Orf (ecthyma contagiosum) is an infection of the skin caused by a DNA virus belonging to the genus Parapoxvirus. We recently observed 7 cases of orf in Muslim men living in the metropolitan area of Milan, Italy, who acquired the infection after the Feast of Sacrific

F. Vaira

G. Nazzaro

L. Esposito

P. Pontini

S. Veraldi

English

Veraldi S.

Esposito L.

Pontini P.

Vaira F.

Nazzaro G.

AIR Universita degli studi di Milano

MICs. Taken together, our data suggest that ST307 is high-ly drug resistant and harbors an extended repertoire of an-timicrobial resistance genes, which might have accelerated its recent emergence and wide dissemination.This work was supported by grants from the National Institutes of Health, National Institute of Allergy and Infectious Diseases R01 AI116939 (A.-C.U.). The funders had no role in study design, data collection, interpretation, or the decision to submit the work for publication. A.-C.U. has received research funding from Merck, unrelated to the current study. All other authors declare no conflict of interest.About the AuthorDr. Rojas is medical director of Centro Medico Luperon and the hospital epidemiologist at Hospital General de la Plaza de la Salud in Santo Domingo, Dominican Republic. Her research interests include healthcare-associated infections and detection and control of carbapenemase-producing Enterobacteriaceae.References  1. US Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. 2013 Apr [cited 2017 Oct 10]. http://www.cdc.gov/drugresistance/threat-report-2013/index.html  2. Zarkotou O, Pournaras S, Tselioti P, Dragoumanos V, Pitiriga V, Ranellou K, et al. Predictors of mortality in patients with bloodstream infections caused by KPC-producing Klebsiella pneumoniae and impact of appropriate antimicrobial treatment. Clin Microbiol Infect. 2011;17:1798–803. https://doi.org/10.1111/j.1469-0691.2011.03514.x  3. Long SW, Olsen RJ, Eagar TN, Beres SB, Zhao P, Davis JJ, et al. Population genomic analysis of 1,777 extended-spectrum beta- lactamase-producing Klebsiella pneumoniae isolates, Houston,  Texas: unexpected abundance of clonal group 307. MBio. 2017;8:e00489–17. https://doi.org/10.1128/mBio.00489-17  4. Giddins MJ, Macesic N, Annavajhala MK, Stump S, Khan S,  McConville TH, et al. Successive emergence of ceftazidime- avibactam resistance through distinct genomic adaptations in  blaKPC-2-harboring Klebsiella pneumoniae sequence type 307  isolates. Antimicrob Agents Chemother. 2018;62:e02101–17.  5. Escandón-Vargas K, Reyes S, Gutiérrez S, Villegas MV. The  epidemiology of carbapenemases in Latin America and the  Caribbean. Expert Rev Anti Infect Ther. 2017;15:277–97.  https://doi.org/10.1080/14787210.2017.1268918  6. Pasteran FG, Otaegui L, Guerriero L, Radice G, Maggiora R, Rapoport M, et al. Klebsiella pneumoniae carbapenemase-2,  Buenos Aires, Argentina. Emerg Infect Dis. 2008;14:1178–80. https://doi.org/10.3201/eid1407.070826  7. Falco A, Ramos Y, Franco E, Guzmán A, Takiff H. A cluster of KPC-2 and VIM-2-producing Klebsiella pneumoniae ST833  isolates from the pediatric service of a Venezuelan Hospital.  BMC Infect Dis. 2016;16:595. https://doi.org/10.1186/s12879- 016-1927-y  8. Castanheira M, Costello AJ, Deshpande LM, Jones RN. Expansion of clonal complex 258 KPC-2-producing Klebsiella pneumoniae in Latin American hospitals: report of the SENTRY Antimicrobial  Surveillance Program. Antimicrob Agents Chemother. 2012; 56:1668–9, author reply 1670–1. https://doi.org/10.1128/AAC.05942-11  9. Robledo IE, Aquino EE, Vázquez GJ. Detection of the KPC  gene in Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii during a PCR-based  nosocomial surveillance study in Puerto Rico. Antimicrob Agents Chemother. 2011;55:2968–70. https://doi.org/10.1128/AAC.01633-1010. Morrill HJ, Pogue JM, Kaye KS, LaPlante KL. Treatment options for carbapenem-resistant Enterobacteriaceae infections. Open  Forum Infect Dis. 2015;2:ofv050. https://doi.org/10.1093/ofid/ofv050Address for correspondence: Anne-Catrin Uhlemann, Columbia University, Department of Medicine, Division of Infectious  Diseases, 630 W 168th St, New York, NY 10032, USA; email:  au2110@columbia.eduFeast of Sacrifice and Orf,  Milan, Italy, 2015–2018Stefano Veraldi, Luigi Esposito, Paolo Pontini, Fabrizio Vaira, Gianluca NazzaroAuthor affiliation: Università degli Studi di Milano, Milan, ItalyDOI: https://doi.org/10.3201/eid2508.181063Orf (ecthyma contagiosum) is an infection of the skin caused by a DNA virus belonging to the genus Parapoxvirus. We recently observed 7 cases of orf in Muslim men living in the metropolitan area of Milan, Italy, who acquired the infection after the Feast of Sacrifice.Orf (ecthyma contagiosum) is an infection of the skin caused by a DNA virus of the genus Parapoxvirus, family Poxviridae. Skin lesions (e.g., vesicles, blisters, pustules, erosions, ulcers, papules, nodules) occur at sites of inoculation of the virus 3–15 days after infection. Hands are usually affected (1). The differential diagnosis for orf includes milker’s nodule, anthrax, tularemia, fish tank granuloma, cutaneous leishmaniasis, pyogenic granuloma, and keratoacanthoma (1). The disease spontaneously heals within 6 weeks, although pain, bacterial superinfections, and regional lymphadenitis are possible (1). Treatment is based on topical antiseptics (1).Orf virus usually infects sheep and goats. Humans are infected by handling infected meat from these ani-mals; orf is considered an occupational disease in shep-herds, shearers, veterinarians, butchers, and cooks (1).  Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 25, No. 8, August 2019 1585RESEARCH LETTERSIn the last few years, orf has occurred after the Muslim Feast of Sacrifice (Eid al-Adha) (1–10). In 2014, we re-ported a case of orf that appeared after sheep slaugh-tering for this feast (1). During 2015–2018, we ob-served 7 additional cases in Muslim men 18–61 years of age who were of Moroccan, Tunisian, or Egyptian origin. They had been infected 2–3 weeks after lamb slaugh-tering for the feast (Table). One patient was a butcher. In all patients, 1 hand and/or fingers were involved. In 4 patients, orf presented with erythematous pus-tules; 3 of these patients had ulcerated nodules. In all patients, clinical diagnosis was confirmed by histopatho-logic examinations.Orf acquired during the Feast of Sacrifice was report-ed in 1982 in Turkey (2). Other cases were subsequently reported in France (3,10), Belgium (4,5), Italy (1), Turkey (6,7,9), and the United States (8). Epidemics also were reported: in Belgium, 23 cases in 2000 and 44 cases in 2001 (4,5), and in Turkey, 9 cases in 2005 and 29 cases in 2009 (6,7).In most reported cases, orf appeared days or weeks af-ter the Feast of Sacrifice. This feast is celebrated 2 months and 10 days after the end of Ramadan; the exact date varies (4). During the feast, many Muslim families kill a lamb, which has to be bled alive (4). Only men may kill the lamb. Orf occurs more often in men; however, it occurs also in women, who often handle the infected meat with bare hands during preparation and cooking.In conclusion, in the metropolitan area of Milan, where ≈250,000 Muslims reside, we recently observed 7 patients with orf acquired during the Feast of Sacri-fice. Prevention measures are difficult. For example, most of the Muslims living in the metropolitan area of Milan are Moroccans, who travel to Italy by car, carry-ing the infected meat; thus, no prevention measures have been taken.About the AuthorDr. Veraldi is a dermatologist and venereologist at the Dermatology Unit and head of the Postgraduate School of Dermatology and Venereology at the University of Milan. His primary research interests are infectious and parasitic diseases of the skin.References  1. Veraldi S, Nazzaro G, Vaira F, Çuka E. Presentation of orf (ecthyma contagiosum) after sheep slaughtering for religious feasts. Infection. 2014;42:767–9. http://dx.doi.org/10.1007/s15010-014-0591-7  2. Günes AT, Gezen C, Kapdağhi H, Marschall HJ. Ecthyma contagio-sum epidemics in Turkey [in German]. Hautarzt. 1982;33:384–7.  3. Guibal F, Cosnes A, Wechsler J, Miseri E, Revuz J, Chosidow O. Religious ritual practices as a contamination mode of human orf. Eur J Dermatol. 1996;6:41–2.  4. Ghislain PD, Dinet Y, Delescluse J. Orf contamination may occur during religious events. J Am Acad Dermatol. 2000;42:848.  http://dx.doi.org/10.1067/mjd.2000.103271  5. Ghislain PD, Dinet Y, Delescluse J. Orf in urban surroundings and religious practices: a study over a 3-year period [in French]. Ann Dermatol Venereol. 2001;128:889–92.  6. Uzel M, Sasmaz S, Bakaris S, Cetinus E, Bilgic E, Karaoguz A,  et al. A viral infection of the hand commonly seen after the Feast of Sacrifice: human orf (orf of the hand). Epidemiol Infect. 2005;133:653–7. http://dx.doi.org/10.1017/S0950268805003778  7. Gündüz K, Inanir I, Sacar T. Orf and religious practices.  J Dermatol. 2005;32:306–8. http://dx.doi.org/10.1111/  j.1346-8138.2005.tb00769.x  8. Malik M, Bharier M, Tahan S, Robinson-Bostom L. Orf acquired during religious observance. Arch Dermatol. 2009;145:606–8. http://dx.doi.org/10.1001/archdermatol.2009.69  9. Sasmaz S, Uzel M, Sener S, Ucmak H. Rare presentation  of human orf as multiple lesions. J Dermatol. 2011;38:825–6. http://dx.doi.org/10.1111/j.1346-8138.2010.01082.x10. Nougairede A, Fossati C, Salez N, Cohen-Bacrie S, Ninove L, Michel F, et al. Sheep-to-human transmission of orf virus  during Eid al-Adha religious practices, France. Emerg Infect Dis. 2013;19:102–5. http://dx.doi.org/10.3201/eid1901.120421Address for correspondence: Stefano Veraldi, University of Milan, Dermatology Unit, Via Pace 9, 20122 Milan, Italy; email:  stefano.veraldi@unimi.it1586 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 25, No. 8, August 2019RESEARCH LETTERS Table. Characteristics of orf in Muslim men after Feast of Sacrifice, Milan, Italy, 2015–2018 Patient no. Age, y Location Characteristic 1 34 Left hand Erythematous, ulcerated nodule 2 42 Back of right hand Erythematous pustule 3 44 Back of right hand Erythematous pustule 4 18 Back of second right finger Ulcerated nodule 5 21 Palm of right hand 3 Erythematous pustules 6 44 Back of second left finger Erythematous pustule 7 61 Third right finger Ulcerated nodule  

Feast of sacrifice and orf, Milan, Italy, 2015–2018

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Feast of sacrifice and orf, Milan, Italy, 2015&#8211;2018

Feast of sacrifice and orf, Milan, Italy, 2015–2018

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Feast of sacrifice and orf, Milan, Italy, 2015&#8211;2018

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Feast of sacrifice and orf, Milan, Italy, 2015–2018