A 6-year-old boy is brought to the office due to a fever and "lump" on his neck. The patient has had a fever for the past 6 days, and the mother felt the lump when she was bathing him yesterday. This morning, he awoke with a rash on the trunk and redness of the eyes. The patient has had no cough, rhinorrhea, diarrhea, or emesis. He has a history of intermittent asthma and takes albuterol as needed. Vaccinations are up to date. Current temperature is 39.4 C (102.9 F), blood pressure is 90/60 mm Hg, and pulse is 125/min. Physical examination shows an irritable child who is intermittently consoled by his mother. Bilateral conjunctivae are injected. A 2-cm, tender, mobile anterior cervical lymph node is palpated. Heart rate is regular with mild tachycardia and no murmurs, rubs, or gallops. A blanching erythematous rash is present across the trunk. The tongue and lips appear erythematous, and the posterior pharynx has no exudates or tonsillar hypertrophy. Which of the following additional examination findings would be consistent with this patient's presumed diagnosis?
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Kawasaki disease is a systemic vasculitis that is most common in children age <5 of East Asian ancestry. In addition to prolonged fever (≥5 days), patients have at least 4 of the 5 following mucocutaneous findings:
Extremity changes are often the last to develop; however, a high index of suspicion must be maintained because the diagnostic findings do not always present in a particular order, and some symptoms may resolve prior to the onset of others during the course of illness. Diagnosis is often delayed in children age >5 due to the relatively low incidence of Kawasaki disease in this age group.
(Choices B and E) Prolonged fever, diffuse lymphadenopathy (eg, inguinal, axillary), and splenomegaly can be seen with infectious mononucleosis (eg, Epstein-Barr virus [EBV]) or malignancy (eg, leukemia). However, patients with EBV typically have an exudative pharyngitis as well as posterior cervical lymphadenopathy (not seen here), and leukemia does not explain this patient's blanching rash or conjunctivitis. Moreover, lymphadenopathy in malignancy is often nontender and matted, unlike this patient's tender and mobile cervical node. Splenomegaly and noncervical lymphadenopathy are not features of Kawasaki disease.
(Choice C) Petechiae would be expected in Rocky Mountain spotted fever, which can present with rash and fever. Unlike this case, however, patients often have severe abdominal pain, and the rash typically spreads from the extremities toward the trunk. In addition, an isolated, enlarged cervical lymph node would be atypical.
(Choice D) Scarlet fever may present with fever, exudative pharyngitis, and a sandpaper-like rash most prominent along the skinfolds (eg, axillae, groin). This patient has no posterior pharyngeal findings, and the rash is present only on the trunk.
Educational objective:
Kawasaki disease presents with fever ≥5 days, in addition to 4 of 5 mucocutaneous findings: conjunctivitis, mucositis, rash, distal extremity changes, and cervical lymphadenopathy.