Anogenital warts in prepubertal children; sexual abuse or not?

Prevalence and Type of HPV Genital Infection in Girls: A Systematic Review and Meta-Analysis

OBJECTIVES

This investigation explored the prevalence of human papillomavirus (HPV) infection by subtypes in girls aged up to 12.

METHODS

Four indexed databases, PubMed, EMBASE, Cochrane, and LILACS, were evaluated. Twenty-nine observational studies published between 1992 and 2018 were included.

RESULTS

The prevalence of genital condyloma acuminatum or HPV-positive serology due to prior infection among girls with suspected/confirmed sexual abuse was 25%, and without a history or information about abuse, 8%. The analysis indicated that low-risk HPV types were the most prevalent among this group, corresponding to 86.6% of the identified types. Human papillomavirus 6 and 11 were the most prevalent types, followed by HPV 16 and 2. Moreover, the analysis identified limited epidemiological data on genital warts in children up to 12 years. Several studies focused on convenience sampling, sexually abused girls, or failed to separate data by gender.

CONCLUSION

Findings of our systematic review and prevalence meta-analysis indicate that the occurrence of HPV infection in girls aged 12 or younger is relatively rare, underscoring the significance of understanding the prevalence of HPV in the pediatric population. However, it is essential to be cautious when applying these results to the pediatric population, given cases of girls who are suspected of or have suffered sexual abuse. There is a pressing need for further research to fill the information gap on HPV infection in this vulnerable group.

Anogenital warts and relationship to child sexual abuse: Systematic review and meta-analysis

BACKGROUND/OBJECTIVES

In children, distinguishing anogenital warts (AGW) acquired innocently from those acquired by child sexual abuse (CSA) is challenging. High-quality studies examining this relationship are sparse. Here, we sought to evaluate the association between AGW and sexual abuse in children 12 years of age and younger with respect to wart location, age, and gender.

METHODS

A systematic review of Ovid MEDLINE, Embase, and Web of Science was performed for studies published on or before 2/16/2018. Studies were eligible for inclusion if they contained at least 10 patients 12 years old and younger and reported the number of patients who were sexually abused. The principal summary measures were the odds ratios (OR) of reported CSA with respect to subject age, wart location, and gender.

RESULTS

Three hundred twenty-seven studies were identified through record search. Twenty five were included in a summary synthesis (791 subjects); 10 were included in the final statistical analysis (199 subjects). In our overall review, 102 of 468 (21%) females and 36 of 204 (18%) males with AGW were abused or probably abused. Overlapping HPV types were found in abused and non-abused subjects. Perianal location and gender were not significant predictors of abuse. Both age and genital wart location (penis, vulva) did significantly predict CSA (α = .05). The odds ratio for sexual abuse of children aged 3-4 years was 7.45; 6.52 for ages 5-8 years; and 6.93 for ages 9-12 years compared to those 0-2 years of age. Genital location was associated with an OR of CSA of 5.93.

CONCLUSIONS

Our systematic review supports a significant association between AGW in a child greater than 2 years of age and odds of CSA. Genital wart location significantly predicts CSA as well. HPV typing is not a reliable method to ascertain CSA. Male family members and acquaintances were the most likely perpetrators of abuse.

Current concepts on human papillomavirus infections in children

Current evidence is strong enough to conclude that human papillomavirus (HPV) can be transmitted both sexually and non-sexually. The debate on HPV infections in children still continues but it is more focused on HPV prevalence than on transmission modes. HPV DNA detection in amniotic fluid, foetal membranes, cord blood and placental trophoblastic cells all suggest HPV infection in utero, i.e. prenatal transmission. Based on recent meta-analysis, vertical transmission occurs in approximately 20% of cases. Most of the mucosal HPV infections in infants are incident, persistent infections in oral and genital mucosa being found in less than 10% and 2% respectively. The mother seems to be the main transmitter of HPV to her newborn, but subsequent HPV infections are acquired horizontally via saliva or other contacts. Bimodal peak prevalence is seen for skin warts, oral papillomas and recurrent respiratory papillomatosis (RRP) in younger and older age groups, suggesting similar epidemiology. Of the clinical HPV diseases, juvenile-onset-RRP and genital condylomata are problematic; the former because of its life-threatening potential and the latter because of possible sexual abuse. HPV6 and 11 are the most common genotypes in both the lesions. Early in life, infections by the high-risk HPV genotypes may also remain persistent for a considerable period, and should be of considerable importance for HPV vaccination strategies.

Successful treatment of perianal warts in a child with 5% imiquimod cream

Treatment of anogenital warts in children is difficult. Commonly used therapeutic regimes can be painful, variably effective and recurrence rates are high. Imiquimod is a recently developed imidazoquinolin heterocyclic amine that is an immune response modifier. Topical imiquimod has been used successfully to treat anogenital warts in adults. This case documents the effective use of topical imiquimod in the treatment of perianal warts in children.

Cutaneous mimickers of child abuse: a primer for pediatricians

The annual incidence of child abuse was estimated to be 2.8 million by the national incidence study conducted in the USA in 1993, which is a two-fold increase compared to 1986. Awareness of child abuse has been increasing since the 1960s. Although most victims of child abuse present with cutaneous lesions, many genuine skin diseases may appear as non-accidental injuries which, if not recognized, may lead to misdiagnosis of child abuse. Here, we review the most common cutaneous mimickers of child abuse in order to increase awareness of these disorders and reduce erroneous diagnosis of child abuse.

[Carbon dioxide laser therapy for anogenital warts in children]

BACKGROUND

Management of anogenital condylomas in children can be delicate especially in the event of profuse lesions and raises the issue of identification of the mode of contamination.

PATIENTS AND METHODS

The dossiers of all children referred to the laser unit of "La Conception" University Teaching Hospital in Marseille between 1995 and 2005 for treatment of profuse anogenital condylomas were studied retrospectively. The main objective was to evaluate the efficacy and tolerability of CO2 laser treatment for anogenital condylomas. The secondary objective was to invstigate the mode of contamination.

RESULTS

Seventeen children aged 2-11 years were treated. All were examined in routine fashion, as were their parents and siblings, for signs of PVH infection and sexual abuse. Laser was performed by the same operator under general anaesthesia. For all of these children, healing was rapid and without complication or functional sequelae. Two children were lost to follow-up. Ten children (66.7% of the treated children) presented no recurrence after only one session of CO2 laser. Vertical transmission was diagnosed for 6 children and horizontal transmission for 7 children. For 4 children, the mode of contamination remained unknown. No cases of sexual abuse were proven.

CONCLUSION

Due to its painless nature, rapid healing, low rate of complications and recurrence, and minimal risk of scarring, CO2 laser is an effective treatment for the management of profuse anogenital condylomas in children. Vertical transmission is the most frequent mode of contamination and sexual abuse remains rare, although clinicians must keep this possibility in mind.

High-Risk Types of Human Papillomavirus (HPV) DNA in Oral and Genital Mucosa of Infants during Their First 3 Years of Life: Experience from the Finnish HPV Family Study

BACKGROUND

This study is aimed to clarify data on the acquisition, persistence, and clearance of high-risk types of human papillomavirus (HPV) DNA from the mucosa and the determinants of persistent mucosal HPV infection in infants.

METHODS

Oral and genital scrapings from 324 infants were collected at birth, 3 days after delivery, and 1, 2, 6, 12, 24, and 36 months after delivery and tested for the presence of HPV DNA by nested polymerase chain reaction and hybridization with 12 high-risk HPV oligoprobes. HPV status and demographic data for parents were analyzed.

RESULTS

During the follow-up period (median duration, 26.2 months), HPV DNA was found to be present in 12%-21% of oral scrape samples and in 4%-15% of genital scrape samples obtained from the infants. Oral HPV infection was acquired by 42% of children, cleared by 11%, and persisted in 10% of the infants, whereas 37% were never infected. The corresponding figures for genital HPV infection were 36%, 14%, 1.5%, and 47%. Kaplan-Meier analysis revealed that both the cumulative incidence of infection and clearance of HPV were parallel in oral and genital sites. Persistent oral HPV infection in the child was significantly associated with persistent oral HPV infection in the mother at month 36 of follow-up, hand warts in the mother, young age at onset of sexual activity for the mother, and the mother's use of oral contraception, as well as with the father's oral HPV status at 24 months. Persistent genital HPV infection in the infant was predicted by if the mother had started smoking at 18-21 years of age and by a history of genital warts.

CONCLUSIONS

Persistent carriage of high-risk HPV types was detected in oral and genital mucosa specimens obtained from 10% and 1.5% of the infants during their first 26 months of life. The rates of acquisition and clearance of HPV were similar in oral and genital mucosa.

Anogenital and respiratory tract human papillomavirus infections among children: age, gender, and potential transmission through sexual abuse

OBJECTIVES

To evaluate human papillomavirus (HPV) presentation among children <13 years of age and its association with suspected child sexual abuse (CSA), and to assess sexual abuse consideration among different clinical services treating these children.

METHODS

Records of children <13 years of age from 1985 to 2003 were selected for review if the children had a HPV-related International Classification of Diseases, Ninth Revision, code or had been examined in the CSA clinic. Abstracted data included demographic features, clinical findings, clinical services involved, age at diagnosis, age when care was first sought, and age when symptoms were first noted.

RESULTS

HPV was identified by clinical examination and/or biopsy for 124 children, 40 with laryngeal lesions, 67 with anogenital lesions, 10 with oral lesions, and 7 with both anogenital and oral lesions. The mean age at HPV diagnosis was 4.0 +/- 2.9 years, compared with 6.4 +/- 3.0 years for 1565 HPV-negative children. Among 108 HPV cases with data for age when symptoms were first noted, the mean age was 3.3 +/- 2.9 years (median: 2.2 years) for children with anogenital and oral HPV and 2.4 +/- 2.3 years (median: 1.9 years) for children with laryngeal HPV. Among HPV-positive patients, 56% were female, compared with 82% of HPV-negative children. Fifty-five (73%) of 75 children with anogenital HPV infections were referred to the CSA clinic for evaluation, compared with none of 49 children with laryngeal or oral HPV infections treated by the otolaryngology service. Laryngeal cases presented earlier than anogenital and oral lesions. Abuse was considered at least possible for 17 of 55 children with any CSA evaluation. The mean age of likely abused, HPV-positive children was 6.5 +/- 3.8 years (median: 5.3 years), compared with 3.6 +/- 2.3 years (median: 2.6 years) for likely not abused, HPV-positive children. The likelihood of possible abuse as a source of HPV infection increased with age. The positive predictive value of HPV for possible sexual abuse was 36% (95% confidence interval: 13-65%) for children 4 to 8 years of age and 70% (95% confidence interval: 35-93%) for children >8 years of age.

CONCLUSIONS

The data from this epidemiologic study of HPV suggest that many anogenital and laryngeal HPV infections among preadolescent children are a result of nonsexual horizontal transmission, acquired either perinatally or postnatally. It seems that many children >2 years of age acquire HPV infection from nonsexual contact. Different subspecialties vary greatly in their suspicion and evaluation of CSA. At this time, there remains no clear age below which sexual abuse is never a concern for children with anogenital HPV infections. Every case needs a medical evaluation to determine whether enough concern for abuse exists to pursue additional investigations.

Human Papillomavirus Infections of the Genital and Respiratory Tracts in Young Children

Human papillomavirus (HPV) causes papillomas (warts) on the skin and respiratory mucosal surfaces (laryngeal and oral papillomas) in addition to condyloma acuminata (anogenital warts). HPV has become one of the most common sexually transmitted diseases in adults. Vertical transmission from mother to infant during birth is well recognized. Laryngeal papillomas are the most common tumors of the larynx in children worldwide, and recurrent lesions are common occurrences. Anogenital warts in children are problematic in that child sexual abuse is a potential means of acquisition, but many cases are acquired perinatally. Postnatal acquisition by nonsexual means also can occur. The likelihood of sexual abuse as the mode of acquisition increases with increasing age in childhood. The virus infects primarily epithelial cells, where it can exist as a long-term latent infection that can reactivate or persist actively (even subclinically), with resultant accumulation of host chromosomal mutations. The latter accounts for the oncogenic potential of a number of HPV types, and childhood infections may lead to neoplasia later in life. Regression of papillomas over the course of months to years is the usual natural course. Numerous treatments are available, but most do not prevent persistent infection or problematic recurrences. Multivalent HPV vaccines have been developed, and early results of clinical trials appear to be very promising.

Genital warts in children: problems of management

Anogential warts are much less common in children than in adults. In children the presence of anogenital warts have been suggested as an indicator for sexual abuse because of the association of genital warts with sexual activity. Difficulties of establishing mode of transmission arise because of the long latency of human papillomavirus and possibility of vertical and non-sexual transmission. A multidisciplinary approach is advised for the proper care of children with anogenital warts.

Human papillomavirus infections in children: the potential role of maternal transmission

To date, more than 100 types of human papillomavirus (HPV) have been identified. In the past 20 years, there has been an increasing interest in HPVs because of their potential role in the pathogenesis of malignant tumors. HPV infections are known to affect predominantly adult, sexually active age groups, whereas skin warts, at various anatomic sites, are usually associated with younger individuals. The modes of viral transmission in children remain controversial, including perinatal transmission, auto- and hetero-inoculation, sexual abuse, and, possibly, indirect transmission via fomites. Recent studies on perinatal infection with HPV have been inconclusive. It is still unclear how frequently perinatal infection progresses to clinical lesions, whether genital, laryngeal, or oral. Conflicting reports have been published on the prevalence of HPV infections in children. The current consensus is, however, that newborn babies can be exposed to cervical HPV infection of the mother. The detection rate of HPV DNA in oral swabs of newborn babies varies from 4% to 87%. The concordance of HPV types detected in newborn babies and their mothers is in the range of 57% to 69%, indicating that the infants might acquire the HPV infection post-natally from a variety of sources. HPV antibodies have been detected in 10% to 57% of the children, and there is usually no correlation between seropositivity and the detection of HPV DNA in either the oral or the genital mucosa. There is also evidence that transmission in utero or post-natal acquisition is possible. The mode of in utero transmission remains unknown, but theoretically the virus could be acquired hematogenously, by semen at fertilization, or as an ascending infection in the mother. The understanding of viral transmission routes is important, particularly because several vaccination programs are being planned worldwide. The serologic response to HPV detected in different populations of young women or women at risk of cervical cancer might be due to genital infections, but the possibility that HPV infection has been acquired earlier in life through the oral mucosa or respiratory tract cannot be ruled out.

The prevalence of genital human papillomavirus infections in abused and nonabused preadolescent girls

OBJECTIVE

To compare the prevalence of genital human papillomavirus (HPV) infections in sexually abused and nonabused preadolescent girls and assess the feasibility of conducting a longitudinal study of the natural history of HPV infection in this population.

METHOD

Consecutively referred, 5- to 12-year-old girls who were evaluated for sexual abuse by a Child Advocacy and Protection Team were invited to participate in the study. During a standard forensic medical examination, 2 specimens for HPV testing were obtained (one by rubbing a Dacron swab over the perineum and the other by lavaging the vagina with phosphate-buffered saline). The specimens were evaluated for HPV DNA by polymerase chain reaction using MY09/11 consensus primers and high-risk (16,18,31,33,35,39,45,51,52, 56,58) and low-risk (6,11,42,43,44) types were detected with a solution hybridization assay, the SHARP Signal System (Digene Diagnostics). The genital area was examined for warts and subclinical, colposcopic evidence of HPV. Participants were invited to return for longitudinal evaluation at 4-month intervals for 2 years.

RESULTS

Sexual abuse was confirmed in 29 (72.5%) of the 40 study participants, suspected in 2 (5%), and ruled out in 9 (22.5%). None of the girls had genital warts or abnormal colposcopic findings. HPV DNA was detected in 5 (16%) of the 31 girls with confirmed or suspected sexual abuse (1 with high-risk and 4 with low-risk types) and none of the nonabused girls (Fisher's exact test). Girls who tested positive and negative for HPV did not differ significantly in age or type of abuse. Despite close telephone follow-up and numerous attempts to schedule appointments, none of the participants returned for follow-up.

CONCLUSIONS

Genital HPV infection is more common among sexually abused than nonsexually abused girls, with the majority of infections not clinically apparent. Because it is so difficult to study the natural history of these infections in abused children, it may be necessary to draw inferences about the long-term sequelae of pediatric HPV infections from longitudinal studies of girls who voluntarily initiate sexual activity soon after menarche.

Detection of human papillomavirus DNA on the fingers of patients with genital warts

OBJECTIVE

To determine whether patients with genital warts carry human papillomavirus (HPV) DNA on their fingers.

METHODS

14 men and eight women with genital warts had cytobrush samples taken from genital lesions, finger tips, and tips of finger nails. Samples were examined for the presence of HPV DNA by the polymerase chain reaction.

RESULTS

HPV DNA was detected in all female genital samples and in 13/14 male genital samples. HPV DNA was detected in the finger brush samples of three women and nine men. The same HPV type was identified in genital and hand samples in one woman and five men.

CONCLUSION

This study has identified hand carriage of genital HPV types in patients with genital warts. Although sexual intercourse is considered the usual mode of transmitting genital HPV infection, our findings raise the possibility of transmission by finger-genital contact.

Sexually transmitted diseases in children. A practical approach

Basically, all sexually transmitted diseases occurring in adults can be transmitted to children. Patterns of transmission are as follows: intrauterine, perinatal, by sexual abuse, by voluntary sexual contact, by accidental autoinoculation or heterinoculation, or indirect transmission. In children between 2 and 10 years of age, sexual abuse is first in possible ways of transmission. Taking into consideration the age of the child, the sexually transmittable agent and the localization of the infection helps in assessing the possibility of sexual abuse.

Common association of HPV 2 with anogenital warts in prepubertal children

Anogenital (AG) warts in 31 prepubertal children were HPV typed by nonisotopic in situ hybridization (NISH) using digoxigenin-labeled probes for human papilloma virus (HPV) types 1-5, 6, 11, 16, 18, 31, and 33. Mode of transmission was determined from historical, clinical, and laboratory data independent of HPV typing. HPV 2 was detected most commonly (13/31 warts) followed by HPV 6 (7/31), HPV 11 (5/31), and HPV 16 (1/31). Although not reaching statistical significance, our results suggested that a mucosal HPV type (6, 11, 16) in a child's AG warts implied transmission from mucosal warts and conversely cutaneous HPV 2 transmission from warts at a cutaneous site. HPV typing provided no helpful information regarding actual mode of transmission of AG warts in these children. The high prevalence of HPV 2 in children's AG warts and the low prevalence of sexual abuse (2 of 31 children) found in this study suggest innocent auto- or heteroinoculation from cutaneous warts may be a common means by which children acquire AG warts.

Condyloma acuminata in infants and children. A survey of colon and rectal surgeons

PURPOSE

Condyloma acuminata are anogenital warts caused by a human papillomavirus. Human papillomavirus is a tissue-specific, site-specific, double-stranded DNA virus, which is capable of inducing high-grade genital intraepithelial neoplasia and malignancy. The incidence of anogenital warts in the pediatric age group is rising, and sexual abuse has been implicated as a potential cause.

METHODS

Accumulated data from separate questionnaires sent to practicing colorectal surgeons who are members of The American Society of Colon and Rectal Surgeons and fellows in colon and rectal training programs have been analyzed.

RESULTS

Thirty percent of those polled responded to our survey. Of the respondents, 93 percent see less than two pediatric cases per year. Seventy-two percent stated that tissue specimens would be sent routinely for histopathologic identification. Although 73 percent of surgeons consider anogenital warts a potentially sexually transmitted disease, only 26 percent reported screening for other sexually transmitted diseases. A diagnostic and therapeutic protocol is followed by 19 percent of respondents. Patient follow-up varied from six months (43 percent) to lifelong examinations (3 percent). Sixty-four percent of respondents agreed that a diagnostic and therapeutic protocol based on current knowledge would be beneficial.

CONCLUSION

We conclude that colon and rectal surgeons have a low exposure to anogenital warts in infants and children. Furthermore, we believe that a diagnostic and therapeutic protocol based on the current literature would be helpful.

Hand-genital transmission of genital warts? An analysis of prevalence data

The role of hand-genital transmission in the aetiology of genital warts is unclear. However this route is suggested by a number of observations including the relatively high proportion of genital warts in children which contain HPV types 1-4 (15% for children and 2% for adults). We compared two transmission models; one which assumes that hand-genital transmission occurs and one that it does not, and determined the conditions in which each model can reflect the available prevalence data. Hand-genital transmission provides a simple explanation of the observed differences in the proportions of genital warts containing HPV types 1-4 and 6/11 in children and adults. If hand-genital transmission does not occur, the observed difference could only be explained by an eightfold greater probability of transmission to children of types 1-4 than types 6/11, or by an eightfold greater duration of infection with types 1-4. Our findings provide support for the view that genital warts may be transmitted by hand-genital contact.