Secondary bacterial and fungal skin or soft-tissue infections may occur. The vesicular skin rash results in a breach of the integrity of the cutaneous barrier to bacterial skin infection, especially when scratched or otherwise traumatized. Necrotizing soft-tissue infections, soft-tissue abscesses, cellulitis, paronychia, lymphangitis, and pyomyositis have all been reported. Antibiotic treatment is recommended. Surgery may be required, with some cases requiring extensive surgical debridement or amputation of an affected extremity. Permanent pitted scarring and discoloration secondary to infection is a common long-term sequelae.
Patients with a heavy rash burden may develop exfoliation, similar to partial thickness burns in severe cases. Lesions can coalesce until large sections of skin slough off. Minimize insensible fluid loss and promote skin healing. Ensure adequate hydration and nutrition. Debridement may be needed. Skin grafting may be required rarely.
Can occur in up to 86% of cases with lymphadenopathy. When combined with multiple oropharyngeal lesions, patients may be at risk of retropharyngeal abscess or respiratory compromise. Corticosteroid treatment may be required.
Identification of sepsis should be done rapidly using established criteria. Management follows the same principles as for bacterial sepsis and should include: broad-spectrum empirical antibiotic therapy, ideally given within 1 hour of recognition; rapid intravenous fluid resuscitation with assessment of response; vasoactive therapy; appropriate airway management and oxygen administration.
May occur in severe disease because intravascular fluid tends to be lost through fever, rash, and capillary leak. The accompanying systemic inflammatory response syndrome may cause hypotension as well. This combination of factors reduces renal blood flow and promotes acute kidney injury. Early recognition by monitoring urine output and blood biochemistry will indicate whether intravenous fluids are necessary.
Patients are at risk of bacterial pneumonia. Pulmonary involvement with nodular lesions has been reported. Broad-spectrum antibiotic treatment should be given. Severe pneumonia will cause hypoxia requiring oxygen therapy and possibly mechanical ventilation in an intensive care unit.
Hypotension may be exacerbated by superadded bacterial sepsis and possible viral myocarditis. Hypotension unresponsive to adequate fluid replacement will require treatment with inotropes. If superadded bacterial sepsis is suspected, broad-spectrum antibiotics should be given intravenously.
Cases of myocarditis, pericarditis, and myopericarditis have been reported rarely. The most common presentation is chest pain. Cases are usually self-limiting and require supportive care only.
Ocular manifestations are uncommon, but may result in corneal scarring and permanent vision loss. They may occur as a result of autoinoculation. Patients may present with conjunctivitis, blepharitis, keratitis, subconjunctival nodules, or periorbital cellulitis. Ocular involvement appears to be rare in the 2022 global outbreak, with approximately 1% of patients affected (compared with 9% to 23% in previous outbreaks).
Ophthalmic consultation is recommended in patients with ocular involvement. Slit-lamp exam and dilated funduscopic exam may be helpful for determining whether anterior or posterior segment structures are involved.
Vitamin A supplementation is recommended. Eye lubrication and saline-soaked eye pads may be helpful. Ophthalmic antibiotics/antivirals may be required for coinfection. Topical trifluridine (also known as trifluorothymidine) is recommended for the management of keratitis, in consultation with an ophthalmologist. It may also be used prophylactically in certain patients with lesions near the eye to prevent autoinoculation; however, the risk of corneal epithelial toxicity with prolonged use must be taken into account. Topical corticosteroids should be avoided as they may cause corneal damage or viral persistence.
Oral tecovirimat should be considered for all patients with severe disease, which includes ocular manifestations. Case reports on its use for ocular complications have been published. See Treatment algorithm.
Vaccinia immune globulin may be considered on a case-by-case basis in consultation with an infectious disease specialist. However, caution is recommended in people with active keratitis, as increased corneal scarring was observed in an animal model study. See Emerging.
Tonsillar complications were not previously known to be typical. However, they have been reported rarely in the 2022 global outbreak (e.g., tonsillitis, peritonsillar cellulitis, tonsillar/peritonsillar abscess, necrotizing tonsillitis), likely as a consequence of practising oral-receptive sex. Airway management, antibiotic therapy, and surgery may be required depending on the presentation.
Epiglottitis was not previously known to be a typical complication. However, it has been reported rarely in the 2022 global outbreak. Urgent management, particularly of the airway, may be required.
Paraphimosis/phimosis was not previously known to be a typical complication. However, it has been reported rarely in the 2022 global outbreak as a consequence of lesions causing severe penile/scrotal edema. Paraphimosis is a medical emergency and surgery may be required if there is evidence of ischemia or necrosis.
Perianal/groin abscesses and rectal perforation were not previously known to be typical complications. However, they have been reported rarely in the 2022 global outbreak. Bowel lesions may be exudative and cause significant tissue edema leading to obstruction. Lesions may lead to bowel strictures and scarring. Antibiotic therapy and surgery may be required.
Urinary retention (e.g., due to severe penile edema or urethritis) was not previously known to be a typical complication. However, it has been reported rarely in the 2022 global outbreak. Lesions may lead to urethral strictures and scarring. Catheterization may be required.
Patients with severe disease are at risk of encephalitis, transverse myelitis, and seizures. Few neurologic complications have been reported with the 2022 global outbreak. However, cases of encephalomyelitis have been reported. It is unknown whether this is a result of direct viral invasion of the central nervous system, or whether it is a parainfectious autoimmune process triggered by systemic infection. Treatment is primarily supportive. There may be a role for antiviral agents but there is no supportive evidence. Antibiotics/antivirals may be indicated for coinfections. Anticonvulsants should be administered if required.
Inoculation with traditional vaccinia may cause eczema vaccinatum (a generalized vesicular rash in the presence of eczema), generalized vaccinia (a self-limiting illness consequent upon vaccinia viremia occurring in the absence of preexisting skin disease), or progressive vaccinia. Progressive vaccinia starts as a localized but relentlessly progressive spread of vaccinia at the inoculation site and is potentially fatal. It occurs in the markedly immunosuppressed (e.g., congenital immunodeficiencies, cytotoxic chemotherapy, advanced HIV disease). Progressive vaccinia is rare, but fatal if untreated. Tecovirimat (or other antivirals) or vaccinia immune globulin are options for the treatment of complications due to vaccinia vaccination.
Use of this content is subject to our disclaimer