Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Appropriate antibiotic treatment for streptococcal perianal dermatitis
- Ulrich Heininger (7 May 2009)
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Easily missed but remember child abuse and neglect
- Deborah Tamara Hodes (22 May 2009)
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Streptococcal proctitis or anal sexual abuse?
- Richard Lehman (28 May 2009)
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Streptococcal perianal infection and guttate psoriais
- D Graeme Stewart (4 June 2009)
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Vital need for perennial perianal research
- Dr Viera Scheibner (10 June 2009)
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Ulrich Heininger, Attending Physician Paediatric Infectious Diseases University Children's Hospital Basel, Switzerland
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I would like to add some information on the appropriate treatment of streptococcal perianal dermatitis. The authors state that "Observational evidence suggests a better response to treatment with oral co-amoxiclav or clarithromycin for 7-10 days than with oral phenoxymethylpenicillin (penicillin V)." The reference to this statement dates back to 1987. We have recently published a first randomized treatment study of streptococcal perianal dermatitis which the authors may have missed (1). In this study, we investigated the efficacy of oral penicillin (for 10 days) compared to cefuroxime (for 7 days) for group A beta-hemolytic Streptococcus pyogenes (GABHS) perianal dermatitis in children 1-16 years of age. A perianal swab was obtained on first presentation of the patients and at the end of treatment to document eradication of GABHS. Severity of disease was assessed with a clinical score throughout the course of the study. Clinical improvement was more rapid in the cefuroxime group (p=0.028) and GAHBS was successfully eradicated in 13 of 14 patients treated with cefuroxime compared to only 7 of 15 patients in the penicillin V group (p <0.01). Five patients with penicillin treatment failure were then treated with 7 days of cefuroxime. This cross-over treatment was successful in 4 instances whereas one patient continued to show signs of perianal dermatitis and also perianal culture remained positive for GABHS; finally this patient was treated successfully with clindamycin. We concluded that 7 days of cefuroxime was more efficacious than 10 days of penicillin V and therefore should be considered as the initial treatment of choice for perianal dermatitis due to GABHS today. Reference Meury SN, Erb T, Schaad UB, Heininger U. Randomized, comparative efficacy trial of oral penicillin versus cefuroxime for perianal streptococcal dermatitis in children. J Pediatr 2008;153:799-802. Competing interests: None declared |
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Deborah Tamara Hodes, Consultant Community paediatrician Kentish Town health Centre London NW5 2AJ
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Dear Sir Lehman and Pinder quite rightly draw our attention to the lack of awareness of perianal streptococcal infection amongst general practitioners in Oxfordshire (1) and the difficulty of establishing the diagnosis of inflamed perianal lesions. It is an important diagnosis given the discomfort and spread to other members of the family if untreated. However, it is misleading to use the McCann study (2) to make the point that there is no evidence that perianal redness and fissures are indicators of child sexual abuse (CSA). The Royal College of Paediatrics and Child Health evidence-based review and guidance for best practice (3) states there is evidence that erythema is more likely to be seen in the abused child if examined early and one study found that fissures are a frequent finding in anally abused children. In practice after an allegation and after excluding other medical causes and accidental trauma, erythema and fissures can also be signs of CSA. Unlike streptococcal perianal infection, CSA is common; in a recent UK survey, 11% of 18 – 24 year olds considered themselves to have been sexually abused when they were aged 12 years or less (3). It also maybe missed because of lack of awareness, by not including it in the differential diagnosis, by not remembering that it may coexist with another condition and not asking the child and/or parent as part of thorough history taking. After Baby P, the public wants reassurance that in asking about possible child maltreatment, we are really trying to protect children coming to our attention. References 1. Lehman R, Pinder S. Streptococcal perianal infection in children. BMJ 2009; 338: 1201-1202. 2. McCann J, Voris J, Simon M, Wells R. Perianal findings in prepubertal children selected for nonabuse: a descriptive study. Child Abuse Negl 1989; 13:179-93. 3. Royal College of Paediatrics and Child Health. Physical signs of child sexual abuse London: Royal College of Paediatrics and Child Health, 2008 Yours sincerely Deborah Hodes
Competing interests: None declared |
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Richard Lehman, GP Hightown Surgery,Hightown Gardens, Banbury, OX16 9DB
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Dr Hodes’ response to our Easily Missed piece on streptococcal perianal infection in children raises issues about the diagnosis of child sexual abuse which we were unable to discuss fully within the tight space limits of the series. We wrote as primary care doctors from the perspective of primary care. However, we were careful to state, not that perianal redness and fissures cannot be signs of sexual abuse, but that they do not in themselves constitute evidence of abuse. Dr, Hodes cites a figure of 11% for all recollected sexual abuse before the age of 13, but this is not the issue. Rather it is the relative likelihood of findings such as perianal redness, fissures, and bleeding being caused by anal sexual abuse rather than streptococcal infection in children brought to general practitioners by their parents. We know that streptococcal perianal infection is seen in an average sized general practice about 8-12 times a year, mostly in pre-school children. Anal abuse sufficient to cause these physical signs may be commoner than we realise, but we are not aware of any data to suggest it presents to primary care with such frequency. Following the Baby P case, the public needs to know that doctors will not overlook the physical signs of gross life-threatening injury. Equally, if and when some of the 121 children taken into care in Cleveland in 1987 finally seek legal redress, the public will need to know that all doctors looking after children are aware of the causes of anal physical signs which do not necessarily – or even commonly – indicate sexual abuse. Competing interests: None declared |
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D Graeme Stewart, Consultant Dermatologist Dudley Group of Hospitals, DY12HQ
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Dear Sir, I would agree with Lehman and Pinder that this condition is not widely recognised. It is certainly a cause of guttate psoriais and symptoms should be actively inquired about, and the peri-anal skin examined, in patients in this age group presenting with guttate psoriasis. In their article the authors state that it can cause " an illness similar to scarlet fever (guttate psoriasis)". Streptococcal infection can cause a scarletiniform, desquamating erythematous rash, but this is a distinct condition from guttate psoriasis. Yours sincerely D Graeme Stewart Competing interests: None declared |
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Dr Viera Scheibner, Scientist (Retired)/Author Blackheath NSW Australia
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“Streptococcal perianal infection in children”, by Lehman and Pinder, has stirred up an interesting discussion which is related to the attitude that has been shown by some medicos when they are short on facts and fail to turn to published medical research; instead they may tend to attack the patients, in this case the parents of a child suffering an illness that is well-documented but sadly not always known to the treating physicians. The first mention of accusation of a mother of causing what was in fact her child’s reaction to the smallpox vaccine occurred some two hundred years ago. One would think that with the accumulated and easily accessible published information, today’s doctors would not fall into the trap of a mediaeval vindictive attitude. In addition to this, parts of the legal and judicial system still seem to be stuck in Charles Dickens’ times. Now I will endeavour to demonstrate that far from being rare or unknown, perianal ulceration is a common and recognised metastatic, extraintestinal symptom and complication of Crohn’s disease and ulcerative colitis. Wallis and Walker-Smith (1976. An unusual case of Crohn’s disease in a West Indian child. Acta Paediatr Scand; 65: 749-751) wrote that “although perianal ulceration is common in Crohn’s disease, extensive perineal ulceration particularly in children is rare.” Then they proceeded to describe a case of a 13-year old black Jamaican girl who gave a 21- month history of progressive hypertrophy and ulceration of the vulva and groins associated with a profuse purulent discharge. There had been no inguinal lymphadenopathy. An examination under anaesthetic (EUA) had excluded the presence of a vaginal foreign body and the hypertrophy had been thought to be secondary to lymphatic obstruction arising from recurrent low grade infection.” Surprisingly, they ascertained that “There was nothing relevant in her previous health or family history. She has never been outside England.” The diagnosis of Crohn’s disease was made following emergency admission to hospital with a week’s history of diarrhoea containing fresh blood, transient lower abdominal pains and a weight loss of over 2 kilograms. Her clinical examination included pigmented skin lesions over her tibia suggestive of healing erythema nodosum. The child, “in spite of active rectal disease, has so far had a surprisingly good response to steroids, Azathioprine and wound courettage and has continued to improve despite reduction in the steroid dosage, as quick relapse followed the initial more rapid reduction. However, her improvement has been maintained at the expense of marked steroidal side effects and we have yet to see if she can be successfully weaned off steroids completely.” Rankin et al. (1979. National cooperative Crohn’s disease study; Extraintestinal manifestations and perianal complications. Gastroenterology; 77 (4), Part2: 914-920) wrote that among 569 patients with Crohn’s disease. 24% had a history of at least one extraintestinal manifestation and 36% had a history of perianal disease before randomisation. The perianal complications of anal fissure, perianal fistulae , or abscess were combined as perianal complications. External fistulae included enterocutaneous fistulae, enterovesicular fistulae, and enterovaginal fistulae. Markowitz et al. (1984. Perianal disease in children and adolescents with Crohn’s disease. Gastroenterology; 86: 829-833) delineated clinical and pathological features of perianal disease in children and adolescents with Crohn’s disease. Of the 149 patients (mean age 12.1 Yr, 73 had perianal disease including 51 with fissures and tags. Perianal disease was defined as: anal canal lesions, large oedematous skin tags or chronic, deep anal fissures, or both. These lesions, located anywhere in the anal canal, could be easily distinguished from more acute, superficial stercoral fissures usually situated in the midline anteriorly or posteriorly, or both. Schrodd et al. (1999. Metastatic Crohn’s disease presenting as chronic perivulvar and perirectal ulceration in an adolescent patient. Pediatrics: 500-503) described a case of a 13-year-old African-American girl with a 6-month history of haemorrhoids, constipation, perianal and perivulvar fissures, skin tags, and weight loss. Physical examination revealed multiple erythematous, indurated, tender papules and plaques, with granulomatous vegetations and ulcerations involving the inguinal, perivulvar, perineal, and perirectal regions. A few oedematous, inflamed papillomas were noted in the perirectal area. Histopathology revealed ulcerated fibromembraneous tissue, diffuse acute and chronic inflammation with lymphocytic infiltrate and noncaseating granuloma formation with multinucleated giant cells consistent with metastatic Crohn’s Disease (MCD). A colonoscopy with bowel wall biopsy revealed active colorectal disease without evidence of sinus tract of fistula formation. Intestinal mucosa histopathology showed inflammation with chronic inflammatory infiltrates, fibrosis, and granuloma formation consistent with CD. More recent research has demonstrated that Crohn’s disease and other forms of ulcerative colitis are immunological disorders. Shanahan (2002. Crohn’s disease. Lancet; 359: 62-69) wrote that “Crohn’s disease is a disorder mediated by T lymphocytes which arises in genetically susceptible individuals as a result of a breakdown in the regulatory constraints on mucosal immune responses to enteric bacteria.” Furlano et al. (2001. 138: 366-372) wrote that histology demonstrated lymphocytic colitis in autistic children, in an article titled “Colonic CD8 and gamma deltas T-cell infiltration with epithelial damage in children with autism”. It should come as no surprise that Kawashima et al. (2000. Digestive Diseases and Sciences; 45 (4): 723-739) detected and sequenced measles virus (consistent with being vaccine strains) from peripheral mononuclear cells from patients with inflammatory bowel disease and autism, since this virus is known to have a predilection for the epithelium. Perhaps I will quote one more article, namely Kirschner and Stein’s “The mistaken diagnosis of child abuse. A form of medical abuse?” (Am J Dis Childhood; 139: 873-875) who wrote “Although the histories related by the parents were in all cases truthful and consistent with the results of physical examinations of the child, the involved physicians failed to make a correct diagnosis. Not only a lack of experience with severe childhood illness and death but also an attitude of suspicion and/or hostility probably contributed to these misdiagnoses.” Competing interests: None declared |
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