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Cover page of the Journal of Health Sciences


 
 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 242-244

Milker's nodule


1 Department of Dermatology, JNMC, Belgavi, Karnataka, India
2 Department of Dermatology, KLE Academy of Higher Education and Research, JN Medical College, Belgavi, Karnataka, India

Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Snehal Balvant Lunge
Department of Dermatology, JNMC, Belgavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_11_19

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  Abstract 


Milker's nodule is caused by a cylindrical parapoxvirus that is most commonly endemic in cattle. It affects those in close contact with animals harboring the virus. We report a 30-year-old female, milkmaid who presented with painful raised lesions over the right hand of 8-day duration. No lymphadenopathy was noted. Skin biopsy revealed epidermal hyperkeratosis, parakeratosis, and acanthosis with dense inflammatory infiltrate in the papillary dermis. The patient was treated with a course of antibiotics for the secondary infection, as there was no specific treatment for the same.

Keywords: Cowpox, milker's nodule, parapoxvirus


How to cite this article:
Lunge SB, Doshi B, Manjunathswamy B S, Mudgal S. Milker's nodule. Indian J Health Sci Biomed Res 2019;12:242-4

How to cite this URL:
Lunge SB, Doshi B, Manjunathswamy B S, Mudgal S. Milker's nodule. Indian J Health Sci Biomed Res [serial online] 2019 [cited 2019 Nov 19];12:242-4. Available from: http://www.ijournalhs.org/text.asp?2019/12/3/242/269191




  Introduction Top


Milker's nodules are caused by parapoxvirus genes and paravaccinia species.[1],[3] It is a DNA virus that multiplies in the cytoplasm of infected cells. It causes infection of the teats of cow and ulcers in the mouth. It affects those in close contact with the animals harboring the virus, like milker's, veterinary personnel. The incubation period ranges from 5 to 14 days. The most common sites affected are hands and occasionally face. It begins as a red raised papule on the digits. These then turn into papulovesicles and then to bluish tender nodules. Few ulcerate to form crust or eschar. A zone of erythema surrounding the lesion is present. Minimal constitutional symptoms may be present. History of exposure to the cattle often directs to the diagnosis. Histopathological changes are not diagnostic. Serological tests including visualization of the virus by electron microscope, tissue culture, and polymerase chain reaction technique help to distinguish it from the other parapoxviruses.


  Case Report Top


A 30-year-old female, milkmaid by occupation presented with painful red raised lesions over the fingers of the right hand of 8-day duration. There was no history of constitutional symptoms. There was a history of similar lesions over the teats of the cow for 1 month. Cutaneous examination showed two erythematous nodules with central umbilication and crust formation each present over the palmar aspect of the right middle finger and dorsal aspect of the right ring finger [Figure 1] and [Figure 2]. There was no lymphadenopathy. Skin biopsy revealed epidermal hyperplasia, parakeratosis, and acanthosis showing ballooning degeneration of the keratinocytes along with inclusion bodies. Dermis showed dense inflammatory infiltrate in the papillary dermis, composed of lymphocytes and neutrophils [Figure 3] and [Figure 4]. Cell culture could not be done for want of facilities. Other routine investigations were not contributory. Hence, we reached the diagnosis on the basis of history, clinical findings, and histopathology concluded as milker's nodules. The patient was treated with prophylactic antibiotics and anti-inflammatory drugs. The patient was followed up and spontaneous regression of the lesions was observed which resolved with hyperpigmentation.
Figure 1: Erythematous nodules with central umbilication and crust formation each present over the palmar aspect of the right middle finger

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Figure 2: Erythematous nodules with central umbilication and crust formation each present over the dorsal aspect of the right ring finger

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Figure 3: Skin biopsy revealed epidermal hyperplasia, parakeratosis, and acanthosis. Dermis showed dense inflammatory infiltrate in the papillary dermis, composed of lymphocytes and neutrophils

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Figure 4: Skin biopsy H and E, ×10. Dermis showed dense inflammatory infiltrate in the papillary dermis, composed of lymphocytes and neutrophils

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  Discussion Top


Milker's nodules are most commonly seen in persons whose occupation brings them regularly in contact with cattle. In our patient, the history and clinical features were supportive. Our patient was immunocompetent. It is considered as an occupational viral skin disease of universal distribution. Histopathological changes are not diagnostic which can vary from hyperkeratosis, parakeratosis, acanthosis to intracytoplasmic eosinophilic inclusions, and granulomatous reaction in the upper dermis or mononuclear cell infiltration in the dermis.[2] Differential diagnosis of orf [4] was considered, although it was ruled out by history as orf is often caused by infected goats and sheep. Another important differential considered was cutaneous anthrax,[5] which has a short incubation period, and histopathological examination shows hemorrhagic necrosis with gelatinous edema containing large amount of bacterial capsular material. Another differential diagnosis of milkers nodule is cowpox [6] also differentiation shown in [Table 1].
Table 1: Differential diagnosis of milkers nodule

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The disease is self-limited. Follow-up is expectant and sequential until remission of clinical picture. As there was no specific treatment, our patient was treated with a course of oral antibiotics and anti-inflammatory drugs. The lesions healed on their own with residual pigmentation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kaviarasan PK, Yamini M, Prasad P, Viswanathan P. Milker's nodule. Indian J Dermatol 2009;54:78-9.  Back to cited text no. 1
  [Full text]  
2.
Groves RW, Wilson-Jones E, MacDonald DM. Human orf and milkers' nodule: A clinicopathologic study. J Am Acad Dermatol 1991;25:706-11.  Back to cited text no. 2
    
3.
Werchniak AE, Herfort OP, Farrell TJ, Connolly KS, Baughman RD. Milker's nodule in a healthy young woman. J Am Acad Dermatol 2003;49:910-1.  Back to cited text no. 3
    
4.
Haenssle HA, Kiessling J, Kempf VA, Fuchs T, Neumann C, Emmert S, et al. Orthopoxvirus infection transmitted by a domestic cat. J Am Acad Dermatol 2006;54:S1-4.  Back to cited text no. 4
    
5.
Thappa DM, Karthikeyan K. Cutaneous anthrax: An Indian perspective. Indian J Dermatol Venereol Leprol 2002;68:316-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Mittal RR, Jain C, Gupta V, Kaur S. Cowpox of vulva. Indian J Dermatol Venereol Leprol 1993;59:1389.  Back to cited text no. 6
  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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