White Coat Underground

In February, a young woman visited an urgent care clinic complaining of painful vaginal ulcers.  The differential diagnosis of genital ulcers is interesting.  Common sexually transmitted infections such as gonorrhea and chlamydia don’t cause ulcers, but syphilis, herpes, chanchroid do (as do other diseases, but they are not common in the U.S.).  Syphilis is typically painless, so most painful genital ulcers turn out to be herpes, and sometimes chanchroid.  She revealed to the doctors that she had recently had sex with her boyfriend, a soldier who had just been vaccinated against smallpox.  The clinic treated her for chanchoid and herpes, as well as gonorrhea and chlamydia, and perhaps cellulitis.  She didn’t get better.  

The history of smallpox vaccination is pretty cool. In fact, the word “vaccination” comes from the name of the virus used to immunize against smallpox. The vaccinia (“cowpox”) virus was used in the first inoculations against smallpox, and is still the basis for current vaccines. It is also used in a very clever way to help vaccinate animals against rabies.  Smallpox is not the safest vaccine, and given that the disease has been eradicated, the risk-benefit ratio rarely justifies its use, which is currently restricted to certain military personnel, lab workers, and first responders. 

To vaccinate people against smallpox, vaccinia, a closely related virus, is injected into the skin causing a localized infection.  This infection produces an antibody response and memory response.  Because vaccinia and smallpox are so closely related, the antibody response is close enough to give immunity to both cowpox and smallpox.  But that viral infection on the upper arm can be problematic, as this weeks Morbidity and Mortality Weekly Report illustrates.

After being treated for multiple STDs, the young woman went to another doctor because her rash was worse.  He attempted to test her for cowpox, but sent off the wrong sort of tube and the specimen couldn’t be tested.  The infectious disease expert he referred her to collected the correct specimen, and she eventually healed.
The Epidemiology Intelligence Service (EIS) investigated and found that her boyfriend had removed the bandage from his vaccination site, and that their sexual activity had included digital vaginal manipulation.
This is really cool for a variety of reasons.  STDs are common, and the presenting lesions were not atypical of some common STDs.  Still, the doctors were handed the data that she had been potentially exposed to vaccinia.  But vaccinia is vanishingly rare, and patients are often ignored.  The next doctor tried to do the right thing, but made the same mistake many of us would likely make—he sent a swab for a viral disease in a standard viral medium, which turned out to be wrong.
It’s often said that most diagnoses can be made with a careful history and physical exam.  It’s also said that when you hear hoofbeats, you should think of horses rather than zebras.  In this case, a careful history and physical might have revealed to an astute clinician that a zebra was in the room. 
 
This isn’t the first report of cowpox being sexually transmitted, but it’s the first one I’ve ever read about.   I guess I’ll be adding this to my differential for genital ulcers.  
References

Centers for Disease Control and Prevention (CDC) (2010). Vaccinia virus infection after sexual contact with a military smallpox vaccinee — washington, 2010. MMWR. Morbidity and mortality weekly report, 59 (25), 773-5 PMID: 20592687

Comments

  1. #1 Dean Austin
    July 1, 2010

    If the infection resulted from “digital vaginal manipulation”, is it really accurate to say that the infection was sexually transmitted?

  2. #2 PalMD
    July 1, 2010

    Well, I don’t know about you, but I think that if one person is touching another person’s vagina in the pursuit of sexual pleasure, it’s hard to call it anything else.

  3. #3 chantal
    July 1, 2010

    I’m actually participating in a clinical research trial for a smallpox vaccine that doesn’t have the same risks attached. It’s pretty nifty– the first shot gave me a 10cm red blotch on my arm that was incredibly tender and hot to the touch. I believe my last antibody titer (3 months out) came back with similar levels of antibodies to the vaccine version currently in use, but we’ll see how the rest of the study goes.

  4. #4 Coturnix
    July 1, 2010

    I remember smallpox. It was a part of my life growing up – I was 7 at the time. I got vaccinated several times until finally the immunization “took”. But I remember the panic, the quarantines, the news coverage, and the martial law that forced everyone to get immunized. For more, Wikipedia page is pretty good:

    http://en.wikipedia.org/wiki/1972_outbreak_of_smallpox_in_Yugoslavia

  5. #5 PalMD
    July 1, 2010

    Bora, you’ve gotta write about this…

  6. #6 Coturnix
    July 1, 2010

    I remember very little. I can ask my Mom for more memories. And read some documents and articles from the time…

  7. “…their sexual activity had included digital vaginal manipulation. This is really cool for a variety of reasons.”

    Yes it is.

  8. #8 Dean Austin
    July 2, 2010

    Well, I don’t know about you, but I think that if one person is touching another person’s vagina in the pursuit of sexual pleasure, it’s hard to call it anything else.

    Posted by: PalMD Author Profile Page | July 1, 2010 5:52 PM

    So any time the genitals are infected, no matter how or from where, it’s a “sexually transmitted disease”? I thought STD meant genital-to-genital transmission.

  9. #9 PalMD
    July 2, 2010

    Nope.

  10. #10 JustaTech
    July 6, 2010

    And that’s why I was a very good little lab monkey and missed an entire summer of swimming, so I wouldn’t infect other people with my vaccinia. I think that’s the challenge of immunizing people who aren’t in the medical/health sciences. It’s really hard to impress the risks and responsibilities on an entire platoon of Army recruits so they remember in 6 weeks.

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