Article

Triage of a febrile patient with a rash: A comparison of chickenpox, monkeypox, and smallpox

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Abstract

The immediate and correct recognition of an infectious exanthema can be aided with a focused history and minor assessment. False alarms can consume health care resources and create unnecessary anxiety. Clinicians can use specific references to not only help with educating staff, but to ensure a more accurate diagnosis and trigger notification of appropriate infectious disease protocols. The authors recommend that al emergency departments have a process in place to immediately isolate suspicious cases until a more thorough medial workup can be performed.

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... The key points for diagnosing a suspicious febrile patient with rash in triage include the principal signs (general condition, the characteristics of the fever, the risks of exposure to infected people, a recent journey, immunodepression, etc.), associated symptoms (headache, relevant lymphoadenopathy, nucal stiffness, etc.) and a physical examination (vi- tal signs, general status, skin and mucosal lesions) (Seguin and Halpern Stoner, 2004). ...
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With the aim of identifying intervention programmes within the framework of basic and permanent nursing training, we evaluated the knowledge of 187 nurses and nursing students concerning biological emergencies. A questionnaire was used to identify their knowledge of the pathogens that may be used in a terrorist attack and measures for containing them, and their perception of the danger to public health. Analysis of the responses showed that the undergraduates studying for the Triennial Degree were the best informed, and those studying for the specialist degree were the least informed. The question relating to the precautions adopted against transmission of Bacillus anthracis was the most predictive of the total score because it was the only one with a substantial number of correct answers (79/187). It seems that the information derived more from the generalist media than from academic training. We conclude that there is a need to train qualified personnel capable of responding to a possible emergency in terms of both preventive and interventional medicine.
... The key points for diagnosing a suspicious febrile patient with rash in triage include the principal signs (general condition, the characteristics of the fever, the risks of exposure to infected people, a recent journey, immunodepression, etc.), associated symptoms (headache, relevant lymphoadenopathy, nucal stiffness, etc.) and a physical examination (vital signs, general status, skin and mucosal lesions) (Seguin and Halpern Stoner, 2004). ...
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The health care staff is potentially more exposed to contract infectious diseases at work. This risk becomes true if the DPI are not utilized and the operators don't work according to the standard protocol, and, with regard to the health care students, they begin their clinical training without the right knowledges. To verify the adequacy of knowledges and the consequent behaviours we effected a study among the students at first year of the D. U. for nurses in the University of L'Aquila, through a questionnaire. It came out many gaps of knowledges about the standard practice and about the Universal Precautions in about 20% of the interviewed.
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Objective To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of smallpox as a biological weapon against a civilian population.Participants The working group included 21 representatives from staff of major medical centers and research, government, military, public health, and emergency management institutions and agencies.Evidence The first author (D.A.H.) conducted a literature search in conjunction with the preparation of another publication on smallpox as well as this article. The literature identified was reviewed and opinions were sought from experts in the diagnosis and management of smallpox, including members of the working group.Consensus Process The first draft of the consensus statement was a synthesis of information obtained in the evidence-gathering process. Members of the working group provided formal written comments that were incorporated into the second draft of the statement. The working group reviewed the second draft on October 30, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.Conclusions Specific recommendations are made regarding smallpox vaccination, therapy, postexposure isolation and infection control, hospital epidemiology and infection control, home care, decontamination of the environment, and additional research needs. In the event of an actual release of smallpox and subsequent epidemic, early detection, isolation of infected individuals, surveillance of contacts, and a focused selective vaccination program will be the essential items of an effective control program.
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Seven outbreaks of disease characterized by a pustular rash and suspected to have been caused by human monkeypox virus were investigated. The outbreaks occurred between February and August 2001 in the province of Equateur in the Democratic Republic of Congo. The outbreaks involved a total of 31 persons and caused five deaths. Specimens from 14 patients were available and were analyzed by electron microscopy, virus isolation, and PCR assays specific for monkeypox virus and varicella-zoster virus. We provide evidence that two outbreaks were indeed caused by monkeypox virus (16 cases, with four deaths), that in two outbreaks both monkeypox and varicella-zoster virus were involved (seven cases, with one death), and that two outbreaks were cases of chickenpox caused by infection with varicella-zoster virus (six cases, with no deaths). In one outbreak, no evidence for either monkeypox or chickenpox was found (two cases, with no deaths).
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Diagnostic advances have resulted in earlier and more frequent recognition of pituitary tumors. Pituitary tumors cause problems owing to the hormones they secrete or the effects of an expanding sellar mass--hypopituitarism, visual field abnormalities, and neurologic deficits. Prolactin-secreting tumors (prolactinomas), which cause amenorrhea, galactorrhea, and hypogonadism, constitute the most common type of primary pituitary tumors, followed by growth hormone-secreting tumors, which cause acromegaly, and corticotropin-secreting tumors, which cause Cushing's syndrome. Hypersecretion of thyroid-stimulating hormone, the gonadotrophins, or alpha-subunits is unusual. Nonfunctional tumors currently represent only 10% of all clinically diagnosed pituitary adenomas, and some of these are alpha-subunit-secreting adenomas. Insights into the pathogenesis and biologic behavior of these usually benign tumors have been gained from genetic studies. We review some of the recent advances and salient features of the diagnosis and management of pituitary tumors, including biochemical and radiologic diagnosis, transsphenoidal surgery, radiation therapy, and medical therapy. Each type of lesion requires a comprehensive but individualized treatment approach, and regardless of the mode of therapy, careful follow-up is essential.
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To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of smallpox as a biological weapon against a civilian population. The working group included 21 representatives from staff of major medical centers and research, government, military, public health, and emergency management institutions and agencies. Evidence The first author (D.A.H.) conducted a literature search in conjunction with the preparation of another publication on smallpox as well as this article. The literature identified was reviewed and opinions were sought from experts in the diagnosis and management of smallpox, including members of the working group. The first draft of the consensus statement was a synthesis of information obtained in the evidence-gathering process. Members of the working group provided formal written comments that were incorporated into the second draft of the statement. The working group reviewed the second draft on October 30, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members. Specific recommendations are made regarding smallpox vaccination, therapy, postexposure isolation and infection control, hospital epidemiology and infection control, home care, decontamination of the environment, and additional research needs. In the event of an actual release of smallpox and subsequent epidemic, early detection, isolation of infected individuals, surveillance of contacts, and a focused selective vaccination program will be the essential items of an effective control program.
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The differential diagnosis for febrile patients with a rash is extensive. Diseases that present with fever and rash are usually classified according to the morphology of the primary lesion. Rashes can be categorized as maculopapular (centrally and peripherally distributed), petechial, diffusely erythematous with desquamation, vesiculobullous-pustular and nodular. Potential causes include viruses, bacteria, spirochetes, rickettsiae, medications and rheumatologic diseases. A thorough history and a careful physical examination are essential to making a correct diagnosis. Although laboratory studies can be useful in confirming the diagnosis, test results often are not available immediately. Because the severity of these illnesses can vary from minor (roseola) to life-threatening (meningococcemia), the family physician must make prompt management decisions regarding empiric therapy. Hospitalization, isolation and antimicrobial therapy often must be considered when a patient presents with fever and a rash.
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The last case of endemic smallpox occurred in Somalia in 1977, and eradication of the disease was declared in 1980. With no natural reservoir, variola virus, which causes smallpox, has existed only in laboratories; indeed, the last case of smallpox was due to infection acquired in a laboratory in the United Kingdom in 1978. During the global program of smallpox eradication, the World Health Organization (WHO) made concerted efforts to decrease the number of laboratories retaining variola virus. On the basis of contacts with all countries and a total of 823 microbiology institutions, 76 such laboratories had been identified by . . .
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The clinical course of smallpox infection and the current and future roles of vaccination and strategies for controlling smallpox outbreaks are reviewed. Close personal contact is required for transmission of variola, the DNA virus that causes smallpox. Following an incubation period, infected persons have prodromal symptoms that include high fever, back pain, malaise, and prostration. The eruptive stage is characterized by maculopapular rash that progresses to papules, then vesicles, and then pustules and scab lesions. The mortality rate for smallpox is approximately 30%. Patients having a fever and rash may be confused with having chickenpox. The most effective method for preventing smallpox epidemic progression is vaccination. Until recently, only 15 million doses of smallpox vaccine manufactured 20 years ago were available in the United States. The vaccine is a live vaccinia virus preparation administered by scarification with a bifurcated needle. The immune response is protective against orthopoxviruses, including variola. Vaccination is associated with moderate to severe complications, such as generalized vaccinia, eczema vaccinatum, progressive vaccinia, and postvaccinial encephalitis. Efforts for vaccine production are now focused on a live cell-culturederived vaccinia virus vaccine. Although smallpox was eradicated in 1980, it remains a potential agent for bioterrorism. As a category A biological weapon, its potential to devastate populations causes concern among those in the public health community who have been actively developing plans to deal with smallpox and other potential agents of biological warfare. The only proven effective strategy against smallpox is vaccination.
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Recent events have demonstrated that bioterrorists have the ability to disseminate biologic agents in the United States and cause widespread social panic. Family physicians would play a key role in the initial recognition of a potential bioterrorism attack. Familiarity with the infectious agents of highest priority can expedite diagnosis and initial management, and lead to a successful public health response to such an attack. High-priority infectious agents include anthrax, smallpox, plague, tularemia, botulism, and viral hemorrhagic fever. Anthrax and smallpox must be distinguished from such common infections as influenza and varicella. Anthrax treatment is stratified into postexposure prophylaxis and treatment of confirmed cutaneous, intestinal, or inhalation anthrax. Disease prevention by vaccination and isolation of affected persons is key in preventing widespread smallpox infection. Many resources are available to physicians when a bioterrorism attack is suspected, including local public health agencies and the Centers for Disease Control and Prevention.
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Human monkeypox is a rare viral zoonosis endemic to central and western Africa that has recently emerged in the USA. Laboratory diagnosis is important because the virus can cause disease that is clinically indistinguishable from other pox-like illnesses, particularly smallpox and chickenpox. Although the natural animal reservoir of the monkeypox virus is unknown, rodents are the probable source of its introduction into the USA. A clear understanding of the virulence and transmissibility of human monkeypox has been limited by inconsistencies in epidemiological investigations. Monkeypox is the most important orthopoxvirus infection in human beings since the eradication of smallpox in the 1970s. There is currently no proven treatment for human monkeypox, and questions about its potential as an agent of bioterrorism persist.
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