Clinical scenario 4: Justin

Justin, an 11 month old boy, presents with a history of fever and rash.The following seven questions refer to Justin’s clinical scenario.

Question 18

The features of Kawasaki disease include fever for five days (in the absence of streptococcal infection) plus other signs. Which one of the following is NOT a feature of Kawasaki disease?
Rash
Exudative conjunctivitis
Oral mucositis
Peripheral extremities involvement
Check answer

Explanation

Exudative conjunctivitis. The criteria for Kawasaki disease is five days of fever plus any four of the following:

  • Rash - diffuse rash which is often morbilliform; not vesicular
  • Conjunctivitis - bilateral; non exudative conjunctival injection
  • Oral mucosal changes - strawberry tongue; erythema/cracking of lips and tongue
  • Cervical lymphadenopathy - one enlarged node >1.5cm
  • Peripheral extremities involvement - erythema and oedema of hands and feet or peeling of skin.

Kawasaki disease is a vasculitic disease that is present worldwide but is most common in Japan in children between one and four years. Other clinical features include arthritis, cholecystitis, orchitis, vomiting, diarrhea, cough and occasionally CNS disease. Younger children tend to be extremely irritable.

There is no diagnostic test for Kawasaki disease and thus diagnosis is based on clinical features alone. Children may have an atypical form of the disease without fulfilling the above criteria, which can make diagnosis difficult.

Question 19

Which ONE of the following is the major complication associated with Kawasaki disease?
Pneumonia
Cerebral vascular accident
Renal failure
Coronary artery aneurysm
Liver failure
Check answer

Explanation

Coronary artery aneursyms are seen in 20% of untreated patients, reducing to <1% in treated patients. Onset is usually after six weeks from onset of the disease. Mortality rate is approximately 2%, reducing to 0.3% with treatment. Echocardiograms are ideally performed at diagnosis, with timing of follow up depending on findings.

Question 20

What of the following is NOT the initial treatment for Kawasaki disease?
IV immunoglobulin
PO prednisolone
PO aspirin
Check answer

Explanation

The aim of treatment is to suppress the inflammatory response and reduce the likelihood of carditis and coronary artery aneurysms. IVIG is of proven benefit in the reduction of CAA if given within 7-10 days of onset of symptoms. Aspirin in high dose suppresses inflammation, while in low dose inhibits platelet aggregation. Initial treatment is with high dose aspirin, followed by low dose aspirin. If there is no improvement in 48 hours, IVIG is repeated. Steroids may play a role in those resistant to IVIG.

Question 21

Which ONE of the following is the most concerning diagnosis in a child with fever and non-blanching (petechial/purpuric) rash?
Pneumococcaemia
Viral illness
Henoch schonlein purpura
Coagulopathy
Meningococcaemia
Check answer

Explanation

The incidence of meningococcal disease (MCD) in Australia is about 3/100,000. The classical triad of presentation is fever, ill and non-blanching rash. However about 30% of children who present with meningococcal sepsis will have a blanching rash, <10% of those who present with fever and a non-blanching rash have meningococcal disease, and a few with MCD will present with no fever.

Question 22

What features on examination and investigation do NOT make meningococcaemia more likely? Please note that more than one answer may be correct.
Child looks unwell
High white cell count
Rash in superior vena cava distribution
Purpura
Check answer

Explanation

Rash in superior vena cava distribution. The higher the WCC, the more likely a child is to have a significant bacterial infection. Normal inflammatory markers (procalcitonin and CRP) and a period of remaining well after a period of observation are all supportive of those children not at risk of MCD. Petechiae in the SVC distribution alone, with a history of vomiting or coughing in a well looking child, rule out MCD.

For more information, please see

Fever and non-blanching rash: Management in ED. Practice guideline, Children’s Hospital Westmead.

Question 23

What features of the rash and associated symptoms would NOT be suggestive of measles?
Rash is raised, blotchy and confluent in places
Cough
Exudative conjunctivitis
Ulcers on soft palate
Check answer

Explanation

Rash is raised, blotchy and confluent in places. Measles is a highly infectious paramxyovirus spread by respiratory droplets. Reduced immunization rates have led to recent outbreaks. It is a notifiable disease. Measles has an incubation period of 10-14 days. Prodromal period is 3-5 days prior to rash with fever, irritability, cough, exudative conjunctivitis, otitis media and Koplik spots (white spots on oral mucosa). The rash starts behind the ears and descends. It is blotchy, raised and confluent in places. The child is miserable and febrile when the rash is present.

Question 24

What other illnesses can cause a morbilliform (measles like) rash?
Roseola infantum
Epstein-Barr virus
Kawasaki disease
Scarlet fever
Influenza
All of the above
Check answer

Explanation

In roseloa infantum the child is usually well and afebrile when the rash appears, in contrast to measles. Antibiotics can also cause a morbilliform rash, especially amoxicillin in the context of EBV infection. Enteroviruses and parinfluenza can also cause a morbilliform looking rash..

For more information, please see:

NSW Health guidelines

Children and Infants with Bacterial Meningitis - Acute Management

Children and Infants with Fever - Acute Management

The Children’s Hospital Westmead - guidelines

Fever - parent fact sheet

Lumbar puncture - parent fact sheet

Meningitis - parent fact sheet

UTI GP fact sheet
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