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Updated: Jul 26 2018


  • Snapshot
    • You work for a non-profit organization specializing in infectious diseases. You monitor outbreaks in developing countries. You receive a report of a child with multiple pustular lesions with the densest portion over the face. Concerned about a potential smallpox outbreak, you immediately reach out to find out more about the patient course and to obtain photographs. When you find out that the child did not have a prodrome and that scabs had formed within a week, you feel some relief. However, you still request laboratory confirmation of the disease.
  • Introduction
    • Classification
      • variola
        • a poxvirus
        • an enveloped, linear, double-stranded DNA virus
    • Epidemiology
      • incidence
        • the disease has been eradicated with global vaccination
      • risk factors
        • bioterrorism
    • Pathogenesis
      • patients remain contagious until the lesion scabs and until all scabs fall off naturally
    • Associated conditions
      • smallpox
    • Prevention
      • live-attenuated vaccine
    • Prognosis
      • mortality was very high, with an overall fatality of 30%
  • Presentation
    • Symptoms
      • initial prodrome
        • fever and chills
        • headache
        • spinal pain
        • pharyngitis
        • may have a fine macular rash
      • characteristic rash occurs after prodrome
    • Physical exam
      • characteristic rash has 3 phases and is synchronous (i.e., all lesions are at the same stage of development)
        • initial small red non-blanching macules
        • this develops into firm papules which then develops into pustules and larger vesicles with central umbilication
        • affects both mucosa and skin but is denser on the face
        • lesions develop a scab by the second week
      • conjunctivitis
  • Studies
    • Labs
      • polymerase chain reaction assay
    • Electron microscopy
      • brick-shaped virions with internal dumbbell-shaped core containing viral DNA
      • from vesicular or pustular fluid
    • Making the diagnosis
      • based on clinical presentation
  • Differential
    • Varicella (chicken pox)
      • distinguishing factors
        • typically does not have a prodromal phase and begins with an exanthematous rash
        • progression from initial rash to scab is 7 days (vs 14 days in variola)
  • Treatment
    • Management approach
      • mainstay treatment is supportive care
      • patients should be isolated
    • Conservative
      • supportive care
        • indication
          • all patients
        • modalities
          • intravenous fluids
          • analgesics
          • good wound care
  • Complications
    • Cutaneous scarring
    • Encephalitis
    • Stillbirth
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