CASE 28
She had been sexually active since she was 15, with many sexual partners.
LABORATORY STUDIES
Diagnostic Work-Up
Table 28-1 lists the likely causes of genital diseases. Papanicolaou (Pap) smear is necessary for any abnormal cell types, although it is not sufficient (50% false negative). Further investigation may include
TABLE 28-1 Differential Diagnosis and Rationale for Inclusion (consideration)
Rationale: Multiple etiologies are possible, generally sexually transmitted. Gonorrhea and chlamydia often produce significant discharge, and HSV-2 causes painful vesicles and shallow ulcers. Malignancy is always a concern with lesions as described, and should be ruled out. HPV often leads to verrucous lesions. Syphilis is often painless.
Course
The appearance was suggestive of venereal warts, and a Pap smear showed some atypical cells as well.
MICROBIOLOGIC PROPERTIES
HPVs are nonenveloped viruses of icosahedral symmetry with 72 capsomeres that surround a genome containing double-stranded circular DNA. HPV viruses do not grow in cell culture. There are more than 100 types of HPV, determined by molecular hybridization techniques using molecularly cloned HPV DNA of a known type as the standard. Each type affects certain parts of the body (for example, types 6 and 11 cause genital warts in some women; Table 28-2). HPVs may be classified on the basis of their tropism as either genital (mucosal) or cutaneous. Genital HPVs are subdivided into high-risk and low-risk types, according to their malignant potential and cell-transforming capacity in vitro. Cutaneous HPVs may be subdivided into the classic types associated with cutaneous viral warts (see Table 28-2).
TABLE 28-2 Clinical Groupings of HPVs and Associated Diseases
| Clinical Grouping | Anatomic Locations | Major HPV Types |
|---|---|---|
| Cutaneous lesions in healthy host | Verrucae (common warts) on nongenital tissue | 1, 2, 4, 26, 27, 29 |
| Plantar warts on nongenital skin | 1, 2, 4, 63 | |
| Cutaneotropic lesions in an immunodeficient host | Epidermodysplasia verruciformis | 3, 10, 27, 38 |
| Skin cancers in transplant recipients | 48, 60 | |
| Mucosotropic lesions | Anogenital warts (condylomata acuminata) | 6, 11 |
| Dysplasias and cancer | 16, 18, 31, 33, 35 |
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