Dr.B.Shobika,Dr.C.Jayakumar,Dr.Praveena Bhaskar and Dr.Navya George
AIMS KOCHI
Two year old male child presented to the ER with high Grade intermittent fever of 10 days.
child was febrile,sicklooking,irritable with stable vitals.General examination revealed bilateral cervical lymphadenopathy,congested throat,slightly erythematous lips but Tongue was normal
His systemic examination was normal
Hemogram showed leucopenia and Neutropenia,CRP-194mg/l,procalcitonin-3.43ng/ml,ESR of 135mm.Peripheral smear normal .LFT/RFT/PT/INR ,APTT ,electrolytes urine routine were within normal limits.
Other investigations like Dengue,IgM EBV,parvovirus,IgM and IgG salmonella were Negative.
Cultures of Blood and Urine were normal
Respiratory viral pannel didn’t isolate any virus
Abdominal sonogram was normal
CSF Study was normal
As no focus of infections were found and high grade fever was persisting.
CECT was neck done to r/o retropharyngeal/parapharyngeal abscess were done and showed adenoid hypertrophy and Inhaled nasal Steroids was given
Cardiac evaluation ECHO showed mild pericardial effusion and no dilatation of the coronaries
CSF ,AFB smear Negative,CSF gene Xpert showed trace of MTB(insignificant in the context of viral CSF study with respect to normal cell cytology and protein)
Bone marrow aspiration done showed pauciparticulate marrow with diluted cell trails showing predominantly erythroids and lymphocytes.
He was started on Inj.cefepime,vancomycin and other supportive medication after taking blood and urine for culture and sensitivity.Fever was persisting inspite of the antibiotics.
In this contex atypical Kawasaki disease was considered and 2gm/kg IVIg was started
Criteria fulfilling as atypical kawasaki disease – fever of more than 5 days,cervical lymphadenopathy,erythematous oral mucosa.
Fever spikes reduced after giving IVIG.Labs shows decreasing trend (CRP-15.24,TLC-6.72,N-16.9,ESR 20mm )
Repeat ECHO done was normal.
Carry home message:
Atypical Kawasaki disease should be considered In children below 5 years of age, with persisting fever spikes after ruling out other possibilities and treatment with IviG is justified
We have not given Aspirin in this case as coronaries were normal and as both CRP and ESR were normal
I am Dr sahil. Lifeline hospital adoor.
I referred this case as febrile neutropenia.i was thinking in terms of macrophage activation syndrome .