CLINICS 2012;67(6):689-692 CASE REPORT DOI:10.6061/clinics/2012(06)25 An atypical presentation of Kawasaki disease: a 10- year-old boy with acute exudative tonsillitis and bilateral cervical lymphadenitis Chiew-Yee Yap,I Lung-Huang Lin,I,II Nan-Koong WangI,II I Cathay General Hospital, Department of Pediatrics, Taipei, Taiwan. II Fu-Jen Catholic University, College of Medicine, Hsinchuang, Taipei, Taiwan. Email: lhlinlh@yahoo.com.tw Tel.: 886-0983701395 INTRODUCTION Kawasaki disease (KD) is typically a self-limiting condi- tion that is a common cause of pediatric vasculitis (1) and the leading cause of pediatric acquired heart disease (2). The disease most frequently occurs in children aged between 6 months and 5 years (3) and is often associated with coronary artery aneurysms (4). Indeed, findings from an epidemio- logic survey conducted in Japan revealed that only 1% of KD cases occurred in children aged $9 years (5). There is currently no laboratory test for diagnosing KD. Rather, diagnosis is performed with reference to established clinical criteria (6). Unfortunately, atypical manifestations of KD appear to be on the rise (1), decreasing the likelihood of timely diagnosis and appropriate treatment. Herein, we report an unusual case of KD: a 10-year-old boy who presented with acute exudative tonsillitis and bilateral cervical lymphadenitis. CASE DESCRIPTION A 10-year-old boy presented with a 4-day history of fever, sore throat, and neck pain. The boy had taken oral medication (acetaminophen, 500 mg QID) before presenta- tion without effect. A physical examination revealed inflamed tonsils with a yellowish purulent coating (Figure 1A) and bilateral neck masses of approximately 563 cm2. The neck masses were firm and movable, tender upon palpation, and associated with neck stiffness. There were no other abnormal physical examination findings. Non-specific complaints included cough, rhinorrhea, and abdominal cramping and pain with nausea and vomiting. Blood testing revealed the following: hemoglobin, 14.6 g/ dL; white blood cell (WBC) count, 13,720/mm3, with neutrophil predominance (84.3%); platelet count, 197,000/ mm3; and C-reactive protein (CRP) concentration, 9.4 mg/ dL. Soft-tissue neck films showed no evidence of retro- pharyngeal abscess or masses, whereas a neck ultrasound revealed bilateral hypoechoic masses suggestive of cervical lymphadenitis (Figure 1B, C). Acute exudative tonsillitis with cervical lymphadenitis was suspected, and treatment Copyright 2012 CLINICS – This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. No potential conflict of interest was reported. 689 with intravenous benzyl penicillin (106104 U/kg IV Q6H) was initiated. Despite 72 hours of intravenous antibiotic treatment, a persistent high-spiking fever was noted. Three days after admission, the patient developed a rough-textured and sandpaper-like erythematous maculopapular skin rash with pruritus on the lower body (Figure 2A, B). Vesicular and bullous formations were apparent in the axillary region. The skin rash resolved and reappeared intermittently during hospitalization. Four days after admission, the patient developed strawberry tongue and bilateral conjunctivitis (Figure 2C, D). Blood tests performed four and seven days after admission revealed WBC counts of 16,580/mm3 (day 4) and 22,460/mm3 (day 7) and CRP concentrations of 25.7 mg/dL (day 4) and 25.4 mg/dL (day 7). The patient’s condition had not improved, and the neck masses remained painful. Four days after admission, the patient’s temperature spiking had not resolved, and he exhibited enlarged cervical nodes and acute exudative tonsillitis. Because the patient had failed to respond to initial therapy with benzyl penicillin within 72 hours, a bacterial-resistant infection was suspected, and the treatment regimen was changed to intravenous amoxicillin/clavulanic acid. The change in medication resulted in a significant improvement of the patient’s condition. Seven days after admission, the interval between febrile episodes was prolonged, with lower peak temperatures. Reductions in neck mass size and tenderness were also apparent. Nine days after admission, the patient’s fever had subsided, and all of the other symptoms had resolved. The patient was discharged. Testing before discharge revealed 3 the following: WBC count, 14,410/mm ; platelet count, 508,000/mm3; CRP concentration, 10.7 mg/dL; erythrocyte sedimentation rate, 102 mm/h and 112 mm/2 h; and anti- streptolysin O and Epstein-Barr virus (EBV) antibody titers within normal limits. The throat swab cultures taken at the time of admission were positive for Streptococcus viridans, whereas blood cultures were negative for all organisms. Fourteen days after the onset of fever, the patient presented to our outpatient department with sheet-like desquamation of the hands, feet, and perianal region (Figure 2E and F). Laboratory analyses revealed normocytic, normochromic anemia (hemoglobin 11 g/dL, hematocrit 34.8%) and thrombocytosis with a platelet count of 718,000/ mm3. On the same day, echocardiography revealed bilateral coronary artery dilatation with a right coronary artery