Smallpox: Difference between revisions
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*Caused by the variola virus<ref>Rosen, Peter, John A. Marx, Robert S. Hockberger, and Ron M. Walls. "Smallpox." Rosen's Emergency Medicine Concepts and Clinical Practice. 8th ed. Vol. 2. Philadelphia, PA: Elsevier/Saunders, 2013. 1579-1580.</ref> | *Caused by the variola virus<ref>Rosen, Peter, John A. Marx, Robert S. Hockberger, and Ron M. Walls. "Smallpox." Rosen's Emergency Medicine Concepts and Clinical Practice. 8th ed. Vol. 2. Philadelphia, PA: Elsevier/Saunders, 2013. 1579-1580.</ref> | ||
*Passed through direct contact with the person, with body fluids, as well as with airborne droplets of an infected, symptomatic person | *Passed through direct contact with the person, with body fluids, as well as with airborne droplets of an infected, symptomatic person | ||
**Can survive for 24-48 hours in the environment | |||
*Most infectious during the first week of symptoms, but will remain infectious until the last pox scab falls off | *Most infectious during the first week of symptoms, but will remain infectious until the last pox scab falls off | ||
*Humans are the only known host<ref>Barquet, Nicolau, MD, and Pere Domingo, MD. "Smallpox: The Triumph over the Most Terrible of the Ministers of Death." Annals of Internal Medicine 127 (1997): 635-42.</ref> | *Humans are the only known host<ref>Barquet, Nicolau, MD, and Pere Domingo, MD. "Smallpox: The Triumph over the Most Terrible of the Ministers of Death." Annals of Internal Medicine 127 (1997): 635-42.</ref> | ||
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*There are stocks of the virus in 2 laboratories – one in Atlanta, Georgia, USA and one in Moscow, Russia | *There are stocks of the virus in 2 laboratories – one in Atlanta, Georgia, USA and one in Moscow, Russia | ||
*There are concerns some laboratories may illegally have the virus and could release it as a weapon of bioterrorism<ref>Anderson PD. Bokor G. Bioterrorism: pathogens as weapons. J Pharm Pract. 2012 Oct;25(5):521-9.</ref> | *There are concerns some laboratories may illegally have the virus and could release it as a weapon of bioterrorism<ref>Anderson PD. Bokor G. Bioterrorism: pathogens as weapons. J Pharm Pract. 2012 Oct;25(5):521-9.</ref> | ||
* | *It is considered a potential bioterrorism threat as most people are now considered to be vulnerable to the virus because vaccination programs have stopped | ||
===Vaccination History=== | ===Vaccination History=== | ||
*The vaccine “vaccinia variola” was made from a closely-related virus | *The vaccine “vaccinia variola” was made from a closely-related virus | ||
*Vaccination is considered successful if at least one pustule forms at the injection site | *Vaccination is considered successful if at least one pustule forms at the injection site | ||
*Does have serious side effects, especially in the immunocompromised, including death in rare cases | *Does have serious side effects, especially in the immunocompromised, including death in rare cases | ||
*Due to the side effects and the current eradication, it is not used anywhere in the world currently | *Due to the side effects and the current eradication, it is not used anywhere in the world currently | ||
*Many governments have large stockpiles of the vaccinia vaccine and plans in place for rapid response and vaccination if an outbreak were to occur | **Only select groups of individuals will be vaccinated, including some members of the US military (depending on where they are deployed) <ref> http://www.usamma.amedd.army.mil/net/assets/doc/pdf/Vaccines/SVP_Q_A_8July2014.pdf </ref> | ||
*Many governments have large stockpiles of the vaccinia vaccine and plans in place for rapid response and vaccination if an outbreak were to occur | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:Child with Smallpox Bangladesh.jpg|thumbnail|Child with Smallpox]] | |||
[[File:PMC3223485 eplasty11e47 fig1.png|thumb|Man with small pox displaying the characteristic rash.]] | |||
*Incubation period: 7-19 days | *Incubation period: 7-19 days | ||
*Initial phase begins as a fever, fatigue/weakness, dorsal-lumbar pain, myalgias, nausea/vomiting | *Initial phase begins as a fever, fatigue/weakness, dorsal-lumbar pain, myalgias, nausea/vomiting | ||
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**Lesions will generally all be at same stage | **Lesions will generally all be at same stage | ||
**Lesions begin as clear fluid-filled vesicles, progress to pustules, and then harden and form a crust, ultimately falling off in about 3-4 weeks | **Lesions begin as clear fluid-filled vesicles, progress to pustules, and then harden and form a crust, ultimately falling off in about 3-4 weeks | ||
== | ===Clinical Forms=== | ||
*Variola major and minor (90% of cases) | |||
**Variola major | |||
***More severe, mortality rate 30% | |||
**Variola minor | |||
***Less severe, mortality rate 1% | |||
***Fewer pox | |||
*Other (10% of cases) | |||
**Hemorrhagic | |||
***Hemorrhages occur within the blisters as well as mucus membranes and internal organs, death usually within 5-6 days | |||
**Malignant | |||
***Soft, flattened lesions, does not progress to pustules | |||
***Resolve without forming scabs <ref> Schultz, C., & Koenig, K. Weapons of Mass Destruction. In Rosen's Emergency Medicine: Concepts and Clinical Practice (9th ed.). Philadephia, PA: Elsevier/Saunders. </ref> | |||
==Differential Diagnosis== | |||
{{Peds Rash DDX}} | |||
{{Bullous rashes DDX}} | |||
{{Bioterrorism agents}} | |||
==Evaluation== | |||
*Clinical diagnosis based on symptoms and characteristic rash | *Clinical diagnosis based on symptoms and characteristic rash | ||
*PCR DNA test | *PCR DNA test | ||
*When the disease was present, either electron microscopy of stained crusts of lesions or a slide precipitation method was used | *When the disease was present, either electron microscopy of stained crusts of lesions or a slide precipitation method was used | ||
== | ==Management== | ||
{{Smallpox Treatment}} | {{Smallpox Treatment}} | ||
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**due to viral shedding | **due to viral shedding | ||
===Isolation === | ===Isolation=== | ||
*Airborne and contact isolation with negative pressure | *Airborne and contact isolation with negative pressure | ||
*Personal protective wear level D with N95 respirator | *Personal protective wear level D with N95 respirator | ||
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[[Category:ID]] | [[Category:ID]] | ||
[[Category: | [[Category:Toxicology]] |
Latest revision as of 16:14, 7 September 2022
Background
- Caused by the variola virus[1]
- Passed through direct contact with the person, with body fluids, as well as with airborne droplets of an infected, symptomatic person
- Can survive for 24-48 hours in the environment
- Most infectious during the first week of symptoms, but will remain infectious until the last pox scab falls off
- Humans are the only known host[2]
- Declared eradicated in 1980 after a global immunization campaign from 1966-1980; last known natural case was in Somalia in 1977; last known cases were in England in 1978 after a laboratory accident[3]
Bioterrorism
- There are stocks of the virus in 2 laboratories – one in Atlanta, Georgia, USA and one in Moscow, Russia
- There are concerns some laboratories may illegally have the virus and could release it as a weapon of bioterrorism[4]
- It is considered a potential bioterrorism threat as most people are now considered to be vulnerable to the virus because vaccination programs have stopped
Vaccination History
- The vaccine “vaccinia variola” was made from a closely-related virus
- Vaccination is considered successful if at least one pustule forms at the injection site
- Does have serious side effects, especially in the immunocompromised, including death in rare cases
- Due to the side effects and the current eradication, it is not used anywhere in the world currently
- Only select groups of individuals will be vaccinated, including some members of the US military (depending on where they are deployed) [5]
- Many governments have large stockpiles of the vaccinia vaccine and plans in place for rapid response and vaccination if an outbreak were to occur
Clinical Features
- Incubation period: 7-19 days
- Initial phase begins as a fever, fatigue/weakness, dorsal-lumbar pain, myalgias, nausea/vomiting
- 2-4 days later the characteristic rash appears
- Worst on the face, arms, legs, and includes the palms and soles
- Lesions will generally all be at same stage
- Lesions begin as clear fluid-filled vesicles, progress to pustules, and then harden and form a crust, ultimately falling off in about 3-4 weeks
Clinical Forms
- Variola major and minor (90% of cases)
- Variola major
- More severe, mortality rate 30%
- Variola minor
- Less severe, mortality rate 1%
- Fewer pox
- Variola major
- Other (10% of cases)
- Hemorrhagic
- Hemorrhages occur within the blisters as well as mucus membranes and internal organs, death usually within 5-6 days
- Malignant
- Soft, flattened lesions, does not progress to pustules
- Resolve without forming scabs [6]
- Hemorrhagic
Differential Diagnosis
Pediatric Rash
- Atopic dermatitis
- Bed bugs
- Contact dermatitis
- Drug rash
- Erythema infectiosum (Fifth disease)
- Hand-foot-and-mouth disease
- Henoch-schonlein purpura (HSP)
- Herpangina
- Herpes simplex virus (HSV)
- Infectious mononucleosis
- Meningitis
- Measles
- Molluscum contagiosum
- Roseola infantum
- Rubella (German measles)
- Scabies
- Scarlet fever
- Smallpox
- Varicella (Chickenpox)
Vesiculobullous rashes
Febrile
- Diffuse distribution
- Varicella (chickenpox)
- Smallpox
- Monkeypox
- Disseminated gonococcal disease
- DIC
- Purpural fulminans
- Localized distribution
Afebrile
- Diffuse distribution
- Bullous pemphigoid
- Drug-Induced bullous disorders
- Pemphigus vulgaris
- Phytophotodermatitis
- Erythema multiforme major
- Bullous impetigo
- Localized distribution
- Contact dermatitis
- Herpes zoster (shingles)
- Dyshidrotic eczema
- Burn
- Dermatitis herpetiformis
- Erythema multiforme minor
- Poison Oak, Ivy, Sumac dermatitis
- Bullosis diabeticorum
- Bullous impetigo
- Folliculitis
Bioterrorism Agents[7]
Category A
Category B
- Ricin
- Brucellosis
- Epsilon toxin
- Psittacosis
- Q Fever
- Staph enterotoxin B
- Typhus
- Glanders
- Melioidosis
- Food safety threats
- Water safety threats
- Viral encephalitis
Category C
- Influenza
- Yellow fever
- Tickborne hemorrhagic fever
- Tickborne encephalitis
Evaluation
- Clinical diagnosis based on symptoms and characteristic rash
- PCR DNA test
- When the disease was present, either electron microscopy of stained crusts of lesions or a slide precipitation method was used
Management
- IMMEDIATE NOTIFICATION OF PUBLIC HEALTH AUTHORITIES
- Vaccine administered up to 3 days post-exposure was effective in preventing infection as well as lessening the severity of the disease if infection occurred [8]
Post-Exposure Prophylaxis
- Vaccinia Vaccine (administer within 72hrs of exposure)
Active Disease
- Supportive care and wound care for open lesions
- Vaccinia Vaccine within the first 72hrs can decrease total disease severity and within 7 days may decrease symptoms
- Vaccination is not efficacious once the patient has developed rash[9]
Vaccinia Vaccine Complications
Contraindications for administration include:
- Pregnancy
- Severe cardiac disease
- Immunocompromise
- Same living quarters as other person with above contraindications
- due to viral shedding
Isolation
- Airborne and contact isolation with negative pressure
- Personal protective wear level D with N95 respirator
See Also
References
- ↑ Rosen, Peter, John A. Marx, Robert S. Hockberger, and Ron M. Walls. "Smallpox." Rosen's Emergency Medicine Concepts and Clinical Practice. 8th ed. Vol. 2. Philadelphia, PA: Elsevier/Saunders, 2013. 1579-1580.
- ↑ Barquet, Nicolau, MD, and Pere Domingo, MD. "Smallpox: The Triumph over the Most Terrible of the Ministers of Death." Annals of Internal Medicine 127 (1997): 635-42.
- ↑ Ellner, P. D. "Smallpox: Gone but Not Forgotten." Infection 26.5 (1998): 263-69.
- ↑ Anderson PD. Bokor G. Bioterrorism: pathogens as weapons. J Pharm Pract. 2012 Oct;25(5):521-9.
- ↑ http://www.usamma.amedd.army.mil/net/assets/doc/pdf/Vaccines/SVP_Q_A_8July2014.pdf
- ↑ Schultz, C., & Koenig, K. Weapons of Mass Destruction. In Rosen's Emergency Medicine: Concepts and Clinical Practice (9th ed.). Philadephia, PA: Elsevier/Saunders.
- ↑ https://www.niaid.nih.gov/topics/biodefenserelated/biodefense/pages/cata.aspx Accessed 02/26/16
- ↑ Kman NE, Nelson RN. Infectious agents of bioterrorism: a review for emergency physicians. Emerg Med Clin North Am. 2008 May;26(2):517-47
- ↑ Cdc.gov. 2020. Prevention and Treatment | Smallpox | CDC. [online] Available at: <https://www.cdc.gov/smallpox/prevention-treatment/index.html> [Accessed 11 September 2021].