Indian J Pediatr (April 2014) 81(4):406–407 DOI 10.1007/s12098-014-1353-3
SCIENTIFIC LETTER
Facial Nerve Palsy Complicating a Case of Kawasaki Disease Raju P. Khubchandani & Anita Dhanrajani
Received: 30 October 2013 / Accepted: 13 January 2014 / Published online: 6 March 2014 # Dr. K C Chaudhuri Foundation 2014
To the Editor: Although neurological manifestations like aseptic meningitis are described in Kawasaki disease (KD), facial nerve palsy is uncommon, with 30 cases reported since 1974 [1]. We describe a 3-y-old girl, refractory to the first dose of IVIG who presented to us with unilateral infranuclear facial nerve palsy. She was diagnosed as KD on the basis of a constellation of features including fever, irritability, conjunctival injection, strawberry tongue, cracked lips, edematous hands and feet and perianal excoriation. 2D Echo done on day 23, showed diffuse dilatation of all coronary arteries and aneurysm of left anterior descending and proximal right coronary artery with minimal pericardial fluid. IVIG was given at a dose of 2 g/kg on day 23. We first saw her on day 27 of illness, with persistent fever despite IVIG. On presentation, she had the above mentioned signs and periungual peeling. We also noticed a left sided facial deviation, obliteration of the right nasolabial fold and incomplete closure of right eye, suggesting a right sided infranuclear facial palsy (Fig. 1). A repeat 2D Echo on day 27 showed similar findings as the earlier ECHO with resolution of the pericardial effusion. A repeat dose of 2 g/kg of IVIG, led to normalization of the fever and other signs within 48 h. The facial nerve palsy persisted. On follow up after 3 wk the facial palsy had resolved. Neurological complications of KD include irritability, aseptic meningitis, ataxia, seizures, focal encephalopathy, cranial nerve palsies, cerebral infarction, and transient hemiplegia [2]. In a prospective study of 115 patients on complications of KD, one patient (0.9 %) had facial nerve palsy [3]. Most reported cases of facial nerve palsy occur in the convalescent phase, are self limiting, (duration ranging from 2 d to R. P. Khubchandani (*) : A. Dhanrajani Department of Pediatrics, Jaslok Hospital and Research Center, Mumbai, Maharashtra 400026, India e-mail: [email protected]
Fig. 1 Photograph of the child showing slightly wider right sided palpebral fissure, obliteration of the right nasolabial fold, and mild assymetry of the angles of mouth, suggesting right infranuclear facial palsy
3 mo) are commoner in females (1.4:1) are unilateral [3], and are associated with more severe and frequent (more than 50 %) coronary artery lesions [4, 5], as in our case. The pathogenesis is speculated to be an ischemia of the arteries supplying the facial nerve secondary to the underlying generalized vasculitis in addition to the immune activation known in KD [1]. The facial nerve palsy recovers spontaneously although IVIG may hasten recovery. It is known that delayed administration of IVIG increases the likelihood of coronary affliction, like in our case, yet role of IVIG in treating or preventing neurological complications still remains to be established. Facial nerve palsy has also been described in cases with incomplete KD [3]. Contribution Dr. Raju P Khubchandani will act as guarantor for this paper. Conflict of Interest None. Role of Funding Source None.
Indian J Pediatr (April 2014) 81(4):406–407
References 1. Lim TC, Yeo WS, Loke KY, Quek SC. Bilateral facial nerve palsy in Kawasaki disease. Ann Acad Med Singapore. 2009;38:737–8. 2. Wright H, Waddington C, Geddes J, Newburger JW, Burgner D. Facial nerve palsy complicating Kawasaki disease. Pediatrics. 2008;122: e783–5.
407 3. Alves NR, Magalhães CM, Almeida Rde F, Santos RC, Gandolfi L, Pratesi R. Prospective study of Kawasaki disease complications: Review of 115 cases. Rev Assoc Med Bras. 2011;57:295–300. 4. Poon LK, Lun KS, Ng YM. Facial nerve palsy and Kawasaki disease. Hong Kong Med J. 2000;6:224–6. 5. Kocabas A, Kardelen F, Aldemir Kocabas B, Akcurin G, Ertug H. Facial nerve palsy and Kawasaki disease. Indian J Pediatr. 2014;81: 186-8.
SCIENTIFIC LETTER
Facial Nerve Palsy Complicating a Case of Kawasaki Disease Raju P. Khubchandani & Anita Dhanrajani
Received: 30 October 2013 / Accepted: 13 January 2014 / Published online: 6 March 2014 # Dr. K C Chaudhuri Foundation 2014
To the Editor: Although neurological manifestations like aseptic meningitis are described in Kawasaki disease (KD), facial nerve palsy is uncommon, with 30 cases reported since 1974 [1]. We describe a 3-y-old girl, refractory to the first dose of IVIG who presented to us with unilateral infranuclear facial nerve palsy. She was diagnosed as KD on the basis of a constellation of features including fever, irritability, conjunctival injection, strawberry tongue, cracked lips, edematous hands and feet and perianal excoriation. 2D Echo done on day 23, showed diffuse dilatation of all coronary arteries and aneurysm of left anterior descending and proximal right coronary artery with minimal pericardial fluid. IVIG was given at a dose of 2 g/kg on day 23. We first saw her on day 27 of illness, with persistent fever despite IVIG. On presentation, she had the above mentioned signs and periungual peeling. We also noticed a left sided facial deviation, obliteration of the right nasolabial fold and incomplete closure of right eye, suggesting a right sided infranuclear facial palsy (Fig. 1). A repeat 2D Echo on day 27 showed similar findings as the earlier ECHO with resolution of the pericardial effusion. A repeat dose of 2 g/kg of IVIG, led to normalization of the fever and other signs within 48 h. The facial nerve palsy persisted. On follow up after 3 wk the facial palsy had resolved. Neurological complications of KD include irritability, aseptic meningitis, ataxia, seizures, focal encephalopathy, cranial nerve palsies, cerebral infarction, and transient hemiplegia [2]. In a prospective study of 115 patients on complications of KD, one patient (0.9 %) had facial nerve palsy [3]. Most reported cases of facial nerve palsy occur in the convalescent phase, are self limiting, (duration ranging from 2 d to R. P. Khubchandani (*) : A. Dhanrajani Department of Pediatrics, Jaslok Hospital and Research Center, Mumbai, Maharashtra 400026, India e-mail: [email protected]
Fig. 1 Photograph of the child showing slightly wider right sided palpebral fissure, obliteration of the right nasolabial fold, and mild assymetry of the angles of mouth, suggesting right infranuclear facial palsy
3 mo) are commoner in females (1.4:1) are unilateral [3], and are associated with more severe and frequent (more than 50 %) coronary artery lesions [4, 5], as in our case. The pathogenesis is speculated to be an ischemia of the arteries supplying the facial nerve secondary to the underlying generalized vasculitis in addition to the immune activation known in KD [1]. The facial nerve palsy recovers spontaneously although IVIG may hasten recovery. It is known that delayed administration of IVIG increases the likelihood of coronary affliction, like in our case, yet role of IVIG in treating or preventing neurological complications still remains to be established. Facial nerve palsy has also been described in cases with incomplete KD [3]. Contribution Dr. Raju P Khubchandani will act as guarantor for this paper. Conflict of Interest None. Role of Funding Source None.
Indian J Pediatr (April 2014) 81(4):406–407
References 1. Lim TC, Yeo WS, Loke KY, Quek SC. Bilateral facial nerve palsy in Kawasaki disease. Ann Acad Med Singapore. 2009;38:737–8. 2. Wright H, Waddington C, Geddes J, Newburger JW, Burgner D. Facial nerve palsy complicating Kawasaki disease. Pediatrics. 2008;122: e783–5.
407 3. Alves NR, Magalhães CM, Almeida Rde F, Santos RC, Gandolfi L, Pratesi R. Prospective study of Kawasaki disease complications: Review of 115 cases. Rev Assoc Med Bras. 2011;57:295–300. 4. Poon LK, Lun KS, Ng YM. Facial nerve palsy and Kawasaki disease. Hong Kong Med J. 2000;6:224–6. 5. Kocabas A, Kardelen F, Aldemir Kocabas B, Akcurin G, Ertug H. Facial nerve palsy and Kawasaki disease. Indian J Pediatr. 2014;81: 186-8.
