Pediatric Annals

Sexually Transmitted Diseases in Adolescence

Tomas J Silber, MD; Kathy Woodward, MD

Abstract

The incidence of sexually transmitted diseases (STDs) has increased markedly among adolescents in the last 20 years. One reason for this is an increase in adolescent sexual activity. ' Less evident, but nevertheless important, is societal improvement in sanitation: many infections that used to be acquired in childhood are now deferred to the adult years. Genital herpes is a good example. In 1930, 90% of the people in the United States had been infected in childhood by HSV-I, thereby acquiring at least partial protection against HSV-2 infection. At present the figure is under 50%. The same concept applies to cytomegalovirus, hepatitis virus, the genital wart virus and the agent of molluscum contagiosum. Whenever an infectious disease is not acquired during childhood, sexual contact becomes the major mode of transmission. At present more than 20 STDs may produce illness in adolescents. They may range from vulvovaginitis and urethritis to septicemia and may leave sequelae as serious as infertility, ectopie pregnancy and cancer. This article presents information about the clinical manifestations of and approach to the diagnosis and management of the four most important STDs of adolescence: gonorrhea and chlamydial infections (the most common), syphilis (the most serious) and herpes (the "new" STD).

Once an adolescent is found to have an STD, an overall medical assessment must be done to investigate concomitant infections. In addition the pediatrician needs to develop skills in the areas of screening, tracing contacts, patient education, psychosocial assessment and STD followup.

Screening

The following population should be screened routinely for STD.

* Adolescents who admit to being sexually active

* Adolescents suspected of being victims of rape, sex abuse or incest

* Pregnant adolescents

* Promiscuous adolescents and adolescent prostitutes

* Adolescent male homosexuals

* Contacts with venereal disease or those suspected of having it

* Adolescents living in group homes or in detention homes

* Male adolescents with leukocyturia

* Adolescents with recurrent urinary tract infection

In the case of suspected sexual abuse the screening ought to include the oropharynx and rectum in addition to the traditional genital assessment."

Tracing Contacts

Although obtaining contact information is often difficult and time consuming, it is important to obtain such data and to relay it to the local health department. Patients should be asked to inform their contacts of the need for examination and treatment. The pediatrician should explain to the adolescent patient that the disease will be reported to the local health department but offer assurance that it will be handled in a confidential manner. If the doctor exhibits a positive attitude in working with health agencies, the adolescent patients will respond in the same way. The right to confidentiality must always be weighed against possible danger to the patient, and in cases involving abuse or incest, reporting these to the police authority (juvenile division) is mandatory.

Psychosocial Assessment

Because most STD agents cannot survive outside the human body, STDs in adolescents can almost always be traced to sexual exposure to an infected individual. This is why the very young adolescent with STD has to be highly suspect of being a victim of incest or sexual abuse.

Certain patterns of psychosocial problems may be detected: an adolescent girl may be promiscuous, which may be a sign of clinical depression or she may be pregnant. Adolescents may be in need of contraceptive counseling or they may be involved in complicated sentimental situations involving jealousy, rage and disappointment. In short, STDs in adolescents may serve as markers in the detection of psychosocial difficulties.'

Patient Education

Patient education should include exploring the adolescent's lifestyle, providing accurate information, promoting the use of condoms…

The incidence of sexually transmitted diseases (STDs) has increased markedly among adolescents in the last 20 years. One reason for this is an increase in adolescent sexual activity. ' Less evident, but nevertheless important, is societal improvement in sanitation: many infections that used to be acquired in childhood are now deferred to the adult years. Genital herpes is a good example. In 1930, 90% of the people in the United States had been infected in childhood by HSV-I, thereby acquiring at least partial protection against HSV-2 infection. At present the figure is under 50%. The same concept applies to cytomegalovirus, hepatitis virus, the genital wart virus and the agent of molluscum contagiosum. Whenever an infectious disease is not acquired during childhood, sexual contact becomes the major mode of transmission. At present more than 20 STDs may produce illness in adolescents. They may range from vulvovaginitis and urethritis to septicemia and may leave sequelae as serious as infertility, ectopie pregnancy and cancer. This article presents information about the clinical manifestations of and approach to the diagnosis and management of the four most important STDs of adolescence: gonorrhea and chlamydial infections (the most common), syphilis (the most serious) and herpes (the "new" STD).

Once an adolescent is found to have an STD, an overall medical assessment must be done to investigate concomitant infections. In addition the pediatrician needs to develop skills in the areas of screening, tracing contacts, patient education, psychosocial assessment and STD followup.

Screening

The following population should be screened routinely for STD.

* Adolescents who admit to being sexually active

* Adolescents suspected of being victims of rape, sex abuse or incest

* Pregnant adolescents

* Promiscuous adolescents and adolescent prostitutes

* Adolescent male homosexuals

* Contacts with venereal disease or those suspected of having it

* Adolescents living in group homes or in detention homes

* Male adolescents with leukocyturia

* Adolescents with recurrent urinary tract infection

In the case of suspected sexual abuse the screening ought to include the oropharynx and rectum in addition to the traditional genital assessment."

Tracing Contacts

Although obtaining contact information is often difficult and time consuming, it is important to obtain such data and to relay it to the local health department. Patients should be asked to inform their contacts of the need for examination and treatment. The pediatrician should explain to the adolescent patient that the disease will be reported to the local health department but offer assurance that it will be handled in a confidential manner. If the doctor exhibits a positive attitude in working with health agencies, the adolescent patients will respond in the same way. The right to confidentiality must always be weighed against possible danger to the patient, and in cases involving abuse or incest, reporting these to the police authority (juvenile division) is mandatory.

Psychosocial Assessment

Because most STD agents cannot survive outside the human body, STDs in adolescents can almost always be traced to sexual exposure to an infected individual. This is why the very young adolescent with STD has to be highly suspect of being a victim of incest or sexual abuse.

Certain patterns of psychosocial problems may be detected: an adolescent girl may be promiscuous, which may be a sign of clinical depression or she may be pregnant. Adolescents may be in need of contraceptive counseling or they may be involved in complicated sentimental situations involving jealousy, rage and disappointment. In short, STDs in adolescents may serve as markers in the detection of psychosocial difficulties.'

Patient Education

Patient education should include exploring the adolescent's lifestyle, providing accurate information, promoting the use of condoms to protect both partners, and making patients aware of the medical rights of minors in those states where they are recognized. Such legislation often establishes a right to the treatment of STD without parental consent. The same counseling may be provided, in a preventive fashion, to the adolescent community at large.

Followup

Recurrence of one or more STDs in adolescence is not unusual. This is usually due to a reinfection. Révaluation is necessary at least one week after treatment is completed. The pediatrician needs to remain alert to longterm sequelae, such as urethral strictures, infertility, ectopie pregnancy, and chronic pelvic inflammatory disease.

GONORRHEA

Gonorrhea is the most common reportable infectious disease of adolescence.4 Its incidence surpasses that of chickenpox, measles, mumps and rubella combined. Three million cases of gonorrhea occur each year: one case in every four is a teenager. Gonorrhea is difficult to control for several reasons:

* Gonorrhea has a short incubation period.

* There are large numbers of asymptomatic carriers, especially girls, among whom the rate is four times higher than adolescent boys.5

* The transmission rate is rapid.

* Accurate screening can only be done through an examination of the male genitalia or a pelvic examination. Serologie tests cannot indicate whether an infection is current or old.

* Gonorrhea may be recurrent; immunity does not occur following infection.

Gonorrhea in adolescents usually presents with the following symptoms:

* Purulent urethral discharge

* Dysuria and urinary frequency

* Bartholinitis

* Cervicitis

* Rectal pain, tenesmus, urge to defecate

* Peritoneal signs, pelvic inflammatory disease

* Sore throat, tonsillitis, painful swelling of neck lymph nodes

* Purulent conjunctivitis

* Disseminated infection (fever, chills, septic appearance)

* Polyarthralgia followed by monoarthritis and or tennosynovitis

* Right hypochondrial pain (gonococcal perihepatitis)

All these symptoms of gonorrhea are manifestations of the tissue damage produced by the toxic substances contained in the gonococcus. Supuration often occurs in the lining of the genital and urinary tract. Due to its frequency, the severity of its course and its serious sequelae. Pelvic Inflammatory Disease (PID) merits a note here. The first episode of PID in adolescents has been traditionally thought of as due to gonorrhea. However, PID may be the final common pathway for infections with Neisseria gonorrhea, chlamydia and many other secondary invaders. The annual incidence in adolescence is estimated to be 250,000 cases. Each episode of PI D carries an estimated risk of infertility of 1 5%. This explains how every decade approximately a million women are found to be sterile.

LABORATORY CONFIRMATION OF DIAGNOSIS

The importance of laboratory confirmation of infection with Neisseria gonorrheas cannot be overemphasized when dealing with minors, because in addition to the clinical implications the presence or absence of infection often becomes a medicolegal matter.

To confirm the diagnosis of gonorrhea the following studies must be done:

Gram stain smean The presence of gram negative intracellular diplococci obtained from urethral discharge in the male is sufficient to establish a presumptive diagnosis and permit treatment to be initiated.

Other Neisseria species may be present in the cervix, thus it is necessary to count at least eight or more pairs of gram negative diplococci in each of at least two polymorphonuclear leukocytes in order to establish the presumptive diagnosis of gonorrhea in adolescent females.6

Bacterial culture: This requires a selective medium such as the Thayer- Martin, ora modification of it such as Trans-Grow, which is now used by many state health departments. A rectal culture increases the chance of obtaining a positive culture in symptomatic patients by 5%. When ordering such cultures, it is important to obtain a specimen not contaminated by feces, otherwise, there will be an overgrowth of Proteus and E.coli, and this would not allow N, gonorrheas to appear on the plate.

Whenever a follow-up culture of a treated patient is positive for gonorrhea further laboratory evaluation for the possibility of a penicillinase producing, penicillin resistant gonococcus is required.

Sugar fermentation test: The sugar fermentation test is mandatory whenever a positive culture is obtained from the oropharynx because it is the only way through which N, gonorrheae may be differentiated from the other Neisserias such as N. catarrhalis or N. meningitidis.1

Serologie test for syphilis: It is possible to have more than one STD simultaneously. A serologie test for syphilis should be performed on any adolescent suspected of having gonorrhea in order to determine whether the patient has also been infected with syphilis.

MANAGEMENT

The following patients should be treated:

* Proven cases, even if asymptomatic

* Sexual partners

* Rape victims when the attacker is unknown

* Symptomatic patients in whom the clinical diagnosis is compatible (for example sexually active adolescents with lower abdominal pain and cervical discharge)

Adolescents may be treated with 4,800,000 units of procaine penicillin and I gm of probenecid P.O. The one exposure treatment is preferred for adolescents. If they refuse the injections, adequate treatment may be provided with 3.5 gm of oral ampicillin or amoxicillin plus probenecid. The procaine penicillin/ probenecid combination aborts incubating syphilis. Those who are allergic to penicillin may be treated with 9 gm of tetracycline over five days (precaution: rule out pregnancy).8 A single dose of antibiotics is insufficient for complicated gonorrhea. In PID, for instance, even if the initial agent is the gonococcus, the fact remains that the ensuing peritonitis is often associated with a mixture of aerobic and anaerobic bacteria.

The most important step in healing PID is early recognition. The pediatrician needs to suspect PID in any adolescent complaining of lower abdominal pain. Patients with fever, adnexal tenderness, leukocytosis and high erythrosedimentation rate constitute less than half of laparoscopically proven cases of PID. It is possible to have damaging PID with very mild symptoms. The white blood count, sedimentation rate and temperature are helpful to assess the severity of PID but not its evidence or absence.

It is not unusual to see women attending infertility clinics who are diagnosed as having bilateral tubai scarring but cannot remember ever having a salpingitis. The conclusion is that a pediatrician who sees a sexually active adolescent complaining of low abdominal pain and a vaginal discharge is entitled to diagnose PID regardless of the absence of any other supportive evidence. Treatment is justified even though the diagnosis may be uncertain. The potential risk from antibiotic treatment is outweighed by the greater risk of delaying treatment. Moreover, antibiotic therapy will not interfere with a subsequent evaluation for appendicitis, ectopie pregnancy, endometriosis, and ovarian cyst.

The treatment of PID remains controversial. Adolescents presenting with peritoneal inflammatory signs ora pelvic mass should be hospitalized. Other indications for hospitalization include high fever, severe abdominal pain, and questionable patient compliance. In case of doubt it is preferable to err on the side of hospitalization at least until it is established that the disease is well under control. There are no studies comparing the various in-patient treatment regimes. For definite gonococcal PID, the Centers for Disease Control recommend penicillin G 10,000,000 µ a day intravenously.8 If the patient does not improve or there is a pelvic abscess, a triple antibiotic treatment is used by physicians. Such antibiotic treatment should cover coliforms, anaerobics and bacteroidis fragilis. Thusclindamycinandgentamycinortobramycin are often added to the penicillin. If with any of the above there is no improvement in 72 hours a culdocentesis or laparoscopy should be obtained for cultures. The entire treatment should last ten to 14 days. At times medical treatment is clearly insufficient and the patient requires a surgical approach. Follow-up cultures should always be taken, preferably during menses.

CHLAMYDIAL INFECTIONS

Chlamydial infections are probably the most common u n reported sexually transmitted diseases in adolescents today. In the United States chlamydial infections are more common than gonorrhea in venereal disease clinics and college health facilities.10 Scandinavian data show Chlamydia trachomatis is responsible for at least two to three times as many cases of PID as N. gonorrhea, and at least half of the patients with culture proven N. gonorrheae also have chlamydial infections." The following characteristics make the chlamydial epidemic difficult to control:

* Chlamydial infections have a long latency period (weeks to years).

* There are large numbers of asymptomatic carriers, especially among women.

* Sexual partners of infected adolescents are not traced or treated, because the disease is not reportable.

* Chlamydial cultures require special cell culture methods and storage of specimens at -70° C and are therefore costly.

* Serologie tests are too expensive for mass screening, and paired sera showing a fourfold rise in IgG or IgM titers must be present for a diagnosis to be made.

Adolescents with chlamydial infections usually present with the following symptoms:

* Mucopurulent urethral discharge

* Dysuria, urgency and urinary frequency

* Bartholinitis

* Cervicitis

* Rectal pain, tenesmus and diarrhea (if anal intercourse leads to infection)

* Peritoneal signs, PID

* Right hypochondria! pain (chlamydial perihepatitis)

* Acute epididymitis

* Disseminated infection (fever, chills, marked adenopathy)

* Post partum or post abortion endometritis

Many adolescents have only non-specific symptoms and often infections are not apparent. Therefore, the pediatrician must have a high index of suspicion in order to make the diagnosis.

LABORATORY DIAGNOSIS OF CHLAMYDIAL INFECTIONS

One of the major handicaps in recognizing and treating chlamydial infections is the lack of an easy, inexpensive diagnostic test. To confirm the diagnosis of chlamydial trachomatis infection the following studies may be obtained.

Gram stain smear: The presence of less than IO polymorphonuclear cells per high power field and the absence of gram negative intracellular dyplococci in a urethral smear of a male is strong evidence of chlamydial infection (a small percentage of non-gonococcal urethritis may be caused by rnycoplasmas; fortunately, these organisms have an antibiotic spectrum similar to C trachomatis). Gram stain has not proven useful in the adolescent female.

Giemsa stain smear: This method was for many years the only way of identifying chlamydial inclusions. It is inexpensive, but has only a 40% accuracy rate.

lmmunofluorescent cytology: Strains of genital (or ocular) material with fluorescent tagged antibodies to chlamydial antigens are a more sensitive means of identifying inclusions than giemsa staining. Although this technique has been used in areas where ocular trachoma is endemic, it is not as yet widely available in the United States,

Culture: The best method of confirming the diagnosis is to culture the chlamydial organism from ocular, respiratory and genitourinary swabs or secretions. The material must be inoculated directly into a transport media containing antibiotics that inhibit bacterial growth. The media may be stored briefly at 40C if it is to be inoculated immediately into tissue culture. If not, it must be stored at -7O0C where it can be kept indefinitely until transfer to culture. Inoculated tissue cultures are grown in monolagen or coverslips and can be stained with Giemsa or immunofluorescent methods to detect cytoplasmic inclusion. This method is by far the more accurate way of diagnosing chlamydial infections, but the facilities for culture are not widely available and are too expensive for mass screening.

Serologie Diagnosis: There are currently complement fixations and im munoflu orescent methods of detecting IgG and IgM antiserum to all the 1 5 serotypes of C, trachomatis. However, the presence of antibodies in the serum does not correlate with active infection. Hence, paired sera and demonstration of rising titer is the way to make the diagnosis of active infection. Chlamydial antibodies can also be detected in tears and cervical secretions and may correlate better with current infection if it can be proven that these antibodies are locally produced and not transudated from the serum.

MANAGEMENT

Chlamydia has been recovered from the fallopian tubes of women with acute salpingitis who had a negative cervical culture and a stationary titer of antibodies. Neither the failure to isolate C. trachomatis from the cervix nor a stationary titer of antibodies to the organism precludes a chlamydial etiology of acute salpingitis.13

The following patients should be treated:

* Proven cases, even if asymptomatic

* Sexual partners

* Symptomatic patients in whom the clinical diagnosis is compatible

The rising number of cases of non-gonococcal PID and the high incidence of infertility and tubai scarring found in Scandinavian studies of documented chlamydial pelvic infections highlight the importance of considering antichlamydial therapy in the treatment of PID. There are some differences between chlamydial PID and gonococcal PID that may give the pediatrician a clue as to the etiology of the salpingitis he may need to treat. Adolescents with chlamydial PID have a less acute presentation. Their symptoms are of longer duration and they have a higher erythrosedimentation rate than do their peers with gonococcal PID.9

In addition to the risk of infertility, other significant morbidity is associated with even asymptomatic cervical infection with chlamydial trachomatis. Chlamydial cervicitis has been found associated with abnormal Papanicolau smear. There may be a risk that dysplasia may be a factor in cervical cancer similar to that of Herpes hominis. Pregnant adolescents who are asymptomatic carriers of C. trachomatis are at risk for endometritis and PID following abortion or delivery. In one study 5% of all women presenting for elective first trimester abortion harbored C. trachomatis and following the procedure 20% of the identified carriers developed acute PID within two weeks.13

Studies on pregnant women also show an asymptomatic carrier rate of 5% to 10% and unfortunately 40% to 70% of all infants born to mothers harboring C. trachomatis will develop neonatal chlamydial infection, either conjunctivitis or pneumonia or in a small percentage, both. Probably 2% to 3% of all newborns will acquire neonatal chlamydial infections with incidence rates of 14 cases of conjunctivitis per 1,000 live births and eight cases of pneumonia per live births, so that chlamydial infection represents a major public health issue to pediatricians.14

Tetracycline or erythromycin (500 mg four times a day for seven days) is the recommended dose for adolescent males and females. Adolescent females with PID should be treated with the same drugs but for a ten-day course or until symptoms subside. Tetracycline is probably effective against incubating syphilis, but this has not been documented so follow-up RPR must always be drawn. Hospitalized adolescents with peritoneal signs may receive tetracycline HCI 250 mg IV four times a day until improved, then complete the ten-day course with oral therapy. Doxycycline at a dose of 100 mg bid can be substituted for tetracycline when concern about compliance or gastrointestinal upset outweighs its additional expense. Neither tetracycline nor doxycycline should be used in the pregnant adolescent; however, erythromycin can be used safely. Sulfisoxazole 500 mg four times a day for ten days, may be used in asymptomatic females and in males with urethritis.8

Lymphogranuloma venereum requires protracted treatment, usually 21 days of tetracycline or erythromycin 500 mg four times a day or sulfisoxazole one gram four times a day."

SYPHILIS

Syphilis is the third most common reportable infectious disease of adolescence. Its incidence is only surpassed by gonorrhea and chickenpox. The highest rate occurs in young adults between the ages of 20 and 29, and it is most prevalent in urban areas and in the rural areas of the southeast. The male/female ratio is 2.5 to I. In large cities, over 50% of all cases of infectious syphilis occur in male homosexuals. The following makes the diagnosis of syphilis difficult.

* The initial lesion may be easily overlooked (inside labia, anus) or may be hidden (cervix).

* The syphilitic chancre heals spontaneously and the patient may therefore dismiss the illness.

* The initial lesion may be in an unsuspected region and with atypical characteristics (chancre of the finger may be erosive and quite painful).

* Syphilis is asymptomatic during the latent period.

* Secondary and late syphilis may mimic a wide range of illness.

* It has not been possible to cultivate Treponema Pallidum in vitro.

Syphilis in adolescents usually presents with one or more of the following:

Primary syphilis (ten to 90 days after contact)

* A papule

* An indurated usually painless ulcer with raised borders

* Regional adenopathy

Secondary syphilis (six or more weeks after infection)

* Malaise, fever, headache, sore throat

* Generalized lymphadenopathy

* Cutaneous lesions (varied lesions, usually symmetric, widespread and nonpruritic, often superficial lesions - papulosquamous). The rash is often quite marked on palms and soles. When the face is afflicted annular lesions tend to occur. Eighty percent of all patients with secondary lues present with a skin rash.

* Mucous membrane lesions (mucous patch and condylomata lata)

* Hepatitis (jaundice is rare but elevated alkaline phosphatase is common)

* Periostitis

Lale Syphilis (any syphilitic involvement following the secondary phase)

* Meningitis (an acute to subacute meningitis may occur after a year of the infection)

* Cerebro vascular accidents (Cerebro vascular accidents due to syphilitic arteritis, may be seen five years after the initial infection.)

* Transverse myelitis and radiculitis

Late Congenital Syphilis

* Eighth nerve deafness

* Interstitial keratítís (10% of patients)

* Saddle nose (periostitis resulting in prominent frontal bone and depressed bridge of the nose)

* Saber skin (periostitis resulting in anterior bowing of the tibia)

* arthritis of the knees (Clutton's joints)

* abnormalities of permanent detention (Hutchin~ son's teeth)

Latent Syphilis

* Asymptomatic (Reactive Serology)

Syphilis is a subacute chronic infection. The primary lesion of syphilis is a focal endarteritis in which lymphocytes, plasma cells and monocytes predominate. In secondary and late syphilis a nonspecific granulomatous reaction may occur. This lesion is due to hypersensitivity to virulent treponems. It is possible that the waxing and waning of syphilitic lesions depends on a balance between cellular immunity and suppression of thymus-derived lymphocyte function. All patients respond to infection by producing numerous antibodies, and in some instances circulating immune complex may be formed. Occasionally, this may produce a nephrotic syndrome characterized by subepithelial basement membrane deposits containing IgG, C3 and treponema! antibody. Rarely, an adolescent may develop paroxysmal cold he m ogl o bin uria. This is due to production of an IgG antibody which binds to the red cell at 4° C and which, on rewarming of the blood in the presence of complement, results in hemolysis.

The most devastating manifestation of syphilis may manifest in adulthood with the iuetic involvement of the brain, meninges and spinal cord. In addition to the already mentioned meningovascular neurosyphilis, this can result in general paresis - dementia paralytica - and tabes dorsalis. Syphilis may also involve the aorta, large vessels and heart, often causing aortic insufficiency and saccular aneurysms of the aorta.

LABORATORY CONFIRMATION OF DIAGNOSIS

Darkfield Examination

Darkfield examination is always positive in patients with primary syphilis and in most lesions of secondary syphilis, although false negatives may occur if the patient has applied medication to the lesions. A single negative reading does not exclude the diagnosis. Adolescents with suspicious lesions and negative darkfield should be instructed to avoid washing the lesions and to return for two successive readings. The state public health department should be called for assistance.

Serologie Tests

Two basic types of antibodies are stimulated by infection with T. Pallidum: a nonspecific antibody directed against cardi olipìn (a normal tissue component) and specific treponemal antibodies. The serological diagnosis is based on these properties.

Nonspecific Tests

The standard tests are the Venereal Disease Research Laboratories test (VDRL) and the Rapid Plasma Reagin test (RPR). These tests are well standardized and inexpensive. They are the tests of choice for screening and for folio wu p of response to treatment. Since they detect antibody against a normal tissue component, however, they may yield false positives. The VDRL and the RPR turn positive a week or two after the onset of the chancre. A negative test does not rule out primary syphilis; seronegative primary syphilis occurs initially in about half of the cases. Ninety-nine percent of patients with secondary syphilis have a positive test. VDRL and RPR reactivity tends to diminish in late syphilis, and only 70% of patients with neurosyphilis and cardiovascular syphilis have a positive test. Quantitative titers are somewhat useful in the diagnosis and quite useful in following up the response to therapy. Most adolescents with secondary syphilis have titers of at least 1:16. (Most false positive tests show less than 1:8.) No single titer by itself is diagnostic; however, fourfold rises in paired sera are strong evidence of acute syphilis.

Treponemal Test

Treponema Pallidum Immobilization test (TPI) is the best test because it is completely specific. Unfortunately, it is difficult to perform, expensive and not routinely done.

The most widely used is the fluorescent treponemal antibody absorption test (FTA-ABS). This test is used as a confirmatory test whenever there is a positive VDRL or RPR. It is sensitive and has a high degree of specificity. It may remain positive for life in late syphilis. False positive tests are rare, though they have been reported in patients with systemic lupus erythematosus. Patients with false positive FTA-ABS almost always have a negative VDRL and RPR and conversely adolescents with false positive VDRL and RPR will have a negative FTA-ABS.

MANAGEMENT

The following patients should be treated:

* Proven cases; even if asymptomatic

* Contacts of patients with syphilis

* When the diagnosis is equivocal but the patient is pregnant

T. Pallidum is highly susceptible to penicillin. It is inhibited by less than 0. 1 mg of penicillin G. Tréponèmes divide slowly and since penicillin acts only on dividing cells it is necessary to maintain adequate penicillin levels for many days. Thus primary, secondary and latent syphilis require 2,400,000 µ of Benzathine Penicillin G. Late syphilis requires three times as much.8 Treating latent syphilis with such a dose is thought to be curative even if the patient has asymptomatic neurosyphilis.

As many as 60% of adolescents with early syphilis experience a transient febrile reaction after penicillin treatment (Herxheimer reaction). This disappears within 24 hours. The temperature elevation is mild and it is sometimes associated with malaise and headaches. On occasion the skin lesions of secondary syphilis are exacerbated and new cutaneous lesions become visible. The Herxheimer reaction is otherwise of no clinical significance and may be treated with aspirin.

All pregnant adolescents should have a VDRL or RPR test. If they are at risk for an STD a second test should be obtained before delivery. Whenever the diagnosis is equivocal, the patient should be treated to prevent possible disease in the newborn.

Evaluation of treatment should be done through periodic (every three months) quantitative RPR. If the adolescent was treated during the primary or secondary stages liters should fall markedly within six months after treatment. Since reinfection is possible a marked increase in titer should be followed by retreatment.

The majority of adolescents with latent syphilis remain seroreactive over a year following their treatment. The positivity may persist in some for many years. It is recommended to examine the cerebrospinal fluid in all patients with latent syphilis before treatment or at the conclusion of the follow-up period (two years). A normal cerebrospinal fluid is assurance that neurosyphilis will never develop.

GENITAL HERPES

Genital herpes infections affect more than five million Americans, and at least 300,000 new cases occur annually. The individual morbidity and significant public health problems associated with genital herpes have been receiving wide recognition in the lay press. As a result of this heightened awareness many adolescents now seek medical care and information about genital herpes. Unfortunately there is a great deal of fear, confusion, and stigma being attached to the disease.

In man, herpes infections are caused by two different types of viruses - Herpes simplex virus Type I (HSV-I) and Type II (HSV-II). Classically medical teachings stated that herpetic lesions above the waist were caused by HSV-I and below the waist by HSV-II. This distinction is not well documented, neither type is discriminating and either may infect at any site. Typically 90% of genital herpes infections are attributed to HSV-II; however, several studies (especially of younger patients) show that HSV-I may account for as much as 20% to 50% of cases of genital herpes. The type of virus is irrelevant since both produce genital herpes with the same clinical course, treatment and prognosis.

The following factors make genital herpes particularly difficult to control:

* Herpes simplex infections have a short incubation period, usually two to 20 days with an average of six days.

* The transmission rate is rapid.

* There is a significant number of asymptomatic carriers.

* Adolescents may not seek care since the lesions heal spontaneously.

* Most adolescents have detectable antibodies for HSV-I secondary to herpes labia lis as children. Rising titers can be documented for initial, but not recurrent, infections.

* The presence of antibodies to HSVconferimmunîty neither to initial infections of the other strain nor to recurrent infections with the same strain. Recurrent infections are not mediated by serum antibodies. The virus is transmitted by direct cell to cell contact or by shedding of virus particles within the axon sheath of sensorv nerves.

The initial infection of genital herpes in adolescents may present with the following symptoms:

* Pain, itch or paresthesia in the genital area

* Lesions in the genital region that appear within seven days of sexual contact and progress from erythema to papules to vesicles to painful erosions with crusts. Healing occurs without scarring.

* Dysuria, especially in females.

* Dyspareunia may accompany vaginal or penile lesions.

* Vaginal discharge and /or pruritus

* Fever, sore throat, headache, malaise and tender, swollen inguinal lymph nodes.

Primary HSV infections can produce systemic symptoms similar to those of influenza. The majority of adolescents seek medical care when the skin lesions are most painful, which is in the vesicular or erosion phase of the lesions. In female patients lesions may be present on the labia majora, labia minora, fourchette, clitoris, vagina, cervix, buttock or thigh. In male adolescents penile vesicles are the most common but perianal and thigh lesions also occur.

Untreated, the lesions usually heal within two to three weeks; however, virus particles ascend to the sacral ganglia via the sensory nerves, where they remain latent and protected from the host's immune system.

For many patients recurrences are milder and have smaller localized eruptions. Sometimes there is only one vesicle present. There may be a triggering factor - menstruation, emotional factors or sexual intercourse.

In both females and males the recurrence may be painless. This poses a serious problem: adolescents who may not see an active lesion often engage in intercourse during this infectious period.

LABORATORY CONFIRMATION OFTHEDIAGNOSIS

The diagnosis of genital herpes is usually made on clinical evidence, however since the lesions present on moist surfaces and do not crust, diagnosis is sometimes difficult. The differential diagnosis for genital herpes includes early syphilis, early lymphogranuloma inguinale, herpes zoster and early vulvar carcinoma.

Cytologie Methods

Positive Tzanck smears reveal m u It !nucleated giant cells, or Tzanck cells, that develop after staining with Wright's stain. This is probably the most widely used method to diagnose genital herpes and will detect HSV 60% to 80% of the time. In females, Papanicolau smears have been reported to detect 66% to 759? of specimens positive for herpes simplex. Electron microscopy of the vesicular fluid can be used to identify virus panicles.

Viral Culture

Isolation of the virus is the most sensitive means of diagnosing genital herpes. Vesicles may be cultured by swabs after breaking the lesions with a stenle needle. Crusted lesions should be sampled by gently removing the crust and sampling the base of the lesion. Swabs are inoculated into a modified Eagles medium and may be kept frozen at -7O0C if not passed immediately into cell culture. The typical cy to pathological effect of herpes simplex virus may be seen in tissue culture within one to four days, with identification confirmed by a neutralization test. In many areas of the country viral isolation is not easily available and referral to a medical resource center is necessary.

Serologie Methods

Serologie tests have limited value in the diagnosis of genital herpes. Antibodies to HSV-I are almost universal by adolescence because herpes labialis infections are so common. The differentiation between antibodies of Type I or Type II is not totally reliable. Since recurrent genital herpes does not typically cause a rise in titers, paired sera are only helpful in initial infections.

MANAGEMENT

Treatment for the adolescent patient with genital herpes is primarily symptomatic and supportive. The genital region should be kept clean and dry. Sitz baths followed by drying (with a handheld dryer) is often helpful. Topical application of 2% xylocaine jelly may produce some local analgesia. Aspirin can produce systemic analgesia. In the rare severe cases mild narcotics are prescribed. Dysuria may be decreased by having the female adolescent void in a tub of water. Loose-fitting clothing is also recommended.

Many efforts have been made to develop a topical treatment for relieving genital herpes. Photodynamic dyes (neutral red, méthylène blue or proflavin painted on lesions then exposed to ultraviolet light) failed to produce any benefit in co ntrolled studies. They should not be used since there is a possibility of malignant cell transformation. Topical ether has no effect on the lesions. Some topical treatments such as povidone-iodine, lysine and thymol have been reported to be successful, but they have not been studied in a controlled manner. Five percent of idoxuridine in dimethyl sulfoxide proved superior to placebo in decreasing healing time for recurrent herpes in one study. In small controlled studies acylovir has been found effective in decreasing viral shedding, speeding healing time of lesions and decreasing the duration of pain in patients with initial infections.15 The earlier the application of acylovir, the greater the effect. Acylovir is applied topically every three hours for seven days, and appears to be well tolerated by patients. Unfortunately acylovir appears to be of little benefit in recurrent genital herpes or herpes labialis, although it may decrease viral shedding. Use of topical acylovir when lesions are not present has no preventive effect on recurrent herpes.

Since 1966 there has been a clearly demonstrated but unexplained relationship between genital herpes and cervical carcinoma. The adolescent female patient should be advised of this association and of the importance of yearly Papanicolau smears. Furthermore, genital herpes infections during pregnancy may cause significant health problems for the offspring. Primary genital infections with HSV in the first trimester may be associated with spontaneous abortion. To date there have been only rare reports of congenital anomalies associated with maternal HSV infection and therefore elective abortion is not indicated in the pregnant adolescent who develops genital herpes infection eariy in the first trimester. HSV genital infections in the last trimester of pregnancy are associated with premature labor and a high risk for neonatal HSV infections.

There is a 40%to 60% risk that neonates born to culture positive mothers will develop neonatal infections. The illness may manifest itself anytime in the first month of life. About 70% of infants will have cutaneous, or mucosal lesions, but 30% of infants have no external evidence of their CNS disease, making diagnosis difficult. There is still a signficant mortality (40% to 60% of infants affected) with neonatal herpes infections and one-half of the survivors are left with neurologic or ocular sequelae. The devastating nature of this illness has prompted the American Academy of Pediatrics (AAP) to promote a plan to prevent neonatal herpes infections.16 The AAP recommends that patients with a history of recurrent genital HSV infection, those with active disease during current pregnancy and those whose sexual partners have proven HSV infection, should be monitored at least twice during the last six weeks of pregnancy with virologie studies, cytologie studies or both. If none of these tests are positive, a vaginal delivery is possible. If any of these tests are positive or the patient has active genital herpes, delivery by cesarean section is recommended if the pregnancy is at term, or preterm delivery seems likely and amniotic membranes have been ruptured for less than four hours. Sexual abstinence in the last months prior to delivery is suggested if the partner has documented genital infection. Fetal scalp electrodes have resulted in direct inoculation of maternal infection to the infant and should be used with caution.

Infants born to adolescent mothers with infected genital tracts should be isolated using standard wound and skin precautions. Appropriate viral cultures, liver function studies and evaluation of CSF should be made. Infants born by cesarean section should be isolated and observed several days prior to discharge and receive weekly followup during the first month of life.

The adolescent with genital herpes requires special attention.* The recurrent unpredictable attacks and ultimate incurability of genital herpes can lead to anxiety, loss of self esteem and sexual dysfunction in adults. Adolescents may be even more vulnerable psychologically. There are real fears of intimacy and rejection by their partners when they reveal that they are "herpetics." The adolescent must be supported so that intimacy can be achieved, but this must be balanced with the adolescent's responsibility as a carrier of HSV for life. Sexual contact with only one partner and the use of condoms may prevent infections. Diaphragms, contraceptive jellies and foam are probably not effective.

SUMMARY AND CONCLUSION

STDs extract a heavy toll from the adolescent population. The major syndromes and complications that may come to the attention of the pediatrician include vulvovaginitis, urethritis, acute epididymitis, enteritis, colitis, proctitis, arthritis, PID, perihepatitis and sepsis, to name but a few. In addition infected pregnant adolescents may deliver a stillborn child or an infant with pneumonia, congenital malformations, deafness or cognitive impairment.

Future consequences range from infertility, ectopie pregnancy, cervical dysplasia and cancer to cardiac insufficiency, meningoencephalitis and dementia. This list is not exhaustive. Once an adolescent is found to have an STD, an overall medical assessment must be done to investigate concomitant infections and rule out the existence of concomitant problems (sexual exploitation, unprotected intercourse, etc.).

All pediatricians need to develop skills in the areas of venereal disease screening, contact tracing, psychosocial assessment, patient education and medical treatment and followup of the most common sexually transmitted diseases.

REFERENCES

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3. L o u rie R: Menial health aspects of venereal disease in adolescents. Arch Environ Health 1966; 12:684.

4. Silber T: Gonorrhea in children and adolescents. Medical Aspects of Human Sexuality 1982; 16:92.

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6. WaId ER: Diagnosis of gonorrhea in the female adolescent by Gram Stain. Am J Dis Child 1977; 131:1094.

7. Lennate EH. Spaulding EH, Traunt JP (eds): Manual of Clinical Microbiology. Washington, American Society for Microbiology, 1974.

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10. McCormack WM, Evrard JR, Laughlin CF, et al: Sexually transmitted conditions among women college students. Am J Ohsifi Gynecol 1981; 139:130.

11. Holmes KK. Stamm W: Chlamydial genital infections, a growing problem. Hosp Pract October 1979, p 105.

12. Svensso n L, Westrom L, Mardh P: Acute sal p ing it is with Chlamydia trachomatis isolated from the Fallopian tubes: Clinical, cultural and serologie findings. Sexually Transmuted Diseases 1981.

13. Moller BR, AhronsS, Lau ri n J, et al: Pelvic infection after elective abortion associated with Chlamydia trachomatis. Obstet Gynetol 1982; 59:201.

14. Hammerschlag MR: Chlamydial infections. Pediatrics in Review 1981; 3:77.

15. American Academy of Pediatrics Committee on Fetus and Newborn. Committee on Infectious Disease: Perinatal herpes simplex virus infections. Pediatrics 1980; 66:147.

16. Corey L, Nahmias A. Guînan M. et al: A trial of topical acylovir in genital herpes simplex virus infection. N Engl J Med 1982; 306:1313.

10.3928/0090-4481-19821001-12

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