What is the likely treatment for a child with a high fever, bilateral conjunctivitis, and a desquamating rash presumed to have a vasculitic disease such as Kawasaki disease?

Treatment for Kawasaki Disease in a Child with High Fever, Bilateral Conjunctivitis, and Desquamating Rash

The most appropriate treatment for a child with high fever, bilateral conjunctivitis, and desquamating rash presumed to have Kawasaki disease is aspirin and intravenous immunoglobulin (IVIG). 1

Diagnosis Confirmation

The clinical presentation strongly suggests Kawasaki disease (KD):

• High fever
• Bilateral conjunctivitis (non-exudative)
• Desquamating rash

These findings represent several of the classic criteria for KD diagnosis. The desquamating rash is particularly significant as peeling of the fingers and toes typically occurs 2-3 weeks after onset of symptoms 1.

First-Line Treatment

IVIG Administration

• Administer a single infusion of IVIG at 2 g/kg of body weight 1
• IVIG should be initiated within 10 days of fever onset if possible
• Even if presentation is after 10 days, IVIG should still be administered if fever or other signs of inflammation persist 1

Aspirin Therapy

• High-dose aspirin (80-100 mg/kg/day divided into four doses) should be given concurrently with IVIG 1
• After fever resolution (48-72 hours of being afebrile) or 14 days after symptom onset, reduce to low-dose aspirin (3-5 mg/kg/day as a single dose) 1
• Continue low-dose aspirin for 6-8 weeks if no coronary abnormalities develop, or indefinitely if coronary abnormalities are present 1

Treatment Efficacy and Evidence

High-dose IVIG combined with aspirin has been shown to significantly reduce the risk of coronary artery abnormalities (CAAs) compared to aspirin alone:

• Without treatment, 15-25% of KD patients develop coronary artery abnormalities 1
• With prompt IVIG and aspirin therapy, this risk decreases to approximately 5% for any abnormality and 1% for giant coronary artery aneurysms 1
• IVIG probably reduces CAA incidence compared to aspirin alone (OR 0.60,95% CI 0.41 to 0.87) 2

Management of Treatment-Resistant Cases

If fever persists beyond 36 hours after initial therapy (occurs in 10-15% of patients):

1. Administer a second dose of IVIG (2 g/kg) 1
2. If fever persists after second IVIG dose, consider:
   • Corticosteroids (though controversial) 1
   • Other therapies in refractory cases may include infliximab, pentoxifylline, or abciximab 1

Important Considerations and Precautions

• Timing is critical: Early treatment (within 10 days of fever onset) is associated with better outcomes 1

• Aspirin precautions:

  • Avoid ibuprofen in children taking aspirin as it may antagonize aspirin's antiplatelet effect 1
  • Monitor for Reye's syndrome risk during influenza or varicella infection 1
  • Annual influenza vaccination is recommended for children on long-term aspirin therapy 1

• Monitoring: All patients should have baseline echocardiography and follow-up assessments to detect coronary artery abnormalities 1

Common Pitfalls to Avoid

1. Delayed diagnosis: KD can mimic common childhood illnesses (adenovirus, scarlet fever) leading to treatment delays 1
2. Incomplete recognition: Some children present with incomplete or atypical KD that doesn't meet all classic criteria but still requires treatment 1
3. Inadequate IVIG dosing: Lower-dose IVIG regimens are less effective at preventing coronary complications 2
4. Premature discontinuation of aspirin: Antiplatelet therapy should be continued for at least 6-8 weeks even after symptom resolution 1

The combination of IVIG and aspirin remains the cornerstone of KD treatment, with strong evidence supporting its efficacy in reducing the most serious complications of this vasculitic disease.