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