A 39-month-old boy is brought to the office due to fever. He has had fever spikes the past 5 days that have not improved with oral acetaminophen. He has been very cranky and his appetite has decreased. The patient has had a slightly stuffy nose but no cough, emesis, or diarrhea. He has also developed a bad diaper rash that has not improved with topical barrier ointments. The patient does not attend day care, and there are no sick contacts at home. Medical history is significant for an episode of otitis media last year and occasional upper respiratory infections, but he has had no chronic medical illnesses. Immunizations are up to date, and the patient takes no medications. Temperature is 40 C (104 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 18/min. On physical examination, the child is awake and alert but very cranky. The head is normocephalic and atraumatic. The conjunctivae are injected without discharge bilaterally, and the pupils are equal and reactive to light and accommodation. There is scant nasal congestion. The lips, tongue, and oral mucosa are erythematous, but there is no pharyngeal erythema or exudate. Neck is supple without lymphadenopathy. S1 and S2 are normal without murmurs; lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, and nondistended, without organomegaly. There is nontender erythema and peeling of the skin in the perineum and inguinal folds and several erythematous, blanching macules on the trunk; there are no other skin lesions.
Which of the following is the most appropriate next step in the management of this patient?

Question

A 39-month-old boy is brought to the office due to fever.  He has had fever spikes the past 5 days that have not improved with oral acetaminophen.  He has been very cranky and his appetite has decreased.  The patient has had a slightly stuffy nose but no cough, emesis, or diarrhea.  He has also developed a bad diaper rash that has not improved with topical barrier ointments.  The patient does not attend day care, and there are no sick contacts at home.  Medical history is significant for an episode of otitis media last year and occasional upper respiratory infections, but he has had no chronic medical illnesses.  Immunizations are up to date, and the patient takes no medications.  Temperature is 40 C (104 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 18/min.  On physical examination, the child is awake and alert but very cranky.  The head is normocephalic and atraumatic.  The conjunctivae are injected without discharge bilaterally, and the pupils are equal and reactive to light and accommodation.  There is scant nasal congestion.  The lips, tongue, and oral mucosa are erythematous, but there is no pharyngeal erythema or exudate.  Neck is supple without lymphadenopathy.  S1 and S2 are normal without murmurs; lungs are clear to auscultation bilaterally.  Abdomen is soft, nontender, and nondistended, without organomegaly.  There is nontender erythema and peeling of the skin in the perineum and inguinal folds and several erythematous, blanching macules on the trunk; there are no other skin lesions. 
Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1ce_842d_8f63_399046edfdd9_MD0005_00 This boy age <5 has had fever for 5 days as well as the following symptoms: Rash (inguinal folds, perineum, trunk) Nonexudative conjunctivitis Mucositis (erythematous lips, tongue ["strawberry tongue"], oral mucosa) He therefore meets 3 of the 5 diagnostic criteria of Kawasaki disease (KD), a febrile vasculitis of unknown etiology. An additional criterion (cervical lymphadenopathy or extremity erythema/edema) is required for diagnosis. However, KD symptoms often do not manifest simultaneously; therefore, when <3 diagnostic criteria are met in a child with >5 days of fever, C-reactive protein or erythrocyte sedimentation rate (inflammatory markers that are elevated in KD) should be ordered, with daily follow-up scheduled to assess for new symptoms. KD can present a diagnostic challenge because viral illnesses can cause fever >5 days and similar features (eg, rash, conjunctivitis, oropharyngeal erythema). However, failure to treat KD in a timely manner significantly increases the risk of serious sequelae (eg, coronary artery aneurysms), with substantial risk after the 10th day of illness. Therefore, unless a definite alternate diagnosis has been established, waiting 3-4 days without performing laboratory studies or reexamination is inappropriate (Choice E). (Choice B) Scarlet fever, treated with oral amoxicillin, is caused by a streptococcal infection and presents with a "sandpaper" rash (small papules), "strawberry tongue," and circumoral pallor. However, it typically accompanies streptococcal pharyngitis (eg, pharyngeal erythema/exudate) and would not cause conjunctivitis. "sandpaper" rash (Choice C) Oral antibiotics would be necessary for rashes caused by cellulitis or toxic shock syndrome. Bacterial cellulitis does not typically cause a nontender, peeling perineal rash with papules on the trunk. Toxic shock syndrome can cause desquamation but is usually seen with tampon use and associated with hypotension. (Choice D) Fungal diaper dermatitis (beefy red skin with satellite lesions) is common in children; however, the presence of fever, conjunctivitis, and oral erythema is not suggestive of this diagnosis. In addition, even if fungal dermatitis is suspected, topical antifungal treatment (not simply topical barrier ointments) should be attempted first. Educational objective: Kawasaki disease is a febrile vasculitis of childhood, diagnosed based on fever >5 days with >4 of the following: conjunctivitis, mucous membrane changes, rash, lymphadenopathy, and extremity edema/erythema. Because symptoms required for diagnosis do not always present simultaneously, patients who have been febrile for >5 days but who fill <3 diagnostic criteria should have supporting laboratory studies (C-reactive protein or erythrocyte sedimentation rate) ordered and should be reexamined the following day. References: Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. (http://www.ncbi.nlm.nih.gov/pubmed/15574639) Kawasaki disease. (http://www.ncbi.nlm.nih.gov/pubmed/18765469)

A 39-Month-Old Boy Is Brought to the Office Due to Fever