FACTS ON FINGER TIPS

 20. GENITAL WARTS                                                                              

     Salient Features (MIMS)

Aetiology

1. Caused by papilloma virus (HPV)
2. About a third of the 80 types of HPV affect genital tissue  - some strains cause cervical cancer, and some genital warts
3. Usually sexually transmitted
4. Incubation period can be eight months or even longer

Symptoms

1. Any age group may be affected, but genital warts are more common in the young and the sexually active
2. The warts are fleshy pink, may be pointed, papular or macular, and may occur singly or in clusters
3. Usually painless but are occasionally itchy or tender
4. Warts may bleed after intercourse
5. The vulva, penis, cervix, vagina, perineum and perianal region are the areas that are usually affected, but lesions can occur on the face and mouth
6. Genital warts in children raise concerns about the possibility of sexual abuse

Investigations

1.  Genital warts are often associated with other Sexually Transmitted Infections, so full screening is advisable
2. Colposcopy, proctoscopy or histology may be needed
3. Laboratory tests may identify HPV DNA in latent cases
4. A cervical smear may pick up changes in cervical intraepithelial neoplasia that require follow-up

Treatment

1. Untreated warts usually grow and spread, but occasionally resolve spontaneously
2. The patient should use condoms in any new sexual relationship
3. Treatment aims to destroy the warts but recurrence rates are high
4. Podophyllotoxin or podophyllin paint must be applied weekly by a doctor or a nurse
5. With instruction, men can apply podophyllotoxin to penile warts
6. Surgical removal under general anaesthetic may be needed if the warts are extensive

7. DISORDERS AND /OR ADVERSE REACTIONS - INFECTIONS & INFESTATIONS  - SUMMARY

 Refer other information

Contents

1.Evidence Based Medicine                                                                                                 i Genital Herpes   

2.Facts on Finger Tips                                                                                                          i.Genital Warts                                                                                                             ii.Chicken Pox                                                                                                                 iii. Herpes Management                                                                                                               

3.Disorders and/or Adverse Reactions                                                                               Items 1 to 4

                              1. EVIDENCE- BASED MEDICINE (April 2003)

FACTS ON FINGER TIPS

 21. CHICKEN POX                                                                         

     Salient Features (MIMS)

Epidemiology

1. Common infection of early childhood
2. Most frequently seen in spring.

Spread & Incubation period

1. Spread by respiratory droplets or direct contact
2. Incubation period is about 14 days

Clinical features

1. Rash is first sign of illness- it appears in crops every few days
2. Begins on face and scalp, spreading to trunk and limbs
3. Rash progresses through macular, papular, vesicular, and pastular changes before drying to form scabs
4. Lesions may occur in mouth and other mucous membranes
5. Pruritus

Complications

1. Secondary bacterial infection
2. Encephalitis, which typically presents with ataxia
3. Varicella pneumonia
4. Haemorrhage chickenpox is very rare but serious complication

Management

1. Antipruritic creams
2. Nails to be trimmed to reduce risk of secondary skin infection
3. Acyclovir for high-risk patients

Key Points

1.  Usually a mild and self-limiting condition
2. Morbidity is greatly increased in the immunocompromised neonates, and adults, particularly pregnant women
3. Varicella- zoster immunoglobulin is advisable for non-immune individuals at increased risk of severe disease who have been exposed to a case
4. Susceptible individuals who are taking systemic steroids should seek urgent medical attention if they come into contact with chickenpox

 FACTS ON YOUR FINGER TIPS

 3. HERPES MANAGEMENT 

1. Herpes simplex viruses 1 and 2 are close, but distinct strains of DNA virus in the herpes virus class. Primary infection occurs in childhood.  It is characterised by painful blistering of the lip and the peri-oral area. accompanied by fever, malaise and enlargement of cervical lymph nodes (herpes labialis) . Transfer of infection to the fingers can cause a herpetic whitlow                    
2.  After primary infection, HSV-1 can remain in a latent state in the trigeminal ganglion from where it can be reactivated by fever, sunlight, and psychological stress. Reactivation is highly likely in sunlight and psychological stress. Reactivation is highly likely in immunocompromised patients, and prophylaxis may be advisable

3. Cold sores are a manifestation of HSV reactivation. The antibody induced by primary infection reduce severity but do not prevent recurrence. Secondary bacterial infection is a risk
4. HSV-1 and HSV-2 can be sexually transmitted, leading to ulceration of the penis, vulva, cervix, and vagina. Primary infection can lead to painful ulceration, dysuria, vaginal discharge and enlargement of lymph glands, a week or so after exposure. In women urinary retention may occur.
5. Re-emergence of HSV from sacral ganglia causes recurrent genital herpes, which may be symptomatic. Genital ulceration increases the risk of acquiring STDs other than HSV, so use of condoms is vital
6. Transmission of HSV-2 from mother to baby during delivery is likely after primary maternal infection., but less so with recurrent infection. The neonates will have no protective antibodies, so consequences of infection are severe. Between five and 21 days after delivery, skin and ocular lesions, jaundice, enlargement of liver and spleen and encephalitis may occur. Without antiviral treatment, most affected babies will die.
7. HSV infections are diagnosed clinically and anti-viral treatments need to be started at once. Viral culture takes a week to confirm the diagnosis, but DNA amplification techniques are quicker.
8. Prophylactic use of  oral acyclovir can reduce the frequency and severity of attacks of herpes labialis. Valacyclovir  may also be used for treatment of primary or recurrent HSV infection, but early use of topical antivirals is usually sufficient in cold sores
9. Acyclovir, Valacyclovir and Famciclovir are effective and well tolerated for acute episodes of genital herpes and for suppression of recurrent episodes, particularly in immunocompromised patients
10. HSV infection (usually HSV-1) can cause a severe kerato-conjunctivitis and corneal ulceration, so topical steroids should be avoided in undiagnosed painful red eye. HSV encephalitis is rare but life threatening. Urgent hospital admission is also needed for eczema herpeticum, a widespread blistering condition occurring in children with atopic eczema

7.DISORDERS  AND /OR ADVERSE REACTIONS - INFECTIONS & INFESTATIONS - SUMMARY

 
 ( Ref- Harrisons - Priniciples of Internal Medicine Ninth Edition )

1. Fever (55)
2. Drug induced lupus erythematous ( 355 )
3. Serum sickness ( 386 )
4. Anaphylaxis ( 342 )

1. Fever (55)

Fever is consequence of many stimuli, including bacteria and their endotoxins, viruses, yeasts,antigen-antibody reactions, hormonal substances, exemplified by etiocholanone , drugs, and synthetic ploynucleotides like  I:poly C. These substances, which have been collectively termed exogenous pyrogens, are both diverse and complex. It has been postulated that they act through an intermediary substance termed as endogenous pyrogen (EP). Most of the knowledge concerning EP has come from work on experimental animals.

  Adverse reaction- drugs
   1. Penicillins
   2.Novibiocin
   3. p-aminosalicylic acid
   4. Amphotericin B
   5. Antihistamines
   6. Cephalosporins
   7. Barbitutes
   8. Phenytoin
   9. Quinidine
   10. Sulfonamides
   11. Iodides
   12. Thiouracil
   13. Phenolthalein
   14. Methydopa
   15. Procainamide

2. Drug induced lupus erythematous ( 355 )

Systemic lupus erythematous ( SLE ) is a disease of unknown cause. However, abundant evidence shows that immunological mechanisms of tissue injury are important in pathogenesis.
 The clinical presentation and the course of SLE are variable. A hallmark of this is the        presence of a number of antibodies of neuclear components, but other imnological abnormalites exist as well.

  Adverse reaction- drugs ( 386 )
   1. Hydralazine
   2. Procainamide
   3. Isoniazid

3. Serum sickness ( 386 )

Serum sickness results from deposition of circulating drug-antibody complexes on endothelial surfaces. Complement activation occurs, chemotactic factors are generated locally and an inflammatory response appears at site of complex entrapment. arthalgias, lymphodenopathy, glomerulonephritis, or cerbritis may result. Penicillin is most common cause of serum sickness today.

 Time taken for the disapperance of the concentration-dependent adverse effect will depend upon on the time taken for the concentration to fall below the range associated with the adverse effect. Adverse effects of drugs such as phenobarbital which have long half-lives will take a considerable time to disappear.
 

  Adverse reaction- drugs
   1. Aspirin
   2. Penicillin
   3. Strptomycin
   4. Sulfonamides
   5. Propylthiouracil

4. Anaphylaxis ( 342 )

Life threatening anaphylactic response of a senistized human appears within minutes after admininstration of specific antigen and is manifested by respiratory distress often followed  by vascular collapse or shock without anticipatory respiratory difficulty
 
 Adverse reaction- drugs (386)
  1. Bromosulphalein
  2. Penicillins
  3. Cephalosporins
  4. streptomycin
  5. Dextran
  6. Iron dextran
  7. Procaine
  8. Insulin
  9. Demeclocycline
  10. Iodinated drugs or contrast media
  11. Lidocaine