Appendices

Rare
Not so common
Common
Low morbidity
Considerable morbidity
Serious

With the marked increase in international travel in the past decades among persons of all walks of life and all ages, it is necessary to ask patients with skin lesions where they have lived and traveled. This is particularly true for infectious skin disease or infectious systemic disease with skin manifestations. Website http://www.cdc.gov/travel/index.com gives information on diseases endemic in different parts of the world and on modes of acquisition. Links provide updated information relevant to diagnosis and thus appropriate treatment.

It is important to keep in mind that a patient with an infection acquired in one geographic location may undergo medical evaluation in another location where the infection is not endemic. Also, many infections may be rare or sporadically acquired in regions outside of endemic areas. An example is anthrax. Sporadic infection may be acquired in any geographic location by way of contact with imported contaminated animal products.

Equally important to note is that infections that require a specific vector for transmission have a distribution limited by the vector distribution. However, presence of the vector is not sufficient for disease to occur. For example, a mosquito competent to transmit dengue is found in many states in the southern United States. However, in recent years, transmission of dengue has been documented only rarely within the United States (Texas). Dengue, of course, is common in Asia and in other parts of the world.

The use of microbial pathogens as potential or actual weapons of terrorism and warfare dates from antiquity. In 2001, the anthrax attacks via the U.S. postal system resulted in 12 cutaneous and 10 inhalational cases of anthrax with 4 deaths. These caused a tremendous amount of anxiety, had an impact on the U.S. postal system, and led to a functional interruption of the activities of the legislative branch of the U.S. government. The Working Group for Civilian Biodefense has compiled a list of characteristics of biologic agents that can be used as bioweapons (Table B-1), and the U.S. Centers for Disease Control and Prevention (CDC) has classified potential biologic agents into three categories: A, B, and C (Table B-2). Category A agents are the priority pathogens requiring special attention for public health preparedness. Many of these lead to skin signs and symptoms and are therefore of major concern to dermatologists. The potential bioterrorism diseases with dermatologic manifestations are

• Anthrax
• Plague
• Smallpox
• Smallpox vaccine (vaccinia)
• Tularemia
• Viral hemorrhagic fevers

Table B-1 Key Features of Biologic Agents Used as Bioweapons

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