A 25 year old farmer with joint pain Laura Zakowski, MD* * No financial disclosures

Case n Flu-like symptoms 3 weeks PTA n Improved after a few days n Onset of rash and joint pain n Continued fever n Emergency room u Negative rapid strep u Placed on Penicillin

Case n Continued joint pain, rash and fever n Referred to UW n 20 lb weight loss over the last month with decreased appetite n No ill contacts n No significant travel

n Past medical history unremarkable n Takes no medications n Family history of gout in his father n Crop farmer from Ripon n Married 5 months

Physical exam n Temp 100 n Remaining vitals normal

n Neck exam: enlarged and non-tender lymph nodes n Lungs clear n Heart regular with a 2/6 systolic murmur at right upper sternal border n Joint exam: no synovitis, right knee effusion

Laboratory n WBC/plt normal, Hgb/Hct 10.4/29 n Lytes/Bun/creat normal n ESR 89 n CRP 30

Laboratory n AP 149 (35-130) n GGT 112 (0-85) n AST 276 (0-50) n ALT 375 (0-65) n Albumin 3.0, INR 1.3 n U/A normal n Arthrocentesis: no crystals, incr WBC

Differential diagnosis

n Polyarthralgias/Arthritis: u Viral (B,C, parvovirus) u Reactive (IBD, rheumatic fever, post strep)

Differential diagnosis n Fever and rash: u Viral (EBV, parvo, measles) u Vasculitis u Scarlet fever/Rheumatic fever u Staph or strep toxic shock u Stevens-Johnson syndrome

Differential diagnosis n Enlarged lymph nodes u Strep lymphadenitis u Viral (CMV, EBV, Parvo) u Toxoplasmosis

Kawasaki disease n List the clinical features n Identify current treatment n Recall the differences between adult and child Kawasaki disease

Kawasaki disease n First recognized case: 1961 n “Mucocutaneous lymph node syndrome” n Medium vessel vasculitis u Especially coronary arteries n Unknown etiology n Infectious? u Peak in winter and spring u Rare in infants and adults

Kawasaki disease n Criteria with fever for at least 5 days: u Bilateral conjunctival injection u Mucous membrane involvement u Polymorphous rash u Extremity involvement u Cervical adenopathy

Other findings n Normochromic normocytic anemia n Hyponatremia n Elevated transaminases n Pyuria n Inflammatory body fluids

n Self-limited disease n Begins to resolve after 10 days n Serious sequelae: u Coronary artery aneurysms develop in % of children u Depressed ejection fraction from myocarditis u Pericarditis and Valvulitis

n Treatment best initiated within the first 10 days: u Aspirin u IVIG: reduced aneurysms n Steroids controversial, used for persistent fevers

Adults vs. children n 57 cases reported as of 2005 n Adenopathy 93% n Arthralgias 61% n Elevated LFTs 65% n Aneurysm 5% n 67 per 100,000 CA n 135 per 100,000 HI and Japan n 15% n 30% n 10% n 20-25%

Adults vs. children n Conjunctivitis u 93% n Strawberry tongue u 80% n Erythema hands/feet u 80% n Desquamation u 96% u 95% u 77% u 88% u 94%

Follow up n Negative echocardiogram n Negative CT angiogram of coronary arteries n Treated with IVIG and ASA n Improved anemia, LFTs, CRP, ESR n Joint pain resolved