(P11) Images in Emergency Medicine Case: A Woman Presenting for Bug Bites

Friday, September 8, 2023

12:30 PM - 1:30 PM EEST

Poster Presenter / Co-Author(s)

Joseph S. Colla, MD, MBA

Associate Professor
Department of Emergency Medicine, University of Illinois Hospital and Health Science System, Chicago, IL
Chicago, Illinois, United States

Primary Author(s)

Lauren E. Lamparter, MD

Resident, PGY1
Department of Emergency Medicine, University of Illinois Hospital and Health Science System, Chicago, IL
Chicago, Illinois, United States

Faculty Advisor(s)

PI

P.Charles Inboriboon, MD

Associate Professor of Emergency Medicine
University of Illinois Hospital and Health Science System, Chicago, IL
Chicago, Illinois, United States

Co-Author(s)

YF

Yurissa Flores-Sanchez, n/a

Medical Student
Western University of Health Sciences of the Pacific Northwest
Salem, Oregon, United States
CP

Christopher W. Parker, DO

Director of EM Ultrasound
OSF Little Company of Mary Medical Center
Evergreen Park, Illinois, United States

Chief Complaint : painful bug bites.

History of Present Illness : A 22-year-old female presented to the emergency department (ED) with painful bug bites. Patient noticed two small bumps on her right arm four days ago after spending the evening outside with friends. The following day, her pain had worsened, and she noticed small blisters in the area.

Pertinent Physical Exam: Exam of her right upper arm revealed a cluster of white vesicles on an erythematous base that were tender to palpation (Figures 1 and 2). There were no oral, genital or other lesions. Workup included HSV 1/2 and Varicella Zoster PCR/culture of the lesions.

Pertinent Laboratory Data:

Case Discussion: DIAGNOSIS: Herpes simplex virus 2 (HSV2) cutaneous infection.

HSV2 most commonly presents as a sexually transmitted, genital infection, occurring from direct viral contact with mucosal or nonintact skin.1,2 The classic presentation is a prodrome of localized pain, followed by the eruption of vesicles on an erythematous base.2 While HSV2 is most often localized to the genitals, it has been reported on thighs, buttocks, and perineum of both sexes.2 Alternatively, HSV1, has been described in alternate cutaneous locations such as the extremities, but usually secondary to contact sports (i.e. herpes gladitorum) allowing for easy viral spread from saliva.3 However, presentation of HSV2 to an extremitiy, in immunocompetent individuals outside the context of contact sports, as in this case, has not commonly been reported. This case illustrates the importance of considering HSV infection when evaluating vesicular skin lesions in immunocompetent patients whether or not they have history of HSV exposure.

References and Acknowledgements (Optional): Gupta R, Warren T, Wald A. Genital herpes. Lancet. 2007 Dec 22;370(9605):2127-37. doi: 10.1016/S0140-6736(07)61908-4. PMID: 18156035.
Tintinalli’s EM Comprehensive Study Guide – Ch 153: Sexually Transmitted Infections
Selling B, Kibrick S: An outbreak of herpes simplex among wrestlers (herpes Gladiatorum). N Engl J Med 1964; 270: 979–82.