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Case 11
5-YEAR-OLD WITH FEVER AND ADENOPATHY -
JASON
Author: Robert Drucker, M.D., Duke University School of Medicine
Learning Objectives
1. Identify the features needed to make a diagnosis of Kawasaki disease.
2. Discuss the acute management of Kawasaki disease.
3. List complications associated with Kawasaki disease.
4. Recognize common viral exanthems.
5. Develop a differential diagnosis for fever and rash.
6. Develop a differential diagnosis for unilateral cervical adenopathy.
Persistent fever
Irritability
Key Findings from History Rash
Conjunctivitis
Refusal to walk
Maculopapular rash
Nonpurulent conjunctivitis
Key Findings from
Mucosal changes
Physical Exam
Unilateral cervical adenopathy
Swelling in extremities
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Stevens-Johnson syndrome
Juvenile rheumatoid arthritis
Measles
Kawasaki disease
Differential Diagnosis
Rocky Mountain spotted fever
Meningococcemia
Scarlet fever
Enterovirus
Case highlights: The case teaches which lab tests to order to narrow the
differential diagnosis and how to manage Kawasaki disease and its complications
acutely and long-term. Multimedia highlights include photos of rashes and other
manifestations of several viral exanthems and echocardiograms showing both a
normal heart and one with a coronary aneurysm.
Enterovirus: Rash usually erythematous and maculopapular and may involve the
palms and soles. In hand-foot-and-mouth disease (caused by Coxsackievirus),
there is a vesicular rash on hands and feet, with ulcers in the mouth.
Measles: Initial rash appears on buccal mucosa as red lesions with central bluish
white spots (Koplik spots). After prodromal fever (over 101 Fahrenheit), cough,
coryza, and conjunctivitis, a maculopapular rash starts on neck, behind ears, and
along hairline. Rash spreads downward and reaches feet in two to three days.
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Roseola: Macular or maculopapular rash starts on trunk and spreads to arms and
neck. Rash preceded by three to four days of high fevers, which end as rash
appears. Usually in patients under two years of age.
Varicella: Rash starts on trunk and spreads to extremities and head. Each lesion
progresses from erythematous macule to papule to vesicle to pustule, and then
crusts over. Lesions at various stages of development. Self-limited disease lasting
approximately one week.
Skills
Physical exam:
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Differential diagnosis
1. Kawasaki disease: If patient febrile for five or more days, consider
Kawasaki disease. Other manifestations of this disease of unknown etiology
often elicited by history include a non-purulent conjunctivitis (which may
have cleared prior to presentation), rash, and swelling and erythema of the
hands and/or feet. The swelling in the feet can lead to painful walking. Must
have four of the following criteria in addition to fever (as well as no other
apparent cause for the illness) for diagnosis:
Changes in oral mucosa
Extremity changes (redness/swelling)
Unilateral cervical lymphadenopathy
Rash
Conjunctivitis
2. Stevens-Johnson syndrome: Mucocutaneous disorder characterized by
fever, severe stomatitis, conjunctivitis, and erythema multiformetype (i.e.,
hypersensitivity reaction), blistering rash. Formerly called erythema
multiforme major.
Studies
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Blood culture:
In this case, the clinical course is long for bacteremic illnesses, though the
height of the fever and the clinical appearance of the patient could justify
obtaining a culture.
Liver enzymes:
Clean-catch urinalysis:
Management
Acute treatment of Kawasaki disease:
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Prevention of complications:
Continue low-dose aspirin for at least six weeks following acute phase.
Since if coronary artery aneurysms develop they usually do so within four
weeks of the acute illness, follow-up visits with cardiology after discharge
for repeat echocardiograms are essential.
May require lifelong cardiology follow-up.
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