Adult Recurrence of Kawasaki Disease Mimicking Retropharyngeal Abscess

Parapharyngeal and retropharyngeal infections in children: Kawasaki disease needs vigilance

OBJECTIVE

Kawasaki Disease (KD) may mimic Parapharyngeal (PPI) and Retropharyngeal Infections (RPI), leading to misdiagnosis as Deep Neck Infections (DNIs). The treatment plans for the two diseases are different, and delayed treatment can lead to serious complications. Therefore, prompt diagnosis and management are necessary. This study was performed to evaluate the clinical features of KD mimicking DNIs and explore the treatment options.

METHODS

Children with cellulitis or abscess in parapharyngeal or retropharyngeal space in neck CT were included in this study. The medical records of enrolled children were retrospectively reviewed.

RESULTS

In total, 56 children were diagnosed with PPI or/and RPI. Twenty-two (39.3%) participants were eventually diagnosed with KD, and 34 (60.7%) were diagnosed with DNIs. Compared with the DNIs group, the KD group had a higher body temperature (p=0.007), and higher levels of AST (p=0.040), ALT (p=0.027), and ESR (p=0.030). Deep cervical cellulitis (p=0.005) were more common in the KD group. However, deep neck abscess often occurred in the DNIs group (p=0.002), with parapharyngeal abscess being the most common type of abscess (p=0.004). The KD mimicking DNIs cases did not respond to antibiotic treatment, but symptoms significantly improved after the use of Immunoglobulin (IVIG) and aspirin.

CONCLUSION

Children with KD may exhibit retropharyngeal or parapharyngeal inflammation in the early stages. KD should be considered a differential diagnosis for children with DNIs, high fever, and no response to antibiotic therapy. Surgery in KD mimicking deep neck abscess requires caution.

LEVEL OF EVIDENCE

I.

Two Cases of Adult-onset Kawasaki Disease with a Difficult Diagnosis

We encountered two consecutive cases of adult-onset Kawasaki disease (AKD) that were difficult to diagnose. In both cases, Kawasaki disease was not considered as a differential diagnosis in the early stages. However, it was possible to make a diagnosis by citing the disease as a differential diagnosis and introducing the patients to the pediatrics department. AKD has a minimal incidence rate and may have a clinical course different from that of childhood-onset Kawasaki disease. Therefore, it is necessary to incorporate Kawasaki disease into the differentiation of an adult fever and to consult with a pediatrician for its diagnosis.

Magnetic resonance imaging accuracy before surgery in children with retropharyngeal abscesses

AIMS

Retropharyngeal abscess (RPA) is a deep neck infection occurring in childhood. The gold standard technique for diagnosis is computerised tomography (CT) with a contrast medium. The aim of this study is to answer the question of whether magnetic resonance imaging (MRI) can be an alternative in diagnosing RPA and predicting pus drainage at surgery.

METHODS

This is a retrospective study conducted at the paediatric emergency department of a tertiary level children hospital. The medical records of 31 children admitted to the Otorhinolaryngology and Paediatric ward, with a suspected diagnosis of RPA, were reviewed. The primary study outcome was the diagnostic accuracy of CT and MRI in predicting the amount of pus during surgery.

RESULTS

Twenty-two patients (71%) underwent surgery. Among them, 18 had imaging before surgery. Eleven patients evaluated with CT scan underwent surgery: four had non-significant purulent drainage, three of them were reported to have a significant fluid collection (negative predictive value 66% and positive predictive value of 55%). Nine patients evaluated with MRI underwent surgery: four cases had non-significant purulent drainage, three of them showed a significant fluid collection at MRI (negative predictive value of 60%; positive predictive value of 56%).

CONCLUSION

MRI and CT scans showed similar accuracy in predicting successful pus drainage during surgery; therefore, it could be a valid alternative in the diagnosis of RPA in children.

Retropharyngeal edema: A rare manifestation of eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by excessive eosinophil accumulation in the peripheral blood and affected tissues with development of granulomatous vasculitic organ damage. Although upper airway and neck involvement is seen in patients with EGPA, retropharyngeal inflammation has never been reported. We report a case of retropharyngeal edema in a 70-year-old woman with EGPA. Her symptoms improved and the retropharyngeal edema disappeared on computed tomography following treatment. EGPA should be considered as a differential diagnosis in patients with asthma presenting with neck swelling and dysphagia.

Adult-onset recurrent Kawasaki disease: an unusual cause of fever of unknown origin

We present the case of a 20-year-old man with a background of transposition of the great arteries presenting with fever of unknown origin, who developed a shock like syndrome with respiratory failure necessitating intubation. After extensive investigation, a diagnosis of adult-onset Kawasaki disease was made, and he was successfully treated with IVIg and corticosteroids. We present the clinical findings clinicians should be aware of, and review the literature on managing this rare presentation in adult, highlighting the importance of early diagnosis in improving outcomes. Both children and adults with Kawasaki disease require long-term follow-up, as they remain at increased risk of both coronary artery aneurysms and early acute coronary syndrome.

Infliximab as an alternative therapy for refractory adult onset Kawasaki disease: A case report

RATIONALE

Kawasaki disease (KD) is an acute febrile illness predominantly affecting children less than 5 years of age and characterized by systemic inflammation in all medium-sized arteries. Adult-onset KD (AKD) is rare with only 105 case reports published. Recently, the efficacy of infliximab (IFX) for patients with refractory KD has been demonstrated.

PATIENT CONCERNS

A previously healthy 24-year-old man was admitted because of a persistent fever, and elevated serum level of AST, ALT, LDH, and CRP.

DIAGNOSIS

The patients met the diagnostic criteria for KD based on the findings of persistent fever, polymorphous exanthema, unilateral cervical lymphadenopathy, non-purulent palpebral conjunctivitis and membranous desquamation. Echocardiogram revealed the dilatation at the proximal sites of the right coronary artery (7.9 mm) and left anterior descending artery (5 mm). The patient was treated with high-dose intravenous immunoglobulin (1 g/kg/day for 2 days) and ASA (100 mg daily). However, his fever and arthralgia persisted.

INTERVENTIONS

He was administered single 5 mg/kg doses of IFX.

OUTCOMES

He became afebrile the next day and his arthralgia improved.

LESSONS

We report the first case of administration of IFX in a patient with AKD refractory to intravenous immunoglobulin (IVIG), and successful reduction of systemic inflammation. However, the effectiveness of IFX in the regression of coronary artery aneurysm remains to be determined.