On March 7, 2007, the Chicago Department of Public Health and the University of Chicago Pediatric Infectious Disease Service and Infection Control Program notified CDC of a child with presumed eczema vaccinatum (EV), a life-threatening complication of vaccinia virus infection (1). This is the first reported EV case in the United States since 1988 (2). This report summarizes the epidemiologic and environmental investigations conducted by local, state, and federal public health authorities in Illinois and Indiana to determine the source of exposure and to identify and monitor other persons at risk for vaccinia virus infection. This case highlights the need for clinicians to maintain a high index of suspicion when evaluating recently vaccinated patients and their family members with vesiculopustular rash.
On January 26, 2007, an active-duty U.S. service member received a first-time smallpox vaccination in preparation for overseas military deployment. He had a history of childhood atopic dermatitis (i.e., eczema) and household contact with persons with eczema (two of his three children), both of which are contraindications to vaccination. His deployment was delayed, so he made an unplanned visit home to visit his family in Indiana during February 16-20. During this period, he spent time with his son, aged 28 months, who has severe eczema and a history of failure to thrive. The father reported his vaccination site had scabbed over and that the scab had separated before the visit home; he also reported that he kept the site bandaged during the visit. His routine activities with his son included hugging, wrestling, sleeping, and bathing.
On March 3, the child was taken to a small, local Indiana hospital because of a generalized papular, vesicular rash on the face, neck, and upper extremities. Because of the severity of the illness, he was transferred to a tertiary-care facility in Chicago later that day; contact precautions were implemented at the hospital. The child’s mother indicated that the boy had a fever 2 days before his hospital admission and weeping skin lesions as early as February 24. By March 7, the rash had progressed to umbilicated lesions with an erythematous base, primarily involving the child’s hands, forearms, neck, chest, face, and knees and encompassing 50% of his keratinized skin (Figure). On March 8, lesion specimens were analyzed at the Illinois Department of Public Health Laboratory (IDPHL) in Chicago by real-time polymerase chain reaction (PCR) orthopoxvirus generic assay and nonvariola orthopoxvirus assay. The results of the assays were positive for orthopoxvirus DNA, supporting the clinical diagnosis of EV. The diagnosis Of vaccinia was confirmed at CDC.
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During March 8-28, the child was treated with a combination of immunotherapy and antivirals targeting vaccinia virus. The initial treatment included Vaccinia Immune Globulin Intravenous (Human) (VIGIV); supportive care included sedation, intubation, and mechanical ventilation. Despite these interventions, on March 10, the child’s illness had progressed to hypothermia and hemodynamic instability requiring vasopressor support. Antiviral therapies with cidofovir and an investigational drug, ST-246 (SIGA Technologies, Corvallis, Oregon) under an Emergency Investigational Drug application, were initiated sequentially, * and additional infusions of VIGIV were administered. After approximately 1 week of interventions, the child began to improve. On April 19, the child was discharged home after 48 days of hospitalization; he has no known sequelae other than possible scarring of the skin.
Clinical specimens (e.g., lesion material, blood, and serum) collected during the patient’s hospitalization were analyzed in the CDC Poxvirus Laboratory. All specimens collected during the first 10 days of his hospitalization were positive for orthopoxvirus DNA using a real-time PCR assay. Before VIGIV administration, serum was positive for antiorthopoxvirus immunoglobulin M (IgM) and negative for immunoglobulin G (IgG) by enzyme-linked immunosorbent assay.
On March 6, the child’s third hospital day, hospital staff members noticed that the patient’s mother had approximately six vesicular lesions on her face; additional lesions subsequently developed on her right index finger and near her eyelid. The mother had a history of facial acne flare-ups and reported that she had rested her cheek on the child’s abdomen while he was being treated in the hospital. Lesion material was analyzed by IDPHL and found to contain orthopoxvirus DNA signatures. The mother was isolated voluntarily in the same room as her son; on March 10, she received VIGIV treatment. Within 72 hours of the initiation of VIGIV treatment, her lesions began to scab over. Evaluation of serum collected from the mother on March 8 indicated that she had not yet developed an antiorthopoxvirus humoral immune response (IgG and IgM negative).
The couple has two other children, one with a history of eczema. Both children left the family residence at the time of the child’s hospitalization and were cared for by their grand parents. Neither child had symptoms of vaccinia infection at the time of this report.
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