Children’s high fever does not retreat, antibiotics are ineffective, must be Kawasaki disease?

Also may be this common disease!

A 3-year-old boy, Zhuangzhuang, had a fever for 7 days. He still had a fever after receiving antibiotics for 3 days in the pediatrics outpatient department. He was so anxious that his family was ruined.

Father input on the net “3 year old boy fever 7 days infusion antibiotic invalid what disease may be?”
, the first thing that jumps into my eyes is Kawasaki disease — the disease is mainly fever in the early stage, if not treated in time, there will be heart complications, and even sudden death!

The frightened father told the family the news, and the family panicked and took the children to the pediatrician’s clinic.

Diagnosis and treatment after

Pediatrician: Hello, how old is the baby?
What seems to be the problem?

Children’s grandmother: doctor you hurry to give us a look, my family zhuang zhuang 3 years old, has fever for 7 days, also infusion for 3 days, how still not better?
His dad looked it up on the Internet and said it was Kawasaki disease, something I’d never heard of before.
Also said, if not early and timely treatment, to get heart disease!
How could a three-year-old be so sick?

Pediatrician: OK, take your time. I think the baby is generally OK.
These 7 days, the child besides fever, what other uncomfortable performance?
Like cough, vomiting, diarrhea, pain in the urine, a rash?
Children eat, drink, spread, sleep and play all right?

Father: I have a cough for three days, but it has been three days since I received the infusion. My fever has not improved, but I have a cough again.
Rash is also nearly 2 days some, fever from time to time, with antipyretic antipyretic, rash also disappeared.
I read on the Internet that Kawasaki disease is “a rash when you have a fever, and the rash disappears after using some antipyretic”. I was scared!
The infusion of this cephalosporin antibiotic did not work, the child is not Kawasaki disease, is it?

The child that paragraph of time news reports to say a foreign country was infected by novel coronavirus, serious meeting appears “kawasaki disease is like reaction”, nucleic acid of our child novel coronavirus also checked, it is negative.
Moreover, our whole family has not been infected with novel coronavirus, the child has not left home, should not be novel coronavirus Kawasaki disease like reaction?

Pediatrician: Don’t worry, maybe it’s not that serious!
I have just done a general examination of the child. As you have all seen, the child has no skin mucosal changes such as eye congestion, mouth, lip and tongue mucosal congestion, hard edema and peeling of hands and feet, and no swelling of neck lymph nodes.

The current fever lasts for seven days, the cough lasts for three days, and the rash when the fever occurs — all of which can happen with many pathogens.
Of course, Kawasaki disease cannot be completely ruled out.
So, we have to examine further assays, clear diagnosis.

Child’s mother: the child has received cephalosporin infusion for 3 days and still has fever. Can it be said that antibiotics are ineffective?
The child has been calorific 7 days do not improve, should not be virus infection?
Nucleic acid of our influenza virus was checked also, nucleic acid of virus of A flow second flow is negative.

If not Kawasaki disease, what other pathogen infection could look like this?
What if the diagnosis is delayed and the child has a heart attack?

Pediatrician: Yes, Kawasaki disease can’t be completely ruled out at this time. On the contrary, Kawasaki disease is one of the diseases that we are focusing on right now.
You also looked at the diagnostic criteria for Kawasaki disease. In addition to fever, the child met the diagnostic criteria, and only one of the five other diagnostic criteria was “skin rash.”

But because the heart injury is the most terrible place of Kawasaki disease, we will do a heart echocardiogram for the child first, if there is no problem more assured, there is a problem can also be one of the conditions of diagnosis.

Father: Yes, thank you, doctor!
So, what other tests should we do to look for other causes?

Pediatrician: Yes!
Children fever 7 days cough 3 days, lung auscultation also some phlegm, need to take an X-ray chest film to understand the lung situation, chest film can also see the heart situation.
In addition, we need to draw blood again to test the blood image, to understand the inflammatory indicators such as white blood cell count, erythrocyte sedimentation rate and C-reactive protein, and to test the common respiratory pathogens such as Mycoplasma at the same time.

Parents: Thank you, doctor, we have understood, listen to you, we will check according to the checklist!

(After 2 hours)

Parent: Thank you, doctor. You are right. The ultrasound of the child’s heart was all right.
The child is really suffering from pneumonia. His cough is not bad and he is breathing well.
But how did it get pneumonia?
And, the result of this blood assay also is positive of mycoplasma antibody, be the pneumonia that mycoplasma infection causes so?
Is this pneumonia easy to treat?

Pediatrician: Mycoplasma pneumonia is certainly easier to treat than Kawasaki disease, most of the use of azithromycin can quickly see the effect.
But because cephalosporin against mycoplasma is ineffective, so the child lost 3 days cephalosporin symptoms did not improve.
Mycoplasma pneumonia is also relatively common and most have a good prognosis.
The child’s current chest X-ray is not serious, need not be nervous.
We gave the baby azithromycin at once.

Parent of a child: OK. When will you see the effect?

Pediatrician: Quick, you can see the effect in 24 hours after the infusion, but generally, it can be said that it is invalid only after 3 days.

Parent: Well, if the infusion is not effective for 3 days, isn’t the child delayed for 3 days?

According to your prescription, the infusion cost of azithromycin today is much cheaper than that of cephalosporin yesterday, which is less than 50 yuan in total. Is it effective?
Give the child some good, expensive medicine, the illness can not be put off any longer!

Pediatrician: don’t worry, most mycoplasma infection to this common azithromycin is effective, how much money depends on the condition of the need.
Of course, if it is Kawasaki disease, the need to inject gamma globulin, the drug is blood products, more expensive, a day may cost thousands of yuan.

Parent: OK, let’s first inject azithromycin for 1 day to see the effect.

The boy’s condition improved significantly 24 hours after the infusion of azithromycin, which further supported the diagnosis of mycoplasma pneumonia and ruled out the possibility of Kawasaki disease.

Cases to reassure

Mycoplasma infection that is easily misdiagnosed or missed diagnosed

Mycoplasma is a kind of microorganism between virus and bacteria. Mycoplasma infection is distributed throughout the year, in winter in northern China, and in summer and autumn in southern China.

Although people of all ages are generally susceptible to mycoplasma, but children are the most susceptible group, the peak of the onset in early school age and school age, often in schools, nursery institutions, summer camps and other closed groups.

The clinical manifestations are diverse, ranging from asymptomatic to nasopharyngitis, sinusitis, otitis media, pharyngeal tonsillitis, tracheobronchitis, bronchiolitis, pneumonia, etc. Fever and cough are common clinical manifestations.

Mycoplasma pneumonia was once known as atypical pneumonia, because its chest radiographic manifestations are more serious than pulmonary signs, and it can have systemic complications, or it can be misdiagnosed and missed as the first onset of extrapulmonary symptoms.
Mycoplasma infection may occur in a variety of rashes, evident in fever, a small number of exudative pleomorphic erythema.
At present, most mycoplasma infections are still sensitive to azithromycin.

Two, dangerous Kawasaki disease, how to detect early?

Kawasaki disease, also known as cutaneous mucosal lymph node syndrome, is an acute systemic vasculitis syndrome of unknown etiology.
Most often in infants and young children, nearly 90% of the onset of children under the age of 5 years old.
The incidence is higher in boys than girls.

Its early clinical manifestations include acute onset of fever, rash, conjunctiva, and oral mucosal congestion, often requiring initial diagnosis and observation in the pediatric emergency department, followed by stiff hand-foot edema and cervical lymph node enlargement.

Its biggest threat is heart complications, mainly coronary artery disease.
About 15% to 30% of children without standard treatment will develop coronary artery dilatation or coronary aneurysm, which can lead to ischemic heart disease, myocardial infarction, and even sudden death.
Kawasaki disease has now replaced rheumatic fever as the leading cause of childhood heart disease in most countries worldwide.

So, how to diagnose Kawasaki disease early?

For Kawasaki disease, it was clearly diagnosed as “early diagnosis” within 10 days of onset.
It is generally based on the diagnostic criteria issued by the Kawasaki Disease Research Institute of Japan, which are as follows:

Patients with fever for more than 5 days with 4 of the following 5 clinical manifestations can be diagnosed as typical Kawasaki disease:

Conjunctival congestion in both eyes, non-suppurative;

Lips bright red, chapped and bayberry tongue;

Hard swelling of hands and feet, erythema of palms and toes, peeling of fingers and toes;

Erythematous pleomorphic rash;

The lymph node of the neck is enlarged.

If only 3 of the above 5 clinical manifestations, but echocardiography or angiography confirmed coronary aneurysm (or arterial dilation), on the basis of the exclusion of other diseases, can also be diagnosed as Kawasaki disease, also called atypical Kawasaki disease.

It should be noted that Kawasaki disease should be differentiated from such diseases as scarlet fever and septicaemia caused by bacterial infection, mycoplasma infection, childhood rheumatoid disease, suppurative lymphadenitis, and myocarditis.

In conclusion, pediatric outpatient and emergency department is an important threshold for the early diagnosis of Kawasaki disease, and pediatricians and parents of children should improve the awareness of Kawasaki disease.

However, parents need not be too nervous, Kawasaki disease is a typical self-limited disease, after standard treatment of most children have a good prognosis.
Among them, early and timely diagnosis and adequate use of human immunoglobulin is the key to treatment, which plays an important role in preventing coronary artery lesions caused by Kawasaki disease.

For patients with coronary artery dilation, long-term follow-up and echocardiography should be performed at least once every six months until the coronary artery dilation disappears and the coronary aneurysm disappears in more than 2 years.
Patients without coronary artery dilatation were given a comprehensive examination, including medical history inquiry, physical examination, electrocardiogram and echocardiography, at 1, 3, 6 months and 1~2 years after discharge.

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