Vaccinia uptake and autoinoculation; Vaccinia reaction; This case was obtained from a scientific literature on date 20JUN2019.  A 20-year-old male patient developed vaccinia reaction and vaccinia uptake and autoinoculation, following the administration of ACAM2000 (smallpox vaccine, live) vaccine.  Case report: A 20-year-old male patient presented with rash on his left upper arm/ vaccinia reaction. He reported getting a mild sunburn nine days prior. Three days after the sunburn, he received routine vaccinations before overseas deployment. The vaccines included anthrax, hepatitis A and B, Japanese encephalitis virus vaccine, typhoid vaccine, and vaccinia virus (smallpox). He first noted a small, slightly erythematous, raised rash on his left upper deltoid area two days before presentation. Within 24 hours, the rash had become several times larger. The patient reported discomfort in the area. He did not have a fever or history of similar episodes.   On physical examination, the patient was comfortable and in no acute distress. His skin examination revealed a 5x 2 cm erythematous plaque on the left upper lateral deltoid area that continued distally with an 8 × 4 cm area of coalescing umbilicated papules.  Author's comment: The diagnosis was vaccinia reaction. The patient's skin findings of a large, coalesced plaque with transmitted lesions distal to the inoculated site are consistent with a robust vaccinia uptake and autoinoculation. When smallpox was eradicated in 1979, routine vaccination ended. After the 2001 anthrax attacks, vaccination of certain populations resumed, first responders, and civilian public health care professionals. The patient's skin findings of a large, coalesced plaque with transmitted lesions distal to the inoculated site are consistent with a robust vaccinia uptake and autoinoculation. The vaccine is administered via scarification, which is more effective than intramuscular injection used in other vaccines. In this process, the needle penetrates the patient's epidermis 15 times in the deltoid area. After vaccination, patients will have a skin reaction that lasts an average of 14 to 21 days. There is some risk with the vaccinia virus vaccine because it uses a live virus. Robust uptake leads to development of a large erythematous plaque and induration of at least 10 cm. Autoinoculation (accidental inoculation) typically occurs via transmission by the hands from the inoculation site to another area, typically the face. In a generalized vaccinia reaction, the lesions are papulovesicular and become pustules; they are typically extensive following vaccination. A progressive vaccinia reaction is rare but often severe and can result in the destruction of local skin and underlying soft tissue structures.  The Company agrees with the reporter that the lesions were associated to the vaccination and considers to be definitively related to the ACAM2000. The lesion at the vaccination site, described as rash with erythema and edema is described in the prescription information as "robust take" or exaggerated reaction to the vaccination and the lesions are characteristic vaccinia poxes that disseminated around the vaccination to a more than 3 cm were consistent with an autoinoculation that are usually caused by contamination from the vaccination site. The Company considers this case as serious (medically important).; Sender's Comments: The Company agrees with the reporter that the lesions were associated to the vaccination and considers to be definitively related to the ACAM2000. The lesion at the vaccination site, described as rash with erythema and edema is described in the prescription information as "robust take" or exaggerated reaction to the vaccination and the lesions are characteristic vaccinia poxes that disseminated around the vaccination to a more than 3 cm were consistent with an autoinoculation that are usually caused by contamination from the vaccination site. The Company considers this case as serious (medically important).