Verma and colleagues reported an interesting case of recurrent fever of
immunological origin . The first episode probably favors a diagnosis
of Kawasaki disease because of the presence of coronary artery
dilatation, which normalized with anti-inflammatory therapy. During the
second episode, the child had high-grade fever with oral mucosal changes
and cervical lymphadenopathy with no identifiable infective cause on
basic laboratory evaluation. The coronary arteries were normal. The rise
in acute phase reactants was not very impressive. It seems reasonable to
consider Kawasaki disease among the differential diagnosis of this
condition, but the following issues need reconsideration:
1. A lot of emphasis has been given to skin
desquamation. Episodes of skin desquamation during febrile episodes
have been reported even beyond 5 years from the initial episode of
Kawasaki disease . Hence caution should be exercised in
considering skin desquamation in diagnosing disease recurrence.
2. Recurrent fevers with features of generalized
inflammation after Kawasaki disease might represent patients with a
genetic predisposition to inflammatory disorder .
3. Skin desquamation cannot be considered
pathognomonic of Kawasaki disease. It is a feature of many
infectious and immunological diseases, including Scarlet fever 
and Leptospirosis. The skin desquamation in Kawasaki disease is
generally limited to the palms and soles and severe peeling in
sheets occurs only in a small proportion of patients.
4. The lower risk of disease recurrence in India
more likely points to the lack of proper disease reporting systems.
Experience suggests that recurrence commonly occurs in children who
suffered a more severe disease with coronary artery involvement at
initial presentation . The disease recurrence frequently results
in additional coronary involvement.
This essentially highlights that the lack of a
confirmatory laboratory test leaves us reliant on clinical criteria for
diagnosis of Kawasaki disease. Recent work on the pathogenesis of the
vasculitics gives hope that a solution for this complex problem may be
on the way sooner than later.
1. Verma P, Agarwal N, Maheshwari M. Recurrent
Kawasaki disease. Indian Pediatr. 2015;52:152-4.
2. Michie C, Kinsler V, Tulloh R, Davidson S.
Recurrent skin peeling following Kawasaki Disease. Arch Dis Child.
3. Broderick L, Tremoulet AH, Burns JC, Bastian JF,
Hoffman HM. Recurrent fever syndromes in patients after recovery from
Kawasaki syndrome. Pediatrics. 2011;127:e489-93.
4. Gerber MA. Group A Streptococcus In:
Kliegman RM, Stanton BF, Geme JW, Schor NF, editors. Nelson
Textbook of Pediatrics. 19th ed. Philadelphia: Elsevier; 2011.
5. Balasubramanian S, Krishna MR, Dhanalakshmi K,
Amperayani S, Ramanan AV. Factors associated with delay in diagnosis of
Kawasaki disease in India. Indian Pediatr. 2012;49:663-5.