FEVER AND STRAWBERRY TONGUE - CPA Chennai

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FEVER AND STRAWBERRY TONGUE

Dr Geetha, DNB PG
Dr S Balasubramanian’s Unit

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NEED FOR THIS PRESENTATION

— Of late, children presenting with fever and strawberry
tongue is on the rise.

— Presentation is variable,
- ± cervical adenopathy.
- ± skin peeling.

• Aimed to study the various causes.
• To help us in appropriate management.

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HAS THE FREQUENCY OF CHILDREN PRESENTING
WITH RED STRAWBERRY TONGUE INCREASED?

RETROSPECTIVE ANALYSIS OF CHILDREN WITH
STRAWBERRY TONGUE OVER THE LAST 3 MONTHS
REVEALED….

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STRAWBERRY TONGUE PROLFILE IN 3 MONTHS

AGE FEVER STRAWBERRY SKIN OTHER LABS PROVISIONAL
FEATURES DIAGNOSIS
TONGUE PEELING CBC-N,
RASH THROAT SCARLET FEVER
4 ½ + ( 3 D) + + ( AT SWAB-VE
REVIEW) CBC, ESR,
CRP- N
ECHO-N

5 ½ + (5D) + + RASH THROAT SCARLET FEVER
CERVICAL SWAB- VE TREATED WITH
+ (AT ADENOPATHY CBC-N, ASPIRIN
REVIEW PERIORAL / ESR- MILDLY
AFTER 1 PERIANAL ELEVATED,
WEEK) ERYTHEMA(AT CRP- N
REVIEW AFTER ECHO-N
10 DAYS)
14 + + CBC-N INCOMPLETE
YR RASH / PLAT- 6.7L KAWASAKI/
CERVICAL CRP, ESR – N ASPIRIN
ADENOPATHY ECHO-
ERYTHEMATOUS PERICARDIAL
LIPS EFFUSION

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STRAWBERRY TONGUE PROLFILE IN 3 MONTHS

AGE FEVER STRAWBERR SKIN OTHER LABS PROVISION
AL
Y TONGUE PEELING FEATURES DIAGNOSIS

3 ½ + (2 D) + + (AT R RASH CBC, ESR, CRP -N, VIRAL ILLNESS
AFTER 20 - ECHO-N
4 ½ BIPHASIC + DAYS)
FEVER 2 CBC, ESR,CRP- N VIRAL ILLNESS
WEEKS + OVER ECHO-N
PALM

4 ½ BIPHASIC + + PERIANAL RASH LEUCOCYTOSIS KD – IVIG/
FEVER 2
WEEKS CERVICAL N- PLAT ASPIRIN

ADENOPATHY ESR- , CRP-

CHEILITIS ECHO-N

4 MO +(4 D) + _ BCG ERYTHEMA LEUCOCYTOSIS KD – IVIG/

RASH N- PLAT ASPIRIN

CHEILITIS ESR- , CRP-

ECHO-N

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STRAWBERRY TONGUE PROLFILE IN 3 MONTHS

AGE FEVER STRAWBERR SKIN OTHER LABS PROVISIONA
Y TONGUE PEELIN FEATURES L DIAGNOSIS
G

4YR + - + RASH LEUCOCYTOSIS KD – IVIG/
N- PLAT ASPIRIN
CHEILITIS ESR- , CRP-
ECHO-N
CERVICAL
ADENOPATHY

4 YR + + _ RASH LEUCOCYTOSIS KD – IVIG/

NON PURULENT N- PLAT ASPIRIN

CONJUNCTIVITI ESR- , CRP-

S ECHO-N

CERVICAL

ADENOPATHY

15 + + + RASH LEUCOCYTOSIS KD – IVIG/
YRS
CERVICAL N- PLAT ASPIRIN

ADENOPATHY ESR- , CRP-

ERYTHEMATOUS ECHO-N

LIPS

CONJUNCTIVAL

SUFFUSION

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— Why this diagnostic dilemma?
— Why this clustering of cases in a short span?

- infectious etiology considered.
- super antigen theory.

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— We saw a male and a female twin with febrile illness within
the same week, one developed classic kawasaki who
improved with IVIg and the other twin, did not have features
of kawasaki and improved spontaneously.

— Subclinical coronary artery vasculitis may be present in
monozygotic twins, laboratory testing and echo should be
considered.

ü Kottek et al, Kawasaki disease in monozygotic twins. Pediatric
infectious disease journal, 2011 dec; 30(12):1114-6.

• Kawasaki et al, genetic analysis of kawasaki syndrome. American
journal of human genetics. 1986 oct; 39(4): 537-539.

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IS THIS SCENARIO OF FEVER WITH STRAWBERRY
TONGUE CAUSING DIAGNOSTIC DILEMMA?

HOW TO PROCEED WITH DIAGNOSIS…

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STRAWBERRY TONGUE

A characteristic enanthem of the tongue, which is characterised by
hypertrophy of the fungiform papillae, accompanied by changes of the
filiform papillae in a bright red background.

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KAWASAKI MIMICS

Ø Group A streptococcal infections (scarlet fever and toxic
shock syndrome).

Ø Viral infections – measles
- echovirus
- adenovirus
- EBV.

Ø Stevens- johnson syndrome.
Ø Acrodynia.
Ø Yersinia pseudotuberculosis infection.

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POINTERS FOR DIAGNOSIS OTHER THAN KAWASAKI
DISEASE

§ Exudative conjunctivitis,
§ Exudative pharyngitis,
§ Generalized (rather than cervical) lymphadenopathy,
§ Discrete intraoral lesions,
§ A bullous or vesicular rash.

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Kawasaki disease Scarlet fever

AGE <5 2-8 > 10
< 10 D
FEVER PERSISTENT VARIABLE, < 10 D CONJUNCTIVITIS

EYES NON EXUDATIVE NORMAL ERYTHEMATOUS
CONJUNCTIVITIS
SWELLING OF HAND
ORAL MUCOSA STRAWBERRY TONGUE STRAWBERRY AND FEET, LATE
TONGUE DESQUAMATION
ERYTHRODERMA
EXTREMITIES INDURATIVE SWELLING, FLAKY
SHEETLIKE PERIUNGUAL DESQUAMATION NORMAL
DESQUAMATION
THROMBOCYTOPENI
RASH POLYMORPHOUS RASH SANDPAPER RASH, A
PERIORAL PALOR

CERVICAL ATLEAST 1 NONTENDER PAINFUL NODES

ADENOPATHY NODE > 1.5CM

LABS SYSTEMICINFLAMATION, + VE THROAT
PLAT > 7 D OF ILLNESS CULTURE

OTHERS ARTHRITIS MENTAL CHANGES,
DIC, SHOCK

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Kawasaki disease Stevens- johnson
syndrome

AGE <5 ANY AGE

FEVER PERSISTENT PERSISTENT

EYES NON EXUDATIVE CONJUNCTIVITIS EXUDATIVE
CONUNCTIVITIS,
ORAL MUCOSA STRAWBERRY TONGUE KERATITIS

EXTREMITIES INDURATIVE SWELLING, SHEETLIKE ERYTHEMA, ULCERATION
PERIUNGUAL DESQUAMATION WITH PSEUDOMEMBRANE

NORMAL

RASH POLYMORPHOUS RASH TARGET LESIONS

CERVICAL ATLEAST 1 NONTENDER NODE > NORMAL
ADENOPATHY 1.5CM
LABS ARTHRALGIA, ASSO
SYSTEMICINFLAMATION, PLAT > 7 D HERPES INFECTION
OTHERS OF ILLNESS

ARTHRITIS

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DIFFERENTIAL DIAGNOSIS

ü VIRAL EXANTHEMS
- measles
- adenovirus
- rubella
- roseolla
- enterovirus

Ø Fever disappears with the onset of rash. Prodromal symptoms are
prominent.

vHowland hartley at al, Infectious exanthems. Pediatrics in review
vol. 9 no. 10 april 1988.

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DIFFERENTIAL DIAGNOSIS

ü ACRODYNIA- mercury hypersensitivity reaction.
- fever, rash, swelling of hand and feet, red tongue and
photophobia.

- Diagnosis is less likely unless there is a convincing history of
mercury exposure.

vJanelle et al, Recognotion of kawasaki disease. The
Permanente Journal/ Winter 2009/ Volume 13 No. 1

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DIFFERENTIAL DIAGNOSIS

— Yersinia pseudotubeculosis infection mimicking kawasaki
disease.

vSato et al, Yersinia pseudotuberculosis infection in children,
resembling Izumi fever and Kawasaki syndrome. Pediatr Infect
Dis. 1983 Mar-Apr;2(2):123-6.

vUsui et at, Yersinia pseudotuberculosis type 4a infection meeting
the diagnostic criteria for Kawasaki disease complicated by
disseminated intravascular coagulation. Kansenshogaku Zasshi.
2005 Nov;79(11):895-9.

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SYMPTOMS DIAGNOSIS MANAGEMENT
IVIG/ ASPIRIN
FEVER/ CLINICAL KD ASPIRIN / FOLLOW UP
ECHO
CRITERIA/ LABORATORY
NO TREATMENT
FINDINDS +VE

NO FEVER / VAGUE RECOVERING KD
CLINICAL FEATURES /
MILDLY ELEVATED
INFLAMMATORY
MARKERS

NO FEVER / VAGUE VIRAL ILLNESS
CLINICAL FEATURES /
NORMAL
INFLAMMATORY
MARKERS

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— Children presenting primarily to a tertiary care centre in
India are more likely to be associated with early diagnosis of
KD than those initially seen by pediatricians in the
community.

Ø Maniram et al, Factors associated with delay in diagnosis of
kawasaki disease in india. Accepted and awaited publication in
Indian pediatrics.

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TAKE HOME MESSAGE

— Children presenting with strawberry tongue is on the rise.
— Kawasaki disease is a clinical diagnosis.
— Scarlet fever is relatively rare in our set up and we are unable

to prove it by throat swab.
— We are unable to prove the viral trigger in patients with such

varied presentation because of lack of facilities – viral
culture/ serology.

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