(30) Kawasaki Disease Presenting as Inguinal Cellulitis

Background: Kawasaki disease can present in a number of ways outside of the typical manifestations, ranging from pancreatitis to torticollis. These atypical presentations propose a challenge to the diagnosis and ultimately can delay the proper management of Kawasaki disease. Cutaneous manifestations beyond the typical rash are rare, although the prevalence has not been reported in the literature.

Objectives: The objectives are to highlight an abnormal presentation of Kawasaki and the need to maintain a broad differential when evaluating presumed cellulitis, especially when recalcitrant to broad-spectrum antibiotics.

Design/Methods: We describe the case of a 4-year-old male who presented to our hospital and the diagnostic workup, treatment, and outcome.

Results: A previously healthy 4-year-old male initially presented with lower abdominal pain. Abdominal and pelvic CT showed mild left external iliac and inguinal lymphadenopathy. The next day, he developed a low-grade fever and an erythematous patch over the left groin. He was diagnosed with cellulitis and oral trimethoprim-sulfamethoxazole was initiated. He re-presented 24 hours later with worsening rash, leukocytosis, and an elevated C-reactive protein (CRP) of 16 mg/dL. He was started on IV clindamycin, ampicillin-sulbactam, and oral azithromycin. CRP increased to 21 mg/dL. New findings included dry, cracked lips; a pinpoint erythematous rash; bilateral conjunctival injection. Rapid progression of the erythema along with systemic signs raised concern for a necrotizing soft tissue infection prompting initiation of piperacillin-tazobactam and vancomycin. Fever persisted despite broad-spectrum antibiotics, and advanced imaging was negative for fasciitis. Conjunctivitis and rash progressed, raising concern for incomplete KD, which was supported by laboratory criteria. Intravenous immunoglobulin and moderate-dose aspirin were administered and antibiotics were discontinued. The patient defervesced, skin findings improved, and CRP decreased to normal range.

Conclusions: Early detection of Kawasaki disease is important in patients as prompt treatment impacts clinical outcomes. IVIG should be started within 10 days of fever onset to decrease risk of coronary aneurysm. In our patient, the differential was broadened after no improvement on broad spectrum antibiotics, and Kawasaki disease was considered. This case highlights the importance of considering Kawasaki disease for a patient presenting with a localized rash, several days of fevers, and laboratory abnormalities for the appropriate treatment to be initiated.