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General
Clinical evaluation and a careful patient history of recent smallpox vaccination or contact with a recent vaccinee are the mainstays of diagnosis of smallpox vaccine-related adverse events. In situations where clinical diagnosis is not straightforward, laboratory diagnostics for vaccinia might be helpful and might prevent inappropriate use of potentially toxic therapies. However, diagnostics for conditions easily confused with vaccinia infections (i.e., varicella, herpes zoster, herpes simplex, and enteroviruses), should be considered initially, in particular for a nonvaccinee or someone believed to be a noncontact of a vaccinee.
Diagnostic Tests
Expert consultation with the CDC regarding diagnostic evaluation and treatment of serious vaccine-related adverse events can be obtained through the Clinicians Information Hotline at 1-877-554-4625.
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Laboratory diagnosis of infectious complications consists of rapid diagnostic tests and traditional culture techniques. Tests for varicella include special stains of smears of lesions, direct and indirect immunofluorescent methods, the polymerase chain reaction and culture. Electron microscopy of lesion material can be useful in differentiating herpesviruses from poxviruses such as vaccinia, but a limited number of centers have this capability. Vaccinia can be readily grown in routine cell culture and definitively identified by referral to a specialty laboratory in the LRN and/or CDC. A polymerase chain reaction assay configured to detect vaccinia is under evaluation for deployment to the LRN.
In all instances the LRN laboratory should be consulted immediately to determine the appropriate test for the clinical circumstances and the correct method for collection of specimens and transport to the laboratory.
Immunologic studies are suggested for serious complications to better understand the pathogenesis of adverse events. Tests for the presence of HIV antibody and flow cytometry to determine degree of immunodeficiency in HIV-positives is indicated. Workup for hematologic malignancy or lymphoma may be appropriate.
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