A mildly overweight 8-year-old Hispanic female in rural Colorado is brought to her primary care provider’s (PCP) office with right neck pain and right-sided neck swelling of a day’s duration. The patient’s mother also stated that her daughter had a maximum temperature (T-max) of 102°F that started that morning. The patient denied any sore throat, rash, headache, rhinorrhea, cough, nasal congestion, abdominal pain, vomiting, or diarrhea.
The patient also denied any swelling of her tongue, hands, or feet. Her mother was concerned that the neck swelling may be related to a recent cat scratch. The patient and her family do not have any cats in the home, but the patient did play with one at a friend’s house in the past week. The mother denied any history of recent travel. No one else in the home had similar symptoms.
Prior to this patient’s presentation, she was in a normal healthy state. She does have a past medical history that includes Kawasaki disease (KD) diagnosed at 3 months of age. She has had regular follow-up with Pediatric Cardiology and there have been no concerns for residual cardiac complications.
On initial exam, the patient was well appearing and was noted to have posterior pharyngeal erythema with asymmetrical tonsils (R 2+, L 1+), and right-sided nonfluctuant anterior cervical/submandibular lymphadenopathy with a supple neck (Figure 1).
As the patient was in school at the time with possible exposure, a rapid group A Streptococcus test was obtained (negative), and culture was sent. The mother was also mildly concerned about the possibility of recurrent KD. She (a medical assistant at the PCP’s clinic) was informed that KD could not be diagnosed in the absence of 5 days of fever. Also, the patient had no other symptoms of KD such as cracked lips, desquamation of hands/feet, or conjunctivitis. The patient was sent home with instructions for supportive care for a presumed viral infection and advised to follow up if her symptoms worsened or did not improve within the next week.
The patient returned to her PCP’s office 3 days later as she had developed worsening right-sided lymphadenitis and continued to have fevers (her last fever was the previous night). Her mother noted that the patient had complained of fatigue the previous night, but otherwise had no new symptoms. Her fevers occurred nightly. The patient’s exam was consistent with the mother’s history of increasing neck swelling, and “2-cm x 3-cm nonfluctuant, mildly tender to palpation, right submandibular prominence” with full range of motion was documented. She remained well appearing.
It was time to supplement the differential diagnosis (Table 1) with further laboratory evaluation (Table 2).
1. Centers for Disease Control and Prevention (CDC). About Kawasaki disease, Available at: https://www.cdc.gov/kawasaki/about.html. Last reviewed October 24, 2018. Accessed September 6, 2019.
2. Sudo D, Nakamura Y. Nationwide surveys show that the incidence of recurrent Kawasaki disease in Japan has hardly changed over the last 30 years. Acta Paediatr. 2017;106(5):796-800.
3. Yang HM, Du ZD, Fu PP. Clinical features of recurrent Kawasaki disease and its risk factors. Eur J Pediatr. 2013;172(12):1641-1647.