ECZEMA

By
Department

Audrey

H.

of Pediatrics,

2EMA

Reynolds,

University

M.D.,

of Southern

is a form

VACCINATUM

VACCINATUM

of

and

gen-

eralized
vaccinia
occurring
chiefly
on
eczematous
skin. Although
infrequent,
it is
the most
common
and
most
serious
complication

to

smallpox

vaccination.1

portant,
eczema
both iatrogenic
ent

purpose

cent

cases

is to describe
resulting

childlren

with

atopic

vaccinated

siblings,

additional

cases

drens

key

emphasize

the
Los

files

recommendations,

simple

and

of

Angeles.

effective

and

shall

prophy-

laxis.

Case

REPORTS

buccal

were

The

confluent

cvte

count

47,000/mm3

cells,

20% band

drens

Hospital

atopic

with

eczema
two

school
vehoped

vaccination
a t-pical

his

audi

amld

tions,

been

vaccinated

contact.

There

extremities.

including

vaccinated

in

ineffective.

Adrenocorticosteroids
systemically.

vomiting
and
cal sensitivities

urticaria,

were

had

suffered

incomplete
chiefly

the

been

but

been

specific

hospital,
and

his

temperature

respirations
(Accepted
This

(H.A.J.)

study

from

ADDRESS:

When

FINDINGS:

was

32/mimi.
February
was

He

18, 1958;
conducted

the Los
(H.A.J.)

he

in

entered

39#{176}C,pulse

serum

Angeles
County
Heart
4614 Sunset
Boulevard,

an

of

to

repeatedly

from

the sixth
sensitive

from

isalated

the

from

pattern
normal.
Micrococcus

chhoramphenicol,
and
bacitracin,
the

skin

skin.

stools.

beta
and

ervthiso-

vesicular

Pseudomonas
B and oxy-

enterococcus
albamycin,

All three
Blood

was
and

hospital
day
to polymyxin
a

of

of electrolytes

hemolytic

sensitive
albamycin

lated

a normal

ml, 9%
paper

by

approximated

positive

tured

December
tinder

and

Repeated

0.6 gm/l00
of serum

Concentrations

consistently

160

submitted
part

in the

tetracycline,
and
tive to erythromycin

acutely

measured
Analysis

age.

the

appeared

second

Concentrations

revealed

for

fluid. On
aeroginosa,

Alhad

occimrred.
PHYSICAL

protein.

proteins

pyogenes,
romycin,

clini-

the

and globulin
on the day of admission
3.8 and 1.1 gm/100
ml, respectively,
and

Coagulase

caused

2 days

counts were

respectively.

unrevealing.

forms

reduced

count

on

days,

were

band

Eosinophih

and

before

was

a platelet

rose

day

day

of

count

10,400/mm3

hospital

electrophoresis

medicanot

and

gamma-globulin
of the total

re-

not been
recognized.
other
than
eczema

manifestations

were

remishead,

white

other

albumin

death;

count

the

proportion

of
leuko-

segmented

hospital

on

Platelet

lymph

the

leukocyte

fourth

6,000/mm3.

urinahvses

generally

had
Egg

before
was

fourth

in

the

60%.

to

2,400

known

topical
had

the

slightly

of

54%

with

10,200/mm3

although

3 days
hater

whom
deThe patient
no

Various

had

of

been

he

antibiotics,

administered

lergic

weeks

on

increased
of

Three

sibling

had

simplex.
of age
and
involving

Chil-

exacerbation

program,
oie
primary
reaction.

contact
with herpes
Since
5 months
peated
exacerbations
sions
of eczema
neck

entered

duration.

had

siblings

successfull-

intimate

severe

3 days

of

earlier

male

of ulceraand

ml and

The

arms

concentration

gm./100

forms.

ob-

on

areas
cold

The

FINDINGS:

12.2

corneae
were

enlargement

was

death
A 15-month-old

with

was

lesions,

Vesicles

were

hemoglobin

to

neck

vesicles

mucosa.

extremities

declined

HISTORY:

not

legs

the

and
and

umbihicated

to 72,000/mm3

CASE

Angeles

crusted

Conjunctivae

but

LABORATORY

thera-

for

hemorrhagic.
on

face

oozing,

cyanotic.
Generalized
nodes was striking.

in particular,

precautions

of the

purulent,

clear,

tion.

We

features,
and,

of

were

recently
Chil-

of Los

surface

1). The

mass

served

the

M.D.
Hospital

(Fig.
partly

seven

Joos,

ill, the skin massively

covered
by
lesions
of varied
character.
The
were circular
umbilicated
vesicles
of 3 to 5 mm diameter,
largely
distribution
of chronic
eczema

re-

A.
Childrens

and critically
new and old
recent lesions
and pustules
limited
to the

between

and

diagnostic

peutic

two

to summarize

from
of

frequently
Our pres-

contact

eczema

and

Hospital

is

in detail

from

im-

More

vaccinatum
and preventable.

Howard
and the

California

were

orgamiisms

cultures

were

sensicul-

were
sterile

18, 1957.)

Established

Association.
Los Angeles

Investigatorship

Grant

to

one

of

the

authors

27, California.
PEDIATRICS,

259

Downloaded from by guest on August 19, 2016

August

1958

ECZEMA

260

1. Case

Fi;.

the

until

iiionas

eighth

cerel)rospinal
til

Ii051)ital

aerognmosa

vas

fismid

s-as

da-s

mortem

dla\

the

on

audi

examination,

was

920

FINDINGS:

ing abnormal
days

hater,

verse

dhiameter

the fourth

on
the

nificantlv

day
of

virus

isolatedl
taken

of

cinia

vesicular
tops

mortem
A
isolated

the

titer

virus
at

was
the

of

the

Los

fluid
inhibitioml
admission

of

probable
was

from
titer

tissue
of vac-

in serum
was
1:5;

obpost

I :320.f
vaccimmia-variola

Angeles

City

Viral

group
was
and Rickett-

sial I)isease
Laboratory
and the
California
State
1)epartinent of Public
I lealth
Laboratory,
Berkeley.
f Wc are indebted to C. Henry Kempe, M.D., for
his generous
co-operation
in performing
time vac#{231}iliiahemagglutination
inhibition tests and in sup-

most

On

and

from

stituted

for

bamycin,

began
to
appeared

which

fever
day,

after

amid

remained

On

the

nig

kg,

tenth
and

contimlued

was

On that
extremities

was
was

applicatiomi,
given

day

vaccinal

al-

mouth.

the

eighth
diedlilied

tmntil
polymvxin

100

sub-

and

daily

subnormal

day
amid

aeroginosa
solution,

temperature

streptomvcin,

al-

sixth
hosthe skin of

through

which

hospital

Downloaded from by guest on August 19, 2016

hos-

6 and

skin
the
on

improve.
on the

was

plying
the iiyperimmune
used in this and in Case

the

ulceration

through
lesions

in topical

mg/kg,

hospital

eighth
days

the

B, 0.1%

Spiking
rapidly

the
tenth

Pseudomonas

saline

30

to

vaccinal
gammailltramnuscularh

until

the

Polymyxin

for
COIl-

applied

Confitmence,

crusting
advanced
day, after
which

face,

rotmte

soaked

injected.

involved.

pus

kg,

Chlortetracy-

was

ninth

ill-

mg

same

were

5 days.

appeared

lesions

cultured.

the

through

were

the abdomen
green,
foul

given
50

given

second
the

totally

and
pital

for

Hyperimmune
ml,
was

respectively,
New

sig-

group
and

ml,

by

ointment

the

day.

were

lesions

saline

10

from

pital

trans-

appearance
amid

of vesicles.#{176} The
of

the

Six

increased

vaccinia-variola

iiemagglutination
on tile
day

tained

the

congestion

the

from
from

had

with
ophthalmic

conjunctivae.
globulin,

noth-

day.

to death,

heart
with

ptmhmommiry
vascular
bronchopneurnonia.
A

daily

hospital

prior

the

association

in

Roentgeno-

daily

The

8 days.

tinuously

fluids

chioramphenicol,

adminstered

dine

of the chest revealed

examination

and

first

forms.
Pseudo-

cultured.

ROENTGENOGRAPHIC

graphic

the

disclosed

however,

cells 1 00 iiil,
85
polvmorphonuclear
Pandy
test was strongly positive, and
imionas aeroginosa

was

post-

vesicles.

Appropriate

travenously,

hospiat

fluidi

and

COURSE:

of

fourth

Spinal

pustules

Pseudo-

Exaniination

first

unrevealing.

1. Umbilicated

lien

cultured.

VACCINATUM

mg

death.
B,

kg,

were

gatmumia-globiilii

ARTICLES

FIG.

261

2 (Upper).
Post-niorteni
photograph
of child
described in Case 1. Areas of
are secondarily infected with
Pseudomonas
aeroginosa,
\Iicrococeus
pyogemies
and beta enterococcus.
FIG.
:3 (Lower).
Case 2. Discrete tmmhilicated vesicles of eczema
vaccinatum.

gangrene

added

in (hiVidled

No
the

intramuscumlar

fresh lesions of
seventh

tue eighth

On

da.

however,

progressive

gangrene

with
the
appearance
nients and
progressive
Coarse
heard

and

rhonchi
bilaterally.

the

liver

of

minor

edige

given

hospital day,
hess

(Fig.

2).

13

hospital
convumlsive

was

ings

day,

acute

mo-

dlifficulty.

palpate(1

expired
dlavs

4 to 5 cm

Hydrocortisone,
6 hours
early

on

the

after omiset of the

In

NECROPSY:

after

first appeared

respiratory

intraniumscularly

patient

death. The

daily.

meningitis

suppurative

in25

before

addition

was

disruption
findings

infected

patchy
Moderately

of
multiple

embohi

atelectasis
severe

stitial myocarditis

acute
was

severe,

Severe,

acute
with

epithehium.
areas
septic

patchy

Other
of

thrombi,

with
and

find-

demonstrated,

included

bronchopneumonia,
otis

clinical

tile

amid ventriculitis.
bronchitis

considerable

td)

necropsv#{176}revealed

described,

pulmonary

aiid diffuse sticky rales were

Facial
ediema
became
severe

feri()r to the costal margin.

nig, was

(loses
appeared

vaccinia

early
numer-

infarction,
emphysema.

inflammnatorv
demonstrated

interin

the

eleventh
acute

ill-

Tad

Perfonned
by
Sato, M.D.

Robert

Downloaded from by guest on August 19, 2016

S. Cleland,

M.D.,

an(i

ECZEMA

262
myocardiuin

was

the

of

observed

invading

the

were

right

in the
inner

not

detected

FINDINGS

IN

ventricle.

adrenal

Hemorrhage

medulla,

cortex.

in the

cination

bodies

of any

tissue.

MEMBERS

pes

OF

at

which

time

age

the

had eczema
chiefly
spaces,
undergoing

of chronic

administered

atopic
arms

lichenified

dermatitis
and

over

legs,

since

late

areas

the

flexor

which

childhood.

sur-

She

had

remissions

never

nized.

She

lesions

of primary

hospital,

hamids.

Three

days

were

observed

vesicles
and

face.

bulbar

later

on her

A single

lesion

conjunctiva.

Disease
eral

Unit

variola

Los
a

group

was

after

eventfully. Scarring
The

maternal

amid lived

patient
and

for

lesions.

recovering
was

the

hospital

days

she

the

neck.

lesion

The

had

father

been

twice

recently
the patient

ITlost

after

14

trunk
Eyes

and

.3 days.

Twenty-two

been
from

vaccinated,
the home

with

recent

5 days,

which
primary

turned

home

which

no

vaccinated
a doll of
her home
The
for

for

earlier

a sibling

had

and the patient

was removed
because
the danger
of contact

vaccination

at

vesicular

days

was

time

the

recognized.

sibling

vaccination,
a brief

had
the

half-hour

comltact

occurred

sibling,

although

she

The
17

authors
are
indebted
permission
to include

early

patient

period

direct

that
sibling.
permanently

After
an

reduring

with
did

play

patient
returned
days
after
the
to
Case

Elsie
2.

the
with
to
vacFerreil,

ill.

140/mimi

and

the

widespread,

was

vesicles

were

scattered

over

(Fig.

super-

free

The

14.9

revealing.

declined
discharge.

Eosinophil

Concentrations

total
the

ml.

measured

Coagulase

count

was
and

leuko-

72% segleukocyte

1.3

ml,

gm/100

hemohytic

on
un-

1,540/mm3.

globulin
ml,

The
electrophoretic
proteins
was
normal
positive

The

with
The

3.6 and 2.5 gm/100

protein.
plasma

cer-

to 17,300/mm3
Urinalysis
was

of albumin

were

(eggand

concentration

gm/100

cyte
count
was
42,900/mm3
mented
cells,
22% band
forms.
count
gradually
the day
before

Axillary

present.

FINDINGS:

was

skin

enlarged
inguinal

also

neck,

edematous.

of lesions.

marked

was

the

3). The

and

massively

or

LABORATORY

A 3-year-old
female
entered
Chilwith atopic eczema
infected
for

severely

were
were

of hemoglobin

globulin

Hospital

entered

and

stmrfaces

mouth

adenopathy

on the
com-

she

erythernatous

vical

2*

HISTORY:

generally

serum

drens

M.D.,

was

Fever
followed

plication.

Case

were

pophiteal

Moderate

two lesions
of primary
vaccinia
appeared
fathers
lower
lip. They
resolved
without

When

Eczema

vesicles

and

size).

suc-

of acute

acutely

umbihicated

a single

years
ago.
the hospital,

attacks

Senrecog-

imposed,
chiefly
involving
hands
and
feet.
Vesicles
were confluent
in these areas and several
ulcerations
were
present.
Discrete
urnbilicated

un-

been

40#{176}C,pulse

40/mm.

nodes

vaccinated

about
entered

was

lymph

resolved

been

days.

not

several

appeared

numerous

un-

eventfully.
cessftmlly,
Two
days

and

had

FINDINGS:

she

the

after

noted

on the
adenopathy

which

PHYSICAL

She

unvaccinated

Four

reaction
cervical

after

Gen-

vaccinia-

minimal.

family.

vaccinia
pronounced

1 week

was

the

had

Six

had

asthma.

respirations

left

Contagious

the

days,

the

entered

primary

from
5

chest

County
of

had

had

entirely.

for several

antigens

Temperature

in the

Angeles

grandmother

with

neck,

the

virus

isolated

discharged

was

arms,

entered

where

own

umbihicated

appeared

She

of the

Hospital

typical

her

patient

the

hands
and popliteal
exacerbations
and

clearing

parenterally

to specific

typical

on

only

been
no
with her-

adrenocorticosteroids

stivitv
bronchial

of the
numerous
never

earlier

been
vaccinated.
Two days
after
the patient
entered
the hospital,
the mother
observed
four
vaccinia

but

months

been

had

had

had
none

of 3 months

The vaccinal
infection
involved
other
members
of the family.
The mother
had had
eczema
as an infant
and asthma
as a child.
She still suffered
periodic
acute
exacerbations
of

sibling

There
and

simplex.

Since

THE

FAMILY:

faces

the

a small
residual
eschar.
other contact
with vaccinia

in places

Inclusion

cells

OTHER

VACCINATUM

and

in the
gamma-

21% of the
pattern
of
for
age.

Micrococcus

pyo-

genes,
sensitive
to chloramphenicol,
tetracycline, erythromycin,
albamycin
and bacitracin,
was isolated
from the skin. Blood cultures
were
sterile.
A virus
of the vaccinia-variola
group
was
isolated
from vesicular
fluid and from samples
of tissue

taken

titer of vaccinia
serum
obtained
the hospital
was
* See

footnote
f See footnote

from

the

tops

of vesicles.#{176} The

hemagglutination
11 days
after
1:320.f
page
page

Downloaded from by guest on August 19, 2016

260.
260.

inhibition
admission

in
to

ARTICLES

263

TABLE
SITMMAIIY

OF

SEEN

PATIENTS

zlge
.lqe

ex

No.

( oat act

Con/art

rezema

face

sums.

general

Treat

general

eye

exts.

direct

18

face,

vacc.

1957

JUNE

men!

Outcome

sth.

general

general

sibs.

sib.

Blood
Penicillin

searred,

Chlor-

Recovered

Recovered. Face
irido-keratitis resolved

amphenicol

trunk

13

exts.

Chlor-

trunk

TO

(days)

VAcCINATuM-1949

Duration
(days)

Extent

to un.se!

(mo)

ECZEMA

from

I ace.

of

I ee ma

I
WITH

Time

Extent

of

(yr)

hOSPITAL

a,

Onset
(a.se

ChILDRENS

AT

Recovered

amphenicol

11

general

2O

14

general

Blood
Chloramphenicol

Recovered

Chlor-

Recovered

amnphenucol

gemmeral

-1

hospital

general

Blood
Clilor-

Pltietit

Died

anmphenicol

Penicillin
M

COURSE

tinuously,

Affected
later

konium

chloride,

bamycin

1 : 2000

and

chloramphenicol

were

given
ointment

junctivae.

Hperimmune
of

Fresh

the

advanced
as

high

as

hospital
improved,
evident.

from

the

lesions

vaccinal

but

areas

did

footnote

page

260.

the

patient
Two

manifested

the

from

large

dosage

of

1 month

Again,

ex-

patient
in spite

gamma-globulin

earlier.

were

uneventful.

the
rubeola

typical

clinical

were not selecskin. Course

were

discharge

but

weeks

typical

varicella

after

weeks
mild

ex-

was

inadvertently.
she

recovery

Four
perienced

of

administhe

course

and

uneventful.

in-

the
had

result

Other

Cases

of Eczema

Seven additional
from the records
Los

Angeles

marized

tient

was

in

cases
of the

during

in

months
one

See

#{176}

discharge

recovery

slough
not

varicehla

varicella,
the lesions
of which
tively
distributed
to eczematoid

tered

on

of superficial
scarring

after

days.#{176}

of fever

wrists

Recovered

hospitalization
to

lesions

declined

and

During

and

on

discharged

Hands

lesions.

mg/

of vaccinia
4 das

temperature
was

Significant

100

older

After

da!.

mg/

Neosporin

hospital
and

40.3#{176}C, the

eighth
were

third

All

She

Al-

40

intramuscularly

thereafter.

to normal.

greatly

and

3 days.

sharply

saline.

Chloramphenicol

posed

applied
to the convaccinal
gamma-

appeared

rapidly

con-

benzal-

doses.

injected

second

for

voluted

soaked

with

orally

was

was

lesions

were

hours,

in divided

ophthalmic

each

exts.

in isotonic

kg/day,

10 ml,

exts.

intramuscularly,

kg/day,

globulin,

neck

administered

15

face

tieck

areas

every

17

12 sibs.

face

12

Table

I.
One

exposed

the

of eczema
Childrens

the

to 4 years.

to

hospital

Vaccinatum

last

8 years

All

were

was

directly

Downloaded from by guest on August 19, 2016

are

males,

a recenfly

where

vaccinatum
Hospital
age

vaccinated;
vaccinated

the

of

sum-

eczema

pa-

was

ECZEMA

264
11 n(ler
treatment.
the disease
from

The reniaining
five
recently
vaccinated

VACCINATUM
vaccinia.9

contracted
siblings.

Inquiries

tricians,

allergists

days

disclosed

less

after
contact
with
saccinia.
Complete
recovery
usually
re(luiredl
2 to :3 weeks.
One patient
died.

in their

collective

Uml)ihicate(I

The

vesicles

others

appearedl

recovered

tiOIis,

except

one

cant

scarring

of

without

17

further

patient
the

to

who
face

signifi-

resolved

irido-

keratitis.

The

over-all

cinatum

is not

incidence
not

reported

cases

cases

of

forms

cinia

other

or

eczema

clearly

is

of

with

only

1 in

mass

1947.;

150,000

mediate

figures

quoted.5

There

cases

of the

are

significance

in

of

an

ill

are
cause

ingly

rare

in

reported

tion.

Varicella
we

Willard

not

and

Parker

Hospital

eczema

study

of

61

complications,

tered

none

patients
Glaser

with

not
and

varicehla,

smears

of tissue

for

intracutaneous
fluid

into

and

and

elementary
inoculation

rabbit,

inhibition
tests,

portive

planned

must

of

complement

hemagglutination

measures

fluid
bodies,

and

culture

emhryo.lol2

and

be

general

supas care-

fully and pursued

tensive
and severe

as diligently
as for an exburn.
Secondary
bacterial

infection

especially

may

be

has usually
been
cases.
Hyperimmune
is now
It

peated

Variola
has

not

for

specific

intramuscularly

ported

tinuous

from
comIn

eczema

mI/kg.

This

therin

dose

may

doses
be

re-

daily

The
of

In
for

1.0

1)

is insufficient
regarding

to support
its effective-

ness.

coincidence
varicella

to

(Case

cause
of death
in
vaccinia
gamma-

available

given

present
experience
a reliable
conclusion

it is exceedand

0.6

is

grave

the

if fresh
lesions
continue
to appear
and advance
in a severely
ill patient.
Despite
its theoretic
therapeutic
advantages,

mentioned.8

with

of
(3

of

observed

was

of the lesions

with

reported.
with

distribution

titers,
virus
neutralization
of the virus
on the chick
Local
care of the lesions

apy.

consideration,

eczema

patients

ob-

in differentia-

the

re-

Such

States

found

cases

alone.

but

require

test,

globulin

and

of eczema

a problem

may

the

eczema

herpeticum.

United

distribution

of

cannot
be reliably
eczema
vaccinatum
b

vesicles

vesicular

and
fatal

ec-

fever

is not

atopic

picture,

as

2,534

plications,
a

the

pox
of

atopic

with

pathognomonic
eczema

have

chicken
series

of

a similar

been

of

child

infection

almost
or

may

but

lesions

bacterial

vaccinatum

nine

urnlesions

early

Umbilication

in the

as

of

appearing

1), the
to areas

acutely

secondary
lesions

in the

stained

fixation

low

on recognition

suddenly
(Fig.

lymphadenopathy.
served

deaths

first

in distribution

zema

eczema
as

and

the

Pauls

in

series.

vesicles

limitedi

two

depends

bilicated

from

several

the course
of the illness.
History
contact
with
a recent
vaccination

from

City

selective

in

herpeticum
from

specially

although
intermore
commonly

4Q%,1

were

to

during

York

reported

as

present

Diagnosis

20,000
it occurred

mortality

high

always

vaccinations

the

as

in

in New

is variously

and

not

varicella
did
to eczema-

to 21 days)
or with a recent
typical
infection
of herpes
simplex
is strong
presumptive
evidence
for the
specific
cause.
Laboratory
procedures
of particular
assistance
include

vac-

vaccinatum

although

Similarly,

4%

are
once

vaccinations

vaccinatuim

generalized

occur

vaccinations,25

and

cases
details
are

audi

lesions
of
selectively

although

have

such

to us.

or by
direct

of

of pedia-

(lozeIl

experience,

the character

cases

etiology

Eczema

to

vac-

Most

unconfirmed,

herpeticum

said

100,000

eczema

The

differentiated.

been

the

of
known.

reported.

many

the

observed

Eczema
differentiated

accurately

probably

has

skin,

was

ported
DISCUSSION

are

toid

a number
dermatologists

a half

than

few. In Case
2 the
not appear
to localize

complica-

suffered

and

from
and

with

Edwards

encoun-

although

one

had

cases
sporadic

complication
cation
we
and entirely
implications
It is not
eczematous

reported

here

elsewhere2,l115

and

those

illustrate
occurrence

the
of

this

recongrave

to vaccination.
It is a compliregard
as frequently
iatrogenic
preventable.
The
medicolegal
of such
situations
are obvious.

enough
child.

Downloaded from by guest on August 19, 2016

to avoid
Most

vaccinating

of the

cases

the
and

the

ARTICLES
large

majority

sulted

of those

from

and

contact

a recently

member

vaccinated

of

that

his

be

vaccination

reminded

that

if

eczema
monition

tinent

years

being

be

in

danger

to

mother

with

tiley

tion

child

give

We

have

eczema

age

children.

ing

child

when

of

pertinent

sent

of

of

parents

New

reply.

No

for

forms

at all

states
or

stated

local

or

dication

This

in

forms.

separation

lance

vaccination.

Children

chronic

disease

or another

state
amend

and
local
public
their
forms
for

tion

to

form

skin

include
should

should

be consulted

or any

member

other

any

is of

interest

whose

eczema

be

is illegal

where

the

has

eczema

family
disorder

of

vaccination
in

that

there
at

least

one

the
of

any

is

a
large

necessity

for

vigi-

Patients

of the

the

on wards
eczema,

burns,

or healing

patients

about

the

In addition,

danger

of contact

herpetic

vaccination

from

strongly

age,17

onset

of

particularly

allergic
may

families.

be

gamma-globulin.

exposed

to

indicates

many

with

infec-

be recom-

may

of

vaccination
the

atopic

or active

at 2 months

way

with

of skin are ensimple

precauwarned
as early

In

accomplished

that
from

he
that

may

be

at

disease

vaccinal

It

cated

should
of

be

baby

coincidently

with

a baby

is

partly

pro-

administration

gamma-globulin.

urgently
eczema,

mdi-

the

protected

perimmune
gamma-globulin
not to interfere
significantly
velopment
of active
immunity.

Downloaded from by guest on August 19, 2016

atopic

evidence

least

by

is considered
a

of

suggestive

If vaccination
for

cases

If such

smallpox,

of hyperimmune

child
Euro-

skin,

or

child

case

be allowed
from
atopic

for

vaccinal

tected

doctor

skin.

recently

eczema.
If a baby
with
atopic
eczema
is inadvertently
exposed
to vaccinia,
he should
probably
be
treated
with
hyperimmune

authorities
to vaccina-

warning

the
wards.

before

that

in cases

environment

city.14

health
consent

vac-

at
ec-

urge

and

or

that

We

without

or

of the
has

signed

of his

disease

warned

disorder.

a specific
not

this

immunized
family

complete

after

vaccination

for babies

forms

two

home.

21 days

caring

mended

allergy

be

of the

zema

tion.

form

contrain-

Washington,

parents

member

to

as possible

severe

be

child

the

at least

eczema
and other
diseases
couraged
to take additional
tions.
Parents
should
be
a recent

of

the

from

incisions.

either

not

are

if any

diseases

use

with

Nowhere

danger

other

the

One

must

Physicians

children.

such

vac-

in vaccinateczema
even
and

removed

pediatric

surgical

states.

County,
should

of

con-

or

eczema

is recognized

vaccinated
should
not
with patients
suffering

failed

one

with

8 emphasizes
on

in nine

warning

danger

until

Case

form

of

did
in

cination.

used

Only

any

Seattle-King

states:

school.

are

from

as a step in asand preventable

the

is

compromise

request-

of

that

of a patient

risk

to the

obtaining

Mississippi

allow

implied
to

used

and

the
eczema

it failed

1950,
in

vaccination

Jersey

Thirty-five
state

used

a sibling

with

contraindica-

since

forms

inferred

department
cases
included

to vaccination.

2 illustrates

the

The
but

delay,

vaccinatum

a copy

Only

pean

simi-

written
all state
departments
inquiring
about
the incidence

health

ing

in

Case

to the

incomplete-

be

recommend

complication

to vaccination.

public
of

or

may

be made
reportable
attention
to a serious

of

eczema

figures

I. We

per-

the

these

fact that the California

know
of the seven

in

inquiry.

known

Tile

cinatum
suring

dermatitis
when
consenting
to vaccina-

without

warning

of

unaware

with

school

consent

parents

were

Table

parents

should

1950

reportable
to our

departments.

admore

less

not

replying

since

health
of

was

states

has

atopic

a form

of their

tions

literature

it is no

1 were

chronic

signed

urged
to

the

be

This

safeguard,

The

Case

the
not

family

vaccinated

informed.

described

the

the

and

ness

and

46

cases

state

must

vaccinatum

of the

Sixteen

asso-

know

disorder.

As a further

children

larly

in

others

of

skin

ago,16

today.

and

member

Eczema
any

requires

vaccination

other

reeczema

usually

programs,

appeared

50

than
of

any

or any

with

Prevention

nurses,

with

avoided

literature

person,

family.

physicians,

ciated

in the

of a patient

265

which
with

baby

with

hy-

is said
the de-

ECZEMA

266

VACCINATUM

SUMMARY
Nine

of

cases

presented,
were

eczema

including
caused

zema

by

with

contact

superimposed
almost

upon

mere

secondary

is

flOW

Eczema
genic

and

The
prophylaxis

2) No
member
skin

disorder

disorder.

with

3)

Parents

21

days.

5)

health
vaccination

disease.
be

excluded

ing

patients

eases

of

incisions.

state

vaccinated

pediatric

wards

atopic

eczema,

burns

or

Vaccination

at

2 months

babies

from

strongly

of

age,

allergic

local

15.

Dock,

17.

on accidental
vaccination,
York M.
83:11,
1906.
Doorschodt,
H.
Vaccinations

dis-

2.

3.

families.

4.

Arch.

amid Rickettsial
Consideration

Disof
CamBrit.

M.

J.,

1:91, 1943.
5. Hershey,
F. B.,

and

Smith,

W.

presentate

contacto

J.

their
Public
Health
Significance.
bridge,
Harvard,
1940,
p. 217.
Jubb,
A. A.: Generalized
vaccinia.

Es

IN

E.:

Gen-

mente

vaccinate

umbilicate
zema

Septe

juveniles

ectopic

es

INTERLINGUA

de

eczema

Le
diagnostic

per

con

he

recente-

apparition

superimposition

vaccinate
o eczema
herpetic.
Istos
in mermente
secundari
infectiones

Le tests
que
definitemente
buhina
gamma

vaccinate,

causate

eczematose
in

quasi

against

children.

esseva

fraternos.

vesiculos

New

Vaccinate

9 casos

2 mortes.

de

work

1904.

Maand25:1,
1957.
Ab164:610,
1957.

Eczema
incluse

Blochmanns

young

J.A.M.A.,

SUMMARIO

SmallNorth

vac-

J.:

Kindergenusk.,

stract,

for

Kempe,
C. H., and Benenson,
A. S.:
pox
and
vaccinia.
Pediat.
Chin.
America,
February,
1955,
p. 19.
Tedder,
W.: Eczema
vaccinatum.
Dermat.,
34:1008,
1936.

Ross, R. A.: In Virus

eases
with
Especial

F.

in very

schr.

REFERENCES
1.

Professor

smallpox

recom-

especially

G.:

J.,

surgical
be

progressive

16.

containother

1947.

J.

to

must

healing
may

14.

6) Ecreportable

3:355,

cinia.
Arch.
Dermat.,
75:837,
1957.
Fasal,
P.: Eczema
vaccinatum
successfully
treated
with
chloramphenicol
(Chloromycetin#{174}). J.A.M.A.,
144:759,
1950.
Graves,
G. W.,
and
Dowrnan,
C.:
Accidental
smallpox
vaccination
and eczema
vaccinatum.
New York
Med., 37:183.3,
1937.
Strickler,
A.:
Kaposis
varicelliform
eruption.
A report
of five cases,
all in children.
Urol.
& Cutan.
Rev.,
48:340,
1944.

13.

appropriate

recently

skin,

mended

and

Med.,

agammaglobulinemic

of

consent

an

with
8)

12.

for at least

parents

include

from
the

child

contraindications.
should
be

7) Patients

if any
or other
with

J.

Am.

Sexton,
G. B., Labzoffsky,
N. A., and Ross,
W. G.:
Kaposis
varicelliform
eruption.
Arch.
Dermat.,
75:361,
1957.
Lewis,
H. M., and
Johnson,
F. C.:
Fatal

11.

children

by

for

should

Smallpox.

vaccinated.

at the onset
from
vaccination

that

used

departments

warning
of the
zema
vaccinatum

10.

of a child with atopic

he must
be com-

from

Forms

be

of

4) If a sibling
is vaccinated,
separated

J.

for
eczema

be vaccinated
has eczema

eczema
should
be notified
the disease
of the danger

pletely

J.,

9.
iatro-

atopic

J.

J.

recommended

should

child
should
of his family

contact.
eczema

infection.

preventable.
child

cc-

Wishik,
S. M., and Bullowa,
G. M.: Complications
of varicella.
II. Surface
complications.
Am.
Dis.
Child.,
49:927,
1935.
Glaser,
and Edwards,
W. M.: Hospital
mortality
and
morbidity
of
infantile
eczema.
Am.
Dis.
Child.,
60:526,
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Heath,
F. K., ed.: Combined
Staff Clinics:

gamma-globulin

are

atopic

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8.

occur

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due to

Pediat.,
32:532,
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C. F., and Ross,
R. A.: Genvaccinia
and eczema
vaccinaM. Chin. North
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22:785,

turn.

or

specific
therapy.
is frequently

steps

: 1) No
skin

are

not

bacterial

uniformly

following

or other

do

vaccinal

available
for
vaccinatum

7.

complicating

child.

J.

zema.
McKhann,
eralized

vesicles

vaccinatum

virus

vaccinia

ec-

eczema

eczema

These

Hyperimmune

with

sibling.

atopic

of

herpeticum.

with

a child!

umbilicated

diagnostic

eczema

Seven

vaccinated

appearing

are

fatalities.
of

a recently

Suddenly

vaccinatum

two

eralized
vaccinia
in an eczematous
Am. J. Dis. Child.,
69:33,
1945.
6. Fries, J. H., Borne,
S., and Barnes,
Varicelliform
eruption
of Kaposi

de
a

pro

eczema

non

occurre
bacterial.

ec-

existe
pro estabhir
le diagnose
es enumerate.
Hyperimmun
gbvaccinal
es hodie
disponibile

Downloaded from by guest on August 19, 2016

ARTICLES
Un

therapia

specific.

frequentelnente
venibile.

Le

Nulle
altere

UD

vaccinate.

(2)

debe

esser

vaccinate

si un

familia

debe

informate

del

con

vaccinatos.

condition

o puera
minus

con

eczema

SosaE

C.

altere
o tin

juveniles

al

tempore

(5)

Le

ASPECTS

OF

engrossed

o puera

inter

he

del

un

disease

the

atopic,

esser

al

con

BIOSYNTHESIS

May

del

altere

esser
esser

disordines

inchudite

reportate

cutanee,

chinmrgic

incomplete.

(8)

Vaccination

al etate

infantes

ab

con

in stato

TmoR

qui

IMPORTANCE

TO

MEDICINE,

3, 1958.)

problems
it is often

of
difficult

diagnosis
to

and

appreciate

management
tile

of

interconnec-

tion
hetwemi
fundamental
laboratory
investigations
and their
application
to better
understanding
of clinical
conditions.
This is an interesting
and readable
account
of
the present
knowledge
of the details
of synthesis
of hemoglobin,
and
the manner
in
which
this
knowledge
accounts
for the
otherwise
mysterious
findings
in clinical
conditions,
such
as sickle
cell anemia
and
thalassemia.
It provides
an exceptionally
inspirihi
opportumiity
for
those
who choose
to look upon medicine
as an intellectual
experience
as well
as a humanitarian
service.
A historical
review
is given of the reniarkable
discoveries
which
have
enabled
us to penetrate
into the wonderful
mechanisms
by
which
tile
body synthesizes
the gbobin and heme
portions
of hemoglobin.
This affords
a background
for orderly
explanation
of the seemingly
unrelated
and greatly
varied
symptoms
and signs of the aneniias
dependent
upon inborn
errors of metabolism.
For
example,
fronl

in
normal

abnormal
hemoglobin

tile

lies

for a molecule
of glutamic
relatively
slight
abnormalities
consequences
one observes

al

globin
which
produces
the
sickle
cell
trait,
the difference
in the substitution
of a molecule
of the amino
acid
vahine
acid in one of the polypeptide
chains
of globin.
Similarly,

in globin
or heme
synthesis
give rise to the serious
in fully developed
clinical
syndromes.
Congenital
porphyria
likewise
results
fronl
a defect
in the system which controls
the utilization
of
coproporphyrin
I in the synthesis of henie.
Some
of the abnormalities
in globin
and
heme
synthesis
which
occur
in natural
disease
states
are being
duplicated
by in-vitro
expennlents.
The autilor holds out hope that we may sonic day be able to control
the
abnormal
synthesis
which
occurs
in afflicted
persons,
and thus be in a position
to
make
a direct
attack
upon
their
disability
instead
of resorting
to all the ftmmbling
nieans
of management
now at our disposal.

Downloaded from by guest on August 19, 2016

ar-

de
pote

de 2 menses,

famihias

allergic.

AND

e statal

contraindicationes.

debe

incisiones

pro

local

del parentes
ah
deberea
includer

Individuos
qui ha recentemente
debe
esser excludite
ab salas
se trova
patientes
con eczema

recommendate

mente

sanitate

deberea

que

o con

cialmente

es usate

practical

morbos

essite
vaccinate
pediatric
ubi

illes

in patients,

mention

vaccinate
(7)

dituras,
re-adhesion

de

le consentimento
de br filios e filias

autoritates.

puero

M. J., 1:1017,
with

of

Eczema

declara-

HAEMOGLOBIN
(Brit.

lmlanifcstatioIS

appropriate

durante
que

departimentos

(6)

vaccinate,

formularios

Riniington.

\Vhen

es

completemente

obtener

cutanee

de comitactos
de

le

vaccination

disordine
del

per

pro
un

eczematose

fratermlo

atopic

es
con

membro
altere

de

Si tin

separate

21 dues.

puero

in re le periculo
(4)

esser

Nulbe

eczema

Parentes

esser

tion

debe

ha

(3)

pre-

o puera

disordine

esser

mesnie

es

semper

prophylactic

puero

debe

cutanee.

es

mesuras

(1)

atopic

vaccinate

Illo

sequente

recommnendate.
eczema

Eczema

iatrogene.

267

spe-

es forte-

ECZEMA VACCINATUM
Audrey H. Reynolds and Howard A. Joos
Pediatrics 1958;22;259
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1958 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

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ECZEMA VACCINATUM
Audrey H. Reynolds and Howard A. Joos
Pediatrics 1958;22;259

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
/content/22/2/259

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1958 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on August 19, 2016