INFECTIONS AND OTHER PATHOLOGIES IN PREPUBERTY (Part four)

Chlamydia trachomatis

Chlamydia is an infection caused by Chlamydia trachomatis. In 27% of cases, it is accompanied by gonorrhea. It is transmitted through perinatal contamination and sexual abuse. Perinatal transmission persists for at least up until 3 years. Vaginal colonization occurs from ocular and respiratory infections.

Clinically, it presents with vaginitis, urethritis, pyuria.

The most common complications are conjunctivitis 5-7 days after birth, pneumonia

Diagnosis is made through vaginal culture (direct immunofluorescence)

Treatment: Under 8 years old, erythromycin 50mg/kg orally divided into 4 daily doses for 14 days. Over 8 years old, use doxycycline 100 mg twice a day for 7 days, azithromycin 1g single dose.

Syphilis

It is an infection caused by Treponema pallidum. It is a microbe that is transmitted sexually or through hematogenous transplacental passage.

21 days after contamination, primary syphilis appears in the form of a non-painful genital chancre. Lesions are also found in the mouth and perineal region. Secondary syphilis, not common in pediatric age. Appears 1 or several months after the initial contact as cutaneous erythema. Tertiary syphilis appears several years to 20 years later causing various complications especially in the CNS.

Differential diagnosis: condyloma, trauma, herpes simplex virus, pityriasis rosea, tinea versicolor, psoriasis, viral diseases, drug reaction, sexual abuse.

Treatment: benzathine penicillin 50,000 U/kg per day im without exceeding a dose of 2.4 million units.

Condyloma

Caused by Human Papilloma Virus (HPV). It is transmitted through sexual and perineal contact, close physical contact, sexual abuse. Vertical transmission, due to the aspiration of fetal respiratory pathways of infected maternal secretions causes laryngeal lesions. They have a high rate of recurrence.

It appears in the form of red-colored fragile warts. Lesions are found in the mucous membranes of the vagina, urethra, urinary bladder, mouth, and eyes.

Clinically, it presents with vaginal bleeding, rectal bleeding, dysuria, vaginal secretions, painful defecation.

Diagnosis is made by applying 3-5% acetic acid to infected areas, after 10-15 minutes lesions turn white.

Differential diagnosis: secondary syphilis, perineal tumors, urethral prolapse, villoglandular sarcoma, contagious mollusk.

Treatment: Diluted solution 5-15% of podophyllin resin. The solution is removed with water and soap after 4 hours. 5% fluorouracil cream can also be used locally, cryotherapy, carbon laser, electrosurgical necrotization. Therapy is individualized.

PREPUBERTAL PELVIC MEASURES

General

Pelvic measures can be gynecological (adnexal, uterine), urinary system, and from the intestines. Due to the small pelvic capacity in prepuberty, pelvic masses grow quickly and in localization become abdominal while palpation or abdominal examination reveals a larger size.

Ovarian masses can be asymptomatic or present signs of chronic pressure on the intestines and urinary symptoms or acute pain from torsion or rupture.

Diagnosis

1 - Ultrasound

It is one of the main examinations for the diagnosis and characteristics of the mass (unilocular cyst, multilocular cyst, solid mass).

This includes eco Doppler, which determines whether the mass is vascularized or not.

2 - CT

3 - MRI

They provide more complete data regarding the mass, its placement, dimensions, characteristics, and its relation to surrounding organs.

4 - Tumor markers (AFP, hCG)

Follow-up

Initially, we determine the mass through abdominal and pelvic examination. We perform an ultrasound examination and determine whether the mass is ovarian or non-ovarian. If we have a non-ovarian mass, follow-up and treatment are done by the respective specialists. If we have an ovarian mass, its nature is determined whether it is unilocular, multilocular or solid, and its size.

In case of unilocular masses, with thin walls, the child's age is determined. If we are in premenarche, it is observed for 2-3 months and if the mass reduces, only clinical follow-up is done. If the mass appears in postmenarche, it is observed by treating it with OCs, if the mass reduces in size, further clinical follow-up is done. If the mass increases in size and persists, then tumor markers (AFP, hCG) are evaluated and treated with surgery by removing the mass.

In case of multilocular masses, the child's age is determined. If we are in premenarche, karyotype, tumor markers (AFP, hCG) are done and treated accordingly with surgery. If we are in postmenarche, it is observed for 2-3 months while being treated with OCs. If the mass reduces, only clinical follow-up is done. If the mass increases in size and persists, tumor markers (AFP, hCG) are evaluated and treated with surgery.

If we have a solid mass with dimensions of 8-10 cm, it is directly treated with surgery.

Characteristics

• Less than 2% of malignant ovarian tumors occur in adolescents and younger ages.
• 1/2 to 2/3 of ovarian neoplasms up to the age of 20 are germ cell tumors.
• Under 9 years old, 80% of ovarian neoplasms are malignant.
• Epithelial neoplasms are rare
• Over 10 years old, 60% of masses are non-neoplastic and 2/3 of neoplastic masses are benign.

Management

Unilocular cysts, almost always benign, regress within 3-6 months. The risk of torsion and rupture is discussed with parents. Recurrence occurs in up to 50% after cyst aspiration.

Solid masses, with dimensions over 8 cm and that rapidly increase in size, require surgical intervention.