105: HIV & Things That Make You Itch and Burn

Hello and welcome to Season 2, Episode 105 of the Physician Assistant Exam Review Podcast. This week, we’re going to be continuing our discussion of infectious disease, specifically viral diseases. Amazingly, this is the third time I’m recording this intro because I can’t seem to get it right. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. And I’ve been behind this microphone for 11 years, and I still can’t get this part right. I struggle every single time I record it.

Anyway, thank you so much for being here. Thank you so much for being a part of the show. If you find the show useful, if you find it enlightening, if you get something out of it, please share it with a classmate. Please share it with a friend. Please share it with a professor who can share it with other people. If you get something out of it, you can definitely pass it along and help those around you. It would help me, and it would help them.

This week, we’re going to be talking about viral infections. We’re going to continue with viruses for a little while. And, well, let’s just go ahead and get started.

Let’s start with our priming questions. List four diseases that will show a Tzanck cell. List four diseases that will show a Tzanck cell. How often is a pap smear recommended for screening of cervical cancer? How often is a pap smear recommended for the screening of cervical cancer? A dew drop on a rose petal is the description of the lesion associated with what infection? A dew drop on a rose petal is the description of the lesion associated with what infection?

And lastly, what CD4 count defines AIDS? What CD4 count defines AIDS?

All right, well, continuing with our herpes viruses, human herpes number three is varicella zoster and initially causes the chickenpox. This is one we all, well, maybe you guys aren’t as familiar with it as I am having, maybe with the vaccination, never having gotten the experience of the chickenpox. So the primary infection is the chickenpox. Incubation period is 10 to 21 days. The person is infectious from a few days before the rash appears until the lesions are completely dry. This is transmitted through droplet or direct contact with the lesions. And then herpes zoster, the shingles version, is a recurrent disease with about a 15% reactivation.

We’ll get to that in a minute. Clinical presentation: fever, loss of appetite, headache, general malaise, and then the rash is really going to be the mainstay here. This is a papule that turns into a vesicle that turns into a pustule that then crusts over. The description you will see in the textbooks is a dew drop on a rose petal. Because of the way that vesicle sits on there, it kind of looks like a dew drop on a rose petal, an irregular papule with a clear vesicle on top.

Now, as I always say, this is a key term, right? Dew drop on a rose petal. It’s something you should know. It is not something you are going to see on your exam. What you’re going to see on your exam is a description of a rash with an irregular papule with a clear vesicle on top. It won’t say dew drop on a rose petal. That’s just there to help remind you of the description, help you build a picture in your mind of what this thing looks like.

Rather than just holding on to words, that helps you build a picture. You will not see those words on your test. They will not appear there, but it’s important to know them.

All right, I hope that’s clear. These form in crops of lesions, meaning that you get a bunch of them, and then they move through that transition from papule to vesicle to pustule to crust as a group. And then another group will come in, another group, and another group, and it lasts about seven to 10 days. These are extremely pruritic, right? Everybody knows that. Chickenpox is extremely itchy. I had the particular pleasure of having a broken wrist at the time I got the chickenpox.

So, I was in a cast when I was seven, maybe eight years old, up above my elbow, and then it was cut down. So, it was just on my, or just below my elbow, just distal to my elbow. And I remember when they cut this thing off, my cast that is, inside of my cast were paperclips and pen caps and all sorts of things that I had been using to scratch at the the rash underneath my cast. So I hope that helps you to remember, especially if you haven’t ever had the lovely experience of the chickenpox. Physical exam findings is just going to be that rash, perhaps a fever. Primarily, this is going to be a clinical diagnosis with the presence of a typical characteristic rash, possibly oral sores, and the prodromal symptoms. You can do a Tzanck smear if you really want to try to prove this, which is the scraping of the ulcer, the base of the ulcer to look for Tzanck cells.

These are large multinucleated cells that are, I don’t want to say obvious, but are different and will show up a lot of times in a viral infection like this. So Tzanck cells can be found in a bunch of different places. So they’re not pathognomonic, but they will usually indicate a virus and often a herpes type virus. So you can find them in a herpes simplex. We talked about that last show, varicella zoster. You can also find them in cytomegalovirus and pemphigus vulgaris, so a couple other places. So just to be aware that that list exists.

It is not pathognomonic, but it is helpful. You can get a direct fluorescent antibody test, and you can do a blood test to identify a response to acute infection, IgM, or a previous infection and subsequent immunity, IgG. Again, that’s probably further than most people are going to go because generally the treatment isn’t real complicated. The treatment is going to be mostly, I was going to say palliative. That’s not the word I’m looking for. Mostly supportive. Supportive is a better term for this.

You can use things like acetaminophen for the fevers, calamine lotion for the itching, oral antihistamines for the itching. Definitely maintain hydration. Regular bathing. If you have kids, keeping their nails short and clean is helpful to keep them from scratching too much or getting an infection in there. Cool, loose, fitting clothing is helpful, obviously.

Now, one issue with chickenpox is that it can become more complicated. It can get worse for some people. So you can wind up with a pneumonia, a very severe skin infection, and even CNS involvement. So you’ve got to be a little cautious with this. And it seems to be as people get older with their first infection, they have worse symptoms, more complications. So you can use oral antivirals to help with that. Obviously, you should be aware there’s all there’s a chickenpox vaccine.

And in cases of people who are at risk for complications of the chickenpox, there is an immunoglobulin, VZIG, that people can get if they’ve been exposed and they are in a position where they could be at high risk for complications. Things like being pregnant or a newborn or someone who’s severely immunocompromised, those sorts of things.

All right. Shingles is next. So, this is also human herpes virus three. This is the recurrent disease, right? So, we get a burning itching sensation along one dermatome. That’s the important thing here. This time, the rash is along one dermatome and it’s a burning itching because it’s like a nerve pain, right?

The What’s happened is that virus was never cleared. It was never completely cleared. It hangs out inside of the nerve. And it pretty much stays there. It’s under wraps. It’s doing okay until, for some reason, your immune system loses a little bit, loses some ground. And then that virus attacks out from that nerve.

And that’s where you get that burning, itching, and rash is from that virus winning for a little bit. And there can be lots of reasons for this. We tend to see it in older patients, people over 50, whose immune systems are not quite as strong as they should be. And for one or another reason, I actually had a good buddy, right when I got out of college, it was a guy I went to college with, we were working together, and he got a horrible case of shingles. So it can happen to younger people. I mean, I think we were, I don’t know, I want to say 23, 24, something like that. But what happens is it’s when your immune system takes a hit that you have trouble with something like the shingles.

So there can be lots of reasons for that. You can be immunocompromised for a bunch of different reasons. One, it can simply be stress though, right? And that tends to be one for a lot of people. So, you get this burning and itching sensation along one dermatome. Then several days later, you get a rash that appears along that same dermatome. So, it’s one-sided.

It’s usually I want to say it’s usually along the back, wrapping around to the front. These are red fluid filled blisters. You get hyperesthesias meaning that you have pain with the lightest touch. So, even sleeping with a sheet on over your body can feel extremely painful. You can get paresthesias, fevers, chills, and headaches along with this, but those are kind of secondary characteristics that round out the picture. It’s really that burning, itching, nerve pain, and then the rash that are the real cues to this. The diagnosis here is generally a clinical diagnosis.

You can do a direct fluorescent antibody staining of the varicella zoster virus. You can do PCR or a Tzanck smear. Treatment, shingles is vaccination is recommended for people over 50. So we’re going to do prevention first. Medications, you can do antivirals like acyclovir, valacyclovir, famciclovir. These will reduce pain and speed up recovery. Anti-inflammatories will help.

Narcotic medications may be necessary for as an analgesic. Antihistamines can help. Numbing gels or patches help reduce pain, like lidocaine. Zostrix cream can help reduce the post herpetic neuralgia. Calamine lotion might help. Cold wet compresses to the rash may help. So really you’re just dealing with that pain and trying to fight that off.

All right. Then we move into HPV, human papillomavirus. This is the most common sexually transmitted infection. The most common sexually transmitted infection. Transmission is through direct contact, most commonly sexual contact.

Now, this is something that I want you to round out the picture on and understand. There are two general classifications of HPV. You have a low-risk type and a high-risk type. The low-risk type tends to cause warts and generally does not lead to cancer. The high-risk type may lead to cancer, or some may lead to abnormal cell changes, and then eventually to cancer. So things like, excuse me, genital warts is usually referred to as HPV6 and 11. As opposed to the HPV that we find in most cervical cancers, like 90% of cervical cancers, the patients will have HPV 16, 18, 31, or 45, or a combination of those.

16 and 18, HPV 16 and 18, make up the majority of that, with over 70% of cervical cancer cases having HPV 16 or 18. So I want you to understand that there are basically two different categories, two classification, not really classifications, two categories for low risk and high risk, and it’s just a little bit different how they affect the body. So when I talk about clinical presentation, it depends on what we’re talking about, right? It depends on if we’re talking about the high-risk version or the low-risk version. The high-risk version, I’m sorry, the low-risk version causes common warts, plantar warts, genital warts. Like I said, generally, a lot of times we think of HPV6 and 11. These are flat cauliflower-like lesions.

In women, they’re most commonly found on the vulva, but maybe near the anus, in the vagina, or on the cervix. In men on the penis, scrotum, or near the anus. The clinical presentation for the changes associated with cervical cancer, you’re not going to see, right? And you’re not really going to have symptoms associated with it, especially not early on. So that’s what we’re going to do, or that’s why we do screening tests. That’s why we do a pap smear, which is a cervical swab and microscopic examination of the cells looking for abnormalities which may represent cancerous or precancerous cells on the cervix or of the cervix. This is recommended every three to five years for female patients ages 21 and above.

We’re looking for those changes in the cells caused, we believe, by HPV that then lead to cervical cancer. You can do a nucleic acid amplification test to check for high-risk types of HPV that can be linked to genital cancers. And we can see on physical exam, if it’s the low-risk type, we can see visible warts. You can do a vinegar solution test, which is a vinegar solution that’s applied, and it turns HPV-infected genital areas white, which helps in identifying difficult-to-see flat lesions. Treatment. There is an HPV vaccination. It’s currently recommended for children, both males and females, before they become sexually active.

If we’re talking about warts, we can use salicylic acid. We can freeze with liquid nitrogen, electrocautery, so kind of burn them off, laser surgery, or just a scalpel and cut them off. If we’re talking about cervical cancer, that’s a whole other situation that really we don’t need to know for the PANCE, but generally speaking, it’s going to be a surgical removal either of a portion of the cervix, which is like a cone biopsy, all the way up to radical hysterectomy with lymph node dissection, followed by chemotherapy and radiation.

Next, we have HIV and AIDS. This section is a little bit longer, but I want you to understand that you probably have the basics here, and it’s probably enough, at least as far as I’m concerned, for the PANCE. I’m going to go into a little bit more detail than I probably need to, but it’s it’s largely just to paint the picture for you, not because I think you need to hold on to all of this. So, first of all, as you know, HIV is a retrovirus requiring reverse transcript transcriptase. HIV primarily, primarily affects CD4 lymphocytes, causing the destruction of these immune cells. It’s transmitted through direct contact with body fluids, including blood, semen, rectal fluids, vaginal fluids, and breast milk. Staging of HIV and AIDS is, I found a couple different classifications here.

Some have three stages, some have four. You’ll get to just as we go, whether you combine them all and combine them into three or leave it as four. It’s more important to me that you get the overarching theme. Stage one is the acute infection. During this time, one, you may not be able to identify. You may not come up positive in a short little window at the beginning during the acute infection, but very quickly we get high levels of HIV virus, and then you can find HIV antibodies in the blood. People may have flu or mono-like symptoms, but generally speaking, these go kind of unnoticed.

Not unnoticed, but you don’t really look further into them. Stage 2 is clinical latency, where we can get some minor symptoms. We get some unexplained weight loss, recurrent respiratory tract infections like sinusitis, otitis media, pharyngitis. You can get shingles. Again, we were talking about that before. Recurrent oral ulcerations, seborrheic dermatitis, fungal nail infections, just kind of these little… I want to call them opportunistic infections, but they’re not quite there yet.

You’ll see as we go on why some of these others are more opportunistic. These are sort of things you could get, but usually you don’t. But as your immune system wanes just a touch, some of these things start to come out. Stage three can sometimes be referred to as HIV disease or AIDS-related complex, ARC. Here we can get some moderate symptoms. So unexplained severe weight loss, over 10% of the measured body weight. Unexplained chronic diarrhea for longer than a month.

Unexplained persistent intermittent fevers. And then we can get things like persistent oral candida, oral hairy leukoplakia, pulmonary tuberculosis acting up, more severe bacterial infections like pneumonia, pyomyositis, bone infections, meningitis, gingivitis, periodontitis. You can also get an unexplained anemia or a chronic thrombocytopenia. Stage four is full-blown AIDS. You can get HIV wasting syndrome. And then, so here’s where we talk about AIDS is defined as a CD4 count below 200 or development of, or I don’t want to say development of, one of the opportunistic infections that you really only see in an AIDS patient. So things like Kaposi’s sarcoma, histoplasmosis, Pneumocystis jirovecii pneumonia, toxoplasmosis, significant cytomegalovirus infection, cryptococcus infection, those kind of things.

You can also wind up with more severe… you get an esophageal candidiasis which is more severe than the persistent oral candidiasis, extra pulmonary tuberculosis, HIV encephalopathy, disseminating mycosis, recurrent septicemia, lymphoma, and the list goes on. So like I said, there’s a big long list here. I’m not sure that you need to memorize all of these things, but I need you to have a good picture and pick out a handful that you do recognize as indicative of fulminant AIDS. As the CD4 count drops and the viral load increases, opportunistic infections and malignancies become increasingly frequent. That’s really the hallmark here. So again, if I just were to list out a clinical presentation, it’s hard because of the different stages.

But things you could use are things like persistent lymphadenopathy, fever, night sweats, weight loss, nausea, vomiting, diarrhea, sore throat, and again, any of these opportunistic infections. Lab studies and physical exam findings. So there are fourth-generation antigen-antibody combination immunoassays available. And initially, these are recommended. There are point-of-care ones and then lab ones. The lab ones are going to be more accurate. But it seems to me that you’re still going to want to prove it with an ELISA, which is an enzyme-linked immunosorbent assay.

These are used as a first stage, but they can have false positives. So then we follow up with a Western blot, which is more expensive and prohibitively expensive for the initial test. But it can confirm the diagnosis in anybody with a positive ELISA. Then we’re going to do, once we have a positive test, you’re going to monitor the CD4 count and monitor the viral load with nucleic acid amplification assays. And you’re going to treat people based on their CD4 count and their viral load. Treatment. We’re going to start with prevention.

So, if this is spread through contact with body fluids, we’re going to do everything we can to avoid contact with body fluids from other people who we think may be at risk for an infection. So, barrier protection for sexual intercourse is a good idea. Screening of all blood products. So, for so all… I’m trying to rephrase that, I can’t think of a good way to do it. So, all blood products that you’re going to give patients need to be screened for HIV, and avoid used needles. That should be a good plan for everyone.

Post-exposure prophylaxis with antiretrovirals begin within 72 hours and continue for at least four weeks. Needle stick injuries from known HIV positive patient has a 0.3% chance of causing disease. That in particular, I believe that that information comes from a needle you would use to suture, one that does not have a hollow bore to it, the one that is completely sealed. So it’s like a suturing needle, so you don’t get blood that sits inside the needle. How are we going to treat? Once we have an HIV infection, we’re going to use antiretroviral therapy, ART or ART. I don’t think you’re going to need to know the details here, but there are a few classifications that fall under this category.

Nucleic reverse transcriptase inhibitors. I’m going to butcher a bunch of names now. Zidovudine and lamivudine. So, AZT and 3TC fall into that category. Non-nucleoside reverse transcriptase inhibitors, Sustiva and Viramune, protease inhibitors, integrase inhibitors, and entry inhibitors are all classifications we can use. And again, I’m not sure how much detail you’re going to need as far as actually treating an HIV or an AIDS patient. And you should be aware of some of these names and have an idea of the presentation and the course.

But I’d be shocked if you need to know the specifics of a treatment. Let me know if you come across that, someone who takes the PANCE and they find that they do because I can certainly update it. But in the notes, like I said at the beginning, if you head over to the website, physicianassistantexamreview.com, you can find, I have these all listed out in the notes. I’m not going to go through them here so you don’t have to listen to me destroy the names of these medications. Then you’re going to aggressively treat opportunistic infections because you’re going to know that these people are going to be at risk for them, so that’s going to be the plan.

All right, that wraps up our viruses for this week. We’re going to continue next episode with viruses. We’re not quite done there, but before we move on today, we’re going to hit our study tip, but for today, it’s actually going to be a little bit different. It won’t be a study tip. It will be a rotation tip. One of the things that I think should be obvious but isn’t quite so obvious as you go through your rotations is that everyone asks the same questions. Every setting you’re in is similar.

So what do I mean by that? I mean, when you show up somewhere, you’re going to be in a conversation with someone, whether it’s in surgery, whether it’s in the clinic, whether it’s in an office, whether it’s in a hospital. Your preceptors, your attendings will tend to ask the same questions over and over because it’s sort of like talking about the weather. It’s a way to break the ice. It’s a way to communicate. So yes, will they be asking you about patients? Absolutely.

But they will also ask you some very obvious questions time and again. Things like, what’s your favorite rotation? What have you done so far? What are you excited to see? What specialty are you thinking of going into? I would guess during your rotations, you’ll be asked those questions, I don’t know, 50, 100 times. It makes sense to have answers to those planned out ahead of time.

It makes you a much more interesting student if you can create a conversation from those questions, because that’s really what the person asking them is trying to do. They’re trying to start a conversation with you. In my case, I’m in the operating room, so I’m starting to start a conversation because we’re in there for six, seven hours. We need something to do. So we need to have conversation to keep ourselves sane. So if you answer with one or two words, we don’t go anywhere. It’s kind of boring.

Not to mention, we’re trying to create a rapport. And as I begin to trust my students, I let them do more and more, right? We gain trust through that conversation, through watching you work. So if someone asks you questions, have a story. Have something to talk about. Don’t just say, I don’t know. Say, you know, I’ve only had these three rotations so far.

I think GYN has been my favorite. This is why. You know, I like procedures. I like going in the OR. Obviously, you don’t disparage other rotations. But you want to have something to talk about. You want to have something to say.

And the same goes for asking questions. One of the great ways for you to create rapport with your preceptors, with your attendings, with your residents is to ask them about what they do. That’s why you’re there in the first place and everybody loves to talk about their work and what they’re doing. So please ask questions of your surgeons. How many of these do you usually do in a week? What’s the recovery period for this? How soon do they see you back?

When do the stitches come out? When do they start walking on this? Do they need physical therapy for this? Will they be in the hospital tonight, a week? All of those things are such easy, low hanging fruit for you to be able to ask, for you to participate in the surgery, and help you to build that rapport. Same thing happens in the clinic. I can’t come up with them as quickly off the top of my head because that’s not where I work.

But you have those repetitive things that happen. How often do you see this diagnosis? How do you treat it in someone who’s older versus someone who’s younger? I see that you ordered these labs. What are you looking for? If you ask good questions, most people will give you the time and answer them and have that discussion with you. So our tip for today is have stories, have questions.

Make yourself an interesting student that people want to teach, that people want to trust. And you’ll find that rotations go a whole lot better.

All right, let’s answer our priming questions. Oops. There we go. List four diseases that will show a Tzanck cell. So I want Tzanck cells to be pathognomonic, but they’re not. We talked about them in the last episode where you could scrape a herpes simplex lesion and look under a microscope, stain the cells, and you could see Tzanck cells, these large multinucleated cells with a particular characteristic. You could also see them with the varicella.

Infection, but you can also see them with cytomegalovirus or pemphigus vulgaris. So they’re not pathognomonic, but they do help push you in a direction. How often is a pap smear recommended for screening of cervical cancer? Every three to five years in patients over 21. A dew drop on a rose petal is the description of the lesion associated with what infection? Varicella zoster, chickenpox. What CD4 count defines AIDS?

Less than 200. All right. Well, thank you so much for tuning in again. Thank you so much for being part of the community. Again, if you got something out of the show, if you found it valuable, please share it with your classmates, share with your friends, share it with your professors, and let them know that they could also, too, maybe get something valuable out of this. And in addition to that, head over to physicianassistantexamreview.com. And you can get all of the notes, show notes and sign up for the email list there where you will get all the tips and tricks and philosophies I send out on a daily basis to help you through PA school.

All right, take care and I’ll see you soon. I think I’ll see you in the new year, right?

All right, take care.