Godfrey 25/3/04 13:07 Page 202

Unusual presentations of
cowpox infection in cats
Cowpox virus infections are reported typically to cause focal (Bennett and others 1999). Pneumonia is
a severe complication which is occasion-
ulcerated, crusted skin lesions, sometimes with mild systemic
ally associated with cowpox infection but
illness and concurrent oral lesions. Severe systemic illness usually there are only two detailed case reports
documenting this in cats (Hinrichs and
only occurs in young or immunosuppressed individuals. This report
others 1999, Hübner 2002). To date, cases
describes four cases of cowpox infection in cats which illustrate with signs confined to oral lesions have not
been reported. Likewise, cases that have
variations to the usual presentation of the virus. The poxvirus
exhibited large areas of skin necrosis,
infections were confirmed histopathologically, serologically and by intractable oedema or loss of digits are
not recorded in the existing veterinary
PCR analysis.
literature.

D. R. GODFREY, C. J. BLUNDELL, INTRODUCTION CASE HISTORIES

S. ESSBAUER*, M. PFEFFER*,
D. H. SHEARER†, J. R. REST‡
ft AND J. F. M. BAKER†
Journal of Small Animal Practice (2004)
45, 202–205
e to be a reservoir for cowpox virus (Maren-
o nikova and others 1978, Kaplan and oth-
e autumn, and are associated with the peak
Nine Lives Veterinary Practice for Cats,
2068 Stratford Road, Hockley Heath, West
Midlands B94 6NT
*World Health Organization Centre for Collection
and Evaluation of Data on Comparative Virology,
Consulting Laboratory for Poxviruses,
Institute of Medical Microbiology, Infectious
and Epidemic Diseases, Veterinärstrasse 13,
D-80539 Munich, Germany
†Finn Pathologists, Weybread, Diss,
Norfolk IP21 5TT
‡24 Lower End, Swaffham Prior,
Cambridge CB5 0HT
C. J. Blundell’s present address is The
Oxfordshire Cat Clinic, Larkmead Veterinary
Group, Cholsey, Oxfordshire OX14 9PA
M. Pfeffer’s present address is Institute
of Microbiology, German Armed Forces,
Neuherbergstrasse 11, D-80937 Munich,
Germany
D. H. Shearer’s present address is Vetcutis,
Holly House, Pulham St Mary, Diss, Norfolk
IP21 4QQ
J. F. M. Baker’s present address is Patolovet-
Patologia Veterinaria Unipessoal, Lda. Av. Duarte
Pacheco, 232. 8135-104 Almancil, Portugal
Cowpox virus is an Orthopoxvirus found
only in Western Europe and Asia. The dis-
ease it causes in cats has been called ‘feline
cowpox’ and ‘catpox’. Wild rodents seem
ers 1980, Bennett and others 1999,
Chantrey and others 1999, Hazel and oth-
ers 2000, Wolfs and others 2002). Cases in
domestic cats are typically seen in the
population of the rodent hosts (Chantrey
and others 1999, Pfeffer and others 2002).
Human infections in Great Britain are
reported to be in single figures per year and
are often associated with disease in pet
cats (Baxby and others 1994, Baxby and
Bennett 1997).
In cats, the typical initial skin lesion is
an ulcerated nodule with crust, usually
on the head or forelimbs. This is the site
where the cat will have had direct contact
with the rodent and local virus replication
has occurred. After one or two weeks, sec-
ondary skin lesions appear. They start as
macules or small erythematous nodules
that often ulcerate, scab and later heal,
producing scarring (Bennett and others
1999). Concurrent oral lesions have been
reported to occur in about 20 per cent of
feline cases (Bennett and others 1990).
The appearance of systemic signs is
unusual, other than mild pyrexia, depres-
sion and occasionally diarrhoea, which
are associated with transient viraemia
Case 1
A four-year-old, neutered male, domestic
shorthair cat presented with an acute-
onset, non-pruritic dermatosis in August
1999. The animal was a rodent hunter and
showed no evidence of systemic disease.
There was no history of previous der-
matoses and no evidence of contagion to
humans or in-contact pets. The skin
lesions were confined to the lips and were
bilateral and roughly symmetrical. They
consisted of ulceration with small areas of
dark brown crust (Fig 1). Under general
anaesthesia, three ulcers (<5 mm diameter)
were found on the caudal tongue and soft
palate. There was moderate bilateral
enlargement of the submandibular lymph
nodes. No other lesions were found on
thorough examination.
Punch biopsies were taken from the
lip lesions. Histopathology of the muco-
cutaneous junction showed hydropic de-
generation of keratinocytes; eosinophilic,
intracytoplasmic inclusion bodies; and
deep dermatitis with perifolliculitis, folli-
culitis and furunculosis (Fig 2). This was
considered consistent with cowpox infec-
tion. Embedded tissue was deparaffinised
with xylene (Merck), rehydrated and
washed in phosphate-buffered saline.
DNA was extracted using the QIA Mini
Kit (Qiagen; Hilden). A PCR with primers
targeting the Orthopoxvirus gene of the 14
kDa protein (A27L) was performed, as
described by Essbauer and others (2002).

202 JOURNAL OF SMALL ANIMAL PRACTICE • VOL 45 • APRIL 2004

Godfrey 25/3/04 13:07 Page 203
FIG 1. Gross appearance of the skin lesions on presentation of case 1.
The lesions were bilateral
DNA of vaccinia virus strain Munich 1
was used as a positive control. The finding
of 280 bp-sized DNA fragments (Fig 3)
was a positive result. A second PCR, spe-
cific for the gene encoding the acidophilic
inclusion protein A-type inclusion body
(ATI), as described by Meyer and others
(1994), was performed. This was also pos-
itive (data not shown).
Treatment with 5 mg/kg clindamycin
(Antirobe; Pharmacia & Upjohn) was
given orally, twice a day, for 10 days. The
cat completely recovered in less than three
weeks and no lesions reappeared in the
subsequent two years.
Case 2
A four-year-old, rodent-hunting, neutered
female, domestic shorthair cat presented in
May 2000 with left foreleg lameness of one
day’s duration. The leg was moder-
ately swollen from the paw to the elbow.
There was a 1 cm erosion on the landing
pad. The leg was painful and the cat
was given an 8/10 lameness score. A full
clinical examination revealed no other
abnormalities.
Under sedation the wound was lavaged
with saline. The cat was subcutaneously
injected with 8·75 mg/kg clavulanic
acid-potentiated amoxycillin (Synulox;
Pfizer). The treatment was then continued
orally at a dose of 12·5 mg/kg twice daily.
A single 4 mg/kg dose of carprofen
(Rimadyl; Pfizer) was given subcuta-
neously.
The cat was presented again three days
later. It had gone missing and, therefore,
had been unmedicated for two days. There
was gross swelling of the entire left foreleg.
The soft tissue was particularly firm on the
JOURNAL OF SMALL ANIMAL PRACTICE • VOL 45 • APRIL 2004
FIG 2. Diagnostic eosinophilic intracytoplasmic inclusion bodies in the
keratinocytes of the epithelium in case 1. Haematoxylin and eosin. 250
paw and over the triceps muscle. There
was an area of necrotic skin (2 cm diame-
ter) on the dorsal aspect of the paw,
extending distally on to the proximal por-
tion of the dorsal aspect of digits II to IV.
There was widespread erythema. A few
macules, nodules and crusted nodular
lesions were seen scattered on the lateral
aspect of the upper leg, the left flank and
the head. The rectal temperature was con-
sidered to be slightly high (39·5°C).
A wedge biopsy was taken from the
lower leg. Histopathology showed spon-
giosis, necrosis and ulceration of the
epidermis, with intracytoplasmic eosino-
philic inclusion bodies of varying size in
the surviving epithelium. The dermis and
subcutis had dense inflammatory infil-
trates of mononuclear cells and neu-
trophils with necrosis. A piece of crust
taken from the foreleg was positive for
poxvirus by isolation in feline kidney
cells and vero cells. On day 7, blood sam-
ples were taken for limited haematology FIG 3. Agarose gel electrophoresis of 280 bp
and biochemistry (Table 1). The only sig- amplicons derived from 14 kDa protein gene
nificant abnormality found was a moder- PCR. Lane 1 = Vaccinia virus strain Munich 1,
Lane 2 = Case 3, Lane 3 = Case 1, Lane 4 =
ate hypoalbuminaemia. Serological tests Case 4, Lane 5 = 100 bp molecular weight
for feline immunodeficiency virus (FIV) marker, Lane 6 = Negative control (aqua test,
antibodies and feline leukaemia virus were no DNA)
negative (One Step Assay; QCR & Trio
Diagnostics). On day 9, an oesophagostomy tube was
Treatment on days 4 to 9 consisted of: placed. On day 18, the cat was depressed
11 mg/kg clindamycin (Antirobe) by and anorexic but due to tube feeding its
mouth, twice daily; 10 mg/kg doxycycline bodyweight was unchanged. New pox
(Ronaxan; Merial Animal Health) and 5 lesions had appeared on the trunk,
mg/kg enrofloxacin (Baytril; Bayer), both although there were never more than six
by mouth, once daily. Thereafter, the cat lesions at any time. The left foreleg was
was treated only with clavulanic acid- still severely swollen. There was a
potentiated amoxycillin at the doses 5  15 cm area of necrotic skin from the
previously stated, either subcutaneously point of the shoulder laterally and caudally
or orally. into the axilla, extending onto the flank. In
203
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Table 1. Results of haematological and biochemical tests Table 2. Comparison of the cat infections and proof of
performed on case 2 the cowpox virus infection
Normal Day 7 Day 9 Day 11 Day 18 Case 1 Case 2 Case 3 Case 4

Haematocrit 24-45% 31·5 30·4 26·4 17 Age, sex 4 y, m 4 y, f 2 y, m 1 y, m

Haemoglobin 8-15 g/dl 9·5 9·3 8·1 5·4 Main area of Lips Foreleg, Oral Forepaw,
MCHC 30-36·9 g/dl 30·2 30·6 30·9 31·8 pocks/crusts trunk mucosa, head
WBC 5-18·9  109/litre 11·8 15·9 13·1 11·6 pharynx,
Granulocytes 2·5-12·5  109/litre 8·7 11·5 10·2 7·0 tonsil
Lymphocytes/ 1·5-7·8  109/litre 3·1 4·4 2·9 4·6 A-type inclusion body + + + Negative*
monocytes (dermatohistopathology)
Platelets 175-500 170 163 281 180 Virus culture nd + nd +
Albumin 26-39 g/litre 19 21 21 21 OPXV-specific serology nd nd + (1:1024) nd
Globulin 28-51 g/litre 30 34 31 41 OPXV-specific PCR + nd + +
Total protein 57-89 g/litre 49 55 52 62
*Primary skin lesions had healed when histopathology was performed
ALT 12-130 iu/litre 43 y Years, m Male, f Female, OPXV Orthopoxvirus, nd Not determined
ALP 14-111 iu/litre 26
Urea 5·7-12·9 mmol/litre 10·3
Creatinine 71-212 µmol/litre 88
Sodium 150-165 mmol/litre 151 149 necrosis of the skin of digits II and III.
Potassium 3·5-5·8 mmol/litre 3·9 3·7
There were scattered scabs with underlying
Chloride 112-129 mmol/litre 120 122
erosions on the paw and the head. Viral
MCHC Mean corpuscular haemoglobin concentration, WBC Total white blood cell count,
ALT Alanine aminotransferase, ALP Alkaline phosphatase
culture from a scab was positive for cow-
pox virus. Cefadroxil was given at a dose of
20 mg/kg daily for three weeks and then
places this could be peeled away to reveal tion. The lamina propria had a moderate, 12·5 mg/kg clavulanic acid-potentiated
granulation tissue with exudate. The oede- lymphocyte-rich, mixed inflammatory cell amoxycillin was given orally, twice daily,
matous swelling extended from the fore- infiltrate. The lymph node biopsies had for a further four weeks.
leg to the trunk. Haematology showed a a mixed population of large and small On day 47, surgery was performed to
significant reduction in the haematocrit lymphocytes with occasional scattered remove diseased and oppose healthy tis-
(Table 1). A blood smear revealed evidence eosinophils. No follicular differentiation sues. Most of the necrotic skin had slough-
of regeneration. was recognised, probably due to the small ed and healed but digit III was completely
On day 19, the cat vomited and dis- size of the samples. lost. The foot had healed by day 60. Skin
placed the oesophagostomy tube. Because Biopsy tissue from the mouth was sub- removed on day 47 was submitted for
of the uncertain prognosis the cat was mitted for PCR testing by the method histopathology and showed furunculosis
euthanased. A postmortem examination detailed for case 1 and was positive for but no viral inclusion bodies. PCR, using
was not permitted. Orthopoxvirus. Two weeks later, serum was the technique described previously, dem-
taken for a pox antibody neutralisation test onstrated that this tissue was positive for
Case 3 using standard virus solution and vero cell cowpox virus.
A two-year-old, neutered male, domestic plates. The titre was considered to be very
shorthair cat presented in July 1999 with a high (1/1024). A small scab found on the
history of intermittent coughing and left front leg was submitted for Ortho- DISCUSSION
choking for four days. The cat was a poxvirus culture and proved negative.
known rodent hunter. No other abnormal- Oral treatment with 20 mg/kg Ideally, all cases of suspected cowpox infec-
ities were reported. Clinical examination cefadroxil (Cefa-Tabs; Fort Dodge) once tion would be confirmed by finding char-
revealed that the left submandibular daily was administered for one week. Two acteristic histopathological lesions and
lymph node was moderately enlarged. A weeks after biopsy the oral lesions were proving the presence of the virus by
total of four erosions were found in the unchanged but they had disappeared three culture, immunohistochemistry, electron
caudal mouth and over each tonsil. months after presentation. microscopy, PCR analysis or by demon-
Two wedge biopsies plus Trucut needle strating a rising antibody titre. All of the
biopsies of the lymph node were taken. Case 4 cases reported here were positive for cow-
Both oral biopsies showed ulcerative stom- A one-year-old, neutered male cat was pre- pox disease using at least two of these gen-
atitis with superficial exudates of fibrin sented in December 2001 with acute erally accepted tests (Table 2). Comparison
admixed with neutrophils. Remaining swelling of the left forepaw. It was a rodent with a 14 kDa protein (A27L) using PCR
epithelium exhibited hydropic degenera- hunter. There was no response to clavu- revealed amplificates for the three cat sam-
tion of keratinocytes and the presence of lanic acid-potentiated amoxycillin, which ples for which this test was available. So far,
abundant hyaline, eosinophilic, intra- was given orally at a dose of 12·5 mg/kg more than 100 Orthopoxvirus strains and
cytoplasmic inclusion bodies, consistent twice daily for five days, and 0·1 mg/kg isolates have been successfully amplified
with poxvirus inclusions. In one of the meloxicam (Metacam; Boehringer Ingel- with this PCR (H. Meyer, unpublished
biopsy samples there was also marked, heim) given orally with food daily. Five data). In this small case series, finding
mainly lymphocytic, superficial inflamma- days later the cat was re-presented with pathognomonic A-type inclusions on der-

204 JOURNAL OF SMALL ANIMAL PRACTICE • VOL 45 • APRIL 2004

Godfrey 25/3/04 13:07 Page 205
matohistopathology was useful and is a rel-
atively rapid diagnostic technique. In con-
junction with PCR, these four unusual
cases could be clearly diagnosed.
All four cats were typical candidates for
cowpox infections as they lived in rural
locations and were active hunters of
rodents. Three cases presented between
May and August, the low season for the
disease in the UK (Bennett and others
1999). The reason for this is unknown.
Case 1 was unusual in that the skin disease
was confined to ulceration of the oral
mucocutaneous junction. Case 3 was
unusual in that oral lesions were found
without skin lesions. Oral disease in the
absence of skin disease has not previously
been reported. More usual differential
diagnoses for cases 1 and 3 would be aller-
gic or contact irritant diseases, eosinophilic
granuloma complex, bacterial infections,
autoimmune and neoplastic diseases,
FIV, herpesvirus or calicivirus infections
(Hargis and Ginn 1999, Stokes and others
1999, Thiel and Konig 1999).
Cats presenting with lesions similar
to those of case 2 have differential diagnoses
of trauma, allergic oedema, bacterial infec-
tions, neoplasia and obstructive oedema. A
similar presentation has recently been
reported with a novel virulent feline cali-
civirus (Pedersen and others 2000). The rea-
son for case 2 failing to recover is unknown.
The animal was apparently healthy prior to
the cowpox infection but an additional
immunosuppressive disease could not be
ruled out. Use of in-house biochemistry and
haematology analysers is not ideal. The
hypoalbuminaemia was thought to be
secondary to loss of albumin into the oede-
matous tissue. The anaemia was not investi-
gated because the cat was euthanased.
Anaemia and hypoalbuminaemia have been
© British Small Animal Veterinary Association. All rights reserved
JOURNAL OF SMALL ANIMAL PRACTICE • VOL 45 • APRIL 2004
previously reported in cats with extensive
cowpox disease associated with FIV (Brown
and others 1989, Hübner 2002). Such
extensive skin lesions and oedema caused
by cowpox virus is not reported in the lit-
erature.
Case 4 was worth reporting because the
literature does not state that cowpox can
cause such severe deformation. The initial
differential diagnoses considered were bac-
terial and fungal infections, vasculitis,
envenomation, neoplasia, blunt trauma
and thermal damage.
Conclusions
These four cases of cowpox in cats demon-
strate the need to consider cowpox virus as
a potential cause of a range of clinical pre-
sentations. Cowpox lesions may be hid-
den, as in case 3, and oedema can be a
prominent sign. Seasonality is an unreli-
able factor (Pfeffer and others 2002). The
only common feature is that affected cats
are rodent hunters. Therefore, veterinary
surgeons should always enquire about a
cat’s hunting habits when taking a clinical
history.
Acknowledgements
Poxvirus cultures and poxvirus serology
were performed at the clinical pathology
diagnostic service, at the Department of
Clinical Veterinary Science, University of
Bristol. The authors would like to thank
those involved.
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