Rash Illness Protocol

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Rash Illness Protocol
Karin Galil, MD, MPH National Immunization Program
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Generalized Vesicular or Pustular Rash Illness
Protocol
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RISK OF SMALLPOX BY
CLINICAL HISTORY AND EXAMINATION High Risk
for Smallpox Febrile prodrome and gt2 other major
smallpox criteria?REPORT IMMEDIATELY
Moderate Risk Febrile prodrome and 1 other major
and gt2 minor smallpox criteria? EVALUATE
URGENTLY Low risk No major smallpox
criteria?manage as clinically indicated

• Significant viral prodrome occurring 1-4 days
  before rash onset fever gt101 and at least one of
  the following prostration, headache, backache,
  chills, vomiting or severe abdominal pain. All
  smallpox patients have a prodrome. The fever may
  drop with rash onset.
• Lesions are deep, firm/hard, round,
  well-circumscribed may be umbilicated or
  confluent
• On any ONE part of the body (I.e. the face, or
  the arm) lesions are all in the same stage of
  development
• Greatest concentration of lesions on face and
  distal extremities (centrifugal)

• Lesions first appeared on oral mucosa/palate,
  face, forearms
• Patient appears toxic or moribund
• Lesions evolve from macules to papules?pustules
  over days
• Lesions on the palms and soles

Major Criteria
Minor Criteria
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Common Conditions With Vesicular or Pustular
Rashes
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Variant presentations of smallpox approximately
of persons never vaccinated for smallpox will
present with hemorrhagic smallpox in 3-5 (see
photo-- can be mistaken for meningococcemia,
hemorrhagic varicella, Rocky Mountain spotted
fever, erlichiosis, acute leukemia) or flat-type
smallpox in 5-7 (see photo). Both variants are
highly infectious and carry a high mortality.
Smallpox in previously vaccinated individuals
may present with milder prodrome, fewer lesions
and less systemic illness (more likely to be
mistaken for chickenpox). Little is known about
the presentation of smallpox in severely
immunocompromised persons.
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Varicella in a Healthy Adult
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Varicella infected lesions
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Varicella in Pregnancy
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Herpes zoster
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VARICELLA
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Varicella
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Varicella in a leukemic child with encephalopathy
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Smallpox
Day 3 Day 5
Day 7
Chickenpox
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Drug Rash
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Eczema herpeticum
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Herpes simplex
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Bullous pemphigoid
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Secondary syphilis
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Molluscum contagiosum
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Hand, Foot and Mouth
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Hand, Foot And Mouth Disease
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Scabies
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Eczema herpeticum
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Hemorrhagic Varicella
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Hemorrhagic Varicella
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Hemorrhagic Rashes Meningococcemia
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Meningococcemia
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• Laboratory Testing for Varicella
• Direct fluorescent antibody (DFA)rapid, depends
  on adequate specimen
• Serologic testing an IgG (collected at time of
  rash) provides evidence of prior varicella, and
  makes acute varicella infection unlikely but does
  not rule out herpes zoster in persons at risk of
  dissemination. IgM is not useful for diagnosis.
• Polymerase chain reaction (PCR) (available in
  research labs, some tertiary care centers)
• VZV cultureresults delayed, useful only if
  processed in-house
• Electron microscopy (EM)cannot distinguish VZV
  from HSV
• How to Collect a Specimen for Direct Fluorescent
  Antibody (DFA) Testing
• Unroof (open) vesicle or pustule with a sterile
  lancet
• Swab base of vesicle vigorously with a sterile
  swab
• Smear swab onto 3 areas (or wells) of a
  microscope slide
• Allow slide to air dry
• Transport to lab for immediate fixing and
  staining
• VZV positive specimens are seen with varicella
  (chickenpox) and herpes zoster (shingles)
• The hospital lab performs _________________ test
• For DFA, call ________________ (specimen is
  tested at outside lab)