How Do You Treat Invasive Salmonella Infections?

Patient Presentation
A 16-year-old female came to the emergency room with a 36 hour history of diarrhea and emesis.
She had been on a school trip in Europe and during the day she was leaving to return to the United States had 2 bouts of diarrhea, one of which was accompanied by emesis.
During the flight back, she had more diarrhea and emesis. She then had to drive home 4 hours.
At home she was taken to the emergency room where she was given intravenous fluids for dehydration.
As she was being discharged she began to have a fever so she was admitted for further evaluation.
Additional history revealed that the diarrhea did not contain blood or mucous and was described as watery. The emesis occurred usually around the time of the diarrhea.
She could not remember how many episodes she had had, but did state that she had not eaten or drunk anything since being in Europe.
She complained of crampy abdominal pain around the episodes, and nausea inbetween them.
The past medical history and family history were non-contributory.
The review of systems was negative for fever, chills, cough, upper respiratory symptoms, dysuria, or rashes.
The social history revealed that she had traveled to several countries, had swum in a lake, and had eaten mainly eggs, rice and vegetables as she was a vegetarian.
Several other students on the trip had been ill with diarrhea of short duration 3 days before her symptoms began.
The pertinent physical exam at admission showed a tired, ill-appearing female with a temperature of 38.5 degrees Celsius.
She had mild left lower quadrant tenderness with deep palpation without guarding. The rest of the examination was negative.
The work-up was begun and included an abdominal radiograph and laboratory testing.
Over the next 2-3 hours as the testing was being completed, her temperature increased to 40.3 degrees Celsius and she complained of neck and back pain.
On repeat physical examination, she had a non-specific confluent red flat rash over her neck and upper shoulders. She complained of pain with flexion of her neck and legs at the hips.
She had no abdominal tenderness at that time.
The patient was begun on ceftriaxone intravenously and a lumbar puncture was performed which had a normal glucose, protein and cell count.
As this was occurring her previous testing became available and showed hemoglobin of 13.2 g/dl, hematocrit of 37%, white blood cell count of 9.0 x 1000/mm2 with 900 neutrophils, 4140 bands, 1700 lymphocytes and 180 reactive lymphocytes.
The C-reactive protein was 28.2 mg/dl and the erythrocyte sedimentation rate was 27 mm/hour.
She continued to be febrile from 38-39.5 degrees Celsius over the next 10-12 hours, but her rash disappeared as did her neck and back pain.
At this time, she became afebrile but began to complain of left lower quadrant pain again that now radiated to her umbilicus.
The radiologic evaluation of an abdominal CT showed a non-inflamed appendix but with an appendicolith, a small amount of fluid in the pelvis and thickened bowel walls.
Surgical consultation was obtained who took the adolescent to the operating room for an elective appendectomy due to the presence of the appendicolith and exploration.
The appendix was normal with no abscess or perforation but the surgeons noted that the patient had an extremely inflamed colon.
The patient continued to clinically improve on the ceftriaxone without fever, with 3-4 episodes of non-bloody, non-mucous diarrhea per day. On day 3, as she was being readied for discharge on home ceftriaxone, she began to have bloody diarrhea.
Her initial stool culture was also now growing Salmonella, which was subsequently identified as Salmonella enteritidis confirming the diagnosis of enteric fever.
She received a total of 10 days of ceftriaxone and at followup her diarrhea had resolved. Repeat stool cultures were negative.
The airline, state public health department and the U.S. Centers for Disease Control were also contacted at various points during her illness to provide appropriate information to protect the public’s health.


Figure 66 – Axial computed tomography image of the lower
abdomen obtained with intravenous, oral, and rectal contrast reveals
the cecum to be filled with liquid stool, a small appendicolith in
the appendix medial to the cecum without evidence of appendicitis and
mild thickening of the wall of the descending colon consistent with
colitis.

Discussion
Salmonella is a highly contagious organism causing an estimated 17 million cases of typhoid fever and 600,000 deaths yearly worldwide.
It causes a spectrum of illness. Most commonly it causes gastroenteritis with diarrhea, abdominal cramps and fever.
Bacteremia may be intermittent or continuous
Focal infections such as meningitis or osteomyelitis occur in up to 10% of patients with bacteremia.

Enteric fever is caused by Salmonella typhi and other Salmonella serotypes when there is a protracted bacterial illness.
It may begin gradually with constitutional symptoms (i.e. anorexia, headache, lethargy and malaise), fever, abdominal tenderness and pain, hepatosplenomegaly, and mental status changes. Diarrhea is common and may or may not be bloody.

The transmission is mainly through food such as poultry, beef eggs and dairy products. Other food contaminated from humans may also transmit Salmonella such as vegetables, fruits and bakery products.
Other transmission routes include contaminated water and contact with amphibians and reptiles.
The incubation period for gastroenteritis is shorter usually 12-36 hours with a range of 6 -72 hours. The incubation period for enteric fever is longer; usual period is 7-14 days with a range of 3-60 days.

Salmonella has more than 2,640 serotypes. Human disease causing organisms are classified according to their O-antigen group (A-E).
In the US about 50% of all Salmonella is caused by Salmonella typhimurium (B), Salmonella enteritidis (D) and Salmonella Newport (E).
Salmonella typhi is a D serotype.

A carrier state is not uncommon with 45% of children < 5 years old and 5% of older children and adults being still excreting organisms in their stool 12 weeks later.
At one year, 1% of patients still excrete organisms.
Unfortunately instead of eliminating carriage, antibiotics tend to increase the carrier state. Enteric fever patients (~15%) may relapse requiring re-treatment.

Learning Point
Patients with localized invasive disease are initially treated with an expanded-spectrum cephalosporin such as cefotaxime or ceftriaxone. Once susceptibility results become available, ampicillin, ceftriaxone or cefotaxime for susceptible strains lasting at least 4 weeks in duration is recommended.
This should be increased to 6 weeks for meningitis. Localized disease means patients with abscess, meningitis, osteomyelitis, or patients with HIV and bacteremia.

For patients with invasive, nonfocal infections (e.g. bacteremia or enteric fever) the administration route, drug choice, and duration are based on the strain susceptibility, clinical response, host and site of infection.
A minimum 10-14 days of antibiotics is recommended. Salmonella typhi can be multidrug-resistant, and empiric treatment with an expanded-spectrum cephalosporin, azithromycin or fluoroquinolone may be necessary.

Chronic carriage of Salmonella typhi in children may be treated with high-dose parenteral ampicillin or high-dose oral amoxicillin with probenecid. Ciprofloxacin is recommended for adults.
Cholecystectomy is sometimes indicated for adult patients where gallstones contribute to the carrier state.

Questions for Further Discussion
1. What are the indications for corticosteroid use in patients with Salmonella?
2. What are the indications for typhoid vaccine use?
3. What commonly prescribed travel medication needs to be administered after oral typhoid vaccine because of potential interactions?
4. What percentage of patients with Salmonella get enteric fever?

Related Cases

To Learn More
To view pediatric review articles on ther topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Salmonella Infections and Food Contamination and Poisoning.

To view current news articles on ther topic check Google News.

To view images related to ther topic check Google Images.

Graham SM.
Salmonellosis in children in developing and developed countries and populations.
Curr Opin Infect Dis. 2002 Oct;15(5):507-12.

American Academy of Pediatrics. Salmonella, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;579-584.

Linam WM, Gerber MA.
Changing epidemiology and prevention of Salmonella infections.
Pediatr Infect Dis J. 2007 Aug;26(8):7.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills

    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    August 25, 2008

  • How Common is RhD Isoimmunization?

    Patient Presentation
    A 1-month-old female came to clinic for her follow-up evaluation.
    She was known to have RhD isoimmunization that had required one blood transfusion and phototherapy for 5 days after birth at 38 weeks gestation.
    She was seen at 10 days of age, was breastfeeding well, and was past her birth weight.
    Her mother reported that she was sleepier than her other two children. The infant cried and easily awoke to feed, fed well for 20-30 minutes and then generally fell back to sleep.
    She had no problems sucking, stopping to feed, sweating or color changes during feeding. Her mother also denied any bruising, bleeding or edema.
    She also had been urinating and stooling well and her mother reported that the jaundice seems to slowly be fading away.
    The family history was positive for the patient’s mother becoming Rh sensitized with her first pregnancy. Her second child did not require intrauterine or post-natal transfusions, but did require prolong phototherapy.
    The review of systems was otherwise normal.
    The pertinent physical exam showed a sleeping infant who appeared somewhat pale and slightly yellow on her skin and sclera. Her vital signs were normal with a heart rate of 145 beats/minute. Her weight was 3.92 kg (25-50%) and she had been gaining 32 grams/day.
    The cardiac examination showed a regular rate and rhythm with no murmur. The abdominal examination showed no hepatomegaly or masses.
    The laboratory evaluation showed a total and direct bilirubin of 8.9/0.3 mg/dl. Her complete blood count showed a hemoglobin of 7.4 mg/dl, hematocrit of 23%, platelets of 434 x 1000/mm2 and a reticulocyte count of 28%.
    The diagnosis of anemia and jaundice secondary to RhD isoimmunization was made.
    The physician contacted the hematologist who had seen the infant just after birth.
    The hematologist was comfortable continuing to monitor the patient as an outpatient as the infant did not have any signs or symptoms of end organ failure and had an expected reticulocyte response.
    The hematologist did note the sleepiness but felt that this could still be followed as an outpatient.
    The infant was to return to the clinic in one week for re-evaluation and sooner if her mother noted any difficulty eating, skin color changes, or any other concerns.

    Discussion
    RhD isoimmunization luckily has decreased in incidence since the introduction of RhD immunoglobulin (RhIg) in 1968.
    There are 3 major rhesus antigens on red blood cells. The D antigen determines if a person has a positive or negative blood grouping.
    An RhD-negative woman is at risk of developing RhD isoimmunization when exposed to RhD-positive antigens from her RhD-positive fetus through fetal-maternal hemorrhage.
    Usually her initial antibody response is mainly composed of IgM which is a large molecule and cannot cross the placenta.
    But after this IgG is produced which can cross the placenta. A subsequent exposure to RhD-positive blood cells such as with a second pregnancy, produces a rapid and proliferative IgG response.
    The infant’s RhD-positive blood cells can then be attacked by the IgG causing fetal anemia, erythroblastosis fetalis and possibly intrauterine fetal death.

    Prophylactic RhIg can be given to women which binds to the infant’s red blood cells in the maternal circulation. This blocks the RhD-positive antigen on the infants red blood cells and the mother does not make an antibody reponse to the foreign RhD-positive antigen.
    If the mother does become sensitized at some point, she needs to be followed closely during any subsequent pregnancy. The fetus may need intrauterine transfusions.

    Neonates affected by RhD isoimmunization may need immediate blood transfusions after birth because of anemia. They are also at risk for severe jaundice.
    Both the anemia and jaundice may require exchange transfusion. Some neonates require later blood transfusions in the first few months of life and therefore need to be followed closely.

    Learning Point
    Without prophylatic RhIg, there is a 16% chance that an RhD-negative woman giving birth to an RhD-postive+ infant will become RhD isoimmunized.

    In 1991, the Centers for Disease Control estimated that the incidence of RhD hemolytic disease was 10.6 per 10,000 total births.
    This corresponds to ~4000 affected infants. In contrast, in 1970 two years after RhIg was licensed, the incidece was 45.1 per 10,000 total births.

    Although there has been a substantial decrease in RhD hemolytic disease over the past 40 years, other red cell antigens continue to cause isoimmunization for some women for which there is no current prophylactic treament available.
    For example, frequencies for all women with a positive antibody screen in a New York tertiary care health center were 18.4% for anti-D and 22% for anti-Kell.

    Questions for Further Discussion
    1. What are the indications for red cell blood transfusions?
    2. At what age is the physiological red blood cell nadir? How would this change if the infant was premature, or had intrauterine or neonatal blood transfusions?
    3. What are the current guidelines for adminstration with RhIg of a reproductive age female who has experienced a spontaneous abortion, threatened abortion, elective termination, or ectopic pregnancy?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: High Risk Pregnancy and Blood and Blood Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Geifman-Holtzman O, Wojtowycz M, Kosmas E, Artal R. Female alloimmunization with anti-
    bodies known to cause hemolytic disease. Obstet Gynecol 1997;89:272-5.

    Harkness UF, Spinnato JA.
    Prevention and management of RhD isoimmunization.
    Clin Perinatol. 2004 Dec;31(4):721-42, vi.

    De Boer IP, Zeestraten EC, Lopriore E, van Kamp IL, Kanhai HH, Walther FJ.
    Pediatric outcome in Rhesus hemolytic disease treated with and without intrauterine transfusion.
    Am J Obstet Gynecol. 2008 Jan;198(1):54.e1-4.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills

    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice

    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    August 11, 2008

  • What Drugs Can Trigger Malignant Hyperthermia?

    Patient Presentation
    A 4-year-old male was transferred to a regional children’s hospital for continued treatment of malignant hyperthermia.
    He had a tonsillectomy the previous day and he tolerated the procedure well.
    In the recovery room his heart rate was slightly elevated but he was discharged home.
    Over the evening he developed a low grade fever and began to complain of pain in his extremities.
    In the morning, the patient had muscular rigidity where his feet were dorsiflexed and relaxed.
    His parents took him to see his regular physician who went with him to the emergency room of the local hospital.
    His temperature was now elevated to 39 degrees Celsius.
    In the emergency room, the patient was given intravenous fluids and dantrolene.
    His mother reports that the muscular rigidity was lessened after the dantrolene was given but the muscle pain continued.
    Laboratories in the emergency room showed normal electrolytes but a creatinine phosphokinase of 7684 U/L.
    The past medical history showed that he had a previous pressure equalizing tube placement but he was not intubated for that surgery.
    He also had multiple episodes of otitis medias in the past and significant snoring. He had 3 episodes of strep throat during the previous winter.
    The family history revealed his parents had also had surgeries but did not know if they had been intubated. No other family members had problems with anesthesia.
    The review of systems was otherwise normal.
    The pertinent physical exam showed an anxious male with normal vital signs except for a temperature of 38 degrees Celsius. He could speak clearly, had no masseter muscle rigidity or trismus.
    His cranial nerves were intact. Deep tendon reflexes were present without clonus. He had difficulty raising his arms or legs against gravity but could with some effort. He had to be carried.
    He had tender muscles to palpation but no bone or joint pain. He did have back pain with flexion of legs to chest. He had full range of motion in all joints.
    The diagnosis of malignant hyperthermia was again confirmed.
    The laboratory evaluation was repeated as several hours had gone by since the last testing.
    The electrolytes, urinalysis, coagulation profile and electrocardiogram were all normal.
    The creatine phosphokinase was now 3408 U/L.
    He received another dose of dantrolene. Laboratories were repeated every 6 hours.
    The Malignant Hyperthermia Association of the United States (MHAUS) protocol was accessed by Internet before the patient arrived.
    The MHAUS hotline was contacted and there also was verbal consultation with local anesthesia consultants after the patient was evaluated.
    They both agreed with the treating team’s management plan.
    The MHAUS also said that they would assist the family with obtaining a medical alert bracelet for the child and with genetic testing of the family.
    The patient’s clinical course over the next 2 days found him gradually regaining his strength.
    At discharge he had no pain and his neurological examination was normal. His CPK was 172 U/L.
    He was to see his primary care physician the next day and genetic testing and counseling would be done at the children’s hospital within the next month.

    Discussion
    Malignant hyperthermia is a medical emergency. It is caused by an abnormality where the metabolism of intracellular calcium is altered causing a hypermetabolic state.
    It is triggered by various drugs used for anesthesia. It may occur during anesthesia and in the post-anesthesia period. Symptoms may not be recognized though until hours later.
    Signs and symptoms of malignant hyperthermia include:

    • Tachycardia/tachypnea
    • Increasing temperature (may be a late sign)
    • Body rigidity including trunk or total body
    • Masseter muscle rigidity or trismus
    • Myoglobinuria
    • Increasing end tidal CO2
    • Mixed respiratory and metabolic acidosis

    Malignant hyperthermia can cause extreme fever, rhabdomyolysis, coagulopathy and even cardiac arrest.
    It should be considered with these signs and symptoms and treatment instituted promptly.
    Treatment includes halting the procedure if possible, discontinuing volatile anesthetic agents and succinylcholine and/or changing to non-triggering anesthetic agents,
    hyperventilating the patient with 100% oxygen, treating with dantrolene sodium, cooling the patient with ice and/or lavage of body cavities, giving intravenous fluids with bicarbonate and monitoring and treating electrolyte abnormalities particularly hyperkalemia.
    Intensive care management and monitoring may be necessary in the acute phase.

    Dantrolene sodium is given for acute crisis at a dose of 2.5 mg/kg intravenously. It is also available in oral form.
    Intravenous treatment may be repeated as often as necessary until the hypermetabolic state is normalized and all symptoms have disappeared
    Usually this is 1-4 doses. Other diagnoses should be considered if more than 20 mg/kg is used without benefit.

    The MHAUS has a 24 hour hotline available for consultation in the United States and Canada at 800-644-9737,
    and internationally at
    0011-315-464-7079.

    Laboratory tests to order/monitor include (often done every 6 hours until normalized):

    • Electrolytes – particularly for hyperkalemia
    • Creatinine phosphokinase
    • Myoglobin
    • Arterial blood gas – particularly for acidosis
    • Coagulation profile
    • Electrocardiogram
    • Urine including for myoglobin
    • End tidal CO2

    Some patients with malignant hyperthermia have identifiable genetic markers.
    These markers may make it possible to identify at risk family members and therefore potentially they can be screened for mutations.
    Some patients and family members need to have a muscle biopsy and contracture testing to evaluate malignant hyperthermia susceptibility.

    Learning Point

    According to the MHAUS, anesthetic agents that are unsafe for patients with malignant hyperthermia are listed below.
    “All other anesthetic agents outside of these two categories of Volatile anesthetic agents and depolarizing muscle relaxants are considered safe.”

    • Depolarizing muscle relaxants
      • Succinylcholine (Suxamethonium)
    • Inhaled General Anesthetics
      • Chloroform (Trichloromethane, Methyltrichloride)
      • Desflurane
      • Enflurane
      • Halothane
      • Isoflurane
      • Methoxyflurane
      • Sevoflurane
      • Trichloroethylene
      • Xenon

    Questions for Further Discussion
    1. What consultants are available locally to manage suspected malignant hyperthermia?
    2. How does dantrolene work?
    3. Are patients with malignant hyperthermia more susceptible to heat illnesses?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Anesthesia and Muscle Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Brandom BW.
    The genetics of malignant hyperthermia.
    Anesthesiol Clin North America. 2005;23(4):615-9, viii.

    Dantrolene: Pediatric Drug Information. UpToDate.
    Available from the Internet at http://www.uptodateol.com/online/content/topic.do?topicKey=ped_drug/52419&selectedTitle=23~46&source=search_result (rev. 2008, cited 7/20/08).

    Malignant Hyperthermia Association of the United States. Medical Professionals
    Available from the Internet at http://medical.mhaus.org/ (rev. 2008, cited 7/20/08).

    Malignant Hyperthermia Association of the United States. Anesthetic Agent Choice for the MH-Susceptible Patient.
    Available from the Internet at http://medical.mhaus.org/index.cfm/fuseaction/Content.Display/PagePK/AnestheticList.cfm (cited 7/20/08).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills

    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    August 11, 2008

  • How Can I Make My Sexual Interview More Gender Neutral?

    Patient Presentation
    An 18-year-old female came to clinic for a health supervision examination prior to starting college in a distant city.
    During the interview, the physician asked if she had “???been sexually active now or in the past with boys, girls, men or women?”The women paused, took a deep breath and quietly said yes.
    The physician then inquired what she was saying yes to.
    The woman confided that she was in a lesbian relationship for the past 6 months.
    During the discussion, she said that she “always knew that I was a lesbian” and that she could not remember ever being sexually attracted to men or boys.
    Her current relationship was mutually monogamous as far as she knew and she trusted her partner.
    They both had been seen at a local reproductive health clinic for routine gynecological care and testing for sexually transmitted infections and human immunodeficiency virus before beginning their sexual relationship.
    They did not use condoms or dental dams during sexual encounters.
    When asked who knew about her sexual orientation, she stated that a few trusted, same-aged friends, but no family members.
    She denied any harassment or violence, depression, or suicidal ideation.
    The past medical history,
    family history,
    and review of systems were non-contributory.
    The pertinent physical exam showed a quiet female with normal vital signs and growth parameters.
    Her physical examination was normal.
    The diagnosis of a healthy female who had disclosed lesbian homosexual orientation was made.
    At this time, she had no plans to disclose her sexual orientation to her family and a general discussion of possibly how to do so was discussed.
    The physician utilized the room’s computer to access local LGBTQ resources (i.e. lesbian, gay, bisexual, transgender and questioning people) at her college’s health center and community.
    This information was printed after the woman stated she had a safe place to keep the information at home and felt comfortable taking it with her.
    In addition to the other anticipatory guidance and health care provided, the physician reiterated that she could confidentially telephone to the office if she had questions.
    The physician did encourage electronic mail correspondence if the issue was not sensitive, but not for any sensitive information particularly about her sexual orientation.

    Discussion
    Sexuality and social and family functioning and relationships are important components of comprehensive medical care and should be discussed at every health supervision for children and adolescents.
    Homosexuality in children and/or their parents is common and pediatric health care providers should be aware of the specific needs of each child, adolescent and family.
    Some sexual definitions include:

    • Sexual orientation is the sexual desire for a particular gender, or an intensive internal physiological desire for a particular gender. Homosexual, heterosexual and bisexual are examples of sexual orientation.
      Sexual orientation is stable over time, and is resistant to conscious control. It is not a choice.

    • Sexual behavior are physical behaviors that are conscious choices. These behaviors are usually motor, (e.g. “he plays with dolls”, “she’s so macho”) and may or may not change over time.
    • Gender identity is a person’s self concept of their own gender and includes an integration of the person’s biological sex, gender role expression and sexual orientation.
    • Gay refers to a male whose primary, loving, sexual and/or intimate relationships are with men.
    • Lesbian refers to a woman whose primary, loving, sexual and/or intimate relationships are with women.
    • Bisexual refers to a person who is sexually, emotionally and/or intimately attracted to either sex but not necessarily at the same time.
    • Transgender is a general term for crossing gender lines. It may refer to persons who are transsexuals or transvestites/cross-dressers.
    • Questioning refers to individual who is not sure about their sexual orientation.
    • LGBTQ (lesbian, gay, bisexual, transgender and questioning people) terminology describes sexual orientation, not sexual behavior.

    It is very common for adolescents and adults to engage in sexual behaviors that others may define as homosexual in nature.
    Since these are sexual behaviors, they are subject to conscious choice and can change over time.
    Many of these “experimenting” individuals would identify themselves as having a heterosexual orientation.
    Individuals may also consider themselves heterosexual but may engage in homosexual sexual behaviors to gain money and /or favors. One example is prostitution.

    This confusion between sexual orientation and sexual behavior can lead to imprecise/inaccurate communication and even research.
    In a recent study in The Lancet of global sexual behavior, it appears that there was significant underreporting of homosexual sexual behavior in persons who report themselves as heterosexuals.
    This is particularly true of men who are married to women.

    Persons who are homosexual may experience a variety of medical or social problems that can affect their health.
    These include:

    • Mental health – including isolation, depression, suicide, poor self-esteem, fear
    • Sexually transmitted infections and pregnancy – especially Gonorrhea, Hepatitis B and C, Human Immunodeficiency Virus, Syphilis.
    • Social and legal – difficulties identifying where and how to socialize, discrimination in employment, housing, public accommodations, public events
    • Substance abuse
    • Violence – including bullying, harassment, sexual violence/abuse, physical violence/abuse or death

    It is not uncommon for adolescents to “experiment” with different sexual behaviors and therefore even those persons who have a homosexual orientation should be counseled about safe-sex practices and contraception options.

    Learning Point
    In addition to assuring and maintaining information confidentiality with all patients, using gender-neutral questions on health questionnaires and during the health interview may allow youth and their families to give more accurate information.
    For example, health questionnaires that ask for information about a mother and a father, may not gather all the pertinent information in a 2-adult gay/lesbian household or a foster care family.
    Using a generic term such as “Guardian” as the header with a follow-up question about the “Relationship to Patient” offers more flexibility.
    Some people recommend to have at least 4 spaces on the health form for “Guardian” because of the high rate of divorce, kinship care, and foster and adoptive care.

    The following are some suggestions for gender-neutral sexual questions. The terms men and women can be substituted or added as is appropriate to the terms boys and girls used below:

    • Many of my patients are dating other boys, girls or both. Are you interested in dating?
    • Have you ever dated or gone out with someone? Are you dating or going out with someone now?
    • Have you ever been attracted to girls, boys or both? Are you especially attracted to any boys or girls?
    • Many boys and girls are sexual with other boys or girls. They may kiss, hug, pet or have oral, anal or vaginal intercourse. Have you every had any sexual experiences like these or other experiences with girls or boys or both?
    • What kind of sexual experiences have you had? Did you have them with boys? Did you have them with girls? Did you have them with both?
    • What kind of protection did you and your partner(s) use for pregnancy and sexually transmitted diseases?
    • Do you have any concerns about your sexual feelings or the sexual things you have been doing or want to do in the future?
    • Have you ever talked with someone about your sexual feelings?
    • Do you consider yourself to be gay/lesbian, bisexual or straight (heterosexual)? Are you asking/questioning what you want to call yourself?

    Some adolescents may be reticent to disclose their sexual behaviors or use different terminology to describe them. Therefore the healthcare provider may need to be very explicit when describing sexual behaviors to elicit precise information from patients.

    Questions for Further Discussion
    1. When compared to children raised in other households, do children raised in gay/lesbian homes differ in psychosocial development?
    2. Parents who find out they have a daughter or son who is gay/lesbian have what characteristic psychological reaction?
    3. In your state, what is the legal status of same-sex households?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check Gay, Lesbian and Transgender Health and Teen Sexual Health.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Perrin EC, Cohen KM, Gold M, Ryan C, Savin-Williams RC, Schorzman CM.
    Gay and lesbian issues in pediatric health care.
    Curr Probl Pediatr Adolesc Health Care. 2004 Nov-Dec;34(10):355-98.

    Tasker F.
    Lesbian mothers, gay fathers, and their children: a review.
    J Dev Behav Pediatr. 2005 Jun;26(3):224-4.

    Wellings K, Collumbien M, Slaymaker E, Singh S, Hodges Z, Patel D, Bajos N.
    Sexual behaviour in context: a global perspective.
    Lancet. 2006 Nov 11;368(9548):1706-28.

    Selekman J.
    Homosexuality in children and/or their parents.
    Pediatr Nurs. 2007 Sep-Oct;33(5)453-7.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    August 4, 2008