Boy in Okinawa presents with painful, itchy sore near his eye
What’s your diagnosis?
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The following case, provided by Michael Cater, MD, a pediatrician at Children’s Hospital of Orange County, California, is the first of a two-part series.
Check back next month for the second installment.
Boy develops sore near left eyelid
In 1972, a 6-year-old boy in Okinawa is seen for a sore near the margin of his left lower eyelid. It appeared 2 days earlier, accompanied by some mixed pain, itching and mild erythema and swelling of the infraorbital soft tissue.
Figure 1. Boy presents with a lesion near the margin of his left lower eyelid. Image: Michael Cater, MD.
The parents deny any recent injury to the eye or illness, and his overall health is described as very good. Likewise, his past medical history is that of a healthy child with immunizations up to date. In fact, he had recently received his required immunizations before starting first grade. He has had no recent sick contacts.
His examination was that of a healthy 6-year-old with normal vital signs. A focused exam of his left eye confirmed the findings noted earlier (Figure 1). The rest of his exam was positive only for a cluster of blistering lesions on his right upper back, with some surrounding erythema (Figure 2).
Figure 2. A 6-year-old boy with a blistering sore on his right upper back. Image: Michael Cater, MD.
What’s your diagnosis?
A. Autoinoculation of herpes simplex virus
B. Autoinoculation of smallpox vaccine virus
C. Dacryocystitis
D. Molluscum contagiosum
Answer and discussion:
The answer is B, autoinoculation of smallpox vaccine, which contains live vaccinia virus, and can easily be transferred by hand to other mucocutaneous sites, such as lips, eyes (Figure 3), the anal area (Figure 4) — wherever a child’s fingers may roam. This is why it is generally recommended that the vaccine site be covered and/or placed in an area that is not easily reachable by the child’s hand, such as the upper back, as shown in Figure 2.
Figure 3. A child with autoinoculation of smallpox vaccine to both eyelids and lower lip. Image: James W. Bass, MD, MPH.
The vaccinia virus is related to the variola virus that causes smallpox but does not cause severe disease in healthy people. When inoculated with the live vaccinia virus, cross-immunity against the variola virus occurs. The hints may be obvious to those of us who have had smallpox vaccine and lived through the end of the smallpox era but might be a challenge for those who have never seen smallpox or had a smallpox vaccine. The last case of smallpox in the United States was in 1949. The last “natural case” of smallpox in the world was in 1977 in a man named Ali Maalin of Somalia (for a picture and details, just Google him). He was apparently so grateful for surviving smallpox that he became dedicated as a professional vaccinator with the WHO and helped with the eradication of smallpox and in the polio campaign. Unfortunately, he died of malaria in 2013.
To get the correct answer, one would need to know that in many areas of the world, smallpox was still being seen in 1972, and to know that at that time, those areas required a smallpox vaccine before starting school — usually first grade, and that no other immunization would produce a blistering lesion. Also, as noted, no other immunization would normally be placed on the upper back, which limited the child’s ability to reach it. However, there obviously were exceptions, which is why covering the site was advisable. However, you cannot control what happens after the family leaves the office.
Figure 4. A child with autoinoculation of smallpox vaccine to the anal area. Image: James W. Bass, MD, MPH.
The last case of smallpox occurred in 1978, secondary to a lab accident at the University of Birmingham Medical School in the United Kingdom, with infectious material rising from the lab through the ventilation system to a photography studio one floor above and infecting an employee named Janet Parker, resulting in her death. This was the last recorded case of smallpox, which was subsequently declared eradicated from the world in 1980. This case also highlights the fact that lab accidents can happen. The only place the smallpox virus can be found today are in labs under the control of the CDC and in Russia. Several agreed-upon dates for the simultaneous destruction of the remaining viruses by the U.S. and Russia have come and gone without action. So, theoretically, smallpox could make a comeback through irresponsible acts of others.
There will be more on the fascinating history of smallpox and the vaccine that eradicated it in part 2 next month.
As for the other choices, autoinoculation with herpes simplex is certainly possible, but most young children with lesions about the face (Figure 5) likely acquired the primary lesion at birth, and what we see is reactivation of the virus rather than autoinoculation. If located about the eye, it needs to be taken very seriously, making sure to rule out ocular involvement, with its potential for sight-threatening complications. For management, I would refer you to the Red Book, or John Nelson’s Yellow Book for treatment guidance, and if there is eye involvement, an ophthalmologist should be involved.
Figure 5. A child with reactivation of HSV involving the lower lid of the right eye and infraorbital area. Image: James H. Brien, DO.
Dacryocystitis is inflammation of the lacrimal sac, usually due to an infection stemming from obstruction of the nasolacrimal duct. Examination usually reveals the typical erythema between the nose and infraorbital tissue along with the discrete swelling of the sac (Figure 6). These infections are typical in appearance and easy to diagnose, but treatment is best managed by an ophthalmologist, as these are very delicate structures that could be damaged by simply trying to drain with pressure or with instrumentation.
Figure 6. A child with dacryocystitis of the left nasolacrimal duct and sac. Image: James H. Brien, DO.
Lastly, molluscum contagiosum is a dermatologic condition caused by the molluscum contagiosum virus (MCV), which is a DNA virus in the Poxviridae family. Included among the viruses of the Poxviridae family are smallpox, monkeypox, cowpox and vaccinia — all relative to the subject of this column. MCV invades the superficial layer of the skin (epidermis), producing the characteristic dome-shaped, fleshy lesions that go on to develop central umbilication, with a core of whitish material that contains the viral particle. When this core is removed, the virus is removed. The virus spreads from person to person by direct contact and also by contaminated fomites, such as towels. These can occur on the face and about the eye as shown in Figure 7 (from the July 2018 column). Over time, the lesions will resolve, but the vast majority of patients want them gone soon after diagnosis. This can be done by curettage or freezing or the use of a variety of topical agents (see the Red Book). For areas about the eyes, it may be prudent to refer to an ophthalmologist or dermatologist for therapy about this sensitive area. Also, lesions in the inguinal area should be treated to prevent spread in sexually active patients.
Figure 7. A child with multiple molluscum contagiosum lesions about the right eye. Image: James H. Brien, DO.
Columnist comments:
Keep your “thinking cap” on, as part 2 of this historic topic will appear next month in the July column.
References:
American Academy of Pediatrics. Committee on Infectious Diseases. Red Book. 2021–2024 Report of the Committee on Infectious Diseases. Academy of Pediatrics; 2024. https://redbook.solutions.aap.org/redbook.aspx. Accessed June 7, 2024.
Bradley JS, Nelson JD, eds. 2024 Nelson’s Pediatric Antimicrobial Therapy. 30th ed. American Academy of Pediatrics; 2024.
For more information:
Brien is a member of the Healio Pediatrics Peer Perspective Board and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at jhbrien@aol.com.