View source for Kawasaki disease

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{{DiseaseDisorder infobox |
  Name           = Kawasaki disease |
  ICD10          = {{ICD10|M|30|3|m|30}} |
  ICD9           = {{ICD9|446.1}} |
  ICDO           = |
  Image          = |
  Caption        = |
  OMIM           = 300530 |
  OMIM_mult      = |
  MedlinePlus    = 000989 |
  eMedicineSubj  = med |
  eMedicineTopic = 1223 |
  eMedicineSubj  = ped |
  eMedicineTopic = 1236 |
  DiseasesDB     = 7121 |
  MeshID         = D009080 |
}}
{{SI}}

{{CMG}}; {{AE}} {{CZ}}

===[[The Heart in Kawasaki Disease | For the heart in Kawasaki disease click here]]===
==Overview==
'''Kawasaki disease''', also known as '''lymph node syndrome''', '''mucocutaneous node disease''', '''infantile polyarteritis''' and '''Kawasaki syndrome''', is a poorly understood self-limited [[vasculitis]] that affects many organs, including the [[skin]] and [[mucous membrane]]s, [[lymph node]]s, [[blood vessel]] walls, and the [[heart]]. It does not seem to be contagious.<ref name=CDCKawasaki> Kawasaki Disease. Centers for Disease Control and Prevention (2013). http://www.cdc.gov/kawasaki/ Accessed on July 28, 2016.</ref> It was first described in 1967 by Dr. Tomisaku Kawasaki in Japan.<ref>{{cite journal | author = Kawasaki T | title = [Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children] | format=in Japanese | journal = Arerugi | volume = 16 | issue = 3 | pages = 178-222 | year = 1967 | id = PMID 6062087}}</ref>.  Kawasaki disease is predominantly a disease of young children, with 80% of patients younger than 5 years of age. Additional risk factors in the United States include Asian race and male sex.  Kawasaki disease can cause vasculitic changes (inflammation of blood vessels) in the coronary arteries and subsequent coronary artery aneurysms.  Common symptoms of kawasaki disease include high grade fever, red eyes, bright red and cracked lips,
red mucous membranes in the mouth, strawberry tongue, white coating on the tongue or prominent red bumps (papillae) on the back of the tongue, red palms of the hands and the soles of the feet, swollen hands and feet, and rash.  Intravenous Immunoglobulin (IVIG) and [[aspirin]] are indicated in kawasaki disease. 

==Historical Perspective==
Kawasaki disease was mentioned in the television programs Nip/Tuck and Without a Trace <ref>Episode 86 (4x16) - The Little Things (2 March, 2006)</ref>.  In the episode All In of the TV series House, it was inexplicably mentioned as a possible diagnosis for a 6 year old boy that was admitted with bloody diarrhea and coordination problems, as well as an elderly woman with unexplained respiratory, cardiovascular and neural deficiencies. Maxie Jones, a fictional character on General Hospital suffers from it. According to John Travolta and Kelly Preston, their son Jett Travolta also suffers from the disease.
 
==Classification==

 
==Pathophysiology==

 
==Causes==

The causative agent of Kawasaki disease is still unknown. However, current [[etiology|etiological]] theories center primarily on [[immune system|immunological]] causes for the disease. Much research is being performed to discover a definitive [[toxin]] or [[antigen]]ic substance, possibly a [[superantigen]], that is the specific cause of the disease. An unknown virus may play a role as an inciting factor as well.


==Differentiating Kawasaki disease from other diseases==
Different [[rash]]-like conditions can be confused with [[Kawasaki disease]] and are thus included in its differential diagnosis. The various conditions that should be differentiated from [[Kawasaki disease]] include:<ref name="pmid25250996">{{cite journal| author=Hartman-Adams H, Banvard C, Juckett G| title=Impetigo: diagnosis and treatment. | journal=Am Fam Physician | year= 2014 | volume= 90 | issue= 4 | pages= 229-35 | pmid=25250996 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25250996  }} </ref><ref name="pmid27265069">{{cite journal| author=Mehta N, Chen KK, Kroumpouzos G| title=Skin disease in pregnancy: The approach of the obstetric medicine physician. | journal=Clin Dermatol | year= 2016 | volume= 34 | issue= 3 | pages= 320-6 | pmid=27265069 | doi=10.1016/j.clindermatol.2016.02.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27265069  }} </ref><ref name="MooreSeward2006">{{cite journal|last1=Moore|first1=Zack S|last2=Seward|first2=Jane F|last3=Lane|first3=J Michael|title=Smallpox|journal=The Lancet|volume=367|issue=9508|year=2006|pages=425–435|issn=01406736|doi=10.1016/S0140-6736(06)68143-9}}</ref><ref name="pmid26612370">{{cite journal| author=Ibrahim F, Khan T, Pujalte GG| title=Bacterial Skin Infections. | journal=Prim Care | year= 2015 | volume= 42 | issue= 4 | pages= 485-99 | pmid=26612370 | doi=10.1016/j.pop.2015.08.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26612370  }} </ref><ref name="pmid26566601">{{cite journal| author=Ramoni S, Boneschi V, Cusini M| title=Syphilis as "the great imitator": a case of impetiginoid syphiloderm. | journal=Int J Dermatol | year= 2016 | volume= 55 | issue= 3 | pages= e162-3 | pmid=26566601 | doi=10.1111/ijd.13072 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26566601  }} </ref><ref name="pmid25855021">{{cite journal| author=Kimura U, Yokoyama K, Hiruma M, Kano R, Takamori K, Suga Y| title=Tinea faciei caused by Trichophyton mentagrophytes (molecular type Arthroderma benhamiae ) mimics impetigo : a case report and literature review of cases in Japan. | journal=Med Mycol J | year= 2015 | volume= 56 | issue= 1 | pages= E1-5 | pmid=25855021 | doi=10.3314/mmj.56.E1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25855021  }} </ref><ref name="pmid23176858">{{cite journal| author=CEDEF| title=[Item 87--Mucocutaneous bacterial infections]. | journal=Ann Dermatol Venereol | year= 2012 | volume= 139 | issue= 11 Suppl | pages= A32-9 | pmid=23176858 | doi=10.1016/j.annder.2012.01.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23176858  }} </ref>

{| class="wikitable"
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Disease}}
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Features}}
|-
| style="background: #DCDCDC; padding: 5px;"|[[Impetigo]] 
|
*It commonly presents with pimple-like lesions surrounded by [[erythematous]] [[skin]]. Lesions are [[pustules]], filled with [[pus]], which then break down over 4-6 days and form a thick crust. It's often associated with insect bites, cuts, and other forms of [[trauma]] to the [[skin]].
|-
| style="background: #DCDCDC; padding: 5px;"|[[Insect bite]]s
|
* The insect injects [[formic acid]], which can cause an immediate [[skin]] reaction often resulting in a [[rash]] and swelling in the injured area, often with formation of [[vesicles]].
|-
| style="background: #DCDCDC; padding: 5px;"|[[Kawasaki disease]] 
|
* Commonly presents with high and persistent [[fever]], red [[mucous membranes]] in mouth, "[[strawberry tongue]]", [[swollen lymph nodes]] and [[skin rash]] in early disease, with peeling off of the [[skin]] of the [[hands]], [[feet]] and [[genital area]].
|-
| style="background: #DCDCDC; padding: 5px;"|[[Measles]] 
|
* Commonly presents with high [[fever]], [[coryza]] and [[conjunctivitis]], with observation of [[oral mucosa|oral mucosal]] lesions ([[Koplik's spots]]), followed by widespread [[skin rash]].
|-
| style="background: #DCDCDC; padding: 5px;"|[[Monkeypox]]
|
* The presentation is similar to [[smallpox]], although it is often a milder form, with [[fever]], [[headache]], [[myalgia]], [[back pain]], [[swollen lymph nodes]], a general feeling of discomfort, and exhaustion. Within 1 to 3 days (sometimes longer) after the appearance of [[fever]], the patient develops a papular [[rash]], often first on the face. The lesions usually develop through several stages before crusting and falling off.
|-
| style="background: #DCDCDC; padding: 5px;"|[[Rubella]]
|
* Commonly presents with a facial [[rash]] which then spreads to the [[trunk]] and [[limbs]], fading after 3 days, low grade [[fever]], swollen [[glands]], [[joint pain]]s, [[headache]] and [[conjunctivitis]]. The [[rash]] disappears after a few days with no staining or peeling of the [[skin]]. ''[[Forchheimer's sign]]'' occurs in 20% of cases, and is characterized by small, red [[papules]] on the area of the [[soft palate]].
|-
| style="background: #DCDCDC; padding: 5px;"|Atypical [[measles]]
|
* The symptoms commonly begin about 7-14 days after infection and present as [[fever]], [[cough]], [[coryza]] and [[conjunctivitis]]. Observation of [[Koplik's spots]] is also a characteristic finding in measles.
|-
| style="background: #DCDCDC; padding: 5px;"|[[Coxsackievirus]]
|
* The most commonly caused disease is the [[Coxsackie A]] disease, presenting as ''hand, foot and mouth disease''. It may be [[asymptomatic]] or cause mild [[symptoms]], or it may produce [[fever]] and painful [[blisters]] in the mouth ([[herpangina]]), on the palms and fingers of the hand, or on the soles of the feet. There can also be [[blisters]] in the [[throat]]  or above the [[tonsils]]. Adults can also be affected. The [[rash]], which can appear several days after high temperature and painful sore throat, can be itchy and painful, especially on the hands/fingers and bottom of feet.
|-
| style="background: #DCDCDC; padding: 5px;"|[[Acne]]
|
* It is typical of teenagers, usually appears on the [[face]] and upper neck, but the [[chest]], [[human back|back]] and [[shoulder]]s may have [[acne]] as well. The upper [[arm]]s can also have [[acne]], but lesions found there are often [[keratosis pilaris]], not [[acne]]. The typical [[acne]] lesions are [[comedones]] and [[inflammatory]] [[papules]], [[pustules]], and [[nodules]]. Some of the large [[nodules]] were previously called "[[cyst]]s"
|-
| style="background: #DCDCDC; padding: 5px;"|[[Syphilis]] 
|It commonly presents with gneralized systemic [[symptoms]] such as [[malaise]], [[fatigue]], [[headache]] and [[fever]]. [[Skin]] eruptions may be subtle and [[asymptomatic]] It is classically described as:
* Non-pruritic bilateral symmetrical mucocutaneous [[rash]]
* Non-tender regional [[lymphadenopathy]]
* Condylomata lata and 
* Patchy [[alopecia]].
|-
| style="background: #DCDCDC; padding: 5px;"|[[Molluscum contagiosum]]
|
* The lesions are commonly flesh-colored, dome-shaped, and pearly in appearance. They are often 1-5 millimeters in diameter, with a dimpled center. Generally not painful, but they may itch or become irritated. Picking or scratching the lesions may lead to further [[infection]] or scarring. In about 10% of the cases, [[eczema]] develops around the lesions. They may occasionally be complicated by secondary [[bacterial infections]].
|-
| style="background: #DCDCDC; padding: 5px;"|[[Mononucleosis]]
|
* Common [[symptoms]] include low-grade [[fever]] without [[chills]], [[sore throat]], white patches on [[tonsils]] and back of the throat, [[muscle weakness]] and sometime extreme [[fatigue]], tender [[lymphadenopathy]], [[petechial hemorrhage]] and [[skin rash]].
|-
| style="background: #DCDCDC; padding: 5px;"|Toxic [[erythema]] 
|
* It is a common [[rash]] in infants, with clustered and [[vesicular]] appearance.
|-
| style="background: #DCDCDC; padding: 5px;"|[[Rat-bite fever]] 
|
* It commonly presents with [[fever]], [[chills]], open sore at the site of the bite and [[rash]], which may show red or purple plaques.
|-
| style="background: #DCDCDC; padding: 5px;"|[[Parvovirus B19]]
|
*The [[rash]] of fifth disease is typically described as "slapped cheeks," with [[erythema]] across the cheeks and sparing the nasolabial folds, forehead, and mouth.
|-
| style="background: #DCDCDC; padding: 5px;"|[[Cytomegalovirus]]
|
* The common [[symptoms]] include [[sore throat]], swollen [[lymph nodes]], [[fever]], [[headache]], [[fatigue]], [[weakness]], [[muscle pain]]  and [[loss of appetite]].
|-
| style="background: #DCDCDC; padding: 5px;"|[[Scarlet fever]] 
|
* It commonly includes [[fever]], punctate red [[macules]] on the hard and soft [[palate]] and [[uvula]] ([[Forchheimer's spots]]), bright red [[tongue]] with a "strawberry" appearance, [[sore throat]] and [[headache]] and [[lymphadenopathy]].
|-
| style="background: #DCDCDC; padding: 5px;"|[[Rocky Mountain spotted fever]] 
|
* The [[symptoms]] may include [[maculopapular rash]], [[petechial rash]], [[abdominal pain]] and [[joint pain]].
|-
| style="background: #DCDCDC; padding: 5px;"|[[Stevens-Johnson syndrome]] 
|
* The [[symptoms]] may include [[fever]], [[sore throat]]  and [[fatigue]]. Commonly presents [[ulcers]] and other lesions in the [[mucous membranes]], almost always in the [[mouth]] and lips but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. [[Conjunctivitis]] of the eyes occurs in about 30% of children. A [[rash]] of round lesions about an inch across, may arise on the face, trunk, arms and legs, and soles of the feet, but usually not on the scalp.
|-
| style="background: #DCDCDC; padding: 5px;"|[[Varicella-zoster virus]] 
|
* It commonly starts as a painful [[rash]] on one side of the face or body. The [[rash]] forms blisters that typically scab over in 7-10 days and clears up within 2-4 weeks.
|-
| style="background: #DCDCDC; padding: 5px;"|[[Chickenpox]] 
|
* It commonly starts with [[conjunctival]] and catarrhal [[symptoms]] and then characteristic spots appearing in two or three waves, mainly on the body and head, rather than the hands, becoming itchy raw pox (small open sores which heal mostly without scarring). Touching the fluid from a [[chickenpox]] blister can also spread the disease.
|-
| style="background: #DCDCDC; padding: 5px;"|[[Meningococcemia]] 
|
* It commonly presents with [[rash]], [[petechiae]], [[headache]], [[confusion]], and [[stiff neck]], high [[fever]], mental status changes, [[nausea]] and [[vomiting]].
|-
| style="background: #DCDCDC; padding: 5px;"|[[Rickettsialpox|Rickettsial pox]]
|
* The first [[symptom]] is commonly a bump formed by a mite-bite, eventually resulting in a black, crusty scab. Many of the [[symptoms]] are [[flu]]-like including [[fever]], [[chills]], [[weakness]] and [[muscle pain]] but the most distinctive [[symptom]] is the [[rash]] that breaks out, spanning the person's entire body.
|-
| style="background: #DCDCDC; padding: 5px;"|[[Meningitis]] 
|
* It commonly presents with [[headache]], [[nuchal rigidity]], [[fever]], [[petechiae]] and [[altered mental status]].
|}

{| class="wikitable"
|+
! rowspan="2" |Disease
! rowspan="2" |Epidemiology
! rowspan="2" |Predisposing factors
! colspan="2" |'''Clinical features'''
! rowspan="2" |'''Lab abnormalities'''
|-
|'''Signs'''
|'''Symptoms'''
|-
|Toxic shock syndrome
|Occurs in  both adults and children (9:1 female predominance)
|Occurs in association with [[vaginitis]] during [[menstruation]] following tampon use (S. aureus); as a complication of soft tissue infections ([[Streptococcus pyogenes|S. pyogenes]] or GAS) or in females undergoing medical [[abortion]] ([[Clostridium sordellii|C. sordellii]]).
|[[Hypotension]], [[tachycardia]], [[mucous membrane]] [[Hyperaemia|hyperemia]] (vaginal, oral, [[Conjunctiva|conjunctival]])
|Fever, diarrhea, vomiting, diffuse scarlantiform rash
|[[Hyponatremia]] and [[uremia]]. Hepatic dysfunction (total [[bilirubin]], serum asparate aminotransferase or serum alanine aminotransferase levels >2 times upper normal limit), [[leukocytosis]] with a [[Polymorphonuclear cells|polymorphonuclear shift]] to the left. [[Platelet|Platelets]] < 100,000 per mm<sup>3</sup> ([[thrombocytopenia]]), [[pyuria]] of [[renal]] origin.
|-
|[[Kawasaki disease|Kawasaki]] 
[[Kawasaki disease|disease]]
|Occurs in children, usually age 1-4 years
|Interaction of genetic and environmental factors, possibly including an infection in combination with genetic predisposition to an autoimmune mechanism ([[Vasculitis|autoimmune vasculitis]])
|Non-[[suppurative]], painless bilateral conjunctival [[inflammation]] ([[conjunctivitis]]), strawberry tongue (marked redness with prominent [[Papillae of the tongue|gustative papillae]]), deep transverse grooves across the nails may develop (Beau’s lines), [[lymphadenopathy]] present(acute, non-[[purulent]], cervical), may lead to [[Coronary arteries|coronary artery]] [[Aneurysm|aneurysms]]. 
|High and persistent fever that is not very responsive to normal treatment with [[acetaminophen]] or [[Non-steroidal anti-inflammatory drug|NSAIDs]],  diffuse [[Maculopapular|macular-papular]] [[erythematous]] rash
|Liver function tests may show evidence of hepatic [[inflammation]] and low serum [[albumin]] levels, low hemoglobulin and age-adjusted hemoglobulin concentrations, '''[[thrombocytosis]]''', [[anemia]].  [[Echocardiography|Echocardiographic]] abnormalities, such as [[valvulitis]] ([[Mitral valve|mitral]] or [[Tricuspid valve|tricuspid]] [[Regurgitation (circulation)|regurgitation]]) and [[Coronary arteries|coronary artery]] lesions, are significantly more common in [[Kawasaki disease]]. <ref name="pmid26222065">{{cite journal |vauthors=Lin YJ, Cheng MC, Lo MH, Chien SJ |title=Early Differentiation of Kawasaki Disease Shock Syndrome and Toxic Shock Syndrome in a Pediatric Intensive Care Unit |journal=Pediatr. Infect. Dis. J. |volume=34 |issue=11 |pages=1163–7 |year=2015 |pmid=26222065 |doi=10.1097/INF.0000000000000852 |url=}}</ref> [[Pyuria]] of uretheral origin.
|-
|[[Scarlet fever]]
|Distributed equally among both genders. Most commonly affects children between five and fifteen years of age.
|Occurs after streptococcal [[pharyngitis]]/[[tonsillitis]]
|Pastia's sign (puncta and skin crease accentuation of the [[erythema]]), strawberry tongue, cervical [[lymphadenopathy]] may be present. [[Scarlet fever]] appears similar to [[Kawasaki disease|Kawasaki's disease]] in some aspects, but lacks the eye signs or the swollen, red fingers and toes
|Characteristic sandpaper-like rash which appears days after the illness begins (although the rash can appear before illness or up to 7 days later), rash may first appear on the neck, underarm, and groin
|[[Leukocytosis]] with [[left shift]] and possibly [[eosinophilia]] a few weeks after convalescence. Anti-deoxyribonuclease B, [[Antistreptolysin O titer|antistreptolysin-O]] titers (antibodies to streptococcal [[extracellular]] products), antihyaluronidase, and antifibrinolysin may be positive.
|}
{|

Kawasaki disease must be differentiated from other causes of fever and rash in infants

{| style="border: 2px solid #DCDCDC; font-size: 90%; width: 83%;"
|+ '''Differential Diagnosis of Measles.''' Table adapted from CDC Pinkbook.<ref name=CDC90>{{cite web | title = Epidemiology and Prevention of Vaccine-Preventable Diseases | url = http://www.cdc.gov/vaccines/pubs/pinkbook/table-of-contents.html }}</ref>
|-
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Disease}}
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Agent}}
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Typical Season}}
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Typical Age}}
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Prodrome}}
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Fever}}
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Duration of the rash (days)}}
! style="width: 500px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Rash}}
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Other Signs & Symptoms}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''[[Measles]]'''
| style="background: #DCDCDC; padding: 5px;"| [[Paramyxovirus]]<br>Measles virus
| style="background: #F5F5F5; padding: 5px;"| Winter - Spring
| style="background: #DCDCDC; padding: 5px;"| 1 to 20 years
| style="background: #F5F5F5; padding: 5px;"| 2-4 days of [[cough]], [[conjunctivitis]], and [[coryza]]
| style="background: #DCDCDC; padding: 5px;"| High
| style="background: #F5F5F5; padding: 5px;"| 5 - 6
| style="background: #DCDCDC; padding: 5px;"| Erythematous, irregular size, maculopapular; starts on temples and behind ears; progresses down from face; fades to brownish
| style="background: #F5F5F5; padding: 5px;"| Koplik's spots: C blue-white papules (salt grains) on bright red [[mucosa]] opposite premolar [[teeth]] 
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''[[Kawasaki disease]]'''
| style="background: #DCDCDC; padding: 5px;"| Unknown
| style="background: #F5F5F5; padding: 5px;"| Winter - Spring
| style="background: #DCDCDC; padding: 5px;"| < 5 years
| style="background: #F5F5F5; padding: 5px;"| 3 days of abrupt [[fever]]
| style="background: #DCDCDC; padding: 5px;"| High; [[fever]] of 5 days is a diagnostic criteria
| style="background: #F5F5F5; padding: 5px;"| 5 - 7
| style="background: #DCDCDC; padding: 5px;"| Erythematous, morbilliform, maculopapular or scarlatiniform, central distribution; erythematous, indurated palms and soles
| style="background: #F5F5F5; padding: 5px;"| Acute: dry, fissured and injected lips, [[strawberry tongue]]; [[irritability]]; cervical [[lymphadenopathy]]; [[conjunctival injection]]; peripheral [[edema]]; Subacute: finger-tip desquamation; Complications: [[arthritis]], [[carditis]] 
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Roseola Infantum (exanthem subitum)'''
| style="background: #DCDCDC; padding: 5px;"| Human [[herpes virus]] type 6
| style="background: #F5F5F5; padding: 5px;"| Any season 
| style="background: #DCDCDC; padding: 5px;"| 6 months to 2 years
| style="background: #F5F5F5; padding: 5px;"| None
| style="background: #DCDCDC; padding: 5px;"| High
| style="background: #F5F5F5; padding: 5px;"| 1-2; it follows defervescence
| style="background: #DCDCDC; padding: 5px;"| Discrete erythematous macules, rarely involves face, begins as fever ends
| style="background: #F5F5F5; padding: 5px;"| [[Lymphadenopathy]], [[irritability]]
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''[[Rubella]]'''
| style="background: #DCDCDC; padding: 5px;"| [[Togavirus]]
| style="background: #F5F5F5; padding: 5px;"| Spring
| style="background: #DCDCDC; padding: 5px;"| 7 months to 29 years
| style="background: #F5F5F5; padding: 5px;"| 0 - 4 days; mild malaise, fever; absent in children
| style="background: #DCDCDC; padding: 5px;"| Low grade
| style="background: #F5F5F5; padding: 5px;"| 1 - 3
| style="background: #DCDCDC; padding: 5px;"| Discrete, rose-pink, diffuse, maculopapular; progresses downward from face, may change quickly 
| style="background: #F5F5F5; padding: 5px;"| [[Arthralgia]] (usually in adults), tender posterior cervical and suboccipital [[lymphadenopathy]], [[malaise]], [[petechiae]] on [[soft palate]]
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''[[Scarlet Fever]]'''
| style="background: #DCDCDC; padding: 5px;"| ß-hemolytic [[streptococci]] 
| style="background: #F5F5F5; padding: 5px;"| Winter
| style="background: #DCDCDC; padding: 5px;"| > 2 years
| style="background: #F5F5F5; padding: 5px;"| 0 - 6 day, marked
| style="background: #DCDCDC; padding: 5px;"| Low to high
| style="background: #F5F5F5; padding: 5px;"| 2 - 7 
| style="background: #DCDCDC; padding: 5px;"| Scarlet "sunburn" with punctate papules "sandpaper", circumoral pallor, increased intensity in [[skin]] folds, blanches stars face/head, upper trunk and progresses downward 
| style="background: #F5F5F5; padding: 5px;"| [[Sore throat]], exudative [[tonsillitis]], [[vomiting]], [[abdominal pain]], [[lmphadenopathy]], white then red [[strawberry tongue]]
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''[[Erythema Infectiosum]] ([[Fifth Disease]])'''
| style="background: #DCDCDC; padding: 5px;"| [[Human parvovirus]] type B19
| style="background: #F5F5F5; padding: 5px;"| Spring
| style="background: #DCDCDC; padding: 5px;"| 5 - 10 years
| style="background: #F5F5F5; padding: 5px;"| None, usually in children, may occur in adults
| style="background: #DCDCDC; padding: 5px;"| None to low-grade
| style="background: #F5F5F5; padding: 5px;"| 2 - 4
| style="background: #DCDCDC; padding: 5px;"| Starts as “slapped cheek”, maculopapular; progresses to reticular (lacy) pattern; can recur with environmental changes such as sunlight exposure
| style="background: #F5F5F5; padding: 5px;"| [[Arthralgia]]/[[arthritis]] in adults, [[adenopathy]]
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''[[Enterovirus]]'''
| style="background: #DCDCDC; padding: 5px;"| [[Echovirus]]<br>[[Coxsackie virus]]
| style="background: #F5F5F5; padding: 5px;"| Summer - Fall
| style="background: #DCDCDC; padding: 5px;"| Mainly childhood
| style="background: #F5F5F5; padding: 5px;"| 0 - 1 day fever and myalias
| style="background: #DCDCDC; padding: 5px;"| Low to high
| style="background: #F5F5F5; padding: 5px;"| 1 - 5
| style="background: #DCDCDC; padding: 5px;"| Fine, pink, always affects face; variant is Boston exanthem (large ~ 1 cm, discrete maculopapules)
| style="background: #F5F5F5; padding: 5px;"| [[Sore throat]], [[headache]], [[malaise]], no [[lymphadenopathy]], [[gastroenteritis]] 
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''[[Dengue Fever]]'''
| style="background: #DCDCDC; padding: 5px;"| [[Flavivirus]]<br>[[Dengue virus]] types 1 - 4 
| style="background: #F5F5F5; padding: 5px;"| 
| style="background: #DCDCDC; padding: 5px;"| 
| style="background: #F5F5F5; padding: 5px;"| None
| style="background: #DCDCDC; padding: 5px;"| High
| style="background: #F5F5F5; padding: 5px;"|1 - 5
| style="background: #DCDCDC; padding: 5px;"| Generalized maculopapular rash after defervescence; spares palms and soles 
| style="background: #F5F5F5; padding: 5px;"| [[Headache]], [[myalgia]], [[abdominal pain]], [[pharyngitis]], [[vomiting]] 
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''[[Drug induced rash]]'''
| style="background: #DCDCDC; padding: 5px;"| Many
| style="background: #F5F5F5; padding: 5px;"| Any
| style="background: #DCDCDC; padding: 5px;"| Any
| style="background: #F5F5F5; padding: 5px;"| Possible due to underlying [[illness]]
| style="background: #DCDCDC; padding: 5px;"| Possible
| style="background: #F5F5F5; padding: 5px;"| Varies
| style="background: #DCDCDC; padding: 5px;"| Typically diffuse but may be concentrated in diaper area, typically no progression, erythema multiform rash can progress over a few days 
| style="background: #F5F5F5; padding: 5px;"| Possibly due to underlying [[illness]] or [[complications]] 
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''[[Infectious Mononucleosis]]'''
| style="background: #DCDCDC; padding: 5px;"| [[Epstein-Barr Virus]]
| style="background: #F5F5F5; padding: 5px;"| None
| style="background: #DCDCDC; padding: 5px;"| 10 - 30 years
| style="background: #F5F5F5; padding: 5px;"| 2 - 5 days of [[malaise]] and [[fatigue]]
| style="background: #DCDCDC; padding: 5px;"| Low to high
| style="background: #F5F5F5; padding: 5px;"| 2 - 7
| style="background: #DCDCDC; padding: 5px;"| Trunk and proximal extremities. Rash common if [[Ampicillin]] given 
| style="background: #F5F5F5; padding: 5px;"| [[Pharyngitis]], [[lymphadenopathy]], [[splenomegaly]], [[malaise]]
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''[[Pharyngoconjunctival Fever]]'''
| style="background: #DCDCDC; padding: 5px;"| [[Adenovirus]] types 2, 3, 4, 7, 7a
| style="background: #F5F5F5; padding: 5px;"| Winter - Spring
| style="background: #DCDCDC; padding: 5px;"| < 5 years
| style="background: #F5F5F5; padding: 5px;"|
| style="background: #DCDCDC; padding: 5px;"| Low to high
| style="background: #F5F5F5; padding: 5px;"| 3 - 5
| style="background: #DCDCDC; padding: 5px;"| Starts on face and spreads down to trunk and extremities
| style="background: #F5F5F5; padding: 5px;"| [[Sore throat]], [[conjunctivitis]], [[headache]], [[anorexia]]
|}

The following table is a list of differential diagnosis oral lesions presenting similar to measles:
<div style="width: 70%;">
{| class="wikitable"
!Disease
!Presentation
!Risk Factors
!Diagnosis
!Affected Organ Systems
!Important features
!Picture
|-
!
!
!
!
|-
|[[Coxsackie virus]]
|
*[[Fever]] 
*[[Sores]] in the [[mouth]]
*[[Rash]] with [[blisters]]
*[[Aches]]
|
*[[Pregnancy]]
*[[immunodeficiency]]
|
*[[History]] and [[Physical exam]]
*[[Throat swabs]]
*Swabs from the lesion 
*[[Tzanck test]]
|
*[[Oral cavity]]
*[[Skin]]
|
*Symptomatic treatment
|[[File:Hand foot mouth disease 07a.jpg|Hand-foot-and-mouth disease|300x300px]]
|-
|[[Chickenpox|Chicken pox]]
|
*[[Conjunctival symptoms]]
*[[Catarrhal symptoms]] 
*Characteristic [[spots]] on the trunk appearing in two or three waves
*[[Itching]]
|
*[[Pregnancy]]
*[[Premature infants]] born to susceptible mothers
*All [[infants]] born at less than 28 weeks [[gestation]] or who weigh ≤1000 grams
*[[Immunocompromised]]
|
*[[History]] and [[physical exam]]
*[[PCR]] to detect [[VZV]] in [[skin lesions]] ([[vesicles]], [[scabs]], [[maculopapular lesions]])
|
*[[Oral cavity]]
*[[Skin]]
|
*[[Sodium bicarbonate]] in baths or [[antihistamines]] for [[itching]]
*[[Paracetamol]] ([[acetaminophen]]) for [[fever]]
*[[Prednisolone]] is [[contraindicated]]
|[[File:Chickenpox18a.jpg|Chickenpox|300x300px]]
|-
|[[Measles]]
|
*[[Fever]]
*[[Rash]]
*[[Cough]]
*[[Coryza]] (runny nose)
*[[Conjunctivitis]] (pink eye)
*[[Malaise]]
*[[Koplick spots]] in mouth
|
*[[Unvaccinated]] individuals<ref name="pmid11135778">{{cite journal| author=Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE| title=Individual and community risks of measles and pertussis associated with personal exemptions to immunization. | journal=JAMA | year= 2000 | volume= 284 | issue= 24 | pages= 3145-50 | pmid=11135778 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11135778  }} </ref><ref name="pmid9009400">{{cite journal| author=Ratnam S, West R, Gadag V, Williams B, Oates E| title=Immunity against measles in school-aged children: implications for measles revaccination strategies. | journal=Can J Public Health | year= 1996 | volume= 87 | issue= 6 | pages= 407-10 | pmid=9009400 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9009400  }} </ref>
*Crowded and/or [[unsanitary]] conditions
*Traveling to less developed and [[developing countries]]
*[[Immunocompromized]]
*[[Winter]] and [[spring]] seasons
*Born after 1956 and never fully vaccinated 
*Health care workers
|
*[[History]] and [[examination]]
*[[PCR]] for [[Measles]]-specific [[IgM antibody]]
*[[PCR]] for [[Measles]] [[RNA]]
|
*[[Oral cavity]]
*[[Skin]]
*[[Respiratory tract]]
*[[Eyes]]
*[[Throat]]
|
*Caused by [[Morbillivirus]]
*Primary site of infection is the [[respiratory epithelium]] of the [[nasopharynx]]
*Transmitted in [[respiratory secretions]], via [[aerosol droplets]] containing [[virus particles]]
|[[File:Koplikspot1a.jpg|Koplick spots (Measles)|300x300px]]
|-
|[[Herpangina]]
|
*Sudden [[fever]]
*[[Sore throat]] and [[dysphagia]]- These can occur several hours(up to 24 hours), before the appearance of the enanthem.
*[[Vomiting]]
*[[Abdominal pain]]
*[[Myalgia]] 
*[[Headache]]
*Pharyngeal lesions
|
*Attendance at a kindergarten/child care center
*Contact with herpangina cases
*Residence in rural areas
*Overcrowding
*Poor hygiene
*Low socioeconomic status
|
*Clincial diagnosis
*Pharyngeal [[viral]] and [[bacterial]] cultures can be taken to exclude [[HSV]] infection and [[streptococcal pharyngitis]].
|
*Skin
*Oral Cavity
|
*Characteristic enanthem- Punctate [[macule]] which evolve over a period of 24 hours to 2-4mm erythematous papules which vesiculate, and then centrally ulcerate.
*The lesions are usually small in number, and evolve rapidly. The lesions are seen more commonly on the [[soft palate]] and [[uvula]]. The lesions can also be seen on the [[tonsils]], posterior pharyngeal wall and the [[buccal mucosa]].
|
[[File:Herpangina3.jpg|center|300x300px|alt=Erythema, vesicles and ulcerating lesions in herpangina|Erythema, vesicles and ulcerating lesions in herpangina]]
|-
|Primary herpetic gingivoestomatitis<ref name="KolokotronisDoumas2006">{{cite journal|last1=Kolokotronis|first1=A.|last2=Doumas|first2=S.|title=Herpes simplex virus infection, with particular reference to the progression and complications of primary herpetic gingivostomatitis|journal=Clinical Microbiology and Infection|volume=12|issue=3|year=2006|pages=202–211|issn=1198743X|doi=10.1111/j.1469-0691.2005.01336.x}}</ref>
|
*Pin-head [[vesicles]] rupture to form painful irregular ulcerations covered by yellow-grey membrane
*Severe pain 
*[[Submandibular lymphadenopathy]]
*[[Halitosis]]
*It involves [[buccal mucosa]], [[tongue]], posterior [[pharynx]], and [[gingival]] and palatal [[mucosa]]
|
*Direct contact
*[[HIV infection]]
|
*[[Tzanck test]] demonstrates multinucleated epithelial giant cells<ref name="pmid12626280">{{cite journal| author=Chauvin PJ, Ajar AH| title=Acute herpetic gingivostomatitis in adults: a review of 13 cases, including diagnosis and management. | journal=J Can Dent Assoc | year= 2002 | volume= 68 | issue= 4 | pages= 247-51 | pmid=12626280 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12626280  }} </ref>
*Viral [[culture]] is the gold standard for diagnosis
*Direct [[immunofluorescence]]
|
*Oral cavity
*Mucous membranes
|
*Ulcers are common on lips, gums, throat, front of tongue, inside of the cheeks and roof of the mouth
*Treatment is with antiviral agents such as [[Valacyclovir]] and [[Famciclovir]]
|
[[File:Herpes labialis - opryszczka wargowa.jpg|300x300px]]

|}

Koplik spots must be differentiated from other diseases causing oral lesions such as leukoplakia and herpes simplex virus infection.

{| class="wikitable"
!Disease
!Presentation
!Risk Factors
!Diagnosis
!Affected Organ Systems
!Important features
!Picture
|-
! colspan="3" |Diseases predominantly affecting the oral cavity
!
!
!
!
|-
|[[Oral candidiasis|Oral Candidiasis]]
|
* [[Dysphagia]] or [[odynophagia]]
* White patches on the mouth and tongue
|
*[[Newborn]] babies

*Denture users

*Poorly controlled [[diabetes]]

*As a side effect of medication, most commonly having taken [[antibiotic]]s. Inhaled [[corticosteroids]] for the treatment of lung conditions (e.g, [[asthma]] or [[COPD]]) may also result in oral candidiasis which may be reduced by regularly rinsing the mouth with water after taking the medication.

*People with poor [[nutrition]], specifically [[vitamin A]], [[Iron deficiency anemia|iron]] and [[Folate deficiency|folate deficiencies]].

*People with an [[immune deficiency]] (e.g. as a result of [[AIDS]]/[[HIV]] or [[chemotherapy]] treatment).

*Women undergoing hormonal changes, like [[pregnancy]] or those on [[birth control pills]].

*[[Organ transplantation]] patients
|
* Clinical diagnosis
* Confirmatory tests rarely needed
|'''Localized candidiasis'''
* [[Oral candidiasis|Oral]] and [[Esophageal candidiasis|esophageal candidasis]]
* [[Candida vulvovaginitis]]
* [[Chronic mucocutaneous candidiasis]]

'''Invasive candidasis'''
* [[Candidiasis|Candidaemia]]
* [[Endocarditis|Candida endocarditis]]
* [[Osteoarthritis|Candida osteoarticular disease]]
|
* [[Osteoarthritis|Oral candidiaisis is]] a benign self limiting disease unless accompanied by [[immunosuppression]].
|[[File:Human tongue infected with oral candidiasis--By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=11717223.jpg|thumb|Tongue infected with oral candidiasis - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=11717223.jpg|400x400px]]
|-
|[[Herpes simplex|Herpes simplex oral lesions]]
|
* [[Fever]]  
* [[Sore throat]]
* Painful [[ulcer]]s
|
* Stress
* Recent [[URTI]]
* Female sex
|
* Physical examination
* [[Viral culture]]
* [[Tzanck smear]]
|
* Orofacial Infection
* [[Herpes simplex anogenital infection|Anogenital Infection]]
* [[Herpes simplex ocular infection|Ocular Infection]]
* [[Herpes simplex encephalitis|Herpes Encephalitis]]
* [[Herpes simplex neonatorum|Neonatal Herpes]]
* [[Herpetic whitlow|Herpetic Whitlow]]
* [[Herpes gladiatorum|Herpes Gladiatorum]]
|
* The symptoms of primary [[HSV]] infection generally resolve within two weeks
|[[File:Herpesinfection - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=19051042.jpg|thumb|Oral herpes simplex infection - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=19051042.jpg|400x400px]]
|-
|[[Aphthous ulcer|Aphthous ulcers]]
|
* Painful, red spot or bump that develops into an open [[ulcer]]
|
* Being a female
* Between the ages of 10-40
* Family history of [[Aphthous ulcer|aphthous ulcers]]
|
* Physical examination
* Diagnosis of exclusion
|
* Oral cavity
|
* Self-limiting , [[Pain]] decreases in 7 to 10 days, with complete healing in 1 to 3 weeks
|[[File:Afta foto - By Ebarruda - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=7903358.jpg|thumb|Apthous ulcer on the lower surface of the tongue - By Ebarruda - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=7903358|400x400px]]
|-
|[[Squamous cell carcinoma]]
|
*Non healing [[ulcer]], [[nodule]], indurated plaque or mass
*May involve [[skin]], [[lips]], inside the [[mouth]], [[throat]] or [[esophagus]]
|
* Chronic sun or [[Ultraviolet|UV exposure]]
* Fair [[skin]]
* [[Elderly]] age (>45 yrs)
* [[Male sex]]
* [[Smoking]]
|
*[[Physical exam]]
*[[Biopsy]]
|
*[[Oral Cavity]]
**Floor of [[mouth]]
**Lateral [[tongue]]
*[[Throat]]
*[[Esophagus]]
|
*[[Malignant]]
*Can spread to [[TMJ]]
*Some times associated with [[leukoplakia]]
|[[File:PLoS oral cancer.png|thumb|400x400px| |Squamous cell carcinoma - By Luca Pastore, Maria Luisa Fiorella, Raffaele Fiorella, Lorenzo Lo Muzio - http://www.plosmedicine.org/article/showImageLarge.action?uri=info%3Adoi%2F10.1371%2Fjournal.pmed.0050212.g001, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=15252632]] 
|-
|[[Leukoplakia]]
|
*White leathery spots on the [[mucous membranes]] of the [[tongue]] and inside of the [[mouth]]
*Lateral borders of [[tongue]]
|
*Atypical [[Tobacco]] use
*Chronic [[irritation]]
*[[Immunodeficiency]]
*[[Bloodroot]] ([[Sanguinarine|sanguinaria]])
|
*[[Physical exam]]
*Diagnosis of exclusion
*[[Biopsy]]
|
*[[Vulva|Vulvar]] lesions occur independent of oral lesions
|
*Associated with [[HIV]]
*Persistant white spots
*[[Benign]] but can progress to [[carcinoma]] after almost 10 years
*Oral proliferative [[Leukoplakia|verrucous leukoplakia]] is an aggressive sub type with multiple lesions and higher conversion to [[warts]] or [[carcinoma]]<ref>{{Cite journal
 | author = [[Ann M. Gillenwater]], [[Nadarajah Vigneswaran]], [[Hanadi Fatani]], [[Pierre Saintigny]] & [[Adel K. El-Naggar]]
 | title = Proliferative verrucous leukoplakia (PVL): a review of an elusive pathologic entity!
 | journal = [[Advances in anatomic pathology]]
 | volume = 20
 | issue = 6
 | pages = 416–423
 | year = 2013
 | month = November
 | doi = 10.1097/PAP.0b013e3182a92df1
 | pmid = 24113312
}}</ref>
|[[File:Oral hairy leukoplakia (EBV, in HIV)a.jpg|thumb|400x300px|Leukoplakia - By Aitor III - Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9873087]]
|-
|[[Melanoma]]
|
*A lesion with [[ABCD]]
**[[Asymmetry]]
**Border irregularity
**Color variation
**[[Diamete]]r changes
*[[Bleeding]] from the lesion
|
*[[Ultraviolet|UV radiations]]
*[[Genetic predisposition]]
*[[Old age]]
*[[Male gender]]
*Family or personal history of [[melanoma]]
*Multiple benign or atypical [[Nevus|nevi]]
|
*[[ABCD]] characteristics
*[[Bleeding]] or [[ulceration]] may show [[malignancy]]
*Serum [[LDH]] may be elevated in case of [[malignancy]]
*[[Biopsy]]
|
*Can [[metastasize]]
*All [[UV radiation]] or sun exposed areas can be effected independently
*1-2 to hundreds of [[granules]]
|
*[[Neural crest cell]] derivative
*Development begins with disruption of [[nevus]] growth control
*Progression involves [[MAPK/ERK pathway]]
*[[RAS|N-RAS]] or [[BRAF]] [[oncogene]] also involved
|[[File:Palate malign melanoma 01.jpg|thumb|400x400px|Oral melanoma - By Emmanouil K Symvoulakis, Dionysios E Kyrmizakis, Emmanouil I Drivas, Anastassios V Koutsopoulos, Stylianos G Malandrakis, Charalambos E Skoulakis and John G Bizakis - Symvoulakis et al. Head & Face Medicine 2006 2:7 doi:10.1186/1746-160X-2-7 (Open Access), [1], CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=9839811]]
|-
|[[Fordyce spots]]
|
*Rice-like [[granules]] or [[spots]]
*Small, [[painless]], [[raised]], [[pale]], red or white
*1 to 3 mm in [[diameter]]
|
*Greasy skin types
*Some [[Rheumatic|rheumatic disorders]]
*[[Hereditary nonpolyposis colorectal cancer]]
**Lower [[gingiva]] (gums) 
**[[Vestibular system|Vestibular mucosa]]
|
*[[Physical exam]]
*Small [[keratin]]-filled [[pseudocysts]]
*May be seen on [[incidental]] [[mucosal]] [[biopsy]]
**[[Biopsy]] not done for them primarily
|
*[[Oral cavity]]
**[[Vermillion border|Vermilion border]] of the lips
**[[Oral mucosa]] of the upper lip
*[[Buccal mucosa]] in the commissural region often bilaterally
*[[Genitals]]
|
*[[Benign neoplasms]] with [[sebaceous]] features
*Visible [[sebaceous glands]]
*No surrounding [[mucosal]] change
*Several adjacent [[glands]] may coalesce into a larger cauliflower-like cluster
|[[File:Fospot.jpg|thumb|400x400px|Fordyce spots - Por Perene - Obra do próprio, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=19772899]]
|-
|[[Burning mouth syndrome]]
|
*Burning or [[tingling]] on the [[lips]], [[tongue]], or entire [[mouth]]
|
*[[Nutritional deficiencies]]
*Chronic [[anxiety]] or [[depression]]
*[[Diabetes type 2]]
*[[Menopause]]
*[[Oral thrush]] or [[dry mouth]], or damaged [[nerves]] transmitting taste
*[[Female gender ]]
*[[Menopause]]
|
*[[Presentation]]
*[[Physical exam]]
|
*[[Oral cavity]]
|
*Pain typically is low in the morning and builds up over the day
*Low dosages of [[benzodiazepines]], [[tricyclic antidepressants]] or [[anticonvulsants]] may be effective
|
|-
|[[Torus palatinus]]
|
*Bony growth on midline of the [[hard palate]]
*[[Nodular]] mass covered with normal [[mucosa]]
|
*[[Genetic predisposition]]
**[[Autosomal dominant]]
|
*[[Physical exam]]
*Types
**[[Torus palatinus|Flat tori]]
**[[Torus palatinus|Spindle tori]]
**[[Torus palatinus|Nodular tori]] 
**[[Torus palatinus|Lobular tori]] 
|
*[[Hard palate]]
|
*More common in [[Asian]] and Inuit populations
*Twice more common in [[females]]
*Repeated [[trauma]] can cause [[bleeding]]
*[[Surgery]] may be required in symptomatic
|[[File:06-06-06palataltoria.jpg|thumb|Torus palatinus|400x400px|Torus palatinus - By Photo taken by dozenist, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=846591]]
|-
| colspan="4" |'''Diseases involving oral cavity and other organ systems'''
|
|
|
|-
|[[Behçet's disease|Behcet's disease]]
|
*Painful [[mouth sores]]
*[[Acne]] like skin lesions
*Headache, [[fever]], poor [[balance]], [[disorientation]]
*[[Abdominal pain]], [[diarrhea]] or [[bleeding]]
*[[Uveitis]]
*Joint [[swelling]] and joint [[pain]]
*Genital [[sores]] wit [[pain]] and [[scaring]]
*[[Aneurysms]]
|
*Over active [[immune system]]
|
*[[Physical examination]]
|
*[[Mouth]]
*[[Genitals]]
*[[GIT]]
*[[Eye]]
*[[Joints]]
*[[Skin]]
*[[Vascular system]]
*[[Brain]]
|
*[[Outbreaks]] of exaggerated [[inflammation]]
*Affects smaller [[blood vessels]]
|[[File:Behcets disease.jpg|thumb|400x400px|Behcet's disease - By Ahmet Altiner MD, Rajni Mandal MD - http://dermatology.cdlib.org/1611/articles/18_2009-10-20/2.jpg, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17863021]]
|-
|[[Crohn's disease]]
|
*Chronic, episodic [[diarrhea]] or [[constipation]]
*[[Abdominal pain]]
*[[Vomiting]]
*[[Weight loss]] or [[weight gain]]
|
*[[Smoking]]
*[[Whites]] and [[European]] [[Jews]]
*[[Hormonal contraception]]
*Diets high in microparticles, sweet, fatty or refined foods
*Industrialized country
|
*Typical [[history]] and [[symptoms]]
*[[Skip lesions]] on [[biopsy]]
*[[Anti saccharomyces cerevisiae antibodies|Anti-Saccharomyces cerevisiae antibodies (ASCA)]]
*[[Anti-neutrophil cytoplasmic antibodies]] ([[ANCA]])
|
*[[Eyes]]
*[[Joints]]
*[[Skin]]
|
*May lead to
**[[Obstruction]]s
**[[Abscess]]es
**Free [[perforation]]
**[[Hemorrhage]]
|
|-
|[[Agranulocytosis]]
|
*[[Fever]] or [[chills]]
*Frequent [[infections]]
*Unusual [[redness]], [[pain]], or [[swelling]] around a wound
*Mouth [[ulcers]]
*[[Abdominal pain]]
*[[Burning sensation when urinating]]
*[[Sore throat]]
|
*[[Medications]]<ref name="PMID17142169">{{cite journal |author=Andrès E, Zimmer J, Affenberger S, Federici L, Alt M, Maloisel F. |title=Idiosyncratic drug-induced agranulocytosis: Update of an old disorder. |journal=Eur J Intern Med. |volume=17|issue=8 |pages=529-35 |year=2006|pmid 17142169|doi=|url=https://www.ncbi.nlm.nih.gov/pubmed/17142169}}</ref>
*[[List of chemotherapeutic agents#Cytotoxic Chemotherapy|Cytotoxic chemotherapy]]
*[[Hematological malignancy|Hematologic malignancies]]
*[[Autoimmune disorders]]
|
*[[Neutropenia]] <100 cells per micro litre
*[[Eosinopenia]]
*[[Basopenia]]
|
*[[Oral cavity]]
*[[Skin]]
*[[GIT]]
*[[Urinary system]]
*[[Conjunctiva]]
|
*[[Immunocompromised|Immunocompromization]]
*Types
**[[Drug-induced]]
**[[Malignant]]
**[[Autoimmune]]
|
|-
|[[Syphilis]]<ref> title="By Internet Archive Book Images [No restrictions], via Wikimedia Commons" href="https://commons.wikimedia.org/wiki/File:A_manual_of_syphilis_and_the_venereal_diseases%2C_(1900)_(14595882378).jpg"</ref>
|
*[[Chancre]]
*Regional [[lymphadenopathy]]
|
*[[Multiple sexual partners]]
*Illicit [[drug use]]
*[[Unprotected sex]]
*[[Homosexual men|Men who have sex with men]]
*Residence in highly prevalent areas
*[[Human Immunodeficiency Virus (HIV)|HIV]] infection
*Presence of other [[STI]]s
*Previous history of [[Sexually transmitted disease|STIs]]
*[[Intravenous drug use]]
|
*[[Darkfield microscope|Darkfield microscopy]]
*Non [[Treponema|treponemal]] tests like [[VDRL]] and [[RPR test]]) 
*[[Treponema|Treponemal]] tests[[FTA-ABS|FTA-ABS tests]], (TP-PA) assay, [[Enzyme linked immunosorbent assay (ELISA)|enzyme immunoassays]], and [[Chemiluminescence|chemiluminescence immunoassays]])
|
*[[Oral cavity]]
*[[Penis]]
*[[Cervix]]
*[[Labia]]
*[[Anal canal]]
*[[Rectum ]]
*[[CNS]]
*[[Cardiovascular|CVS]]
|
*[[Primary syphilis]]
**[[Chancre]]
*[[Secondary syphilis]]
**[[Condyloma latum|Condylomata lata]]
*[[Latent syphilis]]
**[[Asymptomatic]]
*[[Tertiary syphilis]]
**[[Gumma|Gummas]]
**[[Neurosyphilis]]
|[[File:Hutchinson teeth congenital syphilis PHIL 2385.rsh.jpg|thumb|400x400px|oral syphilis - By CDC/Susan Lindsley - http://phil.cdc.gov/phil_images/20021114/34/PHIL_2385_lores.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=2134349]]
|-
|[[Coxsackie virus]]
|
*[[Fever]] 
*[[Sores]] in the [[mouth]]
*[[Rash]] with [[blisters]]
*[[Aches]]
|
*[[Pregnancy]]
*[[immunodeficiency]]
|
*[[History]] and [[Physical exam]]
*[[Swabbing|Throat swabs]]
*Swabs from the lesion 
*[[Tzanck test]]
|
*[[Oral cavity]]
*[[Skin]]
|
*Symptomatic treatment
|[[File:Hand foot mouth disease 07a.jpg|thumb|400x400px|Coxsackie virus stomatitis - Adapted from Dermatology Atlas.<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>]]
|-
|[[Chickenpox|Chicken pox]]
|
*[[Conjunctival]] symptoms
*[[Catarrhal]] symptoms 
*Characteristic [[spots]] on the trunk appearing in two or three waves
*[[Itching]]
|
*[[Pregnancy]]
*[[Premature infants]] born to susceptible mothers
*All [[infants]] born at less than 28 weeks [[gestation]] or who weigh ≤1000 grams
*[[Immunocompromised]]
|
*[[History]] and [[physical exam]]
*[[PCR]] to detect [[VZV]] in [[skin lesions]] ([[vesicles]], [[scabs]], [[Maculopapular|maculopapular lesions]])
|
*[[Oral cavity]]
*[[Skin]]
|
*[[Sodium bicarbonate]] in baths or [[antihistamines]] for [[itching]]
*[[Paracetamol]] ([[acetaminophen]]) for [[fever]]
*[[Prednisolone]] is [[contraindicated]]
|[[File:Herpangina2016.jpg|thumb|400x400px|Chickenpox - By James Heilman, MD - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=52872565]]
|-
|[[Measles]]
|
*[[Fever]]
*[[Rash]]
*[[Cough]]
*[[Coryza]] (runny nose)
*[[Conjunctivitis]] (pink eye)
*[[Malaise]]
*[[Koplick spots]] in mouth
|
*Unvaccinated individuals<ref name="pmid11135778">{{cite journal| author=Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE| title=Individual and community risks of measles and pertussis associated with personal exemptions to immunization. | journal=JAMA | year= 2000 | volume= 284 | issue= 24 | pages= 3145-50 | pmid=11135778 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11135778  }} </ref><ref name="pmid9009400">{{cite journal| author=Ratnam S, West R, Gadag V, Williams B, Oates E| title=Immunity against measles in school-aged children: implications for measles revaccination strategies. | journal=Can J Public Health | year= 1996 | volume= 87 | issue= 6 | pages= 407-10 | pmid=9009400 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9009400  }} </ref>
*Crowded and/or unsanitary conditions
*Traveling to less developed and developing countries
*Immunocompromized
*Winter and [[spring]] seasons
*Born after 1956 and never fully vaccinated 
*Health care workers
|
*[[History]] and [[examination]]
*[[PCR]] for [[Measles]]-specific [[IgM|IgM antibody]]
*[[PCR]] for [[Measles]] [[RNA]]
|
*[[Oral cavity]]
*[[Skin]]
*[[Respiratory tract]]
*[[Eyes]]
*[[Throat]]
|
*Caused by [[Morbillivirus]]
*Primary site of infection is the [[respiratory epithelium]] of the [[nasopharynx]]
*Transmitted in [[respiratory secretions]], via [[aerosol droplets]] containing [[Virus|virus particles]]
|[[File:Koplik spots, measles 6111 lores.jpg|thumb|400x400px|Koplick spots (Measles) - By CDC - http://phil.cdc.gov/PHIL_Images/20040908/4f54ee8f0e5f49f58aaa30c1bc6413ba/6111_lores.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=824483]]
|}
</div>

== Epidemiology and Demographics ==
KS occurs worldwide, with the highest incidence in Japan, and it most often affects boys and younger children. KS may have a winter-spring seasonality, and community-wide outbreaks have been reported occasionally. In the continental United States, population-based and hospitalization studies have estimated an incidence of KS ranging from 9 to 19 per 100,000 children younger than 5 years of age. Approximately 4248 hospitalizations for KS, of which 3277 (77%) were for children under 5 years of age, were estimated among children younger than 18 years of age in the United States in the year 2000.

CDC uses hospital discharge data, a passive KS surveillance system, and special studies to describe the incidence and epidemiology of KS in the United States. The KS surveillance system has been maintained by CDC since 1976 and is based on voluntary reporting of KS cases by health care providers and local and state health authorities. A standardized case report form is used to collect information on patients. 

For epidemiologic surveillance, CDC defines a case of KS as illness in a patient with fever of 5 or more days duration (or fever until the date of administration of intravenous immunoglobulin if it is given before the fifth day of fever), and the presence of at least 4 of the following 5 clinical signs:

*Rash 
*Cervical lymphadenopathy (at least 1.5 cm in diameter) 
*Bilateral conjuctival injection 
*Oral mucosal changes 
*Peripheral extremity changes. 

Patients whose illness does not meet the above KS case definition but who have fever and coronary artery abnormalities are classified as having atypical or incomplete KS.

===Incidence===
By far, the highest incidence of Kawasaki disease occurs in Japan (175 per 100,000), though its incidence in the United States is increasing. Kawasaki disease is predominantly a disease of young children, with 80% of patients younger than 5 years of age. Additional risk factors in the United States include Asian race and male sex.

==Risk Factors==

==Screening==

==Natural History, Complications, and Prognosis==
===Natural History===

===Complications===

===Prognosis===
The [[cardiac]] complications are, by far, the most important aspect of the disease. Kawasaki disease can cause vasculitic changes (inflammation of blood vessels) in the [[coronary arteries]] and subsequent '''coronary artery [[aneurysm]]s'''. These aneurysms can lead to [[myocardial infarction]] ([[myocardial infarction|heart attack]]) even in young children. Overall, about 10&ndash;18% of children with Kawasaki disease develop coronary artery aneurysms<ref>{{cite journal | author = Belay E, Maddox R, Holman R, Curns A, Ballah K, Schonberger L | title = Kawasaki syndrome and risk factors for coronary artery abnormalities: United States, 1994-2003. | journal = Pediatr Infect Dis J | volume = 25 | issue = 3 | pages = 245-9 | year = 2006 | id = PMID 16511388}}</ref>, with much higher prevalence among patients who are not treated early in the course of illness.  Kawasaki disease is the most common cause of acquired heart disease among children in the United States.

With early treatment, rapid recovery from the acute symptoms can be expected and the risk of coronary artery aneurysms greatly reduced.  Untreated, the acute symptoms of Kawasaki disease are self-limited (''i.e.'' the patient will recover eventually), but the risk of coronary artery involvement is much greater. Overall, about 2% of patients die from complications of coronary vasculitis. Patients who have had Kawasaki disease should have an [[echocardiogram]] initially every few weeks, and then every 1&ndash;2 years to screen for progression of cardiac involvement.

It is also not uncommon that a [[relapse]] of symptoms may occur soon after initial treatment with [[IVIG]]. This usually requires re-hospitalization and retreatment. Treatment with [[IVIG]] can cause allergic and non-allergic acute reactions, aseptic meningitis, [[fluid overload]] and, rarely, other serious reactions. Aspirin may increase the risk of bleeding from other causes and may be associated with Reye's syndrome. Overall, life-threatening complications resulting from therapy for Kawasaki disease are exceedingly rare, especially compared with the risk of non-treatment.


==Diagnosis==
===Diagnostic Criteria===

Kawasaki disease is diagnosed clinically (by [[medical sign]]s and [[symptom]]s), and there exists no specific laboratory test that can tell if someone has it. It is normally difficult to establish the diagnosis, especially early in the course of illness, and frequently children are not diagnosed until they have seen their doctor several times, or visited a number of different health care providers. Many other serious illnesses can cause similar symptoms, and must be considered in the [[differential diagnosis]], including [[scarlet fever]], [[toxic shock]] syndrome, and [[juvenile idiopathic arthritis]].

Classically, five days of fever plus four of five [[diagnostic]] criteria must be met in order to establish the diagnosis. 

The criteria are: 

(1) [[erythema]] of the lips or oral cavity or cracking of the lips; 

(2) rash on the trunk; 

(3) swelling or erythema of the hands or feet; 

(4) red eyes (conjunctival injection) 

(5) swollen lymph node in the neck of at least 15 millimeters.

Many children, especially infants, eventually diagnosed with Kawasaki disease do not exhibit all of the above criteria. In fact, many experts now recommend treating for Kawasaki disease even if only three days of fever have passed and at least three diagnostic criteria are present, especially if other tests reveal abnormalities consistent with Kawasaki disease. In addition, the diagnosis can be made purely by the detection of coronary artery aneurysms in the proper clinical setting.

===History and Symptoms===
Kawasaki disease often begins with a high and persistent [[fever]] that is not very responsive to normal doses of [[acetaminophen]] or [[ibuprofen]]. The fever may persist steadily for up to two weeks and is normally accompanied by irritability. Affected children develop red eyes, red [[mucous membrane]]s in the mouth, red cracked lips, a "[[strawberry tongue]]", iritis, keratic precipitates (detectable by an ophthalmologist but usually too small to be seen by the unaided eye), and swollen [[lymph node]]s. [[Skin rash]]es occur early in the disease, and peeling of the skin in the [[genital area]], hands, and feet (especially around the nails and on the palms and soles) may occur in later phases. Some of these symptoms may come and go during the course of the illness. If left untreated, the symptoms will eventually relent, but coronary artery aneurysms will not improve, resulting in a significant risk of death or disability due to myocardial infarction (heart attack).  If treated in a timely fashion, this risk can be mostly avoided and the course of illness cut short.

* High-grade fever (greater than 39&nbsp;°C or 102&nbsp;°F; often as high as 40&nbsp;°C  or 104&nbsp;°F) that normally lasts for more than a week if left untreated.
* Red eyes ([[conjunctivitis]]) without pus or drainage, also known as "conjunctival injection"
* Bright red, chapped, or cracked lips
* Red [[mucous membrane]]s in the mouth
* Strawberry tongue, white coating on the tongue or prominent red bumps ([[papillae]]) on the back of the tongue
* Red palms of the hands and the soles of the feet
* Swollen hands and feet
* Rash which may take many forms, but not vesicular (blister-like), on the trunk
* Swollen [[lymph node]]s (frequently only one lymph node is swollen), particularly in the neck area
* Joint pain ([[arthralgia]]) and swelling, frequently symmetrical
* Irritability
* [[Tachycardia]] (rapid heart beat)
* Peeling (desquamation) palms and soles (later in the illness); peeling may begin around the nails

==Physical Examination==
A physical examination will demonstrate many of the features listed above.

=== Laboratory Findings ===
*There are no specific laboratory findings associated with [disease name].

*A  [positive/negative] [test name] is diagnostic of [disease name].
*An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
*Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Blood tests
* [[Complete blood count]] (CBC) may reveal normocytic [[anemia]] and eventually [[thrombocytosis]]
* [[Erythrocyte sedimentation rate]] (ESR) will be elevated
* [[C-reactive protein]] (CRP) will be elevated
* [[Liver function tests]] may show evidence of hepatic inflammation and low [[serum albumin]]
 
===Imaging Findings===

 
=== Other Diagnostic Studies ===
Other tests (may or may not be performed)
* [[Electrocardiogram]] may show evidence of [[ventricular]] dysfunction or, occasionally, [[arrhythmia]] due to [[myocarditis]]
* [[Echocardiogram]] may show subtle coronary artery changes or, later, true aneurysms.
* [[Ultrasound]] or [[computerized tomography]] may show hydrops (enlargement) of the [[gallbladder]]
* [[Urinalysis]] may show white blood cells and protein in the urine ([[pyuria]] and [[proteinuria]]) without evidence of bacterial growth
* [[Lumbar puncture]] may show evidence of [[aseptic meningitis]]
* [[Angiography]] was historically used to detect coronary artery aneurysms and remains the gold standard for their detection, but is rarely used today unless coronary artery aneurysms have already been detected by echocardiography.

==Treatment==
===Medical Therapy===
[[Intravenous Immunoglobulin]] ([[IVIG]]) and [[aspirin]] are indicated in the treatment of Kawasaki Disease.  It is imperative that treatment be started as soon as the diagnosis is made to prevent damage to the [[coronary arteries]].  Except for Kawasaki disease and a couple of other indications, aspirin is otherwise normally not recommended for children due to its association with [[Reye's syndrome]].  Children with Kawasaki disease should be hospitalized.  

*1. '''Initial treatment''' <ref>{{cite web | title = Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease
| url =http://circ.ahajournals.org/content/110/17/2747.full }}</ref>
:* Preferred regimen: [[IVIG]] 2 g/kg single infusion within the first 7-10 days of illness {{and}} [[Aspirin]] 80-100 mg/kg/day qid , reduce the aspirin dose after the child has been afebrile for 48 to 72 hours, then begin low-dose aspirin (3 to 5 mg/kg/day) and maintain it until the patient shows no evidence of coronary changes by 6 to 8 weeks after the onset of illness
:* Note (1): Other clinicians continue highdose aspirin until day 14 of illness and 48 to 72 hours after fever cessation
:* Note (2): For children who develop coronary abnormalities, aspirin may be continued indefinitely

*2. '''Treatment of Patients Who Failed to Respond to Initial Therapy (persistent or recrudescent fever ≥ 36 hours after completion of the initial IVIG infusion)'''
:* Preferred regimen: [[IVIG]] 2 g/kg q24h for 1-3 days {{or}} [[Methylprednisolone]] 30 mg/kg IV for 2-3 hours q24h for 1-3 days

===Surgery===

===Prevention===

==References==
{{Reflist|2}}

==External links==
*[http://www.kdfoundation.org/ Kawasaki Disease Foundation]
*[http://www.kdforum.org/ Kawasaki Disease Forum]
*[http://www.kdcanada.ca/ Kawasaki Disease Canada]
*[http://www.emory.edu/CHCS/p_histmed_Kawasaki.ht Kawasaki Disease Research Program]
* [http://heartcenter.seattlechildrens.org/conditions_treated/kawasaki_disease.asp Kawasaki Disease information] from Seattle Children's Hospital Heart Center
*{{GPnotebook|1751842816}}

{{Diseases of the musculoskeletal system and connective tissue}}

[[Category:Cardiology]]
[[Category:Pediatrics]]
[[Category:Rheumatology]]

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[[de:Kawasaki-Syndrom]]
[[es:Síndrome de Kawasaki]]
[[fr:Maladie de Kawasaki]]
[[it:Sindrome di Kawasaki]]
[[he:מחלת קווסקי]]
[[nl:Ziekte van Kawasaki]]
[[ja:川崎病]]
[[pl:Choroba Kawasaki]]
[[th:โรคคาวาซากิ]]
[[tr:Kawasaki Hastalığı]]
[[zh:川崎氏病]]