Cowpox: How dangerous could it be for humans?
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Cowpox is a rare zoonosis transmitted to humans mainly from cats. The disease usually causes skin lesions; however, the ocular form may lead to serious complications. A 35-year-old male, with no significant past medical history, was referred with a necrotic lesion of the left eyelid, with possible suspicion of anthrax. One week prior to admission to the local hospital, the patient had contact with homeless kittens who had diarrhea. Initially, the patient had diarrhea and fever up to 39?°C for three consecutive days. Next, intense edema of his left upper eyelid, cervical lymphadenopathy, and myalgia appeared, and the patient was admitted to the emergency room.

During the ophthalmology examination, the examiner described a large swelling and dropping of the left upper eyelid, a narrowing of the left-eyelid fissure, redness, and pain on palpation of the left eyelid, conjunctival edema, and a purulent discharge in the conjunctival sac. Laboratory tests revealed WBC 5,69?×?103/?l, CRP 30?mg/l. A suspicion of preseptal orbital cellulitis and conjunctivitis of the left eye was made. The patient was given cefuroxime orally and amikacin eye drops. A computed tomography (CT) of the orbit revealed an enlargement of the left lacrimal gland and inflammation of the soft tissues of the left eyelid. The conjunctival sac was filled with a thick, purulent content. The patient was treated intravenously with ampicillin and sulbactam, followed by benzylpenicillin and metronidazole, azytromycine and vancomycin, and eyedrops with amikacin, followed by tobramycin, and dexamethasone and gentamycine.

Upon admission, the patient had intense and painful edema of the left eyelid with a black necrotic eschar on the upper eyelid approximately 2?cm in length and 1,5?cm in width. The attempts of opening the eyelids were unsuccessful due to excruciating pain. The computed tomography of the orbits showed air bubbles subcutaneously. Due to the presence of the black eschar and the CT image, the suspicion of cutaneous anthrax of the eyelid was made. A diagnostic surgery of the eyelids was accompanied by excision of the necrotic tissues and histopathological samples were performed. Histopathology analysis of the lesion revealed necrosis with inflammatory cells – mainly granulocytes. The blood cultures were negative. The Gram stain did not reveal a GRAM?+?rod. A culture of the pus from the left eyelid revealed Staphylococcus haemolyticus resistant to methicillin. Serum anti-IgM antibodies for Bartonella henselae and Francisella tularensis were negative.

Another CT of the orbit was performed, which showed high degree thickening, increased density, and soft tissue structure obliteration of left superior and inferior eyelid, lower degree ST obliteration of supraorbital ridge, infraorbital region, and left temporal bone. Under the superior and inferior eyelids, a contrast-enhanced fluid cavity, with the size of 34?×?16?x?29?mm was observed. The patient was initially treated with levofloxacin and anti-inflammatory drugs, followed by vancomycin and doxycycline. Due to intense pain, the patient also received buprenorphine. A PCR for CPXV was positive for gene b9R and +/- for d11?L which confirmed the diagnosis of Cowpox/Catpox virus infection. On the 19th day of the hospitalization the patient noted worsening of the vision in his left eye. Keratitis of the left eye was diagnosed, and the patient was transferred back to the Ophthalmic University Hospital. There he was treated with topical gentamicin, ofloxacine, and tropicamide to the left eye and the wet chamber.

The patient was then referred to a plastic surgery clinic, where he underwent reconstruction surgery of the left eyelid, later followed by the correction of the medial canthus. The leucomatous opacity and the neovascularization of the cornea were present. The patient then underwent the corneal neurotization and supraorbicularis-nerve transplantation and currently is awaiting transplantation surgery of the cornea. Unfortunately, the patient lost vision in his left eye.

Source:https://www.ijidonline.com/article/S1201-9712(20)32586-8/fulltext?rss=yes
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