An unusual finger injury

BMJ 2016;353:i2680 doi: 10.1136/bmj.i2680 (Published 25 May 2016)
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CASE REVIEW
An unusual finger injury
1 2
1
David A Pettitt doctoral research fellow and clinical fellow , Ashwin Pai clinical fellow , Emma
1
Bradbury general practitioner , Suresh Anandan associate specialist in plastic and reconstructive
1
1
surgery , Mahendra Kulkarni consultant plastic and reconstructive surgeon
Department of Plastic and Reconstructive Surgery, Wexham Park Hospital, Slough SL2 4L, UK; 2Department of Paediatrics, University of Oxford,
Oxford, UK
1
A 39 year old female farmer with no medical history presented
to the emergency department with a painless swelling over her
right index finger. The problem started two weeks earlier after
she had been bitten by a lamb. After the injury the finger
appeared “bruised.” This bruising continued and a swelling
gradually developed. She reported no pain, changes in sensation,
or reduced range of movement.
On clinical examination she was afebrile and haemodynamically
stable. Her right index finger exhibited a full range of movement
and was neurovascularly intact. The finger was not tender on
direct palpation and it seemed to be the same temperature as
her other fingers. The finger had a laceration on the radial aspect
proximal to the nail fold, with a demarcated and raised area of
reddish-blue discoloration measuring about 2 cm × 1.5 cm (fig
1). There was no palpable lymphadenopathy within the axilla.
Fig 1 Injured right index finger
Questions
1.What are the differential diagnoses?
2.What is the most likely diagnosis?
3.What investigations might be ordered?
4.How is this condition managed?
Answers
1.
What are the differential diagnoses?
Short answer
Bruising (eg post-trauma), paronychia, herpetic whitlow, orf
virus infection, Milker’s nodule, pyogenic granuloma,
keratoacanthoma, and osteomyelitis.
Discussion
Bruising is a common soft tissue injury (fig 2). It is often
secondary to trauma and is characterised by a bluish or purple
coloured patch as a result of underlying capillary damage.
Bruising is typically painful initially and usually resolves within
a few weeks, fading to a greenish-yellow colour before the skin
finally returns to normal.
Fig 2 Bruising to the finger. Credit: Dr P Marazzi/Science
Photo Library.SPL
In paronychia (fig 3) the infection generally starts in the
paronychium at the side of the nail, with local redness, swelling,
and pain. The lesion is tender on palpation and may be warmer
than the surrounding tissue. There is usually a pre-existing injury
or some predisposing factor. It can be acute or chronic and of
bacterial or fungal origin.1
Correspondence to: D A Pettitt dapettitt@doctors.org.uk
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BMJ 2016;353:i2680 doi: 10.1136/bmj.i2680 (Published 25 May 2016)
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Fig 6 Pyogenic granuloma on the finger . Dr P
Marazzi/Science Photo Library.SPL
Fig 3 Paronychia infection of the finger. Credit: Dr P
Marazzi/Science Photo Library.SPL
Herpetic whitlow is a lesion or lesions on a finger or thumb
caused by the herpes simplex virus (fig 4). It is a painful
infection that typically affects fingers or thumbs. The vesicular
lesions are usually small, localised, and grouped together. It is
most commonly contracted by dental workers and medical
workers exposed to oral secretions.2
Keratoacanthoma is characteristically dome shaped,
symmetrical, surrounded by a smooth wall of inflamed skin,
and capped with keratin scales and debris (fig 7). It grows
rapidly, reaching a large size within days or weeks. If left
untreated, it almost always undergoes necrosis, sloughing, and
healing with scarring over a few months. It is commonly found
on sun exposed skin, often the face, forearms and hands.4
Fig 7 Keratoacanthoma on the back of the hand. Dr P
Marazzi/Science Photo Library.SPL
Fig 4 Herpes infection causing blisters on fingers (herpetic
whitlow). Credit: Dr P Marazzi/Science Photo Library.SPL
Orf virus infection is a zoonotic disease, which humans can
contract through direct contact with infected animals (usually
sheep and goats) or with fomites carrying the orf virus. It causes
a purulent appearing papule locally (fig 5) and generally no
systemic symptoms. It is caused by a parapox virus.1 2
Osteomyelitis is inflammation of the bone (fig 8), usually caused
by infection with Staphylococcus aureus. It can be acute or
chronic, and both patterns have similar symptoms, including
fever and nausea and localised symptoms around the affected
bone, such as tenderness, warmth, erythema, and reduced range
of motion. A diagnosis is usually made using radiography or
magnetic resonance imaging.5
Fig 8 An infected ischaemic toe. Dr P Marazzi/Science
Photo Library.SPL
2.
Fig 5 Orf disease lesion on the finger. Credit: Dr P
Marazzi/Science Photo Library.SPL
Milker’s nodule is a cutaneous condition most commonly
transmitted from the udders of infected cows. Also known as
milkmaid blisters, it is caused by the paravaccinia virus. Disease
in humans is similar to orf infection but can be differentiated
with a thorough history.3
Pyogenic granuloma is a small, benign vascular lesion (fig 6)
that occurs on both mucosa and skin (often on the hands, arms,
or face). It is caused by irritation, physical trauma, or hormonal
factors and it appears as an overgrowth.2 4 These granulomas
are often found at the site of recent injury and bleed easily on
contact.2
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What is the most likely diagnosis?
Short answer
Orf virus infection is the most likely diagnosis because of the
history of an animal bite followed by the appearance of a
painless blue-black maculopapular lesion that does not affect
range of movement.
Discussion
This patient had an orf virus infection. Orf (also known as
Ecthyma contagiosum) infection is a viral zoonotic infection
caused by a dermotropic double stranded DNA parapoxvirus.
It typically presents three to four weeks after an animal bite as
a painless swelling, which is blue-black in colour. There is
usually minimal cellulitis and no associated lymphadenopathy.
Orf infection is most common in people who are closely
involved with animal handling,6 such as farmers (particularly
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BMJ 2016;353:i2680 doi: 10.1136/bmj.i2680 (Published 25 May 2016)
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those handling sheep and goats),veterinary professionals, and
butchers.7
Orf progresses through six distinct stages8:
• Stage 1. Maculopapular stage: the lesion appears as an
erythematous macule or papule
• Stage 2. Target stage: an outer halo appears around the
central red area, similar to a target sign
• Stage 3. Acute stage: purulent discharge may be seen from
the nodule
• Stage 4. Regenerative stage: the nodule becomes dry
• Stage 5. Papillomatous stage: the nodule becomes a
papilloma-like lesion
• Stage 6. Regression stage: the papilloma starts to crust over
and ultimately resolves.
Orf infection is often misdiagnosed as a bacterial infection and
ultimately mistreated with antimicrobial therapy, which can
lead to complications such as gastrointestinal upset or
hypersensitivity reactions.9-11
3.
What investigations might be ordered?
Short answer
Orf infection is usually diagnosed clinically, but a finger
radiograph and wound swab might rule out differential
diagnoses. Diagnosis can be confirmed by electron microscopy
or DNA polymerase chain reaction.
Discussion
The diagnosis of orf infection is typically made on clinical
grounds but the following can help rule out differential
diagnoses:
• Finger radiography to identify any signs of osteomyelitis
or bony injury
• Wound swabs are typically negative in orf infection unless
there is a secondary bacterial infection.
Blood tests are not required for orf infection.
Orf infection can formally be diagnosed by electron microscopy
or DNA polymerase chain reaction. Electron microscopy shows
ovoid cross hatched virions, but it cannot distinguish orf virus
from other parapoxviruses, whereas PCR can definitively
identify a parapoxvirus as orf virus.12 13
4.
How is this condition managed?
Short answer
Basic wound care, advice about hand hygiene, and discussion
with plastic and reconstructive surgery specialists if there are
concerns or complications.
Discussion
Both general and hospital practitioners are advised that orf
infection is a benign, self limiting condition, and that in the
absence of complications specific antimicrobial therapy or
specialist management is not needed. Spontaneous healing
usually occurs within a few weeks of infection.
Although several studies on the use of topical imiquimod cream
have had favourable results,14 conservative management,
including basic wound care and advice on hand hygiene (regular
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cleansing with soap and water or saline solution), is
recommended.
With conservative management, the infection normally subsides
within three to four weeks, with no scarring or loss of function.
In rare cases, where the lesions are extremely large, surgical
excision and skin grafting may be needed.11 15
If secondary bacterial infection occurs there may be tenderness
and warmth on palpation, cellulitic skin changes, increasing
pain, and systemic features such as fever and malaise in more
severe cases. In such cases oral antibiotics can be prescribed.
Refer patients who present with surrounding cellulitis and
spreading lymphangitis to their nearest on-call plastic and
reconstructive surgery unit, where they will usually be admitted
for hand elevation and a short course of intravenous antibiotics.
If there are any queries or concerns about complications,
clinicians can contact their nearest on-call plastic and
reconstructive surgery unit.
Clinicians can advise patients at risk of orf infection to consider
taking preventive measures, such as wearing thick,
non-permeable rubber gloves when handling farm animals and
having the animals immunised with a live orf vaccine.8 16
Patient outcome
This patient was discharged home after being reviewed by a
senior plastic surgeon and being given a clinical diagnosis of
orf infection. At review four weeks later in the outpatient plastic
surgery clinic she had made a full recovery, with a full range
of movement and no residual discoloration.
Competing interests: We have read and understood BMJ policy on
declaration of interests and declare the following interests: none.
Provenance and peer review: Commissioned; not externally peer
reviewed.
Patient consent obtained.
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Groves RW, Wilson-Jones E, MacDonald DM. Human orf and milkers’ nodule: a
clinicopathologic study. J Am Acad Dermatol 1991;25:706-11. doi:10.1016/0190-9622(
91)70257-3 pmid:1838751.
Mourtada I, Le Tourneur M, Chevrant-Breton J, Le Gall F. [Human orf and erythema
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Buchan J. Characteristics of orf in a farming community in mid-Wales. BMJ
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Paiba GA, Thomas DR, Morgan KL, et al. Orf (contagious pustular dermatitis) in
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Erbağci Z, Erbağci I, Almila Tuncel A. Rapid improvement of human orf (ecthyma
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BMJ 2016;353:i2680 doi: 10.1136/bmj.i2680 (Published 25 May 2016)
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16
Centers for Disease Control and Prevention. Human orf mimicking cutaneous
anthrax—California. MMWR 1973;22:108.
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