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Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
Cutaneous Signs of Bioterror Agents
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Cutaneous Signs of Bioterror Agents

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  • 1. Cutaneous Signs of Bioterror Agents Adam Goldstein, MD, MPHAdam Goldstein, MD, MPH Associate ProfessorAssociate Professor UNC Department of Family MedicineUNC Department of Family Medicine Chapel Hill, NCChapel Hill, NC aog@med.unc.eduaog@med.unc.edu
  • 2. Objectives  Improve ability to:Improve ability to:  diagnose and manage cutaneous illnessdiagnose and manage cutaneous illness associated with suspected cases of bioterrorassociated with suspected cases of bioterror  Anthrax, plague, tularemia, smallpox, mustardAnthrax, plague, tularemia, smallpox, mustard gasgas
  • 3. Why worry?  ““Subnational attacks using geneticallySubnational attacks using genetically engineered organisms are inevitable”engineered organisms are inevitable”  ““Biologic agents now join nuclear agents”Biologic agents now join nuclear agents”  DeathsDeaths  1 KT H-BOMB1 KT H-BOMB .6M – 2M.6M – 2M  100 Kg ATX100 Kg ATX 1M – 3M1M – 3M (Stansfield Turner, CIA, 2001)(Stansfield Turner, CIA, 2001)
  • 4. Anthrax  Anthrakos = ‘coal’ b/c of black escharAnthrakos = ‘coal’ b/c of black eschar  B. anthracis is gram-positiveB. anthracis is gram-positive sporulatingsporulating bacillusbacillus  Spores areSpores are resistantresistant to heat, cold, drying, &to heat, cold, drying, & chemical disinfectionchemical disinfection  Anthrax isAnthrax is endemicendemic in western Asia (Iranin western Asia (Iran Turkey Afghanistan,) & western AfricaTurkey Afghanistan,) & western Africa (McGovern,(McGovern, Elect Text DermatolElect Text Dermatol, 1999), 1999)
  • 5. Anthrax  SporesSpores viableviable forfor yearsyears top 6 cmtop 6 cm of soil & inof soil & in animal productsanimal products  Disease transmitted from infected animals orDisease transmitted from infected animals or productsproducts via skin abrasionsvia skin abrasions > 90% of cases> 90% of cases  GoatsGoats > sheep > cattle > horses > pigs > dogs> sheep > cattle > horses > pigs > dogs
  • 6. Anthrax  BurnBurn dead animals, not buried, to preventdead animals, not buried, to prevent long-term environmental contaminationlong-term environmental contamination
  • 7. History of Anthrax  1500 B.C. -- Fifth/sixth Egyptian plagues, ? Anthrax1500 B.C. -- Fifth/sixth Egyptian plagues, ? Anthrax  1600s -- "Black Bane," ? anthrax, kills 60,000 cattle1600s -- "Black Bane," ? anthrax, kills 60,000 cattle  1876 -- Koch confirms bacterial origin of anthrax1876 -- Koch confirms bacterial origin of anthrax  1880 -- Immunization of livestock against anthrax1880 -- Immunization of livestock against anthrax  1915 -- German agents in U.S. inject horses/cattle with1915 -- German agents in U.S. inject horses/cattle with anthrax on way to Europe during WW Ianthrax on way to Europe during WW I  1937 -- Japan starts biological warfare program1937 -- Japan starts biological warfare program  1942 -- Britain experiments with anthrax1942 -- Britain experiments with anthrax  1943 -- U.S. begins developing anthrax weapons1943 -- U.S. begins developing anthrax weapons  1945 -- Anthrax outbreak in Iran kills 1 million sheep1945 -- Anthrax outbreak in Iran kills 1 million sheep
  • 8. Historical  1950s and '60s -- U.S. biological program continues1950s and '60s -- U.S. biological program continues  1969 -- Nixon ends U.S. offensive biological program.1969 -- Nixon ends U.S. offensive biological program.  1970 -- Anthrax vaccine approved by U.S. FDA1970 -- Anthrax vaccine approved by U.S. FDA  1972 -- International convention outlaws development1972 -- International convention outlaws development or stockpiling of biological weaponsor stockpiling of biological weapons  1978-80 -- Human anthrax epidemic strikes Zimbabwe,1978-80 -- Human anthrax epidemic strikes Zimbabwe, infecting > 6,000 and killing 100infecting > 6,000 and killing 100  1979 -- Aerosolized anthrax spores released at Soviet1979 -- Aerosolized anthrax spores released at Soviet military facility, killing 68military facility, killing 68  1991 -- U.S. troops vaccinated for Gulf War I1991 -- U.S. troops vaccinated for Gulf War I  1990-93 -- Terrorists release anthrax in Tokyo; no1990-93 -- Terrorists release anthrax in Tokyo; no injuriesinjuries
  • 9. Historical  1995 -- Iraq produced concentrated anthrax in1995 -- Iraq produced concentrated anthrax in biological weapons programbiological weapons program  1998 -- U.S. approves anthrax vaccinations for all1998 -- U.S. approves anthrax vaccinations for all militarymilitary  2001 -- Letter with anthrax spores mailed to NBC2001 -- Letter with anthrax spores mailed to NBC one week after 9/11 terrorist attacks on Pentagonone week after 9/11 terrorist attacks on Pentagon & WTC. Several die after inhaling.& WTC. Several die after inhaling.
  • 10. Anthrax pilot plant used to produce billions of anthrax spores at Fort Detrick, Md. U.S. ended offensive biological weapons research in 1969
  • 11. Al Hakam, Iraq's major facility for production of biological agents. Plant destroyed by Iraqi workers in 1996.
  • 12. Forms of Anthrax
  • 13. Pulmonary Anthrax  Wool-sorter’s diseaseWool-sorter’s disease  18 cases reported in U.S. 1900-198018 cases reported in U.S. 1900-1980  Symptoms: vague prodrome withSymptoms: vague prodrome with feverfever,, malaisemalaise,, myalgiasmyalgias andand coughcough  Within days- rapidly developing precordialWithin days- rapidly developing precordial discomfort, cyanosis, stridor, diaphoresis,discomfort, cyanosis, stridor, diaphoresis, moist rales, pleural effusion and deathmoist rales, pleural effusion and death
  • 14. Pulmonary Anthrax
  • 15. X-ray findings: hemorrhagic mediastinitis, but not true pneumonia; widened mediastinum
  • 16. X-ray findings
  • 17. Cutaneous Anthrax Incubation period 7 days (1-12 range)Incubation period 7 days (1-12 range) 1)1) Initial painlessInitial painless papulepapule (head, neck, extremity)(head, neck, extremity) • May resemble spider bite and may itchMay resemble spider bite and may itch • Surrounding erythema & edemaSurrounding erythema & edema 1)1) Vesicle or bullaVesicle or bulla rapidlyrapidly evolvesevolves 2)2) PainlessPainless hemorrhage & necrosishemorrhage & necrosis • Fluid becomes blackFluid becomes black • Lesion ulcerates & develops black escharLesion ulcerates & develops black eschar with surrounding edemawith surrounding edema • Pearl-like satellite vesicles may occurPearl-like satellite vesicles may occur
  • 18. Cutaneous Anthrax  Lesions progress from:Lesions progress from:  papule - erythema - vesicle - necrosis - ulcer - escharpapule - erythema - vesicle - necrosis - ulcer - eschar  with or without antibiotic therapywith or without antibiotic therapy  progression d/tprogression d/t toxintoxin  Lesions may be solitary or multiple (same part of body)Lesions may be solitary or multiple (same part of body)  Occasionally associated:Occasionally associated:  Tender lymphadenopathyTender lymphadenopathy  FatigueFatigue  Fever and/or chillsFever and/or chills (Caruscci,(Caruscci, JAADJAAD 2001)2001)
  • 19. Cutaneous Anthrax - Painless Lesions  SurroundingSurrounding edemaedema or regionalor regional lymphadenopathy may be painful.lymphadenopathy may be painful.  DebridementDebridement of skin lesionsof skin lesions notnot indicatedindicated b/c risk of spreading infectionb/c risk of spreading infection
  • 20. Cutaneous AnthraxCutaneous Anthrax
  • 21. Cutaneous Anthrax- painless papuleCutaneous Anthrax- painless papule
  • 22. Cutaneous Anthrax- vesicle with edemaCutaneous Anthrax- vesicle with edema
  • 23. Cutaneous Anthrax- early necrosisCutaneous Anthrax- early necrosis
  • 24. Cutaneous Anthrax- escharCutaneous Anthrax- eschar
  • 25. Cutaneous AnthraxCutaneous Anthrax
  • 26. Cutaneous AnthraxCutaneous Anthrax
  • 27. Cutaneous AnthraxCutaneous Anthrax
  • 28. Cutaneous AnthraxCutaneous Anthrax
  • 29. Cutaneous AnthraxCutaneous Anthrax
  • 30. Cutaneous AnthraxCutaneous Anthrax
  • 31. Cutaneous AnthraxCutaneous Anthrax
  • 32. Cutaneous AnthraxCutaneous Anthrax
  • 33. Cutaneous Anthrax: Diagnosis  Notify local Health DepartmentNotify local Health Department  BeforeBefore doing diagnostic testsdoing diagnostic tests  MaskMask notnot required &required & personnel not at riskpersonnel not at risk  Disease acquired through contact withDisease acquired through contact with sporesspores,, notnot active bacteriaactive bacteria
  • 34. Diagnosis  Swab exudatesSwab exudates for Gram stain & culture (fresh vesicles)for Gram stain & culture (fresh vesicles)  4-mm punch biopsy4-mm punch biopsy full-thickness (through entire dermis)full-thickness (through entire dermis)  permanent sectionspermanent sections  immunohistochemistry studiesimmunohistochemistry studies  polymerase chain reaction (PCR)polymerase chain reaction (PCR)  A second punch biopsyA second punch biopsy for Gram stain, bacterial, fungal &for Gram stain, bacterial, fungal & atypical mycobacterial culturesatypical mycobacterial cultures  Send clinical history (& lesion picture if possible)Send clinical history (& lesion picture if possible)  Negative bx does not r/o cut. anthrax b/c skin lesionsNegative bx does not r/o cut. anthrax b/c skin lesions caused by toxinscaused by toxins
  • 35. Diagnosis  Draw 5 mL of blood in red-topped tubeDraw 5 mL of blood in red-topped tube  Transfer to laboratory for isolation of serum &Transfer to laboratory for isolation of serum & subsequent storage at –70°C- label tube:subsequent storage at –70°C- label tube: “Anthrax serology.“Anthrax serology.  Store serum at –70°C for special pick-up.”Store serum at –70°C for special pick-up.”  Draw 5 mL of blood into a purple-topped tubeDraw 5 mL of blood into a purple-topped tube  RefrigerateRefrigerate  Hold for pick-up- PCR diagnostic tests by CDCHold for pick-up- PCR diagnostic tests by CDC
  • 36. Gram Stain
  • 37. Culture (24-36 hours)
  • 38. Differential Diagnosis: (eschar/ulceration)  Pruritic and papularPruritic and papular arthropod bitesarthropod bites  Brown recluse and otherBrown recluse and other spider bitesspider bites  Pustular diseasesPustular diseases  Antiphospholipid antibodyAntiphospholipid antibody syndrome ulcerssyndrome ulcers  AspergillosisAspergillosis  Coumadin or heparinCoumadin or heparin necrosisnecrosis  Ecthyma gangrenosumEcthyma gangrenosum  Cutaneous leishmaniasisCutaneous leishmaniasis  MucormycosisMucormycosis  PlaguePlague  Rickettsial poxRickettsial pox  Staphylococcal &Staphylococcal & streptococcal ecthymastreptococcal ecthyma  Tropical ulcerTropical ulcer  TularemiaTularemia  Typhus, scrub and tickTyphus, scrub and tick
  • 39. Differential Diagnosis: (ulceroglandular)  ChancroidChancroid  GlandersGlanders  Herpes simplexHerpes simplex  CutaneousCutaneous leishmaniasisleishmaniasis  LymphogranulomaLymphogranuloma venereumvenereum  MelioidosisMelioidosis  Cutaneous nocardiosisCutaneous nocardiosis  PlaguePlague  Sporotrichosis & otherSporotrichosis & other deep fungal diseasesdeep fungal diseases  Staphylococcal &Staphylococcal & streptococcal adenitisstreptococcal adenitis  TuberculosisTuberculosis  TularemiaTularemia
  • 40. Treatments http://www.bt.cdc.gov/agent/anthrax/index.asp
  • 41. Treatments  If suspected anthrax, begin appropriate txIf suspected anthrax, begin appropriate tx  Tx regimen differs by symptomatologyTx regimen differs by symptomatology (systemic or localized), location (extremity(systemic or localized), location (extremity vs head/neck), edema (extensive or not)vs head/neck), edema (extensive or not)  IfIf systemicsystemic signs,signs, headhead oror neckneck location, orlocation, or extensiveextensive edemaedema,, IV therapyIV therapy indicatedindicated
  • 42. Treatment for cutaneous anthrax patientsTreatment for cutaneous anthrax patients withoutwithout systemicsystemic symptoms, not located on the head or neck, not withsymptoms, not located on the head or neck, not with extensive edema, & not in children younger than 2 yearsextensive edema, & not in children younger than 2 years CategoryCategory Initial oral therapyInitial oral therapy Duration (days)Duration (days) AdultsAdults Ciprofloxacin, 500 mg bidCiprofloxacin, 500 mg bid 6060 or doxycycline, 100 mg bidor doxycycline, 100 mg bid ChildrenChildren Ciprofloxacin, 15 mg/kg q12hCiprofloxacin, 15 mg/kg q12h 6060 (not to exceed 1 g/d)(not to exceed 1 g/d) or doxycycline: >8 y o, >45 kg,or doxycycline: >8 y o, >45 kg, 100 mg q12h; all other children,100 mg q12h; all other children, 2.2 mg/kg q12h2.2 mg/kg q12h PregnantPregnant Ciprofloxacin, 500 mg bid (preferred)Ciprofloxacin, 500 mg bid (preferred) 6060 or doxycycline, 100 mg bidor doxycycline, 100 mg bid Immunocomp SameImmunocomp Same 6060
  • 43. Treatment of cutaneous anthraxTreatment of cutaneous anthrax withwith systemic symptoms,systemic symptoms, extensive edema, involving the head or neck, or children <extensive edema, involving the head or neck, or children < than 2 yo (same as for inhalational anthrax)than 2 yo (same as for inhalational anthrax) CategoryCategory IV therapyIV therapy Duration (daysDuration (days)) AdultsAdults Ciprofloxacin, 400 mg q12h,Ciprofloxacin, 400 mg q12h, IV initially, oralIV initially, oral or doxycycline,100 mg q12h,or doxycycline,100 mg q12h, when stable, 60 dayswhen stable, 60 days and 1-2 additional agentsand 1-2 additional agents Children Ciprofloxacin, 10 mg/kg q12hChildren Ciprofloxacin, 10 mg/kg q12h IV initially, oralIV initially, oral (not to exceed 1 g/d)| or(not to exceed 1 g/d)| or when stable, 60 dayswhen stable, 60 days doxycycline: >8 y old and >45 kg,doxycycline: >8 y old and >45 kg, 100 mg q12h; all other, 2.2 mg/kg100 mg q12h; all other, 2.2 mg/kg q12h and 1-2 additional agentsq12h and 1-2 additional agents Pregnant & Same as for nonpregnantPregnant & Same as for nonpregnant SameSame ImmunocomImmunocom and immunocompetent adultsand immunocompetent adults & children& children
  • 44. Spider bites: Usually painful  Usually painfulUsually painful  Bites from spiders of theBites from spiders of the genusgenus LoxocelesLoxoceles begin as palebegin as pale ecchymotic lesions thatecchymotic lesions that rapidly turn purple.rapidly turn purple.  Lesions may ulcerate andLesions may ulcerate and develop necrotic centersdevelop necrotic centers  Borders are irregularBorders are irregular,, ill-ill- defineddefined andand withoutwithout thethe significant surroundingsignificant surrounding edemaedema..
  • 45. Spider bites
  • 46. Plague  BoubonBoubon is Greek for groinis Greek for groin  Y. Pestis, 200 million deaths in historyY. Pestis, 200 million deaths in history http://www.emedicine.com/derm/topic905.htm#target11
  • 47. Plague  Gram neg non–spore-forming coccobacillusGram neg non–spore-forming coccobacillus http://www.emedicine.com/derm/topic905.htm#target11
  • 48. Plague  TenderTender, erythematous, erythematous lymphadenopathylymphadenopathy  Most cases involve bubonic plagueMost cases involve bubonic plague  Tx with streptomycin, gentamicin,Tx with streptomycin, gentamicin, tetracycline & doxycyclinetetracycline & doxycycline
  • 49. Plague  In bloodstream causes septicemiaIn bloodstream causes septicemia
  • 50. Tularemia  6 clinical forms:6 clinical forms:  ulceroglandular, glandular, oropharyngeal or gastrointestinal,ulceroglandular, glandular, oropharyngeal or gastrointestinal, typhoidal, septicemic, and pulmonarytyphoidal, septicemic, and pulmonary  Sudden onset of:Sudden onset of:  Fever, chills, headache, generalized myalgiasFever, chills, headache, generalized myalgias and arthralgiasand arthralgias  Incubation 2-10 daysIncubation 2-10 days  Ulcer generally seen at bite or inoculation siteUlcer generally seen at bite or inoculation site
  • 51. Tularemia  PainfulPainful,, pruriticpruritic, ulcer w/, ulcer w/ RAISEDRAISED bordersborders
  • 52. Tularemia  Ulcero-Ulcero- glandularglandular 80%80%
  • 53. Tularemia  In ‘50s and ‘60s, the U.S. made biologicIn ‘50s and ‘60s, the U.S. made biologic weapons containing tularemiaweapons containing tularemia  Streptomycin and tetracyclines are drugs ofStreptomycin and tetracyclines are drugs of choicechoice
  • 54. Meliodiosis  Whitmore’s diseaseWhitmore’s disease  Infectious disease caused byInfectious disease caused by BurkholderiaBurkholderia pseudomalleipseudomallei  Endemic in SE Asia andEndemic in SE Asia and northern Australianorthern Australia  Common causative agent ofCommon causative agent of community-acquiredcommunity-acquired septicemiasepticemia (Tran, Clinical & Experimental Dermatology, 2002)
  • 55. Meliodiosis
  • 56. Glanders  An infectious disease causedAn infectious disease caused by bacteriumby bacterium Burkholderia mallei, alsoBurkholderia mallei, also called “farcy”called “farcy”  Primarily affects horsesPrimarily affects horses  Cutaneous via cut or scratchCutaneous via cut or scratch in the skin, with ulcerationin the skin, with ulceration and pus 1-5 days at siteand pus 1-5 days at site  No cases in U.S. > 60 yearsNo cases in U.S. > 60 years
  • 57. Mustard Gas  Odor/taste (mustard,Odor/taste (mustard, garlic, onion), & colorgarlic, onion), & color (tan to brown to yellow)(tan to brown to yellow)  Oily liquidOily liquid is DNAis DNA alkylatingalkylating  Absorbed within minutesAbsorbed within minutes  Symptoms begin 2-24Symptoms begin 2-24 hours laterhours later  SkinSkin erythemaerythema followedfollowed byby vesiclesvesicles
  • 58. Mustard Gas
  • 59. Mustard Gas  EyesEyes develop conjunctivitisdevelop conjunctivitis  PulmonaryPulmonary symptoms- hoarsenesssymptoms- hoarseness  Death rate during World War I: 3%Death rate during World War I: 3%  Decontaminate w/ 0.5% hypochloriteDecontaminate w/ 0.5% hypochlorite (1/10 bleach to water)(1/10 bleach to water)
  • 60. Smallpox  Classic generalized exanthemClassic generalized exanthem  Latin word for “spotted” referring to raisedLatin word for “spotted” referring to raised bumps on the face and bodybumps on the face and body http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp
  • 61. Smallpox  Rash, high fever & mortality rate 30%Rash, high fever & mortality rate 30%  Last natural case Somalia in 1977Last natural case Somalia in 1977
  • 62. Smallpox (Days 3, 5, 7)
  • 63. Smallpox  Exanthem fromExanthem from vaccinationvaccination  1/100,0001/100,000  Vaccinia rash orVaccinia rash or outbreak of soresoutbreak of sores  GeneralizedGeneralized vacciniavaccinia  ErythemaErythema multiformemultiforme http://www.bt.cdc.gov/agent/smallpox/
  • 64. Smallpox  Exanthem fromExanthem from vaccinationvaccination  1/100,0001/100,000  Vaccinia rash orVaccinia rash or outbreak ofoutbreak of soressores  GeneralizedGeneralized vacciniavaccinia  ErythemaErythema multiformemultiforme
  • 65. Smallpox  Exanthem fromExanthem from vaccinationvaccination  1/100,0001/100,000  Vaccinia rash orVaccinia rash or outbreak of soresoutbreak of sores  GeneralizedGeneralized vacciniavaccinia  ErythemaErythema multiformemultiforme
  • 66. Smallpox  FromFrom VaccinationVaccination  1/50,0001/50,000  EczemaEczema vaccinatumvaccinatum  ProgressiveProgressive vacciniavaccinia  PostvaccinalPostvaccinal encephalitisencephalitis
  • 67. Smallpox  FromFrom VaccinationVaccination  1/50,0001/50,000  EczemaEczema vaccinatumvaccinatum  ProgressiveProgressive vacciniavaccinia  PostvaccinePostvaccine encephalitisencephalitis
  • 68. Monkeypox Virus
  • 69. Monkeypox Virus
  • 70. References  Carucci JA, McGovern TW, Norton AS. Cutaneous anthraxCarucci JA, McGovern TW, Norton AS. Cutaneous anthrax management algorithm. J Am Acad Dermatol 2001; online at:management algorithm. J Am Acad Dermatol 2001; online at: http://www.eblue.org/scripts/om.dll/serve?http://www.eblue.org/scripts/om.dll/serve? action=searchDB&searchDBfor=art&artType=fullfree&id=a121613action=searchDB&searchDBfor=art&artType=fullfree&id=a121613  Update: Investigation of bioterrorism-related anthrax and interimUpdate: Investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy,guidelines for exposure management and antimicrobial therapy, October 2001. MMWR Morb Mortal Wkly Rep 2001;50:909-19.October 2001. MMWR Morb Mortal Wkly Rep 2001;50:909-19. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5042a1.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5042a1.htm  Dixon TC, Meselson M, Guillemin J, Hanna PC. Anthrax. N Engl JDixon TC, Meselson M, Guillemin J, Hanna PC. Anthrax. N Engl J Med 1999;341:815-26.Med 1999;341:815-26. http://content.nejm.org/cgi/content/fall/341/11/815http://content.nejm.org/cgi/content/fall/341/11/815  Inglesby TV, Henderson DA, Bartlett JT, Ascher MS, Eitzen E,Inglesby TV, Henderson DA, Bartlett JT, Ascher MS, Eitzen E, Friedlander AM, et al. Anthrax as a biological weapon: medical andFriedlander AM, et al. Anthrax as a biological weapon: medical and public health management. Working Group on Civilian Biodefense.public health management. Working Group on Civilian Biodefense. JAMA 1999;281:1735-45.JAMA 1999;281:1735-45. http://jama.amaassn.org/issues/v281n18/ffull/jst80027.htmlhttp://jama.amaassn.org/issues/v281n18/ffull/jst80027.html
  • 71. Thank you.

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