Letters to the Editor
Genital Herpes Mimicked by Smallpox Vaccination Exposure
to the editor: A 23-year-old active-duty Marine woman presented to an outpatient military clinic in Okinawa, Japan for sexually transmitted disease screening after developing painful vesicular lesions of the labia and vagina. The patient was initially diagnosed with a primary genital herpes outbreak. Viral culture was collected, and the preliminary isolate suggested herpes simplex. The culture was sent to a reference laboratory in Tokyo, Japan, for final identification that revealed vaccinia, the live virus used in the smallpox vaccine. The patient's medical record revealed that she had not received the smallpox vaccine.
Upon further questioning, it was discovered that the patient's sexual partner, also an active-duty Marine, had received the smallpox vaccination (in preparation for deployment to Iraq) approximately seven days before sexual contact with the patient. Four days after this exposure, the patient presented to the clinic with vaginal vaccinia, suggesting inadvertent inoculation.
The smallpox vaccine available in the United States and used by the U.S. military is a live virus preparation of vaccinia virus, a pox-type virus. The vaccine does not contain actual smallpox virus (variola).
Approximately four days after vaccination, an extremely itchy lesion develops at the vaccination site that contains high titers of vaccinia virus, which can be easily transferred to other body sites (autoinoculation) or other persons (inadvertent inoculation) through scratching and negligent hygiene. Transfer of vaccinia virus from the primary site to other body parts or other persons is the most common complication of smallpox vaccination, and is estimated by the Centers for Disease Control and Prevention to occur in 529 persons per 1 million primary vaccinees.1
As biologic warfare continues to be a threat, many people (military, first-responders) will continue to receive the smallpox vaccination. Patients presenting to their family physician with unusual vesicular rashes should be evaluated for exposure to the smallpox vaccine.
REFERENCE
1. Centers for Disease Control and Prevention. Title? Accessed online April 25, 2005, at: http://www.cdc.gov/smallpox.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Navy Medical Department or the U.S. Navy Service at large.
Physicians Should Be Trained in Handling End-of-Life Issues
to the editor: I read with great interest the article “Making Decisions with Families at the End of Life,”1 by Drs. Lang and Quill. I am a faculty physician responsible for teaching residents and students, and end-of-life issues often arise, especially on the wards. I agree with the approach used by the authors1 to address this issue, but I would add two other points. In the article’s section entitled “Communication Pitfalls,” the authors suggest another way of forming a question about end-of-life issues (i.e., obtaining a “do not resuscitate” [DNR] order or continuing total care) by asking: “Do you want to have everything done for comfort or everything done for survival?” I agree that, to some patients and their families, “do not resuscitate” translates as “do nothing” and has a negative connotation. For residents and attending physicians, especially those who admit unassigned patients to the hospital and who have not had the opportunity to develop a rapport with the patient or family, bringing up the subject of end-of-life issues can be seen very negatively in the eyes of the patient or the patient’s family. I would suggest that revising the wording be taken further regarding the question or statements concerning DNR orders. I suggest we use the term “allow natural death.” Also, as is done in some institutions, after the question “Do you want everything done for comfort?,” ask “Do you want everything done for comfort and to allow natural death?”
My second point is that this article1 demonstrates that physicians must do a better job of addressing this issue before hospitalization, when possible. Before you can address end-of-life issues with patients or their families, you must be comfortable having this discussion.2 How to initiate and complete this discussion seldom is emphasized during physician training. We must become better at teaching this skill during medical school and residency when we, as educators, have the greatest impact on our younger physicians.
REFERENCES
1. Lang F, Quill T. Making decisions with families at the end of life. Am Fam Physician 2004;70:719-23,725-6.
2. Davidson KW, Hackler C, Caradine DR, McCord RS. Physicians’ attitudes on advance directives. JAMA 1989;262:2415-9.
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