a 6-8 week course
6. “Diagnosis of Exclusion”

Question 3

Differential Diagnosis of Kawasaki (10)

Answer 3

1. Stevens-Johnson Syndrome
2. Group B Streptococcal Infection
3. Toxic Shock Syndrome
4. Adenovirus
5. Meningitis
6. Measles
7. Scarlet Fever
8. Epstein-Barr Virus
9. SJRA- Systemic Juvenile Rheumatoid Arthritis
10. Echovirus

Question 4

Etiology of Kawasaki

Answer 4

Exact is unknown, but it’s linked to:

1. Infectious Agents (STREP A) .. caused by an immune regulated response
   OR
2. Environmental Toxins

Question 5

Phases of Kawasaki (3)

Answer 5

1st: Acute Febrile → ~ 5-14 days, fever and hallmark
symptoms

2nd: Subacute → ~25 days post fever, peeling of hands
and feet, arthralgic pain

3rd: Convalescent → ~ 6-8 weeks after onset, clinical
signs are gone, lab values returning to normal

Question 6

Stage 1 Hallmark Signs and Symptoms (5)

Answer 6

Acute febrile stage ~5-14 days, fever and hallmark symptoms:

1. Bilateral painless conjunctival injection- limbus sparing,
   without exudate
2. Truncal polymorphous exanthema (maculopapular rash)
3. Cervical lymphadenopathy, usually unilateral > 1.5 cm
4. Edematous and erythematous hands and feet
5. Erythematous mouth and mucus membranes, “strawberry
   tongue”, and chapped dry lips
6. Acute febrile - high fever

Question 7

Subacute stage

Answer 7

25 days post fever –> peeling of hands and feet, arthralgic pain

Question 8

Convalescent stage

Answer 8

6-8 weeks after onset, clinical signs are gone, but lab values still returning to normal; Elevated platelet count
*Greater risk for clot

Question 9

Lab values (6)

Answer 9

1. Elevated ESR and CRP (inflammation)
2. Elevated platelets
3. Anemia
4. Elevated WBC
5. Sterile pyuria –> WBC in the urine
6. Low serum albumin - vessels are leaky and permeable

Question 10

Specialists to consult

Answer 10

1. Cardiologist for concern of later stages (high risk for aneurysm)
2. Infectious disease

Question 11

Treatment (5)

Answer 11

1. Hospitalized, CICU or PICU
   * Otherwise, 20% of patients will develop dilated coronary arteries, have constriction problems, and develop aneurysm
2. IV infusion of immunoglobulin (IVIG): to reduce dilation of coronary
   arteries and prevent aneurysms, and help with fever reduction.
3. Aspirin: as an antipyretic, anti-inflammatory, and antiplatelet agent
4. Supportive care: cautious rehydration, comfort, and pain
   management as necessary
5. Skin care: Cool cloths, application of aquaphor/unscented lotions, and use of light soft cotton clothing.

Question 12

Hallmark of Kawasaki Conjunctival Injection (5)

Answer 12

1. Painless injection
2. Extremely bloodshot eyes
3. Limbus sparing
4. White outline
5. No exudate

Question 13

Common feature of Kawasaki that may result a few weeks after initial onset (2)

Answer 13

1. Peeling of rashes –> starting to heel and disappear

2. Verry irritable

Question 14

Necessary follow ups (6)

Answer 14

1. Aspirin, low doses for 6-8 weeks
2. No contact sports during aspirin therapy
3. Healthy diet (+/- Na+ restriction)
4. Pediatric cardiologist follow-up for serial echocardiograms (echo) to assess coronary artery status and left ventricular function/contractility
   @ 2 weeks post diagnosis, 6-8 weeks, 12 months
5. Hold Varicella and MMR- no live flu vaccines for several months after IVIG
6. Cardiac catheterization in extreme cases