by:

Wiston E. Ilagan
This is a case of D.K, 5 months old,
male, Filipino, Roman Catholic,
presently residing at 336 Quilo-Quilo
North P. Garcia, Batangas, who was
admitted due to fever of 21 days.
21 days PTA
Initially presented with fever (38 39 C) for 2 days
Paracetamol (10 mkdose),
Temporary relief of fever.

19 days PTA
Fever escalated (40 C)
Not relieved by Paracetamol.
Prompt consult at NL Villa Memorial Medical Center in
Lipa City Batangas.
Urinary Tract Infection based on urinalysis.
started with Ceftriaxone IV (123 mkdose)
17 days PTA
Defervescence
Ceftriaxone IV was shifted to Cefexime (6 mkday)
Discharged
In the afternoon of the same day, there was
reoccurrence of fever.

14 days PTA
Readmitted
Febrile (39.5 ), remittent
Cefixime discontinued
Shifted to Azithromycin
Irritable
ESR ( 48 mmol/hr) and CRP were requested
which showed increased values.
Given Hydrocortisone (5mkdose),
Diphenhydramine (1mkdose) and Ampicillin-
Sulbactam (100 mkday)

13 DAYS PTA
( + ) dry fissured lips, strawberry tongue , redness of the
bilateral eye and brawny edema of hands and feet
More irritable that he cant sleep.
Febrile (39 C).
Started on aspirin 80 mkD



11 days PTA
Given IVIG 2 g/kg.
Apparently well and disappearance of signs and
symptoms of KD
Deferevescence were noted, 48 hours after
administration.
Still on Azithromycin and developed loose stools.
Subsequently sent home on Aspirin tablet (80 mkday)
and Azithromycin.

9 days PTA
Initially asymptomatic but developed fever (39C)
in the afternoon
3 episodes of loose stools upon discharge
which
Prompted re-admission.
Referred to Pedia Intensivist
Looked up for alternative focus of infection.
Blood, urine and stool C/S was done that all
eventually turned negative .
8 days PTA
Started on piperacillin-tazobactam 89 mkd.
Referred to a pediatric cardiologist.

7 days PTA
2D echo was done: Dilated right coronary artery and left
coronary at 0.3 cm proximal and distal, minimal pericardial
effusion
Febrile (39 C).
Desquamating lesion on chest, abdomen and
extremities.
Erythematous rashes in the groin and buttocks area.
Started on methylprednisolone 255 IV
Aspirin was increased to 170 mg/tab 1 tab every 6
hours.
Stool and blood culture and sensitivity showed no
growth.
6 days PTA
IV methylprednisolone was shifted to oral
methylprednisolone 8 mg BID.
4 days PTA
Started on metronidazole.
Febrile (~38C).

3 days PTA
Febrile (39 C),
HAMA
discharged with home medications: Paracetamol
drops (10 mkdose), Metronidazole 125/ml,
Methylprednisolone 8 mg tab BID, and ASA 8
mg 1 tab tab OD.

2 days PTA
Febrile (38 C).
Paracetamol was given and was relieved.
1 day PTA
Afebrile, active, not irritable with decreasing signs
and symptoms of Kawasaki Disease.
His parents decided to bring him to Manila for
further evaluation.
Few hours PTA .
Upon examination in the clinic, febrile (38.4 C)
Admission

No previous hospitalizations or surgeries.
No known allergies to food or medications.

Born to a 30-year old G2P1.
Denied any illnesses or exposure to smoking/alcohol
intake/radiation during her pregnancy.
Term via normal spontaneous delivery
With no fetomaternal complications.


P
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Hypertension
Diabetes
mellitus
Lung
carcinoma
M
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Hypertension
Diabetes
mellitus
Breast
carcinoma
Social smile at 1 month.
Good head control; laughs loudly; and reaches for
objects
Follows moving objects with eyes and takes bottle in
mouth = 4 months


Breastfeeding until age of 2 with formula of S-26,
1:1 dilution
Consuming approximately 4 cm
.
Lives in a well-lit, well-ventilated house with 3
other household members.
Water source for consumption is distilled water,
not boiled. Garbage is collected daily.
Active and cheerful child and smiles to everyone
BCG, Hepa B, 1 dose of 5-in-1 (HiB/DPT/IPV)
vaccine, and 1 dose of 6-in-1
(HiB/IPV/DPT/HepaB) vaccine
no weight loss General
No jaundice, no cyanosis Skin
No swelling, discharge, tenderness,
discharge epistaxis, discharge, mass
HEENT
No cough, colds, difficulty of
breathing
RESPIRATORY
No cyanosis Cardiovasular
no hematemesis, constipation,
hematochezia
Gsstrointestinal
No polyuria, hematuria, discharge, (+)
erythematous rash in inguinal area
Genitourinary
No loss of consciousness, stiffening of
muscles, blank stare, drooling of saliva,
muscle twitching
Neurology
General
awake, alert, not in cardiorespiratory distress
Height: 70 cm Weight: 7.5 kg Length/Ht for age = O
Weight for Age = + 1
Vital Signs
Temperature = 36 C RR = 36 cpm HR = 142 bpm
Skin
(+) brownish desquamation on the chest and trunk
HEENT
normocephalic, pink palpebral conjunctiva, anicteric sclera, non
sunken eyeball, no nasal discharge, (+) erythematous, dry lips and
buccal mucosa, nonhyperemic posterior pharyngeal wall, tonsils not
enlarged, (+) right palpable cervical lymphadenopathies = 1 cm
Chest/Lungs
symmetrical chest expansion, no retractions, clear and equal breath
sounds, no wheezes/crackles
Cardiovascular
normal rate and regular rhythm, no murmurs
Abdomen
globular, no visible pulsations, normoactive bowel
sounds, soft, nontender
Genitourinary
(+) perineal erythema
Extremities
(+) erythematous palms and soles, no cyanosis,
(+) edema dorsa of the hands and foot, pulses full
and equal
KAWASAKI DISEASE
S/P
INTRAVENOUS
IMMUNOGLOBULIN
May 15 (Day 1)
Temp = 36 C RR= 32 cpm HR =
118 bpm
Vital signs
decrease desquamating lesion on
chest and abdomen
Skin:
moist mucosa, improving oral
mucosa (+) CLAD
HEENT
Equal expansion, clear breath
sounds
Lungs
Adynamic precordium, regular rate,
normal rhythm, no murmur
Heart
Perineal erythema, (+) lesions Genitourinary
Slightly edema of hands and feet,
Full equal pulses
Extremities
May 15, 2012
Day 1 afebrile
3-4 episodes of pasty loose stools
Improved activity
Good suck
less irritable
2D echo was done with the follewing
results:
Advised for second round of IVIG

Discontinue Methylprednisolone
Start Dyprimadole 25 mg / tablet,
prepare 6.25 mg papertab twice a
day
Give second dose of IVIG (2g/kg) 6
vials
May 16, 2012 (Day 2)
Temp = 36.3 C RR= 30 cpm HR
= 120 bpm
Vital signs

decrease desquamating lesion on
chest and abdomen
Skin:
Moist lips, improving Oral mucosa,
(+) CLAD
HEENT
Equal expansion, clear breath
sounds
Lungs
Adynamic precordium, regular rate,
normal rhythm, no murmur
Heart
Flabby, not distended, soft, non
tenderNormoactive bowel sounds,
Abdomen
Decreased perineal erythema Genitourinary
Full equal pulses, Extremities
May 16, 2012
Day 2 afebrile
good suck
not irritable
Decided to transfer to other
hospital for IVIG
Take home medications:
Aspirin 100 mg / tablet # 10
(prepare 150 mg papertablet
and give 1 papertablet every
6);
Dipyridamole 25 mg /tablet #
12 (prepare 6-25 mg paper
tablet two doses a day)
5 month old
(+)Bilateral bulbar conjunctival injection, nonpurulent
(resolved)
(+) Changes in the mucosa, dry fissured lips,
strawberry tongue (resolving)
(+) Changes of the peripheral extremities, such as
edema and/or erythema of the hands or feet and
periungual desquamation (resolving)
(+) Rash, primarily truncal; polymorphous but
nonvesicular (resolving)
(+) Cervical adenopathy, lymphadenopathy (1 cm),
uniateral right

35.5
36
36.5
37
37.5
38
38.5
39
39.5
40
40.5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Series 1
May 6 48 (<10
mmol/hr)
May 9 51 (<10
mmol/hr)
May 11 81 (<10
mmol/hr)
Parameters MAY 6 MAY 9 MAY 11 MAY 14 NORMAL
VALUES
WBC 19.8 23.8 22.3 5.6 5,000-10,000
Henoglobin 9 9.8 9.6 10 12-15
Hematocrit 28 30 30 30 37-45
Segmenters 54 47 50 53 55-65
Lymphocytes 32 36 31 43 26-35
Monocytes 8 17 14 --- 2-6
Eisonophiles 6 6 5 --- 2-4
Platelet 457,00
0
768,00
0
772,00
0
916,000 150,000-400,000
UNIT
Cu. Mm.
g/dl
Vol %
%
%
%
%
Cu. Mm.
Parameters MAY 12 MAY 14
Color Light yellow Yellow
Turbidity Clear Clear
Glucose Negative Negative
Protein Negative Negative
pH 6.0 6.0
Specific Gravity 1.020 1.020
WBC 0-1 0-1
RBC 0-1 0-1
Casts None seen None seen
Parameters Result (May 5)
Color yellowish brown
Consistency Semi-formed
WBC 0-1
RBC 0-1
Baxteria Few
Parasites None
May 6
Blood C/S: no growth after 24 hours of
incubation
May 8
Blood C/S: no growth after 2 days

May 7
There is haziness of the inner lung markings
Impression: Consider Bronhitis. No
consolidation identified.


Normal abdominal sites
Apex on the left
Dilated right coronary artery and left coronary at
0.3 cm proximal and distal
Normal chamber sizes
Minimal pericardial effusion
Good left ventricular systolic function
Left sided aortic arch


Intact interarterial / interventricular septae
Normal cardiac valves and cardiac dimensions
Dilated Left and Right Coronary artery. Left coronary
artery approximately 2.5 to 3.4 mm. The right coronary
artery measures approximately 2.3 to 2.9 mm
There is saccular aneurysm at proximal coronary
artery measuring 3.8 4.3 mm
Good left ventricular systolic function
Small pericardial effusion
No thrombus / vegetation seen
Color flow Doppler study reveal tricuspid regurgitation
and pulmonic regurgitation


Steven-Johnson Syndrome
Age = 5 mos, Prolonged
fever, conjunctivitis,
keratitis, target lesions,
erythema of oral
mucosa,
pseudomembrane
formation
normal extremities, (-)
CLADS, exudative
conjunctivitis, vesiculr
rash with crusting.
associated with Herpes
Virus infection, athralgia
Streptococcal Scarlet fever
Fever = variable usually
10 days; strawberry
tongue, flaky
desquamation,
sandpaper rash, (+) CL,
irritable
Normal eyes, pharyngitis,
positive throat culture for
Group A strep
Rapid clinical response to
appropriate antibiotic
therapy
Measles
High fever, rash , non-
exudative conjunctivitis,
lymphadenopathy,
desquamation severe
cases.
Solitary enlarged
lymphadenopathy, fever
= 5 days only, Koplik
spots and morbiliform
rash

Predisposing factors:
Age-5 mosr old, Sex-Male, Race-Asian
Precipitating Factors:
Unknown yet linked with unknown etiologic agent and environmental factors
Entry of
KD AGENT
Autoimmune Response
Release of Chemical
Mediators
Vasodilation and Cellular
Permeabilty
Attraction of Phagocytes
and WBC
Entry of antigen on
lymphatic capillaries
S/S:
Redness, Swelling, Heat

Phagocytosis by neutrophils and
macrophages (antigens are localized
and inflammation happens
Increase pressure due to
inflammation and entry
of antibodies
Entry of pathogens in the systemic circulation

Regulation of toxins in the body

Release of pyrogen

Stimulation of the hypothalamus

Increase or alteration of thermoregulation

Increase in body temperature

Hyperthermia
Swelling of tissues

Disruption of skin surfaces

Skin desquamation and Rash

Impaired skin integrity
Systemic blood vessels involvement (inflammation of
small & medium size vessels)
If treated:
IVIG

GOOD PROGNOSIS


Refractory symptoms

Give another round of IVIG

If not treated:
Complications developed


Pericarditis




Myocarditis




Cardiomegaly

Myocardial infarction
Heart failure


Ruptured coronary
aneurysym



DEATH

Formerly known as mucocutaneous
lymph node syndrome or infantile
polyarteritis nodosa
Acute febrile vasculitis of childhood
First described by Dr. Tomisaku
Kawasaki in Japan in 1967
Occurs worldwide with Asians at
higher risk
Leading cause of acquired heart
disease in children
Acute, multisystem, self-limited vasculitis
Small-medium vessels: panvasculitis
Age1: 0.5-5 years (90% of cases)
Peak 9-24 months
Male: female = 1.3-1.7:1
Incidence2-4: (per 100,000/yr of < 5 yrs old)
360 for Japanese
95 for Chinese
77 for Hawaiians
56 for Filipino
7 for Caucasians
Recurrence: 1.3-3%

Fever > 5 days + 4/5 criteria of

Bilateral conjunctival injection
Changes in lips and oral cavity
Cervical lymphadenopathy
Polymorphous exanthem
Changes in extremities
Exclusion of other diseases

15-20% of KD1
Age: <1 yr
ESR > 40 mm/hr
CRP > 3 mg/dL
> 3/6 Supplemental Criteria2
Alb < 3 g/dL
Elevate ALT
Anemia for age
Plt after 7d > 450,000/mm3
WBC > 15,000/mm3
UA > 10 WBC/HPF