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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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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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Affiliation(s)
- Eric McGrath
- Wayne State University, Detroit, MI, USA
- Children's Hospital of Michigan, Detroit, MI, USA
| | - Yamini Jadcherla
- Children's Hospital of Michigan, Detroit, MI, USA
- Pediatric Education Department, Residency Program, Children's Hospital of Michigan, Detroit, MI, USA
| | - Jaclyn Held
- Children's Hospital of Michigan, Detroit, MI, USA
- Pediatric Education Department, Residency Program, Children's Hospital of Michigan, Detroit, MI, USA
| | - Jocelyn Y Ang
- Wayne State University, Detroit, MI, USA
- Children's Hospital of Michigan, Detroit, MI, USA
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Tanaka T, Shimizu M, Tokuda O, Yamamoto H, Matsunoshita N, Takenaka K, Kawasaki K. Kawasaki Disease with an Initial Manifestation Mimicking Bacterial Inguinal Cellulitis. Case Rep Pediatr 2020; 2020:8889827. [PMID: 33194239 PMCID: PMC7641693 DOI: 10.1155/2020/8889827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 09/18/2020] [Accepted: 09/25/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Kawasaki disease (KD) is typically characterized by fever, oral cavity erythematous changes, bilateral bulbar conjunctival injection, skin rash, erythema and edema of the hands and feet, and cervical lymphadenopathy. Some atypical patients with KD initially develop cervical and pharyngeal cellulitis; however, an initial presentation with inguinal cellulitis is extremely rare. In addition, to our knowledge, no report has documented the cytokine profile in a KD patient with cellulitis. Case presentation. A previously healthy 8-year-old Japanese girl was hospitalized following a 2-day history of fever and a 5-day history of pain and erythema in the left inguinal region. She was diagnosed with bacterial inguinal cellulitis and was administered antibiotics. The next day, a polymorphous rash emerged on her trunk. After 3 days of antibiotics, however, her fever continued and the cellulitis had spread over the entire lower abdomen. Simultaneously, the bilateral bulbar conjunctival injection without exudate became more prominent and her lips became erythematous. In addition, erythematous changes on her palms appeared a few hours later, which led to the diagnosis of KD. Since she had a high risk score that predicted no response to initial intravenous immunoglobulin (IVIG) at the initiation of treatment, she was treated with IVIG, intravenous prednisolone (PSL), and oral aspirin. The KD symptoms improved the next day, but the cellulitis did not completely resolve until 2 months after discharge. The patient's serum cytokine profile at admission had an IL-6 dominant pattern which was consistent with that of patients with KD despite her initial lack of KD symptoms, and the pattern observed at admission was sustained until IVIG and PSL administration. CONCLUSION KD should be included in the differential diagnosis for patients presenting with inguinal cellulitis who are unresponsive to initial empiric antibiotics.
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Affiliation(s)
- Tsukasa Tanaka
- Department of Pediatrics, Kita-Harima Medical Center, Ono, Hyogo, Japan
| | - Masaki Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, Health Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Oshi Tokuda
- Department of Pediatrics, Kita-Harima Medical Center, Ono, Hyogo, Japan
| | - Hiroko Yamamoto
- Department of Pediatrics, Kita-Harima Medical Center, Ono, Hyogo, Japan
| | | | - Kanae Takenaka
- Department of Pediatrics, Kita-Harima Medical Center, Ono, Hyogo, Japan
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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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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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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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Park BS, Bang MH, Kim SH. Imaging and Clinical Data Distinguish Lymphadenopathy-First-Presenting Kawasaki Disease from Bacterial Cervical Lymphadenitis. J Cardiovasc Imaging 2019; 26:238-246. [PMID: 30607392 PMCID: PMC6310750 DOI: 10.4250/jcvi.2018.26.e29] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Kawasaki disease (KD) sometimes presents with only fever and cervical lymphadenopathy before other clinical signs materialize. This lymphadenopathy-first-presenting Kawasaki disease (LKD) may be misdiagnosed as bacterial cervical lymphadenitis (BCL). We investigated characteristic imaging and clinical data for factors differentiating LKD from BCL. METHODS We compared imaging, clinical, and laboratory data of patients with KD and BCL. We included patients admitted to a single tertiary center between January 2015 and July 2018. RESULTS We evaluated data from 51 patients with LKD, 63 with BCL, and 218 with typical KD. Ultrasound imaging revealed multiple enlarged lymph nodes in both LKD and BCL patients. On the other hand, computed tomography (CT) showed more abscesses in patients with BCL. Patients with LKD were younger and showed higher systemic and hepatobiliary inflammatory markers and pyuria than BCL patients. In multivariable logistic regression, younger age and higher C-reactive protein (CRP) retained independent associations with LKD. A comparison of the echocardiographic findings in LKD and typical KD showed that patients with LKD did not have a higher incidence of coronary artery abnormalities (CAA). CONCLUSIONS LKD patients tend to have no abscesses on CT and more elevated systemic hepatobiliary inflammatory markers and pyuria compared to BCL patients. The absence of abscess on CT, younger age, and elevated CRP were the most significant variables differentiating LKD from BCL. There was no difference in CAA between LKD and typical KD.
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Affiliation(s)
- Byung Sung Park
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Myung Hoon Bang
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sung Hye Kim
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang, Korea
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12
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Marchesi A, Tarissi de Jacobis I, Rigante D, Rimini A, Malorni W, Corsello G, Bossi G, Buonuomo S, Cardinale F, Cortis E, De Benedetti F, De Zorzi A, Duse M, Del Principe D, Dellepiane RM, D'Isanto L, El Hachem M, Esposito S, Falcini F, Giordano U, Maggio MC, Mannarino S, Marseglia G, Martino S, Marucci G, Massaro R, Pescosolido C, Pietraforte D, Pietrogrande MC, Salice P, Secinaro A, Straface E, Villani A. Kawasaki disease: guidelines of the Italian Society of Pediatrics, part I - definition, epidemiology, etiopathogenesis, clinical expression and management of the acute phase. Ital J Pediatr 2018; 44:102. [PMID: 30157897 PMCID: PMC6116535 DOI: 10.1186/s13052-018-0536-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 05/03/2018] [Indexed: 12/18/2022] Open
Abstract
The primary purpose of these practical guidelines related to Kawasaki disease (KD) is to contribute to prompt diagnosis and appropriate treatment on the basis of different specialists' contributions in the field. A set of 40 recommendations is provided, divided in two parts: the first describes the definition of KD, its epidemiology, etiopathogenetic hints, presentation, clinical course and general management, including treatment of the acute phase, through specific 23 recommendations.Their application is aimed at improving the rate of treatment with intravenous immunoglobulin and the overall potential development of coronary artery abnormalities in KD. Guidelines, however, should not be considered a norm that limits treatment options of pediatricians and practitioners, as treatment modalities other than those recommended may be required as a result of peculiar medical circumstances, patient's condition, and disease severity or complications.
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Affiliation(s)
- Alessandra Marchesi
- Bambino Gesù Children's Hospital, Rome, Italy, Piazza S. Onofrio n. 4, 00165, Rome, Italy.
| | | | - Donato Rigante
- Fondazione Policlinico Universitario A. Gemelli, Università Cattolica Sacro Cuore, Rome, Italy
| | | | | | | | | | - Sabrina Buonuomo
- Bambino Gesù Children's Hospital, Rome, Italy, Piazza S. Onofrio n. 4, 00165, Rome, Italy
| | | | | | - Fabrizio De Benedetti
- Bambino Gesù Children's Hospital, Rome, Italy, Piazza S. Onofrio n. 4, 00165, Rome, Italy
| | - Andrea De Zorzi
- Bambino Gesù Children's Hospital, Rome, Italy, Piazza S. Onofrio n. 4, 00165, Rome, Italy
| | - Marzia Duse
- , Università degli Studi Sapienza, Rome, Italy
| | | | | | | | - Maya El Hachem
- Bambino Gesù Children's Hospital, Rome, Italy, Piazza S. Onofrio n. 4, 00165, Rome, Italy
| | | | | | - Ugo Giordano
- Bambino Gesù Children's Hospital, Rome, Italy, Piazza S. Onofrio n. 4, 00165, Rome, Italy
| | | | | | | | | | - Giulia Marucci
- Bambino Gesù Children's Hospital, Rome, Italy, Piazza S. Onofrio n. 4, 00165, Rome, Italy
| | | | | | | | | | | | - Aurelio Secinaro
- Bambino Gesù Children's Hospital, Rome, Italy, Piazza S. Onofrio n. 4, 00165, Rome, Italy
| | | | - Alberto Villani
- Bambino Gesù Children's Hospital, Rome, Italy, Piazza S. Onofrio n. 4, 00165, Rome, Italy
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13
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Murakami D, Sugita G, Gunduz M, Suenaga T, Takeuchi T, Suzuki H, Hotomi M. Adult onset Kawasaki disease presenting with acute epiglottitis findings. Braz J Otorhinolaryngol 2017; 86 Suppl 1:67-71. [PMID: 29102400 PMCID: PMC9422665 DOI: 10.1016/j.bjorl.2017.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/07/2017] [Accepted: 09/11/2017] [Indexed: 11/04/2022] Open
Affiliation(s)
- Daichi Murakami
- Wakayama Medical University, Department of Otorhinolaryngology-Head and Neck Surgery, Wakayama, Japan
| | - Gen Sugita
- Wakayama Medical University, Department of Otorhinolaryngology-Head and Neck Surgery, Wakayama, Japan
| | - Mehmet Gunduz
- Wakayama Medical University, Department of Otorhinolaryngology-Head and Neck Surgery, Wakayama, Japan
| | - Tomohiro Suenaga
- Wakayama Medical University, Department of Pediatrics, Wakayama, Japan
| | - Takashi Takeuchi
- Wakayama Medical University, Department of Pediatrics, Wakayama, Japan
| | - Hiroyuki Suzuki
- Wakayama Medical University, Department of Pediatrics, Wakayama, Japan
| | - Muneki Hotomi
- Wakayama Medical University, Department of Otorhinolaryngology-Head and Neck Surgery, Wakayama, Japan.
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14
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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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15
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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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16
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Kwon M, Seo JH, Cho KJ, Won SJ, Woo SH, Kim JP, Park JJ. Suggested Protocol for Managing Acute Suppurative Cervical Lymphadenitis in Children to Reduce Unnecessary Surgical Interventions. Ann Otol Rhinol Laryngol 2016; 125:953-958. [PMID: 27553593 DOI: 10.1177/0003489416665194] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The indications and benefits of surgery in the management of pediatric acute suppurative cervical lymphadenitis (ASCL) remain unclear. We aimed to design a management protocol focusing on the avoidance of unnecessary operation in pediatric ASCL patients. METHODS The study population consisted of 45 pediatric patients with ASCL treated with antibiotics alone and 30 surgically treated patients. The primary outcome was the determination of differences in patient characteristics and radiologic findings in the 2 groups. The secondary outcome, after matching 20 cases with 20 controls, was to determine the benefits of surgery to patients. RESULTS There were no significant differences between the 2 groups in patient characteristics and radiologic findings at initial presentation. In the matched case-control analysis, intravenous antibiotics alone yielded successful treatment outcomes when compared with surgery, with no significant differences in time to symptom resolution, normalized laboratory test results, and duration of hospitalization (all P > .05). CONCLUSIONS The size and location of suppurated lymph nodes are not absolute determinants for surgical drainage in the stable pediatric ASCL patients. If patients show no clinical improvements despite appropriate second- and third-line antibiotics, patients should be carefully reevaluated and image-guided aspiration considered.
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Affiliation(s)
- Minsu Kwon
- Department of Otorhinolaryngology, Gyeongsang National University School of Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Ji-Hyun Seo
- Departments of Pediatrics, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Gangnam-ro Jinju, Republic of Korea
| | - Ki Ju Cho
- Departments of Otorhinolaryngology, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Seong Jun Won
- Departments of Otorhinolaryngology, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Seung Hoon Woo
- Departments of Otorhinolaryngology, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jin Pyeong Kim
- Departments of Otorhinolaryngology, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jung Je Park
- Department of Otorhinolaryngology, Gyeongsang National University School of Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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17
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The ABCs (Airway, Blood Vessels, and Compartments) of Pediatric Neck Infections and Masses. AJR Am J Roentgenol 2016; 206:963-72. [DOI: 10.2214/ajr.15.15812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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18
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Itamura S, Ishiguchi Y, Kuwabara K, Yasui K, Kamada M. Cellulitis-Like Rash Associated with Kawasaki Disease. Pediatr Dermatol 2016; 33:e32-3. [PMID: 26577413 DOI: 10.1111/pde.12712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We present the case of a 5-year-old-boy who developed a fever and cellulitis-like groin rash 5 days before developing conjunctivitis and 6 to 7 days before other typical signs of Kawasaki disease (KD) appeared. The cellulitis failed to respond to antibiotics and no pathogens were isolated. His fever and clinical signs resolved with intravenous immunoglobulin and high-dose aspirin after discontinuation of antibiotics. Nonbacterial cellulitis is a rare presenting sign of KD, but in the appropriate clinical setting and population, a diagnosis of KD should be considered when cellulitis and fever fail to respond to an appropriate antibiotic regimen and no pathogen can be isolated.
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Affiliation(s)
- Shinji Itamura
- Department of Pediatrics, Hiroshima City Hospital, Hiroshima, Japan
| | - Yukiko Ishiguchi
- Department of Pediatric Cardiology, Hiroshima City Hospital, Hiroshima, Japan
| | - Kentaro Kuwabara
- Department of Pediatrics, Hiroshima City Hospital, Hiroshima, Japan
| | - Kozo Yasui
- Department of Pediatrics, Hiroshima City Hospital, Hiroshima, Japan
| | - Masahiro Kamada
- Department of Pediatric Cardiology, Hiroshima City Hospital, Hiroshima, Japan
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