what is your reaction to this?

My first case today was fascinating from diagnosis point of view. She was brought to me after fall injuring her right side of face. The whole side was swollen and yesterday they took her to a doctor and he prescribed analgesic. She is an old patient with treated brain aneurysm. My first look told me she needs a scan. My second closer look told me no need. She had an erythematous vesicular eruption. Herpes Zoster. Wait, why She got after fall? Yes, this is "Herpes gladiotorum". Herpes simplex type 1 reactivation due to fall. Treatment Acyclovir.



Great! Valuable opinion@Dr. Jagesh Kamath

I am glad Dr Vijaykumar sinh ji, that you are seriously following the 3 Ds of learning suggested by me irreplaceable to the first post of the day by Dr Jaggi Sir . Firstly let me clarify that the case is not a one that could be called. as explained at length by me in my reply . You must have also noticed in my reply about the ambiguity between the vesivles reported as to whether they are HZ as state first or the update which is related to the HSV 1 SINCE I am commenting on the update, my discussion is centered around HSV 1 . Since the contact sports which is the heart of this diagnosis is missing here a as possible link between the fall and appearance of vesicles. It is not meant to convey that all falls will be followed by virus reactivation . trauma is mentioned but not its magnitude . The trauma is face saving explanation and that there is no certainty that it could have caused . Even the stress associated with fall and it's consewuences could have triggered . So the ground on which you are shooting (qustions) is quite slippery and hypothetical I know you don't want all these "window dressing" and expect answers to your questions , straight and " point blank " ! The answers may not be in seriatum . 1.) The 2 to 20 days time is for the initial infection , not to ,reactivation of the HSV 1 which take shelter in sensory ganglion and travel through sensory nerves -to nerve endings. on to the skin . Reactivation can certainly appear within a day . Observe the so called fever Blisters which appear simultaneously or shortly after . HSV 2 is found to be reactivated with in the next day of even sexual trauma or masturbation . So, the doubt must have been cleared . 2) it is easy to distinguish between the vescles of HSV 1and those produced by the trauma. The former are minute vesicles that are always grouped but not veicles due to trauma . The oedema produced by trauma is extensive and non inflamatory where as HSV 1 Vesicles cause limited oedema if any which is inflamatory in origin. The vesicles of HSV 1 dry up faster than the first infection due to the CMI developed after primary infection . The traumatic oedema induced oedema may be associated with injuries like bruise or abrasions , but not not in HSV 1. 3) whether HSV 1 can cause such extensive oedema ? This has already answered above . 4) Regarding aneurysm and CT scan have no bearing on HSV 1 or HG . No comments are made on this matter by me . Dr Jagesh has to answer as he changed his decision between first and second look. However, the dermatologists concern is rash and if deemed he would have referred to a surgeon or N S . So no point in questioning on matters not concerned with a dermafogist . 6 . Fortunately , the fomites , cups and glasses etc are not incremented in transmission . Strictly it is skin to skin, or skin to mucous membrane or mucus membrane , or skin or between mucus membrane to mucus membrane . 7. HSV 1 does not cause headaches (unless pt has HSV1 encephaliyos) or tingling etc Any further doubts welcome ! "It is always better to sort out doubts than follow the bandwagon " ! @ Dr Vijaykumar Singh and Sr Jagesh kamat , Sirs @

Thank you for such detailed explanations provided Dr. Asv. Much appreciated 🙏👏 I am always eager to learn - in fact maybe more than needed 😄 ---- Like I said in my first comment where I had all those questions - I don't know much about dermatological conditions and its merely the words "fall injuring her right side of face" that got my attention. My thought was "I could face a similar case some day and I would like to be better equipped with knowledge to offer a correct diagnosis and maybe guide that patient to someone who can provide the correct treatment". The point being I should know which cases to forward to a dermatologist rather than keep treating him and see the patient not improve - which would become frustrating both for me and the patient. Excellent explanations provided Dr. Asv but I still have a couple of doubts:- 6. I was under the impression that for a short period of time fomites / objects (like a glass used to drink which might have his saliva on it, sharing soaps, towels or cellphones and such) are capable of transmitting the HSV. From what you said this notion seems to be baseless. Not sure if I should believe the Wisconsin Department of Health Services (link below) --> I will take your word for it over theirs. 7. Not sure if a patient needs to have HSV-1 encephalitis to get a headache. Latent HSV1 also can reside in Cranial nerves and ganglions - for instance the Trigeminal nerve and ganglion and can get reactivated from time to time with stress, injury, etc. Also, both active and inactive viral lesions of the trigeminal nerve can cause pain in the trigeminal territory which also includes part of the head. Again this is not my area of expertise and I would take your word for it if you say that HSV-1 does not cause headache unless encephalitis ensues. ---- * https://www.dhs.wisconsin.gov/disease/herpes-gladiatorum.htm * https://www.aaopt.org/detail/knowledge-base-article/trigeminal-nerve-manifestations-herpes-simplex-virus-female-siblings * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892378/

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Herpes simplex virus? Herpes Zoster

Hello Sir, A very Happy New Year to you and Dr. Asv - the most dynamic doctors on Curofy. ✨🎁🎉 The only doctors who actually entertain actual discussion with points for and against a statement without getting offended. ---- To be honest I don't know much about "Herpes gladiatorum" (HG for the sake of convenience) or any skin infection for that matter. However, your post was quite intriguing. I have heard how "Curiosity killed the Cat" and know that my being inquisitive about dermatological problems might not be of much use. However, since trauma was involved, I felt the need to equip myself with some know-how related to this particular entity. Did some reading including the links shared by you which were quite interesting and informative indeed. From what I could gather and from the bit of knowledge I have related to trauma, I have some thoughts (mostly questions) : 1. Like Dr. Asv pointed out, its unlikely that she got a fresh infection due to the fall. Assuming a scenario where she managed to infuriate a wrestler enough for him to hit the old lady with his head/face resulting in her fall. Those interesting articles I went through suggest that it could take anywhere between 2 to 20 days for the sores / blisters of HG to appear. Or is it likely that she fell yesterday and presented today with vesicles of reactivated HG? 2. The HSV-1 virus in cases of HG may spread through contact (actual skin to skin contact as in athletes involved in contact sports) but could also be fomite borne spreading with something as simple as sharing a glass for drinking or sharing a phone. So, indeed she could have had the virus in her. No questions there from me. 3. The flare-up / reactivation of HG can in fact be triggered by stress, illness, surgery or minor trauma to the skin. However, blisters due to HSV-1 reactivation appearing right after facial trauma or within a day - does that seem likely or would that take a couple of days at least to appear? 4. From my experience with trauma - vesicles can appear anywhere on the skin that is markedly swollen and this can happen within hours. These vesicles can contain serous or clear fluid. Erythema can also be caused by injury. In such cases, now with a better knowledge of HG, the question arises in my mind about - how can we differentiate between the two clinically. What specific features to look for? Can HG cause a significant one-sided swelling of face as can occur in trauma and how long would it take following a trauma to develop such a swelling due to HG? 5. An old lady with pre-existing cerebral aneurysm + fall + facial swelling. Since she has been treated earlier for aneurysm, do we know if the aneurysm had resolved, regressed or is it still there? Was it treated surgically, with coiling or with medicines? I am only asking because in cases of cerebral aneurysm there have been occasions where even a minor trauma lead to aneurysmal rupture. The effects depend upon the amount and speed of hemorrhaging and might not be evident until the bleed / hematoma becomes of significant size to cause pressure effects. So, in her case, should we or should we not consider a scan? 6. Even after minor head (including facial) trauma - headache is one of the indications for a brain scan. HG can also cause headache. Another indication for a scan would be tingling or numbness in any area following head trauma. HG can also cause tingling (not sure about numbness). So, should we or should we not get a scan? 7. For new doctors or doctors like me who do not have experience with skin conditions, how would you suggest we approach such confusing cases?

Dr.Singh, your questions I will answer but do give me a day to ruminte over the excellent questions raised. Sure, with your instructions will get her MRI done. Many thanks Dr.Singh for your kind words about Mr.Holmes and me Watson, Sure Mr.ASV Holmes will reciprocate the same! Regards and best wishes. Jagesh "H"

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Reactivation of herpes simplex can occur even with injury not necessarily skin to skin contact. The purpose of this communication is to highlight on the rarely recognized Herpes Gladiotorum. Thanks to Dr.Prasad for his excellent analysis and clarification.

Valuable opinion @Dr. Jagesh Kamath 👍

My reaction is one of confusion . Herpes gladiotorum,the HSV 1 infection , is acquired from person to person coming in close contact like as in wrestling ,which setting the condition earned it's name . It is just a fanciful name suited to such a manner of acquisition of HSV 1 and is no way different from other close contact like kissing ( kiss longus or brevis ! ) . So the emphasis is on close contact than either the punches they deliver between them or getting floored by the other Hear, the poor lady is not a wrestler or gladiator , and she has just fallen without a chance of getting it by close contact and hence doesn't merit the diagnosis hit upon . I hope Sir, if you took a hard look, you should have more rational explanation , " Reactivation of a latent HSV 1 due to trauma, ( fall) which is a known trigger for the virus reactivation . Again I am confused when you started with Herpes Zoster and ended with HSV 1. So my reaction is one of confusion, compounded by transmitted confusion ! Hope this reply does not turn both off us into gladiators and give chance for herpes gladiatotorum , Sir ! ( in lighter vein only ) Regards and New Year Wishes to you ,Sir

I agree

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