Images in Clinical Medicine
NEJM
Rubins and Relman 348 (5): 414, Figure 1     January 30, 2003




 <http://content.nejm.org/content/vol348/issue5/images/large/07f1.jpeg>

Photographs show the progression of a lesion from vaccination in a healthy,
previously unvaccinated 23-year-old woman. Undiluted smallpox vaccine
(Dryvax, Wyeth Laboratories) was introduced into the skin of the upper arm
by scarification with 15 punctures from a bifurcated needle. Tender axillary
lymphadenopathy developed bilaterally on day 6 and was more marked on the
ipsilateral side. Erythema and induration were noted from the 8th day after
vaccination through the 11th day and measured 10 cm in diameter. On day 9,
an erythematous streak appeared, extending anteriorly toward the axilla. Two
physicians who examined the patient on day 10 (oral temperature, 37.3°C)
suspected bacterial cellulitis. The erythema resolved on day 11 without
antibiotic treatment. The peripheral-blood leukocyte count peaked at 12,600
per cubic millimeter on day 13. The eschar detached on day 26; however, the
lesion did not fully resolve until day 63. This case illustrates the effects
and skin findings associated with smallpox vaccination in a healthy person.
Features suggestive of bacterial cellulitis may be common. The numbers in
the lower right corner of each photograph indicate the number of days after
inoculation.


Edward E. Rylander, M.D.
Diplomat American Board of Family Practice
Diplomat American Board of Palliative Medicine