Case report

A 9-month-old male child was admitted to our institution with complaints of high-grade fever of 10–12 days, swelling of the hands and feet, bilateral non-suppurative conjunctivitis, and oral erythema. His physical exam findings were significant for extreme irritability, and the above-mentioned features with no significant lymphadenopathy. On initial investigations, he was found to be anaemic (haemoglobin: 8.5 gm/dl {12–17}), had an elevated total leucocyte count (25,000 cells/µl {4000–11,000}), and had thrombocytosis (13.8 lakhs/cu.mm {1.5–4.5 lakhs}). The acute phase reactants were also significantly elevated with the erythrocyte sedimentation rate and C-reactive protein being 120 mm/hour (0–15) and 22 mg/L (0–5), respectively. Given his history, physical exam findings, and laboratory findings, viral syndromes (like adenovirus) and Kawasaki disease was considered as one of the most probable differential diagnoses, and an echocardiogram was performed on day 1 of admission, which demonstrated a structurally normal heart, normal biventricular function, and aneurysmal dilation of the proximal coronary arteries. The left main coronary artery aneurysm measured 3.2 mm (z score +4.2), left anterior descending was 2.95 mm (z score +4.9), and the right coronary artery was 3.56 mm (z score +5) (Figure 1). In view of the above findings, the patient was diagnosed with Kawasaki disease and given a 2 g/kg single dose of intravenous immunoglobulin over 24 hours and anti-inflammatory dose of oral aspirin was initiated simultaneously, in addition to other supportive measures. He responded well to treatment and demonstrated a decreasing trend in total leucocyte count, platelets, and acute phase reactants. He was discharged home on anti-thrombotic dose of oral aspirin. A repeat echocardiogram 2 weeks later demonstrated improvement in the proximal coronary artery aneurysm dimensions, with the left main coronary artery measuring 2.8 mm (z score +2), left anterior descending measuring 2.7 mm (z score +2.89), and right coronary artery measuring 2.7 mm (z score +2.3) (Figure 2). The coronary artery aneurysms continued to show regression on subsequent echocardiograms until the dimensions and z scores showed complete normalisation by the 5th month from the initial diagnosis of Kawasaki disease (left main coronary artery z score −0.05, left anterior descending artery z score +0.98, and right coronary artery z score +0.49).

The patient remained clinically well on follow-up visits up to 1 year after treatment at which time he was readmitted with complaints of 4 days of fever and bilateral non-suppurative conjunctivitis. Due to his prior history, a high index of suspicion for recurrent Kawasaki disease was entertained and an echocardiogram was performed, which demonstrated a recurrence of aneurysm in the right coronary artery with the proximal measurements of left main, left anterior descending, and right coronary arteries being 2.9 mm (z score +1.29), 2.1 mm (z score +0.76), and 3.2 mm (z score +3.87), respectively (Figure 3). A diagnosis of recurrent Kawasaki disease was made, and patient’s parents were advised to repeat a course of intravenous immunoglobulin, but due to parental denial and leaving against medical advice, treatment could not be initiated and the patient was subsequently lost to follow-up.