Spatio-temporal evolution of onychomadesis in a child with missed Kawasaki disease

Excerpt

A 4.5-year-old boy presented with shedding of the left index fingernail. He had fever 6 weeks back with rash, oral mucosal erythema, red cracked lips, and periungual skin peeling. At presentation (6 weeks into the illness), his fingernails showed different stages of onychomadesis; right index, left middle, and left little fingernails had just begun to separate, displaying a transverse white discoloration resembling leukonychia (red arrows in Fig. 1a); frank onychomadesis of right thumbnail (black arrow in Fig. 1a); and left index fingernail already shed off with a residual transverse groove (blue arrow in Fig. 1a). Investigations (at presentation to us, i.e., 6 weeks into the illness) showed thrombocytosis (450 × 10⁹/L) and elevated C-reactive protein (18 mg/L). Kawasaki disease was diagnosed, and he was treated with intravenous immunoglobulin (2 g/kg) and aspirin (4 mg/kg/day). At 2 weeks of follow-up (8 weeks into the illness), nails which had just started to separate developed frank onychomadesis and right thumb nail had shed off leaving behind a transverse groove similar to left index finger. His 2-dimensional echocardiography showed normal coronaries on all visits, and aspirin was stopped at 6 weeks of follow-up (12 weeks into the illness). At this time all fingernails had healed completely (without any transverse grooves).

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