letter to Editor References

Anogenital Condyloma Acuminata In A Toddler: The Dilemma Of Sexual Abuse Versus Non-Abuse.

Malan Malumani
Livingstone Central Hospital, Department of Internal Medicine, Head of Dermatology and Venereology Section
https://orcid.org/0000-0002-9149-002X

Owen Ngalamika
University of Zambia School of Medicine, Zambia

DOI: https://doi.org/10.55320/mjz.49.1.1004

Keywords: Condyloma accuminata, Human papillomavirus, Quadrivalent HPV vaccine, Non-Sexual Abuse infection, genital warts

Dear Editor

Condyloma acuminata, commonly known as genital warts, is a sexually transmitted infection.1,2 It is caused by human papillomavirus(HPV)- subtypes 6 and 11, low-risk oncogenic virus3; otherwise, other subtypes are implicated 2, 40, 42, 43, and 54. The high-risk subtypes are 16 and 18, which are the cause of most cervical cancer.4 Mixed infections with both the low-risk and high-risk oncogenic HPV has been reported.5

With the knowledge that genital warts are sexually transmitted, when parents or guardians are told that their child has genital or anogenital warts as opposed to some "simple trivial skin rash," there is a lot of anxiety on the part of parents trying to imagine that their child has been sexually assaulted and they had no idea.

Despite not having documented statistics of these ailments, figure 1(A and B) depict a toddler with anogenital warts with no discernable infection source in an immunocompetent client. Sexual child assault was ruled out.

Human papillomavirus has been transmitted via non-sexual routes via fomites or inanimate objects like bathing tiles, scrubbing brushes, clothing items, and pavements at swimming pools.6 The biggest question is why these children present with anogenital warts? Sexual abuse or assault is ruled out, yet these children present with 'sexually transmitted lesions,' should we reassign this condition as just an infectious agent? Is there another mode of contact transmission that we are missing or not paying particular attention to? Is this infection acquired from communal toilet seats or bathing tabs or buckets, as in Low to middle-income countries? What is the common intersection which all members of the household use? Is it the tablet or bar of bathing soap? Could a tablet of the bathing soap be the linking factor in the spread of HPV infection, especially in the pediatric population? Yes, the soap tablet is the commonest inanimate object or fomite used by members of both the nuclear and extended family.

The HPV infection is significant because of its association with neoplasias transformation, both benign and malignant.7,8 Vaccination using the quadrivalent HPV vaccine, which covers HPV 6, 11, 16, and 18-related diseases such as cervical, vaginal, vulvar, anal, penile, and head and neck carcinomas and genital warts, is beneficial with regards reduction in the incidence of HPV induced neoplasias.9,10

This surge of pediatric cases of anogenital condyloma accuminata in our population calls for further investigations and stratification of the kind of HPV infection acquired and improved healthcare delivery for those who have been found with the lesions. Also, increased sensitization on the need for vaccination of both girls and boys since hygiene is not beneficial in preventing HPV infection, as evidenced by Petca A et al.,2020. This practice has been shown to have an incremental benefit in incidence reduction of HPV associated neoplasias.9,10

HPV infection is a real burden in the Lower Middle-Income Countries, requiring the urgent attention it deserves. Soon or later we may be seeing HPV associated malignances at a much younger age due to the double burden with Human Immunodefiency Virus. A molecular epidermiological study in our patients or community is warranted.

Conflict of interest: Authors declare no conflict of interest.
Ethical consideration: Consent was obtained from the patient's guardian, and no identifying information was used in the document.
Financial support: Nil
Author contribution: All authors were involved.

References

  1. Park IU, Introcaso C, Dunne EF. Human Papillomavirus and Genital Warts: A Review of the Evidence for the 2015 Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. Clin Infect Dis Off Publ Infect Dis Soc Am. 2015;61 Suppl 8:S849-855.
  2. Dunne EF, Friedman A, Datta SD, Markowitz LE, Workowski KA. Updates on human papillomavirus and genital warts and counseling messages from the 2010 Sexually Transmitted Diseases Treatment Guidelines. Clin Infect Dis Off Publ Infect Dis Soc Am. 2011;53 Suppl 3:S143-152.
  3. Dareng EO, Adebamowo SN, Famooto A, et al. Prevalence and incidence of genital warts and cervical Human Papillomavirus infections in Nigerian women. BMC Infect Dis. 2019;19.
  4. Clifford GM, Smith JS, Plummer M, Muñoz N, Franceschi S. Human papillomavirus types in invasive cervical cancer worldwide: a meta-analysis. Br J Cancer. 2003;88(1):63-73.
  5. Padilla-Mendoza JR, Gómez-López LA, López-Casamichana M, et al. Human Papillomavirus Coinfection in the Cervical Intraepithelial Lesions and Cancer of Mexican Patients. BioMed Res Int. 2020;2020.
  6. Sabeena S, Bhat P, Kamath V, Arunkumar G. non-sexual modes of transmission of human papilloma virus. J Obstet Gynaecol Res. 2017;43(3):429-435.
  7. Gross G. Genitoanal human papillomavirus infection and associated neoplasias. Curr Probl Dermatol. 2014;45:98-122.
  8. Grulich AE, Jin F, Conway EL, Stein AN, Hocking J. Cancers attributable to human papillomavirus infection. Sex Health. 2010;7(3):244-252.
  9. Gross G. Impact of prophylactic human papillomavirus vaccines on dermatology and venereology. G Ital Dermatol E Venereol Organo Uff Soc Ital Dermatol E Sifilogr. 2008;143(4):259-265.
  10. Marty R, Roze S, Bresse X, Largeron N, Smith-Palmer J. Estimating the clinical benefits of vaccinating boys and girls against HPV-related diseases in Europe. BMC Cancer. 2013;13:10.

Medical Journal of Zambia, 49, 1