The MMWR (Morbidity and Mortality weekly report) is a weekly publication by the CDC.
It gives surveys of diseases, and if a new disease pops up, it is our “headsup” that something is going on.

This week’s issue includes three women who caught measles after they went to Guangdong Province in China to adopt. If you want to read about measles, go HERE if you are a doctor, or you can check the Microbial world website, complete with neat photos of the rash and Koplik spots, for an easier description.

The ironic thing is that none of these nice ladies were diagnosed with measles until the lab came back. That is for two reasons. One, measles rash looks like a dozen other rashes, including penicillin allergy with fever (serum sickness), and (for the lady in Missouri), Rocky Mountain spotted fever.
There are traditionally five “look alike” rashes that we learn about in medical school. Measles, German Measles (rubella), Roseola, Scarlet Fever, and Fifth disease. (The name “Fifth disease” is a medical joke, since it is the fifth rash, and for years we didn’t have a lab test for it.)

There are a lot of other things that cause funny rashes, from Dengue to Rocky Mountain Spotted Fever to Lyme disease to syphillis to Kawasaki’s disease.
Measles starts with a fever, and you feel rotten. Often you have a stuffy nose, and then sore eyes. The day before the rash starts, you get Kolik spots on the inner cheeks of your mouth, and then you break out in a rash, starting with the face.
So nowadays, if someone comes in with a rash and fever, and they are on Penicillin, you figure they don’t have Measles or Rubella since most folks have had the shots. Since in medicine, the way you think is “When you hear hoofbeats, think horses, not zebras”, you start trying to figure out what’s in the neighborhood, and go on from there.
For lady number one, in Missouri, they did what I would have done in Oklahoma: High fever, treat Rocky Mountain spotted fever. In tick regions, any high fever in summer is RMSF until proven otherwise, because if you wait for the rash, they can get very sick. But the rash of RMSF starts at the wrists and ankles and moves in, not at the face and moves out. So someone must have noticed that the rash was wrong, so so they tested furthur and found measles.

The other people were also diagnosed late, only by blood tests, mainly because when lady number one got diagnosed, they checked all the people on her plane.

One was thought to have a serum sickness allergic reaction to antibiotic, where you don’t get hives, you get a rash and fever. Another they tested for hepatitis, which can cause rashes.

The whole thing is that rashes look alike. But there is a clue to measles, but you have to look for it carefully, and it is only present very early, starting the day before the rash. That is Koplik spots. Think of your inner cheek being red, with whiteheads. That’s koplik spots.

Apparantly no one saw them, or if they saw them they didn’t recognize it, because few American docs under the age of 60 have ever seen a case.

The other clue is travel history. That is probably why the MMWR put out the notice, for ordinary docs to have a headsup to think of measles if their patient just came back from China.

Finally, there is one more thing I worry about after reading this article.

When my kids were teenagers, our high school had an outbreak of measles in teenagers. It turned out that the shots given as babies don’t give life long protection. So we now give two shots, one at age 18 months and one before school starts at age 5.

All three ladies had two MMR shots. So I suspect that in the future if there is measles in the area, we will have to give our adult contacts another measles immunization.

Luckily, I’m old enough to have had the disease, so am immune.
And for those who think, well why get the shot if it might not work and some people think it might increase autism, my answer is:
All you need to see is one case of measles encephalitis, and you will change your mind.
And in children with immune problems (such as HIV positive kids, or in third world countries, from poor nutrition) it can be fatal.


Nancy Reyes is a retired physician living in the rural Philippines. Her webpage is Finest Kind Clinic and Fishmarket. She posts longer medical essays on HeyDoc Xanga blog

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