Pediatric Dennatology Vol. 9 No. 4 329-334
Sexually Transmitted Diseases in Children Gabriela Lowy Rio de Janeiro, Brazil
A b s t r a c t : Sexually transmitted diseases (STDs) in children may be transmitted by sexual abuse, by accidental contact, or perinataily. Aithough only 2% to10% of abused chitdien become infected, childhood syphilis, gonorrhea, condylomata acuminata, and Chlamytlia trachomaUs must aiways be considered. We reviewed data from our hospitai regarding the frequency, prevaience, routes of transmission, and clinicai features of these infections. Ninety-five percent of acquired syphiiis in children is transmitted by sexuai abuse. The perpetrator is usually someone the chiid icnows or trusts. Of our 21 patients under 14 years of age with acquired syphilis, most were 4 to 8 years old. Girts were infected twice as often as boys. Sexuai contact was confirmed in 71.4%. A chancre sore was infrequent in chiidren; condylomata iata was the most frequent cutaneous lesion (80.9%). In the last 10 years, 102 cases of congenitai syphilis were diagnosed in our hospitai. The main clinicai findings were bone invoivement (78.7%), hepatosplenomegaiy (68.8%), cutaneous iesions (50.8%), and jaundice (15.1%). Gonorrhea was detected in only nine chiidren. Vuivovaginitis was the most common clinicai manifestation. Sexual transmission was documented in tiiree patients. Accidental contact with their infected mother occurred in two sisters. Three newboms acquired tfie disease during delivery. The STDs in chiidren are a worrisome probiem. Evaiuation for sexuai abuse shouid be done in aii cases. Prevention and treatment of aduits are the main steps to prevent these infections in chiidren.
Sexually transmitted diseases (STDs) in children are hard to imagine, since children are rarely sexually active, but they do occur due to sexual abuse, accidental contacts, or nonsexual transmission during pregnancy or delivery. Sexual abuse is one of the most important concerns related to STDs in children. Recent publications show that its prevalence has increased from 12% to 28% (I), including a wide range of molestations such as kissing, fondling, genital manipulation, oral-genital contact, anal contact, and vaginal or rectal penetration (2). In two studies of 409 and 532 victims under 14 years of age, genital manipulation and vaginal penetration were the most common complaints, 32.7% in one study and 66.2% in the
other. Anal penetration and orogenital contacts followed in frequency in both studies (3,4). Transmission of STD pathogens occurs in 2% to 10% of abused children, and it is presumed that when penetration occurs, the risk is higher. In adults more than 20 distinct pathogens are now recognized as being sexually transmitted, but despite specific treatment, these infections continue to increase throughout the world. Changes in sexual behavior, such as premature sexual activity, numerous sex partners, and exchange of sex for drugs are some factors responsible for the high frequency of STDs. Children's STDs parallel those in adults. As more adults are infected, the likelihood of children
329
330 Pediatric Dennatology Vol. 9 No. 4 December 1992 contracting STDs increases, mainly syphilis, gonorrhea, condylomata acuminata, and Chlamydia trachomatis. We reviewed data concerning epidemiology, routes of transmission, and clinical aspects of these infections.
SYPHILIS
Syphilis in children may be acquired or congenital. A significant increase of primary and secondary disease in youngsters under 14 years of age has been reported in the last years in several countries. This gradual rise is exemplified well in United States statistics where, from 1985 to 1990, the frequency doubled (5), Infected adults transmit the disease to children by sexual or nonsexual ways, or, as occurs most frequently, during pregnancy. Acquired syphilis in children exhibits almost all the features seen in adults, but differs in transmission, primary sore (chancre), and skin lesions. Transmission in 95% of cases is related to sexual abuse and the offender usually is someone the child knows and probably trusts (6). Clinical evidence of the primary sore is infrequent, and the skin lesion that predominates is the condyloma latum. AD these characteristics were noted in 21 patients reviewed from 1973 to 1991. The children were less than 14 years old; most were between 4 and 8 years of age. Girls were affected twice as often as boys. Transmission by sexual contact was confirmed in 15 patients (71.4%). In one child transmission was by nonsexual contact through infected parents, and iti five it could not be traced. All of these children were under 5 years of age, with no clinical evidence of sexual intercourse; however, sexual transmission could not be ruled out. For children who identified the offender, the individuals were neighbors (4 cases), father (3), cousin (2), uncle (1), foster father (1), and mother's boyfriend (1). Condyloma latum was the most frequent cutaneous lesion, present in 17 children (80.9%) (Fig. 1). In six patients oral mucous patches were also observed. Eroded papules around the genital area were evident in two. The primary sore occurred in only one patient. The lymph nodes were palpable in all patients, but general symptoms were absent. The diagnosis was confirmed by the presence of Treponema pallidum on Darkfield examination in 10 patients and by serologic tests. Treatment consisted of intramuscular benzathine penicillin G 50,000 U/kg up to the adult dose of 2.4 million U.
Figure 1. Early acquired syphilis. Condylomata lata. CONGENITAL SYPHILIS
Congenital syphilis is transmitted by the pregnant woman to her fetus through the placenta. Its epidemiology parallels that of early syphilis in women. Statistics from several countries mention a striking increase in the last years. Good examples come from the United States, where from 1985 to 1990 a 10-fold increase was evidenced (5) and from England, where the lowest recorded level was in 1983 with only one case reported. Four were reported in 1984 and three in 1985, but in 1986 the number increased to nine (7). In developing countries, congenital syphilis continues to be quite common. In our hospital 102 cases were diagnosed in the last 10 years. These increases were mainly due to the increase of syphilis in women of childbearing age and to inadequate prenatal care. Congenital syphilis results from untreated infection during pregnancy. In our study only 16.8% of pregnant women had prenatal care. The risk of fetal transmission is estimated to range from 70% to 100% for un-
Lowy: STD in Children 331 treated early syphilis. Depending on the severity of the infection in the newborn, several organs may be affected. In a recent review published by the Centers for Disease Control the main clinical findings in 460 patients were osteochondritis, periostitis, jaundice, hepatosplenomegaly, and cutaneous lesions (8,9). Similar results were seen in our series of 102 patients. Bone involvement was present in 78.7%, enlargement of the liver and spleen in 68.8%, cutaneous lesions in 50.8%, and jaundice in 15.1%. The most common cutaneous lesions were desquamation of palms and soles (43.5%) (Fig. 2), papular lesions (16.6%) (Fig. 3), periorificial rhagades (14.4%) (Figs. 4 and 5), bullae on the palms and soles (3.7%), paronychia (3.3%), and condylomata lata (1.6%). The diagnosis was confirmed by Darkfield examination and serologic tests. Treatment consisted of aqueous crystaline penicillin G 100.000 U/kgfor 10 days, or procaine penicillin 50,000 U/kg for 10 days.
Figure 3. Congenital syphilis. Papular lesions.
GONORRHEA Gonorrhea is one of the most frequent STDs in adults. Its frequency has increased markedly in recent years, and a concomitant rise has been reported in children (5). Transmission in adults and adolescents is almost always sexual. Children and preadolescents acquire the disease mainly by sexual abuse or occasionally by a nonsexual mode, mainly owing to overcrowded living conditions, poor hygiene, or inappropriate sharing of equipment such as towels, bedsheets, and so on. Most studies accept that all gonococca! infections in children must be regarded as sexually transmitted, but others think that nonvenereal contact with an infected adult, mainly the mother, plays an important role in transmission (12,13).
Figure 4. Congenital syphilis. Periorificial rhagades.
Figure 2, Congenital syphilis. Desquamation on palm.
Newborn gonococcal infection is transmitted mainly from the infected mother during delivery, but contamination of the fetus may also occur in utero by rupture of the membranes. The estimated rate of transmission from the infected mother to the newborn is 30% to 50% (14). Occasionally the new-
332 Pediatric Dennatology Vol. 9 No. 4 December 1992
Figure 6. Gonorrhea. Ophthalmia neonatorum.
Figure 5. Congenital syphilis. Perianal rhagades.
bom or infant may be contaminated accidentally through infected secretion from the mother or other close relatives. The clinical spectrum of gonorrhea is wide, but in children the genital area and conjunctivae are the most affected sites. Vulvovaginitis is manifested by labial redness, swelling, and itching, with purulent vaginal discharge. Gonococcal ophthalmia neonalorum is mainly acquired during delivery and usually develops within the first week of life. It shows intensive inflammation with edema of the eyelids, acute conjunctivitis, and profuse purulent discharge. It is always bilateral, and without treatment the infection progresses rapidly to corneal perforation and blindness (Fig. 6). Skin lesions in gonorrhea are rare and seen only in disseminated infection. About 50% of these patients have septic arthritis. The classic skin lesion is a red papule on a hemorrhagic base with a gray umbilicated center. Lesions are few in number, are mainly located on the joints or on the face, and heal spontaneously in four to six days.
In our experience gonorrhea in children less than !4 years of age was rare, occurring in only nine children in the last 10 years. Vulvovaginitis was the most common clinical manifestation (55%). Transmission by sexual abuse was confirmed in three patients age 5, 8, and 9 years. Transmission by casual contact with infected parents occurred in two sisters age 2 and 3 years. Ophthalmia neonatorum transmitted by the infected mother during delivery occurred in three patients, and occurred accidentally in a 2-year-old contaminated by the infected mother. Diagnosis is confirmed by Gram's stain, culture, and demonstration of gonococcal antigens by enzyme immunoassay. Ceftriaxone 25 to 50 mg/ day for 7 days is now the treatment of choice. If the gonococcal isolate is susceptible to penicillin, crystaline penicillin 100,000 kg/day may be given in two equal doses. CONDYLOMATA ACUMINATA Common warts in children are relatively frequent, but genital warts are not, and several authors have reported an increase in their frequency. In our records from 1981 to 1991 condylomata acuminata occurred in 3.9% of patients with warts: common warts in 277 (83.9%), plantar warts in 31 (9.4%), anogenital warts in 13 (3.9%), and flat warts in 9 {2.1%). Condylomata acuminata or genital warts are caused by the human papilloma virus (HPV). At present, more than 63 HPV types have been identified, many of them specifically associated with a particular type of wart (15). In children, genital warts are associated mainly with HPV types 6 and 11, which are responsible for genital warts in adtilts. Recent studies also noted the association of condylomata acuminata with HPV types 1 and 2 responsible for common warts.
Lowy: STD in Children 333 From our series of 13 patients with condylomata acuminata, nine (69%) were girls and four (31%) were boys. Two were less than 1 year old, five were 1 to 3 years of age, three were 3 to 6, and three were over 6 years old. Condylomata acuminata may occur at any age, but the age of onset is an important clue to the mode of transmission. Occurrence in children under age 2 suggests vertical transmission. The anal and perianal areas were the most affected (4 boys, 2 girls). Anal and genital lesions were present in four (3 girls, 1 boy) (Fig. 7). Lesions exclusively on the genital area occurred only in girls. We did not find lesions on the urethra or the scrotum. One patient had warts on both his anal and oral mucosae and his finger, and another had warts on the anal region and finger. In adults condylomata acuminata are sexually transmitted, but in infants the mode of transmission is controversial. The warts may occur as a result of sexual contact, nonsexual familial contact, from an infected birth canal, or by autoinoculation or heteroinoculation from another part of the body. Sex-
ual abuse is supported by many authors as the main mode of transmission (16,17), but the noosexual way has been widely accepted since virologic studies disclosed that comnion warts may induce anogenital condylomata acuminata in children (18,19). In our study, despite the impossibility of isolating the virus, the most likely modes of transmission were nonsexual in five patients (38.4%) whose parents had condylomata acuminata. Vertical transmission was considered in three newborns (23.3%) whose mothers had condylomata acuminata at the time of the delivery, and transmission by sexual abuse was confirmed in two patients and suspected in one (23.1 %). Autoinoculation from common hand warts was probable in two patients with common warts on their fingers (15.3%). Complications of condylomata acuminata are rare. Secondary infection may occur, and malignant transformation has been reported in adults, induced by types 16 and 18 (20). As these types have a high potential for neoplastic changes, long-term observation is recommended. Treatment of the disorder in children is problematic. Several methods may be used. In our experience electrocoagulation and podophyllin are the most effective methods. CHLAMYDIA TRACHOMATIS
Figure 7. Condylomata acuminata.
Chlatnydia trachomatis is a very common STD pathogen. It can be transmitted by direct inoculation into the newborn's eyes during delivery from the infected mother, and in older children and adolescents by sexual contact. It is stated that 50% to 75% of infants bom to infected mothers will develop eye disease, which varies from mild conjunctivitis to purulent, severe ophthalmia. Asymptomatic infection of the vagina and rectum may occur in as many as 15% of infants bom to infected mothers. Vagina! infection may persist for several years either after birth or after sexual contact, and may remain largely asymptomatic (21). Studies suggest that the presence of C. trachomatis in young children and preadolescenis should be considered as sexual abuse (22). Chlamydia trachomatis coinfection was found in up to 30% of children with gonococcal infection. Testing for the organism should be done on any patient with possible gonococcal infection. The STDs in children are worrisome health problems. Prevention and treatment of adults are the most important steps to prevent these infections in children.
334 Pediatric Dermatology Vol. 9 No. 4 December 1992
REFERENCES !. Leventhal JM. Have there been changes in the epidemiology of sexual abuse of children during the 20th century? Pediatrics 1988;82:766-773. 2. Emans SJ, Wcx)d ER, Flagg NT, Freeman A. Genital findings in sexually abused symptomatic and symptomatic girls. Pediatrics 1987;79:778. 3. White ST, Loda FA, Ingram D, Pearson A. Sexually transmitted diseases in sexually abused children. Pediatrics 1983 ;72. 4. De Jong AR. Sexually transmitted diseases in sexually abused children. Sex Transm Dis !986,13:t23. 5. Sexually transmitted diseases. Surveillance 1990 July 1991. 6. Ginsburg CM. Acquired syphilis in prepubertal children. Pediatr Infect Dis 1983;2:232. 7. Anonymous. STD in Britain 1985-6. Genitourin Med 1989;65:117-t21. 8. MMWR 1988;37:486-487. 9. Ewing CI, Roberts C, Davidson DC, Arya OP. Early congenital syphiiis still occurs. Arch Dis Child 1985; 60:1128-1133. 10. Verdish JV. Venereal diseases in children and sexual abuse. Ugeskr Laeger 1989;15:555-557. 11. Ingram DL, White ST, Durfee MF, Pearson AW. Sexual contact in children with gonorrhea. Am J Dis Child 1982;136. 12. Shore WB, Winkelstein JA. Nonvenereal transmission of gonococcal infection to chiidren. J Pediatr 1971;661-663.
13. Sevashevich AV, Gurina OP, PoUakova GN. The characteristics of gonorrhea in children. Vestn Dermatol Venerol 1989;6:58-61. 14. Laga M, Mehens A, Piot P. Epidemiology and control of gonococcal ophthalmia neonatorum. WHO Bull 1989;67:471-77. 15. Beutner KR. Human papilloma virus infection. J Am Acad Dennatol 1990;22:547-565. 16. Seidel J, Zonata J, Totten E. Condylomata acuminata as a sign of sexual abuse in children. J Pediatr 1979; 95:553-554. 17. Roussey C, Dabadie A, Chevrant Breton O, Chevrant Breton S, Lemarec C. Arch Fr Pediatr 1988;45: 429-434. 18. Padel AF, Venning VA, Evans MF, Quantril A, Fleming KA. Human papilloma viruses in anogenital warts in chiidren typing by in situ hybridization. Br Med J 1990,300:1491-1494. 19. ObaSek S, Jablonska S, Favre M, Walczak L, Orth G. Condylomata acuminata in children frequent association with papillomaviruses responsible for cutaneous warts. J Am Acad Dermatol 1990;23:205-213. 20. Boyd AS. Condylomata acuminata in pediatric population. Am J Dis Child 1990;144:817-824. 21. Schachter J, Pattei BJ. Sexually transmitted diseases in victims of sexual assault. N Bngl J Med 1987;316: 1023. 22. Keskey TS, Suarez M, Gleicher N, Friberg J, Levy HB. Chlamydia trachomatis infection in sexually abused children. Mount Sinai J Med 1987;5:129-134.
Sexually Transmitted Diseases in Children Gabriela Lowy Rio de Janeiro, Brazil
A b s t r a c t : Sexually transmitted diseases (STDs) in children may be transmitted by sexual abuse, by accidental contact, or perinataily. Aithough only 2% to10% of abused chitdien become infected, childhood syphilis, gonorrhea, condylomata acuminata, and Chlamytlia trachomaUs must aiways be considered. We reviewed data from our hospitai regarding the frequency, prevaience, routes of transmission, and clinicai features of these infections. Ninety-five percent of acquired syphiiis in children is transmitted by sexuai abuse. The perpetrator is usually someone the chiid icnows or trusts. Of our 21 patients under 14 years of age with acquired syphilis, most were 4 to 8 years old. Girts were infected twice as often as boys. Sexuai contact was confirmed in 71.4%. A chancre sore was infrequent in chiidren; condylomata iata was the most frequent cutaneous lesion (80.9%). In the last 10 years, 102 cases of congenitai syphilis were diagnosed in our hospitai. The main clinicai findings were bone invoivement (78.7%), hepatosplenomegaiy (68.8%), cutaneous iesions (50.8%), and jaundice (15.1%). Gonorrhea was detected in only nine chiidren. Vuivovaginitis was the most common clinicai manifestation. Sexual transmission was documented in tiiree patients. Accidental contact with their infected mother occurred in two sisters. Three newboms acquired tfie disease during delivery. The STDs in chiidren are a worrisome probiem. Evaiuation for sexuai abuse shouid be done in aii cases. Prevention and treatment of aduits are the main steps to prevent these infections in chiidren.
Sexually transmitted diseases (STDs) in children are hard to imagine, since children are rarely sexually active, but they do occur due to sexual abuse, accidental contacts, or nonsexual transmission during pregnancy or delivery. Sexual abuse is one of the most important concerns related to STDs in children. Recent publications show that its prevalence has increased from 12% to 28% (I), including a wide range of molestations such as kissing, fondling, genital manipulation, oral-genital contact, anal contact, and vaginal or rectal penetration (2). In two studies of 409 and 532 victims under 14 years of age, genital manipulation and vaginal penetration were the most common complaints, 32.7% in one study and 66.2% in the
other. Anal penetration and orogenital contacts followed in frequency in both studies (3,4). Transmission of STD pathogens occurs in 2% to 10% of abused children, and it is presumed that when penetration occurs, the risk is higher. In adults more than 20 distinct pathogens are now recognized as being sexually transmitted, but despite specific treatment, these infections continue to increase throughout the world. Changes in sexual behavior, such as premature sexual activity, numerous sex partners, and exchange of sex for drugs are some factors responsible for the high frequency of STDs. Children's STDs parallel those in adults. As more adults are infected, the likelihood of children
329
330 Pediatric Dennatology Vol. 9 No. 4 December 1992 contracting STDs increases, mainly syphilis, gonorrhea, condylomata acuminata, and Chlamydia trachomatis. We reviewed data concerning epidemiology, routes of transmission, and clinical aspects of these infections.
SYPHILIS
Syphilis in children may be acquired or congenital. A significant increase of primary and secondary disease in youngsters under 14 years of age has been reported in the last years in several countries. This gradual rise is exemplified well in United States statistics where, from 1985 to 1990, the frequency doubled (5), Infected adults transmit the disease to children by sexual or nonsexual ways, or, as occurs most frequently, during pregnancy. Acquired syphilis in children exhibits almost all the features seen in adults, but differs in transmission, primary sore (chancre), and skin lesions. Transmission in 95% of cases is related to sexual abuse and the offender usually is someone the child knows and probably trusts (6). Clinical evidence of the primary sore is infrequent, and the skin lesion that predominates is the condyloma latum. AD these characteristics were noted in 21 patients reviewed from 1973 to 1991. The children were less than 14 years old; most were between 4 and 8 years of age. Girls were affected twice as often as boys. Transmission by sexual contact was confirmed in 15 patients (71.4%). In one child transmission was by nonsexual contact through infected parents, and iti five it could not be traced. All of these children were under 5 years of age, with no clinical evidence of sexual intercourse; however, sexual transmission could not be ruled out. For children who identified the offender, the individuals were neighbors (4 cases), father (3), cousin (2), uncle (1), foster father (1), and mother's boyfriend (1). Condyloma latum was the most frequent cutaneous lesion, present in 17 children (80.9%) (Fig. 1). In six patients oral mucous patches were also observed. Eroded papules around the genital area were evident in two. The primary sore occurred in only one patient. The lymph nodes were palpable in all patients, but general symptoms were absent. The diagnosis was confirmed by the presence of Treponema pallidum on Darkfield examination in 10 patients and by serologic tests. Treatment consisted of intramuscular benzathine penicillin G 50,000 U/kg up to the adult dose of 2.4 million U.
Figure 1. Early acquired syphilis. Condylomata lata. CONGENITAL SYPHILIS
Congenital syphilis is transmitted by the pregnant woman to her fetus through the placenta. Its epidemiology parallels that of early syphilis in women. Statistics from several countries mention a striking increase in the last years. Good examples come from the United States, where from 1985 to 1990 a 10-fold increase was evidenced (5) and from England, where the lowest recorded level was in 1983 with only one case reported. Four were reported in 1984 and three in 1985, but in 1986 the number increased to nine (7). In developing countries, congenital syphilis continues to be quite common. In our hospital 102 cases were diagnosed in the last 10 years. These increases were mainly due to the increase of syphilis in women of childbearing age and to inadequate prenatal care. Congenital syphilis results from untreated infection during pregnancy. In our study only 16.8% of pregnant women had prenatal care. The risk of fetal transmission is estimated to range from 70% to 100% for un-
Lowy: STD in Children 331 treated early syphilis. Depending on the severity of the infection in the newborn, several organs may be affected. In a recent review published by the Centers for Disease Control the main clinical findings in 460 patients were osteochondritis, periostitis, jaundice, hepatosplenomegaly, and cutaneous lesions (8,9). Similar results were seen in our series of 102 patients. Bone involvement was present in 78.7%, enlargement of the liver and spleen in 68.8%, cutaneous lesions in 50.8%, and jaundice in 15.1%. The most common cutaneous lesions were desquamation of palms and soles (43.5%) (Fig. 2), papular lesions (16.6%) (Fig. 3), periorificial rhagades (14.4%) (Figs. 4 and 5), bullae on the palms and soles (3.7%), paronychia (3.3%), and condylomata lata (1.6%). The diagnosis was confirmed by Darkfield examination and serologic tests. Treatment consisted of aqueous crystaline penicillin G 100.000 U/kgfor 10 days, or procaine penicillin 50,000 U/kg for 10 days.
Figure 3. Congenital syphilis. Papular lesions.
GONORRHEA Gonorrhea is one of the most frequent STDs in adults. Its frequency has increased markedly in recent years, and a concomitant rise has been reported in children (5). Transmission in adults and adolescents is almost always sexual. Children and preadolescents acquire the disease mainly by sexual abuse or occasionally by a nonsexual mode, mainly owing to overcrowded living conditions, poor hygiene, or inappropriate sharing of equipment such as towels, bedsheets, and so on. Most studies accept that all gonococca! infections in children must be regarded as sexually transmitted, but others think that nonvenereal contact with an infected adult, mainly the mother, plays an important role in transmission (12,13).
Figure 4. Congenital syphilis. Periorificial rhagades.
Figure 2, Congenital syphilis. Desquamation on palm.
Newborn gonococcal infection is transmitted mainly from the infected mother during delivery, but contamination of the fetus may also occur in utero by rupture of the membranes. The estimated rate of transmission from the infected mother to the newborn is 30% to 50% (14). Occasionally the new-
332 Pediatric Dennatology Vol. 9 No. 4 December 1992
Figure 6. Gonorrhea. Ophthalmia neonatorum.
Figure 5. Congenital syphilis. Perianal rhagades.
bom or infant may be contaminated accidentally through infected secretion from the mother or other close relatives. The clinical spectrum of gonorrhea is wide, but in children the genital area and conjunctivae are the most affected sites. Vulvovaginitis is manifested by labial redness, swelling, and itching, with purulent vaginal discharge. Gonococcal ophthalmia neonalorum is mainly acquired during delivery and usually develops within the first week of life. It shows intensive inflammation with edema of the eyelids, acute conjunctivitis, and profuse purulent discharge. It is always bilateral, and without treatment the infection progresses rapidly to corneal perforation and blindness (Fig. 6). Skin lesions in gonorrhea are rare and seen only in disseminated infection. About 50% of these patients have septic arthritis. The classic skin lesion is a red papule on a hemorrhagic base with a gray umbilicated center. Lesions are few in number, are mainly located on the joints or on the face, and heal spontaneously in four to six days.
In our experience gonorrhea in children less than !4 years of age was rare, occurring in only nine children in the last 10 years. Vulvovaginitis was the most common clinical manifestation (55%). Transmission by sexual abuse was confirmed in three patients age 5, 8, and 9 years. Transmission by casual contact with infected parents occurred in two sisters age 2 and 3 years. Ophthalmia neonatorum transmitted by the infected mother during delivery occurred in three patients, and occurred accidentally in a 2-year-old contaminated by the infected mother. Diagnosis is confirmed by Gram's stain, culture, and demonstration of gonococcal antigens by enzyme immunoassay. Ceftriaxone 25 to 50 mg/ day for 7 days is now the treatment of choice. If the gonococcal isolate is susceptible to penicillin, crystaline penicillin 100,000 kg/day may be given in two equal doses. CONDYLOMATA ACUMINATA Common warts in children are relatively frequent, but genital warts are not, and several authors have reported an increase in their frequency. In our records from 1981 to 1991 condylomata acuminata occurred in 3.9% of patients with warts: common warts in 277 (83.9%), plantar warts in 31 (9.4%), anogenital warts in 13 (3.9%), and flat warts in 9 {2.1%). Condylomata acuminata or genital warts are caused by the human papilloma virus (HPV). At present, more than 63 HPV types have been identified, many of them specifically associated with a particular type of wart (15). In children, genital warts are associated mainly with HPV types 6 and 11, which are responsible for genital warts in adtilts. Recent studies also noted the association of condylomata acuminata with HPV types 1 and 2 responsible for common warts.
Lowy: STD in Children 333 From our series of 13 patients with condylomata acuminata, nine (69%) were girls and four (31%) were boys. Two were less than 1 year old, five were 1 to 3 years of age, three were 3 to 6, and three were over 6 years old. Condylomata acuminata may occur at any age, but the age of onset is an important clue to the mode of transmission. Occurrence in children under age 2 suggests vertical transmission. The anal and perianal areas were the most affected (4 boys, 2 girls). Anal and genital lesions were present in four (3 girls, 1 boy) (Fig. 7). Lesions exclusively on the genital area occurred only in girls. We did not find lesions on the urethra or the scrotum. One patient had warts on both his anal and oral mucosae and his finger, and another had warts on the anal region and finger. In adults condylomata acuminata are sexually transmitted, but in infants the mode of transmission is controversial. The warts may occur as a result of sexual contact, nonsexual familial contact, from an infected birth canal, or by autoinoculation or heteroinoculation from another part of the body. Sex-
ual abuse is supported by many authors as the main mode of transmission (16,17), but the noosexual way has been widely accepted since virologic studies disclosed that comnion warts may induce anogenital condylomata acuminata in children (18,19). In our study, despite the impossibility of isolating the virus, the most likely modes of transmission were nonsexual in five patients (38.4%) whose parents had condylomata acuminata. Vertical transmission was considered in three newborns (23.3%) whose mothers had condylomata acuminata at the time of the delivery, and transmission by sexual abuse was confirmed in two patients and suspected in one (23.1 %). Autoinoculation from common hand warts was probable in two patients with common warts on their fingers (15.3%). Complications of condylomata acuminata are rare. Secondary infection may occur, and malignant transformation has been reported in adults, induced by types 16 and 18 (20). As these types have a high potential for neoplastic changes, long-term observation is recommended. Treatment of the disorder in children is problematic. Several methods may be used. In our experience electrocoagulation and podophyllin are the most effective methods. CHLAMYDIA TRACHOMATIS
Figure 7. Condylomata acuminata.
Chlatnydia trachomatis is a very common STD pathogen. It can be transmitted by direct inoculation into the newborn's eyes during delivery from the infected mother, and in older children and adolescents by sexual contact. It is stated that 50% to 75% of infants bom to infected mothers will develop eye disease, which varies from mild conjunctivitis to purulent, severe ophthalmia. Asymptomatic infection of the vagina and rectum may occur in as many as 15% of infants bom to infected mothers. Vagina! infection may persist for several years either after birth or after sexual contact, and may remain largely asymptomatic (21). Studies suggest that the presence of C. trachomatis in young children and preadolescenis should be considered as sexual abuse (22). Chlamydia trachomatis coinfection was found in up to 30% of children with gonococcal infection. Testing for the organism should be done on any patient with possible gonococcal infection. The STDs in children are worrisome health problems. Prevention and treatment of adults are the most important steps to prevent these infections in children.
334 Pediatric Dermatology Vol. 9 No. 4 December 1992
REFERENCES !. Leventhal JM. Have there been changes in the epidemiology of sexual abuse of children during the 20th century? Pediatrics 1988;82:766-773. 2. Emans SJ, Wcx)d ER, Flagg NT, Freeman A. Genital findings in sexually abused symptomatic and symptomatic girls. Pediatrics 1987;79:778. 3. White ST, Loda FA, Ingram D, Pearson A. Sexually transmitted diseases in sexually abused children. Pediatrics 1983 ;72. 4. De Jong AR. Sexually transmitted diseases in sexually abused children. Sex Transm Dis !986,13:t23. 5. Sexually transmitted diseases. Surveillance 1990 July 1991. 6. Ginsburg CM. Acquired syphilis in prepubertal children. Pediatr Infect Dis 1983;2:232. 7. Anonymous. STD in Britain 1985-6. Genitourin Med 1989;65:117-t21. 8. MMWR 1988;37:486-487. 9. Ewing CI, Roberts C, Davidson DC, Arya OP. Early congenital syphiiis still occurs. Arch Dis Child 1985; 60:1128-1133. 10. Verdish JV. Venereal diseases in children and sexual abuse. Ugeskr Laeger 1989;15:555-557. 11. Ingram DL, White ST, Durfee MF, Pearson AW. Sexual contact in children with gonorrhea. Am J Dis Child 1982;136. 12. Shore WB, Winkelstein JA. Nonvenereal transmission of gonococcal infection to chiidren. J Pediatr 1971;661-663.
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