Twenty minutes before closing time, a purple car rattles into the empty parking lot outside the after-hours care center. From my perch near a side window, I observe the young couple as they gather their toddler from the back seat. Soon the nurse has ushered the trio into an examination room. Like a fly on the wall, I hover in the adjacent laboratory and listen to the conversation.
“She started scratching 3 days ago,” the mother is saying, “and every place she scratches one of these red marks comes up. My mom thinks she might have hand-foot-and-mouth like she did the other year, but I don't know. She's been out in the backyard most every evening, and the mosquitos are out. We had her in to see the doctor earlier this week, and he said it was bug bites, but I'm not sure.”
“Is she taking any medicine?” the nurse asks.
“They've got her on another course of antibiotics—this is the fourth round—these ear infections just don't seem to be clearing up.”
“What antibiotic is she taking?”
A moment of silence ensues. “Prim something,” the father says. “Primsol?”
“Never heard of it,” the nurse says. “Prim—can you spell it? P-R-I-M...”
“S-O-L, I think,” the father says.
“S. O. L.,” I muse to myself and smile.
“He'll be in to see her shortly,” the nurse says and pulls the door closed behind her. She hands me the clipboard with the encounter form. “There's quite a bit for you to sort out in there,” she says. “Good luck.”
I rap on the door and enter the examination room with a smile. “So this is the little girl with the itchy spots,” I say. “When did they come up?”
“A couple of days ago,” the mother says. “Her pediatrician said they were bug bites, but we're not sure. He barely looked at them.”
I slide the clipboard onto the counter, pick up the otoscope, and approach the 2-year-old girl sitting on the examination table. Gently, I run my fingertips over the few firm pink papules on her arms and legs. Some are excoriated; none are vesicular. The palms and soles are clean. I peek into the child's ears with the otoscope, note the glistening pearly-gray tympanic membranes, and ask her to open her mouth. “Let's see that big tongue,” I say. I note the well-demarcated maplike patches of red and white papillae and toss the tongue blade into the waste basket. The parents look at me expectantly.
“It's definitely not hand-foot-and-mouth,” I say. “She's got no fever; her palms, soles, and throat are clear. She might have a few mosquito bites, but I can't be certain that she isn't having some sort of generalized eruption from the antibiotic. Her ears are crystal clear at this point, so she really doesn't need to take that medicine anymore. You can stop it now, and give her some diphenhydramine for the itch. That should help to dampen things down. I think she'll do just fine.”
The parents nod their heads. Then the mother says, “What about her tongue? It looks so nasty.”
“Yes; well, that's one of those things we sometimes see in kids. Again, nothing to worry about.”
“But what is it?”
“The surface of the tongue is composed of little papillae. You can think of them as tiny cobblestones, just like a cobblestone street. Sometimes some of the cobblestones turn pale; others stay pink. That's what gives the two-tone appearance of the tongue.”
I can tell by the puzzled looks on the parents' faces that they don't understand my explanation.
“Think of it like this,” I say. “Have you ever stood on the bank of a lazy river, watching the current bend and twist? Sometimes a light breeze might blow across and make little waves, disturbing the surface of the water. Some spots are smooth as glass, others are rough; but they mingle together. That's a picture of the surface of her tongue.”
“Oh, I get it!” the father says. “Yeah, it looks just like that! Well, whaddaya know!”
“So she's really okay?” the mother says.
I nod my head. “She's fine. Just stop the antibiotic, try some diphenhydramine and follow up in 3 days if the itch hasn't improved.”
The couple leaves with smiles on their faces.
“What's the final diagnosis?” the nurse asks me, as I hand her the clipboard.
“Papular urticaria and geographic tongue,” I say. “Insect bites, and a meandering river in a gentle morning breeze.”