Case 25: Fever & Rash

Parents come to the ER with their fully vaccinated 8 month old who has had fever and rash for 4 days. They saw the pediatrician yesterday in the office. He told them it looked like the fever and conjunctivitis were probably from adenovirus. Desitin was recommended for the diaper rash. Today they say he is more irritable and the rash looks worse. The child has URI symptoms, but no GI symptoms. On exam he is calm in mom’s lap with normal vital signs except for a temperature of 101.2. His exam is normal except for the findings shown in the images below.

What is the differential diagnosis? What should you do next?

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Answer: KD. Excerpt on Kawasaki’s Disease from

“QUICK ESSENTIALS: EMERGENCY MEDICINE“

Kawasaki’s: AKA Mucocutaneous Lymph-node Syndrome. Usually irritable. Age ū <8y
Dx: F>39.4 x 5d + 4/5 of: bilateral conjuntivitis:90, mucous membrane (lip ,OP, tongue), palm/sole, rash on trunk(scarletiniform, E. multiformoid, diaper), neck nodes(rare in USA)
Other: Can have URI Sx. Inflammation at prior BCG vaccination site or draining node
Incomplete: Fx5d and 2 or 3 of the 5 cardinal signs. Usually eyes & rash
If 3 abnormal labs (below) start IVIG esp. if age <1.
Tests: ESR>40, CRP>3, albumin<3, ALT, WBC>15, anemia, platelets>450K, pyuria, EKG/echo
DDx: Drug rxn, viral, RMSF, measles, scarlet fever, Steven-Johnson, rheumatoid, leptospirosis…
Comps: Coronary artery aneuryms in 20% and thrombosis/MI (more common age <1y), cholecystitis, pancreatitis, orchitis, meningitis, vasculitic ischemia.
Rx: IVIG 2g/k, ASA 20/k qid. Rx decreases complications
Err on side of overdiagnosing & treating early (<7days), especially in age <12mo
Steroids are controversial. Some give if refractory (fever lasts >48h after IVIG), or GI comps
Goal is to start IVIG prior to abnormalities on Echo or EKG, ideally before 7days of fever

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