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Radiographs of the chest show patchy pulmonary infiltrates, often more prominent than the physical signs would suggest
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Viral, mycoplasmal, and bacterial pneumonias, viral hepatitis, brucellosis, tuberculosis, psittacosis, and other animal-borne diseases must be considered The history of exposure to animals or animal dusts or tissues (eg, in slaughterhouses) should lead to appropriate specific serologic tests Unexplained fevers with negative blood cultures in association with embolic or cardiac disease should make one consider Q fever Q fever is also one of the most common causes of culturenegative endocarditis
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Fever, bilateral conjunctivitis, oral mucosal changes, rash, cervical lymphadenopathy, peripheral extremity changes Elevated erythrocyte sedimentation rate and C-reactive protein levels
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Prevention is based on detection of the infection in livestock, reduction of contact with infected animals or dusts contaminated by them, special care when working with animal tissues, and effective pasteurization of milk A vaccine of formalininactivated phase 1 Coxiella is being developed for persons at high risk for infection and appears to be protective A vaccine is available in some countries for persons with high-risk exposures
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Kawasaki disease is a worldwide multisystemic disease initially described by Tomisaku Kawasaki in 1967 It is also known as the mucocutaneous lymph node syndrome It occurs mainly in children under age 5 years but occasionally in adults, at times in epidemic fashion The higher risk among Asian children may be explained by receptor polymorphisms A leading current theory for Kawasaki disease is an aberrant reaction to common infectious agents among genetically susceptible persons IgA plasma cell infiltration is noted in the visceral organs, lungs, and coronary arteries of patients with Kawasaki disease
Treatment & Prognosis
For acute infection, treatment with doxycycline (100 mg orally twice daily) can suppress symptoms and shorten the clinical course but does not always eradicate the infection The newer macrolides and fluoroquinolones may be an alternative Treatment should continue through 3 full days of defervescence, which usually occurs within 72 hours Even in
Clinical Findings
The disease is characterized by fever and four of the following for at least 5 days: bilateral nonexudative conjunctivitis,
CMDT 2008
are also used by some in disease refractory to two or more episodes of IVIG, appear to be associated with a hastened resolution of fever and inflammatory markers and a shortened duration of hospitalization Their role in increasing the likelihood of the development of coronary aneurysms is controversial Limited case reports document successful use of infliximab, a monoclonal antibody of tumor necrosis factor , in treating refractory disease Aspirin, traditionally recommended in a high dose, does not appear to lower the risk of the development of coronary abnormalities Its use (80 100 mg/kg/d orally in divided doses with subsequent tapering) is recommended indefinitely for patients with persisting coronary abnormalities Warfarin is indicated in addition for aneurysms larger than 8 mm in diameter Regular follow-up by a cardiologist is recommended for patients with coronary artery disease or aneurysms Success is reported with interventional catheter treatment, including stent implantation in patients with long-term cardiac complications Rare patients with irreversible myocardial dysfunction have successfully undergone cardiac transplantation
Bergner D et al Kawasaki disease: what is the epidemiology telling us about the etiology Int J Infect Dis 2005 Jul;9(4): 185 94 [PMID: 15936970] Burns JC et al Infliximab treatment for refractory Kawasaki syndrome J Pediatr 2005 May;146(5):662 7 [PMID: 15870671] Hsieh KS et al Treatment of acute Kawasaki disease: aspirin s role in the febrile stage revisited Pediatrics 2004 Dec;114 (6):e689 93 [PMID: 15545617] Newburger JW et al Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association Pediatrics 2004 Dec;114 (6):1708 33 [PMID: 15574639]
mucous membrane changes of at least one type (injected pharynx, erythema, swelling and fissuring of the lips, strawberry tongue), peripheral extremity changes of at least one type (edema, desquamation, erythema of the palms and soles, induration of the hands and feet, Beau s lines [transverse grooves of the nails]), a polymorphous rash, and cervical lymphadenopathy greater than 15 cm A major complication is arteritis of the coronary vessels, occurring in about 25% of untreated patients, on occasion causing myocardial infarction, and more common among patients over 6 years of age Its frequency is reduced by the use of intravenous immune globulin (IVIG) to about 10% Exacerbations refractory to IVIG are associated with increased risk of coronary aneursyms Noninvasive diagnosis can be made with magnetic resonance angiography or transthoracic echocardiography Factors associated with the development of coronary artery aneurysms are leukocytosis and elevated Creactive protein Pericardial effusions occur in 30% of cases Myocarditis is common in the acute phase of the disease, and mitral regurgitation may be present in 30% of patients but is usually mild Arteritis of extremity vessels, peripheral gangrene, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), and the hemophagocytic syndrome are also reported Cerebrospinal fluid pleocytosis is reported in one-third of cases The cause of these complications is also unknown Differentiation from disseminated adenovirus infection is important and can be performed with rapid adenovirus assays
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