Sex: F
Vaccine: SMALL, SMALL, SMALL
Symptoms: Secondary transmission, Vaccinia virus infection, Vaginal lesion, Vaginal swelling, Vaginal ulceration
Clinical narrative: This case was retrieved from the scientific literature on 01 July 2010. A female patient in her 20's experienced contact transmission after being exposed on 20 February 2010 to a vaccinee who had received ACAM2000 (lot not reported). The patient had a history of eczema as a child, but had no other relevant medical history; she had not previously received a smallpox vaccine. Her boyfriend was her only sex partner. The patient's boyfriend was a member of the military, and on 15 February 2010 he had received a ACAM2000 at a military base. On 20 February 2010 he removed the bandage covering his vaccination site; that same day, he and the patient had unprotected sexual intercourse preceded by digital vaginal contact. Four days later, on 24 February 2010, the patient noted a lesion on her right labia majora. On 26 February 2010 she presented to an urgent-care clinic with a 2-day history of painful, ring-shaped, vaginal swellings. She denied fever or other symptoms. Physical exam revealed a single, raised, circular lesion with central ulceration on the right labia majora. The patient reported that her boyfriend had recently been vaccinated with ACAM2000. No diagnosis was made, however she was cultured for gonorrhea, chlamydia, and herpes virus, and treatment at that time included valacyclovir, azithromycin, cefaxolin, and ceftriaxone. On 01 March 2010 she presented to another clinic with complaints of increased pain at the site of the lesion, with new sores in her vaginal and vulvar areas and an enlarged and tender right inguinal lymph node. She expressed concern about the possibility of vaccinia virus infection, and on physical exam was noted to have painful, circular, nonvesicular lesions with raised borders and ulcerated centers. Inguinal lymphadenopathy was also noted, with an enlarged and tender right inguinal lymph node and shotty, tender left inguinal lymphadenopathy. The treating physician sent a lesion swab specimen for testing, and referred the patient to an infectious disease specialist. The following day, on 02 March 2010, she was seen by an infectious disease specialist and a second swab specimen was obtained. The specialist noted a single 1.5 - 2.0 cm inguinal lymph node; a 3 cm region of ulceration in the vaginal vault; and three ulcers ranging in size from 1 cm to 2 cm on the vulva. The cervix appeared normal. The diagnosis was "suspected vaccinia infection", and the patient was given VICODIN for pain control with counseling regarding infection control. On 03 March 2010, the specimen was tested using real-time polymerase chain reaction for orthopoxvirus and for nonvariola orthopoxvirus, both of which yielded positive results. Duplicate swab testing performed by the Center for Disease Control (CDC) confirmed the results using a vaccinia-specific real-time PCR assay. The patient's boyfriend was deployed overseas, and could not be interviewed. One week later the patient followed up with the specialist, and at that time was noted to have healing vaginal lesions which were smaller and more superficial, with some granulation tissue.