Human Facial Cowpox Obtained from a Cat
CID 2006:43 (15 September)
but the lymphadenitis in the buccal and periorbital areas de-veloped into subcutaneous abscess cavities, which ranged insize from 3 to 40 mm. The largest of these abscess cavitiesmeasured mm and extended from the paranasal region40
25into the right cheek (ﬁgure 1
). The subcutaneous fat layer atthe site of the abscess cavity underwent a complete necrosis.Repeated needle punctures produced a whitish, smeary dis-charge, a specimen of which was sent for general and speciﬁcbacterial culture and, subsequently, for virus isolation on 19December 2000.Approximately 6 weeks after the onset of symptoms, thedermis in the region of the paranasal abscess became extremely thin and was at risk of necrosis and perforation. Three punc-tuations, which were made under general anesthesia during aninterval of 3–5 days, had no effect on the condition, and in-cision became inevitable. Because of the risk of dermalnecrosis,hyperbaric oxygen (HBO) treatment was chosen as therapy, toimprove the chances that the infection would resolve and tostabilize the atrophied skin before incision. The patient un-derwent 5 courses of HBO treatments, in 6 hourly intervals,between the 21st and the 23rd of December in the pressurechamber at the Karlskrona Naval Base.After the ﬁrst course of HBO treatment, the huge paranasalabscess was evacuated by incision, and a drain was inserted.The discharge diminished gradually, and the drainwasremovedafter 5 days. The patient’s condition quickly improved, and 6weeks after she underwent HBO therapy and the incision, theskin had recovered completely, including a reappearance of thesubcutaneous fat layer. However, some lymph nodes continuedto vary in size, and the bluish discoloration of the adjacent skinareas remained. Nodes of 2–3 mm in diameter in generalshowed spontaneous regression, but nodes with a diameter of 5–15 mm required needle aspirations several times, for up to5 months after the onset of the disease. Histologic examinationof the discharge showed degeneratedhyperplasticunidentiﬁablecells. Examination of ﬁne-needle biopsy specimens from theupper jugular lymph nodes, which never necrotized, revealedreactive lymphadenitis.The aspirate obtained on 19 December was subjected tovirusisolation at the Department of Virology at Malmo¨ University Hospital (Malmo¨, Sweden). Ten days after inoculation ongreen-monkey kidney cells, a cytopathic effect (CPE) appeared,which, on subpassage, yielded syncytial formation of the cells.The CPE was caused by an agent that was ﬁlterable through a0.45-
m ﬁlter. The results of PCR and immunoﬂuorescencetesting for mumps virus were negative.The CPE pattern directed our suspicions to poxvirus infec-tion, and the culture material was sent to the Swedish Institutefor Infectious Disease Control in Stockholmon9February2001for investigation for poxvirus. Orthopoxvirus-like particleswere detected in the culture medium by electron microscopy (ﬁgure 1
). The diagnosis was further conﬁrmed by PCR anal- ysis, which noted a 339-bp fragment of the viral thymidinekinase gene, where direct sequencing revealed 100% homology with an earlier published Swedish isolate, H2 ; direct se-quencing also revealed, as expected, 99% homology with vac-cinia virus sequences. A serum sample, which had been col-lected 5 weeks after the onset of symptoms, was positive forantibodies to orthopoxvirus (vaccinia virus) by plaque reduc-tion neutralization test.The healing process of the numerous areas of lymphadenitiswas markedly prolonged. Two years after onset of symptoms,a single ﬁrm node situated in the medial angulus of the righteye was removed (ﬁgure 1
). Electron microscopy evaluationof this node yielded negative results, but PCR of the node waspositive for orthopoxvirus DNA. Sequence analysis showed to-tal homology with the PCR product obtained from the patientin February 2001.
After cowpox infection was di-agnosed (almost 3 months after the onset of symptoms), thepatient recalled having had close contact with 2 domestic cats.One of the cats used to lick her face and nose. Close contactwith the cats was especially frequent after she came home fromthe holiday in Spain. On this occasion, the cat’s tongue pen-etrated the right nasal cavity;
2 weeks later, the ﬁrst symptomsappeared. No scratches were found on the girl’s nose. The catswere in good health when examined by a veterinarian in Feb-ruary 2001. None of them had lesions of the paws, mouth, ornose or enlarged lymph nodes of the neck. Serum samplesobtained from both cats were tested for orthopox virus anti-bodies at the Swedish Veterinary Institute (Uppsala), and theresults were negative.
Poxviruses are the largest enveloped DNA viruses, with an av-erage dimension of nm. The virus particle contains230
300a linear, double-stranded genome of 140–300 kb in length thatencodes several hundred polypeptides. Vertebrate poxvirusescontain 8 genera, of which 4 (Orthopoxvirus, Parapoxvirus,Yatapoxvirus, and Molluscipoxvirus) contain viruses patho-genic to humans , all of which, with the exception of small-pox (variola), vaccinia virus, and molluscipoxvirus, are trans-mitted to humans by animals (zoonosis).Smallpox was caused by the variola virus, a member of theOrthopoxvirus genus. It was globally eradicated in the late1970s by mass vaccination, which was successful, because thevariola virus did not have an animal reservoir. Vaccinia, knownas the “Jenner virus,” was the virus used for successfulsmallpoxvaccination, but the exact origin of vaccinia virus is uncertainand there is no known natural host.Vaccination with vaccinia virus provided cross-protectionagainst several orthopoxviruses, includingmonkeypoxvirus,thethird orthopoxvirus. Normally, vaccinia causes mild and local