This case discusses a 4 month old female child who presented with fever, cough, vomiting and abdominal distension. Initial assessments found the child to be stable. Imaging showed bowel distension resembling pseudo-obstruction. Though treated for suspected septic ileus, the child's fever did not improve with antibiotics. Laboratory findings of thrombocytosis, sterile pyuria, and elevated inflammatory markers led to a diagnosis of incomplete Kawasaki disease. The child received IVIG which was initially ineffective, requiring a second dose. Echo showed coronary abnormalities resolving with treatment. The child was discharged on aspirin with follow up.

1. INTERESTING CASES
By Dr A.SASIDHARAN (JR)
DR. KARUNAKAR (SR)
Moderator: Dr GUNASEKARAN
Professor, Pediatrics

2. Index case
B/O SUSANA MARY , H- 803767, 4 months/female
DOA-06/11/2019
DOD - 18/11/2019
CHIEF COMPLAINTS :
• Fever for 1 day
• Cough and cold for 1 day
• Vomiting for 1 day
• Abdominal distension for 1 day

3. Primary assessment
Airway:
Maintainable
Breathing:
RR: 32/min
Pattern: normal
Efforts: normal
Auscultation: B/L AE+, No added sounds
Circulation:
HR : 132/min
CFT: < 3 sec
BP : 80 / 50 mmHg
Central pulse: good
Peripheral pulse: good
Skin temp: normal
ECG: Normal sinus rhythm
Disability:
GCS: E4V5M6
Pupils: R-2mm;L-2mm
Reacting to light
Motor Activity: Symmetrical
Blood sugar: 126 mg/dl
Exposure:
Temp: 99.4 0F
Colour: normal
Surface findings: normal
Final physiological
categorization:
stable
Triage classification:
Level 4 (less urgent )

4. HOPI
2 months old, developmentally normal female
child was brought with the complaints of
 fever for 1 day, moderate, intermittent type,
not associated with chills and rigor and relieved
with medications,
 cough and cold for 1 day and vomiting for
1 day, 6-10 episodes , bilious and non – blood
stained.
 History of poor feeding and abdominal
distension for 1 day. History of irritability for
past 1 day.

5. • No h/o loose stool
• No h/o rashes, Petichae
• No h/ o altered sensorium
• No h/o respiratory distress

6. • Past History: Nil significant
• Family History: Nil significant
• Development history: Appropriate for age
• Antenatal History: Nil significant
• Birth History: Term /AGA/SVD/ BW: 2.90 kg / Cried at
birth/No history of NICU stay
• Immunization history: Immunized up to age

7. Focussed examination in casualty
• GPE: No Pallor, Icterus, Cyanosis, Lymphadenopathy, Edema
• S/E:
 CVS - S1S2 heard, no murmur
 RS - Bilateral NVBS, no added sounds
 Per abdomen - soft, non tender,no organomegaly
 CNS – GCS-E4M6V4, Pupils NSNR, No focal Neurological
deficit, No signs of Meningeal Irritation.

8. Management in A/E
• A 4 month old female child admitted for the above
complaints, initially based on bilious vomiting, fever and
abdominal distension, Septic ileus was initial probable
diagnosis and the child was started on IV cefotaxime. Child
was kept on NPO, Nasogastric tube was inserted and kept a
drain and started on IV fluids.
• The child was shifted to ward after stabilizing

9. CXR WITH ABDOMEN
• ?? Intestinal psudo-obstruction

10. Questions in mind
• If it is septic ileus , then why not improving
with IV antibiotics ??
• Abdominal X-ray showing pictures of bowel
distension looking like pseudo obstruction
• What could be the cause of pseudo obstruction
• Any underlying pathology mimic intestinal
pseudo – obstruction

11. Course and management in ward
• The child was continued on IV antibiotics , for more than 48 hours fever was not
responding with anti – pyretic and antibiotics.
• Child clinically irritable and loose stool episodes ( developed in the hospital) were
present with
persistent fever not responding to IV antibiotics,
Rapid thrombocytosis
sterile pyuria
Anal region excoriation ( anal excoriation ) and
Elevated inflammatory markers like ESR and CRP are suggestive
and fitting into criteria of INCOMPLETE (ATYPICAL) KAWASAKI DISEASE , workup was
planned for the same.

12. Decision of IVIG
• IV antibiotics and syp. Oseltamivir were stopped after blood culture was sterile.
• ECHO heart done on 9/11/19 was showing small coronary aneurysms of
LMCA & RCAD and dilation of LAD & RCM. with normal ventricular
function. IVIG (2 gm/ Kg) was infused on 9/11/19. Moderate dose of Tab.
Aspirin @ 60 mg/kg/day was started.

13. IVIG RESISTANT KAWASAKI
• Following IVIG infusion, the child had persistent fever spikes came down to
intermittent fever spikes, for 36 hrs.
• Child had clinically improved in terms of reduced irritability, improved feeding
and decreased episodes of loose stools. Since, the fever persisted post IVIG
infusion for more than 36 hrs, IVIG RESISTANT KAWASAKI DISEASE
was presumed and another dose of IVIG (2gm/ Kg) infusions was given on
14/11/19 and post IVIG the child had 2 low grade fever spikes and currently
afebrile for more than 36 hrs.

14. REPEAT ECHO
• Repeat ECHO heart was done on 16/11/19 was showing resolution in
aneurysm of LMCA and dilation of LAD and RCM & Persistence of
small aneurysm of RCAD. The child was clinically stable and planned for
discharge with T. Aspirin 5mg /kg/ day and advised to be under further
follow up.

15. INVESTIGATIONS

16. Hemogram
Date 06/11/2019 08/11/2019 14/11/2019
Hb 8.9 8.6 8.4
TLC 27680 24390 21590
DLC N54L28M13 N44L40M15 N40L45M11
Platelets 4.42Lakhs 6.62 lakhs 8.58 Lakhs

17. RFT and LFT
Date 05/11/2019 08/11 /2019 11/11/2019 15/11/2019
Ur/Cr 11/0.20 9/0.08 8/0.15 12/ 0.17
Na/K 131/5.15 132/5.61 134/4.19 132/ 4.5
Bil(t)/Bil(d) 0.28/ 0.11 0.31/ 0.32/0.05
STP/Alb 4.8 / 3.1 6.4/2.8 7.5/3.2
AST/ALT 17/ 7 20/7 31/6
ALP/GGT 160 / - 209 / - 184/-

18. Investigations
• 5/11/19: X-ray chest and abdomen: Right
Paracardiac infiltrates present , dilated air
filled bowel loop. S/o ileus
• 5 /11/ 19: blood culture – sterile
• 5/11/19: USG abdomen: most of visualized
bowel loops are gas filled. No abnormal
dilated / edematous bowel loops noted.

19. Investigations
• 6/11/19: throat swab – negative for
respiratory viruses
• 8/11/19 urine M/E: 300 cells/ high power
field (sterile pyuria)
• 8/11/19: ESR : 37 mm @ end of 1 hr
• 8/11/19: CRP: 4.8 mg/dl (elevated)

20. Echo heart
• 9/11/19: ECHO HEART:
• 3 mm OS – ASD Left – right shunt
• Coronaries: LMCA: 2.5 mm (3.08 Z) – small aneurysm
• LAD: 1.7 mm (2.37 Z) – dilation
• LCX: 1.4 mm (1.61 Z) – normal
• RCA : 1.4 mm ( 0.93 Z) – normal
• RCM : 1.6 mm ( 2.23 Z) – dilation
• RCAD : 1.7 mm( 3.002Z) – small aneurysm

21. Investigations
• 9 /11/19: Febrile illness panel: negative for
dengue, chickungunya, scrub typhus
• 11/11/19: urine culture: sterile after 2 days
• 11/11/19: CRP : 2.4 mg/ dl
• 13 / 11/ 19: ESR: 100 mm @ end of 1 hr
• 14/11/19: CRP: 4.8 mg/dl

22. Echo heart
• 16/11/19: ECHO HEART:
• LMCA: 1.2 mm (-0.39 Z) – normal
• RCA : 1.6 mm ( 1.58 Z) – normal
• RCM : 1.4 mm ( 1.56 Z) – normal
• LAD: 1.0 mm ( -0.052 Z) – normal
• LCX: 0.07 mm (-2.98 Z) – normal
• RCAD : 1.7 mm( 3.00 Z) - small aneurysm