Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 11  |  Issue : 2  |  Page : 59-62

Recalcitrant finger ulcer in HIV patient; think herpetic whitlow, save the finger


Department of Surgery, Plastic Surgery Unit, Federal Teaching Hospital, Gombe, Nigeria

Date of Web Publication10-Mar-2016

Correspondence Address:
Emeka Nwakire
Department of Surgery, Plastic Surgery Unit, Federal Teaching Hospital, Gombe
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0794-9316.178452

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  Abstract 

This is a case report to highlight the atypical presentation of hand ulcers caused by herpes simplex virus (HSV) in immunocompromised patients. We report a case of a 43-year-old right-handed female who developed a nonhealing and progressive ulcer involving the left middle finger and extending to the palm for which she was referred to our facility. Initial clinical diagnosis following examination was squamous cell carcinoma. However, carefully observed similar new lesions she developed while being investigated was in favour of HSV infection. She had remarkable response on acyclovir which substantiated the diagnosis. Awareness and a high index of clinical suspicion are required of physicians who may come across similar lesions.

Keywords: Atypical herpes simplex infection, hand, HIV, middle finger


How to cite this article:
Kaltungo ZY, Nwakire E. Recalcitrant finger ulcer in HIV patient; think herpetic whitlow, save the finger. Nigerian J Plast Surg 2015;11:59-62

How to cite this URL:
Kaltungo ZY, Nwakire E. Recalcitrant finger ulcer in HIV patient; think herpetic whitlow, save the finger. Nigerian J Plast Surg [serial online] 2015 [cited 2019 Dec 8];11:59-62. Available from: http://www.njps.org/text.asp?2015/11/2/59/178452


  Introduction Top


Herpetic whitlow is a painful viral infection affecting the fingers or thumbs caused by herpes simplex virus (HSV). HSV infection of the hand may be caused by a primary or recurrent infection with either HSV1 or HSV2. It is considered an acquired immune deficiency syndrome defining disease in a previously diagnosed HIV (human immune deficiency syndrome) patient. It presents as a group of vesicles on an erythematous base.

This case report is aimed at drawing attention to the peculiarity of HSV infection in the immunocompromised state and the need for a high index of suspicion in enabling precise diagnosis.


  Case Report Top


A healthy looking 43-year-old right-handed female accountant was referred on account of non-healing and progressive wound involving the left middle finger and extending to the palm of 1year duration [Figure 1] and [Figure 2].
Figure 1: Dorsal surface appearance at presentation

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Figure 2: Volar surface appearance at presentation

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The lesion started at the radial nail fold and subsequently spread to involve the whole of the finger and distal hand. There was neither fever nor other constitutional symptoms.

She had debridement twice and various wound dressing regimens before referral without improvement. She was diagnosed with HIV 5 years before presentation and has been anti-retroviral tenofovir, lamivudine, and efavirenz for 4 years.

Pastmedical history of laparotomy for ectopic pregnancy was noted.

Examination revealed a healthy looking lady who was afebrile, anicteric, and not dehydrated.

The left middle finger was grossly swollen with multiple punctate ulcers extending to, but not crossing the distal palmar crease. The palmar ulcers were confluent with raised everted edges. The skin islands in between the punctate ulcers were variegated with areas of normal and hypopigmentation. The floor of the ulcers was covered with scab. The inter and metacarpophalangeal joints were stiff, with pain on the active and passive extension. The supratrochlear and axillary lymph nodes were not enlarged.

Clinical diagnosis was Kaposi sarcoma to rule out a verrucous variant of squamous cell carcinoma.

Wound swab microscopy grew Gram-negative cocci, culture and sensitivity yielded Klebsiella species sensitive to levofloxacin, ceftriaxone, and ciprofloxacin.

She was planned for a wound biopsy for histology and possible ray amputation. CD4 count was requested, but she declined presenting the result until she was discharged from our service.

Complete blood count was normal. Plain X-ray showed no bony lesions.

Blood samples were negative for HSV1 and HSV2 IgM, but positive for HSV1 and 2 IgG.

The clinical impression, however, changed in favour of HSV infection when she developed fresh lesions which were vesiculopapular on the radial aspect of the ipsilateral ring finger and contralateral middle finger 2 weeks later. The lesions were nontender and involved the radial nail fold [Figure 3] and [Figure 4].
Figure 3: Fresh lesion on the contralateral finger

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Figure 4: Two weeks on acyclovir (note the whitish topical acyclovir cream applied)

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She was commenced on empirical acyclovir at 200 mg 4 hourly for 2 weeks and to reduce the frequency to 200 mg 6 hourly depending on the response.

Following 1week of the treatment, most of the wounds had healed, and she requested to use topical acyclovir to speed up healing. She was duly informed that would probably be of no added benefit. She was instructed to reduce the frequency of acyclovir to 200 mg 6 hourly for 2 weeks after the first 2 weeks on 200 mg 4 hourly.

The wound healed completely within 3 weeks with marked hypopigmentation reminiscent of a poorly treated full thickness burn wound [Figure 5] and [Figure 6].
Figure 5: Healing with obvious hypo pigmentation

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Figure 6: Gradual repigmentation

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The patient was discharged back to her primary care physician thereafter.


  Discussion Top


HSV infection of the hand may be caused by a primary or recurrent infection with either HSV1 or HSV2.[1],[2]

Occurrence ranges from children with oral gingivostomatitis to adult healthcare professionals who deal with potentially infected oral and respiratory secretions.[3]

Herpetic infections in children and healthcare workers are most often the result of viral inoculation from the oropharynx by HSV1.

In adults however, HSV2 predominates and is often due to inoculation from genital herpes. HSV of the hand typically involves the fingers or thumb.

It starts with a prodromal phase of approximately 72 h duration, pain, or tingling the affected digit.[1] The patient complaints of erythema and swelling. Vesicles appear and coalesce often around the eponychium and lateral nail fold. The coalescent ulcers mimic verrucous carcinoma, hence the initial clinical impression in this patient. Superficial necrosis occurs and results in a turbid color which often is confused with a bacterial infection. The whole process takes about 2 weeks and then resolves again in another 7–10 days. Regional lymphadenopathy may accompany these findings, however, systemic are rare.[2],[4]

Atypical presentation of herpes is not uncommon in immunocompromised patients.[5],[6] Ulcers can appear in single or multiple locations much like in this patient and more likely to become chronic and extensive. It may present as a widespread non-healing growth sometimes referred to as herpes vegetans. This is an exophytic proliferative growth closely mimicking verrucous and malignant lesions.[7]

Positive Tzank smear reveals multinucleated giant cells and inclusion bodies.

Rest elevation and anti-inflammatory analgesia are very crucial. Antiviral drugs used include acyclovir, famciclovir, and valacyclovir. Acyclovir selectively inhibits the formation of viral DNA polymerase and terminates viral DNA synthesis.[8],[9],[10]

Topical acyclovir has minimal effect on healing and does not prevent new lesions. Resistant cases may be managed with intravenous Foscarnet.


  Conclusion Top


A recalcitrant hand ulcer should raise the suspicion of atypical presentation of herpetic whitlow and possibly underlying immunosuppression.

 
  References Top

1.
Adamson HG. Herpes attacking the fingers. Br J Dermatol 1909;21:323-4.  Back to cited text no. 1
    
2.
Clark DC. Common acute hand infections. Am Fam Physician 2003;68:2167-76.  Back to cited text no. 2
    
3.
Lewis MA Herpes simplex virus: An occupational hazard in dentistry. Int Dent J 2004;54:103-11.  Back to cited text no. 3
    
4.
Glickel SZ. Hand infections in patients with acquired immunodeficiency syndrome. J Hand Surg Am 1988;13:770-5.  Back to cited text no. 4
    
5.
Dinotta F, De Pasquale R, Nasca MR, Tedeschi A, Micali G. Disseminated herpes simplex infection in a HIV patient. GItal Dermatol Venereol 2009;144:205-9.  Back to cited text no. 5
    
6.
Wynn SW, Elhassan BT, Gonzales MH. Infections of the hand in the immunocompromised host. J Am Soc Surg Hand 2004;4:121-7.  Back to cited text no. 6
    
7.
Patel AB, Rosen T. Herpes vegetans as a sign of HIV infection. Dermatol Online J 2008;14:6.  Back to cited text no. 7
    
8.
Widenfalk B, Wallin J. Recurrent herpes simplex virus infections in the adult hand. Scand J Plast Reconstr Surg Hand Surg 1988;22:177-80.  Back to cited text no. 8
    
9.
Gill MJ, Arlette J, Buchan K, Tyrrell DL. Therapy for recurrent herpetic whitlow. Ann Intern Med 1986;105:631.  Back to cited text no. 9
    
10.
Donn J, Nghia CH, Annette HS, Truong NT. Chronic hand ulcer in a woman with HIV infection. Infect Dis Clin Pract 2008;16:247-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
References
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