Smallpox physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Depending on the stage of the disease, physical findings may include: high fever, tachycardia secondary to the fever, rash of the oral mucosa, skin rash with typical progression, ophthalmological changes, abdominal pain, and altered mental status.

Physical Examination

Appearance of the Patient

Depending on the stage of the disease, the smallpox patient may have different appearances. These may range from:^[1]^[2]

Asymptomatic, if it is a patient who had contact with someone with smallpox, got the infection, and is currently in the incubation period
Extremely ill, if it is someone who is in the prodromal period and appears extremely ill, is vomiting and fatigued

Vitals

Temperature

A fever is often present, particularly in the prodromal period

Rate

Tachycardia is often present

Blood Pressure

Hypotension may be present

Skin

A rash is often present
Lesions may be present

Eyes

Extra-ocular movements may be abnormal
Pupils may not react to light
Sclera may show inflammation, ulceration and/or hemorrhage

Throat

The throat may be erythematous
There may be exudate on the throat
There may be petechiae on the throat

Abdomen

Abdominal distention may be present
Abdominal tenderness may be present
Hepatomegaly may be present
Splenomegaly may be present

Extremities

Edema may be present

Neurologic

Mental status may be altered

Gallery

Classic maculopapular rash due to an ordinary, or “discrete” smallpox infection. Note distribution of the rash included his chest, left arm and hand, and left thigh and leg, affecting the contralateral side in the same manner.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Male from Sierra Leone. Case of “modified” smallpox, in which the patient had received a smallpox vaccination some months before. Note the sparse amount of maculopapular skin lesions dispersed over his face. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right lower lip and chin region of a 25 year old woman, who had been accidentally infected on her face after her daughter was vaccinated against smallpox. Here we see the residual scarring left behind,Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Upper arm revealing the site of a newly-administered smallpox vaccination, which had been performed using a “Ped-O-Jet®” jet injector. Notice the wheal type morphology of the vaccination site.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
This was a vaccinial lesion that had manifested itself on the face of a mother who had acquired the virus after her daughter’s smallpox vaccination.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
This image depicts the smallpox vaccination site, which in the case of this recipient, displayed a reaction after a period of seven days.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
This image depicts the right shoulder region of a male patient from a lateral perspective, who’d received a smallpox vaccination, while ill with chickenpox. Note the intense reaction at the vaccination site.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
African Cameroonian boy in the process of receiving his vaccinations during the African Smallpox Eradication and Measles Control Program.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Girl who received a smallpox vaccination in the left upper arm displayed a local complication at the vaccination site, where a chronic superinfection resulted in a granulation tissue reaction. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Child’s arm after having received a smallpox vaccination in the country of Sierra Leone. Note intradermal wheal, which is a raised area at the site where the Ped-o-jet® delivered the smallpox vaccine. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Newborn infant delivered during its 28th week of gestation, to a mother who’d received a primary smallpox vaccination during the 23rd week of her pregnancy. Upon delivery, this infant displayed typical vaccinial skin lesions, and died at 8 days of age. Vaccinia virus was isolated from the placenta. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right eye of the same 80 year-old female patient who's been accidentally infected by her grandchild, who’d been vaccinated not long before. Note the severe distortion of the palpebral margins due to the typical vaccinial lesion of the outer canthus.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right eye of a 6 year-old child, who'd been accidentally inoculated with the vaccinia virus, and subsequently developed these severe conjunctival vaccinial lesions. The child had received a primary vaccination, and inadvertently transferred the vaccinial virus to his/her own eye.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
6 year-old boy, who'd been accidentally inoculated with the vaccinia virus, and subsequently developed these vaccinial lesions upon his face. This boy's lesions healed with no residual scarring.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Left upper arm of a middle-aged woman who’d received a primary smallpox vaccination, and thereafter, developed local erythema, and a “bull’s eye” surrounding the site. This type of “local involvement is common in older, primary vaccines.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
After having received a smallpox vaccination on the small of his back, a 14 month old infant manifested a non-specific rash in the form of extensive erythematous patches over his entire body, except for relative paring of the soles of his feet.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Accidental vaccinial inoculation of a two year-old boy’s left eye. This boy’s mother had been vaccinated 12 days before his ocular vaccinia became apparent. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
70 year-old female smallpox patient who’d received a smallpox vaccination, and subsequently developed a severe reaction to the vaccine known as “vaccinia necrosum”.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Initial vaccination site. This was a case of progressive vaccinia, also known as vaccinia necrosum, and despite intensive treatment, this patient died, and was found to have a deficiency in her cellular immunity mechanism.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Dorsum of the right hand of a 71 year-old woman revealing a metastatic lesion of vaccinia necrosum, also known as progressive vaccinia. The margins of this lesion display the characteristic of typical confluent vaccinial growth. Despite intensive treatment, this patient died, and was found to have a deficiency in her cellular immunity mechanism.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Female who’d received a smallpox vaccination, and subsequently developed a severe reaction to the vaccine known as “vaccinia necrosum”. This woman was also a chronic lymphocytic leukemia patient. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
7 year-old male patient with microcephaly, and cerebral palsy, subsequently developed progressive vaccinia after having received a smallpox vaccination in his left shoulder. Note the large necrotic area at the vaccination site. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Left arm and shoulder area of child with deficient cellular immunity, who had sustained the ravages of vaccinia necrosum, after having received a smallpox vaccination 4 month earlier. Appearance of the severely-necrotic wound two weeks after having performed a surgical intervention, involving the debridement of necrotic tissues.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Left arm and shoulder area of child with deficient cellular immunity, who had sustained the ravages of vaccinia necrosum, after having received a smallpox vaccination 4 month earlier. Note massive necrosis and destruction of tissue caused by this condition.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right lower lip and chin region of a 25 year old woman, who had been accidentally infected on her face after her daughter was vaccinated against smallpox.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
22 month-old male with Bruton’s hypogammaglobulinemia accompanied by vaccinia necrosum. Note the large necrotic area at the vaccination site.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Plantar surface of the right foot of a 5 week-old Washington State male patient who after receiving a smallpox vaccination, developed an erythema multiforme reaction. In this particular view, note how the maculopapular rash had spread to his the plantar surface of his right foot. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Left lower extremity of a 5 week-old male patient who after receiving a smallpox vaccination, developed an erythema multiforme reaction. Note how the maculopapular rash had spread to his left, lower extremity.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right lower extremity of a 5 week-old male patient who after receiving a smallpox vaccination, developed an erythema multiforme reaction. Note how the maculopapular rash had spread to his right thigh and calfAdapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right chest surface of a 2 year-old female patient who after receiving a smallpox vaccination in her left shoulder region, developed an erythema multiforme reaction. Note maculopapular rash, which had spread to her chest and left upper arm. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Chest surface of a 2 year-old female patient who after receiving a smallpox vaccination in her left shoulder region, developed an erythema multiforme reaction. Note the maculopapular rash, which had spread to her chest and left upper arm.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
2 year-old female patient who after receiving a smallpox vaccination in her left shoulder region, developed an erythema multiforme reaction. Note left shoulder vaccination site. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
2 year-old Georgian female patient who after receiving a smallpox vaccination, developed an erythema multiforme reaction. Note maculopapular lesions on her chest, arms, and face. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
6 year-old child, who after having received a smallpox vaccination, sustained what is termed an “accidental implantation” of the newly-introduced vaccinia virus. Note the erythematous blush over his cheeks, and inflamed nasal lesion, as well as the overall lethargic posture all due to this accidental implantation.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
2 year-old child, who after having received a smallpox vaccination, sustained what is termed an “accidental implantation” of the newly-introduced vaccinia virus. Note the erythema and swelling around her left eye due to this accidental implantation of the vaccinial virus.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Recipient of a smallpox vaccination, and subsequently developed a generalized, full-body rash, due to an allergic reaction to the vaccination. Note the erythematous blush on the baby’s cheeks.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Child developed a case of eczema vaccinatum after having received a smallpox vaccination.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Child developed a case of eczema vaccinatum after having received a smallpox vaccination. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Face and right shoulder of a young child after receiving a smallpox vaccination in the right shoulder region. Note the erythematous halo surrounding the vaccination site. The morbilliform skin rash, i.e., resembling measles,consists of numerous flattened erythematous, amorphous macules.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Face and back of a young child after receiving a smallpox vaccination in the right shoulder region. Note the erythematous halo surrounding the vaccination site and morbilliform skin rash, i.e., resembling measles(numerous flattened erythematous, amorphous macules)Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Face and upper torso of a young child after receiving a smallpox vaccination in the right shoulder region. Note the erythematous halo surrounding the vaccination site, and morbilliform skin rash, i.e., resembling measles (numerous flattened erythematous, amorphous macules)Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Two year-old African-American boy developed a case of eczema vaccinatum after having received a smallpox vaccination.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Two year-old African-American boy developed a case of eczema vaccinatum after having received a smallpox vaccination.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Post-smallpox vaccination complication, this 21 month-old male infant developed secondary facial vaccinial infection involving both eyes and bilateral periorbital areas.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Post-smallpox vaccination complication, this 21 month-old male infant developed secondary facial vaccinial infection involving both eyes and bilateral periorbital areas. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Post-smallpox vaccination complication, this 21 month-old male infant developed secondary facial vaccinial infection involving both eyes and bilateral periorbital areas.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Post-smallpox vaccination complication, this 20 month-old male infant developed a secondary right periocular vaccinial infection.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Post-smallpox vaccination complication, this 20 month-old male infant developed a secondary right periocular vaccinial infection.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Post-smallpox vaccination complication, this 20 month-old male infant developed a secondary right periocular vaccinial infection.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right side of a 5 year-old male patient's torso, who after receiving a smallpox vaccination, developed an erythema multiforme reaction. This view reveals the red, erythematous amorphous rash pattern. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
5 week-old male patient developed erythema multiforme after having received a smallpox vaccination. Note the diffuse rash over all body regions.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
7 year-old male patient with microcephaly, and cerebral palsy, subsequently developed progressive vaccinia after having received a smallpox vaccination in his left shoulder. Note large necrotic area at the vaccination site.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
59 year-old male patient developed progressive vaccinia after having received a smallpox vaccination in his left shoulder.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
59 year-old male patient developed progressive vaccinia after having received a smallpox vaccination in his left shoulder.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
59 year-old male patient developed progressive vaccinia after having received a smallpox vaccination in his left shoulder. Note the vaccinial lesion on the proximal left ring finger.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
59 year-old male patient developed progressive vaccinia after having received a smallpox vaccination in his left shoulder. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Arm of a 64 year-old male, who developed a case of generalized vaccinia, after having received a smallpox vaccination in this left shoulder.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
6 month-old male infant was a recipient of a smallpox vaccination in his left shoulder, and subsequently developed a generalized, full-body rash, due to an allergic reaction to the vaccination. Note the diffuse rash on this child’s extremities, and torso.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Ganian mother holding her child, both of whom displayed the characteristic maculopapular rash of smallpox.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Mouth and oral cavity of a 2 year-old Oregonian child, who after having received a smallpox vaccination, sustained what is termed an “accidental implantation” of the newly-introduced vaccinia virus. Accompanying this phenomenon, the child also developed hand, foot and mouth disease. Note that the tongue displayed a maculopapular lesion attributed to this accidental implantation.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
2 year-old child, who after having received a smallpox vaccination, sustained a “accidental implantation” of the newly-introduced vaccinia virus. Note the left flank region, and the cutaneous maculopapular lesion in this area.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Buttocks and upper thighs of a 2 year-old child, who after having received a smallpox vaccination, sustained what is termed an “accidental implantation” of the newly-introduced vaccinia virus.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right hand of a 2 year-old child, who after having received a smallpox vaccination, sustained an “accidental implantation” of the newly-introduced vaccinia virus. Note the lesions on both the right ring finger and thumb.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Left hand of a 2 year-old child, who after having received a smallpox vaccination, sustained an “accidental implantation” of the newly-introduced vaccinia virus. Note the left middle finger, and the lesion on this appendage.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right hand of a 2 year-old child, who after having received a smallpox vaccination, sustained what is termed an “accidental implantation” of the newly-introduced vaccinia virus. Note the lesion on the right thumb.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Back and buttocks of a 2 year-old child, who after having received a smallpox vaccination, sustained an “accidental implantation” of the newly-introduced vaccinia virus. Note the cutaneous lesions about the child's buttocks and upper thighs.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Recipient of a smallpox vaccination in his left shoulder, who subsequently developed a generalized, full-body rash, due to an allergic reaction to the vaccination.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Hands of an adult smallpox patient, which display the characteristic maculopapular rash due to the smallpox virus.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Back of a smallpox patient, who’d presented with a case of vaccine-modified smallpox.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Face of a smallpox patient, displaying the characteristic maculopapular rash due to this viral disease.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Hands, and knee region of both legs of a smallpox patient, displaying the characteristic maculopapular rash due to this viral disease.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right arm, right thigh, and left hand of an adult, displaying the characteristic maculopapular rash due to the smallpox virus.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Right arm of an adult woman, which displays the characteristic maculopapular rash due to the smallpox virus.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Child’s arm, which displays the characteristic maculopapular rash due to the smallpox virus.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]
Dorsal surface of a child’s right arm, which displays the characteristic maculopapular rash due to the smallpox virus.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.^[3]