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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 146-148

Uncommon cutaneous manifestations in buffalopox

1 Department of Skin and V.D., SBH Medical College, Dhule, Maharashtra, India
2 Department of Skin and V.D., MGM Medical College and Hospital, Aurangabad, Maharashtra, India
3 Department of Skin and V.D., S.B.H. G.M.C., Dhule, Maharashtra, India

Date of Submission18-Jul-2018
Date of Acceptance21-Nov-2018
Date of Web Publication18-Aug-2020

Correspondence Address:
Anirudha Gulanikar
Department of Dermatology, MGM Medical College and Hospital, Aurangabad, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CDR.CDR_28_18

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Context: Buffalopox is a zoonotic disease caused by buffalopox virus. The natural host being buffaloes, it has been known to infect cows and humans as well. Recent trends suggest that increasing numbers of outbreaks in the Indian subcontinent are being recorded, but awareness about diagnosis, treatment and preventive measures in humans is much less. Aim: To report the rare occurrence of lesions in humans at atypical sites like face and eyes and also indirectly involving non-milkers. Methods and Material: The study was carried out in Dhule, Maharashtra where twenty-eight patients were diagnosed with the condition based on history and clinical examination. The diagnosis was confirmed by viral nucleotide sequencing by polymerase chain reaction. Results: Total twenty-eight patients were diagnosed with buffalopox with a male predominance. Most of them were milkers but two children who were not directly involved in milking were also affected. Lesions were mostly present over hands and forearms. We found involvement of atypical sites like face and eyes in some patients. Prophylactic antibiotic treatment was given, draining of pus and debridement done and hygienic practices like use of gloves were promoted. Conclusions: Early interventions in such conditions help limit the disease itself; however, the involvement of children and presentation of atypical sites may indicate increased virulence of the virus. This may lead to a severe epidemic in the future. Atypical presentations, and new sites of development of clinical lesions should be kept in mind. Awareness should be created regarding the emergence of poxvirus infections in future.

Keywords: Buffalopox, orthopoxvirus, zoonoses

How to cite this article:
Gore S, Gulanikar A, Rajput C, Sharma S, Malani S. Uncommon cutaneous manifestations in buffalopox. Clin Dermatol Rev 2020;4:146-8

How to cite this URL:
Gore S, Gulanikar A, Rajput C, Sharma S, Malani S. Uncommon cutaneous manifestations in buffalopox. Clin Dermatol Rev [serial online] 2020 [cited 2023 Feb 5];4:146-8. Available from: https://www.cdriadvlkn.org/text.asp?2020/4/2/146/292472

  Introduction Top

According to the Joint Expert Committee on Zoonoses, buffalopox is an emerging contagious viral zoonoses with high morbidity.[1] The causative agent, buffalopox virus (BPXV), is a member of the orthopoxvirus, Poxviridae family, and is closely related to Vaccinia virus.[2],[3]

Increasing reports of both mild and severe forms of the disease from various states of India have been documented.[4],[5],[6],[7],[8],[9] The disease is mainly prevalent in the Indian subcontinent and some South Asian countries, but similar outbreaks of pox-like infections have been reported from Brazil also.[10],[11],[12]

Although the natural host is buffalo, occasionally cows and humans are also affected. The disease in animals is characterized by disseminated pustular lesions mostly on the skin of udder, teat, medial aspect of the thigh, and inguinal region. Lesions are localized in mild form whereas, in severe form, which is uncommon, lesions may be generalized.[13],[14] In milk attendants, lesions are found mainly over hands and forearms and are associated with fever and lymphadenopathy. The rising trend of this disease in our country prompted us to carry out this study to spread awareness among milkers, who are most exposed to this. In this article, we bring forward the atypical presentation of this rare disease.

  Subjects and Methods Top

The study was carried out in a town called Dhule in Maharashtra. The index case was a 31-year-old male who presented with tender pustular lesions over hands for 4–5 days associated with fever and axillary lymphadenopathy. Within the next few days, many patients with similar presentation reported. Detailed history revealed buffaloes in the village and some more humans having similar lesions. A total of 28 humans were inflicted with the disease in a week.

On investigating these patients, the Gram-staining and acid-fast bacilli staining of fluid from lesions were negative. Potassium hydroxide mount did not show any fungal element. On histopathology, lesions showed multiple intraepithelial microabscesses, filled with acute inflammatory cells, eosinophilic inclusion bodies, and koilocytic changes. Dermis showed dense lymphoplasmacytic infiltrates [Figure 1]. Viral nucleotide sequencing by polymerase chain reaction confirmed the presence of BPXV in the swabs from lesions.
Figure 1: Dermis showed dense lymphoplasmacytic infiltrate

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Patients were given supportive treatment in the form of systemic and topical antibiotics and anti-inflammatory drugs such as nonsteroidal anti-inflammatory drugs. This treatment helped prevent a secondary infection as well. Patients were followed up at an interval of 7 and 15 days.

  Results Top

Twelve buffaloes and four cows were found to have lesions over udder, teats, and thighs. Twenty-three human cases were reported between the ages of 15 and 40 years; three cases were above 40 years and two were below 15 years who were not directly associated with the process of milking. Twenty (71%) out of the total number of patients were male. All cases were having painful erythematous papular, nodular, pustular, few crusted, and ulcerated lesions over fingers, hands, and forearm [Figure 2].
Figure 2: Lesions on the hand of a milker due to direct contact

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Three cases had lesions over the face, with one having ocular involvement. All of them had febrile illnesses, with 12 complaining of malaise and 4 having abdominal pain. Fourteen cases had lymphadenopathy, with axillary lymphadenopathy in eight, epitrochlear in four, and cervical lymphadenopathy in two cases.

An important finding was the new site of involvement and development of skin lesions in a child who was not exposed to affected buffaloes. One patient had lesion near the eye, watering of the eye, conjunctival erythema, and orbital cellulitis [Figure 3]. Another patient had facial vesicular and pustular lesions [Figure 4].
Figure 3: Lesions on the face of a patient with orbital cellulitis

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Figure 4: Vesicles and pustules on the face with surrounding erythema

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  Discussion Top

The clinical presentation and the investigations confirmed the diagnosis of buffalopox in affected humans. A total of 28 patients were found to be affected, along with 12 buffaloes and 4 cows. The outbreak has occurred during early summer similar to previously reported outbreaks by Kolhapure et al.[6] Most of the lesions in animals were over udder and teats, strongly implying the spread to animals through a common milkman. Along with buffaloes, cows were also affected.[7]

Most of the affected human cases had lesions over hands and forearms, suggesting the spread from animals to humans through direct contact. Earlier outbreaks reported lesions in mostly milk attendants having direct contact with infected cattle, whereas, in this study, children without direct contact were also affected. Recently, Goyal et al. and Gurav et al. also found the presence of disease among children.[7],[8] As with our report of involvement of eyes and face, only one previous study by Goyal et al. reported ophthalmic involvement during the outbreak.[7] Involvement of atypical sites such as eyes, face, and occurrence of the disease in children indirectly through infected family members or other close contacts can be an indication of increased virulence of the viruses.

Buffalopox is a reemerging zoonosis associated with increased morbidity in humans and animals. Considering the zoonotic impact and productivity losses of buffalopox infection, the appropriate control measures, a high index of suspicion of disease and awareness of atypical presentation has to be taken into consideration in the public health impact of the disease. Milkers, farmers, and other livestock handlers should receive education on control measures such as restriction of movement of animals with lesions and basic hygiene practices such as use of gloves and proper handwashing techniques.

Our clinical presentation of involvement of new sites such as eyes, face, and affecting noncontact children indicates that virulence of virus may be increasing and such findings have rarely been reported in previous outbreaks.

  Conclusion Top

To conclude the study, we would like to stress on the importance of educating the community of milkers in our country about zoonotic diseases such as this one and the practice of wearing gloves while milking to help stop the spread of the disease from infected animals to noninfected animals as well as humans. Doctors should also be kept informed about infrequent clinical presentation as seen in these patients. There is no specific treatment for this condition; however, a secondary infection should be avoided with supportive treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

FAO/WHO. Expert Committee on Zoonoses: Poxvirus Infection. Geneva: Third Report, WHO Technical Report Series; 1967. p. 378.  Back to cited text no. 1
Mathew T. Immunological studies on pox group of viruses with special reference to buffalo pox virus. Indian Vet J 1975;52:517-25.  Back to cited text no. 2
Classification and nomenclature of viruses. Fourth report of the international committee on taxonomy of viruses. Intervirology 1982;17:1-99.  Back to cited text no. 3
Sharma GK. An interesting outbreak of variola Vaccinia in milch cattle in Lahore. The imperial council of agricultural research. Selected clinical articles. Misc Bull 1934;8:1-4.  Back to cited text no. 4
Dumbell K, Richardson M. Virological investigations of specimens from buffaloes affected by buffalopox in Maharashtra state, India between 1985 and 1987. Arch Virol 1993;128:257-67.  Back to cited text no. 5
Kolhapure RM, Deolankar RP, Tupe CD, Raut CG, Basu A, Dama BM, et al. Investigation of buffalopox outbreaks in Maharashtra state during 1992-1996. Indian J Med Res 1997;106:441-6.  Back to cited text no. 6
Goyal T, Varshney A, Bakshi SK, Barua S, Bera BC, Singh RK, et al. Buffalo pox outbreak with atypical features: A word of caution and need for early intervention! Int J Dermatol 2013;52:1224-30.  Back to cited text no. 7
Gurav YK, Raut CG, Yadav PD, Tandale BV, Sivaram A, Pore MD, et al. Buffalopox outbreak in humans and animals in Western Maharashtra, India. Prev Vet Med 2011;100:242-7.  Back to cited text no. 8
Prasad VG, Nayeem S, Ramachandra S, Saiprasad GS, Wilson CG. An outbreak of buffalo pox in human in a village in Ranga Reddy district, Andhra Pradesh. Indian J Public Health 2009;53:267.  Back to cited text no. 9
[PUBMED]  [Full text]  
Singh RK, Hosamani M, Balamurugan V, Bhanuprakash V, Rasool TJ, Yadav MP, et al. Buffalopox: An emerging and re-emerging zoonosis. Anim Health Res Rev 2007;8:105-14.  Back to cited text no. 10
Damaso CR, Esposito JJ, Condit RC, Moussatché N. An emergent poxvirus from humans and cattle in Rio de Janeiro state: Cantagalo virus may derive from Brazilian smallpox vaccine. Virology 2000;277:439-49.  Back to cited text no. 11
de Souza Trindade G, da Fonseca FG, Marques JT, Nogueira ML, Mendes LC, Borges AS, et al. Araçatuba virus: A vaccinialike virus associated with infection in humans and cattle. Emerg Infect Dis 2003;9:155-60.  Back to cited text no. 12
Chandra R, Garg SK, Rana UV, Rao VD. Poxinfection in buffaloes. Farm Anim 1987;2:57-9.  Back to cited text no. 13
Ramakrishna M, Ananthapadmanabham K. An experimental study of virus of buffalopox. Indian Vet J 1957;34:23-30.  Back to cited text no. 14


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


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