Age: 31.0
Sex: F
Vaccine: SMALL
Symptoms: Pregnancy test negative
Clinical narrative: The member was examined in flight medicine clinic on 04Feb09. Her symptoms The patient filled out SF 600 Small Pox questionnaire and responded "yes" to several questions  and was sent to her provider for review.  The patient's medical record was reviewed during her visit. She has no previous encounters for eczema. There is no documentation of any previous atopic dermatitis in the patient's chart. Form was reviewed and it did not indicated any h/o of rashes, allergies, or medications used to treat any type of atopic dermatitis. When patient was interviewed, she reported that she had a h/o eczema. She stated that flare ups were limited and rare. She reported that she has not had a rash of any kind in over a year. She was not currently taking any meds for atopic dermatitis. She stated that she had used topical hydrocortisone cream in the past, however she stated that she had not used any steroid creams in over a year.  Her medication list was reviewed and showed that her last prescription for a steroid cream was in 2005 and it was prescribed for a facial rash. Physical exam was negative for rash, thickened skin, or any hypo/hyper pigmented skin. CBC was order to confirm normal WBC count. Pregnancy test was ordered to confirm that she was not pregnant. It was my understanding that she was deploying to a high risk area. I consulted another provider and was informed that atopic dermatitis is not an absolute contraindication to the vaccine and that patients with unclear, remote, or even limited histories are usually vaccinated. Based on the patient's chart/med review, history, and physical exam; I felt the patient to be a low risk for adverse reaction. Although people with a history of atopic dermatitis have a higher chance of adverse reactions to the vaccine, they also are at greater risk of dying from smallpox disease if exposed. I concluded that the benefit was greater than the risk. (The reviewing physician did consult with another provider for input in guiding her to make this decision). were mainly dermatological (pruritic erythematous papular and patchy  indurations, generalized including palmar and plantar areas, without mucosal involvement). There were no other systemic symptoms such as fever and/or malaise. Her vital signs were stable and she was not in distress. The member was given a prescription for oral antihistamine (cetirizine) as the treatment. Our conclusion, after a consultation with an expert who reviewed the photographs of the member's skin  lesions, is that it is an allergic dermatosis (induced by either vaccine  itself or the dressing material) and is NOT a case of eczema vaccinatum. The member and this provider had a discussion on clinical impression, course of treatment, duty restriction and expected prognosis. She will return to clinic for follow up.  3/18/09 MR received from reporter.  Seen 2/4/09 with c/o progressive rash all over body x 1 week.  Initially had localized rash at vaccine site with spreading lesions including palms and soles.  No mucosal involvement, but some genital itching. Went to local ER and was told rash was generalized vaccinia. Has had some loose stools x 3 days and external vaginal itching.  Numerous pruritic erythematous maculopapular indurative patches noted on PE. Injection site has dry crusted abscess surrounded by erythematous induration.  Assessment:  Smallpox vaccination reaction generalized. Also contact dermatitis from tape covering site. Consultant concluded not eczema vaccinatum probably a cutaneous allergic reaction. Tx: antihistamine.  F/U 2/6/09 with continued rash.  itching decreased with Zyrtec. Assessment:  Dermatitis.