The Wrong Place at the Right Height: Scalp Orf in a Toddler

Summary: A three-year-old male presented to the emergency department with a tender, 1-cm vesiculobullous lesion with superficial scale to the right posterior occipital scalp. The patient also had fever of one day duration and lymphadenopathy in the posterior cervical nodes. There was a history of exposure to a neighbor’s goats two weeks prior. Bacterial culture of the wound showed no growth, and testing for varicella zoster virus and herpes simplex virus 1 and 2 was negative. A shave biopsy was performed, revealing epidermal necrosis, massive papillary dermal edema, and brisk mixed inflammation with abundant neutrophils. No bacterial or fungal organisms were identified on special stains. These findings, in conjunction with the clinical history, led to a diagnosis of ecthyma contagiosum, otherwise known as orf, which is a parapox virus infection acquired from goats and sheep. An abundance of neutrophils is uncommon in ecthyma contagiosum, with limited case studies documenting this finding. The scalp is an unusual site for infection; in this case, we noted that the child’s head was roughly at the height of a goat's mouth when standing. This case highlights the importance of considering orf in the differential diagnosis for vesicular lesions and assessing animal exposure history.