A 9-Month-Old Boy with a 3-Week History of Fever

This 9-month-old boy was evaluated for a 3-week history of fever. Initially, he started having fever 5 weeks before admission and was unable to receive his fl u shot at the 9-month visit because of low-grade fever. Three weeks before admission, his fever became higher and he received amoxicillin for otitis media. Daily fever with rhinorrhea continued and he received two doses of ceftriaxone. Two days before admission, there was no improvement in the fever and a third dose of ceftriaxone was doubled. He continued to have cough, fever, decreased intake, and decreased activity; the day of admission, he was sent to the emergency room for evaluation for possible Kawasaki disease. Review of systems was remarkable for illdefi ned “eye redness.” Birth history was unremarkable. Family history is quite remarkable. The mother was diagnosed with non-Hodgkin’s lymphoma shortly after delivery, and she was at this time being treated as an inpatient for Aspergillus pneumonia. On physical exam, he was an alert, cranky boy who was easily consoled. Weight was in the 60th percentile, length in the 75th, head circumference in the 10th. Initial temperature was 100.5°F, pulse 160, respiratory rate 38, and blood pressure 96/50. There were no rashes. On HEENT examination, he had mild bilateral conjunctival injection. Tympanic membranes were normal. Neck was supple without signifi cant adenopathy. Lungs were clear. S1 and S2 were normal. There was II/VI vibratory, systolic ejection murmur heard best at the left lower sternal border. Abdomen was soft and non-tender. Liver was palpable 3 cm below the right costal margin and spleen was palpable 2 cm below the left costal margin. Genitalia were normal. He had full range of motion of his extremities. There was slight erythema and puffi ness on the dorsum of his feet. Neurologic exam was unremarkable. Signifi cant laboratory testing on admission included hemoglobin 7.9 g/dL with MCV 70; white blood cell count 15,000/mm3 with 30% neutrophils, 26% bands, 31% lymphocytes; platelet count 290,000. Chem14 was remarkable for albumin 2.6 g/dL, ALT 160 IU/L, and AST 131 IU/L. C-reactive protein was 10 mg/dL and sedimentation rate was 77 mm/hour. Urinalysis was unremarkable save for three to fi ve red blood cells and three to fi ve white blood cells per high-powered fi eld. Chest X-ray was normal. Robert Listernick, MD, moderator: Gestalt? Evan Anderson, MD, pediatric infectious disease physician: The initial concern in the emergency department was for Kawasaki disease (KD). Certainly, there were some supportive clinical features, including the prolonged fever, conjunctival injection, red, puffy feet, elevated infl ammatory markers and mildly elevated serum transaminases. He was quite cranky and the abdominal examination was diffi cult. The splenomegaly was not reliably identifi ed. If present, it would have been unusual for KD. Overall, I saw no urgency in treating him with intravenous immunoglobulin, as the diagnosis of KD was shaky at best. Stanford T. Shulman, MD, pediatric infectious disease physician: The diagnosis of incomplete KD can be quite challenging, particularly in infants. At times, we will treat a child with intravenous immunoglobulin and aspirin, even if we are not sure of the Dr. Listernick is professor of pediatrics at Feinberg School of Medicine, Northwestern University, and director of the Diagnostic and Consultation Service, Division of General Academic Pediatrics, Children’s Memorial Hospital, Chicago, IL.

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