It was the middle of a Friday afternoon, and the week was coming to an end. I was looking forward to a weekend off. My next patient, 11-year-old Mark, came in with a chief complaint of cough, sneezing and just feeling horrible for around four days. He woke up with a fever and, according to mom, his eyes were looking red. He appeared ill; his eyes were glazed over and a bit bloodshot. He had a noticeable brassy cough. As I began to get the history, mom interjected, “I just noticed that Mark has a rash...it wasn’t there this morning”.
Mark was sitting in the chair, looking peaked with his hair going in every direction. His temperature was 102.1 degrees, and cheeks were flushed. It seemed to be quite an effort to get up on the examining table as he said every part of his body hurt. Taking off his shirt I noticed the rash mom was talking about. It looked like the beginnings of a rash, not yet well defined or specific for a particular disease. It simply looked like a “viral “ rash. This raised my curiosity.
Systematically I did my exam of Mark to be sure nothing was missed. He could move his neck freely, eliminating my concern about meningitis. The eyes were slightly red, but not a true conjunctivitis. The eardrums were normal; his throat was beefy red but without any pus pockets on the tonsils. Strep throat was a possibility, I thought, but the rash wasn’t the typical sandpapery kind found with strep. He did have some enlarged lymph nodes in his neck, but they weren’t too impressive. Although he did have a brassy cough, the lungs were clear, thus, pneumonia was not likely. The rest of the exam was entirely normal. I went down the list of possible diagnoses in my mind, and nothing fit. Re-examining Mark was to no avail.
A strep test and a test for mononucleosis were administered, both of which were negative. This came as no big surprise since these did not fit our set of findings. It was possible that Mark had a “non-specific” virus, but I was uncomfortable with this diagnosis. It seemed that he had something specific, unclear as yet. I explained to mom that it was certain Mark did not have a serious illness, and time would sort it out. I wanted Mark to be seen the next day, even if he was miraculously recovered. Mom promised to bring him in. Since I was not going to be in the office the next day my partner who was on call and WOULD be in the office came to examine Mark with me. We went over the history together, and checked Mark from head to toe. We came to the same conclusion. Mom was given explicit instructions about what to do for Mark’s symptoms, and was told any changes she should be alarmed about and what to call us for. She was comfortable with this.
The next morning I got a call from my partner. “I thought you’d like a follow-up on Mark,” he said in an excited voice. “He’s got classic measles. He doesn’t even look like the same boy I saw yesterday.” Apparently Mark’s fever had shot up during the night; his cough worsened and the rash became very pronounced. When he was seen in the office the temperature was now 103.6 degrees. The rash was all over his trunk and around the face and neck. Very large lymph nodes were in his neck and behind his ears. What clinched the diagnosis, however, were grayish-white dots that looked like little grains of sand on a red base located on the inside of his cheeks just opposite his lower molars. These “Koplick spots” are pathognomonic for measles, meaning you don’t find these in any other illness. They are fleeting and only last from 12-18 hours. It just so happened that they were present when my partner re-examined Mark; thus cinching the diagnosis.
Mark did fine and by five days was looking and feeling pretty much back to normal. The question now was, why should Mark get measles? It turned out that he did receive his MMR (measles-mumps-rubella) at one year of age, as is the standard of care. But he did not get the second MMR, which is now given at five years of age and is a requirement to enter kindergarten in most states. When Mark began school, the MMR could be given at five or ten years. Being so healthy, he hadn’t had a physical for a few years. His mom thought he’d get the MMR before junior high school.
So why did Mark get measles after receiving the vaccine? The MMR is a good vaccine, certainly as good as any that are available. As with most “good” vaccines, it is about 94-96% successful. That means that 94-96 out of 100 recipients will be protected...4-6 out of a hundred won’t. The second MMR, therefore, is NOT a booster shot. It is merely given to capture, or pick up, the remaining 4-6% who did not mount a permanent protective response with the one MMR.
This was reported to the Public Health Department as required by law. Mark’s sister did receive two MMR’s, as they were needed to enroll in school. Fortunately for mom and dad, both were born before 1957 and did not need the vaccine. It is felt that anyone born before 1957 either has had measles or has natural protection from passive immunity.
Mark’s case was fascinating because measles is now a rare disease, thanks to the vaccine. It is not uncommon for a pediatric resident to complete a full three-year residency and never see a case. Mark was relatively lucky because he had a fairly average case. Measles can be a devastating disease, especially for the younger patients. It can have serious complications such as pneumonia, myocarditis (inflammation of the heart) or encephalitis.