NEJM

Rubins and Relman 348 (5): 414, Figure 1     January 30, 2003

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