We report the case of gonococcal vulvovaginitis in an 11-year-old prepubertal Austrian girl almost certainly contracted from bathing in a contaminated hot pool. It is imperative that all cases of gonococcal infection in children are fully investigated, including examining all other relevant family members, to determine whether sexual assault has occurred. This is not a diagnosis to be missed. However, both sexual and nonsexual transmission is possible. The consequences of the presumption that a gonococcal infection must be diagnostic of sexual abuse can also be dire, with children wrongfully removed from their parents’ care, and their caregivers facing false charges of sexual crimes.
The Specchio di Venere pools are shallow, murky, glass-green-colored from algae, and almost stagnant, although some water exchange occurs through the loosely stacked boulder walls. Hot water and gas bubbles (98% CO2) enter the pools through small holes in the sediment. Gradients in temperature develop within the pools from the source of the springs (> 40 °C) to where they mix with the lake water at the pools’ edges (~ 37°). Hence, the water is near body temperature, slightly acidic (pH 6.3–6.9), and closely isotonic (conductivity of 14–17 mS/cm at 25 °C), and contains mineral and organic particles as potential substrates for biofilms [8,9,10], potentially increasing the survival of gonococcus.
Prior to the advent of antibiotics, the source of gonorrhea epidemics in children’s hospitals was traced to common baths [11,12,13], as well as to towels, wash rags, diapers, bandages, bed linens, instruments, and children’s hands [13,14,15,16,17,18,19,20,21,22,23,24]. Epidemics of gonococcal conjunctivitis continue to occur in rural African and Australian aboriginal communities, thought to be mediated by flies, dirty fingers, and face cloths [25,26,27]. Case reports and cases series of probable household nonsexual transmission from sharing towels, clothes, and beds are also reported, from an index sexually transmitted case [28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49]. Unusual cases of nonsexual transmission include autoinoculation from a contaminated public toilet seat in an 8-year-old girl [50], and transmission from intercourse with an inflatable doll [51]. We report a case of vulvovaginal nonsexual transmission. This was presumably acquired from bathing in a shallow thermal pool frequented by many tourists, which is more likely than from using a public toilet. Hot pools have been recognized as sources of various serious infections [16, 17]. This rare event is likely due to a number of unique factors, including the timing of the child’s bathing in relation to that of an infected visitor, but those using these pools need to be alerted to the possibility of such exposure, including the risk of possible conjunctival infection, on occasion. It would be valuable to conduct experiments whereby water from the pools is inoculated with Neisseria gonorrhoeae, the temperature and CO2 aeration maintained, and then assays conducted to see if gonococcus can be cultured at different durations following inoculation, but this is beyond the scope of these authors.
There needs to be public understanding that people bathing in heavily frequented shallow thermal pools risk exposure to pathogens through inoculation by other bathers, including Neisseria gonorrhoeae, but also fecal contaminants such as Escherichia coli and Pseudomonas sp. We suggest provision of a shower and antibacterial soap near the hot springs. A sign should make visitors aware of strict hygiene before entering the pools.
The strength of this case report is that it adds to the literature by reporting a case of nonsexual transmission of Neisseria gonorrhoeae causing vulvovaginitis in a prepubertal child. The report draws on many other cases of nonsexual transmission reported in the literature, plus empirical published data demonstrating that the temperature, pH, and tonicity of the pools in question provide an environment in which gonococci might flourish. The case weakness is that, inevitably, it is impossible to prove that the pool was the definitive source of infection.
Gonococcal infections in prepubertal children occur very infrequently. Acquisition from sexual abuse must always be the first consideration, and should be investigated as a cause. However, authorities are reluctant to acknowledge that the mode of transmission may also be nonsexual, and that the infection is not definitive evidence of sexual assault. National guidelines may state that gonococcal infection in prepubertal children is always, or almost always, diagnostic of sexual abuse, without any discussion of possible nonsexual modes of transmission [7, 52, 53]. In her role as forensic physician, the lead author has encountered cases of nonsexually transmitted genital gonorrhea in prepubertal girls in Australia, New Zealand, the USA, Canada, and Denmark, where the child abuse authorities inform the courts that transmission can only be through some form of sexual activity with mucous membrane to mucous membrane contact. These cases include probable transmission from an infected mother using a towel to dry herself and then her 3-year-old daughter; an infected father sharing a towel with his 3-year-old daughter, and an 8-year-old girl using a wash cloth and towel immediately after her infected father had used them.
