1. A. R. Markos FRCOG FRCP Consultant in Genito Urinary Medicine and Sexual Health Mid Staffordshire NHS Foundation Trust, Stafford Hospital

2. Mid Staffordshire NHS Foundation Trust NHS History: 2 year old girl with vulval soreness O/E: Slight discharge, dirty perineum, no bruising or scratching Vulval swabs: Herpes Simplex Virus PMH: Recurrent chronic constipation: (repeated enemas, intestinal biopsies, tertiary referral) SH: Other siblings in Social Care Dispute on paternity: DNA testing Allegations of Sexual Abuse

3. Mid Staffordshire NHS Foundation Trust NHS 1. Conflicting account of Clinical Examination: “No bruising or scratching at the introitus” “Soiled at edge of introitus/Gaping /No hymen seen” 2. Missing Community Paediatrics Notes 3. Missing Child Protection Committee Notes

4. Mid Staffordshire NHS Foundation Trust NHS Herpes Simplex Virus Type I and II (HSV-I and HSVUII) Aymptomatic Expression Symptomatic Expression:Herpes Genitalis Herpes Libialis Gingivo-stomatitusExtra-genital Latent Infection Activation: Fever, Pneumonia, UV, Stress, Menses, Trauma…

5. Mid Staffordshire NHS Foundation Trust NHS Prevalence - Population group, Race, Social Class, Age sensitive Transmission - Mucousal surface, Skin- Mucousal junctions, Skin cracks Silent Clinical Lesions Extra-Genital Lesions - Fingers, Eyes (Autoinoculation, Viraemia)

6. Mid Staffordshire NHS Foundation Trust NHS 2106 serum samples 0-19 years old HSV-I 1-2y20% 1-4y24% 15-19y37% HSV-II0.5% Scand J Infect Dis 2003;35(8):498-502

7. Mid Staffordshire NHS Foundation Trust NHSCalifornia: 198511.7/100,000 Live Births, 1990 11.3/100,000 Live Births 1995 11.4/100,000 Live Births J Infect Dis 1999;180(1):199-202

8. Mid Staffordshire NHS Foundation Trust NHS British Isles 1986 – 1991 76 Infants UK 1.6/100,000 Live Births 25HSV-I 24 HSV-II 27 Unknown 27 Disseminated Infection 23 Herpetic Encephalitis 26 Localised infection 19 Neonatal Death (26%) 25 Long term siqualae / Death (33%) 1/2Post discharge presentation 21 Maternal evidence of Herpes Genitalis Paed Perinat Epidemiol 1996;10(4):432-42

9. Mid Staffordshire NHS Foundation Trust NHS 4 Girls and 2 Boys 5 HSV-I 1 HSV-II Sexual Abuse 4/6 Genital HSV possible indicator of Sexual Abuse Am J Dis Child 1984: 138(9):872-4

10. Mid Staffordshire NHS Foundation Trust NHS 1. Vertical Transmission/Trans placental : maternal Antibodies 2. Autoinoculation: Virus inactivated readily in room temp & drying Close contact, fresh, large inoculum 3. Fomites and Inanimate objects: Possible but not likely 4. Direct contact: Most likely

11. Mid Staffordshire NHS Foundation Trust NHSScarce American School: “Transmission by sexual contact is the most common source of childhood Genital Herpes” RCP Working Party: “The virus is transmitted by close personal contact (including genital to genital and oral to genital contact)” “Identifying HSV/II as a cause of Genital Herpes in a child cannot prove or disprove sexual contact as means of transmission”

12. Mid Staffordshire NHS Foundation Trust NHS Expert committee reports or opinions and/or clinical experience of respected authorities (Level IV)

13. Royal College of Obstetricians and Gynaecologists Setting standards to improve women’s health Risk Management and Medico-Legal Issues In Women’s Health Joint RCOG/ENTER Meeting Please turn off all mobile phones and pagers