A PERSISTENT FEVER
History
Ben is a 2-year-old boy who presents to the rapid referral paediatric clinic with a 10 day history of fever, blood shot eyes, a sore throat and a rash. He also has an occasional cough. His mum describes him as being miserable with a poor appetite. There is no history of travel or contact with infections. Ben has already had a 6 day course of amoxyl from his GP that made no difference. He had an inguinal hernia operated on at 2 weeks of age. There is no other medical history of note.
Examination
Temperature 39.8C. He has bilateral conjunctivitis, erythematous, cracked lips and an erythematous pharynx. There is a non-specific maculopapular rash over the trunk. There is cervical lymphadenopathy with the largest node being 2 cm in diameter, but no lymphadenopathy elsewhere. His chest is clear and there are no other abnormalities
INVESTIGATIONS
Normal
Haemoglobin 10.7 g/dL 10.5–13.5 g/dL
White cell count (WCC) 26.3 109/L 4.0–11.0 109/L
Neutrophils 18.2 109/L 1.7–7.5 109/L
Platelets 430 109/L 150–400 109/L
Sodium 137 mmol/L 135–145 mmol/L
Potassium 3.7 mmol/L 3.5–5.0 mmol/L
Urea 4.2 mmol/L 1.8–6.4 mmol/L
Creatinine 58 mol/L 27–62 mol/L
C-reactive protein (CRP) 63 mg/L 6 mg/L
Erythrocyte sedimentation rate (ESR) 107 mm/hour 0–15 mm/hour
Questions
• What is the likely diagnosis?
• What is the treatment?
Medicine
Fever and rash are very common in paediatrics. Most rashes are non-specific viral rashes but some illnesses are accompanied by typical rashes. For instance, chickenpox is characterized by a maculopapular rash that evolves into vesicles and meningococcal septicaemia by a petechial non-blanching rash. The most likely diagnosis in this case is Kawasaki’s disease which is a vasculitis. This disorder occurs mainly in young children (80 per cent 5 years). It is diagnosed clinically. Criteria for diagnosis are:
• The presence of a fever for 5 or more days and four of the following five features:
– non-purulent conjunctivitis
– cervical lymphadenopathy
– skin rash
– erythema of the oral and pharyngeal mucosa
– erythema and swelling of the hands and feet (followed a week later by skin desquamation). Accompanying features are a raised WCC, CRP and ESR. In the second week of the illness a thrombocytosis usually develops. When assessing a child with a prolonged fever (7 days), the following conditions should be considered.
Causes of a prolonged fever
• Infections, e.g. tuberculosis, HIV
• Malignant diseases, e.g. lymphoma
• Autoimmune diseases, e.g. juvenile idiopathic arthritis
• Miscellaneous, e.g. drugs, inflammatory bowel disease
Treatment consists of an infusion of immunoglobulins on the day of diagnosis, initially high-dose aspirin at anti-inflammatory doses followed by low-dose aspirin at antithrombotic doses. The main complication of this disorder is coronary artery aneurysms that can, in some cases, lead to myocardial infarction and sudden death. A prolonged fever (16 days), male sex, age 1 year, cardiomegaly, raised inflammatory markers and raised platelets are all risk factors. An echocardiogram at diagnosis and follow-up echocardiograms are required to rule out this complication. The prognosis is related to the cardiac complications. The risk of cardiac complications if treatment with immunoglobulins was commenced within 10 days of diagnosis is 10 per c
KEY POINTS
• Kawasaki’s disease should be considered in all children with a prolonged fever.
• Treatment consists of immunoglobulins and aspirin.
• The main long-term complication is coronary artery aneurysms.
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