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Letter
Generalized Vaccinia 2 Days
after Smallpox Revaccination
James R. Miller,* Nick M. Cirino,* and Edward F. Philbin†
*New York State Department of Health, Albany, New York, USA; and †Albany
Medical College, Albany, New York, USA
Suggested citation
for this article: Miller
JR, Cirino NM, Philbin EF. Generalized vaccinia 2 days after smallpox
revaccination. Emerg Infect Dis [serial online] 2003 Dec [date cited].
Available from: URL: http://www.cdc.gov/ncidod/EID/vol9no12/03-0592.htm
To the Editor: Hospital and public health personnel are currently
receiving smallpox vaccination in a national effort to increase preparedness
for a possible deliberate release of smallpox (1). Generalized
vaccinia (GV) is a typically self-limited adverse event following vaccination
(incidence 23.4–238.2 cases per million primary vaccinees and 1.2–10.8
cases per million revaccinees) (2,3).
We report the clinical course and laboratory diagnosis of GV in a 37-year-old
woman with a history of at least one uncomplicated childhood inoculation
that left a vaccination scar. She was revaccinated on March 12, 2003.
Before revaccination, the patient reported no contraindications to vaccination
and denied any conditions that typically weaken the immune system (including
HIV/AIDS, leukemia, lymphoma, other cancers, radiation, chemotherapy,
organ transplant, posttransplant therapy, immunosuppressive medications,
severe autoimmune disease, and primary immune deficiency). The patient
also confirmed that she did not have a skin disease or a history of eczema
or atopic dermatitis, nor was she pregnant or allergic to a vaccine component.
On March 14, some 44 hours after vaccination, the patient reported headache,
chills, pruritus, chest pain (described as chest “heaviness”), recurrent
vomiting, and maculopapular lesions. The lesions, characterized by the
patient as “mosquito bites,” first appeared on the face, then the legs,
and then the trunk and upper extremities. Maximum oral temperature was
37.7°C. Over the next 4 days, approximately 30 pustules developed, several
of which began to drain. Nausea persisted, and the patient had a stiff
neck and recurring chest tightness, but physical examination, echocardiography,
electrocardiography, and chest radiography results were within normal
limits. By March 25, the patient’s lesions had all scabbed, the scabs
had fallen off, and she felt well enough to return to work. Pustular material
obtained on March 18 from two unroofed lesions on the shoulder (Figure)
and back tested positive at the Wadsworth Center-Axelrod Institute, New
York State Department of Health, for vaccinia virus DNA by a TaqMan (Applied
Biosystems, Foster City, CA) real-time polymerase chain reaction assay
provided by the Laboratory Response Network, Centers for Disease Control
and Prevention. The presence of orthopoxvirus was confirmed by electron
microscopy of lesion fluid.
This case is the first report of a laboratory-confirmed case of GV among
recent civilian vaccinees and is notable for the GV occurrence in a revaccinee.
GV was not reported among 132,656 military personnel recently revaccinated
(4). A single case of GV in a revaccinee among 38,514
recent civilian vaccinations (5) yields a ratio that
exceeds the rate in revaccinees observed in earlier reports and the difference
would be even greater if civilians who received primary vaccinations were
excluded.
This laboratory confirmation of GV demonstrates the potential of laboratory
testing to determine the cause of a post-vaccination rash. Possible cases
of GV in earlier surveillance efforts represented a mixed group of rashes,
some of uncertain etiology (6). This patient’s clinical
course is notable for the onset of GV 2 days after vaccination, as compared
to a mean of 9 days (range 1–20+) after (generally primary) vaccination
(2) and suggests that viremia can occur quickly after
vaccination.
Acknowledgments
We thank the patient,
as well as our colleagues Peter Drabkin, Christina Egan, Cassandra Kelly,
Debra Blog, Stephen Davis, William Samsonoff, Kimberly A. Musser, and
Jill Taylor.
References
- Wharton M, Strikas RA, Harpaz R, Rotz LD, Schwartz
B, Casey CG, et al. Recommendations
for using smallpox vaccine in a pre-event vaccination program. Supplemental
recommendations of the Advisory Committee on Immunization Practices
(ACIP) and the Healthcare Infection Control Practices Advisory Committee
(HICPAC). MMWR Recomm Rep 2003;52(No.RR-7):1–16.
- Lane JM, Ruben FL, Neff JM, Millar JD. Complications
of smallpox vaccination, 1968. N Engl J Med 1969;281:1201–8.
- Neff JM, Levine RH, Lane JM, Ager EA, Moore H, Rosenstein BJ, et
al. Complications
of smallpox vaccination United States 1963. II. Results obtained by
four statewide surveys. Pediatrics 1967;39:916–23.
- Grabenstein JD, Winkenwerder W. US
military smallpox vaccination program Experience. JAMA 2003;289:3278–82.
- Centers for Disease Control and Prevention. Smallpox Vaccination Program
Status by State [cited October 9, 2003]. Available from: URL: http://www.cdc.gov/od/oc/media/spvaccin.htm
- Neff JM, Lane JM, Pert JH, Moore R, Millar JD, Henderson DA. Complications
of smallpox vaccination. I. National survey in the United States, 1963.
N Engl J Med 1967;276:125–32.
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