A 3-year-old female came to clinic with a rash around her mouth and on her finger. She had 3 days of fever and some drooling with decreased appetite and had complained of a sore throat. Her mother noticed red, blister-like lesions in clusters near the right upper lip, that began the evening before. That morning the mother noticed her right index finger was red and generally swollen. This was the same finger she sucked. The mother denied upper respiratory illnesses or ear pain and the child had been drinking and urinating well. The past medical history showed her to be previously well.
The pertinent physical exam revealed a tired but interactive child with a temperature of 38.6°C and normal vital signs. Her growth parameters were 50-75%. By her upper lip she had 5 clustered vesicular lesions (2-4 mm in size) with an erythematous base and clear fluid. It appeared that she was also developing another area on the left corner of the mouth. There was generalized erythema of the pharynx and one ulceration of the inner lower lip. The HEENT examination showed shoddy anterior cervical adenopathy but the rest of the examination was normal including her eyes. The proximal interphalyngeal joint to the tip of the index finger was generally red and slightly edematous. There were 2 clustered, flat lesions with clearish-yellow fluid in them with a surrounding erythema next to the base of the fingernail. The rest of her examination was normal.
The diagnosis of herpes labialis and herpetic whitlow was made. The child was begun on acyclovir. The patient’s clinical course showed when she returned for followup the next day that the right-sided lip lesions appeared to be stable, and there was no left sided lesion. The lesions on her finger were decreasing slightly in size and the finger was slightly less edematous. It was still erythematous but the erythema had not spread. Her mother said she was complaining of pain in her mouth and hand but it was controlled with ibuprofen. She had no other lesions include a negative eye examination. On telephone followup the next day, her mother said that the right lip lesion was decreasing and her finger was now only pink in color with the lesions appearing “improved.” Her fever had also resolved and she was eating soft food without problems.
Primary herpes simplex virus (HSV) infection usually shows symptoms 2-20 days after contact. The virus enters the skin or mucous membranes and may then enter the dorsal root gangilons and become latent only to reactivate months to years in the future. Humans are the only known host. Recurrent infections may be caused by various stresses, including mental stress, fever, temperature extremes, sun or ultraviolet light exposure, trauma and immunosupression. HSV-1 usually causes gingivosomatitis and usually enters the trigeminal neuron. HSV-2 usually causes herpes genitalis and enters the sacral nerves. Primary oral HSV-1 usually has fever, with mouth lesions occurring and cervical and submandibular lymphadenopathy
In primary oral HSV-1, symptoms may include a prodrome of fever, followed by mouth lesions with submandibular and cervical lymphadenopathy. Other recognized forms of herpes include herpes gladiatorum where lesions occur on the skin in wrestlers, and herpetic sycosis, where lesions occur in the beard area due to autoinnoculation from shaving, or direct spread.
Herpetic whitlow has vesicular, clear to yellow lesions with an erythematous base on the fingers or hands that occurs in children who suck their hands. It can also occur in healthcare workers exposed when not wearing gloves. In children whitlow is caused almost exclusively by HSV-1 but in adults may be caused by HSV-1 or HSV-2. Direct transmission from saliva to the hand causes whitlow, although patients may be unaware that they are shedding virus and only present with whitlow. Vesicles are clear or pale yellow and have an erythematous base. The lesions may spread around and under the nail. Satellite lesions may occur in the first two weeks. Whitlow is treated with acyclovir and not incision and drainage. If not treated, herpetic whitlow resolves in about 3 weeks.
Acute paronychia and periungual felon may look like herpetic whitlow. They are caused by bacteria and usually appear with opaque, purulent fluid along the nail bed, and often will have surrounding erythema. The pressure may increase because of the paronychia and therefore incision and drainage is necessary, along with antibiotics.
Viral culture is the most sensitive test for herpetic whitlow but Tzank smear with multinucleated giant cells can be positive in 50-60% of cases. Tzank is not specific for herpes but can also be positive in varicella.
Questions for Further Discussion
1. What are the potential complications of herpetic whitlow?
2. What are the possible problems with a neonate or immunocompromized person who contracts HSV?
3. What is the treatment for herpes ocularis?
4. what is the treatment for herpes genitalis?
- Symptom/Presentation: Extremity Problems | Fever and Fever of Unknown Origin | Vesiculobullous Lesions
- Age: Preschooler
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Usatine RP, Tinitigan R. Nongenital herpes simplex virus. Am Fam Physician. 2010 Nov 1;82(9):1075-82.
Rubright JH, Shafritz AB. The herpetic whitlow. J Hand Surg Am. 2011 Feb;36(2):340-2.
Richert B, Andre´ J. Nail disorders in children: diagnosis and management. Am J Clin Dermatol. 2011 Apr 1;12(2):101-12.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital