The Progression of Human Papillomavirus Lesions in Sexual Assault Victims

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EXPERIENCE AND REASON 1163

ISRAEL ALFONSO, MD

Department of Neurology Miami Children’s Hospital

Department of Neurology

University of Miami

OSCAR PAPAZIAN, MD

JEAN AICARDI, MD

Department of Neurology Miami Children’s Hospital

HOWARD E. JEFFRIES.

Tulane University

New Orleans, LA

REFERENCES

1.Daoust-Roy J, Seshia 55. Benign neonatal sleep myoclonus. A

differen-tial diagnosis of neonatal seizures. Am IDis Child. 1992;146:1236-1241 2. Coulter DL, Allen RJ. Benign neonatal sieep myoclonus. Arch Neurol.

198239:191-192

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1984;74:505-507

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5. Tardieu M, Khoury W, Navelet Y, Questiaux E, Landrieu P. Un

syn-drome spectaculaire et benin de “convulsions neonatales” les

myocbo-mes du sommeil profond. Arch Fr Pediatr. 1986;43:259-260

6. Resnick TJ, Moshe SL, Perotta L, Chambers HJ. Benign neonatal sieep myoclonus. Relationship to sleep states. Arch Neurol. 1986;43:266-268 7. Tsur M, Amit R. Benign neonatal sleep myocbonus. Harefuah. 1988;1 15:

179-180

8. Reggin JD, Johnson MI. Exacerbation of benign neonatal sleep

myoclo-nus by benzodiazepines. Ann Neurol. 1989;26:455

9. RichelmeC, Delpont E, Deswarte M, Dolisi C, Mariani R. Apropos d’un cas de myocbonies du sommeil profond du nouveau-ne. Pediatrie. 1990;

45:191-192

10. Quesada RR. Myoclonias del sueno del recien nacido. Neuroeje. 1991;2: 38-43

,I. Di Capua M, Fusco L, Ricci 5, Vigevano F. Benign neonatal sleep myoclonus: clinical features and video-polygraphic recordings. Mm’ Disord. 19938:191-194

12. Smith U, Thomas NH. Benign neonatal sleep myocbonus. AJDC. 1993; 147:817

13. O’Brien MJ, Lems YL, Prechtl HFR. Transient flattening in the EEG of

newborns: abenign variation. Electroencephalogr Clin Neurophysol. 1987;

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Jitteriness in full term neonates; prevalence and correlates. Pediatrics.

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fentanyl infusion. IPediatr. 1991;119:649-651

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Philadelphia: WB Saunders Co; 1995:172-207

The

Progression

of Human

Papillomavirus

Lesions

in

Sexual

Assault

Victims

Human papifiomavirus (HPV) infections are seen

in up to 15% of adolescents who present to a

gyne-cology clinic.’ Anogemtal HPV develops in some

adolescents as a result of sexual assault. Sexual

as-sault protocols address detection and follow-up for chiamydia, gonorrhea, syphilis, human immunode-ficiency virus (HIV) and hepatitis,2’3 but follow-up

for detection of HPV lesions is not formally

ad-dressed. Early detection of HPV lesions is important for treatment and long-term management, because subtypes 6, 10, 11, 16, 18, 31, 33, and 35 have been associated with cervical cancer.4 Although 6 and II

are the most common subtypes found in

condylo-mata acuminata, types 1, 2, 10, 16, and 18 are also found in anogenital lesions.5 In one stud? HPV

cer-vical disease was found in 70% of patients with

vulvar condylornas.

Anogenital HPV has variable clinical appearances. Lesions may be flesh colored or purple,7 pink, or gray.’ Morphology may be papular,7 exophytic,7

flu-iform, or flat.’ Genital lesions tend to begin within the posterior fourchette and labia, later progressing to other genital sites.7 It is thought that HPV infects those areas traumatized by sexual activity or assault.8

The incubation period for HPV is from I to 20

months,9 with an average of 2 to 3 months.’#{176}The use of a colposcope in the detection of early lesions of

anogenital HPV has been described.” Treatment of

anogenital HPV may vary with the extent of disease; smaller condylornas are amenable to topical treat-ments, whereas larger lesions may require laser or surgical treatment. Detection of HPV in earlier stages of development may spare patients from more inva-sive and painful methods of treatment.

We present the cases of two adolescents with ano-genital warts detected by colposcopy 12 and 34 days after sexual assault. Implications for clinical treat-ment and follow-up are discussed.

METhODS

Serial photographs with the Leisegang (Leisegang Medical Inc,

Boca Raton, FL) photocolposcope (magnification, x 15) were taken of two adolescents presenting for sexual assault examinations. Suspicious lesions were followed for up to 73 days after the assaults.

Case 1

RESULTS

This 15-year-old girl initially presented to the sex-ual abuse clinic 12 days after a sexual assault. She described digital-vaginal and vaginal-penile

penetra-tion by a gang member. She denied any sexual

ac-tivity before the assault. On initial examination, a cleft was noted at the 5 o’clock position, and friability was seen in the posterior vestibule. A 2-mm white bump resembling a half-moon was seen in the lateral vestibule at the 3 o’clock position (Fig IA). On mi-croscopic examination of vaginal secretions, 15 to 20 white blood cells per high-power field were noted. Vaginal and anal cultures for chiamydia and gonor-rhea were negative. Cultures for rapid plasma

rea-gin, HIV, and 3-human chorionic gonadotropin were

Received for publication Oct 24, 1994; accepted Dec 27, 1994.

Reprint requests to (ND-K.) University of Texas Health Science Center at San Antonio, Department of Pediatrics, Division of General Pediatrics, 7703

Floyd Curl Dr, San Antonio, TX 78284-7808.

PEDIATRICS (ISSN 0031 4005). Copyright t1 1995 by the American

Acad-emy of Pediatrics.

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

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Fig 2. Patient 2. A, 1 day after sexual assault. Submucosal

hem-orrhages are seen at the 7 and 12 o’clock positions. B, 34 days after

sexual assault. The hymen is reflected medially to reveal

condy-lomatous growths in the left lateral vestibule. C, 45 days after sexual assault. D, 73 days after sexual assault.

1164 EXPERIENCE AND REASON

Fig 1. Patient 1. A, 12 days after sexual

assault. B, 45 days after sexual assault.

C, 73 days after sexual assault.

negative. Patient I was treated for bacterial vaginosis

with metronidazole (Flagyl, C. D. Searle and Co.

Chicago, IL).

The patient was next seen 45 days after the assault. The lesion at the 3 o’clock position had enlarged (Fig

IB) and remained white-gray in color. When exam-med 73 days after the assault, the lesion at the 3 o’clock position was more prominent, and an addi-tional suspicious lesion was seen at the 6 o’clock position (Fig 1C). A 20% solution of podophyllum resin was applied to these areas, and the patient was referred to a gynecologist for a pap smear and fol-low-up. One month later, the result of the pap smear

was normal, and no condylomatous lesions were

seen.

Case 2

Patient 2 was a 16-year-old girl who initially pre-sented 36 hours after a sexual assault. She reported vaginal-penile, penile-oral, and penile-anal penetra-tion by at least two gang members. During the initial

visit, her recall of events was somewhat impaired by

alcohol intoxication and marijuana use. She reported sexual activity with at least six partners during the preceding 2 years but stated that her last consensual sexual contact was 8 months before the assault. On initial examination, there was diffuse vulvar and vaginal swelling, and submucosal hemorrhages were seen at the 7 and 12 o’clock positions (Fig 2A). Sev-eral acute anal tears were noted.

Patient 2 returned for follow-up 34 days after the assault. The submucosal hemorrhages had resolved, and clusters of 2-mm papular vascular lesions were seen in the vestibule at the 3 o’clock position (Fig 2B). At 45 days after the assault these lesions had prolif-erated, and additional condylomas were seen at the 6 and 8 o’clock positions in the vestibule (Fig 2C). At this time patient 2 was referred to a gynecology clinic for treatment and follow-up. She was seen by gyne-cologists 50 and 59 days after the assault. They noted

an “endocervical polyp,” which was normal on

bi-opsy. Gynecologists found “no evidence of condy-loma” and treated her for Candida vaginitis. Patient 2 returned to the sexual abuse clinic 73 days after the assault. Several coalescing papular vascular lesions were noted at the 3, 6, and 8 o’clock positions in the vestibular walls (Fig 2D). Results of all other cultures and tests for chlamydia, gonorrhea, HIV, and rapid

plasma reagin were negative. Patient 2 was then

referred to another gynecologist for treatment. At-tempts to contact the patient 4 months later were

unsuccessful.

DISCUSSION

These two cases demonstrate several points of in-terest. First is the need for follow-up of adolescents involved in high-risk sexual assault or activity. The perpetrators in both of these cases were gang mem-bers. Perpetrators who are gang members or at Viet Nam:AAP Sponsored on September 1, 2020

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EXPERIENCE AND REASON 1165 ers or whose sexual activity is prolific are more likely

to be infected with sexually transmitted diseases. Follow-up of sexual assault victims for HPV lesions is not addressed in published guidelines.2” A pro-spective study would be helpful in determining the actual risk for HPV infections after sexual assault. We suggest that adolescents involved in high-risk sexual activity or assault be examined for HPV le-sions I to 2 months after such an incident occurs.

In this case series, very early anogenital lesions were detectable by colposcopy at 12 and 34 days after

exposure. Although patient 2 may have become

in-fected with HPV 8 months earlier during consensual sexual activity, it seems most likely that the lesions were a result of the more recent gang rape. Clinical detection of HPV lesions during the earlier phase of growth may eliminate the need for more invasive and painful treatment,5 including surgical removal. Further studies are needed to determine whether early detection and treatment lower the recurrence rate of HPV lesions.

The HPV lesions in these patients were variable in morphology. In patient 1, the lesions were

white-gray, raised, and flat; in patient 2, the lesions were vascular, flliform, and clustered. Initially, gynecolo-gists did not detect the lesions in patient 2. The variable clinical appearances of anogenital HPV may hinder detection for clinicians not familiar with these presentations. In addition, anogenital HPV at times may be confused with condylornata lata, molluscum contagiosum, and normal anatomic variants, includ-ing epithelial papillae and sebaceous glands. Tech-niques that enhance detection and differentiation of

HPV lesions include acetowhitening with 3% to 5%

acetic acid applied to the vulva and vagina and

bi-opsy. Alternate detection techniques include DNA

methods such as ViraType (Digene Diagnostics,

mc,

Silver Spring, MD) and polymerase chain reaction,

which could be used in cases of acute sexual assault

to detect minute amounts of HPV DNA. Follow-up

for clinical evidence of HPV disease would be

mdi-cated in those patients in whom HPV DNA is

de-tected.

The initial locations of the HPV lesions in these

patients were surprisingly similar, involving the

lat-eral vestibule at or near the 3, 6, and 9 o’clock

posi-tions. In both patients condylornata acuminata

ap-peared initially at the 3 o’clock then the 6 o’clock

position. It is also of interest that in patient 2, who

had significant anal injuries, anal HPV lesions did

not develop during the follow-up interval. It is

pos-sible that the infected assailant penetrated her vagina

and not the anus. Alternately, the pattern of HPV

distribution in these two patients may reflect those

areas most traumatized during the assault and most

favorable for HPV colonization. Further studies are

necessary to address these questions.

Treatment of condylomatous lesions depends on

location, extent of disease, and degree of potential

discomfort.5 Topical treatment with podophyllum

resin or trichloroacetic acid are the most frequent

therapeutic approaches.’2 Podophyllum resin is most

effective when applied to small, moist lesions5 such

as the condylomas in patient 1. An 85% solution of

trichioroacetic acid applied weekly is slightly less

successful than podophyllum resin.’3 Although

re-peated weekly applications of topical agents for up

to 3 weeks is indicated 70% to 80% of the time,’3

patient discomfort tends to be minimal. Cryotherapy

is considered more effective for skin and mucous

membrane lesions but is more painful. Other more

invasive treatment methods are indicated for more

extensive lesions and lesions that do not respond to

topical treatment. These methods include surgical

removal and carbon dioxide laser treatment;

disad-vantages include moderate discomfort and the use of

general anesthesia in some patients.

Immunother-apy, 5-fluorouracil, and interferon are more

contro-versial methods of treatment.

In summary, these case reports demonstrate early

HPV condylornatous lesions in two victims of sexual

assault. The condylornas were variable in

morphol-ogy but are located within the same areas of the

vestibule. When lesions are detected earlier, less

in-vasive and less painful methods of treatment may

prove effective. In at least one patient a one-time

application of podophyllum resin was successful in

short-term follow-up. We recommend close

surveil-lance and careful examinations for HPV lesions in

adolescents involved in high-risk sexual experiences.

NANCY D. KELLOGG, MD

JUAN M. PARRA, MD, MPH

Department of Pediatrics

Division of General Pediatrics

University of Texas Health Science Center at San Antonio

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1995;96;1163

Pediatrics

Nancy D. Kellogg and Juan M. Parra