Evaluating patients with acute generalized vesicular or pustular rash illnesses
Download
1 / 59

Evaluating Patients With Acute Generalized Vesicular or Pustular Rash Illnesses - PowerPoint PPT Presentation


  • 151 Views
  • Uploaded on

Evaluating Patients With Acute Generalized Vesicular or Pustular Rash Illnesses. Need for a Diagnostic Algorithm?. No naturally acquired smallpox cases since 1977 Concern about use of smallpox virus as a bioterrorist agent

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Evaluating Patients With Acute Generalized Vesicular or Pustular Rash Illnesses' - akando


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

Need for a diagnostic algorithm
Need for a Diagnostic Algorithm? Pustular Rash Illnesses

  • No naturally acquired smallpox cases since 1977

  • Concern about use of smallpox virus as a bioterrorist agent

  • Heightened concerns about generalized vesicular or pustular rash illnesses

  • Clinicians lack experience with smallpox diagnosis

  • Public health control strategy requires early recognition of smallpox case


Need for a diagnostic algorithm1
Need for a Diagnostic Algorithm? Pustular Rash Illnesses

  • ~1.0 million cases varicella (U.S.) this year (2003) and millions of cases of other rash illnesses:

    • If 1/1000 varicella cases is misdiagnosed1000 false alarms

  • Need strategy with high specificity to detect the first case of smallpox

  • Need strategy to minimize laboratory testing for smallpox (risk of false positives)


Assumptions limitations
Assumptions/Limitations Pustular Rash Illnesses

  • Will miss the first case of smallpox until day 4-5 (by excluding maculo-papular rashes)

  • Will miss an atypical case of smallpox (hemorrhagic, flat/velvety, or highly modified) if it is the first case


Justification
Justification Pustular Rash Illnesses

  • System cannot handle thousands of false alarms

  • Several days of delay in diagnosis will not have major impact:

    • Supportive treatment for smallpox

    • Appropriate contact/respiratory precautions will limit spread in hospital


Smallpox disease
Smallpox Disease Pustular Rash Illnesses

  • Incubation Period: 7-17 days

  • Pre-eruptive Stage (Prodrome): fever and systemic complaints 1-4 days before rash onset


Smallpox disease1
Smallpox Disease Pustular Rash Illnesses

  • Rash stage

    • Macules

    • Papules

    • Vesicles

    • Pustules

    • Crusts (scabs)

  • Scars


Smallpox surveillance clinical case definition
Smallpox Surveillance Pustular Rash IllnessesClinical Case Definition

An illness with acute onset of fever > 101o F (38.3o C) followed by a rash characterized by firm, deep-seated vesicles or pustules in the same stage of development without other apparent cause.


Clinical determination of smallpox risk major criteria
Clinical Determination of Smallpox Risk: Major Criteria Pustular Rash Illnesses

  • Prodrome (1-4 days before rash onset):

    • Fever >101oF (38.3oC) and,

    • >1 symptom: prostration, headache, backache, chills, vomiting, abdominal pain.

  • Classic smallpox lesions:

    • Firm, round, deep-seated pustules.

  • All lesions in same stage of development (on one part of the body).


Clinical determination of smallpox risk minor criteria
Clinical Determination of Smallpox Risk: Minor Criteria Pustular Rash Illnesses

  • Centrifugal (distal) distribution

  • First lesions: oral mucosa, face, or forearms

  • Patient toxic or moribund

  • Slow evolution (each stage 1-2 days)

  • Lesions on palms and soles


Smallpox day 2 of rash
Smallpox: Pustular Rash Illnesses Day 2 of Rash


Smallpox day 4 of rash
Smallpox: Day 4 of Rash Pustular Rash Illnesses


Smallpox rash vesicles pustules
Smallpox Rash Pustular Rash IllnessesVesicles Pustules

Day 4 and 5

Days 7-11


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Classic Smallpox Lesions: Pustules Pustular Rash Illnesses


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Rash Distribution Pustular Rash Illnesses


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Varicella is the most likely illness Pustular Rash Illnesses

to be confused with smallpox.


Differentiating features varicella
Differentiating Features: Varicella Pustular Rash Illnesses

  • No or mild prodrome.

  • No history of varicella or varicella vaccination.

  • Superficial lesions “dew drop on a rose petal.”

  • Lesions appear in crops.


Differentiating features varicella1
Differentiating Features: Varicella Pustular Rash Illnesses

  • Lesions in DIFFERENT stages of development.

  • Rapid evolution of lesions.

  • Centripetal (central) distribution.

  • Lesions rarely on palms or soles.

  • Patient rarely toxic or moribund.


Varicella
Varicella Pustular Rash Illnesses


Varicella adult case
Varicella Adult Case Pustular Rash Illnesses


Varicella infected lesions
Varicella: Infected Lesions Pustular Rash Illnesses


Variola
Variola Pustular Rash Illnesses

Varicella


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Differentiation of Rash Illness Pustular Rash Illnesses

Smallpox


Smallpox
Smallpox Pustular Rash Illnesses

Chickenpox


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Distribution of Rash Pustular Rash Illnesses

Chickenpox


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Distribution of Rash Pustular Rash Illnesses

Smallpox


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Distribution of Rash Pustular Rash Illnesses

Smallpox


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Differential Diagnosis Pustular Rash Illnesses


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Differential Diagnosis Pustular Rash Illnesses


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Differential Diagnosis Pustular Rash Illnesses


Differential diagnosis herpes zoster
Differential Diagnosis Pustular Rash IllnessesHerpes Zoster


Differential diagnosis drug eruptions
Differential Diagnosis Pustular Rash IllnessesDrug Eruptions

  • History of medications:

    • Prescription

    • Over the Counter

    • Prior Reactions


Differential diagnosis drug reaction
Differential Diagnosis Pustular Rash IllnessesDrug Reaction


Differential diagnosis hand foot and mouth disease
Differential Diagnosis Pustular Rash IllnessesHand Foot and Mouth Disease


Differential diagnosis molluscum contagiosum
Differential Diagnosis Pustular Rash IllnessesMolluscum Contagiosum


Differential diagnosis secondary syphilis
Differential Diagnosis Pustular Rash IllnessesSecondary Syphilis


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Differential Diagnosis Pustular Rash IllnessesHSV2

Disseminated HSV2 lesions on

face/scalp

Disseminated HSV2 lesions

on palms


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Clinical Determination of Pustular Rash Illnesses

the Risk of Smallpox

Variations on Smallpox

Hemorrhagic smallpox: Misdiagnosed as meningococcemia?

Flat-type smallpox: Difficult

diagnosis


Goal rash illness algorithm
Goal: Rash Illness Algorithm Pustular Rash Illnesses

  • Systematic approach to evaluation of cases of febrile vesicular or pustular rash illness.

  • Classify cases of vesicular/pustular rash illness into risk categories (likelihood of being smallpox) according to major and minor criteria developed for smallpox according to the clinical features of the disease.


Investigation tools
Investigation Tools Pustular Rash Illnesses

  • Available at www.cdc.gov/smallpox:

    • Rash algorithm poster:

      • Health care providers link to view and print poster.

    • Worksheet (case investigation)


Investigation tools1
Investigation Tools Pustular Rash Illnesses

  • Case investigation worksheet for investigation of febrile vesicular or pustular rash illnesses:

    • Questions on prodromal symptoms, clinical progression of illness, history of varicella, vaccinations for smallpox and varicella, exposures, lab testing.

    • Worksheet can be downloaded and printed from www.cdc.gov/smallpox.


Smallpox major criteria
Smallpox: Major Criteria Pustular Rash Illnesses

  • Prodrome (1-4 days before rash onset):

    • Fever >101oF (38.3oC) and,

    • >1 symptom: prostration, headache, backache, chills, vomiting, abdominal pain.

  • Classic smallpox lesions:

    • Firm, round, deep-seated pustules.

  • All lesions in same stage of development (on one part of the body).


Smallpox minor criteria
Smallpox: Minor Criteria Pustular Rash Illnesses

  • Centrifugal (distal) distribution.

  • First lesions: oral mucosa, face, or forearms.

  • Patient toxic or moribund.

  • Slow evolution (each stage 1-2 days).

  • Lesions on palms and soles.


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Rash Evaluation Flow Pustular Rash Illnesses


Immediate action for patient with generalized vesicular or pustular rash illness
Immediate Action for Patient with Generalized Vesicular or Pustular Rash Illness

  • Airborne and contact precautions instituted

  • Infection control team alerted

  • Assess illness for smallpox risk


Safety precautions
Safety Precautions Pustular Rash Illness

  • Respiratory and contactprecautions

  • Isolation Rooms

  • Gloves

  • Hand Washing


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Clinical Determination of Pustular Rash Illness

the Risk of Smallpox

High Risk of Smallpox  report immediately

  • Prodrome AND,

  • Classic smallpox lesions AND,

  • Lesions in same stage of development.


Response high risk case
Response: High Risk Case Pustular Rash Illness

  • Infectious diseases (and possibly dermatology) consult to confirm high risk status

  • Obtain digital photos

  • Alert public health officials that high risk status confirmed:

    • specimen collection

    • management advice

    • laboratory testing at facility with appropriate testing capabilities


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Clinical Determination of Pustular Rash Illness

the Risk of Smallpox

Moderate Risk of Smallpox  urgent evaluation

  • Febrile prodrome AND

  • One other MAJOR smallpox criterion OR

  • >4 MINOR smallpox criteria


Response moderate risk case
Response: Moderate Risk Case Pustular Rash Illness

  • Infectious diseases (and possibly dermatology) consult

  • Laboratory testing for varicella and other diseases

  • Skin biopsy

  • Digital photos

  • Re-evaluate risk level at least daily


Evaluating patients with acute generalized vesicular or pustular rash illnesses

Clinical Determination of Pustular Rash Illness

the Risk of Smallpox

Low Risk of Smallpox  manage as clinically indicated

  • No/mild febrile prodrome

  • OR

  • Febrile prodrome AND

  • < 4 MINOR smallpox criteria (no major criteria)


Response low risk case
Response: Low Risk Case Pustular Rash Illness

  • Patient management and laboratory testing as clinically indicated


Smallpox pre event surveillance
Smallpox Pre-event Surveillance Pustular Rash Illness

  • Goal  to recognize the first case of smallpox early without:

    • Generating high number of false alarms through conducting lab testing for smallpox cases that do not fit the case definition

    • Disrupting the health care and public health systems

    • Increasing public anxiety



Cdc rash illness response team experience with use of algorithm
CDC Rash Illness Response Team Experience with Use of Algorithm

  • 25 calls to CDC January 1 – December, 2002

  • Smallpox risk classification:

    • High risk = 0

    • Moderate risk = 4

    • Low risk = 21


Cdc rash response team experience with use of algorithm
CDC Rash Response Team Experience with Use of Algorithm Algorithm

  • >50% of the cases including 2 deaths have been varicella

  • 14 diagnoses confirmed by lab and/or pathology; 11 clinically diagnosed

  • Other diagnoses:

    • drug reaction

    • erythema multiforme, Stevens Johnson

    • disseminated herpes zoster

    • disseminated HSV2

    • contact dermatitis

    • other dermatological disorders


Experience with implementation of rash algorithm
Experience with Implementation of Rash Algorithm Algorithm

  • Rule in VZV!!

  • Algorithm has limited variola testing by standard approach to evaluation