Age: 34.0
Sex: M
Vaccine: SMALL, SMALL
Symptoms: Intensive care, Joint swelling, Joint warmth, Laboratory test normal, Liver function test normal
Clinical narrative: This case was received on 02 September 2009 via a QScan search of the VAERS database, under reference number 350022. A 34 year old male patient received a percutaneous injection in the left deltoid of ACAM2000 (lot number VV04003A) on 29 April 2009. The patient received the following vaccines 6 days earlier on 23 April 2009: dose 1 of anthrax vaccine, dose 1 of hepatitis B vaccine, influenza vaccine (intramuscular) and typhoid vaccine. The manufacturer, lot number and site of administration were not reported. The patient was admitted to the hospital on 13 May 2009 with presumptive disseminated vaccinia and right knee cellulitis. Approximately 12 days after receiving ACAM2000, the patient developed fever, chills, malaise, loss of appetite, headache, sore throat, productive cough and mild shortness of breath. The patient was initially seen on Day 12 (11 May 2009) for upper respiratory illness (URI)-type symptoms. The patient reported a 3 week history of intermittent chest congestion. He was diagnosed with pharyngitis and prescribed Z-pack, ZYRTEC and MUCINEX-D. That night, the patient noted pain and swelling at the smallpox vaccination site and an increase in temperature (not measured). He was seen in the Emergency Room and diagnosed with left arm cellulitis. The patient was prescribed SEPTRA and Clindamycin. The patient was seen at a medical center for follow-up on 12 May 2009. He had a fever of 101.7 Fahrenheit. He also had a small tender pustule in right axilla and right knee pain and swelling. By 13 May 2009, the patient developed scattered pustular lesions over the scalp, right hip, and left leg. He also had increased right knee pain and swelling. He was admitted to hospital with a presumptive diagnoses of right knee cellulitis and disseminated vaccinia. An initial assessment by Infectious Disease (ID) performed on 14 May 2009 indicated: overall clinical improvement, but continued right knee swelling and warmth without tenderness; blanchable red rash at smallpox vaccine injection site (stable pustule), and over right knee; multiple scattered tense blisters, not excluding palms and soles: vesicles in various stages, characterized as yellow on erythematous base, umbilicated or ruptured, some becoming pustular, some with honey-colored crusts; distributed over scalp, neck, shoulders, axillae, upper extremities, trunk, buttocks, lower extremities. Laboratory tests performed between 13 May 2009 and 15 may 2009 include: ESR 66-75 (high); CRP 10-12 (high); WBC 3000 range (low); Hematocrit 31-32 (low); Platelet 65-74 (low); normal chemistries, liver panel, LDH, ferritin, retic count, coagulation tests, and urinalysis; negative wound, blood, and urine cultures. The patient recovered. Note: There may be a discrepancy between the event date field and the onset date information in the free text narrative field in the data reported. Latency has been calculated using the event date. Follow-up information was received from a health care professional on 14 July 2010 via a search of the scientific literature. In addition to this case, the article mentioned  7 other patients who experienced similar events; these events are captured in case numbers 2009-00675, 2010-03865, -03866, 03867, -03868, -03869, and 03870. In addition to the symptoms previously listed, the patient also presented with dizziness on post-vaccination day 11. The following evening, he presented to the emergency department with a small erythematous-based pustule in his right axilla and left groin. Upon admission to the hospital, he was started on intravenous clindamycin and vancomycin and transferred to the intensive care unit on post-vaccination day 15. At that time, the dermatology consultant noted that all lesions were in a similar morphologic state. Laboratory evaluation revealed a nonspecific elevation in inflammatory makers (erythrocyte sedimentation rate, C-reactive protein) and pancytopenia attributed to viral bone marrow suppression. On day 16, the patient was noted to have the interval development of a vesicle on his left ulnar, distal upper extremity and subsequent resolution of the right knee erythema, induration, warmth, and tenderness. Blood and wound cultures were negative for bacterial growth, and viral cultures were also negative. Initial vaccinia PCR testing confirmed the presence of vaccinia virus, and test results were later confirmed by the Centers for Disease Control and Prevention (CDC). A punch biopsy specimen from a vesicle on the right wrist revealed superficial epidermal necrosis with a mixed pustular/vesicular spongiotic dermatitis, including scattered neutrophils and eosinophils. The patient showed overall clinical improvement on post-vaccination day 16, and was discharged to home with a 2-week prescription of clindamycin. He was seen by an infectious disease physician in an outpatient clinic on post-vaccination day 28, at which time he was noted to have complete resolution of his cellulitis and vesiculopustular eruption, except for the smallpox immunization site which was described as ulcerating with crusting. He continued to have ongoing pancytopenia, and on post-vaccination day 44 he was seen by a hematology/oncology consultant. At that time his pancytopenia was noted to be resolving, and thought to be secondary to generalized vaccinia. At the time that the article was written, the patient was deployed to a remote location and was to follow-up with immunologic and hematologic evaluations upon his return. List of documents held by sender: none.