Anogenital condylomata acuminata in young children: not always result of sexual transmission

Abstract

Condylomata acuminata lesions, commonly known as anogenital warts, are caused by human papillomavirus and manifest as flesh-coloured or hyperpigmented papules or plaques in the anogenital region. We report the case of a previously healthy young child that presented with anal condyloma lesions without other accompanying symptoms. His mother had similar lesions in the genital area. After careful investigation, no evidence of sexual abuse was found. Gradual clinical improvement was observed without treatment. This case highlights a disease that, when diagnosed in children, should alert the physician to the possibility of sexual abuse. However, other transmission routes, such as vertical transmission or autoinoculation and heteroinoculation during non-sexual contact, should also be considered.

Description

An otherwise healthy male in early childhood presented to the emergency department with a 2-month history of anal lesions. He was accompanied by both parents, who denied that he had experienced itching, pain or rectal bleeding. Additionally, other symptoms such as cough or hoarseness were not noticed. The patient, an only child, lived with his parents and did not attend day care. He was taken care of by his mother, and they often bathed together and shared towels. The primary caregiver complained of similar lesions in the genital area, but none of the other family members were symptomatic. The patient had no known history of sexual assault, and a physical examination showed a well-developed and well-nourished child without any signs of acute or chronic trauma. An anogenital examination revealed the presence of flesh-coloured papules in the perianal area, which were consistent with condylomata acuminata. No lesions were observed on the penile shaft. Considering the possibility of sexual transmission, we performed a screening for other sexually transmitted infections, namely HIV, syphilis, and hepatitis B and C, which showed negative results. The patient was then referred to the multidisciplinary social paediatric in-hospital team and to the legal authorities, who found no evidence of sexual abuse. Medical care was provided to the family members, and the patient was also referred to a dermatologist for further evaluation. As many cases of condylomata acuminata resolve spontaneously within a few years, a wait-and-see approach was adopted and regular follow-up appointments were scheduled. Nine months following the diagnosis, the lesions had subsided slightly, and no psychological distress was reported by the family or the multidisciplinary team. Good hygiene practices, such as frequent hand washing, were promoted and family members were advised to avoid sharing household linens (towels and bedding).

Condylomata acuminata, also known as anogenital warts, are common benign tumours that develop as a result of human papillomavirus (HPV) infection.^1–4 Mucosotropic types 6 and 11 are the most frequent HPV genotypes identified in anogenital warts.^4–6 This condition manifests as flesh-coloured, pink, or brown papules that may coalesce into larger plaques with a cauliflower-like shape. In male children, warts develop most commonly in the perianal area and are rarely present on the penile shaft.^{3 6} In adults, the disease is most frequently acquired through sexual transmission. In children, vertical and horizontal transmission by auto or heteroinoculation should also be considered.^4–9 The association of HPV infection with sexual abuse varies with age and appears to be greater in children older than 4 years. However, age is not the only factor that should be acknowledged.^{1 4 10} A detailed medical and social history should be obtained, followed by a complete physical examination and a screening for other sexually transmitted infections.^9–12 Vertical transmission of HPV, particularly perinatal transmission during delivery, can lead to anogenital condyloma or laryngeal papilloma. Most cases of vertical transmission are diagnosed in the first 2 years of life; however, the variable latency period of HPV makes it difficult to establish an upper age limit for perinatal infection. Autoinoculation from non-genital warts and heteroinoculation during non-sexual contact have also been reported in the literature. Finally, transmission via fomites has been previously suggested, but evidence supporting this mode of transmission is limited.^1–5

Managing condylomata acuminata in children benefits from a multidisciplinary approach involving paediatricians, dermatologists, family physicians, psychologists and social workers.^{3 4} Spontaneous resolution is common in immunocompetent children; therefore, a wait-and-see approach is an acceptable option for asymptomatic patients.^{3 6 13} Treatment may be initiated if the child develops symptoms, presents with extensive disease or if the lesions cause marked emotional or social distress.^{1 3}

Learning points.

• The presence of anogenital warts should alert physicians to the possibility of sexual transmission, but it is not pathognomonic.

• In children younger than 2 years of age without a history of neglect or abuse, signs of physical injury, abnormal behaviour, or evidence of other sexually transmitted infections, non-sexual transmission is more likely to be the cause of human papillomavirus infection.

• A multidisciplinary approach is recommended in such cases.

Ethics statements

Patient consent for publication

Consent obtained from parent(s)/guardian(s).