Genital warts

Genital Warts

1. GENITAL WARTS

2. Genital warts - Introduction Epidermal manifestation attributed to epidermotropic human papilloma virus About 100 types of ds HPV have been isolated and about 35 types have affinity to genital sites frequently affected sites: penis, vulva, vagina, cervix, perineum, and perianal area The mucosal lesions occasionally can be found in the oropharynx ,larynx, trachea and extremities

3. Introduction contd … Two categories of genital HPV exist: low-risk benign HPV lesions and high-risk neoplastic HPV lesions The low-risk strains are responsible for genital warts, recurrent respiratory papillomatosis (RRP),low-grade cervical lesions. Types 6 and 11account for more than 90% of genital warts and most cases of RRP. Type 16,18,31,33 and 35 are found as coinfection with HPV 6 and 11 and are associated with foci of high grade intraepithelial neoplasia (HIV infection)

4. Human Papillomavirus (HPV)

5. Human Papillomavirus Features Description Family Papillomaviridae Virion Icosahedreal , 55 nm in diameter composition Ds DNA (10%) and 2 structural protein (90%) envelope absent Outstanding features Restricted host range and tissue tropism Significant cause of human cancer – cervical cancer Viral oncoproteins interact with cellular tumor supression proteins

6. Genital Warts Features: Usually asymptomatic but can be painful or pruritic Flat, papular or pedunculated growth on genital mucosa Sites: introitus in women under foreskin of uncircumcised penis shaft of circumcised penis Anogenital epithelium: cervix, vagina, urethra, perineum, perianal skin and scrotum

7. Genital Warts -Appearance Condylomata acuminata ( anogenital warts ) Cauliflower-like appearance Skin-colored, pink or hyper pigmented keratotic on skin and non-keratinized on mucosal surfaces

8. Genital Warts - Appearance contd …. Smooth papules : Usually dome-shaped and skin-colored Flat papules : Macular to slightly raised Flesh-colored with smooth surface commonly found on internal structures (cervix) but also occur on external genitalia

9. Genital Wart-Appearance contd …. Keratotic warts :Thick horny layer that can resemble common warts or seborrheic keratosis

10. Skin Papilloma HPV infection occur at the basal cell layer of stratified Squamous epithelial cells Stimulate cellular proliferation in epithelium and infected cells interaction between viral proteins and cellular proteins (anti- oncoproteins ) that normally function to regulate the cell cycle. Two of these antioncogenic cellular proteins are p53 (cellular growth suppressor protein) and pRb (retinoblastoma gene product) Display a broad spectrum of changes ranging from benign hyperplasia to dysplasia to invasive cancer

11. Pathogenesis

12. Clinical manifestations Painless bumps, pruritus and discharge: chief complaints multiple lesions rather than a single wart Oral, laryngeal, or tracheal mucosal lesions (transfer through oral-genital contact) Urethral bleeding or urinary obstruction: wart involving the meatus. Vaginal bleeding during pregnancy: due to condyloma eruptions Coital bleeding also may occur h/o of previous or current sexually transmitted diseases (STDs) Lesions may regress spontaneously, remain static, or progress

13. Clinical Diagnosis visual inspection confirmed by biopsy and is indicated if: the diagnosis is uncertain the lesions do not respond to standard therapy the disease worsens during therapy the lesion is atypical the patient has comprised immunity application of 3%–5% acetic acid causes skin color to turn white used to detect HPV-infected genital mucosa(not recommended) Papanicolaou test Non specific tests :immunoassay, insitu hybridization and PCR ( HPV doesnot grow in routine tissue culture )

14. Papanicolaou test- Pap test cervical screening used to detect potentially pre-cancerous and cancerous processes in the  cervix Findings: perinuclear cytoplasmic vacuolization and nuclear enlargement Abnormal findings are often followed up by more sensitive diagnostic procedures aiming to prevent progression to cervical cancer

15. Pharmacological therapy

16. Management during pregnancy Genital warts can proliferate and become more friable during pregnancy Cytotoxic agents ( podophyllin , podofilox , imiquimod ) should not be used Cryotherapy , Trichloroacetic acid(TCA), bichloroacetic acid(BCA) and surgical removal may be used HPV types 6 and 11 can cause recurrent respiratory papillomatosis in childrens

17. Genital Warts in HIV infected patients No data that treatment should be different Larger, more numerous warts Might not respond as well to therapy More frequent recurrence of lesions after treatment Squamous cell carcinomas arising in or resembling genital warts might occur more frequently among immunosuppressed persons Require biopsy for confirmation of diagnosis for suspicious cases, and referral to a specialist.

18. Prevention :HPV vaccine Gardasil ™ and Cervarix ™: licensed by the FDA and recommended by the CDC Gardasil : quadrivalent vaccine against HPV 6, 11, 16, 18 FDA-approved: females and males, 9-26 years old prevent gential warts and HPV-related genital cancers

19. HPV Vaccine (contd..) Ceravix : bivalent vaccine against HPV 16, 18 FDA-approved: females 10-25 years old (not approved for males) prevent HPV-related genital cancers

20. REFERENCES Kyan J. Kenneth,Sherris medical microbiology, 4 th edition Jawetz medical microbiology, 26 th edition Robbins pathologic basis of disease, 7 th edition cdc.gov/ hpv / whatishpv (retrieved on 28 th july 2015) emedicine.medscape.com/article/763014-clinical#b4 (retrieved on 27 th july 2015) medicinenet.com/image-collection/ genital_warts_hpv_picture (retrieved on 28 th july 2015)