Ultrasonographic Evaluation of Cervical Lymph Nodes in Kawasaki Disease
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Ultrasonographic Evaluation of Cervical Lymph Nodes in Kawasaki Disease Norimichi Tashiro, MD; Tomoyo Matsubara, MD; Masashi Uchida, MD; Kumiko Katayama, MD; Takashi Ichiyama, MD; and Susumu Furukawa, MD ABSTRACT. Objective. Kawasaki disease (KD) is one tery lesions (CAL), which can lead to myocardial of the common causes of cervical lymphadenopathy dur- infarction or even death.2 Early diagnosis and treat- ing early childhood. The purpose of this study was to ment with intravenous gammaglobulin (IVGG) can compare the ultrasonographic feature of cervical lymph reduce the risk of cardiac complications of KD.3 Be- nodes in patients with KD, bacterial lymphadenitis, and cause there are no specific diagnostic tests for KD, infectious mononucleosis. Design. We studied 22 patients with KD, 8 with pre- the diagnosis is established by the presence of 5 of 6 sumed bacterial lymphadenitis, and 5 with Epstein-Barr criteria in the absence of some other explanation for virus infectious mononucleosis. We examined the cervi- the illness.1 The Japanese diagnostic criteria include cal nodes by ultrasonography using a 7.5-MHz or 10- the following: 1) fever persisting for 5 days or longer; MHz transducer of a B-mode sector scanner in all pa- 2) nonexudative conjunctival injections; 3) oral mu- tients with a chief complaint of fever and a visible cosal changes; 4) changes of the peripheral extremi- cervical mass during a fixed time interval (July 1995- ties; 5) rash, primarily truncal; and 6) cervical lymph- March 2000). adenopathy (at least 15 mm in diameter). Cervical Results. In KD patients, transverse ultrasonograms demonstrated multiple hypoechoic-enlarged nodes form- lymphadenopathy is the least common diagnostic ing one palpable mass, which resembled a cluster of criterion and is present in approximately 50% to 75% grapes. The ultrasonographic appearance of these nodes of KD patients. In contrast, the other 5 criteria are was similar in patients with acute Epstein-Barr virus present in greater than 90% of patients with KD.4 infection, but differed from the pattern in presumed Nevertheless, we have experienced patients who had bacterial lymphadenitis. Five KD patients had had fever only fever and cervical lymphadenopathy at the ini- and cervical lymphadenopathy for several days before tial examination.5 The clinical presentation in KD other manifestations of KD were noted. In these patients, patients may initially resemble that of other infec- it was possible to differentiate by ultrasonography be- tious diseases, including bacterial and viral infec- tween KD and presumed bacterial lymphadenitis at an early stage. tions. It is important to recognize KD at an early Conclusion. Ultrasonographic features of cervical stage so that appropriate therapy can be initiated. lymph nodes were different for KD than for presumed For this reason, we investigated cervical lymphade- bacterial lymphadenitis. Ultrasonographic evaluation nopathy by ultrasonography as a means of differen- might be of value for diagnosis of KD patients with tiating between KD and other infectious diseases, cervical lymphadenopathy at an early stage of the such as presumed bacterial lymphadenitis and acute disease. Pediatrics 2002;109(5). URL: http://www. Epstein-Barr virus (EBV) infection presenting as in- pediatrics.org/cgi/content/full/109/5/e77; Kawasaki dis- fectious mononucleosis (IM). ease, cervical lymphadenopathy, ultrasonography, bacte- rial lymphadenitis, EB virus infection. MATERIALS AND METHODS ABBREVIATIONS. KD, Kawasaki disease; CAL, coronary artery Patients lesions; IVGG, intravenous gammaglobulin; EBV, Epstein-Barr Eligible patients were those who presented to our hospital with virus; IM, infectious mononucleosis; WBC, white blood cell; CRP, fever and lymphadenopathy that was visible as an anterior or C-reactive protein. posterior cervical mass. Illness day 1 was determined as the first day of fever for all patients. All of the patients were Japanese. Informed consent for participation in the study was obtained from awasaki disease (KD) is an acute febrile illness the participants’ parents. of unknown cause that occurs primarily in Kinfants and young children.1 Between 20% and 25% of untreated patients develop coronary ar- KD KD patients were diagnosed by the standard diagnostic crite- ria.1 Only KD patients who had a cervical mass at presentation From the Department of Pediatrics, Yamaguchi University School of Med- were included. All patients were examined by ultrasound before icine, Yamaguchi, Japan. receiving standard Japanese treatment with IVGG (Venilon, Teijin Received for publication Sep 6, 2001; accepted Jan 4, 2002. Co, Ltd, Tokyo, Japan), 400 mg/kg/d for 5 days and oral aspirin Reprint requests to (T.M.) Department of Pediatrics, Yamaguchi University (30 mg/kg/d). This treatment was initiated on diagnosis. Two- School of Medicine, 1–1-1 Minamikogushi, Ube, Yamaguchi 755-8505, dimensional echocardiography was used to detect the presence of Japan. E-mail: [email protected] CAL. Coronary arteries with diameters of 4 mm or more were PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad- classified as abnormal, in accordance with the KD Cardiovascular emy of Pediatrics. Lesion Diagnostic Criteria of the Research Committee on KD.6 http://www.pediatrics.org/cgi/content/full/109/5/Downloaded from www.aappublications.org/newse77 by guestPEDIATRICS on September Vol.24, 2021 109 No. 5 May 2002 1of5 Presumed Bacterial Cervical Lymphadenitis sedation. Photographs of ultrasound images were recorded by one The diagnosis was based on clinical symptoms of acute bacte- investigator (N.T.). rial lymphadenitis that included a tender cervical neck mass with overlying erythema and red color, and supportive laboratory data RESULTS including an elevated white blood cell count (WBC) and C-reac- Over the 4-year study period, 35 patients who tive protein (CRP) level. Aspirates for bacterial culture were per- formed when clinically indicated. Diagnosis of bacterial lymph- presented with fever and a cervical neck mass were adenitis was further confirmed by a clinical improvement on enrolled. Twenty-two patients ultimately met the di- appropriate intravenous antibiotic therapy. Ultrasound examina- agnostic criteria for KD, 8 patients were diagnosed tion was performed before initiation of intravenous antibiotics. with presumed bacterial lymphadenitis, and 5 pa- tients were diagnosed with EBV-IM. EBV-IM The diagnosis was based on a clinical presentation of sore throat, fever, and bilateral cervical lymphadnopathy accompanied KD by atypical lymphocytes in the peripheral blood. All patients were Of the 22 patients who ultimately met the diagnos- positive for IgM and IgG antibodies to EBV capsid antigen and tic criteria for KD, 15 were boys and 7 were girls were negative for antibody to EBV nuclear antigen during the (mean age: 2.6 years; range: 0.2–7.0 years; Table 1). acute stage. No patients required steroid therapy. Ultrasonographic evaluation of cervical lymph nodes Ultrasonography was performed on the patients on illness day 2 to 7 The measurement of the cervical neck mass was performed by (mean: 4.0) on admission. In these patients, the diag- one investigator (N.T.). When bilateral lymphadenopathy was nosis for KD was made on illness day 4 to 7 (mean: present, the larger of the neck masses was examined by ultra- 5.0). The mean peripheral WBC and neutrophil sonography. At the time of admission, ultrasonograms of cervical counts were 16 150/mm3 (range: 9200–30 500/mm3) lymph nodes were obtained using a 7.5-MHz or 10-MHz trans- 3 3 ducer of a B-mode sector scanner (Aloka SSD-2200, Aloka Co, Ltd, and 11 612/mm (range: 4554–23 790/mm ), and the Tokyo, Japan). Ultrasonography required 3 to 5 minutes per pa- mean CRP level was 9.0 mg/dL (range: 2.7–20.9 mg/ tient and adequate studies were obtained from all patients without dL) at the time of the cervical lymph nodes evalu- TABLE 1. Patients With KD, Presumed Bacterial Lymphadenitis, and EBV-IM Variable Case Age Gender Neck Mass Illness Day‡ Culture Numbers* Size (mm)† US Evaluation Diagnosis§ KD 1 6 F 1 u 30 ϫ 20 4 5 ND 22 M 1u50ϫ 40 5 5 ND 33 M 1u45ϫ 40 2 5 ND 43 M 1u25ϫ 25 3 5 ND 53 F 1u55ϫ 50 3 5 ND 63 M 1u25ϫ 25 7 6 ND 7 0.2 M 1 u 30 ϫ 20 3 4 ND 82 M 1u30ϫ 30 3 5 ND 93 M 1u50ϫ 30 3 5 ND 10 2 M 1 u 40 ϫ 35 2 4 ND 11 2 M 1 u 20 ϫ 20 3 4 ND 12 2 M 1 u 40 ϫ 30 5 5 ND 13 2 F 1 u 50 ϫ 30 6 6 ND 14 0.6 F 1 u 30 ϫ 30 5 5 ND 15 2 M 1 u 40 ϫ 20 7 7 ND 16 1.1 M 1 u 50 ϫ 30 3 5 ND 17 4 F 1 u 40 ϫ 40 4 7 ND 18 7 M 1 u 30 ϫ 20 2 5 ND 19 1.5 F 1 u 30 ϫ 20 4 4 ND 20 5 M 1 u 50 ϫ 50 5 5 ND 21 1.3 M 1 u 30 ϫ 20 4 4 ND 22 4 F 1 u 30 ϫ 20 5 5 ND Presumed bacterial 1 7 F 1 u 30 ϫ 30 4 ND cervical 2 1 M 1 u 60 ϫ 20 5 ND lymphadenitis 3 0.7 F 1 u 60 ϫ 50 8 Staphylococcus aureus 4 0.7 M 1 u 60 ϫ 60 12 ND 53 M 3b15ϫ 15 2 ND 64 F 2b50ϫ 50 6 Staphylococcus aureus 7 0.4 M 1 u 60 ϫ 40 4 ND 84 F 1u30ϫ 30 3 ND EBV-IM 1 1 M 3 b 50 ϫ 30 5 ND 22 M 3b40ϫ 30 10 ND 35 F 4b50ϫ 40 23 ND 4 1.7 M 2 b 40 ϫ 30 2 ND 54 F 2b65ϫ 45 13 ND US indicates ultrasonography; u, unilateral; b, bilateral; ND, not done.