ILLUSTRATIVE CASE
An Atypical Presentation of Atypical Kawasaki Disease Brit L. Anderson, MD,* Amy B. Guiot, MD,Þ and Nathan L. Timm, MD*
Abstract: Kawasaki disease (KD) is a well-known inflammatory disorder that, despite its classic description, can pose a diagnostic challenge. We report a case of a 3-year-old girl who presented to the emergency department with a limp and urinary incontinence who was ultimately diagnosed with KD. She was found to have a large coronary artery aneurysm on echocardiogram. We discuss the challenges in diagnosing incomplete KD. Key Words: Kawasaki disease, limp, coronary artery aneurysm (Pediatr Emer Care 2014;30: 491Y492)
A
3-year-old previously healthy girl presented to the emergency department (ED) with a chief complaint of a limp. Her father reported that she was well until 7 days before presentation, when she developed fever and vomiting. The vomiting persisted for 2 days and had resolved 5 days before presentation. Her father also reported that the duration of the fever was only 4 days; she had been afebrile for 3 days before presentation. However, beginning 2 days before presentation, her father noted a slight limp and occasional urinary incontinence. She had been toilet trained several months prior, and the incontinence prompted her father to bring her to the ED. Her father reported no injuries. He had not noticed any joint swelling, redness, warmth, or rashes. She had not complained of pain with urination, increased urinary frequency, or increased thirst. She had otherwise been acting normally. On examination in the ED, her vital signs were as follows: temperature of 98.2-F, heart rate of 117, respiratory rate of 24, and blood pressure of 124/72 mm Hg. She appeared generally well and had an age-appropriate mental status and interaction with the examiner. She had bright red lips with an otherwise clear oropharynx and slightly erythematous conjunctivae (although crying during part of the examination). She had shotty anterior cervical lymphadenopathy (all nodes were G1 cm). Her lungs were clear to auscultation. She had normal heart sounds without a murmur, and her abdomen was soft without tenderness or masses. Musculoskeletal examination revealed normal passive and active range of motion of bilateral hips, knees, ankles, and toes without apparent tenderness. She had no lower extremity tenderness with palpation and no joint effusions, redness, or warmth. She had no spinal tenderness or limitation of range of motion. She had a subtle antalgic gait, favoring her right leg, but she had normal strength of the lower extremities. She had normal lower extremity sensation and reflexes bilaterally and down-going Babinski reflexes. Her skin was clear
From the *Division of Emergency Medicine and †Department of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. Disclosure: The authors declare no conflict of interest. Reprints: Brit L. Anderson, MD, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229 (e
An Atypical Presentation of Atypical Kawasaki Disease Brit L. Anderson, MD,* Amy B. Guiot, MD,Þ and Nathan L. Timm, MD*
Abstract: Kawasaki disease (KD) is a well-known inflammatory disorder that, despite its classic description, can pose a diagnostic challenge. We report a case of a 3-year-old girl who presented to the emergency department with a limp and urinary incontinence who was ultimately diagnosed with KD. She was found to have a large coronary artery aneurysm on echocardiogram. We discuss the challenges in diagnosing incomplete KD. Key Words: Kawasaki disease, limp, coronary artery aneurysm (Pediatr Emer Care 2014;30: 491Y492)
A
3-year-old previously healthy girl presented to the emergency department (ED) with a chief complaint of a limp. Her father reported that she was well until 7 days before presentation, when she developed fever and vomiting. The vomiting persisted for 2 days and had resolved 5 days before presentation. Her father also reported that the duration of the fever was only 4 days; she had been afebrile for 3 days before presentation. However, beginning 2 days before presentation, her father noted a slight limp and occasional urinary incontinence. She had been toilet trained several months prior, and the incontinence prompted her father to bring her to the ED. Her father reported no injuries. He had not noticed any joint swelling, redness, warmth, or rashes. She had not complained of pain with urination, increased urinary frequency, or increased thirst. She had otherwise been acting normally. On examination in the ED, her vital signs were as follows: temperature of 98.2-F, heart rate of 117, respiratory rate of 24, and blood pressure of 124/72 mm Hg. She appeared generally well and had an age-appropriate mental status and interaction with the examiner. She had bright red lips with an otherwise clear oropharynx and slightly erythematous conjunctivae (although crying during part of the examination). She had shotty anterior cervical lymphadenopathy (all nodes were G1 cm). Her lungs were clear to auscultation. She had normal heart sounds without a murmur, and her abdomen was soft without tenderness or masses. Musculoskeletal examination revealed normal passive and active range of motion of bilateral hips, knees, ankles, and toes without apparent tenderness. She had no lower extremity tenderness with palpation and no joint effusions, redness, or warmth. She had no spinal tenderness or limitation of range of motion. She had a subtle antalgic gait, favoring her right leg, but she had normal strength of the lower extremities. She had normal lower extremity sensation and reflexes bilaterally and down-going Babinski reflexes. Her skin was clear
From the *Division of Emergency Medicine and †Department of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. Disclosure: The authors declare no conflict of interest. Reprints: Brit L. Anderson, MD, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229 (e
