Sex: F
Vaccine: SMALL
Symptoms: Biopsy, Dyshidrotic eczema, Eczema, Epidermal necrosis, Erythema multiforme
Clinical narrative: Acral papulovesicular eruption; This literature case, derived from a full-text article, was received on 15JUN2022.    A 21-year-old female patient developed acral papulovesicular eruption (PT: Rash papular) following the administration of ACAM2000 (smallpox vaccine, live).  Case report: A 21-year-old female soldier who was otherwise healthy presented to the dermatology clinic with a pruritic papular eruption involving the upper and lower extremities of 1 week's duration. The lesions first appeared 8 days after she received the ACAM2000 vaccine. She received no other concurrent vaccines, had no history of atopic dermatitis, and had no systemic symptoms. Physical examination revealed numerous erythematous indurated papules involving the dorsolateral hands and fingers, as well as the extensor surfaces of the elbows, knees, and thighs. Based on the clinical presentation, the differential diagnosis included lichen planus, verruca plana, dyshidrotic eczema, and smallpox vaccine reaction. Erythema multiforme was considered; however, the absence of palmoplantar involvement and typical targetoid lesions made this diagnosis less likely.  Biopsies of lesions on the arm and thigh were performed. Histologic findings revealed interface and spongiotic dermatitis with scattered necrotic keratinocytes and extravasated erythrocytes. There was no evidence of viral cytopathic effects. Similar clinical and histologic findings have been reported in the literature as acral papulovesicular eruptions following smallpox vaccination or papular spongiotic dermatitis of smallpox vaccination. The presence of eosinophils was not conspicuous in the current case and was only a notable finding in 1 of 2 cases. This may simply be due to an idiosyncratic drug reaction.  Based on these findings, the patient was diagnosed with an acral papulovesicular eruption following smallpox vaccination. Of note, the patient's presentation was not consistent with other described smallpox vaccine reactions, which included eczema vaccinatum, autoinoculation, generalized vaccinia, and progressive vaccinia. The patient was treated supportively with triamcinolone acetonide cream 0.1 percent, cool compresses, and oral diphenhydramine as needed for pruritus. The lesions notably improved within the first week of treatment.  Author's comment: Acral papulovesicular eruption is a distinct cutaneous presentation that has been described in Military service members following vaccination with the second-generation smallpox vaccine (ACAM2000). Although further research is needed to discern the pathogenesis of this reaction, it is benign and self-limited, and patients have fully recovered with supportive care. Our patient represented a unique case of a papulovesicular eruption following smallpox vaccination with no history of concurrent vaccines.  Company comment: A 21-year-old patient received ACAM2000 and developed acral papulovesicular eruption (rash papular). In response to the event, she was treated with triamcinolone acetonide cream, and oral diphenhydramine and improved within the first week of treatment. Considering the case information, the causality of the event rash papular is assessed as possible with  ACAM2000. The case is considered non-serious as per medical assessment.; Sender's Comments: A 21-year-old patient received ACAM2000 and developed acral papulovesicular eruption (rash papular). In response to the event, she was treated with triamcinolone acetonide cream, and oral diphenhydramine and improved within the first week of treatment. Considering the case information, the causality of the event rash papular is assessed as possible with  ACAM2000. The case is considered non-serious as per medical assessment.