Case report: palmar herpetic whitlow and forearm lymphangitis in a 10-year-old female
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Herpetic whitlow is a viral infection caused by the herpes simplex virus (HSV) types 1 or 2, and occurs in the pediatric population primarily on the fingers and toes due to autoinoculation from oral secretions. Because of this cited prevalence, other locations of herpetic whitlow may go unrecognized.
We present an atypical presentation of palmar herpetic whitlow with delayed recognition and associated viral lymphangitis. The patient presented as a transfer from an outside hospital with a progressive, three-day history of a suspected left hand abscess preceded by left hand pain and itching. She was initially evaluated by Orthopedic Surgery, who described an erythematous, edematous, tender, left palmar abscess with associated erythematous streaking up her forearm. The lesion was surgically managed with an incision and drainage. Wound cultures were obtained during which “minimal drainage” was noted. After admission to the General Pediatrics Hospital service, the lesion was noted to appear vesicular and subsequently obtained PCR samples were positive for HSV type 1, confirming her diagnosis of herpetic whitlow. Although she remained afebrile with negative wound cultures throughout her hospitalization, a secondary bacterial infection could not be conclusively excluded due to the accompanying lymphangitis. Thus, she was discharged with oral antibiotics and anticipatory guidance of potential recurrence of palmar lesions.
Herpetic whitlow should be included in the differential diagnosis of palmar lesions that appear vesicular or abscess-like to ensure appropriate treatment. Additionally, these palmar lesions may present with associated lymphangitis without evidence of bacterial infection.
KeywordsHSV Herpetic whitlow Lymphangitis Palmar lesion Vesicular lesion
Herpes Simplex Virus
Methicillin-resistant Staphylococcus aureus
Methicillin-susceptible Staphylococcus aureus
Polymerase Chain Reaction
Herpetic whitlow is a painful cutaneous infection caused by the herpes simplex virus (HSV) types 1 or 2, and occurs in the pediatric population primarily due to autoinoculation from oral or genital secretions. Classic presentations of infection include a deep-seated, swollen, erythematous, and vesico-ulcerative lesion of the fingers that may be preceded by prodromal numbness, tingling, burning, pain, or itching in the affected location [1, 2, 3]. Associated symptoms can include fever, lymphangitis, and regional lymphadenopathy . Pharmacological therapy is usually not necessary as the course is self-limiting. Herpetic whitlow can be misdiagnosed as a bacterial infection resulting in unnecessary incision and drainage, as vesicles may be slow to develop or not develop at all .
Here, we present a case of herpetic whitlow on the palm with delayed recognition and associated forearm lymphangitis. The delay in diagnosis was likely due to the cited prevalence of cases on fingers and toes [4, 5, 6, 7]. In 1992, one previously reported case of pediatric herpetic whitlow was found to be a primary palmar infection as seroconversion was documented . However, autoinoculation may also occur on any part of the patient’s extremities, as demonstrated in this report. Lack of knowledge of alternate locations may lead to delayed diagnosis, incorrect management, and subsequent complications. Our report highlights an atypical presentation of palmar herpetic whitlow with forearm lymphangitis in an HSV type 1 positive child.
Discussion and conclusion
Here, we presented a case of a left, palmar lesion caused by herpetic whitlow that was initially mistaken for a left palmar abscess caused by MSSA or MRSA. Classically, herpes infection of the hand in children is associated with finger sucking in asymptomatic salivary carriers . However, viral vesicles can involve any region of the hand. While reviewing her history, certain points hint to this eventual diagnosis, including the prodromal symptoms (pain and itching in the affected area), the history of a previous occurrence, the palm sucking and biting, the lack of leukocytosis, and the lack of any significant or purulent drainage. The palm sucking and biting behavior is unusual in a 10 year-old child, indicating that the patient may have had a behavioral disorder that contributed to this habit. However, no documented evaluation was present in the patient’s chart. Our diagnosis was confirmed by PCR, but our results were complicated by the fact that antibiotics were started at the outside hospital prior to the drawing of wound cultures.
Although the initial diagnosis was a bacterial abscess secondary to MSSA or MRSA, other causes of palmar lesions include herpetic whitlow (as in this case), cellulitis, coxsackie viruses, erythema multiforme, sporotrichosis, syphilis, rat bite fever, impetigo, or trauma. In cases of herpetic whitlow, incision and drainage is contraindicated for risk of viremia, secondary bacterial superinfection, and HSV encephalitis [7, 10, 11]. While our patient did not experience any of these secondary complications, it is important to carefully consider a broad differential diagnosis prior to surgical management. For consideration to begin acyclovir prophylaxis, several recurrent episodes within 1 year would need to occur. Since the patient had only two reported occurrences of HSV type 1 lesions, prophylaxis was not indicated at the time. However, confirming the diagnosis of herpetic whitlow allowed us to provide adequate anticipatory guidance to the patient regarding the recurrence of these lesions and awareness of the prodromal phase during which treatment can be initiated.
Our case was further complicated in that our patient had an associated viral lymphangitis, a rarely reported complication of HSV [12, 13, 14]. The presence of associated lymphangitis raised initial concerns for a bacterial infection. Our report aims to document a case in which palmar lesions in combination with lymphangitis broadened the initial differential, but was ultimately an atypical presentation of HSV type 1 herpetic whitlow to be considered for future cases.
LL drafted the initial manuscript. AB critically reviewed and revised the manuscript. DC and FG treated the patient and critically reviewed and revised the manuscript. All authors provided important intellectual content to the final manuscript and agree to be accountable for the published work.
No funding sources were required for this publication.
Ethics approval and consent to participate
Consent for publication
Written informed consent from the patient’s legal guardian was obtained.
The authors declare that they have no competing interests.
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