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Are you prepared? — Bioterrorism Attacks Involving Pediatric Patients Conclusion December 14, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

Case Recap:

Your next patient is a 2-year-old girl with a 3-day history of high fevers, body aches, fatigue, and a rash. Her vital signs are; temperature, 40.5°C (104.9°F); heart rate, 105 beats/min; and blood pressure, 100/60 mm Hg. The physical examination reveals pustular vesicles with central umbilication in the same stage of development on her face, torso, and extremities. The mother says the lesions started in the girl’s mouth 3 to 4 days ago. The patient’s past medical history is notable only for severe eczema.

What features of this suggests a potential bioterrorism threat? Does the patient require isolation? What public health notifications are needed?

Case Conclusion:

The 2-year-old girl with a history of high fevers, body aches, fatigue, and rash concerned you because you remembered a rash like this from textbooks, though you had never seen a rash like this before in person. An older nurse called you from triage and said, “I’ve placed her in a negative pressure room. I think this is smallpox—I remember the pictures from when I was little.” You recalled the CDC diagnostic guidelines for smallpox and noted that the patient had (1) febrile prodrome > 38.3°C (101°F), (2) classic appearing smallpox lesions, and (3) lesions in the same stage of development. Thus, the patient met the high-risk criteria. You initiated airborne and contact precautions and alerted the infection control team and dermatology. They agreed with your risk analysis and the local health department was called. The smallpox response team was dispatched to your facility to collect lab specimens. You were fortunate that 2 of the clinicians on staff received the smallpox vaccine when they were younger because of prior military deployments. They volunteered to care for the patient using appropriate PPE in coordination with the infection control team. You later found out that the patient was the daughter of a military parent who was recently deployed for a high-risk mission requiring vaccination for smallpox. The child likely had a case of contact vaccinia.

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What influenza testing do you choose? — Influenza in the ED Conclusion December 12, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:

Your patient is a 32-year-old man with the following chief complaints: cough and fever. His maximum temperature over the past 5 days was 40˚C (103.9°F). He has been taking over-the-counter cold remedies without relief, and today he is markedly short of breath. The patient has no regular primary care provider and has no significant past medical history. His initial vital signs are: temperature 39.2˚C (102.5°F); heart rate, 118 beats/min; respiratory rate, 28 breaths/min; blood pressure, 134/78 mm Hg; and oxygen saturation, 88% on room air. On examination, he appears uncomfortable, with notable tachypnea. The oropharynx is clear and the neck supple. Crackles are noted in the right lower lung field, without any wheezing. The abdomen is soft and nontender. The patient is given oxygen via face mask, with an improvement in saturation to 100%. Chest x-ray reveals a right lower lobar pneumonia with a small pleural effusion. You start IV antibiotics and request an inpatient bed, as he is hypoxic with his pneumonia. 

You wonder whether influenza testing is indicated, and if so, what type of test to do?

Case Conclusion:

Delving further into the CDC website, you find that the false-negative rate with rapid antigen testing for influenza can be significant, especially when disease prevalence is high, as it is in your region. Based on this information, you decide to start your more seriously ill 32-year-old patient on oseltamivir 75 mg twice a day for 5 days despite the initially negative result reported by the hospital laboratory.

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Are you prepared? — Bioterrorism Attacks Involving Pediatric Patients December 7, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 7comments

Your next patient is a 2-year-old girl with a 3-day history of high fevers, body aches, fatigue, and a rash. Her vital signs are; temperature, 40.5°C (104.9°F); heart rate, 105 beats/min; and blood pressure, 100/60 mm Hg. The physical examination reveals pustular vesicles with central umbilication in the same stage of development on her face, torso, and extremities. The mother says the lesions started in the girl’s mouth 3 to 4 days ago. The patient’s past medical history is notable only for severe eczema.

What features of this suggests a potential bioterrorism threat? Does the patient require isolation? What public health notifications are needed?

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What influenza testing do you choose? — Influenza in the ED December 5, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 15comments

Your patient is a 32-year-old man with the following chief complaints: cough and fever. His maximum temperature over the past 5 days was 40˚C (103.9°F). He has been taking over-the-counter cold remedies without relief, and today he is markedly short of breath. The patient has no regular primary care provider and has no significant past medical history. His initial vital signs are: temperature 39.2˚C (102.5°F); heart rate, 118 beats/min; respiratory rate, 28 breaths/min; blood pressure, 134/78 mm Hg; and oxygen saturation, 88% on room air. On examination, he appears uncomfortable, with notable tachypnea. The oropharynx is clear and the neck supple. Crackles are noted in the right lower lung field, without any wheezing. The abdomen is soft and nontender. The patient is given oxygen via face mask, with an improvement in saturation to 100%. Chest x-ray reveals a right lower lobar pneumonia with a small pleural effusion. You start IV antibiotics and request an inpatient bed, as he is hypoxic with his pneumonia. 

You wonder whether influenza testing is indicated, and if so, what type of test to do?

Sign up for our email list below and come back on Dec 12th to see if you got it right!

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Last Modified: 12-16-2018
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