eMedicine Specialties > Infectious Diseases > Viral Infections
Vaccinia: Treatment & Medication
Updated: Aug 24, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
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Treatment
Medical Care
Treatment for the complications associated with vaccinia virus is supportive.
- VIG may be helpful in selected patients, such as those with generalized vaccinia and eczema vaccinatum. VIG is less successful when used for treatment of progressive vaccinia and CNS complications.
- VIG was developed from pooled sera collected from vaccinated patients in the 1960s and is available from the Centers for Disease Control and Prevention (CDC) in Atlanta, Ga.
- VIG is contraindicated in patients with allergies to VIG or sensitivity to human pooled serum.
- Cidofovir is being investigated to evaluate the clinical effect and outcomes as a secondary treatment of vaccinia-related complications that do not respond to VIG treatment.
Surgical Care
Surgery usually is not helpful in cases of vaccinia complications, although debridement of nonviable tissue in cases of vaccinia necrosum may be considered. Obtaining a biopsy of suspected lesions may aid in the diagnosis.
Consultations
- Suspected cases of vaccinia-related complications should be treated in consultation with an expert in infectious diseases and poxvirus virology.
- Selective consultation for specific adverse events is indicated (eg, an ophthalmologist for eye complications, a neurologist for nervous system complications).
- Consultation with a dermatologist may be helpful when the diagnosis of a skin lesion is in doubt.
Diet
No special dietary precautions apply to patients with vaccinia-related complications.
Activity
No specific activity limitations apply to patients with vaccinia-related complications.
Medication
VIG is the only drug available for amelioration of some vaccinia-related complications. VIG is produced from pooled human sera taken from vaccinia-immunized individuals and is available only from the CDC. VIG has been effective when administered early in cases of vaccinia necrosum and eczema vaccinatum. VIG has not been effective in cases of encephalopathy. The use of VIG for generalized vaccinia reactions usually is not necessary. Vaccinia immune globulin, intravenous (VIGIV) has recently been approved by the US Food and Drug Administration.
Cidofovir (Vistide, Gilead Sciences, Foster City, Calif), a nucleotide analogue of cytosine, has demonstrated antiviral activity against certain orthopoxviruses in cell-based in vitro and animal model studies. The CDC proposes an investigational use of cidofovir in the treatment of vaccinia-related complications, which has not been studied among humans and thus the benefits are uncertain.
Immune globulins
Are used for passive immunity. Therapy consists of administration of immunoglobulin pooled from serum of immunized subjects.
Vaccinia immune globulin (VIG)
Produced from the pooled sera of vaccinia-immunized individuals. Preparation contains antibodies targeted against vaccinia virus. Indicated for the treatment of vaccinia necrosum and eczema vaccinatum.
Adult
0.6 mL/kg IM in divided doses over 24-36 h; repeat dose q2-3d prn
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; sensitivity to human pooled serum
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Introduction of any active biologic agent or pooled sera must be performed cautiously; potential for serious adverse reactions, including anaphylaxis, exists; risk of infectious complications with any blood product also possible
Vaccinia immune globulin intravenous, human
Derived from human plasma and manufactured from pooled plasma donors who received booster immunizations with smallpox vaccine (Dryvax). Contains increased antibody levels against vaccinia virus. Indicated to treat rare adverse reactions and aberrant infections caused by vaccinia virus, including aberrant infections (eg, accidental implantation in eyes, mouth, other potentially hazardous areas), eczema vaccinatum, progressive vaccinia, severe generalized vaccinia, and vaccinia infections in immunocompromised individuals.
Adult
100 mg/kg (2 mL/kg) IV infusion; may repeat, depending on severity of symptoms and response to initial dose; may consider higher dose (200-500 mg/kg) if response to initial dose is inadequate (see Precautions)
Infusion rate: 1 mL/kg/h IV for first 30 min, then 2 mL/kg/h for next 30 min, then 3 mL/kg/h for remaining infusion
Pediatric
Not established
Antibodies present in immune globulin preparations may interfere with immune response to live virus vaccines (eg, polio, MMR); defer vaccination with live virus vaccines for 6 mo following VIGIV administration; may alter immune response of vaccines administered shortly before VIGIV
Documented hypersensitivity to this or other human IVIGs; vaccinia keratitis; selective IgA deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure; general precautions for all IVIGs include aseptic meningitis, hemolysis (because of blood group antibodies), transfusion-related lung injury (pulmonary edema), and infections (eg, CJD); acute renal failure, osmotic nephrosis, proximal tubular nephropathy, and death may occur because of high sucrose levels (typically associated with doses >400 mg/kg/dose); call manufacturer to identify appropriate lot with low IgA level if administering to individual with selective IgA deficiency
Antiviral Agent
Cidofovir will be released for civilian use by the CDC and for military use by the Department of Defense if the patient meets the following criteria: (1) VIG treatment fails to elicit a response, (2) a patient is near death, or (3) all inventories of VIG have been exhausted. This proposed use of cidofovir is investigational, and its effectiveness in the treatment of vaccinia-related complications among humans is unknown.
Cidofovir (Vistide)
Not licensed for use as a treatment for smallpox. Currently approved for treatment of CMV retinitis in AIDS. Cidofovir is the first member of a group of antivirals known as acyclic phosphonate nucleotide analogs. Cidofovir diphosphate, the active intracellular metabolite of cidofovir, inhibits herpes virus polymerases at concentrations that are 8- to 600-fold lower than those needed to inhibit human cellular DNA polymerases alpha, beta, and gamma. Incorporation of cidofovir into the growing viral DNA chain results in reductions in the rate of viral DNA synthesis. Adefovir, cidofovir, and ribavirin are under investigation for smallpox. Ribavirin as an aerosol treatment for pediatric respiratory syncytial virus is under investigation.
Adult
5 mg/kg IV over 1 h
Pediatric
Not established
Coadministration of aminoglycosides, amphotericin B, IV pentamidine, and foscarnet may increase nephrotoxicity
Documented hypersensitivity; coadministration with other nephrotoxic agents; serum creatinine >1.5 mg/dL; a CrCl <55 mL/min; urine protein >100 mg/dL
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor neutrophil counts; renal toxicity is major adverse effect; prehydrate with normal saline IV and coadminister probenecid with each infusion to minimize nephrotoxicity (monitor renal function); monitor serum creatinine and urine protein levels 48 h prior to treatment (adjust dose accordingly); granulocytopenia may occur
More on Vaccinia |
| Overview: Vaccinia |
| Differential Diagnoses & Workup: Vaccinia |
 Treatment & Medication: Vaccinia |
| Follow-up: Vaccinia |
| Multimedia: Vaccinia |
| References |
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References
Breman JG, Henderson DA. Diagnosis and management of smallpox. N Engl J Med. Apr 25 2002;346(17):1300-8. [Medline].
Buller RM, Palumbo GJ. Poxvirus pathogenesis. Microbiol Rev. Mar 1991;55(1):80-122. [Medline].
Carroll MW, Moss B. Poxviruses as expression vectors. Curr Opin Biotechnol. Oct 1997;8(5):573-7. [Medline].
Casey CG, Iskander JK, Roper MH, et al. Adverse events associated with smallpox vaccination in the United States, January-October 2003. JAMA. Dec 7 2005;294(21):2734-43.
Damon I. Orthopoxviruses: Vaccinia (Smallpox Vaccine), Variola (Smallpox), Monkeypox, and Cowpox. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 6th ed. Orlando, FL:. Churchill Livingstone;2005:1742-1755.
Friedman HM. Smallpox, Vaccinia, and Other Poxviruses. In: Isselbacher, et al, eds. Harrison's Principles of Internal Medicine. 13th ed. New York, NY:. McGraw-Hill;1994:798-799.
Grabenstein JD, Winkenwerder W. US military smallpox vaccination program experience. JAMA. Jun 25 2003;289(24):3278-82.
Haga IR, Bowie AG. Evasion of innate immunity by vaccinia virus. Parasitology. 2005;130 Suppl:S11-25.
Harrop R, Ryan MG, Golding H, et al. Monitoring of human immunological responses to vaccinia virus. Methods Mol Biol. 2004;269:243-66.
Hopkins RJ, Lane JM. Clinical efficacy of intramuscular vaccinia immune globulin: a literature review. Clin Infect Dis. Sep 15 2004;39(6):819-26. [Medline].
Lane HC, Fauci AS. Microbial bioterrorism In: Kasper, et al, eds. Harrison's Principles of Internal Medicine. 16th ed. New York, NY:. McGraw-Hill;2005.
Lane JM, Millar JD. Risks of smallpox vaccination complications in the United States. Am J Epidemiol. Apr 1971;93(4):238-40. [Medline].
Lewis FS, Norton SA, Bradshaw RD, et al. Analysis of cases reported as generalized vaccinia during the US military smallpox vaccination program, December 2002 to December 2004. J Am Acad Dermatol. Jul 2006;55(1):23-31.
Moss B. Vaccinia virus: a tool for research and vaccine development. Science. Jun 21 1991;252(5013):1662-7. [Medline].
Moss B. Genetically engineered poxviruses for recombinant gene expression, vaccination, and safety. Proc Natl Acad Sci U S A. Oct 15 1996;93(21):11341-8. [Medline].
Moss B. Poxvirus entry and membrane fusion. Virology. Jan 5 2006;344(1):48-54.
Neff JM. Vaccinia Virus (Cowpox). In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, Pa:. Churchill Livingstone;2000:1553-1555.
Paoletti E. Applications of pox virus vectors to vaccination: an update. Proc Natl Acad Sci U S A. Oct 15 1996;93(21):11349-53. [Medline].
Redfield RR, Wright DC, James WD. Disseminated vaccinia in a military recruit with human immunodeficiency virus (HIV) disease. N Engl J Med. Mar 12 1987;316(11):673-6. [Medline].
Savona MR, Dela Cruz WP, Jones MS, et al. Detection of vaccinia DNA in the blood following smallpox vaccination. JAMA. Apr 26 2006;295(16):1898-900.
Sejvar JJ, Labutta RJ, Chapman LE, et al. Neurologic adverse events associated with smallpox vaccination in the United States, 2002-2004. JAMA. Dec 7 2005;294(21):2744-50.
Sepkowitz KA. How contagious is vaccinia?. N Engl J Med. Jan 30 2003;348(5):439-46.
Stark JH, Frey SE, Blum PS, Monath TP. Lack of transmission of vaccinia virus. Emerg Infect Dis. Apr 2006;12(4):698-700.
Further Reading
Keywords
vaccinia, vaccinia virus, smallpox, variola, cowpox, poxviruses, Poxviridae, vaccinia necrosum, eczema vaccinatum, vaccinia immune globulin, VIG, orthopoxvirus
