What percentage of genital ulcerations in pediatric patients are caused by infections, such as Herpes Simplex Virus (HSV)?

Infectious Causes of Genital Ulcerations in Pediatric Patients

In pediatric patients, the vast majority of genital ulcerations (approximately 75-90%) are caused by infectious agents, with herpes simplex virus (HSV) being the predominant cause.

Primary Infectious Causes

Genital ulcerations in pediatric patients are predominantly caused by:

1. Herpes Simplex Virus (HSV) - Most common cause in the United States and industrialized nations 1, 2

   • Can be either HSV-1 or HSV-2
   • Primary infections cause more severe lesions than recurrent episodes
   • HSV accounts for approximately 38.5-50% of genital ulcers 3

2. Treponema pallidum (Syphilis) - Second most common infectious cause 4

   • Accounts for approximately 16% of genital ulcers 3
   • Requires serologic testing for diagnosis

3. Chlamydia trachomatis (LGV strains) - Less common cause 3

   • Accounts for approximately 1% of genital ulcers

4. Haemophilus ducreyi (Chancroid) - Rare in pediatric populations in the US 4

   • Previously more common but now rarely detected in recent studies 3
   • May co-occur with other infections in approximately 10% of cases

5. Epstein-Barr virus (EBV) - Rare but documented cause 5

   • Can present as genital ulcerations in adolescents with infectious mononucleosis

Diagnostic Approach

When evaluating genital ulcers in pediatric patients:

• Clinical diagnosis based solely on physical examination is often inaccurate 4

• Complete diagnostic evaluation should include:

  • Serologic test for syphilis (mandatory)
  • HSV culture or PCR testing
  • Testing for other potential pathogens based on clinical suspicion

• Even with complete testing, approximately 25-50% of genital ulcers have no laboratory-confirmed diagnosis 4, 3

Special Considerations in Pediatric Patients

• Genital ulcers in children should raise concern for possible sexual abuse and require appropriate evaluation
• HIV testing should be considered, especially with confirmed syphilis or chancroid 4
• Management of pediatric patients with STIs requires referral to or consultation with physicians familiar with pediatric infectious diseases 4

Co-infections

• Multiple infections may be present in 3-10% of patients with genital ulcers 4
• Gonorrhea and/or chlamydia infections are found in approximately 27% of patients with genital ulcers 3
• HIV infection is more common in patients with genital ulcers, particularly those with HSV (68.6% vs 41.8% in non-HSV ulcers) 3

Treatment Considerations

• Treatment should target the most likely cause based on epidemiology and clinical presentation
• When diagnosis is unclear, treatment for both syphilis and HSV may be warranted
• Pediatric dosing requires special consideration and should be managed by physicians familiar with pediatric infectious diseases 4

Pitfalls and Caveats

1. Relying solely on clinical appearance for diagnosis is inadequate and leads to misdiagnosis
2. Failing to consider non-infectious causes (approximately 25-50% of cases)
3. Missing co-infections, which occur in 3-10% of cases
4. Not considering rare causes like EBV in the appropriate clinical context
5. Overlooking the possibility of sexual abuse in pediatric patients with genital ulcers

The management of genital ulcers in pediatric patients requires thorough evaluation, appropriate laboratory testing, and consideration of both infectious and non-infectious etiologies, with recognition that HSV remains the predominant infectious cause.