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患儿男,3岁,因发热半月、双下肢走路不稳1天入院。查体:T38.8℃,双眼睑水肿并脱皮。咽充血,双侧颈部可触及肿大淋巴结,轻压痛。双下肢走路不稳,步态蹒跚,各项神经反射正常,脑膜刺激征(-),皮肤感觉正常,双眼对称无震颤,指鼻试验(-),跟膝试验(±),昂白试验(+)。追问病史,患儿于15天前突起高热,体温39℃;第2天出现双眼充血,眼睑浮肿;第3天出现双手指肿胀,关节活动受限,同时全身出现散在皮疹;第5天双眼充血消失;第7天手指肿胀消失,皮疹消退,但眼睑皮肤脱皮严重,持续用抗生素无效,体温波动在38.4～39.5℃;第14天出现走路不稳,左右歪斜,步态蹒跚。实验室检查:血常规、血小板、血沉、细胞及体液免疫均正常,CPR(+)。心电图及二维心动超声正常,颅脑CT未查见异常。拟诊为川畸病并共济失调。给予阿司匹林30mg/(kg.d),潘生丁、维生素C等药物治疗,1周后体温降至正常,2周后共济失调逐渐好转,
Male child, 3 years old, due to fever half a month, two lower limbs walk instability 1 day admission. Examination: T38.8 ℃, double eyelid edema and peeling. Pharyngeal hyperemia, bilateral neck palpable lymph nodes, mild tenderness. Both lower limbs walk unsteadily, gait hobbled, the normal reflexes, meningeal irritation (-), the skin feel normal, bilateral symmetry without tremor, finger nose test (-), knee test +). Asked about the history of the disease, the children raised high fever 15 days ago, body temperature 39 ℃; the first two days of congestion of the eyes, eyelid edema; the third day there are two fingers swollen, joint activity is limited, while systemic scattered rash; Disappeared. On the seventh day, the swelling of the fingers disappeared and the rash subsided. However, the skin of the eyelid was severed and the antibacterial was not used continuously. The body temperature fluctuated between 38.4 and 39.5 ℃. On the fourteenth day, walking instability, left and right skew, and staggering gait were found. Laboratory tests: blood, platelets, erythrocyte sedimentation rate, cell and humoral immunity were normal, CPR (+). Electrocardiogram and two-dimensional echocardiography was normal, abnormal brain CT was not detected. To be diagnosed as Kawasaki disease and ataxia. Given aspirin 30mg / (kg.d), dipyridamole, vitamin C and other drugs, 1 week after the temperature dropped to normal, ataxia gradually improved after 2 weeks,