Generalized Vesicular Or Pustular Rash Illness Protocol

G eneralized Vesicular or Pustular Rash Illness Protocol

Patient with Acute, Generalized A suspected case of s mallpox is a p u blic he alth a n d m e dical em er ge n cy.

Vesicular or Pustular Rash Illness Clinical case definition of s m allp o x: a n illness with acute onset of fever >101°F follo wed by a rash characterized by vesicles or firm pustules in the sa m e sta g e of ev olutio n with o ut other ap p are nt ca u s e.

Report ALL suspected cases (without waiting for lab results) to: 1. Hospital Infection C o ntrol ( ) ___-____ or ( ) ___-____ Pager Institute Airborne & Contact Precautions 2. (Local) health depart m e nt ( ) ___-____ or ( ) ___-____ Pager 3. (State) health departm ent ( ) ___-____ or ( ) ___-_____ Alert Infection Control on Admission Questions ? Centers for Disease Control and Prevention: (404)639-3532 days; Nights/weekends/holidays: (770) 488-7100

Low Risk for Smallpox Moderate Risk of Smallpox High Risk for Smallpox Conditions With Vesicular or Pustular Rashes (see criteria below) (see criteria below) (see criteria below)

Condition Clinical Clues

History and Exam Diagnosis ID and/or Derm Consultation ID and/or Derm Consultation Varicella (primary infection Most common in children <10 years; children Highly Suggestive Uncertain VZV +/- Other Lab Testing Alert Infx Control & with varicella-zoster virus) usually do not have a viral prodrom e of Varicella as indicated Local and State Health Depts Disse minated herpes zoster Prior history of chickenpox; im munoco mpro mised hosts

Impetigo (Streptococcus H oney-colored crusted plaq u e s with bullae are pyogenes, Staphylococcus clas sic b ut m a y be gin as vesicles; regional not Varicella Testing Test for VZV Non-Smallpox No Diagnosis Made Response Team Advises aureus) disse min ate d Optional and Other Conditions Diagnosis Cofirmed Ensure Adequacy of Specimen on Management & as Indicated Report Results to Infx ControlID or Derm Consultant Specimen Collection Dru g eruptions and contact Exposure to medications; contact with possible dermatitis allergens Re-evaluates Patient Erythe ma multiforme (incl. Major for m involves m u c o u s m e m bra n es an d Stevens Johnson Sd) conjunctivae

Enteroviruses incl. Hand, Su m mer and fall; fever and mild ph aryngitis at Foot and Mouth disease sa me time as rash; distribution of small Cannot R/O Smallpox Testing at CDC vesicles on hands, feet and mouth or CRITERIA FOR DETER MINING RISK OF SMALLPOX Contact Local/State Health Dept disse min ate d Disse minated herpes simplex Lesions indistinguishable fro m varicella; High Risk for S m allpox Æ report im mediately im munoco mpro mised host 1. F e brile prodro me (see below) AN D 2. Classic s m allpox lesions (see below and photo at right) AND NOT SmallpoxSMALLPOX Scabies; insect bites (incl. Pruritis; in scabies, look for burrows (vesicles 3. L e sio n s in sa me stage of develop ment (see below) fleas) and nodules also occ ur); flea bites are pruritic, Further Testing patient usually unaware of flea exposure M o derate Risk for S m allpox Æ urgent evaluation Molluscu m contagiosu m Healthy afe brile children; HI V + individuals 1. F e brile prodro me (see below) AN D 2. One MAJOR smallpox criterion (see belo w) Bullous Pe mphigoid Bullous lesions. Positive Nikolskisign. OR 1. F e brile prodro me (see below) AN D Secondary syphilis R a s h can mi mic m a ny diseases; rash may 2. >4 MIN O R s mallpox criteria (see below) involve palms and soles; 95% maculo- papular, may be pustular. Sexually active persons Lo w Risk for S m allpox Æ manage as clinically indicated 1. N o viral prodro m e O R 2. F e brile prodrome and <4 MINOR smallpox criteria (no major criteria) Variant presentations of sm allpox: approximately 3-5% of persons (see below) never vaccinated for s m allpo x will pres e nt with he m orrhagic s mallpox (see photo--can be mistaken for meningococce mia, he morrhagic varicella, Rocky Mountain spotted fever, erlichiosis, acute leuke mia) an d 5-7 % with flat-type s m allpox (see photo). Both MAJOR SMALLPOX CRITERIA variants are highly infectious and carry a high m ortality. CHICKENPOX (VARICELLA) IS THE MOST LIKELY CONDITION TO BE MISTAKEN FOR SMALLPOX. ƒFEBRILE PRODRO ME: occurring 1-4 days before rash onset: fever >102°F and at least one of the follo wing: prostration, headache, backache, chills, vo miting or severe abdo minal pain. All smallpox patients have a febrile prodro m e. The fever may drop H o w varicella (chickenpox) differs: Laboratory Testing for Varicella: Collect at least 3 good specimens fro m each patient with rash onset. ƒNo or mild, brief (1 day) prodro m e ¾ Direct fluorescent antibody (DFA)— rapid, depends on adequate specimen ƒCLASSIC SMALLPOX LESIONS: d e e p, firm/hard, round, (see below) well-circu m s cribed; may be umbilicated or confluent ƒL e sio n s are su p erficial vesicles: “de w drop on a rose petal” ¾ Indirect fluorescent antibody (IFA) —rapid, depends on adequate specimen (see below) ƒLesions appear in crops; on any one part of the body there are lesions in different stag es ¾ Poly merase chain reaction (P C R)--availa ble in research labs, so m e tertiary ƒLESIONS IN SAME STAGE OF DEVELOPMENT: on any one part of the body (e.g., care centers the face, or ar m) all the lesio n s are in the sa m e stage of develop ment (i.e. all are (papules, vesicles, crusts) ¾ Serologic testing: an Ig G (collected at time of rash) provides evidence of prior vesicles, or all are pustules) varicella, an d m a k es acute varicella infection unlikely but does not rule out ƒCentripetal distribution: greatest co n c e ntration of lesions on the trunk, fe w est lesions on herpes zoster in perso n s at risk of disse min ation. Ig M is not useful for distal extre mities. May involve the face/scalp. Occasionally entire body equally affected. dia g n o sis. ¾ VZV culture —results delayed, useful only if processe d in-house ¾ E M (electron microscopy) —can ide ntify herpes viruses ƒFirst lesions appear on the trunk, or occasionally on face MINOR SMALLPOXCRITERIA How to Collect a Specimen for DFA or IFA Testing ƒPatients rarely toxic or moribund ƒCentrifugal distribution: greatest co n c e ntration of lesions on face and distal 1. Unroof(open) vesicle or pustule with a sterile lancet 2. S wab base of vesicle vigorously with a sterile swab extremities ƒRapid evolution: Lesions evolve from macules Æ papulesÆ vesicles Æcrusts quickly (<24 3. S m ear swab onto 3 areas (or wells) of a microsco p e slide hours) 4. Allo w slide to air dry ƒFirst lesions on the oral mucosa/palate, face, forear m s 5. Transport to lab for im mediate fixing and staining 6. V Z V positive sp eci m e n s are se e n with varicella (chickenpox) and herpes ƒP al m s and soles spared z oster (shingles) ƒPatient appears toxic or moribund ƒPatient lacks reliable history of varicella or varicella vaccination The hospital lab performs ______test ƒSl o w e v olution: lesions evolve from macules to papulesÆpustules over days For DFA/IFA , call ______(specimen is teste d at outside lab) ƒ50-80 % recall an exposure to chickenpox or shingles 10-21 days before rash onset A4 - 17 ƒLesions on the pal m s an d soles ( m ajority of cases)