The Journal of Hand Surgery (Eur) 40(6)
The orf virus: a case report Dear Sir, Orf (contagious ecthyma) is a zoonotic viral infection commonly infecting the mouths and nostrils of sheep and goats (Schimmer et al., 2004). The word “orf” is probably derived from the Anglo-Saxon name for cattle; however, no cases have been reported of cattle infected by this virus. It is a double-stranded DNA parapoxvirus that can be transmitted to humans by direct contact with infected animals or indirectly, because the virus is capable of surviving months on animal products (Al-Qattan, 2011). The orf virus enters its host via damaged skin. Hands and arms are most commonly affected (Huerter et al., 1991; Nougairede et al., 2013). A 61-year-old woman who owned sheep visited the emergency room with a painless lesion on the dorsal site of the midphalanx of her left little finger (Figure 1). The patient had suffered two wounds whilst walking in the woods 1 week earlier. The patient sought help as she had signs of lymphangitis appearing on her lower forearm. She was otherwise well with no palpable axillary lymph nodes. The general and plastic surgeons first considered the differential diagnoses of ecthyma gangrenosum and fasciitis necroticans. However, the consulting dermatologist made the correct diagnosis of ecthyma contagiosum with secondary bacterial infection. The patient was treated with flucloxacillin intravenously for 1 day and orally for 1 week. A wound culture showed a coagulase-negative staphylococcus infection. Three weeks later in the outpatient clinic, the lesion had healed without any scarring or loss of function. As all humans acquire the orf virus from contact with infected animals, infection is typically associated with occupational animal contact. These professionals rarely present to hand surgeons because they know the infection is self-limiting. Hence, most patients who present are non-professionals. In all countries with a Muslim population, orf infection of the hand is seen as a yearly outbreak because it is related to the feast of sacrifice (Al-Qattan, 2011; Schimmer et al., 2004). The incubation period varies from 5 days to 2 weeks (Al-Qattan, 2011). There is usually a single skin lesion that passes through six different clinical stages. Initially, there is an erythematous macule/papule (macula–papular stage), which acquires a reddish centre with an outer halo (target stage). The nodule starts to weep (acute stage) and subsequently becomes dry (regenerative stage). The resulting papilloma-like lesion (papillomatous stage) forms a dry
Figure 1. Two small macules surrounded by a haemorrhagic bulla on the dorsal site of the midphalanx of the patient’s left fifth digit.
crust and undergoes spontaneous resolution (regressive stage) (Huerter et al., 1991; Schimmer et al., 2004). Most infections are self-limiting, resolving spontaneously in 4 to 9 weeks with little or no residual scarring. Potential complications include erythema multiforme, bullous pemphigoid, deforming scars, and secondary bacterial infections. Severe and/or more complicated infections are rare, but occur primarily in immune-compromised hosts (Al-Qattan, 2011; Schimmer et al., 2004). Orf infection is rare in the general community. Therefore, most physicians have not encountered patients with orf and might mistakenly identify orf lesions as a life-threatening condition, such as cutaneous anthrax, tularaemia, or a neoplasm. Differential diagnoses also include herpes simplex infection, milker’s nodules, fish-tank granuloma, pyogenic granuloma, and keratoacanthoma. Rapid diagnosis is critical for preventing unwarranted psychological stress, extensive diagnostic workup, unnecessary operations, and inappropriate antibiotic use (Al-Qattan, 2011; Huerter et al., 1991). Patients are mainly diagnosed with orf based on a history of contact with animals and the clinical appearance of the lesion (Al-Qattan, 2011). Further investigations are only necessary if the physician is uncertain
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Short report letters about the diagnosis. The presence of the parapoxvirus can be accurately detected by electron microscopy and broad spectrum PCR (sensitivity 96%); these methods are preferred over more invasive methods (e.g., skin biopsy) (Nougairede et al., 2013; Schimmer et al., 2004). Serum titre determination of orf virus antibodies during the acute and convalescent phases can be used as well (Huerter et al., 1991). Because of the benign, self-limiting nature of the infection, no treatment other than basic wound care is required. In cases of secondary bacterial infection, systemic antibiotic treatment is indicated. In a case series, imiquimod was found to be effective in shortening the healing time of orf lesions when applied twice a day for 5 to 10 days (Huerter et al., 1991; Schimmer et al., 2004). The management of giant and multiple lesions in immune-compromised hosts can be problematic. In those cases a treatment with topical imiquimod has also proven more effective than antiviral agents, with limited side effects. Giant hand lesions that do not respond to medical therapy may require wide surgical excision and skin grafting. Recurrence at the skin resection margins is not uncommon (Al-Qattan, 2011). Public health officials need to educate people with occupational or household exposure to sheep and goats about the possibility for disease transmission and ways to avoid infection (Nougairede et al., 2013). Wearing non-permeable gloves is an effective preventive measure against infection. Injuries that occur during animal slaughter or meat processing should be cleansed thoroughly with soap and water. Veterinary vaccines (live orf virus) are available and intended to produce controlled infections in flocks. Immunity caused by vaccines or natural infection is neither complete nor life-long. Farm animals that appear ill with orf-consistent lesions should be quarantined until veterinarian evaluation to prevent visitors from getting infected (Al-Qattan, 2011). Conflict of interests The author declares that there is no conflict of interest.
References Al-Qattan MM. Orf infection of the hand. J Hand Surg Am. 2011, 36: 1855–8. Huerter CJ, Alvarez L, Stinson R. Orf: case report and literature review. Cleveland Clin J Med. 1991, 58: 531–4. Nougairede A, Fossati C, Salez N et al. Sheep-to-human transmission of orf virus during Eid al-Adha religious practices, France. Emerg Infect Dis. 2013, 19: 102–5.
Schimmer B, Sprenger HG, Wismans PJ et al. Drie patiënten met orf (ecthyma contagiosum). Ned Tijdschr Geneeskd. 2004, 148: 788–91.
T. R. Friebel and J. F. A. van der Werff Plastic Surgery Department, ‘t Lange Land Ziekenhuis, Toneellaan, Zoetermeer, the Netherlands. Corresponding author: [email protected]
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A4 Annular Flexor Pulley Injury in a Baseball Pitcher Dear Sir, A 23-year-old left-handed college baseball pitcher presented with a painful left long finger. He noticed some pain in his finger while pitching during training. The pain was vague and located over the volar aspect of the finger. Later that week, he felt a “pop” in the finger while throwing a fastball and had difficulty moving the long finger. He was seen several days later and was noted to have localized pain and swelling over the middle of the long finger. He had limited active flexion of both the distal and proximal interphalangeal (DIP and PIP) joints of that finger. PIP joint motion was −35° to 95°, with a flexion contracture. Grip strength was reduced to 75% of the contralateral side. A 3T magnetic resonance imaging (MRI) ordered before his clinic visit showed a rupture of the long finger A4 pulley with volar displacement of the flexor tendon (Figure 1). A thermoplastic splint was fabricated, which was placed over the middle phalanx level of the injured finger, and a gradual active motion exercise program for the finger was started. He was prescribed an oral anti-inflammatory medication. At his last visit at 4 months after initial evaluation, grip strength was 115% of the contralateral hand and PIP joint motion was −5° to 95°. He had returned to pitching with minimal discomfort. Flexor tendon pulley injuries are seen in rock climbers, occurring in up to 26% of all climbers (Kubiak et al., 2006; Lourie et al., 2011; Schöffl and Schöffl, 2006). This has been attributed to the stresses from specific hand grips and positioning (Kubiak et al., 2006; Schöffl and Schöffl, 2006). The A2 pulley of the ring finger is most frequently involved, although there can be a combined injury
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