Case Report The Interpretation of Repeat Positive Results for Gonorrhea and Chlamydia in Children Vinod Rao MD 1,2, Jennifer Canter MD, MPH 1,2,* 1 2
New York Medical College, Valhalla, New York Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, New York
a b s t r a c t Background: The diagnosis of gonorrhea and/or chlamydia in a prepubertal child beyond the neonatal period is confirmatory of mucosal contact with infective bodily secretions and therefore highly concerning for sexual abuse. When such a diagnosis is made, a report to protective authorities is warranted so that safety and potential criminal activity may be evaluated concurrent with the medical management. Occasionally, despite perceived adequate medical management and protective safety plans, a child may present with a repeat positive result for sexually transmitted infections. In this scenario, it is important for medical providers to carefully consider and be aware of the possible reasons for the repeat positive result: (1) treatment failure, (2) a new infection from repeated abuse, or (3) a false-positive result due to the limitations of nonculture testing. Case: Prepubertal sisters were diagnosed with gonorrhea and Chlamydia and treated with antibiotics, and the individual identified as having sexually abused them was removed from the home. Summary and Conclusion: Over a 4-month period, both children continued to have positive testing for chlamydia via the nucleic acid amplification test and/or culture. Concurrent with using alternate antibiotic treatment options, protective authorities were alerted to the fact that this was likely a reinfection. The investigative team later determined that a second adult, who tested positive for gonorrhea and chlamydia, was also sexually abusing both girls. Disclosures of abuse regarding both adult individuals were deemed credible by authorities and supported with collateral information. Key Words: Sexual abuse, Child abuse, Follow-up in sexual abuse, Gonorrhea, Chlamydia, Delayed disclosure, Treatment failure, Warts, Human papilloma virus, HPV, Cultures, Nucleic acid amplification test (NAAT), Sibling testing with sexually transmitted infections (STIs), Time frame for chlamydia, Time frame for gonorrhea
Introduction
The diagnosis of gonorrhea and/or chlamydia is confirmatory of mucosal contact with infective bodily secretions.1 Outside of the time period when perinatally acquired infection can occur, the diagnosis of gonorrhea and/or chlamydia in a prepubertal child is indicative of intimate anogenital contact.2 Continued follow-up of these patients after treatment is important to address treatment success and explore the possibility of continued abuse. Interpretation of repeat positive results can also be complicated by the various testing methods available and the length of time that testing may remain positive after successful treatment. For these reasons, children with positive results for sexually transmitted infections (STIs) require close follow-up. It is essential for medical providers conducting assessments on children who may have been abused to understand testing ramifications and how this may relate to child safety. When available, consultation with a child abuse pediatrician or infectious disease specialist may be of great value for a practitioner unfamiliar with these complex cases. Concurrently, the significance of these results should be
The authors indicate no conflict of interest. * Address correspondence to: Jennifer Canter, MD, MPH, Cedarwood Hall, 20 Hospital Oval West, Valhalla, NY 10595; Phone: (914) 493-5333 E-mail address: [email protected] (J. Canter).
communicated to investigative authorities in a manner that is understandable to assist in their investigation and safety planning of the child's environment. Case
A 7-year-old girl presented to her pediatrician with vaginal discharge and dysuria, and a nucleic acid amplification test (NAAT) (Qiagen [Quest Laboratories, Madison, NJ] HC2 Chlamydia trachomatis and Neisseria gonorrhea amplified DNA assay) and a genital culture were performed. Subsequently, a report to protective authorities was made, prompting referral for a forensic interview the following morning, during which the child disclosed only digital/ vaginal contact by an adult male relative (adult 1) with caregiving responsibilities who lived in the home. This individual was immediately removed and had no further contact with the patient or her siblings. On the day of the forensic interview, the girl had a medical evaluation with physical examination by a child abuse pediatrics (CAP) fellow, which demonstrated copious yellow-green vaginal discharge obscuring the structures of the vaginal vestibule. Cultures for gonorrhea and chlamydia, as well as blood testing for HIV, hepatitis B, hepatitis C, and syphilis, were performed. The day after this examination, the original NAAT and vaginal culture results were positive for gonorrhea, and the pediatrician referred the patient to a local emergency
1083-3188/$ - see front matter Ó 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2014.09.014
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V. Rao, J. Canter / J Pediatr Adolesc Gynecol 28 (2015) e109ee112
department, where she received only ceftriaxone.3 Three days after treatment, her vaginal discharge was fully resolved and she had a normal genital examination via colposcopy performed by the CAP fellow. Given the high incidence of coinfection with chlamydia when gonorrhea has been diagnosed and given the lack of antibiotics to address that possibility, the CAP fellow retested the index patient for chlamydia via vaginal culture and treated presumptively for chlamydia with oral azithromycin.3,4 Subsequently, the chlamydia culture returned with a positive result. Four weeks following this treatment, the patient had follow-up laboratory testing via urine NAAT, which was negative for both gonorrhea and chlamydia. The patient's 6-year-old sister presented for a medical evaluation by a board-certified child abuse pediatrician 7 days after the index patient's initial presentation. She had significant developmental communication delays precluding a forensic interview. This child also had a yellow-green vaginal discharge and an otherwise normal genitourinary/ anal examination. Vaginal cultures and urine NAAT (Aptima
Case
[Quest Laboratories, Madison, NJ] Combo 2 RNA TMA) for gonorrhea and chlamydia, as well as blood testing for HIV, hepatitis B, hepatitis C, and syphilis, were performed. Her urine NAAT was positive for both gonorrhea and Chlamydia, and her vaginal gonorrhea culture was positive (chlamydia culture was negative). She was treated with intramuscular ceftriaxone and oral azithromycin, as observed by nursing staff in the emergency department, thereby ensuring adequate dosage and consumption of medication. At the 6-year-old sibling's 5-week follow-up, testing via urine NAAT (Aptima Combo 2 RNA TMA) and cultures were again positive for Chlamydia, and she was treated with intravenous [IV] azithromycin and IV ceftriaxone. Results of follow-up testing via urine NAAT (Aptima Combo 2 RNA TMA) after treatment were negative. The repeat positive culture and NAAT in the 6-year-old sister raised concern for ongoing abuse by another individual given that adult 1 was confirmed to have been incarcerated since the original diagnosis. Due to this possibility, the mother and children moved to a new
Item
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GC culture
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+
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–
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–
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GC treatment
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Chl culture Chl NAAT Chl treatment 2
IV CTX
IM CTX
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+
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– Not
Oral
given
AZ
GC culture
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GC treatment Chl culture
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+ IV AZ, home 7 days PO levofloxacine
Finished levofloxacine
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CTX
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AZ
IV AZ, home 7
Levofloxacin
10 days IV
days PO
Started 10
ciprofloxacin
days IV
InpaƟent
levofloxacine
ciprofloxacin
Fig. 1. Detailed timeline of symptoms, testing, treatment, and exposure for both children. AZ, azithromycin; Chl, chlamydia; CTX, ceftriaxone; GC, gonorrhea; IM, intramusclar; IV, intravenous; NAAT, nucleic acid amplification test; 1, index patient; 2, sibling; A, last exposure to adult 1; B, last exposure to adult 2.
V. Rao, J. Canter / J Pediatr Adolesc Gynecol 28 (2015) e109ee112
environment with no further exposure to the other adult males in the home. Subsequently, the index patient made additional disclosures of penile/vaginal contact by another adult male relative (adult 2) with child care responsibilities to whom both girls were still exposed. When results for all household contacts became available, it became known that adult 2 had tested positive for gonorrhea and Chlamydia, while adult 1 and the biological mother were negative. At 1.5 months later (14 weeks after initial presentation), both patients had a follow-up appointment at which they were asymptomatic and again tested positive for chlamydia via urine NAAT (Aptima Combo 2 RNA TMA). Because there had been 3 days of continued exposure to adult 2 after the last round of treatment, it was most likely that this was another reinfection that took time to incubate since the last exposure. With guidance from pediatric infectious disease consult, it was decided to treat them both for the 2 possibilities of this positive results, representing (1) a reinfection or (2) a persistent infection despite having received adequate dosages of azithromycin in the past. Therefore, they both received IV ceftriaxone, IV azithromycin, and a 7day course of oral levofloxacin. The index patient completed the antibiotic course at home. The second patient was unable to tolerate oral levofloxacin and was hospitalized for a 10-day course of IV ciprofloxacin. Thereafter, with no further exposure to adult 1 or 2, both girls had negative follow-up urine NAAT (Aptima Combo 2 RNA TMA) and culture results, as well as negative testing for HIV, hepatitis B, hepatitis C, and syphilis, at 2, 6, 12, and 24 weeks after the last positive test. Figure 1 provides a detailed timeline of symptoms, testing, treatment, and exposure for both children. Summary and Conclusion
Continued follow-up over time was crucial in this case for the diagnosis, treatment, and safety of these siblings. Had the children not come back for follow-up, the continued infections and abuse would not have been identified. Nevertheless, this complex case presents various challenges and opportunities for education in terms of properties of different diagnostic tests that must be considered, efficacy of treatment regimens, and child safety. Multiple methods are available when testing for gonorrhea and chlamydia; however, for forensic purposes, as of 2010, culture remained the preferred method for diagnosis.3 In 2014, the CDC published new data indicating the use of NAAT testing via urine or vaginal swab specimens for gonorrhea and chlamydia diagnosis as being an accepted alternative to culture for prepubertal females with concerns of sexual abuse. However, for males and extragenital sites in females, culture remains the preferred test.5 These children's presentation preceded this new recommendation. The release of this recommendation further supported and validated the results of these patients as being an adequate result to make the diagnosis of a true positive. For NAAT testing, there are multiple options: urine vs swab collection, DNA vs RNA, and single organism vs combination organism. In general, compared with culture, NAAT testing methods are cited in the literature as having higher sensitivity and
e111
either equivalent or slightly lower specificity.6 Clinicians must understand the limitations of these diagnostic methods when interpreting test results. Relevant to this case is that if an NAAT is repeated less than 3 weeks after treatment, it may be falsely positive, but cultures should be negative within 5 days of treatment.3,7 At the time of the second positive result with the sibling, the strong concern for a possible second adult having abused the children was expressed by the CAP attending to protective authorities. On retrospectively reviewing the timeline of exposure to adult 1 and adult 2, this positive result was confirmed to have occurred during a time when there was ongoing exposure and opportunity for sexual contact by adult 2, who was found to be positive for gonorrhea and chlamydia. Regarding the third and final positive chlamydia via urine NAAT for the patients; given the fact that both children tested negative 2 weeks earlier, this was likely due to an incubating reinfection from the continued exposure to adult 2. However, in an abundance of caution they were also treated for the possibility of persistence of infection despite having received age and weight appropriate doses of antibiotics. Of note, investigative authorities put great effort into seeking contact testing in this case. However, a positive or negative test result in a contact does not positively identify a potential vector given the natural history of resolution,8 possibility of treatment, and the imperfect sensitivity of testing itself. The index patient's later disclosure regarding adult 2 highlights the importance of understanding that many factors can play a part in how and when a child will disclose abuse.9,10 A child's perception of their safety and possible continued exposure to an individual may impact his or her ability and willingness to disclose.9,10 For example, continued exposure to the perpetrator may preclude the child from disclosing. It was not until after the index patient moved away from adult 2 that she made the additional disclosures. An additional point highlighted by this case is the interpretation of normal examinations. After treatment, both girls had completely normal genitourinary and anal examinations initially. Given the disclosures by the index child and the positive gonorrhea and chlamydia results for both children, the diagnosis of child sexual abuse was clear, demonstrating that a normal examination does not discount the possibility of sexual abuse.11,12 While the ability of the genital structures to stretch can be a factor that results in no findings after vaginal penetration, another reason for a normal examination is that sexual contact may not involve penetration and only involve close contact of male and female genitalia, which can still result in transmission of STIs. This case highlights the importance of medical provider communication and education for investigative multidisciplinary team members on these complex cases. Although the investigators were confident that adult 1 did indeed abuse the children, the continued positive chlamydia results over time made it clear that abused by an additional individual had to be considered because children can be abused by more than 1 individual at the same time.
e112
V. Rao, J. Canter / J Pediatr Adolesc Gynecol 28 (2015) e109ee112
References 1. Kellogg N: American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics 2005; 116:506 2. Adams JA: Medical evaluation of suspected child sexual abuse: 2011 update. J Child Sex Abus 2011; 20:588 3. Workowski KA, Berman S: Centers for Disease Control and Prevention (CDC): Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59(RR-12):1 4. Lyss SB, Kamb ML, Peterman TA, et al, Project RESPECT Study Group: Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med 2003; 139:178 5. Centers for Disease Control and Prevention: Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae: 2014. MMWR Recomm Rep 2014; 63(RR-02):1 6. Black CM, Driebe EM, Howard LA, et al: Multicenter study of nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria
7. 8.
9.
10. 11.
12.
gonorrhoeae in children being evaluated for sexual abuse. Pediatr Infect Dis J 2009; 28:608 Ferris DG, Lawler FH, Horner RD, et al: Test of cure for genital Chlamydia trachomatis infection in women. J Fam Pract 1990; 31:36 Geisler WM, Wang C, Morrison SG, et al: The natural history of untreated Chlamydia trachomatis infection in the interval between screening and returning for treatment. Sex Transm Dis 2008; 35:119 Lippert T, Cross TP, Jones L, et al: Telling interviewers about sexual abuse: predictors of child disclosure at forensic interviews. Child Maltreat 2009; 14: 100 Goodman-Brown TB, Edelstein RS, et al: Why children tell: a model of children's disclosure of sexual abuse. Child Abuse Negl 2003; 27:525 Adams JA, Harper K, Knudson S, et al: Examination findings in legally confirmed child sexual abuse: it's normal to be normal. Pediatrics 1994; 94:310 Kellogg ND, Menard SW, Santos A: Genital anatomy in pregnant adolescents: “normal” does not mean “nothing happened”. Pediatrics 2004; 113:e67
New York Medical College, Valhalla, New York Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, New York
a b s t r a c t Background: The diagnosis of gonorrhea and/or chlamydia in a prepubertal child beyond the neonatal period is confirmatory of mucosal contact with infective bodily secretions and therefore highly concerning for sexual abuse. When such a diagnosis is made, a report to protective authorities is warranted so that safety and potential criminal activity may be evaluated concurrent with the medical management. Occasionally, despite perceived adequate medical management and protective safety plans, a child may present with a repeat positive result for sexually transmitted infections. In this scenario, it is important for medical providers to carefully consider and be aware of the possible reasons for the repeat positive result: (1) treatment failure, (2) a new infection from repeated abuse, or (3) a false-positive result due to the limitations of nonculture testing. Case: Prepubertal sisters were diagnosed with gonorrhea and Chlamydia and treated with antibiotics, and the individual identified as having sexually abused them was removed from the home. Summary and Conclusion: Over a 4-month period, both children continued to have positive testing for chlamydia via the nucleic acid amplification test and/or culture. Concurrent with using alternate antibiotic treatment options, protective authorities were alerted to the fact that this was likely a reinfection. The investigative team later determined that a second adult, who tested positive for gonorrhea and chlamydia, was also sexually abusing both girls. Disclosures of abuse regarding both adult individuals were deemed credible by authorities and supported with collateral information. Key Words: Sexual abuse, Child abuse, Follow-up in sexual abuse, Gonorrhea, Chlamydia, Delayed disclosure, Treatment failure, Warts, Human papilloma virus, HPV, Cultures, Nucleic acid amplification test (NAAT), Sibling testing with sexually transmitted infections (STIs), Time frame for chlamydia, Time frame for gonorrhea
Introduction
The diagnosis of gonorrhea and/or chlamydia is confirmatory of mucosal contact with infective bodily secretions.1 Outside of the time period when perinatally acquired infection can occur, the diagnosis of gonorrhea and/or chlamydia in a prepubertal child is indicative of intimate anogenital contact.2 Continued follow-up of these patients after treatment is important to address treatment success and explore the possibility of continued abuse. Interpretation of repeat positive results can also be complicated by the various testing methods available and the length of time that testing may remain positive after successful treatment. For these reasons, children with positive results for sexually transmitted infections (STIs) require close follow-up. It is essential for medical providers conducting assessments on children who may have been abused to understand testing ramifications and how this may relate to child safety. When available, consultation with a child abuse pediatrician or infectious disease specialist may be of great value for a practitioner unfamiliar with these complex cases. Concurrently, the significance of these results should be
The authors indicate no conflict of interest. * Address correspondence to: Jennifer Canter, MD, MPH, Cedarwood Hall, 20 Hospital Oval West, Valhalla, NY 10595; Phone: (914) 493-5333 E-mail address: [email protected] (J. Canter).
communicated to investigative authorities in a manner that is understandable to assist in their investigation and safety planning of the child's environment. Case
A 7-year-old girl presented to her pediatrician with vaginal discharge and dysuria, and a nucleic acid amplification test (NAAT) (Qiagen [Quest Laboratories, Madison, NJ] HC2 Chlamydia trachomatis and Neisseria gonorrhea amplified DNA assay) and a genital culture were performed. Subsequently, a report to protective authorities was made, prompting referral for a forensic interview the following morning, during which the child disclosed only digital/ vaginal contact by an adult male relative (adult 1) with caregiving responsibilities who lived in the home. This individual was immediately removed and had no further contact with the patient or her siblings. On the day of the forensic interview, the girl had a medical evaluation with physical examination by a child abuse pediatrics (CAP) fellow, which demonstrated copious yellow-green vaginal discharge obscuring the structures of the vaginal vestibule. Cultures for gonorrhea and chlamydia, as well as blood testing for HIV, hepatitis B, hepatitis C, and syphilis, were performed. The day after this examination, the original NAAT and vaginal culture results were positive for gonorrhea, and the pediatrician referred the patient to a local emergency
1083-3188/$ - see front matter Ó 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2014.09.014
e110
V. Rao, J. Canter / J Pediatr Adolesc Gynecol 28 (2015) e109ee112
department, where she received only ceftriaxone.3 Three days after treatment, her vaginal discharge was fully resolved and she had a normal genital examination via colposcopy performed by the CAP fellow. Given the high incidence of coinfection with chlamydia when gonorrhea has been diagnosed and given the lack of antibiotics to address that possibility, the CAP fellow retested the index patient for chlamydia via vaginal culture and treated presumptively for chlamydia with oral azithromycin.3,4 Subsequently, the chlamydia culture returned with a positive result. Four weeks following this treatment, the patient had follow-up laboratory testing via urine NAAT, which was negative for both gonorrhea and chlamydia. The patient's 6-year-old sister presented for a medical evaluation by a board-certified child abuse pediatrician 7 days after the index patient's initial presentation. She had significant developmental communication delays precluding a forensic interview. This child also had a yellow-green vaginal discharge and an otherwise normal genitourinary/ anal examination. Vaginal cultures and urine NAAT (Aptima
Case
[Quest Laboratories, Madison, NJ] Combo 2 RNA TMA) for gonorrhea and chlamydia, as well as blood testing for HIV, hepatitis B, hepatitis C, and syphilis, were performed. Her urine NAAT was positive for both gonorrhea and Chlamydia, and her vaginal gonorrhea culture was positive (chlamydia culture was negative). She was treated with intramuscular ceftriaxone and oral azithromycin, as observed by nursing staff in the emergency department, thereby ensuring adequate dosage and consumption of medication. At the 6-year-old sibling's 5-week follow-up, testing via urine NAAT (Aptima Combo 2 RNA TMA) and cultures were again positive for Chlamydia, and she was treated with intravenous [IV] azithromycin and IV ceftriaxone. Results of follow-up testing via urine NAAT (Aptima Combo 2 RNA TMA) after treatment were negative. The repeat positive culture and NAAT in the 6-year-old sister raised concern for ongoing abuse by another individual given that adult 1 was confirmed to have been incarcerated since the original diagnosis. Due to this possibility, the mother and children moved to a new
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GC NAAT
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Chl culture Chl NAAT Chl treatment 2
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IM CTX
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AZ
IV AZ, home 7
Levofloxacin
10 days IV
days PO
Started 10
ciprofloxacin
days IV
InpaƟent
levofloxacine
ciprofloxacin
Fig. 1. Detailed timeline of symptoms, testing, treatment, and exposure for both children. AZ, azithromycin; Chl, chlamydia; CTX, ceftriaxone; GC, gonorrhea; IM, intramusclar; IV, intravenous; NAAT, nucleic acid amplification test; 1, index patient; 2, sibling; A, last exposure to adult 1; B, last exposure to adult 2.
V. Rao, J. Canter / J Pediatr Adolesc Gynecol 28 (2015) e109ee112
environment with no further exposure to the other adult males in the home. Subsequently, the index patient made additional disclosures of penile/vaginal contact by another adult male relative (adult 2) with child care responsibilities to whom both girls were still exposed. When results for all household contacts became available, it became known that adult 2 had tested positive for gonorrhea and Chlamydia, while adult 1 and the biological mother were negative. At 1.5 months later (14 weeks after initial presentation), both patients had a follow-up appointment at which they were asymptomatic and again tested positive for chlamydia via urine NAAT (Aptima Combo 2 RNA TMA). Because there had been 3 days of continued exposure to adult 2 after the last round of treatment, it was most likely that this was another reinfection that took time to incubate since the last exposure. With guidance from pediatric infectious disease consult, it was decided to treat them both for the 2 possibilities of this positive results, representing (1) a reinfection or (2) a persistent infection despite having received adequate dosages of azithromycin in the past. Therefore, they both received IV ceftriaxone, IV azithromycin, and a 7day course of oral levofloxacin. The index patient completed the antibiotic course at home. The second patient was unable to tolerate oral levofloxacin and was hospitalized for a 10-day course of IV ciprofloxacin. Thereafter, with no further exposure to adult 1 or 2, both girls had negative follow-up urine NAAT (Aptima Combo 2 RNA TMA) and culture results, as well as negative testing for HIV, hepatitis B, hepatitis C, and syphilis, at 2, 6, 12, and 24 weeks after the last positive test. Figure 1 provides a detailed timeline of symptoms, testing, treatment, and exposure for both children. Summary and Conclusion
Continued follow-up over time was crucial in this case for the diagnosis, treatment, and safety of these siblings. Had the children not come back for follow-up, the continued infections and abuse would not have been identified. Nevertheless, this complex case presents various challenges and opportunities for education in terms of properties of different diagnostic tests that must be considered, efficacy of treatment regimens, and child safety. Multiple methods are available when testing for gonorrhea and chlamydia; however, for forensic purposes, as of 2010, culture remained the preferred method for diagnosis.3 In 2014, the CDC published new data indicating the use of NAAT testing via urine or vaginal swab specimens for gonorrhea and chlamydia diagnosis as being an accepted alternative to culture for prepubertal females with concerns of sexual abuse. However, for males and extragenital sites in females, culture remains the preferred test.5 These children's presentation preceded this new recommendation. The release of this recommendation further supported and validated the results of these patients as being an adequate result to make the diagnosis of a true positive. For NAAT testing, there are multiple options: urine vs swab collection, DNA vs RNA, and single organism vs combination organism. In general, compared with culture, NAAT testing methods are cited in the literature as having higher sensitivity and
e111
either equivalent or slightly lower specificity.6 Clinicians must understand the limitations of these diagnostic methods when interpreting test results. Relevant to this case is that if an NAAT is repeated less than 3 weeks after treatment, it may be falsely positive, but cultures should be negative within 5 days of treatment.3,7 At the time of the second positive result with the sibling, the strong concern for a possible second adult having abused the children was expressed by the CAP attending to protective authorities. On retrospectively reviewing the timeline of exposure to adult 1 and adult 2, this positive result was confirmed to have occurred during a time when there was ongoing exposure and opportunity for sexual contact by adult 2, who was found to be positive for gonorrhea and chlamydia. Regarding the third and final positive chlamydia via urine NAAT for the patients; given the fact that both children tested negative 2 weeks earlier, this was likely due to an incubating reinfection from the continued exposure to adult 2. However, in an abundance of caution they were also treated for the possibility of persistence of infection despite having received age and weight appropriate doses of antibiotics. Of note, investigative authorities put great effort into seeking contact testing in this case. However, a positive or negative test result in a contact does not positively identify a potential vector given the natural history of resolution,8 possibility of treatment, and the imperfect sensitivity of testing itself. The index patient's later disclosure regarding adult 2 highlights the importance of understanding that many factors can play a part in how and when a child will disclose abuse.9,10 A child's perception of their safety and possible continued exposure to an individual may impact his or her ability and willingness to disclose.9,10 For example, continued exposure to the perpetrator may preclude the child from disclosing. It was not until after the index patient moved away from adult 2 that she made the additional disclosures. An additional point highlighted by this case is the interpretation of normal examinations. After treatment, both girls had completely normal genitourinary and anal examinations initially. Given the disclosures by the index child and the positive gonorrhea and chlamydia results for both children, the diagnosis of child sexual abuse was clear, demonstrating that a normal examination does not discount the possibility of sexual abuse.11,12 While the ability of the genital structures to stretch can be a factor that results in no findings after vaginal penetration, another reason for a normal examination is that sexual contact may not involve penetration and only involve close contact of male and female genitalia, which can still result in transmission of STIs. This case highlights the importance of medical provider communication and education for investigative multidisciplinary team members on these complex cases. Although the investigators were confident that adult 1 did indeed abuse the children, the continued positive chlamydia results over time made it clear that abused by an additional individual had to be considered because children can be abused by more than 1 individual at the same time.
e112
V. Rao, J. Canter / J Pediatr Adolesc Gynecol 28 (2015) e109ee112
References 1. Kellogg N: American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics 2005; 116:506 2. Adams JA: Medical evaluation of suspected child sexual abuse: 2011 update. J Child Sex Abus 2011; 20:588 3. Workowski KA, Berman S: Centers for Disease Control and Prevention (CDC): Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59(RR-12):1 4. Lyss SB, Kamb ML, Peterman TA, et al, Project RESPECT Study Group: Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med 2003; 139:178 5. Centers for Disease Control and Prevention: Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae: 2014. MMWR Recomm Rep 2014; 63(RR-02):1 6. Black CM, Driebe EM, Howard LA, et al: Multicenter study of nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria
7. 8.
9.
10. 11.
12.
gonorrhoeae in children being evaluated for sexual abuse. Pediatr Infect Dis J 2009; 28:608 Ferris DG, Lawler FH, Horner RD, et al: Test of cure for genital Chlamydia trachomatis infection in women. J Fam Pract 1990; 31:36 Geisler WM, Wang C, Morrison SG, et al: The natural history of untreated Chlamydia trachomatis infection in the interval between screening and returning for treatment. Sex Transm Dis 2008; 35:119 Lippert T, Cross TP, Jones L, et al: Telling interviewers about sexual abuse: predictors of child disclosure at forensic interviews. Child Maltreat 2009; 14: 100 Goodman-Brown TB, Edelstein RS, et al: Why children tell: a model of children's disclosure of sexual abuse. Child Abuse Negl 2003; 27:525 Adams JA, Harper K, Knudson S, et al: Examination findings in legally confirmed child sexual abuse: it's normal to be normal. Pediatrics 1994; 94:310 Kellogg ND, Menard SW, Santos A: Genital anatomy in pregnant adolescents: “normal” does not mean “nothing happened”. Pediatrics 2004; 113:e67
