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In August 2003 a prepubescent 8 year old girl presented with a sudden onset history of a non-irritating, odourless heavy green vaginal discharge which had developed overnight. She had arrived back in Sydney approximately 24 hours earlier by an international air flight following an overseas holiday with her mother and two adolescent siblings. The family had spent 72 hours in transit flying from Rome to Sydney via Moscow.
The child was taken initially to her family doctor and a heavy growth of Neisseriagonorrhoeae was isolated. The organism was resistant to both penicillin and ciprofloxacin. One week later, following an initial course of antibiotics, the child was referred to the author for assessment of possible sexual abuse and ongoing management of the N gonorrhoeae infection.
Before boarding a flight to Moscow the family had spent 3 days in a hotel, sightseeing and the previous 2 days with relatives. During the 8 days before arriving in Sydney, the mother had unusually close contact with the child, had shared a bedroom with her, and had accompanied her almost continually. The child’s behaviour and demeanour had shown no change and both the child and the siblings were asymptomatic. When questioned by her mother, the child strongly denied any history of genital contact.
The flights to and from Moscow were noted to be full with no spare seats. Both the mother and the child stated that there were queues to use the toilets during both flights and that by the end of the flights the “toilets were very dirty.”
The mother stated that when the child used a public toilet the child always wiped the seat with toilet paper before using it. The child confirmed this. She said her fingers occasionally became dirty while wiping the seat.
Genital examination of the child revealed no significant redness of the introitus or physical abnormality. She had an intact annular hymen; however, the absence of genital injury has no relevance in making a diagnosis that excludes sexual abuse.1
As part of the routine investigation, the matter was reported the New South Wales Department of Community Services and all family members were tested for N gonorrhoeae and were negative.
It is important that all cases of N gonorrhoeae in children be fully investigated for sexual abuse, and reported to the relevant child protection authorities. There is no doubt that almost all gonococcal vaginal infections in prepubertal children are sexually transmitted,2 and this may include those previously reported as non-sexual.3 However it is also accepted that cases of non-sexual transmission of N gonorrhoeae in children do occur,4 but proof beyond all doubt can be very difficult to document scientifically.
On the basis of the demeanour of the child, reports of increasing rates of gonorrhoea in the former Soviet Block countries,5 the incubation period for symptomatic N gonorrhoea, the history from the mother and her unusually close supervision of the child, as well as the child’s known behaviour in public toilets, it is the belief of the author that the child most probably contracted the infection via autoinoculation while using a mixed toilet in a crowded aeroplane.