A 2-year-old girl is brought to the emergency department for fever. Eight days ago, the patient developed fever, abdominal pain, vomiting, and watery diarrhea. Her gastrointestinal symptoms subsided in 3 days, but her fever has persisted and has not responded to ibuprofen and acetaminophen. The patient has also been irritable with decreased oral intake. Temperature is 39.4 C (102.9 F), blood pressure is 110/60 mm Hg, pulse is 120/min, and respirations are 24/min. Examination shows injected sclera and dry, red, cracked lips. Heart and lungs are clear to auscultation. The abdomen is soft and nontender without organomegaly. Perineal erythema and a macular rash are present over the trunk and distal extremities. Laboratory results are as follows: Which of the following is the most appropriate next step in management?

Question

A 2-year-old girl is brought to the emergency department for fever.  Eight days ago, the patient developed fever, abdominal pain, vomiting, and watery diarrhea.  Her gastrointestinal symptoms subsided in 3 days, but her fever has persisted and has not responded to ibuprofen and acetaminophen.  The patient has also been irritable with decreased oral intake.  Temperature is 39.4 C (102.9 F), blood pressure is 110/60 mm Hg, pulse is 120/min, and respirations are 24/min.  Examination shows injected sclera and dry, red, cracked lips.  Heart and lungs are clear to auscultation.  The abdomen is soft and nontender without organomegaly.  Perineal erythema and a macular rash are present over the trunk and distal extremities.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d2ba_ff20_bc81_fbbcb53c2872_MD0003_00 This patient has had fever ≥5 days, plus conjunctivitis, mucositis (ie, red, cracked lips), rash, and extremity changes, findings consistent with Kawasaki disease (KD). Nonspecific gastrointestinal (eg, vomiting, diarrhea) or respiratory (eg, cough, congestion) symptoms may precede the development of mucocutaneous findings, as seen here. Kawasaki disease Laboratory evidence supportive of systemic inflammation in KD includes leukocytosis and thrombocytosis, as seen in this case. Sterile pyuria, which represents urethral inflammation, is also classic and characterized by urinary white blood cells with no bacteriuria. Although mild anemia is common, this patient's elevated hematocrit may represent hemoconcentration from poor fluid intake. Treatment of KD is with intravenous immunoglobulin (IVIG). Presumably due to its anti-inflammatory effect, IVIG decreases the risk of coronary artery aneurysms, which is highest in patients with delayed treatment. Therefore, IVIG therapy should be initiated within 10 days of symptom onset in all patients with KD. Aspirin is also administered for its anti-inflammatory and antiplatelet effects but does not affect aneurysm development. (Choice A) Colonoscopy evaluates for suspected inflammatory bowel disease, a rare condition in children age <5. Initial findings may include fever, gastrointestinal symptoms (eg, abdominal pain, diarrhea [often bloody]), and laboratory evidence of systemic inflammation; however, presentation is typically chronic and insidious. In addition, perineal examination is more likely to reveal fissures, skin tags, or fistulas rather than erythema alone, and other extraintestinal findings can include aphthous ulcers (not red lips) and erythema nodosum (not a truncal, macular rash). (Choices B and E) Urinary tract infection can present with fever and pyuria, and dysuria may not be prominent in young children; intravenous antibiotic therapy (eg, ceftriaxone) and renal ultrasound may be indicated for some patients (eg, those unresponsive to oral therapy). However, bacteria on urinalysis/urine culture is required for diagnosis and not present here. Moreover, mucocutaneous findings are inconsistent with this diagnosis. (Choice D) Peripheral flow cytometry can aid in the diagnosis of leukemia, which often presents with prolonged or recurrent fever. However, supportive findings include hepatosplenomegaly, diffuse lymphadenopathy, pallor, or bleeding/bruising along with laboratory abnormalities of leukocytosis/leukopenia, anemia, and thrombocytopenia. None of these clinical features are seen, and this patient has thrombocytosis. Educational objective: Classic manifestations of Kawasaki disease are typically accompanied by laboratory findings of systemic inflammation, such as thrombocytosis, leukocytosis, and sterile pyuria. Treatment includes intravenous immunoglobulin to decrease the risk of coronary artery aneurysms. References: Intravenous immunoglobulin for the treatment of Kawasaki disease. (http://www.ncbi.nlm.nih.gov/pubmed/28079915)

A 2-Year-Old Girl Is Brought to the Emergency Department for Fever