A Constellation of Nail Changes in A Child with Kawasaki Disease.

Abstract

A two-year-old boy was brought with high grade intermittent fever of 6 days duration with congestion of eyes, perioral and perianal skin peeling of two days duration. On examination, he had an enlarged right upper deep cervical lymph node of size 2x2 cm, dry and cracked lips, red tongue, congested oropharynx, bilateral nonpurulent conjunctival infection, perioral and perianal desquamation, macular rash with central clearing in his neck and trunk, swollen hands and feet. Investigations revealed neutrophilic leukocytosis, ESR of 98 mm/hr, platelet count of 2 lacs/cubic mm and positive CRP. Blood antistreptolysin O was negative. There was no history of sore throat, difficulty in swallowing or history of any drug intake. As the boy satisfied the clinical criteria for Kawasaki disease [1], antiinflammatory therapy was started with which he became afebrile in 48 hours. Echocardiogram did not reveal coronary aneurysms. On day ten of illness, he was noticed to have periungual desquamation (red arrow), orange brown discolouration (chromonychia) of nail on right ring finger (blue arrow), transverse nail crease ( yellow arrow) on his right middle finger and spontaneous separation of nail (onychomadesis) on his right index finger (white arrow) [Table/Fig-1]. On follow-up, his nail changes normalized and he continued to remain free of coronary aneurysms. [Table/Fig-1]: Nails in Kawasaki disease Extremity changes in Kawasaki disease are well known and include erythematous swelling of hands and feet in the acute phase followed by periungual desquamation in the convalescent phase [1]. Several nail changes have been described in Kawasaki disease. Spontaneous nail separation from the matrix or onychomadesis resulting from inhibition of nail plate growth due to inflammation of nail matrix [2], Beau`s lines [3], pincer nails (transverse over curvature of nails) [4], leukonychia (non uniform white discolouration of nail plate) and transverse orange brown chromonychia [5]. However, all the nail changes occurring in a single child has not been reported previously, to the best of our knowledge.