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The New England Journal of MedicineCase 16-2024: A 20-Year-Old Man with a Pustular Rash

Herpes gladiatorum in a young athlete: Analyzing the clinical presentation, diagnostic challenges, and management of a vesiculopustular rash with potential implications for managing skin infections in contact sports.

A 20-year-old male athlete presented with a diffuse pustular rash, progressively worsening despite initial antimicrobial treatment. His history, clinical examination, and the potential for various infectious and noninfectious etiologies were meticulously analyzed, leading to the diagnosis of herpes gladiatorum. This case underscores the importance of recognizing and managing skin infections in athletes, particularly in contact sports like wrestling.

Key Points:

  • Patient Presentation:
    • A 20-year-old man with a diffuse pustular rash that progressed over several days.
    • Initially treated with oral trimethoprim-sulfamethoxazole and topical mupirocin.
    • Rash expanded from the left forearm to other areas including the chest, face, and ears.
    • History of close contact with another individual with a similar rash.
  • Medical History:
    • Notable for oral herpes simplex virus (HSV) infection, allergic rhinitis, patellar tendinosis, and a past methicillin-sensitive Staphylococcus aureus infection.
    • Medications included trimethoprim-sulfamethoxazole, loratadine, and inhaled albuterol.
    • Immunocompetent with no known drug allergies or family history of significant conditions.
  • Clinical Examination:
    • Dozens of grouped, raised vesiculopustular lesions at various stages of development.
    • Lesions found on antecubital fossae, cheeks, torso, back, axilla, abdomen, calves, occiput, and posterior to the ears.
    • Normal vital signs and other physical examination findings.
  • Diagnostic Evaluation:
    • Normal blood levels of electrolytes, glucose, albumin, globulin, liver enzymes, and kidney function.
    • Negative tests for SARS-CoV-2 and HIV.
    • Promyelocytes present in automated differential count, requiring follow-up.
  • Differential Diagnosis:
    • Considered noninfectious causes: autoimmune diseases, drug reactions, neutrophilic dermatoses, erythema multiforme.
    • Considered infectious causes: viral (HSV, VZV, molluscum contagiosum, mpox), bacterial (S. aureus folliculitis, pseudomonas folliculitis), fungal, and parasitic infestations.
    • History of close contact and pattern of rash distribution suggested an infectious etiology, particularly herpes gladiatorum.
  • Diagnosis and Management:
    • Clinical impression supported herpes gladiatorum.
    • HSV-1 nucleic acid testing confirmed the diagnosis.
    • Infection-control measures implemented due to mpox concerns, including patient isolation and use of personal protective equipment.
    • Empirical treatment with tecovirimat (for mpox) and valacyclovir (for herpes) initiated while awaiting diagnostic results.
    • Valacyclovir continued post-diagnosis, tecovirimat discontinued.
  • Public Health and Preventive Measures:
    • Contact tracing and investigation by the Massachusetts Department of Public Health (MDPH).
    • Education on prevention for athletes, trainers, and coaches emphasized.
    • Prophylactic antiviral treatment recommended for high-risk athletes.
  • Follow-Up:
    • One week later, patient’s lesions had scabbed, no new lesions developed.
    • Prophylactic valacyclovir recommended for the duration of the wrestling season.

“When I saw the rash, I became more concerned because it was far more extensive than I had ever seen in a patient with herpes gladiatorum.”
— Dr. Howard M. Heller

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