Eur J Pediatr (1993) 152:1040-1041 European Journal of Pediatrics 9 Springer-Verlag 1993 Carbamazepine hypersensitivity and rickettsiosis mimicking Kawasaki disease S. Parha, A. Garoufi, P. Yiallouros, Ch. Theodoridis, Th. Karpathios Second Department of Paediatrics, "A. P. Kyriakou" Children's Hospital, Thivon and Livadias, Goudi, GR-Athens 11527, Greece Received: 22 December 1992 / Accepted: 21 April 1993 Abstract. We report on two patients whose clinical pre- sentation resembled that of Kawasaki disease. The first patient was a boy with epilepsy, whose symptoms first appeared following treatment with carbamazepine. The second boy had Mediterranean Spotted Fever. The sig- nificance of medical history in avoiding overdiagnosis of Kawasaki disease is emphasized. Key words: Kawasaki-like disease - diagnosis Introduction The aetiology of Kawasaki disease is unknown although an infectious agent is suspected I-6, 8, 12]. Since no specific diagnostic test is available, the diagnosis is based on clini- cal criteria [7]. Before a firm diagnosis of Kawasaki dis- ease is made, other clinical entities must be excluded that may mimic the disease. We report on two patients who fulfilled the clinical cri- teria for Kawasaki disease but their medical history and/or laboratory findings made the diagnosis improbable. Case reports Case 1 This 10-year-old boy with epilepsy was receiving carbamazepine (15 mg/kg/day) for 8 days before the onset of the present illness. He was admitted to "A. P. Kyriakou" Children's Hospital with pyrexia and generalized rash of 1 day duration. On admission he had chills and fever up to 40 ~ C, generalized maculopapular rash that coalesced, bilateral conjunctivitis, in- flamed lips and pharynx and enlarged (> 1.5 • 1 cm) cervical lymph nodes. The liver and spleen were palpable 2 cm and 1 cm below the respective costal margins. Total white blood cell count was 9.3 • 109/1 (0.84 poly- morphonuclear cells, 0.13 lymphocytes, 0.0033 monocytes) and Correspondence to: T. Karpathios platelet count 168 • 109/1. Erythrocyte sedimentation rate was 20 mm in the 1st h and C-reactive protein 214 mg/1. The serum aspartate aminotransferase (SGOT) was 100 U/1 and the alanine aminotransferase (SGPT) 66 U/1. The throat swab culture re- vealed normal flora and blood cultures were negative. The disease was attributed to carbamazepine hypersensitivity and the medication was discontinued. It is worth mentioning that in the past, while on phenytoin treatment, the patient had de- veloped a generalized rash which subsided a few days after dis- continuation of the drug. After discontinuation ofcarbamazepine the clinical symptoms and signs persisted for 5 more days. Gener- alized desquamation appeared on day 7. On day 14, while the child was asymptomatic and the serum transaminase levels had returned to normal, with his parent's consent a low dose of carbamazepine was readministered (5 mg/kg). A similar picture promptly presented, although this time transaminase values did not rise. An echocardiogram performed on day 17 was normal. During hospitalisation the platelet count rose above the level of 400 • 109/1 only once, on day 14, following carbamazepine readministration. This patient could have been diagnosed as having Kawasaki disease but carbamazepine hypersensitivity seems to be a more probable diagnosis. Case 2 This 17-month-old boy was bitten by a tick on his right ear 10 days before the appearance of his symptoms. He was admitted to our hospital with a 5-day history of fever and generalized maculopapular rash which also involved the palms and soles. The patient had bilateral conjunctivitis, pharyngitis, a strawberry tongue and an enlarged right cervical lymph node (2 x 2 cm). The liver and spleen were left 3 cm and 2 cm below the respective costal margins. A mild oedema on the hands and feet was also evident and the child was unable to walk. On admission the white cell count was 10 • 109/1 (0.45 poly- morphonuclear, 0.05 lymphocytes, 0.005 monocytes) and platelet count 223 x 109/1. Erythrocyte sedimentation rate was 34 mm in the 1st h and C-reactive protein was 121 mg/1. Serum sodium was 129 mmol/1 and serum chloride 92 mmol/1. Serum transaminases and protein levels were normal. Blood cultures were negative and CSF analysis was normal. Although we had enough criteria for the diagnosis of Kawasaki disease, the history of the tick bite made us consider rickettsiosis