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Child Abuse Case 10


This photo demonstrates a finding observed on a 3-year-old boy with perianal itching and pain. He has had a few blood-streaked stools. His mother has been applying nystatin cream to the area, but it continues be inflamed and sharply demarcated. She denies any history of sexual abuse or trauma to his rectal area.


Case 10

Source: A. S. Botash, MD, used with permission


Which of the following statements is most likely?

  1. This is a case of resistant Candida.
  2. The redness is likely from chronic abuse and a hotline report should be made.
  3. Thayer Martin is the most appropriate culture media for a diagnosis.
  4. A throat culture will likely reveal the same organism as a culture of the perianal area.
  5. C and D

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The answer is D.

The photograph demonstrates an area of erythema and induration commonly seen with perianal Group A beta hemolytic streptococcal (GABHS) cellulitis or dermatitis. Because this infection can occur anywhere in the perineum, it has also been called perineal streptococcal cellulitis. The infection commonly occurs in children aged 6 months to 10 years, and boys are affected more commonly than girls. Painful defecation or blood-streaked stools may occur.

Over 90% of children with this disease have concomitant positive streptococcal pharyngeal cultures. However, these patients usually do not have pharyngeal or systemic symptoms. Fever, scarlet fever rash and subsequent desquamation are rare with perianal streptococcal disease. Flares of guttate psoriasis have been observed by some, and for this reason, some recommend swabbing the perianal area for strep cultures in cases of guttate psoriasis. Follow-up urinalysis is recommended due to the potential for the rare occurrence of post-strep glomerulonephritis that was reported following a case of vaginal strep. Symptoms may rarely be caused by Group B or G beta hemolytic streptococcus or by Staphylococcus aureus.

The condition can be diagnosed by a rapid strep test or plating a swabbed specimen onto blood agar, not Thayer Martin media. Thayer Martin media is used for the detection of Neisseria species, including N. gonorrhoeae. Although gonorrhea may present as a perianal infection, anorectal infection is generally asymptomatic with no anal symptoms.

This disease is commonly misdiagnosed as Candida dermatitis and may be misdiagnosed as a finding from trauma or sexual abuse. Lack of satellite lesions, presence of a mucoid discharge and lack of response to treatment with antifungals should alert the provider to the true diagnosis. Without a history of trauma, infection is a more likely diagnosis. Pinworms generally do not cause such significant redness.

Treatment with penicillin or penicillin-derivative antibiotics is recommended, similar to the dosing for pharyngeal infection, but with prolonged treatment (14 days by some authors, 21 days recommended by others). Penicillin-allergic patients may receive erythromycin or topical mupirocin. However, recurrence of the infection is common and repeat culture in follow up after treatment is recommended. Some physicians recommend swabbing and testing asymptomatic siblings.

Reference:
Herbst, RA. Perineal streptococcal dermatitis/disease recognition and management. Am J Clin Dermatol. 2003; 4(8):555-560.


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