A Puzzling Facial Rash on a 17-Year-Old Boy

Faisal M. Mawri, MD; Nida Yousef, MD; Ammar Alhmood, MD; Walid Abuhammour, MD, FAAP, FIDSA


July 09, 2018

HSV is a double-stranded DNA virus. About 80% of adults have antibodies to HSV-1, and about 20% of the population has antibodies to HSV-2. HSV-1 is commonly known to cause herpes labialis and keratitis. Most childhood herpes simplex virus infections are caused by HSV-1. HSV-2 is commonly known to cause genital herpes infections, which is one of the most common sexually transmitted diseases in the United States. HSV-2 is transmitted primarily by direct contact with lesions, and it is most often transmitted venereally.

Generalized or localized cutaneous and mucosal lesions characterize initial infection by HSV. Recurrent infections are milder because fewer viruses are shed and a stronger immune response is elicited. HSV remains dormant in the nerve ganglia; febrile illness, stress, immunosuppressive drugs, and ultraviolet light can precipitate recurrent eruptions. In rare cases, the initial replication of herpes simplex virus can lead to meningitis or encephalitis. HSV persists for life in a latent form. The virus is sometimes confused with herpes zoster because the site of latency for herpes simplex virus is the trigeminal ganglion. HSV may also manifest as a severe and/or life-threatening infection in immunocompromised individuals and in newborn babies. Specifically, disseminated infections can result in esophagitis, pneumonitis, encephalitis, hepatitis, and adrenal necrosis.[1,5]

The National Collegiate Athletic Association (NCAA) estimated an incidence of herpes gladiatorum as high as 40% among wrestlers.[6] The most common locations of herpes gladiatorum, in descending order, are the head, face, neck, chest, and shoulders. Typically, lesions are observed on the head, face, neck, cheeks, forehead, shoulders, and arms. According to most studies, about two thirds of wrestlers have the herpetic lesions on the right side of the body. Hence, herpes gladiatorum is transmitted during close skin-to-skin physical contact, known in wrestlers' terminology as the "lock-up position."[2,5]

PHG generally presents with an erythematous rash, sore throat, fever, cervical lymphadenopathy, and vesicles. Occasionally, the herpes gladiatorum lesion lacks the grouped vesicles on an erythematous base, and it is sometimes mistaken for impetigo, acne, tinea corporis, atopic dermatitis, varicella, or scabies. A significant complication of PHG in wrestlers is dendritic keratitis with subsequent corneal scarring. Other ocular complications of PHG include conjunctivitis, scleritis, and uveitis.

Fluid from the base of unroofed vesicles can be sent for testing by PCR, the test of choice for diagnosing PHG. A Tzanck smear of scrapings from the base of vesicles demonstrates multinucleated giant cells, a finding that is highly indicative of herpes simplex virus infection.


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