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A. R. Markos FRCOG FRCP Consultant in Genito Urinary Medicine and Sexual Health

Early Childhood Herpetic Vulvitis : Autoinoculation, Vertical Transmission, Fomites or Sexual Abuse The Level of Medical Evidence. A. R. Markos FRCOG FRCP Consultant in Genito Urinary Medicine and Sexual Health Mid Staffordshire NHS Foundation Trust , Stafford Hospital.

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A. R. Markos FRCOG FRCP Consultant in Genito Urinary Medicine and Sexual Health

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  1. Early Childhood Herpetic Vulvitis:Autoinoculation, Vertical Transmission, Fomites or Sexual AbuseThe Level of Medical Evidence A. R. Markos FRCOG FRCP Consultant in Genito Urinary Medicine and Sexual Health Mid Staffordshire NHS Foundation Trust, Stafford Hospital

  2. Medical History History:2 year old girl with vulval soreness O/E:Slight discharge, dirty perineum, no bruising or scratching Vulvalswabs: Herpes Simplex Virus PMH:Recurrent chronic constipation: (repeated enemas, intestinal biopsies, tertiary referral) SH:Other siblings in Social Care Dispute on paternity: DNA testing Allegations of Sexual Abuse

  3. Medical Records’ Problems: • Conflicting account of Clinical Examination: “No bruising or scratching at the introitus” “Soiled at edge of introitus/Gaping /No hymen seen” • Missing Community Paediatrics Notes • Missing Child Protection Committee Notes

  4. Herpes Genitalis: Herpes Simplex Virus Type I and II (HSV-I and HSVUII) AymptomaticExpression Symptomatic Expression: Herpes Genitalis Herpes Libialis Gingivo-stomatitus Extra-genital Latent Infection Activation: Fever, Pneumonia, UV, Stress, Menses, Trauma…

  5. HSV-I & HSV-II Prevalence - Population group, Race, Social Class, Age sensitive Transmission - Mucousalsurface, Skin- Mucousaljunctions, Skin cracks Silent Clinical Lesions Extra-Genital Lesions- Fingers, Eyes (Autoinoculation, Viraemia)

  6. Prevalence HSV Antibodies: 2106 serum samples 0-19 years old HSV-I 1-2y 20% 1-4y 24% 15-19y 37% HSV-II 0.5% Scand J Infect Dis 2003;35(8):498-502

  7. Neonatal HSV California: 1985 11.7/100,000 Live Births, 1990 11.3/100,000 Live Births 1995 11.4/100,000 Live Births J Infect Dis 1999;180(1):199-202

  8. Neonatal HSV British Isles 1986 – 1991 76 Infants UK 1.6/100,000 Live Births 25 HSV-I 24 HSV-II 27 Unknown 27 Disseminated Infection 23 Herpetic Encephalitis 26 Localised infection 19 Neonatal Death (26%) 25 Long term siqualae / Death (33%) 1/2 Post discharge presentation 21 Maternal evidence of Herpes Genitalis PaedPerinatEpidemiol 1996;10(4):432-42

  9. Prevalence of Genital Herpes Simplex in Children 4 Girls and 2 Boys 5 HSV-I 1 HSV-II Sexual Abuse 4/6 Genital HSV possible indicator of Sexual Abuse Am J Dis Child 1984: 138(9):872-4

  10. Transmission to Newborn and Early Childhood • Vertical Transmission/Trans placental : maternal Antibodies • Autoinoculation: Virus inactivated readily in room temp & drying Close contact, fresh, large inoculum • Fomites and Inanimate objects: Possible but not likely • Direct contact: Most likely

  11. Literature and Research for Childhood Herpes Genitalis Scarce American School: “Transmission by sexual contact is the most common source of childhood Genital Herpes” RCP Working Party: “The virus is transmitted by close personal contact (including genital to genital and oral to genital contact)” “Identifying HSV/II as a cause of Genital Herpes in a child cannotprove or disprove sexual contact as means of transmission”

  12. The level of medical evidence for Early Childhood Herpetic Vulvitis Expert committee reports or opinions and/or clinical experience of respected authorities (Level IV)

  13. Setting standards to improve women’s health Royal College ofObstetricians andGynaecologists Risk Management and Medico-Legal Issues In Women’s Health Joint RCOG/ENTER Meeting Please turn off all mobile phones and pagers

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