Depressing Reality

Dear Colleagues,

Please help me with a 4 year-old lad who was referred today by his GP for genital warts. A court-appointed foster parent brought him in for evaluation. His 21 year-old mother left him recently with relatives. She is an inattentive parent with an alcohol and possibly a drug problem. The child was in pre-school but was suspended a few days ago because he was using sexually explicit language, being physically abusive to his peers, discussing French kissing and saying he was going to shoot himself.

The exam showed a quiet, calm and health 4 year-old. The only findings were lobulated and verrucous flesh-coloured papules grouped on the shaft of the penis. There were no bruises or evidence of trauma.

Diagnosis: Condyloma acuminata.

Photos were removed at advice of a pediatrician. Apparently, FBI may moniter some sites. Gets my Canadian soul anxious!

Discussion:
Although genital warts in children can occur in the absence of child sexual abuse, this case is suspicious. The child's broken home, the fact that he has been left with numerous teenage girls as baby sitters, his sexually explicit language, his antisocial behavior and language all are red flags for a child at risk.

Here, in Nova Scotia, we are mandated to report such children to the authorities. I would like to ask wo questions:

1) Your opinion as to whether reporting this child is appropriate.
2) How should he be treated?
a) electrosurgery under general anesthesia
b) cryo therapy
c) imiquimod or podophyllin.

Your thoughts and comments are most welcome.

Hamish Dunwoodie, M.D. FRCPC - Paediatrics
Moncton, NS, Canada