Correspondence

Smallpox Vaccination

N Engl J Med 2003; 348:1925May 8, 2003

Article

To the Editor:

Rubins and Relman, in their Image in Clinical Medicine (Jan. 30 issue),1 mention that a lymphangitic streak was present on day 9 and that “two physicians who examined the patient on day 10 . . . suspected bacterial cellulitis.” The lesion apparently resolved within two days after its appearance, without the use of antimicrobial agents. It is nonetheless a matter of concern that antimicrobial agents were withheld despite the clinical suspicion of cellulitis.

Although it is well known that lymphangitis and cellulitis may be seen during the major cutaneous reaction associated with successful smallpox vaccination (a “robust take”), it can be quite difficult clinically to discern a nonbacterial lesion from a secondary bacterial infection of the site. The Centers for Disease Control and Prevention (CDC) recently reported that 9 of 191 of its vaccinees (4.7 percent) met the criteria for a robust take; all 6 who sought medical attention were treated with systemic antibacterial agents.2 My colleagues and I have had a similar recent experience with smallpox vaccination. Given the potentially dire consequences of an untreated, rapidly progressive, bacterial soft-tissue infection and the fact that clinicians may soon face this issue as the smallpox-vaccination program progresses, one must ask whether empirical antimicrobial agents are indicated.

Andrew W. Artenstein, M.D.
Center for Biodefense and Emerging Pathogens, Pawtucket, RI 02860
artenstein@brown.edu

2 References

1. 1

   Rubins K, Relman DA. Progression of the lesion at the site of inoculation after smallpox vaccination. N Engl J Med 2003;348:414-414
   Full Text | Web of Science | Medline

2. 2

   Smallpox vaccination and adverse reactions: guidance for clinicians. MMWR Morb Mortal Wkly Rep 2003;52:1-28
   Medline

Author/Editor Response

We agree that bacterial soft-tissue infection, including bacterial cellulitis, can be difficult to distinguish on a clinical basis from a robust take to the Dryvax smallpox vaccine. Lymphangitis may occur with each. In cases with features that are strongly suggestive of bacterial infection, a decision to provide treatment with antibiotics may be unavoidable. In this particular case, antibiotics were in fact prescribed; however, the patient did not begin this therapy immediately, and by the next morning, the erythematous streak had already improved, even though the patient had not yet started taking the antibiotics.

We also wish to clarify another feature of this case. The persistence of an open cutaneous lesion on day 51, after detachment of the eschar, is not typical of smallpox-vaccination sites and may have resulted from daily application of topical antibacterial ointment, which is not included in standard recommendations for the care of robust takes (Table 2 in the CDC's recommendations).1 Besides drawing attention to these management issues, this case emphasizes the important need for newer-generation smallpox vaccines with less severe accompanying features.

Kathleen Rubins, B.S.
Stanford University School of Medicine, Stanford, CA 94305

David A. Relman, M.D.
Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304
relman@stanford.edu

1 References

1. 1

   Smallpox vaccination and adverse reactions: guidance for clinicians. MMWR Morb Mortal Wkly Rep 2003;52:5-7, 12