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CASE PRESENTATION

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Small Pox vs. Chicken Pox. Becomes ill 7-17 days after exposure ... Pox are most numerous on the body - never found on the palms & soles ... – PowerPoint PPT presentation

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Title: CASE PRESENTATION


1
CASE PRESENTATION 15
  • Jim Pointer, MD. FACEP
  • Alameda County EMS
  • Medical Director

2
The Call
  • You are called to a home in a gated community for
    shortness of breath.
  • Upon arrival, a distraught middle-aged woman
    rushes you into the upstairs bedroom. She
    shouts, my husband is very sick.

3
Initial Assessment
  • Uncomfortable African-American male lying in bed
    complaining of
  • severe headache
  • back pain
  • fever
  • ABCs intact
  • GCS 15

4
Focused History andPhysical Exam
  • Patient had sudden onset (6 hours ago) of
    headache all over, severe mid and lower back
    pain, and fever to 104º F.
  • The fever has been minimally responsive to
    therapeutic doses of acetaminophen.
  • He denies any other symptoms except for a mild
    cough.

5
Focused History andPhysical Exam (cont.)
  • Pertinent Findings
  • B/P 152/92, RR 32, PR 126
  • Temperature 103.8º F. p.o.
  • Pulse Ox 98 on room air
  • Exam within normal limits except for increased
    body warmth and dry mucous membranes.

6
Focused History andPhysical Exam (cont.)
  • Past Medical History
  • No serious illnesses or operations
  • Hypertension controlled with Altace, 5 mg.
    q.d.
  • Patient travels frequently and was on a plane
    from Mumbai, India six days prior.

7
Initial Treatment
  • IV Normal Saline, 1 liter
  • Dextrostix 80 mg/dl
  • Transport to hospital
  • You and your partner observe universal
    precautions and place a mask on the patient.

8
Uh-Oh
  • Your partner recalls that you have responded to 5
    patients with fever, headache, and back pain
    during your 12-hour shift.

9
Hospital Findings
  • Uncomfortable middle-aged male complaining of
    headache and backache.
  • Vital Signs
  • B/P 155/94, PR 128, RR 28
  • Temperature 103.8 F. p.o.
  • Pulse Ox 97 RA

10
Hospital Findings (cont.)
  • The emergency department staff can find no
    specific positive physical findings.
  • The patient is hydrated and sent home with
    ibuprofen for fever and a diagnosis of viral
    syndrome.
  • You overhear the emergency physician tell a nurse
    that he has seen 4 patients in the past 4 hours
    with the same presentation.

11
The next day. . .
  • . . .you pick up the Daily Planet

Mumbai (AP) A 40 year old Saudi has been
detained after he sprayed a canister of an
unknown substance in the coach section of an Air
India flight from Mumbai to New York.
Daily Planet FBI Releases Details of Aerosol
Release Aboard Flight from India
12
Anyone know what this is?
13
Smallpox
  • History as a biological weapon
  • Used in French and Indian wars in 1796.
  • Edward Jenner demonstrated that cowpox infection
    protected against smallpox.
  • Eradicated in 1977.
  • Two laboratories (US Russia) retained stocks of
    smallpox.
  • Aerosolization possible.
  • No vaccination in US since 1972.

14
Epidemiology
  • Two principal forms
  • Variola Major 30 death rate
  • Variola Minor 1 death rate
  • Exposure
  • Person-to-person droplet transmission, clothing,
    bed linens
  • Predominantly hospital household spread
  • Incidence highest during winter spring
  • Most infectious from onset of rash through
    first 7-10 days
  • DNA virus Orthopoxvirus

15
Pathogenesis Clinical Presentation
  • Virus implants on mucosa in mouth and lungs
  • Spread
  • regional nodes ? primary viremia ? spleen, bone
    marrow, all nodes ? secondary viremia ? fever,
    toxemia ? small blood vessels, in dermis and
    beneath oral mucosa
  • Incubation period 12-14 days (range 7-17)

16
Pathogenesis Clinical Presentation (cont.)
  • Initial signs symptoms
  • High fever
  • Malaise
  • Back pain
  • Headache
  • Maculopapular - rash
  • Mucosa of mouth
  • Pharynx
  • Face
  • Forearms
  • Trunk and legs

17
Pathogenesis Clinical Presentation (cont.)
  • Vescicular ? pustular rash
  • (round, tense, deep)
  • Crusts on 8th or 9th day
  • Scabs ? scarring
  • Death caused by toxemia from circulatory immune
    complexes and soluble antigens

18
Small Pox vs.Chicken Pox
  • Becomes ill 7-17 days after exposure
  • Has fever and feels ill 2-4 days before rash
    appears
  • Pox appear over 1-2 days
  • Lesions are all in the same stage of development
  • Most numerous on face, arms, legs - usually
    present on palms soles
  • Scabs form in 10 - 14 days and fall off 14 - 28
    days after rash appeared
  • Centrifugal distribution
  • Becomes ill 14-21 days after exposure
  • Usually has no symptoms until the rash appears
  • Pox are most numerous on the body - never found
    on the palms soles
  • Scabs form in 4 7 days and fall off within 14
    days after rash appeared
  • Centripetal distribution

19
Small Pox vs. Chicken Pox
20
Small Pox vs. Chicken Pox
21
  • Laboratory confirmation
  • Electron microscopy shows brick-shaped virions

A False-Color Electron Micrograph Shows the
Smallpox Variola Virus
Picture from London School of Hygiene and
Tropical Medicine /Science Source Photo
Researchers, Inc.
22
Vaccination (vaccinia)
  • Immune status of those vaccinated before 1972 is
    unclear
  • 15 million doses are available in US (additional
    70-90 million have been identified)
  • Bifurcated needle used 15 jabs in dermis of
    upper deltoid
  • 110 dilution of vaccine results in 97 success
    rate
  • Some protection if vaccine given within 4 days of
    exposure

23
VaccinationDay 0 day 14
Papule Jennerian
Crust
pustule
24
Vaccination Complications(per 1 million)
  • Death
  • Progressive vaccinia
  • Encephalitis
  • Eczema
  • Erythema multiforme
  • Generalized vaccinia
  • Accidental innoculations
  • Vaccinia Immune Globulin used
    in treating complications (CDC)
  • Dose 0.6 mL/kg IM

1 2 12 39 165 242 529
25
Accidental Innoculation
26
Bio-terrorism Prevention
  • Vaccination priorities
  • Exposed individuals
  • House-hold, face-to-face contacts
  • Care givers
  • Hospital workers
  • Laboratory workers
  • Isolation of contacts (at home) if
    Temperature gt 38 C

27
Bio-terrorism Prevention (cont.)
  • Admitted patients confined to negative pressure
    rooms
  • Universal precautions
  • mask gloves gown
  • Laundry autoclaved
  • Victims cremated, if possible
  • Reporting of clustering of symptom complexes

28
References
  • Henderson DA, et al Smallpox as a biological
    weapon. JAMA 1999 281 2127-37.
  • Berman JG, Henderson DA Diagnosis and management
    of smallpox. NEJM 2002 346 1300-08
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