Attending Physician: Dr.

Bernadette Balatero-Terencio Date: August 29, 2018

Presentors: Cabili, Janina Bianca G.
Rodriguez, Aedrian C.

CASE PROTOCOL

Informant: Mother
Reliability: 85%

IDENTIFYING DATA:
This is a case of S.R.I., a 3-year old, female, Filipino, Seventh Day Adventist from Silang, Cavite

CHIEF COMPLAINT: Fever

HISTORY OF PRESENT ILLNESS:

9 days prior to admission, patient developed high grade fever (Tmax 40.6°C) with no other
associated signs and symptoms. Patient was given Paracetamol but was not relieved, hence was given
Ibuprofen which afforded temporary relief. No consult done.
8 days prior to admission, fever persisted associated with pain on the right post auricular area and
the mother noted an enlarged lymph node measuring >1 cm, tender, well-demarcated borders. No other
associated signs and symptoms such as cough & colds, and sore throat.
7 days prior to admission, she was brought to a private clinic due to the persistence of symptoms
wherein she was prescribed with Co-Amoxiclav at 33 mkday for Bacterial Lymphadenitis.
4 days prior to admission, fever persisted now associated with 3-4 episodes of watery, brownish,
non-bloody, and non-foul-smelling stool. They consulted to the same MD. CBC was done which revealed
elevated WBC at 15.3 with predominance of neutrophil at 75. Antibiotic was continued.
3 days prior to admission, she had another 2-3 episodes of watery stools and “dry lips” was noted
by the mother. Fecalysis was done which showed: Greenish, watery, pH 7, Occult blood (+), WBC 6-10,
RBC 1-3, E. histolytica cyst/E. dispar cysts 0-2/hpf. Patient was started with Metronidazole.
2 days prior to admission, patient had 2 episodes of watery stool and now associated with macular
rash on the chest and abdomen.
1 day prior to admission, patient developed sore eyes. They contacted the same private MD, who
suspected Kawasaki Disease, and advised admission at our institution.

REVIEW OF SYSTEMS:
General: (-) chills, (-) fatigability, (-) failure to thrive, (-) malaise
Skin, Hair, and Nails: (-) itching, (-) dryness, (-) color changes, (-) peeling
Head: (-) headache, (-) dizziness, (-) lightheadedness
Eyes: (-) pain, (-) excessive tearing, (-) blurring of vision
Ears: (-) hearing loss, (-) pain, (-) discharge, (-) tinnitus
Nose: (-) discharge, (-) epistaxis
Throat: (-) sore throat, (-) hoarseness
Respiratory: (-) hemoptysis, (-) cough, (-) colds, (-) difficulty of breathing
Cardiovascular: (-) chest pain, (-) palpitations, (-) orthopnea
Gastrointestinal: (-) loss of appetite, (-) nausea, (-) constipation, (-) diarrhea, (-) abdominal pain
Urinary: (-) dysuria, (-) polyuria, (-) oliguria
Musculoskeletal: (-) muscle/joint pain, (-) stiffness (-) redness, (-) swelling of joints
Neurologic: (-) fainting, (-) seizures, (-) numbness, (-) tremors
Hematologic: (-) bleeding, (-) easy bruising
PAST MEDICAL HISTORY:
Patient had Hand Foot and Mouth Disease and Complex Febrile Convulsion secondary to
Systemic Viral Illness last 2015. Patient has no known allergies to food and medications.

FAMILY HISTORY:
Unknown to adoptive parents

IMMUNIZATION HISTORY:

Vaccine Number of doses Age given

BCG 1 at birth
Hepatitis B 4 at birth, 6 weeks, 10 weeks, 14
weeks
Measles 1 9 months
MMR 1 12 months

BIRTH HISTORY:
Patient was born full term to a 28-year old G4P4(4004) via Normal Spontaneous Delivery at a
lying-in clinic. There were no fetomaternal complications. And was given to the adoptive parents the
following day.

NUTRITIONAL HISTORY:
Patient was fed with expressed breast milk from birth up to 1 month then shifted to formula milk.
She had no vitamin supplementation. Currently, she prefers vegetables, rice, and fish.

DEVELOPMENTAL HISTORY:
At par with age. Social smile at 2 months and can walk alone at 1 year old.

PERSONAL AND SOCIAL HISTORY:

The patient lives with her adoptive parents, maternal grandparents and uncle since she was 1-day
old. Her primary caregiver was her adoptive parents. Her biological father currently works and lives at
Quezon Province and visits her approximately 2x a month. Her drinking water comes from a potable
water source. No smoker nor pets noted in the household.

PHYSICAL EXAMINATION:

General Survey: Patient was awake, weak-looking, coherent and not in cardiorespiratory distress

Anthropometric Measurements:
Z-score
Weight 17.7 kg Above 0
Height 104 cm Below +2
BMI 16.4 Above 0
Vital Signs:

BP 90/60
HR 134
RR 32
T 38°C

Skin: (+) macular erythematous rash on chest, abdomen and arms, warm, good turgor and mobility

HEENT: anicteric sclerae, (+) conjunctival injection with limbal sparing, no nasoaural discharge, no
tonsillopharyngeal congestion, (+) dry red lips, (+) lymphadenopathy, measuring 1 x 1 cm at right
post auricular movable, tender.

Chest/ Lungs: Symmetrical chest expansion, clear breath sounds, no retractions

Heart: Adynamic precordium, distinct heart sounds, no heaves nor thrusts, no palpable thrills, normal
rate, regular rhythm, no murmur.

Abdomen: Flabby, soft, non-tender, no lesions, no mass, no tenderness, normoactive bowel sounds.

Genitals: Grossly female, no rashes and lesions

Extremities: No gross deformities, no cyanosis, no edema, no tremors, full and equal pulses. Capillary
refill time <2 seconds

ADMITTING DIAGNOSIS: Kawasaki Disease

COURSE IN THE WARD:

Upon admission, patient was weak-looking, febrile at 38°C. CBC was done showing a high white
blood cell count of 17.10, with segmenters predominance at 68% and low lymphocytes at 20. ESR was
increased at 105 mm/hr, and CRP was positive at 130.11 mg/L. Patient put on mild hydration and was
given Paracetamol at 10 mkdose as needed for temperature >37.8°C and Ibuprofen at 10 mkdose. IVIg
was ordered and was referred to Pedia Cardio Service, who agreed with IVIg transfusion and was
scheduled for 2DEcho the next day
Upon arrival of the IVIg She was transferred to PICU for transfusion with a test dose of 8.8 cc/hr,
17.7 cc/hr on the second hour, and 70.8 cc/hr for 10 hours and was also given Diphenhydramine 20 mg IV
before initiating IVIg therapy.
On the first hospital day, patient was now afebrile, with no more rashes but still with cracked red
lips. 2D echo results was normal however small pericardial effusion was noted. Cardio service ordered for
Aspirin to be given at 3.3 mkday once afebrile for 48 hours and once ALT, AST, and Alkaline
Phosphatase are normal.
On the second hospital day, Laboratory results showed normal Alkaline Phosphatase, and normal
AST and ALT. Patient was started on Aspirin for 3 weeks.
On the third hospital day, Aspirin was tolerated and patient may go home with home medications
given such as Aspirin 500 mg/tab made into 60 mg/paper tab each, 1 paper tab OD for 3 weeks after
meals.

FINAL DIAGNOSIS: Kawasaki Disease

LABORATORY RESULTS:

August 4, 2018

CBC
RESULT REFERENCE RANGE
RBC L 3.86 10^12/L 4.50 – 4.80 10^12/L
Hematocrit L 0.34 L/L 0.35 – 0.41 L/L
Hemoglobin 111 g/L 110 – 160 g/L
WBC H 17.10 10^9/L 5.00 – 13.00 10^9/L
Differential Count
Lymphocyte L 20 % 28 – 49 %
Monocyte 8% 4–9%
Eosinophil 3% 0–3%
Basophil 1% 1 – 3%
Segmenters H 68 % 43 – 64 %
Morphology
Platelet H 515 10^9/L 150 – 450
MCV 89.0 fL 82.0 – 91.0
MCH 28.6 pg 27.0 – 31.0
MCHC 32.2 g/dL 32.0 – 36.0

RESULT REFERENCE RANGE

ESR H 105 mm/hr 0 – 20 mm/hr

RESULT REFERENCE RANGE

C-Reactive Protein 130.11 mg/L (Positive) 0 – 6 mg/L

August 5, 2018

PEDIATRIC ECHOCARDIOGRAPHY RESULT

Impression: Normal Intracardiac Anatomy; Normal Coronary Arteries; Small Pericardial Effusion

FECALYSIS RESULT
Color Brown
Consistency Semi Formed
Mucus +
pH Neutral
Occult Blood Negative
Microscopic Exam
Pus Cells 1 – 3/HPF
RBC 0 – 2/HPF
Parasite and Ova None Seen
 August 6, 2018

RESULT REFERENCE RANGE

Alkaline Phosphatase 163 U/L 145-420 U/L
SGOT 31.0 U/L 20-60 U/L
SGPT 7.0 U/L 5-45 U/L

August 7, 2018
STOOL CULTURE AND SENSITIVITY
Identified Organism Klebsiella pneumoniae (HEAVY GROWTH)
Sensitivities
Amikacin S
Gentamicin S
Amoxicillin/Clavulanic Acid R
Ceftazidime R
Cephalothin R
Ceftriaxone R
Cefuroxime R
Cefoxitin R
Trimethoprim/Sulfamethoxazole S
Ampicillin R
Chloramphenicol S
Ciprofloxacin S