303

MUCOCUTANEOUS LYMPH-NODE SYNDROMEAND PARAINFLUENZA 2 VIRUS INFECTION

SIR We have seen a patient with the mucocutaneous

lymph-node syndrome (Kawasaki disease) from whom para-influenza virus type 2 was isolated and in whom seroconver-sion to the virus was demonstrated.A 4-year-old White girl who had always lived in Massachu-

setts was admitted to the Massachusetts General Hospital onFeb. 23, 1977, with fever and jaundice. 6 days previously shehad started a 4-day course of oral penicillin prophylaxis forteeth cleaning, a murmur of questionable significance having

; been detected some months before. The evening after the pro-cedure, 3 days before admission, she became febrile and com-

plained of neck pain. A slightly tender 3 cm lymph-node wasobserved at the angle of her left jaw. Over the next 3 dayssevere bilateral conjunctival suffusion, a non-pruritic, erythe-matous macular rash over her trunk and proximal extremities,and jaundice developed.On admission she was irritable with a temperature of

394°C. Apart from the above findings, she also had a brightred buccal mucosa and red dry lips. The hands and feet werenot swollen or red. The heart sounds were distant. There wasno other adenopathy or splenomegaly. The liver was slightlyenlarged.

Initial temperatures were in the range of 39.4-40.6°C.Soon after admission myocarditis developed, with cardiome-galy, electrocardiographic changes, and congestive heart-fail-ure which responded to fluid restriction and diuretics. By thethird hospital day, she began steadily, if slowly, to improve. Onthe eleventh day desquamation of the skin of her fingers andtoes developed. -Her admission leucocyte-count was 16 300/µl with a marked

polymorphonuclear predominance, and it peaked on the sixthhospital day at 64 800/µl. Other significant laboratory findingswere: erythrocyte-sedimentation rate 72 mm/h; serum-biliru-bin 6.3 mg/dl (52 direct); S.G.O.T. 78 U/dl; serum-IgE 168mg/dl (normal 20-1000). c.s.F. examination was normal, andcultures of urine, sputum, and blood showed no bacterialgrowth. Heterophile antibody, cold agglutinins, anti-streptoly-sin 0, Widal, OX, and Brucella agglutinins, HB, Ag and HBsAb, and serum complement levels were unremarkable. By the28th day of illness, liver-function tests had returned to normal,and the patient had no evidence of persisting inflammation orof heart-disease.A throat swab, obtained on the first hospital day, was cul-

tured on human embryonic lung and kidney and monkey kid-ney cell monolayers. Cytopathic effects and hsemadsorption ofguinea pig erythrocytes were observed by 7 days in the infectedmonkey-kidney cells. Haemadsorption-inhibition studies con-firmed the isolate as parainfluenza 2 virus. Virus cultures ofrectal swab, conjunctival swab, and urine were negative. Acuteand convalescent sera were obtained on days 1 and 13. Comple-ment-fixation titres against parainfluenza 2 virus rose from <8to 64; rises from 32 to >256 were also detected against mumpsand parainfluenza viruses 1 and 3. Seroconversion was notdemonstrated against leptospires, Mycoplasma pneumoni&aelig;,Toxoplasma gondii, or the following viruses: herpes simplex,cytomegalovirus, rubeola, varicella, Epstein-Barr, adenovirus,and influenza A and B.We believe this girl had the mucocutaneous lymph-node syn-

drome described by Kawasaki et al.’ Detailed surveys for var-ious causative agents in this syndrome have proved negative.Some workers have specifically noted unsuccessful attempts todemonstrate parainfluenza virus infection.3.4 Except for para-influenza 2 virus, we could find no cause for this girl’s illness.An allergic reaction to penicillin was considered, but the en-largement of a single node and the development of acute myo-carditis argue against this diagnosis.1. Kawasaki, T., and others Pediatrics, 1974, 54, 271.2. Melish, M. E., Hicks, R. M., Larson, E. J. Am. J. Dis. Child. 1976, 130, 559.3. Goldsmith, R. W., Gribeta, D., Strauss, L. Pediatrics, 1976, 57, 431.4. Della Porta, G., Alberti, A. Lancet, 1977, i, 797.

We believe that our patient was infected with parainfluenza2 virus about the same time as the mucocutaneous lymph-nodesyndrome developed. A causal relationship is possible, and stu-dies for parainfluenza 2 virus should be included in the evalua-tion of children with Kawasaki disease.

Departments of Pediatrics and Medicine,Massachusetts General Hospital

and Harvard Medical School,Boston, Massachusetts 02114, U.S.A.

DANIEL E. KEIMEVELYN W. KELLERMARTIN S. HIRSCH

TRANSITORY THROMBOCYTOPENIA INSMALL-FOR-DATES INFANTS, POSSIBLY RELATED

TO MATERNAL SMOKING

SIR,-In small-for-dates babies platelet-counts may be lowwhen growth retardation in utero is associated with intrauter-ine infections (rubella, cytomegalovirus, toxoplasmosis, syphi-lis)’ or with hyperviscosity syndromes.2

In 31 infants with birth-weight below the 10th percentile3 (mean birth-weight 1780 g) platelet-counts were recorded dur-ing the first 2 weeks after birth. Platelets were counted byphase-contrast microscopy. In 23 children (74%) platelet-counts fell below 100x109/l. Individual lowest counts werefound between days 1 and 10. The platelet-count alwaysreturned to normal spontaneously by day 15. The mean

platelet-count fell below 100 x 109/1 during the first 9 days (seefigure). In no patient did pathological bleeding develop, but 1baby was given a platelet transfusion when the platelet-countfell to 7.5 x 109/l.

1. Avery, G. B. Neonatology: Pathophysiology and Management of the New-born, p. 145. Philadelphia, 1975.

2. Gross, G. P., Hathaway, W. E., McGaughey, H. R. J. Pediat. 1973, 82,1004.

3. Blystad, W. Unpublished.

DAYS AFTER BIRTH

Mean and range of platelet-counts in 31 small-for-dates infants.

The last value is for day 18.