Understanding Herpes Gladiatorum: A Wrestler's Skin Infection Case Study

Table of Contents

• Case Presentation: The 20-Year-Old Wrestler
• Medical History and Examination Findings
• Laboratory Test Results
• Possible Causes: Differential Diagnosis
• Doctor's Clinical Impression
• Infection Control Considerations
• Diagnostic Testing and Treatment Approach
• Final Diagnosis and Discussion
• What This Means for Patients
• Source Information

Case Presentation: The 20-Year-Old Wrestler

A 20-year-old male college wrestler arrived at the emergency department with a spreading pustular rash that had developed over several days. The rash first appeared on his left forearm three days earlier, causing stinging sensations during showers. As a student athlete, he consulted his athletic trainer, who referred him to the student health clinic.

The next day, the rash had spread to his right arm. Healthcare providers prescribed oral trimethoprim-sulfamethoxazole (an antibiotic combination) and topical mupirocin (an antibiotic ointment). Despite this treatment, the rash continued to progress, with new lesions appearing on his chest, face, and ears by the following day.

After consulting his primary care physician who referred him to a dermatologist, the patient was unable to schedule an immediate appointment and therefore presented to the emergency department. He reported that the rash was very itchy (pruritic) and had continued to spread despite antimicrobial therapy. Importantly, he disclosed having had close contact with another man who had a similar rash several days before his symptoms began.

Medical History and Examination Findings

The patient's medical history included oral herpes simplex virus (HSV) infection, allergic rhinitis, patellar tendinosis, and tonsillectomy. Three years earlier, he had been treated for a methicillin-sensitive Staphylococcus aureus infection on his right arm with topical antibiotics. His current medications included the prescribed trimethoprim-sulfamethoxazole, loratadine (an antihistamine), and inhaled albuterol as needed.

He had received two SARS-CoV-2 vaccinations but had not received the mpox vaccine because he had no identified risk factors. The patient reported being sexually active with women, had a history of vaping, but did not use alcohol, tobacco, or illicit substances. He lived in a college dormitory and was an active member of the wrestling team.

On examination, his vital signs were normal: temperature 36.2°C, heart rate 88 beats per minute, blood pressure 129/74 mm Hg, respiratory rate 18 breaths per minute, and oxygen saturation 98% on room air. He weighed 77 kg and appeared muscular.

The skin examination revealed dozens of grouped, raised vesiculopustular lesions (fluid-filled blisters with pus) with red bases at various stages of development. Some lesions were pustular, some were umbilicated (had a central dent), and others had formed scabs or eschars (dry, dark scabs). Some areas showed confluence where lesions had merged together.

Lesions were distributed on multiple areas including:

• Antecubital fossae (inner elbows)
• Cheeks
• Torso and back
• Left axilla (armpit)
• Lower right abdomen
• Calves
• Occiput (back of head)
• Area behind the ears

The patient also had redness in intertriginous areas (skin folds where skin rubs against skin). The remainder of his physical examination was normal.

Laboratory Test Results

Blood tests showed normal electrolyte levels, glucose, albumin, globulin, liver enzymes (alanine aminotransferase and aspartate aminotransferase), and bilirubin. Kidney function tests were also normal. Other laboratory findings included:

Complete Blood Count Results:

• Hemoglobin: 15.3 g/dL (normal range: 13.5-17.5 g/dL)
• Hematocrit: 46.8% (normal range: 41.0-53.0%)
• White blood cell count: 4,650 per μL (normal range: 4,500-11,000 per μL)
• Neutrophils: 2,390 per μL (normal range: 1,800-8,100 per μL)
• Lymphocytes: 1,150 per μL (normal range: 1,200-5,200 per μL)
• Monocytes: 740 per μL (normal range: 200-1,400 per μL)
• Eosinophils: 210 per μL (normal range: 0-1,000 per μL)
• Immature granulocytes: 1.5% (normal range: 0-0.9%) including metamyelocytes, myelocytes, and promyelocytes
• Platelet count: 198,000 per μL (normal range: 150,000-400,000 per μL)

Tests for SARS-CoV-2 and HIV types 1 and 2 were negative. The presence of immature granulocytes prompted concern but required further investigation with a manual differential count.

Possible Causes: Differential Diagnosis

The medical team considered multiple possible causes for the patient's vesiculopustular rash, categorized into non-infectious and infectious causes.

Non-infectious possibilities included:

• Autoimmune diseases (sarcoid, perforating dermatologic disorders, porphyria)
• Cancerous conditions (leukemia cutis or other hematologic cancers)
• Drug reactions (particularly to sulfa-containing antimicrobials)
• Erythema multiforme (an allergic skin reaction)
• Neutrophilic dermatoses (such as Sweet's syndrome)
• Vesicular pityriasis rosea
• Eczema vaccinatum

Infectious causes considered:

1. Viral infections: Herpesviruses (HSV-1, HSV-2, varicella-zoster virus), poxviruses (molluscum contagiosum, mpox virus), parvovirus, enterovirus, measles virus, and HIV
2. Bacterial infections: Staphylococcus aureus folliculitis, pseudomonas folliculitis, rickettsia infection, anthrax, nontuberculous mycobacterial infection, syphilis, and scrub typhus
3. Fungal infections: Cryptococcosis, histoplasmosis, and talaromycosis
4. Parasitic infestation: Nodular scabies

The patient's mild symptoms without fever or systemic illness made many severe infections unlikely. His wrestling background and report of contact with someone with a similar rash suggested an infection transmitted through skin-to-skin contact. The rash progression from arms to core (centripetal distribution) and lesions at different stages of development helped narrow the possibilities.

Doctor's Clinical Impression

The consulting physician noted that while the patient's presentation initially suggested herpes gladiatorum (HSV infection in wrestlers), the extensive nature of the rash was concerning. During the global mpox outbreak occurring at the time, even patients without typical risk factors were developing mpox infections.

The physician contacted the patient's wrestling coach and learned that several teammates had recently similar rashes that resolved with trimethoprim-sulfamethoxazole treatment. This information was crucial but also concerning given the team was traveling for competition while diagnostic tests were pending.

The decision to test for mpox was complicated because it required special handling that could delay other diagnostic tests. The medical team contacted the Massachusetts Department of Public Health and the hospital's special pathogens program to expedite testing for both mpox and HSV infection.

Infection Control Considerations

Given the potential for mpox infection, the hospital implemented strict infection control measures. The hospital used an electronic decision-support tool to guide mpox evaluations, and this patient met the criteria for concern.

Infection control protocols for suspected mpox included:

• Placing the patient in a single room with a dedicated bathroom
• Using specific personal protective equipment: gown, gloves, eye protection, and N95 respirator
• Following the "identify-isolate-inform" approach for emerging infectious diseases
• Communicating with public health authorities

The hospital's clinical decision support system, deployed during the mpox outbreak, had demonstrated a 35% positive predictive value and 99% negative predictive value in identifying mpox cases based on analysis of 668 uses.

Diagnostic Testing and Treatment Approach

While awaiting test results, the patient received two treatments:

1. Tecovirimat through an expanded-access protocol for possible mpox infection
2. Valacyclovir for possible herpesvirus infection

The Massachusetts Department of Public Health Laboratory performed nucleic acid testing for nonvariola orthopoxviruses (including mpox virus) to ensure fastest possible results. The patient was discharged with instructions to isolate at home until test results became available.

Public health officials confirmed that the patient's traveling teammates showed no symptoms of mpox. The test results returned showing:

• Negative for nonvariola orthopoxvirus (mpox)
• Negative for HSV-2
• Negative for varicella-zoster virus (VZV)
• Positive for HSV-1

These results confirmed herpes simplex virus type 1 infection as the cause. The tecovirimat treatment was discontinued, and valacyclovir therapy was continued for the HSV infection.

Final Diagnosis and Discussion

The final diagnosis was herpes gladiatorum caused by HSV-1 infection. This condition was first described in 1964 among wrestlers and has been well-documented in contact sports including wrestling and rugby (where it's sometimes called "herpes rugbiorum").

A significant outbreak occurred in 1989 at a Minnesota high school wrestling camp affecting 60 participants. Transmission typically occurs through direct skin-to-skin contact or contact with contaminated surfaces like wrestling mats. The nature of wrestling provides prolonged close contact that facilitates transmission.

Autoinoculation (self-spreading) can occur, explaining why lesions appear in multiple stages of development. Lesions typically appear on areas of exposed skin that contact opponents during wrestling, particularly the face, neck, and forearms.

Treatment guidelines recommend:

• Valacyclovir twice daily for 10-14 days for primary infection
• Valacyclovir twice daily for 5-7 days for recurrent infections

What This Means for Patients

This case illustrates several important points for patients, particularly athletes in contact sports:

For wrestlers and contact sport athletes:

• Herpes gladiatorum is a known risk in contact sports with skin-to-skin contact
• Early recognition and treatment are important to prevent spread
• Lesions typically appear on exposed skin areas that contact opponents
• Inform healthcare providers about sports participation when seeking care for skin conditions

Regarding infectious disease concerns:

• Similar symptoms can represent different conditions requiring different treatments
• Complete information about exposures and activities helps accurate diagnosis
• Public health measures during outbreaks may affect treatment approaches
• Isolation may be necessary while awaiting test results for certain infections

General health advice:

• Report any similar symptoms among close contacts to healthcare providers
• Complete prescribed treatments even if symptoms seem to improve
• Follow isolation recommendations to prevent spreading infections to others
• Discuss vaccination options with healthcare providers based on activities and exposures

Source Information

Original Article Title: Case 16-2024: A 20-Year-Old Man with a Pustular Rash

Authors: Demetre C. Daskalakis, Howard M. Heller, Erica S. Shenoy, Katherine Hsu

Publication: The New England Journal of Medicine, May 30, 2024

DOI: 10.1056/NEJMcpc2312737

This patient-friendly article is based on peer-reviewed research from Massachusetts General Hospital case records.