Pediatrics 1973 Abbott 287 9

8/12/2019 Pediatrics 1973 Abbott 287 9

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28 7 E X P E R IE N C E A N D R E A S O N -B R IE F L Y R E C O R D E DM o rbid ity M ortality W ee kly R ep ., 20 :67 ,1971 .

7 . U .S . D epartm en t of H ea lth , E d uca tion , andW elfare, P ub lic H ealth S erv ice : C en te r ForD isease C on tro l, M orb id ity M o rtality W eek -ly R ep ., 21 :44 5 , 1 972 .8. B arre tt-C o nner, E . : G on orrhea and the Ped i-atr ician . A m er. J . D is . C h ild ., 125 :233 ,1973 .

9. S now e, R . J ., an d W ilfe rt, C . M . : E pidemicreappearance of gonoco cca l oph tha lm ia flea -natorum. Pediatr ics 5 1 : 1 10 , 1973 .

10 . H o lt, L . E . : G on oc oc cu s in fe ction s in ch i ld ren ,w ith spec ia l re fe rence to the ir p reva lence ininstitu tions an d m eans of p reven tion . N ewY ork M ed . J ., 81 :52 1 , 1 905 .

1 1. C oop erm an , M . B . : G on ococcus arth r itis in in -fancy . A m er. J . D is . C h ild ., 3 3 :932 , 192 7 .

13 . C ooperm an , M . B . : E nd resu lts o f gon orrhea larthritis. A m e r . J. S urg ., 5 :2 41 , 192 8 .

12 . Fe ldm an , H . A . : M e n in g oc o cc u s an d gonococc us : N e ver th e tw a in w ell, ha rd ly ever.N e w E ng . J . M ed ., 285 :5 18 , 19 71 .

14 . S hore , W . B ., and V in ke ls te in , J . A . : N on-ve nere al tran sm iss ion o f g ono cocca l in fec -tio ns to c h ild ren . J . Ped ia t., 79 :6 61 , 1971 .

G o no co cc al T o ns illit is P h ar yn g itis in a5 Y ear O Id G ir l

T he rising inc idence o f venerea l d isease inch ildh ood an d ado lescence is an increasingsource of concern fo r ped ia tric ians and phys i-c ians w ho care fo r ch ild ren .1 R ep orts have ap-peared regard ing the ep id em ic p rop ortions o fgo nococca l d isease , the c lin ica l sp ec trum ofthe d isease in ch ild ren , and po ss ib le m echa-n ism s o f transm is sion .57 T h is p ap er w ill de -sc r ibe a p re sen ta tion of g ono co cca l d isease inch ild hoo d w hich w e hop e is ra re bu t m ay b em ere ly in frequen tly recogn ized , s tressing itspo ten tia l im po rtan ce as a m an ifes ta tion of ch ildabuse .

C A S E H IS T oR YR .J . is a 53k -y ea r-o ld w hite fem a le w ho w as

seen in F ebruary 1969 at the S an F ranc iscoG enera l H osp ita l O u tp atien t D ep ar tm en t witha c lin ical d iagno sis o f he rpes g in g ivo stom atitisand in D ecem ber 1 969 , fo r an ep isode of b i-la te ra l o titis m ed ia and no nsp ec ific v u lvovag i-n itis . T he o titis respon ded to m ed ica l the rapyand the v u lvovag in itis w as trea ted w ith M y-co lo g cream w ith ou t su bsequ en t in d ica tion of

c lin ica l resp onse. N o cu ltu res o r sm ears o f theth roa t o r vag ina w ere t a ke n on eith er occasio n .

T h e ch ild w as no t seen ag ain u n til Ju ly 1 7 ,1972 , w hen sh e aga in p re sen ted w ith co rn -p lain ts o f in te rm itten t so re th roa t fo r the prev i-ou s m o nth w ith ou t o the r a ssoc ia ted sy stem icsy m ptom s. T he m other had a lso n o ted scan tb loo dy vag in al d is ch arge fo r on e d ay , w h ichreported ly p rec ip ita ted th e v isit, an d w h ich sh edescribed as p oss ib ly secon dary to self-man ipu -lat ion w ith a ba llpo in t pen . T he m othe r a lsoadvanced a h isto ry o f the m o le sta tion of thech ild a t the ag e of 3 y ears by a teen-age bo yan d frequen t sexua l exp lo ra tion w ith ano th eryoung g irl friend .

O n phy sical exam ina tio n on Ju ly 1 7 , shew as foun d to b e an in trove rted bu t w e ll-ap -pear ing ch ild . A ll f ind in gs w ere normal e xc e p tfor slig h t in jectio n o f the p oste rio r p ha ryn x ,w ithou t exuda te o r to nsilla r h ype rtrop hy . T he rew as m ild in f lam m ation of th e pe rineal a rea ,w ith d ried se rosang u ino us m a te ria l m a tted ove rthe in tro itus an d tw o sm all vene rea l w a r t s ad -jacen t to the c lito r is . C lin ical im press io n a t tha ttim e w as m ild p ha ry ngea l infection an d co n-dy lo m ata acum ina ta . A cu ltu re o f the th ro a td one o n b loo d aga r w as ap pa ren tly los t; nocu ltu re o r sm ear o f the v ag ina w as do ne . S hew as treated w ith loca l ap p lica tion of pedop hy -line and s itz ba ths.

Reexaminat ion tw o days la te r (Ju ly 19) an dag ain on Ju ly 21 , 197 2 , dem on stra ted re so lu -tio n of th e co ndy lom a ta . T he re is no reco rd ofco ntinue d sym pto m s of p ha ry ng itis on thesev s ts

S he w as nex t seen on A ugus t 6 , 1972 , w ithcom pla in ts o f abdo m ina l pa in in the righ t up-pe r qua dra n t an d vo m iting o nce on th e ev en in gof th e v isit. E xam ina tion wa s ag a in n eg ativ eexcep t fo r m ild ph aryng eal in jec t ion an d c ry p-t ic n on ex ud at iv e to nsilla r hy pe rtroph y . Im p res-sio n w as u pper-resp ira to ry trac t in fec tion andtrea tm en t w as sy m pto m a tic . A cu ltu re o f theth roa t o n b loo d agar w as nega tive fo r g roup Abeta -hem oly tic s trep tococcus. T hree days la te rthe ch ild w as brou gh t in w ith co n tinu ed corn -plain ts of so re th roa t (A u gus t 9 ) F ind ings o nph ysica l exam ina tio n w ere unchang ed and acu ltu re o f the th roa t w as do ne on T h ay er-M artin m ed ia to ru le ou t gono co ccu s, on ly be-cause of the p rev ious vague h is to ry of sexua lmolesta t ion . N o corre spo nd in g vag in al cu l-

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G O N O C O C C A L A R T H R IT IS 28 8h ire w as ob tain ed . O n A ugu st 1 2 , th e th roa tcu ltu re w as re por ted p osi tiv e for g on oco ccu safter c on firm ation by pos itiv e d ex tro se andnega tive m a ltose and su crose fe rm en ta tion .

O n reex am ina tion on A u gust 1 5 , she con-tinued to co m pla in of so re th ro at. S he w asfou nd to have po ste rio r pharyn geal in jection ,c ryp tic h ypertrop h ied tons ils w ith pa tchy w hiteexud ate , an d soft pa lata l sw elling and ery -them a. T here w ere no u lcerations or adeno-pa thy . Ph ysica l exam ina tion w as o therw ise neg -ativ e excep t fo r a m u co id w h ite vag in al d is-charge an d d ir t-f illed in tro itu s . R epea t cu ltu re sof v ag ina and th ro at on T h ay er-M ar tin m ed iaw ere sub sequen tly reported as nega tive . N ovag in al sm ear w as ta ken and a V D R L test onA u gu st 22 w as non reactiv e. T h e ch ild w astrea ted w ith o ne in jec tion of p rocain e pen ic illinG (2 .4 x 1 06 un its , in tram uscu la rly ) R epea t cu l-tu re s of th e th ro at on T hayer-M artin and b loo daga r o n S e pte m b er 9 and Sep tem ber 1 8 , 1 972 ,w ere nega tive fo r gon ococcu s o r strep tococcu s.T houg h she con tinu ed to com pla in of in term it-ten t so re th roa t and abdom ina l pa in , p hys ica lex am ina tions o n these occas ions w ere u nre -vea l ing .

T he ch ild s so cia l s itua tion w as inv estiga tedafter th e po sitive gon ococcal cu ltu re . T h is re -vealed a m arked ly d istu rb ed hom e setting ,w ith the m other liv ing w ith four m en , severa lof w h om w ere ch ro n ic a lcoho lics and on e ofw h om had a past reco rd o f ch ild m ole sta tion .B eca use o f a co m b ina tio n o f o the r fa cto rs inthe ho m e su ggesting pa ren tal neg lec t and po s-sib ility o f sexua l abu se , the pa tien t and a 2-year -o ld fem ale sib ling w ere rem oved fro m theh o m e . L ack of coo pe ra tion p reven ted cu ltu r-ing of o ther ho useho ld m em bers on T hayer-M artin p la tes .

D I sC u S s I O NO rop ha ry ngea l in fec tion w ith N e isse ria g on

orrhea h as b een docum ented in adu lts w ith in -creas ing frequ en cy . T h ere has been d ifficu ltyin the p ast in asce rta in ing the frequency ofgonococca l ph aryngea l in fec tion because o f in -a deq uac ies in sp ecific bac ter io lo g ic iden tifica -tion , va ria tion s in pa tien t g roup s sam pled , andchang es in the behav io r p atte rns o f 4 5T he use o f T haye r-M artin m ed iu m and d iffer-en tia l sugar fe rm en ta tion techn iqu es has en-hanced d ifferen tia tion of the gon ococcu s fro mo the r pa tho gen ic an d nonpathogen ic Neisseriain th e p ha ry nx .

T h e d ocum en ted c lin ica l spectrum of g ono -

co cca l o roph a ryn gea l in vo lv em en t in c ludesasymptomat ic carr ier acu te sy m pto-mat ic e xu da ti ve t on si ll it is -p ha ry ng it is { 76}ch ro n ic recu rren t ton sillitis-p ha ry ng itis , andgonococcal gingivi t is , titi7 and p aro -titis.8 T h e pha rynx m ay be th e so le sou rce o fg o n o co ccem i a w ith its po ten tial a r th r itic , d e r-m ato log ic and o th er system ic m an ifes ta tions .1 4W i esn e r et d1 fo und p ha ry ngea l in vo lv em en tin te n of 6 0 pa tien ts w ith d issem in ated g ono -cocca l in fec tio n , inc lud ing f iv e w ith no iden t i -f led sou rce o f in fec tion b eyon d the ph a ryn x .

E pidem io log ica lly , all cases repor ted to d a teh av e inv o lved docum en ted or strong ly sus-pected cunn ilingu s and /o r fe lla tio w ith in -fec ted co n tacts . T h is im p lie s d irect transm is-sio n o f th e go nococcus to the p ha ryn x v ia u re -th ra l o r vag ina l sec retio ns. W iesne r e t a l.foun d n o d irect ev id ence fo r ph a ryn gea l-to -p ha ry ngea l o r pha ryng eal- to -gen ita l transm is-sion , bu t these m od es o f transm ission can no tb e de fin ite ly exc lud ed . T h e p ossib ility o f fin ge rtransm ission from v ag ina to ph aryn x m u st alsob e c on sid ere d.

A cu te go nococcal tonsillitis in a ch ild hasb een reported o n ly on ce p rev io usly in a 4 -y ea r-o ld b oy fo llow ing orog en ital co n tac t w ithan in fec ted ma le . T he g ir l de sc ribed in th isp ap er p re sen ted o n ly a poss ib le sou rce o f go n-o co cca l in fec tion , w ith th a t pauc ity o f de fin i-live ev idence of su spec ted sexua l abuse in ch il-d ren w h ich usua lly co nfron ts the phy sician .T he impor tance o f ap propriate soc ia l se rv iceand ep idem io lo g ical eva lua tion in such caseshas been s tressed by B ranch and Pax ton ,5 w hono ted th e h igh frequen cy o f m o les tatio n -ac -qu ired go nococcus in ch ild ren und er 9 y ears o fage . A h ig h ind ex of susp ic ion shou ld be m a in -tam ed w ith re sp ec t to the p ossib ility o f go no-coccal o roph aryn geal o r gen ita l-an al in fec tion insuspected instances o f ch ild hoo d ab use . T h euse o f app ro pria te T h ay er-M artin cu ltu res m ayprov ide con firm a to ry ev id en ce o f sexu al m ole s-tation usefu l in a id in g the ch ild in a dang erou senv ironm en ta l se tting .

T he clin ica l c ou rs e of g ono cocca l pha ryn -git is in this ch ild m ust rem a in con jec tu ra l, intha t the tim e of in fectio us expo su re w as no tde te rm ined w ith certa in ty . T he p haryngea lfin d in gs w ere rela tiv ely equ ivo cal eve n at 22days fo llow ing h er in itia l p re sen ta tion w ith so reth roa t, an d sy m pto m s w ere reported ly a lsopresen t during the p rev iou s m o n th . T h e ea rliersym ptom s m ay have b een n on specif ic , pe rhapsre f lec ting a c ry fo r h elp , o r m ay have rep re -



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2 89 E X P E R IE N C E A N D R E A S O N -B R IE F L Y R E C O R D E Dsen ted an acu te o r ch ron ic gon ococcal o ro -pha ryng eal ep isod e, depend ing on the t ime ofex po su re. S eve ra l repo rts have co m m entedon the re lativ e lack of co rrela tion in ad u lts be -tw een sym ptom s from g onococca l pharyn g itisan d e rad ica tion o f th e o rgan ism w ith an t ib io t icthe rapy . T h e n eg ativ e th roa t and vag in al cu l-h ire s ob ta ined prio r to the o nse t o f trea tm en ta re con sis ten t w ith th e frequen tly reported d if-f icu l ty of cu ltu rin g g ono co ccus , even un de r op-tim a l lab o rato ry con d ition s, an d m ay rela te toin ad eq uacie s in ob ta in ing an d p lan tin g th e cu l-tu res, and /o r the basic frag ility o f the gon o-coccus.

A D D E N D U MSince su bm iss io n of th is paper, a 3 -year-o ld g irl

w ith cu tan eous ev id ence of ph ysica l abuse , a pun t-len t v ag in al d isch arge , and u lce ra tive tons illitis w asseen a t S an Fran cisco G en eral H osp ita l. C u ltu reson T hayer-M artin m ed ia o f vag in a, an us, andoropharynx w ere a ll p ositive fo r fe rm en tation -docum ented g onococcus .

S U M M A R YA case is p resen ted of gon ococca l to nsillitis -

pharyng itis in a 5-year-o ld g irl w ith a brie f rev iewof the c lin ica l spec trum of go nococca l o rop haryn-gea l in fec tion . T he im por tance is s tressed of recog-n izin g th is en tity as a po ten tia l m an ifesta tion ofc hil d m o le st at io n.

ST E P H E N L . A B B O T r , M . D .D ep ar tm en t o f P ed iatric sU n iv ersity o f C a lifo rn ia -S an F ranc iscoSan F ranc isco G enera l H osp ita l

S an F ra nc isc o C alifo rn ia 9 41 10M oses G rossm an , M . D . and M rs. A n ne M .

Schm id g ave adv ice and assistance in preparingth e manuscr ip t .

R E F E R E N C E S1 . B arre tt-C onner, E . : G ono rrhea and the ped i-

a tric ian . A m er. J . D is . C h ild ., 125 :233 ,1973 .

2 . C om m ittee on Y o uth , A m erican A cadem y ofPed iatr ics : V en er ea l d isease and the ped ia -trician. P ed ia tr ic s 50 :492 , 1972 .

3 . N azarian , L . F . : T he cu rren t p reva lence ofgo nococca l in fec tions in ch ild ren . P ed ia tr ic s39 :372 , 196 7 .

4 R eport o f th e N ation al C om m ission on V ene-rea l D isease . A tlan ta, G eorg ia : C en ter fo rD isease C on tro l, 1972 .

5 . B ranch , C . and P ax ton , R . : A stud y of go no-coccal in fections am on g in fan ts and ch il-d ren . P ub lic H ea lth R ep ., 80 :3 47 , 1965 .

6 . Sh ore , W . B ., and W ink els tein , J. A . : N o n -v ene real transm issio n o f gon oc occ al in fec -lio ns to ch ild ren . J . P ed ia t., 7 9 :661 , 197 1 .

7 . A sn es , R . S ., and G reb in , B . : G o nococca l in -fec tion s in ch ild ren ( L e tte r) . J . P ed ia t.,81 :1 92 , 1972 .

8 . F ium ara , N . J ., W ise , H . M . J r., and M any ,M . : G on orrhea l pharyn g itis . N ew E ng . J.M e d . 276 :12 48 , 1 967 .9 . C ow an , L . : C ono co cca l u lce ratio n o f thetongue in the gono co cca l derm atitis syn-d r o m e . B ri t . J. V ener. D is ., 4 5 :228 , 19 69 .

10 . T h a tcher, R . W ., M cC raney , W . T ., K ellog ,D . S . an d W haley , W . H .: A sym ptom aticgonorrhea . J A M A 2 1 0 : 3 15 1 9 6 9 .

1 1 . B ro-Jo rgensen , A ., and Jen sen , T .: G on ococcaltonsila r in fec tion s, B rit. M ed . J ., 4:660 ,1971 .

1 2 . R od in , P ., M onte iro , C . E ., an d S crim g eo ur,C : C o n o co cca l pharyng itis . B r it. J . V ene r.D is ., 48 :1 82 , 1972 .

1 3 . R a tna tunga , C . S . : G ono co cca l p haryng itis.B r i t . J. V ener. D is ., 48 :184 , 1972 .

14 . W iesner, P . J. , T ronc a, E ., B o nin , P ., Pe de r -sen , A . H . B . an d H o lm es , K . K . : C lin ica lspec t rum of pharyngea l g ono co cca l in fec -tion . N ew E ng . J. M ed . 2 8 8 :1 8 1 1 9 7 3 .

15 . F e ldm an , H . A . : M eningococcus and gon ococ-cus : never the tw a in w ell, h ard ly ev er .N ew E ng . J . M ed ., 285 :518 , 19 71 .

16 . S chm id t, H ., H jo rting -H ansen , E ., and P h ilip -sen , H . P . : G o nococca l stom atitis . A c taD erm atov ener., 4 1 :324 , 1 9 6 1 .

17 . B ronson , F . R .: G onorrhea bucca lis . A m er. J .Uro l . , 15 :59 , 1919 .

18 . D ie fenbach , W . C . : C ono rrhea l paro titis . O ra lS urg ., 6 :974 , 19 53 .

19 . M etzger, A . L . : C on ococca l ar th ritis com pli-ca ting go norrh ea l pharyng itis . A nn . In te rnM ed . , 7 3 :267 , 1970 .

20 . T hayer, J. D . an d M oo re , M . : G onorrhea :P resen t kn ow led ge , re sea rch , and c on t ro leffo rts. M ed Clin . N . A m er., 48 :7 55 , 19 64 .

2 1 . Joh nso n , D . W ., H olm es, K . K ., and K vale, P .A . : A n ev alu atio n of go no rrhe a ca se fin d in gin th e ch ron ica lly in fec ted fem ale . A m er. J.Ep idein . , 90 :438 , 1969 .

P a tien t R esp on se To w ard a C h ang e inth e System of H ea lth C are D e liv ery

W ith the e m p ha s is be in g p lac ed on c om pre -h en sive h ea lth care , ou tpa tien t clinics in m ajo rc ity ho sp ita ls h av e fou nd it necessary to re -eva lua te the ir m e t h o d s o f h ea lth ca re de live ry .A n inc reasing nu m ber o f pa tien ts w ho fa il toschedu le o r keep m ed ica l ap po in tm en ts ap pea rfo r c ris is ca re , re su ltin g in a h igher cost o fh osp ital o pe ra tion due to un necessa ry u tiliza -lion of em ergency room s and the w asting o ft im e o f c le ric a l a nd p ro fe ss io na l p erson ne l, a sw ell a s p oor qua lity o f h ea lth ca re d ue to



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Pediatrics 1973 Abbott 287 9

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