Severe genital human papillomavirus infection in a sexually abused child

Abstract

A two-year-old female child was admitted to the emergency room for a mild respiratory infection. Surprisingly, physical examination of the genital area revealed large verrucous lesions spreading around the vulva and perianal zone (Figure 1). No relevant medical history of the child was noted. The mother declared to have no sexually transmitted disease and additional physical examination was negative for genital lesions or skin warts. A PAP smear was normal, as was the one performed six months previously. The parents were divorced and only weekend visits were permitted to the father. The case was reported to the local child sexual assault service; later investigations concluded in a sexual abuse case, after finding similar lesions and obtaining a confession from the father. Other family members were also examined without abnormal findings. A diagnosis of condyloma acuminata was made based on the physical examination and the investigation conducted by the pertinent authorities. As the best treatment option, surgical excision was performed successfully. Condyloma acuminata is one of the most common sexually transmitted diseases in adults, but its presence in children is rare and could be associated with sexual abuse.1Jayasinghe Y. Garland S.M. Genital warts in children: what do they mean?.Arch Dis Child. 2006; 91: 696-700Crossref PubMed Scopus (48) Google Scholar, 2Syrjanen S. HPV infections in children.Papillomavirus Report. 2003; 14: 93-110Crossref Scopus (15) Google Scholar Even though association can vary from 0 to 80% according to studies,3Moscicki A. Genital infections with human papillomavirus (HPV).Pediatr Infect Dis J. 1998; 17: 651-652Crossref PubMed Scopus (9) Google Scholar, 4Pitche P. Kombate K. Gbadoe A.D. Tchangai-Walla K. Anogenital warts in young children in hospital consultation in Lome (Togo). Role of transmission by sexual abuse.Med Trop (Mars). 2001; 61: 158-162PubMed Google Scholar appropriate investigation in all cases to rule out sexual abuse is still controversial, as similar lesions in the mother or siblings are frequently observed in sexual and non-sexual transmission.4Pitche P. Kombate K. Gbadoe A.D. Tchangai-Walla K. Anogenital warts in young children in hospital consultation in Lome (Togo). Role of transmission by sexual abuse.Med Trop (Mars). 2001; 61: 158-162PubMed Google Scholar, 5Jones V. Smith S.J. Omar H.A. Nonsexual transmission of anogenital warts in children: a retrospective analysis.ScientificWorldJournal. 2007; 7: 1896-1899Crossref PubMed Scopus (40) Google Scholar According to some epidemiological studies, sexual transmission is more frequent among patients older than two years of age, reaching the highest prevalence at over eight years old.6Sinclair K. Woods C. Kirse D. Sinal S.H. Anogenital and respiratory tract human papillomavirus infections among children: age, gender, and potential transmission through sexual abuse.Pediatrics. 2005; 116: 815-825Crossref PubMed Scopus (118) Google Scholar Under two years old, transmission is more commonly through direct contact with infected genital maternal tract during delivery or transplacentally, as postulated in some studies.6Sinclair K. Woods C. Kirse D. Sinal S.H. Anogenital and respiratory tract human papillomavirus infections among children: age, gender, and potential transmission through sexual abuse.Pediatrics. 2005; 116: 815-825Crossref PubMed Scopus (118) Google Scholar, 7Hornor G. Ano-genital warts in children: sexual abuse or not?.J Pediatr Health Care. 2004; 18: 165-170Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 8Tang C. Shermeta D. Wood D. Congenital condyloma acuminata.Am J Obstet Gynecol. 1978; 131: 912-913PubMed Scopus (83) Google Scholar, 9Tseng C. Lin C. Wang R. Chen L.J. Chang Y.L. Hsieh T.T. Pao C.C. Possible transplacental transmission of human papillomavirus.Am J Obstet Gynecol. 1992; 166: 35-40Abstract Full Text PDF PubMed Scopus (91) Google Scholar The management of this problem is not solely medical. Social, legal and psychosocial implications for the future of the nuclear family and child development should be considered.1Jayasinghe Y. Garland S.M. Genital warts in children: what do they mean?.Arch Dis Child. 2006; 91: 696-700Crossref PubMed Scopus (48) Google Scholar It is important that primary-care providers and pediatricians have an understanding of the potential for human papillomavirus genital infections in children and the need to report these cases to the appropriate authorities as soon as a clinical diagnosis is made and relevant social history is suspected. Conflict of interest: No conflict of interest to declare.