Cytomegalovirus Cutaneous Manifestations — MCQs
After 4 months of renal transplantation, a patient is likely to develop which infection?
A child presents with a fever and a rash. Urine examination showed cells with owl's eye appearance. What is the most likely diagnosis?
A 30 month old deaf boy whose development is slower than normal is being followed for congenital cytomegalovirus (CMV) infection in your clinic.The child's mother is pregnant again and is worried about her new baby. Which of the following is true?
After a renal transplant, what is the most common opportunistic infection?
An organism produces cutaneous disease (malignant pustule or eschar) at the site of inoculation in handlers of animal skins. Most likely organism is:
Congenital varicella infection causes all except:
Condyloma acuminatum is caused by which virus?
Which HPV type is most commonly implicated in genital warts?
Verrucosa vulgaris is caused by which virus?
A patient presents with vesicles over erythematous plaques in the T3 dermatome region of the trunk. Which of the following would be the most likely causative agent?
Cytomegalovirus Cutaneous Manifestations Indian Medical PG Practice Questions and MCQs
Question 1: After 4 months of renal transplantation, a patient is likely to develop which infection?
- A. EBV
- B. CMV (Correct Answer)
- C. Candida
- D. Histoplasma
Explanation: ***CMV*** - **Cytomegalovirus (CMV)** infection is very common in solid organ transplant recipients, particularly in the period between **1 to 6 months post-transplant**, known as the **intermediate period** [1]. - This timing is due to the cumulative effect of **immunosuppression** compromising the patient's ability to control latent viral shedding or newly acquired infection. *EBV* - **Epstein-Barr virus (EBV)** infection is also common in transplant recipients, but it is more significantly associated with the development of **post-transplant lymphoproliferative disorder (PTLD)**, rather than being the *most likely* general infection at 4 months [2], [3]. - While EBV can occur, CMV is typically more prevalent as a symptomatic viral infection in the intermediate post-transplant period [1]. *Candida* - **Candida** infections (fungal) are more common in the **early post-transplant period** (within the first month), often associated with surgical complications, indwelling catheters, or broad-spectrum antibiotic use [1]. - While possible, it is less likely to be the *most common* infection at 4 months compared to CMV. *Histoplasma* - **Histoplasma** infections are a **systemic fungal infection** that is typically seen in transplant patients who have been exposed to endemic areas. - It is not a common opportunistic infection universally seen in transplant recipients at 4 months post-transplant but rather depends on geographical exposure and specific risk factors.
Question 2: A child presents with a fever and a rash. Urine examination showed cells with owl's eye appearance. What is the most likely diagnosis?
- A. Herpes simplex virus infection
- B. Toxoplasmosis caused by Toxoplasma gondii
- C. Cytomegalovirus (CMV) infection (Correct Answer)
- D. Infectious mononucleosis caused by Epstein-Barr virus
Explanation: ***Cytomegalovirus (CMV) infection*** - The presence of cells with an **owl's eye appearance** in urine sediment is a classic histological hallmark of **CMV infection**. - CMV can cause a variety of symptoms in children, including **fever and rash**, making this the most likely diagnosis. *Herpes simplex virus infection* - HSV causes characteristic **vesicular lesions** on mucocutaneous surfaces, often associated with fever. - While HSV can cause systemic illness, it does not typically present with **owl's eye inclusions** in urine cells. *Toxoplasmosis caused by Toxoplasma gondii* - **Toxoplasmosis** can cause fever and rash, especially in congenital infections or immunocompromised individuals. - However, it does not lead to **owl's eye inclusions** in urinary cells, which are pathognomonic for CMV. *Infectious mononucleosis caused by Epstein-Barr virus* - **Infectious mononucleosis** commonly presents with fever, fatigue, and lymphadenopathy, sometimes with a rash. - **Epstein-Barr virus (EBV)** infection does not produce cells with an **owl's eye appearance** in the urine; that is specific to CMV.
Question 3: A 30 month old deaf boy whose development is slower than normal is being followed for congenital cytomegalovirus (CMV) infection in your clinic.The child's mother is pregnant again and is worried about her new baby. Which of the following is true?
- A. The new infant should be isolated from the older child
- B. The mother has antibodies to CMV that are passed to the fetus (Correct Answer)
- C. Termination of pregnancy is advised
- D. The mother's infection cannot become reactivated
Explanation: ***The mother has antibodies to CMV that are passed to the fetus*** - The mother has a history of CMV infection, meaning she has developed **antibodies** against the virus. These maternal **IgG antibodies** can cross the placenta and provide passive immunity to the fetus. - This passive immunity helps protect the unborn baby from initial infection or reduce the severity of disease if exposure occurs, although it doesn't guarantee complete protection. *The new infant should be isolated from the older child* - Isolation is generally not necessary in this scenario because CMV is widespread and transmission through casual contact is common; strict isolation would be impractical and not significantly reduce risk. - While CMV can be shed in urine and saliva, the risk of symptomatic infection in the new infant from an older sibling with congenital CMV, especially if the mother is seropositive, is relatively low. *Termination of pregnancy is advised* - Termination of pregnancy is a major medical decision and is not advised solely based on a previous CMV infection in an older child. - The risk of severe congenital CMV in a subsequent pregnancy when the mother is already seropositive is significantly lower compared to a primary maternal infection during pregnancy. *The mother's infection cannot become reactivated* - CMV is a **herpesvirus** that establishes **latency** after primary infection, meaning it can reactivate later in life. - While reactivation can occur, particularly in immunocompromised individuals, it typically poses a much lower risk to a developing fetus compared to a primary infection during pregnancy, especially if the mother has pre-existing antibodies.
Question 4: After a renal transplant, what is the most common opportunistic infection?
- A. Varicella Zoster Virus (VZV)
- B. Coxsackie Virus
- C. Epstein-Barr Virus (EBV)
- D. Cytomegalovirus (CMV) (Correct Answer)
Explanation: ***Cytomegalovirus (CMV)*** - **CMV** is the most common opportunistic infection after renal transplantation, particularly in the first 6 months due to immunosuppression [1]. - It can cause a range of clinical syndromes, including **fever**, **leukopenia**, **gastroenteritis**, **pneumonitis**, and **hepatitis**, and can also have indirect effects that increase the risk of graft rejection. *Varicella Zoster Virus (VZV)* - While VZV can cause opportunistic infections in transplant recipients (e.g., **shingles**), it is less common than CMV [1]. - VZV typically occurs later post-transplant and is characterized by a **vesicular rash** in a dermatomal distribution. *Coxsackie Virus* - **Coxsackie virus** infections are less frequently reported as significant opportunistic infections in renal transplant recipients compared to other viral pathogens. - They are generally associated with hand-foot-and-mouth disease, herpangina, or myocarditis, which are not the most common post-transplant complications. *Epstein-Barr Virus (EBV)* - **EBV** can cause post-transplant lymphoproliferative disorder (PTLD), which is a serious complication, but EBV infection itself is not the most common opportunistic infection overall [1]. - PTLD is more common in the first year after transplant and often presents with **lymphadenopathy**, **fever**, or **graft dysfunction**.
Question 5: An organism produces cutaneous disease (malignant pustule or eschar) at the site of inoculation in handlers of animal skins. Most likely organism is:
- A. Neisseria meningitidis
- B. Bacillus anthracis (Correct Answer)
- C. Pseudomonas aeruginosa
- D. Cryptococcus neoformans
Explanation: ***Bacillus anthracis*** - This description is classic for **cutaneous anthrax**, characterized by a **malignant pustule** or **eschar** that develops at the site of inoculation. - The context of handling **animal skins** (e.g., wool-sorter's disease) is a key epidemiological clue for _Bacillus anthracis_ infection. *Neisseria meningitidis* - Primarily causes **meningitis** and **meningococcemia**, involving a petechial or purpuric rash, not a single eschar or malignant pustule. - There is no direct association with handling animal skins. *Pseudomonas aeruginosa* - This bacterium is often associated with **opportunistic infections** in immunocompromised individuals, burn patients, or those with indwelling medical devices. - While it can cause skin lesions (e.g., **ecthyma gangrenosum**), these are distinct from the anthrax eschar and are not linked to animal skin exposure. *Cryptococcus neoformans* - A **fungus** that primarily causes **cryptococcal meningitis** or pulmonary infections, especially in immunocompromised individuals. - Skin manifestations, when they occur, are typically papules, nodules, or ulcers, not the classic **cutaneous anthrax eschar**.
Question 6: Congenital varicella infection causes all except:
- A. Macrocephaly (Correct Answer)
- B. Cortical atrophy
- C. Cicatrix
- D. Limb hypoplasia
Explanation: ***Macrocephaly*** - **Macrocephaly** is generally not a direct consequence of congenital varicella infection; rather, **microcephaly** due to brain damage is more commonly observed. - Congenital varicella typically causes destructive lesions leading to tissue loss, not increased head circumference. *Cortical atrophy* - **Cortical atrophy** results from the destructive effects of the virus on the developing brain, leading to **neuronal loss** and reduced brain volume. - This can manifest as **microcephaly**, an indirect but common finding associated with congenital varicella. *Cicatrix* - **Cicatrix** (zig-zag scarring) is a classic dermatological manifestation of congenital varicella, resulting from the virus's impact on developing skin. - These characteristic **skin lesions** are one of the most identifiable features of the syndrome. *Limb hypoplasia* - **Limb hypoplasia**, involving underdeveloped limbs, is a hallmark feature of congenital varicella, often due to **viral damage** to limb buds and associated neural structures. - This can lead to **bone shortening** and muscle atrophy in affected limbs.
Question 7: Condyloma acuminatum is caused by which virus?
- A. Herpes Simplex Virus (HSV)
- B. Human Papillomavirus (HPV) (Correct Answer)
- C. Human Immunodeficiency Virus (HIV)
- D. Varicella-Zoster Virus (VZV)
Explanation: **Explanation:** **Condyloma acuminatum**, commonly known as anogenital warts, is caused by the **Human Papillomavirus (HPV)**. It is a sexually transmitted infection characterized by soft, cauliflower-like growths on the skin and mucous membranes of the genital and perianal regions. The virus infects the basal keratinocytes, leading to epidermal hyperplasia. * **Why HPV is correct:** Specifically, **HPV types 6 and 11** are responsible for approximately 90% of cases. These are considered "low-risk" types because they have a low potential for malignant transformation, unlike "high-risk" types (16 and 18) which are linked to cervical and anal carcinomas. * **Why other options are incorrect:** * **HSV (A):** Causes Herpes Simplex (Type 1: orofacial; Type 2: genital), presenting as painful, grouped vesicles on an erythematous base, not warty growths. * **HIV (C):** While HIV is a sexually transmitted virus that can coexist with HPV, it does not directly cause condyloma. However, HIV-induced immunosuppression can lead to more extensive and recalcitrant HPV lesions. * **VZV (D):** Causes Chickenpox (primary infection) and Herpes Zoster/Shingles (reactivation), characterized by dermatomal vesicular rashes. **High-Yield Clinical Pearls for NEET-PG:** 1. **Histopathology:** Look for **Koilocytes** (keratinocytes with perinuclear halo and wrinkled "raisinoid" nuclei) in the upper epidermis. 2. **Diagnosis:** Usually clinical; application of 5% acetic acid (Acetowhitening) can help visualize subclinical lesions. 3. **Treatment:** Options include Podophyllotoxin, Imiquimod (immunomodulator), Cryotherapy, or Electrocautery. 4. **Note:** Do not confuse *Condyloma acuminatum* (HPV) with *Condyloma lata* (Secondary Syphilis).
Question 8: Which HPV type is most commonly implicated in genital warts?
- A. HPV-16
- B. HPV-18
- C. HPV-31
- D. HPV-6 (Correct Answer)
Explanation: **Explanation:** **Genital warts (Condyloma acuminatum)** are caused by the Human Papillomavirus (HPV). HPV types are broadly classified into "low-risk" and "high-risk" based on their oncogenic potential. * **Correct Answer (D): HPV-6** (along with HPV-11) is responsible for approximately 90% of all genital warts. These are considered **low-risk types** because they cause benign proliferative lesions rather than invasive squamous cell carcinoma. **Analysis of Incorrect Options:** * **A & B (HPV-16 & 18):** These are the most common **high-risk (oncogenic)** HPV types. They are strongly associated with cervical, anal, and vulvar cancers. While they can be found in genital lesions, they typically cause flat dysplastic changes (intraepithelial neoplasia) rather than the classic cauliflower-like warts. * **C (HPV-31):** This is another high-risk type associated with cervical cancer, though it is less prevalent than types 16 and 18. **High-Yield Clinical Pearls for NEET-PG:** 1. **HPV 6 & 11:** Most common cause of Condyloma acuminatum and Recurrent Respiratory Papillomatosis (RRP). 2. **HPV 16 & 18:** Most common cause of Cervical Carcinoma and Bowenoid papulosis. 3. **HPV 1, 2 & 4:** Associated with common warts (Verruca vulgaris) and plantar warts. 4. **HPV 3 & 10:** Associated with plane warts (Verruca plana). 5. **Histopathology:** The hallmark of HPV infection is the **Koilocyte** (a squamous cell with a perinuclear halo and wrinkled "raisin-like" nucleus). 6. **Treatment:** Podophyllin, Imiquimod (immunomodulator), or destructive methods like cryotherapy and CO2 laser.
Question 9: Verrucosa vulgaris is caused by which virus?
- A. Human Papillomavirus (HPV) (Correct Answer)
- B. Epstein-Barr Virus (EBV)
- C. Cytomegalovirus (CMV)
- D. Human Immunodeficiency Virus (HIV)
Explanation: **Explanation:** **Verruca vulgaris**, commonly known as the common wart, is caused by the **Human Papillomavirus (HPV)**. This is a double-stranded DNA virus that infects the basal layer of the epithelium. Specifically, Verruca vulgaris is most frequently associated with **HPV types 2 and 4** (though types 1, 3, 27, and 57 are also implicated). The virus induces localized proliferation of keratinocytes, leading to the characteristic hyperkeratotic papules with a "verrucous" or cauliflower-like surface. **Analysis of Incorrect Options:** * **Epstein-Barr Virus (EBV):** A herpesvirus associated with Infectious Mononucleosis, Nasopharyngeal carcinoma, and Oral Hairy Leukoplakia (often seen in HIV patients), but not common warts. * **Cytomegalovirus (CMV):** Primarily causes systemic infections in immunocompromised individuals or congenital infections (TORCH); it does not manifest as verrucous skin lesions. * **Human Immunodeficiency Virus (HIV):** While HIV causes immunosuppression that can lead to *extensive* or recalcitrant warts, the direct causative agent of the wart itself remains HPV. **High-Yield Clinical Pearls for NEET-PG:** * **Auspitz Sign vs. Punctate Bleeding:** When the hyperkeratotic surface of a wart is shaved, "black dots" are seen. These represent thrombosed dermal capillaries (a key diagnostic feature). * **Koebner Phenomenon:** Warts can exhibit this (linear spread of lesions along the site of trauma/scratching). * **Histopathology:** Look for **Koilocytes** (keratinocytes with pyknotic nuclei and perinuclear halos) in the upper epidermis, which are pathognomonic for HPV infection. * **Other HPV associations:** Verruca plana (Types 3, 10), Plantar warts (Type 1), and Condyloma acuminatum (Types 6, 11).
Question 10: A patient presents with vesicles over erythematous plaques in the T3 dermatome region of the trunk. Which of the following would be the most likely causative agent?
- A. Varicella zoster (Correct Answer)
- B. Herpes simplex
- C. Pox virus
- D. Papilloma virus
Explanation: **Explanation:** The clinical presentation of **vesicles on an erythematous base** (often described as "dewdrops on a rose petal") distributed along a specific **dermatome** (unilateral and localized) is the hallmark of **Herpes Zoster** (Shingles). 1. **Why Varicella Zoster is correct:** Herpes Zoster is caused by the reactivation of the **Varicella-Zoster Virus (VZV)**, which remains latent in the sensory dorsal root ganglia after a primary chickenpox infection. When immunity wanes, the virus travels down the sensory nerve, resulting in a painful, dermatomal eruption. The T3 dermatome (trunk) is a common site for involvement. 2. **Why other options are incorrect:** * **Herpes Simplex (HSV):** Typically causes grouped vesicles on an erythematous base but usually involves the oral (HSV-1) or genital (HSV-2) regions. It does not follow a dermatomal pattern. * **Poxvirus:** The most common cutaneous poxvirus is *Molluscum Contagiosum*, which presents as firm, pearly, umbilicated papules, not vesicles on a dermatomal distribution. * **Papilloma Virus (HPV):** Causes various types of warts (verrucae), which are hyperkeratotic papules or plaques, not fluid-filled vesicles. **High-Yield Clinical Pearls for NEET-PG:** * **Tzanck Smear:** A rapid diagnostic test showing **multinucleated giant cells** and acantholytic cells (seen in both VZV and HSV). * **Hutchinson’s Sign:** Vesicles on the tip of the nose indicating involvement of the nasociliary branch of the ophthalmic nerve; a precursor to ocular shingles. * **Post-Herpetic Neuralgia (PHN):** The most common complication, defined as pain persisting >90 days after the rash heals. * **Ramsay Hunt Syndrome:** Involvement of the geniculate ganglion (CN VII) leading to facial palsy and ear vesicles.
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