Genital HSV infection in childhood

KEY POINTS
  • All children with suspected genital herpes infection should be referred for specialist assessment and management.
  • Genital herpes is less common in childhood than in adulthood, but can occur.
  • When assessing a child or young person with genital ulcers the diagnosis of herpes simplex should be considered, but not presumed.
  • Ulcers can occur as a manifestation of aphthosis in response to acute illness.106 The appearance of aphthous genital ulcers is also usually preceded by a history of fever, malaise and headache, but viral cultures are negative.
  • Epstein-Barr virus and cytomegalovirus infections have also been reported to cause genital ulceration.
  • Any genital ulcers should therefore be swabbed and cultured before decisions are made about management.

Pre-adolescent children

Genital herpes infection may present in pre-adolescent children. When it does it is important to explore carefully in the history the aetiology of the herpes infection. Possible sources of transmission include an orolabial lesion or a herpetic whitlow in another family member and autoinoculation. For example genital herpes in a child under one year of age may result from kissing ‘all over’ by a pre-school aged sibling with orolabial herpes.

If an obvious source of the infection cannot be identified then sexual transmission should be considered. The diagnosis must be confirmed by culture or PCR with typing of the herpes virus. The presence of HSV-1 does not rule out sexual transmission, but a non-sexual route of transmission should be carefully sought, especially if there are no other pointers to suggest sexual abuse. Also the presence of HSV-2 in the genital area does not automatically imply sexual contact, but does mean that sexual abuse, as a cause of the infection, must be seriously considered. In a recent local review of 2,162 children who had an examination in the context of allegations of sexual abuse, eight of the 1,909 children who underwent laboratory screening for sexually transmitted infections were positive for HSV and a sexual transmission was thought likely for six of these children.107

Because of these very difficult issues in diagnosis, all children with suspected genital herpes infection should be referred to a paediatrician for assessment and treatment. The paediatrician may in turn seek advice from a DSAC (Doctors for Sexual Abuse Care) doctor with special training in the area of recognition of child sexual abuse.

Adolescents

If genital herpes is present, a history suggesting aetiology should be carefully documented as for pre-adolescent children. During the interview it is important to ensure privacy. Confidentiality and the limitations of confidentiality, where there are concerns about safety, need to be discussed. The adolescent should be asked whether they are sexually active and whether their involvement in sexual activity has been consensual. If non-consensual activity is reported and they are under the age of 17, it is recommended that a referral be made to Child Youth & Family (CYF) and the Police. It is preferable that the referral be discussed with the adolescent and, where appropriate, the parents. Any referral to CYF for safety concerns of a child or adolescent can be made under the protection of the Children & Young Persons Act. In adolescents over 17 years of age, discuss with them the option of reporting to the Police. If further advice is required, contact the local DSAC doctor.

The above is based upon on internationally accepted standards of practice. Grade C