Neisseria gonorrhoeae conjunctivitis in a prepuberal girl a dilemma

sexual violence or non-sexual transmission?

Abstract

Sexually transmitted infections (STIs) are a public health issue of global concern and frequently lead to important sequelae if not diagnosed and properly treated. Neisseria gonorrhoeae (NG) infection is one of the most prevalent STIs worldwide and recently presents increasing incidence and antimicrobial resistance rates. Apart from the neonatal period, NG infection during childhood is considered evidence of sexual violence (SV). However, defining perpetration of violence can be challenging in clinical practice. Objective: To report a case of conjunctivitis due to NG in a prepuberal girl and discuss possible means of infection acquisition and medical forensic implications. Case report: A 7-year-old female Caucasian student from São Paulo was referred to the Rape Care Center (Núcleo de Atendimento a Vítimas de Violência Sexual – NAVIS) outpatient clinic to investigate sexual violence in September 2013. At admission, she reported right ocular hyperemia for 10 days with no response to tobramycin eye drops. Personal history: nothing noteworthy. She lived with her mother and grandmother and visited her father every two weeks. Physical and gynecological examinations were normal. Eye examination: Left eye — nothing noteworthy. Right eye — palpebral edema, conjunctival hyperemia with purulent exudate and upper corneal perforation. Bacterioscopy of conjunctival secretion was positive for Gram-negative diplococci and NG was isolated in culture. The patient was submitted to suturing of right eye perforation and received 1g intravenous ceftriaxone per day for 10 days. During investigation at the NAVIS outpatient clinic, the mother denied any SV episode or school behaviour change. Multidisciplinary psychosocial care was provided to the child and her mother for over 6 months, but SV could not be characterized. STIs investigation for HIV, hepatitis B and C infections and syphilis resulted negative. Based on the literature, a hypothesis of accidental intra-familial non-sexual transmission of NG was then considered. Endocervical, vaginal and urethral secretions were collected from the mother and yielded isolation of endocervical beta-lactamase producing NG. Hygiene measures and contact isolation were recommended and the mother underwent treatment with ceftriaxone single dose 1G. During follow-up the child developed corneal opacity in her right eye. Conclusion: In prepuberal children presenting with unusual but compatible clinical manifestations, STIs should always be considered and investigated to enable prompt treatment and avoid sequelae. If gonococcal infection is diagnosed, the possibility of sexual violence should be thoroughly investigated, preferably in a comprehensive multidisciplinary approach to rule out non-sexual contamination and avoid emotional damage to the child and family. Clearly defining SV and proposing proper interventions in these circumstances is, however, challenging for healthcare providers.