HOSPITAL Mahnoush Momeni Assistant Professor of General Surgery Department of Plastic Surgery Burn Research Center Iran University of Medical Science Tehran Iran Faranak Alinejad Infectious Disease Specialist ID: 913355
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Slide1
INTRODUCTION TO A CASE OF ORF DISEASE IN BURN WOUND AT MOTAHARI HOSPITAL
Mahnoush
Momeni
Assistant Professor of General Surgery, Department of Plastic Surgery .
Burn Research Center, Iran University of Medical Science, Tehran, Iran
Faranak
Alinejad
Infectious Disease Specialist
Burn Research Center, Iran University of Medical Science, Tehran, Iran
Slide2The cause of Orf disease is a double -stranded DNA virus of the Parapoxvirus
family.
Human Orf disease is usually due to occupational hazard and mostly occurs in abattoir workers, veterinarians, and farm workers.
(1, 2)
Orf disease may also occur in some part of world like Iran, during the feast of sacrifice.
(3)
1-Afzali H,
Momen-Heravi
M, Human Orf
Disease:a
case series in Kashan City, Iran
Internatinal
Archives of Health Science 2015;2(3):129-132
2-Becher P,
Konig
M, Muller G, Siebert U, Thiel
HJ.Characterization
of
sealpox
virus,a
separate member of the
parapoxvirus
. Arch
Virol
. 2002; 147(6):1133-40
3-Uzel M,
Sasmaz
S,
Bakaris
S,
Cetinus
E,
Bilgic
E,
Karaguz
A, et al. A viral
infectin
of the hand commonly seen after the feast of sacrifice: Human Orf (
orf
of the hand).
Epidemiol
Infec
. 2005; 133(4):653-7
Slide3Manifestations:Goats and S
heep
:
sore mouth, scabby mouth or contagious postural dermatitis.
(1
)
Human Infection
:
Isolated
lesion on arms and hands,
face
or
peri
anal area .
(4)
Benign
neoplastic lesions
Mostly
self-limited.
Fever
and lymphadenopathy.
(5
)
4-Bayindir Y,
Bayracdar
M,
Karadag
N,
Ozcan
H,
Kayabas
U,
Otulo
B, et al. Investigation and analysis of a human
orf
outbreak among people living on the same farm. New
Microbiologica
. 2011; 34(1):37-43
5-Taghipour M,
Babamahmoodi
F,
Arashnia
P,Taghipour
S Orf Virus in human (
EchtymaContagiosum
): A Report of Eight Cases in the North of Iran.
Int
J Med Invest 2015;
vol
4;
num
1; 183-186
Orf lesions manifest in different pattern in the human body: Erythematous maculopapular lesion
Target
shape lesion with a red center.
Regeneration
stage
:dry
lesion with black dots
Papillomatous
and dry crust
. (6, 7
)
6-Zimmerman JL. Orf. JAMA. 1991;266(4):476
7-Mendez B, Burnett JW.
Orf.JAMA
. 991;266(4):476
Slide5Diagnosis:History of contact with infected animalThe presentation of clinical lesion Viral culture (3)
Treatment
:
Supportive care with topical antibiotic
when the wound infected by bacteria, systemic antibiotic may be applied
Recovery often happens within 2-3 weeks.
Larger lesions sometimes need surgery.
(8)
Treatment with Imiquimode and ribavirin.
(9)
8-Buller RML. Poxviruses. In Cohen J, Powderly WG, Opal SM, eds. Infectious
Diseas
, 3rd
edn
.
Philadelphia:Mosby
Elsevier, 2010: 1577-1582
9-Mandell Douglas, Bennet John E, Dolin Raphael, Blaster Martin J,DNA virus Chapter, Mandell, Douglas, and
Bennettes
Principle and Practice of Infectious Disease, 8th
edn,Philadelphia
: Churchill Livingstone Elsevier, 2015: 1701
Slide6Case: There was an 18 year old female shepherd who was burned 22% TBSA, on July 10th, 2015 while starting a campfire, and was admitted to the local hospital. Dressing was changed daily and early surgical debridement was performed, then upper extremity was skin grafted and it took, but later vegetative granulomatous ulceration appeared on improved as well as the grafted areas.
Slide7Slide8Lab test results: White
blood cell count
:
normal
Hemoglobin
levels
;a
little low.
Blood
culture
:negative
Wound at the time of admission
:
There was some vegetated granular
lesions
Slide9Wound Management In Central Hospital:Wound disinfection with Dakin’s solutions
Excision after
4 days of dressing change.
Usage of Sulfamylon
(Mafenide) topical was used on excised
area
Wound coverage with
allograft 4 days later.
Replacement of allograft with autograft
after 12
days
Slide10Slide11The result of the first wound culture in Motahari hospital : Pseudomonas MDR
.
The histology
report of the previous hospital
:
hyperkeratosis
and pseudoeptheliamatous hyperplasia, dermal edema and congestion with dermal spindle cell proliferation.
The report of tissue culture of the patient in Motahari hospital
:
Granulation type hemangioma with ulceration.
Slide12The report of tissue culture in Virus lab:
Viral DNA was extracted for a tissue biopsy using High Pure DNA extraction kit (ROCHE, Germany).
Sample was tested for camel pox, Capri pox, Sheep pox, Goat pox using PCR by specific printing.
The results showed that the PCR test for Parapoxvirus was
positive.
Slide13Discussion:Orf disease is a disease of goat, sheep and cows . (1)
Individuals are infected by direct contact with infected animals.
(5)
The disease occurs worldwide, but it has been reported more in Europe and New Zealand
(
10)
The
virus survives in the skin of the animal up to one month after improvement.
(5
)
10-Damon IK. Other poxvirus that infect
humans:Parapoxvirus
,
Molluscomcontagiosum
, and
Yatapoxviruse
. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and
Bennettes
Principle and Practice of Infectious Disease, 7th
edn
. Philadelphia : Churchill Livingstone Elsevier, 2010:1933-1936
Slide14Incubation period for Parapoxvirus in human is 3-7 days.
The course of Orf infection is 4-8 weeks.
Neither Orf infection, nor smallpox vaccination grant permanent immunity
.(11)
11-Amira
A.
Roess
, Ph.D.,
Anjela
Galan, M.D., Edward
Kitces
, M.D., Ph.D., Yu Li, Ph.D., Hui Zhao, M.D., Christopher D. “Novel Deer-Associated Parapoxvirus Infection in Deer Hunters.”
N
Engl
J Med 2010; 363:2621-2627
Slide15In persons who work with animals the disease mostly appears as :A solitary lesion on the finger, forearm and/or hand lens-shaped nodule with red center and pale circle.
(12)
larger exudative lesions .
Black spots in regenerative phase.
Small papilloma.
Healed lesion.
(5)
The Orf disease is a self-limited diseases.
12-shirazi
MR,
Pedram
N,
Orf:Report
of eleven cases in five Iranian Families. Iranian Journal of Clinical Infectious Disease. 2007;2(2):83-85
In our patient Partial thickness injuries converted to deep ones
and required skin grafting for coverage. The
lesions
spread
over
the entire
donor
site too and previous grafted area failed.
Slide17Reports of Orf disease peaked the most in Norway during 1975 (13) and New Zealand in 1983 (14)
In Shamsedini’s et al. study, considers that in 15012 patients older than 20 years between 1991-1996 in a dermatology center, the Orf incidence has been reported about 0.4%
(15)
Nedim
et al. reported 5 cases of children Orf disease in farmers in western part of Ireland within a decade
.(16)
13-Johannessen
JV, Krogh HK, Solberg L,
Delan
A, van
Wijngaarden
H, Johansen B. Human
orf.Cutan
Pathol.1975;2(6):265-83
14-
Robinson
AJ,Petersen GV. Orf virus infection of workers in the meat industry. N Z Med J.1983;96(725):81-515-Shamsaldini S, Rezaei A. Incidence of orf disease in dermatology center clinic in Kerman. Razi J Med Sci.1999;5(2)30-5.[Persian]16-Nadeem M, Curran P, Cooke R, Ryan CA, Connolly K. Orf: Contagious pustular dermatitis. Ir Med J.2010;103(5):152-3
International Reports of Orf Disease
Slide18Shirzad et al. reported a patient with Orf disease, who had a history of cutting meat with an infected knife. The patient was infected following a finger injury. Contact with such a wound will transmit the disease. (12)Middli
et al. reported patients with Orf disease whom were infected by scissors, ointments and water tanks .
(17)
Roess
et al
. Reported Deer-Associated Parapoxvirus Infection in Deer Hunters in North America
(11)
17-Midilli
K,
Erikilic
A,
Kuskuko
m,
Analay
H,
Benzonana
N. “Nosocomial outbreak of disseminated
orf infection in a burn unit, Gazinatep, Turkey, October to December 2012.”European Journal of Infectious disease epidemiology prevention and control 2013;18(11) International Reports of Orf Disease cont.
Slide19CONCLUSION Orf disease could infect burn wound and even the healing area of superficial burn could be deepened and thus may require skin grafting.
In burn patient with a history of probable contamination, the disease should also be considered.
Manipulation of the disease in the early stages of the burn wound, could also potentially spread the disease and change the degree of the wound, as was the case in our patient.
Slide20For prevention of nosocomial outbreak of Orf:Wound care and wound disinfection should be carried out impeccably
Isolation and disinfection of all the dressing tools should also be done precisely.
The proper training of wound care providers in burn units should be provided
Perfect wound disinfection must be performed to protect the patient from cross contamination following this phase.