Herpes Simplex Virus Infection of the Hand A Profile of 79 Cases
M. JOHN GILL, M.B., M.Sc., F.R.C.P.C. JOHN ARLETTE, M.D., F.R.C.P.C. KENNETH BUCHAN, M.B., Ch.B. Calgary, Alberta,
Seventy-nine cases of herpes simplex (HSV) infection of the hand were documented by viral culture over a 40-month period. A marked bimodal age distribution was found with 32 cases occurring in adults aged 21 to 30 years and 16 occurring in children less than 10 years old. The infection most commonly occurred on the fingers (69 percent) and thumb (21 percent). All 20 herpes simplex type 2 (HSV-2) isolates came from patients over 20 years old. All of the 13 specimens that were typed after isolation from patients under 20 years old were herpes simplex type 1 (HSV-1). Only seven of the 49 adult cases were identified in health care professionals. In this series, HSV infection of the hand occurred in 2.4 cases per 100,000 population per year. In adults, women with recurrent infections from HSV-2 and a history compatible with genital herpes predominated. In children, a primary HSV-1 infection associated with gingivostomatitis was common. Herpes simplex virus (HSV) infection of the hand was first described in 1909 [I]. Since then, it has been described sporadically in the literature under a variety of different names including herpetic whitlow, recurrent traumatic herpes, and herpetic paronychia [2-61. From published series, this infection would appear to be a significant occupational hazard, occurring principally in health care professionals after inoculation of the hand with exogenous HSV from an infected patient’s secretions [3,724]. Two other population groups at risk have been identified. Adults with genital herpes and children or adults with herpetic gingivostomatitis both appear to be at risk of autoinoculating endogenous HSV onto their hands and then having a second site of infection develop [25-281. Unfortunate ly, most reports are limited to a small number of highly selected cases, usually health care workers, with only limited, if any, virologic studies being undertaken. In this series, we report the profile of 79 unselected cases with culture-proven HSV infection of the hands. PATIENTS AND METHODS
From the Divisions of Infectious Diseases and Dermatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada. Dr. Gill receives funds from the Alberta Heritage Foundation for Medical Research as a Clinical Investigator. Requests for reprints should be addressed to Dr. M. John Gill, Division of Infectious Diseases, Department of Medicine, University of Calgary, 3330 Hospital Drive Northwest, Calgary, Alberta, Canada T2N 4N1. Manuscript submitted June 5, 1987, and accepted in revised form October 2, 1987.
Patient Population. The Public Health Laboratory of Alberta is the only laboratory in Southern Alberta (population approximately 1.1 X 1 06) providing viral diagnostic services. Demographic data on this population were based on health care registration during this period as provided by the Provincial Government. We have reviewed all 79 isolates received by this laboratory between January 1983 and April 1986 in which a specimen taken from a site on the hand was positive on viral culture for herpes viruses. When details were missing, information additional to that submitted with the original requisition was often obtained by a discussion with the referring physician. Twenty patients were followed by us. No attempt was made during this study either to boost the general awareness of this
The American Journal of Medicine
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occurred oh the fingers. In 12 of the 20 cases that we followed ourselves, the digital pulp space was the primary site. Only three of the 20 lesions involved the periungual surfaces of the lateral or proximal nail folds or distal nail groove area. The site in two of these patients was the lateral nail fold and in one patient was the proximal nail fold. In the remaining five cases, the lesions occurred on the lateral aspect of the digit between the metacarpalinterphalangeal and distal interphalangeal joint, or in the interdigital web space. The next most common site was the thumb (22 percent). The palm and wrist area accounted for the remaining sites (11 percent). All of the hand lesions occurred on the palmar surface except for one lesion in the anatomic “snuffbox area” of the right hand. Lesions occurred on the left or the right hand with equal frequency. In 43 cases, the virus was saved and the type of HSV was determined. The breakdown by patient age and type of HSV isolated is shown in Figure 2. HSV- 1 was found in 23 cases and HSV-2 was found in 20 cases. The age distribution of the 21 patients with HSV-1 isolates whose ages were known showed that 13 specimens came from patients less than 20 years old and eight came from patients older than 20 years. All 20 HSV-2 isolates came from adults. The female to male ratio was 2:l. In 15 cases of proven HSV-2 infection on the hand, a previous history of genital herpes or recurrent genital tract infections could be elicited. Five female adults had HSV-2 infection of the hand but had not had any known episodes of genital herpes. Two of these five patients had never had any gynecologic infections requiring medical attention. In 35 patients (nine children, 26 adults), clear information regarding the primary or recurrent nature of the condition was available. Eight infections were primary episodes and 27 infections were recurrent. In 25 of these 35 patients, the virus was available for typing. Fifteen of the 16 viruses isolated from patients with recurrent episodes were HSV-2, and all of these occurred in patients over 20 years of age. Only one isolate from a recurrent episode was HSV- 1 and this isolate came from the thumb of a ICmonth-old child. Only one isolate from a primary infection was HSV-2 and that occurred in a 24-year-old woman with a simultaneous recurrence of genital herpes. The eight other viral isolates from a primary infection were all HSV- 1. Four of these isolates were from children
r”“‘N”“‘x”“‘A”“‘Af”“‘A lo-20 O-10
AGE IN YEARS
Figure 1. Distribution by age and sex of 74 patients culture-proven HSV infection of the hand.
condition or to encourage a definitive viral diagnosis in cases previously diagnosed on clinical grounds. Virology. All specimens were transported in a standard viral transport medium (Hanks’ balanced salt solution with 10 percent bovine serum albumin, penicillin 100 IU/ml, streptomycin 100 pg/ml, and sodium bicarbonate 4.5 percent. Specimens were planted onto both human embryonic lung and primary human amnion cell lines. The presence of herpes virus was confirmed by electron microscopy. Fortythree specimens were saved and viral typing was undertaken using monoclonal fluorescent antibodies (Syntex Corp., Palo Alto, California). Patient Data. All patients included in this study had culture-proven herpetic lesions involving the cutaneous surface of the hand distal to the wrist flexure. Immunosuppressed patients with disseminated herpes were not included. Complete information ‘on each patient’s age, sex, occupation, and the site of the infection was obtained in 67 cases, with only partial information available in the remaining 12 cases. RESULTS
The age of each patient was recorded at the time of the first positive result on viral culture. The age and sex distribution of 74 cases is shown in Figure 1. A clear bimodal distribution of the patients’ ages is apparent with 16 cases in the pediatric age group less than 10 years old and 32 cases in the age group 20 to 30. The sex distribution differed markedly between the adult and pediatric cases. In the pediatric age group, the number of female patients approximated that of the male patients, but in the age group over 20 years old the ratio of women to men was 2.3:1. In southern Alberta, the number of males approximates the number of females in all age groups. The exact site on the hand infected by the herpes virus infection was clearly documented in 67 cases. The sites are listed in Table I. The majority of lesions (67 percent)
Sites Involved by the Herpetic the Hand in 67 Patients
SiteofInfection Fingers Thumb Palm/wrist Dorsum of hand
Numberof Cases 45 (67%) 15 (22%) 7(11%) 0 (0%)
less than 15 years old, three came from health care workers, and the remaining isolate came from an adult with a simultaneous primary oral herpes infection. In 69 cases, information regarding the patient’s occupation(s) was available. This information is listed in Table II. Twenty-five patients were either infants or school children 15 years or younger. Herpes infection of the hand was documented in only seven health care professionals. One of these patients also had recurrent genital herpes and had HSV-2 documented at both sites. A slight preponderance of patients with occupations that involved active and intricate use of their hands was noted, e.g., secretarial work, musician.
Occupations of 69 Patients infection of the Hand
with Herpetic Number of Patients
Health care workers Nurses Respiratory technologists Physicians/dentists Children/students Other non-health-care occupations Not stated
7 3 2 3 25 35 12
(31%) (45%) (15%)
groups-most of whom have contact with patients’ oral secretions. Nurses, anesthesiologists, surgeons, dentists, and dental hygienists all belong to the large number of health care professions in which herpetic infections of the hand have been reported as being an occupational hazard [7-241. The wealth of published clinical cases in health care workers has led to the general belief that HSV infection of the hand is most often seen in health care practitioners . Unfortunately, the majority of these reports consist of a small number of preselected cases with only limited, if any, virology. Since our data (Table II) clearly failed to show this marked occupational predisposition, we contacted the staff health care units at the four major hospitals in Calgary. Only two cases of documented herpetic infection of the hand in health care workers (respiratory technologist) and a nurse were found over the previous three years. A survey of 300 licensed dentists in Calgary was also conducted. From the 143 replies only one case of possible herpetic infection of the hand was reported. All of these results suggest that this infection now occurs only rarely in health care professionals. This apparent change in the epidemiology from that previously reported might represent a heightened awareness of the condition and stricter infection control precautions when dealing with patients’ oral secretions [lo]. Our study suggests that the well-publicized belief that herpetic infections of the hand are primarily an occupation-related infection is no longer correct . In this series, only seven cases occurred in health care professionals and, if one excludes the patient with both genital and digital infection, the occupational risk would appear to be marginal. Herpetic infections of the hand in the pediatric age group have been recognized for many years. The presence of this infection has been associated with the practice of finger and thumb sucking in children, leading to viral autoinoculation from the mouth . Such a route of infection has also been proposed in adults with herpetic paronychia possibly acquired by nail biting . In our series, the simultaneous occurrence of a HSV gingivostomatitis and infection on fingers was present in three pediatric cases and it would readily explain the isolation of
After the original description of herpes infection of the hand in 1909, this condition was described only sporadically in various case reports for the next 50 years [ 11. The majority of reported infections appeared to follow trauma, burns, or cuts, and the phrase “recurrent traumatic herpes” was introduced . In 1959, Stern et al  were the first to describe a series of 54 cases of health care workers with herpetic infection of the digits, and they named the entity herpetic whitlow. All of their cases presented to the Septic Hand Clinic at a major hospital, and they occurred in nursing staff. The infection was believed to have been acquired from occupational exposure to patients’ oral secretions. In most cases, no antecedent trauma was documented. All of the lesions occurred on the digits-mainly on the thumb or the index finger. In the seven cases that were followed for a short time, several recurrences were documented at the same site on the fingers. In only 13 cases was the diagnosis confirmed by viral culture [ 131. In subsequent articles, herpetic infections of the hand have been noted in a variety of health care professional
Figure 2. Distribution by age and viral type of patients with culture-proven HSV infection on the hand.
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HSV-1 in all our pediatric isolates. Recurrences in this population appeared to be infrequent. The complications occasionally associated with herpetic infection of the hand were not noted in this series [3 l-331. In two small series, herpetic infection of the hand has been noted to be associated with genital herpes [25,26]. One study looked at 13 patients with culture-proven herpetit infection of the hand 1251. Seven of these patients also had documented genital herpes and, in 11 of 13 cases, the virus isolated from the hand was HSV-2. A second article described three female patients who had both hand and genital herpetic infections . In our series, in one patient with a primary hand infection, HSV2 was cultured from both the genital area and the hand. The virus isolated from 15 to 16 patients with recurrent herpetic infections of the hand was HSV-2, suggesting that recurrent lesions in adults are usually HSV-2. A similar predisposition of HSV-2 to cause more frequent recurrences than HSV-1 has been shown in genital herpes infections . Overall, we found an incidence of 2.4 cases per 100,600 population per year in southern Alberta. However, of the 79 cases in this series, 75 lived within the city of Calgary, which has a population of 665,000, suggesting an urban incidence of about five cases per 100,000 per year. We were unable to ascertain if this represented a significant under-reporting from rural areas due to a more limited use of laboratory facilities or if it were due to herpetic hand infections being primarily an “urban” disease. We have found a bimodal distribution of the ages of our patients at the time of diagnosis. In the 35 patients with recurrent lesions in whom a reliable clinical history was available, the diagnosis was made within five years of the onset of the condition. A delay in diagnosis would appear
to be an unlikely cause of bias producing a bimodal distribution. In the 25 infections occurring before the age of 20, the number of males approximated the number of females. In the patients older than 20, a marked preponderance of women was noted. This preponderance of women might indicate a predisposition in females to herpetic infection of the hand, particularly in the presence of genital herpes, or it could represent a reluctance by males to seek medical attention. In the 16 cases of genital herpes and herpetic whitlow described [25,26], the authors also noted a preponderance of females with this condition. The term herpetic whitlow has been used to cover herpetic infection of the digits [lo]. However, whitlow and its synonym felon refer to a purulent infection or abscess of the pulp of the distal phalanx of the finger . Other authors have used the term herpetic paronychia [6,17]. Both herpetic whitlow and herpetic paronychia describe HSV infections involving the digit. These terms are neither appropriate nor precise in 40 percent of the cases that were evaluated in this study. It would be better to consider that herpetic infection of the hand is simply another manifestation of HSV infections developing at the end of a nerve distribution. The term herpes manus would be more accurate and descriptive of the group of HSV infections that occur on the hand. In conclusion, we suggest that herpetic infection of the hand is not a rare condition. In our series, it occurred principally in adults aged 20 to 30 and in children. Health care workers were occasionally infected but they only accounted for 8 percent of all cases. In pediatric patients the condition was usualfy a primary infection caused by HSV- 1. In adults, women with recurrent infections predominated and there was a strong association with genital herpes.
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