With the advent of Mixed Martial Arts, and the increased use of Brazilian Jiu Jitsu in the martial arts world today, one has to remember that sometimes there are consequences to having close physical "skin on skin" contact with other athletes. Well known in the high school and college wrestling world, Herpes Gladiatorum, a herpes simplex viral infection, is something to be acutely aware of when practicing close contact sports as is done in some of the martial arts. Here's a brief synopsis from the medical journals about the condition.


herpes gladiatorum"Outbreaks of herpes gladiatorum have occurred countless times during the last decade; several outbreaks of herpes gladiatorum have occurred among wrestlers across the United States. It is critical that health care providers, athletic trainers, coaches, and athletes recognize the threat of herpes gladiatorum skin infection to minimize the risk of outbreaks. Vigilant surveillance and appropriate antiviral treatment will curtail the transmission of herpes gladiatorum among wrestlers.

Herpes simplex virus is a double-stranded DNA virus. About 80% of adults have antibodies to HSV-1, and about 20% of the population has antibodies to HSV-2. HSV-1 is commonly known to cause herpes labialis and keratitis. Most childhood herpes simplex virus infections are caused by HSV-1. HSV-2 is commonly known to cause genital herpes infections, which is one of the most common sexually transmitted diseases in the United States. HSV-2 is transmitted primarily by direct contact with lesions, and it is most often transmitted venereally. Generalized or localized cutaneous and mucosal lesions characterize initial infection by herpes simplex virus. Recurrent infections are milder because fewer viruses are shed and a stronger immune response is elicited. Herpes simplex virus remains dormant in the nerve ganglia; febrile illness, stress, immunosuppressive drugs, and ultraviolet light can precipitate recurrent eruptions. In rare cases, the initial replication of herpes simplex virus can lead to meningitis or encephalitis. Herpes simplex virus persists for life in a latent form. The virus is sometimes confused with herpes zoster because the site of latency for herpes simplex virus is the trigeminal ganglion. Herpes simplex virus may also manifest as a severe and/or life-threatening infection in immunocompromised individuals and in newborn babies. Specifically, disseminated infections can result in esophagitis, pneumonitis, encephalitis, hepatitis, and adrenal necrosis.

Currently, no epidemiologic studies accurately identify the true incidence of herpes gladiatorum; however, the National Collegiate Athletic Association (NCAA) estimated an incidence of herpes gladiatorum as high as 40% among wrestlers. The most common locations of herpes gladiatorum, in descending order, are the head, face, neck, chest, and shoulders. Typically, lesions will be observed on the head, face, neck, cheeks, forehead, shoulders, and arms. According to most studies, about two thirds of wrestlers will have the herpetic lesions on the right side of the body. Hence, herpes gladiatorum is transmitted during close skin-to-skin physical contact, known in wrestlers' terminology as the "lock-up position."

herpes gladiatorumPHG generally presents with an erythematous rash, sore throat, fever, cervical lymphadenopathy, and vesicles. Occasionally, the herpes gladiatorum lesion will lack the grouped vesicles on an erythematous base, and it is sometimes mistaken for impetigo, acne, tinea corporis, atopic dermatitis, varicella, or scabies. A significant complication of PHG in wrestlers is dendritic keratitis with subsequent corneal scarring. Other ocular complications of PHG include conjunctivitis, scleritis, and uveitis. Fluid from the base of unroofed vesicles can be sent for testing by PCR, the test of choice for diagnosing PHG. A Tzanck smear of scrapings from the base of vesicles will demonstrate multinucleated giant cells, a finding that is highly indicative for herpes simplex virus infection.

The NCAA has developed recommendations on “time until return to competition” for primary herpes gladiatorum and for recurrent infection. For a primary outbreak of herpes, the wrestler must be examined by a clinician or an experienced certified athletic trainer; the following recommendations must be met before a wrestler returns to competition[3]:

* The athlete must have no signs of systemic symptoms of viral infection.
* The athlete must be free of any new lesions for 3 days or more prior to the start of competition.
* Skin lesions must be dry and surmounted by a firm adherent crust.
* The wrestler must have been on appropriate antiviral therapy for at least 120 hours before the beginning of a competition.

For recurrent herpes gladiatorum, the NCAA has also established several recommendations. First, vesicles must be completely dry and crusted. Second, the wrestler must have been on appropriate dosage of antiviral therapy for 120 hours or more at the time of tournament. For questionable cases, a Tzanck preparation should be performed, and the wrestler's status should be deferred until Tzanck prep or herpes simplex virus assay results are available.

Antiviral drugs with activity against viral DNA synthesis have been effective against PHG infections. Acyclovir, famciclovir, and valacyclovir inhibit virus replication and suppress clinical manifestations, but they are not a cure for PHG because herpes simplex virus remains latent in sensory ganglia. Oral acyclovir has been shown to be effective in suppressing PHG in wrestlers; it is the drug of choice for treating PHG. Acyclovir reduces the duration of symptomatic lesions and is indicated for patients presenting within 2-3 days of the appearance of a herpetic rash. Most patients on acyclovir will experience less pain and quicker resolution of their vesicular lesions. Several effective treatments for adult patients include oral acyclovir 200 mg 5 times daily or 400 mg 3 times daily for 7-10 days or until clinical resolution occurs. The recommended dose of acyclovir for PHG in the pediatric age group is 20-30 mg/kg/d, in 5 divided doses, for 7-10 days. As with all infections, prevention is better than treatment.

In addition to the above treatment, wrestlers must practice effective hygiene immediately after wrestling. It is critical to frequently clean competition gear and change towels. Regular hand-washing and thorough cleaning of the mats is critical. Wrestling mats should be cleaned between matches with household bleach (one-quarter cup of bleach in 1 gallon of water). Early identification and treatment can allow the wrestler to return to participation earlier and prevent teammates from contracting the disease. Despite these precautions, PHG will spread during wrestling and other close-contact sports resulting from contact with asymptomatic infected athletes. MEDSCAPE"