Extensive condylomata lata in an adolescent: An uncommon and unusual presentation.

Sexually transmitted infections (STIs) in children account for a great physical and psychosocial morbidity. Being rare, they require a high index of suspicion for diagnosis. STIs may also be the first indication of child sexual abuse (CSA). Consequences of an undetected infection are potentially devastating; conversely, a false suspicion can have equally detrimental effects on both the child and the parents. Herein, we report a case of acquired secondary syphilis in a child presenting with unusually extensive condylomata lata at multiple sites and review the literatue to understand the possible interrelationship of syphilis and CSA. Copyright:

INTRODUCTION

Sexually transmitted infections (STIs) in children are uniquely associated with complex physical, social, and medicolegal issues compared to those in adults.[1] The current trends show a rise in the prevalence of STIs in children, largely of viral etiology.[1] Although syphilis was a common etiology of STI in children in the past, it is now rarely reported as either congenital or acquired form in the postantibiotic era etiological.[1] Though rare, syphilis in children still exists. However, its myriad of initial presentations as well as presence of a latency and waning phase likely create a high risk of being under-diagnosed.[1] We report a case of acquired secondary syphilis in a child presenting with unusually extensive condyloma lata at multiple sites.

CASE REPORT

An 11-year-old boy presented with a chief complaint of lesions over the genitalia and perianal region for the past 2 months. There was no prior history of skin rash, fever, or other constitutional symptoms and no significant medical history. The child lived with his parents and his 7-year-old brother. He was born of a normal full-term vaginal delivery. His mother had no history of abortions or stillbirths and no evidence of STI at the time of pregnancy and delivery. His parents denied a history of any extramarital sexual contact. The child was interviewed alone followed by pediatric and psychiatric workups, but no indications to suspect abuse were found. No possible mode of nonsexual transmission was evident.

General physical examination was unremarkable. Systemic examination did not reveal any stigmata of late congenital syphilis. On genital examination, multiple flat-topped, well-defined, papules of size 0.5 cm × 0.5 cm, with moist-eroded smooth surface, at places coalescing into plaques, were noted circumferentially over the undersurface of the prepuce and glans penis [Figure 1a]. Similar lesions were present around the root of the penis [Figure 1b], lateral and posterior surfaces of the scrotum, over the bilateral inguinal areas [Figure 1c], and in the perianal region, over a diameter of 6 cm around the anal orifice [Figure 1d]. The inguinal lymph nodes were bilaterally enlarged, nontender, and firm in consistency. There was no urethral or rectal discharge. No anogenital injuries were identified. Examination of oral cavity, scalp, palms, and soles revealed no abnormality.

Figure 1

(a) The moist, smooth papules, and plaques of condylomata lata present circumferentially over the undersurface of the prepuce and glans penis, (b) around the root of penis, (c) on the lateral and posterior surfaces of the scrotum and over the bilateral inguinal areas, especially those in close proximity to the scrotum, and (d) in the perianal region

The child's venereal disease research laboratory (VDRL) test was significantly positive at a dilution of 1:128. Treponema pallidum hemagglutination assay was also reactive. Radiographic, dental, ophthalmologic, and audiology evaluations for syphilis were unremarkable. Based on examination findings and serological tests, a diagnosis of condylomata lata was made. Urethral and rectal smears were negative for gonococcal and chlamydial infections. Acetic acid testing did not reveal any subclinical human papillomavirus-associated lesions. HIV serology was negative at the time of presentation and repeat testing after 3 months was advised. His parents' VDRL tests were nonreactive. The patient's sibling was not brought for testing.

The child was treated with a single dose of injection benzathine penicillin G 50,000 units/kg administered intramuscularly after sensitivity testing. The patient did not come for follow-up.

DISCUSSION

The most salient feature of secondary syphilis is a maculopapular rash seen in 80%–95% of cases.[2] The eruption may, however, simulate many more common disorders such as viral exanthem and pityriasis rosea, and thus may often be missed as an initial sign of secondary syphilis. Condylomata lata, the highly infectious, intertriginous moist papules, are more readily recognized, but a less common presentation of secondary syphilis, reported in 9%–44% of cases.[2] Despite the classic features, the uncommon nature of this condition in children may cause diagnosis of syphillis to again be missed. Rather, a more common diagnosis of acuminata may be made. From this point of view, our case highlights that condylomata lata may occur as the only physical sign of pediatric syphilis. Such extensive and exuberant lesions, over multiple sites, as in our case, have not been reported earlier in the pediatric age group, to the best of our knowledge.

A correct diagnosis of pediatric syphilis is not only important to treat the infection and prevent further morbidity but also to identify cases of child sexual abuse (CSA), a worldwide problem seen in all socioeconomic groups.[3] Transmission of STIs is seen in 2%–10% of abused children.[1] Syphilis is not very common, documented in only <1% cases in most studies of child abuse. Among these reported cases of syphilis secondary to abuse, the diagnosis was based on serologic screening as most of them were asymptomatic. The cases of symptomatic syphilis were limited to anecdotal reports.[4]

The detection of child abuse is challenging when based on medical evidence alone, as an accurate history is often concealed by the patient and family. Furthermore, the majority of children do not manifest behavioral changes to arise suspicion.[5] According to the American Academy of Pediatrics guidelines, a new diagnosis of acquired syphilis in children concurrently makes the diagnosis of CSA.[6] If the primary lesion is found on genital or anal site, it is a prima facie evidence of CSA.[7] Accidental inoculation by a diseased individual via breastfeeding, hand-feeding, kissing, and fomites has been suggested in the past for cases of extragenital chancres and secondary stage lesions in preschoolers. These cases are referred to as syphilis brephotrophica or lues insontium.[89] However, treponemes have not been demonstrated to penetrate unbroken epidermis, suggesting that infection requires intimate skin-to-skin contact.[7] Nowadays, almost all syphilis cases in children are felt to be acquired by sexual contact, reflecting a heightened awareness of CSA in pediatric care.[7] As a result, in our case, the absence of an identified source of infection does not make sexual transmission any less likely.

The evaluation of a child presenting with anogenital complaints must include a screen for all STIs. An assessment should be done for both familial risk factors and sexual acting out behavior in the child, considering the possibility of both receptive and penetrative sexual contact.[3] The child's environment should be thoroughly investigated to protect the child from possibly ongoing abuse.

Dermatologists must maintain a high index of suspicion and an awareness of the varied presentations of pediatric syphilis. A multidisciplinary approach is required between dermatologists, pediatricians, psychiatrists, social workers, and investigative officers for appropriate management of these cases. The key role of a dermatologist is not to state whether or not abuse has occurred, but to initiate an evaluation for the possibility. Under The Protection of Children from Sexual Offences Act, 2012, it is mandatory for doctors to register a medicolegal case in all cases of CSA, failure of which could result in 6-month imprisonment and- or- a fine under Section 21.[10]

To appropriately identify and manage cases of CSA, firm steps are required to increase awareness for early reporting and contact tracing of pediatric STIs.

We report this case to highlight a rare presentation of secondary syphilis and to stimulate about the medicolegal implications in children and adolescents. Increased vigilance is needed for children in order to aid proper diagnosis and early treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.