Form CDPH8575 "Spotted Fever Rickettsioses Case Report" - California

What Is Form CDPH8575?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2013;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CDPH8575 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8575 "Spotted Fever Rickettsioses Case Report" - California

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State of California—Health and Human Services Agency
Local ID Number ___________________________
California Department of Public Health
Center for Infectious Diseases
(Please use the same ID Number on the preliminary
Division of Communicable Disease Control
and final reports to allow linkage to the same case.)
Infectious Diseases Branch
Surveillance and Statistics Section
Report Status (check one)
MS 7306, P.O. Box 997377
 Preliminary
 Final
Sacramento, CA 95899-7377
SPOTTED FEVER RICKETTSIOSES
CASE REPORT
Check one:
  Rocky Mountain spotted fever (Rickettsia rickettsii)
  Rickettsia philipii (strain 364D)
  Other spotted fever rickettsiosis (including Rickettsia parkeri, etc.)
This form should be completed only for cases of Rocky Mountain spotted fever and other spotted fever rickettsioses. Ehrlichiosis and
anaplasmosis cases should be reported on the Ehrlichiosis/Anaplasmosis Case Report form. Cases of typhus and other non-spotted
fever rickettsioses should be reported on the Typhus and Other Non-Spotted Fever Rickettsioses Case Report form.
PATIENT INFORMATION
Primary Language
Last Name
First Name
Middle Name
Suffix
 English
 Spanish
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
 Years
 Other:_____________________
 Months
 Days
Ethnicity (check one)
Address Number & Street - Residence
Apartment / Unit Number
 Hispanic / Latino
 Non-Hispanic / Non-Latino
 Unk
City / Town
State
Zip Code
Race*
(check all that apply, race descriptions on page 8)
Census Tract
County of Residence
Country of Residence
 African-American / Black
 American Indian or Alaska Native
Country of Birth
If not U.S. Born - Date of Arrival in U.S. (mm/dd/yyyy)
 Asian (check all that apply)
 Asian Indian
 Japanese
 Cambodian
 Korean
Home Telephone
Cellular Phone / Pager
Work / School Telephone
 Chinese
 Laotian
 Filipino
 Thai
E-mail Address
Other Electronic Contact Information
 Hmong
 Vietnamese
 Other:_____________________
Work / School Location
Work / School Contact
 Pacific Islander (check all that apply)
 Native Hawaiian
 Samoan
Gender
 Guamanian
 Male
 Female
 Other: _______________________________
 Other:_____________________
 White
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
 Yes
 No
 Unk
 Other:____________________
 Unk
Medical Record Number
Patient’s Parent/Guardian Name
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 6)
Other Describe/Specify
The response to this item should be based on the
patient’s self-identity or self-reporting. Therefore,
patients should be offered the option of selecting
Occupation (see list on page 6)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
CDPH 8575 (revised 2/13)
Page 1 of 6
State of California—Health and Human Services Agency
Local ID Number ___________________________
California Department of Public Health
Center for Infectious Diseases
(Please use the same ID Number on the preliminary
Division of Communicable Disease Control
and final reports to allow linkage to the same case.)
Infectious Diseases Branch
Surveillance and Statistics Section
Report Status (check one)
MS 7306, P.O. Box 997377
 Preliminary
 Final
Sacramento, CA 95899-7377
SPOTTED FEVER RICKETTSIOSES
CASE REPORT
Check one:
  Rocky Mountain spotted fever (Rickettsia rickettsii)
  Rickettsia philipii (strain 364D)
  Other spotted fever rickettsiosis (including Rickettsia parkeri, etc.)
This form should be completed only for cases of Rocky Mountain spotted fever and other spotted fever rickettsioses. Ehrlichiosis and
anaplasmosis cases should be reported on the Ehrlichiosis/Anaplasmosis Case Report form. Cases of typhus and other non-spotted
fever rickettsioses should be reported on the Typhus and Other Non-Spotted Fever Rickettsioses Case Report form.
PATIENT INFORMATION
Primary Language
Last Name
First Name
Middle Name
Suffix
 English
 Spanish
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
 Years
 Other:_____________________
 Months
 Days
Ethnicity (check one)
Address Number & Street - Residence
Apartment / Unit Number
 Hispanic / Latino
 Non-Hispanic / Non-Latino
 Unk
City / Town
State
Zip Code
Race*
(check all that apply, race descriptions on page 8)
Census Tract
County of Residence
Country of Residence
 African-American / Black
 American Indian or Alaska Native
Country of Birth
If not U.S. Born - Date of Arrival in U.S. (mm/dd/yyyy)
 Asian (check all that apply)
 Asian Indian
 Japanese
 Cambodian
 Korean
Home Telephone
Cellular Phone / Pager
Work / School Telephone
 Chinese
 Laotian
 Filipino
 Thai
E-mail Address
Other Electronic Contact Information
 Hmong
 Vietnamese
 Other:_____________________
Work / School Location
Work / School Contact
 Pacific Islander (check all that apply)
 Native Hawaiian
 Samoan
Gender
 Guamanian
 Male
 Female
 Other: _______________________________
 Other:_____________________
 White
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
 Yes
 No
 Unk
 Other:____________________
 Unk
Medical Record Number
Patient’s Parent/Guardian Name
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 6)
Other Describe/Specify
The response to this item should be based on the
patient’s self-identity or self-reporting. Therefore,
patients should be offered the option of selecting
Occupation (see list on page 6)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
CDPH 8575 (revised 2/13)
Page 1 of 6
California Department of Public Health
SPOTTED FEVER RICKETTSIOSES CASE REPORT
First three letters of
patient’s last name:
SIGNS AND SYMPTOMS
Symptomatic?
Onset Date (mm/dd/yyyy)
Date First Sought Medical Care (mm/dd/yyyy)
 Yes
 No
 Unk
Signs and Symptoms
Yes
No
Unk
If Yes, Specify as Noted
Highest temperature (specify °F/°C)
Fever
Chills
Sweats
Headache
Muscle pain
Joint(s)
Joint pain
Eye pain
Abdominal pain
Nausea or vomiting
Diarrhea
Location / size / appearance
Rash or other cutaneous lesion
Cough
Date measured (mm/dd/yyyy)
Systolic / Diastolic
Hypotension
Other signs / symptoms (specify)
HOSPITALIZATION
Did patient visit emergency room for illness?
Was patient hospitalized?
If Yes, how many total hospital nights?
 Yes
 No
 Unk
 Yes
 No
 Unk
If there were any ER or hospital stays related to this illness, specify details below.
HOSPITALIZATION - DETAILS
Hospital Name 1
Street Address
Admit Date (mm/dd/yyyy)
City
Discharge / Transfer Date (mm/dd/yyyy)
State
Zip Code
Telephone Number
Medical Record Number
Discharge Diagnosis
Hospital Name 2
Street Address
Admit Date (mm/dd/yyyy)
City
Discharge / Transfer Date (mm/dd/yyyy)
State
Zip Code
Telephone Number
Medical Record Number
Discharge Diagnosis
OUTCOME
Outcome?
If Survived,
Date of Death (mm/dd/yyyy)
 Survived
 Died
 Unk
Survived as of ________________________________(mm/dd/yyyy)
CDPH 8575 (revised 2/13)
Page 2 of 6
California Department of Public Health
SPOTTED FEVER RICKETTSIOSES CASE REPORT
First three letters of
patient’s last name:
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY - SEROLOGY
Specimen Type 1
Collection Date (mm/dd/yyyy)
Type of Test
Antigen
Results
Laboratory Name
Telephone Number
Specimen Type 2
Collection Date (mm/dd/yyyy)
Type of Test
Antigen
Results
Laboratory Name
Telephone Number
LABORATORY RESULTS SUMMARY - OTHER
Hematology?
Collection Date (mm/dd/yyyy)
WBC
HCT
Hb
Platelets
 Yes
 No
 Unk
Serum chemistry?
Collection Date (mm/dd/yyyy)
ALT
AST
 Yes
 No
 Unk
Other laboratory diagnostics performed (e.g., PCR, buffy coat smear)?
If Yes, describe
 Yes
 No
 Unk
EPIDEMIOLOGIC INFORMATION
ANIMAL AND INSECT EXPOSURES
Observe any of the following at or around home?
Observe any of the following at place of employment?
 Dogs  Cats o Rodents  Opossums  Fleas  Ticks
 Dogs  Cats o Rodents  Opossums  Fleas  Ticks
  
Did patient recall any insect bites in the 10 days prior to illness?
If Yes, specify all locations, type of insect bite, and dates below.
 Yes
 No
 Unk
INSECT BITE HISTORY - DETAILS
Location (city, county, state, country)
Date of Insect Bite (mm/dd/yyyy)
Type of Insect Bite
Bite 1
 Flea  Other:_______________________
 Tick
Location (city, county, state, country)
Date of Insect Bite (mm/dd/yyyy)
Type of Insect Bite
Bite 2
 Flea  Other:_______________________
 Tick
TRAVEL HISTORY
Did patient travel out of county of residence during the incubation period ?
If Yes, specify all locations and dates in the Travel History - Details Table.
 Yes
 No
 Unk
TRAVEL HISTORY - DETAILS
Location (city, county, state, country)
Date Travel Started (mm/dd/yyyy)
Date Travel Ended (mm/dd/yyyy)
CDPH 8575 (revised 2/13)
Page 3 of 6
California Department of Public Health
SPOTTED FEVER RICKETTSIOSES CASE REPORT
First three letters of
patient’s last name:
NOTES / REMARKS
REPORTING AGENCY
Investigator Name
Local Health Jurisdiction
Telephone Number
Date (mm/dd/yyyy)
First Reported By
 Clinician  Laboratory  Other (specify):______________________
DISEASE CASE CLASSIFICATION
Case Classification (see case definition below)
 Confirmed
 Probable
 Suspected
STATE USE ONLY
State Case Classification
 Confirmed
 Probable
 Suspected
 Not a case
 Need additional information
CASE DEFINITION
SPOTTED FEVER RICKETTSIOSIS (2010)
CLINICAL DESCRIPTION
Spotted fever rickettsioses are a group of tickborne infections caused by some members of the genus Rickettsia. Rocky Mountain spotted fever (RMSF) is
an illness caused by Rickettsia rickettsii, a bacterial pathogen transmitted to humans through contact with ticks. Dermacentor species of ticks are most
commonly associated with infection, including Dermacentor variabilis (the American dog tick), Dermacentor andersoni (the Rocky Mountain wood tick), and
more recently Rhiphicephalus sanguineus (the brown dog tick). Disease onset averages one week following a tick bite. Age-specific illness is highest for
children and older adults. Illness is characterized by acute onset of fever, and may be accompanied by headache, malaise, myalgia, nausea/vomiting, or
neurologic signs; a macular or maculopapular rash appears 4-7 days following onset in many (~80%) patients, often present on the palms and soles. RMSF
may be fatal in as many as 20% of untreated cases, and severe, fulminant disease can occur. In addition to RMSF, human illness associated with other
spotted fever group Rickettsia species, including infection with Rickettsia parkeri (associated with Amblyomma maculatum ticks), has also been reported.
In these patients, clinical presentation appears similar to, but may be milder than, RMSF; the presence of an eschar at the site of tick attachment has been
reported for some other spotted fever rickettsioses.
CLINICAL EVIDENCE
Any reported fever and one or more of the following: rash, eschar, headache, myalgia, anemia, thrombocytopenia, or any hepatic transaminase elevation.
LABORATORY CRITERIA FOR DIAGNOSIS
The organism in the acute phase of illness is best detected by polymerase chain reaction (PCR) and immunohistochemical methods (IHC) in skin biopsy
specimens, and occasionally by PCR in appropriate whole blood specimens taken during the first week of illness, prior to antibiotic treatment. Serology can
also be employed for detection, however an antibody response may not be detectable in initial samples, and paired acute and convalescent samples are
essential for confirmation.
For the purposes of surveillance:
Laboratory confirmed:
• Serological evidence of a fourfold change in immunoglobulin G (IgG)-specific antibody titer reactive with Rickettsia rickettsii or other spotted fever
group antigen by indirect immunofluorescence assay (IFA) between paired serum specimens (one taken in the first week of illness and a second
2-4 weeks later), OR
• Detection of R. rickettsii or other spotted fever group DNA in a clinical specimen via amplification of a specific target by PCR assay, OR
• Demonstration of spotted fever group antigen in a biopsy or autopsy specimen by IHC, or
• Isolation of R. rickettsii or other spotted fever group rickettsia from a clinical specimen in cell culture.
(continued on page 5)
CDPH 8575 (revised 2/13)
Page 4 of 6
California Department of Public Health
SPOTTED FEVER RICKETTSIOSES CASE REPORT
CASE DEFINITION (continued)
LABORATORY CRITERIA FOR DIAGNOSIS (continued)
Laboratory supportive:
• Has serologic evidence of elevated IgG or IgM antibody reactive with R. rickettsii or other spotted fever group antigen by IFA, enzyme-linked
immunosorbent assay (ELISA), dot-ELISA, or latex agglutination.
Note: Acute specimens must be collected within 45 days of disease onset date. Current commercially available ELISA tests are not quantitative, cannot
be used to evaluate changes in antibody titer, and hence are not useful for serological confirmation. IgM tests are not strongly supported for use in
serodiagnosis of acute disease, as the response may not be specific for the agent (resulting in false positives) and the IgM response may be persistent.
Complement fixation (CF) tests and other older test methods are neither readily available nor commonly used. CDC uses in-house IFA IgG testing (cutoff
of ≥1:64), preferring simultaneous testing of paired specimens, and does not use IgM results for routine diagnostic testing.
EXPOSURE
Exposure is defined as having been in potential tick habitats within the past 14 days before onset of symptoms. Occupation should be recorded if relevant to
exposure. A history of a tick bite is not required.
CASE CLASSIFICATION
Suspected: A case with laboratory evidence of past or present infection but no clinical information available (e.g. a laboratory report).
Probable:
A clinically compatible case (meets clinical evidence criteria) that has supportive laboratory results.
Confirmed: A clinically compatible case (meets clinical evidence criteria) that is laboratory confirmed.
CDPH 8575 (revised 2/13)
Page 5 of 6