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Kawasaki disease mimicking retropharyngeal abscess.

Ganesh R, Srividhya VS, Vasanthi T, Shivbalan S - Yonsei Med. J. (2010)

Bottom Line: Kawasaki disease is an acute, self-limiting febrile mucocutaneous vasculitis of infants and young children.Retropharyngeal lymphadenopathy is a rare presentation of Kawasaki disease.We present a case of Kawasaki disease mimicking a retropharyngeal abscess, with upper airway obstruction resulting in delayed diagnosis.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, Kanchi Kamakoti Childs Trust Hospital, 12- A, Nageswara road, Nungambakkam, Chennai-600034, TamilNadu, India. ganeped79@rediffmail.com

ABSTRACT
Kawasaki disease is an acute, self-limiting febrile mucocutaneous vasculitis of infants and young children. Retropharyngeal lymphadenopathy is a rare presentation of Kawasaki disease. We present a case of Kawasaki disease mimicking a retropharyngeal abscess, with upper airway obstruction resulting in delayed diagnosis.

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CT scan showing hypointense lesion between C2-C6 levels in posterior pharyngeal space.
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Figure 1: CT scan showing hypointense lesion between C2-C6 levels in posterior pharyngeal space.

Mentions: An 8-year-old boy presented with fever, pain on the left side of the neck associated with restricted neck movements, and trismus for 1 day. He also had difficulty in swallowing and breathing. On examination he was febrile (104℉), toxic, anxious, irritable, and a throat examination revealed a 4×5 cm swelling in the posterior pharyngeal wall to the left of the midline. He also had upper deep left cervical lymphadenopathy and there was no cyanosis. His respiratory rate was 48/min, and he had suprasternal indrawing and stridor. His systemic examination was normal. Investigations revealed a total white blood count (WBC) count: 20,800/mm3, polymorphs: 80%, platelet count: 3.5 lacs/mm3, erythrocyte sedimentation rate (ESR): 55 mm/hr, and a C reactive protein (CRP) of 48 mg/dL. Blood cultures showed no growth. A lateral neck X-ray revealed widening of the retropharyngeal space and narrowing of the upper airway. Computed tomography (CT) of the neck revealed ill-defined hypodense lesion extending from the C2-C6 vertebral level in the posterior pharyngeal space with no contrast enhancement compatible with a diagnosis of retropharyngeal abscess (Fig. 1). In light of the high fever and toxemia, he was started on antibiotics (Cefotaxim 100 mg/kg/day) and surgical aspiration was undertaken within 24 hours of the antibiotics and yielded only 2 cc of pus, which were sterile on bacterial cultures. In light of the upper airway obstruction and dysphagia with only a scant aspirate, a tracheostomy was done. His pain reduced post surgery, but the fever and swelling persisted. He was started on amikacin and metronidazole continuing cefotaxim. On day 3, his fever persisted but the swelling reduced in size and there was no dysphasia or respiratory difficulty, and thus he was decannulated and stable. For the next few days he was febrile. During this period the ultrasonography of his abdomen, chest radiograph, echocardiography, and repeat blood and urine cultures were all normal. During the 9th day of his illness, with a persisting fever he developed a bilateral non-purulent bulbar conjunctival injection and erythema of the hands and feet. On the 10th day he developed a polymorphous generalized erythematous rash and a systolic murmur. Investigations at this point in time revealed a total count of 15,100/mm3 with polymorphonuclear leucocytosis, elevated ESR 110 mm/hr, CRP-192 mg/dL, and a platelet count of 9.5 lac/mm3. The repeat echocardiogram revealed a fusiform aneurysm of the proximal and mid right coronary artery 6.5×6 mm. The left main, anterior descending and circumflex coronary arteries were normal. The left ventricular systolic and diastolic functions were normal with an ejection fraction of 68% and a fractional shortening of 37%. There was no pericardial effusion. With these constellation of clinical and laboratory features, the diagnosis of Kawasaki disease was entertained and he was started on intravenous immune globulin (IVIG) 2 g/kg over 24 hours along with aspirin of 100 mg/kg/day. Within 36 hours he became afebrile; his murmur disappeared and he was cheerful. On the follow-up after 14 days he was afebrile, with an ESR of 48 mm/hr, and platelet count of 4.7 lacs/mm3. His repeat echocardiogram (ECHO) at 2 weeks still showed fusiform aneurysmal dilatation of the proximal and mid right coronary artery 6.5×6 mm and he continues to be on a low dose aspirin.


Kawasaki disease mimicking retropharyngeal abscess.

Ganesh R, Srividhya VS, Vasanthi T, Shivbalan S - Yonsei Med. J. (2010)

CT scan showing hypointense lesion between C2-C6 levels in posterior pharyngeal space.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2908875&req=5

Figure 1: CT scan showing hypointense lesion between C2-C6 levels in posterior pharyngeal space.
Mentions: An 8-year-old boy presented with fever, pain on the left side of the neck associated with restricted neck movements, and trismus for 1 day. He also had difficulty in swallowing and breathing. On examination he was febrile (104℉), toxic, anxious, irritable, and a throat examination revealed a 4×5 cm swelling in the posterior pharyngeal wall to the left of the midline. He also had upper deep left cervical lymphadenopathy and there was no cyanosis. His respiratory rate was 48/min, and he had suprasternal indrawing and stridor. His systemic examination was normal. Investigations revealed a total white blood count (WBC) count: 20,800/mm3, polymorphs: 80%, platelet count: 3.5 lacs/mm3, erythrocyte sedimentation rate (ESR): 55 mm/hr, and a C reactive protein (CRP) of 48 mg/dL. Blood cultures showed no growth. A lateral neck X-ray revealed widening of the retropharyngeal space and narrowing of the upper airway. Computed tomography (CT) of the neck revealed ill-defined hypodense lesion extending from the C2-C6 vertebral level in the posterior pharyngeal space with no contrast enhancement compatible with a diagnosis of retropharyngeal abscess (Fig. 1). In light of the high fever and toxemia, he was started on antibiotics (Cefotaxim 100 mg/kg/day) and surgical aspiration was undertaken within 24 hours of the antibiotics and yielded only 2 cc of pus, which were sterile on bacterial cultures. In light of the upper airway obstruction and dysphagia with only a scant aspirate, a tracheostomy was done. His pain reduced post surgery, but the fever and swelling persisted. He was started on amikacin and metronidazole continuing cefotaxim. On day 3, his fever persisted but the swelling reduced in size and there was no dysphasia or respiratory difficulty, and thus he was decannulated and stable. For the next few days he was febrile. During this period the ultrasonography of his abdomen, chest radiograph, echocardiography, and repeat blood and urine cultures were all normal. During the 9th day of his illness, with a persisting fever he developed a bilateral non-purulent bulbar conjunctival injection and erythema of the hands and feet. On the 10th day he developed a polymorphous generalized erythematous rash and a systolic murmur. Investigations at this point in time revealed a total count of 15,100/mm3 with polymorphonuclear leucocytosis, elevated ESR 110 mm/hr, CRP-192 mg/dL, and a platelet count of 9.5 lac/mm3. The repeat echocardiogram revealed a fusiform aneurysm of the proximal and mid right coronary artery 6.5×6 mm. The left main, anterior descending and circumflex coronary arteries were normal. The left ventricular systolic and diastolic functions were normal with an ejection fraction of 68% and a fractional shortening of 37%. There was no pericardial effusion. With these constellation of clinical and laboratory features, the diagnosis of Kawasaki disease was entertained and he was started on intravenous immune globulin (IVIG) 2 g/kg over 24 hours along with aspirin of 100 mg/kg/day. Within 36 hours he became afebrile; his murmur disappeared and he was cheerful. On the follow-up after 14 days he was afebrile, with an ESR of 48 mm/hr, and platelet count of 4.7 lacs/mm3. His repeat echocardiogram (ECHO) at 2 weeks still showed fusiform aneurysmal dilatation of the proximal and mid right coronary artery 6.5×6 mm and he continues to be on a low dose aspirin.

Bottom Line: Kawasaki disease is an acute, self-limiting febrile mucocutaneous vasculitis of infants and young children.Retropharyngeal lymphadenopathy is a rare presentation of Kawasaki disease.We present a case of Kawasaki disease mimicking a retropharyngeal abscess, with upper airway obstruction resulting in delayed diagnosis.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, Kanchi Kamakoti Childs Trust Hospital, 12- A, Nageswara road, Nungambakkam, Chennai-600034, TamilNadu, India. ganeped79@rediffmail.com

ABSTRACT
Kawasaki disease is an acute, self-limiting febrile mucocutaneous vasculitis of infants and young children. Retropharyngeal lymphadenopathy is a rare presentation of Kawasaki disease. We present a case of Kawasaki disease mimicking a retropharyngeal abscess, with upper airway obstruction resulting in delayed diagnosis.

Show MeSH
Related in: MedlinePlus