Case report: palmar herpetic whitlow and forearm lymphangitis in a 10-year-old female.

BACKGROUND: Herpetic whitlow is a viral infection caused by the herpes simplex virus (HSV) types 1 or 2, and occurs in the pediatric population primarily on the fingers and toes due to autoinoculation from oral secretions. Because of this cited prevalence, other locations of herpetic whitlow may go unrecognized. CASE PRESENTATION: We present an atypical presentation of palmar herpetic whitlow with delayed recognition and associated viral lymphangitis. The patient presented as a transfer from an outside hospital with a progressive, three-day history of a suspected left hand abscess preceded by left hand pain and itching. She was initially evaluated by Orthopedic Surgery, who described an erythematous, edematous, tender, left palmar abscess with associated erythematous streaking up her forearm. The lesion was surgically managed with an incision and drainage. Wound cultures were obtained during which "minimal drainage" was noted. After admission to the General Pediatrics Hospital service, the lesion was noted to appear vesicular and subsequently obtained PCR samples were positive for HSV type 1, confirming her diagnosis of herpetic whitlow. Although she remained afebrile with negative wound cultures throughout her hospitalization, a secondary bacterial infection could not be conclusively excluded due to the accompanying lymphangitis. Thus, she was discharged with oral antibiotics and anticipatory guidance of potential recurrence of palmar lesions. CONCLUSIONS: Herpetic whitlow should be included in the differential diagnosis of palmar lesions that appear vesicular or abscess-like to ensure appropriate treatment. Additionally, these palmar lesions may present with associated lymphangitis without evidence of bacterial infection.

Obstructive Lymphangitis Precedes Colitis in Murine Norovirus-Infected Stat1-Deficient Mice.

Murine norovirus (MNV) is an RNA virus that can prove lethal in mice with impaired innate immunity. We found that MNV-4 infection of Stat1-/- mice was not lethal, but produced a 100% penetrant, previously undescribed lymphatic phenotype characterized by chronic-active lymphangitis with hepatitis, splenitis, and chronic cecal and colonic inflammation. Lesion pathogenesis progressed from early ileal enteritis and regional dilated lymphatics to lymphangitis, granulomatous changes in the liver and spleen, and, ultimately, typhlocolitis. Lesion development was neither affected by antibiotics nor reproduced by infection with another enteric RNA virus, rotavirus. MNV-4 infection in Stat1-/- mice decreased expression of vascular endothelial growth factor (Vegf) receptor 3, Vegf-c, and Vegf-d and increased interferon (Ifn)-γ, tumor necrosis factor-α, and inducible nitric oxide synthase. However, anti-IFN-γ and anti-tumor necrosis factor-α antibody treatment did not attenuate the histologic lesions. Studies in Ifnαßγr-/- mice suggested that canonical signaling via interferon receptors did not cause MNV-4-induced disease. Infected Stat1-/- mice had increased STAT3 phosphorylation and expressed many STAT3-regulated genes, consistent with our findings of increased myeloid cell subsets and serum granulocyte colony-stimulating factor, which are also associated with increased STAT3 activity. In conclusion, in Stat1-/- mice, MNV-4 induces lymphatic lesions similar to those seen in Crohn disease as well as hepatitis, splenitis, and typhlocolitis. MNV-4-infected Stat1-/- mice may be a useful model to study mechanistic associations between viral infections, lymphatic dysfunction, and intestinal inflammation in a genetically susceptible host.

[Herpetic recurrent upper limb lymphangitis]. / Lymphangite récurrente du membre supérieur d'origine herpétique.

Upper limb lymphangitis often complicates varied wounds on the hand or forearm and improvement is obtained in a few days with adapted antibiotic therapy. A 28-year-old woman presented since few years episodes of lymphangitis of the arm associated with vesicles on an erythematous base, on the palmar face of the first phalanx of the index finger, spontaneous relief within 10 days, without antibiotic therapy. Herpetic origin was confirmed on viral culture. No primary infection neither recurrence was noted. Because of the recurrences, a prophylactic treatment with valaciclovir was instituted. There was no reported recurrence at two years follow-up. Upper limb lymphangitis rarely complicates herpetic whitlow in immunocompetent patient. Clinicians should be aware of viral lymphangitis, which is often overlooked and associated with diagnostic errors and treatment delay.