case STUDY

SEPTEMBER 01, 2006
Lauren S. Schlesselman, PharmD

CASE: QT, a 1-year-old boy, was brought to the pharmacy by his mother. His mother complained that QT refused to eat, taking in only minimal fluids. The mother explained that QT had a fever that would not resolve. For the last 6 days, he had a temperature of 104°F. After the first day of the fever, QT developed a diffuse, "blotchy" rash. Initially, the rash was limited to the diaper area, but it had spread to his trunk and extremities. The mother reported that QT's perineal area was also red and raw-appearing. She said the outer layer of skin around the perineum appears to be scaling off. Today, the mother noticed that the inside of QT's mouth looked irritated and red. She also feels a "lump" on his neck that she thinks is a "really big lymph node just like my brother had when he was sick as a child."

Upon further questioning, the pharmacist learns that QT's mother's pregnancy with him was unremarkable, resulting in a full-term spontaneous delivery without complications. QT is upto- date on his immunizations. He does not have any known allergies. Currently, the only medications he is receiving are acetaminophen and ibuprofen for his fever. QT has not recently had a runny nose, cough, vomiting, or diarrhea. He is an only child who has not been exposed to other sick children.

While asking QT's mother for more information, the pharmacist notices that QT is extremely irritable and ill-appearing. She notes that the rash is maculopapular. His eyelids appear swollen. She also notices subtle edema of the dorsal, palmar, and plantar surfaces of QT's hands and feet. When QT cries, the pharmacist notices an inflamed oral mucosa, a "strawberry tongue,"and cracked lips.

The pharmacist and the mother are unaware that another woman is standing only a few feet away, listening to their entire conversation. As the woman steps out from behind the wall that had obscured her from view, she points at QT and attempts to apologize for interrupting. She explains that her English is not fluent but that she understood what they were discussing. Although the pharmacist and mother are unable to comprehend most of what she says, the pharmacist hears the word "Kawasaki."

Suddenly the pharmacist remembers that Kawasaki disease is characterized by:

  • Fever lasting at least 5 days
  • Changes in the mouth, including diffuse erythema and fissures
  • Conjunctival swelling
  • Enlarged cervical lymph nodes
  • Erythematous rash, often with perineal scaling
  • Edema of the hands and feet, followed by skin peeling

The pharmacist explains to QT's mother that she thinks the other woman was attempting to say that she believed QT has Kawasaki disease. She also explains that QT's symptoms are consistent with the syndrome.

Relieved that she has a tentative diagnosis, the mother says she feels "better just having an idea what is wrong with my baby. It is difficult to see your own child sick." She thanks the pharmacist for her time and turns to leave.

Should the pharmacist allow the mother to simply walk away or should she advise her to seek medical care for QT?

Dr. Schlesselman is an assistant clinical professor at the University of Connecticut School of Pharmacy.

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CASE: The pharmacist should advise QT's mother to seek medical attention for him. The pharmacist can provide the mother with numerous reasons that medical care is needed:

1. Although the diagnosis of Kawasaki disease is based on clinical presentation, a physician can more accurately diagnose the cause of QT's illness than the pharmacist.

2. With such a young child, prolonged fever can lead to severe dehydration.

3. If QT does have Kawasaki disease, the physician will treat QT with a single infusion of intravenous immune globulin and oral high-dose aspirin. Early treatment can reduce the risk of developing the most serious adverse effect associated with Kawasaki, coronary artery aneurysm.Without treatment, 20% of children will develop a coronary artery aneurysm.