Age: 26.0
Sex: F
Vaccine: SMALL
Symptoms: Swelling face, Visual acuity reduced
Clinical narrative: A 26 year old Japanese female patient presented to ER on 2/22/03 with complaints of severe pain and swelling on right eye with large amount of exudate. Patient was admitted with right periorbital cellulitis. CT scan indicated preseptal cellulitis, no keratitis. No vesicles noted. Symptoms (swelling, pain, discharge on right eye) started on 2/17. She went to medical clinic on Tuesday and they referred her to a medical center where she went the next day. Patient stated they gave her some eye drops and referred her to an opthalmologist. The symptoms were reportedly worsening. The patient saw a doctor on Wednesday, Thursday, and Friday and she was given more eye drops and then some pills. The symptoms did not improve. Patient complained of swelling on entire right side of face, difficulty opening the right eye, and impaired vision on right eye with increased exudate. She was then instructed to go to hospital where she presented on Saturday. On 2/25, the hospital lab contacted the public health lab to request testing for vaccinia. Laboratory initiated an investigation; specimens were picked up from hospital for testing.  Interviews with the hospital epidemiologist, nurse and ID consult were conducted. Patient is on IV antibiotics (Vancomycin and Cefotaxime), and antibiotic eye drops (Cipro and eyrthrymycin) and responding well to treatment. Per ID physician, the diagnosis is viral conjunctivitis but they are testing for chlamydia. Patient was discharged to home on 2/25. Patient was an intimate contact of a recent smallpox vaccinee. Boyfriend was vaccinated 4 weeks ago. Since boyfriend has been vaccinated, patient had intimate contact with him 3xw for 3 weeks. Their last contact was 2/17. Boyfriend was deployed overseas. Patient states that the vaccination site was not always covered and both the boyfriend and the patient did not practice good hand washing techniques. Follow up on 2/26/03. The patient was re-contacted today by ophthalmology after the clinical microbiology lab viral culture results of conjuctival fluid collected prior to discharge revealed cytopathologic changes consistent with viral infection. This individual is now admitted as an in-patient. A doctor received a phone call from an infectious disease specialist who evaluated this individual on the previous hospitalization and again today who described the individual as delusional today. The results of drug screen are negative and spinal tap for further studies are under consideration. The patient's medication outpatient medication included: on oral Augmentin started at discharge after approximately two days of IV antibiotics as well as Zoloft (take prior to evaluation). Today she has been started on tri-flouridine eye drops. There has been no request to the CDC for VIG at this time. Further lab testing is underway. The first DFA specimen was not conclusive. A second DFA will be set up late in the afternoon (2/26/03) which was subsequently confirmed as positive approximately 7:00PM in the evening. A conference call was held on the evening of 2/26/03 with the CDC Clinical information line and all agreed upon the release of VIG. The patient was interviewed who confirmed the above history and took digital photos of the conjuctivitis. CS gave a coherent history and was back to baseline mental status and it was decided a lumbar puncture was not needed. The patient received IV VIG on the afternoon of 2/27/03. A press release was released on the afternoon of 2/27/03. Testing for GC and chlamydia are pending at this time.