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Abstract

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. References

Group A beta-hemolytic streptococcus cause most vulvovaginal infections seen in prepubertal girls. Bacterial vaginosis is a common cause of abnormal vaginal discharge in women of childbearing age but is rare in children. Data are insufficient to suggest that bacterial vaginosis is an exclusively sexually transmitted disease. We report a 10-year-old girl with no history or suspicion of sexual abuse who developed bacterial vaginosis in the context of a lichen sclerosus being treated with tacrolimus ointment. Secondary bacterial infection in lichen sclerosus is uncommon. We speculate that the immunosuppressive effect of topical tacrolimus could have triggered the infection.

Evidence indicates that group A beta-hemolytic streptococcus is one of the most common bacteria isolated in prepubertal girls with symptomatic vulvovaginitis. Other bacteria that have been isolated are Haemophilus influenzae, Staphylococcus aureus, and those of a fecal origin, such as Proteus mirabilis, Enterococcus faecalis, and Escherichia coli, although gram-negative organisms are unlikely to be true pathogens, and the presence of a microorganism does not always imply causality [1-3]. Recent studies have confirmed that Candida albicans is rarely found in vaginal isolates in this age group unless the patient has taken oral antibiotics or was immunosuppressed or diabetic [2]. Bacterial vaginosis (BV) is a common cause of abnormal vaginal discharge in women of childbearing age but is rare in children [4]. Gardnerella vaginalis (GV) is one of a group of organisms that cause BV [4]. Some previous studies have concluded that symptomatic prepubertal girls with GV infection should be examined for sexual abuse [5], although American Academy of Pediatrics guidelines for the evaluation of child sexual abuse state that this is inconclusive [6].

Case Report

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. References

A 10-year-old girl with no suspicion of sexual abuse presented at the Pediatric Dermatology Unit of our hospital in November 2011 with lichen sclerosus (LS) (Fig. 1). There was no vaginal discharge on initial examination. Histopathology confirmed the diagnosis of LS, and microbiological cultures were negative. Treatment with clobetasol propionate ointment once daily for 1 month and then maintenance with tacrolimus 0.1% ointment once daily was effective. Nevertheless, in April 2012, while the patient was being treated with tacrolimus ointment, a watery, homogeneous, light gray vaginal discharge with an unpleasant odor appeared. No foreign bodies were observed. Two further swabs to sample secretions were also negative. A low vaginal swab was performed, and wet mount microscopy and Gram stains evidenced the presence of 20% or more of clue cells with gram-negative rods and no leukocytes, which was diagnostic for BV (Fig. 2). Other organisms (including Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma spp. and Trichomonas vaginalis) were not isolated. BV was treated effectively with oral metronidazole. Tacrolimus ointment was also suspended, with no recurrence of the primary disease during the 10-month follow-up of the patient.

image

Figure 1. Genital LS: ivory to white plaques with small telangiectasias and purpuric areas surrounding the vulvar area.

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Figure 2. A clue cell on wet mount microscopy: an epithelial cell of the vagina with peripheral clumps of gram-negative bacteria, which imparts a stippled, granular appearance.

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Discussion

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. References

Although prepubertal girls lack vaginal wall glycogen and Döderlein’s bacillus, they are nevertheless not particularly susceptible to infection [1]. Vulvovaginitis is commonly attributed to nonspecific irritants (e.g., excessive washing with soap), but it can occur in the setting of bacterial infection, anatomic anomalies, pinworms, skin diseases of the vulva, or as a consequence of antibiotic treatment, the presence of a foreign body, or sexual abuse [1]. Fischer et al [7] recently reported one of the largest series of chronic vulvitis in prepubertal girls, with most of them being classified as having psoriasis or atopic dermatitis as a probable etiology of their vulvitis. None of them had LS because girls with a specific vulval condition, such as this disease, were excluded from the study. Microbiologic cultures were positive in 26% of patients, usually in the context of a dermatosis or foreign body. Group A beta-hemolytic streptococcus and H. influenzae were the most common agents isolated. GV was not isolated in any patient. Focusing exclusively on LS, a significant upregulation of antimicrobial peptides and proteins in this entity has recently been demonstrated. This could be reflective of an innate defense response caused by greater risk of local infection [8]. Nevertheless, there is scarce information about secondary bacterial infections in LS, and its exact incidence is unknown. Streptococci and E. coli were the most common infective organisms found in girls with uncomplicated LS [9].

BV is characterized by an imbalance in the vaginal flora, with the replacement of Lactobacillus spp. by anaerobic bacteria [10]. BV can arise and remit spontaneously, but often presents as a chronic or recurrent disease. The accepted clinical diagnostic criteria for BV in adult women are the presence of three of four signs and symptoms (vaginal pH >4.5, fishy smell on addition of 10% potassium hydroxide to the discharge, homogeneous gray-white discharge, and clue cells on wet mount microscopy) [4, 11]. Our patient was diagnosed with BV because she had the last three diagnostic criteria. The first diagnostic criterion cannot be easily applied to prepubertal children because of the alkaline environment of the immature vagina [11]. Although BV is associated with infectious diseases of the upper genital tract and complications during pregnancy, uncomplicated BV is not responsible for other symptoms [4].

One of the main anaerobic organisms that cause BV, GV has been observed in sexually active and nonactive individuals [12], but it has rarely been isolated in the anogenital area of nonabused preschool children [13]. Some studies have observed an increasing isolation rate of GV with increasing age [14]. Myhre et al [14] recently reported a longitudinal study that followed a group of children from prepubertal age into puberty; GV was isolated from vaginal samples from two girls with no related or suspected sexual activity in whom GV was not detected at the first examination. On the other hand, other studies have found that GV colonization is frequent in children suspected for sexual abuse, although prospective case–control studies with children without suspicion for sexual abuse as the control group are necessary [15]. Therefore, as in adults, BV may be linked to sexual activity, but sexual transmission has not been clearly documented, so BV should not be considered an exclusively sexually transmitted infection [11]. There was no history or suspicion of sexual abuse in our patient either.

The etiology of BV remains poorly understood [4, 10]. Although sexual activity has a role in the appearance and severity of symptoms, the development of BV may also depend on other nonsexual risk factors that make women more susceptible to vaginal flora imbalances [4, 10]. Growing evidence points to the association between poor micronutrient status, diets high in total energy and fat, and variation in dietary indices with BV [10]. Personal hygiene behavior is also important, with vaginal douching consistently related to BV [16]. These risk factors were not present in our patient; her diet seemed to be healthy and well balanced, and she changed some hygienic behaviors only after vaginal odor and discharge appeared, such as showering two to four times a day instead of daily, but never douching. We hypothesize that the use of topical tacrolimus to treat LS when BV appeared in our patient could have played some role in triggering the infection, because it is an immunosuppressive agent. There are anecdotal reports of the occurrence of cutaneous infections (mainly viral infections, but also bacterial and fungal ones) during tacrolimus treatment, although clinical trials did not indicate an increase in their overall incidence [17]. Regarding LS, Bilenchi et al [18] also reported the reactivation of human papillomavirus after topical tacrolimus therapy of anogenital LS [18]. Three antibiotics (metronidazole, tinidazole, and clindamycin) are approved for treatment of BV, but recurrences are common [4]. Nonantibiotic treatments such as acidification and lactobacilli have been extensively tested; some studies indicate that the adjuvant use of lactobacilli after an initial course of antibiotics can be useful to prevent recurrence [4].

Little is known about BV in children because it is rarer than in adults. The etiology is unknown, although there are increasing data about risk factors that may change vaginal homeostasis. BV can be sexually transmitted in adults but is not considered a sexually transmitted infection in children.

References

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. References