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==Overview==
==Overview==
The physical findings of [[anthrax]] infection depend on the mode of anthrax exposure in the patient (cutaneous, ingestion, inhalation, injection). Common findings associated with [[cutaneous]] anthrax infection include [[fever]], [[tachycardia]], [[skin rash]] with formation of a typical [[scar]], [[edema]] and [[lymphadenopathy]]; with [[gastrointestinal]] anthrax infection include [[fever]], [[tachycardia]], [[mucosal]] [[ulcer]] and [[edema]] in case of [[oropharyngeal]] lesion and [[edema]] and [[pallor]] in more severe cases; with [[inhalation]] anthrax infection includes: [[fever]], [[tachycardia]], [[bradypnea]] in severe cases, [[pallor]], [[cyanosis]] and decreased [[heart]] and [[lung]] sounds in the presence of [[pleural effusion]]; and with anthrax infection due to injection include [[fever]], typical skin [[scar]] at the site of injection, [[edema]] and [[subcutaneous]] and/or muscular [[abscess]].


==Cutaneous Anthrax==
===Vitals===
====Temperature====
* A [[fever]] is rarely present<ref name="pmid12610093">{{cite journal| author=Spencer RC| title=Bacillus anthracis. | journal=J Clin Pathol | year= 2003 | volume= 56 | issue= 3 | pages= 182-7 | pmid=12610093 | doi= | pmc=PMC1769905 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12610093  }} </ref>


==Physical Examination==
====Pulse====
* [[Tachycardia]] is often present
====Blood Pressure====
* [[Hypotension]] may be present in severe systemic cases
===Skin===
* A [[rash]] is often present.
** The [[rash]] initially appears as a small [[papule]]. A ring of [[vesicles]] develops around the [[papule]], often with [[exudate]]. Between days 5 - 7, the initial [[papule]] ulcerates to form a typical [[scar]].
** Cutaneous lesions are single, but sometimes two or more lesions are present.
** Cutaneous lesions are seen on exposed unprotected regions of the body, mostly on the [[face]], [[neck]], [[hand]]s and [[wrist]]s.
* [[Edema]] may be present
* Regional [[lymphadenitis]] may be present
 
===Neck===
*[[Lymphadenopathy]] may be present, particularly if initial lesion is located near the neck
===Abdomen===
*[[Abdominal tenderness]] may be present, particularly if there is exuberant vomiting
===Extremities===
*[[Edema]] may be present, particularly around the site of the initial lesion
===Neurologic===
* The [[mental status]] may be altered in case of severe systemic anthrax


===Appearance of the Patient===
==Gastrointestinal Anthrax==
The appearance of the patients and physical exam will depend on the type of anthrax present in that patient.
===Vitals===
===Vitals===
====Temperature====
====Temperature====
*A [[fever]] is often present
* A [[fever]] is often present
*[[Hypothermia]] may be present
* [[Tachycardia]] is often present
====Blood Pressure====
* [[Hypotension]] may be present in severe systemic cases
====Respiratory Rate====
* [[Bradypnea]] may be present in severe cases


===Skin===
* [[Edema]] may be present, particularly in the [[neck]] region
* [[Pallor]] may be present in cases of systemic anthrax with [[shock]]
===Throat===
* The [[throat]] may be [[erythematous]] if the lesion is located on the [[oropharyngeal]] mucosa
* [[Exudate]] may be present if the lesion is located on [[oropharyngeal]] mucosa
* Tonsillar [[inflammation]] may be present if the lesion is located on [[oropharyngeal]] mucosa
===Neck===
* Painful [[lymph nodes]] may be present
* [[Edema]] may be present in [[oropharyngeal]] anthrax
===Abdomen===
* [[Abdominal distention]] may be present
* [[Abdominal tenderness]] may be present
===Extremities===
* [[Edema]] may be present
===Neurologic===
* The [[mental status]] may be altered in case of severe systemic anthrax
* [[Coma]] may be present
==Inhalation Anthrax==
===Vitals===
====Temperature====
* A [[fever]] is often present
* [[Tachycardia]] is often present
====Blood Pressure====
* [[Hypotension]] may be present in severe systemic cases
====Respiratory Rate====
* [[Bradypnea]] may be present in more severe cases
===Skin===
* [[Cyanosis]] may be present
===Neck===
* [[Edema]] may be present
* Regional [[lymphadenopathy]] may be present
===Auscultation===
* [[Heart]] and [[lung]] sounds may be decreased in the presence of [[pleural effusion]]
===Extremities===
* [[Cyanosis]] may be present
* [[Edema]] may be present
===Neurologic===
* The [[mental status]] may be altered in case of severe systemic anthrax
* [[Coma]] may be present
==Injection Anthrax==
===Vitals===
====Temperature====
* A [[fever]] is often present
====Pulse====
====Pulse====
=====Rate=====
* [[Tachycardia]] is often present
====Blood Pressure====
* [[Hypotension]] may be present in severe systemic cases
===Skin===
* A [[rash]] is often present. The [[rash]] initially appears as a group of small [[blisters]] located on the site of injection. Afterwards, a skin sore with black center replaces the [[blister]]s, surrounded by an area of [[edema]]
 
* Regional [[lymphadenitis]] may be present
* A nodular [[abscess]] is often palpated on the site where the drug was injected
 
===Neck===
*[[Lymphadenopathy]] may be present, particularly if the initial lesion is located in that region
 
===Abdomen===
*[[Abdominal tenderness]] may be present, particularly if there is exuberant vomiting
===Extremities===
*[[Edema]] may be present, particularly around the initial lesion
===Neurologic===
* The [[mental status]] may be altered in case of severe systemic anthrax


=====Cutaneous Anthrax=====
==Gallery==
<gallery>
Image:Cutaneous A1.png| Day 1 of development and resolution of uncomplicated cutaneous anthrax lesion.”<SMALL><SMALL>''[http://www.who.int/en//  Adapted from World Health Organization (WHO)]''<ref name="WHO">{{Cite web | title = World Health Organization | url = http://www.who.int/en/}}</ref></SMALL></SMALL>


Image:CutaneousA2.png| Day 2 - 3 of development and resolution of uncomplicated cutaneous anthrax lesion.”<SMALL><SMALL>''[http://www.who.int/en//  Adapted from World Health Organization (WHO)]''<ref name="WHO">{{Cite web | title = World Health Organization | url = http://www.who.int/en/}}</ref></SMALL></SMALL>


=====Gastrointestinal Anthrax=====
Image:CutaneousA3.png| Day 4 of development and resolution of uncomplicated cutaneous anthrax lesion.”<SMALL><SMALL>''[http://www.who.int/en//  Adapted from World Health Organization (WHO)]''<ref name="WHO">{{Cite web | title = World Health Organization | url = http://www.who.int/en/}}</ref></SMALL></SMALL>


Image:CutaneousA4.png| Day 6 of development and resolution of uncomplicated cutaneous anthrax lesion.”<SMALL><SMALL>''[http://www.who.int/en//  Adapted from World Health Organization (WHO)]''<ref name="WHO">{{Cite web | title = World Health Organization | url = http://www.who.int/en/}}</ref></SMALL></SMALL>


Image:CutaneousA5.png| Day 11 of development and resolution of uncomplicated cutaneous anthrax lesion.”<SMALL><SMALL>''[http://www.who.int/en//  Adapted from World Health Organization (WHO)]''<ref name="WHO">{{Cite web | title = World Health Organization | url = http://www.who.int/en/}}</ref></SMALL></SMALL>


=====Inhalation or Pulmonary Anthrax=====
Image:CutaenousA58.jpg| "Female patient shown here on the 24th day of a Bacillus anthracis infection involving her left eye.”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>


Image:CutaneousA59.jpg| Female patient shown here on the 5th day of a Bacillus anthracis infection involving her left eye.” <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>


Image:CutaneousA60.jpg| "Female patient shown here on the 5th day of a Bacillus anthracis infection involving her left eye.”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>


=====Injection Anthrax
Image:CutaneousA61.jpg| Symptoms of cutaneous anthrax due to B. anthracis.” <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>


Image:CutaneousA62.jpg| "Symptoms of cutaneous anthrax due to B. anthracis.”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>


=====Rhythm=====
Image:CutaneousA69.jpg| High magnification of 12,483X, this scanning electron micrograph (SEM) depicted spores from the Sterne strain of Bacillus anthracis bacteria.”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*The pulse is regular
*The pules is irregularly irregular
=====Strength=====
*The pulse may be weak
*The pulse may be bounding
*The pulse may be alternating in strength ([[pulsus alternans]])
*A [[paradoxical pulse]] may be present


=====Symmetry=====
Image:Milzbrand.jpg| "Anthrax lesion on the skin of the forearm caused by the bacterium Bacillus anthracis”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*The pulses may be asymmetric


====Blood Pressure====
Image:CutaneousA79.jpg| "Anthrax lesion on the neck”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*[[Hypotension]] may be present
 
*[[Hypertension]] may be present
Image:Anthrax-6.jpg| "Anthrax lesion on volar surface of right forearm”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*A [[wide pulse pressure]] may be present
 
*A [[narrow pulse pressure]] may be present
Image:CutaneousA106.jpg| "Anthrax, skin of left forearm”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>


====Respiratory Rate====
Image:CutaneousA107.jpg| "Anthrax, skin of right forearm, 4th day”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*[[Tachypnea]] may be present
*[[Bradypnea]] may be present
* [[Kussmaul respirations]] may be present


===Skin===
Image:CutaneousA109.jpg| "Anthrax, skin of face, 13th day”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*[[Cyanosis]] may be present
*[[Jaundice]] may be present
* A rash may be present
* [[Pallor]] may be present
* Lesions may be present


===Head===
Image:CutaneousA110.jpg| "Anthrax, skin of face, 11th day”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
* Abnormalities of the head/hair may include ___
* There may be evidence of trauma


===Eyes===
Image:CutaneousA111.jpg| "Anthrax, skin of face, 8th day”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*Icteric sclera may be present
* [[Nystagmus]] may be present.
* Extra-ocular movements may be abnormal
*Pupils may not react to light
*Ophthalmoscopic exam may be abnormal with findings of ___


===Ears===
Image:CutaneousA112.jpg| "Anthrax, skin of face, 6th day”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
* Hearing acuity may be reduced
*[[Weber test]] may be positive
*[[Rinne test]] may be positive
* There may be [[exudate]] from the ear canal
* There may be [[tenderness]] on movement of the pinnae


===Nose===
Image:CutaneousA113.jpg| "Anthrax, skin of face, 4th day”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
* Nares may be inflamed
* There may be [[epistaxis]]
* There may be [[purulent]] exudate from the nares
* There may be [[tenderness]] to percussion of the sinuses
* The nares may be congested


===Throat===
Image:CutaneousA114.jpg| "Anthrax, skin of right forearm, 7th day.”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
* The throat may be erythematous
* There may be [[exudate]] in the throat
* There may be [[petechiae]] seen in the throat
* There may be tonsillar inflammation


===Neck===
Image:CutaneousA115.jpg| "Anthrax, skin of right forearm, 5th day”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*[[Jugular venous pressure]] may be elevated
*[[Carotid bruits]] may be present
*[[Lymph nodes]] may be present
*[[Thyromegaly]] may be present
*[[Hepatojugular reflux]] may be present


===Lungs===
Image:CutaneousA116.jpg| "Anthrax, skin of right forearm, 12th day.”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*[[Pulmonary edema]] and [[rales]] may be present
*[[Wheezing]] may be present
*Consolidation may be present with reduced breath sounds auscultated
*[[Rales]] may be present
*[[Egophony]] may be present
* Chest movement may be assymetric


===Heart===
Image:CutaneousA118.jpg| "Cutaneous anthrax lesion on neck of man”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*A [[heave]] may be present
*A [[thrill]] may be present
*A [[friction rub]] may be pressent
====Auscultation====
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A [[systolic murmur]] best heard at the base may be present
*A [[systolic murmur]] best heard at the apex may be present
*A [[diastolic murmur]] may be present


===Abdomen===
Image:CutaneousA119.jpg| "Cutaneous anthrax, lesion on the left forearm”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*[[Abdominal distention]] may be present
*[[Abdominal tenderness]] may be present
*[[Rebound tenderness]] may be present
*An [[acute abdomen]] may be present
*An abdominal mass may be present
*Guarding may be present
*[[Hepatomegaly]] may be present
*[[Splenomegaly]] may be present
*Genitourinary exam if relevant


===Extremities===
Image:CutaneousA133.jpg| "Anthrax skin lesion on face of man. Cutaneous”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
*[[Clubbing]] may be present
*[[Cyanosis]] may be present
*[[Edema]] may be present


===Neurologic===
Image:CutaneousA134.jpg| "Anthrax skin lesion on neck of man. Cutaneous”<SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
* Mental status may be altered
</gallery>
* Glasgow coma scale is ___
* Clonus may be present
* Hyperactive reflexes may be present
* There are deficits in cranial nerves ___


==References==
==References==
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Latest revision as of 20:26, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

The physical findings of anthrax infection depend on the mode of anthrax exposure in the patient (cutaneous, ingestion, inhalation, injection). Common findings associated with cutaneous anthrax infection include fever, tachycardia, skin rash with formation of a typical scar, edema and lymphadenopathy; with gastrointestinal anthrax infection include fever, tachycardia, mucosal ulcer and edema in case of oropharyngeal lesion and edema and pallor in more severe cases; with inhalation anthrax infection includes: fever, tachycardia, bradypnea in severe cases, pallor, cyanosis and decreased heart and lung sounds in the presence of pleural effusion; and with anthrax infection due to injection include fever, typical skin scar at the site of injection, edema and subcutaneous and/or muscular abscess.

Cutaneous Anthrax

Vitals

Temperature

Pulse

Blood Pressure

Skin

  • A rash is often present.
    • The rash initially appears as a small papule. A ring of vesicles develops around the papule, often with exudate. Between days 5 - 7, the initial papule ulcerates to form a typical scar.
    • Cutaneous lesions are single, but sometimes two or more lesions are present.
    • Cutaneous lesions are seen on exposed unprotected regions of the body, mostly on the face, neck, hands and wrists.
  • Edema may be present
  • Regional lymphadenitis may be present

Neck

  • Lymphadenopathy may be present, particularly if initial lesion is located near the neck

Abdomen

Extremities

  • Edema may be present, particularly around the site of the initial lesion

Neurologic

  • The mental status may be altered in case of severe systemic anthrax

Gastrointestinal Anthrax

Vitals

Temperature

Blood Pressure

Respiratory Rate

Skin

  • Edema may be present, particularly in the neck region
  • Pallor may be present in cases of systemic anthrax with shock

Throat

Neck

Abdomen

Extremities

Neurologic

  • The mental status may be altered in case of severe systemic anthrax
  • Coma may be present

Inhalation Anthrax

Vitals

Temperature

Blood Pressure

Respiratory Rate

  • Bradypnea may be present in more severe cases

Skin

Neck

Auscultation

Extremities

Neurologic

  • The mental status may be altered in case of severe systemic anthrax
  • Coma may be present

Injection Anthrax

Vitals

Temperature

Pulse

Blood Pressure

Skin

  • A rash is often present. The rash initially appears as a group of small blisters located on the site of injection. Afterwards, a skin sore with black center replaces the blisters, surrounded by an area of edema
  • Regional lymphadenitis may be present
  • A nodular abscess is often palpated on the site where the drug was injected

Neck

  • Lymphadenopathy may be present, particularly if the initial lesion is located in that region

Abdomen

Extremities

  • Edema may be present, particularly around the initial lesion

Neurologic

  • The mental status may be altered in case of severe systemic anthrax

Gallery

References

  1. ↑ Spencer RC (2003). "Bacillus anthracis". J Clin Pathol. 56 (3): 182–7. PMC 1769905. PMID 12610093.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 "World Health Organization".
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.21 3.22 "Public Health Image Library (PHIL), Centers for Disease Control and Prevention".
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