title: Novel poxvirus infection in 2 patients from the United States.
abstract: BACKGROUND
  Some human poxvirus infections can be acquired through zoonotic transmission. We report a previously unknown poxvirus infection in 2 patients, 1 of whom was immunocompromised; both patients had known equine contact.
  
  
  METHODS
  The patients were interviewed and clinical information was abstracted from the patients' medical files. Biopsies of the skin lesions were collected from both patients for histopathology, immunohistochemistry, and transmission electron microscopy analysis. Oral and skin swabs were collected from animals with frequent contact with the patients, and environmental sampling including rodent trapping was performed on the farm where the immunosuppressed patient was employed. "Pan-pox and high Guanine-cytosine" polymerase chain reaction assays were performed on patient, animal, and environmental isolates. Amplicon sequences of the viral DNA were used for agent identification and phylogenetic analysis.
  
  
  RESULTS
  Specimens from both human cases revealed a novel poxvirus. The agent shares 88% similarity to viruses in the Parapoxvirus genus and 78% to those in the Molluscipoxvirus genus but is sufficiently divergent to resist classification as either. All animal and environmental specimens were negative for poxvirus and both patients had complete resolution of lesions.
  
  
  CONCLUSIONS
  This report serves as a reminder that poxviruses should be considered in cutaneous human infections, especially in individuals with known barnyard exposures. The clinical course of the patients was similar to that of parapoxvirus infections, and the source of this virus is currently unknown but is presumed to be zoonotic. This report also demonstrates the importance of a comprehensive approach to diagnosis of human infections caused by previously unknown pathogens.
authors.affiliation: Epidemic Intelligence Service, Division of Scientific Education and Professional Development Program Office Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Lynda U
authors.initials: LU
authors.lastname: Osadebe
authors.affiliation: Division of Pediatric Infectious Disease, Vanderbilt University Medical Center.
authors.forename: Kalpana
authors.initials: K
authors.lastname: Manthiram
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Andrea M
authors.initials: AM
authors.lastname: McCollum
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Yu
authors.initials: Y
authors.lastname: Li
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Ginny L
authors.initials: GL
authors.lastname: Emerson
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Nadia F
authors.initials: NF
authors.lastname: Gallardo-Romero
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Doty
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Wilkins
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Hui
authors.initials: H
authors.lastname: Zhao
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Clifton P
authors.initials: CP
authors.lastname: Drew
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Maureen G
authors.initials: MG
authors.lastname: Metcalfe
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Cynthia S
authors.initials: CS
authors.lastname: Goldsmith
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Atis
authors.initials: A
authors.lastname: Muehlenbachs
authors.affiliation: Knoxville Dermatopathology Laboratory.
authors.forename: Paul B
authors.initials: PB
authors.lastname: Googe
authors.affiliation: Tennessee Department of Health.
authors.forename: John
authors.initials: J
authors.lastname: Dunn
authors.affiliation: Animal and Plant Health Inspection Service, US Department of Agriculture Regional Office, Nashville, Tennessee.
authors.forename: Todd
authors.initials: T
authors.lastname: Duenckel
authors.affiliation: Tennessee Department of Health.
authors.forename: Heather
authors.initials: H
authors.lastname: Henderson
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Darin S
authors.initials: DS
authors.lastname: Carroll
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Sherif R
authors.initials: SR
authors.lastname: Zaki
authors.affiliation: Knoxville Dermatopathology Laboratory.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Denison
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Mary G
authors.initials: MG
authors.lastname: Reynolds
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Inger K
authors.initials: IK
authors.lastname: Damon
mesh_terms: D001706:Biopsy; D004279:DNA, Viral / Q000235:genetics; D006801:Humans; D008969:Molecular Sequence Data; D016133:Polymerase Chain Reaction; D011212:Poxviridae / Q000145:classification* / Q000235:genetics / Q000302:isolation & purification*; D011213:Poxviridae Infections / Q000175:diagnosis* / Q000473:pathology / Q000821:virology*; D017422:Sequence Analysis, DNA; D012867:Skin / Q000473:pathology / Q000821:virology; D014481:United States
chemical_list: D004279:DNA, Viral
keywords: imiquimod; immunocompromised; parapoxvirus; poxvirus; skin infection