Kawasaki disease: High index of suspicion needed in a febrile child.

A six-month-old Caucasian boy presents with a three-day history of fever. The parents report that he had red eyes without pus two days previously. On examination, otitis media is noted as well as a nonexudative pharyngitis. Amoxicillin is prescribed. They return on the sixth day of illness and report that the child is still febrile, not responding to antipyretics and has a rash. The rash appears urticarial and the otitis media persists. A different antibiotic is prescribed. The family presents to the emergency room on the eighth day of fever. The child is irritable and difficult to console. He is noted to have red, cracked lips and a nonexudative pharyngitis. He has bilateral otitis media, no lymphadenopathy or conjunctivitis, and has a maculopapular rash on his trunk and extremities. Swelling of the hands and feet or palmar/plantar erythema is not noted. Other than tachycardia, the cardiovascular examination is unremarkable, as is the rest of the examination. Investigations reveal a white blood cell count of 22×109/L (normal range 6×109/L to 17.5×109/L) with a left shift, hemoglobin level of 90 g/L (normal range 95 g/L to 135 g/L) and platelet count of 425×109/L (normal range 140×109/L to 450×109/L). His erythrocyte sedimentation rate is 65 mm/h (normal range 3 mm/h to 13 mm/h) and C-reactive protein level is 188 mg/L (normal range 0 mg/L to 5 mg/L). His liver enzyme levels are mildly elevated and albumin level is low. No pyuria is noted. The diagnosis of incomplete Kawasaki disease (KD) is suspected and the child is admitted. He is given intravenous immunoglobulin (IVIG) and acetylsalicylic acid (ASA). Echocardiography reveals a small coronary artery aneurysm.