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March 2003
A 7-year-old girl was admitted to the hospital for evaluation and treatment of painful swelling of her left pinna. The symptoms began several days earlier, accompanied by a low-grade fever. She was seen at that time and given amoxicillin-clavulanate (Augmentin, GlaxoSmithKline), with no response. The patient was seen again the day before admission and given a dose of ceftriaxone (Rocephin, Roche), but again, was not better the next day. There was no known injury or insect bites. The young girl had previously been healthy up to this incident. Her immunizations were up to date and documented, and she had a history of chickenpox when she was a baby. There has been no travel or camping trips recently. Examination revealed a healthy 7-year-old girl with a low-grade fever and a somewhat swollen and erythematous left auricle. Some vesicular, crusty, yellowish lesions were seen on the upper, outer part of the pinna (figures 1 and 2).
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Why is this important to know? The answer is in the treatment.
The recommended therapy may be different depending on which it is. If antiviral therapy is going to be used, one must remember that varicella virus requires a much higher dose of acyclovir than herpes. In either case, treatment should be initiated as soon as possible.
The only way to be certain what you are dealing with, is to recover the virus by culture or rapid antigen testing. Zoster about the face is fairly common — even in children. To see it involve the pinna is not unusual. An initial problem may be differentiating HSV or zoster from bacterial perichondritis and chondritis (figure 7). If this condition is not treated appropriately, both medically and surgically, it may result in cartilage necrosis and require reconstructive surgery. As a result, we almost always admit these patients to the hospital for parenteral antibiotics and ENT consult early on.
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If there is associated surgery or trauma (figure 8) and/or cellulitis, the cause is usually Staphylococcus aureus, and we generally select anti-staphylococcal penicillin or a second-generation cephalosporin to start with, pending cultures. It may be advisable to add an anti-pseudomonas antibiotic if there is an associated canal infection, similar to conditions such as malignant otitis externa. This is almost always seen in adult diabetics, but we occasionally see a milder version in children. Of course, there is often enough overlap of findings to make differentiating between these entities too risky not to treat with two antibiotics, and then narrow the spectrum when the cause is known.
Impetigo with methicillin resistant S. aureus (MRSA) should always be considered in cases of impetigo that is not responding to the usual anti-staphylococcal antibiotics. Community-acquired MRSA is rapidly becoming more common. The differentiating factor in this case is the vesicular appearance of the lesion shown.
Certainly, allergic reactions (contact dermatitis) can cause swelling and erythema of an auricle. Usually there are other clues such as other patches of reaction at other sites. Additionally, these patients complain more of itching rather than pain.
Lastly, Cutaneous fungal infections of the ear are possible, but not likely to be acute in nature, and again, not likely painful.
Have you ever wondered where the terms varicella, zoster, herpes and shingles came from and why we use them the way we do? For example, are shingles, zoster and herpes zoster the same thing? And if this condition is caused by the varicella-zoster virus, why is it not called varicella zoster instead of herpes zoster? Even though varicella is one of the eight human herpes viruses, using this term could result in confusing shingles with cutaneous herpes. Also, why do we refer to varicella as chickenpox?
Well, here goes. The word “herpes” comes from the Greek word, herpein, meaning to creep. I am not sure why there would be reference to creeping. Perhaps it has to do with the slow course to resolution or the way it spreads, but I really don’t know. Zoster is also a Greek word meaning girdle — presumably for the way the rash wraps around the patient — following the course of a dermatome. Shingles comes from the Latin word, cingulus, also meaning girdle. Girdle appears to have its origin in Old English for something that encircles, confines or wraps around. Varicella, a diminutive form of Variola, apparently is a New Latin word. In other words, varicella is a small version of Variola (smallpox), which is not to be confused with the great pox (syphilis). The origin of chickenpox is not quite as clear. According to Anne A. Gershon MD, in her chapter on Varicella-zoster virus in Feigin & Cherry’s Textbook of Pediatric Infectious Diseases, 4th edition, chickenpox may come from the French pois chiche, meaning chick pea. I suppose a chick pea is about the same size and appearance of a varicella vesicle. Lastly, the word pox is an alteration of the Old English word pock meaning spot or mark or pustule. I am sure this is a highly simplified explanation of these terms to a true intellectual. But my limitations require me to keep it simple.
I am frequently fascinated by the origin of medical words, but at the same time confused by how some words and terms have been able to stand the test of time. Think how strange it would sound if we were naming these entities today. For example, shingles might be called the girdles or girdled, and herpes might be the creeps or creeping rash, not to be confused with the creeping eruption (cutaneous larva migrans). I guess as long as we understand the disease the word represents, it probably makes no difference what we call it.
For Your Information:
- James H. Brien, DO, Pediatric Infectious Disease, Scott and White's Children's Health Center and Texas A&M University, College of Medicine, Temple, Texas. E-mail: jhbriend@aol.com
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