Barnyard Zoonoses Tammie Ferringer, MD Geisinger Medical Center, Depts of Dermatology and Pathology, Danville, PA

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1 Barnyard Zoonoses Tammie Ferringer, MD Geisinger Medical Center, Depts of Dermatology and Pathology, Danville, PA Zoonoses: Any infectious disease that can be transmitted (vectored) from animals, both wild and domestic, to humans. Bacterial CAT SCRATCH DISEASE Cause: Gram negative Bartonella henselae Host Animals: Asymptomatic cats Transmission: Cat scratches, rarely fleas Clinical Symptoms: 1-2 weeks after inoculation, usually on the hand, a red papule develops followed by tender regional lymphadenopathy Diagnosis: Serologic testing but cross reactivity exists, if available PCR, histology with stellate abscess and/or granuloma and organisms on Warthin-Starry silver stain or tissue Gram stain. Fastidious to culture. Immunohistochemistry is available but low sensitivity. Treatment: Spontaneously resolves in 2-4 months, antibiotics have been anecdotal including azithromycin, trimethoprim-sulfamethoxazole, ciprofloxacin BACILLARY ANGIOMATOSIS Cause: Gram negative Bartonella henselae and Bartonella quintana Host Animals: Asymptomatic cats with Bartonella henselae Transmission: Cat scratches, bites, or by cat flea Clinical Symptoms: Most common in immunocompromised, especially AIDS, as single or multiple red papules and subcutaneous nodules with normal or dusky overlying skin. Cutaneous lesions are a marker for possible internal involvement. Diagnosis: Histology is a vascular proliferation with neutrophils and granular aggregates of organisms highlighted by Warthin-Starry Treatment: Erythromycin; the anti-angiogenic effect may be more important than the antimicrobial effect. ERYSIPELOID Cause: Non-spore forming Gram positive rod, Erysipelothrix rhusiopathiae Host Animals: Associated with exposure to fish, marine animals, swine, or poultry. Commonly seen in fisherman. Transmission: Minor skin wounds Clinical Symptoms: 1-7 days after exposure a red to violaceous macule develops with disproportionate pain, usually on the hands or fingers. Rarely septicemia, septic arthritis, or endocarditis may occur. Lymphangitis and/or lymphadenopathy occur in about onethird. Diagnosis: May not be demonstrated in tissue. Culture may be misinterpreted as alpha hemolytic streptococci. PCR.

2 Treatment: Untreated, resolution occurs in 3-4 weeks but treatment may hasten healing, reduce systemic complications, and reduce relapse. Penicillin or amoxicillin for 7-10 days for skin limited disease. TULAREMIA (Rabbit fever, Deer fly fever, Ohara s disease) Cause: Gram negative coccobacilli, Francisella tularensis Host Animals: Rabbits (most), cats, hamsters Transmission: Ingest contaminated meat or water, inhaled in dust, handling infected animals, inoculated with a bite or scratch of an infected animal or bite of an arthropod vector. The infectious dose is very low and thus a potential bioterrorism agent. Clinical Symptoms: Seven patterns- 1) Ulceroglandular (most), 2) Glandular (primary site unknown), 3) Oculoglandular (conjunctival inoculation), 4) Oropharyngeal (ingestion), 5) Typhoidal (ingestion), 6) Pneumonic (inhalational), 7) Septicemic. Ulceroglandular form characterized by flu-like symptoms, papule at inoculation site that eventually becomes pustular then ulcerates in a few days with or without eschar. Typically regional lymphadenopathy +/-fluctuance and rupture Diagnosis: Serology. PCR. Routine culture often negative due to fastidious and slow growth; also a risk to lab personnel. Prevention: Live attenuated vaccine was available in US to at-risk personnel but with suboptimal respiratory protection. Alternate vaccines are in preclinical testing. Treatment: Streptomycin is the drug of choice but gentamicin has been used and tetracyclines are more practical. Beta lactams are ineffective. ANTHRAX Cause: Spore forming Gram positive Bacillus anthracis Host Animals: Herbivores such as bison, deer, cattle, sheep, and goats Transmission: GI, inhalational, or cutaneous that is usually associated with handling sick animals or contaminated wool, hair, or animal hides. Recent reports in Europe of subcutaneous anthrax associated with intravenous drug use. Clinical Symptoms: 1-12 days after inoculation a painless papule develops a vesicle and finally an ulcer with black eschar. Mild to moderate fever, headaches, malaise and regional adenopathy often accompany the illness. Diagnosis: Culture of unroofed blister/eschar or ulcer base; a risk to lab personnel Treatment: Ciprofloxacin, doxycycline MYCOBACTERIA Cause: Mycobacterium marinum Host Animals: Ulcers, fin erosion, weight loss, and unusual coloration are signs of disease in fish but fish may show no external signs. Transmission: Infection follows trauma and exposure to an aquarium, salt water, or marine animals, such as fish and turtles. Clinical Symptoms: An erythematous or bluish papule develops 2-16 weeks after inoculation, usually on the finger or hand. Subsequent lesions develop along the lymphatic drainage (sporotrichoid). Diagnosis: Culture takes 4 to 6 weeks. Biopsy may show acid fast organisms. PCR is not widely available and does not provide susceptibilities.

3 Treatment: Often self limited. Tetracyclines or clarithromycin are appropriate with continued treatment for 4-6 weeks after resolution. BITES Cause: Infection is typically a mixture of organisms reflecting the oral flora of the biting animal. Pasteurella multocida (cats) and Pasteurella canis (dogs) being most common but also anaerobes, Streptococci, human skin flora and rarely Capnocytophaga canimorsus (formerly Dysgonic fermenter-2). Host Animals: Normal oral flora of cats and dogs Transmission: Dogs bites are more common in the ER but cat bites are more likely to lead to clinical infection. Clinical Symptoms: Cellulitis, lymphangitis or abscess. Pasteurella is the most common cause of infection in the first 24 hours after the bite. After 24 hours Staph and Strep are more likely. Capnocytophaga canimorsus can cause fulminant sepsis in patients with asplenia or the immunocompromised. Diagnosis: Aerobic and anaerobic culture if clinically infected. Rabies diagnosis can be made by skin biopsy from the posterior neck involving scalp follicles in a symptomatic patient through direct fluorescent antibody staining of the fresh-frozen tissue. Treatment: Tetanus and rabies immunization should be considered, wound irrigation, amoxicillin/clavulanate. Evidence supports prophylactic antibiotics only for animal bites to the hand and human bites. MRSA Cause: Methicillin resistant Staphylococcus aureus Host Animals: Dogs, cats, rabbits, horses, and pigs are all known carriers. Animals can be asymptomatic or have clinical infection. A high prevalence of human nasal MRSA colonization has been reported in those in contact with pigs in the Netherlands. Transmission: Between humans and animals, transmission can occur in both directions, Treatment: Human infection may not be eradicated until the animal is also treated. Viral COWPOX (Catpox) Cause: Orthopoxvirus Host Animals: Rodents, cows, and cats in Europe Transmission: Contact Clinical Symptoms: Umbilicated vesicles with surrounding erythematous edema that forms central necrosis evolving into ulceration with black eschar. Lymphadenopathy Treatment: Regress with scarring after 6-8 wks. Attenuated disease occurs in those with smallpox vaccination in the last decade. ORF (Ecthyma contagiosum) Cause: Parapoxvirus Host Animals: Sheep and goats have pustular encrustation on the lips, nostrils, oral mucous membranes and occasionally urogenital sites.

4 Transmission: Contact with infected animal or fomites Clinical Symptoms: Usually develop a single lesion on the hand 2-6 days after inoculation. Six stages each lasting one week 1) Erythematous maculopapular 2) Targetoid 3) Acute weeping nodule 4) Dry crusted nodule 5) Papillomatous 6) Regressive Treatment: Spontaneous regression in up to 6wks MILKERS NODULE (pseudocowpox) Cause: Poxvirus: Paravaccinia Host Animals: Cattle have circinate or horseshoe-shaped crusted erosions around the nose or papules and erosions on the teats. Transmission: Contact Clinical Symptoms: Mostly on hands and arms after an incubation of 4 days to 3 weeks. Same six stages as orf. Treatment: Self limited (5-7 weeks) DEER ASSOCIATED PARAPOXVIRUS Cause: Unique parapoxvirus Host Animals: Eastern US deer Transmission: Contact Clinical Symptoms: Similar incubation, course and presentation as orf or milkers nodule Treatment: Self limited (5-7 weeks) Fungal TINEA Trichophyton mentagrophytes: Mice, rodents Trichophyton equinum: Horses Trichophyton erinacei : Hedgehogs Trichophyton verrucosum: Cattle Microsporum canis : Cats, dogs Microsporum nanum: Soil/Pigs In humans, zoophilic dermatophytes result in more inflammatory lesions than anthropophilic dermatophytes. Tinea barbae: Common causes include T mentagrophytes var. mentagrophytes and T verrucosum Tinea capitis: Zoophilic disease includes M canis which can often be identified by green fluorescence with Wood s light. Griseofulvin is more effective than terbinafine for tinea capitis caused by M canis. SPOROTRICHOSIS Cause: Sporothrix schenckii

5 Host Animals: Cats and less often birds, dogs, horses, and rats Transmission: Cats with sporotrichosis skin lesions can transmit infection to humans even without penetrating injury. Transmission by other animals has occurred without visible infection, implying that they were carriers of the fungus. Clinical Symptoms: Papule or nodule at site of puncture with subsequent nodules along the lymphatic drainage. Treatment: Itraconazole, potassium iodide Ectoparasites FLEAS Cause: Ctenocephalides canis and C. felis Host Animals: Dog and cats may have no visible disease. Eczematous dermatitis can be seen on the hind legs and abdomen of dogs and crusted papules on the lower back and neck of cats. Fleas will bite humans if the pet isn t available. Clinical Symptoms: Bites are present in groups, often on the legs. Some people do not react to flea bites. Treatment: Bites in humans are treated symptomatically. Flea control requires veterinarian evaluation and treatment of the pet(s) with flea dips/powders/sprays and treatment of the environment with flea bombs/sprays. SCABIES Cause: Sarcoptes and Notoedres Host Animals: Intense pruritus with hair loss, secondary bacterial infections and lichenification in relatively hairless parts of the body (abdomen, ears, and limbs). The mites are relatively host specific. S. scabiei var canis: dogs, also cats, pigs, foxes, rabbits, and guinea pigs Notoedres cati: cats, also dogs, rabbits, foxes, rodents, bats, and raccoons S. scabiei var suis: pigs, also dogs and rabbits S. scabiei var bovis: cattle S. scabiei var equi; horses S. scabiei var ovis: sheep, also goats and camels S. scabiei var caprae: goats, also cattle, sheep, and dogs Transmission: Contact Clinical Symptoms: 20-30% of in-contact humans are attractive to these mites. Pruritic erythematous papules in areas of contact (lower chest, abdomen, and forearms). Burrows are absent and scrapings are negative. Treatment: Treatment of pet with lime sulfur baths or ivermectin NON-BURROWING MITES Cause: Cheyletiella Host Animals: Cheyletiella yasguri (dogs), C blakei (cats), C parasitovorax (rabbits and cats). Some animals are asymptomatic carriers. Others have dry, scaly dermatitis that resembles dandruff with pruritus on the back, shoulders and ears. Transmission: Contact, holding the pet or sharing a bed

6 Clinical Symptoms: Non-burrowing mite. Pruritic, erythematous papular eruption over the arms, chest, abdomen and thighs % of human contacts are susceptible Treatment: Treatment of the source animal and cleaning of the environment Parasites CUTANEOUS LARVA MIGANS Cause: Ancylostoma braziliense (intestinal hookworm) Host Animals: Dog and cat Transmission: Larvae penetrate the skin at the beach, in crawl spaces, or sandboxes contaminated by animal feces. Clinical Symptoms: Migrates at a few millimeters per day resulting in pruritic, erythematous serpiginous tracts. Treatment: Self limited but relief of symptoms may require treatment with oral or topical thiabendazole or oral ivermectin Selected References General Stevens DL, et al; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis Nov 15;41(10): Elliot DL, Tolle SW, Goldberg L, Miller JB. Pet-associated illness. N Engl J Med Oct 17;313(16): Goscienski PJ. Zoonoses. Pediatr Infect Dis Jan-Feb;2(1): Tan JS. Human zoonotic infections transmitted by dogs and cats. Arch Intern Med Sep 22;157(17): Parish LC, Schwartzman RM. Zoonoses of dermatological interest. Semin Dermatol 1993: 12: Wilson M, Lountzis N, Ferringer T. Zoonoses of dermatologic interest. Dermatol Ther Jul-Aug;22(4): Aquino LL, Wu JJ. Cutaneous manifestations of category A bioweapons. J Am Acad Dermatol Dec;65(6):1213.e e15. Dutkiewicz J, Cisak E, Sroka J, Wójcik-Fatla A, Zając V. Biological agents as occupational hazards - selected issues. Ann Agric Environ Med Dec;18(2): Bartonella La Scola B, Raoult D. Culture of bartonella quintana and bartonella henselae from human samples: A 5-year experience (1993 to 1998). J Clin Microbiol 1999: 37: Hansmann Y, DeMartino S, Piemont Y, et al. Diagnosis of cat scratch disease with detection of bartonella henselae by PCR: A study of patients with lymph node enlargement. J Clin Microbiol 2005: 43: Florin TA, Zaoutis TE, Zaoutis LB. Beyond cat scratch disease: Widening spectrum of Bartonella henselae infection. Pediatrics 2008: 121: e Chomel BB, Kasten RW, Floyd-Hawkins K, et al. Experimental transmission of Bartonella henselae by the cat flea. J Clin Microbiol 1996: 34:

7 Meghari S, Rolain JM, Grau GE, et al. Antiangiogenic effect of erythromycin: An in vitro model of Bartonella quintana infection. J Infect Dis 2006: 193: Rolain JM, Brouqui P, Koehler JE, et al. Recommendations for treatment of human infections caused by Bartonella species. Antimicrob Agents Chemother 2004: 48: Erysipeloid Reboli AC, Farrar WE. Erysipelothrix rhusiopathiae: An occupational pathogen. Clin Microbiol Rev 1989: 2: Fidalgo SG, Longbottom CJ, Rjley TV. Susceptibility of erysipelothrix rhusiopathiae to antimicrobial agents and home disinfectants. Pathology 2002: 34: Robson JM, et al. Erysipelothrix rhusiopathiae: an uncommon but ever present zoonosis. Pathology Nov;30(4): Tularemia Conlan JW. Tularemia vaccines: recent developments and remaining hurdles. Future Microbiol Apr;6(4): Singh-Behl D, La Rosa SP, Tomecki KJ. Tick-borne infections. Dermatol Clin 2003: 21: 237,44, v. Jellison WL. Tularemia in North America, Missoula: University of Montana; 1974: Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon: Medical and public health management. JAMA 2001: 285: Enderlin G, Morales L, Jacobs RF, Cross JT. Streptomycin and alternative agents for the treatment of tularemia: Review of the literature. Clin Infect Dis 1994: 19: Mason WL, Eigelsbach HT, Little SF, Bates JH. Treatment of tularemia, including pulmonary tularemia, with gentamicin. Am Rev Respir Dis 1980: 121: Anthrax Knox D, Murray G, Millar et al. Subcutaneous anthrax in three intravenous drug users: a new clinical diagnosis. J Bone Joint Surg Br Mar;93(3): Swartz MN. Recognition and management of anthrax--an update. N Engl J Med 2001: 345: Stern EJ, Uhde KB, Shadomy SV, Messonnier N. Conference report on public health and clinical guidelines for anthrax. Emerg Infect Dis 2008: 14: Mycobacteria Dodiuk-Gad R, Dyachenko P, Ziv M, et al. Nontuberculous mycobacterial infections of the skin: A retrospective study of 25 cases. J Am Acad Dermatol 2007: 57: Posteraro B, Sanguinetti M, Garcovich A, et al. Polymerase chain reaction-reverse cross-blot hybridization assay in the diagnosis of sporotrichoid Mycobacterium marinum infection. Br J Dermatol 1998: 139: Wagner D, Young LS. Nontuberculous mycobacterial infections: A clinical review. Infection 2004: 32: Bites Abrahamian FM, Goldstein EJ. Microbiology of animal bite wound infections. Clin Microbiol Rev Apr;24(2):

8 Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database Syst Rev 2001:(2): CD DOI: / CD Weber DJ, Wolfson JS, Swartz MN, Hooper DC. Pasteurella multocida infections. Report of 34 cases and review of the literature. Medicine (Baltimore) May;63(3): Herbst JS, Raffanti S, Pathy A, Zaiac MN. Dysgonic fermenter type 2 septicemia with purpura fulminans. Dermatologic features of a zoonosis acquired from household pets. Arch Dermatol Oct;125(10): Schupbach A, Zhang L, Thomas B, Ellerbroek J, Leone D. Fatal human rabies infection confirmed with skin biopsy specimen. J Am Acad Dermatol Aug;67(2): MRSA Boost M, Ho J, Guardabassi L, O'Donoghue M. Colonization of Butchers with Livestock-Associated Methicillin- Resistant Staphylococcus aureus. Zoonoses Public Health Dec;60(8): Lin Y, Barker E, Kislow J, et al. Evidence of multiple virulence subtypes in nosocomial and community-associated MRSA genotypes in companion animals from the upper midwestern and northeastern United States. Clin Med Res Mar;9(1):7-16. Lozano C, Aspiroz C, Lasarte JJ, et al. Dynamic of nasal colonization by methicillin-resistant Staphylococcus aureus ST398 and ST1 after mupirocin treatment in a family in close contact with pigs. Comp Immunol Microbiol Infect Dis Jan;34(1):e1-7. Rich M, Roberts L. MRSA in companion animals. Vet Rec 2006: 159: Juhasz-Kaszanyitzky E, Janosi S, Somogyi P, et al. MRSA transmission between cows and humans. Emerg Infect Dis 2007: 13: Sing A, Tuschak C, Hormansdorfer S. Methicillin-resistant Staphylococcus aureus in a family and its pet cat. N Engl J Med 2008: 358: van Duijkeren E, Wolfhagen MJ, Box AT, et al. Human-to-dog transmission of methicillin-resistant Staphylococcus aureus. Emerg Infect Dis 2004: 10: Weese JS, Rousseau J, Traub-Dargatz JL, et al. Community-associated methicillin-resistant Staphylococcus aureus in horses and humans who work with horses. J Am Vet Med Assoc 2005: 226: Walther B, Wieler LH, Vincze S, Antão EM, Brandenburg A, Stamm I, Kopp PA, Kohn B, Semmler T, Lübke- Becker A. MRSA variant in companion animals. Emerg Infect Dis Dec;18(12): Parapoxvirus Roess AA, Galan A, Kitces E, et al. Novel deer-associated parapoxvirus infection in deer hunters. N Engl J Med Dec 30;363(27): Buchan J. Characteristics of orf in a farming community in mid-wales. BMJ 1996: 313: White KP, Zedek DC, White WL, et al. Orf-induced immunobullous disease: A distinct autoimmune blistering disorder. J Am Acad Dermatol 2008: 58: Geerinck K, Lukito G, Snoeck R, et al. A case of human orf in an immunocompromised patient treated successfully with cidofovir cream. J Med Virol 2001: 64: Erbagci Z, Erbagci I, Almila Tuncel A. Rapid improvement of human orf (ecthyma contagiosum) with topical imiquimod cream: Report of four complicated cases. J Dermatolog Treat 2005: 16:

9 Cowpox Favier AL, Flusin O, Lepreux S, et al. Necrotic Ulcerated Lesion in a Young Boy Caused by Cowpox Virus Infection. Case Rep Dermatol Sep;3(3): Vogel S, Sárdy M, Glos K, et al. The Munich Outbreak of Cutaneous Cowpox Infection: Transmission by Infected Pet Rats. Acta Derm Venereol Nov 1. Levin NK. Emedicine: Cowpox Infectioin. Available at: Knorr CW, Allen SD, Torres AR, Smee DF. Effects of cidofovir treatment on cytokine induction in murine models of cowpox and vaccinia virus infection. Antiviral Res 2006: 72: Tinea Cafarchia C, Romito D, Capelli G, et al. Isolation of Microsporum canis from the hair coat of pet dogs and cats belonging to owners diagnosed with M. canis tinea corporis. Vet Dermatol 2006: 17: Elewski BE, Caceres HW, DeLeon L, et al. Terbinafine hydrochloride oral granules versus oral griseofulvin suspension in children with tinea capitis: Results of two randomized, investigator-blinded, multicenter, international, controlled trials. J Am Acad Dermatol 2008: 59: Radentz WH. Fungal skin infections associated with animal contact. Am Fam Physician Apr;43(4): Sporotrichosis Schubach A, Barros MB, Wanke B. Epidemic sporotrichosis. Curr Opin Infect Dis Apr;21(2): Barros MB, Costa DL, Schubach TM, et al. Endemic of zoonotic sporotrichosis: profile of cases in children. Pediatr Infect Dis J Mar;27(3): Barros MB, Schubach Ade O, do Valle AC, et al. Cat-transmitted sporotrichosis epidemic in Rio de Janeiro, Brazil: Description of a series of cases. Clinical Infectious Diseases 2004: 38: Dunstan RW, Langham RF, Reimann KA, Wakenell PS. Feline sporotrichosis: A report of five cases with transmission to humans. J Am Acad Dermatol 1986: 15: Scabies Charlesworth EN, Johnson JL. An epidemic of canine scabies in man. Arch Dermatol 1974: 110: Burroughs RF, Elston DM. What's eating you? Canine scabies. Cutis 2003: 72: Rivers JK, Martin J, Pukay B. Walking dandruff and cheyletiella dermatitis. J Am Acad Dermatol 1986: 15: Shelley ED, Shelley WB, Pula JF, McDonald SG. The diagnostic challenge of nonburrowing mite bites. Cheyletiella yasguri. JAMA 1984: 251: Fleas The Merck Veterinary Manual, 9th ed.: Fleas and Flea Allergy Dermatitis. Available at Sousa CA. Fleas, flea allergy, and flea control: A review. Dermatol Online J 1997: 3: 7. Available at: Cutaneous Larva Migrans Bouchaud O, Houze S, Schiemann R, et al. Cutaneous larva migrans in travelers: A prospective study, with assessment of therapy with ivermectin. Clinical Infectious Diseases 2000: 31:

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