Vaccinia Necrosum after Smallpox Vaccination -- Michigan
On April 1, 1982, a 61-year-old female with a 2-year history of
severe recurrent genital herpes received a smallpox vaccination in
an
attempt to treat the disease. A persistent ulcer developed at the
vaccination site on her left arm. When, on May 5, she was
hospitalized for the first time for treatment of the vaccinia
necrosum, the ulcer measured 5x5 cm and yielded vaccinia virus on
culture. She had multiple erythematous perineal ulcers from which
herpes virus was recovered. Initial work-up revealed a hemoglobin
of
10.8, white blood cell count of 3,200/mm((3)), and normal
immunoelectrophoresis, but specific immunoglobulins were low (IgA =
10
mg/100 ml, IgG = 310, and IgM = 15). Intermediate PPD,
histoplasmin,
candida, and mumps skin tests were negative. During
hospitalization
from May 5 to May 15, she received vaccinia immune globulin (VIG),
oral thiosemicarbazone, and intravenous acyclovir. The perineal
ulcers cleared almost entirely and became negative on virus
culture.
However, the left arm ulcer was unchanged and continued to yield
vaccinia virus.
During follow-up as an outpatient, her arm ulcer gradually
enlarged. When the patient was rehospitalized from June 1 to June
14,
the arm ulcer measured approximately 8x7 cm, but she had no
evidence
of active genital herpes. During the second hospitalization, she
received VIG, oral thiosemicarbazone, and interferon--5 million
units
intramuscularly daily for 10 days. When she was discharged on June
14, her arm ulcer was approximately the same size as on admission,
and
a small lesion, believed to be a minor scratch or mosquito bite,
was
present on the left thigh. The patient was treated as an
outpatient
with intravenous interferon, 8 million units, three times a week.
The
left arm ulcer remained approximately the same size but showed some
signs of epithelialization. The lesion on her left thigh, however,
increased in size to an ulcer approximately 2.5 cm in diameter.
Both
the left arm and the left thigh ulcers repeatedly yielded vaccinia
virus. The patient was hospitalized for the third time from July
15
to July 20 for surgical removal of the ulcer on her left thigh and
retreatment with interferon, thiosemicarbazone, and VIG. In
addition,
she received four doses of transfer factor at the University of
Michigan--Ann Arbor. On last examination, the site of the leg
lesion
was still positive for vaccinia virus, and the arm lesion has shown
no
signs of improvement. Other modes of therapy being considered
include
surgical removal of the left-arm ulcer and treatment with thymosin.
Reported by M Gurwith, MD, Div of Infectious Diseases, Michigan
State
University, Dept of Medicine, East Lansing, NS Hayner, State
Epidemiologist, Michigan State Health Dept; International Health
Program Office, CDC.
Editorial Note
Editorial Note: To date, the patient has required three
hospitalizations for treatment of smallpox vaccination
complications
for which none of the usual treatments has been effective. The
severe
course of her herpes and vaccinia infections suggest underlying
immunosuppression or deficiency, but no specific immunologic defect
has been identified.
This case of vaccinia necrosum demonstrates the risk of using
smallpox vaccination, a treatment with no proven effectiveness, for
herpes disease (1). The Food and Drug Administration recently
published a warning to all physicians on the inappropriate use of
smallpox vaccination for herpes infection (2).
References
CDC. Smallpox Vaccine, MMWR 1980;29:417.
Inappropriate use of smallpox vaccine. FDA Drug Bulletin.
1982;12:12.
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