Updated: 5/25/2020

Human Papilloma Virus

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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) 
    • 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 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) 
    • 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 

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Questions (4)
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(M1.MC.14.70) 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?

QID: 106492
FIGURES:
1

Treponema pallidum

6%

(5/79)

2

Chlamydia trachomatis

8%

(6/79)

3

Herpes simplex virus 1

1%

(1/79)

4

Human papillomavirus

71%

(56/79)

5

Trichomonas vaginalis

11%

(9/79)

M 2 D

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