Prolonged Fever in Young Children: Early Signs of Kawasaki Disease!
Update Date：2024/08/05，
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When you see a headline like this, do you think: Is there a new infectious disease emerging? What is causing this unexplained fever? How can we prevent it? Is it contagious? How serious is it? Could it be life-threatening?
Kawasaki disease is one such illness. It was first reported in 1967 by Dr. Tomisaku Kawasaki in Japan. Decades of research have provided preliminary directions and guidelines for diagnosing and treating Kawasaki disease, significantly reducing the risk of severe complications in children. However, the exact cause of Kawasaki disease remains unknown. The symptoms of Kawasaki disease may not always appear simultaneously, and some patients may not exhibit typical symptoms, making it challenging to diagnose Kawasaki disease promptly.
In 2010, the Taiwan Pediatric Association conducted a survey of over 500 pediatric specialists nationwide and found that Kawasaki disease was considered the most challenging illness by pediatric specialists. This reflects the significant challenges in the clinical diagnosis of Kawasaki disease.
However, if children with Kawasaki disease do not receive timely treatment, the disease can lead to serious complications, such as coronary artery dilatation and aneurysms formation. Therefore, prompt diagnosis and treatment are crucial. According to current treatment guidelines, intravenous immunoglobulin (IVIG) and aspirin are the first-line treatments. These therapies can quickly improve clinical symptoms in children and significantly reduce the risk of coronary artery complications.
Recently, our hospital admitted a one-year-old girl who presented with fever, runny nose, and vomiting. After a series of examinations, she was diagnosed with Kawasaki disease. The child had no significant medical history before. Four days prior to admission, she began experiencing fever, runny nose, and vomiting. Two days later, her parents took her to a clinic, where she started taking symptom-lytic medications. However, her symptoms did not improve, and she continued to have a high fever and vomiting. Her parents then brought her to our pediatric emergency room.
In the emergency room, a physical examination revealed red, cracked lips, bilateral conjunctival injection, redness and swelling of the hands and feet, a rash on the trunk, and redness at the BCG vaccination site. As these signs met the clinical criteria for diagnosing Kawasaki disease, she was promptly treated with IVIG and aspirin. The child's fever subsided and her clinical symptoms improved. After 36 hours of continuous observation without a recurrence of fever, she was discharged.
However, a week later, the child experienced a recurrence of fever and vomiting, with red and swollen eyelids. She was taken to our outpatient clinic, where the echocardiograms revealed dilatation of the coronary arteries, leading to a diagnosis of refractory Kawasaki disease. She was immediately readmitted and received second- and third-line treatments for Kawasaki disease. Although her fever initially subsided and blood tests showed improving inflammation markers, the fever recurred after several days.
Subsequently, fourth-line medication was administered, which finally brought her condition under control. Due to the coronary artery abnormalities, she required continuous anticoagulant medication to prevent thrombus formation. After a year of follow-up and treatment, the child's coronary artery condition was well-managed, with no incidents of narrowing or thrombus formation of the coronary arteries.
The aforementioned case of a one-year-old girl is a relatively uncommon instance of Kawasaki disease. Here are some key signs for early identification of Kawasaki disease. If a child has a persistent fever for more than five days accompanied by four or more of the following symptoms, it is crucial to be vigilant:
Changes in the oral mucosa (red, cracked lips, red tongue, etc.)
Bilateral conjunctival injection (usually without discharge)
Cervical lymphadenopathy (usually unilateral)
Redness and swelling of the hands and feet
Polymorphous rash (typically on the trunk and limbs)
If Kawasaki disease is diagnosed, clinical physicians may order blood tests to assess the child’s inflammatory status and an echocardiogram to evaluate any impact on the coronary arteries. The first-line treatments are IVIG and aspirin. Most children with Kawasaki disease will have a significant reduction in fever and improvement in clinical symptoms within 24 hours. After discharge, the doctor will schedule regular follow-up echocardiograms to monitor for coronary artery abnormalities.
However, if the child continues to have a fever after the first-line treatment, or if any of the following conditions occur, refractory Kawasaki disease should be suspected:
- Persistent Fever: If the child continues to have a fever 24 to 36 hours after completion of initial IVIG therapy.
- Return of fever: If the child has a fever recurrence within two weeks after treatment, unexplained by any cause other than Kawasaki disease.
- Other symptoms and signs of failed initial therapy: This includes manifestations of inflammation associated with Kawasaki disease and progressive dilatation of the coronary arteries.
Since children with refractory Kawasaki disease have a higher risk of developing coronary artery abnormalities, and current research on the best treatment methods for refractory cases is still evolving, it is crucial for clinicians to:
- Timely Identify and Assess: Recognize the possibility of refractory Kawasaki disease and assess the child's condition promptly.
- Develop Personalized Care Plans: Create individualized evaluation and treatment strategies based on the child's specific needs.
- Communicate Effectively: Provide thorough explanations and support to parents and caregivers.
Addressing these issues is essential for managing refractory Kawasaki disease and ensuring comprehensive care for affected children.
Pediatric cardiologist, Wan-Fu Hsu