Bilateral facial nerve palsy in Kawasaki disease.

Dear Editor, A previously well, developmentally normal 6-yearold Indian boy was admitted for evaluation of fever. He was fi rst seen at our outpatient service at the onset of fever. At that time, upper respiratory tract symptoms of rhinorrhoea and nasal congestion together with bilateral non-purulent conjunctivitis suggested a viral aetiology. He was initially treated symptomatically but empiric antibiotics were started on day 4 of illness when his fever persisted and a leukocytosis of 19.7K/μL was noted on complete blood count. Haemoglobin (Hb) was 10.3g/dL and platelet counts were 554K/μL. It was thought that he might have an early acute bacterial sinusitis. A chest radiograph performed was also normal. He was admitted to hospital on day 7 of illness when his fever did not resolve despite the above measures. Our patient’s fever was unremitting and peaked around 39oC, with transient response to routine antipyretics. On admission, leukocyte count was 24.3 K/μL, platelet count was 705 K/μL and Hb 9.4g/dL. Westergren sedimentation rate was 101 mm/h. We considered the possibility of incomplete Kawasaki Disease (KD) in view of the persistent conjunctivitis, raised infl ammatory markers, anaemia and rising platelet levels. At no time did our patient demonstrate any rash, acral or mucosal change, or any signifi cant lymphadenitis. An echocardiogram on day 8 of illness showed aneurysms of the left main coronary artery (LCA), right main coronary artery (RCA), left anterior descending coronary artery (LAD) and left circumfl ex coronary artery(LCx) thus confi rming the diagnosis of incomplete KD. We started our patient immediately on high-dose aspirin (100 mg/kg/day) and administered intravenous immunoglobulin (IVIg) at a dose of 2 g/kg according to published guidelines. Following IVIg, fever continued but at a lower grade than before, with a maximum temperature of 38oC. On day 10 of illness, right-sided facial asymmetry was noted. Our patient was unable to shut his right eye and experienced drooping of the right side of his mouth. An examination revealed features of a pure lower motor neuron palsy of the right facial nerve (FNP). There was no decreased salivation, hyperacusis, ear pain or loss of taste. He was otherwise asymptomatic and a detailed neurological assessment did not reveal other cranial nerve defects. The auditory canal and tympanic membrane were normal. When our patient’s temperature started to spike towards 39oC on day 11 of illness, we administered a second dose of IVIg. This time, there was a complete resolution of fever. Bilateral Facial Nerve Palsy in Kawasaki Disease