Case-Patient 1

Figure 2

Figure 2. Vaccinia lesions in patients with secondary and tertiary cases, New York, USA, 2010. Top row, case-patient 1; bottom row, case-patient 3.

On March 11, a 26-year-old male wrestler with no noteworthy medical history visited a dermatologist after being referred by his private physician who had prescribed trimethoprim/sulfamethoxazole for presumed methicillin-resistant Staphylococcus aureus from lesions on his face, neck, and chest (Figure 2). The lesions developed suddenly, starting March 1, two days after wrestling. Molluscum contagiosum and impetigo were included in the differential diagnosis, and a culture was sent to a local laboratory to test for methicillin-resistant S. aureus. The dermatologist notified the local health department of the patient’s possible exposure to VACV. A NYSDOH public health physician evaluated the patient on March 12. On examination, he had clinically compatible VACV lesions, including papular, umbilicated lesions with overlying vesicles and a few pustules.

Case-Patient 2

On March 11, a 24-year-old male wrestler with no noteworthy medical history was contacted by the NYSDOH because he was a wrestling contact of the vaccinee. He reported lesions on his face, neck, chin, and left eye that developed several days after the wrestling event and were associated with substantial pruritus, exudate, and erythema. At his public health evaluation on March 12, he had numerous papular lesions that were umbilicated with overlying vesicles, several of which were draining serous fluid, and VACV was clinically diagnosed. He had involvement of the left lower eyelid with substantial erythema and early blepharitis. He received slit-lamp examination by a local ophthalmologist, who after consultation with CDC and NYSDOH, treated him with trifluridine ophthalmic solution (4). The blepharitis and eyelid erythema resolved within 48 hours after initiation of trifluridine.

Case-Patient 3

On March 10, a 25-year-old male wrestler and roommate of the vaccinee sought treatment for vesicular lesions on his trunk and chest. His medical history included recent mild eczema involving his hands. He reported that several pruritic papules had developed 2 days after wrestling case-patient 1. The physician thought the lesions appeared to be molluscum contagiosum, but given the patient’s history, consulted an infectious disease physician, who observed lesions compatible with VACV. At the public health clinical evaluation on March 12, the patient had grouping of vesicular lesions with central umbilication on mildly erythematous bases on his trunk (Figure 2), with a solitary lesion near his left areola and on the volar aspect of his right forearm. VACV was clinically diagnosed.

Case-Patient 4

On March 9, lesions developed along the mandible of the 29-year-old household contact of case-patient 1. On March 11, she was evaluated by a dermatologist, who performed a punch biopsy for suspected herpes. Over the next several days, fever, chills, arthralgias, and submandibular swelling developed. She was seen by the NYSDOH public health physician on March 16, and VACV was clinically diagnosed. The most plausible route of exposure was a shared hand towel with case-patient 1. Over the next several days, her lesions started draining and became substantially more erythematous and painful. She reported a lesion in her right nostril on March 18. After consultation between her physician, NYSDOH, and CDC, varicella immune globulin was released from the Strategic National Stockpile for administration because of the new mucosal involvement (5). Varicella immune globulin was administered with no complications on March 19 at a local hospital. The patient reported that the pain associated with her lesions resolved over 24 hours. Her nostril lesion resolved on March 22 with the loss of a small scab.

All 4 cases were clinically diagnosed vaccinia. Samples were obtained by unroofing vesicles, collecting the tissue, performing slide touch preps of the unearthed base of each vesicle, and obtaining viral swabs by using pox collection kits that had been distributed through NYSDOH. All patient specimens were tested at the NYSDOH Wadsworth Center (Albany, NY, USA) by real-time PCR, and preliminary results indicated VACV.

VACV subsequently was confirmed in all 4 patients by real-time PCR at the NYSDOH Wadsworth Center. The complete hemagglutinin gene was sequenced by CDC for 3 of the samples (cases 1, 3, 4) and was identical to that of ACAM2000 (6).

NYSDOH provided appropriate transmission precautions and wound care instructions to all 4 case-patients (7). Follow-up continued until lesion resolution; no additional VACV cases were identified. Vaccine Adverse Event Reporting System reports were submitted for each case.