In an afebrile 2‑year‑old boy with a diffuse maculopapular erythematous rash on the torso, neck, and face, bilateral purulent conjunctivitis, and cracked erythematous lips, what is the most likely diagnosis and appropriate initial management?

Kawasaki Disease

This clinical presentation is classic for Kawasaki disease, and the child requires immediate intravenous immunoglobulin (IVIG) and high-dose aspirin to prevent coronary artery aneurysms. 1

Key Diagnostic Features

The constellation of findings in this 2-year-old is pathognomonic for Kawasaki disease:

• Bilateral purulent conjunctivitis (nonpurulent conjunctivitis is actually more typical, but bilateral conjunctival injection is a cardinal feature) 1
• Diffuse maculopapular erythematous rash on torso, neck, and face 1
• Cracked erythematous lips (strawberry tongue is also characteristic) 1
• Age 2 years falls within the peak incidence (primarily affects children, highest between ages 20 months to 5 years) 1

Critical Diagnostic Criteria

Kawasaki disease requires fever of 5 days or more plus at least 4 of 5 principal features 1:

• Bilateral conjunctival injection (present in this case)
• Oral mucosal changes including red, swollen tongue and cracked lips (present)
• Polymorphous rash (present)
• Cervical lymphadenopathy (not mentioned but assess)
• Extremity changes: swollen, red skin on palms/soles (not mentioned but assess)

Why This Is NOT Infectious Conjunctivitis

The bilateral nature with systemic findings (rash, lip changes) in an afebrile child points away from isolated bacterial or viral conjunctivitis. 1

• Gonococcal conjunctivitis would present with marked eyelid edema, severe purulent discharge, and rapid progression to corneal involvement 1
• Viral conjunctivitis (adenovirus, measles) typically has watery discharge, not purulent, and would have respiratory symptoms 1
• Bacterial conjunctivitis would not explain the systemic rash and oral findings 1

Immediate Management Algorithm

1. Confirm diagnosis clinically - assess for all 5 principal features of Kawasaki disease 1

2. Obtain baseline echocardiogram immediately to assess coronary arteries 1

3. Initiate treatment within 10 days of fever onset (even if afebrile now, determine when symptoms began) 1:

• IVIG 2 g/kg as single infusion
• High-dose aspirin 80-100 mg/kg/day divided four times daily until afebrile for 48 hours
• Then low-dose aspirin 3-5 mg/kg/day for 6-8 weeks

4. Admit to hospital for monitoring during IVIG infusion 1

Life-Threatening Complication to Prevent

Coronary artery aneurysm is the lethal complication of Kawasaki disease and occurs in 15-25% of untreated children. 1 Early treatment with IVIG within 10 days of fever onset reduces this risk to less than 5%. 1

Common Pitfall

Do not mistake this for infectious conjunctivitis and treat with antibiotics alone. The purulent appearance of the conjunctivitis may mislead clinicians, but the systemic features (rash, oral changes) in the appropriate age group demand consideration of Kawasaki disease as a vasculitic process. 1 The conjunctivitis in Kawasaki disease is part of the systemic inflammatory response, not a primary infection. 1