The Rash

Tonight, I had a patient with The Rash. At least, that was my first impression, then it took me a bit to recover. I was face to pustular face with a young man, and all the training pictures I’ve had screamed “Smallpox!” at me. After a thorough physical exam and history, I decided this wasn’t the case, that he probably just has the absolutely worst viral exanthem I’ve ever seen, but for a brief period of time I was really concerned. (For the reading docs: on steroids for “strep throat” along with cephalexin; rash started 5 days before, hands first then centripetal spread, has had chicken pox, has had the college immunizations, no mucosal or conjunctival lesions, lesions not painful, fever but no vomiting or diarrhea; reticular infiltrate on cxr, more on one side than another; admitted to ID in isolation).
As an Emergency Physician, we’re constantly being told that we’re the first ones who will see a Biologic(al) Warfare attack (and then only half-jokingly told that Infectious Disease will figure it out three days later). This has brought up to me my personal shortcomings in this area, most notably in the ‘who are my immediate diagnostic resources’ and ‘who ‘ya gonna call’. I now have the 24 hour pager number for Public Health for my county, and am working on the other.
Smallpox was an ages-old, horrendous infection, eradicated by man through far-sighted public health, and is now considered to be a major BW potential agent, as we’re now all non-immune (the smallpox immunization you got a long time ago was a weak antibody, and probably only lasted about 5 years). There is serious and significant debate about vaccinating US citizens against the virus, which I have been following, wondering if I wanted the immunization; tonight I made up my mind: I’m getting the immunizations, potential side effects and all. When they’re offered; you see, we have the vaccine but cannot decide who gets it, so for now nobody gets it.

Update: The Washington Post reports a change of heart in the administration; I may get immunized, if I can wait 2 years.