Human Papilloma virus (HPV). There are over 70 different types of the virus.
Different types of the virus are associated with distinct clinical manifestations.
HPV Type
Associated Disease
6, 11, 42, 43, 44, 54
Genital warts, laryngeal papillomas
16, 18, 31, 33, 39, 45, 51, 52
Dysplasia and carcinoma of the cervix
Other types cause warts of the skin such as plantar warts.
B. Epidemiology
Genital warts caused by HPV 6 and 11 are the most common STD in the United
States. Over a million cases are seen per year.
HPV DNA (types 16, 18 mostly) has been found in over 90% of the cervical
carcinomas and is believed to be the major cause of invasive cervical carcinoma.
Transmission of the virus is not very well understood.
Direct contact with the lesion is believed to result in spread of the disease.
C. Manifestations
Soft, fleshy, cauliflower-like lesions on
the skin, genitalia, perineum, and perianal
regions. The HPV infected cells of the cervix do not have any recognizable
lesion. Only after the addition of dilute acetic acid can one see an "acetowhite"
epithelium.
Placing dilute acetic acid on the cervix can reveal the acetowhite epithelium.
A "PAP" smear should be performed and the pathologist will look for
koilocytosis.
In situ DNA hybridization or PCR of the biopsy material. Not very
commonly performed.
VII. Lymphogranuloma
venereum or LGV is
a sexually transmitted disease caused by Chlamydia trachomatis and is characterized
by acute inguinal lymphadenitis + genital ulceration. - it is also called:
Durand-Nicolas-Faver disease
Tropical or climate bubo
Poradenitis
Lymphopathia venereum
Lymphogranuloma inguinale
A. Etiology
There are 2 main serologically distinct groups of Chlamydia, C. trachomatis
and C. psittacosis; the LGV chlamydias belong to the C. trachomatis
group.
Within this group, 3 separate immunotypes, designated L1 - L3
based on surface antigens, can cause LGV.
B. Epidemiology
The disease is transmitted primarily through sexual contact.
The disease predominates in tropical and subtropical nations of Africa
and Asia.
C. Manifestations
Following an incubation period of 3 to 30 days, a primary genital lesion
develops, usually a herpetiform lesion; it is usually very transitory.
After the initial lesion heals the patient develops lymphadenitis which
is the 2nd chief manifestation; followed by genito anorectal syndrome.
Primary inguinal syndrome:
Begins 2-6 weeks after exposure as a painful inguinal
lymphadenopathy. -- During the acute stage there may be systemic manifestations
fever
chills
headache
anorexia
myalgias
arthralgias
hypergammaglobulinemia
splenomegaly
Genito-anorectal syndrome which occurs either following rectal intercourse
or via spread from genital infection sites. (usually seen in women).
Chlamydia enter the body through small breaks or abrasions in the
skin and induce a local genital lesion as well as regional lymph node involvement
and systemic effects because macrophages phagocytize them and carry them
around as intracellular parasites.
The histologic picture of the initial genital lesion is essentially that
of a nonspecific granuloma.
Inguinal lymphadenopathy is extensive and may split the inguinal mass into
1/2s separated by Poupart's ligament, producing
an almost pathopneumonic groove sign for LGV.
E. Diagnosis is based on
Clinical manifestations
LGV complement fixation test (LGV-CFT) not very sensitive or specific.
Look for a four-fold rise in titer between acute and convalescence serum.
Ultimate isolation of the organism using tissue culture (LGV grows well
in McCoy cells). -- Culturing the organism is not routinely attempted
F. Prognosis;
the initial lesion is very transient and the lymphadenitis resolves in
several months; serious disease is rare and rectal stricture is the most
common complication.
G. Therapy
Doxycycline 100 mg orally twice a day for 21 days or Erythromycin base
500 mg orally four times a day for 21 days.
Surgical drainage of pus and correction of rectal strictures as well as
other fistulas.
Check patient at weekly intervals for resolution of lesions.
Check sex partners.
IX. Granuloma
inguinale (also
called lupoid ulceration granuloma of the pudenda and granuloma contagiosa)
is a chronic, indolent, ulcerative, granulomatous disease of the skin and
lymphatics.
A. Etiology
Calymmatobacterium granulomatis is the etiological agent; it is
a Gram -rod with characteristic bipolar staining so they have a safety
pin-like appearance in stained tissue preparation. -- We call them Donovan
bodies.
B. Epidemiology
It is endemic in the tropics and very rare in the U.S.; probably < 100
cases/year.
A venereal disease that is sexually transmitted but is not very contagious.
C. Manifestations
Genital lesions are present in 90% of infected patients and in 80% of these
there is no other area of involvement.
Initially the lesions are papules that tend to ulcerate slowly.
The ulcerated lesions are irregular in shape with a rolled border on a
beefy red, cobblestone base (image 1
and
2).
Patients develop subcutaneous granulomas in the inguinal regions; they
do not involve the lymph nodes usually, so we call them pseudo-buboes.
D. Pathology and pathogenesis
The organism gains entry by direct inoculation through skin abrasions or
mucous membranes.
One or more indurated papules form which progress to characteristic ulceration.
The most important sign is the presence of mononuclear cells with intra
cytoplasmic vacuoles packed with the bacteria or Donovan
bodies as they are called.
E. Diagnosis
Evaluate the nature of the lesion (nodules which erode to form painless,
beefy, granulomatous ulcers) and sexual history.
Demonstrate the pathopneumonic enlarged mononuclear cells containing vacuoles
filled with Donovan bodies.
F. Therapy
In order of preference:
Trimethoprim-sulfamethoxazole one double-strength tablet orally twice a
day for a minimum of 3 weeks, OR
Doxycycline 100 mg orally twice a day for a minimum of 3 weeks.
Alternative therapy
Ciprofloxacin 750 mg orally twice a day for a minimum of 3 weeks, OR
Erythromycin base 500 mg orally four times a day for a minimum of 3 weeks.
