Acute Abdomen in Kawasaki Disease
Condition: Kawasaki Disease; Appendicitis
MeSH terms: Appendicitis; Mucocutaneous Lymph Node Syndrome; Abdomen, Acute
Study type: Observational

Summary: 
      Clinical and histopathological description of three cases of Kawasaki disease with acute
      abdomen.
    

Detailed description: 
      CASE PRESENTATION Case 1 An 8 year-old male started 48 hrs prior to admission with abdominal
      pain in the right lower quadrant associated with vomiting and fever. The physical examination
      revealed discrete bilateral conjunctival hiperemia, right cervical adenomegaly, and severe
      abdominal pain in the right lower quadrant with a positive McBurney sign. Laboratory tests
      showed CBC: Hb 14.1 g/dl, WBC 13,800, NT 81%, LT 3%, Plt 383,000/μl. C-reactive protein 230.9
      mg/dl, BNP 106.4 pg/ml (0-99). Abdominal ultrasound confirmed the diagnosis of appendicitis.
      A laparoscopic appendectomy was performed, and appendiceal distal enlargement with
      fibrinopurulent tissue was found. Twelve hours after surgery, the patient presented increased
      conjunctival hyperaemia, generalized rash as well as upper extremities edema and
      desquamation, meeting criteria for Kawasaki disease. Cardiological evaluation showed mild
      pericardial effusion (3mm), normal coronary arteries. Intravenous immunoglobulins (IVIG),
      aspirin and steroids were started with resolution of the fever, rash and the conjunctival
      erythema.

      Case 2. A 6-year-old male started 15 days prior to admission with fever. He presented hands
      and feet edema and a generalized exantema. He was diagnosed with scarlet fever. The patient
      presented conjunctival hyperemia and cheilitis. On day 15 the patient had severe abdominal
      pain (right lower quadrant), and was hospitalized with the diagnosis of appendicitis. An
      appendicetomy was performed and two perforations of the appendix were found. Appendicitis was
      found (Figure 1). The patient persisted with fever and desquamation of perineal area, fingers
      and toes were added to the clinical picture. Laboratories reported blood count: Hb 13 g/dl,
      WBC 47,700/mm3 neutrophils 95% bands 8% platelets 551,000/μl, C-reactive protein 19.7 mg/dl,
      ESR 53 mm/hr, hypoalbuminemia 2.2 g/dl. Diagnosis of KD was established and IVIG 2 g/kg and
      aspirin were administered. Echocardiogram was normal. Surgical wound culture was reported
      positive for Enterococcus faecium and Escherchia coli. Antibiotic therapy was administered
      for 14 days with good evolution.

      Case 3. A 5-year-old male patient, presented with a history of fever for 5 days diagnosed as
      bacterial tonsillitis and treated with antibiotics without resolution. On the fifth day the
      patient developed bilateral conjunctivitis, erythema on the lips, morbilliform exanthema in
      the anterior and posterior thorax and abdominal pain in mesogastrium and right lower
      cuadrant. His physical examination revealed non-purulent bilateral conjunctivitis, cracked
      lips, strawberry tongue, cervical lymphadenopathy of 0.5 x 1 cm, exanthema in thoracic and
      dorsal region, with significant erythema of palms and soles, without skin exfoliation. The
      patient presented with severe abdominal pain located in the right lower quadrant, with signs
      of peritoneal irritation. Abdominal ultrasound was performed and was suggestive of acute
      appendicitis. Laboratories reported blood count: Hb 14.1 g/dl, Hcto 40.5%, WBC 3400 /uL,
      neutrophils 3100/uL, lymphocytes 300 103/uL, platelets 41,000 103/uL; ferritin 1700 ng/ml,
      triglycerids 190 mg/dl, C-reactive protein 8 mg/dl, normal hepatic and renal function. A
      diagnosis of KD and acute appendicitis was made. Treatment was started with IVIG and aspirin.
      The boy was taken to diagnostic laparoscopy where periappendicular inflammation was found.
      The cecal appendix biopsy presented normal morphology up to the serous layer, with congestive
      vessels, interstitial edema, and mild inflammatory infiltrate with predominantly mononuclear
      cells within the lymphatic vessels (Figure 2). A final diagnosis of mild mononuclear
      periappendicitis was made. The patient had an uneventful evolution with resolution of the
      symptoms.
    

Intervention name(s): appendicectomy
Intervention type(s): Procedure
Observational model: Case-Only
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        Kawasaki disease patients