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Ratnapalan S, Thevaranjan J, Perera N, Nassarallah B, Wolter NE. Retropharyngeal and parapharyngeal infections in children: A retrospective analysis. Pediatr Neonatol 2025; 66:162-167. [PMID: 39019720 DOI: 10.1016/j.pedneo.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/31/2023] [Accepted: 12/13/2023] [Indexed: 07/19/2024] Open
Abstract
OBJECTIVES To describe presentations, management and outcomes of retropharyngeal and parapharyngeal infections in children presenting to a tertiary care pediatric emergency department. METHODS A retrospective chart review of children with deep neck infections such as retropharyngeal or parapharyngeal infection from January 2008 to December 2018 was conducted at a pediatric hospital. RESULTS There were 176 retropharyngeal, 18 parapharyngeal and 6 with both retropharyngeal and parapharyngeal infections treated during the 10-year study period. Males were 60% of the cohort and the mean age was 4.3 (SD: 3.2) years. No significant differences in age or sex ratio or presentations were seen in children with retropharyngeal infections compared with parapharyngeal infections. All received parenteral antibiotics; 42% (84/200) of children underwent surgery and four of them had more than one surgical drainage. Age <12 months and the diagnosis of parapharyngeal infections were associated with significantly higher rates of surgical treatment. Children under 12 months of age were sicker at presentation and had a high complication rate of 23% compared with 1% in the older children (p = 0.002). Seven children had co-existence of Kawasaki disease with deep neck infections. CONCLUSIONS Early diagnosis of retropharyngeal and parapharyngeal infections especially in infants under a year of age is important as they are more likely to have complications and need surgical management. Most paediatric patients with retropharyngeal and parapharyngeal infections have a phlegmon or very small abscesses and are treated non-operatively with parenteral antibiotics.
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Liu J, Zhou SH. Parapharyngeal and retropharyngeal infections in children: Kawasaki disease needs vigilance. Braz J Otorhinolaryngol 2024; 90:101405. [PMID: 38490013 PMCID: PMC10955290 DOI: 10.1016/j.bjorl.2024.101405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/20/2023] [Accepted: 01/13/2024] [Indexed: 03/17/2024] Open
Abstract
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.
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Affiliation(s)
- Jia Liu
- Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Department of Otolaryngology, Hangzhou, Zhejiang Province, China
| | - Shui-Hong Zhou
- Zhejiang University, College of Medicine, The First Affiliated Hospital, Department of Otolaryngology, Hangzhou, Zhejiang, China.
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Chen J, Wen Y. Incomplete Kawasaki Disease Presenting as Retropharyngeal Abscess: A Case Report and Review of the Literature. EAR, NOSE & THROAT JOURNAL 2023:1455613231218140. [PMID: 38083854 DOI: 10.1177/01455613231218140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
Kawasaki disease (KD) is a cryptic and self-limiting vasculitis predominantly seen in children, often posing a diagnostic challenge due to its varied clinical presentations. Among these, the emergence of deep neck infections, particularly retropharyngeal abscesses, stands out as an extremely rare manifestation. Herein, we present a case of a 10-year-old girl who was hospitalized for fever, neck pain, swollen cervical lymph nodes, and increased inflammation markers. Although anti-infective treatment was initiated, her condition remained unchanged. A cervical computed tomography scan revealed an abscess in the retropharyngeal space. Remarkably, on the third day post-admission, the patient developed symptoms synonymous with KD, such as conjunctival redness, reddened lips, and a strawberry tongue. Subsequent treatment with high-dose intravenous immunoglobulins (IVIG) and oral aspirin led to swift symptom relief, including complete abscess resolution verified by a follow-up neck magnetic resonance imaging. This unique co-presentation of KD and a retropharyngeal abscess, possibly linked to infections like Streptococcus or Staphylococcus aureus, underscores the importance of quick diagnosis and KD management, especially when conventional treatments prove ineffective.
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Affiliation(s)
- Jun Chen
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Sichuan University, Chengdu, Sichuan, China
| | - Yang Wen
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Sichuan University, Chengdu, Sichuan, China
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Huo LM, Li LM, Peng HY, Wang LJ, Feng ZY. Kawasaki disease with peritonsillar abscess as the first symptom: A case report. World J Clin Cases 2023; 11:5391-5397. [PMID: 37621581 PMCID: PMC10445059 DOI: 10.12998/wjcc.v11.i22.5391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/25/2023] [Accepted: 07/17/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome, is an acute, self-limiting vasculitis of unknown aetiology that mainly involves the medium and small arteries and can lead to serious cardiovascular complications, with a 25% incidence of coronary artery aneurysms. Periton-Sillar abscesses are a rare symptom of KD and is easily misdiagnosed at its early stages. CASE SUMMARY A 5-year-old boy who presented to a community hospital with a 3-d fever, difficulty in opening his mouth, and neck pain and was originally treated for throat infection without improvement. On the basis of laboratory tests, ultrasound of submandibular and superficial lymph nodes and computed tomography of the neck, the clinician diagnosed the periamygdala abscess and sepsis that did not resolve after antibiotic therapy. On the fifth day of admission, the child developed conjunctival congestion, prune tongue, perianal congestion and desquamation, and slightly stiff and swollen bunions on both feet. A diagnosis of KD was reached with complete remission after intravenous immunoglobulin treatment. CONCLUSION Children with neck pain, lymph node enlargement, or airway obstruction as the main manifestations are poorly treated with intravenous broad-spectrum antibiotics. Clinicians should not rush invasive operations such as neck puncture, incision, and drainage and should be alert for KD when it cannot be explained by deep neck space infection and early treatment with aspirin combined with gammaglobulin.
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Affiliation(s)
- Li-Man Huo
- Department of Pharmacy, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Li-Min Li
- Department of Paediatrics, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Hao-Yang Peng
- Department of Ultrasound, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Li-Jia Wang
- Department of Medical Imaging, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Zhang-Ying Feng
- Department of Clinical Pharmacology, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
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Huo LM, Li LM, Peng HY, Wang LJ, Feng ZY. Kawasaki disease with peritonsillar abscess as the first symptom: A case report. World J Clin Cases 2023; 11:5385-5391. [DOI: 10.12998/wjcc.v11.i22.5385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/25/2023] [Accepted: 07/17/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome, is an acute, self-limiting vasculitis of unknown aetiology that mainly involves the medium and small arteries and can lead to serious cardiovascular complications, with a 25% incidence of coronary artery aneurysms. Periton–Sillar abscesses are a rare symptom of KD and is easily misdiagnosed at its early stages.
CASE SUMMARY A 5-year-old boy who presented to a community hospital with a 3-d fever, difficulty in opening his mouth, and neck pain and was originally treated for throat infection without improvement. On the basis of laboratory tests, ultrasound of submandibular and superficial lymph nodes and computed tomography of the neck, the clinician diagnosed the periamygdala abscess and sepsis that did not resolve after antibiotic therapy. On the fifth day of admission, the child developed conjunctival congestion, prune tongue, perianal congestion and desquamation, and slightly stiff and swollen bunions on both feet. A diagnosis of KD was reached with complete remission after intravenous immunoglobulin treatment.
CONCLUSION Children with neck pain, lymph node enlargement, or airway obstruction as the main manifestations are poorly treated with intravenous broad-spectrum antibiotics. Clinicians should not rush invasive operations such as neck puncture, incision, and drainage and should be alert for KD when it cannot be explained by deep neck space infection and early treatment with aspirin combined with gammaglobulin.
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Affiliation(s)
- Li-Man Huo
- Department of Pharmacy, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Li-Min Li
- Department of Paediatrics, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Hao-Yang Peng
- Department of Ultrasound, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Li-Jia Wang
- Department of Medical Imaging, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Zhang-Ying Feng
- Department of Clinical Pharmacology, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
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Galeotti C, Bajolle F, Belot A, Biscardi S, Bosdure E, Bourrat E, Cimaz R, Darbon R, Dusser P, Fain O, Hentgen V, Lambert V, Lefevre-Utile A, Marsaud C, Meinzer U, Morin L, Piram M, Richer O, Stephan JL, Urbina D, Kone-Paut I. French national diagnostic and care protocol for Kawasaki disease. Rev Med Interne 2023:S0248-8663(23)00647-1. [PMID: 37349225 DOI: 10.1016/j.revmed.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/04/2023] [Indexed: 06/24/2023]
Abstract
Kawasaki disease (KD) is an acute vasculitis with a particular tropism for the coronary arteries. KD mainly affects male children between 6 months and 5 years of age. The diagnosis is clinical, based on the international American Heart Association criteria. It should be systematically considered in children with a fever, either of 5 days or more, or of 3 days if all other criteria are present. It is important to note that most children present with marked irritability and may have digestive signs. Although the biological inflammatory response is not specific, it is of great value for the diagnosis. Because of the difficulty of recognising incomplete or atypical forms of KD, and the need for urgent treatment, the child should be referred to a paediatric hospital as soon as the diagnosis is suspected. In the event of signs of heart failure (pallor, tachycardia, polypnea, sweating, hepatomegaly, unstable blood pressure), medical transfer to an intensive care unit (ICU) is essential. The standard treatment is an infusion of IVIG combined with aspirin (before 10 days of fever, and for a minimum of 6 weeks), which reduces the risk of coronary aneurysms. In case of coronary involvement, antiplatelet therapy can be maintained for life. In case of a giant aneurysm, anticoagulant treatment is added to the antiplatelet agent. The prognosis of KD is generally good and most children recover without sequelae. The prognosis in children with initial coronary involvement depends on the progression of the cardiac anomalies, which are monitored during careful specialised cardiological follow-up.
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Affiliation(s)
- C Galeotti
- Service de rhumatologie pédiatrique, centre de référence des maladies auto-inflammatoires rares et des amyloses, CHU de Bicêtre, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France.
| | - F Bajolle
- M3C-Necker-Enfants-Malades, hôpital Necker-Enfants-Malades, université de Paris Cité, Paris, France
| | - A Belot
- Service de néphrologie, rhumatologie et dermatologie pédiatriques, centre de référence des rhumatismes inflammatoires et maladies auto-immunes systémiques rares de l'enfant (RAISE), hôpital Femme-Mère-Enfant, hospices civils de Lyon, Lyon, France
| | - S Biscardi
- Service des urgences pédiatriques, centre hospitalier intercommunal de Créteil, Créteil, France
| | - E Bosdure
- Service de spécialités pédiatriques et médecine infantile, CHU Timone-Enfants, 13385 Marseille cedex 5, France
| | - E Bourrat
- Service de pédiatrie générale, maladies infectieuses et médecine interne, centre de référence des rhumatismes inflammatoires et maladies auto-immunes systémiques rares de l'enfant, hôpital universitaire Robert-Debré, université hospital, Assistance publique-Hôpitaux de Paris, 75019 Paris, France
| | - R Cimaz
- Pediatric Rheumatology Unit, Gaetano Pini Hospital, Department of Clinical Sciences and Community Health, Research Centre for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
| | - R Darbon
- Association France vascularites, Blaisy-Bas, France
| | - P Dusser
- Service de rhumatologie pédiatrique, centre de référence des maladies auto-inflammatoires rares et des amyloses, CHU de Bicêtre, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - O Fain
- Service de médecine interne, hôpital Saint-Antoine, Sorbonne université, AP-HP, 75012 Paris, France
| | - V Hentgen
- Service de pédiatrie, centre de référence des maladies auto-inflammatoires et de l'amylose (CEREMAIA), centre hospitalier de Versailles, Le Chesnay, France
| | - V Lambert
- Service de radiologie pédiatrique, Institut mutualiste Montsouris, CHU de Bicêtre, Le Kremlin-Bicêtre, France
| | - A Lefevre-Utile
- Service de pédiatrie générale et des urgences pédiatriques, hôpital Jean-Verdier, Assistance publique-Hôpitaux de Paris (AP-HP), Bondy, France
| | - C Marsaud
- Service de rhumatologie pédiatrique, centre de référence des maladies auto-inflammatoires rares et des amyloses, CHU de Bicêtre, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - U Meinzer
- Service de pédiatrie générale, maladies infectieuses et médecine interne, centre de référence des rhumatismes inflammatoires et maladies auto-immunes systémiques rares de l'enfant, hôpital universitaire Robert-Debré, université hospital, Assistance publique-Hôpitaux de Paris, 75019 Paris, France
| | - L Morin
- Service de réanimation pédiatrique et néonatale, DMU 3 santé de l'enfant et adolescent, hôpital Bicêtre, université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - M Piram
- Division of Dermatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, Quebec, Canada
| | - O Richer
- Service des urgences pédiatriques, hôpital universitaire de Pellegrin, Bordeaux, France
| | - J-L Stephan
- Service de pédiatrie, CHU Saint-Étienne, Saint-Étienne, France
| | - D Urbina
- Service d'accueil des urgences pédiatriques, hôpital Nord, AP-HM, 13005 Marseille, France
| | - I Kone-Paut
- Service de rhumatologie pédiatrique, centre de référence des maladies auto-inflammatoires rares et des amyloses, CHU de Bicêtre, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
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Chen YC, Pan HG, Jia DS, Wang HC, Li L, Teng YS. Clinical features of Kawasaki disease initially mimicking retropharyngeal abscess: a retrospective analysis. Pediatr Rheumatol Online J 2022; 20:115. [PMID: 36514104 PMCID: PMC9749284 DOI: 10.1186/s12969-022-00778-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/06/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Incomplete Kawasaki disease (IKD) initially presenting as retropharyngeal abnormality is very rare and is prone to misdiagnosis and missed diagnosis, often leading to poor prognosis. Most patients were misdiagnosed with retropharyngeal abscesses. Here, we describe and compare IKD patients initially presenting with retropharyngeal abnormalities, typical KD patients without retropharyngeal abnormalities and retropharyngeal abscess patients. METHODS We performed a retrospective case-control study comparing IKD patients initially presenting with retropharyngeal abnormalities to both KD patients without retropharyngeal abnormalities and retropharyngeal abscess patients admitted to Shenzhen Children's Hospital between January 2016 and December 2021. RESULTS We evaluated data from 10 IKD patients initially presenting with retropharyngeal abnormalities (Group A), 20 typical KD patients (Group B) and 16 surgical drainage confirmed retropharyngeal abscess patients (Group C). Compared to Group B, we observed that Group A was older and had a more intense inflammatory response. On the day of admission, Groups A and C had similar early clinical presentations, and there were no significant differences in any major signs or symptoms. Close observation for the development of new KD signs and symptoms and unresponsiveness to empirical antibiotic therapy after 3 days is extremely important. The CRP (p = 0.011), AST (p = 0.002) and ALT (p = 0.013) levels were significantly higher and the WBC (P = 0.040) levels were significantly lower in Group A than in Group C. Neck radiological findings, such as the presence of ring enhancement (p = 0.001) and mass effects on the airway, are also useful tools for distinguishing these two diseases. CONCLUSION The careful observation of the signs and symptoms of this disease and the comprehensive analysis of the laboratory tests and neck radiological findings may help clinicians become aware of retropharyngeal abnormality as an atypical presentation of KD. Then, unnecessary treatments could be reduced, and the occurrence of serious complications can be avoided.
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Affiliation(s)
- Yong-chao Chen
- grid.452787.b0000 0004 1806 5224Department of Otorhinolaryngology, Shenzhen Children’s Hospital, 7019 Yitian Road, Futian District, Shenzhen, Guangdong China ,grid.412449.e0000 0000 9678 1884Department of Otorhinolaryngology, Shenzhen Children’s Hospital, China Medical University, Shenzhen, Guangdong China
| | - Hong-guang Pan
- grid.452787.b0000 0004 1806 5224Department of Otorhinolaryngology, Shenzhen Children’s Hospital, 7019 Yitian Road, Futian District, Shenzhen, Guangdong China
| | - De-sheng Jia
- grid.452787.b0000 0004 1806 5224Department of Otorhinolaryngology, Shenzhen Children’s Hospital, 7019 Yitian Road, Futian District, Shenzhen, Guangdong China ,grid.412449.e0000 0000 9678 1884Department of Otorhinolaryngology, Shenzhen Children’s Hospital, China Medical University, Shenzhen, Guangdong China
| | - Hao-cheng Wang
- grid.452787.b0000 0004 1806 5224Department of Otorhinolaryngology, Shenzhen Children’s Hospital, 7019 Yitian Road, Futian District, Shenzhen, Guangdong China ,grid.412449.e0000 0000 9678 1884Department of Otorhinolaryngology, Shenzhen Children’s Hospital, China Medical University, Shenzhen, Guangdong China
| | - Lan Li
- grid.452787.b0000 0004 1806 5224Department of Otorhinolaryngology, Shenzhen Children’s Hospital, 7019 Yitian Road, Futian District, Shenzhen, Guangdong China
| | - Yi-shu Teng
- grid.452787.b0000 0004 1806 5224Department of Otorhinolaryngology, Shenzhen Children’s Hospital, 7019 Yitian Road, Futian District, Shenzhen, Guangdong China
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Multisystem Inflammatory Syndrome in Adults Presenting as Retropharyngeal Phlegmon. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rhim JW, Kang JH, Lee KY. Etiological and pathophysiological enigmas of severe coronavirus disease 2019, multisystem inflammatory syndrome in children, and Kawasaki disease. Clin Exp Pediatr 2022; 65:153-166. [PMID: 34809418 PMCID: PMC8990954 DOI: 10.3345/cep.2021.01270] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/01/2021] [Indexed: 12/12/2022] Open
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, a novel multisystem inflammatory syndrome in children (MIS-C) has been reported worldwide since the first cases were reported in Europe in April 2020. MIS-C is temporally associated with severe acute respiratory syndrome coronavirus 2 infection and shows Kawasaki disease (KD)-like features. The epidemiological and clinical characteristics in COVID-19, KD, and MIS-C differ, but severe cases of each disease share similar clinical and laboratory findings such as a protracted clinical course, multiorgan involvement, and similar activated biomarkers. These findings suggest that a common control system of the host may act against severe disease insult. To solve the enigmas, we proposed the protein-homeostasis-system hypothesis in that every disease involves etiological substances and the host's immune system controls them by their size and biochemical properties. Also, it is proposed that the etiological agents of KD and MIS-C might be certain strains in the microbiota of human species and etiological substances in severe COVID-19, KD, and MIS-C originate from pathogen-infected cells. Since disease severity depends on the amounts of inflammation-inducing substances and corresponding immune activation in the early stage of the disease, an early proper dose of corticosteroids and/or intravenous immunoglobulin (IVIG) may help reduce morbidity and possibly mortality among patients with these diseases. Corticosteroids are low cost and an analogue of host-origin cortisol among immune modulators. This study's findings will help clinicians treating severe COVID-19, KD, and MIS-C, especially in developing countries, where IVIG and biologics supplies are insufficient.
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Affiliation(s)
- Jung-Woo Rhim
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jin-Han Kang
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyung-Yil Lee
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea.,Junglock Biomedical Institute, Daejeon, Korea
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Tsujioka Y, Handa A, Nishimura G, Miura M, Yokoyama K, Sato K, Handa H, Jinzaki M, Nosaka S, Kono T. Multisystem Imaging Manifestations of Kawasaki Disease. Radiographics 2021; 42:268-288. [PMID: 34826255 DOI: 10.1148/rg.210070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Kawasaki disease (KD) is a common pediatric vasculitis syndrome involving medium- and small-sized arteries that is especially prevalent in early childhood (ie, age 6 months to 5 years). The diagnosis of KD is made on the basis of clinical features, such as fever, characteristic mucocutaneous changes, and nonsuppurative cervical lymphadenopathy. However, early diagnosis is often challenging because many children with KD present with atypical symptoms. The most serious complication of KD is coronary artery aneurysm caused by coronary arteritis. Prompt intravenous immunoglobulin therapy reduces the risk of cardiac morbidity. In addition, the systemic extension of KD-related vasculitis during the acute phase causes a variety of multisystem manifestations, including encephalopathy, stroke, retropharyngeal edema, pericarditis, myocarditis, KD shock syndrome, pulmonary lesions, intestinal pseudo-obstruction, gallbladder hydrops, arthritis, and myositis. These complications tend to be more common in affected children with atypical presentation. Radiologists can play an important role in the timely identification of diverse KD-associated morbidities and thus may contribute to the early diagnosis of atypical KD. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Yuko Tsujioka
- From the Departments of Radiology (Y.T., T.K.) and Cardiology (M.M.), Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Radiology, Keio University School of Medicine, Tokyo, Japan (Y.T., M.J.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (A.H.); Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (A.H.); Center for Intractable Diseases, Saitama University Hospital, Saitama, Japan (G.N.); Department of Pediatrics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan (K.Y.); Department of Radiology, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan (K.S.); Department of Neurology, Chiba University School of Medicine, Chiba, Japan (H.H.); and Department of Radiology, National Center for Child Health and Development, Tokyo, Japan (S.N.)
| | - Atsuhiko Handa
- From the Departments of Radiology (Y.T., T.K.) and Cardiology (M.M.), Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Radiology, Keio University School of Medicine, Tokyo, Japan (Y.T., M.J.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (A.H.); Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (A.H.); Center for Intractable Diseases, Saitama University Hospital, Saitama, Japan (G.N.); Department of Pediatrics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan (K.Y.); Department of Radiology, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan (K.S.); Department of Neurology, Chiba University School of Medicine, Chiba, Japan (H.H.); and Department of Radiology, National Center for Child Health and Development, Tokyo, Japan (S.N.)
| | - Gen Nishimura
- From the Departments of Radiology (Y.T., T.K.) and Cardiology (M.M.), Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Radiology, Keio University School of Medicine, Tokyo, Japan (Y.T., M.J.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (A.H.); Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (A.H.); Center for Intractable Diseases, Saitama University Hospital, Saitama, Japan (G.N.); Department of Pediatrics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan (K.Y.); Department of Radiology, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan (K.S.); Department of Neurology, Chiba University School of Medicine, Chiba, Japan (H.H.); and Department of Radiology, National Center for Child Health and Development, Tokyo, Japan (S.N.)
| | - Masaru Miura
- From the Departments of Radiology (Y.T., T.K.) and Cardiology (M.M.), Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Radiology, Keio University School of Medicine, Tokyo, Japan (Y.T., M.J.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (A.H.); Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (A.H.); Center for Intractable Diseases, Saitama University Hospital, Saitama, Japan (G.N.); Department of Pediatrics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan (K.Y.); Department of Radiology, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan (K.S.); Department of Neurology, Chiba University School of Medicine, Chiba, Japan (H.H.); and Department of Radiology, National Center for Child Health and Development, Tokyo, Japan (S.N.)
| | - Koji Yokoyama
- From the Departments of Radiology (Y.T., T.K.) and Cardiology (M.M.), Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Radiology, Keio University School of Medicine, Tokyo, Japan (Y.T., M.J.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (A.H.); Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (A.H.); Center for Intractable Diseases, Saitama University Hospital, Saitama, Japan (G.N.); Department of Pediatrics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan (K.Y.); Department of Radiology, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan (K.S.); Department of Neurology, Chiba University School of Medicine, Chiba, Japan (H.H.); and Department of Radiology, National Center for Child Health and Development, Tokyo, Japan (S.N.)
| | - Kozo Sato
- From the Departments of Radiology (Y.T., T.K.) and Cardiology (M.M.), Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Radiology, Keio University School of Medicine, Tokyo, Japan (Y.T., M.J.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (A.H.); Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (A.H.); Center for Intractable Diseases, Saitama University Hospital, Saitama, Japan (G.N.); Department of Pediatrics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan (K.Y.); Department of Radiology, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan (K.S.); Department of Neurology, Chiba University School of Medicine, Chiba, Japan (H.H.); and Department of Radiology, National Center for Child Health and Development, Tokyo, Japan (S.N.)
| | - Hideo Handa
- From the Departments of Radiology (Y.T., T.K.) and Cardiology (M.M.), Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Radiology, Keio University School of Medicine, Tokyo, Japan (Y.T., M.J.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (A.H.); Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (A.H.); Center for Intractable Diseases, Saitama University Hospital, Saitama, Japan (G.N.); Department of Pediatrics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan (K.Y.); Department of Radiology, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan (K.S.); Department of Neurology, Chiba University School of Medicine, Chiba, Japan (H.H.); and Department of Radiology, National Center for Child Health and Development, Tokyo, Japan (S.N.)
| | - Masahiro Jinzaki
- From the Departments of Radiology (Y.T., T.K.) and Cardiology (M.M.), Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Radiology, Keio University School of Medicine, Tokyo, Japan (Y.T., M.J.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (A.H.); Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (A.H.); Center for Intractable Diseases, Saitama University Hospital, Saitama, Japan (G.N.); Department of Pediatrics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan (K.Y.); Department of Radiology, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan (K.S.); Department of Neurology, Chiba University School of Medicine, Chiba, Japan (H.H.); and Department of Radiology, National Center for Child Health and Development, Tokyo, Japan (S.N.)
| | - Shunsuke Nosaka
- From the Departments of Radiology (Y.T., T.K.) and Cardiology (M.M.), Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Radiology, Keio University School of Medicine, Tokyo, Japan (Y.T., M.J.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (A.H.); Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (A.H.); Center for Intractable Diseases, Saitama University Hospital, Saitama, Japan (G.N.); Department of Pediatrics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan (K.Y.); Department of Radiology, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan (K.S.); Department of Neurology, Chiba University School of Medicine, Chiba, Japan (H.H.); and Department of Radiology, National Center for Child Health and Development, Tokyo, Japan (S.N.)
| | - Tatsuo Kono
- From the Departments of Radiology (Y.T., T.K.) and Cardiology (M.M.), Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Radiology, Keio University School of Medicine, Tokyo, Japan (Y.T., M.J.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (A.H.); Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (A.H.); Center for Intractable Diseases, Saitama University Hospital, Saitama, Japan (G.N.); Department of Pediatrics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan (K.Y.); Department of Radiology, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan (K.S.); Department of Neurology, Chiba University School of Medicine, Chiba, Japan (H.H.); and Department of Radiology, National Center for Child Health and Development, Tokyo, Japan (S.N.)
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11
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Daube A, Rickert S, Madan RP, Kahn P, Rispoli J, Dapul H. Multisystem inflammatory syndrome in children (MIS-C) and retropharyngeal edema: A case series. Int J Pediatr Otorhinolaryngol 2021; 144:110667. [PMID: 33752089 PMCID: PMC7931672 DOI: 10.1016/j.ijporl.2021.110667] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/09/2021] [Accepted: 02/28/2021] [Indexed: 11/30/2022]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is thought to follow SARS-CoV-2 infection and presents with fever and multisystem dysfunction. We report three children with suspected MIS-C found to have retropharyngeal edema without evidence of a bacterial etiology. We raise the possibility that an association between MIS-C and retropharyngeal edema exists.
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Affiliation(s)
- Ariel Daube
- Division of Pediatric Critical Care, New York University Grossman School of Medicine, 424 East 34th Street, New York, NY, 10016, United States.
| | - Scott Rickert
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, 424 East 34th Street, New York, NY, 10016, United States.
| | - Rebecca Pellett Madan
- Division of Pediatric Infectious Diseases, New York University Grossman School of Medicine, 424 East 34th Street, New York, NY, 10016, United States.
| | - Philip Kahn
- Division of Pediatric Rheumatology, New York University Grossman School of Medicine, 424 East 34th Street, New York, NY, 10016, United States.
| | - Joanne Rispoli
- Department of Radiology, New York University Grossman School of Medicine, 424 East 34th Street, New York, NY, 10016, United States.
| | - Heda Dapul
- Division of Pediatric Critical Care, New York University Grossman School of Medicine, 424 East 34th Street, New York, NY, 10016, United States.
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12
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Zhu F, Ang JY. 2021 Update on the Clinical Management and Diagnosis of Kawasaki Disease. Curr Infect Dis Rep 2021; 23:3. [PMID: 35194409 PMCID: PMC8851597 DOI: 10.1007/s11908-021-00746-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 12/19/2022]
Abstract
Purpose of Review Provide an updated review of the clinical management and diagnosis of Kawasaki disease with inclusion of potential diagnostic difficulties with multisystem inflammatory syndrome in children (MIS-C) given the ongoing COVID-19 pandemic. Recent Findings Adjunctive corticosteroid therapy has been shown to reduce the rate of coronary artery dilation in children at high risk for IVIG resistance in multiple Japanese clinical studies (most notably RAISE study group). Additional adjunctive therapies (etanercept, infliximab, cyclosporin) may also provide limited benefit, but data is limited to single studies and subgroups of patients with cardiac abnormalities. The efficacy of other agents (atorvastatin, doxycycline) is currently being investigated. MIS-C is a clinically distinct entity from KD with broad clinical manifestations and multiorgan involvement (cardiac, GI, hematologic, dermatologic, respiratory, renal). MIS-C with Kawasaki manifestations is more commonly seen in children < 5 years of age. Summary The 2017 American Heart Association (AHA) treatment guidelines have included changes in aspirin dosing (including both 80–100 mg/kg/day and 30–50 mg/kg/day treatment options), consideration of the use of adjuvant corticosteroid therapy in patients at high risk of IVIG resistance, and the change in steroid regimen for refractory KD to include both pulse-dose IVMP and longer course of prednisolone with an oral taper. A significant proportion of children diagnosed with MIS-C, a post-infectious syndrome of SARS-CoV-2 infection, meet criteria for Kawasaki disease. Further investigation is warranted to further delineate these conditions and optimize treatment of these conditions given the ongoing COVID-19 pandemic.
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Affiliation(s)
- Frank Zhu
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Medical College of Wisconsin, Suite 450C, Pediatric Infectious Diseases, 999 North 92nd Street, Wauwatosa, Milwaukee, WI 53226 USA
| | - Jocelyn Y. Ang
- Division of Pediatric Infectious Diseases, Children’s Hospital of Michigan, Detroit, MI USA
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI USA
- Department of Pediatrics, Central Michigan University College of Medicine, Mount Pleasant, MI USA
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13
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Deep Neck Space Involvement of Kawasaki Disease in the US: A Population-Based Study. J Pediatr 2019; 215:118-122. [PMID: 31477383 DOI: 10.1016/j.jpeds.2019.07.054] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/05/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To describe the rate and risk factors of deep neck space involvement of Kawasaki disease. STUDY DESIGN We performed a retrospective analysis using the Kids' Inpatient Database from 2006, 2009, 2012, and 2016. Kawasaki disease and deep neck space involvement cases were identified using International Classification of Diseases codes among children aged <12 years. Demographic and outcome data of Kawasaki disease cases with and without deep neck space involvement were compared. RESULTS Of 20 787 patients with Kawasaki disease, 0.6% (130 cases) had deep neck space involvement. On multivariable analysis, children aged ≥4 years (OR 8.41; 95% CI 3.79-18.7 in those aged 6-11 years), Asian or Pacific Islanders (OR 3.72; 95% CI 1.90-7.27), non-Hispanic black children (OR 2.39; 95% CI 1.34-4.28), and Northeast hospital region (OR 2.32; 95% CI 1.21-4.46) were associated with deep neck space involvement. Surgical drainage was performed in 21.7% of patients with deep neck space involvement. Deep neck space involvement was associated with longer hospital stay and greater costs. CONCLUSIONS Approximately 0.6% of patients with Kawasaki disease present with deep neck space involvement in the US. Deep neck space involvement of Kawasaki disease occurs primarily in older (≥4 years old), non-white, non-Hispanic children. Deep neck space involvement is associated with operative procedures for presumed abscess, longer hospital stay, and greater costs. In caring for children with suspected deep neck space abscess, particularly when they are not responding to antibiotics, clinicians should evaluate them for the possibility of Kawasaki disease.
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14
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Lim S, Lee NY, Han SB, Jeong DC, Kang JH. Deep Neck Inflammation: Probable Kawasaki Disease in Korean Children. Clin Exp Otorhinolaryngol 2019; 13:77-82. [PMID: 31599139 PMCID: PMC7010501 DOI: 10.21053/ceo.2019.00948] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/23/2019] [Indexed: 11/27/2022] Open
Abstract
Objectives Deep neck infections (DNIs) can cause life-threatening complications, and prompt diagnosis and management are necessary. Kawasaki disease (KD) may be accompanied by deep neck inflammation; making it difficult to distinguish from DNIs. This study was performed to evaluate clinical features and outcomes of children with parapharyngeal and retropharyngeal inflammation. Methods Medical records of the children diagnosed with parapharyngeal and retropharyngeal cellulitis or abscess using cervical computed tomography (CT) between 2013 and 2017 were retrospectively reviewed. Results A total of 47 children were diagnosed with parapharyngeal and retropharyngeal inflammation. Eleven (23.4%) of them were eventually diagnosed with KD, and 36 (76.6%) were diagnosed with DNIs. There were no significantly different clinical and laboratory characteristics on admission between children diagnosed with KD and DNIs; however, significantly more children with KD were febrile for ≥3 days after admission compared to those with DNIs (P=0.009). Deep neck abscesses on CT were observed in 16 children with DNIs (44.4%) and in no child with KD (P=0.009). Among the 36 children with DNIs, 30 (83.3%) were cured with antibiotic therapy only. Conclusion A quarter of children presenting with deep neck inflammation were diagnosed with KD. KD should be considered in children showing deep neck inflammation unresponsive to empirical antibiotic therapy after 3 days, especially in those presenting with deep neck cellulitis rather than deep neck abscess.
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Affiliation(s)
- Sooyeon Lim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Na Young Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Beom Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Han Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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15
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Isidori C, Sebastiani L, Esposito S. A Case of Incomplete and Atypical Kawasaki Disease Presenting with Retropharyngeal Involvement. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16183262. [PMID: 31491922 PMCID: PMC6765912 DOI: 10.3390/ijerph16183262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/25/2019] [Accepted: 08/27/2019] [Indexed: 12/29/2022]
Abstract
Background: Kawasaki disease (KD) is a childhood acute febrile vasculitis of unknown aetiology. The diagnosis is based on clinical criteria, including unilateral cervical lymphadenopathy, which is the only presenting symptom associated with fever in 12% of cases. A prompt differential diagnosis distinguishing KD from infective lymphadenitis is therefore necessary to avoid incorrect and delayed diagnosis and the risk of cardiovascular sequelae. Case presentation: We describe the case of a 4 years old boy presenting with febrile right cervical lymphadenopathy, in which the unresponsiveness to broad-spectrum antibiotics, the following onset of other characteristic clinical features and the evidence on the magnetic resonance imaging (MRI) of retropharyngeal inflammation led to the diagnosis of incomplete and atypical KD. On day 8 of hospitalisation (i.e., 13 days after the onset of symptoms), one dose of intravenous immunoglobulins (IVIG; 2 g/kg) was administered with rapid defervescence, and acetylsalicylic acid (4 mg/kg/day) was started and continued at home for a total of 8 weeks. Laboratory examinations revealed a reduction in the white blood cell count and the levels of inflammatory markers, thrombocytosis, and persistently negative echocardiography. Clinically, we observed a gradual reduction of the right-side neck swelling. Fifteen days after discharge, the MRI of the neck showed a regression of the laterocervical lymphadenopathy and a resolution of the infiltration of the parapharyngeal and retropharyngeal spaces. Conclusion: Head and neck manifestations can be early presentations of KD, which is frequently misdiagnosed as suppurative lymphadenitis or retropharyngeal infection. A growing awareness of the several possible presentations of KD is therefore necessary. Computed tomography (CT) or MRI can be utilised to facilitate the diagnosis.
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Affiliation(s)
- Chiara Isidori
- Department of Surgical and Biomedical Sciences, University of Perugia, 06132 Perugia, Italy.
| | - Lisa Sebastiani
- Department of Surgical and Biomedical Sciences, University of Perugia, 06132 Perugia, Italy.
| | - Susanna Esposito
- Department of Medical and Surgical Sciences, University of Parma, 43126 Parma, Italy.
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Rouault M, Coudert A, Hermann R, Gillet Y, Truy E, Ayari-Khalfallah S. Otorhinolaryngological manifestations and delayed diagnosis in Kawasaki disease. Int J Pediatr Otorhinolaryngol 2019; 121:137-142. [PMID: 30903929 DOI: 10.1016/j.ijporl.2019.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Kawasaki disease (KD) is a febrile multisystemic vasculitis of unknown etiology whose coronary prognosis is improved by early diagnosis and management. The objective of this study was to describe ENT manifestations encountered and to look for a delayed diagnosis associated with these manifestations. METHODS A retrospective descriptive single-center study was conducted in Lyon between January 2009 and December 2017. All children treated for Kawasaki disease were included in the study. Clinical, biological and cardiac ultrasound data were collected. According to the diagnosis made at the first medical visit, children were classified into two groups: diagnosis of ENT spectrum or non-ENT diagnosis. The diagnostic times were compared by a Student test. RESULTS 142 patients were included: 64 in the ENT diagnostic group, 78 in the non-ENT diagnostic group. When the initial diagnosis was of ENT spectrum, the diagnostic time of KD was significantly longer: 8.51 days vs 5.77 days - (p < 0.01). The total duration of fever was also longer - 10.92 vs 8.32 days - (p = 0.013) - and the frequency of antibiotics intake more important - 92.2% vs 46.2% - (p < 0.01). Four children underwent surgery in the ENT diagnostic group: two retro-pharyngeal abscesses, one paracentesis and one cervicectomy. CONCLUSIONS ENT manifestations are frequently at the forefront of KD and constitute a misleading clinical picture responsible for delayed diagnosis and potentially inappropriate medico-surgical management. It is necessary to provide more education to practitioners for earlier recognition of Kawasaki disease.
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Affiliation(s)
- M Rouault
- Service d'ORL Pédiatrique, Hôpital Femme Mère Enfants, Centre Hospitalier et Universitaire, Lyon, France; Université de Lyon, Lyon, France.
| | - A Coudert
- Service d'ORL Pédiatrique, Hôpital Femme Mère Enfants, Centre Hospitalier et Universitaire, Lyon, France; Université de Lyon, Lyon, France
| | - R Hermann
- Service d'ORL, Hôpital Edouard Herriot, Centre Hospitalier et Universitaire, Lyon, France; Université de Lyon, Lyon, France
| | - Y Gillet
- Service d'urgences Pédiatriques, Hôpital Femme Mère Enfants, Centre Hospitalier et Universitaire, Lyon, France
| | - E Truy
- Service d'ORL Pédiatrique, Hôpital Femme Mère Enfants, Centre Hospitalier et Universitaire, Lyon, France; Service d'ORL, Hôpital Edouard Herriot, Centre Hospitalier et Universitaire, Lyon, France; Université de Lyon, Lyon, France; INSERM, U1028, CNRS, UMR5292, Lyon Neuroscience Research Center, IMPACT Team, Lyon, France
| | - S Ayari-Khalfallah
- Service d'ORL Pédiatrique, Hôpital Femme Mère Enfants, Centre Hospitalier et Universitaire, Lyon, France; Service d'ORL, Hôpital Edouard Herriot, Centre Hospitalier et Universitaire, Lyon, France
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17
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Differentiation of Kawasaki Disease From Other Causes of Fever and Cervical Lymphadenopathy: A Diagnostic Scoring System Using Contrast-Enhanced CT. AJR Am J Roentgenol 2019; 212:665-671. [PMID: 30645161 DOI: 10.2214/ajr.18.20262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to determine the characteristic findings of contrast-enhanced CT (CECT) of the neck in patients with Kawasaki disease (KD) and to develop a diagnostic scoring system to facilitate the diagnosis of KD versus other causes of fever and cervical lymphadenopathy. MATERIALS AND METHODS Two blinded radiologists evaluated CECT images of 37 patients with KD and 92 patients without KD who had febrile cervical lymphadenopathy, first independently and then in consensus. Significant findings in CECT images were evaluated through cervical edema and lymph node scores. CT attenuation of the nodal low-attenuation area and its ratio to the CT attenuation of the trapezius muscle were measured. On the basis of these indexes, a diagnostic scoring system was developed to differentiate between patients with and without KD. Its diagnostic performance was determined using ROC curve analysis. RESULTS Retropharyngeal edema, lateral cervical edema, nasopharyngeal wall edema, level IIA lymphadenopathy, and retropharyngeal lymphadenopathy were more common in patients with KD than in patients without KD (p < 0.001, < 0.001, < 0.001, 0.003, and 0.028, respectively). Level VB lymphadenopathy was more common in patients without KD (p = 0.013), and the presence of nodal low-attenuation areas with lower attenuation indexes (attenuation of nodal low-attenuation area ≤ 50 HU, or ratio of attenuation of nodal low-attenuation area to trapezius muscle attenuation ≤ 0.7) was specific to patients without KD. In cases of higher attenuation indexes and cervical edema and lymph node scores of 4 or higher, sensitivity, specificity, and accuracy of the diagnostic scoring system were 86% (32/37), 86% (79/92), and 86% (111/129), respectively, for diagnosing KD. CONCLUSION The proposed diagnostic scoring system was useful in differentiating between patients with and without KD.
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18
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Vervoort D, Donné M, Van Gysel D. Pitfalls in the diagnosis and management of Kawasaki disease: An update for the pediatric dermatologist. Pediatr Dermatol 2018; 35:743-747. [PMID: 30338568 DOI: 10.1111/pde.13620] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Kawasaki disease is easily diagnosed when it presents in its complete form, but because not all characteristic symptoms are always present at the same time, and the diagnosis of incomplete and atypical Kawasaki disease is often challenging, a delay in diagnosis or misdiagnosis often occurs. We present the diagnostic approach to Kawasaki disease with common pitfalls and explain how to avoid them. We also describe current practice and new trends in treatment.
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Affiliation(s)
- Dominique Vervoort
- Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Pediatrics, O.L. Vrouw Hospital Aalst, Aalst, Belgium
| | - Marieke Donné
- Department of Pediatrics, University of Ghent, Ghent, Belgium
- Department of Pediatrics, O.L. Vrouw Hospital Aalst, Aalst, Belgium
| | - Dirk Van Gysel
- Department of Pediatrics, O.L. Vrouw Hospital Aalst, Aalst, Belgium
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Hibino M, Urabe Y, Horiuchi S, Uchida Y, Miyahara K. Adult Recurrence of Kawasaki Disease Mimicking Retropharyngeal Abscess. Intern Med 2017; 56:2217-2221. [PMID: 28781314 PMCID: PMC5596287 DOI: 10.2169/internalmedicine.8399-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/05/2017] [Indexed: 11/06/2022] Open
Abstract
Kawasaki disease (KD) is an acute, self-limited vasculitis of unknown etiology that occurs predominantly in young children (≤5 years of age). We herein report the case of an 18-year-old Japanese man with a history of incomplete KD during infancy; later, despite an initial diagnosis of retropharyngeal abscess, he was ultimately diagnosed with retropharyngeal edema associated with recurrent KD. Adult-onset or recurrent KD is an uncommon event, and retropharyngeal edema is a rare manifestation of this disease. Internists should be aware of the possibility of KD that mimics a retropharyngeal abscess, even in adult patients.
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Affiliation(s)
- Makoto Hibino
- Department of Respiratory Medicine, Shonan Fujisawa Tokushukai Hospital, Japan
| | - Yuko Urabe
- Department of Pediatrics, Shonan Fujisawa Tokushukai Hospital, Japan
| | - Shigeto Horiuchi
- Department of General Medicine, Shonan Fujisawa Tokushukai Hospital, Japan
| | - Yuji Uchida
- Department of Pediatrics, Shonan Fujisawa Tokushukai Hospital, Japan
| | - Kiyoshi Miyahara
- Department of General Medicine, Shonan Fujisawa Tokushukai Hospital, Japan
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Chasset F, Francès C. Cutaneous Manifestations of Medium- and Large-Vessel Vasculitis. Clin Rev Allergy Immunol 2017; 53:452-468. [DOI: 10.1007/s12016-017-8612-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Okada S, Kobayashi-Fujiwara Y, Oga A, Furuta T, Ikemoto K, Fujii H, Sakata Y, Suzuki Y, Hasegawa S, Kusuda T, Itoh H, Yamashita H, Ohga S. Distinct Distribution of Immunocytes in a Retropharyngeal Lymphadenopathy Associated with Kawasaki Disease: A Case Study Compared with Tonsillitis. Cardiology 2017; 137:237-243. [PMID: 28467980 DOI: 10.1159/000467388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 02/27/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Retropharyngeal lesions are often associated with Kawasaki disease (KD). A 4-year-old male first presented a peritonsillar and retropharyngeal abscess-like lesion. Surgical tonsillectomy was performed to avoid a risk of mediastinal abscess, but he fulfilled the diagnostic criteria of KD after the operation. This prompted us to perform a histological study on the KD tonsils. METHODS The histopathology of the KD tonsil specimens were compared with hypertrophic tonsils obtained from 4 patients with chronic tonsillitis unrelated to KD assessed by the immunostainings. RESULTS KD tonsils showed small lymphatic follicles and neutrophil infiltration in the peritonsillar muscle layer, with no evidence of vasculitis or abscess formation. The KD tonsils exclusively showed (1) predominant activated CD4+ T cells in the perifollicular interstitium, (2) sparse scattering of CD68+ monocytes/macrophages in the lymphatic follicles, and (3) polyclonal carcinoembryonic antigen-positive cells in the lymphatic follicles and venules with the high endothelial cells. CONCLUSIONS The uniquely distributed immunocytes suggest the inflammatory process of KD involving the pathogen-associated molecules.
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Affiliation(s)
- Seigo Okada
- Department of Pediatrics, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
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Nozaki T, Morita Y, Hasegawa D, Makidono A, Yoshimoto Y, Starkey J, Kusakawa I, Manabe A, Saida Y. Cervical ultrasound and computed tomography of Kawasaki disease: Comparison with lymphadenitis. Pediatr Int 2016; 58:1146-1152. [PMID: 27097838 DOI: 10.1111/ped.13017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 03/08/2016] [Accepted: 04/05/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Differentiating Kawasaki disease (KD) from cervical lymphadenitis (CL) is clinically difficult but essential given that treatment and outcome differ significantly. Research on differentiation between KD and CL using ultrasound (US) and computed tomography (CT) is limited. The purpose of this study was to identify cervical US and CT findings that may differentiate KD from CL. METHODS We retrospectively reviewed cervical US of 25 KD patients and 25 CL patients, and CT of 14 KD patients, and 14 CL patients. Two radiologists analyzed specific imaging features on US (lymph node size, shape, echogenicity, margins, laterality, necrosis, and presence of normal hilum) and on CT (size and location of enlarged nodes, laterality, perinodal infiltration, and retropharyngeal edema). RESULTS On US, patients with KD more frequently had lymph nodes with a "cluster of grapes" appearance (KD vs CL: 64% vs 32%, P < 0.05) and less frequently had poorly circumscribed margins (0% vs 36%, P < 0.01), necrosis (0% vs 32%, P < 0.01), or non-visualization of the hilum (4% vs 36%, P < 0.01). On CT, KD patients more frequently had retropharyngeal edema (100% vs 29%, P < 0.001) and less frequently had level 4 lymphadenopathy (14% vs 79%, P < 0.01) than CL patients. CONCLUSIONS Ultrasound is mainly useful for excluding purulent lymphadenopathy while CT is a useful diagnostic tool for differentiating KD from CL, especially in patients with incomplete KD, who present with prominent cervical lymphadenopathy and other equivocal principal findings.
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Affiliation(s)
- Taiki Nozaki
- Department of Radiology, St Luke's International Hospital, Tokyo, Japan
| | - Yuka Morita
- Department of Radiology, St Luke's International Hospital, Tokyo, Japan
| | - Daisuke Hasegawa
- Department of Pediatrics, St Luke's International Hospital, Tokyo, Japan
| | - Akari Makidono
- Department of Radiology, St Luke's International Hospital, Tokyo, Japan
| | - Yuri Yoshimoto
- Department of Pediatrics, St Luke's International Hospital, Tokyo, Japan
| | - Jay Starkey
- Department of Radiology, St Luke's International Hospital, Tokyo, Japan
| | - Isao Kusakawa
- Department of Pediatrics, St Luke's International Hospital, Tokyo, Japan
| | - Atsushi Manabe
- Department of Pediatrics, St Luke's International Hospital, Tokyo, Japan
| | - Yukihisa Saida
- Department of Radiology, St Luke's International Hospital, Tokyo, Japan
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23
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Abstract
Kawasaki disease is an acute, self-limited vasculitis of childhood and has become the leading cause of acquired pediatric heart disease in the USA. Prompt treatment is essential in reducing cardiac-related morbidity and mortality. The underlying etiology remains unknown. The disease itself may be the characteristic manifestation of a common pathway of immune-mediated vascular inflammation in susceptible hosts. The characteristic clinical features of fever for at least 5 days with bilateral nonpurulent conjunctivitis, rash, changes in lips and oral cavity, changes in peripheral extremities, and cervical lymphadenopathy remain the mainstay of diagnosis. Supplementary laboratory criteria can aid in the diagnosis, particularly in cases of incomplete clinical presentation. Diagnosis of Kawasaki disease can be challenging as the clinical presentation can be mistaken for a variety of other pediatric illnesses. Standard of care consists of intravenous immune globulin and aspirin. Corticosteroids, infliximab, and cyclosporine A have been used as adjunct therapy for Kawasaki disease refractory to initial treatment. There is ongoing research into the use of these agents in the initial therapy of Kawasaki disease.
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Affiliation(s)
- Frank H. Zhu
- Division of Infectious Diseases, Children’s Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201 USA
- Department of Pediatrics, Wayne State University, School of Medicine, Detroit, MI 48201 USA
| | - Jocelyn Y. Ang
- Division of Infectious Diseases, Children’s Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201 USA
- Department of Pediatrics, Wayne State University, School of Medicine, Detroit, MI 48201 USA
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Tomita H, Yamashiro T, Ikeda H, Fujikawa A, Kurihara Y, Nakajima Y. Fluid collection in the retropharyngeal space: A wide spectrum of various emergency diseases. Eur J Radiol 2016; 85:1247-56. [PMID: 27235871 DOI: 10.1016/j.ejrad.2016.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 03/27/2016] [Accepted: 04/05/2016] [Indexed: 01/01/2023]
Abstract
Fluid collections in the retropharyngeal space (RPS) result from a wide spectrum of diseases, including retropharyngeal abscess, cervical osteomyelitis, and calcific tendinitis of the longus colli muscle. These conditions should be managed by different specialties; beginning with care in the emergency room, physicians from orthopedics, pediatrics, otolaryngology, and oncology are in charge of the treatment. Since these diseases demonstrate similar fluid collections in the RPS on computed tomography (CT) and magnetic resonance imaging (MRI), the radiologist's diagnosis based on the characteristic imaging findings is very important to identify the primary disease. Also, since some of the diseases require immediate surgical intervention to avoid life-threatening mediastinitis or airway obstruction, radiologists must distinguish these diseases correctly and provide recommendations for their management to physicians. Understanding clinical features and imaging findings of these fluid collections in the RPS is crucial for the best care.
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Affiliation(s)
- Hayato Tomita
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan.
| | - Tsuneo Yamashiro
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan; Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa 903-0215, Japan
| | - Hirotaka Ikeda
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Atsuko Fujikawa
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Yoshiko Kurihara
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Yasuo Nakajima
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
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25
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Sensorineural hearing loss--another under-recognized oto-laryngeal complication of Kawasaki disease. Eur J Pediatr 2015; 174:1697-8. [PMID: 26049933 DOI: 10.1007/s00431-015-2564-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 05/07/2015] [Indexed: 10/23/2022]
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26
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Abstract
Kawasaki disease (KD) must be considered in the differential diagnosis of any child with fever for 4 to 5 days and compatible clinical and laboratory features, and in any infant with prolonged fever and compatible laboratory features, even in the absence of the classic clinical signs. Prompt therapy is required, because delayed or unrecognized KD can lead to lifelong heart disease or death in previously healthy children. Most children with KD respond to a single 2 g/kg dose of intravenous gammaglobulin with oral aspirin, but a small subset require additional therapies to resolve the clinical illness.
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Affiliation(s)
- Anne H Rowley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, 310 East Superior Street, Morton 4-685B, Chicago, IL 60611, USA.
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27
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Abstract
Parapharyngeal abscess (PPA)-like lesion is a very rare manifestation of Kawasaki disease (KD). Here we report a Chinese case of KD initially mimicking PPA, which is the first one reported in Asia.A 3-year-old male patient presented with fever, drooling, and bilateral painful cervical lymphadenopathy for 3 days. Chest X-ray and echocardiogram were normal. With substantial elevation of white blood count and C-reactive protein, purulent cervical lymphadenitis was considered. Symptoms did not improve after treatment with vancomycin, and the patient further developed trismus and restricted neck movement. Neck CT revealed a 2 × 1.5 cm hypodense lesion in the right parapharyngeal space with peripheral enhancement. PPA was suspected and on the 3rd day following admission, the patient received surgical incision and drainage. One milliliter of serous fluid was drained without bacterial growth on cultures. Fever persisted after surgery. As the clinical course proceeded, additional major signs of KD gradually evolved, and on the 6th day following admission the patient completely fulfilled the diagnostic criteria for KD. Rapid clinical improvement was observed following treatment with high-dose immunoglobulin and aspirin. Due to the parapharyngeal operation, the patient was fed milk through a nasogastric tube for 15 days. His neck incision became infected but healed gradually following dressing change and antibiotic treatment. Currently he remains asymptomatic during regular follow-up and repeated echocardiograms are normal.Both pediatricians and otolaryngologists can learn from this case that KD may initially manifest as PPA. Careful observation for major signs of KD during the clinical course can help to achieve a prompt and correct diagnosis. Thus, unnecessary surgery and cardiac complications of KD may be avoided.
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Affiliation(s)
- Qianyun Cai
- From the Department of Pediatrics, West China Second University Hospital, Sichuan University (QC, RL, JG, LZ, YQ, DM); and Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu 610041, Sichuan, China (YQ, DM)
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Watanabe T. Kawasaki Disease with Retropharyngeal Edema following a Blackfly Bite. Case Rep Pediatr 2014; 2014:296456. [PMID: 25349761 PMCID: PMC4202199 DOI: 10.1155/2014/296456] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/24/2014] [Accepted: 09/24/2014] [Indexed: 11/18/2022] Open
Abstract
We describe a patient with Kawasaki disease (KD) and retropharyngeal edema following a blackfly bite. An 8-year-old boy was referred to our hospital because of a 3-day-history of fever and left neck swelling and redness after a blackfly bite. Computed tomography of the neck revealed left cervical lymph nodes swelling with edema, increased density of the adjacent subcutaneous tissue layer, and low density of the retropharyngeum. The patient was initially presumed to have cervical cellulitis, lymphadenitis, and retropharyngeal abscess. He was administered antibiotics intravenously, which did not improve his condition. The patient subsequently exhibited other signs of KD and was diagnosed with KD and retropharyngeal edema. Intravenous immunoglobulin therapy and oral flurbiprofen completely resolved the symptoms and signs. A blackfly bite sometimes incites a systemic reaction in humans due to a hypersensitive reaction to salivary secretions, which may have contributed to the development of KD in our patient.
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Affiliation(s)
- Toru Watanabe
- Department of Pediatrics, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata 950-1197, Japan
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