Question

Diagnosis and management of a child with Kawasaki disease having:
Refractory fever despite first dose of IVIG in Kawasaki disease.

Hint:

Early recognition and treatment of refractory fever in Kawasaki disease are critical to prevent long-term cardiovascular complications.

Answer 1

Refractory fever in Kawasaki disease (KD) is defined as persistent fever despite the first dose of intravenous immunoglobulin (IVIG). This is a challenging scenario and often requires further treatment to prevent coronary artery complications.
Step 1: Causes of Refractory Fever:
1. Incomplete Response to IVIG: Some children may have a partial or poor response to IVIG, leading to continued fever. Factors influencing response include delayed administration or severity of the disease.
2. Concurrent Infections: Bacterial or viral infections might coexist, leading to fever despite appropriate IVIG therapy.
3. Dosing Issues: Insufficient IVIG dose or improper administration technique may result in inadequate plasma levels of immunoglobulin.
Step 2: Management Options:
1. Second Dose of IVIG: If fever persists despite the first dose, a second dose of IVIG is often given.
2. Corticosteroids: Steroids are considered in cases where the fever persists after a second IVIG dose. They are used to reduce inflammation and improve outcomes.
3. Infliximab: This biologic agent, an anti-TNF antibody, may be used in cases that do not respond to multiple IVIG doses or steroids.
Step 3: Complications:
Refractory fever may indicate a risk for coronary artery abnormalities, including coronary artery aneurysms, requiring close monitoring and additional therapy.