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柯氏斑點


柯氏斑點。照片由筆者提供

【撰文:雨毛波】

結集:給親愛的吼記哥哥姐姐的一封信

親愛的houseman哥哥姐姐:

我耿耿於懷,為什麼我沒有見過柯氏斑點;正如我做了那麼多年的arrhythmia,都遇不到一條Mahaim fiber一樣,所以某大編輯叫我做「資深醫生」,真是不敢恭維。

什麼是柯氏斑點?即是Koplik's spot。到今時今日,袁教授口口聲聲話要切除麻疹傳播鏈,卻隻字不提封掉香港國際機場,而在機場上班的人士,只有八十六個巴仙有抗體,可以預見,未來兩星期將會有更多的麻疹病人出現在你們面前。我們要回到Dr. Henry Koplik未有疫苗的1896年,靠Koplik's spot去臨床斷症麻疹病人,立即隔離,防止air-borne的麻疹在中央冷氣又天天逼爆的公立醫院散播開去。 

柯醫生是當時美國最著名的兒科醫生,營運紐約曼克頓區的貧民兒童診所,每天以廉宜的價錢提供清潔乾淨的牛奶給寶寶們喝。柯醫生是工作狂,星期一做到星期六,沒有啫好,"Every New York child should be seen by Dr. Koplik at least once",因此柯醫生有大量的臨床經驗: 

On the buccal mucous membrane and the inside of the lips, we invariably see a distinct eruption. It consists of small, irregular spots, of a bright red color. In the centre of each spot, there is noted, in strong daylight, a minute bluish white speck. These red spots, with accompanying specks of a bluish white color, are absolutely pathognomonic of beginning measles, and when seen can be relied upon as the forerunner of the skin eruption.
As the skin eruption begins to appear and spreads, the eruption on the mucous membrane become diffuse, and the characters of a disease eruption disappear and lose themselves in an intense general redness. When the skin eruption is at the efflorescence, the eruption on the buccal membrane has lost the characters of a discrete spotting and has become diffuse red background with innumerable bluish white specks scattered on its surface. The buccal eruption begin to fade even when the skin is at its height, or at least while it is running a late course. The mucous membrane retrogrades to the normal appearances long before the eruption on the skin has disappeared.
Henry Y. Koplik; The diagnosis of the invasion of measles from a study of the exanthema as it appears on the buccal mucous membrane. Arch. Paed 13 918-922

柯氏班點究竟是點形成的呢?根據Nelson話,麻疹有四個階段:第一個階段是virus application,那時候病毒數目很少,病人沒有病徵。第二個階段是病毒數目夠多,細胞開始necrosis。痲疹病毒有兩個receptor CD150同PVRL4,所以專去lymphotropic同epitheliotropic,痲疹病毒同時感染埋CD4 T cell, immunosuppressed咗,所以病毒數目就可以幾何級數地增加。Koplike's spot就是麻疹病毒大量感染mucose membrane細胞,逼爆它們,所以見到Koplik's spot就是病人最infectious的時候。現在被熱搶的麻疹疫苗名字叫做 Edmonston-Enders strain,就是 Dr Enders 由病人的Koplik's spot取得再加工做成的,那麼那個 bluish white specks是什麼來的呢?那是黏膜下的口水腺靜脈擴張喎.

麻疹的疹是身體「開始做嘢」產生抗體對付病毒的時候,那是delayed hypersensitivity reaction,所以越多疹出,口腔裡的斑點就會消失。(待續) 

插圖由筆者提供

 


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