What is the likely diagnosis and recommended management for a few‑week history of fever and vomiting now followed by peeling of the palms and soles and a pruritic rash?

Kawasaki Disease

This clinical presentation is highly consistent with Kawasaki disease (KD), and the patient requires urgent evaluation for coronary artery involvement and consideration for intravenous immunoglobulin (IVIG) therapy, even though the acute febrile phase has passed.

Clinical Reasoning

The constellation of fever and vomiting weeks ago, now followed by peeling of the hands and feet with a pruritic rash, strongly suggests Kawasaki disease in its subacute phase. The periungual desquamation typically begins 2-3 weeks after fever onset, which matches this timeline perfectly 1.

Key Diagnostic Features Present:

• Fever history (occurred weeks ago, consistent with acute phase)
• Extremity changes - The palmar and plantar peeling is pathognomonic for KD when occurring 2-3 weeks post-fever 1
• Rash - While the pruritic nature is somewhat atypical for classic KD (which typically presents with non-pruritic maculopapular, scarlatiniform, or erythema multiforme-like eruptions), the timing and distribution are consistent 1

Critical Diagnostic Considerations:

The diagnosis of classic KD requires ≥5 days of fever plus ≥4 of 5 principal clinical features (bilateral conjunctivitis, oral changes, cervical lymphadenopathy, rash, and extremity changes). However, not all features need to be present simultaneously, and a careful review of prior signs and symptoms establishes the diagnosis 1. The desquamation occurring now, weeks after the fever, is a classic subacute finding.

Immediate Management Algorithm

1. Urgent Cardiac Evaluation

• Obtain echocardiography immediately to assess for coronary artery aneurysms
• Even patients presenting late (beyond the acute febrile phase) require cardiac assessment, as coronary artery damage may have already occurred 1
• Giant aneurysms ≥8 mm or Z-score ≥10 do not resolve and carry significant morbidity risk 1

2. Laboratory Assessment

• Complete blood count (thrombocytosis expected in subacute phase)
• ESR/CRP (may still be elevated)
• Liver transaminases
• Albumin level
• Lipid panel (baseline for long-term management)

3. Treatment Decision

• If within 10 days of fever onset: IVIG 2 g/kg as single infusion plus high-dose aspirin (80-100 mg/kg/day divided four times daily)
• If beyond 10 days but with evidence of ongoing inflammation (elevated ESR/CRP) or coronary artery abnormalities: IVIG still indicated
• If beyond 10 days with no inflammation and normal coronary arteries: Low-dose aspirin (3-5 mg/kg/day) until inflammatory markers normalize

4. Long-term Follow-up

All patients require cardiology follow-up regardless of initial coronary artery status, as late complications can occur

Important Caveats

Common Pitfall: Dismissing the diagnosis because the patient is no longer febrile. The desquamation phase occurs in the subacute period (2-3 weeks post-fever), and delayed diagnosis still requires cardiac evaluation and potential treatment 1.

Differential Considerations: While dengue fever can present with palm/sole involvement and rash 2, 3, the timing of desquamation weeks after fever is pathognomonic for KD rather than dengue. Drug reactions and other viral exanthems typically do not show this delayed periungual peeling pattern 4.

Mortality Risk: Without appropriate recognition and cardiac monitoring, KD carries risk of coronary artery complications including myocardial infarction from thrombosis or stenosis 1. The introduction of IVIG therapy markedly decreased fatality rates 1.