Inguinal Cellulitis as an Initial Manifestation of Kawasaki Disease. Pediatricians should be Aware of Atypical Symptoms of Kawasaki Disease

Introduction: Kawasaki disease (KD) is a systemic vasculitis with signs including fever, oral cavity erythematous changes, bilateral bulbar conjunctival injection, skin rash and edema of the hands and feet, and cervical lymphadenopathy. The acute phase illness may be accompanied by some atypical inflammatory signs such as cellulitis. However, most reports of KD with cellulitis include cervical and pharyngeal cellulitis, and few reports describe KD with inguinal cellulitis.

Case presentation: A previously healthy 4-year-old girl was referred to our hospital with a 2-day history of pain and erythema in the left inguinal region without systemic fever. Physical examination revealed left inguinal lymphadenitis with adjacent cellulitis. Initial laboratory findings showed mild inflammatory response. These data seemed consistent with the diagnosis of bacterial cellulitis, therefore, she was started on IV Cefazolin. Due to worsening, Clindamycin was initiated. Two days later a systemic fever appeared. Laboratory results at this time showed elevated liver tests and worsened Leukocytosis. Therefore, Piperacillin was added. One day later, bilateral bulbar conjunctival injection with erythematous lips and polymorphous rash appeared on her trunk. Steroids were initiated. On the sixth day of hospitalization, edema of the hands and feet appeared. The presentation of five-days fever and all symptoms raised the possibility of KAWASAKI DISEASE. Echocardiograms revealed mild MR with small PFO. The patient was treated with IVIG and oral Aspirin with rapid improvement.

Conclusion: Uncommon signs such as inguinal cellulitis can be initial symptoms of Kawasaki disease. Poor response to initial antibiotic therapy should suggest the possibility of Kawasaki disease.