|Year : 2019 | Volume
| Issue : 3 | Page : 242-244
Snehal Balvant Lunge1, Bhavana Doshi2, BS Manjunathswamy2, Shashikala Mudgal2
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 Publication||15-Oct-2019|
Dr. Snehal Balvant Lunge
Department of Dermatology, JNMC, Belgavi, Karnataka
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
Milker's nodules are caused by parapoxvirus genes and paravaccinia species., 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|| |
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|| |
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. Differential diagnosis of orf  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, 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  also differentiation shown in [Table 1].
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.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]