Viral Diseases

What type of virus is HPV?

Double-stranded DNA virus

What are the cutaneous types of HPV

- Verruca plantaris

- Verruca vulgaris

- Verruca plana

- Butcher's Wart

What is the anogenital type of HPV

- Condyloma acuminatum

Characteristics of mucosal HPV

- Caused by HPV 6, 11, 16

- Can involve the respiratory mucosa

- Can lead to SCC of the oropharynx

How is HPV transmitted?

Skin-to-skin or mucosal contact

When does HPV increase cancer risk?

Persistence beyond 12 months

Characteristics of specific cutaneous warts

- Verruca plantaris -> warts on the soles of the feet

- Verruca vulgaris -> firm hyperkeratotic papules that are usually singular

- Verruca plana -> flat flesh colored warts

- Butcher's wart -> multiple warts on the hands

Which HPV types cause common (verruca vulgaris) and plantar warts (verruca plantaris)?

Types 1, 2, and 4

Which HPV types cause flat warts / verruca plana?

Types 3 and 10

Which HPV types cause Butcher's wart?

Types 2 and 7

Characteristics of Butcher's wart

- Multiple in number and larger than common warts

Which HPV types cause genital / anogenital warts (condyloma acuminatum?

Types 6 and 11

Which HPV type has the highest cancer risk?

- HPV 16 (can cause squamous cell carcinoma)

Which HPV types are most associated with cervical and anal cancer?

Types 16 and 18

What is the most common STI worldwide?

HPV

Peak prevalence of HPV

- 15-25 years old

What reduces but does not eliminate HPV transmission?

Condom use and circumcision

What is the most common clinical manifestation of HPV and which age group experiences them most commonly?

- Cutaneous warts (vulgaris + plantaris + plana + Butcher's wart )

- MC in children and young adults (especially plantar warts)

Risk factors for transmission of anogenital transmission

- Skin to skin contact

- Sex w a new partner

- HIV is a strong risk factor

Risk factor for cutaneous HPV

- Direct skin contact especially with maceration or site of trauma + meat handlers

What are typical features of anogenital warts?

- Soft, asymptomatic, flesh-colored or verrucous lesions

- Can be cauliflower shaped

Characteristics of verruca vulgaris

- Firm + hyperkeratotic papules with thrombosed capillaries

- Associated 1, 2, 4

Characteristics of verruca plana

- Flat flesh colored papules

What is the incubation period of HPV?

3 weeks to 8 months

Diagnostics for HPV

- Usually based on PE but biopsy is definitive

- Do other STI testing

What is first-line treatment for verruca vulgaris/plantaris?

Salicylic acid or cryotherapy with liquid nitrogen

What is treatment for verruca plana?

- Salicylic acid + topical tretinoin + imiquimod (5-FU if resistant)

What is first-line treatment for condyloma acuminata and what are the patient instructions?

- Podophyllotoxin + podophyllum resin (wash off after 4 hours to reduce systemic absorption)

- Trichloroacetic acid / TCA (healthcare provider must apply it; preferred in pregnancy)

- Topical interferon/Imiquimod (avoid sex while using the cream + wash hands after application)

- Topical 5-FU (used if resistant to other tx's; DON'T USE IN PREGNANCY)

What HPV treatment for condylomata acuminata is preferred in pregnancy?

Trichloroacetic acid (must be applied by healthcare workers)

How to prevent HPV

- Wear slippers in public showers + pool deck

- Don't mess with the wart

- STD testing + safe sex

- Pap smears for cervical cancer every year

What vaccine prevents HPV?

Gardasil against HPV 6, 11, 16, 18

At what age is routine HPV vaccination recommended?

- 11-12 years (can start at 9 and up to age 26)

- Not recommended over age 27

What is the vaccination schedule for HPV if pt is 9-14 yo

- 2 doses (1 at time of visit, and the other 6-12 months later)

What is the vaccination schedule for HPV if pt is > 15 yo

- 3 doses ( 1 at time of visit, another 1-2 months later, and the last 6 months after the first dose)

How is HSV-1 most commonly transmitted?

- Oral secretions

- Can be oral-oral or oral-genital or genital-genital contact

Where does HSV-1 remain latent after initial infection?

- Sensory ganglia and reactivates on mucosa + skin

What are the manifestations of primary HSV 1 infection in kids

- MC presents with gingivostomatitis and pharyngitis -> oral vesicles ulcerate

- Other = fever, malaise, myalgias, irritability, and cervical LAD

- The painful ulcers of the mouth may make it difficult to drink so there is a risk of dehydration

What are the manifestations of primary HSV 1 infection in adults

- Oral exudative and ulcerative lesions

- Can also have fever + malaise + myalgia + cervical LAD

Manifestations of recurrent HSV-1

- MC sign = vesicles that ulcerate at the vermillion border (Herpes labialis)

- RARELY ASSOCIATED W SYSTEMIC SYMPTOMS

Precipitating factors for HSV-1 reactivation

- Stress

- Exposure to sunlight

- Fever

What prodrome precedes HSV-1 lesions?

Tingling or burning usually 24 hours before the painful lesions

S/S of primary genital HSV-1 infection

- B/L painful genital ulcerations and tender LAD

- Shedding can occur w/o symptoms (leads to transmission)

What is herpetic whitlow?

- HSV infection of the finger due to autoinoculation via breaks in the skin

What is herpes gladiatorum

- Painful vesiculopustular rash on face + neck + arms of wrestlers

What is eczema herpeticum (Kaposi)?

HSV infection secondary to eczema

What ocular disease is HSV-1 most associated with?

Keratitis + acute retinal necrosis

PE findings indicative of keratitis

- Dendritic lesions of the cornea

Which consult do you call for in a pt with an ophthalmic HSV-1 infection

- Ophthalmology consult ALWAYS bc it can lead to blindness

- You will need to do a PE and get a PCR

What is the most specific + sensitive diagnostic for HSV-1

- HSV PCR (NAAT)

Which HSV type most commonly causes genital herpes?

HSV-2 (can also be caused by HSV-1)

What is the incubation period of HSV-2?

2-12 days

What is the hallmark lesion of HSV-2?

- Painful grouped vesicles on erythematous base

- Erythema progresses to vesicuopustules to erosions and ulceration

Why can HSV-2 cause urinary retention?

- Pain causes the pt to hold in their pee

What is a common prodrome of recurrent HSV-2?

Tingling or shooting pain in the buttocks + leg + hips

What complication is HSV-2 associated with increased risk of?

HIV infection (do testing just in case)

Dx for HSV-2

- PCR (most sensitive)

HSV-1 vs HSV-2

- HSV-1 = transmitted via saliva + usually asymptomatic

- HSV-2 = transmitted sexually or vertically + usually has shallow ulcers + asymptomatic shedding and reoccurrence is more frequent

What drug inhibits HSV DNA synthesis?

Acyclovir

Things to consider with acyclovir

- Cleared via kidneys (accumulates in renal insufficiency) -> nephrotoxic (monitor BUN/Cr)

- PO has low bioavailability, hence frequent admin

- IV is reserved for serious / systemic infx

Which antiviral has best oral bioavailability for HSV?

Valacyclovir (less frequent dosing)

What should be monitored when giving a pt valacylovir?

- Nephrotoxicity

- CNS effects (seizures + change in mental status)

What two diseases are caused by VZV?

Chickenpox (varicella) and shingles (herpes zoster)

What causes shingles?

Reactivation of latent VZV

Who is at highest risk for shingles?

Adults >50 years (incidence increases with age) and immunocompromised pts

Transmission of VZV

Aerosolized droplets + direct cutaneous contact via vesicle fluid from skin lesions

What is the hallmark of shingles rash?

Painful unilateral grouped vesicular/bullae rash in dermatomal pattern

What is the most common complication of shingles and its treatment?

- Postherpetic neuralgia -> continuation of pain months/years after

- Tx = gabapentin + pregabalin or TCAs

What antivirals should be started for shingles and when?

- Oral valacyclovir or famciclovir within 72 hours

- If pt is pregnant, give acyclovir

- Beyond 72 hrs in pts with complications or > 65 years old.

What describes chickenpox rash progression?

Macules → papules → vesicles → crusts

What distinguishes chickenpox lesions?

Lesions in different stages simultaneously

Complication of varicella

- Bacterial superinfections + dehydration + PNA + neurological issues

- Immunosuppressed pts are at risk of disseminated varicella (severe morbidity + mortality)

Treatment for varicella

- < or = to 12 yo = self limited

- Supportive care = antihistamines + tylenol (avoid ASA to prevent Reye's syndrome) + cut fingernails

- If pt is high risk or immunocompromised or pregnant -> start PO valacyclovir or acyclovir within 24 hrs of onset of rash (IV if severe)

What precuations should be taken with VZV pts in-patient?

- Contact + standard airborne precautions until lesions are crusted

What virus causes infectious mononucleosis?

Epstein-Barr virus

How is EBV transmitted?

- Infected saliva

What is the classic triad of EBV?

Fever, pharyngitis w exudate, symmetric posterior cervical LAD

What lab finding is typical in EBV?

Atypical lymphocytosis

What is the gold standard for dx EBV

- EBV specific antibodies

What antibiotic causes rash in EBV patients?

Ampicillin -> causes maculopapular/morbilliform rashes

What activity restriction is required with EBV?

No contact sports for 1 month because of splenomegaly (risk of rupture)

Complications of EBV

- Airway obstruction

- Splenic rupture

- Burkitt lymphoma

TX for EBV

- Supportive care (tylenol/NSAIDs for fever + fluids + rest)

- If there is a risk of airway obstruction -> corticosteroids + emergency ENT consult

What virus causes mono-like illness without pharyngitis?

CMV

How is CMV transmitted

- Close contact (daycares + HCWs + sexual partners + perinatal exposure)

What test differentiates CMV from EBV?

Negative heterophile antibody test

Clinical manifestations of CMV

- Fever + systemic symptoms + can also have ampicillin associated rash

Tx for CMV

- Supportive for most pts

- If pregnant -> tx with valacyclovir or ganciclovir

What retinal finding is seen in CMV retinitis?

Pizza-pie lesions

What virus causes measles?

Rubeola

How is measles transmitted

- Airborne droplets (extremely contagious)

- Risk populations -> pts < 12 months who have not received vaccine yet

4 stages of measles

1) Incubation

2) Prodrome -> 3 C's + Koplik spots

3) Exanthem -> desquamation + LAD + high fever + spreading of rash cephalocaudally

4) Recovery + immunity

What are the "3 Cs" of measles?

Cough, coryza (runny nose), conjunctivitis

What pathognomonic lesion precedes measles rash?

Koplik spots -> whitish/grey/blue evaluations on erythematous base which sloughs off when exanthem appears

How does measles rash spread?

Face → trunk → extremities

What is the most common cause of death in measles?

Pneumonia

Diagnosis for measles

- Mainly clinical (3 C's + Koplik spots)

- (+) serum IgM antibody

Treatment for measles

- Supportive -> antipyretic + fluids + tx for bacterial superinfections + vitamin A supplement

Vaccine and precaution information for rubeola

- MMR or MMRV vaccine at age 12-15 months and 4-6 years old

- If pt is inpatient -> airborne + general precautions

- If pt is outpatient -> private room preferably with negative pressure

What virus causes mumps?

Paramyxovirus (highly contagious via respiratory droplets + direct contact + fomites)

What gland is affected in mumps?

Parotid gland