CLIPP case 11. 5yo with fever and adenopathy

Question 1

5yo B with fever x7 days, rash, conjunctivitis, irritability, refusal to walk. On exam, mucosal changes, unilateral cervical lymphadenopathy, maculopapular rash, and changes in extremities (red, swollen).

Answer 1

• Kawasaki disease

* versus: SJS, juvenile RA, measles, RMSF, meningococcemia, scarlet fever, enterovirus

Question 2

Measles

Answer 2

Koplik’s spots on buccal mucosa and prodromal fever, cough, coryza, conjunctivitis -> maculopapular rash behind ears and along hairline -> downward towards feet in 2-3 days

Question 3

Erythema infectiosum

Answer 3

Fifth disease (parvovirus B19): low-grade fever -> rash 7-10 days later, starting as slapped cheek and moving to trunk (erythematous macular) and extremities (lacy reticular)

Question 4

Meningococcemia

Answer 4

Neisseria meningitides: Abrupt onset of rash, with fever, chills, malaise, and prostration. Initial rash urticarial, maculopapular, or petechial. Fulminant cases, purpuric with large hemorrhages into skin.

Question 5

Roseola

Answer 5

HHV-6: Fevers 3-4 days -> Maculopapular rash on trunk -> arms and neck. Usually in patients under two years of age.

Question 6

Scarlet fever

Answer 6

GAS: Fine erythematous, blanching papular rash, sandpaper-like. Groin, axillae, and neck -> spreads rapidly. High fever < 10 days. Treat to prevent rheumatic fever.

Question 7

Varicella

Answer 7

Rash on trunk -> extremities and head. Lesions at various stages of development. Self-limited disease lasting approximately one week.

Question 8

Enterovirus

Answer 8

Rash erythematous and maculopapular, may involve palms and soles.
*In hand-foot-and-mouth disease (Coxsackievirus), a vesicular rash on hands and feet, with ulcers in the mouth.

Question 9

Diffuse adenopathy DDx

Answer 9

-Infectious mononucleosis
-HIV
-Histoplasmosis
-Toxoplasmosis
-Lymphomas
-Leukemia
-Histiocytosis
-Metastatic neuroblastoma
-Rhabdomyosarcoma
-Measles: marked generalized lymphadenopathy and splenomegaly that may
last several weeks

Question 10

Unilateral cervical adenopathy DDx

Answer 10

• Bacterial cervical adenitis (S. aureus, GAS)
• Cat scratch disease: axillae > cervical, submandibular, inguinal
• Reactive node from pharyngeal infection
• Kawasaki disease
• Mycobacterial infection

Question 11

Strawberry tongue

Answer 11

Kawasaki disease or strep pharyngitis

Question 12

Palmar rash

Answer 12

RMSF, secondary syphillis, coxsackievirus A, enterovirus, Kawasaki disease

Question 13

Kawasaki diagnosis

Answer 13

• Fever + 4 of:
• Changes in oral mucosa
• Extremity changes (redness/swelling)
• Unilateral cervical lymphadenopathy
• Rash
• Conjunctivitis
• Other findings: leukocytosis with PMNs, normocytic anemia, transaminitis (also in SJS), low albumin, elevated APRs (plt in 2nd wk), pyuria from clean catch (urethra)

Question 14

SJS

Answer 14

Mucocutaneous disorder with fever, severe stomatitis, conjunctivitis, and erythema multiforme, blistering rash. Formerly called “erythema multiforme major.”

Question 15

Bone or joint infection

Answer 15

• A concern in a young child who suddenly stops walking, since up to 80% of infections are in the lower extremities.
• However, the fever associated with osteomyelitis or septic arthritis is usually not as high

Question 16

Juvenile idiopathic arthritis (JIA)

Answer 16

A group of common rheumatic diseases. Systemic-onset disease (Stills disease) characteristically has prolonged fever, rash, and arthritis, although arthritis often presents much later.

Question 17

RMSF

Answer 17

Rickettsia rickettsii: most common fatal tick-borne disease in U.S.
-fever, myalgias, headache, and petechial rash on wrists and ankles then centrally

Question 18

Viral syndrome

Answer 18

-The viruses most likely to cause fever, a non-descript rash, and presenting in late summer/early fall would be the enteroviruses. -The fever associated with these viral infections in a normal host usually last no longer than three to five days.

Question 19

Treatment of Kawasaki disease

Answer 19

• Hospitalization
• High-dose IVIG to decrease coronary aneurysm
• High-dose ASA until defervescence, and then low-dose x6 wks for anti-plt effects (watch out for Reye syndrome if influenza)
• Echo at presentation and 2 weeks