Photo Quiz Question – Q.003 – July 1, 2011
31-year-old white male, circa 1951, missionary to Nigeria
Illness started with fever and aching for 2-3 days, followed by development of blistering rash. Above image depicts rash a week into the illness.
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Actually, I changed the date and location to raise the question: is this smallpox?
Of the answers received, Jim H. is correct – this is chicken pox. It is often worse in an adult compared to a child.
Rich S. is also correct in that smallpox does start on the face and radiate outward. And as he points out, smallpox lesions do erupt in a single outbreak and thus should all be in a similar state of healing, unlike chicken pox which tends to erupt in waves over several days.
[Regarding other diagnoses suggested: bad cases of poison ivy that I've seen on the face are either more confluent (for example, from smoke exposure due to burning poison ivy) or streakier (as in plant exposure). Except in immune-compromised individuals, shingles follows the path of a single nerve, usually creating a band half-way around the torso. You shouldn't see a case of shingles that looks like this in an otherwise healthy person.]
KF’s comments on small pox are also correct: if this were smallpox, since the lesions do not all appear to be scabbed over, the patient would still be contagious and should be isolated with respiratory and contact precautions.
Since this is actually chicken pox and not all lesions are scabbed, he is still contagious and should be isolated from individuals who have never had either the disease or varicella vaccine. Anyone who has had shingles is immune to chicken pox. Patients older than age 50 are eligible to receive the shingles vaccine (but should wait a year after an outbreak if they’ve had a case of shingles).
The image below is a case of smallpox. (Public domain image from Wikipedia.)