Spot the diagnosis 1

Sagar Bhattad MD, DM, Assoc FAMS, EBMT Diploma
Consultant, Pediatric Immunology and Rheumatology, Aster CMI Hospital, Bengaluru, Karnataka, India.

Case description: Master K, a 9-month-old boy, presented with bilateral axillary swelling for 8 days. This swelling was insidious in onset and progressive, not associated with pain or redness. His past medical history was significant, as he had been hospitalized at 4 months of age. He experienced high fevers for 19 days, accompanied by erythematous rashes over his trunk, red lips, and red eyes without discharge. He showed marked thrombocytosis and leukocytosis along with elevated inflammatory parameters. During that time, he was suspected to have Multisystem Inflammatory Syndrome in Children (MIS-C) and was treated with oral steroids for 15 days, after which his fever subsided. Upon examination, he displayed bilateral pulsatile axillary swelling.

Images:

Figure a

Figure b

What is the likely diagnosis?

Answer:
Kawasaki disease (missed) with bilateral axillary artery aneurysms.
Image (a) Pulsatile swelling in the left axilla
(b) CT angiography: Large fusiform axillary artery aneurysms.

Further evaluation: Echocardiogram showed giant coronary aneurysms, and CT angiography confirmed axillary aneurysms.

Message: Young infants with Kawasaki disease are at high risk of developing coronary aneurysms. Delayed/missed diagnosis can lead to severe complications, including peripheral aneurysms.