Spotting Kawasaki in 8 Minutes: A PLAB 2 Lifesaver for Pediatric GP Stations

This PLAB 2 case scenario revolves around a pediatric patient presenting to a GP setting with fever and rash. The correct diagnosis is Kawasaki Disease, a pediatric vasculitis that can lead to serious cardiovascular complications if not promptly identified and managed. The station assesses data gathering efficiency, differential diagnosis formulation, emergency recognition, and appropriate referral and management planning.

Key Points:

General Pediatrics / Infectious Disease

Kawasaki Disease vs. Scarlet Fever: Differentiate using rash type (polymorphous vs. sandpaper), hand and foot involvement, lymph node swelling (unilateral for Kawasaki).
Persistent fever unresponsive to antipyretics is a classic feature of Kawasaki.
Scarlet fever typically includes pharyngitis, sandpaper rash, and strawberry tongue.

Emergency Recognition

Kawasaki Disease is a pediatric emergency due to the risk of coronary artery aneurysms.
The case must be escalated from GP to ED urgently.

Differential Diagnosis Approach

Rule out critical conditions early: meningitis should be top of the list in any febrile child.
Structured differentials: use the "Three C's" — Critical (e.g., meningitis), Cancer (e.g., leukemia), Common (e.g., scarlet fever).

Physical Examination

Must specify: general examination, oral examination (to assess "strawberry tongue"), rash assessment, vitals.
Mention investigations like ESR, CRP to aid in diagnosis.

Important Considerations:

Kawasaki Disease is immune-mediated, not bacterial.
The setting is a GP clinic — no acute interventions available, hence referral is crucial.
The fever in Kawasaki is resistant to paracetamol, another diagnostic clue.
Always check and mention if the child is safe to be discharged or needs ambulance support.
Document ideas, concerns, and expectations (ICE) comprehensively.
Don't ignore psychosocial context: who takes care of the child, home support, etc.

Diagnostic Approach:

Initial Presentation Review – Acknowledge the pre-existing information.
Focused History – Duration and characteristics of fever and rash, lymph node swelling.
Rule Out Meningitis – Ask about photophobia, neck stiffness, altered consciousness.
Differentiate Kawasaki vs. Scarlet Fever – Rash quality, lymph node involvement, fever duration.
Mention Examination – Oral cavity, lymph nodes, extremities.
Diagnostic Aids – CRP, ESR, echocardiogram (in hospital).

Management:

Immediate Action – Urgent referral to ED from GP setting.
Treatment Outline – IVIG and high-dose aspirin in a hospital setting.
Supportive Care – Antipyretics (paracetamol), tepid sponging.
Safety Netting – Warn about signs of deterioration.
Follow-up – Arrange review post-hospital discharge.
Leaflets and Education – Provide information on Kawasaki disease.

Communication Skills:

Use simple, clear language for diagnosis explanation.
Avoid jargon or stock phrases.
Elicit and address ICE: concerns and expectations are often revealing in pediatric cases.
Emphasize urgency without alarming the caregiver unduly.
Show empathy and reassurance.

Ethical Considerations:

Confirm understanding and consent, especially for urgent referrals.
Respect caregiver autonomy while guiding clinical decisions.
Ensure child safety in transport and follow-up.
Maintain confidentiality while involving family appropriately.

Additional Resources:

NICE Guidelines on Kawasaki Disease
GMC’s Good Medical Practice
RCPCH Clinical Pathways for Pediatric Emergencies