178 - JEJUNAL PERFORATION IN CONVALESCENT PHASE OF KD

Background: Acute abdomen-like presentation is seen in 2-5% of patients with KD. Cholecystitis, intestinal obstruction, acute appendicitis, acute pancreatitis, acute peritonitis, intestinal volvulus, duodenal, ileal perforation, and intussusception have been reported so far in the acute phase. We report a child with an acute abdomen in the convalescent phase.

Case report:

A 4-year-old girl was brought with vomiting, loose stools, abdominal pain, and high-grade fever for ten days. She also had redness of oral mucosa, conjunctival injection, perianal erythema, and purpuric rashes over trunk extremities. When the child presented on day 10 of illness, with the diagnosis of complete Kawasaki disease (KD), ECHO showed dilatation in LMCA 2.9mm (2.8 Z) and an aneurysm in LAD 2.8mm (3.5 Z), respectively. Her laboratory investigations revealed anemia (75 g/L), thrombocytopenia (75x10³/L), hyponatremia (131 mEq/L), and Hypoalbuminemia (24 g/L), and a high CRP (189mg/L). She was given IVIG 2g/kg, oral prednisolone (2mg/kg), and aspirin at an antiplatelet dose. She became afebrile, her rashes disappeared, and her abdominal symptoms improved. Steroids were tapered and stopped over six weeks. Five months later, she presented with acute abdominal distension and bilious vomiting. X-ray of the abdomen showed gas under the right diaphragm suggestive of intestinal perforation. Laparotomy showed jejunal perforation 200 cm distal to duodeno-jejunal flexure. She underwent resection of an unhealthy small bowel and end-to-end anastomosis. Physical examination revealed the presence of Beau’s lines over all toes. CT coronary angiography showed dilated proximal LMCA 3.2mm(+2.2Z) with no other aneurysms, and abdominal angiography was normal. She was then discharged on aspirin. The child is doing well in the follow-up.

Discussion:

Intestinal perforation in Kawasaki disease is rare; Spontaneous duodenal perforation and ileal perforation have been reported in the acute phase of KD. To the best of our knowledge, this is the first case of spontaneous intestinal perforation in the convalescent phase of KD. It might suggest ongoing endothelial dysfunction /vessel wall involvement even in the convalescent phase.

Conclusion: The index child developed perforation despite receiving treatment intensification, suggesting that abdominal symptoms may represent a severe form of Kawasaki disease. This report highlights that those who present with abdominal symptoms in the acute phase require close monitoring and long-term follow-up as life-threatening complications can occur, necessitating surgery even in the convalescent phase.