What is the diagnosis and treatment for a 2-year-4-month-old child with hyperthermia, cervical lymphadenopathy, red spots on the soft palate, reduced oral intake, wet cough, and odontalgia?

Clinical Diagnosis: Herpangina or Hand-Foot-and-Mouth Disease (Viral Pharyngitis)

This 2-year-4-month-old child most likely has viral pharyngitis (herpangina or hand-foot-and-mouth disease) based on the constellation of high fever, red spots on the soft palate, sore throat, and cervical lymphadenopathy—this is a self-limited viral illness requiring only supportive care with close monitoring for complications.

Immediate Assessment: Rule Out Kawasaki Disease

While viral pharyngitis is most likely, you must urgently evaluate for Kawasaki disease given the fever duration (48 hours so far) and cervical lymphadenopathy:

• Look specifically for: bilateral nonexudative conjunctivitis, oral changes (cracked lips, strawberry tongue), polymorphous rash on trunk/extremities, and erythema or edema of hands/feet 1, 2, 3
• Kawasaki disease requires fever ≥5 days PLUS cervical lymphadenopathy ≥1.5 cm (typically unilateral in anterior cervical triangle) PLUS ≥3 additional principal features 1, 2, 3
• Critical: Children under 3 years (especially <6 months) have the highest risk of coronary complications and require heightened suspicion 2, 3
• If Kawasaki disease is suspected, obtain baseline ESR, CRP, CBC, albumin, transaminases, and urinalysis 1

Current assessment: This child does NOT meet Kawasaki criteria yet (fever <5 days, red palate spots are NOT a principal feature, no other principal features described). However, schedule close follow-up within 24-48 hours to reassess if fever persists beyond 5 days 2, 3.

Most Likely Diagnosis: Viral Pharyngitis

The clinical picture strongly suggests herpangina (caused by Coxsackie A virus) or early hand-foot-and-mouth disease:

• Red spots on soft palate are classic for herpangina—these typically evolve into small vesicles/ulcers on the posterior pharynx and soft palate 4
• High fever (39.9°C), sore throat/mouth pain, and cervical lymphadenopathy are characteristic of viral upper respiratory infections 4
• The wet cough that just started suggests viral upper respiratory tract involvement 4
• Age 2 years 4 months is typical for these viral illnesses 4

Management: Supportive Care Only

No antibiotics are indicated at this time:

• The American Academy of Otolaryngology recommends against empiric antibiotics in the absence of clear bacterial infection signs (warmth, erythema of overlying skin, rapid onset with localized tenderness) 5, 2, 3
• Viral pharyngitis with reactive cervical lymphadenopathy typically resolves within days without treatment 5

Supportive care measures:

• Adequate pain control with acetaminophen or ibuprofen for fever and throat pain
• Encourage oral fluids (cold liquids may be soothing)
• Soft, bland foods to minimize throat irritation
• Monitor hydration status closely given reduced oral intake

Red Flags Requiring Urgent Re-evaluation

Return immediately or within 24 hours if:

• Fever persists ≥5 days (reassess for Kawasaki disease) 1, 2, 3
• Development of conjunctivitis, rash, or extremity changes 1, 2, 3
• Cervical lymph node becomes warm, erythematous, fluctuant, or rapidly enlarging 5, 2
• Signs of dehydration develop (decreased urine output, dry mucous membranes, lethargy)
• Respiratory distress or difficulty breathing 1
• Inability to swallow secretions or drooling (suggests deeper infection/abscess)

Follow-Up Plan

Schedule reassessment in 2 weeks if lymphadenopathy persists:

• Lymph nodes ≥1.5 cm persisting ≥2 weeks without significant fluctuation increase risk for chronic infection (nontuberculous mycobacteria) or malignancy 5, 2
• At age 2 years 4 months, this child is in the peak age range (1-5 years) for nontuberculous mycobacterial (NTM) cervical lymphadenitis 1, 5, 2
• NTM lymphadenitis characteristics: unilateral (95% of cases), non-tender, insidious onset without systemic symptoms, caused by Mycobacterium avium complex in 80% of cases 1, 5, 2

If lymphadenopathy persists at 2-week follow-up:

• Consider tuberculin skin test (PPD) to distinguish tuberculosis from NTM 1, 5
• Refer to otolaryngology for possible excisional biopsy (treatment of choice for NTM with 95% success rate) 1, 5, 2

Common Pitfalls to Avoid

• Do NOT prescribe multiple courses of antibiotics without clear bacterial infection signs—this delays diagnosis of underlying conditions like NTM or malignancy 2, 3
• Do NOT assume partial resolution after antibiotics means bacterial infection—this may represent infection in underlying malignancy 2, 3
• Do NOT miss Kawasaki disease in young children with prolonged fever and cervical lymphadenopathy, even if other classic features are subtle or absent initially 1, 2, 3