A 4-year-old girl is brought to the office by her mother for evaluation of vaginal discharge. The mother states that the discharge started about 2 days ago; she has also noticed that her daughter has been scratching and pulling at her underwear. The mother tried using baby wipes, diaper cream, and an over-the-counter ointment each time her daughter went to the bathroom, with no relief of symptoms. The patient has no chronic medical conditions or previous surgeries. Her vaccinations are up to date. She takes no daily medications and has no known drug allergies. The patient lives with her mother, mother's boyfriend, and 1-year-old stepbrother. She attends day care 3 days a week. Vital signs are normal. On inspection of the external genitalia, the vulva is edematous and erythematous; a malodorous discharge is at the vaginal introitus. There is no hymenal notching, tearing, or bleeding. Perianal inspection reveals no hemorrhoids, anal fissures, or tags. Mild eczema is seen behind the knees and on the arms. The pH of the discharge is 6, and wet-mount microscopy reveals pear-shaped motile organisms. The mother asks about the cause of the girl's symptoms. Which of the following is the most appropriate response?

Question

A 4-year-old girl is brought to the office by her mother for evaluation of vaginal discharge.  The mother states that the discharge started about 2 days ago; she has also noticed that her daughter has been scratching and pulling at her underwear.  The mother tried using baby wipes, diaper cream, and an over-the-counter ointment each time her daughter went to the bathroom, with no relief of symptoms.  The patient has no chronic medical conditions or previous surgeries.  Her vaccinations are up to date.  She takes no daily medications and has no known drug allergies.  The patient lives with her mother, mother's boyfriend, and 1-year-old stepbrother.  She attends day care 3 days a week.  Vital signs are normal.  On inspection of the external genitalia, the vulva is edematous and erythematous; a malodorous discharge is at the vaginal introitus.  There is no hymenal notching, tearing, or bleeding.  Perianal inspection reveals no hemorrhoids, anal fissures, or tags.  Mild eczema is seen behind the knees and on the arms.  The pH of the discharge is 6, and wet-mount microscopy reveals pear-shaped motile organisms.  The mother asks about the cause of the girl's symptoms.  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1db_075c_8f63_4923ad2c19a8_MD0005_00 This patient has vaginitis from Trichomonas vaginalis, a sexually transmitted infection (STI) that presents with a malodorous vaginal discharge and pruritus. Diagnosis is made by visualizing trichomonads, pear-shaped motile organisms, on wet mount; vaginal pH >4.5 is expected. A trichomonal infection in a prepubescent child is indicative of sexual abuse and, by law, it is the physician's responsibility to report suspected abuse to the appropriate agency (eg, child protective services). Victims of sexual abuse are frequently preadolescent girls. Although presentation may be similar to this patient with genitourinary concerns and an STI, a subtle presentation, such as sleep/appetite disturbance, acting out, or inappropriate sexual behavior, is more common. The majority of sexual assaults are committed by a trusted adult. A thorough history and careful examination are necessary and should be performed in a calm setting. The genitalia are visualized for signs of trauma; however, lack of hymenal tearing or bleeding, as in this patient, does not exclude abuse. Forensic evidence is obtained, and testing is typically sent for STIs and pregnancy. Management of this patient includes metronidazole for confirmed trichomonal vaginitis as well as treatment of any other concomitant STIs. Patients are often treated prophylactically for STIs and offered emergency contraception. Given the associated psychosocial sequelae, referral to a mental health specialist is warranted. (Choice A) Although sexual abuse is likely, it is presumptuous to place blame on the boyfriend. (Choice B) T vaginalis is transmitted sexually and cannot be spread via fomites such as clothing. (Choice D) Bacterial vaginosis is a common infection causing vaginal discharge with a fishy odor. Wet mount shows clue cells rather than the motile organisms seen in this patient. (Choice E) Although many states have laws protecting an adolescent's right to confidentiality regarding sexual health and STI testing, this patient is a young child in potential danger. The clinician is expected to notify and discuss with the family the suspicion for abuse and that child protective services will be involved. Educational objective: A sexually transmitted infection, such as trichomonal vaginitis, in a prepubescent child is alarming for sexual abuse and must be reported to child protective services. References: 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)

A 4-Year-Old Girl Is Brought to the Office by Her