Introduction

AGW ( anogenital warts) are a common sexually transmitted disease (STD) in adults[1]. Less is known about AGW in children and in none sexually active individuals. In children AGW have been associated with child sexual abuse although its significance remains unclear [2]. Congenital transmission may take up to 2 years to appear and anogenital warts may arise through non-sexual contact or auto-inoculation [3,4]. Late presentation of vertical transmission in immunocompromised individuals and transmission by formites has been reported [5,6,7]. ^{Here we describe a huge condyloma acuminata in a 14 year old none sexually active girl, HIV positive.}

Case report

A 14 year old HIV positive was referred to the Gynecological Clinic from HIV clinic with a history of abnormal growth on genitalia for 6 months prior admission. The mass was growing slowly and not associated with pain or itching; however sometimes it bled on contact. The patient occasionally had abnormal vaginal discharges which she described as foul smelling.

She was diagnosed with HIV in 2005, which she had probably acquired in utero; her mother was HIV positive and died in 2005. She has not started on antiretroviral drugs. She denied being engaged in any form of sexual activity. She lived with her father and other family members with no history of skin or genital warts.

On physical examination, the patient was found to be a lean female with slight palmar and conjunctival pallor. She had stable vital signs and was afebrile. She had no lymphadenopathy and no oral lesions. Her abdomen was flat and non-tender; on inspection of the external genitalia there were multiple condylomatous masses on the bilateral labia majora extending towards the peri-anal area obstructing the introitus (Figure 1). VDRL was no-reactive, CD 4 count was 436 cells/µl, and hemoglobin was 8.5g/dl.

The clinical impression was that of extensive genital condyloma acuminata. The patient was counseled for excision of warts by electro-cauterization. The patient was then taken to the operating theatre where the excision was performed under spinal anaesthesia. In the theater she was found to have an intact hymen, and there was no involvement of condyloma with the cervix or vagina. Post operatively she was kept on sitz bath daily for five days. She was discharged on the second day in good condition.

After three months the patient was seen at the Gynaecology outpatient clinic for follow-up and the histology results confirmed the diagnosis to be condyloma acuminata (Figure 2). On examination of the patient’s external genitalia, there were no recurrent lesions. She was counseled about the possibility of recurrence and the need for follow-up again after three months. In the mean time she would continue to attend her HIV clinic.

Figure 1

:Multiple lesions coalesce to form a giant genital condyloma

Figure 2

: Biopsy of condyloma acuminatum showing; parakeratotic and ancanthotic squamous epithelium. These are features of HPV infection

Discussion

The transmission of HPV in children remains controversial and may include perinatal transmission, sexual abuse, and indirect transmission through fomites and skin to skin contact [2,5]. ^{This patient was 14 years old so it was unlikely that she had acquired her current HPV infection during birth, as in most cases of perinatal HPV transmission manifest during the second year of life [5]. However the present patient was HIV positive with low CD4 count; HPV reactivation which was vertically transmitted could not be ruled out [1].The fact that this patient was found to have an intact hymen, shows that probably she had acquired HPV infection either through genital touching or peno-anal intercourse [6].}

Medical treatments with podophyllin, imiquimod, or interferon are the preferred treatments for smaller warts. In this case, the lesions were too large, hence the surgical option was considered [1,2]. The recurrence of warts after surgical excision using electrocautery is high at about 50%. The incidence of recurrence may be even higher in immune compromised patients [7]. In this patient however there was no recurrence despite her immune status. Since recurrence is very common in immune compromised patients they should have repeated evaluation over extended period of time [1].

Clinician should carefully approach children and none-sexually active teenage with condyloma acuminata and try to establish the mode of transmission. HPV infection can be transient and asymptomatic for many years and can be reactivated in stress or immunodeficiency and this is probable explanation in the above presented case.

Acknowledgement

We thank staff in the department of Obstetric and Gynaecology, Dr H. Beatrice Im and Dr Peter Rambau for their assistance.