Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Kawasaki Syndrome?
- Florim Cuculoski (19 September 2003)
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THIS CHILD HAD KAWASAKI DISEASE
- VARADARAJAN ARULALAN (19 September 2003)
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Kawasaki disease
- Prasad CSBR (19 September 2003)
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Child with fever and rash
- DA Gauld (19 September 2003)
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Kawasaki Syndrome (Atypical)
- Vinod K Pandey (19 September 2003)
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Kawasaki
- joseph yazbeck (19 September 2003)
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Kawasaki disease
- Dr. Asadullah KHAN (19 September 2003)
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Early diagnosis and treatment is necessary in Kawasaki disease
- Sadik Aksit (19 September 2003)
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Fever with Rash
- NISCHAL K RAO (19 September 2003)
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Kawasaki as a function of vaccine damage?
- Lisa C Blakemore-Brown (19 September 2003)
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SCARLET FEVER
- KAILASH BIHARI (19 September 2003)
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child with rash and fever
- Pablo Rojo (19 September 2003)
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Scarlet fever
- sandeep buddha (19 September 2003)
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viral exanthema
- Omar Bawazir (19 September 2003)
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paediatric cardiology commentator's response
- Nick Archer (20 September 2003)
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Kawasaki UPO
- Anthony N Glaser (20 September 2003)
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Rash and desequamation
- Elizabeth M Norris (20 September 2003)
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infectious mononucleosis
- george sassin gereige, malov V A (21 September 2003)
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kawasaki disease?
- vijayashankara.c. nanjegowda (21 September 2003)
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attitudes
- belche jean (21 September 2003)
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2 year old child with fever and rash
- Somnath Banerjee (21 September 2003)
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r/o Kawasaki and measles but likely other viral exathem
- Robert Perry (22 September 2003)
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2 year child with rash
- Mohammad Zaki Hasan (22 September 2003)
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Atypical Kawasakis Disease
- adrian r crofton (22 September 2003)
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Criteria not met for Kawaski disease
- Mich Lajeunesse (22 September 2003)
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child with rash
- rajavelu ganesan (23 September 2003)
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Primary Immunodeficiency
- Ramzi Y Khamis (23 September 2003)
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Would ISABEL help Elizabeth?
- Benjamin Jacobs (23 September 2003)
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Stevens-Johnson Syndrome
- Velur P Balasubramaniam, Basheer Peer Mohamed, Ramsaravanan Ramaraj (23 September 2003)
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Hypersensitivity syndrome
- Ranjani SG (23 September 2003)
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Our "blind" working response
- Maurice Conlon (24 September 2003)
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Kawasaki's Disease
- Gregory Ho (24 September 2003)
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Challenge of diagnosing Kawasaki's Disease in Primary Care
- joanna I walsh, Knut Schroeder (25 September 2003)
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Differential Diagnosis
- Brian Morgan (25 September 2003)
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Primary Immunodeficiency
- Niranjan Shendurnikar (25 September 2003)
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Paediatric infectious diseases commentator's response
- David Burgner (25 September 2003)
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Re: Would ISABEL help Elizabeth?
- Michael D Innis (25 September 2003)
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answer
- Tom m Nyhan (25 September 2003)
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2 year girl with rash
- Kumar Ganesan (26 September 2003)
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? Kawasaki disease
- Simon Odum (26 September 2003)
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Kawasaki's disease
- Annika Volke (26 September 2003)
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Possible Kawasaki's Disease-interesting case history
- PRAVIN SINGH (27 September 2003)
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answer
- Patricia E Kelly, 101 Foust, Mt. Mpleasant MI 48859 (27 September 2003)
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Kawasaki disease
- Prasad CSBR (27 September 2003)
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Re: Paediatric infectious diseases commentator's response
- Ranjani SG (27 September 2003)
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Kawasaki Disease
- Dr.Suresh Chandran (28 September 2003)
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diagnosis of 2 yrs old child
- imtiaz ahmad salara (28 September 2003)
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Kawasaki
- peter j s baker (28 September 2003)
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2yr old girl with rash & fever Likely Kawasakis disease
- Palla Prabhakara Reddy (28 September 2003)
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KD >SF >SSSS
- Sadasivam Arun (28 September 2003)
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It is Kawasaki`s Disease
- Vijayashankara.C. Nanjegowda (29 September 2003)
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Viral Infection
- Pablo Martinez (29 September 2003)
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Tropical write-up holds the clue?
- Rik M Pelfrene (30 September 2003)
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Probable Kawasaki Disease
- Morgan Keane (30 September 2003)
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Why not a Reye's syndrome?
- Giuseppe Vetrugno, Achille M. Luongo, Leonardo Scorcelletti (30 September 2003)
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Kawasaki disease
- Jeremy M Sager (30 September 2003)
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KAWASAKI DISEASE
- Dr. Asadullah KHAN (30 September 2003)
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Kawasaki 's disease
- Alain Martinole (1 October 2003)
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A 2 year old child with rash and fever
- margit janossa-tahernia (3 October 2003)
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Answers to 3 questions re 2 year old with rash
- Fred W. Whitehouse (3 October 2003)
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Scarlet Fever
- Elizabeth Smedley (3 October 2003)
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Autoimmune Disease
- Mohi U Qureshi, Whittington Hospital (9 October 2003)
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?repeat all the investigations
- Johnson.G Anthony (12 October 2003)
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Florim Cuculoski, Medical Student Basel, Switzerland
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The symptoms of Elisabeth could be explained by a common viral infection but could also mean something more serious. I would consider Kawasaki Syndrome in the differential diagnosis. The typical signs of Kawasaki would be : - Fever, lasting more than 5 days and refractory to appropriate antibiotic therapy - Polymorphous erythematous rash - Nonpurulent conjunctival injection, bilateral - Oropharyngeal changes, including diffuse hyperemia, strawberry tounge, lip changes (swelling, fissuring, erythema) - Peripheral extremity changes, including erythema, edema, induration, and desquamation - Nonpurulent cervical lymphadenopathy. She fullfills almost all of these symptoms (5 out of 6) except the cervical lymphadenopathy. I would do the following tests: Complete blood count, Erythrocyte sedimentation rate, an electrocardiogram, an echocardiogram, a chest X-ray and an urinanalysis. The general practicioner should admit the child to a children's hospital where this diagnosis can be confirmed and treated (with IV gamma globuline and aspirin) or excluded. Kawasaki should be trea Competing interests: None declared |
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VARADARAJAN ARULALAN, primary care paediatrician VELLORE,SOUTH INDIA,632006
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The child lives in UK and had not taken any drugs. Pain on swallowing,redness of tongue,watery discharge,peeling of perineal skin,high grade fever resoloving in 5 days all point to KAWASAKI DISEASE I will do ESR,total and differential count. Take Chest X-ray and ECG. As child is not fully energetic cardiac involvement is a possiblity and I will advise rest. As the mother is pregnant I will ask her to be careful. Subsequent management depends on tests results. KAWASAKI IS NOT RARE IN OUR PART OF INDIA ARULALAN Competing interests: None declared |
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Prasad CSBR, Pathologist Al Hakeem Polyclinic, PO.BOX: 34985, Riyadh-11478, Saudi Arabia
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In cases like this one has to run through a gamut of childhood exanthemes. The most notable points from the presented history and clinical examination include, fever, maculopapular rash starting on the thigh first and later involving whole body, skin peeling in the diaper area, dry red tongue, inflammed eyes with watery discharge, irritabiligy, absence of lymphadenopathy, absence of vesicles, absence of chest involvement, absence of arthritis and fever responding to paracetomol. With the above features I would like to consider the following in my differentials. Staphylococcal scalded skin syndrome (SSSS), Scarlet fever, Kawasaki disease. Though fever with irritability, ?positive Nikolsky sign, rash involving the whole body favour SSSS, response to only just paracetamol rises the threshold to entertain such a diagnosis. However, I would like to undertake investigations to rule it out. Considering all the findings, even with the absence of lymphadenopathy, in my view the best fit will be Kawasaki disease. Nasopharyngeal swab to r/o Measles as it is a notifiable disease. Serum to r/o Rubella as her mother is a pregnant. (Eventhough this is least likely diagnosis here). Complete blood counts (for leucocytosis and toxic granules) ESR/CRP helpful to differentiate viral and bacterial infections and for follow up. Nasal swab / perineal swabs for Staph and Streptococci. ASLO titer to rule out Rheumatic fever. Committing a diagnosis at this stage should not be contemplated as this may cause unnecessary anxiety. She needs a referal. Competing interests: None declared |
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DA Gauld, gp TA81EU
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Probably "a virus",she appears to be recovering,and this to me appears atypical for Kawasaki.I'm concerned about 2 episodes of preorbital cellulititis and other phistory which would make me consider an immune deficiency.As far as parental advice goes?? Mid trimester pregnancy worth thinking carefully but this not VZV/slapped cheek/measles . I'd take an expectant course and carefully reconsider immune deficiency with advice from colleague. Competing interests: None declared |
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Vinod K Pandey, Consultant Paediatrician Nchanga South Mine Hospital, PO 11656, Chingola, Zambia
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Though I would be very much inclined to say that this little girl seems to be having Kawasaki Syndrome, I would like to point out the fact that in typical Kawasaki Syndrome there is peri-ungal peeling (around the nails) rather than perineal peeling. The typical Kawasaki Disease should be associated with extrimity changes whereas none have been reported in this case, as well as there is no mention of cervical adenopathy. According to clinical critaria, there should be a fever of more than 5 days of duration, that also is not the case here. As such, even if this case is diagnosed as Kawasaki Syndrome, it would perhaps be an ATYPICAL case. Steven Johnson Syndrome is another strong differential. Management at this stage should be symptomatic till the diagnosis is proved. Talking to parents about this case in definite terms should better be delayed till we arrive at a defnite diagnosis after observing the course of the disease as it evolves. Competing interests: None declared |
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joseph yazbeck, Physician St Michael's house, Ballymun road, Dublin 11
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In 13 years of general practice I have not seen Kawasaki but this baby looks like one? The child should be admitted for a full work up including a cardiology review. Long term follow up may be indicated if a diagnosis is made. Competing interests: None declared |
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Dr. Asadullah KHAN, Global Marketing Switzerland
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I strongly suspect this child has KAWASAKI disease. Clinical features of this disease include; 1. fever lasting 5 days or more 2. bilateral conjunctival congestion 2-4 days after onset 3. dryness and redness of the lips and oral cavity 3 days after onset 4. acute cervical lymphadenopathy accompanying the fever 5. polymorphic rash involving any part of the body redness and oedema of the palms and soles 2-5 days after onset. Usually 4 out of 5 are sufficient for Dx. This child has 4 of these (1, 2, 3 & 5) Cardiovascular changes in the acute stage include pancarditis and coronary arteritis leading to aneurysms or dilatation. I would suggest a FBC, echo, U & E, CXR. Treatment is with high-dose intravenous gammaglobulin, which prevents the coronary artery disease, followed after the acute phase by aspirin 200 -300 mg daily. The child's father has a sever aspirin allergy so an alternate would be better. Competing interests: None declared |
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Sadik Aksit, pediatrician Ege University Faculty of Medicine, Dept. of Pediatrics, Bornova, 35100, izmir, Turkey
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I read the paper of Sharma R, et al. (BMJ 2003;327:668) with great interest. In my opinion, it is very didactic for what the general approach for these cases should not be. I think the child has Kawasaki disease (KD) with the symptoms and sings of fever, conjunctivitis with watery discharge, painful, red and furrowed tongue, and the rash peeling later. KD is a systemic vasculitis of unknown etiology mostly seen in infants and children younger than 5 years and characterized with prolonged fever (longer than 5 days), bilateral nonexudative conjunctivitis (90%), polymorphic exanthem (maculopapular, scarlatiniform, or erythema multiforme) involving the trunk (90%), cervical lymphadenopathy (70%), and changes of the oral mucosa, such as erythematous, dry, fissured lips or strawberry tongue (50%) in the acute phase. Acute phase reactants are positive (elevated C-reactive protein and erythrocyte sedimentation rate, leucocytosis – neutrophilia) in this stage. This is followed by a subacute phase that begins when fever, rash, and lymphadenopathy resolve 1-2 weeks after the onset of fever. The desquamation of the digits and thrombocytosis are seen in this phase lasting until approximately 4 weeks after the onset of fever. Arthritis or arthralgia, and coronary aneurysms, when present, usually develop in this phase when the risk for sudden death is the highest. After the disappearance of clinical signs, convalescent stage begins and continues until the erythrocyte sedimentation rate returns to normal, usually 6-8 weeks after the onset of KD. Intravenously administered immunoglobulin (IVIG) 2 g/kg as a single infusion and aspirin are given to reduce fever and inflammation of the myocardium and coronary artery wall to prevent subsequent cardiac sequelae in the acute phase. KD can cause coronary artery abnormalities, including coronary aneurysms in 20-25% of patients who are not treated. However, appropriate therapy reduces the incidence of coronary sequelae to approximately 3%. Although her mother is a health personnel (anaesthetist), the parents ask local service’s advice on that matter in place of taking the child to a pediatrician, likely because they think the child has an childhood viral exanthematous diseases. Viral diseases such as rubeola and rubella should be considered in the differential diagnosis of KD, but Elisabeth has received all her childhood vaccinations to date. Also, the advice of the local service to the parents is wrong. They should have recommended to the parents that they must take Elisabeth to the hospital to be seen by a pediatrician because she is at least moderately dehydrated and the diagnosis is unknown. Also, Elisabeth’s general practitioner should have recommended to the family that they take Elisabeth to the hospital for a definite diagnosis and early treatment. Although the is no specific laboratory test to diagnose KD, complete blood count, C-reactive protein, erythrocyte sedimentation rate, transaminases (2-to 3-fold increases can be seen), serum albumin (hypoalbuminemia), electrocardiography and echocardiography are the main tests to support the diagnosis in Elisabeth’s disease now. Sadik Aksit, MD Ege University Faculty of Medicine Dept. of Pediatrics izmir, Turkey Competing interests: None declared |
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NISCHAL K RAO, Locum SpR University Hospital of North Staffordshire
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It is likely that this child has had a Streptococcal infection.I would do ASO titres. Competing interests: None declared |
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Lisa C Blakemore-Brown, Psychologist UK
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On Valentines Day in 2001 - 2 years 7 months ago - bmj published my article 'To the Point' in which I referred to a well recognised case of reaction to pertussis vaccine where the child had developed Kawasaki disease. Her immune system was effectively destroying itself. The 8 year old child presented as Asperger Syndrome. Not all children react to vaccines, but no-one can deny that some do. It is perhaps not surprising to read in this article that 'Her father, a teacher, has adult onset asthma, nasal polyps, and a severe aspirin allergy.' and also that ' At 8 months of age, Elisabeth developed temporary milk intolerance and oral candidiasis.' I know its not `on message` and very dangerous - but could vaccine reaction also be considered? Competing interests: None declared |
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KAILASH BIHARI, GP(Locum) 4,Uplands,Rhondda.CF41 7PG
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Faint rash within 24 hours of febrile illness,red and painful tongue,anorexia that seems to persist even when the temperature returned to normal and no noticiable lymphadenopathy take my thought away from viral exantheme. The published photograph suggests greater intensity of rash in flexural areas and reported peeling of perinium goes in line with observation. Peripheral desquamation once the rash started to fade is a good poiter the cause being group A beta-haemolytic streptococci Child goes to nursery where crowding may have promoted trasmission of the organism from another child or father of the child who has adult onset asthma may be a carrier. Child's GP on noticing the peripheral desquamation checked ear,throat and chest as he made sure that immidiate complications needing urgent help from specialist were not there. 2. I shall check urine for protinuria and send throat swab to confirm the causative organism.ASO titre and FBC and renal profile needs to be determined. I shall not hesitate to seek involvement of ENT UNIT at a slight hint of local complication. 3.He should tell the diagnoses and assure them that his findings does not hint towards any immidiade complication.He should explain what will be his immidiate and future course of action. This may include starting Elizabeth on oral penicillin for 10 days. As mother has a medical qualification she may express her qulified opinion that may incorporate her concerns. The GP should take a serious note of them and honour her wish. If she desires for immidiate 2nd opinion from secondary care, he should not hesitate in refering Elizabeth Urgently. In child care parental conern is paramount. Competing interests: None declared |
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Pablo Rojo, pediatrician Madrid, Spain, Hospital 12 de Octubre
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It seems to me that the child might have Kawasaki disease: the rash with the fever and the changes in the tongue and eyes added to the very typical irritability takes me to that presumed diagnosis. It is enough to start treatment with immunoglobulins and aspirin even if there is no changes in the echocardiography or blood analysis that have to be done. The general practitioner has to say that there is a high suspicion of Kawasaki disease and explain of the importance of treating early to try to prevent complications, specially cardiac complications. Competing interests: None declared |
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sandeep buddha, senior house officer Merthyr tydfil.CF47 9DT
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Dear Sir, The acutely ill patient with fever and rash often presents a diagnostic challange for doctors.The distinctive appearance of an eruption in concert with a clinical syndrome may facilitate a prompt diagnosis. The rash described here is a confluent desquamative eruption which is seen in Scarlet fever, Kawasaki disease, toxic shock syndrome, Staphylococcal scalded skin syndrome. Kawasaki disease most often affects boys than girls. The typical features of kawasaki disease are not present in this baby. The characteristic rash and clinical picture sounds like Scarlet fever. The rash is made up of minute papules, giving a characteristic sand paper feel to the skin. Associated findings include circumoral pallor, strawberry tongue and accentuation of the rash in the skin folds. The rash fades in about 1 week and is succeeded by desquamation. The throat culture remains the gold standard. The GP should admit in the hospital to prevent complications and rule out other possible conditions. Competing interests: None declared |
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Omar Bawazir, ExperiencedSHO in hematolog Ashford, Kent, WHH
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this is most likely vral exanthematous illness, however iwould like to do CBC and in presence of thromobytosis i will arrange for her to have Echocardiography to role out coronary involvement in aypical kawasaki.bear in mind this may be as well drug allergy to paracetamol so if CBC is norma i will reassure the mother as it is ulikely to be any sinister and to notice again any rash with paracetamol. Competing interests: None declared |
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Nick Archer, Consultant Paediatric Cardiologist John Radcliffe Hospital, Oxford OX3 9DU
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Kawasaki Disease (KD) is getting the most votes so far although there are of course a number of other strong contenders as responses have indicated. If this child has KD it is very important to realise that cardiological examination is likely to be normal (apart from sinus tachycardia) and an abnormal ecg or echocardiogram at 5 days would be very unusual. Thus cardiology assessment (and in particular echocardiography) is unlikely to confirm and more importantly cannot rule out the diagnosis of KD. Decisions about what to do will have to be made without relying on an answer coming from cardiological review. Competing interests: None declared |
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Anthony N Glaser, Private practice of family medicine Summerville, SC 29483, USA
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This looks like a good candidate for Kawasaki disease until proven otherwise (UPO), although the duration of fever is a little short and there is no report of cervical lymphadenopathy (which doesn't mean it wasn't there!). The report of a "faint rash" makes one think of a a far more common Group B Strep pharyngitis/scarlet fever or a viral exanthem (particularly roseola/exanthem subitum or Fifth disease), but the photograph is certainly not a "faint rash". The perineal desquamation is classic for Kawasaki's and would be atypical for strep throat of other run-of-the- mill viral exanthems. Measles or rubella are unlikely in view of her complete immunisation history. I would want to quiz the parents in this "medical family" a little more to check that they did not just 'happen" to give this child some amoxicillin or ampicillin they may have had at hand, as these drugs with a viral syndrome could be the cause of the rash. I would have this child admitted and treated empirically for Kawasaki's with cautious use of high dose aspirin (cautiously, due to the father's aspirin allergy) and IVIG. Tests should include a CBC (would classically have increased platelets and a left shift), ESR (expected to be greatly elevated), CRP, urinalysis (sterile pyuria and albuminuria is typical in Kawasaki's, not in the competing diagnoses), LFTs, rapid strep test and throat culture, and a careful neurological examination. An EKG and pediatric cardiology consultation (and possibly echocardiogram) are also indicated. The risks of treating this child are relatively low, but the risk of subsequent cardiac morbidity of an untreated Kawasaki's are relatively high. I would tell the mother that the child may well have Kawasaki's disease which will hopefully resolve without sequelae after appropriate treatment, and that as far as is known this disease presents no risk to anyone else in contact with her child. Competing interests: None declared |
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Elizabeth M Norris, GP Guernsey St Sampson's Medical Practice, Grandes Maisons Road, Guernsey, GY 2 4JS
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As a General Practitioner the first impressions are probably scarlet fever.The "strawberry" tongue can be sore and there may be eye involvement followed by desquamation but this is usually around one week.Unfortunately the same signs are seen in Kawasaki syndrome My greater concern is Kawasaki disease - the persistent fever,desquamation and rash. However there is no mention of lymphadenopathy - particularly a single node perhaps more prominent than the others.Also there may be reddened palms and soles and oedema. The classic teaching for GPs is persistent high fever for 5 days.It would pay to be cautious and try and prove a streptococcal infection with throat swabs, Anti Streptolysin "O" Titre, and to refer for a specialist paediatric opinion. Missing Kawasaki would be a tragedy with the access to Echocardigraphy and current treatment with gammaglobulin. Another possibility might be modified measles in a vaccinated child.The conjunctivitis should be different - exudative in measles. The rash of measles usually begins behind the ears and hairline. Again the full blood count may be useful since the white count should be low Competing interests: None declared |
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george sassin gereige, moscow moscow russia 115487, malov V A
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1- it is similar 2 infectious mononucleosis with secondary allergy, and may be secondary syndrom layla to paracetamol intake 2- i should order total hysical exam 2 find lymph nodes status and liver? and spleen?? 3- i should ask hospitalisation Competing interests: None declared |
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vijayashankara.c. nanjegowda, professor of pediatrics SDUMC.Kolar,India. 563101
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This child has all the classicle features of kawasaki disease except for the presence of cervical lymphnode enlargement and the swellings of the fingers( not mentioned in the case summry). The other possible diagnosis is the possibility of scarlet fever,but the fever subsiding on its own is againist the diagnosis.I would do a complete blood count, a blood culture,and look for the late sign of peeling of skin in the fingers.I would also ask for detailed ECHO study for coronary osteitis and aneurisms.I will discuss with parents about the early treatment with IVIG and aspirin. Competing interests: None declared |
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belche jean, assistant BVS 4100 Seraing
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i think it's a "scarlatine" like we said in french. an infection by Streptococcus that has received special information from a virus. i would like to know the ASL "antistreptolysin antibodies" IgM after a couple of days. i would say to the parents that it's a bactérial infection, that the antibiotics are not necessary at the time of the infection and that the rash will disappear in a few days. return to the scholl or not? inform the school of the infection? that's a good question ...i think that we have to inform the school. in the same way, isn't it obligatory to begin antibiotics because of the close contact... Competing interests: None declared |
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Somnath Banerjee, Associate Specialist, community paediatrics East Kent Hospitals NHS Trust, Queens House, Ramsgate CT11 9DH
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This 2-year-old child’s main symptoms are high fever and maculopapular rash. The important illness that needs to be excluded is Kawasaki disease. A child with Kawasaki disease presents with continuous high fever for few days with other associated symptoms. The child is very miserable throughout the pyrexial phase. Maculopapular rash occurs early in the illness with peeling of fingers and toes after the first week. The clinical description given here does not fit in the diagnosis of Kawasaki disease as per the widely used diagnostic criteria.1 ------------------------------------------------------------ Scalded-skin syndrome (toxic epidermal necrolysis) may be induced by drugs or infection by Staphylococcus aureus of phase II type. The skin lesions are extremely painful and consist of large patches of necrotic epidermis, which comes off with slightest pressure. This child’s presentation is not typical of Staphylococcal scalded-skin syndrome. ------------------------------------------------------------Scarlet fever presents with fever, pharyngitis and erythematous rash. It is caused by Beta-haemolytic Group A Streptococci. It presents with sudden onset of febrile illness, soreness of throat, and vomiting. In a mild attack some children may not complain of a sore throat. The rash appears on second day, which has a typical presentation; appearing on face and evolving downwards. The fine punctate rash fades in one week followed by desquamation for several weeks. It usually follows streptococcal pharyngeal infection. Scarlet fever is rare below 2 years of age. This child’s clinical picture makes scarlet fever unlikely. ------------------------------------------------------------ The benign course of illness and recovery with symptomatic and supportive measures suggest a viral illness. The likely viral infections in this age group are, Rubella, Parvovirus B19, and Human herpesvirus-6. Children aged 4 to 15 years are most susceptible to parvovirus B19 infections. The commonest disease produced by parvovirus B19 is erythema infectiosum or fifth disease (named because it was the fifth disease to be described with similar rashes). It presents as a biphasic illness; a viraemic phase with fever, headache and myalgia followed a week later by a characteristic rash. This begins on face (slapped cheek) which is followed a week later by a maculopapular rash on the trunk and limbs lasting for some time. There are no prodromal symptoms with absent or low-grade fever. The illness may continue from 2-3 weeks to few months with fluctuation in severity of rash. Rubella is an unlikely possibility at 2 years of age because of up to date vaccinations. Human herpesvirus-6 (HHV-6), causes exanthem subitum (roseola infantum). At birth, most children have maternal antibodies against this virus. The antibody level reaches its nadir between 4 to 7 months of age. Children get clinical or subclinical infections and the peak level of antibodies reach between two to three years of age. The illness presents with fever (which may cause febrile fit), erythematous rash and associated systemic symptoms. In majority of young children the illness is over in few days time with symptomatic management. ------------------------------------------------------------ This girl’s most likely diagnosis is HHV-6 infection. The investigations I would like to do are routine full blood count, C- reactive protein, blood culture/sensitivity, urine dipsticks and throat swab for culture/sensitivity. ------------------------------------------------------------ This little girl suffered from two (probably) bacterial infections and a fungal infection in this young age. Although there were no reported problems after immunizations indicating a normal humoral immunity, a baseline investigation of immune system may be advisable. This will include quantitative serum immunogloblulins including IgG subclasses; complement subtypes assays and T lymphocyte numbers (CD3, CD4, CD8). ------------------------------------------------------------ This is Elisabeth’s mother’s second pregnancy. Its most likely that her rubella status was checked in first pregnancy and was positive. Most of viral infections contracted in first trimester of pregnancy may affect the foetus. In second trimester; especially after first 16 weeks of antenatal period it is more assuring that even if a pregnant woman comes in contact with a person with viral infection; the chances of the foetus being affected is less. I would assure Elisabeth’s mother on these lines. ------------------------------------------------------------ Elisabeth’s father’s medical conditions do not seem to have any relationship with her present problem. ------------------------------------------------------------Reference: 1. Shulman ST, Inocencio J, Hirsch R. Kawasaki disease. Pediatr Clin North Am 1995; 42: 1205-22. Competing interests: None declared |
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Robert Perry, Medical Epidemiologist Centers for Disease Control and Prevention, Atlanta, GA 30333 USA
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1. This child may have had an infectious disease, Kawasaki syndrome or an allergic reaction to an infectious agent or something the child was given (food? medication?). Possible infectious agents include viruses such as enteroviruses (echovirus / coxsackievirus), measles, rubella, HHV-6 or 7, parvovirus B19 or EBV. Likely bacterial infections would be streptococcal or infection with scarlet fever or staphylococcal scalded skin syndrome. Kawasaki syndrome seems possible given the irritability, mouth changes, rash w/peeling and fever. An allergic reaction may have occurred to the virus causing a mild URI, to something she ate or to a medicine given for the fever (would need to carefully question as to what else she may have been given). The self-limited nature of the illness argues against a bacterial infection; it would be good to clarify what is exactly meant by "received all her childhood vaccinations" and still to consider measles modified by prior vaccination as it fits the progress of symptoms; the rash in the picture looks more striking than what is described in the text ... the one in the picture looks like enteroviral exanthemata or HHV-6/7 (roseola) though usually the history is a rash appearance that is following sometimes dramatically by the breaking of the fever ... the mouth changes / distribution of rash do not fit exanthem subitum (parvo B19) very well; if the tests below all prove negative it may be that she had a viral infection (enteroviral? HHV-6/7? parvovirus?). It would be interesting to know what the examination revealed regarding other classic findings for Kawasaki syndrome (lymphadenopathy, finger swelling, etc.) 2. At this point, it would be prudent to look for changes in the blood counts, ESR, and liver enzymes suggestive of Kawasaki syndrome, to rule out measles and rubella (both notifiable and she meets the clinical case definition for either one) with blood or oral fluid for IgM testing and to do a throat culture (with rapid testing) for Streptococcus and look at the ASO titres. 3. The GP should discuss the above diagnoses with the parents and ask to do the various tests above. I would hold her at the GP's office until the blood counts, ESR and liver enzymes are back and think strongly about admission overnight for aspirin / IV immunoglobulin / baseline echocardiography. If the rapid strep test is positive she should also receive an antibiotic. She should probably stay out of the nursery at least until the rash has faded and the fever is definitely gone. Competing interests: None declared |
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Mohammad Zaki Hasan, Unemployed E11 2DW
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I think that the child has meningococcemia. She immediately needs a blood culture, CT scan and a lumbar puncture after ruling out cerebral edema. She needs immediate hospital admission in ITU, and needs blind I/V antibiotics therapy. Competing interests: Get a job |
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adrian r crofton, clinical felloow neonatology aberdeen maternity hospital AB25 2ZN
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It's atypical because it doesn't quite meet standard diagnostic criteria. Investigation would include FBC, CRP, ESR, Echocardiogram. There may be other things to exclude (JIA, hypersensitivity). She needs an urgent echocardogram and aspirin. IV immunoglobulin if within 10 days of onset, and close cardiac follow-up. Prognosis is complete resolution unless coronary aneurysms. Competing interests: None declared |
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Mich Lajeunesse, Lecturer in Paediatrics Bristol Royal Hospital for Children, Bristol BS2 8AE
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Although this girl has symptoms similar to those seen in children with Kawasaki (KD) she does not have enough of these to meet diagnostic criteria for the disease but has symptoms suggestive of the diagnosis. As such she presents a difficult clinical scenario - what to do about a potentially serious disease when there is no specific test? Although atypical cases of aneurism positive KD have been reported, the features in this child seem sufficiently unlike KD not to jump to any conclusions. Her atypical features include a fever for only three to four days instead of five - and often continuing instead of recovering, desquamation early in the course of the illness instead of later, and the lack of significant cervical lymphadenopathy. Other possibilities for this child's symptoms include EBV, Group A Streptococcal scarlet fever, Staphylococcal toxic shock syndrome and the penicillin susceptible organism Arcanobacterium haemolyticum. Further tests From the information given to date it is most likely to be due to a scarlet fever type illness and a throat swab should suffice. However, Kawasaki's disease is an important differential and should be kept in mind, especially if the convalescent desquamation is typical for KD - thick peeling of the palms and soles during the second week of the illness. A full blood count showing thrombocytosis at this stage would be helpful in bolstering evidence for the diagnosis in an incomplete presentation. What to say? Well informed parents may have read about KD prior to the consultation and need specific reassurance. Also none of the differentials provide a risk to the unborn child and reassurance should be provided here too. Scarlet fever should be treated with anitbiotics to prevent community spread. In this case, with the possibility of EBV in the differential, penicillin V should be prescribed in preference to amoxicillin or ampicillin. The current exclusion period from nursery should be until after 5 days after the start of antibiotics (http://www.rcpch.ac.uk/publications/clinical_docs/Exclusion_periods.pdf). A clinical review in a few days would also be prudent to check her recovery and review the desquamation. Competing interests: None declared |
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rajavelu ganesan, GP registrar st davids clinic NP20 2LB
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this child has fever, maculopapulo rash, redness of eyes and what appears to be mouth ulcers. mouth ulcers and redness of eyes are uncommon in viral infections. i would be suspicious of a connective tissue disorder and do a screening which includes ESR, Ana. I would keep a careful watch on her visual problems Competing interests: None declared |
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Ramzi Y Khamis, Medical Sho, Barts and the London Medical Training Scheme Homerton University Hospital
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By having had two episodes of periorbital cellulitis and oral candidiasis, this child has met at least one of the warning signs criteria of Primary Immunodeficiency. These crtieria were compiled by the Medical Advisory Board of Jeffery Modell Foundation(1), and are listed below: • 8 or more ear infections within 1 year
Whether this 2 year old's acute illness is Kawasaki syndrome or is another reasonable differential diagnosis such as Staphyloccal Scalded Skin Syndrome, it seems to be settling quite well. The attending physician should concerned and initiate investigations to rule out an underlying immunodeficiency. Therefore, I would take a careful history including a detailed family history. I would also perform a detailed exmination paying particular attention to any morphic features that accompany some of the PI's. Investigations should include a Full blood count (with differentials), ESR, ASOT, an MSU dipstick and microscopy (looking for casts), CRP, Complement levels, Immunoglobulin assay (IgG, IgA and IgM levels) as well as peroneal skin, and throat swabs. Further investigations would depend on the above results and availablity. The parents should be aware of the above differential diagnosis, and since the mother is pregnant in the second trimester all of the above is even more relevant. There would a risk that the expected baby may have a similar immunodeficiency problem, if one was identified. There are more than 80 types of PI's with different inheretnce patterns (2). This would warrent a genetician's and expert paediatrician's invololvemt, if a PI is confirmed in the 2 year old. References: 1. http://www.info4pi.org/ The Jeffery Modell Foundation Website 2.http://www.pia.org.uk/ The Primary Immunodeficiency Association website. Competing interests: None declared |
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Benjamin Jacobs, Consultant Paediatrician Northwick Park Hospital, Harrow, HA1 3UJ
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ISABEL is a website (www.isabel.org.uk) that suggests diagnoses given children's symptoms and signs. The project started after a little girl called Isabel fell ill with complications of chickenpox. She spent 4 weeks in intensive care because her condition was not recognised initially. Elizabeth's story (fever, rash, desquamation, conjunctivitis, glossitis, irritable) yields 7 diagnoses: Kawasaki Disease
We have to wait as the case unfolds, but my clinical sense is that ISABEL gets it right with her first suggestion! Competing interests: Helped assess clinical relevance of ISABEL. |
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Velur P Balasubramaniam, Clinical Fellow in Neonates Royal London Hospital, Whitechapel, London E1 2DR, Basheer Peer Mohamed, Ramsaravanan Ramaraj
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Diagnosis: Stevens-Johnson syndrome Investigations: Anti DNAse B, ASO titre, Mycoplasma serology, viral serology, Immunoglobulin levels Advice: Symptomatic treatment and follow-up with blood results Competing interests: None declared |
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Ranjani SG, GP "Prakruti", Vapasandra, Chickballapur-5620101, Karnataka, India.
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A child with fever, rash, red tongue, unable to swallow even liquids, peeling of skin in diaper area, general condition of the child apparently becoming better after a few days. These features makes me to think of some form of allergic response to an unknown antigen. Further evidence in support of this notion comes from the past history and family history. The child had a history of milk intolerance, periorbital cellulitis and oral candidiasis. Father has nasal polyps and known allergy to aspirin. I would like to entrtain the following differential diagnoses. 1-Steven-Johnson syndrome
I will probe further into history to find out the possible allergen. Food history and h/o any drug usage especially herbal preparations. Unless one probes this will not be volunteered as many think herbal preparations are not drugs and they are natural, non-harming. Viral antigens also can induce SJ-syndrome. With a h/o fever preceeding rash makes this a strong possibility. With the type of lesions presented in this case, Acrodermatitis enteropathica [AE] should be excluded. The feature going against this is improvement of the lesions spontaneously which will not occur in AE. Despite this I will check for zinc levels. Favouring strongly Steven-Johnson syndrome, my approach to this case will be supportive care with the stoppage of all medications except steroids, when tests reasonably excludes bacterial etiology. I will adopt just wait and watch policy. I will draw blood for counts, viral studies, ASLO, CRP, Liver tests (ALAT especially), Zinc levels. This will give me a fairer picture of the case. Blood counts, ASLO, CRP will help me to exclude a bacterial etiology, which is proposed by many in this rapid response column. To the parents I would suggest that the child requires hospitalization. Competing interests: None declared |
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Maurice Conlon, GP principal Ridgacre House Surgery, 83 Ridgacre Road, Quinton, Birmingham B32 2TJ
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Editor, Q1: Our differentials include: Non-specific viral illness (Measles
((Meningitis)) Q2: Investigations:
Q3: We would tell the parents that we are uncertain of the diagnosis. There was general consensus that we would confer with the paediatric team and probably request admission. We differed about mooting the diagnosis of Kawasaki disease to the parents before corroborative opinion and evidence had been gathered by our paediatric colleagues. We intend to respond to your interactive case reports routinely as you publish. We are a primary care team and our opinion is generated in a 10 minute slot during our weekly clinical meetings.We do not check your rapid responses before sending our own. Our contributions should be taken as indications of how we might approach the cases you present should they arise in our surgery. Yours faithfully Maurice Conlon MRCGP
Competing interests: None declared |
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Gregory Ho, GP 46400 Malaysia
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The above case history is strongly suggestive for Kawasaki's Disease(KD).As there are no definite diagnostic tests for KD,diagnosis would be based on clinical grounds alone...Fever within 5/7 not responding well to antipyretics,with features of mucositis,non-purulent conjunctivitis,polymorphous rash & desquamation in the perineal region in the case history definitely fits within the criteria for KD. I would also inspect the BCG scar if she had 1 to look for redness & induration & check for lymphadenopathy as well. My differentials would be for Staphylococcal infection (Scalded Skin Syndrome),Scarlet fever,Measles,Steven Johnsson Syndrome. Possible Ix would be for FBC,ESR,throat swab for C&S,ASOT & CRP. My advice would be to admit for further paediatric management & cardiac echo TRO possible early thrombosis.IV Immunoglobulins(Ig) is indicated early with possible aspirin therapy post IV Ig as there is only a small window period of 10/7 within initial onset of symptoms/signs for Ig therapy to prevent heart disease later. Competing interests: None declared |
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joanna I walsh, GP Whiteladies Health Centre, Whatley Road, Clifton, Bristol, BS8 2PU, Knut Schroeder
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1) We think the most likely diagnosis is Kawasaki's disease. Although the fever settled within 5 days, four other clinical features are highlighted. Also the fever may have started before 'day 1' without the parents having been aware. 2) Tests which may support the diagnosis include full blood count for thrombocytopaenia, urine dipstick for sterile pyuria and possibly liver function tests for raised bilirubin. 3) We would refer for an urgent hospital paediatric assessment. If immunoglobulin treatment is given early it reduces the incidence and severity of aneurysm formation. We would explain the possible diagnoses and consequences to the parents. Competing interests: None declared |
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Brian Morgan, freelance journalist Cardiff CF11 6LF
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Did this include fabricated or induced illness? Competing interests: I may write about this and be paid for it. |
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Niranjan Shendurnikar, Asssociate Professor of Pediatrics Medical College Baroda
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Elisabeth's two episodes of periorbital cellulitis and an episode of hip disease should be an important marker for the investigations of her current illness.These episodes are unusual for an otherwise healthy looking child.She may be having one of the subclass of IgG deficiencies.The descriptions do not fit completely either of Kawasaki Disease or Infectious Mononucleosis.Parvovirus B 19 infection remains a distinct possibility, if she is found to be immunodeficient on her further investigations. Competing interests: None declared |
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David Burgner, Senior Lecturer in Paediatrics and Paediatric Infectious Diseases Physician School of Paediatrics and Child Health, University of Western Australia
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This interesting case has drawn a wide range of opinion from across the globe. The early betting seems to favour Kawasaki disease, but a number of other possibilities have also been raised, including scarlet fever, other toxin-mediated infections, measles, meningococcal disease, human herpes virus-6, Stevens-Johnson syndrome, underlying immune deficiency and various allergic reactions. The crucial question with the initial presentation would seem to be how to differentiate a simple self-limiting viral infection from something more significant, either an acute inflammatory or infectious illness or a recrudescence of a chronic underlying problem. What further data might be useful in this respect from history and examination? Does the child need any investigations and if so, should the child be admitted to hospital? Many have mentioned performing a full blood count and various inflammatory indices (CRP, ESR); if these were normal, would you be completely reassured? Would you perform a more thorough septic work up (e.g. blood, CSF and urine culture) and start empiric antibiotic therapy whilst waiting for results? Are any other investigations (e.g. antistreptolysin titre, viral and bacterial throat swab or others) likely to be helpful in excluding serious illness? If Kawasaki disease is a possible differential here, should empiric treatment be started before the diagnosis is clear? Would this alter long- term outcome? Are there risks in treating for Kawasaki disease if the diagnosis is subsequently not proven? The cardiologists have rightly said that echocardiography would be unlikely to be helpful in these early stages, so would anything else increase the likelihood of this diagnosis? Some responders have mentioned other pertinent areas, such as what you tell the child's mother, who is pregnant, medical and doubtless well aware of the (in)sensitivity of some of the investigations being considered. Others have mentioned the father's history of allergy; is this likely to be relevant here? Competing interests: None declared |
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Michael D Innis, Director Medisets International Home 4575w
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MEDISETS can help ISABEL to confirm the diagnosis of KAWASAKI DISEASE; 1 CD 8 Reduced 2 Anti-endothelial cell antibody POSITIVE 3 AST/ALT > 1 Michael Innis Competing interests: AUTHOR OF MEDISETS |
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Tom m Nyhan, gp 19 mary street dungarvan co waterford ireland
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I would suspect scarlet fever I would listen for any cardiac murmurs
I would tell the parents that their child is no longer infective and can attend the child care facility Competing interests: None declared |
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Kumar Ganesan, Staff Grade Physician in Cardiology Luton and Dunstable Hospital, LU4 0DA
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This girl's history is more suggestive of a systemic illness due to infection. History of periorbital cellulitis, irritable hip at age of 1 year and oral candidiasis at age of 8 months are suggestive of reduced immunity or some level of immunosuppression. This may lead into an active infection following immunisation, In case of recent MMR vaccine around that time we can even suspect a possibility of Measles. In the absence of such history a Gram negative sepsis has to be strongly suspected and needs active investigation. I expect the GP to organise hospital admission and counsell parents. This girl will reguire investigations as follows FBC,u&E's,urine culture and sensitivity, urine analysis,perineal swab, blood culture and sensitivity, Viral serology and a Lumbar Puncture to rule out meningoencephalitis. Competing interests: None declared |
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Simon Odum, Associate Specialist Emergency Medicine North Bristol NHS Trust ED
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The symptomatology and signs would be good for Kawasaki disease, although no mention is made of the presence of lymphadenopathy. Despite this, in the presence of the high temperature and perineal desquamation I would want to get Elizabeth reviewed by a paediatrician. I would be considering the early use of immunoglobulin alongside conservative treatment. I wold advise the parents that the potential diagnosis was one of Kawasaki, and that early intervention with immunoglobulin can reduce the risk of sequelae. Competing interests: None declared |
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Annika Volke, resident Dept. of Dermatology, Tartu University Clinics, Raja 31, 50417 Tartu, Estonia
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The most likely diagnosis is Kawasaki's disease. It should be treated with aspirin. It would be advisable to perform ECG and cardiac ultrasound to detect coronary disease. Parents should be told about the possible consequences from heart and joints. Competing interests: None declared |
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PRAVIN SINGH, GP trainee, formerly SpR in Paediatrics James Paget Hospital , Great Yarmouth NR31 6LA
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1)Though Elisabeth does not meet atleast four out of the five criteria for Kawasakis Disease also know as mucocutaneous lymph node syndrome her clinical features are highly suggestive of Kawasakis Disease. I have seen a case of Kawasaki's in a 4 year old child(Tanya) who presented with bilateral conjunctival injection. She had increased tempreature a couple of days prior to this admission for which she had seen her GP.Her tempreature was thought to have been raised for 4 days or less. She was being referred to the opthalmologists for further investigations for what was intially thought to be iritis. However at the same tiem as Tanya we had another child on one of the Paediatric wards who met the criteria for Kawasaki's and had an Echocardiogram looking for coronary artery aneurysms. It was decided to perform an echo and tanya too. The Echo revealed coronary artery aneurysms. She recieved intravenous immunoglobulins on day9-10 of her illness. Kawasaki's can have atypical presentation and a high index of suspicion is warranted. 2) I would request an Echocardiogram on Elisabeth. A full blood count(looking for a raised platelet count), throat swab,ASO titres,Blood cultures and a CRP/ESR would be other useful investigations. 3)The General practitioner should explain to the parents that this could be Kawasaki's disease which can be fatal in a child and complcations can be prevented if the disease can be diagnosed early.The child would need a referral to the local Paediatric Department with a view of performing an Echocardiogram. It is possible that this may just be scarlet fever or a viral infection like measles for example.However it is better to be safe than sorry. Competing interests: None declared |
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Patricia E Kelly, Associate professor, Central Michigan University PA Program, 101 Foust, Mt. Mpleasant MI 48859
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DX: Kawasaki's Disease Aspirin RX Cardiac/aortic ultrasound Competing interests: None declared |
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Prasad CSBR, Pathologist Al Hakeem Polyclinic, PO.BOX: 34985, Riyadh-11478, Saudi Arabia
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Further development in Elisabeth's condition narrows down my differentials to 1-Kawasaki disease and 2-SSSS. Where in leucocytosis with neutrophilia and an elevated CRP levels can occur. However, lymphadenopathy and periungual skin peeling inches the pointer toward Kawasaki. At this point my greatest concern is child's drowsiness. Is it due to the involvement of cerebral arteries in the inflammatory process? Here I will do an LP to r/o infective process. As it's already more than 15days, I doubt the effectiveness of immunoglobulins. Having said that, I will go ahead with immunoglobulin therapy (after knowing IgE levels and excluding the anti-IgA), because withholding it either may not be beneficial to the child. Fever chart is showing undulating pattern touching a peak of more than 38°C is a strong indicator for the usage of high dose Aspirin. Echocardiography should be done to have a base line for futher monitoring. I will tell the parents that the child needs hospitalization and pediatric care. Competing interests: None declared |
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Ranjani SG, GP "Prakruti", Vapasandra, Chickballapur-5620101, Karnataka, India.
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H/O father's allergy is important here. It may indicate a common environmental antigen/allergen responsible for both father and child's condition. Moreover, they may have some sinister HLA antigen which is making them susceptible for the allergens with different manifestations. Competing interests: None declared |
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Dr.Suresh Chandran, Neonatologist RIPAS Hospital,Brunei. BA 1710
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Undoubtedly this child has Kawasaki Disease. Fever lasting for more than 5 days with changes in the mucosa of oropharynx, bilateral cervical lymphadenopathy, rash,and distal desquamation points to Kawasaki disease.Laboratory findings of raised WBC count and CRP support the diagnosis. Needs an urgent echo. As we see more cases of Kawasaki in Brunei it is very natural that our suspicion is high in any child with fever and irritability, especially with rash to look for other evidences of this disease. Fortunately we did not have any deaths or morbidities from coronary vasculitis after treatment with Intravenous Gamma Globulin(IVGG) and Aspirin. Parents should be told about the natural course of this disease and good prognosis except in cases with documented coronary vasculitis, where long term follow up in required. Usually fever disappears with 24 hours of IVGG infusion. Competing interests: None declared |
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imtiaz ahmad salara, medical student army medical college rawalpindi pakistan
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according to me. pt. is suffering from streptococal sore throat. give benzyle penciline 25000-50000iu/kg/dose Competing interests: None declared |
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peter j s baker, GP locum exeter EX1
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Kawasaki disease - suggested by fever>5d/ conjuctivitis (tho' fleeting)/ cervical adenopathy/ red raw tongue/ finger-tip desquamation raised WBC without excess % neutrophils noted infection may have triggered Kawasaki - should definitely chase the strep - swabs, ASO titre - and probably treat anyway with penicillin (after blood taken for culture) for 10 days. LFTs - and monitor if raised ECHO of heart, looking for aneurisms, MRI probably more accurate IV Gamma globulin to start to reduce complications Peter Baker, GP Competing interests: None declared |
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Palla Prabhakara Reddy, sho 3 paediatrics Princess Royal Maternity
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The clinical picture described ie 2 yr old girl, swinging temperature,peeling of fingers (which is clearly shown in photograph)although coflictingly when seen by paediatrician no peeling was noticed,with raised inflammatory maker&crevical lymphadenopathy the picture more than likely suggest Kawasakis disease. Getting an echocardiography would be useful rather than ECG to look for any evidence of coronary aneurysm. Clearly Immunoglobulins wont help at this stage of illness &symtomatic management will the right management. I would tell the parents the nature of ilness and the associated complications & progress of the illness Competing interests: None declared |
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Sadasivam Arun, Staff Grade in Paediatrics South Tyneside Hospital , South Shields NE34 0PL
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Very thought provoking case details. Considering the rapidity required in actual practice it is prudent to consider Kawasaki's early on for obvious reasons. It is important to note that one does not need to satisfy all the quoted criteria in order to consider KD. Scarlet fever and Staphyloccal SSS will be next in my list of D/D's. Although the effectiveness of IG's at this stage is questionable, it should nevertheless be given. Appropriate antibiotics should have been prescribed for Elisabeth. Did she have blood cultures, ASOT, throat swab, etc? At this stage I believe an ECHO is vital. I would explain the situation to parents in as much detail as appropriate and explain the rationale behind the current management plan to a clinically puzzling situation. I shall await to see how the story evolves and for the authors to unravel Elisabeth's real problem Competing interests: None declared |
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Vijayashankara.C. Nanjegowda, Professor of Pediatrics SDUMC,Kolar,India. 560078
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The late manifestation of peeling of fingers and toes has occurred in this girl; together with the earlier features, the diagnosis of kawasaki disease is certain. The neutrophilic response and the positive C-reactive protein are a part of this disease. The 12 lead ECG is usually normal in the early stages of the disease. I would ask for a thorouh echocardiographic examination for this child. The presence of coronary osteitis or of aneurysmal dilatation confirms the diagnosis. But the absence of these findings do not rule out the diagnosis. The absence of coronary artery changes may indicate a better prognosis. The child will be started on IVIG 2gms/kg single infusion over a period of 10-12 hours. And also the child will be started on tab Aspirin 30mg/kg/day until the CRP titre comes back to normal, then continue with low dose aspirin 2mg/kg/day. The echo examination will be repeated. I will seek a cardiology opinion for the long term management of this child. The parents will be counselled and the details of the disease and its complications, the need for continuous monitoring, the long term management schedules will be discussed with them. Competing interests: None declared |
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Pablo Martinez, Consultant Physician Portsmouth PO6 3LT
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The clinical picture would be in keeping with viral infection especially Measles - though we do not know the presence or absence of occipital nodes, Koplick spots in the mouth. I would have undertaken a lumbar puncture to exclude meningitis in the earlier presentation and even in this late stage I would still recommend this investigation. The story of the mother being immune to Rubella is not known and serology to Rubella and Measles should be undertaken for the child. With the above in mind and knowing that the focus of infection is not in the chest (CXR advisable in this child with persistent fever as well as blood culture and urine microscopy and culture) then I would persevere with paracetamol as antipyretic and reassure the mother with daily clinical review of the child. Competing interests: None declared |
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Rik M Pelfrene, Consultant physician- ICU 2880 Bornem- Belgium
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Dear Sir, With interest I read the interactive case in BMJ. Definitely not being a paediatrician or in any way routinely involved with the problems of the younger ones, I would first have suggested SSSS or even only "fifth disease". However, my mind is focused on "Kawasaki Disease" (KD)....the only reason being that I well remember that a decade ago during my escapades in sweltering SE Asia, I volunteered to a write-up of a case seen by a trainee paediatrician with shortage of time on her hands and exhaustion on her face. I quote: "The diagnosis of KD can be firmly established if one finds fever of at least 5 days duration and 4 out of the 5 following conditions: bilateral conjunctival injection, change in oro-pharyngeal mucous membranes (injected, dry or fissured lips, injected pharynx or strawberry tongue), change of peripheral extremities (oedema, erythema, desquamation), rash (poly-morphous but non-vesicular) and cervical lymphadenopathy." This rests my case. Competing interests: None declared |
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Morgan Keane, Consultant Paediatrician King George Hospital, Goodmayes IG3 8YB
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Given the clinical features a diagnosis of Kawasaki disease must be considered. Intravenous immunoglobulin, oral aspirin and echocardiography. I would tell parents that there may be effects of this disease upon the heart and that a cardiac opinion is necessary to ensure that there are no coronary artery aneurysms, despite the normal ECG. Competing interests: None declared |
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Giuseppe Vetrugno, Resident Roma (Italy) 00168, Achille M. Luongo, Leonardo Scorcelletti
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The young age of the patient, the onset of the clinical symptoms (fever and rash) and the following appearance of the neurological symptoms (the child became clingy and irritable) could suggest a Reye's Syndrome too. It would be important to know if ASA was amministrated to the child when the fever occurred. Competing interests: None declared |
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Jeremy M Sager, Principal in General Practice Leeds LS17 8AE
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This doesn't look like a simple viral illness now. What do you think the diagnosis could be? How would you manage Elisabeth's illness now? What would you say to Elisabeth's parents? ............................................................ The diagnosis is probably Kawasaki disease (mucocutaneous lymph node syndrome) She needs urgent Ig injections and aspirin to minimise the chance of developing coronary artery aneurysms I would tell her parents that she has an unusual condition which is sometimes complicated by heart problems but with treatment we can minimise the complications. Competing interests: None declared |
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Dr. Asadullah KHAN, Global Marketing Switzerland
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1. I would stick to my initial diagnosis of Kawasaki disease. 2. Involving a cardiologist to do two-dimensional echocardiography or angiography to rule out coronary aneurysms. Since Elisabeth was not managed properly initially, I would recommend admission & ruling out a rare complication, aseptic meningitis. In addition to tests done by her paediatrician, I would also do U & E and urinalysis (for albumin). Blood culture & sensitivity?? Would involve a dietician to keep her on a proper diet. She had been going to her nursery & this is an infective disease??, is there a possibility of transmission to other children? Treatment is with high-dose intravenous gammaglobulin, which prevents the coronary artery disease, followed after the acute phase by aspirin 200-300 mg daily. The child’s father has allergy to Aspirin and therefore an alternative should be used. 3. I would tell her parents that the child needs admission to rule out complications. I would also ask them to inform the school doctor about the diagnosis & to check if other children have similar symptoms & signs. Competing interests: None declared |
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Alain Martinole, general practitioner France
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1 Kawasaki's disease 2 hospitalisation, immunoglobulins intravenously a single infusion, aspirin 3 probably no sequelea but monitoring by paediatric cardiologist because of risk of coronary aneurism Competing interests: None declared |
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margit janossa-tahernia, medical osteopath,lecturer British College of Osteopathic Medicine, London, NW3 Finchley Rd
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Q.1 The possible diagnosis is "Kawasaki Disease", caused by hypersensitive immune reaction towards some infectioius agent, e.g. streptococcus Q.2. The immediate examination should be a heart ultrasound for coronary arteries aneurysm, caused by immune vasculitits. The treatment should be : High dose Aspirin and temporaraly Steroid Q3. Explain the parents that if the coronary artery aneurysm is already developed the child need ultrasound monitoring by the specialist. f the diagnosis and treatment would start within a week of onset, the complications of Kawasaki diseases could be avoided. Competing interests: kawasaki disease, immunology |
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Fred W. Whitehouse, Division Endocrinology Henry Ford Medical Group, 2799 W.Grand Blvd. Detroit, MI, 48202 USA
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1) Zahorsky's disease (roseola infantum or exantum subitum) 2) none 3) reassure the parents that the worst is over and the child will return to prior good health. "It was a virus." Time heals. Competing interests: None declared |
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Elizabeth Smedley, Clinical Nurse Consultant, Communicable Diseases 2031
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Scarlet Fever seems the most likely contender. A throat swab needs to be taken. I would advise the parents that, after 24hrs of the appropriate antibiotic treatment, and if the child is well enough, then a return to childcare would not be a problem. Competing interests: None declared |
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Mohi U Qureshi, Clinical Attachment N19 5NF, Whittington Hospital
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With these clinical features my differential diagnosis is 1. Still's Disease
My management plan will include following test
I will start her on NSAIDS (Aspirin). I will discuss my differential diagnosis with her family and my management plan. Competing interests: None declared |
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Johnson.G Anthony, temporary srilanka
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For the 1st question I would repeat the WBC/DC count and CPR investigation For the 2nd question I will wait for the proper results of the above investigations Finally I would get a proper history and do the need ful and advise her parents not to worry . Competing interests: None declared |
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