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 allows for replication and cellular division allows for replication and cellular division allows for replication and cellular division allows for replication and cellular division Associated conditions: cutaneous warts (HPV types 1 and 2) condyloma acuminata/anogenital warts (HPV types 6 and 11) laryngeal papillomatosis (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 6, 11, 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) laryngeal papillomatosis hoarseness, shortness of breath, and chronic cough dysphagia, pneumonia, and recurrent upper respiratory infections 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 Indirect laryngoscopy allows for direct visualization of lesions at the larynx 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 Laryngeal papillomatosis surgical removal, though high recurrance rate adjuvant non-surgical treatments antiviral (e.g., cidofovir) interferon photodynamic therapy Cancer chemotherapy immunotherapy surgical resection +/- radiation therapy Complications Cervical cancer Anal cancer Head and neck cancer Penile cancer