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. The correct diagnosis is made and the appropriate treatment is initiated. What additional assessment is required 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. The correct diagnosis is made and the appropriate treatment is initiated.  What additional assessment is required in the management of this patient?

Quizplus · Accepted Answer

Explanation: All children diagnosed with Kawasaki disease (KD) should have an echocardiogram performed at baseline. Although coronary artery aneurysms usually develop after the 10th day of fever and are often not evident during acute illness, some degree of coronary artery dilation and myocardial dysfunction may be present at diagnosis. Aneurysms may later develop even in patients who receive appropriate treatment, so follow-up studies are indicated at 2 and 6 weeks after treatment, even if the initial study is normal. Due to the high risk of sequelae in patients with KD, it would be inappropriate to omit echocardiography even in the absence of any cardiac complaints (eg, chest pain, difficulty breathing) (Choice D). (Choice A) An antinuclear antibody assay is helpful in screening for systemic lupus erythematosus, which is not associated with conjunctivitis, edema, or mucositis. Although KD is an inflammatory vasculitic condition, the antinuclear antibody is not usually positive and is not helpful in diagnosis. (Choice C) KD is sometimes confused with meningitis, as both can present with high fever and crankiness/irritability, and cerebrospinal fluid pleocytosis may be seen in both cases. However, meningitis is not associated with edema, conjunctivitis, or mucositis; and if a patient meets KD diagnostic criteria, lumbar puncture is an unnecessary and invasive procedure. (Choice E) The patient's erythematous, generalized, maculopapular rash with accentuation in the perineal and inguinal regions is typical of rashes seen in KD. Therefore, unless it fails to resolve after the patient has recovered, skin biopsy is not indicated. Educational objective: Children with Kawasaki disease are at risk for the development of coronary artery aneurysms even after appropriate treatment. They should have an echocardiogram performed at the time of diagnosis, and at 2 and 6 weeks after completion of treatment. 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