Trichomoniasis in a Young Girl: Nonsexual Transmission Is Possible-But Not Likely

I work for the Child Protection Team at a local university. Recently, I saw a 9-year-old girl who had been taken to the local emergency department (ED) with sudden left-sided abdominal pain. Although the pain had passed by the time she arrived at the ED and she had no other GI symptoms, blood work and a urinalysis were ordered. Trichomonas species were found in the urine; the parents were told that this finding is highly suggestive of sexual abuse. The child denied any such abuse. Specimens were then obtained from her vagina to rule out gonorrhea, Chlamydia infection, and other sexually transmitted diseases. The patient was taken to see her primary care physician the next day; a 10-day course of metronidazole was prescribed. She was then referred to our unit for examination and interview by female practitioners. My colleague and I talked to her without her parents present. She told us that she had never had any sexual contact. She is the youngest child in the family and has adult siblings; there are no other caretakers. Based on the physical examination and the child's statements, we found no evidence of sexual abuse. We assured the parents and the child that it is possible that the Trichomonas organisms were passed by a nonsexual mode, such as a shared towel or splash-up from a public restroom. Later, during an Internet search for relevant literature, I read that Trichomonas vaginalis must be differentiated from other species of Trichomonas if it is identified in analysis of urine or stool.¹ I then inquired about testing for trichomoniasis at the local hospital and was told that Giardia organisms resemble the Trichomonas protozoa. What are possible sources for the nonsexual transmission of trichomoniasis, and how can an accurate diagnosis be established?

-----ARNP

REFERENCE:1. Botash AS. Child Abuse Evaluation and Treatment for Medical Providers. Available at: http://www.childabuseMD.com. Accessed January 8, 2008.

I am always distressed to hear that trichomoniasis has been diagnosed in a child because it strongly suggests sexual abuse. Three types of Trichomonas species infect humans, but each has a tissue tropism for a specific anatomical site. It is possible to have species of Trichomonas that are found in the oral cavity, and there is a species in the GI tract; however, these species are not frequently encountered and would not be seen in the urine. The most commonly identified species is Trichomonas vaginalis, which is found only in the genitourinary tract. This is frequently seen in urine, mainly as the result of contamination of the specimen with vaginal secretions. In my experience most laboratories are quite adept at diagnosing Trichomonas species in urine and vaginal specimens, and there would be no confusion with Giardia organisms.

Nonsexual transmission would be quite unusual. Trichomonads can survive on inanimate objects for several hours, but for a person to become infected that object would need to come in close contact with the vaginal mucosa. The overwhelming majority of cases of trichomoniasis result from sexual activity.

You mentioned that the child has adult siblings; I wonder if any of them had been alone with her. As you know, sexual abuse of children is unfortunately common, and I remain concerned for this child.

-----Jane Schwebke, MD
Professor of Medicine
Division of Infectious Diseases
University of Alabama at Birmingham