Progressive vaccinia

Last updated
Progressive vaccinia
Other namesVaccinia gangrenosum, Vaccinia necrosum or disseminated vaccinia
4640 lores.jpg
The patient required a skin graft on her upper left arm in order to correct the necrotic vaccination site, due to the onset of progressive vaccinia, formerly known as vaccinia gangrenosum.
Specialty Dermatology
Symptoms Malaise, fever, vomiting and tender, enlarged axillary lymph nodes; progresses to septic Pseudomonas aeruginosa , likely from a perirectal abscess, Clostridium difficile (bacteria) , Staphylococcus aureus and cell-mediated immunodeficiency.
Complications Necrosis of the injected part, exacerbating to gangrene and eventual amputation. Usually, the pocks tend to go away without scarring; however, the external and internal spread of the virus may have serious consequences in persons with eczema and other forms of atopic dermatitis, in these persons, defects of innate immunity and a high level of Th2 cell activity render the skin unusually permissive to the initiation and rapid spread of vaccinia infection (known as “eczema vaccinatum”) [1] [2]
Usual onset11 days to 6.5 weeks
DurationLong-lasting
CausesInjection by the vaccinia virus ( genus : orthopoxvirus) as a countermeasure for smallpox [3]
Risk factors People with cellular immunodeficiencies
Diagnostic method Fever and headache, then progressive ulceration and necrosis of the injection site for smallpox, albeit the lack of inflammation is noted as the "hallmark of PV" [3]
Differential diagnosis May initially be mistaken for leukemia
PreventionUnknown
TreatmentVaccinia Immune Globulin Intravenous (Human) (VIGIV), Emergency Investigational New Drug (E-IND) both administered orally and topically, (in this case ST-246); CMX001, a lipid conjugate of cidofovir and granulocyte colony-stimulating factor for the exiguous normal white blood cells;supportive care; skin graft
Medication Imiquimod, and thiosemicarbazone
Prognosis Lifelong
Frequencyevery 1 or 2 in a million during routine vaccination during 1963-1968 for smallpox
Deathsfatality rate: 15%

Progressive vaccinia is a rare cutaneous condition caused by the vaccinia virus, characterized by painless but progressive necrosis and ulceration. [4]

Contents

Presentation

Complications

Opportunistic fungal, protozoal, or bacterial infections and the vaccinia virus itself may lead to septic shock and disseminated intravascular coagulation, in addition to necrosis and ulcerated skin tissue. Some of these tissues may eventually become large, requiring not only a skin graft but surgical removal of the destroyed tissue, in order to avoid graft-versus-host disease in organ transplanted patients, in whom immunosuppressive therapy would otherwise have to be discontinued to allow healing of the wound.[ citation needed ]

Pathophysiology

Vaccinia is introduced into the skin by means of multiple punctures of a bifurcated needle. The virus replicates in the basal layer and disseminates from cell to cell, causing necrosis and the formation of fluid-filled vesicles. Nonetheless, the initial spread of the virus is slowed by innate antiviral mechanisms, and, by the second week, the cell-mediated immune response begins to eliminate infected cells [lower-alpha 1] . Neutrophils, macrophages, and lymphocytes infiltrate the inoculation site, forming a confluent pustule and releasing cytokines and chemokines that cause hyperemia and edema in surrounding tissues. This may initially manifest into complaints of malaise and other mild constitutional symptoms, fever, vomiting, and tender enlarged axillary lymph nodes. Some vaccinees develop additional local “satellite” pustules that resolve along with the primary lesion.[ citation needed ]

The virus may gain access to the blood at an early stage, and secondary skin lesions, which follow the same evolution as the inoculation site, may appear across the body. Bacteria, like Staphylococcus aureus, may infect the ulcerated, and necrotic lesions. Coalescent lesions may cover large portions of the body with extensive tissue destruction. Although some vaccinia viruses commonly disseminate through the bloodstream, the NYCBOH strain reportedly causes only limited viremia in a small percentage of recipients during the period of pustule formation. [6] [7] The inflammatory process reaches its peak by days 10–12 after vaccination and begins to resolve by day 14, with the shedding of the scab and other pustules by day 21. This sequence of events, which simulates the development of smallpox "pock", is known as a “take” reaction. A successful "take" is required for the development of antivaccinia antibody and cell-mediated responses. [8] [9] [10] [11]

Diagnosis

Treatment

In addition to a skin graft, some medications also work. Among antiviral substances, cidofovir showed some effect in preliminary studies. Apart from treating opportunistic infections with anti-viral, and antibiotic medications, for HIV or immunocompromised (or at the very least iatrogenic immunosuppression like cancer and autoimmune disease) people, immediate highly active antiretroviral therapy (HAART) in HIV patients and withdrawal of immunosuppressive therapy accompanied by aggressive administration of VIG are given to save the patient's life. Intensive care and supportive treatment are required. VIG is given at up to 10 ml / kg body weight.[ citation needed ]

See also

Note

  1. Immunosuppressed individuals tend to have a larger fatality rate and tendency to get the virus due to HIV infection, iatrogenic immunosuppression, etc. Although these conditions are contraindications to the dermovaccine, inadvertent inoculation after contact with a vaccinee may occur; in layman's terms, inoculation means the introduction of a pathogen or antigen into a living organism to stimulate the production of antibodies. [5] Due to the impaired immune response of the host, the virus multiplies by cell-to-cell spread at the inoculation site, and the lesion expands circumferentially, forming the trademark symptoms called "pocks".

Related Research Articles

<span class="mw-page-title-main">DNA vaccine</span> Vaccine containing DNA

A DNA vaccine is a type of vaccine that transfects a specific antigen-coding DNA sequence into the cells of an organism as a mechanism to induce an immune response.

<span class="mw-page-title-main">Cowpox</span> Disease of humans and animals

Cowpox is an infectious disease caused by the cowpox virus (CPXV). It presents with large blisters in the skin, a fever and swollen glands, historically typically following contact with an infected cow, though in the last several decades more often from infected cats. The hands and face are most frequently affected and the spots are generally very painful.

<span class="mw-page-title-main">Smallpox vaccine</span> Vaccine against Variola virus

The smallpox vaccine is the first vaccine to have been developed against a contagious disease. In 1796, British physician Edward Jenner demonstrated that an infection with the relatively mild cowpox virus conferred immunity against the deadly smallpox virus. Cowpox served as a natural vaccine until the modern smallpox vaccine emerged in the 20th century. From 1958 to 1977, the World Health Organization (WHO) conducted a global vaccination campaign that eradicated smallpox, making it the only human disease to be eradicated. Although routine smallpox vaccination is no longer performed on the general public, the vaccine is still being produced to guard against bioterrorism, biological warfare, and mpox.

In biology, immunity is the state of being insusceptible or resistant to a noxious agent or process, especially a pathogen or infectious disease. Immunity may occur naturally or be produced by prior exposure or immunization.

<span class="mw-page-title-main">Vaccinia</span> Strain of poxvirus

Vaccinia virus is a large, complex, enveloped virus belonging to the poxvirus family. It has a linear, double-stranded DNA genome approximately 190 kbp in length, which encodes approximately 250 genes. The dimensions of the virion are roughly 360 × 270 × 250 nm, with a mass of approximately 5–10 fg. The vaccinia virus is the source of the modern smallpox vaccine, which the World Health Organization (WHO) used to eradicate smallpox in a global vaccination campaign in 1958–1977. Although smallpox no longer exists in the wild, vaccinia virus is still studied widely by scientists as a tool for gene therapy and genetic engineering.

<span class="mw-page-title-main">Eczema vaccinatum</span> Medical condition

Eczema vaccinatum is a rare severe adverse reaction to smallpox vaccination.

Marek's disease is a highly contagious viral neoplastic disease in chickens. It is named after József Marek, a Hungarian veterinarian who described it in 1907. Marek's disease is caused by an alphaherpesvirus known as "Marek's disease virus" (MDV) or Gallid alphaherpesvirus 2 (GaHV-2). The disease is characterized by the presence of T cell lymphoma as well as infiltration of nerves and organs by lymphocytes. Viruses related to MDV appear to be benign and can be used as vaccine strains to prevent Marek's disease. For example, the related herpesvirus found in turkeys (HVT), causes no apparent disease in the birds, and continues to be used as a vaccine strain for prevention of Marek's disease.

Modified vaccinia Ankara (MVA) is an attenuated (weakened) strain of the vaccinia virus. It is being used as a vaccine against smallpox and mpox, having fewer side effects than smallpox vaccines derived from other poxviruses.

Orthopoxvirus is a genus of viruses in the family Poxviridae and subfamily Chordopoxvirinae. Vertebrates, including mammals and humans, and arthropods serve as natural hosts. There are 12 species in this genus. Diseases associated with this genus include smallpox, cowpox, horsepox, camelpox, and monkeypox. The most widely known member of the genus is Variola virus, which causes smallpox. It was eradicated globally by 1977, through the use of Vaccinia virus as a vaccine. The most recently described species is the Alaskapox virus, first isolated in 2015.

Artificial induction of immunity is immunization achieved by human efforts in preventive healthcare, as opposed to natural immunity as produced by organisms' immune systems. It makes people immune to specific diseases by means other than waiting for them to catch the disease. The purpose is to reduce the risk of death and suffering, that is, the disease burden, even when eradication of the disease is not possible. Vaccination is the chief type of such immunization, greatly reducing the burden of vaccine-preventable diseases.

The following are notable events in the Timeline of immunology:

<span class="mw-page-title-main">Canarypox</span> Viral disease of birds

Canarypox virus (CNPV) is an Avipoxvirus and etiologic agent of canarypox, a disease of wild and captive birds that can cause significant losses. Canarypox can enter human cells, but it cannot survive and multiply in human cells. There is a live viral vaccine available which may have beneficial properties against human cancer when used as a mammalian expression vector.. Furthermore, the POXIMUNE® C vaccine does offer direct protection against CNPV in susceptible birds.

<span class="mw-page-title-main">ACAM2000</span> Smallpox vaccine

ACAM2000 is a smallpox vaccine manufactured by Sanofi Pasteur Biologics Co. It provides protection against smallpox for people determined to be at high risk for smallpox infection.

<span class="mw-page-title-main">Smallpox</span> Eradicated viral disease

Smallpox was an infectious disease caused by variola virus which belongs to the genus Orthopoxvirus. The last naturally occurring case was diagnosed in October 1977, and the World Health Organization (WHO) certified the global eradication of the disease in 1980, making smallpox the only human disease to be eradicated.

Avian orthoreovirus, also known as avian reovirus, is an orthoreovirus from the Reoviridae family. Infection causes arthritis and tenosynovitis in poultry. It can also cause respiratory disease.

Variolation was the method of inoculation first used to immunize individuals against smallpox (Variola) with material taken from a patient or a recently variolated individual, in the hope that a mild, but protective, infection would result. Only 1–2% of those variolated died from the intentional infection compared to 30% who contracted smallpox naturally. Variolation is no longer used today. It was replaced by the smallpox vaccine, a safer alternative. This in turn led to the development of the many vaccines now available against other diseases.

Vaccinia immune globulin (VIG) is made from the pooled blood of individuals who have been inoculated with the smallpox vaccine. The antibodies these individuals developed in response to the smallpox vaccine are removed and purified. This results in VIG. It can be administered intravenously. It is used to treat individuals who have developed progressive vaccinia after smallpox vaccination.

Inoculation is the act of implanting a pathogen or other microbe or virus into a person or other organism. It is a method of artificially inducing immunity against various infectious diseases. The term "inoculation" is also used more generally to refer to intentionally depositing microbes into any growth medium, as into a Petri dish used to culture the microbe, or into food ingredients for making cultured foods such as yoghurt and fermented beverages such as beer and wine. This article is primarily about the use of inoculation for producing immunity against infection. Inoculation has been used to eradicate smallpox and to markedly reduce other infectious diseases such as polio. Although the terms "inoculation", "vaccination", and "immunization" are often used interchangeably, there are important differences. Inoculation is the act of implanting a pathogen or microbe into a person or other recipient; vaccination is the act of implanting or giving someone a vaccine specifically; and immunization is the development of disease resistance that results from the immune system's response to a vaccine or natural infection.

Raccoonpox virus (RCN) is a double-stranded DNA virus and a member of the orthopoxviruses in the family Poxviridae and subfamily Chordopoxvirinae which consists of eight genera: Avipoxvirus, Capripoxvirus, Leporipoxvirus, Molluscipoxvirus, Orthopoxvirus, Parapoxvirus, Suipoxvirus and Yatapoxvirus Vertebrates are the natural host of Chordopoxvirinae subfamily viruses. More specifically, raccoons are the natural hosts of RCN. RCN was isolated in 1961 from the upper respiratory tissues of 2 raccoons in a group of 92 observably healthy raccoons trapped close to Aberdeen, Maryland.

Postvaccinal encephalitis (PVE) is postvaccinal complication which was associated with vaccination with vaccinia virus during worldwide smallpox eradication campaign. With mortality ranging between 25 – 30% and lifelong consequences between 16 – 30% it was one of the most severe adverse events associated with this vaccination. The mechanism of its underlying condition is unknown.

References

  1. Copeman, P. W. M.; Wallace, H. J. (10 October 1964). "Eczema Vaccinatum". BMJ. 2 (5414): 906–908. doi:10.1136/bmj.2.5414.906. PMC   1816899 . PMID   14185655.
  2. Engler, Renata J.M.; Kenner, Julie; Leung, Donald Y.M. (September 2002). Written at Walter Reed Army Medical Center, Allergy-Immunology Department, Washington, DC, USA. "Smallpox vaccination: Risk considerations for patients with atopic dermatitis". Journal of Allergy and Clinical Immunology. Maryland Heights, Missouri, United States: jacionline.org. 110 (3): 357–365. doi: 10.1067/mai.2002.128052 . PMID   12209080.
  3. 1 2 Centers for Disease Control Prevention (CDC) (22 May 2009). "Progressive Vaccinia in a Military Smallpox Vaccinee – United States, 2009". Morbidity and Mortality Weekly Report. 58 (19): 532–6. PMID   19478722.
  4. James, William D.; Elston, Dirk; Treat, James R.; Rosenbach, Misha A.; Neuhaus, Isaac, eds. (2019). "Progressive Vaccinia (Vaccinia Necrosum, Vaccinia Gangrenosum)". Andrews' Diseases of the Skin E-Book: Clinical Dermatology. Elsevier Health Sciences. p. 388. ISBN   978-0-323-55188-5.
  5. "inoculation". Merriam-Webster.com Dictionary . Retrieved December 9, 2020.
  6. Fenner, Frank; Henderson, Donald A.; Arita, Isao; Jezek, Zdenek; Ladnyi, Ivan Danilovich; Organization, World Health (1988). Smallpox and its eradication. World Health Organization. hdl:10665/39485. ISBN   978-92-4-156110-5.[ page needed ]
  7. Blattner, Russell J.; Norman, James O.; Heys, Florence M.; Aksu, Ismet (June 1964). "Antibody response to cutaneous inoculation with vaccinia virus: Viremia and viruria in vaccinated children". The Journal of Pediatrics. 64 (6): 839–852. doi:10.1016/s0022-3476(64)80642-9. PMID   14172233.
  8. Frey, Sharon E.; Couch, Robert B.; Tacket, Carol O.; Treanor, John J.; Wolff, Mark; Newman, Frances K.; Atmar, Robert L.; Edelman, Robert; Nolan, Carrie M.; Belshe, Robert B.; National Institute of Allergy and Infectious Diseases Smallpox Vaccine Study Group (25 April 2002). "Clinical Responses to Undiluted and Diluted Smallpox Vaccine". New England Journal of Medicine. 346 (17): 1265–1274. doi: 10.1056/NEJMoa020534 . PMID   11923490.
  9. Frey, Sharon E.; Newman, Frances K.; Cruz, John; Shelton, W. Brian; Tennant, Janice M.; Polach, Tamara; Rothman, Alan L.; Kennedy, Jeffrey S.; Wolff, Mark; Belshe, Robert B.; Ennis, Francis A. (25 April 2002). "Dose-Related Effects of Smallpox Vaccine". New England Journal of Medicine. 346 (17): 1275–1280. doi: 10.1056/NEJMoa013431 . PMID   11923489.
  10. Ennis, Francis A.; Cruz, John; Demkowicz, Jr., Walter E.; Rothman, Alan L.; McClain, David J. (June 2002). "Primary Induction of Human CD8 + Cytotoxic T Lymphocytes and Interferon-γ–Producing T Cells after Smallpox Vaccination". The Journal of Infectious Diseases. 185 (11): 1657–1659. doi: 10.1086/340517 . PMID   12023773.
  11. McClain, David J.; Harrison, Shannon; Yeager, Curtis L.; Cruz, John; Ennis, Francis A.; Gibbs, Paul; Wright, Michael S.; Summers, Peter L.; Arthur, James D.; Graham, Jess A. (April 1997). "Immunologic Responses to Vaccinia Vaccines Administered by Different Parenteral Routes". The Journal of Infectious Diseases. 175 (4): 756–763. doi: 10.1086/513968 . PMID   9086127.