Discordance of Human Genotype of Papilloma Virus in Mother and

Toddler with Condyloma Acuminata

Sekar Sari Arum Palupi

, Prasta Bayu Putra

, Kharisma Yuliasis

Dwi Retno Adi Winarni

, Didik Setyo Heriyanto

, Satiti Retno Pudjiati

Departmentof Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada

Anatomical Pathology Department Faculty of Medicine, Public Health and Nursing

Universitas Gadjah Mada

*Correspondence: +6281328479100, fax: (+62274) 885637,

Keywords: Human Papilloma Virus, Condyloma Acuminata, PCR, Genotype

Abstract: Condylomaacuminata (CA) is a Human Papilloma Virus (HPV) infection that is rarely found in children.

Transmission can be through vaginal contact, sexual abuse, auto or heteroinoculation or fomites.

Polymerase Chain Reaction (PCR) examination is the gold standard for determining the cause of HPV

genotype. This case report aimed to trace CA transmission to toddlers (ages <3 years). A female toddler has

warts around the anus with a history of vaginal delivery and no sign of sexual abuse. The mother has warts

on the genitals and between the fingers in pregnancy. The CA diagnosis was based on toddler's physical

examination, acetowhite tests, and perianal biopsies. The endocervical smear from the mother was in

accordance with the CA and the wart biopsy from the mother's fingers appropriate for verruca vulgaris. PCR

has examined 39 HPV genotypes in the mother and the child. In the child showed HPV genotype 11,

frommother’s cervical swab samplesshowed HPV genotype 87 and indeterminate result from the

mother'sfingers. The discordance of HPV genotypes in the mother and the child is likely due to

heteroinoculation transmission from the family who took care the child, or still possible from the mother but

not detected on PCR examination because it only can examine 39 types of HPV. Identification with whole

PCR is needed to ensure the source of transmission.

1 INTRODUCTION

Condyloma acuminata (CA) or genital warts are

infections of the Human Papilloma Virus (HPV)

which are rarely found in children. Until now, more

than 200 HPV genotypes have been identified using

the PCR method.

(Ghedira et al., 2016;Chen et

al.,2018,Sohrabi et al.,2017) More than 90% of

cases of perianal and anal CA in adults and children

are caused by HPV groups with low risk of

neoplastic namely HPV 6 or 11, but there is also

evidence that HPV 1, 2, 4, 7, 27, 57, 60 and 63 are

the causes Sohrabi et al,2017. Genotypes of HPV

types 16, 18, 31, and 33 are HPV groups with a

tendency to become intraepithelial neoplasia and

invasive squamous cell carcinoma.(Lacour et

al.,2012) Whereas, in HPV 87 there is still little

literature to discuss. This type of HPV is associated

with a tendency to occur in HIV patients.(Menzo et

al.,2001) CA transmission can be through contact

during vaginal delivery, sexual abuse, auto or

heteroinoculation, or through fomites. (Lacour et

al.,2012;Menzo et al.,2001;Tract et al.,2005)

Predilection of lesions in girls with CA is in the

vulva, perianal, vagina, and urethral regions whereas

in boys lesions are most often present in perianal and

rarely occur in the penis.(Boxman et al.,1999)

Polymerase Chain Reaction (PCR) examination is

the gold standard in determining causative HPV

genotypes. (Sonnex et al.,2014)

Although common in adulthood, CA in children

is an unusual condition. In several studies reported

the dominance of female sex in children age with

CA with an average age ranging from 2.8 to 5.6

years. The prevalence of CA from epidemiological

data that occurs in Indonesia is around 5-19%, while

the prevalence in infants and children is less than

4.3%.(Jenison et al,2000) The incidence of CA in

adulthood in Dr. Sardjito Hospital for the past five

years was 605 cases while the toddlers (under three

338

Palupi, S., Putra, P., Yuliasis, K., Winarni, D., Her iyanto, D. and Pudjiati, S.

Discordance of Human Genotype of Papilloma Virus in Mother and Toddler with Condyloma Acuminata.

DOI: 10.5220/0009988203380342

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 338-342

ISBN: 978-989-758-469-5

years old) were only 1 case. This paper reports one

case of CA in toddlers who came to the

Dermatology and Venereology clinic of Dr. Sardjito

Hospital with complaints of warts on the perianal.

The purpose of this case report is to trace the

transmission possibilities.

2 CASE

A 15 months old girl came to the Dermatology and

Venereology clinic of Dr. Sardjito Hospital with the

chief complaint of warts appearing around the anal.

From heteroanamnesis and alloanamnesis found that

warts appeared since a few weeks ago, shaped rough

bumps, skin color, size less than 0.5 cm. It did not

feel itchy, painful, and there was no interference

with bowel movements. They said she never been

treated before. The patient was an only child,

bornwith appropriate gestational age, vaginal

delivery, with a head presentation. There were no

airway disorders, hoarseness, stridor, or eye

disorders. Every day the patient lived and was cared

for by her mother and grandmother, mother had the

habit of using towels alternately with her children to

clean their genitals after urinating and no history of

sexual abuse. Her parents were divorced, and her

father did not live at home.

A mother who was three months pregnant

had been diagnosed by dermatology, and

venereology specialist had genital warts in her

vagina and had been treated. The size of the wart

decreased but did not fall out until postpartum, and

the patient never attends follow up again. The

mother also had a wart with a diameter of 0.5 cm

between the index finger of her right hand.

Physical examination of children showed

right general conditions with vital signs within

normal limits, and there were no signs of sexual

abuse or enlarged lymph nodes. The perianal

examination was revealed a verrucous papule, skin

color, multiple with a size of 0.2 cm-0.5 cm (Figure

1A). The acetowhite test showed positive results,

and on histopathological examination, with

Hematoxylin-Eosin (HE) staining showed results in

the epidermis showed mild hyperkeratosis,

parakeratosis, partial hypergranulosis, spongiosis,

irregular acanthosis, parabasal hyperplasia, and little

lymphocyte acrositosis. Among them were

keratocytes with cytoplasm halo perinuclear and the

nucleus was slightly enlarged (coilocytosis). In the

dermis, there was quite a lot of lymphocytic and

periadnexal infiltration. There was no malignant

sign. Conclusion of perianal histopathology was in

accordance with CA (Figure 1B). PCR

examinationwas performed for 39 types of HPV.

Children and mother's HPV DNA was obtained from

the extraction of CA tissue in paraffin blocks. PCR

examination in perianal CA specimens of children

showed HPV 11 genotype (Figure 2A).

Figure 1: A: Perianal condyloma acuminata on the child; 1B: Histopathological examination with Hematoxylin-Eosin (HE)

staining revealed keratinocyte with halo perinuclear cytoplasm and the nucleus a bit enlarged or coilocytosis (arrow)

Figure 2: A. PCR CA of the child perianal resulted in HPV genotype 11

Discordance of Human Genotype of Papilloma Virus in Mother and Toddler with Condyloma Acuminata

339

The physical examination of the mother when

she came to the Dr.Sardjito Hospital showed no

vaginal CA, and on in speculum examination

(Figure 3A) the cervix appeared to be calm and no

discharge nor verucous papules were found, but

found a skin-colored verucous papule, a solitary size

of about 0.5cm in right manus interdigit II (Figure

3B).

Histopathological examination of verruca skin

tissue specimens with HE staining showed that the

epidermis appears hyperkeratotic, acanthosis,

papillomatosis, partly with hypergranulosis. Among

them were keratinocytes with cytoplasm halo

perinuclear and the nucleus was slightly enlarged

(coilocytosis). The dermis looks puffy with small

perivascular lymphocytes. There was no malignant

sign. Conclusions on histopathological biopsies were

in accordance with verruca vulgaris. (Figure 3C).

Histopathological examination of cervical swabs

appeared ectocervical cells in the form of many

intermediate cells and few parabasal cells. We

obtained a few endocervical epithelial cells and not

finding displaced metaplasia or malignant epithelial

cells. The background was erythrocytes, many

polymorphonuclear leukocytes, and few

lymphocytes. The conclusion to the Pap smear was

Papanicolaou Class I (non-peculiar inflammation,

Bethesda system: Negative for Intraepithelial Lesion

or Malignancy). PCR examination with cervical

swab showed HPV genotype 87 (Figure 4A),

whereas, with skin material, the lesions of verrucae

vulgaris on the fingers were undeterminated (Figure

4B).

Figure 3: A: Inspeculo examination to mother cervix showed calm cervix no discharge found nor verrucous papule. 3B:

Verrucous vulgaris on interdigit of mother hand. 3C: Histopathological examination with Hematoxylin Eosin (HE) of

verucous vulgais on the finger showed coilocyte (red arrow).

Figure 4: A. PCR of mother cervix showed HPV genotype 87.4B. PCR interdigit II manus dextra of the mother

showedundeterminated.

Patients are advised to be referred to an ENT

specialist and ophthalmology specialist to track the

presence or absence of laryngeal papillomatosis and

eye keratitis. Until this case report is made, it has not

been tracked due to limited costs.

3 DISCUSSION

Condylomaacuminata often referred to as chicken

combs or genital warts, is one of the sexually

transmitted infections caused by HPV. Human

Papilloma Virus is included in the papovaviridae

family, the genus polyomavirus. The clinical

manifestations of HPV infection in the genitals can

be classic symptoms, such as prominent cauliflower,

small smooth papules like flesh or hyperpigmented

papules that combine to form keratotic plaques or

papules or like verruca vulgaris The CA diagnosis in

perianal children, in this case, is confirmed by the

suitability of clinical features, histopathology and

the discovery of HPV genotype 11 on PCR

examination. In the mother, it can be concluded that

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

340

it has an asymptomatic CA on the cervix because

there is no lesion clinically, but on histopathological

examination and PCR examination shows HPV

infection genotype 87; while the diagnosis of

verruca vulgaris on the mother's finger is also

matched with the clinical and histopathological

features.

Condyloma acuminata in children can occur due

to transmission through vaginal delivery, sexual

abuse, auto or heteroinoculation, and fomites. In

cases, suspected transmission occurs during vaginal

delivery because CA lesions in children appear at

the age of 15 months while the mother emerges

vaginal CA at 3 months gestation, with an

incubation calculation of about 12 months. The

literature shows that HPV incubation ranges from 1-

12 months.(Chen et al.,2018,Sohrabi et al.,2017)

However, vaginal transmission is still questionable

because it turns out that the HPV genotype in

children is different from the HPV genotype in

mothers. Suspicion of transmission due to sexual

violence can be excluded because neither from

alloanamnesis nor physical examination shows signs

of sexual abuse. Suspicion of transmission through

autoinoculation can be excluded because the patient

does not have a CA at locations other than perianal.

Suspicion of heteroinculation transmission through

the mother's finger when cleaning the patient's anus,

or through fomites due to the habit of using towels

alternately with the patient to clean the genitals or

perianal is indisputable because on PCR

examination the warts on the fingers are

undeterminated or HPV is present but not in

accordance of 39 types of HPV examined. Veruca

vulgaris is a benign proliferation of the skin and

epidermal mucosa caused by HPV. The most

common type of HPV is types 1, 3, 27, and 57.

Whereas based on predilection, most often occur,

especially in places that often experience trauma

such as fingers, hands, and knees. HPV in the hands

and feet is usually typed 1, 2, 4, 27, 57 and 19.

Transmission of the perianal CA in children can be

through the caregiver's fingers to genitalia. .(Menzo

et al.,2001). Based on several studies, the

transmission of CA through fomites often occurs

through surgical equipment, gloves with less

sterilization, floor, toilet seat or through alternating

towels.(Lacour et al.,2012)

PCR examination is the gold standard in

determining HPV genotypes. The use of

ultrasensitive examination methods with real-time

PCR can detect≥ four dominant genotypes in 25% of

CA cases(Sonnex et al.,2014;Jenison et

al,2000;Hawkins et al.,2013)

PCR examination in this case used Ampliquality

Express type HPV with 99% instrument sensitivity

and 98.6% specificity that detected 39 types of HPV

genotypes, namely: 6, 11, 16, 18, 26, 31, 33, 35, 39,

40, 42 , 43, 44, 45, 51, 52, 53, 54, 55, 56, 58, 59, 61,

62, 67, 68a, 68b, 70, 71, 72, 73, 81, 82, 83, 84, 87 ,

89, and 90.

The detection of vaginal transmission

from mother to child can actually be done if the

mother comes when there is still a vaginal CA.

However, when she came to follow up, her vaginal

CA was gone, so the sample was only taken from the

mother's cervical swab. The presence of laryngeal

papillomatosis and eye keratitis as a result of HPV

transmission during vaginal delivery cannot be

detected because the patient refuses to be referred.

The limitations of the PCR method with cervical

swab specimens were only detected by some of the

most dominant types of HPV because of the natural

competition between HPV genotypes of CA. The

types of specimens taken from the cervix also often

do not accurately describe the cause of the HPV

genotype, because some HPV genotypes are only

found in the basal cervical tissue. Skills and

techniques really determine the taking of test

specimens. Whereas, different results can be found

in HPV infections in the skin, where coinfection

caused by more than ten genotypes can be detected

even in deficient amounts.

4 CONCLUSION

One case of perianal CA on toddlers aged 15 months

with mothers suffering from asymptomatic CA in

the cervix and veruca vulgaris in the fingers is

reported, but there is no match for HPV genotypes

between the child and the mother. Thus,

transmission in children cannot be determined. HPV

genotype examination is needed with the whole PCR

method both in mother and child and screening to

the family who care for the child to identify the

transmission source.

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