Images in infectious diseases: milker’s nodule with erythema multiforme after calf bite in a 23-year-old patient
Benjamin T. Schleenvoigt, Christine Kletta, Christine Zollmann, Stefan Hagel, Stefan Glöckner, Eva Krause, Janine Michel, Carlotta Helbig, Andrea Vanegas-Ramirez
Abstract
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Figure 3- —Friedrich-Schiller-Universität Jena (1010)
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TopicsDrug-Induced Adverse Reactions · Eosinophilic Disorders and Syndromes · Chemotherapy-related skin toxicity
A 23-year-old patient presented to the general practitioner´s (GP’s) office with a hard nodule on her right index finger. This had been preceded by a calf bite in the same place 4 weeks earlier. The wound had initially healed within a few days without sequelae. Clinically, the nodule was approximately 1 cm in size, with a whitish margin and central hemorrhagic erythema (Fig. 1).
Fig. 1. Nodule on the right index finger, 4 weeks after the calf bite
The puncture remained dry, and the swab showed no bacterial growth. After starting empirical antibiotic therapy with amoxicillin/clavulanate, a macular pruritic rash occurred, beginning on both distal extremities and spreading to the trunk (Figs. 2 and 3). The patient also reported a general malaise, pain in her limbs and loss of appetite.
Fig. 2. Macular pruritic rash after starting antibiotic treatment
Fig. 3. Macular pruritic rash after starting antibiotic treatment
Amoxicillin/clavulanate was discontinued after 6 days, on the assumption that the rash was drug-related. In view of the previous animal contact, a swab for poxvirus analysis was sent to the Robert Koch Institute, and the PCR test for parapoxviruses returned a positive result [1]. The sample was identified as pseudocowpox virus by Sanger sequencing of the B2L gene. Furthermore, parapoxvirus specific IgM (1:1280) and IgG (1:320) were detected by immunoflourescence assay in a serum sample taken 7 weeks after the bite. In the context of the diagnosis of pseudocowpox, the rash was most likely to be classified as infection-induced erythema multiforme [2].
Topical steroids (mometasone furoate cream 1 mg/g, applied twice daily for two weeks) and systemic steroids (methylprednisolone: 40 mg on day 1, 20 mg for 2 days, 10 mg for 2 days, and 5 mg for 2 days) were administered, complemented by topical antibiotic treatment (Fusidic acid cream) as a preventive measure [3]. Analgesic treatment (Ibuprofen 600 mg) was used as needed. Within the next two weeks, the exanthema gradually subsided, and the nodule on the index finger healed without scarring.
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