A constipating mass in a 12-year-old child as a result of child sex abuse

Introduction

Syphilis is a historical disease, with theories suggesting its origin before the 15th century, but the disease is still relevant and prevalent in the present era. It is caused by Treponema species and is predominantly transmitted through sexual and transplacental routes. ¹ The disease has a varied clinical manifestation and multiorgan involvement. ² The incidence of children having congenital syphilis has declined drastically owing to optimum antenatal screening. ³ However, we do encounter syphilis in children after unfortunate incidents of sexual abuse. The Parliament of India passed the ‘Protection of Children Against Sexual Offences Bill (POCSO) Act on 22 May 2012 ⁴ to safeguard all children from sexual abuse. We report a 12-year-old male who was repeatedly sexually assaulted. Written informed consent for publishing the case has been taken from the parents. The case is reported to highlight the rare and varied cutaneous manifestation of syphilis, which required urgent surgical intervention. We also emphasize the need to sensitize everyone with respect to the responsibilities of health care providers towards the POCSO Act.

Case report

A 12-year-old male child presented with complaints of mass per anus of 3 months’ duration. The size of the mass increased from pea-size to more than 10 times over the next few months, which subsequently caused constipation and painful defecation. He gives history of being sexually assaulted by a known individual multiple times, 3 months prior to the onset of mass. He was threatened and blackmailed (the child was photographed smoking) to prevent reporting of the abuse to parents. The assault was brought upon by the treating team of doctors when leading questions were asked to the child.

Informed consent was taken before examining the child and for reporting the case under the POCSO Act. The case was reported to the administrative authorities and civil police as per hospital medico-legal case policy.

On examination there was a giant oblong fusiform pink pedunculated moist verrucous mass 7  cm × 3 cm in diameter obscuring the anal orifice (Figure 1). Anal funneling was present. A pinkish-white, moist, sessile plaque 2 × 1 cm in the right perianal area at the nine o’clock position (Figure 1(a)). A few flat pink papules were present around the perianal area (Figure 1). A solitary, well-defined, soft pink-colored nodule was seen at the six o’clock position over the coronal sulcus (Figure 1(b)). The soft palate had superficial erosions with rugosities (Figure 1(c)).OPEN IN VIEWER

On investigation, his serum VDRL was reactive with a titre of 1:128, and TPHA was positive with a titre of 1:2560. HBsAg, anti-HCV, and HIV ELISA were negative. Histopathology from the verrucous mass had overlapping features of condyloma lata and condyloma acuminata (Figure 2(a) and (b)). PCR done for HPV DNA from the tissue was negative. He was thus diagnosed with case of secondary syphilis. He also had genital molluscum in the right inguinal folds.OPEN IN VIEWER

Benzathine Penicillin 17 Lacs units (50,000 IU/kg body weight) IM was given. ⁵ Considering the large perianal mass, which was causing severe constipation and painful defecation, the mass was excised in toto under general anaesthesia, and hemostasis was achieved with primary suturing. The perianal mass at the 9′ o’clock position was cauterized with radiofrequency under local anaesthesia. Molluscum contagiosum lesions were enucleated. Psychosocial support was provided by a child psychiatrist. Oral erosions and penile papules resolved after 1 week (Figure 3(a) and (b)). The post-op perianal wound had completely healed at the end of 4 weeks (Figure 3(c)). The child is on follow-up with VDRL monitoring every 6 months. ⁶ OPEN IN VIEWER

Discussion

Syphilis was reported to be the most common STD in India, accounting for 10.4%–36.1% of all cases. ⁷ There is an increased incidence in teenagers in developing countries. Prevalence of acquired syphilis among all the sexually transmitted infections in children is 22.2%. ⁸ Acquired syphilis is divided into early and late syphilis. Early syphilis comprises the primary, secondary, and early latent stages. ⁹ The secondary stage of syphilis is predominantly characterized by lymphadenopathy and mucocutaneous lesions. ¹⁰ This stage is highly infective with a high bacterial load of T. pallidum in blood and tissues and high serologic titres, as in our case. The most pathognomonic cutaneous lesion is condyloma lata, which presents as flat-topped, broad-based nodules and plaques in the moist areas. ¹¹ In our case it was mimicking giant condyloma acuminata completely obscuring the anal orifice, warranting surgical excision.

Owing to child protection issues, the evaluation of a child with a diagnosis of syphilis should be primarily focused on ruling out sexual abuse. A large study conducted by the Ministry of Women and Child Development in 2007 showed that abuse is most common between 12 and 15 years of age, with boys affected almost equally as girls. ¹² It is attributed to a lack of sex education, urbanization, industrialization, an increase in tourist traffic, etc.. ¹³ Physical examination findings suggestive of sexual abuse in girls are mainly found in the posterior area of the hymen and introitus. ¹⁴ Sexual abuse in boys may reveal injuries including fissures, abrasions of the penile shaft or glans penis, tears of the frenulum of the glans penis, petechiae, or marks due to biting or sucking. ¹⁵ Appropriate swabs should be sent for investigating STIs and for forensic evidence. ¹⁶ All such cases should be brought to the notice of the administrative authorities and police without any delay as per the POCSO Act. ⁴ In this case, the police, on receiving the information, began investigating the matter very promptly. However, the present legal aspects of the case are not known.

Conclusion

A case of sexual abuse in a child should be handled with utmost diligence and sensitivity. All healthcare providers need to familiarize themselves with policies of notifying child sexual abuse as per their country’s government laws.