Facial palsy in a 2-month-old infant with Kawasaki disease

Abstract

We read with great interest the article “Facial palsy in a 2-month-old infant with Kawasaki disease” by Kaur et al. [1] published in the November 2009 issue of Rheumatology International. Although the authors were adept in managing the infant well, I would like to share with the readers my views further on the management of the case. There are numerous reports in the literature regarding the pattern of fever in Kawasaki disease (KD). It is an extremely wellknown fact that the fever in KD is high-grade commonly unrelieved by antibiotics and is mostly partially responsive to commonly employed antipyretics. In the present instance, the authors should have suspected KD at the very outset when the infant presented to them, based on the “signiWcant” past history of 2 weeks of high-grade fever not responding to multiple courses of oral and parenteral antibiotics. Although the authors do not mention anything about the responsiveness of the fever to antipyretics, it may be safe to assume that the fever might have been suboptimally responsive to antipyretics as well. Further, the authors describe “extreme irritability” in the child. This clinical sign, although subjective, helps immensely in suspecting KD in a given child, especially in the absence of other classical signs and symptoms. At this juncture, we would like to draw the readers’ attention to a recent report published by us in which we described extreme paucity of clinical signs and symptoms in a child with KD, whose major presenting features were prolonged fever unresponsive to antipyretics and “extreme irritability” [2]. This was followed by another similar report from Turkey by Yilmazer et al. [3]. We believe that instances of KD essentially represent a spectrum with some children on one end manifesting hardly any of the well-known signs and symptoms besides fever, while others at the opposite end of the same spectrum manifesting all the classical signs and symptoms. With increasing recognition of the incomplete forms of KD, and the diYculties associated with diagnosing such cases, the American Heart Association expert committee, 2004 recommended fulWllment of the supplemental laboratory criteria to assist clinicians in diagnosing “incomplete” forms of KD in the presence of two or three clinical signs [4]. These include anemia for age, serum albumin 450,000/mm, white blood cell count (WBC) >15,000/mm and urine >10 WBC per high power Weld. Under these circumstances, treatment with intravenous immunoglobulin (IVIG) is recommended before an echocardiogram is obtained. With regards the infant discussed, supplemental laboratory tests were positive on admission. Given the fact that the authors had an extremely irritable young infant with high-grade antibiotic unresponsive fever of 2 weeks duration with several additional tests of systemic inXammation strongly positive, we feel an immediate twodimensional echocardiography should have been carried out at the very outset to exclude coronary artery changes followed immediately by treatment with IVIG and highdose aspirin without waiting for other signs and symptoms to appear.