Kawasaki Disease Mimicking a Parapharyngeal Abscess

Abstract

Parapharyngeal abscess (PPA)-like lesion is a very rare manifestation of Kawasaki disease (KD). Here we report a Chinese case of KD initially mimicking PPA, which is the first one reported in Asia.A 3-year-old male patient presented with fever, drooling, and bilateral painful cervical lymphadenopathy for 3 days. Chest X-ray and echocardiogram were normal. With substantial elevation of white blood count and C-reactive protein, purulent cervical lymphadenitis was considered. Symptoms did not improve after treatment with vancomycin, and the patient further developed trismus and restricted neck movement. Neck CT revealed a 2 × 1.5 cm hypodense lesion in the right parapharyngeal space with peripheral enhancement. PPA was suspected and on the 3rd day following admission, the patient received surgical incision and drainage. One milliliter of serous fluid was drained without bacterial growth on cultures. Fever persisted after surgery. As the clinical course proceeded, additional major signs of KD gradually evolved, and on the 6th day following admission the patient completely fulfilled the diagnostic criteria for KD. Rapid clinical improvement was observed following treatment with high-dose immunoglobulin and aspirin. Due to the parapharyngeal operation, the patient was fed milk through a nasogastric tube for 15 days. His neck incision became infected but healed gradually following dressing change and antibiotic treatment. Currently he remains asymptomatic during regular follow-up and repeated echocardiograms are normal.Both pediatricians and otolaryngologists can learn from this case that KD may initially manifest as PPA. Careful observation for major signs of KD during the clinical course can help to achieve a prompt and correct diagnosis. Thus, unnecessary surgery and cardiac complications of KD may be avoided.

Suggested Protocol for Managing Acute Suppurative Cervical Lymphadenitis in Children to Reduce Unnecessary Surgical Interventions

“…2 In addition, some patients with Kawasaki disease have been initially misdiagnosed with a retropharyngeal abscess. 7,8 Patients found not to have ASCL at final diagnosis showed a tendency toward occupation of the lower neck compartment with multiplicity, but no statistical analysis was performed due to the low incidence of this finding. In summary, even for the purpose of differential diagnosis or isolation of bacteria, surgery should be postponed in favor of image-guided aspiration/biopsy with careful reevaluation of the patients.…”

“…6 Noninfectious causes of secondary ASCL, such as Kawasaki disease, are not infrequent in children, and there may be questions about the necessity of surgery focused on drainage even in these patients. 7,8 In addition, surgery may not shorten hospitalization compared with antibiotic treatment alone. 9 Finally, there are general considerations to surgery in pediatric patients, including higher risk during general anesthesia, concerns of guardians, scarring, and difficulty in wound management due to low compliance.…”

Diagnosis of Kawasaki disease

“…Unilateral cervical lymphadenopathy is a characteristic clinical sign of KD but is seen in only 60% of patients [8][9][10][11] Often mistaken for suppurative lymphadenitis 12,13 Exclusion of other diseases with similar findings…”

A Case Report of Kawasaki Disease with Manifestations of Acute Renal

“…Therefore, since it is a multi-system ailment, Kawasaki disease may mimic the symptoms of other diseases. Several complications, such as coronary artery aneurysm involvement, are identified for this disease which is the most common cause of acquired pediatric heart disease in children in developed countries, such as Japan and the United States (11,12). However, many adverse Noncardiac complications have been reported for this disease, including kidney disease.…”