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ENDEMIC SPREAD OF HERPES SIMPLEX VIRUS TYPE 1 AMONG ADOLESCENT WRESTLERS AND THEIR COACHES

1999; Lippincott Williams & Wilkins; Volume: 18; Issue: 12 Linguagem: Inglês

10.1097/00006454-199912000-00020

1532-0987

Mark S. Dworkin, Phyllis C. Shoemaker, Christopher Spitters, Anne Cent, A C Hobson, Jeff Vieira, Lawrence Corey, Lyn R. Frumkin,

Toxoplasma gondii Research Studies

Herpes simplex virus type 1 (HSV-1) infection acquired during wrestling (herpes gladiatorum) is one of the most common infections caused by person-to-person contact during athletic activity.1-4 The head, neck and shoulders are the usual sites of lesions, reflecting areas of frequent skin-to-skin contact. Ocular involvement and constitutional symptoms (e.g. fever, malaise, weight loss and lymphadenopathy) also can occur.1-3 Belongia et al.2 first used restriction endonuclease analysis of HSV DNA to define modes of HSV-1 transmission among wrestlers. The clustering of distinct HSV-1 strains within different practice groups that shared similar equipment suggested that HSV-1 was transmitted among wrestlers by direct cutaneous contact and not by fomites. We describe an outbreak of herpes gladiatorum among seven high school wrestling teams and their coaches from three Washington State counties. Restriction endonuclease analysis of HSV-1 isolates from confirmed cases was used to demonstrate three concurrent and geographically distinct outbreaks. Methods.Background. On January 22, 1996, the Snohomish Health District was notified of a possible outbreak of cutaneous infections among members of the wrestling team. The Washington State Department of Health obtained viral cultures of the lesions on January 31. During the following week all high schools in Snohomish County and four surrounding counties (Skagit, King, Pierce and Thurston) were contacted about the outbreak and encouraged to report any similar illness among wrestlers. Epidemiologic investigation. Confirmed herpes gladiatorum case patients were wrestlers or their coaches with a rash appearing during the wrestling season (November, 1995, until February, 1996) and isolation of HSV-1 from the lesion. All wrestlers and coaches suspected of having herpes gladiatorum were given self-administered questionnaires and also interviewed by either a county health official or the Washington State Department of Health. Laboratory investigation. Viral isolates of suspect lesions were confirmed and typed by monoclonal antibody. Restriction endonuclease analysis of HSV DNA was done as previously described by Lonsdale5 with a modified technique. HSV DNA was 32P-labeled as described5 with the exception that Vero cells were used in 34.6-mm wells. After cells were pelleted at 500 × g for 5 min, viral DNA was isolated from infected cultures by incubation at 50°C with 1% sodium dodecyl sulfate and 1 μg/ml proteinase K for 2 h. Samples were then phenol/CHCl3-extracted and precipitated by the addition of glycogen to 1 μg/ml and 2.5 volumes of ethanol. After 2 h to overnight at −20°C, the DNA was collected by centrifugation (10 min, 12 000 × g). DNA was resuspended and digested with BamHI, EcoRI and KpnI (New England BioLabs, Beverly, MA). Digested DNA was analyzed on 0.6% agarose gels followed by autoradiography. Results.Epidemiologic investigation. Seven high school wrestling teams in 3 Washington State counties were identified as having wrestlers with rash illnesses during the wrestling season. Of the 249 wrestlers and coaches from the 7 teams, 12 had culture-confirmed herpes gladiatorum (Table 1) and 40 others had a rash illness only. Three cases of confirmed herpes gladiatorum were in adult team coaches. The location of the rash was the head for 11 (92%) of the 12 confirmed case patients but involvement of the arm and leg also was reported (Table 1). Among the 12 confirmed cases of herpes gladiatorum, 9 of the high school wrestlers reported associated symptoms (headache in 8, fever in 6, chills in 4, sore throat in 5, swollen glands in 7 and pruritic or painful eyes in 5). One coach with confirmed herpes gladiatorum reported swollen glands.TABLE 1: HSV isolate results for confirmed cases of herpes gladiatorum Eleven of the 12 confirmed cases (92%) saw a physician for their rash or lesions. Impetigo or infection with Staphylococcus aureus was diagnosed in 7, fungal infection in 1, eczema in 1 and HSV in 1 case. Only 2 of these patients had a viral culture done as part of their initial evaluation. Laboratory examination. HSV-1 was isolated from 13 cultures (12 cutaneous, 1 ocular), confirming 12 cases (Table 1). Results of restriction endonuclease analysis of 7 of the 8 specimens from cutaneous lesions showed 3 strains of HSV-1 that were geographically segregated (Table 1). One specimen could not be analyzed because of technical problems. Clustering of HSV-1 genotype patterns was observed within 3 groups (Teams A, C with D and G). Strain 1 was isolated from a high school wrestler from Team A, strain 2 from 2 high school wrestlers from Team C and 1 wrestler from Team D and strain 3 from 2 high school wrestlers and 1 coach from Team G. Discussion. This investigation documented multiple circulating strains of HSV-1 in high school wrestlers and their coaches and suggests the occurrence of three concurrent, geographically distinct outbreaks of herpes gladiatorum. All affected members of a given team had identical HSV-1 genotype patterns except for one member of Team D, who had a pattern identical with that of the two affected members of Team C. Although the exact interaction between wrestlers of Teams D and C is unclear, these teams were from the same county and competed with each other during the period of onset of case patient lesions. Direct skin-to-skin contact is most likely the primary mode of HSV-1 transmission in our case patients, consistent with the findings of Belongia et al.2 Aggressive and abrasive cutaneous contact between wrestlers is a central feature of competitive wrestling and is the basis for cutaneous transmission of herpes in this setting. During wrestling the head and neck are major sites of skin-to-skin contact, and these sites accounted for nearly all the locations of lesions in our case patients. In addition, of seven case patients whose lesions were reported as lateralized, six had right-sided lesions (Table 1). In right-handed persons the "locking-up" maneuver used in wrestling places the right side of the body in greatest contact with the right side of the body of the competing wrestler. The differential diagnosis of communicable eruptions reported in wrestlers varies, but it includes acne, impetigo caused by Gram-positive organisms (especially S. aureus and Streptococcus spp.), HSV and ringworm caused by Trichophyton spp. (tinea gladiatorum).6-8 As shown in our investigation herpetic lesions may also be confused with other infectious (e.g. fungal) and noninfectious (e.g. eczema) conditions. One patient (Wrestler 5) had facial and ocular herpes manifested by unilateral follicular conjunctivitis and regional adenopathy and was initially misdiagnosed by his physician as having impetigo. Superinfection of lesions with S. aureus was documented in two of our confirmed case-patients and in one possible case-patient. With an estimated 700 000 competing wrestlers in the United States including 225 000 high school wrestlers (Gary Abbott, USA Wrestling, Colorado Springs, CO, personal communication), a significant number of wrestlers and their coaches are at risk for herpes gladiatorum. Excluding wrestlers and their coaches with suspicious lesions from competition and applying bleach to wrestling mats appears to be a common practice. A better understanding of the natural history of herpes gladiatorum and the role of asymptomatic shedding in the transmission of this disease will help determine whether either of these practices are scientifically sound and might limit the spread of herpes gladiatorum. The use of oral acyclovir for primary attacks of herpes gladiatorum is increasingly frequent, but the benefits of this practice are anecdotal. Although valacyclovir appeared to reduce the incidence of recurrent disease in wrestlers in whom the primary episode was >2 years earlier, the effectiveness of suppressive antiviral therapy to reduce the spread of herpes gladiatorum is unclear and also awaits further study. Acyclovir use in high-risk situations might be a consideration until such studies are conducted. Three coaches had confirmed HSV-1 and the one coach who received HSV-1 genotyping had a pattern identical with that of the two affected members of his team. The finding of a similar HSV strain among a coach who wrestled with his affected team members is not surprising but has not been reported in other investigations of herpes gladiatorum. We recommend heightened awareness of this disease to include coaches of affected wrestlers. Consideration of obtaining microbiologic cultures of suspicious lesions may be equally important as misdiagnosis based on clinical observation may be relatively common. Acknowledgments. We thank Drs. John Horan, John Kobayashi, Ken Mallon, John Pribble and William Welch for helpful advice; Steve LaCroix, Mike McDowell and Beth Weiman for laboratory assistance; and Warren Howe for assistance in case finding. Mark S. Dworkin, M.D., M.P.H.T.M. Phyllis C. Shoemaker, M.P.H. Christopher Spitters, M.D., M.P.H. Anne Cent, M.S. Ann C. Hobson, Ph.D. Jeff Vieira, Ph.D. Lawrence Corey, M.D. Lyn R. Frumkin, M.D., Ph.D. Section of Communicable Disease Epidemiology (MSD, PCS); Epidemic Intelligence Service (MSD); Epidemiology Program Office; Centers for Disease Control and Prevention; Atlanta, GA Snohomish Health District; Everett, WA (CS) Fred Hutchinson Cancer Research Center; Program in Infectious Diseases (JV, LC); Departments of Laboratory Medicine and Medicine (AC, ACH, LC, LRF); University of Washington; Seattle, WA ICOS Corporation; Bothell, WA (LRF)