Professional Documents
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12-28-12
D Spencer Mangum MD, PGY2
Presentation
19 month old presented to the ED with 7 days of
Day 4-5 of illness: Fevers increasing (Tmax 40) Continued fussiness Swelling over right neck with warmth / tenderness
Presentation
Day 5 of illness:
PCP diagnosed strep throat based on pharyngeal
Presentation
PMHx:
Full term previously healthy male No prior hospitalizations / surgeries No regular medications Immunizations: UTD
NKDA
FHx: No significant childhood or congenital illness SHx: Lives with mother / father, only child
Presentation: Exam
VS: T 39.5, HR 123, RR 28, BP 115/86 (crying), O2
Sat 100%RA GEN: Fussy, not easily consoled HEENT: TMs clear, No conjunctivitis, no cracked lips, MMM, mild pharyngeal erythema, 2+ tonsils w/out exudate, no deviation of uvula / masses, no drooling. NECK: 3x4 area of swelling over the right angle of the mandible extending to the ear, +erythema, +warmth, +tenderness. Hard but no fluctuance. RESP: No increased WOB. CTAB. No stridor / highpitched voice. CV: RRR, +S1/S2, no murmur appreciated ABD: Soft, NT/ND, +BS, no hepatosplenomegally EXT: WWPx4, No edema. SKIN: No rash.
Differential Diagnosis?
Rheum:
Kawasaki
Sarcoidosis Lupus
(Complication of pharyngitis Lymphoma leading to thrombophlebitis of the Lymphoproliferative disorders jugular vein Caused by Soft tissue Neoplasm fusobacterium) Cat scratch disease (Bartonella Congenital: Henselae) Thyroglossal duct cyst (midline) TB / Scrofula (Mycobacterium Branchial cleft cyst (anterior scrofulaceum or Mycobacterium along SCM) avium) Cystic hygroma (posterior above clavicles)
Oncology:
Labs / Imaging:
CBC: WBC 17 (33% Bands, 33% Neutrophils,
26% Lymphocytes), Hgb 12, Plt 240 ESR: 69 CRP: 4.4 Head CT: Asymetric soft tissue swelling with enlargement of the right cervical anterior lymph nodes. No abscess appreciated.
Hospital Course
Diagnosed with cervical bacterial lymphadenitis Given a dose of Clindamycin -> an erythematous rash to
the face and trunk was noted and changed to Unasyn Next AM, noticed improved swelling but continued fevers Reassessment:
Dry cracked lips with red tongue and swollen red palms
CRP: 4.4 -> 8 Hgb: 12 -> 10.8 Plt: 240 -> 356
U/A: 10 WBCs with no bacteria, nitrite / leuk esterase AST / ALT: 101 / 100 Albumin 3.3 Kawasaki Disease with isolated lymphadopathy (KDiL) confirmed Patient improved after IVIG x2 and high dose aspirin
Kawasaki Disease
Fever x5 days with 4 of 5 following:
Polymorphous rash Conjunctivitis (non exudative, limbic sparing) Cracked lips / strawberry tongue Cervical lymphadenopathy > 1.5 cm Changes to the palms / soles (red, edema, desquamation)
Unofficial criteria: Fussiness. Not all criteria need to be present at same time (get good
history) Treat with IVIG / High dose aspirin to avoid complications (Coronary artery aneurysm) If not enough clinical criteria met, Incomplete Kawasaki can be met with labs:
ESR>40, CRP>3, WBC>15, Anemia for age, Plt >450, Sterile
pyuria (>10 WBCs), Alb<3, Elevated ALT If ESR / CRP elevated -> get Echo regardless, and treat if 3+ other labs consistent or Echo consistent with KD
KDiL
Initial presentation of only fever / cervical