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BACKGROUND
Kawasaki disease (KD) is an acute systemic vasculitis of infants and young children preferentially affecting coronary arteries. It is typically characterised by persistent fever for at least 5 days, polymorphous rash, inflammatory changes in the lips or oral cavity, bilateral conjunctivitis, changes of the extremities, and cervical lymphadenopathy. 1 , 2 However, clinical presentation can be very polymorphous ("atypical Kawasaki disease") and unusual symptoms that could be attributed to other febrile disorders can be misleading and delay the correct diagnosis and adequate treatment. Gastrointestinal complaints are not common in children affected with KD. 3 This case underlies the risk of misdiagnosis of KD, especially during the first days of illness because of the presence of very uncommon signs.
CASE PRESENTATION
A 4-year-old boy from the Philippines, previously well, was admitted to our hospital with a 3 day history of high swinging fever, vomiting and diarrhoea.
On physical examination he presented in poor general condition, was lethargic and febrile, and had a temperature of 38.7°C. Clinical findings of dehydration such as dry mucous membrane, decreased skin turgor, tachycardia and low blood pressure (79/43 mm Hg) were observed. No clear meningeal irritation symptoms were observed.
The patient had pharyngitis. The chest and abdomen showed no abnormal findings with respect to percussion and auscultation. Lymphadenopathy, skin rash, joint abnormalities or oedema were not evident.
INVESTIGATIONS
Relevant laboratory findings on admission (third day of illness) were as follows: leucocyte count 14 500/mm3 , haematocrit 32%, C reactive protein (CRP) 133 mg/dl, Na+ 121 mEq/l, Cl- 86 mEq/l, K+ 4.2 mEq/l, pH 7.392, HCO3- of 19.6 mmol/l, base excess (BE) -6.2 mmol/l, hyperglycaemia (209 mg/dl), glycosuria with ketonuria and haematuria, blood urea nitrogen (BUN) 36.6 mg/dl, and creatinine 0.5 mg/dl.
At first, hyponatraemia was considered as the result of dehydration due to severe diarrhoea and poor oral intake, according to the evidence of clinical signs of dehydration and low blood pressure. For this reason intravenous fluid therapy was given (1100 ml glucose 5% solution +180 mEq Na/24 h). On the same...