Kawasaki disease misdiagnosed as acute pyelonephritis

Ristoska-Bojkovska, Nadica; Stavric, Katarina; Tasić, Velibor

doi:10.1007/s00467-003-1218-x

Cited by 16 publications

(19 citation statements)

References 4 publications

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“…There are multiple other descriptions in the literature of patients ultimately diagnosed with KS who were initially given the diagnosis of other entities such as cervical adenitis, 10-12 meningitis, 13,14 pneumonia, 15 appendicitis, 16,17 or pyelonephritis. 18 It is interesting to note that in this study, the children in the DDG were overrepresented in the group of children hospitalized before the diagnosis of KS, which suggests that either children in the DDG presented incompletely 19 or the provider was focused on only 1 sign or aspect of illness (ie, adenopathy for admitting diagnosis of adenitis).…”

Section: E430mentioning

confidence: 70%

Delayed Diagnosis of Kawasaki Syndrome: An Analysis of the Problem

2005

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ABSTRACT.Objective. Most pediatric providers in Colorado are familiar with Kawasaki syndrome (KS). However, in a recent outbreak, 30% of cases were diagnosed after illness day 10. We hypothesized that these children saw providers who were not familiar with KS, were given antibiotics for other diagnoses that delayed identification, had access-to-care issues, or presented atypically.Methods. A retrospective chart review of 106 consecutive KS cases seen at the Children's Hospital in Denver during 1994 -2000 was conducted.Results. Twenty-five of 106 children (23.6%) were diagnosed after day 10 of illness (delayed-diagnosis group [DDG]), and these 25 cases were compared with 81 cases diagnosed on or before day 10 (early-diagnosis group [EDG]). There were no differences between patients in the DDG and EDG in age, gender, number of visits, specialty of the primary care physician, time to the first medical visit, number of antibiotics received, coronary artery abnormalities, white blood cell count, or erythrocyte sedimentation rate. Patients in the DDG had significantly more days of fever, rash, red eyes, and oral changes. A platelet count of >450 000/mm 3 occurred more often in the DDG (56%) than the EDG (30%). After additional analysis, patients in the EDG had close clustering of symptom onset in the first few days of illness, but patients in the DDG had onset of symptoms scattered over 9 days. Patients in the DDG were 2.8 times more likely to have coronary artery aneurysms than patients in the EDG (DDG: 24%; EDG: 8.6%).Conclusions. Diagnosis after the 10th day of illness was not linked to type of medical provider, number of antibiotics received, or number of physician visits. Patients in the DDG exhibited the typical features of KS, but the onset of their symptoms was dispersed over time as opposed to the close clustering of symptoms in the EDG. Because coronary artery aneurysms occurred significantly more often in the patients in the DDG, more education is needed to teach health care providers to have a high index of suspicion for KS in young children presenting with fever/rash illnesses.

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Section: E430mentioning

confidence: 70%

Delayed Diagnosis of Kawasaki Syndrome: An Analysis of the Problem

2005

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“…A diagnosis of acute pyelonephritis was established and additional cefotiam hydrochloride was administered. On the 18th hospital day a voiding cystourethrogram showed left vesicoureteral reflux.KD often presents with abnormal urinary findings that are due to urethritis in most cases as shown by RistoskaBojkovska et al [1]. The clinical manifestations of KD are similar to severe infections.…”

mentioning

confidence: 93%

“…We read with interest the article by Ristoska-Bojkovska et al [1]. The authors reported that Japanese pediatricians are very familiar with pyuria coexisting with the nonspecific findings of severe inflammation, such as increased C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in Kawasaki disease (KD).…”

mentioning

confidence: 94%

Really sterile pyuria with Kawasaki disease?

Shiono

Koga

Ito

et al. 2004

Pediatric Nephrology

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Keywords Kawasaki disease · Pyuria · C-reactive protein · Erythrocyte sedimentation rate Sirs,We read with interest the article by Ristoska-Bojkovska et al. [1]. The authors reported that Japanese pediatricians are very familiar with pyuria coexisting with the nonspecific findings of severe inflammation, such as increased C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in Kawasaki disease (KD). A possible diagnosis of urinary tract infection (UTI) is not automatically considered.It is sometimes difficult to differentiate KD from infections such as sepsis, streptococcosis, or pyelonephritis in the early period of KD. Upon admission, we routinely perform the septic work-up, including urine culture, even if the most likely diagnosis is KD. We describe here a patient with KD associated with acute pyelonephritis.A 2-year-old boy was admitted to our center with a 4-day history of high fever (40.0C) and anorexia with moderate throat pain and malaise. He had conjunctivitis, injected pharynx, and lymphadenopathy, but no rash or changes of the peripheral extremities. Initial laboratory results showed an increased ESR of 119 mm/h and CRP of 5.44 g/dl. White blood cell count showed 11,190/mm 3 with neutrophilia (79%). Pyuria was present. Past history included KD with intravenous immunoglobulin therapy (IVIG) (400 mg/kg daily, given for 5 days) and aspirin (30 mg/kg daily) treatment at the age of 11 months. At that time, his urinalysis was normal.A presumptive diagnosis of recurrent KD was made but bacterial lymphadenitis or UTI was undeniable. He was treated initially with intravenous cefotiam hydrochloride (100 mg/kg per 24 h). Two days later, he remained febrile with a temperature of 40.0 º C. Blood analysis showed a CRP of 9.08 g/dl and a white blood cell count of 16,880/mm 3 . We diagnosed recurrent KD and stopped antibiotic therapy. IVIG and flubiprofen (4.2 mg/ kg daily), because of hepatitis (aspartate aminotransferase 169 IU/l, alanine aminotransferase 111 IU/l), were administered. Within 1 day of initial IVIG infusion, the boy became afebrile. On the 14th hospital day, he had periungual desquamation of the fingers and toes, and he met the five clinical signs of KD. His electrocardiogram and echocardiography were normal.The urine culture performed upon admission showed 10 6 colonies of Escherichia coli. On the 2nd hospital day renal ultrasonography demonstrated left hydronephrosis. A diagnosis of acute pyelonephritis was established and additional cefotiam hydrochloride was administered. On the 18th hospital day a voiding cystourethrogram showed left vesicoureteral reflux.KD often presents with abnormal urinary findings that are due to urethritis in most cases as shown by RistoskaBojkovska et al. [1]. The clinical manifestations of KD are similar to severe infections. We diagnose KD after confirming the negative results of cultures of all specimens because the etiology of KD still remains unclear [2]. Moreover, there is no specific diagnostic marker for KD except the clinical criteria. Had we not or...

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“…Although renal disease in KD is relatively rare [9][10][11][12][13][14][15][16][17][18], an abnormal urinalysis result is a well-known finding and includes proteinuria [4,9,22,23], hematuria [4], urinary excretion of casts and renal tubular epithelial cells [4], myoglobinuria [21] and pyuria [2,[4][5][6][7][8]. Although Shiono et al [24] described a KD patient with pyuria and pyelonephritis due to Escherichia coli, all other KD patients with pyuria exhibited sterile pyuria, and this is the most common finding in KD patients with abnormal urinalysis results.…”

Section: Discussionmentioning

confidence: 99%

“…Patients with KD often present with abnormal urinary findings, including proteinuria, hematuria and sterile pyuria [2,4]. Of these, sterile pyuria is the most common abnormal finding in KD and is seen in 33% to 63% of patients with KD in the acute phase [4][5][6][7][8]. Sterile pyuria in KD is considered to be due to urethritis, because spontaneously voided urine samples contain leukocytes whilst urine obtained from the bladder does not contain leukocytes [5].…”

Section: Introductionmentioning

confidence: 97%

Sterile pyuria in patients with Kawasaki disease originates from both the urethra and the kidney

et al. 2007

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To identify the origin of urinary leukocytes in Kawasaki disease (KD) patients with pyuria, we prospectively studied clinical and laboratory findings of 23 KD patients. Patients were divided into three groups: patients without pyuria, patients with pyuria in both voided urine and bladder urine obtained by transurethral catheterization (bladder pyuria) and patients with pyuria only in voided urine (urethral pyuria). Pyuria in voided urine was found in ten of 23 KD patients (43.5%), with subsequent urine cultures proving sterile. Five out of ten patients with pyuria in voided urine also exhibited pyuria in bladder urine, whilst the remaining patients did not have pyuria in bladder urine. Urinary protein levels were higher in patients with bladder pyuria and in patients with urethral pyuria than in patients without pyuria. Urinary beta2-microglobulin concentrations and serum blood urea nitrogen (BUN) and creatinine levels were higher in patients with bladder pyuria than in patients with urethral pyuria or in patients without pyuria, although the serum BUN and creatinine levels of patients with bladder pyuria were within the normal ranges. These results suggest that some patients with KD develop sterile pyuria that originates from the urethra and/or the kidney as a result of mild and subclinical renal injury.

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Kawasaki disease misdiagnosed as acute pyelonephritis

Cited by 16 publications

References 4 publications

Delayed Diagnosis of Kawasaki Syndrome: An Analysis of the Problem

Delayed Diagnosis of Kawasaki Syndrome: An Analysis of the Problem

Really sterile pyuria with Kawasaki disease?

Sterile pyuria in patients with Kawasaki disease originates from both the urethra and the kidney

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