Koplik Spots

Koplik Spot

 

We all know that our diagnosis is built upon the foundation of the history and physical exam. One of the challenges in caring for children in the ED is that the physical exam can be, at times, difficult to do… particularly the oral exam.  While it may be challenging, it is incredibly important to do a thorough exam to make a timely and accurate diagnosis. The common wrestling match (you vs child) is seen during assessment for strep pharyngitis, but let us not forget that the oral exam may be very helpful in assessing the febrile child.  Is this a simple viral illness or is this measles?  Are there Koplik Spots present??

 

Koplik Spots: Their Appearance

  • Millimetric, erythematous, blue-white or grey speck on the buccal mucosa. (Steichen, 2009)
    • Typically appear opposite to the upper molars.
    • Can extend to include the entire buccal mucosa.
  • Seen before the external rash – about 24 hours prior.
  • Persist for 2-3 days.

 

Koplik Spots: Their Importance

  • With the low incidence of measles, the importance of Koplik spots may have faded from our collective memories. (Lefebvre, 2010)
    • Unfortunately, measles has not been erased from existence… so, we should still be aware and vigilant!
  • Regarded as pathognomonic of measles.
    • Seen in 50-70% of patients with measles, if examined early on in the course.
    • Koplik spots are highly predictive of confirmed measles. (Tenner, 2012)
  • Detecting Koplik spots may enable prompt measles management and control measures. (Tenner, 2012)

 

Early Detection is Imperative!

  • Measles is a leading cause of preventable childhood morbidity and mortality worldwide.
  • Measles is one of the most contagious disease known!
    • It is spread through aerosol exposure or contact.
    • It has a 90% transmission rate!
  • Initially, it presents similar to every other febrile, viral illness (cough, coryza, and conjunctivitis).
  • The patient is contagious for ~5 days after the onset of symptoms (yup, when that simple fever started).
  • Early detection is key to limit its spread.
    • Unfortunately, since it may look just like every other viral URI at first… combined with the fact that measles is not encountered that commonly in the US (until, recently)… it may be difficult to detect it early.
    • Koplik Spots may be the key to help you make the diagnosis… but you have to look for them!

 

The Oral Exam: Some Tips

For whatever reason, most kids don’t like strangers looking into their mouths.  This seems to be even more true when they don’t feel well.  Given the fact that finding Koplik spots would dramatically change your management plan, it is imperative that you examine the mouth well.  You probably shouldn’t just give ketamine to everyone who has a fever though… so what can you do?

  1. Don’t be scary.
    • No one wants a stranger prying open their mouth… so don’t be a stranger.
    • Play with the child before jumping to the mouth exam.
    • Or, at least start with areas of the exam that are less intimidating (ex, feet).
  2. Make your first attempt your best attempt.
    • This applies to all procedures… from intubation to lumbar puncture.
    • Rate of success decreases proportionally with each successive attempt
      • This is not scientific, but true…
      • Ok, it might actually be an exponential relationship.
    • Have your tools handy, but hidden…
      • Using ungloved fingers isn’t wise and realizing you need a tongue blade after starting isn’t encouraging for the family.
      • Lighting is imperative!
        • Headlamps are awesome… but a little scary… unless you are super cool and can convince them that you are a quirky Cyclops (part of the fun of being a Ped EM doc… you get to play a lot).
        • The small Mac Blade laryngoscope is ideal.  Consider it a lighted tongue blade.
    • Teach the family how you want them to hold the child before you start.
      • Learning while the child is kicking them in the face is difficult.
      • The traditional method is having the child sitting facing you with parent restraining legs, arms, and head.
  3. Have a Plan C
    • Another option for restraining, that works well, but is a bit odd:
      • Have the child sit facing parent, with his/her legs wrapped around parent’s waist.
      • The child then is reclined onto the parent’s legs with his/her neck slightly extended as it reaches past the parent’s knees.
      • The parent restrains arms and legs.
      • Typically the child’s mouth opens as they are slightly upside down.
      • Be ready with your light and quick hands… and some other assistants if needed!

 

 

References

Li Z1, Zhao W, Ji F. “Catarrhal physiognomy” and Koplik’s spots. Braz J Infect Dis. 2013 Jul-Aug;17(4):491-2. PMID: 23665008. [PubMed] [Read by QxMD]
Zenner D1, Nacul L. Predictive power of Koplik’s spots for the diagnosis of measles. J Infect Dev Ctries. 2012 Mar 12;6(3):271-5. PMID: 22421609. [PubMed] [Read by QxMD]

Lefebvre N, Camuset G, Bui E, Christmann D, Hansmann Y. Koplik spots: a clinical sign with epidemiological implications for measles control. Dermatology. 2010;220(3):280-1. PMID: 20110626. [PubMed] [Read by QxMD]
Steichen O1, Dautheville S. Koplik spots in early measles. CMAJ. 2009 Mar 3;180(5):583. PMID: 19255085. [PubMed] [Read by QxMD]
Tierney LM Jr1, Wang KC. Images in clinical medicine. Koplik’s spots. N Engl J Med. 2006 Feb 16;354(7):740. PMID: 16481641. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. October 22, 2015

    […] finding Koplick’s Spots would alter your […]

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