Milker's Nodules Workup

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

Laboratory Studies

The diagnosis of milker’s nodule primarily rests on a history of contact with infected animal and presence of a typical clinic lesion. Although no laboratory tests are diagnostic of milker's nodule, the clinician may wish to perform tests to help rule out other entities on the list of differential diagnoses. Specific tests would be suggested by the clinical presentation of each patient as well as the expected time until results from definitive tests can be returned. Note the following:

  • Viral culture in milker's nodules: Viral tissue culture of milker's nodule virus on bovine or human cells may be available. This procedure takes several weeks, and tissue culture differences between orf and milker's nodule are subtle.
  • DNA hybridization: Milker's nodule virus can be distinguished from orf virus by DNA hybridization to the relatively less conserved terminal regions.
  • Bacterial culture in milker's nodules: Culture and sensitivity can direct therapy if suspicion exists of bacterial superinfection.
  • Polymerase chain reaction (PCR) in milker's nodules: The “pan-pox” assay is a recently developed PCR assay that can be used for screening and diagnosis of human and animal poxvirus infections. Many laboratories worldwide have access to the technology used in this assay.[9] PCR can differentiate milker’s nodule and orf.[10]
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Other Tests

Electron microscopy in milker's nodules[11, 12] can be rapidly performed on either crust or biopsy material without refrigeration or special preservative solutions. Particles may stay infectious for extended periods. Electron microscopy can be useful in demonstrating virus particles; however, it cannot distinguish between milker's nodule, orf, and bovine papular stomatitis.

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Procedures

A shave biopsy may be performed for hematoxylin and eosin (H&E) tissue histology. A biopsy plus electrocautery of the base handily removes the lesion.

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Histologic Findings

The histologic appearance of milker’s nodule varies with the stage of the disease and is similar to orf. H&E stain of early lesions shows ballooning of keratinocytes, spongiform appearance of vacuolated cells with wispy eosinophilic cytoplasm, vesicle formation, prominent cell membranes, and pyknotic nuclei. There may be eosinophilic intracytoplasmic viral inclusions and rarely intranuclear inclusions.[13] Later in the course of disease, milker’s nodules demonstrate irregular acanthosis with pronounced deep extensions of thin rete ridges. Epidermal necrosis is variable.[14]

In the dermis, a dense infiltrate of lymphocytes and histiocytes, a marked increase in dermal capillaries, and epidermal and dermal edema are observed. Other authors report a mixed infiltrate also including eosinophils, neutrophils, and plasma cells.

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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

  1. Tikkanen MK, McInnes CJ, Mercer AA, et al. Recent isolates of parapoxvirus of Finnish reindeer (Rangifer tarandus tarandus) are closely related to bovine pseudocowpox virus. J Gen Virol. Jun 2004;85:1413-8. [Medline]. [Full Text].

  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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