An 11-year-old boy with fever.

An 11-year-old boy was admitted for fever, ranging from 100°F to 103°F, for 4 weeks. When febrile, he had “cold teeth that are chattering,” and became drenched in sweat. He had been tired and often took naps after school. His mother noted that he had decreased energy and reduced oral intake. He had a documented 8-kg weight loss during the previous 6 months. There was no history of vomiting, diarrhea, hematochezia, or other symptoms. He had not missed any school during the last 4 weeks. There had been no exposures to unusual foods, animals, foreign visitors, or anyone with tuberculosis risk factors. He had not traveled outside of Chicago. His past medical history was remarkable in that he had possible Kawasaki disease at age 4 years. This illness was characterized by prolonged fever, mildly red eyes and oral mucosa, microcytic anemia, thrombocytopenia, and splenomegaly. Echocardiogram revealed a possibly minimally dilated right coronary artery on presentation. Although his fever improved initially after receiving intravenous immunoglobulin and aspirin, he continued to have intermittent fevers and arthralgias for the next several months. The diagnosis of juvenile idiopathic arthritis was entertained, but his fever and other symptoms ultimately improved and he didn’t return for follow-up. He remained well for the ensuing 7 years. Repeat blood count several months later had normal hemoglobin without microcytosis. His family history was remarkable in that his father reportedly had aplastic anemia as a teenager and had a stem cell transplant. On exam, he was a well-appearing boy. His weight was greater than the 95th percentile and height in the 80th percentile. Temperature was 97.8°F, pulse 102, respiratory rate 22, and blood pressure 110/60. HEENT exam was unremarkable. Neck was supple without signifi cant adenopathy. Lungs were clear. S1 and S2 were normal without murmurs or rubs. Abdomen was soft and non-tender without masses or organomegaly. He was Tanner 1. He had full range of motion of all joints without pain or swelling. There were no rashes. Neurologic exam was normal. Rectal examination was normal; stool hemoccult testing was negative. Laboratory evaluation on admission: hemoglobin 8.3 g/dL with MCV 68, white blood cell count 15,000/ mm3 with 85% neutrophils; platelet count 210,000/mm3. RDW was 14.5% (normal 12.5%-16%). CRP was 8 mg/dL and ESR 97 mm/hour. Urinalysis, serum chemistries, and chest X-ray were normal, save for albumin 3.3 mg/dL. PPD was negative. Blood and urine cultures were negative. Echocardiography was normal. Robert Listernick, MD, moderator: Did he have Kawasaki disease (KD) 7 years ago? Ben Katz, MD, pediatric infectious disease physician: Obviously, there’s no way to rule out KD because we don’t have a specifi c diagnostic test. Certainly, splenomegaly and microcytic anemia are not typical features. We occasionally see thrombocytopenia, which is a bad prognostic sign for the development of coronary artery disease. I believe at the time it was reasonable to treat him with intravenous immunoglobulin. However, if his symptoms persisted or if he developed further atypical symptoms for KD, such as arthritis, it would have been reasonable to consider alDr. Listernick is Professor of Pediatrics at Feinberg School of Medicine, Northwestern University; and Director of the Diagnostic and Consultation Service, Division of General Academic Pediatrics, Children’s Memorial Hospital, Chicago, IL. doi: 10.3928/00904481-20110815-04 fi rm rounds • fi rm rounds • • fi rm rounds • fi rm rounds