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Special Feature
February 7, 2011

Picture of the Month—Diagnosis

Arch Pediatr Adolesc Med. 2011;165(2):177-178. doi:10.1001/archpediatrics.2010.281-b

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.