Pediatrics · Year 3 · from Pediatrics

Case 2: Kawasaki Disease

Patient Demographics

  • Age: 3-year-old male
  • Sex: Male

Chief Complaint

"He's had a high fever for 5 days and now has a rash."

History of Present Illness

A 3-year-old previously healthy male presents with 5 days of persistent high fever (39-40°C) that has not responded to acetaminophen or ibuprofen. Over the past 2 days, his parents have noticed red eyes without discharge, cracked red lips, a red rash on his trunk, and swelling of his hands and feet. He has been irritable and refusing to eat. He has had no cough, runny nose, or diarrhea. There is no known sick contacts. He received all vaccinations on schedule and has no significant past medical history.

Physical Examination

  • General: Irritable, ill-appearing child
  • Vital signs: Temp 39.8°C, HR 140 bpm, RR 28/min, BP 90/60 mmHg
  • HEENT: Bilateral conjunctival injection without exudate, cracked erythematous lips, strawberry tongue, right anterior cervical lymph node 2 cm and tender
  • Cardiovascular: Tachycardic, regular rhythm, no murmur, normal S1/S2
  • Respiratory: Clear to auscultation
  • Abdomen: Soft, mildly tender diffusely, no hepatosplenomegaly
  • Skin: Diffuse polymorphous macular rash on trunk and extremities
  • Extremities: Erythema and edema of hands and feet

Workup

  • CBC: WBC 18,000/μL with left shift, Hgb 10.8 g/dL, Platelets 450,000/μL
  • CMP: Normal
  • ESR: 68 mm/hr (elevated)
  • CRP: 12.5 mg/dL (elevated)
  • Urinalysis: Sterile pyuria (15 WBC/hpf)
  • Echocardiogram: Normal coronary arteries, mild pericardial effusion, normal LV function

Diagnosis

Kawasaki disease (acute phase)

Clinical Reasoning

This patient meets diagnostic criteria for Kawasaki disease: fever for at least 5 days plus 4 of 5 clinical criteria (bilateral non-exudative conjunctivitis, oral mucosal changes, polymorphous rash, extremity changes, and cervical lymphadenopathy >1.5 cm). The elevated inflammatory markers and sterile pyuria are supportive findings. Early echocardiogram shows no coronary involvement yet, but he remains at risk without treatment.

Management

  1. IVIG: 2 g/kg as single infusion over 10-12 hours
  2. High-dose aspirin: 80-100 mg/kg/day divided Q6h until afebrile for 48-72 hours
  3. Transition to low-dose aspirin: 3-5 mg/kg/day once afebrile
  4. Repeat echocardiogram: At 2 weeks and 6-8 weeks
  5. Monitor for IVIG resistance: If fever persists >36 hours after IVIG completion, consider second IVIG dose, corticosteroids, or infliximab
  6. Continue low-dose aspirin: For 6-8 weeks if no coronary abnormalities; indefinitely if coronary involvement develops

Clinical Image

Image Description: Clinical photograph demonstrating the classic features of Kawasaki disease including conjunctival injection, cracked erythematous lips, and strawberry tongue.

Source: Wikimedia Commons URL: https://commons.wikimedia.org/wiki/File:Kawasaki_symptoms.png License: CC BY-SA 4.0

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