Heres most of the CME Infectious disease: A 17-year-old male high school student presents to the pediatric infectious disease clinic complaining of a 10-day history of a facial rash that wont get better. The patient had previously visited his primary care provider (PCP), who started the patient on amoxicillin-clavulanic acid 8 days ago. The rash did not improve on the antibiotic, and as a result, it was discontinued and the patient switched to trimethoprim-sulfamethoxazole. No improvement was noted with the second round of antibiotic therapy; the rash continued to spread, and the lesions increased in number. The patient was subsequently advised to follow up with the infectious disease clinic. At the infectious disease clinic, the patient states that the rash started with several pimples over the forehead and cheek and then continued to spread and involve most of the right side of his face. The lesions are not itchy, but they are painful. The patient has no known drug allergies. His immunizations are up to date. He is very active on the wrestling team and was happily preparing for an upcoming competition. The patient denies having any weight loss, headaches, dizziness, photophobia, fever, or chills. The family history is noncontributory. What laboratory study would be most diagnostic for this students rash? Complete blood cell (CBC) count Skin biopsy Enzyme-linked immunosorbent assay (ELISA) Polymerase chain reaction (PCR) Examination Findings On physical examination, the patient is alert and orientated. His oral temperature is 97.0°F (36.1°C). The patient has normal heart sounds, his pulse has a regular rhythm of 97 bpm, and his blood pressure is 125/75 mm Hg. His lungs are clear, and his respiratory rate is 12 breaths/min. The examination of the head, eyes, ears, and nose is remarkable for multiple vesicular lesions measuring about 0.5 cm in diameter (see Figures 1 and 2). There is bilateral submandibular lymph gland enlargement measuring 1.5 × 1 cm. The neck is supple. His abdomen is soft and nontender to deep palpation in the epigastric region, and no organomegaly is noted. A complete blood count (CBC) taken at the PCPs office showed a white blood cell (WBC) count of 7.4 × 103/µL (7.4 × 109/L), with a normal differential; a hemoglobin of 13.6 g/dL (136 g/L); a hematocrit of 38.3% (0.3830); and a platelet count of 298 × 103/uL (298 × 109/L). What is the most likely diagnosis? Hint: The patient was disqualified from wrestling because of his lesions. Tinea faciale Impetigo Bacterial cellulitis Herpes gladiatorum Discussion Herpes gladiatorum is an infection caused by the Herpes simplex virus (HSV) type 1. Herpes gladiatorum most commonly occurs among wrestlers and other athletes who participate in close skin contact sports such as wrestling (herpes gladiatorum) and rugby (herpes rugbiaforum). Herpes gladiatorum is also known as “mat herpes” among wrestlers. Herpes gladiatorum is spread by direct skin-to-skin contact. The lesions appear within 7 to 14 days after exposure on an infected person; however, in some cases the lesions take longer to appear. Our patient presented with a primary herpes gladiatorum (PHG) infection, which is usually more severe than the recurrent infections. His lesions presented with disseminated vesicles, punched-out erosions, and central crusting on the forehead and right cheek. The patient was at an increased risk of contracting PHG because of his participation in wrestling. Herpes simplex virus DNA was detected with a polymerase chain reaction (PCR) examination.[1,2] Which of the following complications of primary herpes gladiatorum should clinicians be most concerned about? Sore throat Cervical lymphadenopathy Dendritic keratitis with subsequent corneal scarring Erythematous rash Which of the following is the drug of choice for treating primary herpes gladiatorum? Famciclovir Valacyclovir Acyclovir Penciclovir Ganciclovir Acyclovir is the drug of choice for treating primary herpes gladiatorum. It reduces the duration of symptomatic lesions and is indicated for patients presenting within 2-3 days of the appearance of a herpetic rash. Most patients on acyclovir will experience less pain and a quicker resolution of symptoms, and it is well-tolerated by the patient. It is also a cost-effective treatment for PHG. Famciclovir and valacyclovir are also treatment options for PHG; however their cost and side-effect profiles make them less ideal choices for the treatment of PHG. Penciclovir is a 1% cream approved for treatment of recurrent orolabial HSV infection. Ganciclovir is the drug of choice for cytomegalovirus. Which of the following recommendations must be met before a wrestler can return to competition, according to the National Collegiate Athletic Association’s (NCAA) “time until return to competition” guideline for primary herpes gladiatorum and for recurrent infection? The NCAA has recommended for primary infection that wrestlers must be on appropriate antiviral therapy for at least 120 hours (5 days) by the time of competition. Wrestlers must be free of any systemic symptoms of viral infection. Oral acyclovir has been shown to be effective in suppressing primary herpes gladiatorum. All lesions must be dry and surmounted by a firm adherent crust, as stated above, and the wrestler must not have developed any new lesions in the last 3 days before competing. A health care provider or certified athletic trainer can perform skin checks before a tournament. For recurrent infection, the lesions must be completely dry and covered by a firm crust at the time of competition. Also, the wrestler must be on an appropriate dosage of antiviral therapy for 3 days. For questionable cases, a Tzank preparation and/or an HSV antigen assay should be performed. The wrestler’s status should be deferred until the result is known.
Posted on: Tue, 08 Apr 2014 18:24:14 +0000
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