More than just a stubborn Fever !

A 5 year old male child presented with high grade fever for 3 consecutive days. His parents took him to his family paediatrician where the child was diagnosed with acute tonsillitis. He was put on oral antibiotics, but his fever persisted even after 48 hours. Parents returned to the doctor on day 5 of illness with complaint that the fever was persistent. The boy had developed red cracked lips and red tongue along with a red eye and rash all over the body.

The child underwent a few blood investigations and was advised admission as he had very high blood counts suggesting infection. He also had high CRP and raised levels of some liver enzymes. He was treated for bacterial infection/typhoid in the hospital. He continued to get spikes of high fever. His investigation reports (for tests sent on admission) were collected on day 6. The reports did not give any clarity on the cause of fever. Even by day 9, the child did not show improvement in fever.

Not satisfied with the outcome, the parents shifted him to another hospital where they were told that the child had measles. As parents googled the symptoms of the child, they were convinced that the doctor was correct in his measles diagnosis. The hospital where the child was shifted made a few modifications to the ongoing treatment and admitted him. But by now, the child had become very irritable. Though the rashes had faded without leaving any mark, his lips had dried and become crusted. He developed some oedema of hands and feet which the parents attributed to the intravenous (IV drips) bottles given to the child.

Unfortunately, even by day 12, his fever kept persisting, without any change in frequency and severity. Even after days of hospitalization and having undergone all required investigations, the cause of the illness could not be determined. This had also ruled out the possibility of a condition known as Pyrexia of Unknown Origin (PUO) where clinicians are not able to identify the cause of illness even after 7 days of hospitalization.

By day 12 of his illness, the child was referred to a higher centre i.e. our hospital. As they reached our hospital, we started from scratch by taking a detailed history of the child, as history has the most importance in such cases. We asked about his condition since day one of fever, asked about every small detail related to his fever, rash, red eye, swelling of body. We asked parents about his routine eating habits like raw milk consumption etc. and if he had exposure to animals or if they had seen any similar cases in the child’s school or community.

Thanks to the smart phone era, the child’s Dadi had all the pictures of the child since the onset of the illness. We could see the picture of the rashes, non-infectious / non-sticky conjunctivitis and red (classical strawberry colour) tongue. This helped us in our diagnosis.

After repeating laboratory investigations and getting a few more reports done, we were convinced that the child had a relatively common disease that was missed many times because of no specific test to prove it. It is called Kawasaki Disease.

By this time, it was day 15 of fever. We put him on standard treatment for Kawasaki Disease. Within 48 hours, the child started showing improvement and was discharged 5 days later. The child is healthy now and has been on regular follow up of more than one year and he has not developed any long term complication associated with Kawasaki Disease.

Scientific Insight:

Kawasaki Disease (KD) is a clinical diagnosis, where other common diseases have to be ruled out in order to confirm KD. KD mimics measles like illness and hence is often mistaken for measles. Often the disease does not present with all the classical symptoms/pictures written and described in text books. KD often has incomplete or atypical presentation in the patient. This makes it very difficult to diagnose KD.

By : Dr. Ankit Mehta

DM Pediatric Critical Care and Critical Medicine (PGIMER Chandigarh)
MD Pediatrics