Updated: 6/25/2020

Human Papilloma Virus

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Snapshot
  • A 45-year-old female finally visits her gynecologist due to her embarrassment of her genital growths. She complains of large bumps on the vulva and groin area for the past year. She denies dyspareunia, vulvar pruritus, change in vaginal discharge, and dysuria. She was sexually active with numerous sexual partners, the last encounter being about 1 year ago. She has an IUD and her last partner used condoms infrequently. Physical exam reveals multiple large flesh colored pedunculated papules on the vulva and inguinal region and medial thigh. A Pap smear and excisional biopsy were carried out.
Introduction
  • Classification
    • virus
      • non-enveloped, circular double-stranded DNA virus
  • Epidemiology
    • only infect humans  
      • most common sexually transmitted infection (STI)
      • among adults ages 18-59 in the U.S.A, prevalence of 45% for men and 40% for women
    • risk factors
      • multiple sex partners
      • individuals with new sex partners
  • Pathogenesis
    • transmission
      • from one epithelial surface to another
      • sexual activity
      • close skin-to-skin contact
    • multiple serotypes (> 75) and serotype determines disease
    • viral oncogenes in high-risk HPV infections (HPV types 16, 18, 31, and 33)  
      • E6 degrades tumor suppressor p53 protein
      • E7 binds to Rb protein and disrupts interaction between Rb and E2F
        • allows for replication and cellular division
  • Associated conditions:
    • cutaneous warts (HPV types 1 and 2)
    • condyloma acuminata/anogenital warts (HPV types 6 and 11) 
    • precancerous and cancerous genitourinary/oropharyngeal lesions (HPV types 16, 18, 31, 33)
      • cervical cancer
      • head and neck cancer
      • anal cancer
      • penile cancer
    • HIV infections promote persistence of HPV infection and may promote HPV-associated oncogenesis
  • Prevention
    • vaccinations  
      • Gardasil 9 in the USA
        • targets HPV types 1, 6, 16, 18, 31, 33, 45, 52, and 58
      • females
        • ages 11-12, may be as early as age 9 
        • catch-up schedule ages 13-26
      • males
        • ages 11-12, may be as early as age 9
        • catch-up schedule ages 13-21
        • extended catch-up schedule to age 26 if MSM (men who have sex with men) or immunocompromised (e.g., HIV/AIDS)
  • Prognosis
    • depends on clinical presentation and conditions
Presentation
  • Symptoms
    • most cases will present asymptomatically and will self-resolve
    • cutaneous warts/common hand warts 
    • condyloma acuminata (anogenital warts) 
    • oropharyngeal neoplasms/cancer
      • typically in young patients
    • genitourinary neoplasms/cancer
      • abnormal bleeding
      • discomfort during sexual intercourse
      • abnormal discharge  
  • Physical exam
    • cutaneous warts/common hand warts 
      • rough, raised bumps on hands, fingers, and soles of feet
    • condyloma acuminata
      • often cauliflower-shaped
    • oropharyngeal neoplasms/cancer
      • lesions occurs mainly at base of tongue and tonsils
      • ulcer, sores, swelling, and painful lesions
    • genitourinary neoplasms/cancer
      • cervical cancer
        • pelvic exam and colposcopy may demonstrate abnormal cells
      • anal cancer
        • digital rectal exam and anoscopy may demonstrate lesions
      • penile cancer
        • abnormal growths or lesions 
Studies 
  • Labs
    • gold standard is in situ hybridization or PCR to detect HPV DNA
      • HPV-16 viral load
  • Histopathology
    • koilocytic cells on biopsy or Pap smear 
  • Screening
    • Pap smear for women beginning at age 21
Differential
  • Condyloma lata of secondary syphilis
    • differentiating factor
      • condyloma lata are more flat-topped
  • Molluscum contagiosum
    • differentiating factor
      • have central dimpling and often in immunocompromised individuals
  • Genital herpes
    • differentiating factor
      • painful ulcerating lesions
Treatment
  • Most HPV infections are cleared by the body’s immune system
  • Common warts
    • often resolve without treatment
    • use of OTC salicylic acid and other prescription medications
    • surgical procedures such as cryotherapy, electrocautery, and laser therapy
  • Cancer
    • chemotherapy
    • immunotherapy
    • surgical resection +/- radiation therapy
Complications
  • Cervical cancer 
  • Anal cancer 
  • Head and neck cancer 
  • Penile cancer 

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(M2.ID.14.134) A 12-year-old girl presents to her primary care physician for a well-child visit. She has a history of asthma and uses her inhaler 1-2 times per week when she exercises. She does not smoke and is not currently sexually active; however, she does have a boyfriend. She lives with her mother in an apartment and is doing well in school. Her temperature is 97.6°F (36.4°C), blood pressure is 124/75 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for a healthy young girl with no findings. Which of the following is most appropriate for this patient at this time?

QID: 104140
1

HPV vaccine

6%

(3/51)

2

Human papilloma virus PCR

4%

(2/51)

3

Hypertension screening

2%

(1/51)

4

Pelvic examination

69%

(35/51)

5

Serum lipids and cholesterol

18%

(9/51)

M 6 E

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