Perianal herpes zoster presenting as suspected child abuse

A Diagnostic Approach to Conditions that Mimic Sexual Abuse

Primary care providers are often the first point of contact when there are concerns of child sexual abuse. The history is the key factor in making the diagnosis as most children who have experienced child sexual abuse do not have an abnormal anogenital examination. When anogenital symptoms precipitate concerns for sexual abuse, especially in the absence of a history of sexual abuse, it is important to be aware of conditions that mimic sexual abuse. Being familiar with such conditions allows the provider to determine appropriate management, differentiate an anatomical variant or medical condition from abuse, and provide reassurance to the patient and family. Unnecessarily reporting these cases can have detrimental effects on the patient and family. If any doubt arises, patients can be referred for further evaluation by an expert in child abuse. This article presents many common medical conditions that can mimic sexual abuse, with a focus on history, examination findings, and management. [Pediatr Ann. 2020;49(8):e334-e340.].

Detection of Herpes Simplex Virus and Varicella-Zoster Virus by Traditional and Multiplex Molecular Methods

Objectives

To compare multiplex nucleic acid amplification tests (NAATs) that detect and differentiate herpes simplex virus (HSV) and varicella-zoster virus (VZV) with traditional virologic assays.

Methods

The HSV ELVIS Test System (Quidel, San Diego, CA) and/or Light Diagnostics VZV direct fluorescent antibody (DFA) kit (Millipore Sigma, Billerica, MA), as well as an ARIES HSV 1&2/VZV assay (Luminex, Austin, TX) and the Solana HSV1 + 2/VZV Assay (Quidel), were performed on non-cerebrospinal fluid specimens.

Results

The sensitivities/specificities for the ELVIS, Aries, and Solana assays for HSV were 71.1%/93.2%, 94.9%/93.2%, and 94.7%/100%, respectively. The sensitivities/specificities for the DFA, Aries, and Solana assays for VZV were 71.4%/100%, 100%/96.0%, and 95.3%/100%, respectively. HSV and VZV were detected but clinically unsuspected in 5.4% and 4.2% of the specimens, respectively.

Conclusions

Both NAAT assays were comparable and more sensitive than traditional methods. The recovery of unsuspected HSV and VZV from clinical specimens supports the implementation of a combined HSV/VZV assay.

A not so simplex case of genital herpes

We report the case of a 28-year-old, HIV-positive woman presenting with painful vesicular and ulcerating lesions in the ano-genital region caused by varicella zoster virus that appeared similar to herpes simplex infection. The case highlights that herpes zoster needs to be considered in the differential diagnosis of genital lesions, particularly in HIV-positive individuals, and the importance of virological diagnosis by PCR to direct appropriate management.

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.

Herpes zoster during treatment with arsenic trioxide

In vitro data suggest that arsenic compounds can suppress cell-mediated immunity by inducing apoptosis of T helper lymphocytes. We describe an occurrence of herpes zoster during treatment with arsenic trioxide (ATO) in two patients who were already in remission from acute promyelocytic leukemia and received ATO as consolidation treatment. During this complication, their leukocyte counts and differentials were within normal limits. Our report suggested the immunosuppressive effect of ATO in vivo. Both patients responded well to an oral antiviral. Clinicians should be aware of this complication during treatment with ATO since early antiviral treatment may help avoid complications including post-herpetic neuralgia.

Detection of varicella zoster virus in genital specimens using a multiplex polymerase chain reaction

OBJECTIVE

To compare the relative proportions of varicella zoster virus (VZV) and herpes simplex viruses in specimens obtained from the genital lesions of adults presenting with presumed genital herpes infection.

METHODS

Swabs of genital lesions from 6210 patients attending general practices, infectious diseases clinics within hospitals, or sexual health centres for treatment of their genital lesions were tested using polymerase chain reaction (PCR) technology. The multiplexed PCR was capable of detecting herpes simplex virus types 1 and 2 (HSV-1, HSV-2), VZV, and cytomegalovirus in a single sample.

RESULTS

A total of 2225 patients had viruses detected by PCR. HSV-1 was detected in 36%, HSV-2 in 61%, and VZV in 2.9% of PCR positive samples. Of the 65 patients with VZV genital infection, many were thought to have HSV infection before laboratory testing.

CONCLUSIONS

The finding of VZV in nearly 3% of virus positive genital specimens demonstrates that this virus needs to be considered as a differential diagnosis for genital herpetic lesions. Advice provided to patients with VZV genital infection regarding the source of infection, likelihood of recurrence, and potential for transmission of the virus will be different from that given to patients with HSV infection.

Varicella-Zoster virus infections of the nervous system: clinical and pathologic correlates

BACKGROUND

Diseases that present with protean manifestations are the diseases most likely to pose diagnostic challenges for both clinicians and pathologists. Among the most diverse disorders caused by a single known toxic, metabolic, neoplastic, or infectious agent are the central and peripheral nervous system complications of varicella-zoster virus (VZV).

METHODS

The pathologic correlates of the neurologic complications of VZV infection, as well as current methods for detecting viral infections, are discussed and presented in pictorial format for the practicing pathologist.

RESULTS

Varicella-zoster virus causes chickenpox (varicella), usually in childhood; most children manifest only mild neurologic sequelae. After chickenpox resolves, the virus becomes latent in neurons of cranial and spinal ganglia of nearly all individuals. In elderly and immunocompromised individuals, the virus may reactivate to produce shingles (zoster). After zoster resolves, many elderly patients experience postherpetic neuralgia. Uncommonly, VZV can spread to large cerebral arteries to cause a spectrum of large-vessel vascular damage, ranging from vasculopathy to vasculitis, with stroke. In immunocompromised individuals, especially those with cancer or acquired immunodeficiency syndrome, deeper tissue penetration of the virus may occur (as compared with immunocompetent individuals), with resultant myelitis, small-vessel vasculopathy, ventriculitis, and meningoencephalitis. Detection of the virus in neurons, oligodendrocytes, meningeal cells, ependymal cells, or the blood vessel wall often requires a combination of morphologic, immunohistochemical, in situ hybridization, and polymerase chain reaction (PCR) methods. The PCR analysis of cerebrospinal fluid remains the mainstay for diagnosing the neurologic complications of VZV during life.

CONCLUSIONS

Varicella-zoster virus infects a wide variety of cell types in the central and peripheral nervous system, explaining the diversity of clinical disorders associated with the virus.

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.

Antiviral treatment of diseases in pediatric dermatology

Pediatric dermatologic disease that have specific therapies and/or specific prophylactic measures are reviewed. Herpes simplex virus and varicella-zoster virus infections, human papillomavirus infections, and molluscum contagiosum infections are discussed with special emphasis on recent advances of therapy and prophylaxis.