EVALUATING PATIENTS FOR SMALLPOX ACUTE, GENERALIZED VESICULAR OR PUSTULAR RASH ILLNESS PROTOCOL

Patient with Acute, Generalized Vesicular or Pustular Rash Illness

Institute Airborne & Contact Precautions Alert Infection Control on Admission

Low Risk Moderate Risk High Risk of Smallpox of Smallpox of Smallpox (see “Risk of Smallpox” below) (see “Risk of Smallpox” below) (see “Risk of Smallpox” below)

ID and/or Derm Consultation ID and/or Derm Consultation History and Exam Varicella +/- Alert Local and State Health Highly Suggestive Diagnosis Other Lab Testing as Indicated Departments Immediately of Varicella Uncertain (contact information below)

Response Team Test for Non-Smallpox No Diagnosis Made Advises on Varicella Testing Varicella and Diagnosis Confirmed Ensure Adequacy of Specimen Management & Specimen Optional Other Conditions Report Results to ID/Derm Consultant Collection as Indicated Infection Control Re-Evaluates Patient

Cannot R/O Smallpox Testing Classify as High Risk at CDC

NOT Smallpox SMALLPOX RISK OF SMALLPOX Further Testing High Risk of Smallpox → Report Immediately 1. Febrile prodrome (defined below) AND 2. Classic smallpox lesion (defined below & photo at top right) AND 3. Lesions in same stage of development (defined below)

Moderate Risk of Smallpox → Urgent Evaluation There have been no naturally occurring cases of smallpox anywhere in the world 1. Febrile prodrome (defined below) AND since 1977. A high risk case of smallpox is a public health and medical emergency. 2. One other MAJOR smallpox criterion (defined below) Report all HIGH RISK CASES immediately (without waiting for lab results) to: OR 1. Hospital Infection Control ______( ) ______- ______1. Febrile prodrome (defined below) AND 2. ≥4 MINOR smallpox criteria (defined below) ______( ) ______- ______2. ______health department ( ) ______- ______Low Risk of Smallpox → Manage as Clinically Indicated ( ) ______- ______1. No febrile prodrome OR 3. ______health department ( ) ______- ______1. Febrile prodrome AND ( ) ______- ______2. <4 MINOR smallpox criteria (defined below)

MAJOR SMALLPOX CRITERIA ƒƒ FEBRILE PRODROME: occurring 1-4 days before rash onset: fever ≥101°F and at least one of the following: prostration, headache, backache, chills, vomiting or severe abdominal pain ƒƒ CLASSIC SMALLPOX LESIONS: deep-seated, firm/hard, round well-circumscribed vesicles or pustules; as they evolve, lesions may become umbilicated or confluent ƒƒ LESIONS IN SAME STAGE OF DEVELOPMENT: on any one part of the body (e.g., the face, or arm) all the lesions are in the same stage of development (i.e., all are vesicles, or all are pustules)

MINOR SMALLPOX CRITERIA ƒƒ Centrifugal distribution: greatest concentration of lesions on face and distal extremities ƒƒ First lesions on the oral mucosa/palate, face, or forearms ƒƒ Patient appears toxic or moribund ƒƒ Slow evolution: lesions evolve from macules to papules → pustules over days (each stage lasts 1-2 days) ƒƒ Lesions on the palms and soles

For more information, please go to the CDC website www.cdc.gov/smallpox

CS265116-A EVALUATING PATIENTS FOR SMALLPOX ACUTE, GENERALIZED VESICULAR OR PUSTULAR RASH ILLNESS PROTOCOL

Chickenpox (varicella) (variola) Smallpox

Classic chickenpox lesions Typical chickenpox Typical smallpox Classic smallpox lesions rash distribution rash distribution

IMAGES OF CHICKENPOX (VARICELLA) IMAGES OF SMALLPOX

Day 3 of rash Day 5 of rash Day 7 of rash

Healthy child Healthy adult Bacterial superinfection with varicella with varicella of varicella lesions

Note centripetal Day 3 of rash Lesions are in different distribution of rash stages of development On any one part of the body, all lesions are in the same stage of development Umbilicated lesions (back of hand)

Healthy adult Healthy adult Pregnant woman Most patients with smallpox have lesions on the palms or soles Confluent lesions with varicella with varicella with varicella

DIFFERENTIATING CHICKENPOX FROM SMALLPOX COMMON CONDITIONS THAT MIGHT BE CONFUSED WITH SMALLPOX

Chickenpox (varicella) is the most likely condition to be confused CONDITION CLINICAL CLUES with smallpox. Varicella (primary infection Most common in children <10 years; children usually do not have a with varicella-zoster virus) viral prodrome In chickenpox: Immunocompromised or elderly persons; rash looks like Disseminated herpes zoster ƒƒ No or mild prodrome varicella, usually begins in dermatomal distribution Impetigo (Streptococcus ƒƒ Lesions are superficial vesicles: “dewdrop on a rose petal” (see photo at top) Honey-colored crusted plaques with bullae are classic but may begin pyogenes, Staphylococcus as vesicles; regional not disseminated rash; patients generally not ill ƒƒ Lesions appear in crops: on any one part of the body there are lesions in aureus) different stages (papules, vesicles, crusts) Drug eruptions Exposure to medications; rash often generalized ƒƒ Centripetal distribution: greatest concentration of lesions on the Itching; contact with possible allergens; rash often localized in pattern Contact dermatitis trunk, fewest lesions on distal extremities. May involve the face/scalp. suggesting external contact Occasionally entire body equally affected. Target, “bull’s eye,” or iris lesions; often follows recurrent herpes simplex Erythema multiforme minor ƒƒ First lesions appear on the face or trunk virus infections; may involve hands & feet (including palms & soles) ƒƒ Patients rarely toxic or moribund Erythema multiforme (incl. Major form involves mucous membranes & conjunctivae; may be Stevens-Johnson Syndrome) target lesions or vesicles ƒ → → → ƒ Rapid evolution: lesions evolve from macules papules vesicles Summer & fall; fever & mild pharyngitis 1-2 days before rash onset; crusts quickly (<24 hours) Enteroviral infection esp. lesions initially maculopapular but evolve into whitish-grey tender, Hand, Foot and Mouth disease flat often oval vesicles; peripheral distribution (hands, feet, mouth, or ƒƒ Palms and soles rarely involved disseminated) ƒƒ Patient lacks reliable history of varicella or varicella vaccination Disseminated herpes simplex Lesions indistinguishable from varicella; immunocompromised host ƒƒ 50-80% recall an exposure to chickenpox or shingles 10-21 days before Scabies; insect bites (incl. fleas) Itching is a major symptom; patient is not febrile & is otherwise well rash onset Molluscum contagiosum May disseminate in immunosuppressed persons

Photo Credits: For more information, please go to the CDC website www.cdc.gov/smallpox Dr. Thomas Mack, Dr. Barbara Watson, Dr. Scott A. Norton, Dr. Patrick Alguire, World Health Organization, American Academy of Pediatrics, American Academy of Dermatology

CS265116-A