About Clinical Variola MajorAfter the recent summary of World Health Organization–authorized research on smallpox, several clinical issues remain. This policy review addresses whether early hemorrhagic smallpox is disseminated intravascular coagulation and speculates about the cause of the high mortality rate among pregnant women and whether ocular smallpox is partly the result of trachoma or vitamin A deficiency.
The joint destruction common in children with smallpox might be prevented by antiviral drugs, but intraarticular infusion of antiviral drugs is unprecedented.
Development of highly effective antiviral drugs against smallpox raises the issue of whether post exposure vaccination can be performed without interference by an antiviral drug. Clinicians should consider whether patients with smallpox should be admitted to general hospitals. Although an adequate supply of second-generation smallpox vaccine exists in the United States, its use is unclear. Finally, political and ethical forces suggest that destruction of the remaining stocks of live smallpox virus is now appropriate.
Variola major resulted in destruction of large joints, particularly of the elbows and knees, in ≈2% of unvaccinated children. It seems likely that that this joint destruction was caused by infection of the joint space or compromise of the blood supply by a viral arteritis, rather than by an immune-mediated arthropathy . Could ST-246 or CMX-001 be injected directly into the joint space, and if so would it help? If the mechanism is predominately poor blood flow secondary to an arteritis, an antiviral drug might not eliminate it. Direct injection of an antiviral drug into the joint spaces might be useful if we could agree on clinical indicators of joint infection that would induce such a therapeutic approach.
Massoudi MS, Barker L, Schwartz B. Effectiveness of postexposure vaccination for the prevention of smallpox: results of a Delphi analysis. J Infect Dis. 2003;188:973–6. PubMed DOI
