287
EXPERIENCE AND REASON-BRIEFLY RECORDEDMorbidity Mortality Weekly Rep., 20:67,
1971.
7. U.S. Department of Health, Education, and
Welfare, Public Health Service: Center For
Disease Control, Morbidity Mortality
Week-ly Rep., 21:445, 1972.
8. Barrett-Conner, E. : Gonorrhea and the
Pedi-atrician. Amer. J. Dis. Child., 125:233, 1973.
9. Snowe, R. J., and Wilfert, C. M. : Epidemic
reappearance of gonococcal ophthalmia
flea-natorum. Pediatrics, 51 : 110, 1973.
10. Holt, L. E. : Gonococcus infections in children,
with special reference to their prevalence in
institutions and means of prevention. New
York Med. J., 81:521, 1905.
1 1. Cooperman, M. B. : Gonococcus arthritis in
in-fancy. Amer. J. Dis. Child., 33:932, 1927.
13. Cooperman, M. B. : End results of gonorrheal
arthritis. Amer. J. Surg., 5:241, 1928.
12. Feldman, H. A. : Meningococcus and
gonococ-cus: Never the twain . . . well, hardly ever. New Eng. J. Med., 285:518, 1971.
14. Shore, W. B., and %Vinkelstein, J. A. :
Non-venereal transmission of gonococcal
infec-tions to children. J. Pediat., 79:661, 1971.
Gonococcal
Tonsillitis-Pharyngitis
in a
5-Year..OId
Girl
The rising incidence of venereal disease in
childhood and adolescence is an increasing
source of concern for pediatricians and
physi-cians who care for children.1’ Reports have
ap-peared regarding the epidemic proportions of
gonococcal disease,’ ‘ the clinical spectrum of
the disease in children,’ and possible
mecha-nisms of transmission.57 This paper will de-scribe a presentation of gonococcal disease in
childhood which we hope is rare but may be
merely infrequently recognized, stressing its
potential importance as a manifestation of child
abuse.
CASE HISToRY
R.J. is a 53k-year-old white female who was
seen in February 1969 at the San Francisco
General Hospital Outpatient Department with
a clinical diagnosis of herpes gingivostomatitis
and in December 1969, for an episode of
bi-lateral otitis media and nonspecific
vulvovagi-nitis. The otitis responded to medical therapy
and the vulvovaginitis was treated with
My-colog cream without subsequent indication of
clinical response. No cultures or smears of the
throat or vagina were
taken
on either occasion.The child was not seen again until July 17,
1972, when she again presented with
corn-plaints of intermittent sore throat for the
previ-ous month without other associated systemic
symptoms. The mother had also noted scant
bloody vaginal discharge for one day, which
reportedly precipitated the visit,
and
which shedescribed as possibly secondary to
self-manipu-lation with a ballpoint pen. The mother also advanced a history of the molestation of the
child at the age of 3 years by a teen-age boy
and frequent sexual exploration with another
young girl friend.
On physical examination on July 17, she
was found to be an introverted but
well-ap-pearing child. All findings were normal
except
for slight injection of the posterior pharynx,
without exudate or tonsillar hypertrophy. There
was mild inflammation of the perineal area, with dried serosanguinous material matted over
the introitus and two small venereal
warts
ad-jacent to the clitoris. Clinical impression at that
time was “mild pharyngeal infection and
con-dylomata acuminata.” A culture of the throat
done on blood agar was apparently lost; no
culture or smear of the vagina was done. She
was treated with local application of
pedophy-line and sitz baths.
Reexamination two days later (July 19) and
again on July 21, 1972, demonstrated
resolu-tion of the condylomata. There is no record of
continued symptoms of pharyngitis on these
visits.
She was next seen on August 6, 1972, with
complaints of abdominal pain in the right
up-per quadrant and vomiting once on the evening
of the visit. Examination was again negative except for mild pharyngeal injection and
cryp-tic nonexudative tonsillar hypertrophy.
Impres-sion was “upper-respiratory tract infection” and
treatment was symptomatic. A culture of the
throat on blood agar was negative for group A
beta-hemolytic streptococcus. Three days later
the child was brought in with continued
corn-plaints of sore throat (August 9) . Findings on
physical examination were unchanged and a
culture of the throat was done on
Thayer-Martin media to rule out gonococcus, only
be-cause of the previous vague history of sexual
cul-GONOCOCCAL ARTHRITIS
288
hire was obtained. On August 12, the throat
culture was reported positive for gonococcus after confirmation by positive dextrose and negative maltose and sucrose fermentation.
On reexamination on August 15, she
con-tinued to complain of sore throat. She was
found to have posterior pharyngeal injection,
cryptic hypertrophied tonsils with patchy white
exudate, and soft palatal swelling and
ery-thema. There were no ulcerations or
adeno-pathy. Physical examination was otherwise
neg-ative except for a mucoid white vaginal
dis-charge and dirt-filled introitus. Repeat cultures
of vagina and throat on Thayer-Martin media
were subsequently reported as negative. No
vaginal smear was taken and a VDRL test on
August 22 was nonreactive. The child was
treated with one injection of procaine penicillin G(2.4 x 106 units, intramuscularly) . Repeat cul-tures of the throat on Thayer-Martin and blood
agar on September 9 and September 18, 1972, were negative for gonococcus or streptococcus.
Though she continued to complain of
intermit-tent sore throat and abdominal pain, physical
examinations on these occasions were
unre-vealing.
The child’s social situation was investigated
after the positive gonococcal culture. This
re-vealed a markedly disturbed home setting,
with the mother living with four men, several
of whom were chronic alcoholics and one of
whom had a past record of child molestation.
Because of a combination of other factors in
the home suggesting parental neglect and
pos-sibility of sexual abuse, the patient and a
2-year-old female sibling were removed from the
home. Lack of cooperation prevented
cultur-ing of other household members on Thayer-Martin plates.
DIsCuSsION
Oropharyngeal infection with Neisseria gon-orrhea has been documented in adults with
in-creasing frequency.’” There has been difficulty
in the past in ascertaining the frequency of
gonococcal pharyngeal infection because of
in-adequacies in specific bacteriologic
identifica-tion, variations in patient groups sampled, and
changes in the behavior patterns of 415
The use of Thayer-Martin medium and
differ-ential sugar fermentation techniques has
en-hanced differentiation of the gonococcus from
other pathogenic and nonpathogenic Neisseria
in the pharynx.’
The documented clinical spectrum of
gono-coccal oropharyngeal involvement includes
asymptomatic carrier ‘ acute
sympto-matic exudative tonsillitis-pharyngitis ,“ #{176}‘
chronic recurrent tonsillitis-pharyngitis,” and
gonococcal
gingivitis,”
titi’7 andparo-titis.’8
The pharynx may be the sole source ofgonococcemia with its potential arthritic,
der-matologic and other systemic manifestations.14”
Wiesner et d1’ found pharyngeal involvement in ten of 60 patients with disseminated
gono-coccal infection, including five with no
identi-fled source of infection beyond the pharynx.”
Epidemiologically, all cases reported to date
have involved documented or strongly
sus-pected cunnilingus and/or fellatio with
in-fected contacts. This implies direct transmis-sion of the gonococcus to the pharynx via ure-thral or vaginal secretions. Wiesner et al.”
found no direct evidence for pharyngeal-to-pharyngeal or pharyngeal-to-genital
transmis-sion, but these modes of transmission cannot be definitely excluded. The possibility of finger transmission from vagina to pharynx must also be considered.
Acute gonococcal tonsillitis in a child has
been reported only once previously in a
4-year-old boy following orogenital contact with an infected
male.”
The girl described in this paper presented only a possible source of gon-ococcal infection, with that paucity of defini-live evidence of suspected sexual abuse in chil-dren which usually confronts the physician.The importance of appropriate social service
and epidemiological evaluation in such cases
has been stressed by Branch and Paxton,5 who
noted the high frequency of molestation-ac-quired gonococcus in children under 9 years of age. A high index of suspicion should be
main-tamed with respect to the possibility of
gono-coccal oropharyngeal or genital-anal infection in suspected instances of childhood abuse. The use of appropriate Thayer-Martin cultures may provide confirmatory evidence of sexual
moles-tation useful in aiding the child in a dangerous
environmental setting.
The clinical
course
of gonococcalpharyn-gitis
in this child must remain conjectural, inthat the time of infectious exposure was not
determined with certainty. The pharyngeal
findings were relatively equivocal even at 22 days following her initial presentation with sore
throat, and symptoms were reportedly also
present during the previous month. The earlier
repre-289
EXPERIENCE
AND
REASON-BRIEFLY RECORDEDsented an acute or chronic gonococcal
oro-pharyngeal episode, depending on the time of
exposure. Several reports” have commented on the relative lack of correlation in adults
be-tween symptoms from gonococcal pharyngitis
and eradication of the organism with antibiotic therapy. The negative throat and vaginal cul-hires obtained prior to the onset of treatment are consistent with the frequently reported
dif-ficulty of culturing gonococcus, even under op-timal laboratory conditions, and may relate to inadequacies in obtaining and planting the
cul-tures, and/or the basic fragility of the
gono-coccus.”
ADDENDUM
Since submission of this paper, a 3-year-old girl
with cutaneous evidence of physical abuse, a
punt-lent vaginal discharge, and ulcerative tonsillitis was
seen at San Francisco General Hospital. Cultures
on Thayer-Martin media of vagina, anus, and
oropharynx were all positive for
fermentation-documented gonococcus.
SUMMARY
A case is presented of gonococcal
tonsillitis-pharyngitis in a 5-year-old girl with a brief review
of the clinical spectrum of gonococcal
oropharyn-geal infection. The importance is stressed of
recog-nizing this entity as a potential manifestation of
child molestation.
STEPHEN L. ABBOTr, M.D.
Department of Pediatrics
University of California-San Francisco
San Francisco General Hospital
San Francisco, California 94110
Moses Grossman, M.D., and Mrs. Anne M.
Schmid gave advice and assistance in preparing
the manuscript.
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pedi-atrician. Amer. J. Dis. Child., 125:233,
1973.
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J.,
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New Eng. J. Med., 285:518, 1971.
16. Schmidt, H., Hjorting-Hansen, E., and
Philip-sen, H. P. : Gonococcal stomatitis. Acta
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19. Metzger, A. L. : Conococcal arthritis
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Patient Response Toward a Change in
the System of Health Care Delivery
With
the emphasis
being
placed
on
compre-hensive health care, outpatient clinics in major city hospitals have found it necessary to
re-evaluate their methods of health care delivery. An increasing number of patients who fail to schedule or keep medical appointments appear for crisis care, resulting in a higher cost of hospital operation due to unnecessaryutiliza-lion of emergency rooms and the wasting of
