A report describes a case of a 6-month-old, term, previously healthy, and fully immunized girl who initially presented to pediatric urgent care with one day of fever, fussiness, and refusal to eat. She was negative for cough, congestion, or rhinorrhea. Examination demonstrated a fussy infant with a temperature of 38.8°C, with no focal signs of infection. A rapid influenza swab and a catheterized urinalysis with urine culture were negative. Thus, she received a diagnosis of viral infection.
On day 2 of the fever, she developed an erythematous, seemingly nonpruritic, blotchy rash and re-presented to care on day 4 of the fever with a persistent rash. Vital signs demonstrated a temperature of 38.3°C, sinus tachycardia (200 beats/minute), and tachypnea with an oxygen saturation of 100%. She showed irritability, limbic sparing conjunctivitis, and dry, cracked lips. However, she was negative for lymphadenopathy and had normal extremities.
The patient has mild subcostal retractions, despite normal breath sounds. Laboratory testing showed a left-shifted white blood cell count with bandemia, normocytic anemia, normal platelets, markedly elevated C-reactive protein of 13.3 mg/dL and an erythrocyte sedimentation rate of 118. She also showed hyponatremia and hypoalbuminemia with otherwise normal chemistries, including liver function tests. Results from respiratory pathogen testing by RT-PCR test and blood culture were negative. A chest radiograph displayed a faint opacity in the left midlung zone.
The patient's parents also gave a history of upper respiratory symptoms three weeks before in their 9-year-old child. The family had self-isolated because of the COVID-19 pandemic the week before and denied any recent travel history.
The patient got referred for admission for Kawasaki Disease(KD) evaluation on day 5 of fever, where she showed limbic sparing conjunctivitis; prominent tongue papilla; a blanching, polymorphous, maculopapular rash; and swelling of the hands and lower extremities (thus meeting classic criteria for KD). She received a single dose of 2 g/kg intravenous immunoglobulin and high-dose acetylsalicylic acid (20 mg/kg 4 times daily), according to treatment guidelines. Her last elevated temperature was 38.3°C, just after completing intravenous immunoglobulin. Her echocardiogram was normal without any evidence of coronary dilation or aneurysm, no pericardial effusion, and normal valvar and ventricular function.
The evening before discharge, her RT-PCR testing for COVID-19 came positive, and the family was instructed to quarantine at home for 14 days from the positive test result date. The patient received a discharge on low-dose acetylsalicylic acid (3 mg/kg daily), with plans to follow up with pediatric cardiology for repeat echocardiographic evaluation two weeks after discharge.
Jones VG, Mills M, Suarez D, et al. COVID-19 and Kawasaki Disease: Novel Virus and Novel Case. Hosp Pediatr. 2020;10 (6): 537–540. https://doi.org/10.1542/hpeds.2020-0123
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