Vaccinia Workup

  • Author: Jennifer J Lee, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 12, 2012
 

Laboratory Studies

  • The diagnosis of vaccinia virus complications is usually straightforward and depends on obtaining the history of recent vaccinia virus exposure by vaccination or contact with a vaccinated individual. A careful workup for immune deficiency should be considered in patients who do not promptly improve.
  • The diagnosis of CNS complications is more difficult because the signs and symptoms are nonspecific. Although rare, postvaccinial encephalitis should be considered in any patient with neurologic symptoms developing 1-2 weeks after exposure to live vaccinia virus. Vaccinia virus has not been isolated from cerebrospinal fluid (CSF) of patients with encephalitis, and CSF analysis usually produces normal results, except for increased pressure; however, CSF analysis may be indicated to exclude other causes of encephalitis.
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Imaging Studies

  • Imaging studies are not useful in the diagnosis of vaccinia infection or a postvaccinial complication, although imaging modalities may be helpful to exclude other causes of disease (eg, MRI of the brain in cases of suspected encephalitis).
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Other Tests

  • Patients who present with skin manifestations usually have live viral particles replicating in the dermal lesions. The presence of vaccinia virus can be confirmed by obtaining a biopsy of the skin lesion and examination through microscopy, plaque titer assay, Western blot, and polymerase chain reaction (PCR) analysis.
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Histologic Findings

Light microscopy may reveal characteristic inclusions (ie, Guarnieri bodies) in the cytoplasm of infected cells. This is distinct from the appearance of cells infected by viruses such as herpes simplex virus, which typically demonstrate intranuclear inclusion bodies.

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Contributor Information and Disclosures
Author

Jennifer J Lee, MD  Resident Physician, Department of Dermatology, University of Texas Southwestern at Austin

Jennifer J Lee, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, California Medical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Dayna Diven, MD  Professor, Department of Dermatology, University of Texas Southwestern Austin Programs

Dayna Diven, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Idaho Medical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Tasneem A Poonawalla, MD  Physician, Department of Dermatology, Dean Clinic

Tasneem A Poonawalla, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Howard L Kaufman, MD  Chief, Division of Surgical Oncology, Columbia University

Howard L Kaufman, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American College of Surgeons, American Medical Association, Association for Academic Surgery, Illinois State Medical Society, Massachusetts Medical Society, New York Academy of Sciences, and Society of Surgical Oncology

Disclosure: Nothing to disclose.

Ken Flanagan  Department of Microbiology and Immunology, Albert Einstein College of Medicine

Ken Flanagan is a member of the following medical societies: American Association for Cancer Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Brenda Jones  MD, Associate Professor of Clinical Medicine, Division of Infectious Diseases, Keck School of Medicine of the University of Southern California

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Richard B Brown, MD, FACP  Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine

Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Thomas W McGovern, MD, to the development and writing of this article.

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This typical pustular lesion following vaccinia immunization usually appears within 5 days of vaccination and forms a scab by 10-14 days. Vaccination usually leaves a permanent indentation.
Table. Frequency of Complications Related to Vaccination
Complication Number of cases from 450,293 vaccinations administered between 12/13/2002 and 5/28/2003 Department of Defense rate per million vaccinees (95% confidence interval) Historical number of cases from 1950s and 1960s
Death00 (0-3.7)Age 1 y at first vaccination - 5 per 1 million primary vaccinees
Age 1-4 y at first vaccination - 0.5 per 1 million primary vaccinees
Age 5-19 y at first vaccination - 0.5 per 1 million primary vaccinees
Age ≥ 20 y at first vaccination - No data
Encephalitis12.2 (0.6-7.2)3 per 1 million primary vaccinees
Vaccinia necrosum/progressive vaccinia00 (0-3.7)Approximately 1 patient per million during primary or revaccination
Usually fatal over a period of several months
Eczema vaccinatum00 (0-3.7)1 per 100,000 primary vaccinees
1 per 1 million revaccinees
Generalized vaccinia3680 (63-100)Occasional occurrence in immunocompetent individuals
3 per 100,000 primary vaccinees
1 per 1 million revaccinees
Accidental vaccinia48107 (88-129)3 per 100,000 to 1 million vaccinees
Erythematous rash3680 (63-100)Approximately 1 per 100,000 primary vaccinees*
Acute myopericarditis3782 (65-102)100 per 1 million vaccinees
*Incidence was slightly higher when vaccination occurred before age 1 year.
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