Giant orf with prolonged recovery in a patient with psoriatic arthritis treated with etanercept.

Orf, also known as contagious ecthyma or contagious pustular dermatitis, is a viral skin infection caused by a parapoxvirus (1). It typically manifests as a nodule of the hands that heals spontaneously within 3–6 weeks, but other sites such as the head and scalp, are occasionally involved. Orf is common among persons with regular contact with sheep and goats, including farmers, butchers and veterinary surgeons (1). In immunocompromised patients the infection many cause lesions with excessive growth and be long-lasting and difficult to treat. Several cases of orf have been reported in patients using im-munosuppressive medications, such as glucocorticoids, cyclosporine, mycophenolate and tacrolimus, after transplantations (2–5), but to our knowledge this is the first report of giant orf in a patient treated with a tumour necrosis factor (TNF) inhibitor. The patient was a 45-year-old man treated for psoria-tic arthritis with etanercept (Enbrel) 50 mg per week for 2 years. He had been a sheep farmer for 28 years, but had never been infected with orf before, although he had observed crusts in the oral area of his lambs, which were probably orf infections, for many seasons previously. The lambs were out at grass all summer, and in the autumn they should be given an oral anti-parasitic solution. In relation to this episode he observed that a few of the lambs had crusts around the mouth. While handling the lambs his face was exposed to saliva from 2 different lambs. On that occasion, he already had an abrasion in the temporal area from an unrelated activity. After this episode the patient developed a rapidly growing tumour in the right temporal area over a period of 3 months and at the same time a more slowly growing tumour on a finger. Clinical examination showed an exo phytic, lobulated and raspberry-like structure rising 5–6 cm above the temporal surface, with the largest transverse diameter of 7 cm (Fig. 1). He also had a typical, but far smaller, lesion on the third finger of the left hand. Histological examination confirmed the clinical diagnosis. As only a few cases of giant orf have been reported in immunosuppressed patients, management of this patient category has not been clearly established. In single cases , treatment with topical cidofovir (2) or imiquimod (5) has been successful, and the use of cryotherapy (3) and surgical excision (4) has also been described. Due to the large size of the temporal …