1. ® Acute Lymphoblastic Leukemia as a Mimic of Sexual Abuse Jennifer Clarke, MD, Nancy Kellogg, MD, Department of Pediatrics, University of Texas Health Science Center Children’s Hospital of San Antonio Texas Pediatric Society Electronic Poster Contest  In the absence of a history for accidental trauma, child sexual abuse is a strong consideration among children presenting with anogenital bruising or bleeding. A finding misinterpreted as abuse can have deleterious effects on the family.  Knowledge of conditions that may mimic anogenital injury is key to the appropriate clinical and protective management of the child.  Although trauma in the setting of an underlying coagulopathy 1 has been cited as a possible cause of anogenital bruising, a Pubmed search revealed no reports of leukemia resulting in isolated anogenital bruising. Objective  To describe a unique presentation of leukemia in a prepubertal female, resulting in anogenital bruising that was initially concerning for sexual abuse. Background Case Presentation A 3-year-old girl with no significant past medical history presented to the ED with fever, vomiting and pain to her “private part.” Physical exam was unremarkable except for rhinorrhea. She was diagnosed with viral syndrome and constipation, and given oral ondansetron and a glycerin enema. She was discharged home with a prescription for polyethylene glycol and ibuprofen. She presented 2 days later with anogenital pain and caregiver reports “small pebble stools.” She was febrile to 101.1, tachycardia to 178 and fussy. Exam was otherwise normal. An abdominal radiograph showed a moderate amount of stool within the ascending colon and splenic flexure. A pediatric fleet enema was given and a small, watery stool was passed. Her urethra was catheterized with a 5-French catheter. Urinalysis showed 2+ occult blood and 1+ bacteria, with no subsequent growth. 5 days after the initial exam, patient presented with fever and rectal pain. She refused to sit due to pain. She was noted to be febrile and tachycardic. Her physical exam showed pallor, rectal bruising and a rectal tear. Blood for laboratory studies was unable to be obtained until several hours after presentation. The perianal findings raised the possibility of sexual abuse and she was referred for a sexual assault exam. Her parents had no concerns for sexual abuse and provided no additional trauma history. No other bruises were noted. Her colposcopic exam revealed: 1.Swelling of the clitoral hood and labia minora; 2.Bruising of the labia minora (white arrow) and anterior vestibule; 3.Urethra appears as a “dark black spot” (blue arrow); 4.Bruising of the perianal tissues with associated tear (Figure 2). References 1.Kellogg, ND, Frasier L. Conditions mistaken for child sexual abuse. In: Reece RM, Christian CW. Child abuse, medical diagnosis and management. 3 rd edn. American Academy of Pediatrics 2.Jensen LS, Bygum A. Childhood lichen sclerosus is a rare but important diagnosis. Dan Med J. 2012 May;59(5):A4424. Lessons for the Clinician This case report of an unusual mimic of child sexual abuse illustrates the importance of considering rare causes of anogenital bruising. While coagulopathy is routinely considered in children with non- genital bruising, iatrogenic trauma in the setting of an underlying coagulopathy secondary to leukemia has not been previously described as a potential cause of isolated anogenital bruising. Table 1 - Differential diagnosis of anogenital bruising Trauma – Accidental, Physical Abuse, Sexual Abuse Lichen sclerosus et atrophicus – See Figure 4 Hemangiomas/varicosities Urethral prolapse Prominent or superficial blood vessels  Figure 3 shows a 4 year old female with bruising of her posterior hymen and vestibule (arrows) after her father digitally assaulted her.  Figure 4 shows lichen sclerosus with subepidermal hemorrhages on the labia minora (arrow), and simulates traumatic bruising. Figure 1 Figure 2 Figure 4  Most physical examinations of sexually abused children are normal or nonspecific. Therefore, a child’s disclosure is the most common reason abuse is detected and diagnosed. In children who cannot disclose, the physical exam may be the only way to assess the likelihood of sexual abuse.  A coagulopathy or significant thrombocytopenia may predispose a child to increased bruising due to minor trauma. The significant anogenital bruising in this child was due to urinary catheterization and enema administration in the setting of severe thrombocytopenia.  When injuries are seen in sexual abuse, they are often seen posteriorly and within the hymen and vestibule, rather than the anterior, periurethral location seen in this patient. See Figure 3.  Other medical conditions may mimic sexual abuse and it is important for the clinician to consider these entities when evaluating anogenital bruising. See Table 1. Discussion Figure 3 CBC showed panycytopenia with 26,000 platelets. She was subsequently diagnosed with acute lymphoblastic leukemia. Based on the history, presentation, and anogenital findings, it was felt her injuries were secondary to iatrogenic trauma in the setting of an underlying medical condition. Child Protective Services was not notified, and no further testing was done for sexually transmitted diseases.