A reddish shortness of breath

Dr Mine Durusu Tanriover, Assistant Professor of Internal Medicine at Hacettepe University, Ankara, Turkey, recounts her experience of treating a patient with severe measles and pneumonia, and stresses the need for increased vaccine uptake.

Dr Durusu Tanriover writes:

We were quite sure that it was the flu, when our 27-year-old emergency medicine resident presented with shortness of breath, cough, generalized muscle aches and fever. It was the high season for influenza, he was at the frontline of the emergency service where most of the flu cases entered the hospital. We admitted our resident to the acute care unit and started oseltamivir 75 mg per oral twice a day and moxifloxacin 400 mg per oral once a day.

Upon admission, he was in mild respiratory distress and fine rales were heard on auscultation. Liver enzymes were elevated, leukopenia and mild thrombocytopenia were evident. The next day, he was no better and moreover he developed red, centripedal, and pruritic rash along with severe conjunctivitis, nausea/vomiting and respiratory distress. Was it a drug reaction? Or was a hemophagocytic syndrome pending? Or was it the wrong diagnosis right from the beginning?

I don’t remember diagnosing measles nor seeing a patient with measles in the recent 20 years, that is throughout my medical life. But, I do show the photographs of measles cases with whitish spots in the buccal mucosa, namely Koplik’s spots, in my propaedeutic lectures. And, there were they! Thanks to our infectious diseases colleagues, Koplik spots were noticed, antibodies against measles were ordered and the patient was diagnosed to have measles. And it was a severe measles case with pneumonia, respiratory failure requiring non-invasive ventilation, conjunctivitis and hepatitis. Ribavirin and high dose vitamin A were started.

On the fourth day of ribavirin therapy the liver aminotransferases peaked and the serum bilirubin level increased to 2.1 mg/dL which forced us to discontinue ribavirin. Fortunately, the patient was feeling better with a decreased need for oxygen and normal body temperature 4 days after admission. He was discharged on the 9th day when the liver enzymes regressed, but it was a 9-days-of-high-anxiety. He could have died of respiratory failure due to measles pneumonia…

This was the case when I realized that there is the thing called ‘the vaccine paradox’. Yes, it is true, as the success of the childhood vaccination programs tops, we no longer see cases with measles, diphtheria or polio, and in turn we, as physicians, lose the ability to diagnose them. The reflection of the vaccine paradox in lay public is much scary, people forget the disease and basically they discard the success of the vaccines that has been established over several years. Measles vaccine is administered since 1970’s in Turkey, however there was a switch to a single dose vaccine between 1987-1998 (9th month).

There was a recent surge of measles cases among adolescents and young adults in Turkey, preceded by an epidemic starting from Eastern Europe and these cases were probably due to the single dose vaccination strategy between 1987 and 1998. Considering the vaccine refusals, anti-vaccine movements and people with no access to preventive healthcare, I am now pretty sure that I may see more patients with a communicable, vaccine preventable disease anytime in my medical and personal life. And, that will once again remind me the lives that were given back to us thanks to the incredible job done by the vaccines and thanks to those who dedicated their lifetimes to develop and use them.