HERPES GLADIATORUM IN ATHLETES
HG is the clinical manifestation of transmission of the HSV virus. Transmission occurs primarily through direct skin-to-skin contact. Sports with increased skin to skin contact include wrestling and rugby. Once an athlete is inoculated, the virus replicates in a sensory ganglion and spreads along the sensory nerve distribution. It often is bilateral and involves multiple dermatomes. The face is involved 70% of the time, with the rest of the body making up the other 30%. Lesions tend to affect the dominant hand, side of head preferred by athlete in the ‘tie position’ in wrestling.
With a primary infection, athletes will have a 4 to 11 day incubation period where infection is subclinical. A prodrome of hyperesthesia and parasthesia can precede cutaneous manifestation and no systemic symptoms are present initially. Once symptomatic, a maculopapular vesicular rash will appear on approximately day 2. They coalesce with a minimally reddened base. In primary infection, athletes will also develop systemic symptoms including malaise, low-grade fever, sore throat, lymphadenopathy, and headache. In addition to the obvious rash, physicians must consider and perform a careful oral exam looking for gingivostomatitis and eye exam looking for herpes keratitis. A fluorescein exam is indicated if the face is affected. Missed herpes keratitis can result in permanent vision loss. The rash can also occur in a beard distribution from autoinnoculation while shaving, a presentation termed Herpetic Sycosis. Secondary HG or recurrence is common but presents with more mild symptoms in the same dermatomal distribution.
Image 2. Primary herpes gladiatorum. Note multiple areas of involvement and regional adenopathy.Peterson, Andrew R., Emma Nash, and B. J. Anderson. “Infectious disease in contact sports.” Sports Health 11.1 (2019): 47-58.
Laboratory evaluation can help confirm the diagnosis and is recommended in most cases. This is typically performed by direct microbiology with either PCR or viral culture. Viral culture is typically cheaper while PCR is faster. Either one is appropriate depending on lab resources. The Tzank smear is no longer favored due to poor sensitivity and specificity. Serology is not recommended due to high rates of positivity with low rates of active disease.
Table 1. Return to play guidelines for Herpes Gladiatorum (click to enlarge).Peterson, Andrew R., Emma Nash, and B. J. Anderson. “Infectious disease in contact sports.” Sports Health 11.1 (2019): 47-58.
Prevention is the cornerstone of managing HG. Athlete hygiene is key including showering immediately after practice or an event, using your own soap, towels and razors and washing towels immediately after use. Athletes should also wash hands frequently, avoid picking or squeezing lesions, and report any suspicious lesions to their trainer or coach. Training equipment should be sanitized daily after use and any gear used should be regularly washed with soap and water. Prophylaxis, as discussed above, has been shown to reduce risk of HSV acquisition, prevent recurrence of previous, and outbreak.
In summary, Herpes Gladiatorum is common among wrestlers. It is caused by the HSV1 virus. Diagnosis is clinical with confirmation by microbiology. Treatment is valacyclovir, removal from participation and return to play following governing body guidelines. Prevention is key! There are few complications if managed correctly, but physicians should always be suspicious of herpes keratitis in presentations on the face and perform a thorough eye exam in those athletes.
|↑1||Belongia EA, Goodman JL, Holland EJ, et al. An outbreak of herpes gladiatorum at a high-school wrestling camp. N Engl J Med. 1991;325:906-910.|
|↑2||Agel J, Ransone J, Dick R, Oppliger R, Marshall SW. Descriptive epidemiology of collegiate men’s wrestling injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train. 2007;42:303-310.|
|↑3||Anderson, B. J. “Prophylactic valacyclovir to prevent outbreaks of primary herpes gladiatorum at a 28-day wrestling camp.” Japanese Journal of Infectious Diseases 59.1 (2006): 6.|
|↑4||Wei, Elizabeth Y., and Daniel T. Coghlin. “Beyond folliculitis: recognizing herpes gladiatorum in adolescent athletes.” The Journal of Pediatrics 190 (2017): 283.|
|↑5, ↑6, ↑9||Peterson, Andrew R., Emma Nash, and B. J. Anderson. “Infectious disease in contact sports.” Sports Health 11.1 (2019): 47-58.|
|↑7||Dworkin, Mark S., et al. “Endemic spread of herpes simplex virus type 1 among adolescent wrestlers and their coaches.” The Pediatric infectious disease journal 18.12 (1999): 1108-1109.|
|↑8||Anderson, B. J. "Prophylactic valacyclovir to prevent outbreaks of primary herpes gladiatorum at a 28-day wrestling camp." Japanese Journal of Infectious Diseases 59.1 (2006): 6.|