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Primary herpes infection of right second finger
Oral medicine Primary herpes infection of right second finger Report
of a case
Ill. I,. S%yder,t D. H. Church, B.S., awl N. H. Rickles, D.D.S., M.S., Portlam~. Ore. DEPARTMENTS UNIVERSITY
OF MICROBIOLOGY OF OREGON
DESTAL
AND
ORAL
PATHOLOGY,
SCHOOL
D
espitc the high incidence of herpes infection in our population and the concomitant resistance, there is increasing recognition of primary herpes infection resulting from skin contact with infected saliva or vesicular fluid, as reported for wrestlers’-4 or nurses.5-7On the other hand, it is possible that many of these infections go unrecognized or are treated as staphylococcal infections, finally to bc turned over to a dermatologist after the patient fails to respond to antibiotics. Lobitz,” in a personal communication, reports that this is the usual sequence of events in our medical center and other hospitals. There is very little in the dental literature about this type of infection. Pascher and Blechman8 in 1959, recorded the first adequately diagnosed primary herpctic infection of the finger of a dental student with a history of patient contact. In 1965, Bart and Fisher9 reported the case of a dentist in whom a herpetic lesion developed on the left index finger 48 hours after a minor injury, but no evidence was provided concerning the source of the virus. Because of the hazard to susceptible dental personnel, it seemspertinent to report a case that we observed in one of our dental students (Dean H. Church). The clinical history, which is typical of this infection, is best described by the patient : On Jan. 3, 1968, I treated a teen-aged girl who at that time had multiple draining vesicles on her lower lip. Although I knew that I had never been infected with herpes, I paid little attention to these lesions as I completed a crown preparation on a mandibular molar. By January 5 I noticed some redness and discomfort around the fingernail of my right second finger, the perionychia of which I remembered had been broken. I awoke on *January 7 with malaise ant1 tenderness in my right axilla. By that evening I had a tem*Dr. Walter C. Lobitz, of Oregon Medical School, t Deceased.
598
Jr., Professor and Portland, Ore.
Head,
Department
of Dermatology,
University
Volume Number
Pig.
Primary
27 5
1. Primary
herpetic
lesion
of right
second
finger
herpes
infection
on tenth
day
of
finger
599
of infection.
perature of 101.5” F. and was rather nauseated. However, I felt much better by the following morning. Since my temperature was normal, I discounted the events of the previous day as a brief bout with the flu, although the inflammation about my fingernail was increasing and now showed some edema. On January 10 I went to the Student Health Service, and the physician there prescribed Polycillin, 250 mg. four times daily, for the infection on my finger. The antibiotics had no observable effect, and by January 12 the finger was severely swollen, was beginning to develop clear yellow vesicles, was very painful, and was beginning to show lymphadenitis with redness across the back of the hand and up the wrist. A culture at that time showed the presence of only a few staphylococci. The Student Health Service I decided to go home to see my recommended hospitalization. Because it was Friday, father-in-law, W. J. Hemphill, M. D., who is a dermatologist. He made a tentative diagnosis of a primary herpes simplex infection and began therapy of Vibramycin, 50 mg. twice, daily, and 2 Chymoral-100, four times daily. He indicated, however, that the antibiotic could do no more than prevent secondary infection if the primary infection was, in fact, herpes simplex. Upon returning to school on January 15, I learned that the culture taken on January 12 showed only a slight growth of staphylococci. I then requested that the lesion be cultured for the presence of herpes simplex virus. This culture was positive for the virus. The lesion healed slowly and was not completely gone until about January 22, nearly 20 days after I first treated the patient with vesicles on her lower lip. The lesion (Fig. 1) was not cultured for herpes virus until late in its course (January 15), but there was no difficulty in obtaining material f,or this purpose. Several drops of cloudy, yellowish fluid were expressed and transferred by swab to culture plates, infusion broth, and slides. The gram stain revealed many degenerated polymorphonuclear leukocytes with a few scattered gram-positive cocci which were identified by culture as Staphylooocozcs epidermidis. However, the vacuolated or balloon cells characteristic of herpetic infection were not observed (Papanicolaou’s stain). The infusion broth was sent to the Oregon State Hygienic Laboratory, where the presence of herpes virus was established by cytopathogenic effect in tissue culture and specific serologic identification. While blood was not taken at that time, a specimen of serum was sent 5 weeks later (on February 23), and the titer reported back was 1:8, which is considered higher than normal and further evidence in support of herpetic infection.
O.K. 0.31. 6s0.1’. May, 1969
As we have mentioned, infections of this nature tend to be overlooked or considered as bacterial infections which eventually heal, even though they do not respond to antibiotic t,hcrapy. While none of the serious sequelac associated with primary herpes infection of the youn g have been recorded in cases involving fingers and hands, the lesion is very painful; thcrc is also malaise and loss of time which, in this case, Teasmore than a week. The hazard of primary infection of the fingers with herpes simplex virus is seldom mentioned; nevertheless, it is a danger to those who are not carriers of the virus. This possibility should be emphasized for susceptible dental personnel, infcct,ion of whom would be avoided by the simple expedient of rescheduling patients with obvious oral herpct~ic lesions or at least waring rubber glows for protection while trrating SLK~I patienk REFERENCES
I. 2. 3. 4. 5. 6. 7. 8. 9.
Selling, B., and Kibrick, S.: An Outbreak of Herpes Simplex Among Wrestlers (Herpes Gladiatorum), New England J. Med. 270: 979, 1964. Wheeler, C. E., and Cabaniss, W. H.: Epidemic Cutaneous Herpes Simplex in Wrestlers (Herpes Gladiatorum), J. A. M. A. 194: 993, 1965. of Herpes Simplex Among Wrestlers, Porter, P. S., and Baughman, R. D.: Epidemiology .T. A. M. A. 194: 998, 1965. Dyke, L. M., Merikangas, IJ. R., Bruton, 0. C., Trask, S. G., and Hetrick, F. M.: Skin Infection in Wrestlers Due to Herpes Simplex Virus, J. A. M. A. 194: 1001, 1965. Stern, H., Elek, S. D.? Miller, D. M., and Anderson, H. F.: Herpetic Whitlow: A Form of Cross-Infection in Hospitals, Lancet 2: 8i1, 1959. Kanaav, P.: Primary Herpes Simplex Infection of Nurses’ Fingers, Nederl. Tijdschr. Geneesk. 110: 1412, 1966. Knyvett, A. F.: Herpetic Whitlow, M. J. Australia 2: 601, 1966. Pascher, F., and Blechman, H.: Primary Herpes Simplex Virus Infection in an Adult, ORAL SURG.,OFCAL MED.& ORAL PATH. 12: 185,1959. Bart, H., and Fisher, H.: Primary Herpes Simplex Infection of the Hand: Report of a Case, J. Am. Dent. A. 71: 74, 1965.
of a case
Ill. I,. S%yder,t D. H. Church, B.S., awl N. H. Rickles, D.D.S., M.S., Portlam~. Ore. DEPARTMENTS UNIVERSITY
OF MICROBIOLOGY OF OREGON
DESTAL
AND
ORAL
PATHOLOGY,
SCHOOL
D
espitc the high incidence of herpes infection in our population and the concomitant resistance, there is increasing recognition of primary herpes infection resulting from skin contact with infected saliva or vesicular fluid, as reported for wrestlers’-4 or nurses.5-7On the other hand, it is possible that many of these infections go unrecognized or are treated as staphylococcal infections, finally to bc turned over to a dermatologist after the patient fails to respond to antibiotics. Lobitz,” in a personal communication, reports that this is the usual sequence of events in our medical center and other hospitals. There is very little in the dental literature about this type of infection. Pascher and Blechman8 in 1959, recorded the first adequately diagnosed primary herpctic infection of the finger of a dental student with a history of patient contact. In 1965, Bart and Fisher9 reported the case of a dentist in whom a herpetic lesion developed on the left index finger 48 hours after a minor injury, but no evidence was provided concerning the source of the virus. Because of the hazard to susceptible dental personnel, it seemspertinent to report a case that we observed in one of our dental students (Dean H. Church). The clinical history, which is typical of this infection, is best described by the patient : On Jan. 3, 1968, I treated a teen-aged girl who at that time had multiple draining vesicles on her lower lip. Although I knew that I had never been infected with herpes, I paid little attention to these lesions as I completed a crown preparation on a mandibular molar. By January 5 I noticed some redness and discomfort around the fingernail of my right second finger, the perionychia of which I remembered had been broken. I awoke on *January 7 with malaise ant1 tenderness in my right axilla. By that evening I had a tem*Dr. Walter C. Lobitz, of Oregon Medical School, t Deceased.
598
Jr., Professor and Portland, Ore.
Head,
Department
of Dermatology,
University
Volume Number
Pig.
Primary
27 5
1. Primary
herpetic
lesion
of right
second
finger
herpes
infection
on tenth
day
of
finger
599
of infection.
perature of 101.5” F. and was rather nauseated. However, I felt much better by the following morning. Since my temperature was normal, I discounted the events of the previous day as a brief bout with the flu, although the inflammation about my fingernail was increasing and now showed some edema. On January 10 I went to the Student Health Service, and the physician there prescribed Polycillin, 250 mg. four times daily, for the infection on my finger. The antibiotics had no observable effect, and by January 12 the finger was severely swollen, was beginning to develop clear yellow vesicles, was very painful, and was beginning to show lymphadenitis with redness across the back of the hand and up the wrist. A culture at that time showed the presence of only a few staphylococci. The Student Health Service I decided to go home to see my recommended hospitalization. Because it was Friday, father-in-law, W. J. Hemphill, M. D., who is a dermatologist. He made a tentative diagnosis of a primary herpes simplex infection and began therapy of Vibramycin, 50 mg. twice, daily, and 2 Chymoral-100, four times daily. He indicated, however, that the antibiotic could do no more than prevent secondary infection if the primary infection was, in fact, herpes simplex. Upon returning to school on January 15, I learned that the culture taken on January 12 showed only a slight growth of staphylococci. I then requested that the lesion be cultured for the presence of herpes simplex virus. This culture was positive for the virus. The lesion healed slowly and was not completely gone until about January 22, nearly 20 days after I first treated the patient with vesicles on her lower lip. The lesion (Fig. 1) was not cultured for herpes virus until late in its course (January 15), but there was no difficulty in obtaining material f,or this purpose. Several drops of cloudy, yellowish fluid were expressed and transferred by swab to culture plates, infusion broth, and slides. The gram stain revealed many degenerated polymorphonuclear leukocytes with a few scattered gram-positive cocci which were identified by culture as Staphylooocozcs epidermidis. However, the vacuolated or balloon cells characteristic of herpetic infection were not observed (Papanicolaou’s stain). The infusion broth was sent to the Oregon State Hygienic Laboratory, where the presence of herpes virus was established by cytopathogenic effect in tissue culture and specific serologic identification. While blood was not taken at that time, a specimen of serum was sent 5 weeks later (on February 23), and the titer reported back was 1:8, which is considered higher than normal and further evidence in support of herpetic infection.
O.K. 0.31. 6s0.1’. May, 1969
As we have mentioned, infections of this nature tend to be overlooked or considered as bacterial infections which eventually heal, even though they do not respond to antibiotic t,hcrapy. While none of the serious sequelac associated with primary herpes infection of the youn g have been recorded in cases involving fingers and hands, the lesion is very painful; thcrc is also malaise and loss of time which, in this case, Teasmore than a week. The hazard of primary infection of the fingers with herpes simplex virus is seldom mentioned; nevertheless, it is a danger to those who are not carriers of the virus. This possibility should be emphasized for susceptible dental personnel, infcct,ion of whom would be avoided by the simple expedient of rescheduling patients with obvious oral herpct~ic lesions or at least waring rubber glows for protection while trrating SLK~I patienk REFERENCES
I. 2. 3. 4. 5. 6. 7. 8. 9.
Selling, B., and Kibrick, S.: An Outbreak of Herpes Simplex Among Wrestlers (Herpes Gladiatorum), New England J. Med. 270: 979, 1964. Wheeler, C. E., and Cabaniss, W. H.: Epidemic Cutaneous Herpes Simplex in Wrestlers (Herpes Gladiatorum), J. A. M. A. 194: 993, 1965. of Herpes Simplex Among Wrestlers, Porter, P. S., and Baughman, R. D.: Epidemiology .T. A. M. A. 194: 998, 1965. Dyke, L. M., Merikangas, IJ. R., Bruton, 0. C., Trask, S. G., and Hetrick, F. M.: Skin Infection in Wrestlers Due to Herpes Simplex Virus, J. A. M. A. 194: 1001, 1965. Stern, H., Elek, S. D.? Miller, D. M., and Anderson, H. F.: Herpetic Whitlow: A Form of Cross-Infection in Hospitals, Lancet 2: 8i1, 1959. Kanaav, P.: Primary Herpes Simplex Infection of Nurses’ Fingers, Nederl. Tijdschr. Geneesk. 110: 1412, 1966. Knyvett, A. F.: Herpetic Whitlow, M. J. Australia 2: 601, 1966. Pascher, F., and Blechman, H.: Primary Herpes Simplex Virus Infection in an Adult, ORAL SURG.,OFCAL MED.& ORAL PATH. 12: 185,1959. Bart, H., and Fisher, H.: Primary Herpes Simplex Infection of the Hand: Report of a Case, J. Am. Dent. A. 71: 74, 1965.