On June 24, 2012, CDC notified Public Health Services, County of San Diego Health and Human Services Agency, of a suspected case of vaccinia virus infection transmitted by sexual contact. The case had been reported to CDC by an infectious disease specialist who had requested vaccinia immune globulin intravenous (VIGIV) (Cangene Corporation, Berwyn, Pennsylvania) for a patient with lesions suspicious for vaccinia.
The patient reported two recent sexual contacts: one with a partner who recently had been vaccinated against smallpox and a later encounter with an unvaccinated partner. Infections resulting from secondary transmission of vaccinia virus from the smallpox vaccinee to the patient and subsequent tertiary transmission of the virus from the patient to the unvaccinated partner were confirmed by the County of San Diego Public Health Laboratory. The smallpox vaccine had been administered under the U.S. Department of Defense smallpox vaccination program.
The vaccinee did not experience vaccine-associated complications; however, the secondary and tertiary patients were hospitalized and treated with VIGIV. No further transmission was known to have occurred. This report describes the epidemiology and clinical course of the secondary and tertiary cases and efforts to prevent further transmission to contacts.
Secondary Vaccinia Case
On June 24, a man went to a private hospital in San Diego County with a painful perianal rash of 3 days' duration and more recent onset of a lesion on the upper lip. The patient reported having had sexual intercourse on June 15 with a man who had recently been vaccinated against smallpox. The patient recalled feeling moisture on an uncovered area of his partner's left upper arm and was concerned that his rash might have been caused by this exposure.
In addition to the rash, the patient reported experiencing fever, malaise, nausea, and vomiting before seeking medical attention. He also reported a history of psoriasis and a possible history of eczema. Atopic dermatitis (i.e., eczema) can be a risk factor for adverse reactions to vaccinia infection (1,2).
While performing the physical examination, the infectious disease specialist noted seven 5-mm umbilicated lesions in the perianal area and a similar lesion on the upper lip. The County of San Diego Public Health Laboratory detected nonvariola Orthopoxvirus by polymerase chain reaction (PCR) on swab specimens from the lesions.
The patient was hospitalized for continued care and observation. Human immunodeficiency virus and other sexually transmitted infections were ruled out during his hospitalization. VIGIV was requested from CDC and administered intravenously on June 25 because of concerns about the location and extent of lesions and the potential for further spread.
The patient experienced mild, transient chest pains the morning after hospitalization. To assess the possibility of postinfection myocarditis (3), an electrocardiogram was performed and the cardiac troponin level was measured. Both tests were normal, and the patient was discharged from the hospital on June 27. By July 6, when the patient had a follow-up examination, his lesions had healed without complication.