LETTERS

Anthony Almudevar1 Clinical signs, symptoms, diagnosis, paracetamol, 325 mg; and rabeprazole, Author affiliation: University of Rochester and management of this case 20 mg) for 5 days. Medical Center, Rochester, New York, USA highlight the need for observance On postinjury day 19, the surgeon and enforcement of strict biosafety advised the patient to take cefuroxime DOI: http://dx.doi.org/10.3201/eid2002.131701 measures within the laboratory. (500 mg/d for 5 days) and use a topical A 28-year-old man (researcher) ointment containing mupirocin to References who was freeze-drying BPXV isolates prevent a delay in healing (Figure, 1. Suzuki M, Dhoubhadel BG, Yoshida in a laboratory in Hisar, India sustained panel F). The lesion healed slowly, and LM, Ariyoshi K. Nasopharyngeal bac- a cut on his right palm through nitrile by postinjury day 30, thickening and terial interactions in children. Emerg gloves by accidental piercing of blackening of the skin was observed Infect Dis [Internet]. 2014;20:323–4. http://dx.doi.org/10.3201/eid2014.121724 shrapnel from a broken ampule. The (Figure, panel G) that extended to 2. Xu Q, Almudervar A, Casey JR, Pi- being freeze-dried (105.5 50% a wider area by postinjury day 38, chichero ME. Nasopharyngeal bacte- tissue culture infectious doses/mL) was and the skin started to peel off by rial interactions in children. Emerg Infect isolated from a buffalo in Jalgaon, India, postinjury day 50. The entire skin of Dis. 2012;18:1738–45 . http://dx.doi. org/10.3201/eid1811.111904 in 2010. The injured site on the palm the palm sloughed off with complete 3. Pettigrew MM, Gent JF, Revai K, Patel was immediately cleaned with 70% healing by postinjury day 85, leaving JA, Chonmaitree T. Microbial interactions ethanol and treated with povidone– a 20-mm blackened eschar over the during upper respiratory tract infections. iodine solution. No untoward reaction area (Figure, panel H). Emerg Infect Dis. 2008;14:1584–91. http://dx.doi.org/10.3201/eid1410.080119 was observed <2 days postinjury. Clinical samples were subjected Erythema appeared at the injury site to laboratory examination. Virus was Address for correspondence: Michael on postinjury day 3. Subsequently, a isolated from tissue samples in a Vero Pichichero, Rochester General Hospital small vesicle developed on postinjury cell line during the first passage. BPXV Research Institute, 1425 Portland Ave, day 5 (Figure, panel A). This vesicle infection was confirmed by PCR Rochester, NY 14621, USA: email: michael. progressed into a pustule with a central amplification of -specific [email protected] area of necrosis by postinjury day 7 A type inclusion gene (552 bp) and a (Figure, panel B). On postinjury day BPXV-specific C18L gene (368 bp) 1On behalf of Qingfu Xu, Janet Casey, and 9, symptoms worsened (onset of high from tissue material and the laboratory- Michael Pichichero. fever and general malaise and pain at isolated virus (BPXV/Human/Lab/11), the affected site), and the researcher according to procedures described by sought medical care. Singh et al. (6). Sequences of these Physical examination showed 2 genes were submitted to GenBank high fever (104°F), unilateral axillary under accession nos. JN653284.1 and lymphadenopathy, and edema of the JN653278.1, respectively. Phylogenetic palm (Figure, panel C). Amoxicillin (500 analysis showed 95%–100% nt Laboratory- mg, 2×/d), cephalexin (500 mg, 2×/d), similarity of the laboratory isolate acquired and analgesic/antipyretic (paracetamol, (BPXV/Human/Lab/11) with other Buffalopox Virus 500 mg, 2×/d) were prescribed to BPXVs from India (online Technical control secondary complications caused Appendix Figure, wwwnc.cdc.gov/EID/ Infection, India by bacterial infection and pain. article/20/2/13-0358-Techapp1.pdf). To the Editor: In India, The next day, the entire palm Antibodies against BPXV were detected buffalopox virus (BPXV), a variant became cyanotic and edema increased in patient serum samples by using an of virus, is associated (Figure, panel D). The researcher was indirect immunoperoxidase test and a with severe disease outbreaks then referred to a specialty hospital 50% plaque-reduction neutralization among buffaloes (1,2), cattle (3), where the lesion was surgically excised test according to methods reported by and humans in contact with these on postinjury day 11 (Figure, panel E) Bera et al. (7). Serum of the infected animals (1,4). Most human BPXV under axial block anesthesia. Blood, patient showed 50% plaque-reduction infections occur in animal attendants necrotic tissue, pustular material, and neutralization test titers of 256 and and milkers (1,4). A similar type swab specimens were obtained for 512 on postinjury days 11 and 28, of vaccinia virus infection has also laboratory examination. Postsurgery respectively. These findings confirmed been reported from rural areas treatment included cleaning of the BPXV infection because the patient had in Brazil (5). We report a case of surgical site on alternate days and not been vaccinated against . laboratory-acquired infection with oral medication (amoxicillin/clavulanic Pre-freezing of the glass ampule BPXV in a researcher in India. acid, 625 mg; ibuprofen, 400 mg; to –80°C caused a hairline crack in

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Figure. Progression of lesion on palm of researcher caused by buffalopox virus infection, India. A) Small vesicle on postinjury day 5. B) Pustule with a central area of necrosis on postinjury day 7. C) Pustule with edema on postinjury day 9. D) Increase in edema on postinjury day 10 (cyanosis is not apparent). E) Lesion after surgical excision on postinjury day 11. F) Lesion on postinjury day 19 (healing was erratic). G) Blackening and thickening around surgical site on postinjury day 30, which then extended to a wider circumference. H) Healed lesion with a black eschar on postinjury day 85. the glass. The ampule broke while This study was supported by the 2. Singh RK, Hosamani M, Balamurugan V, being introduced into the freeze- Indian Council of Agricultural Research. Satheesh CC, Shingal KR, Tatwarti SB, et al. An outbreak of buffalopox in drying manifold and pierced the palm buffalo (Bubalus bubalis) dairy herds of the researcher. As a follow-up Thachamvally Riyesh,1 in Aurangabad, India. Rev Sci Tech. measure, the freeze drying procedure 2006;25:981–7. Shanmugasundaram 3. Yadav S, Hosamani M, Balamurugan V, was reviewed and the pre-freezing 1 Karuppusamy, Bhanuprakash V, Singh RK. Partial temperature was reduced to –60°C. Bidhan C. Bera, Sanjay Barua, genetic characterization of Measures were also taken to ensure Nitin Virmani, Sarita Yadav, isolated from pox-like infection in cattle use of better-quality ampules. Surgical Rajesh K. Vaid, Taruna Anand, and buffaloes: evidence of buffalo pox and contact material associated with virus circulation in Indian cows. Arch Manish Bansal, Praveen Malik, Virol. 2010;155:255–61. http://dx.doi. the lesion was placed in biohazard Inderjeet Pahuja, org/10.1007/s00705-009-0562-y bags for autoclaving before disposal. and Raj K. Singh 4. Gurav YK, Raut CG, Yadav PD, Tandale BV, Sivaram A, Pore MD, In addition, laboratory and hospital Author affiliations: Veterinary Culture staff was apprised of the risk associated et al. Buffalopox outbreak in humans Collection, Hisar, India (T. Riyesh, S. and animals in western Maharashtra, with BPXV transmission. Karuppusamy, B.C. Bera, S. Barua, R.K. India. Prev Vet Med. 2011;100:242–7. Reporting of laboratory-acquired Vaid, T. Anand, M. Bansal, P. Malik); http://dx.doi.org/10.1016/j.prevetmed. 2011.03.008 infections is crucial because infections National Research Centre on Equines, could also spread to other personnel. 5. Kroon EG, Mota BE, Abrahao JS, da Hisar (N. Virmani, I. Pahuja, R.K. Singh); Fonseca FG, de Souza Trindade G. Strict biosafety practices and laboratory and Central Institute for Research of Zoonotic Brazilian vaccinia virus: guidelines are useful in minimizing lab- Buffaloes, Hisar (S. Yadav) from field to therapy. Antiviral oratory-acquired infections. Guidelines, Res. 2011;92:150–63. http://dx.doi. no matter how stringent, are not suffi- DOI: http://dx.doi.org/10.3201/eid2002.130358 org/10.1016/j.antiviral.2011.08.018 6. Singh RK, Balamurugan V, Hosamani M, cient on their own. Laboratory-acquired References Kallesh DJ, Bhanuprakash V. Sequence infections occur because humans or ma- analysis of C18L gene of buffalopox virus: PCR strategy for specific detection chines are not infallible. Thus, laborato- 1. Singh RK, Hosamani M, Balamurugan V, and differentiation of buffalopox ries should have emergency procedures Bhanuprakash V, Rasool TJ, Yadav MP. from . J Virol Methods. Buffalopox: an emerging and in place to deal with such situations. 2008;154:146–53. http://dx.doi.org/10. re-emerging zoonosis. Anim Health 1016/j.jviromet.2008.08.009 Res Rev. 2007;8:105–14. http://dx.doi. 7. Bera BC, Shanmugasundaram K, Barua org/10.1017/S1466252307001259 Acknowledgments S, Venkatesan G, Virmani N, Riyesh T, We thank the physicians, technicians, et al. Zoonotic cases of camelpox infection in and medical staff for assistance and the 1These authors contributed equally to this India. Vet Microbiol. 2011;152:29–38. http:// patient for approval to publish this report. article. dx.doi.org/10.1016/j.vetmic.2011. 04.010

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Address for correspondence: Thachamvally the northern and eastern land borders analysis of the first 567 nt of the N Riyesh, National Research Centre on Equines, of Greece, and wild and domestic ani- gene of the 3 isolates (GR64C/12, Sirsa Rd, Hisar, Haryana, India; email: mals found dead or suspected of hav- GR112C/12, GR238C/12) showed [email protected] ing rabies were collected. This pro- 99.8% nt identity with the N gene of gram was approved by the European a rabies virus (GenBank accession no. Commission. The first rabies case was JQ973884) isolated from a red fox in diagnosed on October 19, 2012, in a FYROM in 2011. Nucleotide identity red fox in Palaiokastro, 60 km from was 100% between the 6 isolates from the Albanian border. The animal was Greece (GR177C/12, GR187C/12, wandering in the village during day- GR217C/12, GR231C/12, GR236C/12, Recurrence of time and attacked a dog before being GR242C/12) and isolate JQ973884, as killed by local hunters and sent to the well as a Serbia strain (GenBank ac- Animal Rabies, National Reference Laboratory for cession no. JF973785). This perfect Greece, 2012 Animal Rabies (Athens, Greece) for nucleotide identity shown with the rabies testing. The second case, iso- Serbia isolate collected >15 years ago To the Editor: Rabies is caused by lated in Ieropigi, 4 km from the Alba- suggests the persistence of some viral 12 recognized virus species within the nian border, was a shepherd dog dem- strains over time in the Balkans, in ac- Lyssavirus genus (family Rhabdoviri- onstrating aggressive behavior against cordance with previous studies (4,9). dae) (1) and each year causes 55,000 dogs and sheep of the flock. Seven Amino acid identity was perfect among deaths worldwide among humans. In additional cases (6 foxes, 1 dog) were all 9 isolates from Greece. Europe, the main reservoir and vec- reported in December 2012 in 2 pre- Phylogenetic analysis of the tor of rabies is the red fox (Vulpes fectures of northern Greece that share partial sequences of the N gene vulpes), followed by the raccoon dog borders with FYROM (5). of isolates from Greece compared (Nyctereutes procyonoides) in central In 2012, a total of 237 domestic with representative sequences from and Baltic Europe (2). Among these and wild animals were submitted to the Balkans (Figure) showed that virus species, the rabies virus (former the National Reference Laboratory isolates from Greece resolved within genotype 1, classical rabies virus) is for Animal Rabies for rabies testing. the East Europe (EE) group of the maintained in reservoir mammals, Samples were tested by the fluores- cosmopolitan lineage. The EE group mainly carnivores. Despite the suc- cent antibody test, rabies tissue cul- encompasses the 9 Greek isolates cessful oral vaccination campaigns of ture infection test, real-time reverse with referenced viral sequences from wildlife that eliminated rabies in large transcription PCR, and heminested FYROM, Bulgaria, Serbia, Bosnia parts of Europe (2), the disease still oc- reverse transcription PCR, as de- Herzegovina, and Montenegro. With- curs in Europe; 4,884 cases in animals scribed (6,7). In brief, viral RNA was in the EE group, <1.5%-nt divergence were recorded in 2012. extracted (Viral RNA Mini Kit, QIA- exists between all analyzed N gene Until 2012, Greece had been free GEN, Hilden, Germany) from 140 μL sequences (567 nt). of rabies since 1987; the last case oc- of homogenized brain suspension su- The perfect nucleotide identity curred in a dog. During 1971–1987, pernatant and subjected to the partial shown between the 6 isolates from a total of 248 cases were recorded in nucleoprotein (N) gene amplification Greece and 2 strains from Serbia and domestic animals, of which only 6 (positions 71–644 compared with PV FYROM demonstrates a close genetic occurred during 1981–1987 (3). The strain genome). The PCR products relationship between them. This find- wide compulsory vaccination of dogs, were bidirectionally sequenced by us- ing supports the hypothesis of move- along with control of stray dogs, were ing the same primers in a 3130xl Ge- ment of rabies-infected hosts in the the main measures leading to the elim- netic Analyzer (Applied Biosystems, western Balkan countries. ination of rabies in Greece. Foster City, CA, USA). The phyloge- Greece was rabies free for 25 years. Greece shares land borders with netic tree was constructed by using the In the 2012 outbreak, the rabies cycle Turkey, Former Yugoslav Republic neighbor-joining method with 1,000 appears to be sylvatic, whereas until of Macedonia (FYROM), and Bul- replicates using MEGA5 (8). 1987, dogs were the main reservoir garia, where rabies is reported in Of 237 animals tested, 9 (7 foxes, of rabies. Measures including public wild and domestic animals (4; www. 2 dogs) were rabies positive by fluo- awareness campaigns and intensified who-rabies-bulletin.org/). After the rescent antibody test, rabies tissue cul- vaccination of stray animals and shep- fox rabies case reported in FYROM ture infection test, and PCR. Positive herd dogs, combined with control of in 2011, ≈0.3 km from Greece (4), ra- samples were subjected to sequencing stray dogs and cats, already have been bies surveillance was improved along analysis of the N gene. The sequence implemented. In accordance with the

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