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Herpetic Whitlow

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Suddenly, my child’s ngertips are swollen, and blisters have formed, causing a lot of pain (Fig.90.1).

The mother of a 13-year-old boy, S, says, “Suddenly a few days ago, the area around my child’s ngernails turned red, swollen, and painful. Upon closer inspection, many blisters have formed!” Upon closer examination with a loupe, clusters of herpes resembling grapes are observed (Fig.90.2).

Herpetic whitlow is a herpes simplex virus infection that occurs around the nails of the ngertips, characterized by sudden onset of erythema, vesicles, swelling, severe pain, and local tenderness. Primary infection occurs by direct transmission from mucosal lesions or direct inoculation of the virus through damaged areas of the epidermis. It can occur due to professional virus contact in doctors, nurses, dentists, etc. It is mainly caused by herpes simplex virus type 1, but herpes simplex virus type 2 can also occur, so it often occurs in children with herpetic gingivostomatitis or women with genital herpes. Fever, local lymphadenitis, etc. are com-

mon, and recurrence is possible. This inammation of the soft tissue at the ngertips needs to be differentiated from purulent bacterial infections such as staphylococcal whitlow. Staphylococcal whitlow is accompanied by severe pain and is prone to progress to osteomyelitis, so it is treated with appropriate antibiotics along with incision and drainage. Herpetic whitlow does not need to burst the blisters, and surgical treatment is unnecessary and can even be harmful, unlike when it is caused by bacteria, so accurate diagnosis is required. It usually recovers within 2weeks, but for immunocompromised patients, the recovery period may be extended. For treatment, take oral antiviral drugs and apply topical acyclovir ointment. “Ah! Then this is the herpesvirus that appears on my lips when I’m tired! What if it keeps recurring?” S’s mother said with a worried expression (Figs.90.3, 90.4, 90.5, 90.6 and 90.7).

Fig. 90.1 Herpetic whitlow observed at the ngertip Fig. 90.2 Herpetic whitlow

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Figs. 90.3 and 90.4 Herpetic whitlow

90 Herpetic Whitlow

Figs. 90.5 and 90.6 Herpetic whitlow

Fig. 90.7 Herpetic whitlow

Shiitake Dermatitis

∗∗∗

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My body is covered in red marks like I’ve been whipped, and it’s incredibly itchy!

Mr. K, a man in his 30s, has been itching all over his body for days to the point of madness. This morning, while taking a shower, he was shocked to see red marks all over his body in the mirror, as if he had been whipped, and came in for treatment. When asked, “Did you eat shiitake mushrooms a few days ago?” He replied, “How did you know? I did eat a lot of raw shiitake mushrooms.” (Fig.91.1).

Shiitake mushrooms, native to East Asia, are widely consumed not only in Asia but also worldwide. It has traditionally been eaten in Korea for a long time and is widely cultivated in the southern coastal region, and since liberation, it has been produced all over the country. The main components are lentinan, lignin, beta-glucan, linoleic acid, ergosterol, lysine, arginine, methionine, phenylalanine, potassium, calcium, magnesium, manganese, iron, copper, and zinc. Diseases related to shiitake mushrooms include bronchial asthma and allergic alveolitis, which occur when people who cultivate or cook shiitake mushrooms are continuously exposed to mushroom spores, contact dermatitis, or urticaria caused by direct contact with shiitake mushrooms, and recently, shiitake dermatitis that occurs after consuming shiitake mushrooms as food has been reported. Shiitake dermatitis was rst reported by Nakamura in 1977 and was mainly reported in Japan, but recently, many cases have been reported in many other countries, including Korea. Even in 2008, Garg and Cockayne reported a case of shiitake dermatitis that was diagnosed only after 16years, stating that it is common in Asian countries but reports in Europe have only recently begun. This dermatitis is a disease diagnosed when, after eating raw shiitake mushrooms, clinically, characteristic skin ndings accompanied by itchiness are observed, and no other cause other than eating shiitake mushrooms can be considered based on the past history. It presents as linear erythematous papules, that is, skin lesions with a characteristic whip mark-like (“agellate”) appearance that occur in each

Fig. 91.1 Shiitake dermatitis

scratched area along with severe itching all over the body (Fig.91.2).

According to previous reports, shiitake dermatitis mostly occurs after eating undercooked or raw shiitake mushrooms, with very small (about 1mm in diameter) erythematous papules and severe itching (78%) accompanied by erythematous papules on the lines (98%) along the scratched area. This is said to be a very characteristic clinical symptom caused by the Koebner phenomenon and is sometimes accompanied by petechial hemorrhages, ne vesicles, and rarely pustules. Most of them occur on the trunk, followed by the arms, neck, face, and head. Rarely, fever, diarrhea, and mucosal involvement have been reported, but in most cases, there are no fever or gastrointestinal symptoms, no mucosal involvement, and no other systemic symptoms. The characteristic skin lesions occur 1 or 2days (12h to 5days) after eating shiitake mushrooms, and they do not disappear even after several days, showing a completely different clinical feature from

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Fig. 91.2 Characteristic whip marks-like “agellate” skin lesions observed in shiitake dermatitis

Fig. 91.3 Shiitake dermatitis initially presents with very small erythematous papules and severe itching, and characteristic linear lesions composed of erythematous papules appear along the scratched area

the dermographism or skin excoriations caused by scratching. They usually disappear without any special pigmentation or scars over a period of several days to 2weeks, and laboratory ndings show increased liver enzyme levels, increased or decreased white blood cells, increased eosinophils, increased LDH, etc. in some cases, but these are known to be unrelated to the cause or course of this disease. Histologically, only nonspecic ndings such as elongation of the epidermal rete ridge and spongiosis and inammatory cell inltration in the dermis can be observed. Similar lesions can be induced by bleomycin, etc., but they rarely involve the mucosa and often do not show hyperpigmentation (Figs.91.3,

91.4 and 91.5).

91 Shiitake Dermatitis

The pathogenesis of Shiitake dermatitis is not yet clearly understood. It is presumed that type 1 and type 4 hypersensitivity reactions are associated with respiratory diseases caused by the inhalation of spores or mycelia of shiitake mushrooms and allergic contact dermatitis and contact urticaria caused by direct contact with shiitake mushrooms. The use of shiitake mushrooms in positive ndings in patch tests or prick tests and the demonstration of antibodies against shiitake mushroom antigens serologically have been reported. However, according to initial reports, lesions occurred 1–2days after eating shiitake mushrooms in almost all cases of shiitake dermatitis. Most showed negative reactions in prick tests using shiitake mushroom extract, or patch tests using cooked and uncooked shiitake mushrooms, and shiitake mushroom alcohol extract. The disease did not always recur in patients who had it before, and all patients showed symptoms after eating undercooked shiitake mushrooms. Although it was reported as a “toxicoderma” because some toxic factor seemed to be involved, one of the reasons why shiitake dermatitis is presumed to be an allergic disease rather than a toxic reaction is that symptoms do not appear in everyone who eats shiitake mushrooms, and shiitake dermatitis only occurs in some. Also, the incidence is low compared to the frequency of consumption. Furthermore, this dermatitis does not occur when the mushrooms are fully cooked, suggesting that the substance causing the dermatitis is a heat-labile protein allergen that is destroyed at high temperatures. However, in 1992, Nakamura reported that this substance is a polysaccharide that easily changes or decomposes due to heat, similar to lentinan, an anticancer substance extracted from shiitake mushrooms. Lentinan induces vasodilation, bleeding, and rash through the secretion of IL-1 and inammatory cytokines, and there are cases (9 out of 500) of cancer patients treated with lentinan showing a skin rash similar to shiitake dermatitis, supporting the claim that shiitake dermatitis is a toxic reaction to lentinan. Despite this, cases have been reported where the disease was caused by dried shiitake mushroom extract, not only undercooked shiitake mushrooms but also fully cooked ones. In a Korean report in 1998, four out of ve cases reported symptoms after eating fully cooked shiitake mushrooms. In a Korean study in 2003, out of 58 patients, 17 cases (29%) boiled the shiitake mushrooms, 16 cases (28%) fried them in oil, 15 cases (26%) half-grilled or slightly blanched them, and the remaining 4 cases (7%) ate them completely raw. Therefore, these results contradict the concept that the substance causing shiitake dermatitis is heat unstable. Among the 58 patients, there were cases where similar skin symptoms were seen in people who ate together in two cases, and seven patients reported having the same symptoms after eating shiitake mushrooms before. Therefore, it is currently unclear whether shiitake dermatitis is an allergic reaction or a toxic reaction.

91 Shiitake Dermatitis

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Figs. 91.4 and 91.5 Shiitake dermatitis is characterized by very small erythematous papules and linear lesions that occur together

Recent reports from other countries mostly assume the cause to be a toxic reaction to lentinan, but the reasons why shiitake dermatitis can be considered an allergic reaction are (1) symptoms only appear in some of the people who consume it, (2) it is the second most commonly cultivated and consumed mushroom in the world, yet its occurrence is low, (3) symptoms do not appear immediately after consumption but occur 12hours to 5days later, (4) there are no reports of mass occurrences from the same food containing shiitake mushroom, (5) in many cases, dermatitis reoccurs if shiitake mushroom is consumed again after dermatitis has occurred, (6) the average age of occurrence in Korean reports is

46.7–48years old and there are no reports of occurrence in children, (7) itching is severe, and (8) it responds to antihistamines and steroids (Figs. 91.6, 91.7, 91.8, 91.9, 91.10,

91.11, 91.12, 91.13, 91.14, 91.15, 91.16, 91.17, 91.18, 91.19,

91.20, 91.21, 91.22, 91.23, 91.24, 91.25, 91.26, 91.27, 91.28,

91.29, 91.30, 91.31 and 91.32).

Treatment is thought to be sufcient with symptomatic treatment, reassurance, and avoidance of consuming shiitake mushrooms. There are also reports advising to avoid exposure to sunlight. Clinical symptoms are reported to disappear on average in 8.5–12.5days, but due to severe itching and peculiar rashes, patients visit the clinic and most improve with general treatment using oral antihistamines and topical steroids. However, in severe cases, systemic steroids must be administered, and there have been reports of cases lasting for more than a month. According

Fig. 91.6 Shiitake dermatitis

to several reports so far, it often occurs when eating shiitake mushrooms that are not fully cooked or raw, so it is recommended to eat them fully cooked to prevent shiitake dermatitis. However, due to the occurrence experience by eating raw shiitake mushrooms, there were several cases where the disease occurred even after eating cooked shiitake mushrooms for prevention. Therefore, once a patient develops shiitake dermatitis, other mushrooms are okay,

but they should not eat shiitake mushrooms. Not only common shiitake mushrooms but also shiitake mushrooms with various names and improved varieties cause the same symptoms, so they should not be eaten. For Mr. K, a treatment period of about 5–7 days is recommended. Despite the delicious taste of shiitake mushrooms, it is advised to avoid them in the future.

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