Spotting measles

There is a sort of game I like to play at work.  Based only on what the triage nurse writes as the chief complaint, I try to guess the final diagnosis. The game is especially fun when the chief complaint is something like "Eats shirts,” but that is a story for another time.  A few weeks ago, a little girl came into the Emergency Department.  The triage note read, "Fever, drooling, mouth sores."  I narrowed my guess to two common viral illnesses.  A good history and exam and the diagnosis would be in the bag. 

My resident saw the patient first.  He came out of the room and described to me a previously healthy, unvaccinated girl with fever, drooling and mouth sores.  Suddenly everything changed. Sure, this child was still most likely to have a common virus, but now I had to consider a list of diseases that I almost never seriously entertain.  Diseases I have never seen because we live in the post vaccine era.

We live in the post vaccine era.  Isn't that amazing?  Vaccines have so changed the landscape of modern medicine that they have earned their own era.  We often talk about how vaccines mean that children are protected against death and morbidity from diseases like tetanus, polio and diphtheria.  While this is true, vaccines have also revolutionized the way that doctors manage infection.  Because of vaccines, I can view fever as nothing more than the normal response of a healthy immune system.  I can confidently tell more parents after a simple, painless examination that their child has an illness he can fight off on his own.  No irradiating him with x-rays or cat scans, no painful blood draws, no tubes shoved into orifices.  It is a great time to be a pediatrician.

As a physician who has only ever known medicine in the post vaccine era, there are some drawbacks.  The most valuable teaching in medical school and residency came from patients and the experienced physicians instructing me.  This is what pneumonia sounds like.  This is what a surgical abdomen feels like.  This is what leukemia looks like.  This.  Right here.  Don't forget this.  Even the best textbook pales in comparison to the real thing.  My knowledge of these vaccine-preventable infections is exclusively from textbooks.

So on the night that I see this little girl with fever and drooling and oral lesions, things go a little differently than usual.  I still think she has a common virus.  But could it be epiglottitis?  I don't know; I've never seen it.  It is probably best to get an x-ray to be on the safe side.  And maybe some labs.  And if we are drawing blood, we better try for an IV.  Could it be measles?  I don't know; I've never seen it.  My resident and I pore over pictures of Koplik's spots.  The textbook says they should have a blue or gray hue, and I don't think that hers do.  It is hard to be confident.  The ramifications of being wrong play out in the back of my mind.

I discharge her.  In my note, I document no cough, no coryza, no conjunctivitis, no rash... no evidence of measles.  Because, according to articles like this US Measles Cases in 2013 May Be Worst in 17 Years, that is a real concern and there may come a day when I no longer have the privilege of saying, "I've never seen that."