Orbital Cowpox
A 28-year-old woman presented to the emergency department with a 5-day history of worsening redness, irritation, and discharge in the right eye. Examination of the eye showed periocular swelling, conjunctival injection, and chemosis as well as purulent discharge. She received topical moxifloxacin, dexamethasone, and ganciclovir and intravenous ceftriaxone, metronidazole, and acyclovir, but despite this treatment, conjunctival necrosis, marked orbital inflammation, and ophthalmoplegia developed (Panel A). Emergency canthotomy and cantholysis were performed to decompress the orbit, and necrotic tissue was débrided (Panel B). Two weeks before the patient’s symptoms had developed, her pet cat had developed lesions on the paws (Panel C) and head. Polymerase-chain-reaction (PCR) tests of scrapings from the lesions taken by a veterinarian were positive for orthopoxvirus, and a PCR test of a conjunctival swab from the patient was also positive for orthopoxvirus. Genome sequencing confirmed a diagnosis of cowpox. The patient was treated with tecovirimat, which inhibits the orthopoxvirus VP37 envelope wrapping protein, and also received oral prednisolone, topical dexamethasone, and topical moxifloxacin. She underwent additional surgical débridement 2 months later and received a prolonged course of tecovirimat. At follow-up 6 months after presentation, visual acuity in the patient’s right eye was 20/20, although she had a mild residual ptosis and some restriction of extraocular movements, mainly elevation and adduction of the right eye.