8/14/2019 cowpox case report Lancet 2005

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Case Report

In August, 2001, three people, a boy aged 14 years, awoman aged 20, and a man aged 54, living in neigh-bouring households in Schirnding, Germany, werescratched while playing with a cat. 2 days later, the20-year-old woman had an itchy nodule, surrounded byerythema, on her right forearm where she had beenscratched. She also had malaise, night sweats, andpainful right axillary lymph nodes. The next day, furtherlesions developed on her right arm and in her left groin.

She was admitted to the Department of Dermatology,University of Regensburg. While she was there, thenodule on her forearm increased to 425 cm (figure)with a necrotic black eschar in the centre with a raisedrim by day 20. The other two people had similar lesions,but these remained localised and neither had anymalaise. The 54-year-old had a history of smallpoxvaccination in childhood. The cat had an ulceratednodule on its right ear.

Histopathology of a skin biopsy specimen and electron-microscopy of scab tissue showed vacuolar degenerationof keratinocytes, eosinophilic cytoplasmic inclusions, andbrick-shaped 200300 nm orthopoxvirus particles.

Confluent African green monkey kidney MA 104 cells(ATCC No. CRL-2378) were used for propagation ofviruses, and extracted DNA was subjected to PCR withprimers targeting the vaccinia virus gene of the 14 kDaprotein (A27L) and the acidophilic inclusion protein gene(A-type inclusion body, ATI).1 PCR products weredifferentiated by RFLP, which showed cowpox in allaffected individuals. Serological tests were also positive.To avoid superinfection, patients were treated withsystemic antibiotics (oxacillin 3 g/d intravenously anderythromycin 15 g/d orally) with topical antisepticdressings, removal of necrotic tissue, and application ofocclusive bandages to avoid autoinoculation. In allpatients, the ulcerated lesions healed uneventfully within

8 to 10 weeks leaving behind atrophic scars. The catbecame unwell and scratched itself all over. It was putdown by a veterinarian. Investigations confirmed cowpoxinfection.

Despite its name, cowpox virus is mostly found in zooanimals and domestic cats who hunt for rodents, thereservoirs of cowpox virus.2 Cowpox virus belongs to thegenus Orthopoxvirus of the family Poxviridae. Severalother members of this genus cause disease in humanbeings, such as smallpox. In the past few years, therehave been an increasing number of reports of humaninfection with cowpox virus, mostly transmitted bycats.3,4 These reports and our observation suggest the

need for increased awareness by health professionals ofthe typical clinical features of human cowpox. Sincescratch wounds are the most frequent way of infection inpeople, the primary infection sites are often fingers andhands. As a rule, the lesions start as inflamed maculesthat become papulo-nodular or vesicular within the firstweek. Subsequently, sterile pustules develop that thenbegin to ulcerate and crust over by the end of the second

week. During the third week, the lesions progress todeep-seated, hard, black eschars of 13 cm in diameteraccompanied by oedema and sometimes induration.Cowpox lesions are invariably painful, and there is locallymphadenopathy. Most patients report some systemicsymptoms including fever, malaise, occasionallyvomiting, and a sore throat. The majority of cases take68 weeks to full recovery always with residual scars.However, in some cases, particularly in atopic andimmunosuppressed individuals, severe generalisedinfection, similar to smallpox, has been reported, somewith a fatal outcome.5 The most important differential isanthrax. The skin lesions of anthrax are relativelypainless and progress rapidly to the eschar stage within

56 days.References:1 Hazel SM, Bennett M, Chantrey J, et al. A longitudinal study of

an endemic disease in its wildlife reservoir: cowpox and wildrodents. Epidemiol Infect 2000; 124: 55162.

2 Burton JL. Of mice and milkmaids, cats and cowpox. Lancet 1994;343: 67.

3 Baxby D, Bennett M, Getty B. Human cowpox 196993: a reviewbased on 54 cases. Br J Dermatol 1994; 131: 598607.

4 Meyer H, Pfeffer M, Rziha HJ. Sequence alterations within anddownstream of the A-type inclusion protein genes allowdifferentiation of Orthopoxvirus species by polymerase chainreaction. J Gen Virol 1994; 75: 197581.

5 Eis-Hubinger AM, Gerritzen A, Schneweis KE, et al. Fatalcowpox-like virus infection transmitted by cat. Lancet 1990; 336:880.

Cowpox and a catBrigitte Coras, Sandra Ebauer, Martin Pfeffer, Hermann Meyer, Josef Schrder, Wilhelm Stolz, Michael Landthaler, Thomas VogtLancet 2005; 365: 446

Department of Dermatology,

University of Regensburg,

Franz-Josef-Strauss-Allee 11,

93053 Regensburg, Germany

(B Coras MD, M Landthaler MD,

T Vogt MD); Institute of

Microbiology, Bundeswehr,

Neuherbergstrasse 11, 80937

Munich, Germany

(S Essbauer PhD, M Pfeffer DVM,

H Meyer DVM, PhD);

Department of Pathology,

University of Regensburg,Franz-Josef-Strauss-Allee 11,

93053 Regensburg, Germany

(J Schroder PhD); Clinic of

Dermatology and Allergology,

Hospital Munich-Schwabing,

Klner Platz 1, 80804 Munich,

Germany (W Stolz MD)

Correspondence to:

Dr Thomas Vogt

thomas.vogt@klinik.uni-

regensburg.de

446 www.thelancet.com Vol 365 January 29, 2005

Figure:Presenting lesion at end of first week

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