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Management Quandary
J Pediatr Adolesc Gynecol (1998) 11:103-104
見，αnagement Quαndary Edited by Elisabeth H. Quint, MD , University of Michigan Medical Center, Ann Arbor , Michigan Contributed by Mark J. Yurchisin , MD , Bowling Green , Kentucky Comments by Susan PokorI哼 ， MD , Women's Center, Houston , Texas
Case 2-1998 Ulcerative Lesion of the Vulva The patient is a 6-year-old girl, who was in her usual state of health, when she awoke complaining of burning with urination and fatigue. She had a low-grade temperature. The mother describes two pimples on the labia majora, and , because her daughter had been playing in the sandbox, she thought they were insect bites. She took her daughter to a local dermatologist, who examined her and performed tests after unroofing one of the lesions, which required three people to hold the patient down. Otherwise, the girl has no medical problems. Her social situation reveals that she lives with her mother, who is divorced and has a new partner, and that the daughter spends part of her time at her father' s house. The doctor then discussed with the mother that he was concerned about herpes and, therefore, sexual abuse. The next day the dermatologist called the patient and her mother to inform them that , indeed , she had herpes and that a sexual abuse examination was indicated. The patient and her mother then presented very upset to her gynecologist. His examination revealed two red papules that had vesiculated on the central portion of the labia. The lesions did not appear to be a typical primary herpes outbreak. Further probing revealed that the patient had had cold sores on her lips in the past but no recent outbreak. He performed a Tzanck smear that confirmed intracytoplasmic inclusions. The patient then was treated symptomatically. Dr. Pokorny's comments: This case shows two salient features of pediatric gynecology that cause great angst. Frequently, when we examine a child with a genital lesion, we have to respond with one of the following phrases: ‘ 'I'm not sure," “It might be . . . but we must investigate further," “I don't know," “I have never seen this before, but it makes me think of . . . ," and so forth. Most clinicians want to be more precise, and, usually they can be , but the field of pediatric gynecology is such a new area that we are all on the upward slope of the infamous "learning curve." The second disturbing feature at the core of pediatric 1083-3188 © 1998 Lippincott-Raven Publishers
gynecology is that a large part of our knowledge base is derived from information gathered from the evaluation of sexually abused children; thus, there is frequently a bias toward thinking about abuse when we view many childhood genital lesions. In this case, the lesions "didn't look like typical herpes," but there are other genital lesions that look very much like, if not identical to, genital herpes. Parvo and enterovirus can cause small shallow mucosal ulcers, and Behc;et's-like syndromes can cause deep, painful genital ulcers. This past spring within 2 weeks of each other, I saw two virginal pubertal ll-year-old girls , each with a complex of high fever (104°F), low white blood cell counts (3000-4000/μL with no left shift), and multiple painful vestibular and labial ulcers. Both girls gave a long history of aphtous mouth ulcers. One girl had a recurrence of the genital ulcers 3 months later and in the interim had a pu中uric facial rash and significant polyarthralgia requiring a course of steroids. This child had no eye findings, which is one of the required signs of Behc;et' s syndron1e. Lichen sclerosus "blood blisters" can become unroofed, causing ulcerative lesions. Severe monilia infections have small blister-like satellite lesions. These lesions persist longer than the central confluent erythematous area and, when seen in isolation, can appear herpetic. The next day the mother called to report that the patient had similar lesions behind her ears , in her axilla and on her abdomen and the pediatrician had confirmed the diagnosis of varicella.
Final Diagnosis: Varicella Dr. Pokorny' s comments: What would I do ifl saw a herpes-like lesion on a child's genitalia? I would explain that, without a herpes culture or DNA viral study, I cannot be sure that it is a herpes. The only prepubertal small child I have seen with classic herpetic lesions had type-I herpes simplex by culture; her grandmother had a fever blister and there were no known risk factors for sexual abuse. If I cannot take my sample from a wet, recently unroofed blister, I inforn1 the family that I am likely to get a false-negative culture.
104
Management Quandary
Fig. 1. Chicken pox lesions of the vulva. I, furthermore, would not hesitate to also explain to the family that many herpetic infections are sexually transmitted, and, therefore, both they and myself have an obligation to perform further investigations if there are any other reasons to suspect sexual abuse.
Editor's Comment This case clearly shows the importance of a good differential diagnosis. As shown in Figs. 1 and 2, lesions from both diseases can look very similar. To diagnose genital herpes simplex, a viral culture needs to be obtained from a freshly unroofed vesicle. A false-positive culture result
Fig. 2. Ulcerative lesions consistent with herpes infection.
may occur with herpes zoster. False-negative cultures may be obtained if the specimen comes from areas that have decreased shedding, eg, recurrent lesions or ulcerated or crusted lesions. Antigen testing has not been evaluated in children. There have been no proven cases of genital herpes transmission through casual nonsexual contact. The possibility exists for autoinoculation from nongenital sites and a thorough examination for asymptomatic nongenital sites, especially oropharynx and hands, needs to be performed. However, most commonly. genital herpes is sexually transmitted and abuse needs to be addressed.
見，αnagement Quαndary Edited by Elisabeth H. Quint, MD , University of Michigan Medical Center, Ann Arbor , Michigan Contributed by Mark J. Yurchisin , MD , Bowling Green , Kentucky Comments by Susan PokorI哼 ， MD , Women's Center, Houston , Texas
Case 2-1998 Ulcerative Lesion of the Vulva The patient is a 6-year-old girl, who was in her usual state of health, when she awoke complaining of burning with urination and fatigue. She had a low-grade temperature. The mother describes two pimples on the labia majora, and , because her daughter had been playing in the sandbox, she thought they were insect bites. She took her daughter to a local dermatologist, who examined her and performed tests after unroofing one of the lesions, which required three people to hold the patient down. Otherwise, the girl has no medical problems. Her social situation reveals that she lives with her mother, who is divorced and has a new partner, and that the daughter spends part of her time at her father' s house. The doctor then discussed with the mother that he was concerned about herpes and, therefore, sexual abuse. The next day the dermatologist called the patient and her mother to inform them that , indeed , she had herpes and that a sexual abuse examination was indicated. The patient and her mother then presented very upset to her gynecologist. His examination revealed two red papules that had vesiculated on the central portion of the labia. The lesions did not appear to be a typical primary herpes outbreak. Further probing revealed that the patient had had cold sores on her lips in the past but no recent outbreak. He performed a Tzanck smear that confirmed intracytoplasmic inclusions. The patient then was treated symptomatically. Dr. Pokorny's comments: This case shows two salient features of pediatric gynecology that cause great angst. Frequently, when we examine a child with a genital lesion, we have to respond with one of the following phrases: ‘ 'I'm not sure," “It might be . . . but we must investigate further," “I don't know," “I have never seen this before, but it makes me think of . . . ," and so forth. Most clinicians want to be more precise, and, usually they can be , but the field of pediatric gynecology is such a new area that we are all on the upward slope of the infamous "learning curve." The second disturbing feature at the core of pediatric 1083-3188 © 1998 Lippincott-Raven Publishers
gynecology is that a large part of our knowledge base is derived from information gathered from the evaluation of sexually abused children; thus, there is frequently a bias toward thinking about abuse when we view many childhood genital lesions. In this case, the lesions "didn't look like typical herpes," but there are other genital lesions that look very much like, if not identical to, genital herpes. Parvo and enterovirus can cause small shallow mucosal ulcers, and Behc;et's-like syndromes can cause deep, painful genital ulcers. This past spring within 2 weeks of each other, I saw two virginal pubertal ll-year-old girls , each with a complex of high fever (104°F), low white blood cell counts (3000-4000/μL with no left shift), and multiple painful vestibular and labial ulcers. Both girls gave a long history of aphtous mouth ulcers. One girl had a recurrence of the genital ulcers 3 months later and in the interim had a pu中uric facial rash and significant polyarthralgia requiring a course of steroids. This child had no eye findings, which is one of the required signs of Behc;et' s syndron1e. Lichen sclerosus "blood blisters" can become unroofed, causing ulcerative lesions. Severe monilia infections have small blister-like satellite lesions. These lesions persist longer than the central confluent erythematous area and, when seen in isolation, can appear herpetic. The next day the mother called to report that the patient had similar lesions behind her ears , in her axilla and on her abdomen and the pediatrician had confirmed the diagnosis of varicella.
Final Diagnosis: Varicella Dr. Pokorny' s comments: What would I do ifl saw a herpes-like lesion on a child's genitalia? I would explain that, without a herpes culture or DNA viral study, I cannot be sure that it is a herpes. The only prepubertal small child I have seen with classic herpetic lesions had type-I herpes simplex by culture; her grandmother had a fever blister and there were no known risk factors for sexual abuse. If I cannot take my sample from a wet, recently unroofed blister, I inforn1 the family that I am likely to get a false-negative culture.
104
Management Quandary
Fig. 1. Chicken pox lesions of the vulva. I, furthermore, would not hesitate to also explain to the family that many herpetic infections are sexually transmitted, and, therefore, both they and myself have an obligation to perform further investigations if there are any other reasons to suspect sexual abuse.
Editor's Comment This case clearly shows the importance of a good differential diagnosis. As shown in Figs. 1 and 2, lesions from both diseases can look very similar. To diagnose genital herpes simplex, a viral culture needs to be obtained from a freshly unroofed vesicle. A false-positive culture result
Fig. 2. Ulcerative lesions consistent with herpes infection.
may occur with herpes zoster. False-negative cultures may be obtained if the specimen comes from areas that have decreased shedding, eg, recurrent lesions or ulcerated or crusted lesions. Antigen testing has not been evaluated in children. There have been no proven cases of genital herpes transmission through casual nonsexual contact. The possibility exists for autoinoculation from nongenital sites and a thorough examination for asymptomatic nongenital sites, especially oropharynx and hands, needs to be performed. However, most commonly. genital herpes is sexually transmitted and abuse needs to be addressed.