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CASE REPORT
Year : 2019  |  Volume : 20  |  Issue : 3  |  Page : 246-248

Secondary syphilis in a preadolescent boy


Department of Dermatology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University, Chennai, Tamil Nadu, India

Date of Web Publication28-Jun-2019

Correspondence Address:
Dr. R Nisha
Department of Dermatology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University, Porur, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_114_18

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  Abstract 


The problem of sexual abuse in children seems to be more common today. We report a case of acquired syphilis in an 11year old boy with painless lesion in penile region along with flat topped whitish plaque lesion in the perianal area. Serological test for syphilis was positive in the affected child. Both the parents and other siblings were negative for syphilis. Acquired syphilis in children is usually due to sexual abuse. Hence syphilitic lesions in preadolescent children should raise the suspicion of possible sexual abuse.

Keywords: Acquired syphilis, sexual abuse, sexually transmitted diseases


How to cite this article:
Nisha R, Priya B, Mahalakshmi V, Murugan S. Secondary syphilis in a preadolescent boy. Indian J Paediatr Dermatol 2019;20:246-8

How to cite this URL:
Nisha R, Priya B, Mahalakshmi V, Murugan S. Secondary syphilis in a preadolescent boy. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Jul 16];20:246-8. Available from: http://www.ijpd.in/text.asp?2019/20/3/246/261864




  Introduction Top


Syphilis is caused by Treponema pallidum. Syphilis in children can be transmitted congenitally (transplacental) or acquired (by sexual contact, sexual abuse, or blood transfusion). Due to better antenatal care and diagnosis of syphilis during the antenatal period, the incidence of congenital syphilis had drastically declined over the years;[1] however, the rate of acquired syphilis is on the rise in children because of child sexual abuse. Due to legal and social implications, identifying children with sexually transmitted diseases (STDs) and sexual abuse is very important.


  Case Report Top


An 11-year-old male child was brought to the dermatology outpatient clinic with lesions in the anal region of 1-month duration. He was born as a third child to a 34-year-old mother whose Venereal Disease Research Laboratory (VDRL) test was nonreactive during the antenatal period. The child was evaluated for constipation by a pediatrician 1 month back, and the child was referred to us in view of painless anal papules. There was no history of bleeding per rectum and no history of blood transfusion. He lives with his parents and along with his two elder siblings, aged 16 years and 13 years, respectively. He was otherwise well with normal anthropometric indices. On physical examination, there was no hepatosplenomegaly and cardiovascular, respiratory, and central nervous systems were normal too. Multiple hyperpigmented macules were noted on the palms and soles [Figure 1] and [Figure 2]. Genital examination revealed moist perianal flesh-colored flat-topped papules 1 cm × 1 cm in diameter without ulcerations [Figure 3]; anal rugae were edematous, but without the evidence of injuries. Anal sphincter tone was normal. White plaques were seen in the penis [Figure 4]. Dark field examination of perianal and penile lesion for Treponema pallidum could not be done. Complete blood count, renal function tests, and liver function tests were normal. VDRL, T. pallidum Hemagglutination Assay (TPHA) was done with the suspicion of secondary syphilis. VDRL was reactive with titres of 1:32 and TPHA was reactive (1:5120) ELISA (Enzyme-Linked Immunosorbent Assay) for HIV was negative. The child was diagnosed to have secondary syphilis and treated with single-dose intramuscular benzathine penicillin (50,000 IU/kg body weight). In view of secondary syphilis, parents were questioned and examined for syphilitic lesions. VDRL and TPHA were negative in parents. Documentation of mother's antenatal records showed that HIV and VDRL tests were negative. The child's two elder male siblings were examined and they were not found to have any lesions suggestive of STDs. Since acquired syphilis is rare in a preadolescent child, we suspected sexual abuse in our patient. Attempts were made to find out the perpetrator, but it was in vain since the child was not giving history regarding abuse or homosexual contact. Psychological counseling was given to the parents, and additional sessions with social worker were done. The child is doing well with a four-fold fall in VDRL titers after 3 months of therapy, and there was a complete resolution of symptoms.
Figure 1: Multiple shiny atrophic macules in the left palm

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Figure 2: Hyperpigmented macule in the left sole

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Figure 3: Verrucous plaques (condyloma lata) in the perianal region

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Figure 4: White plaque in the glans penis

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  Discussion Top


Acquired syphilis is divided into early and late syphilis. Early syphilis comprises the primary, secondary, and early latent stages.[2] Late syphilis refers to late latent syphilis, gummatous, neurological, and cardiovascular syphilis. Primary syphilis is characterized by an ulcer or chancre at the site of infection or inoculation. Secondary syphilis manifestations include a skin rash, condylomata lata, mucocutaneous lesions, and generalized lymphadenopathy.[1],[2] Children have 2%–10% chance of contracting STD pathogens during sexual abuse, and the prevalence of acquired syphilis among all the sexually transmitted infections in children is 22.2%.[3] In the scenario of acquired syphilis in children, it is at times difficult to identify the source of infection because of the challenges in eliciting the history of sexual contact or abuse from young children. Diagnosis of secondary syphilis can be confirmed if T. pallidum is demonstrated by dark-field microscopy or direct fluorescent antibody testing of skin specimens from lesions, but the sensitivity is low for direct demonstration of the spirochete. Hence, serological test remains the principle means of diagnosis, and it traditionally involves screening with nontreponemal tests, followed by a confirmatory treponemal test.[4] Penicillin remains the drug of choice for treating acquired syphilis. A largest national survey in 17,220 children and adolescents by the Government of India under the Ministry of Women and Child Development in 2007 showed that abuse is most common between 12 and 15 years of age, and it further showed that it was more common in boys (52.94%) than the girls (47.06%).[5] Mendiratta et al.[6] in their study reported a rise in the prevalence of STDs in children from 1% to 4.9% in the years 2007–2011 and found it to be more common in adolescent females. Homosexuality was reported in 33% males, outnumbering the cases of sexual abuse. In our case, it is likely to be a case of sexual abuse since primary infection in the anal region is very rare in children when both the parents are negative for syphilis. However, the possibility of homosexual contact could not be completely ruled out in our case. Evaluation of sexual abuse is a multidisciplinary approach. The clinician must be aware of normal pediatric behaviors and developmental milestones and should be well versed in child-interviewing techniques. Physical examination findings suggestive of sexual abuse are acute abrasions and lacerations of the genitalia, bites or suction marks on the genitalia or inner thighs, cleft extending through >50% of the posterior hymenal rim and rapid reflex anal dilatation without a medical reason.[7] In our case, no such findings were demonstrable which could probably be due to a long time gap between the episode of sexual abuse and presentation to us. Psychiatric disturbances such as mutism, anorexia, attempted suicide, recurrent psychosomatic illness and inappropriate behaviour with other children or adults are less specific findings of sexual abuse.[8] Minimum criteria laid by Bays and Chadwick[9] for selective testing of sexually abused children for syphilis include: (1) children with evidence of STDs, (2) adolescents, (3) foreign-born children, (4) children with a parent, family member, or perpetrator with syphilis, and (5) children living in areas with a high incidence of syphilis. Obtaining a history of sexual abuse, in this case, is a delicate and difficult task as the victim is preadolescent. Hence, identifying the source of infection and protecting the child from abuse can prove difficult. Counseling with experts having advanced training in child sexual abuse is mandatory, and efforts are required at the parental and society level to improve the awareness regarding the transmission on STDs. Health education along with behavior therapy is important for affected children and parents.


  Conclusion Top


Rising trends of occurrence of STDs in school children indicate a rampant rise in sexual abuse, and it calls for strict punishment and immediate implementation of mandatory sex education in schools.

Consent

Informed consent was obtained for publishing the patient data and photographs before drafting the manuscript.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Woods CR. Syphilis in children: Congenital and acquired. Semin Pediatr Infect Dis 2005;16:245-57.  Back to cited text no. 1
    
2.
Heston S, Arnold S. Syphilis in children. Infect Dis Clin North Am 2018;32:129-44.  Back to cited text no. 2
    
3.
Dhawan J, Gupta S, Kumar B. Sexually transmitted diseases in children in India. Indian J Dermatol Venereol Leprol 2010;76:489-93.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Kliegman RM, Stanton BF, Schor NF. Nelson Textbook of Pediatrics. 20th ed. Philadelphia: Elsevier Publication; 2016. p. 1473-74.  Back to cited text no. 4
    
5.
Study on Child Abuse. India; 2007. Available from: http://www.WCD.nic.in/childabuse.pdf. [Last accessed on 2018 Sep 20].  Back to cited text no. 5
    
6.
Mendiratta V, Agarwal S, Chander R. Reappraisal of sexually transmitted infections in children: A hospital-based study from an urban area. Indian J Sex Transm Dis AIDS 2014;35:25-8.  Back to cited text no. 6
    
7.
Laecher V. Physical and sexual abuse. In: Harper J, Oranje A, Prose N, editors. Textbook of Pediatric Dermatology. 2nd ed. Oxford: Blackwell Publication; 2006. p. 1850-66.  Back to cited text no. 7
    
8.
Ermertcan AT, Ertan P. Skin manifestations of child abuse. Indian J Dermatol Venereol Leprol 2010;76:317-26.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Bays J, Chadwick D. The serologic test for syphilis in sexually abused children. Adolesc Pediatr Gynecol 1991;4:148-51.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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