Sore throat?

So no fun pictures unfortunately.  Saw an 11 y/o F while moonlighting a couple days ago with Abhi and I thought I'd share it.  Beau saw her eventually in the PICU (uh oh, already giving away stuff), and would love for him to comment also.

Patient has h/o intermittent asthma, comes in on day 1 to PEC for sore throat, fever, and R cervical lymphadenopathy.  Vitals stable, rapid strep neg and mono neg.  CBC/BMP/UA checked, WBC is 15 but otherwise everything else is normal.  Whoops, Cr is 1.16, team figures she's a little dry, gives her a fluid bolus, and discharges home for cervical adenitis with a Rx of Keflex.

Day 2: She comes back with same sx but also a pruritic rash and odynophagia.  Once again V/S are stable and PE doesn't show anything different except the rash.  Discharged, advised to d/c Keflex and start Clindamycin.  Still having intermittent fevers.

Day 6:  So pt returns with same sx, along with intermittent diarrhea, vague report of abdominal pain, chest pain, sob.  Can't really pin down duration or severity of sx exactly.  Vitals are stable.

At this point, Abhi and I know one thing...she's getting admitted.  Looks like a viral picture?  Broaden the w/u, get a CBC, CMP, UA, CXR, and even though she's not tender on exam, we shotgun the approach a little and get an U/S of her RUQ and appendix.

Labs start coming back, and we start freaking. 

Wbc - 18.6 (from 15), Hg - 9.1 (from 12), BUN-23 (from 11), Cr- 1.86 (from 1.16), AST-221, ALT-167, Tbili - 2.4

What is going on here?  Viral hepatitis?  From a sore throat?  We start talking to some peeps in the main room and a couple things start floating around...Mono - induced hepatitis?  atypical HUS?

Then stuff starts getting really interesting.  She slowly but persistently becomes hypotensive.  Initially 110/60 she is continually dipping, as low as 70/30 at one point.  We over a course of a couple hours get 3 L of NS in her.  Get a lactate, and it's 1.8

I do an IVC U/S on her, and it shows a BIG ol' IVC, no resp variation.  At this point, Abhi made sure PICU came down and saw her, and this included the PICU attending.  His response (I am serious)...I have no idea what's going on, but let's get her up RIGHT NOW!  Yes sir.

So, I'm in a rush cuz I'm about to be late to a shift, so I'll wrap it up quickly.

In the PICU they end up starting her on low-dose dopamine, and do a BROAD w/u.  Including viral hepatitis panel, blood cultures, etc, and...troponins/BNP, which are elevated, 0.16 and 1700!  A cardiac ECHO is done the next day and it shows a dilated RCA. 

She ends up getting treated for atypical Kawasaki (IVIG and high dose ASA).  She is also Mycoplasma IgM +....ends up there is some literature showing Mycoplasma induced Kawasakis.

She walks out 4 days later fresher than a daisy.  BOOYA.