Herpes gladiatorum at a high school wrestling camp - Minnesota

Morbidity and Mortality Weekly Report, Feb 9, 1990

In July 1989, the Minnesota Department of Health (MDH) investigated an outbreak of herpes simplex virus type 1 (HSV-1) dermatitis (herpes gladiatorum) in participants at a Minnesota wrestling camp. The camp was held July 2 through July 28 and attended by 175 male high school wrestlers from throughout the United States. The participants were divided into three wrestling groups according to weight (group 1, lightest; group 3, heaviest). During most practice sessions, wrestlers had contact only with others in the same group. The outbreak was detected during the final week of camp, and wrestling contact was subsequently discontinued for the final 2 days.

A case was defined as isolation of HSV-1 from involved skin or eye or the presence of cutaneous vesicles. To identify cases, a clinic was held at the camp to obtain viral cultures and examine skin lesions. Additional clinical data were obtained from review of emergency department records at the facility where all affected wrestlers were referred for medical care. A questionnaire was administered to wrestlers by telephone following the conclusion of camp.

Clinical and questionnaire data were available for 171 (98%) persons. The mean age of these participants was 16 years (range: 14-18 years); 153 (89%) were white; 137 (80%) were high school juniors or seniors. The median length of time in competitive wrestling was 4 years.

Sixty (35%) persons met the case definition, including 21 (12%) who had HSV-1 isolated from the skin or eye. All affected wrestlers had onset during the camp session or within 1 week after leaving camp. Two wrestlers had a probable recurrence of HSV, one oral and one cutaneous, during the first week of camp. Lesions were located on the head or neck in 44 (73%) persons, the extremities in 25 42%), and the trunk in 17 (28%). Herpetic conjunctivitis occurred in five persons; none developed keratitis. Associated signs and symptoms included lymphadenopathy (60%), fever and/or chills 25%), sore throat (40%), and headache (22%). Forty-four (73%) persons were treated with acyclovir.

Attack rates increased by weight group: of 55 wrestlers in group 1, 12 (22%) were affected; of 57 in group 2, 17 (30%); and of 59 in group 3, 31 (53%) p=0.01). Thirty-eight (22%) wrestlers interviewed reported a past history of oral HSV-1 infection. The attack rate was 24% for wrestlers who reported a past history of oral herpes and 38% for wrestlers without a history of oral herpes (relative risk [RR] = 0.6; 95% confidence interval [Cl]=0.3-1.0). Twenty-three percent of affected wrestlers continued to wrestle for at least 2 days after rash onset. Athletes who reported wrestling with a participant with a rash were more likely to have confirmed or probable HSV-1 infection (RR = 2.0; 95% Cl = 1.3-3.1).

Reported by: JL Goodman, MD, EJ Holland, MD, CW Andres, MD, SR Homann, MD, RL Mahanti, MD, MW Mizener, MD, A Erice, MD, Univ of Minnesota Hospital and Clinic, Minneapolis; MT Osterholm, PhD, State Epidemiologist, Minnesota Dept of Health. Div of Field Svcs, Epidemiology Program Office, CDC.

Editorial Note: Herpes gladiatorum (cutaneous infection with HSV in wrestlers and rugby players) was first described in the mid-1960s (1-3). in 1988, an outbreak of herpes gladiatorum was reported among three Wisconsin high school wrestling teams (4). in a national survey of 1477 trainers of athletes, approximately 3% of high school wrestlers were reported to have developed HSV skin infections during the 1984-85 season (5). Lesions occur most often on the head and neck. Primary infection may cause constitutional symptoms with fever, malaise, weight loss, and regional lymphadenopathy. Ocular involvement includes keratitis, conjunctivitis, and blepharitis.

Transmission occurs primarily through skin-to-skin contact. Autoinoculation may lead to involvement of multiple sites. Previous infection with HSV-1 may reduce the risk of acquiring herpes gladiatorum (5). However, the prevalence of antibody to HSV-1 is low among white adolescents (6), and many adolescents are susceptible when they enter competitive wrestling. Control methods should include education of athletes and trainers regarding herpes gladiatorum, routine skin examinations before wrestling contact, and exclusion of wrestlers with suspicious skin lesions. The outbreak in the Minnesota camp might have been prevented if athletes with such lesions had been promptly excluded from contact competition.

References

1. Selling B, Kibrick S. An outbreak of herpes simplex among wrestlers (herpes gladiatorum). N Engl J Med 1964;270:979-82.

2. Porter PS, Baughman RD. Epidemiology of herpes simplex among wrestlers. JAMA 1965; 194:998-1000.

3. Wheeler CE Jr, Cabaniss WH Jr. Epidemic cutaneous herpes simplex in wrestlers (herpes gladiatorum). JAMA 1965;194:993-7.

4. Wisconsin Division of Health. Herpes gladiatorum in high school wrestlers. Wis Epidemiol Bull 1989;11:1-3.

5. Becker TM, Kodsi R, Bailey P, et al. Grappling with herpes: herpes gladiatorum. Am J Sports Med 1988;16:665-9.