Aim Three cases with vesicular lesions in the ano-genital area are presented. In children this presentation always raises concerns of genital herpes and possible sexual abuse. These cases had varied outcomes and the lessons learnt are shared.
Method Two children were referred for child protection examination and the third child presented to A&E but was later discussed with the Named Doctor for Child Protection. All children had child protection medicals and sexually transmitted infection (STI) screen.
Results The first case was a 4 year old girl, swabs confirmed Varicella Zoster Virus infection and rest of her STI screen was negative. She later developed florid chicken pox. Social care investigations were satisfactory but parents were very angry that the referral was made.
The second case was a 4 years old girl who presented to A&E with severe ano-genital rash suggestive of herpetic infection. She tested positive for Herpes Simplex Virus type 1 (HSV-1) but this was misdiagnosed as Eczema Herpeticum not primary genital herpes. Discussion with the Named Doctor for Child Protection resulted in a full STI screen and referral to social care. The outcome of the social care investigation was inconclusive.
The third case was a 9 years old girl who tested positive for HSV-1 but negative for all other STI. A social care referral was made and all siblings were examined. She was followed up due to associated finding of septate hymen. The day after she was discharged, she disclosed, her 16 year old step brother had kissed in the privates and appropriate social care action was taken.
Conclusion Practitioners should keep an open mind and differential diagnosis should include chicken pox, primary and re-activation of genital herpes, bullous impetigo, contact dermatitis and blistering auto-immune lesions of the genitalia.
A heightened awareness of possible sexual abuse is essential but misdiagnosis must also be avoided. All cases should be referred to social care and especially if the child tests positive for HSV on genital swabs as HSV 1 and 2 are equally capable of causing initial infection at any anatomic site.