This is the answer and explanation for a USMLE practice question from the Dr. Ray Makar Facebook page. Try it first, then check your answer below.
The Question
A 3-year-old boy has had a fever for 6 days. He has red eyes without discharge, cracked red lips, a strawberry tongue, a rash on his trunk, swollen hands and feet, and one enlarged lymph node in the neck. What is the most appropriate treatment?
A. Oral amoxicillin
B. Oral prednisone alone
C. Intravenous immunoglobulin (IVIG) and aspirin
D. Supportive care only
Correct Answer: C. Intravenous immunoglobulin (IVIG) and aspirin
This is Kawasaki disease: fever for at least 5 days plus at least 4 of these 5 findings: conjunctivitis without discharge, mouth changes (cracked lips, strawberry tongue), rash, swelling or redness of the hands and feet, and cervical lymphadenopathy. IVIG plus aspirin, ideally within 10 days of fever onset, greatly lowers the risk of coronary artery aneurysms. Get an echocardiogram at diagnosis and again during follow-up.
Why the Other Answers Are Wrong
- Oral amoxicillin: Kawasaki disease is not a bacterial infection. Scarlet fever also causes a strawberry tongue, but it comes with exudative pharyngitis and no conjunctivitis.
- Oral prednisone alone: Steroids are not first-line. They are sometimes added for high-risk or IVIG-resistant cases.
- Supportive care only: Without treatment, about 1 in 4 children develop coronary artery aneurysms.
High-Yield Pearl
Aspirin is usually avoided in children because of Reye syndrome, but Kawasaki disease is a classic exception. Kawasaki disease is the most common cause of acquired heart disease in children in the US.
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