scabies, lice and hpv michael e. hagensee, m.d. ph.d. associate professor department of medicine...
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SCABIES, LICE AND HPVSCABIES, LICE AND HPV
Michael E. Hagensee, M.D. Ph.D.Associate ProfessorDepartment of MedicineSection of Infectious DiseaseLSUHSC
DISCLOSUREDISCLOSURE I have no financial interests or other I have no financial interests or other
relationship with manufacturers of relationship with manufacturers of commercial products, suppliers of commercial products, suppliers of commercial services, or commercial commercial services, or commercial supporters. My presentation will not supporters. My presentation will not include any discussion of the include any discussion of the unlabeled use of a product or a unlabeled use of a product or a product under investigational use.product under investigational use.
STDs AND OTHER STDs AND OTHER GYNECOLOGIC INFECTIONSGYNECOLOGIC INFECTIONS
Objectives:
1. To be able to diagnose and treat scabies
2. To be able to diagnose and treat pubic lice
3. To know about the disease that HPV cause and how to treat/prevent them
SCABIESSCABIES
SCABIESSCABIES
SCABIESSCABIES
A. Etiology: Sarcoptes scabiei-human itch mite B. Epidemiology:
1. More than 100 million cases per year2. Itching due to excretions from burrowing mites3. Increase spread by close contact, crowding4. Medical practitioners are at high risk
C. Clinical manifestations:
1. Itching increases at night and after a hot shower2. Burrows-dark wavy lines ending in small bleb3. Usual sites wrists, fingers, elbows and on penis4. Usually 15 mites per person
SCABIESSCABIES
SCABIESSCABIES
SCABIESSCABIES
5. Norwegian scabies: (crusted)
- thousands to millions of mites per person- seen only in immunosuppressed (HIV) individuals- erythema, thick keratotic crusts and dystrophic nails
D. Diagnosis: Find mite of eggs in scraping vs empiric E. Treatment:
1. 5% permethrin cream2. 1% lindane (not in pregnant women) 3. Anti-pruritics as needed
LICELICE
LICELICE
A. Etiology:
1. Pediculus humanus var. capitis - head lice2. P. humanus var. corporis - clothing3. Pthirus pubic - pubic hair
B. Epidemiology:
1. Lice feed on human blood once a day2. Saliva of lice produce an irritating rash3. Transmitted by close contact, shared combs, clothing
LICELICE
LICELICE
C. Clinical manifestations:
1. Intensely pruritic lesions2. 2-3 mm blue macules (maculae cerulae) at bite sites
D. Diagnosis: Find nits or adult lice in hair or clothing E. Treatment:
1. 1% permethrin2. 0.5% malathion3. 1% lindane - more toxic and must apply a second dose 1 week later
- does not kill nits- not in pregnant women
4. Comb out nits after treatment
HUMAN PAPILLOMAVIRUS (HPV)(HPV)
• Papovavirus
• Most common viral STD
• ds DNA virus of 7.9 kB
• Entire DNA sequence is
known
HPV TYPESHPV TYPES
• 1,2 - plantar and
common warts
• 6,11 - condylomata and
laryngeal warts
• 16,18, and others -
anogenital malignancies
Defined by 10% difference in DNA sequence (L1 gene)Defined by 10% difference in DNA sequence (L1 gene)
METHODS TO DETECT HPV INFECTION
Clinical diagnosis: Genital wartsEpithelial defects
See cellular changes caused by the virus: Pap smear screening
Directly detect the virus: DNA hybridization or PCR*
Detect previous infection: (Research Only) Detection of antibody against HPV*
* Done in the Hagensee Laboratory
GENITAL WARTSGENITAL WARTS
GENITAL WARTSGENITAL WARTS
HPV EPIDEMIOLOGYHPV EPIDEMIOLOGYGENITAL WARTSGENITAL WARTS
• Usually caused by HPV 6 or 11
• Prevalence has increased 2-10x over past 30 years
• Most often found on penile shaft and anus in men,
vulva in women
• Spontaneous regression seen in 20% of cases
GENITAL WARTSGENITAL WARTS
GENITAL WARTSGENITAL WARTS
GENITAL HPV INFECTIONGENITAL HPV INFECTIONDIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
• CONDYLOMA LATUM-SYPHILIS
• MOLLUSCUM CONTAGIOSUM
• FIBROEPITHELIOMA AND OTHER CANCERS
• LICHEN PLANUS
• OTHER-HSV, LGV, CHANCROID,
GRANULOMA INGUINALE
GENITAL HPV INFECTIONGENITAL HPV INFECTIONTREATMENTTREATMENT
• OBSERVATION -20% spontaneous regression
• CRYOTHERAPY -70% cure rate
• PODOPHYLLIN/ TCA -30% cure rate
• SURGERY -laser-85% cure rate
• INTERFERON ALPHA -intralesional and systemic
• IMIQUIMOD -induces local interferon alpha production
• CIMETIDINE (Tagamet) – non-specific immune booster
HPV EPIDEMIOLOGYHPV EPIDEMIOLOGYANOGENITAL MALIGNANCYANOGENITAL MALIGNANCY
• Caused by high risk HPVs-16, 18, 31 and others
• Occurs mainly in older women-average age 54 years
• Associated with increased number of sexual partners,
smoking, and immune suppression
HPV IS ASSOCIATED WITHHPV IS ASSOCIATED WITH ANOGENITAL MALIGNANCIESANOGENITAL MALIGNANCIES
• HPV DNA is found in 50-98% of tumors depending
on location
• Oncogenic genes (E6 and E7) of high-risk types are
expressed in tumors
• E6 and E7 of high-risk types are oncogenic in-vitro
• Support from many epidemiologic studies
CERVICAL CANCERCERVICAL CANCER
CIN II
CERVICAL CANCER
2nd most common malignancy of women worldwide
More than 500,000 cases per year
# of cases declining in USA
Over 13,000cases in US in 1998
Over 35% mortality
15.9
9.4
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1990-1994
1997-2000
Year
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er 1
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CERVIX - ANATOMY
CERVIX - ANATOMY
CERVIX - ANATOMY
COLLECTION OF A PAP SMEAR
CONVENTIONAL
NOW MOST CLINICS HAVE MOVED TO LIQUID-PAP SMEARS(Thin Prep, SurePath)
- preserve the morphology of the cells better
HPV DIAGNOSIS – PAP SMEARHPV DIAGNOSIS – PAP SMEARNormal, ASCUS – Atypical Squamous Cells of Unclear Significance
HPV PAP SMEARSHPV PAP SMEARSPap smear: Normal ASCUS – atypical cells of unclear significance:
repeat Pap vs test for HPV DNA LGSIL – low grade squamous intra-epithelial lesion:
colposcopy with biopsy HGSIL – high grade squamous intra-epithelial lesion:
colposcopy with biopsy and treat
Cervical biopsy: CIN I – mild dysplasia – usually spontaneously regresses CIN II – moderate dysplasia - treat CIN III – severe dysplasia – treat Carcinoma – in-situ – treat Invasive cervical cancer – treat
CERVICAL CANCER CERVICAL CANCER SCREENING METHODSSCREENING METHODS
HPV DNA Testing for questionable cases:
• Normal PAP smear - usual follow up
• ASCUS - may be cost-effective
• LGSIL - most regress
• HGSIL - refer for colposcopy and biopsy
CERVICAL CANCER CERVICAL CANCER SCREENING METHODSSCREENING METHODS
REFLEX TESTING USING HYBRID CAPTURE II
Collect a cervical swab for DNA testing from all women
and store them
Only those women with ASCUS (or LGSIL) – the swab is
sent for HPV DNA testing
HCII – positive for high-risk HPV – then refer to colposcopy
negative for high-risk HPV – then routine yearly screening
SCREENING METHODSSCREENING METHODS
CERVICAL CANCER CERVICAL CANCER SCREENING METHODSSCREENING METHODS
HIGH-RISK HPV INFECTIONHIGH-RISK HPV INFECTIONTREATMENTTREATMENT
• OBSERVATION
• CRYOTHERAPY-LASER
• CONE BIOPSY-SURGERY
• RETINOIDS??
PROPHYLACTIC VACCINES AGAINST HPV
Utilizing in-vitro capsid production: (VLPs – Virus-Like Particles)
Co-discovered by: Zhou et al, Virology 185:251, 1991 Kirnbauer et al, PNAS 89:12180, 1992
Hagensee et al, J. Virology 67:315, 1993
Particles made in the laboratory identical to in-vivo down to a resolution of 5 microns
No infectious potential
Can be made in vaccinia virus, baculovirus, yeast and bacterial expression systems
HPV VLPs
HPV capsids – EM and 3-D Reconstruction
PROPHYLACTIC VACCINES AGAINST HPV
COMPANYCOMPANY HPV TYPEHPV TYPE PHASEPHASE RESULTSRESULTS
MERCKMERCK 6,11,16,186,11,16,18 ApprovedApproved
GardasilGardasil
Serologic responseSerologic response
SafeSafe
MEDIMMUNEMEDIMMUNE
GSKGSK
16, 1816, 18 IIIIII Serologic responseSerologic response
SafeSafe
ACIP RecommendationsACIP Recommendations Routine vaccination with 3 doses of quadrivalent HPV vaccine for Routine vaccination with 3 doses of quadrivalent HPV vaccine for
females 11–12 years of age females 11–12 years of age – Can be started in females as young as 9 years of ageCan be started in females as young as 9 years of age
Catch-up vaccination for females 13Catch-up vaccination for females 13––26 years of age not previously 26 years of age not previously vaccinated or who have not completed the full vaccine seriesvaccinated or who have not completed the full vaccine series– Ideally, vaccine should be administered before potential exposure Ideally, vaccine should be administered before potential exposure
to HPV.to HPV. Each dose of quadrivalent HPV vaccine is 0.5 mL, administered Each dose of quadrivalent HPV vaccine is 0.5 mL, administered
intramuscularly.intramuscularly. Quadrivalent HPV vaccine is administered in a 3-dose schedule.Quadrivalent HPV vaccine is administered in a 3-dose schedule.
– The second and third doses should be administered 2 and 6 The second and third doses should be administered 2 and 6 months after the first dose.months after the first dose.
Quadrivalent HPV vaccine can be administered at the same visit Quadrivalent HPV vaccine can be administered at the same visit at which other age-appropriate vaccines are provided, such as Tdap, at which other age-appropriate vaccines are provided, such as Tdap, Td, and MCV4.*Td, and MCV4.*
Advisory Committee on Immunization Practices (ACIP). ACIP recommendations for the use of quadrivalent HPV vaccine. Available at: http://www.cdc.gov/nip/recs/provisional_recs/hpv.pdf. Accessed December 19, 2006.
*NOTE: Per the Prescribing Information, co-administration of GARDASIL with these vaccines has not been studied.
ACIP Recommendations ACIP Recommendations ((cont.cont.)) Current recommendations for cervical cancer screening have not Current recommendations for cervical cancer screening have not
changed for females who receive quadrivalent HPV vaccine.changed for females who receive quadrivalent HPV vaccine. Females who have an equivocal or abnormal Pap test, a positive Females who have an equivocal or abnormal Pap test, a positive
Hybrid Capture IIHybrid Capture II high-risk test, or genital warts can receive the high-risk test, or genital warts can receive the quadrivalent HPV vaccine.quadrivalent HPV vaccine.– Recipients should be advised that the vaccine will not have Recipients should be advised that the vaccine will not have
therapeutic effect on existing Pap test abnormalities, HPV therapeutic effect on existing Pap test abnormalities, HPV infection, or genital warts. Vaccination would provide protection infection, or genital warts. Vaccination would provide protection against infection with vaccine HPV types not already acquired.against infection with vaccine HPV types not already acquired.
Lactating women can receive quadrivalent HPV vaccine.Lactating women can receive quadrivalent HPV vaccine. Immunocompromised females can receive quadrivalent HPV vaccine.Immunocompromised females can receive quadrivalent HPV vaccine.
– However, the immune response to vaccination and vaccine However, the immune response to vaccination and vaccine effectiveness might be less than in females who are effectiveness might be less than in females who are immunocompetent.immunocompetent.
Quadrivalent HPV vaccine is contraindicated in people with a history of Quadrivalent HPV vaccine is contraindicated in people with a history of immediate hypersensitivity to yeast or to any vaccine component.immediate hypersensitivity to yeast or to any vaccine component.
ACIP. Recommendations for the use of quadrivalent HPV vaccine. Available at: http://www.cdc.gov/nip/recs/provisional_recs/hpv.pdf. Accessed December 19, 2006.
ACIP Recommendations ACIP Recommendations ((cont.cont.))
Quadrivalent HPV vaccine is not recommended Quadrivalent HPV vaccine is not recommended for use in pregnancy.for use in pregnancy.
Individuals should report any exposure to the Individuals should report any exposure to the vaccine during pregnancy to the vaccine vaccine during pregnancy to the vaccine pregnancy registry.pregnancy registry.
Quadrivalent HPV vaccine can be administered Quadrivalent HPV vaccine can be administered to females with minor acute illnesses.to females with minor acute illnesses.– Vaccination of people with moderate or severe acute Vaccination of people with moderate or severe acute
illnesses should be deferred until after the illness illnesses should be deferred until after the illness improves.improves.
ACIP. Recommendations for the use of quadrivalent HPV vaccine. Available at: http://www.cdc.gov/nip/recs/provisional_recs/hpv.pdf. Accessed December 19, 2006.