Case #31

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Chief Complaint

MJ is a six year old girl, brought to the family medicine clinic by her parents for persistent fever. The father reports she has been tired and has a decreased appetite. She was noted to be in her normal state of health until one week ago, at which time she developed conjunctival injection, fever to 103º F, and sore throat. Her parents attributed these symptoms to a recent viral upper respiratory infection that affected several children in Marci’s class. Marci’s mother noted an erythematous rash in her perineal region while bathing her last night and noted peeling of the skin near her fingernails. Marci has begun to complain of joint pains. Her parents note they initially did not give her any antipyretics, but when they gave acetaminophen yesterday, it did not seem to have any effect.
  1. What is fever? Why is it important? What causes it?
  2. Other than increased body temperature, what are some of the other clinical manifestations of fever?
Marci’s parents are worried that a fever of 103oF could be dangerous and cause harm to Marci.

 
  1. Does fever itself cause harm?
As a clinician, you feel that Marci does not look “well.” She appears tired and disinterested in playing with the toys in the waiting room. She appears to move slowly, saying that it hurts her knees to walk around. At six years old, you expect Marci to be able to hold a conversation with you, but she seems too exhausted to talk for long.
  1. How should Marci be evaluated?
  2. What is the optimal management for a child with a fever?
  3. What is the difference between “high risk” infants and “low risk” infants?
  4. Should fever itself be treated? How should fever be treated?
  5. Is there anything concerning about fever with a rash?

Assessment

 

On physical exam, Marci is noted to be an ill-appearing, febrile child. Erythema of the tongue gives it a “strawberry” appearance. Her lips are dry and cracked. Erythema and edema of the feet are noted, and she walks with a slight limp. She has a 1.5 cm palpable cervical lymph node and an erythematous rash of her lower trunk and perineum. Concerned about the possibility of serious illness, the decision is made to admit Marci to the pediatric floor of the hospital for possible Kawasaki syndrome.

  1. What is Kawasaki syndrome?

 

Marci’s parents are upset that they may have waited too long and worry they may have done something to cause Marci’s illness. They are concerned that Marci’s playmates will get the disease as well.
  1. What causes Kawasaki disease?
  2. How common is this disease?
  3. What are the clinical manifestations of Kawasaki’s syndrome?
  4. What other diseases should be considered in the differential diagnosis of Kawasaki syndrome and how do they differ?

 

You give Marci’s parents an informational brochure and step out of the room to give them a few minutes to process the news. When you return, you find Mr. Jenkins visibly upset. The brochure talks about coronary aneurysms and he wants to know more about this complication.
  1. What are the cardiovascular sequelae of Kawasaki syndrome?
  2. Who is at greatest risk for aneurysms and how is it monitored?
Content with the answers you’ve provided thus far, Marci’s parents ask you what to expect for the remainder of their daughter’s illness. They are interested in both duration and symptoms to expect in their daughter.
 
  1. What is the easiest way to conceptualize this disease?

 

You order diagnostic labs for Marci. CBC shows elevated white blood cell count of 22,000/mm3, hemoglobin of 9.0g/dL, hematocrit 28.2 percent, and platelet count of 752,000/mm3. ESR is elevated at 72 mm/hr. An EKG is normal. These findings strongly suggest Kawasaki disease, and Marci’s parents ask about treatment.

 
  1. What is the treatment or management of Kawasaki syndrome? Does it help?

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This page was last updated on October 26, 2006
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