The ‘reactivation’ of a BCG site in this patient is characteristic of Kawasaki disease (KD). The diagnosis was ultimately confirmed when the patient fulfilled the usual criteria for KD: fever for more than five days, bilateral conjunctivitis, cervical lymphadenopathy, generalized rash, erythema of the palms and soles, and subsequent development of erythematous oral mucosa. The patient received both intravenous immunoglobulin (2 g/kg) and acetylsalicylic acid. As well, his neck swelling and irritability improved markedly. He was evaluated by a cardiologist and underwent an echocardiogram, which was normal. He was discharged on acetylsalicylic acid (5 mg/kg/day).
Erythema at the BCG site has been recognized as an early and specific manifestation of KD. The BCG site reactivation can vary from mild erythema and induration to ulceration. In cases where the BCG site has been examined specifically, Ziehl staining, culture and polymerase chain reaction studies for mycobacteria have been negative. The mechanism of this BCG reactivation is unknown. It is speculated that an antigen from the putative infectious agent(s) causing KD cross-reacts with the mycobacterial BCG antigens and thereby contributes to an inflammatory reaction. In Japan, where BCG is routinely administered to children, this phenomenon is widely recognized as an associated feature of KD. This phenomenon is less likely to be observed in North America, where BCG vaccination is uncommon.
Some patients who are suspected of having KD do not demonstrate the full diagnostic criteria; the finding of additional features known to be associated with KD supports the diagnosis of an ‘incomplete’ or ‘atyplcal’ KD. Noncardiac features associated with KD include extreme irritability, aseptic meningitis, pneumonitis, sterile pyuria, elevated liver transaminases, uveitis, otitis media, diarrhea, hydropic gall bladder and reactivation of a BCG site. BCG reactivation and hydrops of the gall bladder are relatively specific for KD, and provide stronger support for ‘atyplcal’ KD than some of the other associated features.
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