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The patient had traveled to New York for a 3-day stay 11 days prior to hospitalization. During her trip, she had sexual relations with 1 military personnel, who had been vaccinated with vaccinia virus 10 days prior to contact with the patient. She was unsure whether the dressing placed over his lesion had remained on the skin during her visit. Five days after returning home, she developed the erythematous papule on her cheek. The patient reported having intercourse with 1 other contact after returning home.

Contact transmission of vaccinia was suspected, and calls to the Centers for Disease Control and Prevention (CDC) and the Kansas Department of Health and Environment were made. A scraping of the base of the lesions on her hand and vulva was sent to the Kansas Department of Health and Environment laboratory for orthopoxvirus polymerase chain reaction. It was identified as a nonvariola orthopoxvirus and subsequently confirmed as vaccinia by polymerase chain reaction at the CDC. The patient was discharged and instructed to maintain contact precautions. After consultation with the CDC, she did not receive vaccinia immunoglobulin, as she was immunocompetent, did not appear systemically ill, and the lesions appeared to be resolving without development of further lesions. At her follow-up appointment 4 days after hospital discharge, the vulvar and hand lesions were scabbed over and all of the lesions showed decreased erythema and swelling. The facial lesion scabs fell off 18 days after hospital admission (Figure 3). Her second sexual contact displayed a lesion on his chin similar to the patient's facial lesions; he declined clinical evaluation but was instructed to keep the lesion covered until the scab fell off.

Inadvertent inoculation is a significant complication of smallpox vaccination. In the 1960s, there were 529 cases of inadvertent inoculation per million vaccinees.¹ In 1979, the World Health Organization declared smallpox to be eradicated worldwide. Routine childhood smallpox immunization was discontinued in the United States in 1972. Owing to the threat of bioterrorism, the United States military resumed smallpox immunization in 2002. From December 13, 2002, to May 17, 2007, more than 1.2 million smallpox vaccinations of military personnel were administered; 61 cases (36 laboratory-confirmed) of contact transfer (primarily spouses and adult intimate contacts) of vaccinia have occurred.²

The most common sites of inadvertent inoculation lesions include the face, nose, eyelids, mouth, anus, and genitalia.¹ Painful ulcers or vesicles generally characterize vulvar vaccinia^3- 4 but at the time of hospitalization, our patient denied pain or burning, although she did state there was mild pruritus. Given their timing of development, it is possible that her genital and hand lesions were the result of autoinoculation from her initial facial lesion rather than direct sexual transmission. Patients with contact vaccinia can have the same symptoms that vaccinees experience approximately 8 to 10 days after vaccination (fever, malaise, headache, lymphadenopathy, myalgia, and nausea).⁵ However, contacts with vaccinia virus usually have only mild constitutional symptoms.

As demonstrated by this case report, vaccinia should be in the differential diagnosis for any skin lesion in a child or adolescent with physical or sexual contact with personnel recently vaccinated with smallpox vaccine. The differential diagnosis for the skin lesions of contact vaccinia includes infection by herpes simplex virus and varicella zoster virus, cutaneous anthrax, ulceroglandular tularemia, and ecthyma gangrenosum. For ulcerative lesions confined to the genital area, the differential diagnosis includes herpes simplex virus infection, syphilis, lymphogranuloma venereum (generally a single tender lesion with tender regional adenopathy), and granuloma inguinale (progressive, painless ulcers without adenopathy).

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Correspondence: Robert R. Wittler, MD, Department of Pediatrics, University of Kansas School of Medicine–Wichita, 1010 N Kansas, Wichita, KS 67214-3199 (rwittler@kumc.edu).

Accepted for Publication: April 29, 2010.

Author Contributions:Study concept and design: Kroeker, Hinkle, Jones, Scrafford, Rohr, and Wittler. Acquisition of data: Kroeker, Hinkle, Jones, Scrafford, and Wittler. Analysis and interpretation of data: Hinkle, Jones, Scrafford, and Wittler. Drafting of the manuscript: Kroeker, Hinkle, Jones, Scrafford, Rohr, and Wittler. Critical revision of the manuscript for important intellectual content: Kroeker, Jones, Scrafford, and Wittler. Administrative, technical, and material support: Wittler. Study supervision: Kroeker and Wittler.

Financial Disclosure: None reported.