Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Challenging Diagnosis in a 3-month-old with high fever: A Case Report Georgia H. O’Leary, M.A. 1 , Marta Moroldo, MD 2 , Hanna S. Sahhar, MD, FAAP, FACOP 1 1. Edward Via College of Osteopathic Medicine, Carolinas Campus, Spartanburg, SC 2. Nemours Children’s Health, Tradition Hospital, Port St. Lucie, FL Introduction Results Discussion

Laboratory work showed no improvement in inflammatory markers, and cultures were negative for 24 hours (tables 1 and 2). The case was discussed with infectious disease specialists due to a suspicion of KD. They concurred with this suspected diagnosis, prompting the initiation of treatment. Treatment included intravenous immunoglobulin, methylprednisolone, and high dose of acetylsalicylic acid. The patient responded well to treatment, with cultures negative for 48 hours and resolution of the fevers and was discharged on Day 8 of illness. Upon follow-up with a pediatric cardiologist, the initial echocardiographic images were reviewed and showed mild aortic dilation (figure 1), and it was unclear at this time if this was related to the disease itself or a preexisting abnormality. On a follow up phone call, the patient’s mother stated infant had desquamation of hands and feet at the end of the second week from presentation.

This patient did not meet criteria for typical KD, as only three out of the five clinical signs were present (table 3). Infants with incomplete KD may be at increased risk of complications due to delay in recognition of the condition. 3

Fever in young infants is a challenging clinical presentation. Most of the time it is due to a non-life-threatening viral infection, but the possibility of a serious invasive bacterial infection is a great concern. The most common source of bacterial infection in this age group is a urinary tract infection (UTI). Standard of care for these infants is to undergo a partial sepsis work up, inpatient management with intravenous antibiotics waiting for cultures results, and possibly performing a lumbar puncture and chest x-ray depending on the presence of pertinent symptoms. Inflammatory states, like Kawasaki disease (KD) among others, share many laboratory findings with infectious processes, but are rare in this age group. Despite criteria being available to diagnose diseases like KD, there is too much overlap with sepsis in both presentation and laboratory findings to delay administering antibiotics in infants. Missing an early diagnosis of KD puts the patient at an increased risk for complications such as coronary artery disease. 1 A 3-month-old full term male infant with no significant past medical history who presented to the emergency department (ED) with a 3-day history of high fever, cough, erythematous macular rash, cheilitis, conjunctivitis, and irritability. Labs showed elevated inflammatory markers. Urinalysis was positive for protein and leukocyte esterase. Chest x-ray indicated no acute cardiopulmonary process. The patient was admitted to the pediatric ward with a diagnosis of suspected UTI. He received ceftriaxone intravenously and systemic steroids in the ED (due to concerns of allergic reaction). On day 4 of illness, the infant continued to have fevers ranging from 100.7-102.2 ° F, elevated heart rate, and persistent irritability so a lumbar puncture was performed. On day 5 of illness (day 2 of admission) despite antibiotic treatment, fevers, cheilitis, and tachycardia were still present but the rash and conjunctival injection had improved. Case Presentation

Kawasaki Disease Definition 2

Our Patient

Fever lasting 5 or more days

Admitted on day 3 of fever

4 of the following 5 clinical signs: • Rash • Swelling and redness of hands and feet • Cervical Lymphadenopathy • Bilateral conjunctival injection • Oral mucosal changes

Rash , bilateral conjunctival injection and oral mucosal changes present

Table 3. Kawasaki disease clinical criteria (left column) and patient’s clinical signs (right column).

References 1. Son MBF, Gauvreau K, Tremoulet AH, et al. Risk model development and validation for prediction of coronary artery aneurysms in Kawasaki disease in a North American population. J Am Heart Assoc 2019; 8:011319. 2. Centers for Disease Control and Prevention. (2024b, May 31). About kawasaki disease. Centers for Disease Control and Prevention. https://www.cdc.gov/kawasaki/about/index.html#:~:text=For%20epidemiologic%20surveillance%2C%20CDC%20 defines,Rash 3. Cimaz R, Sundel R. Atypical and incomplete Kawasaki disease. Best Pract Res Clin Rheumatol 2009; 23:689. 4. OHSU. https://www.ohsu.edu/school-of-medicine/diagnostic-radiology/pediatric-radiology-normal-measurements This patient was diagnosed with incomplete KD and mild ascending aortic dilation. The patient is currently being followed up by cardiology. Acknowledgements We would like to thank Dr. Kenneth Alexander, Pediatric infectious disease specialist and the pediatric nurses for assisting in the care of this patient. We would also like to thank the patient’s parents for agreeing to this presentation. Conclusions We report this case because it is not common that Kawasaki disease presents at this young age. Furthermore, these young infants are at increased risk for complications in the acute phase as well as long term. The proactive entertainment of the diagnosis led to early initiation of treatment with a good response. Currently, we still don’t know if the echocardiographic findings are related to this disease. More follow up is needed. Rash, conjunctivitis and fever have an extensive list of possible diagnoses, both infectious and inflammatory ones. Kawasaki disease is an exclusion diagnosis. We initiated treatment before final cultures were resulted.

Lab

Day 1 Admission Day 2 Admission Reference Range

CRP WBC ESR RBC

7.2 (H) 10.55 20 (H) 2.51 (L) 7.3 (L) 22.8 (L)

10.1 (H) 19.36 (H)

<0.9 mg/dL

6.00-13.32 k/uL 0-15 mm/hr 3.43-4.80 m/uL 9.6-12.4 g/dL 28.6-37.2 % < 0.09 ng/mL

Not ordered

3.20 (L) 9.2 (L) 27.5 (L) 0.61(H)

Hemoglobin Hematocrit Procalcitonin

Not ordered

TNT High Sensitivity Not ordered

13 (H)

<12 ng/L

Table 1. Hematology and inflammatory markers laboratory results.

Microbiological Investigation

Blood culture Stool culture

Negative Negative Negative

Cerebrospinal fluid culture with gram stain

Cerebrospinal fluid analysis Expanded respiratory panel Baseline Echocardiogram

Consistent with aseptic meningitis

Negative

Normal coronary arteries

Table 2. Microbiology laboratory results.

Figure 1. Aortic arch (left) and ascending aortic diameter measuring 13 mm (right). (Normal mean for age 11.8 mm [Normal mean ascending aortic diameter (mm) = 0.72 (age) + 11.55] 4

2025 Research Recognition Day

78