Orbital Cellulitis Presenting as a First Sign of Incomplete Kawasaki Disease
A 6-year-old boy was referred to the Department of Ophthalmology, Marmara University School of Medicine, with the diagnosis of orbital cellulitis. He had had mild fever, pharyngitis and conjunctivitis for 7 days. Four days prior to presenting at our department, he had been referred with complaints of irritation to an ophthalmologist. Consultation with a pediatrician due to his fever resulted in a diagnosis of conjunctivitis and pansinusitis and he was treated with ampicillin-sulbactam and ceftriaxone 100 mg/kg/day. In the following 3 days, restriction of upgaze in the right eye and inflammation of the eyelids began and he was referred to us with a diagnosis of orbital cellulitis. An initial examination revealed normal visual acuity, bilateral conjunctivitis with excessive secretion, periocular inflammation and edema, right preauricular lymphadenopathy and right restriction in the upgaze and his lips were dry and cracked (fig. ). Magnetic resonance imaging confirmed orbital cellulitis and pansinusitis (fig. ).\nHis erythrocyte sedimentation rate on the first day of hospitalization was 55 mm/h and the C-reactive protein level was 22.4 mg/dl. Laboratory findings included a white blood cell (WBC) count of 19,000 cells per mm3, with 81.5% neutrophils, 15.0% lymphocytes, 1.2% monocytes and 0.4% basophils. The antibiotherapy was changed to vancomycin 60 mg/kg/day and meropenem 60 mg/kg/day. After 10 days of hospitalization without a clear response to antibiotherapy, periungual desquamation of the fingers started (fig. ). Pediatric examination revealed a strawberry tongue. Repeated laboratory tests revealed a total WBC count of 15,300 cells per mm3 with 63.8% neutrophils, an elevated platelet count (650,000 mm3), an erythrocyte sedimentation rate of 52 mm/h and an elevated C-reactive protein level of 46.3 mg/dl. The serum transaminase urine examination was normal. Following the algorithm defined previously, we concluded a diagnosis of incomplete KD (table ; online , see ) []. With the first echocardiography, no coronary artery lesions were detected. Aspirin (100 mg/day) was administered and by the third day of its administration, the orbital cellulitis and fever had regressed and the patient was discharged from hospital with oral antibiotics and aspirin. After 6 weeks, his control echocardiography revealed dilatation of the right and left coronary arteries and the diagnosis of incomplete KD was confirmed. He was treated with a single dose of intravenous immunoglobulin, 2 mg/kg over 10 h.