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Cutaneous Manifestations of Biological Warfare and Related Threat Agents

Thomas W. McGovern, MC, USA; George W. Christopher, MC, USAF; Edward M. Eitzen, MC, USA
Arch Dermatol. 1999;135(3):311-322. doi:10.1001/archderm.135.3.311.
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The specter of biological warfare (BW) looms large in the minds of many Americans. The US government has required that emergency response teams in more than 100 American cities be trained by the year 2001 to recognize and contain a BW attack. The US military is requiring active duty soldiers to receive immunization against anthrax. Dermatologists need not feel helpless in the face of a potential BW attack. Many potential agents have cutaneous manifestations that the trained eye of a dermatologist can recognize. Through early recognition of a BW attack, dermatologists can aid public health authorities in diagnosing the cause so that preventive and containment measures can be instituted to mitigate morbidity and mortality. This article reviews bacterial, viral, and toxin threat agents and emphasizes those that would have cutaneous manifestations following an aerosol attack. We conclude with clues that can help one recognize a biological attack.

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Figure 1.

Septicemic plague. Acral necrosis of nose, lips, and fingers and residual ecchymoses over both forearms in a patient recovering from bubonic plague that disseminated to blood and lungs. At one time, the patient's entire body was ecchymotic.114 (Photograph courtesy of Dr Jack Polard.)

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Figure 2.

"Ordinary" smallpox due to variola minor strain in an unvaccinated infant with (centrifugally distributed umbilicated pustules on day 7 of eruption. (Photograph courtesy of I. Arita.) 115

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Figure 3.

Boy with monkeypox in Democratic Republic of the Congo in 1996. Note the centrifugal distribution, as was typical for smallpox. (Photograph courtesy of William Clemm).

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Figure 4.

Ecchymoses encompassing left upper extremity 1 week after onset of Congo-Crimean hemorrhagic fever. Ecchymoses are often accompanied by hemorrhage in other locations: epistaxis, puncture sites, hematemesis, melena, and hematuria. No other hemorrhagic fever virus causes such severe bleeding abnormalities.116 (Photograph courtesy of Robert Swaneopoel, PhD, DTVM, MRCVS, National Institute of Virology, Sandringham, South Africa.)

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Figure 5.

Flavivirus infection with dengue virus, a patient with morbilliform exanthem with characteristic islands of sparing. (Photograph courtesy of Duane Gubler, ScD.)

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Figure 6.

Vaccinia necrosum (progressive vaccinia, vaccinia gangrenosum) represents progressive viral replication in an immunocompromised individual leading to inexorable tissue destruction.115 (Photograph ourtesy of C. H. Kempe.)

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