Does bilateral cervical lymphadenopathy in a febrile child who meets the other Kawasaki disease criteria and now has jaundice and diarrhea alter the diagnosis or management?

Bilateral Lymphadenopathy in Kawasaki Disease with Jaundice and Diarrhea

Bilateral cervical lymphadenopathy, jaundice, and diarrhea do not exclude Kawasaki disease and should not alter the diagnosis or standard treatment approach, as these are recognized features of the disease spectrum. 1

Understanding the Clinical Context

The presence of bilateral lymphadenopathy in this scenario requires careful interpretation:

• Classic Kawasaki disease typically presents with unilateral cervical lymphadenopathy (≥1.5 cm diameter), usually confined to the anterior cervical triangle, and this is the least common of the five principal diagnostic criteria. 1

• However, bilateral lymph node enlargement does occur in Kawasaki disease and has been documented in multiple case series, particularly when imaging studies are performed. 1, 2

• The lymph nodes in Kawasaki disease are characteristically firm, nonfluctuant, without marked overlying erythema, and only slightly tender or nontender—features that help distinguish them from bacterial adenitis. 1

Gastrointestinal Manifestations Are Common

The presence of jaundice and diarrhea should actually increase suspicion for Kawasaki disease rather than exclude it:

• Gastrointestinal complaints including diarrhea, vomiting, and abdominal pain occur in approximately one-third of Kawasaki disease patients. 1

• Hepatic enlargement and jaundice can occur as recognized manifestations of Kawasaki disease. 1

• Acute acalculous gallbladder distention (hydrops) occurs in 15% of patients during the first 2 weeks of illness, which can be identified by abdominal ultrasound. 1

Diagnostic Approach

If this child has fever ≥5 days plus four of the five principal criteria (bilateral conjunctivitis, oral changes, polymorphous rash, extremity changes, and cervical lymphadenopathy), the diagnosis of classic Kawasaki disease should be made regardless of whether the lymphadenopathy is unilateral or bilateral. 1

Key diagnostic considerations:

• The diagnostic criteria require fever for at least 5 days and four or more of the five major clinical features, with exclusion of alternative diagnoses. 1

• Clinical features may not be present simultaneously, making careful history-taking essential. 1

• If typical clinical findings are present with fever for less than 5 days, experienced physicians can still make the diagnosis and initiate treatment. 1

Critical Management Implications

Treatment should not be delayed based on the bilateral nature of lymphadenopathy or the presence of gastrointestinal symptoms:

• First-line treatment is IVIG 2 g/kg as a single infusion, ideally within the first 10 days of fever onset to prevent coronary artery complications. 1, 3

• High-dose aspirin (80-100 mg/kg/day divided into four doses) should be given concurrently with IVIG. 1

• Patients with cervical lymph node enlargement in Kawasaki disease have higher rates of IVIG resistance and Kawasaki disease shock syndrome (KDSS) compared to those without lymphadenopathy, requiring closer monitoring. 2

Important Pitfalls to Avoid

Do not misdiagnose this as bacterial lymphadenitis and delay treatment with multiple courses of antibiotics:

• Kawasaki disease with prominent cervical lymphadenopathy is frequently misdiagnosed as bacterial cervical lymphadenitis, particularly when it is the presenting feature. 1, 4, 5

• Unresponsiveness to broad-spectrum antibiotics in a child with persistent fever and cervical lymphadenopathy should prompt immediate consideration of Kawasaki disease. 4

• Ultrasound findings showing bilateral multiple lymph nodes without liquefaction or abscess formation strongly suggest Kawasaki disease rather than bacterial infection. 2

• Infants and young children with Kawasaki disease have the highest risk of coronary complications, making prompt recognition essential. 3

Differential Considerations

While maintaining high suspicion for Kawasaki disease, briefly consider:

• Bacterial adenitis presents with rapid onset, warmth, erythema of overlying skin, and localized tenderness—features typically absent in Kawasaki disease. 3, 6

• The presence of elevated inflammatory markers (ESR, CRP), neutrophilia, and liver enzyme abnormalities supports Kawasaki disease rather than excluding it. 1, 2

The bottom line: Proceed with standard Kawasaki disease treatment (IVIG 2 g/kg + high-dose aspirin) without delay, as the bilateral lymphadenopathy and gastrointestinal symptoms are consistent with the disease and do not alter management. 1