Presenting History
In children presenting with suspected Kawasaki Disease, document the fever duration, systematically screen for all 5 principal AHA criteria, evaluate for BCG scar reactivation, and check for signs of acute myocarditis.
- Fever Duration & Character:
- Has the high fever persisted for at least 5 days?
- Is the fever continuous, remittent ($102-104^\circ\text{F}$), and unresponsive to standard antibiotics and paracetamol?
- Is the child disproportionately irritable, miserable, and inconsolable (aseptic meningitis)?
- AHA Principal Criteria Screen:
- Bilateral Eye Redness: Did the eyes become glassy red without pus, crusting, or discharge? Is there a clear halo around the iris (perilimbal sparing)?
- Oral Cavity Changes: Are the lips fiery red, cracked, or bleeding? Is the tongue red and bumpy like a strawberry?
- Extremity Changes: Are the palms and soles swollen, indurated, bright red, and painful to stand on?
- Skin Rash: Is there a red blotchy rash over trunk and perineum? Is there early peeling of skin in the groin?
- Cervical Swelling: Is there a tender, non-suppurative lymph node on one side of the neck measuring $\ge 1.5\text{ cm}$?
- BCG Scar Reactivation:
- Has the old BCG scar on the left upper arm become red, swollen, indurated, or crusted?
Negative History (3C 1D Framework)
| Category | Pertinent Negative Question | Rationale / Significance |
|---|---|---|
| Causes | Infections: No history of cough, coryza, Koplik spots, or exudative tonsillitis. Staphylococcus: No honey-colored crusts, bullae, or positive Nikolsky sign. | Rules out measles, adenovirus, and Epstein-Barr virus. Rules out Staphylococcal Scalded Skin Syndrome (SSSS) and toxic shock. |
| Complaints (Differentiating) | Systemic JIA: No history of evanescent salmon-pink rash or once-daily quotidian spikes. Drug Reaction: No history of new antiepileptic or sulfa drug ingestion (rules out SJS/TEN). | Fever in KD is continuous/remittent; rash is fixed and polymorphous. Differentiates severe cutaneous adverse reactions from medium-vessel vasculitis. |
| Complications | Coronary Ischemia / Infarction: No sudden pale clamminess, unexplained vomiting, or acute shock. Congestive Heart Failure: No tachypnea, orthopnea, or gallop rhythm. | Coronary arteritis and thrombosis cause acute myocardial infarction in young children. Acute myocarditis occurs in $>50\%$ during the acute phase. |
| Differentials | MIS-C: Occurs in older children with documented COVID-19 exposure, severe shock, and marked ventricular dysfunction. | Differentiates classic KD from post-COVID Multisystem Inflammatory Syndrome. |
Other Relevant History
- Age Factor: Infants $<6$ months and children $>5$ years are at the highest risk for Incomplete Kawasaki Disease and giant coronary aneurysms.
- Family History & Pedigree: Premature coronary artery disease in family; sibling cases of Kawasaki disease.
History Summary
"Master/Miss `Patient Name`, a `Age` old `male/female` child, `Birth Order` born of a `consanguineous/non-consanguineous` marriage from `City, State`, presented on Day `Day of illness` of high continuous fever unyielding to antibiotics, bilateral non-purulent conjunctival injection, strawberry tongue, induration of hands and feet, polymorphous exanthem, unilateral cervical lymphadenopathy, and BCG scar reactivation, with marked irritability.
In view of the persistent fever $\ge 5$ days with `Number of criteria`/5 principal AHA criteria, I would like to consider a provisional diagnosis of Complete (Classic) Kawasaki Disease on Day `Day` of illness, requiring emergent echocardiography and high-dose IVIG ($2\text{ g/kg}$) therapy."
General & Head-to-Toe Examination
- Behavioral State: Prechtl state (marked irritability, inconsolable crying).
- Vitals: Heart rate (check for tachycardia disproportionate to fever $\rightarrow$ myocarditis), respiratory rate, blood pressure, temperature.
- Systematic AHA Principal Criteria Examination:
- Eyes: Bilateral bulbar conjunctival injection with perilimbal sparing; no exudate.
- Mouth: Erythema and vertical bleeding fissures of lips; Strawberry Tongue; pharyngeal erythema.
- Extremities: Brawny induration and fiery erythema of palms and soles; assess tenderness and weight bearing.
- Skin: Polymorphous non-vesicular exanthem; examine perineum for confluent erythema and desquamation.
- Neck: Measure dimensions of largest cervical lymph node (diagnostic $\ge 1.5\text{ cm}$).
- BCG Site: Inspect left deltoid scar for erythema, induration, or ulceration.
Systemic Examination
Cardiovascular System (CVS)
- Tachycardia disproportionate to temperature; listen carefully for Gallop Rhythm ($S_3$) and soft apical systolic murmur (mitral regurgitation from myocarditis).
Abdomen
- Palpate for right upper quadrant tenderness and hepatomegaly (screen for gallbladder hydrops).
Central Nervous System
- Extreme irritability; check for meningismus (aseptic meningitis).
Final Summary & Diagnosis
"A `Age` old `male/female` child presenting on Day `Day of fever` of illness with high continuous fever, fulfilling `Number of criteria`/5 principal AHA criteria (conjunctivitis, strawberry tongue, extremity edema, rash, lymphadenopathy), accompanied by BCG scar reactivation and sinus tachycardia with gallop rhythm (myocarditis).
My final diagnosis is Complete Kawasaki Disease on Day `Day` of illness, complicated by acute myocarditis, requiring immediate high-dose Intravenous Immunoglobulin (2 g/kg) and anti-inflammatory Aspirin to prevent coronary artery aneurysms."