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Year : 2020  |  Volume : 28  |  Issue : 3  |  Page : 195-197

Sacrifice feast disease: Orf

1 Department of Plastic, Reconstructive and Aesthetic Surgery, Baskent University, Ankara, Turkey
2 Department of Pathology, Gazi Mustafa Kemal State Hospital, Ankara, Turkey

Date of Submission08-Sep-2019
Date of Acceptance20-Oct-2019
Date of Web Publication26-May-2020

Correspondence Address:
Dr. Burak Ozkan
Department of Plastic, Reconstructive and Aesthetic Surgery, Baskent University, Ankara 06900
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_73_19

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Orf disease is a zoonotic infectious caused by parapox virus transmitted by contaminated meat that entered from the disrupted skin. It is usually seen in butchers, farmers, or people who have contact with meat of infected animals commonly in sacrifice feast in Muslim countries. Two patients who admitted to our clinic with orf disease after sacrifice feast were presented. Orf disease should be considered, especially in sacrifice feast term in our country. It heals uneventfully and unnecessary manipulations should be avoided.

Keywords: Orf disease, parapox virus, sacrifice feast, zoonotic infection

How to cite this article:
Ozkan B, Uysal CA, Uner H, Ertas NM. Sacrifice feast disease: Orf. Turk J Plast Surg 2020;28:195-7

How to cite this URL:
Ozkan B, Uysal CA, Uner H, Ertas NM. Sacrifice feast disease: Orf. Turk J Plast Surg [serial online] 2020 [cited 2020 Sep 22];28:195-7. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/3/195/284966

  Introduction Top

Orf disease or ecthyma contagiosum is a zoonotic disease by parapox virus, which causes infection in the oral mucosa and throat of sheep. Virus infects humans by contaminated meat and meat products in case of skin breakdown such as cuts or bites.[1] It is frequently seen after the feast of sacrifice in Muslim countries.[2] Two patients who presented with orf disease to our clinic after sacrifice feast will be presented in this report.

  Case Reports Top

Case 1

A 45-year-old female patient was admitted to the plastic surgery outpatient clinic with a painful lesion on her left hand. Physical examination revealed a 2 cm × 1 cm-sized erythematosus papillomatous mass with caseous umbilication in the center on her dorsal part of the left second finger [Figure 1]. The patient had a history of injuring her left hand second finger while cutting meat at home during sacrifice feast 5 days ago. She had no medical access before admission to our clinic. There were no predefined dermatological and oncologic conditions. Diagnostic incisional biopsy was performed and tissue culture biopsy was taken Prophylactic ciprofloxacin 20 mg/kg daily was started. No bacterial agent was isolated in tissue culture. Microscopic examination of the specimen showed localized eosinophilic appearance and vacuole cytoplasm in keratinocytes in the upper epidermis in small magnification. There were dense vascular structures in the dermis. Rare inclusion bodies seen in the cell cytoplasm and nuclei with vacuole cytoplasm were identified at large magnification [Figure 2]. Orf disease was considered according to clinic and microscopic findings. The patient was followed up without surgical intervention. Secondary recovery with spontaneous minimal scar was observed at 6 weeks [Figure 3].
Figure 1: Clinical presentation of the first case

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Figure 2: Hematoxylin-eosin-stained specimen of the first case. Intranuclear-intracytoplasmic inclusion bodies suggesting parapox virus infection are demonstrated in the marked areas

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Figure 3: Four months follow-up image of Case 1

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Case 2

A 38-year-old male patient was admitted to our outpatient clinic with complaint of foreign body penetration to the sole of his right sole. He stepped on a piece of bone that had fallen to the ground in his house during the holiday of sacrifice 3 days before his admission to our hospital. Physical examination revealed a 5 mm × 5 mm nodular lesion at the base of the right foot with a foreign body entry hole in the middle. No foreign body was detected in 3-plain foot X-ray. Since no pathology was seen on the direct radiography, the current condition was considered as radiolucent foreign body or that foreign body reaction. Thus, the patient underwent complete excision of the lesion. Pathological examination revealed intense intranuclear and cytoplasmic bodies in the epidermis granular layer which was consistent with Orf disease with clinical history [Figure 4]. No recurrence was seen in the postoperative 6th month.
Figure 4: Intranuclear-intracytoplasmic inclusion bodies in granular layer at large magnification (×40). The intranuclear bodies are shown in the vacuolated cytoplasms

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  Discussion Top

Orf is a zoonotic disease caused by parapox virus, a dermotropic DNA virus that causes oral mucosa and throat infection in sheep and goats. The disease is usually seen in butchers, farmers, or after direct contact to contaminated meats of infected animals. Viruses enter the skin at the points where the skin barrier deteriorates.[1] It is usually seen on dorsum of passive hand, and the second finger is most commonly affected.[2] After an incubation period of 3–5 days, it is manifested as hyperemic, vesicular, or papillomatous lesions. Spontaneous recovery is seen with minimal scar in 6–8 weeks spontaneously. Clinical history, course of the disease, and pathological findings should be considered in diagnosis. Pathological findings are not pathognomonic but definitive diagnosis. In the early stage of the disease, it is detected by electron microscopy or DNA pathology or frozen pathology or by swab from the lesion.[3],[4],[5]

The disease is clinically composed of six stages, each lasting for approximately 1 week after the incubation period.[6] These stages are maculopapular, target, acute, nodular, papillomatous, and regression phases. In pathological examination, eosinophilic intranuclear or cytoplasmic bodies are found in maculopapular stage. Vacuolization is seen in granular layer of the epidermis in target phase. Mononuclear cell infiltration is seen in the acute phase. Histiocyte and lichenoid reaction are encountered in the nodular phase. Chronic inflammation and epidermodermal infiltrations are found in papillomatous stage.[7] The patients presented in our report were histopathological consistent with the target stage and maculopapular stage.

The history of animal contact should be considered in the differential diagnosis. Nonanimal contact, clinical-like diseases are herpetic paronychia characterized by group vesicles, keratoacanthoma, and pyogenic granuloma. If there is a history of animal or meat contact, cutaneous anthrax, erysipeloid, and Milker's nodule should be investigated. Cutaneous anthrax caused by Bacillus anthracis manifests with its pathogonomic painless, black eschar. Erysipeloid caused by Erysipelothrix rhusiopathiae is seen in fisherpeople. Milker's nodule, an atypical mycobacterial infection caused by Paravaccinia virus, is usually seen in farmers in contact with cows. Differential diagnosis of orf disease is shown in [Table 1].
Table 1: Differential diagnosis of orf disease

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The course of the disease is benign and usually heals itself. Local lymphadenopathies, fever, and upper infections are rare complications. In immunocompromised patients, amputation may be sufficient to cause amputation.[8] It has been reported to be common during periods of immune system changes such as pregnancy.[9] Successful treatments have been reported with 5-day administration of imiquimod and topical DNA polymerase inhibitor cidofovir to prevent upper infections.[10],[11]

Sheep, goats, and lambs should be under veterinary follow-up to prevent the disease. Contact with infected animals should be avoided, or protective barrier methods should be used, especially in occupational group of livestock workers. Although the vaccine has softened the course of the disease in sheep, it is not yet protective for goats.[12]

  Results Top

Orf disease should be kept in mind in the differential diagnosis with its typical history and clinical findings. Considering the benign prognosis of orf disease, which is more common during feast of sacrifice in Muslim countries, it is important to avoid unnecessary surgical interventions to prevent morbidity.

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

Zimmerman JL. Orf. JAMA 1991;266:476.  Back to cited text no. 1
Uzel M, Sasmaz S, Bakaris S, Cetinus E, Bilgic E, Karaoguz A, et al. A viral infection of the hand commonly seen after the feast of sacrifice: Human orf (orf of the hand). Epidemiol Infect 2005;133:653-7.  Back to cited text no. 2
Sanchez RL, Hebert A, Lucia H, Swedo J. Orf. A case report with histologic, electron microscopic, and immunoperoxidase studies. Arch Pathol Lab Med 1985;109:166-70.  Back to cited text no. 3
Torfason EG, Gunadóttir S. Polymerase chain reaction for laboratory diagnosis of orf virus infections. J Clin Virol 2002;24:79-84.  Back to cited text no. 4
Olson VA, Laue T, Laker MT, Babkin IV, Drosten C, Shchelkunov SN, et al. Real-time PCR system for detection of orthopoxviruses and simultaneous identification of smallpox virus. J Clin Microbiol 2004;42:1940-6.  Back to cited text no. 5
Elder DE, Histopathology of the Skin. 10th ed.. Philadelphia, Pa, USA: Lippincott Williams and Wilkins; 2009.  Back to cited text no. 6
Friedmann PS, Wilkinson M. Occupational dermatoses. In: Bolognia JL, Jorizzo JL, Rapini RP, Schaffer JV. editors. Dermatology. Spain: Mosby; 2003. p. 251-64.   Back to cited text no. 7
Savage J, Black MM. 'Giant' orf of finger in a patient with a lymphoma. Proc R Soc Med 1972;65:766-8.  Back to cited text no. 8
Başkan BE, Yılmaz E, Doǧruk S, Adım BŞ, Tokgöz N, Tunalı Ş. Orf Virus Infection in Pregnancy. Turkiye Klinikleri J Med Sci 2005;25:137-9.  Back to cited text no. 9
Ara M, Zaballos P, Sánchez M, Querol I, Zubiri ML, Simal E, et al. Giant and recurrent orf virus infection in a renal transplant recipient treated with imiquimod. J Am Acad Dermatol 2008;58:S39-40.  Back to cited text no. 10
Geerinck K, Lukito G, Snoeck R, De Vos R, De Clercq E, Vanrenterghem Y, et al. A case of human orf in an immunocompromised patient treated successfully with cidofovir cream. J Med Virol 2001;64:543-9.  Back to cited text no. 11
Musser JM, Taylor CA, Guo J, Tizard IR, Walker JW. Development of a contagious ecthyma vaccine for goats. Am J Vet Res 2008;69:1366-70.  Back to cited text no. 12


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

  [Table 1]


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