Morbilliform

It's another day on the hospital medicine service and you're ready for admissions. As you browse the list, a message from one of the floor nurses pops up asking you to please come and evaluate a rash that a patient is increasingly concerned about. You pull up the patient's chart—an 85-year-old woman with confusion, increased urinary frequency, dysuria, and a urinalysis showing moderate leukocyte esterase and white blood cells. It all seems pretty straightforward. You agree with the current diagnosis of a urinary tract infection and see that the patient is midway through her treatment course with trimethoprim/sulfamethoxazole.

At the bedside, you evaluate the rash. The patient is covered in flat macules and raised papules. From your readings, you recall that such a rash is sometimes termed “morbilliform” and can arise as a drug reaction. After comforting the patient and switching her antibiotic, you return to the workroom and, since it's a slow day, you begin reading more about the term morbilliform, seeing that it means a rash that resembles that seen in measles. You recall the recent news of a measles exposure at the local mall, and a thought stops you—if you saw a case of measles, would you even recognize it?

Thomas Sydenham certainly would. This Englishman is often called the “Father of English Medicine” and the “English Hippocrates.” He was born at Winford Eagle in 1624 and studied at Oxford and in France. After obtaining a medical degree from Cambridge in 1676, he gained a reputation as a great clinician, relying on his powers of observation and vast experience versus commonplace scientific theories of the time. Moreover, he was a meticulous notetaker and is best known for his accurate firsthand accounts of disease manifestations.

He described measles as generally attacking children, manifesting as chills and shivers on the first day before the child succumbs to a full fever with “disquietude, thirst, want of appetite, a white (but not a dry) tongue, slight cough, heaviness of the head and eyes, and somnolence.” He further elaborated that the “nose and eyes run continually; and this is the surest sign of measles.” In this simple line, he succinctly described the phenomena of coryza, which has come to be so closely associated with measles in modern medicine.

He then described the characteristic rash, first appearing on the face in the form of small red spots (papules) before clustering together to form large red blotches (macules). “After taking hold of the face, they spread—down the chest and belly, to the legs and ankles.” In this way, he was an early describer of the cephalocaudal, maculopapular rash pattern that physicians and medical students still associate with measles infection.

Also fascinating is his prescription for how the disease should be treated. He described mixing the oil of sweet almonds, the syrup of violets and maidenhair, and the finest white sugar into an elixir to manage even the most troublesome and debilitating of coughs. Although medicine has advanced greatly since the days of Dr. Sydenham, with the vaccine against measles being first developed in 1963, the accuracy of his original description of the disease remains remarkable.

Although measles has not been commonly seen in the United States, with the exception of recent outbreaks, the morbilliform rash certainly has. Thus, Dr. Sydenham's descriptive work also lives on in daily medicine through the use of this term to describe any maculopapular rash, be it from a drug reaction, other virus, bacterial infection, or autoimmune disease.

Suddenly, a tap on your shoulder jolts you back to reality. A new patient just arrived on the floor. No more time for your morbilliform musings—time to get back to work.