RESEARCH LETTER

Frantisek Kopriva

Recurrent herpetic whitlow in an immunecompetent girl without vesicular lesions

Received: 14 August 2001 /Accepted: 26 October 2001 / Published online: 4 December 2001� Springer-Verlag 2001

Recurrent whitlow of the thumb can be caused by herpes

simplex virus l in an immune competent child without

herpetic stomatitis.

Herpes simplex virus (HSV) is common amonghumans and has a variety of clinical manifestationsinvolving the skin, mucous membranes, eyes, centralnervous system, and genital tract. Herpetic paronychia(whitlow) is a rare manifestation in children. This reportdescribes a case of recurrent whitlow in an immunecompetent girl.

A 7-year-old girl presented to our immunologicaloutpatient clinic at the Department of Paediatrics with arecurrent whitlow. The girl was born to non-consan-guineous parents after an uneventful gestation. No re-markable family history was noted. At 8 months of ageshe presented with aseptic pyuria. She had had a re-current whitlow and blister (diameter 1.0–2.5 cm) of theright thumb four times a year since she was 3 years oldwithout any manifestation of herpetic stomatitis. At thebeginning she received only local therapy from thepaediatrician. Subsequently, the whitlow was incised onsix consecutive occasions. Our presumptive diagnosiswas a herpes simplex infection. We felt that it was im-portant to obtain the contents of the whitlow for routineculture as well as for bacterial, fungal and viral organ-isms and for PCR analysis, specifically for HSV [1]. Theclassical vesicular herpetiform lesions were absent.Laboratory findings revealed a decreased IgA level,positive antibodies for HSV 1 and negative for HSV 2.PCR analysis of the content of the whitlow was positivefor HSV l. Laboratory investigations including leuco-cytes, CRP, ESR, IgM, IgG, phagocytosis, chemilumi-niscence and CD4, CD8, IRI of lymphocytes werenormal.

Recurrent whitlow of the thumb is a rare manifesta-tion in children. It is not surprising therefore, that thispatient was examined by a number of paediatricians andthe diagnosis of HSV infection was not considered.Treatment was initiated without adequate diagnosis.The lesions should not be incised. Subsequently shereceived local treatment with acyclovir cream whichhas been successful.

The human herpes virus family includes eight viruses:HSV types 1 and 2, varicella zoster virus, Epstein-Barrvirus, cytomegalovirus, and human herpes virus types 6,7, and 8. Transmission of HSV involves direct contactwith either active lesions on skin or mucous membranesor, much more commonly, from areas of asymptomaticviral shedding from saliva, semen, or cervical secretions.The virus migrates along the nerves to the neural gangliawhere it remains in a state of latency. HSV 1 is usuallyacquired during childhood, by the age of 5 years, and upto 40% of tested children demonstrate the antibody.Two types of infection are recognised: (1) primaryinfection in a susceptible host is the first experience withthe virus, which in most instances is a subclinical infec-tion. Occasionally there are local superficial lesionsaccompanied by varying degrees of systemic reaction. Innewborn infants and severely malnourished infants, aserious systemic infection, often without superficial le-sions, may occur and (2) recurrent herpetic lesions rep-resent reactivation of a latent infection in an immunehost with the circulating antibodies. Reactivation fol-lows nonspecific stimuli. The lesions tend to be localisedand generally are not associated with systemic reactions.Viral reactivation may take place in the absence ofclinical recurrence, leading to asymptomatic viral shed-ding. Primary HSV infections, in general, tend to bemore severe and persistent than recurrences in normalhost individuals. HSV infections may involve cutaneoussites other than the mouth and genitals [3].

In HIV-positive individuals, primary infections canbe severe enough to be life-threatening. Besidesgingivostomatitis or painful vesicles, HSV in theseindividuals often manifests as chronic ulcerative muco-

Eur J Pediatr (2002) 161: 120–121DOI 10.1007/s00431-001-0879-3

F. KoprivaDepartment of Paediatrics, Palacky University,Puskinova 6, 77520 Olomouc,Czech RepublicE-mail: koprivaf@risc.upol.czTel.:+42-68-5854480Fax:+42-68-5852505

cutaneous lesions, verrucous plaques, and hyperplasticnodules; other less common areas include the glabrousskin such as around the digits. Ulcerated lesions of HSVin immunocompromised patients can mimic such con-ditions as aphtous ulcers, opportunistic atypical myco-bacterial and deep fungal infections, and traumaticulcers [2].

Herpetic paronychia (whitlow) is a herpes virus in-fection of the pulp of the fingertip. The entry of the virusat the thumb is sometimes due to kissing by an infectedperson. Children, however, may inoculate themselveswhile sucking their thumb or biting their nails [4]. HSVmay also be transmitted by infection of digits (whitlows)during contact sports such as rugby or wrestling (herpesgladiatorum). Health care professionals such a dentists,dental hygienists, and nurses with exposure to HSV-contaminated oral secretions are at particular risk ofcontracting this form of infection. Treatment with

Zelitrex (vancyclovir) is sometimes helpful but thenatural evolution can also decreases the frequency ofrecurrence.

References

1. Aurelius E, Johansson B, Skoldenberg B (1991) Rapid diag-nosis of herpes simplex encephalitis by nested polymerase chainreaction assay of cerebral spinal fluid. Lancet 337: 189

2. Garcia-Plata MD, Moreno-Gimenez JC, Velez GA, ValverdoBF, Fernandez RJ (1999) Herpetic whitlow in an AIDS patient.JEADV 12: 241–242

3. Kohl S (1992) Postnatal herpes simplex virus infection. In: RootRK, Sande MA (eds) Viral infections. Contemporary issues ininfectious diseases, vol 10, Churchill Livingstone, New York,pp 331–356

4. Szinnai G, Schaad UB, Heininger U (2001) Multiple herpeticwhitlow lesions in a 4-year-old girl: case report and review ofthe literature. Eur J Pediatr 160: 528–533

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