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Medicine on the Midway | October 2007
October 2007

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She felt no fear, Madelyn Kahana said, as she peered down at the tiny boy barely conscious and wrapped in blankets in his pediatric ICU bed. Despite the pustules covering his face, arms, legs and hands—teeming like hundreds of bees on a keeper—Kahana, MD, chief of pediatric critical care, and nurse Jamie Harrison remained focused on their patient rather than the potential catastrophe his infection threatened.

“Right or wrong,” she said, “we had no fear.”

But they had reason to fear.

This boy would be the University of Chicago Medical Center’s first chance to manage what could have turned into a widespread, national medical emergency. His case mobilized the medical community: dozens of physicians, nurses, pharmacists, environmental services personnel, food services and infection control staff, social workers, the Centers for Disease Control and Prevention—and even the Department of Defense.

When Kahana and Harrison first met the boy, he’d been in the hospital for five days, after being transferred from another hospital and admitted to the general pediatrics floor with a flare of eczema on Saturday, March 3. He wouldn’t leave the medical center for 48 days. Most of that time he spent intubated, drugged and on a ventilator. For a typical case of eczema, this would have been extreme, but the rash consuming the boy’s skin was anything but typical.

On his first day in Comer Children’s Hospital, the 2-year-old had cuddled up to his mother, then pulled away when doctors and nurses came too close. When pediatric infectious disease specialist John Marcinak, MD, checked in on him, the boy was sitting up in his crib, pointing at a cup just out of reach through the crib’s bars. “Cup, cup, cup,” he chanted. At this point, Marcinak said, the patient had no IV for fluids; nobody knew he’d even need one. Marcinak sees now what he didn’t see then: that the virus ravishing the boy’s body was already dehydrating him.

That first weekend, hospitalist Barret Fromme, MD, saw the boy. Pediatric dermatologist Sarah Stein, MD, met him on Monday, March 5. She suspected eczema herpeticum and recommended “aggressive skin care.” Despite such care, his condition worsened—the rash growing in complexity and extent, his awareness levels dropping—as physicians struggled to decipher the cause.

By Wednesday the lesions covering his arms and legs and the skin around his mouth had changed. Juicy pus oozed from them, and they now resembled craters—red blisters with indentations in their centers that resembled some form of pox infection. Stein consulted with Fromme.

“What are we missing?” they asked each other. Their treatments were failing; the boy clearly was growing sicker, seemingly each time they looked at him. That was when something occurred to Fromme: Had the boy been in contact with a member of the military? Could he have contracted a virus from someone’s small pox vaccination, which is required of people in the service?

A live virus

Why yes, his mother said. The boy’s father was in the military, recently deployed to Iraq, and had been vaccinated at the end of January.

Fromme and Stein knew that the chances of the boy having smallpox were slim to none. They also knew that the smallpox vaccination used a live-virus vaccine, and that people with eczema or compromised immune systems—those with HIV, for instance, or who have undergone organ transplants—are especially prone to contracting eczema vaccinatum, a rare smallpox-like infection, if they came into contact with the vaccine.

The physicians suddenly realized what they were facing. “We were fired up when we made the diagnosis. Now we knew: That’s why he’s not getting better!” Stein said. “But then the reality set in of what this meant for the patient.”

Smallpox is a vicious, deadly and extremely contagious virus that by 1980 had been eradicated by universal vaccinations; however, small stockpiles of the virus still exist in government labs, and many physicians fear that it could someday re-emerge as a bio-terrorism agent.

Kahana’s first thought when she saw the boy was a drawn out, “Oh-my-God,” she said. “It’s no wonder so many people died. [The boy’s rash] looked exactly like textbook pictures of smallpox.” His hands surprised her most. “He had so many lesions, mounds and mounds. The density spread his fingers,” she said.

Though the boy’s father was supposed to ship out to Iraq soon after the vaccination, his deployment was delayed, and he went home for a brief visit in February to see his wife and three kids. “Last time we saw him was in July of last year,” the boy’s mother said in an interview with the Northwest Indiana Times, the only interview she granted. “Of course we wanted to see him before he left [for Iraq] because you never know what’s going to happen.”

The father had no intention of exposing his family to his vaccination. He kept that part of his skin—his upper left[?] arm—completely covered and wouldn’t even show it to his wife when she asked.

“This dad had no idea of the risk,” Kahana said, citing page 4 of a Defense Department document about the vaccine that didn’t go any further than mentioning a “risk for people with eczema.”

Two weeks after the father left, the boy’s skin broke out in a rash, and his mother took him to St. Catherine’s Hospital in East Chicago, Ind. “The doctor at St. Catherine’s said he’d never seen anything like it before. Over three to four days, lesions spread over most of his body,” the boy’s mother told the newspaper.

From there, the boy and his mother traveled to the University of Chicago, not knowing that they wouldn’t return home for almost seven weeks.

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