The New York Times
May 18, 2007
By JOHN SCHWARTZ
A 2-year-old boy spent seven weeks in the hospital and nearly died from a viral infection he got from the smallpox vaccination his father received before shipping out to Iraq, according to a government report and the doctors who treated him.
The boy, who lives in Indiana and has recovered, became ill in early March, two weeks after his father’s deployment was delayed and he was allowed to make a trip home. Over the next few weeks, the boy suffered kidney failure and lost most of his skin to the disease, eczema vaccinatum.
Experts said the father, who had eczema in childhood, should never have been given the vaccine because that fact made him more susceptible to side effects like vaccinia infection. And they said military doctors should have been doubly cautious because the son, too, suffered from eczema and would have been highly susceptible to infection. Military procedures call for asking about such conditions in soldiers and their families.
Vaccinia is the live virus used in smallpox vaccine. After vaccination, the body develops a resistance to vaccinia, a disease that is generally milder than smallpox, and the resistance also works against smallpox. The injection site can spread the vaccinia virus, however, and people without strong immune systems are particularly susceptible.
Smallpox was officially declared eradicated by the World Health Organization in 1979, and inoculation of military personnel was suspended in 1990. But after the terrorist attacks of Sept. 11, 2001, and the subsequent cases of anthrax sent through the mail, the government began vaccinating military personnel and many health care workers, with 1.2 million vaccinated as of March of this year.
Since then, a handful of vaccinia cases have been reported to the Centers for Disease Control and Prevention, including one, described in the May 4 Morbidity and Mortality Weekly Report, of vulvar infection in an Alaskan woman whose sex partner was a serviceman.
Dr. Inger Damon, the acting head of the disease center branch concerned with pox viruses, said, “I think this number of cases certainly raised our awareness and led to discussions between ourselves and the D.O.D.”
An account of the case was published this week in the morbidity report. According to the report, which did not give the family’s name, the boy was taken to the University of Chicago Comer Children’s Hospital on March 3.
Dr. Madelyn Kahana, the chief of pediatric intensive care medicine at the hospital, said in an interview that the child had been covered with “mounds of pox” that reminded her of photos of bees swarming over beekeepers. “I’m a veteran of 25 years of practice in the I.C.U.’s, and I thought I’d seen it all,” Dr. Kahana said. “But this was stunning to the eye.”
Dr. John F. Marcinak, an associate professor of pediatrics who worked 16 hours a day with the boy, said that in the first weeks of the case, “it was really touch and go.”
The doctors gave the boy narcotics to render him unconscious and free of pain. They also inserted a breathing tube and put him on mechanical ventilation to counter the breathing problems that can come with heavy doses of narcotics.
Doctors worked with the disease control centers to get shipments of Vaccinia Immune Globulin Intravenous. They also used an antiviral drug, Cidofovir. That drug, which has been associated with kidney problems in some cases, may have caused another crisis in which the boy’s kidneys began failing and his abdomen filled with fluid.
“He looked like he was going to die,” Dr. Kahana recalled.
The doctors worked with the Food and Drug Administration to allow the use of an experimental drug for smallpox, ST-246, from Siga Technologies, which appeared to begin turning the case around.
Meanwhile, doctors drained the boy’s distended abdomen and cut away the dead skin, a process called debridement that is commonly used in burn victims. They put skin from cadavers over his exposed flesh to promote healing underneath and dressed the wounds.
The child’s mother also developed lesions on her face and index finger. She has recovered, but because of her infection, she had to be confined to his room and witnessed every procedure performed on her child. The military brought the father back from Iraq after the boy became ill.
The procedures for smallpox vaccination were hammered out through long discussion to prevent those who were particularly susceptible to the side effects from receiving it, said Dr. William Schaffner, who served on the C.D.C. Advisory Committee on Immunization Practices.
The case, Dr. Schaffner said, raises the question of “whether the stringent procedures that were initially put in place have eroded somewhat.”
In an editorial accompanying the report, the authors said that the military was studying the incident, “which will determine whether screening and education practices need to be modified.”
The boy’s skin grew back at a phenomenal rate and shows remarkably few signs of the ravages of the disease, Dr. Kahana said. She attributed the recovery to “a lot of good, diligent care and a lot of luck — and maybe divine intervention.”
As for his emotional recovery from the ordeal, she said, “He doesn’t remember a thing.” She added, however, “His mom remembers all of it.”