Milker's Nodules Clinical Presentation

  • Author: Justin Finch, MD; Chief Editor: William D James, MD   more...
 
Updated: Mar 26, 2012
 

History

Patients typically have no previous history of milker's nodule. Patients with milker's nodules have had recent contact with infected cows, calves, or viral fomites. (Milker's nodules are contracted from cows; orf nodules are contracted from sheep or goats.) The incubation period for milker's nodules may be as brief as 4 days or as long as several weeks.

Lesions of milker's nodules are often solitary, and they may be pruritic or painful. Some authorities divide the clinical course of milker's nodules into 6 stages, each lasting roughly 1 week, as follows:

  • Erythematous maculopapular
  • Target (a papulovesicular lesion with a red center, white ring, and red periphery)
  • Acute weeping nodule (characterized by loss of epidermis over the center)
  • Dry, crusted nodular
  • Papillomatous
  • Regressive
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Physical

Lesions of milker's nodules are usually found on the fingers, the hands, and the forearms and are nearly identical to those seen in orf.[6] Usually, only a few or even a single lesion is present. Occasionally, many lesions are distributed in a larger area, such as a burn site.[7, 8]

Classic milker's nodules lesions are 0.5-1.5 cm in diameter, firm, movable, dome-shaped papules or nodules. Milker's nodules may be red or purplish red in color, or they may have a targetlike appearance. Central ulceration or crust may occur. Lesions typically have a grayish coating in the target stage and a verrucous surface in the papillomatous stage.

Milker's nodules often present with a vascular appearance resembling pyogenic granuloma. Milker's nodules are on average smaller than orf lesions, but they may not be distinguishable on a clinical basis. Variant lesions may include vesicles, scaly patches, and erosions. (The patient's history guides the differential diagnosis in these cases.) Local lymphadenopathy may be present.

A focused physical examination should be performed. The following findings have been described in patients with milker's nodules:

  • Lymphangitis
  • Regional lymphadenopathy
  • Fever
  • Diarrhea
  • Abdominal cramping
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Causes

Milker's nodules are caused by a double-stranded DNA virus of the genus Parapoxvirus. Milker's nodule is a zoonosis endemic to and common in cattle worldwide.

Human milker's nodules are contracted through direct transmission (ie, handling of infected cow teats, calf muzzles, other sites of active bovine infection) or through indirect transmission (ie, handling of virally contaminated objects).

Evidence suggests that milker's nodule virus (traditionally associated with disease contracted from papulonodular lesions on cow teats) and bovine papular stomatitis virus (traditionally isolated from erosive lesions on calf muzzles) may be different though closely related viruses. It seems that they may both cause milker's nodule in humans. In fact, each may cause both types of lesions in cattle.

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Contributor Information and Disclosures
Author

Justin Finch, MD  Resident Physician, Department of Dermatology, University of Connecticut School of Medicine

Justin Finch, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Steven Brett Sloan, MD  Assistant Professor, Department of Dermatology, University of Connecticut School of Medicine; Residency Site Director, Connecticut Veterans Affairs Healthcare System; Volunteer Clinical Instructor, Yale University School of Medicine

Steven Brett Sloan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Connecticut State Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Franklin Flowers, MD  Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, Affiliate Associate Professor of Pediatrics and Pathology, University of Florida College of Medicine

Franklin Flowers, MD, is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Paul Krusinski, MD  Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Gary W. Cole, MD, and Lily L. Tinkle, MD, PhD, to the development and writing of this article.

References

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  2. Hautaniemi M, Ueda N, Tuimala J, Mercer AA, Lahdenperä J, McInnes CJ. The genome of pseudocowpoxvirus: comparison of a reindeer isolate and a reference strain. J Gen Virol. Jun 2010;91:1560-76.

  3. Lauder IM, Martin B, Martin WB, Nagington J. Milkers' nodule virus infection and its resemblance to orf. Vet Rec. Jun 25 1966;78(26):926. [Medline].

  4. Wolff, Klaus, Richard Johnson, and Thomas Fitzpatrick. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 6th Ed. New York, NY: McGraw-Hill Professional; 2009:768.

  5. Taieb A, Guillot M, Carlotti D, Maleville J. Orf and pregnancy. Int J Dermatol. Jan-Feb 1988;27(1):31-3. [Medline].

  6. Bolognia J, Jorizzo J, Rapini R, eds. Dermatology. Vol. 2. 2nd ed. Spain: Mosby; 2008:1231.

  7. Schuler G, Hackl JM. [Multiple atypical milker's nodes in scalded areas]. Hautarzt. Jul 1982;33(7):388-90. [Medline].

  8. Schuler G, Hönigsmann H, Wolff K. The syndrome of milker's nodules in burn injury: evidence for indirect viral transmission. J Am Acad Dermatol. Mar 1982;6(3):334-9. [Medline].

  9. Li Y, Meyer H, Zhao H, Damon IK. G+C content based universal PCR assays for poxviruses detection: "Pan_Pox". J Clin Microbiol. Nov 11 2009;[Medline].

  10. Töndury B, Kühne A, Kutzner H, Palmedo G, Lautenschlager S, Borelli S. Molecular diagnostics of parapox virus infections. J Dtsch Dermatol Ges. 2010 May 18. [Epub ahead of print].

  11. Davis CM, Musil G, Trochet JA. Electron microscopy for the rapid diagnosis of pseudocowpox and Milker's nodule. Am J Vet Res. Aug 1970;31(8):1497-503. [Medline].

  12. Davis CM, Musil G. Milker's nodule. A clinical and electron microscopic report. Arch Dermatol. Mar 1970;101(3):305-11. [Medline].

  13. Requena L, Requena C. Histopathology of the more common viral skin infections. Actas Dermosifiliogr. Apr 2010;101(3):201-216.

  14. Weedon D & Strutton G. Skin Pathology. 2nd Ed. London, England: Churchhill Livingstone; 2002:461.

  15. Shelley WB, Shelley ED. Surgical treatment of farmyard pox. Orf, milker's nodules, bovine papular stomatitis pox. Cutis. Feb 1983;31(2):191-2. [Medline].

  16. Ceovic R, Pasic A, Lipozencic J, et al. Milker's nodule--case report. Acta Dermatovenerol Croat. 2007;15(2):88-91. [Medline].

  17. Kuokkanen K, Launis J, Morttinen A. Erythema nodosum and erythema multiforme associated with milker's nodules. Acta Derm Venereol. 1976;56(1):69-72. [Medline].

 
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