Age: 0.17
Sex: M
Vaccine: DTAPIPVHIB, PNC13, RV5
Symptoms: Ultrasound scan normal, Urine analysis normal, Vomiting
Clinical narrative: Patient is a 3-month-old male who was admitted from the infectious disease clinic today for further workup of fever and rash.     Patient was seen today in clinic along with both of his parents. History, per chart review:   Symptoms began on Jan. 5th: Vomited forcefully for first time - very forceful. Did not happen again. On the 7th, got first set of immunizations including Rotavirus. Slight fever afterwards x 24 hours. On the 10th/11th, noted to have blood in stool multiple times, resolved within two days of Mom starting dairy free diet.    On the 15th had increased fussiness with fever 101.9 rectal temperature. Mom unbundled him and temperature decreased that night to 100.6. This fever persisted, so they presented to the ER the morning of the 16th. Had Covid nasal PCR (negative), RVAP (negative), normal UA, CXR - normal and work up negative (no LP performed).  Given TYLENOL and d/c'd home. Right before going home, mom noticed a lesion on foot that looked like a "halo". By the time they got home, rash/lesions spread over both feet. Patient continued to have fever 100.6-100.8.     Went back to the ER on the 17th and had T-103 rectally. Rash was worse and spread to palm of right hand and hand reportedly turned blue. Testicles also appeared red and "tight", particularly the left testicle. In ER, eyes began to look "blood shot" and developed more diarrhea. Given TYLENOL had repeat CBC and blood cx.  Was admitted to hospital for observation at that time. US of testicles done, and flow was normal. At this point, eyes were "completely red", and rash appeared on hands. On the 18th, blood in stool re-appeared and fever continued (still in hospital). Labs reportedly all normal except for elevated AST/ALT and thrombocytosis - parents told that this looked like "inflammation".   Evening of the 18th received one dose of Ceftriaxone. Fever decreased but blood in stool continued. Discharged to home at this time. Afebrile x 36 hours, but then fever returned to 100.6 on the 20th and breaking through TYLENOL. Rash started to develop on face/ear at this time. Yesterday (the 21st), fever increased to 101.3 and rash seemed worse. Referred to clinic at this time.   This morning, T- 100.6, given TYLENOL prior to being seen today. Parents state that rash is still progression. Last blood in stool was on the 19th.   No LP or echocardiogram performed during this time period of illness.    No vomiting since this 5th. No obvious swelling of joints but parents state feet were swollen on the 17th/18th. Conjunctival injection now gone.  No lethargy or excessive irritability and continues to smile/interact with parents.    Birth Hx/Fam hx - Mom was COVID tested at 39 and 40 weeks of pregnancy, both negative, but not tested since. Mom breast feeding. Breast feeding schedule good as per mom - usually 1-2 hours during the day and often much longer overnight (has even slept up to 7-8 hours once). Feeds well, growing and developing normally as per parents. Dad healthy, no medications or medical conditions. Dad had COVID test 2 months ago and negative.    Lives at home with both parents, new home (2015).  3 dogs and 2 parakeets at home. Bird cages in different parts of the house. Dogs do not come into nursery, but patient is in contact with dogs. No tick bites noted or ticks on baby. Dogs all treated for ticks. Grandparents have not visited and no visitors in home since he has been born. Father (lawyer) and Mom (accountant) both telecommute for work at this time.    No other complaints.   Last dose of TYLENOL was given for fever, at 5 30 pm.   SUMMARY OF HOSPITAL COURSE:   Admitted to general pediatrics due to concern for atypical Kawasaki Disease. Peds consulted at admission. An echo was obtained and resulted negative for coronary artery aneurysm or ectasia. Also obtained a skull XR to evaluate the lesion on his head which was negative for osseous abnormality. On 1/23, he received IVIG with significant improvement in rash. He was pretreated with TYLENOL and BENADRYL and was also started on high dose aspirin. Blood cultures obtained prior to IVIG resulted no growth. He remained afebrile after receiving IVIG for 48 hours. On the day of discharge, he has been eating well with adequate UOP. He was transitioned to low dose aspirin (5 mg/kg/day), which he should continue for at least 6 weeks, or as determined by Pediatric Cardiology (f/u scheduled for 2/11).  Family was counseled that if Pt develops another fever in the next week, parents should call his PCP or return to ER as he may require additional treatment for atypical KD. Parents were also counseled that Pt should not receive MMR or varicella vaccines for 11 months following IVIG treatment.   Interval History: Mom states that Pt did well overnight. He breast feed almost every hour with no concerns. His energy level is back to normal and his UOP was adequate.   PHYSICAL EXAMINATION AT DISCHARGE:   Discharge Weight:  Wt Readings from Last 1 Encounters:  01/22/21 5.715 kg (12 lb 9.6 oz) (17 %, Z= -0.97) *   * Growth percentiles are based on WHO (Boys, 0-2 years) data.   Visit Vitals BP 89/47 (BP Location: Right leg, Patient Position: Supine)  Pulse 137  Temp 36.8 °C (98.2 °F) (Axillary)  Resp 34  Ht 0.615 m (2' 0.21")  SpO2 100%  BMI 15.11 kg/m²   Temp: [36.2 °C (97.1 °F)-36.9 °C (98.4 °F)]  Heart Rate: [118-156]  Resp: [30-44]  BP: (78-114)/(41-59)  SpO2: [98 %-100 %]   I/O (Last 24 hours) at 1/25/2021 1217 Last data filed at 1/25/2021 0938 Intake?  Output 450 ml  Net -450 ml   UOP: 1.49 ml/kg/hr Mixed: 433 ml  Physical Exam Constitutional: Well, developed, well nourished. No distress  HENT: Anterior fontanelle is flat. Nose normal. No nasal discharge.  Mouth/Throat: Mucous membranes are moist. Oropharynx is clear. No oral or nasal lesions  Eyes: Conjunctivae normal, no injection or discharge  Neck: Normal range of motion. Neck supple. No LAD.  Cardiovascular: Normal rate, regular rhythm. Pulses are palpable. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress.  Abdominal: Soft. Bowel sounds are normal. He exhibits no distension and no mass. There is no hepatosplenomegaly. There is no abdominal tenderness.  Musculoskeletal: Normal range of motion. No tenderness, deformity, signs of injury or edema. No notable joint edema or erythema  Lymphadenopathy: No occipital adenopathy is present. He has no cervical adenopathy.  Neurological: He is alert. He has normal strength. He exhibits normal muscle tone. Suck normal. Strong grasp. Extremities: Orange brown chromonychia on multiple nails improving Skin: Skin is warm and dry. Capillary refill takes less than 3 seconds. Turgor is normal. No petechiae and no purpura noted. He is not diaphoretic. No cyanosis. No mottling, jaundice or pallor. Non-blanching macules/papules that were present at admission have greatly improved. Now mostly present on feet with one spot.    DISCHARGE DISPOSITION: Home with family   FOLLOW-UP APPOINTMENTS/ARRANGEMENTS:  Future Appointments  Date Time  2/11/2021 10:00 AM   Family to schedule follow up as needed with PCP  Patient should not receive MMR or varicella vaccine for 11 months after receiving IVIG.   From Cardiologist: ASSESSMENT/PLAN  Pt is an otherwise healthy 3-month-old male with a recent history of Kawasaki disease, successfully treated with one dose of IVIG. He did not have coronary artery involvement apparent on his acute phase echocardiogram and continues to have normal appearing coronary arteries. The CV sequelae of Kawasaki disease are coronary artery aneurysms, most commonly detected in the acute phase or within 4 weeks of the illness. He has been on low dose aspirin to prevent thrombosis within any coronary artery aneurysms or ectasia that may have developed. He is approximately 4 weeks post the onset of illness and there is no evidence of coronary artery disease today so I will plan to stop his aspirin. Given his young age, I will plan to follow him up again in 1 year to reevaluate for evidence of coronary artery disease. His mother will call if he experiences difficulty feeding, unexplained irritability, or prolonged sustained tachypnea.  Pt also has a patent foramen ovale, which is a part of persistent fetal circulation. This communication is likely to close on its own without significant hemodynamic issues, but we will reassess with echo when he returns for follow up. No interventions or further testing are required in the interim.   Our recommendations are as follows:   Cardiac Medications: may d/c aspirin Activity Restrictions: None SBE Prophylaxis: Not indicated Vaccinations: As recommended by PCP including seasonal flu vaccine. Synagis is not indicated for cardiovascular reasons.  Follow-up: in 1 year  Pediatric Cardiology