Review – Kaplan Pediatrics: Adolescence

MORTALITY/MORBIDITY, SEXUALITY, AND STDS

A 14-year-old girl who has not yet achieved menarche presents to the physician with her concerned mother. The mother is afraid that her daughter is not “normal.” On physical examination, the patient appears well nourished and is in the 50th percentile for height and weight. Her breast examination shows the areolar diameter to be enlarged, but there is no separation of contours. Her pubic hair is increased in amount and is curled but is not coarse in texture. The mother and her daughter wait anxiously for your opinion.

 

 

Introduction to Adolescence and Puberty

• Definition—period bridging childhood and adulthood
• Begins at age 11–12 years, ends at 18–21; includes puberty
• Physical and psychological/behavioral changes
  • Completes pubertal and somatic growth
  • Develops socially, cognitively and emotionally
    • Moves from concrete to abstract thinking
    • Establishes independent identity
    • Prepares for career
  • All adolescents are at increased risk of mortality and
    • Mortality
      • Accidents—especially MVAs
      • Suicide—boys are more successful
      • Homicide—more likely in blacks
      • Cancer—Hodgkin lymphoma, bone, CNS
    • Morbidity
      • Unintended pregnancy
      • STDs
      • Smoking
      • Depression
      • Crime
    • There are 3 stages of

 

 

• Early (Age 10-14 years)
  • Physical changes (puberty) including rapid growth, puberty including develop- ment of secondary sexual characteristics
  • Compare themselves to peers (develop body image and self-esteem)
  • Concrete thinkers and feel awkward
• Middle (Age 15-16 years)
  • More independent and have a sense of identity
  • Mood swings are
  • Abstract thinking
  • Relationships are one-sided and
• Late (Age >17 years)
  • Less self-centered
  • Relationships with individuals rather than groups
  • Contemplate future goals, plans, and careers
  • Idealistic; have a sense of right and wrong

 

Table 23-1. Tanner Stages of Development

	Female	Both	Male
Stage	Breast	Pubic hair	Genitalia
I	Preadolescent	None	Childhood size
II	Breast bud	Sparse, long, straight	Enlargement of scrotum/testes
III	Areolar diameter enlarges	Darker, curling, increased amount	Penis grows in length; testes continue to enlarge
IV	Secondary mound; separation of contours	Coarse, curly, adult type	Penis grows in length/ breadth; scrotum dark- ens, testes enlarge
V	Mature female	Adult, extends to thighs	Adult shape/size

 

• Puberty
• Variability in onset, duration
• No variability in order of changes
• Irreversible
• Physical reflects hormonal
• Variants of development are normal and most cases only require reassurance from the physician to the patient and their
  • Breast asymmetry and gynecomastia often seen in males at Tanner stage 3
  • Irregular menses due to anovulatory cycles seen in females starting to menstruate

 

 

Sexually Transmitted Diseases

Gonorrhea

A 16-year-old girl presents to her physician because of fever, chills, pain, and swelling in the small joints of her hands, and a maculopapular rash on her upper and lower extremities.

 

 

 

• Neisseria gonorrhoeae usually infects mucosal membranes of the genitourinary tract and less commonly the oropharynx, rectum, and
• Clinical presentation includes urethritis, cervicitis, and
• Asymptomatic patients are at higher risk for dissemination, including fever, chills, and
• Physical examination
  • Males present with dysuria and purulent penile
  • Females present with purulent vaginal discharge, cervicitis, abdominal pain, and/or
  • Rectal gonorrhea may present with proctitis, rectal bleeding, anal discharge, and/or
• Tests
  • Culture from discharge
  • Blood cultures if dissemination is suspected
  • Gram strain may show intracellular
• Check for other STDs, including syphilis and HIV infection.
• Treat with single-dose ceftriaxone or single-dose azithromycin; treat
  • Alternatives include doxycycline for 7 days (not in children <9 years of age).

 

Chlamydia

A 16-year-old boy presents to the emergency center with a persistent penile discharge. The patient states that 1 week ago he saw his family physician for this same problem. At that time the physician gave him an IM shot of penicillin. However, the patient states that the discharge did not resolve with the penicillin therapy. He would like a second opinion.

 

• Cause of nongonococcal urethritis
• Intracellular obligate parasites
• Most common STD in developed countries
• Mucoid discharge (mostly females) or lymphogranuloma vernerum
• Tests
  • Nucleic acid amplification (PCR, ELISA)
  • Culture of infected tissue
• Treatment
  • Single-dose azithromycin or doxycycline for 7 days
  • Erythromycin if pregnant

Note

Untreated GC/Chlamydia may result in PID and/or infertility (due to tubal scarring).

 

 

Trichomonas

A 15-year-old presents to her physician because she has a yellow, foul-smelling vaginal discharge. On physical examination, she is noted to have a “strawberry cervix.”

 

• Trichomonas vaginalis is a protozoa resulting in vaginitis
• Girls with multiple sexual partners (although this is the case in all STDs) are at high
• Frothy, foul-smelling vaginal discharge; males asymptomatic
• “Strawberry cervix” due to hemorrhages in the mucosa
• Wet prep shows motile protozoans in females
• In males, examine urine sediment after prostatic massage
• Treat with metronidazole

 

Herpes

A 17-year-old, sexually active boy presents to the physician because of painful ulcerations on his glans penis and on the shaft of his penis. He has multiple sexual partners and does not use condoms. Fever and inguinal adenopathy are also present.

 

• HSV 1: nongenital infections of mouth, eye, and lips most common
• HSV 2: genital, neonatal, oral
  • Cervix primary site in girls; penis in boys
  • Tzanck prep—giant multinuclear cells
  • ELISA testing
• Treat with acyclovir, valacyclovir, famciclovir

 

Table 23-2. Distinguishing Features of Vaginal Discharge

Feature	Bacterial vaginosis	Trichomoniasis	Candida	Chlamydia/ gonorrhea
Discharge	Profuse, mal- odorous, “fishy”	Gray-green, frothy	Cottage cheese	Purulent
Wet prep	Clue cells, “whiff test” with KOH	Motile Trichomonads	Hyphae seen with KOH prep	WBCs
pH	>4.5	>5	<4.5	—
STD	No	Yes	No	Yes

 

 

ACNE

A mother brings her 15-year-old daughter to the dermatologist because she has developed pimples. The mother says that her daughter’s face “breaks out” because she drinks soda pop. The daughter is argumentative about this but admits that she does drink soda pop every day at lunch. The mother would like you to tell her daughter to stop drinking soda pop. On physical examination, the patient has open and closed comedones and pimples on her forehead, nose, and cheeks.

 

 

 

 

• Pathogenesis
  • Due to the bacteria—Propionibacterium acnes, which forms free fatty acids within the sebaceous follicle
  • Abnormal keratinization of follicular epithelium and impaction of keratinized cells in sebaceous follicles
  • Increased sebum production—At puberty, significant increase in sebum from increased adrenal androgens (mostly DHEAS with some role of testosterone and estrogen)
  • Inflammation from lysosomal enzymes, which phagocytose bacteria
• Description
  • Open comedone = blackhead
  • Closed comedone = whitehead (more commonly becomes inflammatory)
  • If comedones rupture, inflammatory lesion and inflammatory contents spill into adjacent dermis; if close to the surface, forms a papule or pustule; deeper forms a nodule
  • With suppuration → giant-cell reaction to keratin and hair; forms nodulocystic lesion
• Treatment must be
  • Cleansing of skin with mild soap
  • Topical therapy used for treatment of comedones and papulopustular acne

°      Benzoyl peroxide

• Tretinoin (Retin-A): single most effective agent for comedonal acne
• Adapalene (Differen gel)
• Topical antibiotics: erythromycin or clindamycin
• Allow 4–8 weeks to assess effect of above agents

• Systemic treatment is indicated in those who do not respond to topical
  • Antibiotics: especially tetracycline, minocycline, doxycycline, erythromycin, clindamycin
  • Isotretinoin: for moderate to severe nodulocystic Very teratogenic; contraindicated in pregnancy. Other major side effect is increased triglycerides and cholesterol: rule out liver disease prior to start and check triglycerides 4 weeks after starting treatment

°      A trial of hormonal therapy can be used in those who are not candidates for isotretinoin.

• Corticosteroid injections may be used to aid in healing painful nodulocystic
• Dermabrasion may help decrease visible

Note

Isotretinoin is very teratogenic and contraindicated in pregnancy.