\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Acquired Syphilis with Flat Condyloma in a 3 year-Old Girl: A Case
Report}



\author[1]{Qing-fu Hu}%
\author[1]{Kun-jie Li}%
\affil[1]{Second Affiliated Hospital of Fujian Medical University}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
The incidence of syphilis in young children is very low, with acquired
syphilis exceptionally rare. A 3 year-old girl presented to our service
with a reddish-brown rash on the external genitals and perianal area.
The rash had been apparent for a period of 1 week. The girl was
asymptomatic and had%
\end{abstract}%



\sloppy


\textbf{Acquired Syphilis with Flat Condyloma in a 3 year old girl: A
Case Report}

Qing-fu Hu\textsuperscript{1},Kun-jie Li\textsuperscript{2}

\textsuperscript{1}Department of General Practice, The Second Affiliated
Hospital of Fujian Medical University, Quanzhou, China, 362000

\textsuperscript{2}Department of Dermatology, The Second Affiliated
Hospital of Fujian Medical University, Quanzhou, China, 362000

First author: Qing-fu Hu, Tel:18259057076, Email:512374863 @ qq.com

Correspondence: Kun-jie Li, Tel:15260412537, E-mail:dervipli @ 163.com

\textbf{ABSTRACT}

The incidence of syphilis in young children is very low, with acquired
syphilis exceptionally rare. A 3 year-old girl presented to our service
with a reddish-brown rash on the external genitals and perianal area.
The rash had been apparent for a period of 1 week. The girl was
asymptomatic and had no history of sexual contact. Syphilis was
suspected and the \emph{Treponema pallidum} Particle Agglutination Test
(TPPA) was found to be positive as well as the Rapid Plasma Reagin Ring
Card Test (RPR), with a titer of 1:64. The girl was diagnosed with
toddler acquired secondary syphilis. The girl was cured of the disease
after three treatments with penicillin. This report points out the need
for clinicians to be aware of non-sexually transmitted syphilis,
acquired in daily life, by children without a history of sexual contact.

\textbf{KEY WORDS:}

Acquired syphilis; Flat condyloma; Young child

\textbf{INTRODUCTION}

At present, the global prevalence of syphilis is a serious medical
issue. It is estimated that there are more than 10 million new cases of
syphilis each year, with more than 90\% of the cases within developing
countries.\textsuperscript{1} The incidence of syphilis in China has
also been increasing year by year. Fujian is a provinces with a high
incidence of syphilis. The incidence of in young children with syphilis
is less than 0.5/100,000 individuals, with the incidence of acquired
syphilis in young children much less common.\textsuperscript{2}

\textbf{CLINICAL REPORT}

A 3.3 year-old girl was found, a week ago, by her mother to have a
scattered pink rash, the size of a soybean, on her perianal area and her
vulva. The child had no history of sexual contact. The mother consulted
a local clinician for diagnosis and treatment for eczema. With treatment
the rash did not subside and gradually increased in size.

\textbf{PAST MEDICAL HISTORY}

The child was the mother's first. Intrauterine pregnancy was 38+2 weeks,
with left occiput anterior delivery by cesarean section. Birth weight
was 3300 g and infant length 0.50 m, with normal development. The child
was healthy, without hereditary disease, history of surgery, or blood
transfusion, and was not sexually assaulted.

\textbf{FAMILY HISTORY}

Her parents are healthy and had no sexual contact before marriage. Her
parents denied extramarital sexual contact and had no family history of
similar or other infectious diseases.

\textbf{PHYSICAL EXAMINATION}

The girl's perianal and external genital areas exhibited scattered round
or round-like reddish-brown papules, with a round or round-like, red or
pink, moist surface, and clear boundaries (Fig. 1). No skin lesions were
found on her trunk, limbs, or in her mouth. The virgin membrane was
present.

\textbf{LABORATORY EXAMINATION}

The \emph{Treponema pallidum} Particle Agglutination Test (TPPA) was
positive, with a value of 22.56 s/co. The Rapid Plasma Reagin Ring Card
Test (RPR) was positive, with a titer of 1:64. Syphilis serological
analysis of her parents, two grandparents, and one grandmother were
negative. However, one grandfather was TPPA and RPR positive, with a
titer of 1:16.

\textbf{TREATMENT}

Based on typical clinical manifestations and laboratory findings the
child was diagnosed with secondary syphilis. Based on the guidelines for
the diagnosis and treatment of syphilis in China,\textsuperscript{3} the
infectious disease was reported according to regulations and the child
administered benzathine penicillin 750,000 U, intramuscularly. The
administration was bilateral hip injection, once a week for 3 weeks.

\textbf{OUTCOME}

After treatment, the rash completely disappeared in the third week (Fig.
2). One month, 3 months, and 6 months post treatment, RPR titers were
1:8, 1:4, and 1:2, respectively.

\textbf{DISCUSSION}

Humans are the only source for syphilis, with most infections due to
sexual intercourse. Few individuals are infected indirectly such as by
blood transfusion or close contact. For young children, there is often
no history of sexual contact or abuse. Such cases are rare and can be
easily misdiagnosed or missed. This case was initially misdiagnosed as
eczema. It has been reported that close contact with children infected
with syphilis, especially in overcrowded or poor family situations,
increases the risk of close sexual transmission of syphilis. Infected
family members or caregivers are a particular risk for
children.\textsuperscript{4}

The child reported herein was healthy, with no hereditary disease, no
history of surgery, blood transfusion, or sexual assault. Her mother
tested negative for syphilis during pregnancy. To determine the source
of infection and mode of transmission, close contacts were tested. Her
parents, two grandparents, and a grandmother were serologically negative
for syphilis. However, one grandfather was TPPA and RPR positive. Based
on this information, it can be inferred that this case of syphilis was
due to close contact during daily life.

\textbf{CONCLUSION}

By this case report, we remind clinicians to be aware of non-sexually
transmitted acquired syphilis in children without a history of sexual
contact. Further, children with syphilis should be educated regarding
the sexual and non-sexual modes of disease transmission in order to
prevent further occurrence.

\textbf{FUNDING INFORMATION}

This research received no specific grant from any funding agency in the
public, commercial, or not- for- profit sectors.

\textbf{Conflict of Interests}

The authors declare that they have no competing interests.

\textbf{CONSENT}

Published with the written consent of the patient.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  World Health Organization. WHO guidelines for the treatment of
  Treponema pallidum (syphilis). Geneva Switzerland: WHO, 2016.
\item
  Yue X, Gong X, Li J, et al. Trends and characteristics of syphilis
  epidemic in China from 2014 to 2019. Chin J Dermatol
  2021;54(08):668-72.
\item
  National Center for STD Control, Chinese Center for Disease Control
  and Prevention; Venereology Group, Chinese Society of Dermatology;
  Subcommittee on Venereology, China Dermatologist Association.
  Guidelines for the diagnosis and treatment of syphilis, gonorrhea and
  genital Chlamydia trachomatis infection. Chin J Dermatol
  2020;03:168-79.
\item
  Hu HH, Xu TH, Li JH, Guo H. Non-sexually transmitted acquired syphilis
  in a three-year-old boy. Indian J Dermatol Venereol Leprol
  2022;88(03):389-91.
\end{enumerate}

\textbf{Figures}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1.} Flat papules visible on the perianal area and vulva.
The size of the papules was similar to a bean or walnut. The surface of
the area was moist, red or pink, and well defined.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2.} Skin lesions subsided 3 weeks after penicillin
treatment.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure1/figure1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure2/figure2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

