A 9-year-old girl presents with 2 weeks of high fever, bilateral non-exudative conjunctival injection, cracked red lips, strawberry tongue, diffuse cervical lymphadenopathy >1.5 cm, and a polymorphous truncal rash. Her CRP is 95 mg/L and ESR 78 mm/hr. She is treated with IVIG 2 g/kg and aspirin. On day 5, she remains febrile. What is the MOST appropriate next step?
- A Repeat echocardiogram and add corticosteroids
- B Add infliximab 5 mg/kg IV
- C Re-dose IVIG 2 g/kg and continue aspirin ✓
- D Increase aspirin to 100 mg/kg/day
Explanation
IVIG-resistant Kawasaki disease is defined as persistent or recurrent fever ≥36 hours after completion of the first IVIG infusion. The initial management of IVIG resistance is a second dose of IVIG at 2 g/kg. In cases of second IVIG failure, corticosteroids (methylprednisolone pulse or prednisolone) or infliximab are considered. Current AHA/AAP Kawasaki guidelines recommend re-dosing IVIG first before escalating to steroids or biologics. Increasing aspirin dose is not the recommended approach for IVIG resistance; aspirin is maintained at anti-inflammatory dose (30–50 mg/kg/day) during the acute phase and is not escalated.
Reference: Ghai Essential Pediatrics, 10th ed.
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