Kawasaki Disease or Incomplete Kawasaki Disease Clinical Pathway — Emergency Department and Inpatient

Incomplete Kawasaki Disease Evaluation

The following algorithm is meant to provide guidance on determining the need for treatment. High suspicion for KD without characteristics described below should be considered and treatment should be individualized based on clinical assessment.

Review common pitfalls in diagnosis for clinical situations in which there should be a strong suspicion for KD diagnosis. Infants ≤ 6 months of age are the most likely to develop prolonged fever without other clinical criteria for KD, and are at greater risk for developing coronary artery aneurysms.1

Children with fever ≥ 4 days and presence or history of ≥ 2 principal clinical features
Infants ≤ 6 months with unexplained fever for ≥ 7 days
3 days of fever and strong clinical suspicion
  • Assess Laboratory Findings
  • Admission should be based on clinical suspicion or need for further monitoring & evaluation
CRP ≥ 3.0 mg/dL
ESR ≥ 40 mm/hr
CRP < 3.0 mg/dL
ESR < 40 mm/hr
  • Assess for supplemental laboratory findings
    • Anemia for age
    • Platelet count of ≥ 450,000 after the 7th day of fever
    • Albumin ≤ 3.0 g/dL
    • Elevated ALT level
    • WBC count of ≥ 15,000/mm3
    • Urine ≥ 10 WBC/hpf
  • Echo within 24 hours
    • Call Cardiology to order echo
    • Discuss echo results with Cardiology
  • Treat as indicated
  • Serial clinical and laboratory
    re-evaluation if fever persists 24 hours
  • Scheduled PCP follow-up after discharge
  • Echocardiogram if typical peeling develops
  • Consider further evaluation for MIS-C if:
    • Lymphopenia < 1 K   or
    • Thrombocytopenia < 150 K   or
    • Na < 135
≥ 3 supplemental
laboratory criteria
Abnormal echocardiogram
< 3 supplemental
laboratory criteria
Normal echocardiogram
Inpatient Management per
pathway guidelines
  • Consider alternative diagnoses
  • Consider consulting Rheumatology or Infectious Diseases
Fever persists
Fever abates
  • Repeat CRP, ESR in 36-48 hours
  • Consider repeat supplemental labs
  • Review other clinical findings
  • Consider alternative diagnoses
  • Repeat echocardiogram if fever and inflammation persist for 48 hours and no alternative diagnosis made
  • Follow Inpatient Management plan if indicated
  • Discharge if clinically improving and afebrile for 24 hours
  • Return to PCP or ED if fever or KD stigmata recur
  • Echocardiogram if typical peeling develops
  1. American Heart Association. 2017 Mar: Circulation 135:00-00. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. McCrindle et al.