Age: 21.0
Sex: M
Vaccine: SMALL
Symptoms: Injection site discharge, Injection site erythema, Injection site pain, Injection site papule, Injection site pruritus
Clinical narrative: Information received from the review of scientific literature on 10AUG2018. This article presents a case of smallpox autoinoculation in a male who reported receiving a "touch up" to a large tattoo directly over his inoculation site 4 days after vaccination. Medical history: pseudofolliculiits barbae. Concomitant therapies: tretinoin and triamcinolone. A 21-year-old male received smallpox vaccination in the left deltoid. Due to concern for improper aftercare of the inoculation site (post vaccine day 8) he was sent to aftercare. His leadership reported that he had been seen not wearing a bandage over the vaccination site as instructed by medical personnel. He had also been observed scratching the site frequently and reported pruritus throughout his left shoulder. The male admitted to receiving a "touch up" of a large tattoo directly over the inoculation site at a local tattoo parlor four days after vaccination. Initial examination revealed isolated, mild non-tender lymphadenopathy of the left axilla. A skin exam showed numerous flesh-colored papules on the left deltoid throughout the tattoo site, most less than 2mm in diameter, without significant erythema, bleeding, purulence or excoriations. The inoculation site had formed a vesicle but was otherwise within normal appearance for the period from initial inoculation. At that time there were no other significant findings and he was placed in isolation in his room until follow up. The tattoo artist who had performed the procedure was found and notified. An investigation determined that there were no concerns of further needle contamination or spread to the local populace. Unit personnel ensured proper notification of local health authorities. The male was seen three days later (day 7 post tattoo). At that time he complained of subjective fevers and increased left shoulder pain. He self treated with ibuprofen and acetaminophen. Upon physical exam, the lesions on the left deltoid had become umbilicated with mild yellow discharge and crusting noted throughout. A 7-day course of trimethoprim-sulfamethoxazole was empirically prescribed for possible secondary bacterial infection. Cultures were not obtained. Thirteen days after vaccination (day 9 post tattoo), the male was afebrile and denied further pain. The lesions on his left deltoid had largely scabbed over and much of the surrounding erythema had likewise resolved. A follow up at 14, 18 and 23 days post vaccination showed continued healing without further complication ultimately resulting in scattered areas of hypo-pigmented scarring. Investigators of the event determined that the likely cause of the post-vaccination complication was individual noncompliance with aftercare orders. Current guidance mandates no new tattoos for 30 days post-inoculation, and the period may be extended to a window of greater than 60 days on a case by case basis. The article concluded that local immune dysregulation of tattoos have the potential to create an organized framework of virus dissemination beyond the initial inoculation site. It was recommended that vaccine providers make every effort to avoid collocating sites of tattoos and smallpox inoculation regardless of tattoo age.