Advertisement

Painful lesions on the arms of a teenage wrestler

  • Daniel Morse
    Correspondence
    Corresponding author at: University of Texas McGovern Medical School at Houston, 6431 Fannin, Suite G400, Houston, TX 77030, United States.
    Affiliations
    University of Texas Health Science Center at Houston, Department of Dermatology, Houston, TX 77030, United States
    Search for articles by this author
  • Ramya Vangipuram
    Affiliations
    Center for Clinical Studies, Webster, TX 77598, United States

    University of Texas Health Science Center at Houston, Department of Dermatology, Houston, TX 77030, United States
    Search for articles by this author
  • Stephen K. Tyring
    Affiliations
    Center for Clinical Studies, Webster, TX 77598, United States

    University of Texas Health Science Center at Houston, Department of Dermatology, Houston, TX 77030, United States
    Search for articles by this author

      Keywords

      1. Case

      A previously healthy 16-year-old female wrestler presented with a 2-week history of a tender and pruritic rash involving the right anterior upper arm. She had not experienced fevers, chills, or malaise. She reported no history of similar oral or genital symptoms. Physical examination revealed several grouped vesicles on an erythematous base, along with crusted erosions, involving the right antecubital fossa (Fig. 1). The rash was not found elsewhere, and there was no associated lymphadenopathy. Prior to presentation, she went to another clinic, where was clinically diagnosed with staphylococcal skin infection and was started on oral and topical antibiotics. Her symptoms failed to respond after three days of therapy. Vesicular fluid was collected and sent for further analysis. What is the Diagnosis?
      Fig. 1
      Fig. 1Grouped vesicles on an erythematous base, along with crusted erosions, involving the right antecubital fossa.

      1.1 Diagnosis

      Herpes gladiatorum; a herpes simplex virus type 1 (HSV-1) infection found in athletes in contact sports.

      2. Discussion

      Athletes involved in sports with skin-to-skin contact have increased likelihood for introduction of HSV into areas of skin abrasion and excoriation. Cutaneous infection with HSV in wrestlers is termed herpetic gladiatorum (HG) [
      • Selling B.
      • Kibrick S.
      An outbreak of herpes simplex among wrestlers (herpes gladiatorum).
      ,
      • Becker T.M.
      • Kodsi R.
      • Bailey P.
      • Lee F.
      • Levandowski R.
      • Nahmias A.J.
      Grappling with herpes: herpes gladiatorum.
      ]. Patients often describe a prodrome of burning, tingling or stinging of the affected skin [
      • Wilson E.K.
      • Deweber K.
      • Berry J.W.
      • Wilckens J.H.
      Cutaneous infections in wrestlers.
      ]. This is followed by the appearance of umbilicated vesicles and pustules on an erythematous base [
      • Wilson E.K.
      • Deweber K.
      • Berry J.W.
      • Wilckens J.H.
      Cutaneous infections in wrestlers.
      ,
      • Anderson B.J.
      The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum.
      ]. These painful vesicles overlying an erythematous base can evolve into “punched out” erosions with hemorrhagic crusting or plaque development [
      • Becker T.M.
      • Kodsi R.
      • Bailey P.
      • Lee F.
      • Levandowski R.
      • Nahmias A.J.
      Grappling with herpes: herpes gladiatorum.
      ]. In addition to the lesions, some presentations of HG include painful lymphadenopathy and systemic symptoms of headache, fever, chills and malaise [
      • Anderson B.J.
      The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum.
      ]. The vesicles normally heal within two weeks and leave no evidence of scarring [
      • Anderson B.J.
      The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum.
      ].
      Typically, the clinician has little difficulty in diagnosing classic intact vesicular HSV lesions (grouped vesicles). Yet athletes with HG are frequently misdiagnosed as the vesicles are often grazed or scraped during training and can appear as various types of dermatoses. As these sheared herpetic lesions appear similar to impetigo or folliculitis, athletes are often mistakenly prescribed antibiotics [
      • Anderson B.J.
      The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum.
      ]. Thus, when examining a rash with erosions in a contact sport athlete, we advise clinicians to have a low threshold for obtaining a viral culture to rule out HSV. Athletes with HG should be separated from other participants and started on oral valacyclovir [
      • Anderson B.J.
      The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum.
      ].

      Funding

      None.

      Conflict of interest

      All authors declare no conflicts of interest.

      References

        • Selling B.
        • Kibrick S.
        An outbreak of herpes simplex among wrestlers (herpes gladiatorum).
        N Engl J Med. 1964; 270: 979-982
        • Becker T.M.
        • Kodsi R.
        • Bailey P.
        • Lee F.
        • Levandowski R.
        • Nahmias A.J.
        Grappling with herpes: herpes gladiatorum.
        Am J Sports Med. 1988; 16: 665-669
        • Wilson E.K.
        • Deweber K.
        • Berry J.W.
        • Wilckens J.H.
        Cutaneous infections in wrestlers.
        Sports Health. 2013; 5: 423-437
        • Anderson B.J.
        The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum.
        Med Sci Sports Exerc. 2003; 35: 1809-1814