Delayed diagnosis of Kawasaki disease presenting with massive lymphadenopathy and airway obstruction

Risk factors for retropharyngeal cellulitis in Kawasaki disease

OBJECTIVE

Kawasaki disease (KD) is an acute multisystemic vasculitis of unknown etiology that occurs in infants and children. Retropharyngeal cellulitis has been reported as a rare manifestation of KD. This study investigated the frequency and characteristics of patients with KD manifesting as retropharyngeal soft-tissue swelling.

METHODS

We retrospectively reviewed 277 patients, with a mean age of 1 year and an age range of 7 months to 12 years, in whom KD had been diagnosed between 2005 and 2011.

RESULTS

In 10 patients (3.6%), contrast-enhanced computed tomography (CECT) showed low-density lesions without ring enhancement in the retropharyngeal spaces. These patients presented initially with fever and cervical lymphadenopathy, and were initially treated by their pediatricians for suppurative lymphadenitis (seven patients) or retropharyngeal abscess (three patients). KD was finally diagnosed either after antibiotics had been ineffective or when other symptoms characteristic of KD emerged.

CONCLUSION

Low-density lesions in the retropharyngeal space were identified by CECT in 3.6% of the KD patients. Early diagnosis of KD is essential because coronary artery lesions develop in 50% of untreated patients. If a child presents with fever, cervical lymphadenopathy, and swelling of the retropharyngeal space, KD should be included in the differential diagnoses.

An update on Kawasaki disease II: clinical features, diagnosis, treatment and outcomes

This is the second of two updates on Kawasaki disease. The first review focused on epidemiology and aetio-pathogenesis. Here, we review the clinical features and diagnosis of Kawasaki disease, as well as recent evidence on treatment, follow-up and cardiovascular outcomes.

A case of Kawasaki disease with coexistence of a parapharyngeal abscess requiring incision and drainage

Kawasaki disease (KD) causes multisystemic vasculitis but infrequently manifests with deep neck infections, such as a peritonsillar abscess, peritonsillar or deep neck cellulitis, suppurative parapharyngeal infection, or retropharyngeal abscess. As its etiology is still unknown, the diagnosis is usually made based on typical symptoms. The differential diagnosis between KD and deep neck infections is important, considering the variable head and neck manifestations of KD. There are several reports on KD patients who were initially diagnosed with retropharyngeal abscess on on computed tomography scans (CT). However, the previously reported cases did not have abscess or fluid collection on retropharyngeal aspiration. Therefore, false-positive neck CT scans have been obtained, until recently. In this case, suspected neck abscess in patients with KD unresponsive to intravenous immunoglobulin could signal the possible coexistence of suppurative cervical lymphadenitis.

Kawasaki disease mimicking retropharyngeal abscess

Kawasaki disease is an acute, self-limiting febrile mucocutaneous vasculitis of infants and young children. Retropharyngeal lymphadenopathy is a rare presentation of Kawasaki disease. We present a case of Kawasaki disease mimicking a retropharyngeal abscess, with upper airway obstruction resulting in delayed diagnosis.

The clinical manifestations and risk factors of a delayed diagnosis of Kawasaki disease

BACKGROUND

Kawasaki disease (KD) is an acute febrile vasculitis and may cause coronary artery abnormalities. Due to the higher incidence in Asian countries, most pediatricians in Taiwan are familiar with KD. However, there are still some patients being diagnosed 10 days after the onset of the illness and not receiving a highly effective therapy. In this study, we analyzed the risk factors and clinical manifestations of patients with a delayed diagnosis of KD.

METHODS

A retrospective review was made of the medical records of the patients diagnosed with KD at our institution between January 1996 and December 2005. The patients were divided into 2 groups: early-diagnosis group (EDG: diagnosis was made within 10 days after the onset of the fever) and delayed-diagnosis group (DDG: diagnosis was made 10 days after the onset of the fever).

RESULTS

Fourteen of a total of 78 children (17.9%) were grouped into the DDG group, and 64 into the EDG group. There were no statistical differences between the 2 groups in terms of age, gender, number of antibiotics used, day of the first medical visit, total days of skin rash, conjunctivitis, mucosa changes, lymphadenopathy or laboratory examinations except for the higher white blood cell count and serum immunoglobulin G level in the DDG group. The patients in the EDG group had a clustered onset of symptoms as compared to the DDG group with a dispersed and late onset of symptoms. There was a higher risk of coronary artery abnormalities in the DDG group than the EDG group (42.9% vs. 14.1%; p = 0.036), and in the patients with KD who were younger than 1 year (29.0% vs. 12.7%; p = 0.043).

CONCLUSION

Patients with delayed diagnosis of KD were associated with higher risk of developing coronary arterial lesions. It is necessary to develop a diagnostic test for KD and provide more education to health care providers for early recognition of KD.

Kawasaki disease resembling a retropharyngeal abscess--case report and literature review

A retropharyngeal abscess is a rare presentation of Kawasaki disease. Herein, we present a case of Kawasaki disease mimicking a retropharyngeal abscess, and review five previously published case reports. Once the correct diagnosis of Kawasaki disease is established, any abscess-like lesion on computed tomography may be just a false-positive finding.

Lack of association of cervical lymphadenopathy and coronary artery complications in Kawasaki disease

BACKGROUND

Cervical lymphadenopathy is a typical feature in some children with Kawasaki disease, but whether its presence or absence delays diagnosis, thereby increasing the risk of coronary artery abnormalities, has remained uncertain.

AIM

: The aim of this study is to review the clinical features of Kawasaki disease with particular reference to investigating the relationship of cervical lymphadenopathy to the development of coronary artery lesions.

METHODS

Demographic and clinical data from all the patients entered into the Hong Kong Kawasaki disease registry during 1994 to 2000 were reviewed. The presenting clinical features, echocardiographically monitored coronary artery lesions and influence of cervical lymphadenopathy (> or = 1 nodes > or = 1.5 cm diameter) on clinical onset-to-diagnosis time and response to immunoglobulin therapy are reported.

RESULTS

We studied 696 patients (99% Chinese, male/female ratio 1.7:1). Their distribution was inversely related to age. Twenty-four percent of the patients presented with cervical lymphadenopathy, the relative incidence of which was directly related to age. Five percent of patients had demonstrable coronary artery aneurysms at 8 weeks after disease onset. A slightly higher percentage of patients with absence of lymphadenopathy had late diagnosis. No significant positive or negative overall association between cervical lymphadenopathy and coronary artery lesions was observed. Time to resolution of fever after immunoglobulin administration did not differ between those with and without cervical lymphadenopathy.

CONCLUSIONS

Cervical lymphadenopathy was present in only 24% of the patients with Kawasaki disease, correlating directly with age. Its absence may delay the timing of diagnosis. There was, however, no overall association between lymphadenopathy and coronary lesions.

Delayed diagnosis of Kawasaki syndrome: an analysis of the problem

OBJECTIVE

Most pediatric providers in Colorado are familiar with Kawasaki syndrome (KS). However, in a recent outbreak, 30% of cases were diagnosed after illness day 10. We hypothesized that these children saw providers who were not familiar with KS, were given antibiotics for other diagnoses that delayed identification, had access-to-care issues, or presented atypically.

METHODS

A retrospective chart review of 106 consecutive KS cases seen at the Children's Hospital in Denver during 1994-2000 was conducted.

RESULTS

Twenty-five of 106 children (23.6%) were diagnosed after day 10 of illness (delayed-diagnosis group [DDG]), and these 25 cases were compared with 81 cases diagnosed on or before day 10 (early-diagnosis group [EDG]). There were no differences between patients in the DDG and EDG in age, gender, number of visits, specialty of the primary care physician, time to the first medical visit, number of antibiotics received, coronary artery abnormalities, white blood cell count, or erythrocyte sedimentation rate. Patients in the DDG had significantly more days of fever, rash, red eyes, and oral changes. A platelet count of >450000/mm3 occurred more often in the DDG (56%) than the EDG (30%). After additional analysis, patients in the EDG had close clustering of symptom onset in the first few days of illness, but patients in the DDG had onset of symptoms scattered over 9 days. Patients in the DDG were 2.8 times more likely to have coronary artery aneurysms than patients in the EDG (DDG: 24%; EDG: 8.6%).

CONCLUSIONS

Diagnosis after the 10th day of illness was not linked to type of medical provider, number of antibiotics received, or number of physician visits. Patients in the DDG exhibited the typical features of KS, but the onset of their symptoms was dispersed over time as opposed to the close clustering of symptoms in the EDG. Because coronary artery aneurysms occurred significantly more often in the patients in the DDG, more education is needed to teach health care providers to have a high index of suspicion for KS in young children presenting with fever/rash illnesses.

The diagnosis and management of Kawasaki disease

Kawasaki disease (KD) is a systemic vasculitis of childhood with a predilection for the coronary arteries. It is the predominant cause of paediatric acquired heart disease in developed countries. The aetiology of KD remains unknown and consequently there is no diagnostic test. The diagnosis is made using a constellation of clinical criteria that in isolation have poor sensitivity and specificity. Early treatment prevents overt coronary artery damage in the majority of children. The long-term effects of childhood KD on later cardiovascular health remain unknown. A recent study showed that treatment of KD in Australia is suboptimal, with late diagnosis occurring in approximately half of the cases and an unacceptably high incidence of acute cardiac involvement. These guidelines highlight the difficulties in the diagnosis of KD and offer some clues that may assist early recognition of this important paediatric disease. They also detail current treatment recommendations and the evidence on which they are based. Increased awareness of the epidemiology and spectrum of the clinical presentation of KD is essential for early recognition and optimal management.

Sensorineural hearing loss and Kawasaki disease: a prospective study

PURPOSE

Kawasaki disease (KD) is an acute, self-limited vasculitis of infants and children that is now the most common cause of acquired heart disease in the pediatric age group in the United States and Japan. Reports have documented the association of acute KD with sensorineural hearing loss. To assess the prevalence of hearing loss following acute KD in a geographically and ethnically diverse population, a prospective, multicenter study of hearing loss in patients with KD was conducted.

MATERIALS AND METHODS

Patients with acute KD were enrolled in 7 clinical centers and underwent a primary audiologic evaluation within 30 days of the onset of fever. Patients were subsequently reevaluated after resolution of the acute phase of the disease. A questionnaire assessing risk factors for hearing loss was also administered.

RESULTS

A total of 62 patients were evaluated during the 29-month study period. At the first audiologic evaluation, 19 patients (30.6%) had sensorineural hearing loss, 6 patients (9.7%) had conductive hearing loss, 17 patients (27.4%) had normal hearing, and 20 patients (32.3%) had inconclusive studies. Overall, 2 of 36 patients (5.5%) had sensorineural hearing loss documented on their second audiologic evaluation. No risk factors for hearing loss were identified by the questionnaire.

CONCLUSIONS

Transient sensorineural hearing loss (20 to 35 dB) is a frequent complication of acute KD and may be related to salicylate toxicity in some patients. Persistent sensorineural hearing loss is uncommon. Parents and primary care providers should be made aware of the potential for persistent sensorineural hearing loss following resolution of KD, but routine audiologic screening of this patient population does not appear to be warranted.

Kawasaki disease presenting as cervical lymphadenitis or deep neck infection

OBJECTIVE

To describe a group of patients with Kawasaki disease who had cervical lymphadenopathy as their dominant initial presentations.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 14 children who were admitted to Chang-Gung Children's Hospital between May 1996 and July 1998 with the initial impression of cervical lymphadenitis, cellulitis, and/or deep neck infection but for which a diagnosis of Kawasaki disease was established later.

RESULTS

Five (35.7%) patients were less than 5 months of age, and 8 (57.1%) patients were more than 53 months of age. The mean duration for establishing a diagnosis of Kawasaki disease from the onset of illness was 8.2 (6 to 20) days. Initially, empiric antibiotics were prescribed in each case with unsatisfactory response. Intravenous immune gamma globulin (2 g/kg) was administered in 13 patients. Three (21.4%) patients developed coronary artery lesions.

CONCLUSION

If a child less than 6 months or more than 4 years of age has a fever and an enlarged cervical lymph node and is unresponsive to empiric antibiotics, Kawasaki disease should be considered.

Head and neck manifestations of Kawasaki disease

Kawasaki disease, also known as acute infantile febrile mucocutaneous lymph node syndrome, is a self-limited vasculitic disease of infants and young children. The cause of the disease remains uncertain. Within the constellation of signs and symptoms, there are numerous otolaryngologic manifestations. The following represents the largest series of patients in the otolaryngology literature, involving 155 confirmed cases of Kawasaki disease as treated at our institution during the last 10 years. The demographic data, clinical pictures of the typical and atypical forms of the illness, as well as the laboratory values, therapy and complications are discussed.

Tuberculin skin test reactivity in Kawasaki disease

A strongly positive tuberculin skin reaction (> 1.5 cm2) was observed during the acute phase of the illness in 11 children with Kawasaki disease (KD), but not in control pediatric patients with other febrile infections (41 patients) or diseases similar to KD (9 patients). The cutaneous sensitivity to intermediate strength [5 tuberculin units (TU)] purified protein derivative (PPD) inoculation had completely disappeared by the second monthly checkup. Peripheral blood T lymphocytes from KD subjects proliferated vigorously and produced significant amounts of IL-2 in response to the stimulation elicited by 0.05 TU/mL of PPD. In contrast, the proliferative response of, and IL-2 release by, control T cells was within background values. Mounting laboratory evidence suggests that heat shock proteins (HSP) may be involved in the pathogenesis of KD. Our clinical and experimental data may, therefore, have been due to immunologic cross-reactivity between mycobacterial derived HSP65 and its human homologue HPS63 (self P1 antigen). Despite the low number of patients investigated, our findings suggest that the tuberculin skin test and its in vitro correlates (T cell mitogenesis and IL-2 production) could provide simple and reliable diagnostic tools for identifying atypical forms of KD, or vice versa, in subjects not vaccinated against tuberculosis.