What Will Be Your Differential Diagnoses for This Patient?
There are several focal infections that can mimic Kawasaki disease (KD). One of the most probable differential diagnosis is childhood polyarteritis nodosa (CPN) (Taskiran et al., 2015). This medical condition usually develops in children under the age of 2. It is a system disease that causes congestive heart failure and renal failure. Another possible diagnosis is juvenile idiopathic arthritis (JIA) (El Maghraoui, 2014). It is the most common type of arthritis that affects infants. The third possible diagnosis that might lead to serious complications is rheumatic fever (Gewitz et al., 2015). It also often develops in infants. Finally, staphylococcal scalded skin syndrome can also cause such conditions (Ross & Shoff, 2017). It is a skin disorder caused by Staphylococcus aureus.
What Specific Physical Exam Findings Support These Differential Diagnoses?
The above-mentioned differential diagnoses might have similar symptoms. These are fever and skin abnormalities such as redness, irritation, or rashes. The physical exam of the patient indicated such symptoms. The child suffers palmar redness, magenta-colored lips, and excoriating rashes in the diaper area.
Of the Differential Diagnoses You Listed, Which Would Be the Most Concerning?
Among the mentioned above differentials, the most dangerous is CPN. This condition and Kawasaki disease might lead to similar pathologies (Eleftheriou et al., 2014). Although CPN is an uncommon disease in children, it is often fatal. Therefore, this diagnosis is of particular importance. CPN is a very serious condition as it affects arteries. CPN is usually part of the spectrum of KD, and these diseases are very difficult to distinguish. Nerve involvement in patients with CPN might cause sensory changes that are accompanied by pain and weakness. The central nervous system might also be affected, which leads to strokes and even epileptic fits. In addition, kidney involvement might result in kidney failure. Hence, CPN often leads to the development of severe conditions.
What Additional Diagnostic Tests Will You Recommend? Why?
There are several additional tests that are necessary to conduct to rule out all differential diagnoses. JIA is very difficult to diagnose, and there are no tests that can confirm this diagnosis. However, some of them help to rule out disorders that cause similar symptoms. The most effective tests, in this case, will be the following: erythrocyte sedimentation rate (ESR), C-reactive protein, anti-nuclear antibody, rheumatoid factor, cyclic citrullinated peptide (CCP), and magnetic resonance imaging (MRI) (“Juvenile idiopathic arthritis,” 2017).
The same problem occurs when it comes to diagnosing rheumatic fever. Therefore, a similar principle is applied to identify this disease. Throat culture, blood cultures, and antibody titer tests are necessary to exclude other possible infections. However, there are several laboratory studies that can identify staphylococcal scalded skin syndrome. These are ESR, a Gram stain, and polymerase chain reaction serum tests (King, 2017). Finally, in order to diagnose or exclude CPN, it is necessary to conduct the following additional studies: serum chemistry panel, antinuclear antibody determination, rheumatoid factor, hepatitis B, quantitative immunoglobulins, and circulating immune complexes tests.
What Would Be Your Focus for Caregiver Education?
Before the patient is discharged home, designated caregivers should learn several important educational recommendations. KD can cause serious complications, and the patient’s family members should know to which symptoms they have to pay particular attention. It is necessary to call 911 if the child has signs of a heart attack (Eleftheriou et al., 2014). Such symptoms might include a chest ache that lasts for several minutes; discomfort in the back, stomach, arms, or neck; shortness of breath, nausea, and weakness. Also, KD can cause a stroke, which produces the following symptoms: numbness on the side of the face, an intense headache, speech difficulties, and the loss of vision.
Differential Diagnoses Testing
As mentioned above, it is necessary to conduct additional laboratory studies to rule out all possible differential diagnoses. The main problem is that the most of such conditions are very difficult to diagnose as there are no special tests that can certainly identify them. Therefore, the set of additional studies can improve chances for correct diagnosis. In order to address this issue, each differential should be checked separately. First, different types of blood tests can help to identify JIA (“Juvenile idiopathic arthritis,” 2017). ESR shows the speed of red blood cells settling, which might indicate inflammation. An ESR level demonstrates the degree of inflammation. A C-reactive protein test is conducted for the same reason. An anti-nuclear antibody test helps to indicate eye inflammation as anti-nuclear antibodies are produced by the immune system in case of such disorders. Rheumatoid and CCP antibodies are often found in the blood of patients with JIA. Second, to identify rheumatic fever, it is necessary to conduct another laboratory studies. A throat culture test is a commonly applied method that helps to find a group A streptococcal infection.
Rapid antigen detection tests also might be effective in confirming this type of bacteria. Antibody titer tests are necessary to detect streptococcal antibodies that signal skin infection. Third, staphylococcal scalded skin syndrome can be detected by means of a Gram stain test, which might confirm staphylococcal infection (King, 2017). Also, a polymerase chain reaction serum test can be effective in this case as this technique amplifies amounts of DNA, which allows producing various copies of a particular DNA sequence. Fourth, there are several relevant methods to diagnose CPN. A serum chemistry panel test is very helpful in determining the general health status of a patient. In addition, it shows if prescribed treatments improve a patient’s condition. The test on hepatitis B is very common in such cases. The next recommended laboratory study is a quantitative immunoglobulins test. It helps to assess an immune system status of a patient. This test might indicate the deficiency of some immunoglobulin classes. Finally, circulating immune complexes are associated with different medical conditions, for example, rheumatological and autoimmune disorders.
Parental Education
The main focus of educational program for the patient’s parents should be on the possible complications of the disease. As mentioned above, these are a heart attack and stroke. However, there are other recommendations that are necessary to follow. The parents should inform a doctor if the child came into contact with people who suffer chicken pox or the flu. In addition, it is important to control that previous symptoms do not occur again. In case of any concerns about the child’s health, it is also necessary to contact a doctor. There are several recommendations regarding medicines. Although aspirin causes bleeding or bruises, it prevents blood clots. Also, if the child was prescribed taking aspirin, the parents should not give him acetaminophen or ibuprofen instead. Anticoagulants make blood thinner, and thus, they also prevent clots (“Anticoagulant medicines,” 2015). However, patients at high risk of heart attacks or strokes should avoid such medicines. The parents should watch for bleeding in their child. For example, blood might be found in urine or feces. Also, the parents should be taught which medicine is not compatible with anticoagulants. They have to strictly follow all prescriptions and continue the treatment until the patient’s doctor stop it. In addition, it is very useful to put a special bracelet on the patient. This bracelet should indicate which medicine this child takes. Finally, it is necessary to inform a doctor if, for whatever reason, the directed prescription was not followed.
References
Anticoagulant medicines. (2015). Web.
Gewitz, M. H., Baltimore, R. S., Tani, L. Y., Sable, C. A., Shulman, S. T., Carapetis, J.,… Mayosi, B. M. (2015). Revision of the Jones criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography. Circulation, 131(20), 1806-1818.
Eleftheriou, D., Levin, M., Shingadia, D., Tulloh, R., Klein, N. J., & Brogan, P. A. (2014). Management of Kawasaki disease. Archives of Disease in Childhood, 99(1), 74-83.
El Maghraoui, A. (2014). Juvenile idiopathic arthritis. Presse Medicale, 43(1), 27-33.
Juvenile idiopathic arthritis. (2017). Web.
King, R. (2017). Staphylococcal scalded skin syndrome (SSSS) workup. Web.
Ross, A., & Shoff, H. W. (2017). Staphylococcal scalded skin syndrome. Web.
Taskiran, E. Z., Batu, E. D., Kilic, L., Akdogan, A., Yilmaz, E., & Ozen, S. (2015). New insights to the pathogenesis of two orphan vasculitides: Childhood polyarteritis nodosa and Behçet disease. Ann Paediatr Rheumatol, 4, 7-11.