VENEREAL DISEASES IN CHILDREN

By Major M. P. Vora

Maharashtra Medical Journal

Volume XXVI: Number – 2 of May1979.

Pages 169 to 174.

VERY OFTEN SEMINARS ARE HELD OR SPECIAL ISSUES OF MEDICAL JOURNALS ARE BROUGHT OUT ON CHILDREN’S DISEASES , but even a cursory reference to venereal diseases is a rarity. No one can dare say that these diseases do not exist or occur in children. In fact, they constitute one of the most important group of childhood diseases. They are relatively uncommon but probably occur more frequently than is generally realised. They may develop in either sex or at any age but their incidence is much higher in children of advanced age. They present certain peculiarities and deserve special mention in children. Their serious sequelae and repercussions on the community add to their importance. Their variable and latent nature frequently eludes an early and correct diagnosis.

The important points to note are:

• Good treatment demands exact diagnosis. The precise diagnosis of V.D., especially in the early stages, cannot be made on the basis of clinical findings alone. It needs laboratory aid also.

• When the diagnosis is made, one must consider the possibility of other venereal diseases. More than one disease may be present concomitantly.

• Rational therapeutics aim to treat the cause and not merely to relieve the symptoms of a disease.

• The doctor’s task does not end by treating the disease simply. He has to strive hard for contact investigations. A tactful inquiry will be rewarding and helps to eliminate the focus of infection.

• Tests of cure are important; they offer trustworthy and reliable evidence of eradication of the infection. It would be simply rash to infer ‘cure’ from the fact that the paitient has been symptom-free. Cure can only be established by doing repeatedly appropriate laboratory tests and physical check-ups over a certain period.

Acquired syphilis

Acquire syphilis in children is a known fact. It may be due to:

• criminal assault or sodomy,
• precocious sexual intercourse,
• deliberate transfer under the erroneous notion of getting rid of one’s own disease,
• accident i.e. close or intimate contact with the maid servant who is highly infectious,
• infection of the pregnant woman in the last few weeks of pregnancy. If an expectant woman acquires syphilis very late in her , the infant escapes intra-uterine infection but develops subsequently typical primary sore after usual incubation period. The infant gets infected during its passage through the genital canal.

Syphilis, acquired very early in infancy, of undetected in time, be later confused with congenital syphilis. Symptoms do not as a rule occur at the onset of infection but only after an interval of a few weeks to three months. Primary sore on the lip, ear, anus, or finger is often misdiagnosed as it appears purely local and trivial in nature. Clinically atypical forma and profound modifications of symptomatology are common these days because of liberal and wide-spread use of antibiotics. The write has come across many cases of acquired syphilis in children below 13-14 years of age. The disease runs usually the same course as in adults.

Failure to appreciate absence of perfectly uniform manifestations or typical picture and that any or all the stages may be omitted or go unrecognised for frequent mistakes in the diagnosis. One has to give up the notion that syphilis is the disease of the genitalia only and to think of it as a possible etiologic factor. ‘Always suspect but be slow to diagnose syphilis’ is an excellent maxlin by Kolmer. While repeated and careful physical examination is indispensable, its value is variable and cannot be relied on in the diagnosis of syphilis. The conclusive and trustworthy measure is the demonstration of Tr. pallidum by the dark field microscopy or the fluorescent antibody technique and later on, by the persistent serologic positivity for syphilis supported by the positive historical and physical findings.

Congenital syphilis

Though congenital syphilis has been wiped out in many countries of the world, it continues to flourish unabated in India with a seropositivity rate of about 6 to 7 percent in the expectant women. Infection of the foetus occurs usually after the 4 th or 5 th month of pregnancy. Inherited or prenatal syphilis differs from the acquired syphilis in that there is no primary stage or the lesion. The unique features are the frequency of the interstitial keratitis, the virtual absence of aortic involvement and the high incidence of latency. Syphilitic infant tends to be wasted with dry shrunken skin, hoarse feeble voice, prominent belly and the appearance of senility. The clinical picture may vary and no chronological order is consistently followed. The signs of congenital syphilis may not appear immediately after the birth or they may be delayed until the age of 15 to 20 years. Sometimes, a truly symptomatic infection (latent or inapparent) may be observed. Secondary and tertiary lesions may appear concomitantly. During the first two years of life, there is a strong tendency for lesions of the skin, the mucous membrane, muco-cutaneous junctions, bones, joints, eyes etc. All lesions subsequent to the third year of life upto the puberty are tertiary in nature. The early congenital syphilis is marked by;

• skin eruptions: macular, papular or bullous on the napkin area, on the skin around the nose and the mouth, and on the palms and soles.

• mucous membrane lesions: whitish patches, erosions, snuffles.

• bone lesions: osteochondritis, periosteitis, craniotabes, Parrot’s nodes.

• joints: arthritis, bursitis, synovitis.

• muco-cutaneous junctions: condyloma lata

• lymph node enlargement: lymphadenitis.

• meningeal irritation during the first few months of life, and

• enlargement of liver and the spleen.

The late congenital syphilis may appear as early as the third life or any time subsequently and show great diversity in appearance, varying from almost asymptomatic to gross clinical picture. The common manifestations are:

• nodular cutaneous lesions, gummata of the skin, bone etc.
• rhagades or scarring of the circumoral area.
• saddle-nose.
• saber-tibia.
• corneal scarring due to interstitial keratitis.
• dental anomalies: Hutchinson’s teeth, Moon’s molars.
• perforation of the palate or nasal septum.
• bilateral deafness.
• cranial nerve palsies.
• optic nerve atrophy, choraditis.
• Clutton’s joints.
• chronic basilar meningitis.
• juvenile tabes or tabo-paresis, and
• general paralysis.

Diagnosis of congenital syphilis depends on:

• clinical signs and symptoms in the infant.

• Dark-ground-Illumination for Tr.pallidum from lesions of the skin or mucous membrane.

• investigations of the parents and other membranes of the family.

• serologic tests in the individual and other members of the family such as the mother, father, brother and sister, and

• X-ray examination of the long bones.

Serology

The results of serologic tests must be interpreted with great reserve in the first few weeks of life. Infants with negative serologic tests may be suffering from active syphilis. On the other hand, non-syphilitic infants may give positive serologic tests, because of the passive transfer of maternal antibodies. Hence a single negative or positive serologic reaction in the infant has no meaning. Quantitative serologic tests, repeated at regular intervals, are useful for the confirmation of the diagnosis. To overcome this difficulty, the specific test, F.T.A.-ABS is used to detect the presence of anti treponemal IgM in the neonate. In cases of early syphilis, the sero-positivity usually disappears 16 to 24 weeks after the successful treatment. In case of latent syphilis, it may persist inspite of treatment, although there is fall in the titer of quantitative tests. In grown-up children with congenital syphilis, the S.T.S. is usually unaffected by antisyphilitic therapy and sero-resistance is common. Ignorance of this fact is often responsible for over-treatment. A case with clinical evidence suggestive of prenatal syphilis, yet with negative or intermittently low titer positive S.T.S. is not a rare occurrence. Such transient serologic abnormalities are often erroneously termed as biologic false positive reactions, unless one carefully discerns residuals of prenatal infection. The syphilitic stigmata in the parents and their siblings should confirm the diagnosis. Though anti-natal blood test for syphilis is in vogue to prevent congenital syphilis, the experience has shown that it is not quite adequate to avoid pitfalls. The expectant mother should be tested again at delivery or soon after it.

Treatment

For early syphilis, blood concentration of penicillin-G 0.03 units per ml, maintained continuously for ten days is considered effective and hence recommended. To fulfill this objective the following schedules are advised for an adult.

• Procain penicillin-G 600,000 units I.M. daily for ten days or

• A dose of 2.4 m.u. of Benzathine or Benethamine penicillin I.M. in one or two injections at one or two sessions at three days interval. It is most speedy and convenient method advised from the point of public health.

In case of penicillin sensitivity, tetracycline or erythromycin 500 mg orally, 6 hourly for 10 to 15 days (total dose of 30 to 45 gm) is recommended. Other antibiotics which are effective are carbomycine and synnematin B.

For congenital syphilis, 440,000 units of penicillin-G per kg body weight is the dose spread over ten days.

The latent and relapsing nature and slow and steady progress of the disease, imperceptible by clinical examination, make the immediate assessment of the effects of treatment for syphilis extremely difficult; a failure to appreciate these factors is responsible for many therapeutic claims that in the hands of those best acquainted with this malady fail to justify themselves. Prolonged and repeated observations are essential to evaluate the effects of treatment.

Tests of cure

The fourth to ninth months after treatment of early syphilis is the most critical period for the relapse either clinical or serological.

During the first year, monthly physical examination and blood test thrice, three monthly the same procedure thrice and the C.S.F. examination at the end of six months.

During the second year, six monthly physical examination and blood test. The C.S.F. study at the end of two years.

The blood test for syphilis should be quantitative as a rule.

Gonococcal infections

These designate maladies which have common etiologic basis but are diverse in their clinical manifestations. Upto puberty, the surface of the vagina is covered with immature columnar epithelium which is very prone to the infection by the gonococcus. So also are the urethra, accessory sexual glands in the vicinity and their ducts. These are often involved in the primary gonococcal infection and produce different manifestations. Individual signs and symptoms will depend to a great extend on the location, extent and duration of the infection and the complications thereof. The most common are: arthritis, tenosynovitis, myositis, hyperkeratosis, conjunctivitis, iritis, condylomata, acuminata, Proctitis, os calcis, epididymitis, prostatitis, stricture urethra, Bartholinitis, salpingitis, oopheritis, chronic pelvic peritonitis and sterility.

Diagnosis is confirmed by the demonstration of Gram-negative intracellular diplococci and their culture. Results of fluorescent antibody technique for the identification of gonococci are very promising. Exclusion of syphilis is necessary since a double infection is not uncommon.

Gonococcal vulvo-vaginitis

This is a common ailment of the female childhood acquired either venereally or non-venereally. In the female children upto the age of 13 to 15, the vulva and the vagina are susceptible to be attacked by gonococcus, because of the juvenile epithelium and the lack of inhibitory influence of Doderlein’s bacillus. The urethra may be affected directly or as a complication. The infection may occur at any time from the birth to puberty but most common after about six to eight years. The infection may be due to direct contact with infectious material or an adult or child; but more frequently it is due to contacts with contaminated towel, napkin, closet or tub-bath. Epidemics have been reported in children’s homes, schools, and hostels. The instances of criminal assault or intentional transfer of the infection under mistaken belief to get cured of one’s infection, are known. The signs and symptoms are scalding pain, frequency of micturition, red swollen and edematous surface of the vulva and the vagina, and purulent vaginal discharge.

Gonococcal urethritis

This has been observed in boys and girls and should be considered in the differential diagnosis of urethritis even in young children. The common age for boys and girls is 12 & 8 respectively. It may result from precocious sexual intercourse, criminal assault, an accidental contact with the fresh and infectious discharge or deliberate transfer of infection or husband and wife game. The signs and symptoms are burning, smarting at micturition, retention of urine, red edematous and pouting external urethral opening, with purulent pus.

Gonococcal proctitis

The infection of the anal canal and the rectum is common in the females. It is often the result of direct extension of the infection from the genital gonorrhoea or faulty methods of hygiene. The condition is also noted occasionally in boys as the result of sodomy or criminal assault. Young boys employed in hotels are frequent victims.

Gonococcal arthritis

It is a real clinical entity, however; it is often misdiagnosed a rheumatic arthritis. It occurs in 4 percent of cases of the specific infection. To confirm its presence in children, a close study of the case, smear examination, culture and the fluorescent antibody technique to detect etiologic evidence are essential.

Gonococcal conjunctivitis

This is due to faulty hygiene, as rubbing of eyes with contaminated fingers. The infection in the mother is a common source of infection in the newborn.

Gonococcus ophthalmia neonatorum

Recently, rise in the cases has been noted all over the world. It is therefore imperative that antenatal care in pregnant women should include adequate steps to exclude the presence of gonococcal infection either active or latent. Specialised facilities for the detection of the infection must be made available. Obstetricians and gynaecologists should screen as a routine their cases by cervical smear, culture and F.A.T. There is also an urgent need to upgrade prophylactic technique. Conjunctivitis or eye discharge in the newborn ought to arouse suspicion and proper investigations.

Gonococcal meningitis is uncommon.

The drugs often used for gonococcal infection are:

• sulpha drugs with potentiating agent, trimethoprim,
• benzyl penicillin-G,
• other antibiotics,
• hormone and steroids.

With combination with antifolic agents, trimethoprim, sulpha drugs have regained their lost glory, and become effective as before. Sulphadiazine or sulphadimidine, 200 mg/ kg body weight per day orally for 5 to 7 days is a dose for acute fresh infection. Along with it, trimethoprim 100mg, four times a day orally for an adult is prescribed.

Dosage of sulpha drugs for children: 1 to 5 years, 2gm per day orally, 6 to 14 years, 4 gm per day orally.

Penicillin : The effective blood level of 0.3 units per ml maintained continuously for at least 3 days is advised for an acute fresh infection. Long-acting penicillin is not recommended. For an adult, 5 m.u. of benzyl penicillin I.M. preceded by 1 gm probenicide orally is recommended.

Other antibiotics : Oxytetracycline, tetracycline, and spiramycine 500 mg 6 hourly orally or amoxicillin 250 mg 6 hourly by mouth for 3 to 7 days, cephaloridine or kanamycine 2 gm I.M. daily for 2 days. In the female children, hormone ovocycline 0.5mg or eticycline 0.025mg twice a day orally is given to convert juvenile to adult epithelium in the vulva and the vagina. Besides, local measures of cleanliness should be employed.

Test of cure : This is an important part of the treatment itself and ensures freedom from the infecting agent. They are spread over 3 to 6 months, during which urine, secretions various glands, cultured etc. are repeatedly examined to rule out the presence of gonococci. The serologic test for syphilis should be done once again at the end of observation period to rule out any possibility of syphilis.

Non-gonococcal vulvo-vaginitis

This malady is common among female children. It may be due to:

• Bacterial infection following filth, friction, sweating and itching of the skin in the genital area. Impetigo, scabies, pediculosis, or herpes may be precursor. The common organisms are enterococci, coliform bacilli, streptococci, diphtheroids and Vincent’s bacilli.
• Protozoal infestation such as trichomonas vaginitis, enterobiasis,
• Viral: herpes progenitalis, chickenpox, smallpox,
• Fungal; Moniliasis or candidosis, erythrasma,
• Foreign body inserted into the vagina
• Systemic disease such as coryza, pneumonia, diabetes, nephritis.

Signs and symptoms are very much similar to those of gonococcal vulvo-vaginitis. Profuse vaginal discharge, excoriation of vulva and of the upper and inner surface of the thighs, itching etc. are common. The most important point is to exclude the possibility of gonococcal infection by proper laboratory tests. It is quite possible that the gonococcal etiology may be masked by the presence of other organisms. Treatment will depend on the exact etiology.

Non-gonococcal urethritis

This is observed both in the male and female children and gives rise to signs and symptoms akin to gonococcal urethritis. Examination of smears and cultures is the only way to differentiate between them. Out of curiosity, bots insert a stalk of dry grass into the urethra. This was a frequent cause of urethritis in boys.

Condylomata acuminata

Venereal warts may be observed in the children. They are often associated with irritating discharges due to various causes.

Balano-posthitis

Inflammation of the mucous membrane covering the glans penis and the inner surface of prepuce may result due to many causes such as itching, scabies, trauma, absence of local cleanliness, warts, ulcer etc. This is likely to mask venereal disease. Thorough and complete examination and investigations are essential.

Herpes progenitalis

The glans penis and the prepuce in boys and the inner surface of labia in girls are frequently the seats of an outbreak of herpes. A sherp burning pain, several tiny grouped vesicles, either confluent or discrete, surrounded by a reddened and oedematous zone are typical.

Lymphogranuloma venereum

This is due to a large virus and gives rise to chronic inflammatory enlargement of lymph nodes, which tend to mat together, adhere to the over-lying skin and finally suppurate with multiple sinuses. The condition may be met with in children as the result of oral or extra-genital infection. The two main clinical types of the disease are inguinal and ano-rectal-genital. Diagnosis is based on Frei’s intra-dermal test, complement fixation test 1 in 32 or above, the E.S.R., Formol-gel test, reversal of A/G ratio.

Granuloma inguinale or Donovanosis

This is an infective granuloma affecting primarily the skin and the mucous membrane. A striking feature is the absence of lymph node involvement. It is caused by Klebsiella granulomatis. It begins as a flat papule, which desquamates and leaves a red granulomatous surface. Chronic spreading ulceration which bleeds easily is the result. Four clinical types are met with: nodular, ulcero-vegetative, hypertropic and cicatrical. Diagnosis is based on the demonstration of intracellular Donovan bodies and their culture. The condition is observed in young children and adolescents.

Chancroid (soft sore)

Occasionally it may be met with in children.