Burn injury complicated by vaccinia

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Burns, 2, 14-15

Burn injury complicated by vaccinia Stuart P. Pegg Surgicat Supervisor, Royal Brisbane Hospital, Queensland, Australia William J. McClean Teaching Medico/Registrar, Royal Brisbane Hospital Summary Opportunistic pathogens are increasingly important in burn injuries. A case is presented of vaccinia complicating a minor burn. This could happen with any burn. The problems of. vaccination in a burns unit are discussed. In this case the possible role of immunoglobulins is discussed. [ HAVE been unable to find this complication o f burn injury mentioned in the literature, except for a brief mention in relation to the complications o f smallpox vaccination, when 4 cases o f a u t o inoculation occurred at the site of a recent burn in 14,014,000 vaccinations. There has been no similar case in the burns unit at this hospital in over 1000 burns in 7 years.

CASE R E P O R T A healthy girl, I 1 years old, was scalded with hot tea on her left thigh and left hand. The burns were superficial and she was treated at horne with Sofratulle dressings and oral penicillin. The burns were healing well, when on day 10 she developed a high fever and became lethargic. A large number of vesicles developed on the area of burned skin on both the thigh and hand. Within !~- days the vesicles became pustutar, umbilicated, and discharged yellow-brown purulent material. Within 2 days of the appearance of the vesicles a generalized blotchy erythematous rash developed. At this stage she was admitted to the Royal Brisbane Hospital. On admission she was extremely ill, with a temperature of 39-6 C and her pulse rate was 110 per minute. The left thigh and buttock and left hand were covered with pox-like lesions, umbilicated, and which coalesced to form some large crater-like areas filled with pus (Fig. 1). There was tender left inguinal lymphadenopathy. All four limbs and the trunk were covered with a maculopapular erythe-

matous rash. The virology report stated that vaccinia virus was isolated. She was treated symptomatically and the large infected areas treated with mafenide (Sutfamylon). She improved symptomatically within 24 hours, the rash disappearing. 'I'he raw areas which developed were subsequently grafted. On questioning, the only contact with vaccinia had been with her hairdresser who had recently been vaccinated. There was no clinical or historical evidence suggesting deficiency in hunaoral or cellmediated immunity in the patient or family.

DISCUSSION Opportunistic pathogens have become increasingly i m p o r t a n t as a complication o f burn injuries since the widespread usage of topical antibacterial agents. Fungi, such as candida, aspergillus a n d other phycomycetes, and viruses such as herpesvirus homhtis and cyton'tegalic virus lmve been reported. These generally occur in severely burned patients who are m a r k e d l y debilitated, a n d who have received topical antibacterial agents a n d multiple antibiotics with resultant changes in bacterial flora. I f such a patient were to become infected with widespread vaccinia, it could well be fatal. This patient was healthy and did not have a severe burn. She h a d Sofratulle dressings a n d took oral penicillin a n d it is unlikely that these contributed to her vaccinia. The usual m e t h o d o f vaccination is by applying the lymph to the skin and by multiple impressions of a needle, break the surface o f the skin. A partial-thickness burn as in this y o u n g patient represents a large b r e a k in the skin. The r e m a i n d e r of her skin was intact a n d not involved. This suggests the occurrence of

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Pegg and Mclean : Burn Injury Complicated by Vaccinia

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Fig. I.

Burn of thigh showing vaccinia pustules.

a widespread p r i m a r y infection by vaccinia. O n day 10 the patient was very ill and lethargic with vesicles appearing on tlae burned areas. In primary vaccination the vesicle appears and enlarges to a m a x i m u m at day 9. This would suggest that this patienl had h e r ' v a c c i n a t i o n ' on d a y l to 2. Studies of i m m u n o g l o b u l i n levels have shown IgE and IgA to be temporarily depressed after burn injury. However, IgG and ]gM are lost into the burn wound, and even in less severe burns they are reported to fall to the lowest levels in the few days following burn injury, returning to n o r m a l levels in 2 weeks. With this patient it can be postulated that m a x i m u m depression of lgG occurred at the time of contact with vaccinia, allowing massive spread o f the virus, with severe systemic reaction. The patient was very ill on admission but settled rapidly over a few days. This is consistent with the effects o f vaccination and vaccinia and vaccinia virus was isolated. Hospitals frequently have smallpox vaccination programmes. This is highly desirable, but the

possible spread to burned patients could be disastrous. Personnel in burns units should be aware of this problem.

BIBLIOGRAPHY ALEXANDER J. W. (1971) Immunologic consideration

and the role of vaccination in burn injury. In: POLK H. C. and S'IONE H. H. (ed.), Contemporary Brow Mattagemenl." Boston, Little, Brown & Co., p. 265. MUNSTER A. M. and PRUITT B. A. jun. (1971) Recent advances in the management of burns. Med. J. Aush 1,484. NEFV J. M., LANE J. M., P~:RT J. H., MOORE R., M1LLAR J. D. HENDERSON D. A. (1967) Complications of smallpox vaccination. New EngL J. Med. 276, i 25. PEC;G S. P. (1972) Adult burns: a survey w;lh as;essment of Suifamylon. Med. J. Aush 1, 350. PRUITT B. A. jun. and CURRERI W. (1971) The burn wound and its care. Arch. Surg. 103, 461. STITZ R. W. (1972) Burns in children, a three, year survey. Med. J. Aust. 1,357.

Requests for reprints shotdd be addressed to: S. P. Pegg. FRCS, FRACS, Royal Brisbane Hospital, Herston Road, Brisbane. Q.4029,

Australia.