Review Question - QID 210085

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Kawasaki Syndrome Treatment Medical QID: 210085 (M2.OMB.18.1)

QID 210085 (Type "210085" in App Search)

A 5-year-old girl is brought to the emergency department with a 6-day history of fevers and irritability. The fevers have ranged from 101-104°F (38.3-40°C) and are unresponsive to ibuprofen. She developed a rash 3 days ago and has refused to wear shoes because they feel “tight.” Other than 2 ear infections she had when she was younger, the patient has been healthy. She is up-to-date on her vaccinations except for the vaccine boosters scheduled for ages 4-6. Her temperature is 103.5°F (39.7°C), blood pressure is 110/67 mmHg, pulse is 115/min, and respirations are 19/min with an oxygen saturation of 98% O2 on room air. Physical examination shows bilateral conjunctivitis, palpable cervical lymph nodes, a diffuse morbilliform rash, and desquamation of the palms and soles with swollen hands and feet. Which of the following is the most appropriate next step in management?

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Acetaminophen

0/43

Aspirin

79%

34/43

Nafcillin

2/43

Penicillin V

2/43

Vitamin A

2/43

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The patient presents with fever, conjunctivitis, rash, adenopathy, hand swelling, and erythema, suggesting the diagnosis of Kawasaki syndrome. Initial treatment includes high-dose aspirin and intravenous immunoglobulin (IVIG).

Kawasaki syndrome is an acute, medium-vessel vasculitis that is common in children under 5 years of age. It is clinically diagnosed by having four of the CRASH and Burn criteria: Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand and foot rash/swelling, and Burn (fever). The fever is high and of at least 5 days duration or more. Management involves an echocardiogram to assess for cardiac abnormalities (coronary artery aneurysm), high-dose aspirin, IVIG, and vaccinations to prevent viral infection following aspirin use.

Ishii et al. review the evidence regarding the diagnosis and treatment of Kawasaki disease. They discuss how IVIG is the standard of treatment for this disease. They recommend considering adjunctive therapies such as steroids.

Incorrect Answers:
Answer 1: Acetaminophen can be used for symptomatic treatment of fever, but often the fever associated with Kawasaki syndrome is unresponsive to acetaminophen or ibuprofen. This medication can be used for fevers due to infectious etiologies.

Answer 3: Nafcillin can be used to treat methicillin-sensitive Staphylococcus aureus (MSSA), such as with staphylococcal scalded skin syndrome (SSSS). SSSS may follow a preceding exposure to MSSA and presents with painful desquamation and superficial skin sloughing, often starting in flexural surfaces.

Answer 4: Penicillin V is indicated for the treatment of scarlet fever to prevent the development of acute rheumatic fever. Scarlet fever presents as a sore throat, fever, strawberry tongue, and a sandpaper-like rash that spreads from the groin and armpits to the trunk and extremities and spares the palms and soles.

Answer 5: Vitamin A is part of the management of measles. It may reduce mortality in children < 2 years of age. Measles presents as a high fever (often > 104°F) with a caudally progressing rash that typically excludes the palms and soles, followed by cough, coryza, and conjunctivitis.

Bullet Summary:
Kawasaki syndrome is managed by high-dose aspirin and IVIG to protect against coronary artery aneurysms.

ILLUSTRATIONS:

History and Future of Treatment for Acute Stage Kawasaki Disease.

Ishii M

Ebato T

Kato H.

General

Ishii M, 2020

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