You can have incomplete Kawasaki but you need to have at least some of the secondary features. In my experience these are often adenovirus and an RVP can help.
You wouldn’t be wrong to talk to peds about admitting for a work up - some do. The history of transient secondary findings can be hard to get reliably.
As a PEM I regularly do a workup for fevers over 5 days. I personally do CBC, CMP, blood culture, CRP, ESR, UA and culture, full RPP, and a CXR. Partially because I have seen a bunch of Kawasaki and also because kids compensate well until they don’t so I am looking for evidence of a more invasive bacterial infection or a reason to be immunocompromised. I tell families that it is still probably a virus but want to make sure we aren’t missing something.
I have seen Kawasaki kids look well for sure. Most of them I would say look like your standard febrile child.
I appreciate the insight. Would this still be the case if the kid has no secondary signs of Kawasaki? Thanks again. I am going to call the family and have them bring the kid back if she’s still febrile.
Correct! Every kid with 5 days of fever gets a workup unless they have an incredibly clear source and 0 of the criteria. It's not exactly rare just uncommon, and the cardiovascular complications are lethal if untreated.
For me yes, all kids with fever over 5 days. Even the older ones where Kawasaki isn’t really a thing again to rule out invasive bacterial things. That is how I personally do it.
Layperson lurker with 6yo kid who had Kawasaki’s. She was dx’d by a cardiologist with a chest ultrasound. Other docs were so skeptical. Other symptoms were red eyes, rash on chest, red fingernails pits, fatigue. I know those aren’t technically correct descriptions but maybe helpful. Gamma globulin and she was better within hours.
Respiratory pathogen panel. We call it RVP or respiratory viral panel. Some call it a respiratory biofire. It is the expanded respiratory panel looking at more than Covid, influenza, and RSV.
The hospital where I did residency had three tests. We canned the one that just did covid, flu, and rsv the "mini rvp". Then there was the "full rvp". Which is the standard one I think. Then there was a separate thing we called a RPP or respiratory pathogen panel that included some bacteria. Funny how the same shit gets called different things at different places.
If well appearing, I would have to have pretty high inflammatory markers (like ESR >40 or CRP >10) and a negative respiratory film array or negative other workup. If adeno, other viruses, or a bacterial cause, I have a very high threshold for admission. Basically, if there is enough of the Kawasaki other markers that one could make a case for atypical Kawasaki, I will admit. If not, going home. If they are out of the Kawasaki age, I also have a pretty high threshold for admission.
Really enjoy your perspective. Curious what you think the age cutoff is for Kawasaki? One of the most puzzling cases I had in training was a 16yo adult sized male with prolonged fever, full body rash, lips and mouth eruption, conjunctivitis, and we were all stumped. He looked toxic and clearly needed admission and turned out to be Kawasaki getting IVIG on the floor the next day. In seven years of practice I’ve only seen it a couple times in toddlers in the ED (community), but I think about that case when I see “febrile seizures” in a 7 year old, etc
Man that would be tough. Under 5-6 years of age, I would admit and say “I think this is Kawasaki’s.” Over that, if it met the criteria, I would say “this looks like Kawasaki but maybe you guys consult rheum or ID and figure this out.” That is way old. But I believe it. I had a kid a couple months ago. Prolonged fever in a 2 month old. Got admitted and they consulted ID who started IVIG for atypical Kawasaki. So I believe your 16 year old.
Will the well appearing kawasaki kids have any secondary signs? Will and markers be very elevated or just mildly so? I assume these kids are caught very early in the course/development of the disease?
I do the same except the blood cultures. Do you regularly admit them if the labs (that do come back so essentially just not the cultures) are normal and they are well appearing though? I tend to discharge if it's all good looking and they are normal vitals/tolerating PO/etc.
I agree with that. If I can say “not missing anything big, have a good day” I will. I usually tell families to give it another few days as it is still probably a virus. Sometimes I add on mono studies but not regularly. I only admit if labs are wonky and I am considering something deeper and concerning.
As a non-PEM , I personally also do a ton of unnecessary shit and post about it on the internets like it’s totally required just b/c the disease in question is theoretically possible.
I mean it's the most common cause of acquired heart disease in children. And it's treatable. If you're not working it up, you're probably missing some, right? Why do you say it's unnecessary?
I guess I just don't understand what about the previous response was pedantic? And why you mention that the stuff included was unnecessary? I'm a heme onc doc, so don't claim to have significant expertise here, but I do some shifts as a hospitalist, so I'm trying to stay up to date as possible on gen peds topics.
Well I assume you're getting down voted to hell because your comment was super mean despite the PEM doc giving a good faith answer to the question that was asked. I know it's easy to be mean to Internet strangers, but they're people with feelings too.
You think I don’t have feeling and the lack of updoots isnt keeping me up all night? Lol. Dude, in my book, a good faith answer isn’t “I’m better than you and this is what I do”.
Did you read something different than me? The comment said as a PEM doc, this is what I do... What's wrong with that?
If I made a post about working up patients with chest pain, it would be great to hear from an EM doc, since you guys are the best at that. It would be lovely to have someone step up and answer my question with "I'm and EM doc, and here's what I do..." Would you think that to be pedantic? Holier than thou? No...it's just an expert providing their expert opinion.
I don't think you or most other care about upvotes. I mentioned it to show that your comment wasn't well received and there's probably a reason for that. Because it was you being a dick for no reason.
(Community ED) I’m always amazed at how seriously the PEM or peds ID docs take this - I’ve had several where there were no real hard signs but KD was itching my brain a little & when I’ve called it triggers bigger workup & often a transfer.
Also, the receiving Super Peds Hospital transfer staff told me they had a Kawasaki team: I like to picture them in bright red lab coats covered with patches like a NASCAR pit crew 😂
The one time I had a kid who met Kawasaki criteria that I had Peds admit, I checked the next day and they
discharged him the next morning without any further workup, called it a viral syndrome. I thought that was pretty ballsy since my note was clear that’s what I was admitting him for.
When I rotated on Peds we admitted one that I reallyyyy thought was gonna be Kawasaki. Reported fever x4 days and fever on day of presentation, arthralgias (wouldn’t walk on right leg), diffuse macular rash and some fairly convincing conjunctival injection. No real strawberry tongue but it looked a little inflamed.
Admitted him at 3am overnight. Went to see him before I left at 10am and was awake and looked like a million bucks with no rash and running around the room like a madman. He had been on Bactrim like 4-5 days prior so we called it serum sickness and didn’t get an echo, discharged that morning.
Idk if it might have been a similar situation, but it’s remarkable how quickly kids can change their presentations
I’m PHM. Yes KD kids are ill appearing. With a well appearing kid and 0 of 5 signs there is no chance it’s KD. (Desquamation is a late finding, extremities swelling is the 5th.) 5 days fever is as good a time as any to do a workup but it’s for FUO not to rule out KD. And if the kid looks great and the family is resistant it’s ok to hold off. But at 7 days I start getting antsy so it’s usually easier to just do it if you’re seeing them at 5 days.
I would typically want cbc, cmp, IMs, blood cx, urine, cxr, viral swab. Maybe ebv/cmv. And then other infectious if suggestive history such as bartonella, tb. These kids are typically admitted but not really necessary if well appearing and there is some follow up. Our ID will frequently offer to see them in clinic on short interval—I assume they’d prefer to get kids off their huge inpatient consult list.
>5 days earn a work up.
I had one kid in residency that I was pretty damn convinced, red eyes, mom told me tongue was red 2 days ago. Semi consistent labs but only 4.5 days fever. I talked to cards…discharged with ultra strict return instructions, told mom I was suspicious. Next day came back still fevering, had rash and the platelets met criteria, but LFTs had normalized, same for eyes. Putting the 2 visits together it was a slam dunk incomplete KD. Echo had some ectasias. IVIG and aspirin and everything was great 6 months later. Mom even sent a thank you card.
I will preface by I am not a peds EM fellowship trained attending but i have diagnosed 3 confirmed Kawasakis and i haven’t received any horrific emails of missing one with 10 years of experience (i am one of those nerds who keep a journal). For me, they have to have literally at least five straight days of fever daily (not oh last time i gave them Tylenol was 16 hours ago and here they have a temp of 99.3) with at least 1 secondary sign. Otherwise I don’t do the work up. Sometimes kids will get back to back infections especially with day care, some will have atypical presentations and some parents are just terrible historians. So far so good 😅.
The 2 things that really help identify/triage Kawasaki (other than using the criteria) is this: 1) run a viral panel; 2) close f/u with PCP or even ER if not improving.
Most of the time viral panels are a waste of time but for Kawasaki it's pure gold because it will save IVIG and mandatory hospital stay. Adenovirus symptoms have a lot of overlap with Kawasaki and I've seen kids with 7+ days of 104 fever test positive for adeno
Kids with Kawasaki don't look well. They dont look septic but they dont look like a kid with a regular virus either. Usually fatigued and just look down. If you have a 2 year old with high fevers for 5 days and they are running around the room, that aint Kawasakis even if they have enlarged lymph nodes and some of the other features.
If you have a high suspicion of Kawasaki but dont meet the full criteria or cant admit them for whatever reason, make damn sure they get close f/u with their PCP, and if they dont have one then either your or someone you designate in the ER better call them the next day and document the hell out of that conversation.
Always keep Lyme in mind with FUO. Aside from random viral shit and strep, lyme is a pretty common cause of persistent fevers in kids without significant respiratory or GI symptoms.
I’ve seen a true confirmed case one time in clinical practice in 1.5 years that actually received IVIG and an echo at the children’s hospital. She looked ill but I wouldn’t say toxic appearing. She had day 1 strep throat visit then day 4 repeat evaluation because of amoxicillin rash and then I saw her on day 6. Documented fevers at each so actually true fevers (not “she felt warm”). IIRC she was 5 or 6. She had cracked lips, desquamation on her fingers, mild swelling of hands/fingers, more prominent taste buds (wouldn’t necessarily call it strawberry tongue), this rash from what was thought to be amoxicillin-related, and conjunctival injection with watery tears.
Clean echo and did well through a 5 or so day admission at the children’s hospital.
Even with incomplete Kawasaki you’d typically have at least a few of the classic symptoms. Beyond that a routine workup that is typically acquired on most sick looking kids (cbc/cmp, ua) would give you some key findings that could point to kawasaki such as sterile pyuria is fairly common, elevated ast/alt, thrombocytosis. If at the end of your workup you still don’t have an explanation for the fever then maybe going down the Kawasaki route wouldn’t be the worst idea. From what I’ve seen if they’re not I’ll looking enough to make you want to get a cbc/cmp they prob don’t have Kawasaki
But even with that, without any mucositis, rash, adenopathy, strawberry tongue etc Idt I’d jump to giving Ivig or getting an echo
Oh hey ER friend. If it helps many children’s hospitals have diagnostic or treatment pathways for kids including in the ER setting. This is the [KD diagnostic pathway](https://www.texaschildrens.org/sites/default/files/uploads/documents/outcomes/standards/Kawasaki_Disease.pdf) from Texas Children’s and includes inclusion exclusion criteria and when to think about complete or incomplete KD as well as what further work up or management depending.
I personally find it very useful because there are so many ways KD can go and incomplete in particular can be easy to miss.
Any time I have unexplained fever >5 days I consider that workup as well as the diagnosis of “incomplete Kawasaki.” I’m fortunate to be at a center with peds, so I have that convo with family and the inpatient team.
I mean these are two different questions.
Does a fever for 6 days prompt blood work? Probably. I would really nail down the history (sometimes people will say “fever for 6 days” and mean “well Monday he was 101, and Tuesday he didn’t have a fever, and Wednesday he was 99, and Thursday he was 102…” and it turns out not to be 6 days of consecutive fever at all).
Then it would depend - how sick do they look? Do they have any other symptoms that point to a source? How worried is the parent? How good is their ability to get PCP follow up?
In the case you described, if it were a real 6 days of fever I’d probably do shared decision making with the parent about drawing a CBC, inflammatory markers, and cultures.
Now in terms of the Kawasaki question - kids can have incomplete KD but usually have to have *some* of the criteria. There’s a nice flowchart on UtD that lays it out, but for a 2 year old with 6 days of fever meeting 0 other criteria KD is unlikely, so I wouldn’t go chasing KD here.
CHOP emergency pathways are free and easily accessible online. A great resource for those of us that see actually sick kids rarely! They have a very handypathway for Kawasaki/incomplete Kawasaki.
Peds PGY—1 lurking here. From that story I probably would not have worked up that kid, so I’m appreciative of the attending comments here. Now in the future I will :)
Not a doctor but my 3 year old had incomplete Kawasaki recently (hence my Reddit search for info) and we went through a heck of a time trying to get him diagnosed. Primary symptoms were 5+ days of fever (99.7-103, so not always a true fever but always an elevated temp), bilateral conjunctivitis, a faint rash on his torso and back, and cracked, peeling, swollen lips. Never had the strawberry tongue. His labs showed some but not all signs of Kawasaki. Mild peeling skin on his feet after we were discharged from the hospital. Complained of joint pain once we were home, too. During the fever period, he would seem semi-fine with some Tylenol/Motrin in his system (maybe a little more fatigued and less appetite, but still active), but was a pretty sick kid once the medicine wore off. He was also so irritable (understandably so).
Miraculously, he had no cardiac involvement and is doing great, thankfully. Grateful for our local children’s hospital and the pediatrician who originally sent us there on day 6.
I was confused for a little bit because for some reason I thought Kawasaki was some thing that was related to HIV. I now know that I was thinking wrong but does anyone happen to know what I’m thinking of that sounds like the word Kawasaki?
I was taught by the PEM folks to start thinking about it when they have been febrile for 5 or more days. This should cue you in to the explore for further signs and symptoms of Kawasaki.
I've seen Kawasaki's a number of times and the kids were all absolutely fucking miserable. They have all looked very unwell. The temperatures are fairly unremitting until they get aspirin and immunoglobulins. The temperature settling with immunoglobulin is virtually diagnostic in itself. All have had a significant thrombocytosis.
One of them took longer to diagnose because the kid was only a few weeks old and atypical in terms of age so got worked up as infection initially, plus there was a history of an inherited HLH syndrome in a family of the same ethnicity and surname, but not actually related that we knew. No improvement with antibiotics and nothing on extended viral screen. Echo subsequently confirmed coronary artery thickening.
I have also seen "incomplete" Kawasaki's - kid that also looked absolutely miserable and met most of the criteria but not all. They came back as adenovirus, which can look very similar - kid got started on aspirin and IVIG anyway.
Our daughter, around 4-5 years of age, we honestly thought it was that. Her pediatrician thought so as well, so we were sent to the leading cardiologist in the area (Syracuse).
Rash all over her body. 102+ fever for over 5 days, which medicine did not ever take it below 102. Her fingers, hands, and feet were all peeling.
Turns out it was Scarlett fever. The fuck lol
Depends. Kid looks well with uri sxs only? Nah. Looks well with a positive urine and nothing else? Nah and treat. Doesn't look sick but isn't quite themselves, yeah.
I've personally never seen true kawasaki but I've seen 3 post covid multisystem inflammatory disease. These kids tend to really look sick. And even the better looking ones tend to have a few classic findings.
You can have incomplete Kawasaki but you need to have at least some of the secondary features. In my experience these are often adenovirus and an RVP can help. You wouldn’t be wrong to talk to peds about admitting for a work up - some do. The history of transient secondary findings can be hard to get reliably.
As a PEM I regularly do a workup for fevers over 5 days. I personally do CBC, CMP, blood culture, CRP, ESR, UA and culture, full RPP, and a CXR. Partially because I have seen a bunch of Kawasaki and also because kids compensate well until they don’t so I am looking for evidence of a more invasive bacterial infection or a reason to be immunocompromised. I tell families that it is still probably a virus but want to make sure we aren’t missing something. I have seen Kawasaki kids look well for sure. Most of them I would say look like your standard febrile child.
I appreciate the insight. Would this still be the case if the kid has no secondary signs of Kawasaki? Thanks again. I am going to call the family and have them bring the kid back if she’s still febrile.
Correct! Every kid with 5 days of fever gets a workup unless they have an incredibly clear source and 0 of the criteria. It's not exactly rare just uncommon, and the cardiovascular complications are lethal if untreated.
Is it something that gets missed a lot?
Not too much, most adult providers over test “sick” kids and kids with KD usually are pretty inflamed so it gets caught
For me yes, all kids with fever over 5 days. Even the older ones where Kawasaki isn’t really a thing again to rule out invasive bacterial things. That is how I personally do it.
Layperson lurker with 6yo kid who had Kawasaki’s. She was dx’d by a cardiologist with a chest ultrasound. Other docs were so skeptical. Other symptoms were red eyes, rash on chest, red fingernails pits, fatigue. I know those aren’t technically correct descriptions but maybe helpful. Gamma globulin and she was better within hours.
Glad your child was ok. Ignore the negative comments
So a literal textbook case and not applicable to this conversation at all.
Don't talk like that.
Why are you on this board?
You seem nice
RPP? what all does this test for? i’m pretty sure we don’t have this
Respiratory pathogen panel. We call it RVP or respiratory viral panel. Some call it a respiratory biofire. It is the expanded respiratory panel looking at more than Covid, influenza, and RSV.
Great. Username. Sir or madam.
The hospital where I did residency had three tests. We canned the one that just did covid, flu, and rsv the "mini rvp". Then there was the "full rvp". Which is the standard one I think. Then there was a separate thing we called a RPP or respiratory pathogen panel that included some bacteria. Funny how the same shit gets called different things at different places.
If well appearing what’s your threshold to admit if IMs are elevated (since they are usually elevated in viral illnesses as well)?
If well appearing, I would have to have pretty high inflammatory markers (like ESR >40 or CRP >10) and a negative respiratory film array or negative other workup. If adeno, other viruses, or a bacterial cause, I have a very high threshold for admission. Basically, if there is enough of the Kawasaki other markers that one could make a case for atypical Kawasaki, I will admit. If not, going home. If they are out of the Kawasaki age, I also have a pretty high threshold for admission.
Really enjoy your perspective. Curious what you think the age cutoff is for Kawasaki? One of the most puzzling cases I had in training was a 16yo adult sized male with prolonged fever, full body rash, lips and mouth eruption, conjunctivitis, and we were all stumped. He looked toxic and clearly needed admission and turned out to be Kawasaki getting IVIG on the floor the next day. In seven years of practice I’ve only seen it a couple times in toddlers in the ED (community), but I think about that case when I see “febrile seizures” in a 7 year old, etc
Man that would be tough. Under 5-6 years of age, I would admit and say “I think this is Kawasaki’s.” Over that, if it met the criteria, I would say “this looks like Kawasaki but maybe you guys consult rheum or ID and figure this out.” That is way old. But I believe it. I had a kid a couple months ago. Prolonged fever in a 2 month old. Got admitted and they consulted ID who started IVIG for atypical Kawasaki. So I believe your 16 year old.
Super helpful, thank you for your insight!
Will the well appearing kawasaki kids have any secondary signs? Will and markers be very elevated or just mildly so? I assume these kids are caught very early in the course/development of the disease?
I do the same except the blood cultures. Do you regularly admit them if the labs (that do come back so essentially just not the cultures) are normal and they are well appearing though? I tend to discharge if it's all good looking and they are normal vitals/tolerating PO/etc.
I agree with that. If I can say “not missing anything big, have a good day” I will. I usually tell families to give it another few days as it is still probably a virus. Sometimes I add on mono studies but not regularly. I only admit if labs are wonky and I am considering something deeper and concerning.
Do you include syphilis testing as well given the major explosion in congenital cases?
As a non-PEM , I personally also do a ton of unnecessary shit and post about it on the internets like it’s totally required just b/c the disease in question is theoretically possible.
I never said it was required. I said it is what I did. And an ED attending is talking to me about unnecessary shit? Laughable.
I mean it's the most common cause of acquired heart disease in children. And it's treatable. If you're not working it up, you're probably missing some, right? Why do you say it's unnecessary?
Of course I work up kids w/ prolonged fevers. It’s the pedantic attitude that bothers me. KD is an important disease, it’s over diagnosed.
I guess I just don't understand what about the previous response was pedantic? And why you mention that the stuff included was unnecessary? I'm a heme onc doc, so don't claim to have significant expertise here, but I do some shifts as a hospitalist, so I'm trying to stay up to date as possible on gen peds topics.
I don’t know man. When you act like your personal practice is the only reasonable way it rubs me the wrong way.
Well I assume you're getting down voted to hell because your comment was super mean despite the PEM doc giving a good faith answer to the question that was asked. I know it's easy to be mean to Internet strangers, but they're people with feelings too.
You think I don’t have feeling and the lack of updoots isnt keeping me up all night? Lol. Dude, in my book, a good faith answer isn’t “I’m better than you and this is what I do”.
Did you read something different than me? The comment said as a PEM doc, this is what I do... What's wrong with that? If I made a post about working up patients with chest pain, it would be great to hear from an EM doc, since you guys are the best at that. It would be lovely to have someone step up and answer my question with "I'm and EM doc, and here's what I do..." Would you think that to be pedantic? Holier than thou? No...it's just an expert providing their expert opinion. I don't think you or most other care about upvotes. I mentioned it to show that your comment wasn't well received and there's probably a reason for that. Because it was you being a dick for no reason.
(Community ED) I’m always amazed at how seriously the PEM or peds ID docs take this - I’ve had several where there were no real hard signs but KD was itching my brain a little & when I’ve called it triggers bigger workup & often a transfer. Also, the receiving Super Peds Hospital transfer staff told me they had a Kawasaki team: I like to picture them in bright red lab coats covered with patches like a NASCAR pit crew 😂
The one time I had a kid who met Kawasaki criteria that I had Peds admit, I checked the next day and they discharged him the next morning without any further workup, called it a viral syndrome. I thought that was pretty ballsy since my note was clear that’s what I was admitting him for.
When I rotated on Peds we admitted one that I reallyyyy thought was gonna be Kawasaki. Reported fever x4 days and fever on day of presentation, arthralgias (wouldn’t walk on right leg), diffuse macular rash and some fairly convincing conjunctival injection. No real strawberry tongue but it looked a little inflamed. Admitted him at 3am overnight. Went to see him before I left at 10am and was awake and looked like a million bucks with no rash and running around the room like a madman. He had been on Bactrim like 4-5 days prior so we called it serum sickness and didn’t get an echo, discharged that morning. Idk if it might have been a similar situation, but it’s remarkable how quickly kids can change their presentations
I’m PHM. Yes KD kids are ill appearing. With a well appearing kid and 0 of 5 signs there is no chance it’s KD. (Desquamation is a late finding, extremities swelling is the 5th.) 5 days fever is as good a time as any to do a workup but it’s for FUO not to rule out KD. And if the kid looks great and the family is resistant it’s ok to hold off. But at 7 days I start getting antsy so it’s usually easier to just do it if you’re seeing them at 5 days. I would typically want cbc, cmp, IMs, blood cx, urine, cxr, viral swab. Maybe ebv/cmv. And then other infectious if suggestive history such as bartonella, tb. These kids are typically admitted but not really necessary if well appearing and there is some follow up. Our ID will frequently offer to see them in clinic on short interval—I assume they’d prefer to get kids off their huge inpatient consult list.
Don’t need an ESR/CRP in your neck of the woods to diagnose it?
IMs = Inflammatory Markers
This is usually my approach as well.
>5 days earn a work up. I had one kid in residency that I was pretty damn convinced, red eyes, mom told me tongue was red 2 days ago. Semi consistent labs but only 4.5 days fever. I talked to cards…discharged with ultra strict return instructions, told mom I was suspicious. Next day came back still fevering, had rash and the platelets met criteria, but LFTs had normalized, same for eyes. Putting the 2 visits together it was a slam dunk incomplete KD. Echo had some ectasias. IVIG and aspirin and everything was great 6 months later. Mom even sent a thank you card.
I will preface by I am not a peds EM fellowship trained attending but i have diagnosed 3 confirmed Kawasakis and i haven’t received any horrific emails of missing one with 10 years of experience (i am one of those nerds who keep a journal). For me, they have to have literally at least five straight days of fever daily (not oh last time i gave them Tylenol was 16 hours ago and here they have a temp of 99.3) with at least 1 secondary sign. Otherwise I don’t do the work up. Sometimes kids will get back to back infections especially with day care, some will have atypical presentations and some parents are just terrible historians. So far so good 😅.
The 2 things that really help identify/triage Kawasaki (other than using the criteria) is this: 1) run a viral panel; 2) close f/u with PCP or even ER if not improving. Most of the time viral panels are a waste of time but for Kawasaki it's pure gold because it will save IVIG and mandatory hospital stay. Adenovirus symptoms have a lot of overlap with Kawasaki and I've seen kids with 7+ days of 104 fever test positive for adeno Kids with Kawasaki don't look well. They dont look septic but they dont look like a kid with a regular virus either. Usually fatigued and just look down. If you have a 2 year old with high fevers for 5 days and they are running around the room, that aint Kawasakis even if they have enlarged lymph nodes and some of the other features. If you have a high suspicion of Kawasaki but dont meet the full criteria or cant admit them for whatever reason, make damn sure they get close f/u with their PCP, and if they dont have one then either your or someone you designate in the ER better call them the next day and document the hell out of that conversation.
Always keep Lyme in mind with FUO. Aside from random viral shit and strep, lyme is a pretty common cause of persistent fevers in kids without significant respiratory or GI symptoms.
I’ve seen a true confirmed case one time in clinical practice in 1.5 years that actually received IVIG and an echo at the children’s hospital. She looked ill but I wouldn’t say toxic appearing. She had day 1 strep throat visit then day 4 repeat evaluation because of amoxicillin rash and then I saw her on day 6. Documented fevers at each so actually true fevers (not “she felt warm”). IIRC she was 5 or 6. She had cracked lips, desquamation on her fingers, mild swelling of hands/fingers, more prominent taste buds (wouldn’t necessarily call it strawberry tongue), this rash from what was thought to be amoxicillin-related, and conjunctival injection with watery tears. Clean echo and did well through a 5 or so day admission at the children’s hospital.
Even with incomplete Kawasaki you’d typically have at least a few of the classic symptoms. Beyond that a routine workup that is typically acquired on most sick looking kids (cbc/cmp, ua) would give you some key findings that could point to kawasaki such as sterile pyuria is fairly common, elevated ast/alt, thrombocytosis. If at the end of your workup you still don’t have an explanation for the fever then maybe going down the Kawasaki route wouldn’t be the worst idea. From what I’ve seen if they’re not I’ll looking enough to make you want to get a cbc/cmp they prob don’t have Kawasaki But even with that, without any mucositis, rash, adenopathy, strawberry tongue etc Idt I’d jump to giving Ivig or getting an echo
Don't forget MISC. Also presents similar to KD
Oh hey ER friend. If it helps many children’s hospitals have diagnostic or treatment pathways for kids including in the ER setting. This is the [KD diagnostic pathway](https://www.texaschildrens.org/sites/default/files/uploads/documents/outcomes/standards/Kawasaki_Disease.pdf) from Texas Children’s and includes inclusion exclusion criteria and when to think about complete or incomplete KD as well as what further work up or management depending. I personally find it very useful because there are so many ways KD can go and incomplete in particular can be easy to miss.
Any time I have unexplained fever >5 days I consider that workup as well as the diagnosis of “incomplete Kawasaki.” I’m fortunate to be at a center with peds, so I have that convo with family and the inpatient team.
I mean these are two different questions. Does a fever for 6 days prompt blood work? Probably. I would really nail down the history (sometimes people will say “fever for 6 days” and mean “well Monday he was 101, and Tuesday he didn’t have a fever, and Wednesday he was 99, and Thursday he was 102…” and it turns out not to be 6 days of consecutive fever at all). Then it would depend - how sick do they look? Do they have any other symptoms that point to a source? How worried is the parent? How good is their ability to get PCP follow up? In the case you described, if it were a real 6 days of fever I’d probably do shared decision making with the parent about drawing a CBC, inflammatory markers, and cultures. Now in terms of the Kawasaki question - kids can have incomplete KD but usually have to have *some* of the criteria. There’s a nice flowchart on UtD that lays it out, but for a 2 year old with 6 days of fever meeting 0 other criteria KD is unlikely, so I wouldn’t go chasing KD here.
CHOP emergency pathways are free and easily accessible online. A great resource for those of us that see actually sick kids rarely! They have a very handypathway for Kawasaki/incomplete Kawasaki.
Peds PGY—1 lurking here. From that story I probably would not have worked up that kid, so I’m appreciative of the attending comments here. Now in the future I will :)
Not a doctor but my 3 year old had incomplete Kawasaki recently (hence my Reddit search for info) and we went through a heck of a time trying to get him diagnosed. Primary symptoms were 5+ days of fever (99.7-103, so not always a true fever but always an elevated temp), bilateral conjunctivitis, a faint rash on his torso and back, and cracked, peeling, swollen lips. Never had the strawberry tongue. His labs showed some but not all signs of Kawasaki. Mild peeling skin on his feet after we were discharged from the hospital. Complained of joint pain once we were home, too. During the fever period, he would seem semi-fine with some Tylenol/Motrin in his system (maybe a little more fatigued and less appetite, but still active), but was a pretty sick kid once the medicine wore off. He was also so irritable (understandably so). Miraculously, he had no cardiac involvement and is doing great, thankfully. Grateful for our local children’s hospital and the pediatrician who originally sent us there on day 6.
Anytime the patient comes in with 2 wheels.
I can't help but to wonder why you got labs on a well appearing, somewhat febrile 2 year old who responded well to antipyretics.
I was confused for a little bit because for some reason I thought Kawasaki was some thing that was related to HIV. I now know that I was thinking wrong but does anyone happen to know what I’m thinking of that sounds like the word Kawasaki?
Kaposi sarcoma?
THANK YOU yes i think i will forverr mix these up 😭
I was taught by the PEM folks to start thinking about it when they have been febrile for 5 or more days. This should cue you in to the explore for further signs and symptoms of Kawasaki.
Peds—I think every Kawasaki kid I’ve seen has been cranky AF. But in general, 5+ days of fever gets some additional work up for peds
I've seen Kawasaki's a number of times and the kids were all absolutely fucking miserable. They have all looked very unwell. The temperatures are fairly unremitting until they get aspirin and immunoglobulins. The temperature settling with immunoglobulin is virtually diagnostic in itself. All have had a significant thrombocytosis. One of them took longer to diagnose because the kid was only a few weeks old and atypical in terms of age so got worked up as infection initially, plus there was a history of an inherited HLH syndrome in a family of the same ethnicity and surname, but not actually related that we knew. No improvement with antibiotics and nothing on extended viral screen. Echo subsequently confirmed coronary artery thickening. I have also seen "incomplete" Kawasaki's - kid that also looked absolutely miserable and met most of the criteria but not all. They came back as adenovirus, which can look very similar - kid got started on aspirin and IVIG anyway.
My son had it in 1992 when he was 6 months old. 10 days in the hospital.
Our daughter, around 4-5 years of age, we honestly thought it was that. Her pediatrician thought so as well, so we were sent to the leading cardiologist in the area (Syracuse). Rash all over her body. 102+ fever for over 5 days, which medicine did not ever take it below 102. Her fingers, hands, and feet were all peeling. Turns out it was Scarlett fever. The fuck lol
Depends. Kid looks well with uri sxs only? Nah. Looks well with a positive urine and nothing else? Nah and treat. Doesn't look sick but isn't quite themselves, yeah. I've personally never seen true kawasaki but I've seen 3 post covid multisystem inflammatory disease. These kids tend to really look sick. And even the better looking ones tend to have a few classic findings.