British Journal of Obstetrics and Gynaecology February 1977. Vol84. pp 141-142
GENITAL HERPESVIRUS INFECTION IN A PREPUBERTAL GIRL BY
M. J. HARE,*Lecturer in Obstetrics and Gynaecology AND
AMENEH MOWLA, SHO in Obstetrics and GynaecoIogy Royal Free Hospital and School of Medicine, Pond Street, London N W3
Summary An episode of acute vulvovaginitis which was found to be due to herpesvirus is described in an eight-year-old girl. The significance of such infections is discussed. ALTHOUGH the first report of genital herpesvirus infection in a prepubertal child appeared in 1853 (Legendre), Nahmias et a1 (1968) writing 115 years later could find only five more cases in the world medical literature. They themselves reported on a further six cases. With the apparent world-wide rise in the incidence of genital herpes in adults, infection in children may also become more common.
an adequate pelvic examination. The vulva, clitoris and surrounding areas were grossly oedematous and covered with small shallow ulcers up to 3 mm in diameter. No vesicles could be seen, and the whole area was secondarily infected. The hymen was still present, its aperture admitting one finger only, and there was no sign of physical trauma. No foreign body could be palpated in the pelvis. The upper vagina, cervix and other pelvic organs appeared normal. The bladder was full, and as the urinary incontinence was thought to be due to retention with overflow, an indwelling catheter was inserted. A provisional diagnosis of herpesvirus infection was made and treatment started with five per cent idoxuridine in dimethylsulphoxide. Co-trimoxazole was given by mouth to reduce secondary infection of the vulva and to prevent urinary tract infection. The lesions healed slowly and the child was discharged from hospital after 15 days. On general culture no specific genital tract pathogens (Neisseria, Trichomonas or Candidu) were isolated, but there was a heavy growth of a coliform organism, thought to be a secondary invader. Catheter specimens of urine remained sterile. Vulva1 material was placed in virus transport medium and later cultured in a strain of human embryo fibroblasts; a herpesvirus was isolated after three days and identified as Herpesvirus hominis (HVH) Type I. Complement fixing serum antibodies to HVH
CASEREPORT An eight-year-old Negro girl was brought to the accident department of the hospital complaining of vulva1 pain and soreness, and urinary incontinence. The symptoms had been present for three days. and for two nights she had laid awake screaming. The pain was worse when she attempted to pass urine. The day before admission her general practitioner had diagnosed vaginal thrush and nystatin ointment had been applied to the vulva. On examination the child was febrile and obviously in pain. There were no mouth or skin lesions and no general lymphadenopathy. There was slight lower abdominal tenderness, but no rebound or rigidity. The inguinal lymph nodes were tender and enlarged. The haemoglobin level was 12.6 g/dl, and the leucocyte count 620O/pl. General anaesthesia was needed to perform
* Present address: University Lecturer in Obstetrics and Gynaecology, Addenbrooke’s Hospital, Cambridge. 141
142
HARE AND MOWLA
Type I rose from a negligible level on admission to a titre of one in 64 after one week. Serological tests for syphilis were negative during the acute infection and also six and twelve weeks later. D~SCUSSION Herpes vulvitis is probably much commoner than the paucity of reported cases would suggest. Although most clinicians will recognize genital herpes in a child if oral herpes is also present, this diagnosis is less likely to be considered if the lesions are confined to the vulva. Of the 12 reported cases, 9 come from personal series over short periods of time, suggesting that awareness of the clinician is the main reason for the diagnosis. Nahmias et a1 (1968) claim that HVH Type I genital infections can be assumed not to be sexually transmitted. This would seem a dangerous premise. In a subsequent paper from the same unit, D o h et a1 (1975) describe sexual transmission of the Type I virus and report that, in their laboratory, approximately one in every nine isolations of herpesvirus from the female genital tract is of Type I rather than Type 11. In our patient, before the Type was known, further enquiries were made concerning
possible sexual contact. The girl then made allegations of assault stopping short of full vaginal penetration by a man cohabiting with her mother and, on information given by the mother, criminal charges were brought against him. It would seem wise, therefore, to assume initially that all herpetic lesions which are confined to the vulva to have been sexually transmitted whichever virus is responsible, for to disregard this possibility could result in the child's return to a dangerous home environment. ACKNOWLEDGEMENTS The authors are grateful to Miss Kathleen Robinson, MD, FRCS, FRCOG, for permission to report this case. The virus isolation was performed by Mr M. Ross, Royal Free Hospital, and the virus typing at the Virus Reference Centre, Public Health Laboratory, Colindale. REFERENCES D o h , R., Gill, F. A,, and Nahmias, A. J. (1975): Journal of' the American Venerea! Diseuse Association, 2, 13. Legendre, F. ( I 853) :Archivesgtnkrules de midicine, 2,171. Nahmias, A. J., Dowdle, W. R., Naib, S. M., Josey, W. E., and Luce, C . F. (1968): Pediutrics, 42, 659.
GENITAL HERPESVIRUS INFECTION IN A PREPUBERTAL GIRL BY
M. J. HARE,*Lecturer in Obstetrics and Gynaecology AND
AMENEH MOWLA, SHO in Obstetrics and GynaecoIogy Royal Free Hospital and School of Medicine, Pond Street, London N W3
Summary An episode of acute vulvovaginitis which was found to be due to herpesvirus is described in an eight-year-old girl. The significance of such infections is discussed. ALTHOUGH the first report of genital herpesvirus infection in a prepubertal child appeared in 1853 (Legendre), Nahmias et a1 (1968) writing 115 years later could find only five more cases in the world medical literature. They themselves reported on a further six cases. With the apparent world-wide rise in the incidence of genital herpes in adults, infection in children may also become more common.
an adequate pelvic examination. The vulva, clitoris and surrounding areas were grossly oedematous and covered with small shallow ulcers up to 3 mm in diameter. No vesicles could be seen, and the whole area was secondarily infected. The hymen was still present, its aperture admitting one finger only, and there was no sign of physical trauma. No foreign body could be palpated in the pelvis. The upper vagina, cervix and other pelvic organs appeared normal. The bladder was full, and as the urinary incontinence was thought to be due to retention with overflow, an indwelling catheter was inserted. A provisional diagnosis of herpesvirus infection was made and treatment started with five per cent idoxuridine in dimethylsulphoxide. Co-trimoxazole was given by mouth to reduce secondary infection of the vulva and to prevent urinary tract infection. The lesions healed slowly and the child was discharged from hospital after 15 days. On general culture no specific genital tract pathogens (Neisseria, Trichomonas or Candidu) were isolated, but there was a heavy growth of a coliform organism, thought to be a secondary invader. Catheter specimens of urine remained sterile. Vulva1 material was placed in virus transport medium and later cultured in a strain of human embryo fibroblasts; a herpesvirus was isolated after three days and identified as Herpesvirus hominis (HVH) Type I. Complement fixing serum antibodies to HVH
CASEREPORT An eight-year-old Negro girl was brought to the accident department of the hospital complaining of vulva1 pain and soreness, and urinary incontinence. The symptoms had been present for three days. and for two nights she had laid awake screaming. The pain was worse when she attempted to pass urine. The day before admission her general practitioner had diagnosed vaginal thrush and nystatin ointment had been applied to the vulva. On examination the child was febrile and obviously in pain. There were no mouth or skin lesions and no general lymphadenopathy. There was slight lower abdominal tenderness, but no rebound or rigidity. The inguinal lymph nodes were tender and enlarged. The haemoglobin level was 12.6 g/dl, and the leucocyte count 620O/pl. General anaesthesia was needed to perform
* Present address: University Lecturer in Obstetrics and Gynaecology, Addenbrooke’s Hospital, Cambridge. 141
142
HARE AND MOWLA
Type I rose from a negligible level on admission to a titre of one in 64 after one week. Serological tests for syphilis were negative during the acute infection and also six and twelve weeks later. D~SCUSSION Herpes vulvitis is probably much commoner than the paucity of reported cases would suggest. Although most clinicians will recognize genital herpes in a child if oral herpes is also present, this diagnosis is less likely to be considered if the lesions are confined to the vulva. Of the 12 reported cases, 9 come from personal series over short periods of time, suggesting that awareness of the clinician is the main reason for the diagnosis. Nahmias et a1 (1968) claim that HVH Type I genital infections can be assumed not to be sexually transmitted. This would seem a dangerous premise. In a subsequent paper from the same unit, D o h et a1 (1975) describe sexual transmission of the Type I virus and report that, in their laboratory, approximately one in every nine isolations of herpesvirus from the female genital tract is of Type I rather than Type 11. In our patient, before the Type was known, further enquiries were made concerning
possible sexual contact. The girl then made allegations of assault stopping short of full vaginal penetration by a man cohabiting with her mother and, on information given by the mother, criminal charges were brought against him. It would seem wise, therefore, to assume initially that all herpetic lesions which are confined to the vulva to have been sexually transmitted whichever virus is responsible, for to disregard this possibility could result in the child's return to a dangerous home environment. ACKNOWLEDGEMENTS The authors are grateful to Miss Kathleen Robinson, MD, FRCS, FRCOG, for permission to report this case. The virus isolation was performed by Mr M. Ross, Royal Free Hospital, and the virus typing at the Virus Reference Centre, Public Health Laboratory, Colindale. REFERENCES D o h , R., Gill, F. A,, and Nahmias, A. J. (1975): Journal of' the American Venerea! Diseuse Association, 2, 13. Legendre, F. ( I 853) :Archivesgtnkrules de midicine, 2,171. Nahmias, A. J., Dowdle, W. R., Naib, S. M., Josey, W. E., and Luce, C . F. (1968): Pediutrics, 42, 659.
