Visual Diagnosis

Presentation

A 16-month-old girl presents to a tertiary care center with a 3-month history of a protruding mass from her vagina. The mass began 3 months ago as a small noticeable nodule in her vagina that rapidly increased in size. The mother states that her daughter has had intermittent white, foul-smelling vaginal discharge with occasional smearing of blood on her diaper. The mother also describes redness of the skin immediately surrounding the mass. The patient has normal urine output and urinary frequency without any evidence of discomfort during urination, and there is no hematuria. There have been no fevers or weight loss, although she has had a decreased appetite for 1 month. The patient initially was evaluated in Mexico by several physicians, who advised her to seek a higher level of care due to the rarity of her presentation. Financial limitations and lack of access to health care after the patient immigrated to the United States resulted in a delay in care.

The patient was born at term by vaginal delivery in Mexico. Her mother denies taking any medications during pregnancy. The child is developmentally normal for age, and she has a maternal great-grandmother who had cervical cancer diagnosed in middle age. The mother denies any history of sexual abuse.

Physical examination reveals an alert, well-appearing child in no acute distress. Vital signs are normal for age, and her weight, height, and head circumference are at the 25th percentile. Abdominal examination reveals a soft, nontender abdomen without hepatosplenomegaly or palpable masses. Multiple bilateral inguinal lymph nodes are noted, most prominently in the left inguinal region, where the largest …