Vaccinia necrosum complicating immunoblastic sarcoma

Abstract

A 59-year-old man is presented who had immunoblastic lymphadenopathy which evolved over a three-year period into immunoblastic sarcoma. His course was complicated by vaccinia necrosum, which necessitated prolonged therapy with Marboran and vaccinia-immune globulin. The persistence of virus was documented at autopsy by positive viral culture and ultra-structural examination. This case illustrates the potential hazards of administration of live viral vaccines to an immune compromised host presumed to be in remission and suggests that the continued activity of viral infection may signal the unsuspected persistence of underlying disease.

British HIV Association guidelines for immunization of HIV‐infected adults 2008

“…In the past, high doses of vaccinia immunoglobulin (VIG) derived from immunized individuals appeared to be effective in halting a proportion of cases of progressive vaccinia. VIG was most effective in patients with less severe immunological defects [206–208]. The experience with VIG for the treatment of progressive vaccinia in persons with AIDS is limited to one reported case [204].…”

Smallpox Vaccination and Patients with Human Immunodeficiency Virus Infection or Acquired Immunodeficiency Syndrome

“…The reaction consists of progressive enlargement of the primary site of inoculation and viremic spread to other sites with 10-20 cutaneous lesions. The lesions show minimal local inflammation, biopsy confirms minimal lymphocytic infiltrates, and cultures of specimens of these distant sites yield vaccinia [4,[12][13][14][15][16]. This com-plication may occur after primary vaccination or revaccination [4,14,16] and is usually fatal.…”

“…The standard treatment is VIG [4,[12][13][14][15][16]20], although it has never been studied in a controlled trial. Availability of VIG is controlled by the CDC (telephone number, 404-639-3670).…”

Vaccinia Necrosum: A Forgotten Disease

“…Complications of this nature almost invariably occur in patients who are immunocompromised. Cases have been reported in patients with immunocompromise caused by chronic lymphocytic leukaemia, 6 as in the present case, or hypogammaglobulinaemia, 7 immunoblastic sarcoma, 8 thymic aplasia, 9 Hodgkin’s disease, 10 mild monoclonal gammopathy 3 and HIV infection. 11 …”