Condyloma lata in a preschooler: The dilemma of sexual abuse versus non-abuse.

It is well-known that syphilis is a sexually-transmitted or an inherited infection. Syphilis in preschoolers is rarely described in modern medical literature. Our case represents the difficulty or dilemma faced by dermatologists after diagnosing syphilis in a girl child due to inability of the young children to provide a history of sexual abuse and more over the parents/guardians also try to hide the history of sexual-abuse. Although rare, we can consider non-sexual transmission after we have thoroughly investigated and ruled out even the remote possibility of sexual abuse, because misdiagnosis of both abuse and non-abuse can be devastating to the patient and family.

INTRODUCTION

People involved in child-care are likely to encounter the diagnostic dilemmas of syphilis in their practice. Cases in children are uncommon, but are expected to have clinical manifestations similar to those in adolescents and adults. We encountered one such case when a 4-year-old girl was referred to us for treatment of peri-anal lesions. The diagnosis of condyloma lata was easy, but establishing the mode of transmission was the real acid test especially in a closed society like ours where talking about sexual issues or sexually transmitted diseases is a taboo. We describe a case where we considered non-sexual transmission to be the most likely cause of secondary syphilis in a girl child.

CASE REPORT

A 4-year-old girl was referred to our hospital for evaluation of peri-anal lesions. About 4 weeks back, she had developed sore-throat, fever and rash involving the trunk and extremities including the palms and soles. She was prescribed syrup cephalexin for 1 week by the pediatrician after which the fever and rash improved. Subsequently, the mother noticed peri-anal lesions and informed the pediatrician who referred the child to us. She was born of a full term normal uncomplicated delivery to a 31 years old woman who received no prenatal care. As both the mother and the child were normal and healthy–no need was felt to investigate either of them after the delivery. The child lived with her parents, two brothers and a sister. The child gave no history of her genitalia being touched by anybody else than her mother. According to the parents, the child did not exhibit any behavioral changes or concerns. Physical examination, at the time of referral revealed a malnourished child with generalized lymph node enlargement. Muco-cutaneous examination revealed condyloma lata in the peri-anal area with a few ulcerated papules in the vicinity [Figure 1]. There was no sign of sexual abuse. Systemic examination was normal. Dark-field examination of the lesions was negative for Treponema pallidum. Serology showed positive venereal disease research laboratory (VDRL) (titre-1:64), T.pallidum particle agglutination assay (>1:80) and negative human immunodeficiency virus (HIV). Cultures for Neisseria gonorrhoeae and Chlamydia trachomatis from the vagina and rectum were negative. She was diagnosed as secondary syphilis and administered benzathine penicillin, 50,000 U/kg in a single dose and her lesions resolved.

Figure 1

Condylomalataintheperianalarea

VDRL titers of the mother and father were also positive 1:32 and 1:16 respectively. Father gave a history of unprotected extra-marital contact with a commercial sex worker 5 months back. After 3 weeks, he developed a genital sore which improved with medicines. Subsequently, he developed fever and rash, for which he was given antibiotics and paracetamol. 1 month after this, mother also developed fever, rash and warty lesions in the genital area for which she received no treatment. Both of them did not have any lesions at the time of examination. They were also treated with benzathine penicillin.

Pediatric, dermatologic and psychiatric work-up did not show any evidence of child abuse. After ruling out sexual abuse, we considered non-sexual transmission of syphilis in the child. Contact of the girl with her infected parents was hypothesized as the mode of infection.

DISCUSSION

Acquired syphilis in children exhibits almost all the features seen in adults. Clinical evidence of the primary sore is infrequent, but Condyloma lata, is the most frequent cutaneous lesion. Lymphadenopathy is commonly seen, but general symptoms may be absent.[12]

The clinical manifestations (e.g., primary chancre, secondary syphilitic rash, presence of Huthinson teeth) may provide insight into the timing of acquisition of infection. However, it may not always help to resolve the dilemma of whether the clinical findings are those of unrecognized congenital syphilis or post-natally-acquired syphilis, which suggests a high likelihood of sexual abuse.[3] In such circumstances where sexual abuse is suspected or has to be ruled out, children should preferably be evaluated by specialists in the area of child sexual abuse. Children diagnosed with syphilis should also be evaluated for HIV infection and other sexually-transmitted diseases as clinically indicated. Genital trauma or a sexually transmitted disease at times can be diagnostic of sexual abuse, identifying the source of abuse and protecting the child from additional molestation can prove difficult without a clear history of sexual contact.[4]

Although syphilis in young children is highly suggestive of sexual transmission, other modes of transmission also exist.[5] Non-sexual transmission of syphilis was frequent during the pre-antibiotic era.[678] Children may acquire syphilis as a consequence of kissing, breast-feeding, handling or pre-chewed food feeding. Two detailed studies by Waugh[8] and Smith[9] in 1938 and 1939 suggested a rate of about 23% of non-sexual transmission in children. The terms syphilis brephotrophica or lues insontium were used to describe non-sexual transmission “transmitted while performing baby care or handling children.”[10] However, these terms have almost become extinct after “the illusionary eradication of syphilis by penicillin” as stated by Ackerman et al.,[5] except for a few sporadic case reports of non-sexual transmission of syphilis in children.[11]

It is well-known that syphilis is sexually-transmitted or occurs as an inherited infection. Syphilis in pre-schoolers is rarely described in modern medical literature. Our case represents the difficulty in management of children after diagnosing syphilis due to their inability to provide a clear history of sexual abuse, which is further complicated by indifferent attitude of the parents. Because the duty of the treating practitioner does not end at diagnosing and treating the case we have to involve the social and legal organizations in rehabilitation of these children who have acquired syphilis by sexual abuse and to protect them from additional harm. The diagnosis of non-sexual transmission can be considered only after thorough investigations and ruling out even the remote possibility of sexual abuse, because misdiagnosis of both abuse and non-abuse can be devastating to the patient and family.