-Case-
During your shift in the pediatric ED, a 4-year-old girl arrives with her exhausted parents. She’s been running a high fever for five days straight and her parents say, “no amount of Tylenol or ibuprofen seems to be helping”. On your exam, her lips are cracked and erythematous, her eyes are red, and she has a new rash on her chest and back. Her vitals are notable for tachycardia and a fever to 104F.
A more prolonged fever (ie., 5+ days) is treated differently in kids as opposed to adults. With this patient’s constellation of symptoms surrounding the fever, what causes come to mind?
-Evaluation-
Whenever you have a patient around 5 years old with a fever for 5 or more days, Kawasaki Disease should pop on your radar. But what is Kawasaki disease? It’s an acute febrile vasculitis that, if missed, can lead to coronary artery aneurysms and other complications.
Let’s talk about the clinical criteria for Kawasaki’s. For this, a helpful mnemonic is “CRASH and Burn”:
- C: Conjunctivitis (often bilateral and non-purulent)
- R: Rash (polymorphous, can look like just about anything)
- A: Adenopathy (usually cervical, unilateral, >1.5 cm)
- S: Strawberry tongue and other mucous membrane changes (cracked lips, red oral mucosa)
- H: Hand and foot changes (swelling/redness or, later on in the disease course, peeling)
- Burn: Fever for ≥5 days (this is non-negotiable for diagnosis)
Now, a lot of the time, a child won’t check all of the boxes for Kawasaki disease. For these cases, lab findings like an elevated CRP/ESR, anemia, thrombocytosis, hypoalbuminemia, and sterile pyuria (sneaky, right?) can help confirm our suspicions. If 4+ “CRASH” symptoms are met, labs aren’t needed, and we skip right to treatment. However, for cases of only 2-3 symptoms and/or fever of 7+ days in kids < 6mo old, we opt for these labs and an echo.
The differential for fever in a kid is vast: Strep throat? Scarlet fever? Viral exanthem? Toxic shock syndrome? All fair guesses. But always at consider Kawasaki’s in these patients with a prolonged fever and our “CRASH and Burn” symptoms.
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-Management-
Kawasaki management isn’t just about fever; it’s about protecting the heart. Our first-line option is IVIG – the powerhouse behind treatment. We give this early to cut down the risk of coronary aneurysms. In fact, IVIG initiation within 10 days of symptom onset has been shown to reduce mortality by 90%! As an adjunct, aspirin’s anti-inflammatory and anti-platelet effects have been shown to help these patients as well.
For monitoring, get that echo ASAP! Again, coronary artery involvement is our biggest concern to watch for. We repeat an echo at diagnosis, 2 weeks out, and 6 weeks post-treatment.
-Fast Facts-
- Remember, Kawasaki disease should always be on your radar in kids under 5 with 5+ days of fever
- Coronary artery aneurysms are essentially the entire reason we take Kawasaki identification/management so seriously
- Be vigilant with incomplete presentations; getting an echo and labs are your friends here!
- When meeting 4+ “CRASH” symptoms, don’t wait for labs! Go right to IVIG treatment
Kawasaki disease is a clinical diagnosis that requires trusting your gut and quick action. Patients and their families are counting on you to notice the clues, confirm the diagnosis, and protect their little hearts. Remember – while Kawasaki patients often presents chiefly for fever, your job is to prevent lifelong consequences.
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Cheers,
Tamir Zitelny, MD