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.



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  • 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.