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A 25 year old farmer with joint
pain
Laura Zakowski, MD*
* No financial disclosures
Case
Flu-like symptoms 3 weeks PTA
 Improved after a few days
 Onset of rash and joint pain
 Continued fever
 Emergency room

 Negative
rapid strep
 Placed on Penicillin
Case
Continued joint pain, rash and fever
 Referred to UW

20 lb weight loss over the last month
with decreased appetite
 No ill contacts
 No significant travel

Past medical history unremarkable
 Takes no medications
 Family history of gout in his father
 Crop farmer from Ripon
 Married 5 months

Physical exam
Temp 100
 Remaining vitals normal

Neck exam: enlarged and non-tender
lymph nodes
 Lungs clear
 Heart regular with a 2/6 systolic murmur
at right upper sternal border
 Joint exam: no synovitis, right knee
effusion

Laboratory
WBC/plt normal, Hgb/Hct 10.4/29
 Lytes/Bun/creat normal
 ESR 89
 CRP 30

Laboratory
AP 149 (35-130)
 GGT 112 (0-85)
 AST 276 (0-50)
 ALT 375 (0-65)
 Albumin 3.0, INR 1.3
 U/A normal
 Arthrocentesis: no crystals, incr WBC

Differential diagnosis
Differential diagnosis

Polyarthralgias/Arthritis:
 Viral
(B,C, parvovirus)
 Reactive (IBD, rheumatic fever, post strep)
Differential diagnosis

Fever and rash:
 Viral
(EBV, parvo, measles)
 Vasculitis
 Scarlet fever/Rheumatic fever
 Staph or strep toxic shock
 Stevens-Johnson syndrome
Differential diagnosis

Enlarged lymph nodes
 Strep
lymphadenitis
 Viral (CMV, EBV, Parvo)
 Toxoplasmosis
Kawasaki disease
List the clinical features
 Identify current treatment
 Recall the differences between adult
and child Kawasaki disease

Kawasaki disease
First recognized case: 1961
 “Mucocutaneous lymph node syndrome”
 Medium vessel vasculitis

 Especially
coronary arteries
Unknown etiology
 Infectious?

 Peak
in winter and spring
 Rare in infants and adults
Kawasaki disease

Criteria with fever for at least 5 days:
 Bilateral
conjunctival injection
 Mucous membrane involvement
 Polymorphous rash
 Extremity involvement
 Cervical adenopathy
Other findings
Normochromic normocytic anemia
 Hyponatremia
 Elevated transaminases
 Pyuria
 Inflammatory body fluids

Self-limited disease
 Begins to resolve after 10 days
 Serious sequelae:

 Coronary
artery aneurysms develop in 2025% of children
 Depressed ejection fraction from
myocarditis
 Pericarditis and Valvulitis

Treatment best initiated within the first
10 days:
 Aspirin
 IVIG:

reduced aneurysms
Steroids controversial, used for
persistent fevers
Adults vs. children





57 cases reported
as of 2005

Adenopathy 93%
Arthralgias 61%
Elevated LFTs 65%
Aneurysm 5%





67 per 100,000 CA
135 per 100,000 HI
and Japan
15%
30%
10%
20-25%
Adults vs. children

Conjunctivitis
 93%

Strawberry tongue
 80%

 77%
Erythema hands/feet
 80%

 95%
 88%
Desquamation
 96%
 94%
Follow up
Negative echocardiogram
 Negative CT angiogram of coronary
arteries
 Treated with IVIG and ASA
 Improved anemia, LFTs, CRP, ESR
 Joint pain resolved
