Spot Diagnosis

An Unexpected Complication of Gingivostomatitis

Marina Mota1, António Sampaio Mesquita2, Maria do Rosário Stilwell3, Cláudia Silva3, Florbela Cunha2
1Department of Pediatrics, Hospital Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal, 2Department of Pediatrics, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal, 3Department of Pediatrics, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal

Address for Correspondence: Hospital Santa Maria, CHULN, Av. Professor Egas Moniz, 1649-035 LISBON, Portugal
Keywords : Gingivostomatitis, herpetic whitlow, herpes simplex virus type 1
Question :
A 2-year-old healthy boy presented to the Emergency Department with 3 days of high fever and poor feeding. Physical examination showed gingivostomatitis. Routine investigations didn’t show any abnormality. Due to anorexia and mild dehydration, he was admitted for rehydration. The following day, localized swelling, redness and tenderness were noted on the second right finger. Bacterial paronychia was considered and intravenous flucloxacillin was started. During hospitalization, it was noted that the child sucked his fingers often. The lesion became larger and vesiculobullous (Figure 1). Surgical incision was performed with drainage of serous fluid.

Figure 1. Swelling, redness, and a large vesiculobullous lesion on the second right finger.
<b>Figure 1.</b> Swelling, redness, and a large vesiculobullous lesion on the second right finger.

What is the diagnosis?

Discussion :
Herpetic Whitlow (HW) is a cutaneous HSV infection of the pulp or nail bed of a finger.1,2 In children, it typically occurs after auto-inoculation from primary oral lesions.1,2 Accurate diagnosis of HW may prevent unnecessary antibiotic treatment and potential harm from surgical debridement, which should be avoided in the absence of secondary bacterial infection.2,3 Although the diagnosis is clinical, laboratory analyses may be necessary.1 Though specific treatment is not necessary in healthy children, acyclovir may attenuate symptoms and shorten the course of the infection, especially in cases of primary infection or multifocal disease.2,3
In this case, the diagnosis of HW was considered after a few days of worsening inflammatory signs and oral acyclovir was initiated. Polymerase chain-reaction of the fluid was positive for herpes simplex virus type 1 (HSV-1) and bacterial culture isolated a methicillin-sensitive Staphylococcus aureus. IgM and IgG for HSV-1 were positive, confirming the diagnosis of HW with staphylococcal superinfection. The oral ulcers and the finger lesion disappeared completely after ten days of flucloxacillin and acyclovir.

References :
  1. Chayavichitsilp P, Buckwalter JV, Krakowski AC, et al. Herpes simplex. Pediatr Rev. 2009 Apr;30(4):119-29; quiz 130. doi: 10.1542/pir.30-4-119. PMID: 19339385.
  2. Szinnai G, Schaad UB, Heininger U. Multiple herpetic whitlow lesions in a 4-year-old girl: case report and review of the literature. Eur J Pediatr. 2001 Sep;160(9):528-33. doi: 10.1007/s004310100800. PMID: 11585074.
  3. Collier E, Parikh P, Martin-Blais R, et al. Herpetic whitlow of the toe presenting with severe viral cellulitis. Pediatr Dermatol. 2019 May;36(3):406-407. doi: 10.1111/pde.13795. Epub 2019 Mar 11. PMID: 30859616.

Correct Answers : yes  100%

Last Shown : Feb 2023
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