CASE PRESENTATION
Abhilash Sailendra
GPST 1
AN 18 MONTH OLD WITH FEVER AND RASH
High fever for 4 days. Four days prior to admission , she
developed high fever and rhinorrhea. She was taken to
see a doctor at a clinic and was diagnosed as "URTI".
She was prescribed paracetamol, and amoxicillin .
Two days ago, she had semi-solid stool.
One day PTA, she developed maculopapular rash at trunk
at extremities.
PMH : Healthy child . Birth weight was 3.0 kgs.
No previous admissions to hospital.
PHYSICAL EXAMINATION
Fully conscious but irritable.
Vital signs: Temp 39.8 C, HR 160 beats/min, RR 40 breaths/min,
BP 98/50 mmHg
Head to Toe : mild injected conjunctiva, no icteric sclera, red lips ,
normal anterior fontanel. No palpable LNs.
Heart: regular rhythm, tachycardia
Lung: clear, no added sounds
Abdomen: soft, no organomegaly
Skin : Erythematous rash at trunk and extremities ,
Extremities: Swelling of dorsal part of hands and feet
Investigations:
FBC: Hb 10.6 gm%, WBC 14 (N 72%,L 28%), platelets
324
U & Es - NAD
URINE: Clear
ESR - 97 mm CRP – 276
ECG: sinus tachycardia , rate 170/min, no ST-T change
Echocardiogram: No structural heart defect, normal left
ventricular function (EF 67%), minimal pericardial
effusion 5mm.
DIAGNOSIS ??
KAWASAKI DISEASE
Syn - Kawasaki's syndrome,
mucocutaneous lymph node syndrome,
infantile polyarteritis nodosa.
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Course in the hospital : ,
She was given a high dose intravenous immunoglobulin
(IVIG) 2g/kg and
High dose oral aspirin ( 80mg/kg/day).
Four hours after IVIG the fever dramatically subsided.
Two days after IVIG ,her irritability, erythematous rash,
red lip and oedema of extremities disappeared. She was
discharged home with low dose aspirin (5mg/kg /day).
Cardiology follow up in 6 weeks time.
FEW FACTS
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Age group – 6 months to 5 years.
Commonest cause of acquired heart disease in UK.
Mortality in UK – 3.7 %
Systemic Vasculitis
Most important complication – Coronary Aneurysms ( 30
% ), and if treated early these could be avoided.
DAIGNOSTIC CRITERION
Along with fever > 38.5 , there must be at least four of the
following to fit the diagnostic criteria (or
echocardiographic evidence of coronary artery
aneurysms):
 Inflammation and irritation of the lips, mouth and/or
tongue
 Erythema, oedema and/or desquamation of the
extremities
 Bilateral dry conjunctivitis
 Widespread non-vesicular rash
 Cervical lymphadenopathy >1.5 cm in size
Classical features of Kawasaki disease
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Fever lasting ≥5 days
Marked irritability of the child
Erythema, swelling and desquamation affecting the skin of the
extremities
Bilateral conjunctivitis
Rash
Inflammation of the lips, mouth and/or tongue
Cervical lymphadenopathy
ATYPICAL SYMPTOMS
Other possible features include lethargy, symptoms of urethritis,
diarrhoea, vomiting, abdominal pain, myalgia, arthralgia and arthritis.
A recent Chinese survey found that there appears to be an appreciable
incidence of atypical or 'incomplete' Kawasaki disease and that such
cases appear to have a high prevalence of coronary artery lesions.
The presence of peri-anal desquamation may be a useful indicator
of the likelihood of such 'incomplete' cases
An 8 year old child presents with his parents to his
Physician. His chief complaint is a rash that began on his
lower extremities a few hours ago. In addition his parents
state that the kid has had a low grade fever, arthritis and
colicky abdominal pain. A purpuric rash limited to the
lower extremities was found on examination. A urinalysis
reveals RBC casts and mild proteinuria. The platelet
count is normal. The mostly diagnosis is –
A . Systemic Lupus Erythematosis ( SLE )
B . Rocky mountain Spotted fever
C . Idiopathic Thrombocytopaenic Purpura ( ITP )
D . Henoch – Schonlein Vasculitis
E . Post Streptococcal GN
A 6 year old girl who appears healthy is brought to the GP
by her mother because of a rash. The mother states that
the child had been well until 2 days ago, when she
developed fever and upper respiratory tract symptoms.
Yesterday the child had erythematous facial flushing that
spread as a macular red lesion to her proximal
extremities and trunk, which now has a lacy appearance.
The most likely diagnosis is –
A . Erythema Infectiosum
B . Roseola
C . German Measles or Rubella
D . Measles
E . Scarlet Fever
A 4 year old presents with a temperature of 40 C, which
she has had for the last 4 days. Her GP had seen her on
the first and 3rd day of fever. He was unable to ascertain
the source of fever, and reassured the mother with
Calpol and Ibuprofen. He now presents to AED. On
examination the child is noted to have conjunctivitis,
erythematous rash, cervical adenopathy and swollen
hands and feet. Lab findings show neutrophilic
leukocytosis, elevated ESR and normal platelets. The
most likely diagnosis is –
A . Scarlet Fever
B . Acute Rheumatic fever
C . Juvenile Rheumatoid Arthritis
D . Toxic Shock Syndrome
E . Kawasaki Disease
A 4 year old boy presents with fever and conjunctivitis. The
mother states that the child had been in good health until
2 days ago when he developed URTI symptoms. She
also mentions that he has photophobia and cervical
adenopathy. On examination red lesions with a white
centre are present on the buccal mucosa. A generalised
blanching erythematous rash is also noted . The most
likely diagnosis is –
A . Kawasaki Disease
B . Rubella
C . Adenovirus infection
D . Measles
E . Still s Disease
TAKE HOME MESSAGES
1 . In a child with a fever you should always consider
conditions with a higher risk of serious outcomes,
including:
 Meningitis
 Pneumonia
 Urinary tract infection
 Septic arthritis/osteomyelitis
 Herpes simplex encephalitis
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Kawasaki disease
2. Any febrile child with purpuric rash is
considered as Meningococcal Septicaemia
unless proved otherwise.
CRASH AND BURN
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CONJUNCTIVITIS
RASH
ADENOPATHY
STRAWBERRY TONGUE
HANDS AND FEET – RED SWOLLEN FLAKY
SKIN
BURN – FEVER > 40 FOR > 5 DAYS
Thank you for your patience….