An 8-year-old girl is brought to the office after her mother noticed bloody spotting in the girl's underwear. The patient has no chronic medical conditions and is up to date on her vaccinations. She plays soccer with her elementary school team, and her parents are divorced. Vital signs are normal. Height and weight are at the 40th percentile. Physical examination reveals sexual maturity rating (Tanner) stage 1 breast development and no acne or axillary hair. Pelvic examination shows multiple 2-mm, raised, fleshy papules on the vulva and anus that bleed on contact with a cotton swab. Which of the following is the best next step in evaluation of this patient's lesions?

Question

An 8-year-old girl is brought to the office after her mother noticed bloody spotting in the girl's underwear.  The patient has no chronic medical conditions and is up to date on her vaccinations.  She plays soccer with her elementary school team, and her parents are divorced.  Vital signs are normal.  Height and weight are at the 40th percentile.  Physical examination reveals sexual maturity rating (Tanner) stage 1 breast development and no acne or axillary hair.  Pelvic examination shows multiple 2-mm, raised, fleshy papules on the vulva and anus that bleed on contact with a cotton swab.  Which of the following is the best next step in evaluation of this patient's lesions?

Quizplus · Accepted Answer

11ec25c8_d670_b437_bc81_c1c270b4b7a2_MD0003_00 This patient's multiple, flesh-colored, raised papules along the vulva and anus are consistent with condyloma acuminata (ie, anogenital warts). Most lesions are asymptomatic, but they can become pruritic and friable, which can cause bloody spotting in patients' underwear. Condyloma acuminata are due to infection with low-risk human papillomavirus (HPV) types 6 and 11, which are typically transmitted via direct contact. HPV can be transmitted via nonsexual contact such as vertical transmission during delivery, autoinfection from other areas of the body, or heteroinoculation from a caregiver (eg, diaper changes). However, because of the association with transmission via direct genital contact, an assessment for sexual abuse is required in all children, particularly those age ≥4. Anogenital warts in children are often self-resolving; therefore, asymptomatic patients typically require only observation. For those with symptomatic or unresolved disease, management options include topical treatments (eg, podophyllotoxin) and surgical removal. (Choice A) The scotch tape test is used to diagnose pinworms (Enterobius vermicularis), which can cause anal pruritus and bloody spotting (secondary to scratching); however, pinworms do not cause skin lesions. (Choice B) Poor vulvar hygiene is a risk factor for nonspecific vulvovaginitis (particularly in prepubertal girls), which can present with vulvovaginal pruritus, erythema, and bleeding. Poor vulvar hygiene does not cause raised vulvar lesions. (Choices C and D) The poor glycemic control and immunosuppression associated with diabetes mellitus (ie, elevated hemoglobin A1c) can cause recurrent vulvovaginal candidiasis and candidal intertrigo. Patients typically have vulvovaginal pruritus and a thick, white vaginal discharge (vulvovaginal candidiasis) or a bright-red lesion over skinfolds (intertrigo). There are no associated multiple, raised, fleshy papules. (Choice F) Vulvar cancer is also caused by HPV infection but is rare in children. It typically presents as a single vulvar mass rather than multiple masses. Because it is associated with infection, family history does not help with the diagnosis. Educational objective: Condyloma acuminata (anogenital warts) occur due to infection with human papillomavirus and can present as friable, raised papules. Although many cases in children are due to nonsexual contact (eg, autoinoculation), the association with disease transmission via direct genital contact requires assessment for sexual abuse. References: Anogenital warts in children: analysis of a cohort of 34 prepubertal children. (http://www.ncbi.nlm.nih.gov/pubmed/29962062) Sexually transmitted infections in children as a marker of child sexual abuse and direction of future research. (http://www.ncbi.nlm.nih.gov/pubmed/26658657) Anogenital warts in pediatric population. (http://www.ncbi.nlm.nih.gov/pubmed/29166505)

An 8-Year-Old Girl Is Brought to the Office After Her