T Keith, K Shah, C Michie


A 17 year old woman presented to the Emergency Department with fever, abdominal pain, constipation, urinary symptoms and rash developing over the preceding fortnight. Dysuria and frequency started two days previously and she was now in urinary retention with concern raised regarding possible bowel obstruction. She was admitted under the surgical team for gastrograffin enema and catheterisation.  Bowel obstruction was excluded and urinalysis revealed findings consistent with urinary tract infection, isolated as coliform. She was then referred to the general medical team as concerns were raised over an unusual rash in a febrile adolescent.

Over the previous two months she had been lethargic with joint pain, fever and sweats and had lost half a stone in weight. She had no past medical history, had received all childhood vaccinations, and took no regular medication, elicit substances or over the counter remedies. She had not been abroad or visited rural areas. Family history of diabetes and arthritis was present but nothing else of note. She was a philosophy student who lived with her parents and had no smoking, alcohol or sexual history.

Examination revealed a febrile, anxious individual who appeared in discomfort. She had a temperature of 37.9ºC. Cardiovascular and respiratory examination were unremarkable. She had generalised abdominal tenderness with soft abdomen and active bowel sounds. Rectal examination was unremarkable. Bilateral inguinal lymphadenopathy was noted with tenderness under the axillae. She complained of joint pain throughout, most notably her knees, hands and wrists. Joints were tender on palpation but no effusions were found.

Dermatological examination revealed white bullous non tender lesions of the palms and finger pulps bilaterally; which were starting to desquamate. [See pictures A and B] This had developed over the last two weeks initially starting as red patches more recently filling with white fluid. An erythematous blanching macular rash was noted on both lower limbs and lower back and white vesicles on the toes; and a reticular macular-papular purpuric rash of arms and feet. Her lips were dry, sore and markedly cracked but she had no oral ulceration or sore throat.

Initial blood tests and chest radiograph were unremarkable and the differential diagnosis was urosepsis, viral illness with mesenteric adenitis and autoimmune disease.

Rheumatological opinion was reactive arthritis secondary to urinary tract infection but all investigation proved negative. Dermatological opinion was that of vasculitis but skin biopsy refuted this.

Paediatric opinion was obtained and incomplete Kawasaki’s disease was suspected due to the patient having a high grade fever of over five days duration with no obvious cause, and three of the five classical criteria namely sore, cracked lips; desquamating rash of the extremities and polymorphous exanthema. She also had supplementary symptoms  supporting the diagnosis of arthralgia, abdominal pain and urethritis resulting in difficulty passing urine.

Her laboratory findings were not classical of Kawasaki disease but some features were present; she had a leucocytosis which peaked at 12.2 x 109/L; a thrombocytosis which developed over week after presentation of 409 x 109/L; and a mildy raised alanine transaminase of 47 IU/L. Her CRP did not go above 6 mg/L and ESR was raised at 11 mm/hr. Echocardiogram was performed to exclude coronary aneurysms. Aspirin 300mg QDS was started with intravenous immunoglobulin and dramatic improvement in symptoms was seen.

She has been subsequently followed up in the infectious diseases clinic and remains well.

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