Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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suspect kawasaki disease
- dr prashant s pawar, - (26 September 2003)
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possible diagnoses
- myles r milhench (27 September 2003)
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Kawasaki Disease
- Niranjan Shendurnikar (27 September 2003)
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2 years old with fever and rash
- Somnath Banerjee (27 September 2003)
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A 2 year old child with rash and fever: Kawasaki disease?
- Anne L. Appleton (27 September 2003)
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Kawasaki's disease as primary suspect
- Robert Chircop (28 September 2003)
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further thoughts
- Khalil A K Mohamed (29 September 2003)
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Kawasaki disease
- Prasad CSBR (29 September 2003)
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A 2 year old child with rash and fever: Kawasaki Disease
- Sarita Jain (29 September 2003)
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Fever & rash in 2 year old
- Rajeev M Shinkar (29 September 2003)
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Reference class: journal case report.
- Christopher J Martin (29 September 2003)
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Undeniably KAWASAKI
- Bernard C BOYD (29 September 2003)
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Kawasaki disease
- Muthuswamy Ramaswamy (29 September 2003)
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Interactive case report: A 2 year old child with rash and fever BMJ 2003; 327: 720
- David Osoba (1 October 2003)
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Rash and Fever
- Polanaickenpalayam S Chandrasekar (1 October 2003)
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Paediatric infectious diseases commentator's response
- David Burgner (1 October 2003)
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what is the cause of raised counts and CRP ?
- VARADARAJAN ARULALAN (1 October 2003)
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Likely diagnosis
- Elene Psiachou-Leonard (2 October 2003)
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The dilemma about to treat or not to treat in the second stage of Kawasaki disease
- Sadik Aksit (2 October 2003)
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Strep infection
- B.C. Rao (3 October 2003)
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Subacute phase of child's illness
- KAILASH BIHARI (3 October 2003)
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A 2 year old child with rash and fever
- Kelvin S Davies (3 October 2003)
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Child with fever and rash
- Sinead Regan, Alastair Hay, Clinical Lecturer in Primary Health Care, University of Bristol (4 October 2003)
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KAWASAKI disease
- Pothen Alexander (4 October 2003)
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Kawasaki - Bowling a "Googley"
- Andrew F Mellon (5 October 2003)
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Re: Kawasaki - Bowling a "Googley"
- Trish Groves (8 October 2003)
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?occult infection
- john sharvill (8 October 2003)
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Kawazaki syndrome
- Mehdi Veisi (10 October 2003)
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dr prashant s pawar, pediatrician in private practise goregaon mumbai, -
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the clinical features are consistent with kawasaki disease eventhough all criteria are not satisfied.however toxic shock syndrome is to be considered as the second differential diagnosis .we should look for a focus of staph. infection in the case . a blood culture should be obtained,2d-echo ought to be done to rule out coronary artery aneurysms. the child should be started on anti- staphylococcal antibiotics like dicloxacillin,gammaglobulins and aspirin should also be started till the diagnosis is made clear by investigations. Competing interests: None declared |
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myles r milhench, consultant anaesthetist downe hospital downpatrick bt30 6ja
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1. brucellosis 2. rheumatic fever Competing interests: None declared |
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Niranjan Shendurnikar, Associate Professor of Paediatrics Medical Colege Baroda INDIA 390001
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The clinical progression of the child's illness fits very well into the description of Kawasaki Disease as she has now developed the evident features of peeling off the skin and cervical lymphadenopathy.As her ECG is unlikely to pick up any significant abnormality at this stage ,she should undergo an echocardiographic evaluation presently and subsequently too. She needs to be put urgently on Intravenous Immunoglobulin to prevent further aneurysm,if any potential benefit is to be obtained.Aspirin is also likely to be of additional benefit to minimize the risk of thrombosis.Even though her temperature has touched normal, she needs a broad spectrum antibiotic coverage in view of her raised white blood cells counts. Competing interests: None declared |
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Somnath Banerjee, Associate specialist community paediatrics Ramsgate, Kent CT16 2QT
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Now it looks like that this illness is taking a bit longer time than expected in a viral illness. Is there an underlying bacterial cause? Scarlet fever is a srong possibility when a child develops a sudden fever with sore throat and vomitings. The rash follows in 24-36 hours; spreading downwards from face. The rash fades in about a week followed by desquamation for several weeks especialy in nail folds of fingers and toes. A throat swab for culture and sensitivity will be helpful as well as starting oral penicillin for a 10 day course. Competing interests: None declared |
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Anne L. Appleton, Médecin-Chef de Sénologie Unité de Sénologie (Breast Unit), Clinique de Genolier, 1272 Genolier, Switzerland CH-1272.
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Despite not being a pediatrician, I agree: the diagnosis seems to be Kawasaki disease, with the classical desquamation of the fingers and toes following the acute phase, bilateral palpable cervical nodes, and a neutrophil leucocytosis with a raised CRP. The parents should be warned of the risk of coronary artery damage resulting from the underlying vasculitis, and further investigations, including echocardiography, should be arranged. Incidentally, is it safe to give an anti-inflammatory dose of aspirin in this age group? What about the risk of Reye's syndrome? Or does the benefit of using aspirin in Kawasaki disease out-weigh this theoretical risk? Competing interests: None declared |
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Robert Chircop, Registrar Emergency Department, John Hunter Hospital, Newcastle, Australia
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Both accounts in your journal point towards a diagnosis of Kawasaki's disease. She definitely has all the features to satisfy the criteria for the disease. Though I have never managed a patient with this condion, I believe that the patient should be treated with Aspirin and intravenous immunoglobulins ASAP. The risk of potentially fatal cardiac sequelae is too big not to. She also needs further investigations, in particular an echocardiogram to assess any coronary involvement, with repeat echocardiograms later on. Competing interests: None declared |
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Khalil A K Mohamed, assitant lecturer of pediatrics cairo university pediatric hospital
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I agree with the proposed diagnosis of kawasaki but i dont think rheumatic fever is likely in this age group i would also think of other rheumatic diseases ,juvenile rheumatoid arthritis :systemic onset 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. [Sorry for this double posting.] Competing interests: None declared |
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Sarita Jain, Staff Dermatologist Poole Hospital NHS Trust, Poole, BH15 2JB
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1. The possible diagnosis is Kawasaki disease (Mucocutaneous Lymph node Syndrome). Patient has all the major diagnostic criteria (set by American Heart Association) for Kawasaki disease.
Raised WBC, neutrophilia and elevated C Reactive Protein also fits in with the diagnosis. 2. Other associated findings not included in the major diagnostic criteria are often present in patients with Kawasaki disease. Most important are the cardiac manifestations. Myocarditis and Pancarditis may occur and coronary artery abnormalities (aneurysms and diffuse ectasia) develop in 20-25% of children with untreated Kawasaki disease. Patients with giant aneurysms are at greater risk for developing coronary thrombosis, myocardial infarction or stenosis. Prompt diagnosis is important as patients not treated within first ten days of illness have an increased risk of developing coronary artery aneurysms.
3. Parents should be informed of the possible risk of coronary artery abnormalities. Competing interests: None declared |
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Rajeev M Shinkar, Fellow PICU Royal Manchester Children's Hospital, M27 4HA
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Kawasaki disease is very likely. Children with this condition are quite irritable. She needs Echocardiogram,Immunoglobulins,high dose Aspirin. Also needs Blood culture & antistaph cover until that is ruled out. Competing interests: None declared |
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Christopher J Martin, GP and lead researcher, Laindon Health Centre Primary Care Research Team High Road, Laindon, Essex, SS15 5TR
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EDITOR – I have read the case reports on the 2 year-old child with a rash and fever with interest.(1) Last week I thought about the problem in two ways. Firstly, as a GP I came up with the following differential diagnosis: 1. Very likely a viral infection.
Viral illnesses that give this pattern of symptoms and signs are very common. Streptococcal pharyngitis is fairly common, but Kawasaki syndrome is rare. Secondly, as a reader of the article I came up with the following differential diagnosis: 1. Very likely - Kawasaki disease.
This was meant to be an interesting case report. The presentation is compatible with early Kawasaki disease, and failure to diagnose it early enough results in serious sequelae. Streptococcal pharyngitis is much more common, but is also less interesting as a case report. Viral illnesses are very common and very uninteresting, so it goes at the bottom of the list. After this week’s update, ‘viral illness’ has dropped of my differential diagnosis. As a GP, Kawasaki disease is clearly the most likely. Streptococcal pharyngitis remains a possibility with the spiking fever heralding the development of rheumatic fever. However, this is rare, especially in a child so young. As a reader, I put streptococcal pharyngitis at the top of the list. The clinical picture is now very obviously Kawasaki disease, and yet there is still another case report to appear next week. The development of an atypical rheumatic fever would be a thrilling finish to the series. This case report like many others illustrates two important points relating to risk as illustrated in this issue. Firstly, a collection of symptoms and signs may be typical and have a have a high sensitivity (e.g. for Kawasaki disease) and yet have a very low positive predictive value because of the rarity of the disease(2) (an incidence of about 1:10,000 in the UK)(3). Secondly, the risk or probability of an outcome is highly dependent on the reference class.(4) In this case, as a GP, my reference class is ‘all cases of 2 year-old children presenting in Primary Care with a rash and fever. As a reader the class is ‘all case reports appearing in this journal’. The context makes an enormous difference to the accuracy of our diagnoses. Reference List (1) Sharma R, Boon A, Harnden A. A 2 year old child with rash and fever. BMJ 2003; 327(7417):720. (2) Loong T. Understanding sensitivity and specificity with the right side of the brain. BMJ 2003; 327(7417):716-719. (3) Harnden A, Alves B, Sheikh A. Rising incidence of Kawasaki disease in England: analysis of hospital admission data. BMJ 2002; 324(7351):1424-1425. (4) Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ 2003; 327(7417):741-748. Competing interests: None declared |
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Bernard C BOYD, Retired Associate lecturer, Community health Private Practice, Arima, TRINIDAD
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The three weeks of symptoms and signs would seem to satisfy the criteria for a fairly firm diagnosis of Kawasaki's Syndrome: 1) Bilateral conjunctival redness
Elisabeth's mother is a specialist colleague. She already found it necessary to seek the help of a friend in the same field. As a family physician (GP), I think Elisabeth's parents should be offered a) a firm diagnosis with an explanation of how the diagnosis was arrived
at,
One must anticipate questions regarding the risk of complications (her mother would probably have done some reading up) and treatment (IMM and/or aspirin)should the diagnosis be correct. I would explain that the answers may be more reliable following appropriate investigations such as an ECHO. I would liaise closely with the consultant so that my own answers later would be supportive. I think that any further delay in seeking full consultant help would be bordering on negligence. B C Boyd Competing interests: None declared |
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Muthuswamy Ramaswamy, Medical Advisor Masonic Medical Centre for Children, Coimbatore,India 641018K
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The clinical profile of this infant's illness is consistent with Kawasaki's disease though desquamation is at times seen in invasive bacterial disease such as streptococcal and staphylococcal infections. Though the platelet count was reportedly normal for her age, elevated White Blood Cell count and positive C Rractive Protein are in favour of on-going inflammatory process. Competing interests: None declared |
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David Osoba, Staff Grade community Paediatrician BR2 9JG
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This presentation with the subsequent lab results is likely to be "Group A streptoccocal" infection.
Apart from regular antipyretics (effective doses), a course of oral penicillin V (erythromycin if allergic) will be appropriate.
Elisabeth is likely to recover with no long-term effects especilally from the peeling skin. She is not likely to suffer pain as the skin lesions are in the "superficial" skin layer.
Competing interests: None declared |
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Polanaickenpalayam S Chandrasekar, Staff Doctor James Paget Hospital,Great Yarmouth. NR31 6LA.
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1.Differential Diagnosis: Systemic Rheumatoid illness Kawasaki's disease 2.Further tests: Rheumatoid factor and Echocardiogram Analgesics and antipyretics Systemic steroids Supportive care 3.Explanation about rheumatoid illness ie..long term illness and management and introduction to support group 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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The majority of respondents favour Kawasaki disease as the most likely diagnosis, although other infectious and autoimmune diseases are also entering the differential. One interesting response contrasted the approaches to such a case when read in a medical journal and when encountered in a busy GP surgery. However, is Kawasaki disease really likely given the normal platelet count and normal ECG? Are any other investigations likely to be helpful? If this child does indeed have Kawasaki disease, should treatment be initiated this late in the disease? The child was afebrile, but had a neutrophilia and a raised CRP. Is there a role for intravenous immunoglobulin here? Should we give her aspirin as well as, or instead of, immunoglobulin? One respondent suggested that she might have Reye's Syndrome, precipitated by salicylates. If you wanted to commence aspirin, what dose would you choose - a high anti-inflammatory dose, or a lower anti-platelet dose? Finally, given that a variety of infectious diseases are still surfacing in the rapid responses (staphylococcal or streptococcal toxic shock, brucella, streptococcal pharyngitis, rheumatic fever, to name a few), would you also give some antibiotics, "just in case"? Competing interests: None declared |
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VARADARAJAN ARULALAN, primary care paediatrician VELLORE,SOUTH INDIA,632 006
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Last 19th I had responded it as KAWASAKI.I still or wish it to be so.Last week nodes were not noticed.This time it is bilateral.What is disturbing is the duration of malaise despite normal XRAY CHEST,ECG Why are the counts so greatly elevated with C Reactive protein above 13? That is why we have to keep one of the collagen vasucular disorder OR even malignacies as possiblites. I will inform honestly the limitation of our knowledge to Elizabeth's mother.Being a medical person I will insist that we cant give drugs like aspirin or immunoglobulins at this stage with out a correct diagnosis.I will ask her to take care of the nutrition status of the child I will do a peripheral smear to look for abnormal cells and carefully examine the child for new rash or joint involvement arulalan Competing interests: None declared |
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Elene Psiachou-Leonard, SpR in Haematology Southampton General Hospital, SO16 6YD.
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The most likely diagnosis is -atypical- Kawasaki disease. The child should have coronary arteries ultrasound. Although according to literature IV Immunoglobulin and aspirin should start early, depending on the results of investigations I would still consider it as an appropriate treatment. Competing interests: None declared |
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Sadik Aksit, pediatrician, consultant Ege University ,Faculty of Medicine, Dept. of Pediatrics, bornova, 35100, izmir, Turkey
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This week, the appearance of cervical lymphadenopathy, peeling of the toes and prolonged fever with no obvious infectious focus are now the findings supporting firmly my previous diagnosis (Kawasaki disease). Although the benefit of treatment with IVIG and aspirin in Kawasaki disease 10 days after onset is doubtful, yet, I would prefer to use single IVIG infusion (2 gm/kg) because some laboratory findings (leucocytosis with neutrophilia, elevated CRP) show that inflammatory process is ongoing and, at least, IVIG will not be so harmful to Elisabeth. In addition, I would consider full-dose aspirin treatment (80-100 mg/kg/d) until acute phase reactants disappear, and then taper the aspirin dose to 3 to 5 mg/kg/d (for a period of 4-6 weeks). The risk of Reye’s syndrome will be very small if varicella and influenza vaccines are administered. Also, I would refer Elisabeth to a pediatric cardiologist for a second echocardiographic evaluation. I would give information about the complications (that can be seen in this stage) of Kawasaki disease and the symptoms of toxicity of aspirin such as tinnitus and any allergic reaction (because of family history). Also, I would recommend influenza vaccine if the season is suitable (assuming that Elisabeth had varicella vaccine). Competing interests: None declared |
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B.C. Rao, G.P Bangalore,India
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Looks like acute streptococcal infection with exaggerated immune response. While awaiting lab reports the baby should be given penicilin. B.C.Rao Competing interests: None declared |
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KAILASH BIHARI, LocumGP Rhondda CF41 7NE
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I am not certain that any of the observation or findings can be taken as pathognomic for a Kawasaki or Scarlet Fever. As a GP, I prefer to go for one that is a more common possibility than a rarer one.Most of the findings projected in Part 2 of the presentation are posssiblities in both the conditions mentioned above. Normal ECG and chest radiograph is some what reassuring that possible damages has not occuered ie carditis or lung lesions. In haematology I note no thrombocytosis,that would have made me to reconsider my opinion in favour of Kawasaki. Leucocytosis and C reactive protein increase lacks specificity for either of the above. Intermittent spiked fever, diminished appetite, increased tendency to fall asleep,irritability and clinginess are all too familiar observation when an inflammatory process continues in a child. That is a good indicator a medical practioner cannot rest assured and further/ deeper search must continue for why. Peeling of finger tip in the photograph matches more closely to Scarletina than Kawasaki case that I have come across. By this time there should more result. But then it would taken heat out of discussion. My answers to questions asked in BMJ- 1. I stay with my previous diagnosis: SCARLET FEVER 2. Elizabeth needs close watch for developing long term sequele. Any suppurating gland may require drainage. I shall look for signs of artheritis in the joint/joints My preferance will be to provide shared care to Eliabeth involving a paedriatcian.Now a watch long term sequele has to be put in place. 3. I shall explain the findings and its significance in short and long term both.They will also know what needs to be watched for and why.Joint ,Heart and Kidney coplication will need empasis.I expect lesser chance of such complications and expressing this to them may be reassuring. Competing interests: None declared |
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Kelvin S Davies, General Practice Hillcrest Medical Centre, 86 Holt Rd., Wrexham, LL13 8RG
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At the time of reading the second part of the interactive case report, I received the journal "Dermatology in Practice volume 11 number 5". It by chance contained an article titled "Childhood exanthems".
Having read this article I would say that the diagnosis was Kawasaki disease. It mentions that there are "extremity changes which includes swelling and erythema in the initial stage and peeling of finger tips in the convalescent stage. The treatment would be intravenous immunoglobulins within the first ten days of illness as this significantly decreases the incidence of coronary aneurysms.However the article does not mention how you would treat this after two weeks. The article also mentions that in scarlet fever, the erythroderma fades after two to three days and generalised desquamation tends to occur after seven to ten days starting with the feet and hands. Competing interests: None declared |
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Sinead Regan, Research Associate and GP Division of Primary Care, University of Bristol, Cotham House, Cotham HillBristol BS3 6JL, Alastair Hay, Clinical Lecturer in Primary Health Care, University of Bristol
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INTERACTIVE CASE REPORT BMJ: Child with fever and rash In week one, Elizabeth is seen on day 5 of her illness because of nursery policy. At this stage, we thought her illness was due to a resolving severe viral illness, measles or a streptococcal infection. It is a statutory duty to notify public health regarding measles which is a clinical diagnosis, but lack of measles specific IgG would show Elisabeth is non-immune.(1) Given her improvement and the distress associated with blood tests, we would not undertake this or ASO titres. Due to decreasing MMR uptake, and despite Elisabeth’s immunisation, it is still possible to contract measles in a vaccinated child. Primary immunization of measles does not confer immunity in 10% of vaccinations. (2) We would advise her mother to return if the baby does not continue to improve, and not rely on her own clinical judgment as this can be distorted dealing with family members. We would establish if mum is immunised, as measles in pregnancy can cause preterm delivery or intrauterine death, although we can reassure her there is a low risk of congenital deformity. (1) Of note, she has had two episodes of periorbital cellulits (often caused by streptococcus) and irritable hip (post infective). Could she be immunolgically compromised causing increase susceptibility to infection? Is her milk intolerance undiagnosed coeliac disease associated with a functional hyposplenism? Unlike other authors, we do not think most GPs would consider Kawasaki at the first presentation, but would by the second contact. The desquamation and swinging fever make Kawasaki’s disease more likely and admission would be prudent. An alternative, an equally rare explanation could be a streptococcal abscess. Cardiac echo for coronary artery aneurysm and ultrasound and blood cultures should assist the diagnosis. Her parents need to know the implications of Kawasaki disease and the associated risk of aneurysms. As her mother is medically trained, she may be feeling guilty as she didn’t pick up this earlier herself. She may be reading lots around the condition and have lots of questions. She needs to be treated as a mother first and doctor second. Ref 1: P Morgan- Capner, NS Crowcroft, on behalf of PHLS Joint Working Party of the Advisory Committees of Virology and Vaccines and Immunisation. Guidelines on management of, and exposure to, rash illness in pregnancy (including consideration of relevant antibody screening programmes in pregnancy) Communicable disease and Public Health Vol 5 no 1 March 2002 Ref 2: Health Protection Agency website: General information- measles (accessed 3 October 2003) Sinead Regan, Research Associate and GP Alastair Hay, Clinical Lecturer in Primary Health Care Division of Primary Care, Cotham House, Cotham Hill, Bristol, BS3 6JL Competing interests: None declared |
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Pothen Alexander, General practitioner and trainer 218 Ifield drive, crawley, RH11 OEP
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I have read the case report of the 2 year old child with fever and rash.This child has Kawasaki disease. She should be referred to paediatric cardiologist for an Echocardiogram.Blood culture should be taken and antibiotics should be started after that because she may have bacterial endocarditis. Parents should be told that kawasaki disease is a viral infection which could affect heart valves.Therefore further investigations and antibiotic treatment are necessary to prevent further complications. Competing interests: None declared |
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Andrew F Mellon, Consultant Paediatrician Sunderland Royal Hospital, England SR4 7TP
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In common with most respondents I would have Kawasaki disease as my top diagnosis; the development of the story has strengthened this differential diagnosis. Would I be happy to treat on the basis of the information already gathered? The answer has to be yes. Diagnostic reasoning points to this being an important diagnosis not to miss, a treatable condition but also one that is notoroious for masquerading as other things. Among children with the described findings it is also common, although as rightly pointed out by others earlier in the course of the illness the child's pressentation easily merges into the vast array of less worrying alternative causes for fever and rash. How would I treat? I would be happy to start aspirin as described by others and found on a quick internet search at the following useful reference: Taubert KA, Shulman ST. Kawasaki disease. Am Fam Physician. 1999 Jun;59(11):3093-102, 3107-8. I would be slightly circumspect, without some other information, about giving intravenous immunoglobulin (IVIG). 1. The child is outside the period of time when we have evidence that clearly supports the use of IVIG to prevent coronary aneurysms. 2. Given the family history of allergy, as well as the past medical history of allergy and potential for immunodeficiency in the child, I would be concerned about the risk of IgA deficiency in this child, which if absolute rather than selective IgA deficiency would carry a significant risk of anaphylaxis when using products such as pooled human IVIG. It is described as a contra-indication on the product information. I would arrange an urgent Ouchterlony test for IgA before considering giving this preparation. If demonstrating an absence of IgA it might be helpful to check for anti-IgA antibodies before giving IVIG. If IgA testing was equivocal I would explain my rationale to the parents, and involve them in the decision about whether to give the IVIG in the absence of coronary aneurysms on ECHO, which would be one based on the relative risk of developing an anuerysm versus that of having an anaphylactic reaction to the IVIG. My inclination would be not to recommend the IVIG in that situation, and to monitor the child's coronary circulation closely. (To the editor) I am increasingly an advocate of using a standard internet search engine to find relevant information and act as an aide memoire for those bits of useful clinical information I just can't quite remember. Searching for immunoglobulin and kawasaki via Google rapidly brought me to Taubert KA, Shulman ST. Kawasaki disease. Am Fam Physician. 1999 Jun;59(11):3093-102, 3107-8. There is a remarkable similarity between the photgraphs in that article and those in the BMJ. More than coincidence? Competing interests: None declared |
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Trish Groves, senior assistant editor BMJ WC1H 9JR
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Thanks for pointing out that the pictures were not of the patient described in this interactive case report. Unfortunately the authors weren't able to supply any pictures to illustrate the story. We wanted to show readers the key clinical signs of this disorder, so we had to resort to images from picture libraries. I'm sorry we didn't make it clearer to readers that the pictures were not of the real patient described, and we'll make sure we get this right in future. The pictures were credited as JKI because giving the full title of the source, the name of an institution specialising in this disorder, would have given the game away. We're really pleased to see that interactive case reports are generating such lively clinical debate. If you have interesting patients who'd be happy to take part in this new kind of learning, please write up their stories as interactive case reports, sending them to us at submit.bmj.com Please obtain the patient's written consent to publication uisng our form at http://bmj.bmjjournals.com/collections/informed_consent/draft_f.shtml Lastly, please follow our advice on how to write up these case reports at http://bmj.bmjjournals.com/cgi/content/full/326/7389/564/DC1 Competing interests: I am the BMJ editor who handled the publication of this case report. |
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john sharvill, Family physician DEAL ct14 7au
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I am replying as a GP who has seen the vast majority of opinion that this is Kawasaki syndrome. Whilst deferring to those with more experience is there not a possibility that this might be a bacterial infection such as osteomyelitis/septic arthritis/ staph renal abscess or a variety of secondary infections following on from an initial apparant self limiting infection? What to do--as a GP, refer to the secondary sector realising that we are beyond primary care managment,and to discuss with the parents the reasons for this. Competing interests: None declared |
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Mehdi Veisi, GP Iran
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This type of symptoms show us the kawazaki syndrome and nothing else would be suggestable. As I am a general practitioner I would send her to a Pediatrist for further treatments but NSAIDS are the choice of drug here. Also we must provide an Echocardiography and alert her parents for the harm of heart problems due to this syndrome. Competing interests: None declared |
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