Time for a Time-out: The Value of a Diagnostic Time-out in Prolonged Fever and Lymphadenopathy.

Abstract

A previously healthy 3-year-old girl was admitted to the inpatient general pediatrics floor with a 2-week history of fevers, unilateral cervical lymphadenopathy, and stomatitis. An ultrasound of the neck revealed a large fluid collection with surrounding enlarged lymph nodes. She had poor oral intake and subjective weight loss over the past 2 weeks. She had a thrombocytosis of 574\u2009000/mL as well as microcytic anemia, which was thought likely to be iron deficiency anemia due to excessive milk intake. Her C-reactive protein and erythrocyte sedimentation rate were elevated at 19.4 mg/dL (norm <1.0 mg/dL) and 129 mm/hour (norm <20 mm/hour). She received intravenous antibiotics for a presumed neck abscess. Because of the constellation of fever duration, unilateral lymphadenopathy, and laboratory results, she was subsequently diagnosed with incomplete Kawasaki disease (KD) that was thought to be complicated by lymphadenitis. Notably, she did not have conjunctivitis, rash, swelling or desquamation of her peripheral extremities, or changes in the lips or oral cavity. She received intravenous immunoglobulin and aspirin therapy. An echocardiogram result was unremarkable for coronary artery abnormalities. Despite treatment, she had no improvement of her neck abscess and therefore underwent a fine-needle aspiration by the otolaryngology service, which revealed a negative culture result. She had negative Epstein-Barr and Bartonella titers. After completing 8 days of antibiotics, she was discharged from the hospital with aspirin and cardiology follow-up.\n\nTwo weeks later, she was readmitted for persistent left-sided neck swelling with worsening pain and new-onset ear drainage. A neck ultrasound was repeated and revealed a …