Red Tongue and Fever: Kawasaki Disease Vs. Strep Throat

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When Your Child’s Tongue Looks Like a Strawberry. Think Kawasaki or Strep.

Strawberry tongue is a swollen, red tongue. The surface looks like a strawberry. Children with Kawasaki disease also tend to have bright red, cracked, sometimes swollen lips.

by James Hubbard, MD, MPH

Your four-year-old develops a 103 degree fever and a rash over her body. Her throat is bright red. In fact, so is her mouth, even her tongue. Not the usual pink. Bright red.

Hmm, you remember reading something The Survival Doctor wrote about fever and a red tongue. Strawberry tongue. You look again. The swollen, red taste buds are, in fact, kind of popped out, making the tongue look like a strawberry. Now you remember. A strawberry red tongue and fever can mean something serious—something that needs to be treated by a doctor. Oh, did I mention you’re in the middle of a disaster? All the phones are down and the roads blocked?

Kawasaki Disease

Several readers have asked me to write a post on Kawasaki disease (or syndrome—same thing). It’s seen in children under eight years old (usually five and under). It’s fairly rare but much more common in Japanese. It’s one of the disorders that can cause that red strawberry tongue, and if you see it, it needs professional treatment soon if possible.

Kawasaki disease is not contagious; it’s one of those weird autoimmune diseases. This one causes severe inflammation inside arteries. It runs its course in about four weeks, but in 25 percent of untreated cases, it causes permanent artery and heart problems—sometimes serious, even deadly. With prompt and proper treatment, the complication rate drops to 5 percent.

So, how to you treat it? First you have to suspect it.

Kawasaki Signs

Most cases start with a high fever and a rash. But many childhood diseases start out that way. The fact is all kids with a high fever and rash should be seen by a doctor. Even then, the exact cause may not be determined. However, we do have tests, like strep cultures and blood tests, that can help rule things in or out.

Of course, in this blog we help you know what to do when you can’t get to a doctor. Here are some signs that would make you lean toward Kawasaki disease as the diagnosis:

1: Strawberry tongue
Many children with Kawasaki disease have a swollen, red tongue. The surface looks like a strawberry. But the same type of red tongue can be seen in scarlet fever, which is strep throat with a rash. And the treatment is completely different. However, a child with Kawasaki disease has more of a tendency to have bright red, cracked, sometimes swollen lips.

2: Red eyes
The whites of both eyes are more than a little injected. They’re red, sometimes swollen. There’s no pus or discharge (which would make you think more of pinkeye).

3: Swollen lymph nodes in the neck
But that’s seen in a lot of infections.

4: Swollen hands or feet

5: Rash on the palms of the hands or soles of the feet

Many infections have these signs and symptoms, but Kawasaki combines them all—high fever (over 102) for over five days, and at least four out of five of the others (diffuse rash, strawberry red tongue, swollen or red hands or feet, swollen lymph nodes in the neck, and red eyes).

Even so, Kawasaki and strep (and for that matter, Rocky Mountain spotted fever and other viral rashes) can look alike. That’s where the lab tests come in. An ECG (heart tracing) can also be useful. But there is no definite test that tells you, for sure, that’s Kawasaki. The doctor has to put all the clues together.

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Kawasaki requires hospital treatment. In order to lessen the risk of complications, the treatment needs to be started within ten days of the onset of symptoms. Treatment consists of intravenous gamma globulin (antibodies) and high-dose aspirin (80 to 100 mg per kg divided into four doses per day).

Strep throat treatment is totally different. It requires antibiotics to treat the strep and lessen the risk for rheumatic fever and the heart problems it can cause.

If your child has a fever and a rash, get them seen as soon as possible. Even with a disaster, try to get them seen at least within ten days of the onset of symptoms. Meantime, just make sure they drink fluids so they don’t get dehydrated, and give them acetaminophen or ibuprofen or lukewarm sponge baths for the fever.

If it’s going to be longer, I would consider starting them on 10 days of the prescription antibiotic amoxicillin, cephalexin, or erythromycin. For Kawaski? You’re not going to find IV gamma globulin outside a hospital setting. And the problem with the aspirin is (1) that’s a high dose, and (2) if it turns out to be a viral illness, aspirin puts them at risk for another serious disease, Reye’s syndrome. Do what you consider best, but I don’t think I’d use aspirin. The odds are it’s a virus. To tell the truth, if I suspected a child I was seeing had Kawasaki. I’d refer them to a pediatrician who probably has seen way more cases of it than I have.

Have any of you ever known anyone who had Kawasaki disease? How was it diagnosed? What was the treatment? The outcome?

What about a strawberry red tongue? Or a high fever and a rash? What did it turn out to be?

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Photo by Kawasaki_symptoms.jpg: Dong Soo Kim derivative work: Natr (Kawasaki_symptoms.jpg) [CC-BY-2.0], via Wikimedia Commons.

  • Shawna

    My son had Kawaski’s 12 years ago at the age of 7 yrs, He had all the classical signs but also had cauliflower look a like around is private areas. Long story short he was so sick that he actually was out of school for a year and 12 years later still has medial problems. Including heart disease. He couldn’t play sports all through school and has had to go out of state for medical treatment for years. He now has a rare kidney disease that medicine brought on. His temperature was 107 for about 2 days with the kawaskis but fevered continuously for a year and had recurrent fevers for many years afterwards that was diagnosed as Periodic Fever Syndrome. My brothers daughter was also diagnosed with this a year earlier at the age of 13 months. She was sick like my son and only lived 30 days after the onset, She was in the hospital most of the time but had too many aneurisms on her little heart, This could be a serious disease and if you suspect Kawaski’s get to the Drs right away.

  • Renee

    Both of my children had Kawasaki’s. My son was 2 1/2 yrs old. He had all the symptoms for 10 days. Nobody knew what he had until a Dr on call had read an article on Kawasaki’s and properly diagnosed him. Fortunately, he has had no ill effects. He is 26 now and healthy. My daughter was 5 months old when my son was diagnosed. She came down with it within the next year. We recognized the symptoms quickly and started treatment. She is also a healthy 24 year old. Doctors in emergency rooms kept telling me my son had the flu and to go home. I knew it was more. If I had not been persistent and a Dr finally admitted him due to dehydration, my son could have had lasting effects or worse, be dead. GO WITH YOUR GUT! If you know something is wrong…keep at it until someone listens.

    • James Hubbard, MD, MPH

      Thanks, Renee. Yes, sometimes you’ve got to take the reins. I’ve learned over the years that a mom’s intuition about her child is something to take very seriously.

  • M

    My son had Kawasaki Disease a year ago–he was 3 and a half years old. We feel fortunate to have been diagnosed and treated quickly as we have a good relationship with our pediatrician (in NYC) who spent a long time on the phone with us over a holiday weekend and took our concerns regarding our child’s symptoms seriously. He (as well as some other family members at home) had all tested positive for stept at around the same time. It is believed that the strept infection triggered the kawasaki disease response. He was hospitalized for a few days and treated with ivig as well as antibiotics for scarlet fever–as the team of specialists assigned to him determined necessary. We had several cardiology follow-ups and he remained on aspirin for a few months too. Based on other parents’ accounts as well as the media–it seems we were lucky to have not had such a dramatic diagnosis. We had an obviously sick child and are thrilled all the people involved noticed it immediately as well.

    • James Hubbard, MD, MPH

      It does sound like everyone did a great job. Thanks for sharing.

  • Charlene LaFosse

    Our Son was exactly 3 months old when he started with the fever on 11/22. The next day,Thanksgiving Day, he was very sensitive to any positional changes and we brought him to the ER thinking it was an ear infection….over the next seven days his 104+ fever continued we watched, and reported all the transient symptoms to our family practice. (all over prickly rash that faded to be replaced with a swollen blotchy rash on his thigh, soles of his feet, fingers and palms of his hands; blood red lips, one bright red blood vessel in an eye that faded to normal within an hour; a blood stain in his diaper; strawberry tongue; and finally an alarmingly swollen belly that caused his inny belly button to “pop” to an outie. The only response I got from the on call Doctor was that it was a virus and would resolve. On day 7 I demanded an appointment with another Doctor for a 2nd opinion and he was alarmed at Bobby’s condition. Bobby was immediately hospitalized (11/27) and suspected of either sepsis, meningitis or Kawasaki Disease. A battery of tests including abdominal x-ray confirmed multiple blood abnormalities and a significantly enlarged liver and spleen. He was transferred to Children’s Hospital Boston who confirmed it was KD on day 8 (11/28). His coronary arteries were already dilated to 4mm and he was quickly placed on multiple blood thinners. Bobby was resistant to the IVIG treatment and received many different treatments designed to minimize inflammation. Unfortunately, due to the caustic treatments, he developed a serious GI bleed and all medications (including anticoagulants) had to be stopped for 24 hours resulting in 5 coronary clots. His aneurysms at the time ranged from 6.5 – 8.5. A clot busting med was administered but had to be discontinued when he developed internal bleeding in his elbow (they had drawn blood from the site the night before to check his heparin level) The swelling got so bad they called in a pediatric surgeon to confirm circulation was not obstructed to his hand. A week later the clots had stabilized and we were discharged from the hospital (12/22). We returned to Children’s Hospital on 12/26 for a follow-up echo that found one of the clots had enlarged and threatened to close off an artery, he was readmitted and TPA was once again administered. Again he had an adverse reaction – unable to control bleeding from the central line placed hours before administering the med and TPA was discontinued. We had no choice but to “wait and see” for 24 hours. Our prayers were answered and Bobby’s clot stabilized and the threadlike structures below it had cleared. We stayed another week to assure all anticoagulants were in therapeutic range and finally released on New Years Day. (32 total days at Children’s Hospital) Over the next year his aneurysms showed remodeling and regression. A cardiocatherization completed at 15 months old confirmed the artery was smooth with no pooling or stenosis and he was able to discontinue 2 of the 3 anticoagulants. He is now 6, soon to be 7, years old and is a picture of health. His aneurysms are no larger than 4 mm, he is only on 81mg of aspirin daily and has no activity restrictions.
    We are adamant that our son is alive today because the Pediatrician at our local hospital correctly diagnosed KD and transferred his care to Dr. Jane Newburger at Children’s Hospital. We are eternally grateful and cherish every day with Bobby.

    • James Hubbard, MD, MPH

      What an ordeal. I’m so glad everything turned out so well in the long run.

  • Sherry Biele

    When my boys were 3 and 4 yrs. of age my oldest presented with a rash of blood blisters and swollen joints. After several doctors and mistreatments we ended up in Mt. Sinai NYC where the doctor diagnosed HSP. Said it would never come back …it did 3 years later.Very scary illness. He was hospitalized both times. He was bleeding internally which caused the stomach pain and vomiting. Six months after this his younger brother has a very high fever and rash and then the skin of his palms and feet peeled off in one large sheet of skin. He had sores in his mouth besides the red tongue. They treated him with steroids and he became puffy, itchy, and pasty looking.We found out around that time that he was allergic to penecillin.Or so we were told. Again, it took several weeks until an infectious disease specialist was brought in and diagnosed Kawasaki Syndrome. They didn’t treat it because it had been 3-4weeks before our doctors gave up and sent us to the specialist We researched it ourselves and took him to a cardiologist who performed and echo cardiogram and we had one done every six months for several years just to make sure there was no damage. Both boys are now in their thirties and very healthy. Thank the Lord. The only link that we could find that might have caused the Kawasaki was we did have our rugs cleaned about every 8 months when they were young and crawling around. A year later there was an article in the paper about an outbreak of Kawasaki in several children who attended the same nursery school. They had just had their rugs cleaned….so who knows?????

    • James Hubbard, M.D., M.P.H.

      Sherry, thanks for sharing your experiences. They’re lucky to have such persistent parents.

  • Mike

    She just remembered lots of EKG’s for the next several years. Thanks, Mike

    • James Hubbard, M.D., M.P.H.

      Mike, Kawasaki Disease was first recognized here in the U.S. in the 1970’s. Here’s a history

      Depending on when your wife was treated, perhaps that was the standard of care at that time.

  • Mike

    My wife had Kawasaki’s at the age of 11. She remembers the high fever, strawberry tongue and she said it looked and felt like her eyes were bleeding. She was a very active kid and her heart was in good shape, so the Doctors told her that she did so well responding to treatment because she was in such good physical shape.

    They did not hospitalize her, but rather put her on high doses of aspirin for the first month, and for several months thereafter. She didn’t remember ever having an IV of any kind. She remembers the Doctors mentioning how deadly this disease was and that she needed to to exactly what she was told. They treated her as she stayed home from school for several months. This occurred in the mid 1980’s in Kingsville, TX.

    I asked her to tell me about her experience so I could share it with you after reading this article. She remembers the recovery taking a very long time. She remembers an entire month of intense therapy treating the Kawasaki’s, two more months of rest out of school, an entire year of aspirin therapy as they weaned her back off of that, and it was probably about 4 months before she could begin to re-engage in the school sports that she loved so much. The family and the Doctors watched her closely for the next two years to make sure no major effects had taken place; especially since she was such an active kid. I guess they were worried that her activity would be hindered by longer lasting effects.

    Last thought from her, the Doctors in Kingsville were credited by her and her family and teachers as diagnosing the condition immediately. They were very aggressive at running down what this was and starting treatment within a few days of the symptoms appearing. After reading your article, she doesn’t know why they never hospitalized her. Its a mystery…

    • Denisa

      Our Family Doctor was against hospitalizing children that could be treated at home by responsible adults. He thought it was dangerous to expose their compromised immune systems to even more illnesses. He also thought the stress of removing a young child from the home could weaken the immune system enough to delay recovery. He warned us against overuse of antibiotics and offered home remedy recipes for symptom relief. He was a firm believer in quarantine and often made house calls to prevent the spread of illness in his waiting room. He came to our home in the 1980’s for a follow up after our kids had chicken pox and had us burn our blankets before he left, just to be sure. I do miss his thoroughness.

      • James Hubbard, MD, MPH

        Sounds like a great guy.