Comorbidity of Kawasaki disease and group a streptococcal pleural effusion in a healthy child: a case report
A 3-year-old female patient presented with a 5-day history of fever, sore throat, and cough, but no rash. Past medical history was unremarkable, as was family history. Immunizations were up to date for age. On admission to the ward, her vital signs were: temperature 39.5°C; pulse 130 beats per minute; blood pressure 100/70 mmHg, respiratory rate 50 per minute; oxygen saturation 90% on oxygen 2/L per minute via nasal cannula; weight 13.8 kg (50th percentile); and length 94 cm (48th percentile). Her skin had normal texture, with no rashes, hypopigmentation, or hyperpigmentation, her capillary refill was around 3 seconds, and the oral mucosa was mildly dry. The patient had decreased air entry and coarse crackles in the right lower and middle zones of the lung. The throat was erythematous and there was no cervical lymphadenopathy. The rest of the physical examination was unremarkable.\nInitial laboratory results were: white blood cells 24,000/μL (neutrophils 60.2%, lymphocytes 35.4%, monocytes 4.3%, basophils 0.1%), hemoglobin 10.3 g/dL, and platelets 206,000/μL. C-reactive protein was 100 mg/L, erythrocyte sedimentation rate was 65 mm/hour, albumin was 18 g/L, creatinine was 66 μmol/L, aspartate aminotransferase was 100 U/L, and alanine aminotransferase was 60 U/L. Serum glucose, blood urea nitrogen, calcium, sodium, chloride, and potassium were normal. Venous blood gas was pH 7.2, pCO2 44 mmHg, pO2 29 mmHg, and HCO3 17 meq/L, with a base excess of 11. Anteroposterior chest radiographs showed a right middle and lower lobar consolidation with moderate pleural effusion.\nThe patient was started on intravenous normal saline 20 mL/kg due to dehydration. She was then transferred to the pediatric intensive care unit due to increased oxygen requirement. A chest tube was inserted and 200 mL of pus was drained. The pleural fluid culture yielded GAS. The patient was started on intravenous cefuroxime and clindamycin. Nasopharyngeal and throat swabs, blood culture, and a Mantoux skin test were all negative.\nOn the eighth hospital day, there was no clinical response to antibiotics, and fever persisted, with new onset of abdominal pain, diarrhea, and slight tachycardia at a heart rate of 150 beats per minute.\nA repeat blood count showed a significant white cell count of 30,000/μL, hemoglobin 7.7 g/dL, platelets 600,000/μL, aspartate aminotransferase 180 U/L, alanine aminotransferase 120 U/L, and albumin 18 g/L, with a rise in erythrocyte sedimentation rate and C-reactive protein.\nThe differential diagnosis included bacterial resistance to antibiotics, nonbacterial etiologies such as a virus or aspiration of a foreign body, bronchiolitis obliterans, hypersensitivity pneumonitis, atypical Kawasaki disease, eosinophilic pneumonia, Wegener’s granulomatosis, pulmonary sequestration, and cystic adenomatoid malformation.\nSince atypical Kawasaki disease was in the differential diagnosis, an echocardiogram was ordered which showed a prominent of left anterior descending artery (0.26 cm, z-score 3.2) and left main coronary artery (0.35 cm, z-score 3.2), with no vegetations or pericardial effusion. Our team decided to give one dose of intravenous immunoglobulin 2 g/kg, and high-dose aspirin (80 mg/kg/day) was started. The fever resolved in 24 hours and the patient’s general condition improved, but desquamation developed on the hands and feet. The diagnosis of atypical Kawasaki disease was confirmed.\nThe patient was discharged home in a stable condition on oral antibiotics for 2 weeks and on an antiplatelet dose of aspirin. She was seen in the outpatient clinic in good condition, and a repeat echocardiogram at 6 weeks was normal.