Pediatric emergency medicine trisk 3011 3011

Children with KD often present with a normocytic, normochromic anemia;
hemoglobin concentrations more than two standard deviations below the mean for age
are noted in approximately one-half of patients within the first 2 weeks of illness.
Urinalysis commonly reveals white blood cells on microscopic examination; the cells
are mononuclear, and so are not detected by dipstick tests for leukocyte esterase. They
also originate in the urethra, so they will be missed on urinalyses obtained by bladder
tap or catheterization, so a clean catch is preferred. Measurement of liver enzymes
often reveals elevated transaminase levels or mild hyperbilirubinemia due to
intrahepatic congestion. In addition, a minority of children may develop obstructive
jaundice from hydrops of the gallbladder. If sampled, other body fluids demonstrate
inflammation as well: CSF typically displays a mononuclear pleocytosis (<100
cells/mm3) with normal glucose and protein concentrations, whereas arthrocentesis of
involved joints demonstrates 50,000 to 300,000 white blood cells/mm3, primarily
neutrophils.
Clinical Assessment of Incomplete KD
When patients do not meet the full diagnostic criteria for KD, “incomplete” KD should
be considered as these patients are also at risk for coronary artery aneurysms and
require prompt recognition and treatment. The term “incomplete” is preferable to
“atypical.” These patients lack sufficient clinical signs of the disease as opposed to
demonstrating atypical features.
In 2017, the AHA put forth an algorithm suggesting an approach for evaluation of
suspected KD ( Fig. 101.15 ). This algorithm includes the classic clinical criteria, and
in suspected cases of incomplete KD, the algorithm takes into account laboratory
studies and findings on echocardiogram. Prolonged fever is still the cardinal
manifestation of KD under the AHA algorithm. Children with 5 or more days of fever
and two or three clinical criteria in which KD is being considered should be evaluated
further for incomplete KD. This starts with a full assessment for possible characteristics
suggesting KD, including those outlined in Table 101.18 . Characteristics suggestive of
an alternative diagnosis are considered as well, including exudative conjunctivitis,
exudative pharyngitis, discrete intraoral lesions, bullous or vesicular rash, and
generalized adenopathy. If the clinical picture is consistent with KD, laboratory tests

are evaluated. If inflammatory markers are relatively unimpressive (CRP <3 mg/dL,
ESR <40 mm/hr), this is less suggestive of KD, though the child should be followed
daily, and formally reassessed if fever persists. Even in children with unimpressive
inflammatory markers whose fever resolves, an echocardiogram should be considered
if typical peeling of the skin develops.
In those children with a clinical picture consistent with KD where only two or three
clinical criteria are met, and with significantly elevated inflammatory markers (CRP ≥3
mg/dL, ESR ≥40 mm/hr), supplemental laboratory criteria are taken into consideration
and an echocardiogram is recommended. The supplemental laboratory criteria include