CARA, Mariel Danica C.

CASE MANAGEMENT - NOVEMBER 20, 2020

What are your salient features?

 3 months old, male
 Intermittent fever (Tmax: 38.4 C)
 Colds, watery
 Decreased in appetite
 Decreased in appetite
 Poor activity
 Multiple, erythematous, non-pruritic, maculopapular rashes
 Frequent diaper changes
 Cough, non-productive, non-distressing
 Minimal bleeding around the lips
 No vomiting and loose stools

PE:
 Weight for length: above +2 = obese
 BMI for age: above +2 = obese
 HEENT: hyperemic sclera with limbal sparing, sunken eyeball, watery nasal discharge,
dry red lips
 Abdomen: hyperactive bowel sounds
 External Genitalia: slight swelling and erythema of the foreskin of the penis,
desquamation of perianal area
 Extremities: polymorphous maculopapular rash, generalized in the neck, back and both
upper and lower extremities
Laboratories:
 Increased C-reactive protein
 Increased ESR
 CBC: increased WBC, increased platelet count, increased neutrophils
 Urinalysis: Glucose-positive (+1), acidic urine, leukocytes: trace, pus cells: 19.0/Ul, RBC:
0.6/Ul, epithelial cells: 9.0/Ul, bacteria: 114/ul

What will be your differential diagnosis?

 MEASLES
RULE IN:
- Fever
- Colds
- Cough
- Multiple, erythematous, non-pruritic, maculopapular rashes
RULE OUT
- No conjunctivitis

 ROSEOLA INFANTUM
RULE IN:
- 3 months old
- Fever
- Cough and colds
- Multiple, erythematous, non-pruritic, maculopapular rashes
RULE OUT:
 - Rashes usually appear after the fever lyses
- No bulging fontanel
- No seizure
 KAWASAKI DISEASE:
RULE IN:
- 3 month old
- Fever
- Cough and colds
- Multiple, erythematous, non-pruritic, maculopapular rashes
- Minimal bleeding around the lips
- PE: HEENT: hyperemic sclera with limbal sparing, dry red lips
RULE OUT:
- Cannot be totally ruled out

 URINARY TRACT INFECTION:

RULE IN:
- Fever
- Frequent diaper changes
- PE: slight swelling and erythema of the foreskin of the penis
- Urinalysis: Pyuria, presence of bacteria
RULE OUT:
- Cannot be totally ruled out

What is your main diagnosis? Why?

 KAWASAKI DISEASE, ATYPICAL to rule out URINARY TRACT INFECTION with
SOME DEHYDRATION, MILD
- Kawasaki disease (KD), formerly known as mucocutaneous lymph node
syndrome and infantile polyarteritis nodosa, is an acute febrile illness of
childhood seen worldwide, with the highest incidence occurring in Asian children.
KD is a systemic inflammatory disorder manifesting as a vasculitis with a
predilection for the coronary arteries.
- This is my main diagnosis because of the signs and symptoms our patient is
presenting, which are commonly seen in Kawasaki disease, such as Fever
(>38.3; in our patient Tmax of 38.4C), and the presence of 3 principal clinical
criteria, such as bilateral nonexudative conjunctival injenction with limbal sparing,
red, cracked lips, with minimal bleeding, multiple, erythematous, non-pruritic,
maculopapular rashes. Perineal desquamation which is seen in acute phase is
present in our patient.
- Other clinical and laboratory findings, that are consistent in our diagnosis,
includes cogh and colds, leukocytosis with neutrophilia, increased CRP and
increased in ESR.
- There is also some dehydration, mild because of the presence of sunken eyes
and dry lips.
- To rule out UTI, because of the pyuria in urinalysis and the presence of bacteria.
What laboratory tests will you do?
 There is no diagnostic test for KD, but patients usually have characteristic laboratory
findings. But there are characteristic findings.
- CBC: Leukocyte count is often elevated, with a predominance of neutrophils and
immature forms. Normocytic, normochromic anemia is common. The platelet
count is generally normal in the 1st wk of illness and rapidly increases by the 2nd
to 3rd wk of illness, sometimes exceeding 1 million/mm3.
 - ESR and CRP: An elevated ESR or CRP value is universally present in the acute
phase of illness. The ESR may remain elevated for weeks, in part from the effect
of IVIG.
- Urinalysis: Sterile pyuria,
- Blood chemistry: mild elevations of the hepatic transaminases,
hyperbilirubinemia
- CSF Fluid Analysis: Cerebrospinal fluid pleocytosis may also be present.
- 2D ECHO: Two-dimensional echocardiography is the most useful test to monitor
for development of CAA
- Urine Culture: to rule out urinary tract infection
What is your management?
PLAN
 Admit the patient.
 Secure consent for treatment and management.
 Hook to D5NaCl to run at a rate of 48 cc/hr in the first 8 hours.
DIET:
 Continue milk feeding if tolerated.
DRUGS:
 Intravenous immune globulin 2 g/kg over 10-12 hr
 Aspirin 30-50 mg/kg/day or 80-100 mg/kg/day divided every 6 hr orally until patient is
afebrile for at least 48 hr
 Discontinue Amoxicillin

What will be your home instruction for the patient?

All children with a history of KD should be counseled regarding:
 A heart-healthy diet, we should advise the mother to continue milk feeding, and to watch
out for the foods that the child will consume in the future.
 Adequate amounts of exercise, since again, our patient is an infant, it is not yet
applicable to him, but we must educate the mother regarding exercise once the child
grows.
 Tobacco avoidance, we should educate the parents regarding smoking, because it will
cause harm to both the child and the smoker, and even to the whole family.
 Intermittent lipid monitoring, again, this is more applicable when the child grows.
We should also advise the mother to always update the child’s immunization.