CASE PRESENTATION

1
CASE PRESENTATION 15

• Jim Pointer, MD. FACEP
• Alameda County EMS
• Medical Director

2
The Call

• You are called to a home in a gated community for
  shortness of breath.
• Upon arrival, a distraught middle-aged woman
  rushes you into the upstairs bedroom. She
  shouts, my husband is very sick.

3
Initial Assessment

• Uncomfortable African-American male lying in bed
  complaining of
• severe headache
• back pain
• fever
• ABCs intact
• GCS 15

4
Focused History andPhysical Exam

• Patient had sudden onset (6 hours ago) of
  headache all over, severe mid and lower back
  pain, and fever to 104º F.
• The fever has been minimally responsive to
  therapeutic doses of acetaminophen.
• He denies any other symptoms except for a mild
  cough.

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Focused History andPhysical Exam (cont.)

• Pertinent Findings
• B/P 152/92, RR 32, PR 126
• Temperature 103.8º F. p.o.
• Pulse Ox 98 on room air
• Exam within normal limits except for increased
  body warmth and dry mucous membranes.

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Focused History andPhysical Exam (cont.)

• Past Medical History
• No serious illnesses or operations
• Hypertension controlled with Altace, 5 mg.
  q.d.
• Patient travels frequently and was on a plane
  from Mumbai, India six days prior.

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Initial Treatment

• IV Normal Saline, 1 liter
• Dextrostix 80 mg/dl
• Transport to hospital
• You and your partner observe universal
  precautions and place a mask on the patient.

8
Uh-Oh

• Your partner recalls that you have responded to 5
  patients with fever, headache, and back pain
  during your 12-hour shift.

9
Hospital Findings

• Uncomfortable middle-aged male complaining of
  headache and backache.
• Vital Signs
• B/P 155/94, PR 128, RR 28
• Temperature 103.8 F. p.o.
• Pulse Ox 97 RA

10
Hospital Findings (cont.)

• The emergency department staff can find no
  specific positive physical findings.
• The patient is hydrated and sent home with
  ibuprofen for fever and a diagnosis of viral
  syndrome.
• You overhear the emergency physician tell a nurse
  that he has seen 4 patients in the past 4 hours
  with the same presentation.

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The next day. . .

• . . .you pick up the Daily Planet

Mumbai (AP) A 40 year old Saudi has been
detained after he sprayed a canister of an
unknown substance in the coach section of an Air
India flight from Mumbai to New York.
Daily Planet FBI Releases Details of Aerosol
Release Aboard Flight from India
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Anyone know what this is?
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Smallpox

• History as a biological weapon
• Used in French and Indian wars in 1796.
• Edward Jenner demonstrated that cowpox infection
  protected against smallpox.
• Eradicated in 1977.
• Two laboratories (US Russia) retained stocks of
  smallpox.
• Aerosolization possible.
• No vaccination in US since 1972.

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Epidemiology

• Two principal forms
• Variola Major 30 death rate
• Variola Minor 1 death rate
• Exposure
• Person-to-person droplet transmission, clothing,
  bed linens
• Predominantly hospital household spread
• Incidence highest during winter spring
• Most infectious from onset of rash through
  first 7-10 days
• DNA virus Orthopoxvirus

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Pathogenesis Clinical Presentation

• Virus implants on mucosa in mouth and lungs
• Spread
• regional nodes ? primary viremia ? spleen, bone
  marrow, all nodes ? secondary viremia ? fever,
  toxemia ? small blood vessels, in dermis and
  beneath oral mucosa
• Incubation period 12-14 days (range 7-17)

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Pathogenesis Clinical Presentation (cont.)

• Initial signs symptoms
• High fever
• Malaise
• Back pain
• Headache
• Maculopapular - rash
• Mucosa of mouth
• Pharynx
• Face
• Forearms
• Trunk and legs

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Pathogenesis Clinical Presentation (cont.)

• Vescicular ? pustular rash
• (round, tense, deep)
• Crusts on 8th or 9th day
• Scabs ? scarring
• Death caused by toxemia from circulatory immune
  complexes and soluble antigens

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Small Pox vs.Chicken Pox

• Becomes ill 7-17 days after exposure
• Has fever and feels ill 2-4 days before rash
  appears
• Pox appear over 1-2 days
• Lesions are all in the same stage of development
• Most numerous on face, arms, legs - usually
  present on palms soles
• Scabs form in 10 - 14 days and fall off 14 - 28
  days after rash appeared
• Centrifugal distribution

• Becomes ill 14-21 days after exposure
• Usually has no symptoms until the rash appears
• Pox are most numerous on the body - never found
  on the palms soles
• Scabs form in 4 7 days and fall off within 14
  days after rash appeared
• Centripetal distribution

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Small Pox vs. Chicken Pox
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Small Pox vs. Chicken Pox
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• Laboratory confirmation
• Electron microscopy shows brick-shaped virions

A False-Color Electron Micrograph Shows the
Smallpox Variola Virus
Picture from London School of Hygiene and
Tropical Medicine /Science Source Photo
Researchers, Inc.
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Vaccination (vaccinia)

• Immune status of those vaccinated before 1972 is
  unclear
• 15 million doses are available in US (additional
  70-90 million have been identified)
• Bifurcated needle used 15 jabs in dermis of
  upper deltoid
• 110 dilution of vaccine results in 97 success
  rate
• Some protection if vaccine given within 4 days of
  exposure

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VaccinationDay 0 day 14
Papule Jennerian
Crust
pustule
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Vaccination Complications(per 1 million)

• Death
• Progressive vaccinia
• Encephalitis
• Eczema
• Erythema multiforme
• Generalized vaccinia
• Accidental innoculations
• Vaccinia Immune Globulin used
  in treating complications (CDC)
• Dose 0.6 mL/kg IM

1 2 12 39 165 242 529
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Accidental Innoculation
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Bio-terrorism Prevention

• Vaccination priorities
• Exposed individuals
• House-hold, face-to-face contacts
• Care givers
• Hospital workers
• Laboratory workers
• Isolation of contacts (at home) if
  Temperature gt 38 C

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Bio-terrorism Prevention (cont.)

• Admitted patients confined to negative pressure
  rooms
• Universal precautions
• mask gloves gown
• Laundry autoclaved
• Victims cremated, if possible
• Reporting of clustering of symptom complexes

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References

• Henderson DA, et al Smallpox as a biological
  weapon. JAMA 1999 281 2127-37.
• Berman JG, Henderson DA Diagnosis and management
  of smallpox. NEJM 2002 346 1300-08