BACKGROUND:To counter the possibility of smallpox being used as a biological weapon, in 2002 the US government restarted a smallpox vaccination campaign. Myopericarditis is a possible cardiac complication of smallpox vaccination. We report 2 cases of vaccine-associated myopericarditis in military recruits who were treated at our facility. Chest pain, shortness of breath, and electrocardiographic changes of pericarditis, with a recent history of smallpox vaccination, were useful in making the diagnosis of probable post-vaccinial myopericarditis. Nonsteroidal, anti-inflammatory drugs (NSAIDs) were used to manage myopericarditis. Both patients had complete resolution of symptoms and electrocardiographic changes and subsequently returned to active duty.

CONCLUSION:Myopericarditis should be suspected when patients with recent history of smallpox vaccination present with chest pain or shortness of breath. Nonsteroidal anti-inflammatory drugs are useful in the management of post-vaccinial myopericarditis.

Vaccinia of the vulva in a 32-year-old married woman is described. The vaccination was apparently due to a heteroinoculation from her husband during sexual contact. Clinically it presented as an indurated ulcer with a few isolated umbilicated vesicles and was associated with an acute biological false-positive serological reactions.

A thirty year old woman in whom an uncommon complication of smallpox vaccination developed is presented herein. In this case, virus was transmitted from the recently vaccinated child to the vulva and the vagina of the incompletely immune mother. The diagnosis was confirmed by a viral culture and a direct smear. The patient was treated intravenously with cytosine arabinoside (Cytosar) 3 mg/kg and was completely cured after seven days.

A patient with basal-cell epithelioma occurring in a smallpox vaccination site is reported. The association is probably not a chance occurrence.

A 52 year old housewife was vaccinated against smallpox at the age of 18, on her right deltoid area. At the age of 50 she noticed erythema and scaling on the vaccination scar and 2 years later a nodule appear that enlarged during the following 3 months. There was no history nor skin changes suggestive of significant sun exposure. The histological examination of an initial biopsy and of the subsequently excised lesion revealed a basal cell carcinoma of the solid type. The relevant literature was reviewed and discussed with emphasis on sex and age incidence, age and site of vaccination, free interval between inoculation and tumor appearance, coexistence or not of other sun induced neoplasias and precancerous lesions and other possibly relevant clinical and etiopathogenetic aspects.

BACKGROUND:Myocarditis is a recognized but rare complication of smallpox immunization. It typically presents within 30 days of immunization and on initial presentation shares many characteristics with acute coronary syndrome. Electrocardiogram findings, elevated cardiac enzymes, and undifferentiated chest pain require immediate implementation of therapy directed towards an acute coronary syndrome. In an austere environment, access to advanced care may be limited.

OBJECTIVES:Smallpox vaccine-mediated myocarditis may present, typically within 30 days of immunization, in such a fashion that it is impossible to distinguish from acute myocardial infarction. The purpose of this article is to alert the clinician to this problem and to provide information to assist in making a suitable diagnosis and disposition in the absence of an absolute diagnosis.

CASE REPORT:We present a case of smallpox vaccine-associated myocarditis in an American serviceman deployed in Iraq, and review the literature to determine management of these cases in an emergency setting.

CONCLUSIONS:This case serves to increase awareness of the association of vaccine-mediated myocarditis in the month after immunization, and the fact that it may present similar to infarction. If the clinical probability of myocarditis is greater than infarction, this will lead the clinician to different treatment modalities.

Two cases of conjugal contact transfer vaccinia are described. Each patient had intimate contact after their respective partners, active-duty military personnel, received the smallpox vaccination.

Three cases of cross-infection after smallpox vaccination are described, in two of which the outcome was fatal. Probably all occurred because simple precautions were not observed at the time of vaccination--for example, exclusion of contraindications and warnings about risks. If those countries still requiring evidence of vaccination for entry were to abolish this rule, however, the risk of cross-infection could be eliminated. Vaccinating a person with contraindications is justified only when exposure to smallpox has occurred.

On March 3, 2007, a 2-year-old boy was hospitalized with eczema vaccinatum. His two siblings, one with eczema, were subsequently removed from the home. Swabs of household items obtained on March 13th were analyzed for orthopoxvirus DNA signatures with real-time PCR. Virus culture was attempted on positive specimens. Eight of 25 household samples were positive by PCR for orthopoxvirus; of these, three yielded viable vaccinia virus in culture. Both siblings were found to have serologic evidence of orthopoxvirus exposure. These findings have implications for smallpox preparedness, especially in situations where some household members are not candidates for vaccination.

A previously healthy boy who had received varicella vaccine developed herpes zoster with meningitis. The vaccine strain recovered from scabs of 3 skin lesions had the wild-type allele at position 108111, a vaccine marker never previously associated with vaccine-associated adverse events. The vaccine strain from cerebrospinal fluid also contained mutations never previously observed at vaccine-associated single nucleotide polymorphisms that would alter amino acid sequences in ORF54 and ORF59. The presence of distinct strains in skin lesions and cerebrospinal fluid indicate that>1 variant strain may reactivate to cause herpes zoster.

The development of vaccines ushered in the most profound advancement in 20th century medicine, and have widely been regarded as the one of the most important scientific discovery in the history of mankind. However, vaccines are not without risk; reactions can range from injection site reactions to life-threatening anaphylaxis. Among the more serious vaccine-related sequela is myocarditis. Although myocarditis has been reported following many different vaccines, the smallpox vaccine has the strongest association. We report a case of a 36-year-old active duty service member presenting with progressive dyspnoea, substernal chest pain and lower extremity swelling 5 weeks after receiving the vaccinia vaccination. The aetiology of his acute decompensated heart failure was determined to be from myocarditis. Although the majority of cases of myocarditis resolve completely, some patients develop chronic heart failure and even death. Vaccine-associated myocarditis should always be on the differential for patients that exhibit cardiopulmonary symptoms after recent vaccinations.

A patient developed severe ocular vaccinia via autoinoculation after acquiring unrecognized contact-transmitted vaccinia from wrestling with vaccinated members of his unit. This case highlights both the need to reinforce infection-control measures among vaccinees and the need for providers to be familiar with the identification and treatment of cutaneous and ocular vaccinia infection.

On June 24, 2012, CDC notified Public Health Services, County of San Diego Health and Human Services Agency, of a suspected case of vaccinia virus infection transmitted by sexual contact. The case had been reported to CDC by an infectious disease specialist who had requested vaccinia immune globulin intravenous (VIGIV) (Cangene Corporation, Berwyn, Pennsylvania) for a patient with lesions suspicious for vaccinia. The patient reported two recent sexual contacts: one with a partner who recently had been vaccinated against smallpox and a later encounter with an unvaccinated partner. Infections resulting from secondary transmission of vaccinia virus from the smallpox vaccinee to the patient and subsequent tertiary transmission of the virus from the patient to the unvaccinated partner were confirmed by the County of San Diego Public Health Laboratory. The smallpox vaccine had been administered under the U.S. Department of Defense smallpox vaccination program. The vaccinee did not experience vaccine-associated complications; however, the secondary and tertiary patients were hospitalized and treated with VIGIV. No further transmission was known to have occurred. This report describes the epidemiology and clinical course of the secondary and tertiary cases and efforts to prevent further transmission to contacts.

BACKGROUND:We report the first confirmed case of eczema vaccinatum in the United States related to smallpox vaccination since routine vaccination was discontinued in 1972. A 28-month-old child with refractory atopic dermatitis developed eczema vaccinatum after exposure to his father, a member of the US military who had recently received smallpox vaccine. The father had a history of inactive eczema but reportedly reacted normally to the vaccine. The child's mother also developed contact vaccinia infection.

METHODS:Treatment of the child included vaccinia immune globulin administered intravenously, used for the first time in a pediatric patient; cidofovir, never previously used for human vaccinia infection; and ST-246, an investigational agent being studied for the treatment of orthopoxvirus infection. Serological response to vaccinia virus and viral DNA levels, correlated with clinical events, were utilized to monitor the course of disease and to guide therapy. Burn patient-type management was required, including skin grafts.

RESULTS:The child was discharged from the hospital after 48 days and has recovered with no apparent systemic sequelae or significant scarring.

CONCLUSION:This case illustrates the need for careful screening prior to administration of smallpox vaccine and awareness by clinicians of the ongoing vaccination program and the potential risk for severe adverse events related to vaccinia virus.

Severe adverse events, including eczema vaccinatum (EV), can result after smallpox vaccination. Persons at risk for EV include those with underlying dermatologic conditions, such as atopic dermatitis. We investigated a case of vaccinia infection, possibly acquired during sexual contact with a recently vaccinated military service member, in a female Maryland resident with atopic dermatitis. The U.S. Department of Defense's Vaccine Healthcare Centers Network (VHCN) and the Centers for Disease Control and Prevention (CDC) worked in conjunction with the patient's physician and the Maryland Department of Health and Mental Hygiene (DHMH) to confirm the diagnosis, ensure treatment, and prevent further transmission. Specimens collected from the patient were tested at the DHMH laboratories and were positive by real-time polymerase chain reaction for nonvariola orthopoxvirus. Testing at the CDC verified the presence of vaccinia-specific DNA signatures. Continuing spread of the patient's lesions led to the administration of vaccinia immune globulin and strict infection control measures to prevent tertiary transmission to vulnerable family members, also with atopic dermatitis. VHCN contacted the service member to reinforce vaccination site care and hygiene. This case underscores the importance of prevaccination education for those receiving the smallpox vaccine to protect contacts at risk for developing severe adverse reactions.

A patient who used contact lenses and had a history of blunt trauma developed vaccinia keratouveitis after accidental ocular autoinoculation from a recent vaccination site. Corneal and conjunctival cultures were taken for bacteria, fungi, Acanthamoeba, and viruses. Viral-like cytopathic effects became evident in tissue culture within three days. Immunofluorescence studies were negative for varicella-zoster virus, herpes simplex virus, adenovirus, measles, mumps, parainfluenza, and influenza. Pox viral particles were identified in the infected tissue cultures by electron microscopy. The Hind III restriction endonuclease profile of the viral DNA isolate was similar to the Lister strain of vaccinia virus. Ocular vaccinia may manifest as a masquerade syndrome and may mimic signs of herpes simplex virus, varicella-zoster virus, and Acanthamoeba infection. Although vaccination with vaccinia is currently limited to a few populations throughout the world, vaccinia must still be considered in the differential diagnosis of infectious keratouveitis.

On March 1, 2010, the Washington State Department of Health (WADOH) notified Public Health - Seattle&King County (PHSKC) of a suspected case of contact transmission of vaccinia virus from sexual contact with a member of the military who had been vaccinated against smallpox. Vaccinia virus infection after sexual contact has been reported previously (1-4). Despite the patient's exposure history and clinical presentation, the diagnosis initially was not considered by the patient's physician, who ordered laboratory testing for several common sexually transmitted infections. The patient was seen by a second physician and referred to an infectious disease specialist, who obtained a swab sample of a genital lesion for laboratory testing for vaccinia virus. Vaccinia virus was confirmed by the Washington State Public Health Laboratory (WAPHL) and the CDC Poxvirus Laboratory. The patient resided in a household with an immunosuppressed renal transplant recipient. Appropriate contact precautions were recommended to the patient. No additional cases of contact transmission were reported. This report describes the patient's clinical course and the associated epidemiologic investigation. Health-care providers caring for U.S. military personnel or their contacts should consider vaccinia virus infection in the differential diagnosis of clinically compatible genital lesions. Contact precautions should be emphasized to all persons who are vaccinated, as well as their contacts with unexplained lesions that might represent vaccinia infection from contact transmission.

Vaccinia virus is an orthopoxvirus used in the live vaccine against smallpox. Vaccinia virus infections can be transmissible and can cause severe complications in those with weakened immune systems. We report on a cluster of 4 cases of vaccinia virus infection in Maryland, USA, likely acquired at a martial arts gym.

On October 10, 2006, an otherwise healthy woman visited a public health clinic in Alaska after vaginal tears that she had first experienced 10 days before became increasingly painful. The patient reported having a new male sex partner during September 22-October 1, 2006. A viral swab specimen from a labial lesion of the woman was submitted to the Alaska State Virology Laboratory (ASVL) for viral culture. The viral isolate could not be identified initially and subsequently was sent to CDC on January 9, 2007, where the isolate was identified as a vaccine-strain vaccinia virus. After vaccinia was identified, investigators interviewed the woman more closely and learned that her new sex partner was a male U.S. military service member stationed at a local military base. Further investigation determined that the service member had been vaccinated for smallpox 3 days before beginning his relationship with the woman. This report describes the clinical evaluation of the woman and laboratory testing performed to identify the isolate. Health-care providers should be aware of the possibility of vaccinia infection in persons with clinically compatible genital lesions who have had recent contact with smallpox vaccinees.