Early Childhood Herpetic Vulvitis: Autoinoculation, Vertical Transmission, Fomites or Sexual Abuse The Level of Medical Evidence

1
Early Childhood Herpetic VulvitisAutoinoculation
, Vertical Transmission, Fomites or Sexual
AbuseThe Level of Medical Evidence

• A. R. Markos FRCOG FRCP
• Consultant in Genito Urinary Medicine and Sexual
  Health
• Mid Staffordshire NHS Foundation Trust, Stafford
  Hospital

2
Medical History

• History 2 year old girl with vulval soreness
• O/E Slight discharge, dirty perineum, no
  bruising or scratching
• Vulval swabs Herpes Simplex Virus
• PMH Recurrent chronic constipation (repeated
  enemas, intestinal biopsies, tertiary referral)
• SH Other siblings in Social Care
• Dispute on paternity DNA testing
• Allegations of Sexual Abuse

3
Medical Records Problems

• Conflicting account of Clinical Examination
• No bruising or scratching at the introitus
• Soiled at edge of introitus/Gaping /No hymen
  seen
• Missing Community Paediatrics Notes
• Missing Child Protection Committee Notes

4
Herpes Genitalis

• Herpes Simplex Virus Type I and II (HSV-I and
  HSVUII)
• Aymptomatic Expression
• Symptomatic Expression Herpes Genitalis
• Herpes Libialis
• Gingivo-stomatitus
• Extra-genital
• Latent Infection
• Activation Fever, Pneumonia, UV, Stress,
  Menses, Trauma

5
HSV-I HSV-II

• Prevalence - Population group, Race, Social
  Class, Age sensitive
• Transmission - Mucousal surface, Skin-
  Mucousal junctions, Skin cracks
• Silent Clinical Lesions
• Extra-Genital Lesions - Fingers, Eyes
  (Autoinoculation, Viraemia)

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Prevalence HSV Antibodies

• 2106 serum samples
• 0-19 years old
• HSV-I 1-2y 20
• 1-4y 24
• 15-19y 37
• HSV-II 0.5
• Scand J Infect Dis 200335(8)498-502

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Neonatal HSV

• California
• 1985 11.7/100,000 Live Births,
• 1990 11.3/100,000 Live Births
• 1995 11.4/100,000 Live Births
•  
• J Infect Dis 1999180(1)199-202

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Neonatal HSV

• British Isles
• 1986 1991 76 Infants
• UK 1.6/100,000 Live Births
• 25 HSV-I
• 24 HSV-II
• 27 Unknown
• 27 Disseminated Infection
• 23 Herpetic Encephalitis
• 26 Localised infection
• 19 Neonatal Death (26)
• 25 Long term siqualae / Death (33)
• 1/2 Post discharge presentation
• 21 Maternal evidence of Herpes Genitalis
•  
• Paed Perinat Epidemiol 199610(4)432-42

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Prevalence of Genital Herpes Simplex in Children

• 4 Girls and 2 Boys
• 5 HSV-I
• 1 HSV-II
• Sexual Abuse 4/6
• Genital HSV possible indicator of Sexual Abuse
• Am J Dis Child 1984 138(9)872-4

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Transmission to Newborn and Early Childhood

• Vertical Transmission/Trans placental maternal
  Antibodies
• Autoinoculation
• Virus inactivated readily in room temp drying
  Close contact, fresh, large inoculum
  
• Fomites and Inanimate objects
• Possible but not likely
• Direct contact
• Most likely

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Literature and Research for Childhood Herpes
Genitalis

• Scarce
• American School
• Transmission by sexual contact is the most
  common source of childhood Genital Herpes
•  
• RCP Working Party
• The virus is transmitted by close personal
  contact
• (including genital to genital and oral to genital
  contact)
• Identifying HSV/II as a cause of Genital Herpes
  in a child cannot prove or disprove sexual
  contact as means of transmission

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The level of medical evidence for Early
Childhood Herpetic Vulvitis

•  
• Expert committee reports or opinions and/or
• clinical experience of respected authorities
• (Level IV)

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Royal College ofObstetricians andGynaecologists
Setting standards to improve womens health
Risk Management and Medico-Legal Issues In
Womens Health Joint RCOG/ENTER Meeting
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