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Appendices
APPENDIX E: Evaluation of Sexually Transmitted Diseases
| Infections with Very High Likelihood of Sexual Transmission |
| Infection and Sites of Infection |
Incubation Period and Symptoms |
Transmission |
Diagnostic Tests |
Gonorrhea (GC)
Neisseria gonorrheae
- Vagina
- Cervix
- Urethra
- Rectum
- Throat
- Pelvis (PID)
- Systemic
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Vaginal infection (vaginitis) in prepubertal girls usually causes discharge within 2-7 days.
Rectal and throat infections in all ages, as well as cervical infections (cervicitis) in adolescents, are often asymptomatic.
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During delivery, an infant may be infected. Eye infections are most common and result in eye discharge within a few days of life. Vaginal and rectal infections are also possible.
Vaginal infections beyond the newborn period should be presumed to be from sexual abuse. There is little known about the persistence of asymptomatic rectal and pharyngeal infections.
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The only acceptable testing method for diagnosis is bacterial culture using a modified Thayer-Martin Medium in a CO2 rich environment.
A positive culture must be confirmed by two other identification tests before the diagnosis is made.
Misidentification will occur if these methods are not followed. Note: NAAT tests are suitable for screening but not diagnosis.
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Chlamydia
Chlamydia trachomatis
- Vagina
- Cervix
- Urethra
- Rectum
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Most chlamydia infections do not cause symptoms.
Tissue culture tests should be positive 5-7 days after contact. Identification earlier than this is very unlikely.
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Perinatal infection may be unrecognized for years.
Asymptomatic vaginal and rectal perinatal infections have been documented for up to 3 years.
Chlamydia pharyngitis has not been reported and pharyngeal chlamydia tests are not recommended.
A chlamydia infection should be presumed to be from sexual abuse if perinatal infection has been excluded.
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The only acceptable method for diagnosis is positive bacterial tissue culture.
Misidentification will occur if other methods are used.
Institutions have specific requirements for obtaining, transport and/or storage of the particular type of medium used.
Note: NAAT tests are suitable for screening but not diagnosis.
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Syphilis
Treponema pallidum
- Primary infection causes a painless ulcer at the site of contact.
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Primary infection usually occurs about 3 weeks after exposure (range from 10 to 90 days).
Secondary syphilis causes rash, fever, and other symptoms 1-2 months later. Condyloma latum, a wart like rash, may be seen around the anus and vagina.
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Perinatal infection often occurs. It is routine practice to screen for maternal syphilis.
Infection is almost always spread by direct sexual contact. Non-sexual transmission, other than perinatal infection, would be extremely unusual. Infection should be presumed to be through sexual abuse unless acquired by perinatal (congenital) infection.
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Although definitive diagnosis can be made by microscopic identification, adequate specimens are usually not available for this type of testing.
Most cases of syphilis are diagnosed through serologic blood tests. A presumptive diagnosis of syphilis can be made if there is a positive non-treponemal test (RPR, VDRL, or ART) and a positive treponemal tests (FTA-ABS or MHA-TP).
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HIV/AIDS
Human immuno-deficiency virus
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Signs of illness are delayed for up to 6 or more years.
Symptoms include swollen lymph nodes, failure to thrive, or fungal and other infections.
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Infection is spread by contact with infected semen, blood, cervical secretions or human milk.
The incidence of developing HIV infection from a single episode of abuse is very low.
Other methods of infection in children include contaminated blood or blood products during transfusion, IV drug abuse or sexual abuse.
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Finding HIV antibodies in the blood makes a presumptive diagnosis. Other tests confirm the diagnosis. In infants under 18 months old, other tests are needed if the infant's mother is HIV positive.
Tests are often positive within 6-12 weeks after exposure, but may take as long as 6 months to become positive.
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Trichomonas
Trichomonas vaginalis
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Many infections are asymptomatic. Male urethral infection is often asymptomatic.
Vaginal discharge may develop between 4-28 days after contact.
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Perinatal vaginal infection may persist for many months following birth.
Infection is usually by sexual contact.
Non-sexual transmission is very unlikely, although possible.
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Microscopic identification or bacterial culture of vaginal secretions.
Must be differentiated from other types of trichomonas if identified in analysis of urine or stool.
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| Infections with Possible Likelihood of Sexual Transmission |
| Infection and Sites of Infection |
Incubation Period and Symptoms |
Transmission |
Diagnostic Tests |
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Herpes
Herpes simplex virus, types I and II
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Painful ulcers occur within 2 weeks following contact.
Reactivation of the infection often occurs and results in ulcers at or near the site of primary infection.
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The most common infection in children is gingivostomatitis, an infection of the mouth. It is not transmitted sexually.
Infection of the genitalia or infection around the anus may be due to sexual contact. Non-sexual transmission is also possible.
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The diagnosis can be made based upon the appearance of the ulcers.
The virus can be cultured if the diagnosis is in question.
Type I and type II both cause genital and peri-anal ulcers.
Identification of the virus type does not differentiate sexual from non-sexual transmission.
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Condyloma acuminata (venereal warts)
Human papillomavirus (HPV)
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Infection may cause skin-colored growths that vary in size from a few millimeters to many centimeters.
Infections may cause no visible warts.
The incubation period may be 2 years or longer.
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Infection may be transmitted prenatally, perinatally, through sexual contact, or by non-sexual contact.
Sexual abuse should be considered in any child with anal or genital warts.
Evaluation for other STDs should be considered.
In a child younger than age 3 with a diagnosis of venereal warts, detailed history of mother's past gynecologic problems may suggest perinatal transmission.
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The diagnosis is usually made by their appearance on physical examination.
In some centers, the virus type can be determined.
It is unclear if determination of the wart type is of any value when evaluating for sexual abuse.
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Pubic lice (crabs)
Pediculus pthirus
- Eyelashes
- Eyebrows
- Genital hair
- Perianal hair
- Beard
- Arm pits
- Scalp (rarely)
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The most common site of infection in young children is the eyelash.
Nits (eggs) can be seen as well as the movement of lice.
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In adolescents, transmission is usually sexual. Non-sexual transmission through contaminated towels is possible.
Sexual abuse should always be considered in children infected with pubic lice.
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The diagnosis is made by the clinical appearance of the lice.
Head lice do not infect eyelashes. Lice infestations of the eyelashes are pubic lice.
Microscopic examination of the louse can be done if there is any doubt about the type of louse causing the infestation.
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Hepatitis B virus (HBV)
Hepatitis C, E may also be sexually transmitted.
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Some children will have no symptoms. Others will have loss of appetite, stomach pain, and jaundice.
Infection can cause death.
The incubation period is 45-160 days after contact.
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Perinatal transmission occurs.
Both sexual and non-sexual transmission occurs. Children living with HBV carriers and in institutions for the developmentally disabled are at risk.
Infection is transmitted through infected blood, wound secretions, semen, cervical secretions, and saliva.
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The diagnosis is made from serologic blood tests (HepBsAg and Ab).
Vaccination is recommended for all children. It is 90% - 95% effective in preventing infection.
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| Infections with Low Likelihood of Sexual Transmission |
| Infection and Sites of Infection |
Incubation Period and Symptoms |
Transmission |
Diagnostic Tests |
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Bacterial vaginosis (BV)
Gardnerella vaginalis and other bacteria
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May cause vaginal discharge. Some infections are asymptomatic.
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This organism is most often seen in sexually active women but has been found in girls and women who have had no sexual contact and have not been sexually abused.
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Identification is made by microscopic analysis and other methods.
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Molluscum contagiosum
poxvirus
- May occur anywhere on the body
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Small bumps with a central depression.
The incubation period is 2 weeks to 6 months.
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This virus is spread by direct contact.
It is most often transmitted by non-sexual contact.
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Diagnosis is made by the clinical appearance of the rash.
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Candida
Candida albicans
- Muco-cutaneous infection (thrush, vulvovaginitis), gluteal or other skin folds, paronychia and onychia
- May be disseminated in immunocom-promised patients.
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May cause itching, discharge or vaginal pain.
Incubation period is unknown.
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Most infections are due to endogenous organisms.
Person to person transmission can occur, including perinatal transmission.
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Diagnosis is generally based on physical examination findings.
Identification can be made of yeast and pseudohyphal forms by microscopic examination of swabs/scrapings suspended in 10% potassium hydroxide (KOH).
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Scabies
Sarcoptes scabiei, subspecies hominus
Sites of predilection in older children and adults:
- Interdigital folds
- Flexor aspects of writs
- Extensor surfaces of the elbows
- Abdomen
- Folds of skin
- Other areas
In children younger than 2 years:
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Intense, pruritis of a papular rash. May see burrows in the skin. Incubation is usually 4-6 weeks.
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Transmission occurs by close personal contact.
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Diagnosis is clinical or based on identification of the mites' eggs or scybaia (feces) from the skin scrapings of unexcoreated lesions.
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Streptococcal peri-anal cellulitis or vaginitis
Streptococcus pyogenes or Group A beta-hemolytic streptococci
- Causes pharyngitis, pyoderma, or impetigo most commonly.
- May cause vaginitis, pericarditis, pneumonia, sepsis, otitis media, cervical adenitis, or perianal cellulites.
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Painful defecation, beefy red perianal area, sometimes peeling. Maybe chronically infected with exacerbations over several months.
Incubation period for pharyngitis is 2-5 days and for impetigo is 7-10 days. For vaginitis and perianal cellulitis, the incubation period is not known but likely within one week.
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Person to person contact.
Streptococci are endogenous to the perianal area.
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Diagnosis by swab of the vagina or rectum and plating on sheep blood agar with use of bacitracin sensitivity discs.
The use of rapid strep antigen tests for genital or peri-anal infections has not been well studied.
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Adapted from Cincinnati Children's Hospital, Mayerson Center Child Abuse Team, internet information on sexually transmitted disease.
www.cincinnatichildrens.org/svc/alpha/c/child-abuse/sexual/disease/
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