The Link - September 2024

A 14-year-old male presented for evaluation of a rash. It started on his neck two years prior to presentation and has gradually spread to involve the chest, back, abdomen and arms. He was treated with topical ketoconazole shampoo for several weeks, and subsequently oral fluconazole, without improvement. At home, various treatments, including topical apple cider vinegar, hydrogen peroxide, and vigorous scrubbing, were attempted but proved ineffective.

Vulvovaginitis is a term that is often used to describe many causes of vulvar inflammation. Here, we will discuss many of the various causes of vulvovaginitis in prepubertal females, including their common presentations. 

Many factors predispose prepubertal females to vulvovaginitis. Their prepubertal anatomy, including lack of pubic hair and labial fat pads, provides less protection of the vulvar area. Lack of estrogen keeps the epithelium thin and the pH more neutral, as opposed to a more acidic pH during and after puberty. In addition, ensuring adequate hygiene in a prepubertal female is challenging due to diaper use and lack of supervision when transitioning to independent toileting.

With over 1.1 million lives saved, the Vaccines for Children (VFC) program has been one of the biggest successes for public health in the United States since the program’s initiation in 1994. Additionally, it’s estimated that through vaccination the program helped prevent 508 million illnesses and 32 million hospitalizations from 1994 to 2023. This is estimated as a savings of 2.7 trillion in societal costs. Cost savings included deaths averted, medical bills from lifelong complications, days children didn’t miss school, and time parents didn’t have to miss work by providing care.

VFC was established in 1994 by Congress after a measles resurgence. (Figure 1) The national resurgence of measles from 1989 to 1991 disproportionally impacted several demographics. Those at highest risk were inner city, preschool-aged Native American, Hispanic or Black children under the age of 5 who were unvaccinated and living in poverty. Cost was identified as one of the biggest barriers to vaccination. The VFC program was established in October of 1994 to provide qualified children with publicly purchased vaccines at no cost. These VFC doses could be administered at clinics or health departments of providers enrolled in the VFC program.

Worldwide human-to-human transmission of clade IIb mpox began in May 2022, with 95,000 global cases in 115 non-endemic countries documented so far. Later that year, widening interest in the infection resulted in a name change from monkeypox to mpox, prompted by the stigmatizing way the name was being used in some quarters. By May 2023, the World Health Organization (WHO) declared an end to the mpox public health emergency, though ongoing circulation of the infection continues, including in the United States. There is now a growing outbreak of a more deadly clade 1 mpox virus in the Democratic Republic of the Congo (DRC), prompting WHO to declare a Public Health Emergency of International Concern on Aug. 14, 2024. To date, this outbreak has caused 1,300 known deaths out of a 27,000 suspected mpox cases in the DRC, with additional cases in Central African Republic, Burundi, Rwanda and Uganda, as well as a few cases related to travel in Kenya (two), Sweden (one), and Thailand (one). In DRC, children under 15 have accounted for 67% of cases and 83% of deaths.

The field of clinical neuroradiology is largely concerned with the diagnosis of neurologic diseases using mainly conventional imaging modalities. While such techniques as CT scans, MRIs and X-rays are clinically valuable and robust in identifying the underlying causes of patient symptoms and diagnoses, they are not — alone — sufficient for the full characterization of network-based diseases. These connectopathies result from altered, lost or gained connections between functional centers within the brain — connections that traditional modalities are inherently unable to delineate.