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Herpetic whitlow: Herpetic infections of the digits
Herpetic whitlow: Herpetic infections of the digits Ten cases of herpes simplex infections of a digit were observed during a 3 year period. The diagnosis was confirmed in seven cases by culture or tests of serum antibodies. In three cases the clinical characteristics were sufficient to suggest the diagnosis. Medical and dental personnel are particularly prone to develop this affliction; their occupations are a frequent clue to the diagnosis . Nonsurgical treatment of this self-limited entity is recommended.
Dean S. Louis, M.D., and Joseph Silva, Jr., M.D., Ann Arbor, Mich.
During the past three years, ten patients with herpetic involvement of the digits have been seen in the Orthopaedic Hand Clinic at the University of Michigan. Eight of the 10 patients were medical personnel, i.e., physicians, nurses, and/or nurse anesthetists. 1- 7 The remaining two patients were an emergency room clerk and an infant of 18 months of age . Their clinical and laboratory characteristics are recorded in Table I. The ages of these patients ranged from 1V2 to 32 years. All hospital personnel were in the third and fourth decades of life. Eight of the 10 patients had professional duties which required direct and frequent contact with the oral, tracheal, or pharyngeal secretions of patients under their care. The thumb, index, and long fingers of the dominant hand were the most commonly affected digits. The initial symptom in all cases was pain in the affected digit. This was followed by erythema of the distal segment, either in a paronychial (Fig. 1) or pulp distribution (Fig. 2). Tenderness to palpation of the affected area was common, but the local tissue tenderness was less than that seen with bacterial paronychia or felons. In some patients small, I to 2 mm vesicles were seen early, later becoming coalescent bullae. Hemorrhagic and purpuric lesions developed at times beneath the nails (Fig. 3) or in the surrounding digital skin. Fluid contained in the early vesicles initially was clear and later became turbid, but never purulent. During the ensuing 2 to 4 weeks, there was a gradual subsiFrom the Departments of Surgery and Medicine, University Hospital, University of Michigan, Ann Arbor, Mich. Received for publication Feb. 15, 1978. Revised for publication July 23, 1978. Reprint requests: Dean S. Louis, M.D., Department of Surgery , Section of Orthopaedics, University Hospital, University of Michigan, Ann Arbor, MI 48109.
90
THE JOURNAL OF HAND SURGERY
Fig. J. D.O., a 30-year-old anesthesia resident, developed pain in the right dominant index finger with increased discomfort over a five day period . The nonpurulent paronychial erythema developed during the ensuing five days. Herpes simplex virus (type I) was isolated from fluid.
dence of pain along with a decrease in the erythema. Gradual crusting of hemorrhagic areas, then desquamation of the involved epidermis took place leaving normal underlying skin. Two of the patients had a similar episode previously. One patient, an orthopaedic resident, had a history of mucocutaneous "cold sores." Two patients had recurrence of the digital infection, but symptomatically less severe than during the initial episode. We believe the signs and symptoms of a typical
0363-5023/79/010090+05$00.50/0 © 1979 American Society for Surgery of the Hand
Vol. 4, No.1 January , 1979
Herpetic whitlow
91
herpetic digital infection are so characteristic that the diagnosis can be made on clinical grounds. A digital lesion developing in hospital personnel should suggest a herpetic involvement.
Case reports Case 1. A 32-year-old male nurse anesthetist developed intense pain and swelling in the dominant left index finger tip. Vesicle formation and erythema of the pulp followed in 5 days . Two days later hemorrhagic lesions developed beneath the nail and in the surrounding pulp. One week later crusting of the initial lesions had resolved almost completely. Increases in immunofluorescent antibody titer to herpes simplex antigen confirmed the diagnosis of herpetic involvement of the index finger. Case 2. A 25-year-old emergency room nurse 6 weeks previously had developed pain and then vesicles about the right index finger. The digital lesions were almost resolved and the immunofluorescent antibody titer was I : 1024. She had similar but more painful lesions previosly while working as a nurse. Case 3. A 30-year-old anesthesiologi st without a history of known herpetic lesions developed a painful lesion of his dominant right index finger. Herpes simplex virus (type I) was isolated in fibroblast culture from the vesicular eruption. The lesion was healed 3 weeks after its onset.
Diagnosis Several techniques are available to assist with diagnosis. A direct culture of vesicular fluid can be made if the lesions are seen early. Herpes simplex characteristically grows rapidly and produces plaques within I to 3 days, thus providing a rapid diagnosis. Several of the patients in this series were seen after the vesicular stage of the disease and indirect methods of confirmation were used. Immunofluorescent titers of serum antibodies to herpex simplex antigens are very helpful if blood samples can be obtained early in the course of the disease and then again in 2 to 3 weeks. A fourfold rise in the titer or a very high titer confirms active or recent infection with herpes simplex . If patients are not seen until the infection has been present for I to 2 weeks and the vesicles have disappeared and fluid is not present for culture, antibody titers may be elevated already and clinical signs must be relied upon for diagnosis.
Discussion Herpes simplex virus is ubiquitous in man and has been implicated in a variety of infections. The mucous membranes of the mouth , lips , eyes, skin , and genitalia are frequent sites of involvement. Herpetic encephalitis is perhaps its most dreaded manifestation. Many medical and dental personnel are especially
Fig. 2. K. T., a 27-year-old emergency room clerk , had a 2 week history of a lesion of the right little finger pulp. Immunofluorescent antibody titer at this time was I : 1024. liable to develop primary herpetic infections. Nahmias and Roizman 8 , 9 indicate that antibodies to herpes simplex virus are found in only 30% to 50% of adults of higher socioeconomic groups as compared to 100% of adults of lower socioeconomic status. Medical and dental personnel who recurrently handle oral , tracheal, and pharyngeal secretions are particularly susceptible to herpetic infections of the digits. Stern et al. 6 found 49% of newly employed nurses in a neurosurgical intensive care unit were without antibodies to herpes simplex virus. During the ensuing 12 months, 16.5% of the group developed herpetic lesions . It is important to recognize the self-limited nature of this infection and to avoid incision and drainage procedures. Incision under these circumstances is not followed by drainage , as there is no purulent material. Rather, secondary bacterial infection may ensue upon the already compromised local tissue. The use of a viral antibiotic such as adenine-orabinoside does not appear to be warranted. Recent reports of Foley et al ., 10 Logan, Tindall, and Elson,11 and Arora et al. 12 further emphasize the predilection of this infection for the chronically ill, severely debilitated and immunologically suppressed patients. It is this group that may require intensive medical care at some time in the course of an illness. If such a debilitated patient comes in contact with medical personnel who have active herpetic lesions, general herpetic dissemination might occur. Dissemination in burned
92
The Journal of HAND SURGERY
Louis and Silva
Fig. 3. G . L. , a 32-year-old male nurse anesthetist, developed an intensely painful left index finger which progressed as seen in A. The white dorsal area is where a bulbous lesion had ruptured . Note the progression of the subungual hemorrhagic area from A, taken at I week , to Band C, taken at 2 weeks after the onset of the illness. Note also the evolution of the desquamation .
Table I Patient
Occupation
HT CR LH
Child Nurse anesthetist Orthopaedic resident Anesthesiologist Emergency room nurse Nurse anesthetist Emergency room clerk Intensive care nurse Surgery resident Intensive care nurse
00 HM GL KT MG EB
SS
Digit involved
Ph
Duration of illness (wk)
Previous herpetic infection
3
'0* 0
25 30
M F F
Right long Right ring Right index
Culture IFA Clinical
4
30 25
M F
Right index Right index
Culture IFA
3 6
32 27
M F
Left index Right little
IFA IFA
28
F
Right thumb
30
M F
Right thumb Right long
25
3
+
Recurrence
0
0 0
+
0
0 0
4 4
0
0
0
0
Clinical
3
+
+
Clinical IFA
3 3
+
0
0
+
Legend: IFA, immunofluorescent antibody titers. *Child also had facial herpes.
patients 10 and in patients with renal transplantation 12 has been observed. Once the suspicion of herpetic digital infection has been made or strongly suspected on clinical grounds, the involved individual should be relieved of all direct patient care until the lesions have evolved to the dry and crusting stage. Nosocomial in-
fections of this nature may lead to severe debilitating illness and even to death. 10 The importance of using gloves when performing suctioning of oropharyngeal secretions, routine tracheostomy care, and similar techniques cannot be emphasized too strongly .
Vol. 4, No . I January , 1979
Summary Herpes simplex virus (type I) may be responsible for digital infections in man. It has a prediliction for medical and dental personnel. The infection is self-limited and usually resolves within 3 weeks. Drainage procedures are not necessary and may lead to secondary bacterial infection . Direct culture of vesicular fluid or immunofluorescent antibody titers also may aide in the diagnosis . The evolution of the lesions is so characteristic that the diagnosis may be made with reasonable certainty on clinical grounds . REFERENCES I. Hamory BH, Osterman CA, Wenzel RP: Herpetic whitlow. N Engl J Med 292:268, 1975 2. Weird JR , Clark L: Primary herpes simplex virus infection of the fingers. JAM A 172:226, 1961 3. Hambrick GW, Cox RP, Senior JR: Primary herpes simplex infection of the fingers of hospital personnel. Arch Dermatol 85:583, 1962
Herpetic whitlow
93
4. Rosato FE, Rosato EF, Plotkin SA: Herpetic paronychia-an occupational hazard of medical personnel. N Engl J Med 283:804, 1970 5. LaRossa D, Hamilton R: Herpes simplex infections of the digit. Arch Surg 102:600, 1971 6. Stem H, et al.: Herpetic whitlow , a form of crossinfection in hospitals . Lancet 2:871 , 1959 7. Juel-Jansen BE: Herpetic whitlows: A medical risk . Br Med J 4:681 , 1971 8. Nahmias AJ, Roizman B: Infection with herpes-simplex viruses I and 2. N Engl J Med 289:781, 1973 9. Nahmias AJ: Disseminated herpes-simplex virus infections. N EngI J Med 282:684 , 1970 10. Foley FD, Greenawald KA , Nash G, Pruitt BA Jr: Herpes virus infection in burned patients. N Engl J Med 282:652, 1970 II . Logan WS, Tindall JP, Elson ML: Chronic cutaneous herpes simplex. Arch Dermatol 103:606, 1971 12. Arora KK , Karalakulasingam R, Raff MJ, Martin DG: Cutaneous herpes virus hominis (type 2) infection after renal transplantation . JAMA 230:1174, 1974
Invited comments Sylvester J . Carter, M.D ., F.A.C.S . New York, N . Y .
Tthe authors Dean S. Louis and Joseph Silva, Jr., are to be congratulated for again reminding surgeons of a potentially serious infection . They have said it all in this paper, but some of it has been presented in such low key that the warning implied could be missed by those who need it the most. Have we the right to modestly intone fire when a limb might be at stake? To begin with, the title itself is confusing to some . This is not the fault of the authors . Both the exotic old Middle English term "whitlow" and the one used in this country, "felon," designate a deep pulp space infection, which this herpetic lesion emphatically is not, unless the pulp space is violated iatrogenically. I have always regretted that when I first wrote about this condition in 1969 1 I did not speak out more forcefully about the disastrous results of penetrating the pulp space through a virus infection of the skin . One of our medical students incised what he thought was a septic felon on the finger of his own infant child. This infection was confirmed later to have been an
aseptic felon (herpetic whitlow). Shortly after this mistake, the child developed a virus encephalitis and was left with severe brain damage . One of our surgical residents had the pulp space of his finger incised following the mistaken diagnosis of septic felon. He developed a horrendous conjugated infection of herpes simplex and Staphylococcus. In spite of vigorous treatment, this infection continued unabated for 21 days, the natural cycle of the virus. He lost the entire distal phalanx of the index finger. Since it is so important to make the correct diagnosis, and since the punishment is so harsh for erroneously transgressing the infected areas, more attention might have been given to practical means of making the diagnosis. * May I offer our method of sorting out this problem. *Serological methods of diagnosis usually are not available to the surgeon when he is presented with the problem and must make a decision either to undertake or to withhold surgical drainage.
Dean S. Louis, M.D., and Joseph Silva, Jr., M.D., Ann Arbor, Mich.
During the past three years, ten patients with herpetic involvement of the digits have been seen in the Orthopaedic Hand Clinic at the University of Michigan. Eight of the 10 patients were medical personnel, i.e., physicians, nurses, and/or nurse anesthetists. 1- 7 The remaining two patients were an emergency room clerk and an infant of 18 months of age . Their clinical and laboratory characteristics are recorded in Table I. The ages of these patients ranged from 1V2 to 32 years. All hospital personnel were in the third and fourth decades of life. Eight of the 10 patients had professional duties which required direct and frequent contact with the oral, tracheal, or pharyngeal secretions of patients under their care. The thumb, index, and long fingers of the dominant hand were the most commonly affected digits. The initial symptom in all cases was pain in the affected digit. This was followed by erythema of the distal segment, either in a paronychial (Fig. 1) or pulp distribution (Fig. 2). Tenderness to palpation of the affected area was common, but the local tissue tenderness was less than that seen with bacterial paronychia or felons. In some patients small, I to 2 mm vesicles were seen early, later becoming coalescent bullae. Hemorrhagic and purpuric lesions developed at times beneath the nails (Fig. 3) or in the surrounding digital skin. Fluid contained in the early vesicles initially was clear and later became turbid, but never purulent. During the ensuing 2 to 4 weeks, there was a gradual subsiFrom the Departments of Surgery and Medicine, University Hospital, University of Michigan, Ann Arbor, Mich. Received for publication Feb. 15, 1978. Revised for publication July 23, 1978. Reprint requests: Dean S. Louis, M.D., Department of Surgery , Section of Orthopaedics, University Hospital, University of Michigan, Ann Arbor, MI 48109.
90
THE JOURNAL OF HAND SURGERY
Fig. J. D.O., a 30-year-old anesthesia resident, developed pain in the right dominant index finger with increased discomfort over a five day period . The nonpurulent paronychial erythema developed during the ensuing five days. Herpes simplex virus (type I) was isolated from fluid.
dence of pain along with a decrease in the erythema. Gradual crusting of hemorrhagic areas, then desquamation of the involved epidermis took place leaving normal underlying skin. Two of the patients had a similar episode previously. One patient, an orthopaedic resident, had a history of mucocutaneous "cold sores." Two patients had recurrence of the digital infection, but symptomatically less severe than during the initial episode. We believe the signs and symptoms of a typical
0363-5023/79/010090+05$00.50/0 © 1979 American Society for Surgery of the Hand
Vol. 4, No.1 January , 1979
Herpetic whitlow
91
herpetic digital infection are so characteristic that the diagnosis can be made on clinical grounds. A digital lesion developing in hospital personnel should suggest a herpetic involvement.
Case reports Case 1. A 32-year-old male nurse anesthetist developed intense pain and swelling in the dominant left index finger tip. Vesicle formation and erythema of the pulp followed in 5 days . Two days later hemorrhagic lesions developed beneath the nail and in the surrounding pulp. One week later crusting of the initial lesions had resolved almost completely. Increases in immunofluorescent antibody titer to herpes simplex antigen confirmed the diagnosis of herpetic involvement of the index finger. Case 2. A 25-year-old emergency room nurse 6 weeks previously had developed pain and then vesicles about the right index finger. The digital lesions were almost resolved and the immunofluorescent antibody titer was I : 1024. She had similar but more painful lesions previosly while working as a nurse. Case 3. A 30-year-old anesthesiologi st without a history of known herpetic lesions developed a painful lesion of his dominant right index finger. Herpes simplex virus (type I) was isolated in fibroblast culture from the vesicular eruption. The lesion was healed 3 weeks after its onset.
Diagnosis Several techniques are available to assist with diagnosis. A direct culture of vesicular fluid can be made if the lesions are seen early. Herpes simplex characteristically grows rapidly and produces plaques within I to 3 days, thus providing a rapid diagnosis. Several of the patients in this series were seen after the vesicular stage of the disease and indirect methods of confirmation were used. Immunofluorescent titers of serum antibodies to herpex simplex antigens are very helpful if blood samples can be obtained early in the course of the disease and then again in 2 to 3 weeks. A fourfold rise in the titer or a very high titer confirms active or recent infection with herpes simplex . If patients are not seen until the infection has been present for I to 2 weeks and the vesicles have disappeared and fluid is not present for culture, antibody titers may be elevated already and clinical signs must be relied upon for diagnosis.
Discussion Herpes simplex virus is ubiquitous in man and has been implicated in a variety of infections. The mucous membranes of the mouth , lips , eyes, skin , and genitalia are frequent sites of involvement. Herpetic encephalitis is perhaps its most dreaded manifestation. Many medical and dental personnel are especially
Fig. 2. K. T., a 27-year-old emergency room clerk , had a 2 week history of a lesion of the right little finger pulp. Immunofluorescent antibody titer at this time was I : 1024. liable to develop primary herpetic infections. Nahmias and Roizman 8 , 9 indicate that antibodies to herpes simplex virus are found in only 30% to 50% of adults of higher socioeconomic groups as compared to 100% of adults of lower socioeconomic status. Medical and dental personnel who recurrently handle oral , tracheal, and pharyngeal secretions are particularly susceptible to herpetic infections of the digits. Stern et al. 6 found 49% of newly employed nurses in a neurosurgical intensive care unit were without antibodies to herpes simplex virus. During the ensuing 12 months, 16.5% of the group developed herpetic lesions . It is important to recognize the self-limited nature of this infection and to avoid incision and drainage procedures. Incision under these circumstances is not followed by drainage , as there is no purulent material. Rather, secondary bacterial infection may ensue upon the already compromised local tissue. The use of a viral antibiotic such as adenine-orabinoside does not appear to be warranted. Recent reports of Foley et al ., 10 Logan, Tindall, and Elson,11 and Arora et al. 12 further emphasize the predilection of this infection for the chronically ill, severely debilitated and immunologically suppressed patients. It is this group that may require intensive medical care at some time in the course of an illness. If such a debilitated patient comes in contact with medical personnel who have active herpetic lesions, general herpetic dissemination might occur. Dissemination in burned
92
The Journal of HAND SURGERY
Louis and Silva
Fig. 3. G . L. , a 32-year-old male nurse anesthetist, developed an intensely painful left index finger which progressed as seen in A. The white dorsal area is where a bulbous lesion had ruptured . Note the progression of the subungual hemorrhagic area from A, taken at I week , to Band C, taken at 2 weeks after the onset of the illness. Note also the evolution of the desquamation .
Table I Patient
Occupation
HT CR LH
Child Nurse anesthetist Orthopaedic resident Anesthesiologist Emergency room nurse Nurse anesthetist Emergency room clerk Intensive care nurse Surgery resident Intensive care nurse
00 HM GL KT MG EB
SS
Digit involved
Ph
Duration of illness (wk)
Previous herpetic infection
3
'0* 0
25 30
M F F
Right long Right ring Right index
Culture IFA Clinical
4
30 25
M F
Right index Right index
Culture IFA
3 6
32 27
M F
Left index Right little
IFA IFA
28
F
Right thumb
30
M F
Right thumb Right long
25
3
+
Recurrence
0
0 0
+
0
0 0
4 4
0
0
0
0
Clinical
3
+
+
Clinical IFA
3 3
+
0
0
+
Legend: IFA, immunofluorescent antibody titers. *Child also had facial herpes.
patients 10 and in patients with renal transplantation 12 has been observed. Once the suspicion of herpetic digital infection has been made or strongly suspected on clinical grounds, the involved individual should be relieved of all direct patient care until the lesions have evolved to the dry and crusting stage. Nosocomial in-
fections of this nature may lead to severe debilitating illness and even to death. 10 The importance of using gloves when performing suctioning of oropharyngeal secretions, routine tracheostomy care, and similar techniques cannot be emphasized too strongly .
Vol. 4, No . I January , 1979
Summary Herpes simplex virus (type I) may be responsible for digital infections in man. It has a prediliction for medical and dental personnel. The infection is self-limited and usually resolves within 3 weeks. Drainage procedures are not necessary and may lead to secondary bacterial infection . Direct culture of vesicular fluid or immunofluorescent antibody titers also may aide in the diagnosis . The evolution of the lesions is so characteristic that the diagnosis may be made with reasonable certainty on clinical grounds . REFERENCES I. Hamory BH, Osterman CA, Wenzel RP: Herpetic whitlow. N Engl J Med 292:268, 1975 2. Weird JR , Clark L: Primary herpes simplex virus infection of the fingers. JAM A 172:226, 1961 3. Hambrick GW, Cox RP, Senior JR: Primary herpes simplex infection of the fingers of hospital personnel. Arch Dermatol 85:583, 1962
Herpetic whitlow
93
4. Rosato FE, Rosato EF, Plotkin SA: Herpetic paronychia-an occupational hazard of medical personnel. N Engl J Med 283:804, 1970 5. LaRossa D, Hamilton R: Herpes simplex infections of the digit. Arch Surg 102:600, 1971 6. Stem H, et al.: Herpetic whitlow , a form of crossinfection in hospitals . Lancet 2:871 , 1959 7. Juel-Jansen BE: Herpetic whitlows: A medical risk . Br Med J 4:681 , 1971 8. Nahmias AJ, Roizman B: Infection with herpes-simplex viruses I and 2. N Engl J Med 289:781, 1973 9. Nahmias AJ: Disseminated herpes-simplex virus infections. N EngI J Med 282:684 , 1970 10. Foley FD, Greenawald KA , Nash G, Pruitt BA Jr: Herpes virus infection in burned patients. N Engl J Med 282:652, 1970 II . Logan WS, Tindall JP, Elson ML: Chronic cutaneous herpes simplex. Arch Dermatol 103:606, 1971 12. Arora KK , Karalakulasingam R, Raff MJ, Martin DG: Cutaneous herpes virus hominis (type 2) infection after renal transplantation . JAMA 230:1174, 1974
Invited comments Sylvester J . Carter, M.D ., F.A.C.S . New York, N . Y .
Tthe authors Dean S. Louis and Joseph Silva, Jr., are to be congratulated for again reminding surgeons of a potentially serious infection . They have said it all in this paper, but some of it has been presented in such low key that the warning implied could be missed by those who need it the most. Have we the right to modestly intone fire when a limb might be at stake? To begin with, the title itself is confusing to some . This is not the fault of the authors . Both the exotic old Middle English term "whitlow" and the one used in this country, "felon," designate a deep pulp space infection, which this herpetic lesion emphatically is not, unless the pulp space is violated iatrogenically. I have always regretted that when I first wrote about this condition in 1969 1 I did not speak out more forcefully about the disastrous results of penetrating the pulp space through a virus infection of the skin . One of our medical students incised what he thought was a septic felon on the finger of his own infant child. This infection was confirmed later to have been an
aseptic felon (herpetic whitlow). Shortly after this mistake, the child developed a virus encephalitis and was left with severe brain damage . One of our surgical residents had the pulp space of his finger incised following the mistaken diagnosis of septic felon. He developed a horrendous conjugated infection of herpes simplex and Staphylococcus. In spite of vigorous treatment, this infection continued unabated for 21 days, the natural cycle of the virus. He lost the entire distal phalanx of the index finger. Since it is so important to make the correct diagnosis, and since the punishment is so harsh for erroneously transgressing the infected areas, more attention might have been given to practical means of making the diagnosis. * May I offer our method of sorting out this problem. *Serological methods of diagnosis usually are not available to the surgeon when he is presented with the problem and must make a decision either to undertake or to withhold surgical drainage.