Submit your First line treatment plan based on one dx from your differential list to the Case Study

8

HUMAN PAPILLOMAVIRUS (HPV)

In the APEA predictor exam I scored lowest in Women’s Health, so the topic that I chose to do this case study on is the Human Papillomavirus HPV. HPV is a virus that spreads from person to person through skin-to-skin contact. HPV infects the epithelium with small, double-stranded DNA viruses. There are many types of HPV, and they are all different. The virus is a sexually transmitted disease. HPV is sometimes usually harmless with no symptoms and goes away on its own, but it can cause genital warts or can lead to cancer in some scenarios. The case below presents the Human Papillomavirus Virus (HPV in women).

Case presentation

Chief complaint CC

Patient AZ is 43 years old who presents to the clinic after not visiting the clinic for the last ten years. She has a chief complaint of a painless genital lesion and lower abdominal pain for the last two months. She presents to the clinic after she was referred to the clinic due to an abnormal pap result from a community screening center.

History of the patient

Patient AZ presents with mild to severe abdominal pains. She also complains of vaginal bleeding and pain.

Past Medical history

Patient AZ was 33 years old when she went for the last pap test. From the medical report, the pap test indicated a low-grade squamous intraepithelial lesion. The HPV test results indicate positive HPV I6. From the results, she was asked to go for further testing but failed to follow up.

Medications: Multivitamins medications for the past six months and blood pressure medications (Diuretics for one year).

Allergies: None

Family History: Mother has diabetes; she has a healthy sibling with no identified illness.

Social History: Patient AZ is married and lives with her husband. She has two children and one sibling. She reports the use of alcohol alongside her meals.

ROS

General: Has no weight loss and sometimes experiences chills and fever, fatigue, and body weakness.

Respiratory: No coughs, shortness of breath, reports having sore throats.

Cardiovascular: negative for chest pains and edema, positives for abdominal pains

GI/GU: mild to severe abdominal pains, changes in the bowel reaction, abnormal vaginal bleeding.

Skin: no skin rashes or itching. Skin is generally warm

Hematologic: Positive for abnormal vaginal bleeding.

Musculoskeletal: no reported back pains, joint pain, or swelling, positive for occasional neck pains.

Neurological: Negative for dizziness, headaches, tingling, and numbness.

Allergic: no reports on anaphylaxis and angioedema.

Physical examination

Temperature: 97.7°F (36.5°C), Blood pressure: 115/80 mm Hg, Heart rate: 68/min

General appearance: the patient is cooperative and attentive, she is unable to maintain a straight posture.

HEENT: Eyes, no blurred vision. Ears, no hearing loss or ear pains. Presence of sore throat, sinus tenderness, and right-side neck mass.

Respiratory: during breathing, there are no whizzing sounds and non-pursed lips breathing.

Cardiovascular: regular heartbeat, no extra heart sounds heard, no murmurs or rub.

Musculoskeletal: Limited movement to the right upper extremity. The Pedal and femoral pulses intact and asymmetrical.

Skin: Normal body temperatures and skin is generally warm.

Diagnostic results: X-ray indicates no broken bones or spine. Cutaneous warts below feet and on hands,

Associated Risk factors and demography

HPV is the most common sexually transmitted infection; the infection shows no significant signs and tends to go away independently, while some types of HPV cause serious medical health problems. In the United States, more than 75 million people have HPV, and doctors diagnose about 14 million cases every year. The risk factors of HPV include individuals whose immunity has been compromised, and related lifestyle factors, multiple sexual partners, and exposure to an individual with HPV, damaged skin, and direct skin to skin contact with someone with HPV (Arbyn, Rezhake, Yuill, and Canfell, 2020). There is no cure for HPV. Medications are though prescribed to reduce the effects of the virus. Though common among both genders, HPV is more prevalent in men compared to women. It is estimated that more than 50% are likely to be infected with one or more types of HPV in their adulthood.

Three common differential diagnoses represented by the CC, including pathophysiology and rationale

Bowens Disease

This is a skin disorder that is characterized by a red patch on the skin. The disease is pre-cancerous, and lesions develop on the upper part of the skin. It is considered a squamous cell carcinoma that affects middle-aged and older people exposed to the sun. The disease presents patches on the trunk, head, extremities, or genitalia. The disease may occur due to exposure to UV, arsenic exposure, and suppression of immunity. Patient AZ presents with lesions and is in her middle age.

Cervical Cancer

Cervical cancer the most common cervical cancer symptoms include abnormal vaginal bleeding, vaginal discomfort, and malodourous discharge (de Martel, Plummer, Vignat, and Franceschi, 2017). Patient AZ is presenting with mild to severe abdominal pains and abnormal vaginal bleeding and pain.

Herpes simplex virus

The virus has no symptoms, and most of the time, the symptoms lay dormant hence may be difficult to know whether they have herpes. There are two types of this virus HSV 1 and HSV 2. HSV one is more of an oral infection, and the symptoms occur in the mouth, lips, and throat. HSV 2 occurs around the genitals hence known as genital herpes. The virus causes itching, painful blisters, and flu-like symptoms. Patient AZ is showing symptoms of fever, and the other symptoms seem to be dormant.

Differentiation in the diseases: occurrence, pathophysiology, and presentation:

Herpes simplex virus is transmitted through contact with a lesion or body fluid of an infected person. The susceptible seronegative person gets exposed to someone who excretes HSV. In order to cause infection, the virus needs to come into contact with mucosal surfaces or abraded skin. HPV presents with direct skin-to-skin contact with an individual with HPV.HPV occurs in the epithelium and tends to go away on its own. For high-risk HPV, it leads to health problems such as cancer (Chipollini, Rosa, Azizi, Shayegan, Zorn, and Spiess, 2019). The majority of HPV infections are asymptomatic and causes no clinical symptoms. Anogenital warts, persistent respiratory papillomatosis, and the development of various cancers are all symptoms of HPV infection.

Occurrence

Infection with HPV is highly common all over the world. Most sexually active adults will contract HPV at some stage in their lives, even though they are totally unaware of it.

Herpes Simplex Virus an estimated 13% of the population has HSV 2 and is genital herpes that is sexually transmitted.

Cervical cancer occurrence is 13·1 per 100 000 women globally and varies widely among countries. The infection with high-risk human papillomaviruses (HPV), an extremely common virus transmitted via sexual contact, is related to a high percentage of all cervical cancer cases (99 percent). While most HPV infections go away on their own with no symptoms, a recurrent infection can lead to cervical cancer in women.

Relevant testing required diagnose/evaluate the severity of the three differential diagnoses:

For both cervical and HPV, a pap test is conducted to diagnose the disease. The test collects cells to check for any abnormalities. The test can be done using the pap test sample or can be collected from the cervix canal.

For Herpes Simplex virus can be tested through viral culture, a PCR test is used to establish HSV or through a blood test that analyzes a blood sample to determine the presence of HSV infection. The Bownes disease, a biopsy, is done on the infected tissue to determine its severity.

Review

Women can begin cervical cancer screening at the age of 25 and have primary human papillomavirus (HPV) testing every five years before they reach the age of 65, according to the American Cancer Society (ACS) (Schiffman and Wentzensen, 2021). Individuals aged 25 to 65 should be screened every five years with contesting (HPV testing combined with cytology) or every three years with cytology alone if primary HPV testing is not available.

References

Arbyn, M., Rezhake, R., Yuill, S., & Canfell, K. (2020). Triage of HPV-positive women in Norway using cytology, HPV16/18 genotyping, and HPV persistence.

Chipollini, J., De la Rosa, A. H., Azizi, M., Shayegan, B., Zorn, K. C., & Spiess, P. E. (2019). Patient presentation, differential diagnosis, and management of penile lesions. Canadian Urological Association Journal, 13(2 Suppl 1), S2.

de Martel, C., Plummer, M., Vignat, J., & Franceschi, S. (2017). Worldwide burden of cancer attributable to HPV by site, country, and HPV type. International journal of cancer, 141(4), 664-670.

Eggersmann, T. K., Sharaf, K., Baumeister, P., Thaler, C., Dannecker, C. J., Jeschke, U., … & Gallwas, J. K. S. (2019). Prevalence of oral HPV infection in cervical HPV-positive women and their sexual partners. Archives of gynecology and obstetrics, 299(6), 1659-1665.

Jin, J. (2018). HPV infection and cancer. Jama, 319(10), 1058-1058.

Schiffman, M., & Wentzensen, N. (2021). Cervical Screening Performance. American Journal of Clinical Pathology.

Wentzensen, N., Schiffman, M., Palmer, T., & Arbyn, M. (2016). Triage of HPV positive women in cervical cancer screening. Journal of Clinical Virology, 76, S49-S55.