Snapshot A 22-year-old man presents to his primary care physician for a sore throat and oral lesions. He said his symptoms began a few days ago and have progressively worsened. Initially, his symptoms were associated with fever and submandibular lymphadenopathy. He endorses having sexual intercourse with multiple female partners without the use of condoms. Physical examination is notable for a perioral papulovesicular lesion without any genital lesions. Introduction Classification an enveloped, double-stranded linear DNA virus from the Herpesviridae family Epidemiology incidence more commonly affects the oral mucosa Transmission respiratory secretions saliva Pathogenesis herpes simplex virus (HSV) 1 inoculates the mucosal surfaces of skin and makes its way to the sensory dorsal root ganglion, where it lies dormant reactivation of HSV 1 from dormancy leads to vesicle formation, pustulations, ulcerations, and scabbing involving the mucosa of the face mouth lips oropharynx eye various triggers can reactivate HSV 1 from dormancy emotional stress immunodeficiency fever menstruation sunlight trigeminal nerve manipulation dental extractions Associated conditions HSV encephalitis Bell palsy erythema multiforme ezcema herpeticum esophagitis Prognosis lesions are typically self-limiting in healthy patients herpetic episodes are more severe and have a longer duration in immunocompromised patients Presentation Symptoms/physical exam gingivostomatitis keratoconjunctivitis esophagitis fever pharyngitis painful vesicular lesions Studies Making the diagnosis this is a clinical diagnosis based on the patient's history and appearance perioral papulovesicular lesions Tzank smear demonstrates multinucleated giant cells (intranuclear eosinophilic Cowdry A inclusions) seen in HSV 1, HSV 2, and VZV infections Real-time HSV PCR assay confirms the diagnosis Differential Aphthous ulcers differentiating factors these ulcers are never preceded by vesicles and only appear on nonkeratinized mucosal surfaces (e.g., inner surfaces of the lips and buccal mucosa Treatment Medical acyclovir, famciclovir, or valacyclovir indications immunocompromised patients patients with frequent outbreaks Complications HSV encephalitis Pneumonitis HSV esophagitis
QUESTIONS 1 of 4 1 2 3 4 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.MC.75) A 5-year-old boy is brought to his pediatrician by his mother with complaints of a sore mouth and fevers over the past several days. The mother reports that she noted blisters on the inside of the boy's mouth, prompting her to bring him to the office for evaluation. His vital signs are as follows: T 38.9 C, HR 102, BP 100/65, RR 22, SpO2 99%. Physical examination reveals the findings shown in Figure A and is also notable for palpable cervical lymphadenopathy. Infection with which of the following organisms is responsible for this patient's presentation? Review Topic QID: 106724 FIGURES: A 1 Herpes simplex virus type 1 65% (17/26) 2 Herpes simplex virus type 2 0% (0/26) 3 Epstein-Barr virus 12% (3/26) 4 Coxsackie A virus 15% (4/26) 5 Human herpes virus type 6 0% (0/26) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (M1.MC.75) A 26-year-old female presents to her family physician with concern for a lesion that recently developed on her lip (Figure A). She states that a similar episode occurred 'a year or so ago', and the lesion gradually dissipated over a few days without any treatment. She denies any recent sick contacts but does report that she has been under a good amount of stress recently at work to meet various deadlines for a project she is working on. Which of the following best describes the infecting organism in this patient's presentation? Review Topic QID: 106737 FIGURES: A 1 Positive sense, single-stranded RNA virus 31% (33/106) 2 Negative sense, single-stranded RNA virus 15% (16/106) 3 Nonenveloped virus 15% (16/106) 4 Host cell nuclear membrane-derived envelope 25% (26/106) 5 Host cell plasma membrane-derived envelope 6% (6/106) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK