A 4-year-old girl is brought to the emergency department due to a 1-week history of fever. Her family has also noticed that the patient is "much crankier than normal" and has decreased oral intake. She has had no cough, rhinorrhea, or emesis. She has no medical conditions, takes no daily medications, and has not received age-appropriate vaccines. Temperature is 39.4 C (102.9 F), blood pressure is 90/60 mm Hg, and pulse is 135/min. On physical examination, the patient is irritable and has mild facial flushing. Bilateral conjunctivae are injected. A 1.7-cm, tender, mobile anterior cervical lymph node is palpated. Cardiac examination demonstrates a regular rhythm and no murmurs, rubs, or gallops. The trunk and extremities have a blanching maculopapular eruption; the hands and feet are erythematous and edematous. An image of the patient's mouth is shown below. The posterior pharynx is mildly injected without exudates or tonsillar hypertrophy. Which of the following is the best next step in management of this patient?

Question

A 4-year-old girl is brought to the emergency department due to a 1-week history of fever.  Her family has also noticed that the patient is "much crankier than normal" and has decreased oral intake.  She has had no cough, rhinorrhea, or emesis.  She has no medical conditions, takes no daily medications, and has not received age-appropriate vaccines.  Temperature is 39.4 C (102.9 F), blood pressure is 90/60 mm Hg, and pulse is 135/min.  On physical examination, the patient is irritable and has mild facial flushing.  Bilateral conjunctivae are injected.  A 1.7-cm, tender, mobile anterior cervical lymph node is palpated.  Cardiac examination demonstrates a regular rhythm and no murmurs, rubs, or gallops.  The trunk and extremities have a blanching maculopapular eruption; the hands and feet are erythematous and edematous.  An image of the patient's mouth is shown below.  The posterior pharynx is mildly injected without exudates or tonsillar hypertrophy.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d634_6f14_bc81_bb7bc080bf7b_MD0003_00 Kawasaki disease (KD) is a vasculitis characterized by ≥5 days of fever plus ≥4 of the following findings: Conjunctivitis: bilateral, nonexudative, limbus sparing Oral mucosal changes: erythema, fissured lips, strawberry tongue Polymorphous rash: often begins in perineal area Distal extremity changes: erythema, edema, desquamation of the hands and feet Cervical lymphadenopathy: >1.5-cm node Irritability, as seen here, is also a common feature. Although KD is self-limited, patients are at risk of developing cardiovascular sequelae, particularly coronary artery aneurysms. Therefore, an echocardiogram should be performed on all patients with suspected KD and repeated after several weeks because arterial diameter can increase after the acute illness. The risk of developing aneurysms is higher in infants, in patients with prolonged fevers (>14 days), and in those with delay in treatment (eg, intravenous immunoglobulin) after 10 days of symptom onset. Although the natural history of most aneurysms associated with KD is regression over years, patients with large aneurysms are at risk for myocardial infarction and sudden death due to coronary artery thrombosis and/or stenosis. (Choice B) Oral penicillin treats scarlet fever, which can cause fever, strawberry tongue, and cervical lymphadenopathy. Unlike this case, patients typically have an exudative pharyngitis and a sandpaper-like rash, and conjunctivitis and extremity edema would not be expected. (Choice C) Parvovirus infection, which can be confirmed with serology, can cause fever and rash, but the classic slapped cheek appearance occurs after the resolution of the febrile illness; this patient's facial flushing is likely due to fever. Moreover, fever in parvovirus is often accompanied by prodromal symptoms of sore throat, cough, and headache, not extremity changes. (Choice D) Pharyngoconjunctival fever caused by adenovirus typically warrants reassurance and observation alone. Symptoms include fever, cervical adenitis, and conjunctivitis, but pharyngitis would be expected, and extremity edema would not be seen. (Choice E) This patient's unimmunized status increases her risk of measles, which is diagnosed with positive measles IgM antibody. However, in addition to fever, rash, and conjunctivitis, patients have cough and coryza (ie, nasal inflammation, sneezing), which are not seen here. In addition, the measles rash spreads cephalocaudally, and this patient has no facial rash. Educational objective: Kawasaki disease is characterized by ≥5 days of fever and ≥4 of the following: nonexudative conjunctivitis, mucositis (eg, strawberry tongue), rash, extremity changes, and cervical lymphadenopathy. Echocardiogram is indicated for all patients to assess for coronary artery aneurysms. References: The role of echocardiography in Kawasaki disease. (http://www.ncbi.nlm.nih.gov/pubmed/29152929)

A 4-Year-Old Girl Is Brought to the Emergency Department Due