Genital warts and sexual abuse in children

Cutaneous mimickers of child abuse: a primer for pediatricians

The annual incidence of child abuse was estimated to be 2.8 million by the national incidence study conducted in the USA in 1993, which is a two-fold increase compared to 1986. Awareness of child abuse has been increasing since the 1960s. Although most victims of child abuse present with cutaneous lesions, many genuine skin diseases may appear as non-accidental injuries which, if not recognized, may lead to misdiagnosis of child abuse. Here, we review the most common cutaneous mimickers of child abuse in order to increase awareness of these disorders and reduce erroneous diagnosis of child abuse.

Sudden infant death syndrome, child sexual abuse, and child development

Since the introduction of the Back to Sleep Campaigns, there has been a dramatic reduction in sudden infant death syndrome in this country. Steven Blatt and Victoria Meguid review the literature surrounding sleep position. Investigators have continued efforts to find other modifiable risk factors of sudden infant death syndrome. A prospective study of more than 33,000 neonates found a link between a prolonged QT electrocardiogram interval and sudden infant death syndrome. Also discussed are investigations seeking to explain the relationship between smoking and sudden infant death syndrome. Ann Botash, Florence Jean-Louis and Mongkae Ploy Siripornsawan review the latest thinking on genital warts and their relation to specific viral etiologies and child sexual abuse. Other symptoms and signs of sexual abuse are the focus of a number of articles that can help the practitioner care for these unfortunate children. Catherine Church reviews medication options for children diagnosed with pervasive developmental disorders or autism spectrum disorders. Finally, in this article, risperidone, fluoxetine and naltrexone are reviewed.

Pitfalls in the diagnosis of child sexual abuse

Case 1: nurses in charge of a 6-year-old girl in a holiday camp noticed some blood spots on the girl's underwear. The possibility of sexual abuse was considered and the girl alleged that her father was responsible. The father was arrested. A surgeon was asked to examine the girl and planned to do it under general anesthaesia. Meanwhile, the girl was brought to the Forensic Medicine Unit. We found a normal hymen and no detectable anal lesions. The girl complained of dysuria and pollakiuria. Urinalysis revealed the presence of blood, leukocytes, and nitrite. Antibiotic treatment for lower urinary tract infection was initiated and all symptoms improved rapidly. The father was released. Case 2: a 7-year-old boy complained of having been sexually assaulted 24 h before. The boy did not report any pain or bleeding during or after the assault. Examination of the perianal region and of the anal sphineter were normal. Proctoscopy did not show any evidence of trauma to the anal canal. Tests to detect spermatozoa in the rectum were positive. The assailant was arrested. The present cases illustrate that: (i) psychological and social consequences of the biased interpretation of common symptoms may be dramatic in the case of child sexual abuse; (ii) both questioning and examining a child may be difficult for non-specialized practitioners; and (iii) tests to detect spermatozoa should be systematically performed in the case of a suspected or alleged recent assault, even in the absence of any clinical lesions.

Condyloma acuminata in infants and children. A survey of colon and rectal surgeons

PURPOSE

Condyloma acuminata are anogenital warts caused by a human papillomavirus. Human papillomavirus is a tissue-specific, site-specific, double-stranded DNA virus, which is capable of inducing high-grade genital intraepithelial neoplasia and malignancy. The incidence of anogenital warts in the pediatric age group is rising, and sexual abuse has been implicated as a potential cause.

METHODS

Accumulated data from separate questionnaires sent to practicing colorectal surgeons who are members of The American Society of Colon and Rectal Surgeons and fellows in colon and rectal training programs have been analyzed.

RESULTS

Thirty percent of those polled responded to our survey. Of the respondents, 93 percent see less than two pediatric cases per year. Seventy-two percent stated that tissue specimens would be sent routinely for histopathologic identification. Although 73 percent of surgeons consider anogenital warts a potentially sexually transmitted disease, only 26 percent reported screening for other sexually transmitted diseases. A diagnostic and therapeutic protocol is followed by 19 percent of respondents. Patient follow-up varied from six months (43 percent) to lifelong examinations (3 percent). Sixty-four percent of respondents agreed that a diagnostic and therapeutic protocol based on current knowledge would be beneficial.

CONCLUSION

We conclude that colon and rectal surgeons have a low exposure to anogenital warts in infants and children. Furthermore, we believe that a diagnostic and therapeutic protocol based on the current literature would be helpful.

[The pediatrician, sexual abuse and anogenital warts in prepuberty]

The increase of incidence in human papillomavirus infection in population has favored the more frequent appearance of anogenital warts in children. Types 6 and 11 are the most frequently associated to this pathology. Though sexual transmission is common, with a very lengthy incubation period, it is not the only way. Sexual abuse is always a possible source of infection and should be excluded in all cases. An actuation protocol has to be established for the pediatrician depending on the clinical, epidemiological and the social characteristics.

Oral and laryngeal papilloma: a pediatric manifestation of sexually transmitted disease?

Laryngeal and oral papilloma in pediatric patients are generally considered transmitted by maternal fetal transmission. In adults and immunocompromised patients, it is well documented that human papilloma virus (HPV) of the oropharynx is sexually transmitted. The possibility of sexual transmission of oral and laryngeal papilloma in children by oral genital contact is discussed.

Presence of human papillomavirus DNA in condylomata acuminata in children and adolescents

The presence of human papillomavirus (HPV) DNA of types 6, 11, 16, 18, 31 and 33 was determined by in situ hybridization on archival paraffin-embedded tissue sections in 21 condylomata acuminata observed in patients aged 20 or less. HPV DNA was detected in 17 of 21 cases: all of these contained HPV 6, five also contained HPV 11, and one also contained HPV 16 and 18. HPVs 31 and 33 were not observed. Among 21 cases, 4 cases were in children under 6 yrs one of whom had a history of sexual abuse. The hybridization data indicate that condylomata acuminata in young people are associated with the same HPV types found in anogenital lesions in adults.

Condylomata acuminata in pre-pubertal children

The medico-legal significance of anogenital warts as a marker of sexual abuse in children is unclear. This review article presents three case reports and discusses the possible modes of transmission of papilloma virus in children. Although genital warts can indicate sexual abuse, non-sexual transmission may also occur.

Human papillomavirus type 6 infection involving cutaneous nongenital sites

Human papillomavirus (HPV) type 6 is classically considered a mucosatropic virus. Interestingly, clinical manifestations of HPV 6 infection that involve nonmucosal or nongenital sites have rarely been described. The reasons for this site specific infectivity of HPV 6 are unknown. We describe a patient who had condylomata acuminata-like lesions that involved cutaneous nongenital sites; HPV 6 DNA was detected in skin biopsy specimens with use of the polymerase chain reaction, followed by hybridization with use of type-specific DNA probes.

Sexually transmitted diseases in children: human papillomavirus infection

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Human papillomavirus infection

The human papillomavirus, well known as the etiologic agent of warts, has recently received much attention in the medical literature for its association with various cancers. This article discusses the virology, epidemiology, pathogenesis, immunology, clinical manifestations, and therapy for human papillomavirus infection. Some newer techniques for identifying human papillomavirus in tissue, based on recent advances in molecular biology, are also covered. Two final topics addressed are human papillomavirus infection in the immunocompromised host, including patients with acquired immunodeficiency syndrome, and the possible role of human papillomavirus in several different carcinomas.

Assessing child abuse in childhood condyloma acuminatum

Adults with condyloma acuminatum are considered to have a sexually transmitted disease. Childhood condyloma acuminatum may often, but not always, be a manifestation of sexual abuse. We provide a checklist of criteria for suspecting child abuse. We recommend that if clinicians find a "yes" response on this checklist when caring for a child with condyloma acuminatum, consultation with local child protective services (CPS) be deemed mandatory.