AAO Poster Submission Alison P. Schuiteman, OD; Victor Malinovsky, OD, FAAO; Susan Kovacich, OD, FAAO

I. Abstract: a. Herpes Gladiatorum is a recurrent form of herpes simplex type 1 virus, contracted through skin to skin contact in wrestling. A case of Herpes Simplex Blepharoconjuctivitis secondary to herpes gladiatorum is presented here.

II. Case History: a. 23 year old Caucasian male b. Patient presented with a red eye that started two days ago, OD. i. (+) discharge, yellowish ii. (+) excessive watering OD iii. (+) mild pain when moving the eye around, OD, mild ache, has gotten much worse since two days ago iv. (+) discomfort along the lid margins OD v. (+) sore in entry of nasal cavity vi. (+) itchiness, mild, feels scratchy and sore OD vii. (-) trauma noted viii. (+) Pneumonia recently, was taking Z pack ix. (+) College wrestler c. Ocular Hx: i. Eye Injury: 1. Tree bark flew in OS, many years ago, (-) sequelae 2. “Pink Eye” 4 times in past couple years, both eyes, was given topical antibiotic and it didn’t help. Tx: Resolved on its own. d. Medical Hx: i. Pneumonia recently, Tx: Z-pack ii. Sores within nasal cavity x 2 days e. Medications: i. Advil prn for muscle aches after wrestling practice ii. Azithromycin, Tx: Pneumonia

III. Pertinent Findings: a. Initial Visit: 1/5/11 i. Pupils: PERRL, No APD OD, OS ii. Confrontation Fields: FTFC OD, OS iii. EOM’s: Full, No Pain or Diplopia noted iv. Slit Lam Exam: 1. Reactive ptosis on lids, chemosis of conj, OD; OS WNL 2. 2 + injection and chemosis of conj, OD; OS WNL 3. (+) Numerous SEI’s along inferior cornea OD; OS WNL 4. (-) cells/flare, OD, OS 5. (-) dendritic lesions 6. (+) staining along lid margins with lissamine green and fluorescein, OD; OS WNL a. Numerous ulcerated lesions noted along upper and lower lid OD; OS WNL v. Assessment: 1. Herpes Simplex Blepharoconjunctivitis OD – Subtle SEI’s vi. Plan: 1. Careful Patient Education on contagious nature of disease and possible herpetic involvement elsewhere 2. Prescribed Zirgan Ophthalmic gel 5x/day x 2 days. 3. Prescribed Acyclovir 400 mg 5x/day x 7 days. 4. RTC 2 days for F/U b. Follow up visit: 1/7/11 i. Pt reports that right eye feels “much better” ii. Patient reports no pain, photophobia, FBS, discharge iii. Minimal watering noted iv. Pupils: PERRL, No APD OD, OS v. Confrontation Fields: FTFC OD, OS vi. EOM’s: Full, No Pain or Diplopia noted vii. Slit Lamp Exam: 1. 1-2+ Chemosis and injection on lids and lid margins, OD; OS WNL 2. 1-2 + injection on bulbar conj OD; OS WNL 3. (+) Resolving SEI’s along inferior cornea OD; OS WNL 4. (-) cells/flare OD, OS 5. (-) dendritic lesions 6. (+) staining along lid margins with lissamine green and fluorescein OD; OS WNL a. Resolving ulcers noted along upper and lower lids OD viii. Assessment 1. Herpes Simplex 2. Herpes Blepharoconjunctivitis- OD resolving ix. Plan: 1. Continue oral acyclovir 400 mg 5x/day x 5 days 2. Decrease Zirgan Ophthalmic gel to TID x 3 days, then BID until F/U 3. RTC 5 days for F/U c. Follow Up Visit: 1/12/11 i. Patient reports eye feels back to normal ii. (-) photophobia, watering, discharge, FBS, new sx iii. Pupils: PERRL, No APD OD, OS iv. Confrontation Fields: FTFC OD, OS v. EOM’s: Full, No Pain or Diplopia noted vi. Slit Lam Exam: 1. (-) chemosis or injection OD, OS 2. (-) SEI’s OD, OS 3. (-) Cells/Flare OD, OS 4. (-) dendritic lesions 5. (+) subtle resolved lesion nasal lower lid OD 6. (-) ulcers/lesions upper lid OD vii. Assessment: 1. Resolved Herpes Blepharoconjunctivitis – OD 2. Herpes Simplex viii. Plan 1. Decrease Zirgan to QD OD x 2 days, then discontinue gel 2. Discontinue Acyclovir. Start maintenance of Valtrex to prevent recurrences during wrestling season. 3. Careful patient education on Herpes Simplex and not to self treat this condition. 4. RTC prn

IV. Differential Diagnosis: a. Ocular Herpes Gladiatorum i. Corneal Abrasion ii. Corneal Erosion iii. Herpes Zoster iv. Bacterial Keratitis v. Fungal Keratitis vi. Corneal Ulcer b. Herpes Gladiatorum – skin lesions i. Impetigo ii. Herpes Zoster iii. Allergic or Contact Dermatitis iv. Eczematoid Dermatitis v. Pyoderma vi. Vacinnia vii. Rickettsialpox viii. Ring Worm (Fungal Infections)

V. Diagnosis and Discussion: a. Herpes Gladiatorum is a permanent, recurrent form of herpes simplex type 1 virus. It is typically contracted through skin to skin contact, most common in high school and collegiate wrestling. Herpes Gladiatorum has also been transferred asymptomatically via saliva. Initially, lesions are most commonly found on the face (71.9% - 73%) or arm region (17.6% - 42%), secondary to the “locking up” position at the beginning of the match. The lesion locations are correlated with the handedness of the wrestlers – right handedness typically shows right sided facial lesions and vice versa for left handedness. Recent data has shown that herpes gladiatorum is present in approximately 29.8% of high school wrestlers, only 2-3% of these wrestlers being aware that they have the virus. This poses concern in that it is very difficult to ‘manage’ the virus when so many wrestlers are asymptomatic. Ocular involvement is rare, however, occurring secondary to the close contact of the wrestler with other wrestlers, as well as contact with the mat throughout the wrestling match. Routine skin checks by athletic trainers and referees before each match combined with quick, proper management is necessary in preventing the spread of herpes gladiatorum throughout the wrestling population.

VI. Treatment, Management: a. Visit 1/5/11 i. Patient was instructed that they were contagious to the rest of the team and should not be participating in wrestling practice. ii. Patient was prescribed Zirgan ophthalmic gel 5x/day x 2 days, as well as acyclovir 400mg 5x/day x 7 days. Patient was informed to return to clinic ASAP if symptoms worsened. The patient’s athletic trainer was also called to report the outbreak of herpes gladitorium. RTC 2 days. b. Visit 1/7/11 i. Patient was instructed to continue current therapy with oral acyclovir. ii. Decrease Zirgan ophthalmic gel application to TID x 3 days, then BID until next visit. RTC 5 days for F/U. c. Visit 1/12/11 i. Discontinue acyclovir, start prophylactic Valtrex 500mg BID P.O. throughout wrestling season. Discussed with patient that this is something that does recur and to RTC immediately if signs and symptoms noted.

VII. Conclusion: a. Herpes gladiatorum is common among wrestlers. Recently, more dangerous dermatological outbreaks have occurred in the wrestling community, including methicillin-resistant Staphylococcus aureus or MRSA. MRSA outbreaks have been found in Colorado, Indiana, Pennsylvania, and Southern California. To protect these athletes and the community, it is our job as optometrists to be aware of these lesions in athletes and to quickly and aggressively treat these problems. While approximately 30% of wrestlers have the acquired herpes gladiatorum, roughly 2-3% are aware that they have the condition. By maintaining accurate, routine skin checks and being aware of the condition easily spreading through the wrestling mat, can help to prevent the quick spread of these conditions.

References:

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Belongia, E., Goodman, J., et. al. “An Outbreak of Herpes Gladiatorum at a High-School Wrestling Camp.” The New England Journal of Medicine. 1991 Sep; (325): 906-910.

Holland, E., Mahanti, R., et. al. “Ocular Involvement in an Outbreak of Herpes Gladiatorum.” American Journal of Ophthalmology. 1992; (114): 680-684.

Johnson, R. “Herpes gladiatorum and other skin diseases.” Clinics in Sports Medicine. 2004; (23): 473-484.

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