how can general practitioners aid prompt referral?

Elisabeth is a first child so her parents have little experience of common childhood illnesses. In addition, her mother is an anaesthetist and may be reluctant to bother a general practitioner unless it is really necessary. Unusually, Elisabeth has had two episodes of a severe infection—periorbital cellulitis—for which investigation for immune deficiency may be indicated. Her parents seek advice after Elisabeth has been unwell for three days with fever, irritability, sore mouth, conjunctivitis, rash, and desquamation and has not passed urine for 24 hours. At this point there may have been some misunderstanding with the out of hours service, which should have advised that the child be seen by a doctor and would generally recommend follow up by the general practitioner next morning.

When the general practitioner sees Elisabeth on day 5 everything seems normal except the rash and perineal desquamation. Like some of the commentators, many general practitioners would consider the differential diagnoses of fever and rash to be common viral infections such as roseola infantum, measles, or rubella; the skin peeling would also raise the possibility of scarlet fever. It would be important to check her mother's antenatal notes to confirm she is immune to rubella. Relevant investigations for Elisabeth include salivary specimens for measles and rubella (as not all immunised children are immune) and a throat swab for streptococcus. Unlike the commentators, I think few general practitioners in the United Kingdom would have considered Kawasaki disease.¹

Clear advice for the parents is vital in such cases. Since Elisabeth has been quite ill, still has a rash and desquamation, has no definitive diagnosis, and has a history of serious illness, her parents should be asked to bring her for review after 1-2 days unless completely better. Then, if she still has a fever she should be referred to a paediatrician.

At its simplest, the role of a general practitioner is to decide if this child is seriously ill and whether she needs to be seen in hospital. Since Elisabeth did not see a paediatrician until day 17, there were possibly three missed opportunities for referral. These were when she was acutely ill and dehydrated on day 3, when first seen by the general practitioner on day 5, and at general practitioner review, which should have been arranged for a few days later. General practitioners in the United Kingdom, at least, are not that aware of Kawasaki disease. Although relatively rare, it should be considered in any child with unexplained fever lasting more than five days.²,³