Posted by Andy Jagoda, MD in: What's Your Diagnosis , trackback
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?
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.