Download C - Emerging Infections Network

4/10/07
IDSA Emerging Infections Network
Report for ‘Diagnostic Approaches to Suspected Poxvirus Infections’ Query
Overall response rate: 212/1080 (19.6%) physicians responded from 2/20/07 to 3/27/07.
• Twenty-nine of these responses could not be linked with our member database, but are included
in the analyses below.
Not all respondents answered all questions, so totals for individual questions vary.
CASE 1: MONKEYPOX
Question 1. Which diagnostic procedures would you pursue?
• Clinical diagnosis alone (no labs)
8 (4%)
• Laboratory diagnostic procedures used
204 (96%)
Table shows [No. (% of 204)]
In-house/local
State/CDC
academia
Swab for PCR/Culture
61 (30%)
140 (69%)
Biopsy for histopath/EM
99 (49%)
68 (33%)
Blood for serology
37 (18%)
106 (52%)
Commercial
reference lab
25 (12%)
8 (4%)
36 (18%)
Question 2: During patient evaluation, what precautionary measures would you take?
Routine precautions alone by 17 (8%)
Contact precautions alone by 45 (21%)
Droplet transmission precautions alone by 11 (5%)
Airborne transmission precautions alone by 32 (15%)
Droplet + Airborne by 1 (0.5%)
Contact + Airborne by 32 (15%)
Contact + Droplet by 14 (7%)
Routine + Airborne by 1 (0.5%)
Routine + Contact by 12 (6%)
Contact + Droplet + Airborne by 11 (5%)
Routine + Droplet + Airborne by 1 (0.5%)
Routine + Contact + Airborne by 12 (6%)
Routine + Contact + Droplet by 8 (4%)
Routine + Contact + Droplet + Airborne by 12 (6%)
[CDC recommendations for possible monkeypox virus infection (or other systemic orthopox infections):
‘A combination of Standard, Contact, and Droplet Precautions should be applied in all healthcare settings.’]
[The majority of respondents correctly answered either droplet or airborne as the highest precaution,
but almost 40% would use a lower level of precautions than appropriate.]
Question 3: Given your suspicion as to the cause of this patient’s illness, which of the following
agencies would be your first point of contact?
None by 5 (2%)
Local infection control by 29 (14%)
Both correct answers
State/local health department by 127 (60%)
CDC by 27 (13%)
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Law enforcement by 3 (1%)
Not sure by 19 (9%)
Other (not specified) by 1 (0.5%)
[Monkeypox is not a nationally notifiable infectious disease in the United States. State reporting
requirements for monkeypox vary; however, reporting under the “rare & exotic disease”
category should proceed. Local and state health departments are always a good starting point
for dialog about communicable disease diagnostics and infection control.
CSTE website for state epidemiologists: http://www.cste.org/members/state_and_territorial_epi.asp .]
CASE 2: ORF
Question 4. Which diagnostic procedures would you pursue?
• Clinical diagnosis alone (no labs)
55 (26%)
• Laboratory diagnostic procedures used
157 (74%)
Table shows [No. (% of 157)]
In-house/local
State/CDC
academia
Swab for PCR/Culture
70 (45%)
72 (46%)
Biopsy for histopath/EM
67 (43%)
23 (15%)
Blood for serology
17 (11%)
46 (29%)
Commercial
reference lab
26 (17%)
6 (4%)
28 (18%)
Question 5: During patient evaluation, what precautionary measures would you take?
Routine precautions alone by 50 (24%) – Correct answer
Contact precautions alone by 102 (49%)
Droplet transmission precautions alone by 4 (2%)
Airborne transmission precautions alone by 6 (3%)
Contact + Airborne by 4 (2%)
Contact + Droplet by 4 (2%)
Routine + Contact by 32 (15%)
Contact + Droplet + Airborne by 3 (1%)
Routine + Contact + Droplet by 1 (0.5%)
Routine + Contact + Droplet + Airborne by 2 (1%)
[CDC recommendations for possible orf virus infection: ‘Standard Precautions.’]
Question 6: Given your suspicion as to the cause of this patient’s illness, which of the following
agencies would be your first point of contact?
None by 59 (29)
Local infection control by 30 (15)
All correct answers
State/local health department by 101 (49)
CDC by 5 (2)
Law enforcement by 3 (1)
Not sure by 10 (5)
[Orf is not a national notifiable infectious disease in the United States. State reporting requirements
vary. Local and state health departments are always a good starting point for dialog about
communicable disease diagnostics and infection control.
CSTE website for state epidemiologists: http://www.cste.org/members/state_and_territorial_epi.asp .]
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7. Seen suspected cases? [No. (row %)]
No
Not sure Yes-1 case Yes, 2-4 cases Yes, ≥5 cases
Contact vaccinia
…in lab workers
197 (94)
2 (1)
8 (4)
2 (1)
0
…in close contacts of vaccinees 185 (89)
3 (1)
10 (5)
7 (3)
2 (1)
…associated with oral rabies
207
0
0
0
0
vaccine
(100)
Orf
150 (73)
3 (1)
36 (18)
14 (7)
2 (1)
Pseudocowpoxvirus infection
197 (96)
4 (2)
3 (1)
2 (1)
0
(milker’s nodule)
Sealpox
205 (98)
0
3 (1)
1 (0.5)
0
Monkeypox
191 (91)
5 (2)
7 (3)
5 (2)
1 (0.5)
Tanapox
205
0
0
0
0
(100)
Molluscum contagiosum
7 (3)
0
8 (4)
38 (18)
158 (75)
Other poxvirus infections*
152 (85)
7 (4)
4 (2)
4 (2)
12 (7)
*Specified as: Chickenpox/varicella by 15, Vaccinia by 5, Rickettsialpox (nonviral) by 1,
Smallpox by 2, Canarypox by 1, Herpes simplex 1 and 2 by 1.
8. Patient criteria deemed important in determining whether smallpox/monkeypox should be
considered:
‘Travel’ or ‘travel history’ by 107 (50%)
‘Exposure history’ or ‘epidemiology’ by 75 (36)
Exposure history with multiple specific items listed by 9 (4)
‘Vaccination’ or ‘immunization history’ (sometimes including history of varicella) by 61 (29)
‘Distribution of lesions/rash’ by 55 (26)
‘Exposure history to animals’ or ‘contact with lab animals’ by 53 (25)
‘Stage of rash’ or ‘are lesions all at same stage’ by 50 (24)
‘Occupation’ (sometimes including specific jobs, e.g., lab researcher) by 44 (21)
‘Age’ by 31 (15)
‘Contact history’ or ‘exposure to sick contacts’ by 27 (13)
Characteristics of the lesions (e.g., superficial, size, morphology, pustular) by 27 (13)
‘Toxicity’ or ‘systemic illness’ by 26 (12)
‘Underlying immune status’ or ‘immunosuppressed’ by 15 (7)
‘VZV history’ or ‘varicella status’ or ‘varicella serology results’ by 13 (6)
Combination of lesion appearance and stage and size by 13 (6)
‘Prodrome’ or ‘incubation’ or ‘prodrome relative to rash’ by 9 (4)
Travel and exposure history (listed together) by 9 (4)
‘Known outbreaks’ or ‘other patients with known poxvirus infection’ by 9 (4)
‘Signs and symptoms’ by 8 (4)
‘Geography’ or ‘location’ by 7 (3)
‘History’ by 6 (3)
‘Lymphadenopathy’ by 4 (2)
‘Medical history’ by 4 (2)
‘Fever’ by 4 (2)
‘Physical exam features’ by 3 (1)
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‘Epidemiologic risk factors’ by 3 (1)
‘Initial lab results’ or ‘biopsy’ by 2 (1)
‘Work, hobby, exposure hx (people, animal contacts’ by 2 (1)
Mentioned by 1 member each: ‘None come to mind’, ‘animal contact & ill human contacts’, ‘Common
things happen commonly’, ‘Large vesicles on finger could be paronychia. So not culturing Strep
or Staph’, ‘Intel on world terrorist activity’, ‘Drug exposure hx (drug rash)’,
‘Smallpox/monkeypox serology’ ‘Culture’.
[The protocol for evaluating patients for smallpox can be viewed as a poster at:
http://www.bt.cdc.gov/agent/smallpox/diagnosis/pdf/spox-poster-full.pdf . The CDC provides
information on monkeypox at: http://www.cdc.gov/ncidod/monkeypox/index.htm .]
9. Additional resources used to answer this query:
‘None’ (sometimes with an additional comment like ‘Now I know my level of ignorance’ or ‘my brain’
or ‘40 years experience’ or ‘probably should have’) by 146
Mandell, Douglas & Bennett’s Principles and Practice of Infectious Diseases by 11
CDC website by 7
AAP Red Book by 1
Hunter’s Tropical Medicine edited by Strickland by 2
UpToDate or eMedicine by 4
Google by 1
Krugman’s Infectious Diseases of Children by 1
Articles in NEJM, MMWR and Emerging Infectious Diseases, mentioned by 1 each
‘ID textbook’ by 2
‘Personal files’ by 1
Current Diagnosis and Treatment in Infectious Diseases by Wilson by 1
Comments about poxviruses or this survey:
Diagnostic Issues
• 1. Would be interesting to know if hospital has a policy dealing with diagnosis and isolation of
exotic diseases (my hospital has such a policy). 2. Would be interesting to know if hospitals
have policy how to collect samples and where to send them. 3. Do hospitals have a group of
vaccinia immune persons who could care for patients with disseminated vaccinia or
monkeypox?
• I was the physician who managed the first Monkeypox identified in Wisconsin. Electron
Microscopy was the test that started us on the right track.
• The commercial labs are useless for poxvirus identification. My case of vaccinia (lab worker)
was identified as varicella on the basis of cell culture histopathology; the state id's it. The
commercial labs should be required to be better at IDs.
• Would like to know more about sources for testing biopsies and serology.
• CDC has nice slide set of differential dx chickenpox vs smallpox. Case1 isolation until
smallpox/varicella ruled out. Also Hlth Dept of San Diego has coordinated network.
• Are there any reliable PCR methods to diagnose poxviruses in academic or commercial labs?
• If this were a real case coming to me, I would likely spend an hour on Up-To-Date, on PubMed,
sending phone pictures to colleagues for help, etc. I would then spend time working with lab
resource person to develop list of appropriate tests. Do you have a list of tests for such
patients? I'll file it for future reference.
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4/10/07
• I don't know off the top of my head what labs are available for pox virus infections. I hope I
would recognize them in the differential, and I would access references and call our lab/state
health dept for help re: what specimens to obtain
Differential Diagnoses
• don't forget disseminated HSV and HZV
• 1 case with concern for monkeypox was in fact severe disseminated varicella in AIDS pt in
Rwanda
• I have treated 3 adults with disseminated vesiculopustular eruptions in the past 3-4 years. All
with chickenpox (2 pregnant). Proper infection control measures and consideration of alternate
diagnosis (ie poxvirus) were slow to take place. Continued first responder and ER education
campaigns seem prudent.
• I would like to comment that tularemia produces vesicle that may be very similar in appearance
to varicella and even to the photo in case number 1. I have seen several cases of tularemia in
children misdiagnosed as varicella or herpes virus infection.
• Other considerations include herpetic whitlow, anthrax, ecthyma, burns
• Orf patients generally look well.
• We had a case of what turned out to be varicella in an adult who had just arrived on a flight from
Asia with a high fever.
General Comments
• Frankly, I am not clinically familiar with these, but I would be concerned if someone were to
present with any disseminated vesiculo-pustular eruption
• Haven't thought about this in a while (since the post 9/11 emphasis on bioterrorism). This should
prompt me to refresh myself on this topic. Life is busy!
• helpful exercise!
• I am familiar with molluscum and teach about smallpox but am not familiar with most others
except by name. I would do a literature search before seeing the patient.
• never seen one except in the textbook
• nice survey.
• You did a fabulous job on the images.
• I am in Columbus, OH where we have Batelle which has BSL-3 labs. Only when we have
Batelle workers do we generally get concerned.
• I don't think my local health department would have expertise on this issue. They would
probably just refer me on to the state or CDC.
• I don't think small pox is a real threat rather a political issue. It is never in my DD.
• I saw a case of myopericarditis in a soldier after smallpox vaccination recently.
• The first pt should have monkeypox, the second orf, neither of which requires isolation. I would
probably still isolate until other diseases (chickenpox) are ruled out.
• No resources used - the point of these surveys was always to answer quickly, not to try to
research the correct answer.
• This seems more like a series of sample board questions than a query. I respectfully decline to
respond.
• absurd waste of my time!
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