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 appropriate study is performed and demonstrates no abnormalities. After treatment is initiated, the patient improves and remains afebrile for 48 hours. He is awake, alert, and active without crankiness. Physical examination demonstrates superficial desquamation of his rash and no other abnormality. Preparations are made for discharge with appropriate follow-up. The patient's mother has concerns about his long-term prognosis. Which of the following is the most appropriate response to her question?

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 appropriate study is performed and demonstrates no abnormalities.  After treatment is initiated, the patient improves and remains afebrile for 48 hours.  He is awake, alert, and active without crankiness.  Physical examination demonstrates superficial desquamation of his rash and no other abnormality.  Preparations are made for discharge with appropriate follow-up.  The patient's mother has concerns about his long-term prognosis.  Which of the following is the most appropriate response to her question?

Quizplus · Accepted Answer

Explanation: The patient has been treated with intravenous immunoglobulin (IVIg), which is composed of pooled antibodies. These antibodies interfere with the body's normal immune response to live vaccines. Because of this, patients should defer live vaccines for 11 months after receiving IVIg. The vaccines typically administered at age 4 include live vaccinations (second dose of measles-mumps-rubella and varicella), so they should be postponed in this 39-month-old patient until the appropriate amount of time has elapsed. (Choice A) The likelihood of relapse and recurrence after an episode of Kawasaki disease is low (<2.5% recurrence during the first 3 years after treatment). (Choice B) Kawasaki disease is a self-limited condition, so treatment is only necessary in the acute phase of illness. Once a patient has responded to initial treatment with IVIg, no further immunosuppression or immune modulation is necessary. (Choices C and D) If the patient had coronary artery dilation, coronary artery aneurysms, or myocardial dysfunction on his baseline echocardiogram, he would be at increased risk for future cardiac events and his participation in contact sports and strenuous activities would need to be restricted. However, his cardiac function is normal, and no restriction is necessary at this time. Educational objective: Intravenous immunoglobulin is composed of pooled antibodies and can alter a person's normal immune response to live vaccines. Because of this, live vaccines should not be administered for 11 months after treatment of Kawasaki disease. References: Epidemiological features of Kawasaki disease in Korea, 2006-2008. (http://www.ncbi.nlm.nih.gov/pubmed/20534021)

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