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We present a case of vaccinia folliculitis that we term sycosis vaccinatum to correctly identify its etiology and scope of infection.
Report of a Case
A healthy, immunocompetent 30-year-old man undergoing basic military training presented with a 4-day history of a progressive vesiculopustular eruption of the anterior neck and chin. The patient denied symptoms of pruritus, burning, or fever at time of presentation. This patient had not received the smallpox vaccination, but he had engaged in simulated unarmed combat with individuals who had recently been vaccinated. Medical history was noncontributory, and the patient was not taking any medications.
Examination revealed more than 2 dozen monomorphic, broad-based folliculocentric pustules with central umbilication, overlying serum crust, and surrounding erythema and edema of the anterior neck, chin, and inferior cheeks (Figure 1). The patient was admitted to the hospital owing to the extensive disease burden and to protect his daughter, who had atopic dermatitis (a risk factor for developing disseminated disease). The patient’s hospital course was notable for continued development of new lesions, fevers to 39°C, progressive edema of the face, and anterior cervical lymphadenopathy. The continued evolution of his disease required vaccinia immune globulin (VIG) therapy.
Vesiculopustules with central umbilication in the beard area at time of presentation.
A punch biopsy taken early in his hospital course demonstrated classic viral changes to the epidermis consisting of ballooning degeneration of keratinocytes with intracytoplasmic inclusions (Guarnieri bodies) and a brisk lymphocytic and neutrophilic infiltrate (Figure 2A and B). The presence of vaccinia virus was confirmed by polymerase chain reaction (PCR). Electron microscopy demonstrated viral particles typical of vaccinia present within the Guarnieri bodies (Figure 2C and D). Two weeks after initial presentation, pink depressed scars were present on the chin and jawline.
A and B, Hematoxylin-eosin–stained specimens. A, Epidermal necrosis and prominent intraepidermal edema with ballooning degeneration (original magnification ×40). B, Early ballooning degeneration, necrotic keratinocytes, neutrophilic infiltrate, and Guarnieri bodies (arrowhead) within the pale staining cytoplasm of a ballooned keratinocyte (original magnification ×600). C and D, Electron microscopic images of specimens. C, Clusters of viral particles (arrowhead) present within necrotic keratinocytes (original magnification ×5000). D, A variety of morphologic forms were present; some were electron dense and had a somewhat homogeneous appearance (single arrowhead); others had a partial clearing of the internal portion of the viral particle (double arrowhead); both forms were bordered by a double limiting membrane and were covered by a dense layer of amorphous material (original magnification ×150 000).
We propose the term sycosis vaccinatum to describe the autoinoculation of vaccinia in the beard area with resulting viral folliculitis seen in the present case. To our knowledge, this reaction has not been discussed in the literature or reported to the vaccine adverse event reporting system (VAERS). In contrast to the term vaccinia folliculitis, sycosis vaccinatum describes the diagnosis and clinical presentation and avoids confusion with postvaccinial nonviral folliculitis (PVNVF).1,2
The course of sycosis vaccinatum parallels the progression at a primary vaccination site from vesiculopustule to crusted papule and ultimately to healing with a depressed scar. The timing of sycosis vaccinatum evolution is 7 to 10 days following vaccination, which is similar to that of PVNVF. However, sycosis vaccinatum is a localized form of autoinoculation, whereas PVNVF is a poorly understood idiosyncratic inflammatory or hypersensitivity response to vaccination.1,2
Findings of PCR, viral cultures, electron microscopy, immunohistochemical (IHC) analysis, and immunofluorescence (IF) studies are negative for the vaccinia virus in PVNVF but positive in sycosis vaccinatum.1,2 We confirmed sycosis vaccinatum by PCR, following the guidelines of the Centers for Disease Control and Prevention (CDC) for confirming a case of inadvertent autoinnoculation.3 Histopathologic analysis in sycosis vaccinatum shows ballooning degeneration of keratinocytes within the epidermis with intracytoplasmic inclusions called Guarnieri bodies.2 An acute inflammatory cell infiltrate composed of neutrophils and lymphocytes extending into the epidermis is also characteristic. Use of IHC analysis and IF studies can also identify the vaccinia virus.3 The preferred diagnostic test is PCR because it is more sensitive than culture and does not require expertise in processing or interpreting electron microscopic specimens.
Treatment for sycosis vaccinatum is primarily supportive, involving local wound care and measures taken to prevent further inoculation (cessation of shaving, covering of the wounds, and avoidance of contact with other people). Sycosis vaccinatum requires VIG therapy if systemic symptoms are present, and any VIG use should follow CDC recommendations for systemically ill patients with generalized vaccinia, progressive vaccinia, or eczema vaccinatum to reduce morbidity and mortality.3
Corresponding Author: Todd T. Kobayashi, MD, Dermatology Residency Program, San Antonio Uniformed Services Health Education Consortium, 2200 Bergquist Dr, 59th Medical Wing/SG07D, Ste 1, JBSA Lackland Air Force Base, TX 78236-9908 (firstname.lastname@example.org).
Published Online: April 22, 2015. doi:10.1001/jamadermatol.2015.0380.
Conflict of Interest Disclosures: None reported.
Braswell MA, Morrissey MW, Ritchie SA, Reddick RL, Kobayashi TT. Sycosis Vaccinatum, a Type of Vaccinia Folliculitis. JAMA Dermatol. 2015;151(7):799–801. doi:10.1001/jamadermatol.2015.0380
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