Updated: 8/7/2018

Human Papilloma Virus

Topic
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Questions
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Snapshot
  • A 38-year-old male presents to the clinic with a history of soft, raised flesh-colored growths on his glans penis, prepuce, and penile shaft. He is sexually active with multiple partners and uses condoms infrequently. Excisional biopsy was 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 promotes 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 age 9-26; males age 9-21
  • 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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Questions (2)
Lab Values
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/L
Female: 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/mL
Female: 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/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative 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/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 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/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 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/min
Female: 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 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 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
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(M1.MC.70) A 31-year-old woman presents to her gynecologist for a routine well-visit. She is sexually active with multiple male partners and uses an intrauterine device for contraception. Her last menstrual period was two weeks ago. She denies abnormal vaginal discharge or sensations of burning or itching. Pelvic exam is normal. Routine Pap smear shows the following (see Image A). Which organism is most likely responsible for her abnormal Pap smear? Review Topic

QID: 106492
FIGURES:
1

Treponema pallidum

0%

(0/16)

2

Chlamydia trachomatis

6%

(1/16)

3

Herpes simplex virus 1

0%

(0/16)

4

Human papillomavirus

75%

(12/16)

5

Trichomonas vaginalis

12%

(2/16)

M1

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