CASE PRESENTATIONCASE PRESENTATION

Abhilash SailendraAbhilash Sailendra

GPST 1 GPST 1

AN 18 MONTH OLD WITH FEVER AND RASHAN 18 MONTH OLD WITH FEVER AND RASH

High fever for 4 days.High fever for 4 days. Four days prior to admission , she Four days prior to admission , she developed high fever and rhinorrhea. She was taken to developed high fever and rhinorrhea. She was taken to see a doctor at a clinic and was diagnosed as "URTI". see a doctor at a clinic and was diagnosed as "URTI". She was prescribed paracetamol, and amoxicillin . She was prescribed paracetamol, and amoxicillin .

Two days ago, she had semi-solid stool. Two days ago, she had semi-solid stool.

One day PTA, she developed maculopapular rash at trunk One day PTA, she developed maculopapular rash at trunk at extremities.at extremities.

PMH : PMH : Healthy child . Birth weight was 3.0 kgs.Healthy child . Birth weight was 3.0 kgs. No previous admissions to hospital. No previous admissions to hospital.

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Fully conscious but irritable.Fully conscious but irritable.Vital signsVital signs: Temp 39.8 C, HR 160 beats/min, RR 40 breaths/min, : Temp 39.8 C, HR 160 beats/min, RR 40 breaths/min, BP 98/50 mmHgBP 98/50 mmHg

Head to Toe :Head to Toe : mild injected conjunctiva, no icteric sclera, red lips , mild injected conjunctiva, no icteric sclera, red lips , normal anterior fontanel. No palpable LNs.normal anterior fontanel. No palpable LNs.

Heart:Heart: regular rhythm, tachycardia regular rhythm, tachycardia

Lung:Lung: clear, no added sounds clear, no added sounds

Abdomen: Abdomen: soft, no organomegalysoft, no organomegaly

Skin : Skin : Erythematous rash at trunk and extremities , Erythematous rash at trunk and extremities ,

Extremities:Extremities: Swelling of dorsal part of hands and feet Swelling of dorsal part of hands and feet

Investigations:Investigations:

FBC:FBC: Hb 10.6 gm%, WBC 14 (N 72%,L 28%), platelets Hb 10.6 gm%, WBC 14 (N 72%,L 28%), platelets 324324

U & Es - NADU & Es - NAD

URINE:URINE: Clear Clear

ESR - 97 mm CRP – 276ESR - 97 mm CRP – 276

ECG:ECG: sinus tachycardia , rate 170/min, no ST-T change sinus tachycardia , rate 170/min, no ST-T change

Echocardiogram:Echocardiogram: No structural heart defect, normal left No structural heart defect, normal left ventricular function (EF 67%), minimal pericardial ventricular function (EF 67%), minimal pericardial effusion 5mm.effusion 5mm.

DIAGNOSIS ??DIAGNOSIS ??

KAWASAKI DISEASEKAWASAKI DISEASE

Syn - Kawasaki's syndrome, Syn - Kawasaki's syndrome, mucocutaneous lymph node syndrome, mucocutaneous lymph node syndrome,

infantile polyarteritis nodosa.infantile polyarteritis nodosa.

Course in the hospital Course in the hospital : , : ,

She was given a high dose intravenous immunoglobulin She was given a high dose intravenous immunoglobulin (IVIG) 2g/kg and (IVIG) 2g/kg and

High dose oral aspirin ( 80mg/kg/day). High dose oral aspirin ( 80mg/kg/day).

Four hours after IVIG the fever dramatically subsided.Four hours after IVIG the fever dramatically subsided.

Two days after IVIG ,her irritability, erythematous rash, Two days after IVIG ,her irritability, erythematous rash, red lip and oedema of extremities disappeared. She was red lip and oedema of extremities disappeared. She was discharged home with low dose aspirin (5mg/kg /day).discharged home with low dose aspirin (5mg/kg /day).

Cardiology follow up in 6 weeks time.Cardiology follow up in 6 weeks time.

FEW FACTSFEW FACTS

Age group – 6 months to 5 years.Age group – 6 months to 5 years. Commonest cause of acquired heart disease in UK.Commonest cause of acquired heart disease in UK. Mortality in UK – 3.7 %Mortality in UK – 3.7 % Systemic VasculitisSystemic Vasculitis Most important complication – Coronary Aneurysms ( 30 Most important complication – Coronary Aneurysms ( 30

%% ), ), and if treated early these could be avoided.and if treated early these could be avoided.

DAIGNOSTIC CRITERIONDAIGNOSTIC CRITERION

Along with fever > 38.5 , there must be at least four of the Along with fever > 38.5 , there must be at least four of the following to fit the diagnostic criteria (or following to fit the diagnostic criteria (or

echocardiographic evidence of coronary artery echocardiographic evidence of coronary artery aneurysms):aneurysms):

Inflammation and irritation of the lips, mouth and/or Inflammation and irritation of the lips, mouth and/or tongue tongue

Erythema, oedema and/or desquamation of the Erythema, oedema and/or desquamation of the extremities extremities

Bilateral dry conjunctivitis Bilateral dry conjunctivitis Widespread non-vesicular rash Widespread non-vesicular rash Cervical lymphadenopathy >1.5 cm in sizeCervical lymphadenopathy >1.5 cm in size

Classical features of Kawasaki diseaseClassical features of Kawasaki disease

Fever lasting ≥5 days Fever lasting ≥5 days Marked irritability of the child Marked irritability of the child Erythema, swelling and Erythema, swelling and desquamationdesquamation affecting the skin of the affecting the skin of the

extremities extremities Bilateral Bilateral conjunctivitisconjunctivitis Rash Rash Inflammation of the lips, mouth and/or tongue Inflammation of the lips, mouth and/or tongue Cervical lymphadenopathyCervical lymphadenopathy

ATYPICAL SYMPTOMSATYPICAL SYMPTOMS

Other possible features include lethargy, symptoms of urethritis, Other possible features include lethargy, symptoms of urethritis, diarrhoeadiarrhoea, vomiting, abdominal pain, myalgia, arthralgia and , vomiting, abdominal pain, myalgia, arthralgia and arthritis. arthritis.

A recent Chinese survey found that there appears to be an appreciable A recent Chinese survey found that there appears to be an appreciable incidence of atypical or 'incomplete' Kawasaki disease and that such incidence of atypical or 'incomplete' Kawasaki disease and that such cases appear to have a high prevalence of coronary artery lesions. cases appear to have a high prevalence of coronary artery lesions. The presence of peri-anal desquamation may be a useful indicator The presence of peri-anal desquamation may be a useful indicator of the likelihood of such 'incomplete' cases of the likelihood of such 'incomplete' cases

An 8 year old child presents with his parents to his Physician. An 8 year old child presents with his parents to his Physician. His chief complaint is a rash that began on his lower His chief complaint is a rash that began on his lower extremities a few hours ago. In addition his parents state extremities a few hours ago. In addition his parents state that the kid has had a low grade fever, arthritis and colicky that the kid has had a low grade fever, arthritis and colicky abdominal pain. A purpuric rash limited to the lower abdominal pain. A purpuric rash limited to the lower extremities was found on examination. A urinalysis reveals extremities was found on examination. A urinalysis reveals RBC casts and mild proteinuria. The platelet count is RBC casts and mild proteinuria. The platelet count is normal. The mostly diagnosis is –normal. The mostly diagnosis is –

A . Systemic Lupus Erythematosis ( SLE )A . Systemic Lupus Erythematosis ( SLE )

B . Rocky mountain Spotted feverB . Rocky mountain Spotted fever

C . Idiopathic Thrombocytopaenic Purpura ( ITP )C . Idiopathic Thrombocytopaenic Purpura ( ITP )

D . Henoch – Schonlein VasculitisD . Henoch – Schonlein Vasculitis

E . Post Streptococcal GNE . Post Streptococcal GN

A 6 year old girl who appears healthy is brought to the GP A 6 year old girl who appears healthy is brought to the GP by her mother because of a rash. The mother states that by her mother because of a rash. The mother states that the child had been well until 2 days ago, when she the child had been well until 2 days ago, when she developed fever and upper respiratory tract symptoms. developed fever and upper respiratory tract symptoms. Yesterday the child had erythematous facial flushing that Yesterday the child had erythematous facial flushing that spread as a macular red lesion to her proximal spread as a macular red lesion to her proximal extremities and trunk, which now has a lacy appearance. extremities and trunk, which now has a lacy appearance. The most likely diagnosis is – The most likely diagnosis is –

A . Erythema InfectiosumA . Erythema Infectiosum

B . RoseolaB . Roseola

C . German Measles or RubellaC . German Measles or Rubella

D . MeaslesD . Measles

E . Scarlet FeverE . Scarlet Fever

A 4 year old presents with a temperature of 40 C, which A 4 year old presents with a temperature of 40 C, which she has had for the last 4 days. Her GP had seen her on she has had for the last 4 days. Her GP had seen her on the first and 3the first and 3rdrd day of fever. He was unable to ascertain day of fever. He was unable to ascertain the source of fever, and reassured the mother with the source of fever, and reassured the mother with Calpol and Ibuprofen. He now presents to AED. On Calpol and Ibuprofen. He now presents to AED. On examination the child is noted to have conjunctivitis, examination the child is noted to have conjunctivitis, erythematous rash, cervical adenopathy and swollen erythematous rash, cervical adenopathy and swollen hands and feet. Lab findings show neutrophilic hands and feet. Lab findings show neutrophilic leukocytosis, elevated ESR and normal platelets. The leukocytosis, elevated ESR and normal platelets. The most likely diagnosis is – most likely diagnosis is –

A . Scarlet FeverA . Scarlet Fever

B . Acute Rheumatic feverB . Acute Rheumatic fever

C . Juvenile Rheumatoid ArthritisC . Juvenile Rheumatoid Arthritis

D . Toxic Shock SyndromeD . Toxic Shock Syndrome

E . Kawasaki DiseaseE . Kawasaki Disease

A 4 year old boy presents with fever and conjunctivitis. The A 4 year old boy presents with fever and conjunctivitis. The mother states that the child had been in good health until mother states that the child had been in good health until 2 days ago when he developed URTI symptoms. She 2 days ago when he developed URTI symptoms. She also mentions that he has photophobia and cervical also mentions that he has photophobia and cervical adenopathy. On examination red lesions with a white adenopathy. On examination red lesions with a white centre are present on the buccal mucosa. A generalised centre are present on the buccal mucosa. A generalised blanching erythematous rash is also noted . The most blanching erythematous rash is also noted . The most likely diagnosis is – likely diagnosis is –

A . Kawasaki DiseaseA . Kawasaki Disease

B . RubellaB . Rubella

C . Adenovirus infectionC . Adenovirus infection

D . MeaslesD . Measles

E . Still s DiseaseE . Still s Disease

TAKE HOME MESSAGESTAKE HOME MESSAGES

1 . In a child with a fever you should always consider 1 . In a child with a fever you should always consider conditions with a higher risk of serious outcomes, conditions with a higher risk of serious outcomes, including:including:

Meningitis Meningitis Pneumonia Pneumonia Urinary tract infection Urinary tract infection Septic arthritis/osteomyelitis Septic arthritis/osteomyelitis Herpes simplex encephalitis Herpes simplex encephalitis

Kawasaki diseaseKawasaki disease

2. Any febrile child with purpuric rash is 2. Any febrile child with purpuric rash is considered as Meningococcal Septicaemia considered as Meningococcal Septicaemia

unless proved otherwise.unless proved otherwise.

CRASH AND BURNCRASH AND BURN

CONJUNCTIVITISCONJUNCTIVITIS RASHRASH ADENOPATHYADENOPATHY STRAWBERRY TONGUESTRAWBERRY TONGUE HANDS AND FEET – RED SWOLLEN FLAKY HANDS AND FEET – RED SWOLLEN FLAKY

SKINSKIN BURN – FEVER > 40 FOR > 5 DAYSBURN – FEVER > 40 FOR > 5 DAYS

Thank you for your patience….Thank you for your patience….