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A 3-year-old child presented with 5 days of fever, pruritic erythematous rash, unilateral cervical lymphadenopathy, conjunctival injection, swollen hands and feet, cracked lips and strawberry tongue. He had raised inflammatory markers, hyponatraemia, and hypoalbuminaemia. He received intravenous immunoglobulin (IVIG) and low-dose aspirin for Kawasaki disease (KD). His echocardiogram showed trivial pericardial effusion and prominent coronary arteries (CAs) without dilatation. Fevers and cervical lymphadenopathy persisted and he developed polyarthritis and right-sided torticollis. Ultrasonography and CT demonstrated right cervical lymphadenopathy but no drainable collection. He remained febrile despite a second IVIG infusion. Fluorodeoxyglucose–positron emission tomography (FDG-PET)–MRI, to exclude a deep neck infection, showed intense uptake in large and small joints (figure 1A); lacrimal glands (figure 1B); right-sided cervical lymph nodes and pre-vertebral region (figure 1C); and the proximal left anterior descending and right CA, indicative of coronary arteritis (figure 1D). His clinical features resolved with 3 doses of pulsed intravenous methylprednisolone, followed by an oral taper. The CA remained prominent with normal Z-scores until 5 months, when echocardiogram showed a small aneurysm in the proximal right CA (RCA 1.7 mm, Z score=−0.44; proximal RCA 2.78 mm, Z score +2.0).
FDG-PET, where available, may have a role in carefully selected patients in whom differentiation of KD from other inflammatory or infective conditions is difficult. The widespread FDG uptake is consistent with polyarthritis, well-described in the pre-IVIG era,1 infrequent reports of dacrocystitis in KD, and similarities between KD and deep neck infection.2 The CA inflammation on FDG-PET, not evident on initial echocardiogram, has not been previously reported in KD and highlights that patients without demonstrable CA dilatation or aneurysms on acute echocardiography may have unappreciated coronary arteritis.3
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MHD and YA contributed equally.
Contributors All authors are responsible for reported content. All authors have participated in the concept and design, analysis and interpretation of the content. Drs MHD and DB drafted the manuscript. All authors participated in revising of the manuscript, compilation of the figure panel and have approved the manuscript as submitted.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.