Giant condyloma acuminatum in a baby boy

Giant condyloma with demise secondary to meningococcemia in an infant boy

Human papilloma virus (HPV) is the most common sexually transmitted disease among adults in the USA; however, the presence of HPV in infants is rare. Condyloma acuminata, a cutaneous, fungating lesion caused by HPV, has a generally mild course that often resolves spontaneously or can be managed both medically and surgically. Typical treatments for condyloma include imiquimoid cream, podofilox gel, podophyllin resin, cryotherapy, laser surgery, tangential shave excision, and electrocautery. Rapidly progressing condyloma acuminata followed by a fatal course of Neisseria meningitis in an infant is an extremely rare presentation that merits further investigation into possible immunologic etiology. A 7-month-old circumcised Caucasian boy presented with a rapidly progressing giant penile condyloma acuminatum. This is the youngest documented case of this type. Refractory to medical and surgical treatments, this otherwise apparently healthy child was referred to pediatric immunology. Normal complete blood count led to deferment, suggesting further medical and surgical treatment. Five days after such treatment, the baby presented with progressive systemic rash, fever and tachycardia. The patient died from meningococcemia. This case serves as a warning concerning the course of condyloma in infants. Immunologic investigation may be critically important in young patients refractory to designated treatments for condyloma.

Pediatric anogenital warts: a 7-year review of children referred to a tertiary-care hospital in Montreal, Canada

The objectives of this study were to delineate the clinical characteristics of a hospital-referred pediatric population infected with anogenital warts and to investigate the possible relationships between human papillomavirus types and the identified clinical characteristics. Over a 7-year period, 72 patients under the age of 12 years were seen at our dermatology clinic for anogenital warts, corresponding to a prevalence of 1.7/1000 in our patient population. Sixty-four percent (46/72) were girls. Congenital, prenatal, ascending infections occurred in two subjects. The onset of anogenital warts occurred before age 2 in 28% and between 2 and 6 years of age in 62% of children and tended to be younger in boys. We identified unusual cutaneomucosal serotypes human papillomavirus 7 and 57 (three and eight instances, respectively). The modes of transmission of anogenital warts in children cannot be identified either by the clinical appearance of the lesions or by human papillomavirus typing. We conclude that the best way to identify possible sexual abuse is still by history taking, careful assessment of the socio-clinical context, and physical examination.

High-risk mucosal human papillomavirus infections during infancy & childhood

Human papillomaviruses (HPVs) are small DNA tumour viruses associated with a variety of proliferative diseases. More than 100 types have been identified and can broadly be grouped into cutaneous and mucosal types according to their site of infection, and can be further subdivided into low-risk (LR) and high-risk (HR) types depending upon their association with malignancy. The main route of transmission of HR mucosal HPVs is through sexual contact, although the acquisition of virus cannot be entirely explained by this mode alone. Evidence also exists for horizontal transmission by other routes and vertical transmission. HR HPVs, particularly HPV-16, have been detected in oral swabs from newborns, infants and children. Such alternative modes of transmission and acquisition may have an important impact in several areas, including vaccination strategies, epidemiological studies, and the clinical management of children with HPV-associated diseases. This article reviews the literature describing the detection of HPV infections during infancy and childhood and provides evidence for a role of vertical transmission in the spread of HPV infection.

Human papillomavirus infections in children: the potential role of maternal transmission

To date, more than 100 types of human papillomavirus (HPV) have been identified. In the past 20 years, there has been an increasing interest in HPVs because of their potential role in the pathogenesis of malignant tumors. HPV infections are known to affect predominantly adult, sexually active age groups, whereas skin warts, at various anatomic sites, are usually associated with younger individuals. The modes of viral transmission in children remain controversial, including perinatal transmission, auto- and hetero-inoculation, sexual abuse, and, possibly, indirect transmission via fomites. Recent studies on perinatal infection with HPV have been inconclusive. It is still unclear how frequently perinatal infection progresses to clinical lesions, whether genital, laryngeal, or oral. Conflicting reports have been published on the prevalence of HPV infections in children. The current consensus is, however, that newborn babies can be exposed to cervical HPV infection of the mother. The detection rate of HPV DNA in oral swabs of newborn babies varies from 4% to 87%. The concordance of HPV types detected in newborn babies and their mothers is in the range of 57% to 69%, indicating that the infants might acquire the HPV infection post-natally from a variety of sources. HPV antibodies have been detected in 10% to 57% of the children, and there is usually no correlation between seropositivity and the detection of HPV DNA in either the oral or the genital mucosa. There is also evidence that transmission in utero or post-natal acquisition is possible. The mode of in utero transmission remains unknown, but theoretically the virus could be acquired hematogenously, by semen at fertilization, or as an ascending infection in the mother. The understanding of viral transmission routes is important, particularly because several vaccination programs are being planned worldwide. The serologic response to HPV detected in different populations of young women or women at risk of cervical cancer might be due to genital infections, but the possibility that HPV infection has been acquired earlier in life through the oral mucosa or respiratory tract cannot be ruled out.

High risk genital papillomavirus infections are spread vertically

It is well recognised that high-risk human papillomaviruses (HPVs) are spread by sexual activity, but the possibility of non-sexual transmission remains controversial. We present evidence for vertical transmission from at least 30% HPV positive mothers to their infants, resulting in persistent infection in children. That the mother is the source of infant infection has been confirmed by DNA sequencing. We also discuss the evidence for oral HPV-16 infection in children. In our own studies, HPV-16 DNA was detected in buccal cells from 48% children, aged 3-11 and transcriptionally active infection was confirmed in some children. Other studies have reported prevalences of 19%-27% among children less than 11 years of age. Studies that have failed to detect high-risk HPVs in children have used techniques which were insufficiently sensitive to detect the low levels of virus present. Serological studies also suggest that < or = 45% prepubertal children have acquired HPV-16. Thus, convincing evidence is now available for vertical transmission of high risk HPVs, which probably results in widespread infection among children. The consequences of such infections remain to be elucidated.

Perinatal infection and persistence of human papillomavirus types 16 and 18 in infants

Perinatal transmission of genital human papillomaviruses (HPVs), including HPV-16 and -18 which are associated with anogenital carcinomas have been described previously [Pakarian et al. (1994): British Journal of Obstetrics and Gynaecology 101:514-517; Kaye et al. (1994) Journal of Medical Virology 44:415-421]. A study was undertaken to investigate whether HPV-16 and -18 DNA in infants contaminated at delivery persists until they are 6 months of age. Of 61 pregnant women recruited, 42 (68.8%) were HPV-16 and 13 (21.3%) were HPV-18 DNA positive. At 24 hr there were transmission rates from HPV DNA positive mothers to their infants of about 73% (HPV-16: 69%; HPV-18: 76.9%). Ten mothers who were both HPV-16 and -18 DNA positive produced six (60%) infants who were also doubly positive at 24 hr. HPV DNA persisted to 6 weeks in 79.5% (HPV-16: 84%; HPV-18: 75%) of those infants who were positive at birth. At 6 months of age, persistent HPV-16 DNA was detected in 83.3% of cases, but HPV-18 DNA persistence at this time was 20%. To extend these observations over a greater age range of children HPV-16 L1 and L2 proteins were expressed in insect cells via recombinant baculoviruses and sera from 229 children were examined to determine at what age IgM antibodies to HPV were acquired. There was a bimodal distribution of IgM seropositivity which peaked between 2 and 5 and 13 and 16 years of age, suggesting that two distinct modes of transmission may occur. The observation that infection with high cancer risk genital HPVs may occur in early life and persist is of considerable importance for HPV vaccine strategies.

Human papillomavirus type 6 associated Buschke-Loewenstein tumor (giant condyloma acuminatum)

The term "Buschke-Loewenstein tumor" has been used for tumors with exophytic, wart-like excrescences in the anogenital region. This broadly includes giant condyloma acuminatum and verrucous carcinoma. We report a 44-year-old Japanese man with a giant condyloma acuminatum Buschke-Loewenstein tumor on the right femoinguinal area. The lesion was a huge grape-like nodule composed of multiple small nodules, reaching 135 x 65 x 40 mm in size. Histologically, it showed a regularly acanthotic papilloma with numerous koilocytes in the upper squamous and granular layers. Ultrastructural findings included gradual differentiation from basal cell layers to uppermost corneocytes without disorganized relationships in the epithelial-stromal junction or cellular atypia. Human papillomavirus type 6 DNA was detected in the tumor tissues by polymerase chain reaction and restriction enzyme analysis, although immunohistochemical staining for papillomavirus common antigen was negative.