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
- 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
- only infect humans
- 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
- transmission
- Associated conditions:
- cutaneous warts (HPV types 1 and 2)
- laryngeal papillomatosis (HPV types 6 and 11)
- precancerous and cancerous genitourinary/oropharyngeal lesions (HPV types 16, 18, 31, 33)
- cervical 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
- Gardasil 9 in the USA
- vaccinations
- Prognosis
- depends on clinical presentation and conditions
Presentation
- Symptoms
- most cases will present asymptomatically and will self-resolve
- 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
- 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
- cervical cancer
- cutaneous warts/common hand warts
- abnormal growths or lesions
Studies
- Labs
- gold standard is in situ hybridization or PCR to detect HPV DNA
- HPV-16 viral load
- gold standard is in situ hybridization or PCR to detect HPV DNA
- Indirect laryngoscopy
- allows for direct visualization of lesions at the larynx
- Histopathology
- Screening
- Pap smear for women beginning at age 21
Differential
- Condyloma lata of secondary syphilis
- differentiating factor
- condyloma lata are more flat-topped
- differentiating factor
- Molluscum contagiosum
- differentiating factor
- have central dimpling and often in immunocompromised individuals
- differentiating factor
- 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