A Case of C.S

A Case of C.
S
NAME: C.S
SEX: FEMALE
AGE: 5 yrs and 9 months
NATIONALITY: FILIPINO
DOB:
RELIGION: ROMAN CATHOLIC
ADMISSION: 01/27/2020
History of Present Illness
6 Days PTA
 INTERMITTENT FEBRILE EPISODES
(TMAX: 38.7 )
 GENERALIZE BODY MALAISE

 SORE THROAT CORYZA
 DECREASE APPETITE COUGH
RASHES
 NAUSEA PALPITATIONS
 VOMITING(OCCASIONAL CHEST DISCOMFORT
EPISODES, SALIVARY URINARY /DEFECATORY PROB
ARTHRALGIA
 PERIUMBILICAL PAIN,
MYALGIA
INTERMITTENT JOINT
SWELLING
EDEMA
MED: PARACETAMOL (AD 14 mkd)
with Temporary lysis of fever
5 Days PTA
 PERSISTENCE OF SYMPTOMS
 ODYNOPHAGIA
 LEFT CERVICAL
LYMPHADENOPATHY
SOUGHT CONSULT
WITH PRIVATE
PEDIATRICIAN CBC AND
DENGUE SCREEN
TAKEN.
MANAGED AS ACUTE
TONSILLOPHARYNGITIS
MED: COAMOXICLAV (NATRAVOX ,
AD: 42.8 mkd),
PCM was CONTINUED
4 Days PTA
 PERSISTENT SYMPTOMS NOW
ASSOCIATED WITH :
 PRURITIC RASH ON DORSAL
ASPECT FEET
MEDS : TOPICAL OINTMENT APPLIED WITH

NOTED TEMPORARY RELIEF; OTHER
MEDICATIONS CONTINUED.
3 Days PTA
 PERSISTENT SYMPTOMS WITH NOTED
 CEPHALAD PROGRESSION OF RASH
(UPPER AND LOWER EXTREMITIES,
TRUNK, BACK
CONSULT SOUGHT W/ ANOTHER PRIVATE

PEDIATRICIAN

MEDS:
• CETIRIZINE (ALNIX, AD 0.1 MKD)
• DICYCLOVERINE (AD 0.2 MKD)—TEMPORARY
RELIEF NOTED.
2 Days PTA
PERSISTENT SYMPTOMS PROMPTED
CONSULT
MEDS: DICYCLOVERINE WAS SWITCHED TO

ALUMINUM HYDROXIDE MAGNESIUM
HYDROXIDE (SIMETHINE); CONTINUED OTHER
MEDICATIONS.
A Day PTA
PERSISTENT SYMPTOMS WITH FEVER OF

NOTED TMAX 39.1OC; CONTINUED
MEDICATIONS.
2 Hours PTA
PERSISTENT SYMPTOMS PROMPTED
THIS ADMISSION.
REVIEW OF SYSTEMS
HEENT
Head: No dizziness, periorbital pain. No

recent head injury.
Eyes: No recent changes in vision,

double vision, blurry vision. Denies of
eye discharge or swelling.
Ears: Denies of ear pain, discharge, or

tinnitus.Nose: No recent colds, nasal
obstruction or nosebleeds.
Mouth: No hoarseness of voice, gum

bleeding, or dysphagia.
NECK No neck pain or stiffness.
RESPIRATORY No dyspnea, hemoptysis, or

wheezing.
CARDIOVASCULAR No orthopnea, chest pain

or discomfort, and palpitations.
GASTROINTESTINAL denies of heartburn,

and excessive passing of gas. Admits no change
in bowel habits and denies of diarrhea, rectal
bleeding or black/ tarry stools.
URINARY No flank pain, dysuria, burning

sensation upon urination, or hematuria; no
recent urinary tract infections. No genital pain
and discharges.
PERIHERAL VASCULAR No claudication
and leg cramps. No color change in fingertips or
toes during cold weather. No bipedal edema.
MUSCULOSKELETAL No myalgia,
arthralgia, joint swelling.
NEUROLOGIC No numbness on both legs;

denies of fainting spells, vertigo, paralysis,
tingling sensation, tremors or other involuntary
movements.
HEMATOLOGIC Denies of easy bruising or

bleeding.
ENDOCRINE Denies of heat or cold

intolerance, excessive sweating/ thirst/ hunger.
PAST MEDICAL HISTORY
 No persistent chronic childhood illnesses or previous
PTB treatment;
 no maintenance medications.
 No history of previous surgeries and/ or blood
transfusion.
 First hospitalization – 2017, Mandaue Hospital,
Urinary Tract Infection-resolved.
FAMILY HISTORY
 Has history of bronchial asthma on paternal side.
 No HPN, DM, CA, epilepsy/childhood seizures,
hereditary hematologic dyscrasias, PTB.
PRENATAL
24-year old G1 P0 mother without
known comorbidities,
First PNC at approximately 8 weeks
AOG at a local health center, regular
thereafter.
 No GDM, GHPN, thyroid problems, and/or infections.

 No intake of drugs other than MV/ prescribed by
obstetrician.
NATAL
Full term
NSD at Eversley Hospital,
BW of 5 lbs;
 No birth trauma/ injury, meconium stain/ingestion,

congenital anomalies or feeding difficulties.
 Hyperbilirubinemia s/p phototherapy.
 NBS done (normal results).
POST NATAL
 Started on milk formula (due to
decreased amount of breast milk),
 Complementary feeding at 6mos of
age,
EPI completed until 2yo at LHC w/o booster doses given.

BCG x1 Penta x3
Hep B x1 MMR x1
OPV x1 Measles x1
PCV x3
PERSONAL AND SOCIAL
HISTORY
 No known FDAs.
 Has unrestricted diet (mainly fish, chicken, meat,
vegetables), not a picky eater.
 Patient is the only child, living with mother,
grandmother, uncle, aunt and 2 cousins; father is an
overseas worker at Taiwan.
 Has second-hand smoke exposure from uncle.
 Source of drinking water: refillable mineral water.
 Practices garbage segregation and recycling.
PHYSICAL EXAMINATION
GENERAL SURVEY:
CS is a child who is lying

comfortably on her bed. She is
awake, alert, coherent,
oriented, responsive,
cooperative, febrile, and
NIRD. Her age is appropriate
to looks and clothing is
appropriate to setting.
VITAL SIGNS
BP = 110/70 mmHg
HR = 129 bpm
RR = 25 cpm
O2 sat = 99% at room air
Temp = 38.6OC
Height = 121 cm
Weight = 24 kg
SKIN:
No pallor, jaundice, cyanosis
or bruises. Skin is rough, warm
and with good turgor. Noted
generalized pruritic, patchy
macular erythematous rash
sparing the face, palms, and
soles.
HEENT:
Head: Normocephalic, atraumatic
w/o lesions. Face is also symmetrical
with no abnormal fascies or
deformities. No lumps/nodules.
Eyes: Symmetric, anicteric sclerae,

pink palpebral conjunctivae, noted
mild conjunctival hyperemia OU.
Extraocular movements are intact,
pupils round, regular, and equally
reactive to light. No abnormal
discharges and/or lacrimation.
Ears: Wax partially obscures right
and left ear canal, no external
abnormalities.
Nose: No deviations in shape and
size. No sinus tenderness, no
discharges.
Mouth & Pharynx: Dry, slightly
cracked lips. Pink and moist buccal
mucosa, noted bilateral non-
exudative, hyperemic tonsils.
Neck: Supple, no restriction or pain
on motion. No unusual pulsations or
bruits noted. Noted a fixed, hard,
non-exudative spherical mass
measuring 3cm on GD located at left
cervical area.
THORAX AND LUNGS: Symmetric, with
equal chest expansion. Lungs are resonant,
with normal tactile fremitus. Clear and w/o
adventitious breath sounds.
CARDIOVASCULAR: Adynamic
precordium. Distinct heart sounds, regular
rhythm. No murmurs or abnormal heart
sounds.
ABDOMEN: flabby, NABS, soft, non-

distended, non-tender, no organomegaly or
palpable mass.
GENITOURINARY: grossly female,
negative CVAT
PERIPHERAL VASCULAR: No
edema, SPP, CRT <2secs.
MUSCULOSKELETAL: Full ROM

in all joints of the upper and lower
extremities. Spine is straight. No
swelling or tenderness; no deformities
or lesions.
NEUROLOGIC: within normal limits
Mental Status awake, alert, placid,

oriented, coherent; speaks in fluent
Visayan vernacular; with good
comprehension and spontaneity.
Cranial Nerves Intact; 5/5 strength in

resisting shoulder shrug and head
turning
Motor Strength is 5/5 in upper and lower
extremities. Good muscle bulk and tone.
Sensory Pinprick, light touch, position,

and vibration intactReflexes 2+ and
symmetrical; no Babinski or myoclonus
Meningeals Absent Brudzinski and

Kernig’s signs.
Cerebellars no dysmetria or
dysdiadochokinesia, no gait ataxia
COURSE IN THE WARD
AT THE ER – 1/27/2020
S Febrile Tmax 38.7C No coryza, cough, (+) odynophagia. No chest discomfort, urinary
or defecatory problems, arthralgia, myalgia, joint swelling, and /or edema
O Vital signs BP: 110/60 HR: 129 RR:25 O2Sat: 99% at room air Temp: 38.6° C
General: Awake, responsive, cooperative, NIRD
Skin: Warm, rough to touch, good turgor and mobility, with generalized pruritic, patchy
maculopapular rash, erythematous noted at the trunk, upper & lower extremities
HEENT: (+) Bilateral mild conjunctival hyperemia, no discharges , Dry, slightly cracked
lips, moist oral mucosa, bilateral non-exudative, hyperemic tonsils (+) LAD, ~3cm Left
Anterior cervical area
C/L: Equal chest expansion, Clear breath sounds
CVS: Adynamic precordium, distinct heart sounds, normal rate and regular rhythm, no
murmurs
Abd: Globular, NABS, soft, nontender
Extremities: No edema. Strong peripheral pulses, CRT<2secs
Musculoskeletal: No swelling or tenderness. Full ROM
AT THE ER – 1/27/2020
A Kawasaki Disease VS Scarlet Fever Day 7

P • Patient was admitted
• Consent to care was secured
• Diet as tolerated
• IVF: D5 0.45 NaCl 1L at 65cc/hr (Maintenance)
• Diagnostics: CBC,UA, CRP, ESR, Na, K, SGPT, ASO Titer, Serum albumin Throat Culture and
sensitivity, 2D Echo with Doppler
• Therapeutics:
1) Paracetamol 120mg/5ml 10ml q4hrs shifted to Ibuprofen 200mg/5ml 5ml PRN for Temp
>38°C
2) Penicillin G 1M U/vial + 10cc PNSS (AD:166,667UkD) slow IVTT q6hrs ANST(Neg)
• Vital signs monitoring q4hrs
• I & O qshift
• Rheumatologist Consult Notes: To observe lysis of fever and improvement of symptoms
48hrs after Penicillin G administration and to re assess after if condition would warrant
IVIg administration
2D-ECHO WITH DOPPLER:
 Sinus solitus.
 Normal cardiac chamber dimensions.
 Normal proximal segments of both coronary arteries.
 Internal diameter of left main coronary artery = 2.1 mm
(z-score: more than 2)
 Internal diameter of proximal right coronary artery = 1.6
mm
(z-score: less than 2)
 Structurally normal atrioventricular and arterial valves
 No pericardial effusion.
 Normal systolic and diastolic functions of both
ventricles.
HOSPITAL DAY1 – 1/28/2020
S Patient still has febrile episodes, last fever 1/28/20 Tmax38.7°C. Fair appetite and
activity. No cough, no coryza, no vomiting, no odynophagia. Complains of generalized
pruritic rash.
O
Vital signs BP: 100/60 HR: 119 RR:22 O2Sat: 99% at room air Temp: 37.2° C
FB: (+) 1055 UO: 1.48cc/kg/hr
General: Awake, cooperative, NIRD
Skin: Warm, good turgor and mobility, with generalized maculopapular rash,
erythematous noted at the trunk, upper & lower extremities
HEENT: (+) Bilateral Conjuctival Injection, no discharges , dry lips, moist oral mucosa, (+)
LAD, ~3cm Left Anterior cervical area
murmurs
Extremities: No edema. Strong peripheral pulses, CRT<2secs
HOSPITAL DAY1 – 1/28/2020
A Kawasaki Disease VS Scarlet Fever Day 7
P • IVFTF: D5 IMB 500cc at 65 cc/hr (Maintenance)
• Diagnostics:
• Therapeutics:
1) Ibuprofen 200mg/5ml 5ml PRN for Temp >38°C
2) Penicillin G 1M U/vial + 10cc PNSS (AD:166,667UkD) slow IVTT q6hrs
3) For possible IVIg Infusion
• Monitor VS q4
• I & O qshift
THROAT CULTURE & SENSITIVITY
Preliminary Report)
Gram: Pus cells: 1-3/OIF
Gram +Cocci in pairs: FEW
Remarks: Culture in progress.
URINE CULTURE
(Preliminary Report)
Gram: Pus Cells: 0-1/OIF
No microorganisms seen.
HOSPITAL DAY 2 – 1/29/2020
S Patient still has febrile episodes. Improving appetite and activity. No cough, no coryza,
no vomiting
FB: (+) 1255 UO: 1.48 cc/kg/hr

Skin: Fading maculopapular rash
HEENT: (+) Bilateral Conjuctival Injection, no discharges , dry lips, moist oral mucosa, (+)
LAD, ~3cm Left Anterior cervical area
murmurs
Extremities: Strong peripheral pulses, CRT<2secs
A Kawasaki Disease Day 8
P • IVFTF: D5 IMB 500cc at 65 cc/hr (Maintenance)
• Diagnostics:
• Therapeutics:
1) Ibuprofen 200mg/5ml 5ml PRN for Temp >38°C
2) Penicillin G 1M U/vial + 10cc PNSS (AD:166,667UkD) slow IVTT q6hrs
3) Aspirin 80mg/tab 6tabs q6hrs (AD: 80mkD)
• Monitor VS q4
• I & O qshift
THROAT CULTURE & SENSITIVITY
(Final Report)
No beta-hemolytic streptococci and other
bacterial pathogens isolated.
URINE CULTURE
Preliminary Report)
No growth after 24hrs of incubation.
S Patient had a febrile episode with Tmax of 38.6. No cough, coryza, or odynophagia. No
episodes of vomiting, chest pain, or abdominal pain. Good appetite and activity.
FB: (+) 1048 U/O: 1.73 cc/kg/hr

HEENT:nonsunken eyeballs, no discharges , dry lips, moist oral mucosa, (+) LAD, ~3cm
Left Anterior cervical area
murmurs
A Kawasaki Disease Day 9
P Diet as tolerated
Start IVIG as follows:
- Test dose
0.01 x 24kgs x 60= 14.4ml in first hour
0.02 x 24kgs x 60= 28.8ml in the second hour
0.04 x 24kgs x 60= 57.6ml in the third hour
- Remaining volume = total volume - test dose volume
960ml- 100.8ml = 859.2 ml to run in 10-12 hours
Monitor for shock (dyspnea, wheeze, chest pain, hypotension, drowsiness, chills, abdominal pain)
Monitor v/s q15 for first hour, q30 for second hour, then q hourly thereafter.
IVF: Shift to PNSS, attach to piggyback
Diagnostics: No new labs
Therapeutics:
1. Ibuprofen 200mg/5ml, give 5ml PRN for Temp >38°C
2. Penicillin G 1M U/vial + 10cc PNSS (AD:166,667UkD) slow IVTT q6hrs
3. Shift aspirin 80mg/tab to chewable, give 6 tabs q6H (AD: 80mkD)
I & O qshift

URINE CULTURE
Final Report)
No growth after 24hrs of incubation.
HOSPITAL DAY - 1/31/2020
S Patient had no febrile episodes in the past 24hrs. Patient complains of burning pain on
epigastric area. No cough, coryza, or odynophagia. Good appetite and activity.
FB: (+) 650 U/O: 1.66 cc/kg/hr

HEENT: nonsunken eyeballs, no discharges , dry lips, moist oral mucosa, (+) LAD, ~3cm
murmurs
A Kawasaki disease, resolving
P Diet as tolerated
Increase fluid intake
Continue IVF
Continue medications
I & O qshift

S Patient had no febrile episodes. No cough, coryza, or odynophagia. Good appetite and
activity.
O Vital signs BP: 100/60 HR: 102 RR:24 O2Sat: 99% at room air Temp: 36.4°

HEENT: nonsunken eyeballs, no discharges , dry lips, moist oral mucosa, (+) LAD, ~3cm
murmurs
A Kawasaki disease, resolving

P • Patient may go home with the following medications:
1.) Co- amoxiclav 642.9mg/5ml, give 5 ml BID for 7 days ( AD: 27mkD)
2.) Aspirin 80mg/tab, give 1 tab OD for 2 weeks
3.) Vitamin C + zinc, give 5ml OD
* For repeat 2D echo on 2/13/20
* For follow up check up on 2/14/19 with 2D echo results

PRIMARY WORKING
IMPRESSION
KAWASAKI DISEASE, COMPLETE
RULE IN RULE OUT
 High fever (38.7-39.1)  CANNOT BE RULED OUT:
 Generalized body malaise
 Sore throat
 Decreased appetite
 Nausea
 Vomiting
 Periumbilical pain.
 Odynophagia
 Left cervical lymphadenopathy.
 Pruritic rash on dorsal aspect feet,
with noted cephalad progression
DIFFERENTIAL DIAGNOSIS
SCARLET FEVER
RULE IN RULE OUT
 ID: 5 y 9 mos  CANNOT BE RULED OUT:
 High fever (38.7-39.1)

 Generalized body malaise
 Sore throat
 Decreased appetite
 Nausea
 Vomiting
 Periumbilical pain.
 Odynophagia
 Left cervical lymphadenopathy.
 Pruritic rash on dorsal aspect feet, with
noted cephalad progression
DENGUE
RULE IN RULE OUT
2nd day of il ness:

 High fever (38.7-39.1) CBC Dengue Screen
 Generalized body malaise HGB 14.8 NS1 neg
 Sore throat HCT 42.6 IgG neg
 Decreased appetite PLT 439 IgM neg
 Nausea
WBC 16.1
 Vomiting
 Periumbilical pain. Segs 87
 Odynophagia Lymph 8
 Left cervical lymphadenopathy. Mono 3
 Pruritic rash on dorsal aspect feet, with Eos 2
noted cephalad progression Baso 0
MEASLES
RULE IN RULE OUT
 Presence of fever  Cephalad progression of rash, with
 Onset of rash at 3rd febrile day sparing of the face, soles, and palms
 Maculopapular rash  Acquired measles vaccine and no known
 Presence of lymphadenopathies exposure to people with measles
 Absence of coryza, cough, and
conjunctivitis
FINAL DIAGNOSIS:
KAWASAKI DISEASE,
COMPLETE
CASE DISCUSSION:
KAWASAKI DISEASE
 Formerly known as mucocutaneous lymph node syndrome
and infantile polyarteritis nodosa
 Highest incidence in Asian children
 Vasculitis with a predilection for coronary arteries
 Untreated children: develop coronary artery abnormalities
including aneurysm; If treated with IVIG <5% will develop
CAA
ETIOLOGY
 Unknown, but certain epidemiologic and clinical features
support an infectious origin

 Features:
o Young age group
o Wave-like geographic spread of illness
o Self-limited nature of acute febrile illness
o Clinical features of rash, fever, enanthem, conjunctival
injection, cervical lymphadenopathy
o Infrequent if <3 mo d/t maternal Ab
o No single infectious etiologic agent has been identified
o Genetics: ITPKC gene- increased susceptibility and more
severe disease
EPIDEMIOLOG
Y
 M > F; mean age 3 yo
 Kobayashi score: high sensitivity and specificity on Japanese
population only
 Predictors of poor outcome:
o Young age
o Male
o Persistent fever
o Poor response to IVIG
o Lab abn: WBC, plt, Na. albumin,CRP, transaminitis
EPIDEMIOLOG
Y
 Predominantly affects medium-sized arteries
 Coronary arteries: most commonly involved, others: popliteal
and brachial
 3 phase process to arteriopathy of KD:
o 1st phase – neutrophilic necrotizing arteritis

occurring in the 1st 2 weeks of illness that begins in
endothelium and moves through the coronary wall
- Saccular aneurysms may form
EPIDEMIOLOG
Y
o 2nd phase – subacute/chronic vasculitis driven by
lymphocytes, plasma cells, and eosinophils which
may last to weeks or years
- Fusiform aneurysms
o 3rd phase – smooth muscle cell myofibroblast
will develop which can cause progressive stenosis
- Thrombi may form in the lumen and obstruct
blood flow
CLINICAL
MANIFESTATIO
N
CLINICAL
MANIFESTATIO
Acute febrile phase N
Subacute phase Convalescent phase
Fever and other acute Desquamation, All clinical signs have
signs that lasts up to 2 thrombocytosis and disappeared and
wks CAA develop in up to continues until ESR
25% of untreated returns to normal 6-8
perineal desquamation patients wks after onset

arthritis and periungual
desquamation of
fingers and toes which
may progress the entire
hand and foot

LABORATORY
 2D echo - most useful test to monitor CAA. Aneurysms may

be small (<5mm internal diameter), or giant (>8 mm internal
diameter)
- Should be done at diagnosis and again after 2-3 wks of illness.
If normal, a repeat should be done 6-8 wks after
- If abn 2D echo or with recurrent fever – more frequent 2d
echo
- 1 yr later – 2d echo and lipid profile then cardio follow up
every 5 yrs
LABORATORY
 WBC with predominance of neutrophils and immature forms
 Normochromic anemia
 Plt – normal in 1st wk then  in 2-3 wks
 ESR and CRP
 Sterile pyuria, mild elevations of hepatic transaminases,
hyperbilirubinemia, CSF pleocytosis
DIAGNOSIS
•Based on presence of clinical signs
Classic KD Atypical or Incomplete

Presence of fever for atleast Fever but fewer than 4 of
4 days and atleast 4 of 5 of the 5
other principal
characteristics Infants – highest likelihood
of CAA

Do labs and 2d echo to
assist in dx
TREATMENT
COMPLICATIO
N
 Small solitary aneurysm – continue Aspirin indefinitely
 Larger or numerous aneurysm – require addition of other
antiplatelet agents or anticoagulation
 Long term: periodic echo with stress testing and possible
angiography if large aneurysm are present
 Coronary stenosis: catheter intervention with percutaneous
transluminal coronary rotational ablation, directional
coronary atherectomy, and stent implantation
PROGNOSIS
 Depends on the severity of coronary disease

 Acute KD recurs in 1-3% of cases
 50% of coronary aneurysms regress to normal lumen
diameter by 1-2 yrs after the illness, with smaller
aneurysms more likely to regress
 Giant aneurysms are less likely to regress and may lead to
thrombosis and stenosis. CABG( arterial grafts) may be
required if myocardial perfusion is impaired

A Case of C.S

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A Case of C.

 GENERALIZE BODY MALAISE

MEDS : TOPICAL OINTMENT APPLIED WITH

CONSULT SOUGHT W/ ANOTHER PRIVATE

MEDS: DICYCLOVERINE WAS SWITCHED TO

PERSISTENT SYMPTOMS WITH FEVER OF

Head: No dizziness, periorbital pain. No

Eyes: No recent changes in vision,

Ears: Denies of ear pain, discharge, or

Mouth: No hoarseness of voice, gum

RESPIRATORY No dyspnea, hemoptysis, or

CARDIOVASCULAR No orthopnea, chest pain

GASTROINTESTINAL denies of heartburn,

URINARY No flank pain, dysuria, burning

NEUROLOGIC No numbness on both legs;

HEMATOLOGIC Denies of easy bruising or

ENDOCRINE Denies of heat or cold

 No GDM, GHPN, thyroid problems, and/or infections.

 No birth trauma/ injury, meconium stain/ingestion,

EPI completed until 2yo at LHC w/o booster doses given.

CS is a child who is lying

Eyes: Symmetric, anicteric sclerae,

ABDOMEN: flabby, NABS, soft, non-

MUSCULOSKELETAL: Full ROM

Mental Status awake, alert, placid,

Cranial Nerves Intact; 5/5 strength in

Sensory Pinprick, light touch, position,

Meningeals Absent Brudzinski and

A Kawasaki Disease VS Scarlet Fever Day 7

General: Awake, cooperative, NIRD

General: Awake, cooperative, NIRD

General: Awake, cooperative, NIRD

A Kawasaki disease, resolving

 High fever (38.7-39.1)

2nd day of il ness:

o 1st phase – neutrophilic necrotizing arteritis

 2D echo - most useful test to monitor CAA. Aneurysms may

•Based on presence of clinical signs

Classic KD Atypical or Incomplete

 Depends on the severity of coronary disease

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