Friday, January 31, 2014

2014 - New case of neonatal herpes following circumcision and oral suction - metzitzah b'peh

 Direct orogenital suction during ritual Jewish circumcision (also known as metzitzah b’peh) has been documented to transmit herpes simplex virus (HSV) type 1 to newborn males (1-4). In January 2014, the New York City (NYC) Department of Health and Mental Hygiene received a report of a new case of HSV-1 infection in a newborn male infant following direct orogenital suction. To date, a total of 14 laboratory-confirmed cases of HSV-infection attributable to direct orogenital suction have been reported to the Health Department since 2000. Two of these infants died, and at least two others suffered brain damage (4).

In the most recent case, the infant was the term product of a full-term pregnancy and normal vaginal delivery. He had ritual Jewish circumcision including direct orogenital suction on day of life 8. On day of life 13, at a well-child visit, a rash was noted on and around genitals. The baby was treated with topical antibacterial ointment. On day of life 16, the baby returned to his provider for worsening rash, and a topical anti-fungal was added to the regimen. On day of life 18, lesions progressed to include the perineum and the right foot. HSV infection was suspected, and the infant was referred to a pediatric dermatologist. The next day, upon evaluation of the baby, the dermatologist, also suspecting HSV, collected specimens for direct visualization and for viral culture, and the baby was admitted to a hospital for treatment. The location of herpes lesions (on the genitals and on the foot, a dermatomal distribution reflecting involvement of sacral nerves), viral type (HSV type 1, which is commonly found in the mouth of adults), and timing of infection (5 days after circumcision) are consistent with transmission during direct contact between the mouth of the ritual circumciser (mohel) and the newly circumcised infant penis.

The document is co-signed by Susan Blank, one of the members of the AAP Task Force on Circumcision from the infamous policy statement of  2012 - the one that says that "the benefits outweigh the risks" - and the one that does not have the guts to say that "orogenital suction" (baby penis in adult's mouth) should not be performed. So much for that Dr. Blank.

1 comment:

  1. Dear circlist,

    I hope that I can post this here.

    A while ago we had a debate with user Steve66 about whether there is scientific
    evidence that the glans of a circumcised male has a higher level of keratiniaztion
    than the glans of an intact man.

    I went ahead and borrowed from the library the book "Histology for pathologists";
    Stephen S Sternberg; 2nd edition (1997). I went to Chapter 44 "Penis" by J. Barreto,
    C. Caballero and A. Cubilla. At page 1042 it describes the glans of an intact male:

    "The glans is covered in the uncircumcised male by a thin, nonkeratinized,
    stratified squamous epithelium five- to sex- cell layers thick. After circumcision
    the epithelium becomes keratinized. Under various pathologic conditions a thin
    granular layer with some keratinization can be present. The superficial cells
    contain no glycogen (Fig. 5)."

    I have a scan of Fig. 5 here:

    A scan of the text above is here:

    Now. There is a newer edition from 2007 "Histology for pathologists" by Stacey E.
    Mills; 3rd edition. It has the same chapters but they have been revised. The Chapter
    "Penis" is now authored by E.F. Velazquez, C.J. Cold, J.E. Barreto and A.L. Cubilla.
    The text describing the glans was now changed to:

    "Both circumcised and intact (uncircumcised) men have partially keratinized
    stratified squamous epithelium five to six layers thick (Figure 38.4). Some
    textbooks state that the circumcised glans is much thicker and more keratinized than in an intact man, but no well-controlled studies support this belief. ..."

    I post here Figure 38.4:

    Unfortunately, the authors do not state whether Figure 38.4 is from a circumcised or
    intact glans. There is a 4th edition of "Histology for pathologists" published in August 2012 but I don't have access to it.

    The take home message is that there is a general consensus among histologists that the circumcised glans might be more keratinized, but more studies are needed to confirm this. Interestingly, later on in the chapter there is the statement:

    "Preputial functions are related to protection of the glans from external irritation
    or contamination, and it has been shown that the foreskin is normal erogenous tissue (8,31,32)."

    It should be obvious that removal of this protective tissue is likely to induce
    thickening of the exposed tissue.