Case Report
Cowpox and a cat
Lancet 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,
Kölner Platz 1, 80804 Munich,
Germany (W Stolz MD)
Correspondence to:
Dr Thomas Vogt
thomas.vogt@klinik.uni-
regensburg.de
446
Brigitte Coras, Sandra Eßbauer, Martin Pfeffer, Hermann Meyer, Josef Schröder, Wilhelm Stolz, Michael Landthaler, Thomas Vogt
In August, 2001, three people, a boy aged 14 years, a
woman aged 20, and a man aged 54, living in neigh-
bouring households in Schirnding, Germany, were
scratched while playing with a cat. 2 days later, the
20-year-old woman had an itchy nodule, surrounded by
erythema, on her right forearm where she had been
scratched. She also had malaise, night sweats, and
painful right axillary lymph nodes. The next day, further
lesions 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, the
nodule on her forearm increased to 42·5 cm (figure)
with a necrotic black eschar in the centre with a raised
rim by day 20. The other two people had similar lesions,
but these remained localised and neither had any
malaise. The 54-year-old had a history of smallpox
vaccination in childhood. The cat had an ulcerated
nodule on its right ear.
Histopathology of a skin biopsy specimen and electron-
microscopy of scab tissue showed vacuolar degeneration
of keratinocytes, eosinophilic cytoplasmic inclusions, and
brick-shaped 200300 nm orthopoxvirus particles.
Confluent African green monkey kidney MA 104 cells
(ATCC No. CRL-2378) were used for propagation of
viruses, and extracted DNA was subjected to PCR with
primers targeting the vaccinia virus gene of the 14 kDa
protein (A27L) and the acidophilic inclusion protein gene
(A-type inclusion body, ATI).1 PCR products were
differentiated by RFLP, which showed cowpox in all
affected individuals. Serological tests were also positive.
To avoid superinfection, patients were treated with
systemic antibiotics (oxacillin 3 g/d intravenously and
erythromycin 1·5 g/d orally) with topical antiseptic
dressings, removal of necrotic tissue, and application of
occlusive bandages to avoid autoinoculation. In all
patients, the ulcerated lesions healed uneventfully within
8 to 10 weeks leaving behind atrophic scars. The cat
became unwell and scratched itself all over. It was put
down by a veterinarian. Investigations confirmed cowpox
infection.
Despite its name, cowpox virus is mostly found in zoo
animals and domestic cats who hunt for rodents, the
reservoirs of cowpox virus.2 Cowpox virus belongs to the
genus Orthopoxvirus of the family Poxviridae. Several
other members of this genus cause disease in human
beings, such as smallpox. In the past few years, there
have been an increasing number of reports of human
infection with cowpox virus, mostly transmitted by
cats.3,4 These reports and our observation suggest the
For personal use. Only reproduce with permission from Elsevier Ltd
Figure: Presenting lesion at end of first week
need for increased awareness by health professionals of
the typical clinical features of human cowpox. Since
scratch wounds are the most frequent way of infection in
people, the primary infection sites are often fingers and
hands. As a rule, the lesions start as inflamed macules
that become papulo-nodular or vesicular within the first
week. Subsequently, sterile pustules develop that then
begin to ulcerate and crust over by the end of the second
week. During the third week, the lesions progress to
deep-seated, hard, black eschars of 1–3 cm in diameter
accompanied by oedema and sometimes induration.
Cowpox lesions are invariably painful, and there is local
lymphadenopathy. Most patients report some systemic
symptoms including fever, malaise, occasionally
vomiting, and a sore throat. The majority of cases take
6–8 weeks to full recovery always with residual scars.
However, in some cases, particularly in atopic and
immunosuppressed individuals, severe generalised
infection, similar to smallpox, has been reported, some
with a fatal outcome.5 The most important differential is
anthrax. The skin lesions of anthrax are relatively
painless and progress rapidly to the eschar stage within
5–6 days.
References:
1 Hazel SM, Bennett M, Chantrey J, et al. A longitudinal study of
an endemic disease in its wildlife reservoir: cowpox and wild
rodents. Epidemiol Infect 2000; 124: 551–62.
2 Burton JL. Of mice and milkmaids, cats and cowpox. Lancet 1994;
343: 67.
3 Baxby D, Bennett M, Getty B. Human cowpox 1969–93: a review
based on 54 cases. Br J Dermatol 1994; 131: 598–607.
4 Meyer H, Pfeffer M, Rziha HJ. Sequence alterations within and
downstream of the A-type inclusion protein genes allow
differentiation of Orthopoxvirus species by polymerase chain
reaction. J Gen Virol 1994; 75: 1975–81.
5 Eis-Hubinger AM, Gerritzen A, Schneweis KE, et al. Fatal
cowpox-like virus infection transmitted by cat. Lancet 1990; 336:
880.
www.thelancet.com Vol 365 January 29, 2005