Human Papillomavirus Infections — MCQs
Which quadivalent HPV vaccine protects against both cervical cancer and genital warts?
Which of the following statements about HPV vaccination is true?
Which statement is TRUE regarding the relationship between HPV vaccination and cervical cancer screening?
Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
Which of the following HPV types is MOST strongly associated with cervical cancer?
A 35-year-old professional businesswoman notices the appearance of several hyperkeratotic, well-demarcated growths on the palmar surface of her index finger and on her toe. They do not change in size and cause her only minimal discomfort. A biopsy of one of the lesions, viewed at 40x magnification, is shown. Which of the following viruses is the most likely etiologic agent?
Koebner's phenomenon is seen in all except
Genital warts are caused by which virus?
A cervical Pap smear report stating that "koilocytic atypia is present" indicates the presence of:
A 60-year-old patient presents with unilateral vesicular lesions in a dermatomal distribution on the torso. The lesions are painful and appeared over the past 2-3 days, progressing from erythematous patches to fluid-filled vesicles. The patient reports prodromal burning and tingling sensation in the affected area. Which of the following is the most likely diagnosis?
Human Papillomavirus Infections Indian Medical PG Practice Questions and MCQs
Question 1: Which quadivalent HPV vaccine protects against both cervical cancer and genital warts?
- A. Shingrix
- B. Gardasil 9
- C. Cervarix
- D. Gardasil (Correct Answer)
Explanation: ***Gardasil***- This **quadrivalent** vaccine protects against **HPV types 6, 11, 16, and 18**. [1]- **HPV 16 and 18** are responsible for most cases of **cervical cancer**, while **HPV 6 and 11** cause approximately 90% of **genital warts**. [1]- Gardasil was the first quadrivalent HPV vaccine approved and remains widely used globally.*Shingrix*- **Shingrix** is a recombinant zoster vaccine used to prevent **herpes zoster (shingles)** in adults.- It is **not an HPV vaccine** and does not provide protection against cervical cancer or genital warts.- It targets varicella-zoster virus, not human papillomavirus.*Gardasil 9*- **Gardasil 9** is a **nonavalent** vaccine, meaning it protects against nine HPV types (6, 11, 16, 18, 31, 33, 45, 52, and 58).- While it does cover the types responsible for cervical cancer and genital warts, it is **not a quadrivalent vaccine** as specified in the question.*Cervarix*- **Cervarix** is a **bivalent** HPV vaccine that protects against **HPV types 16 and 18** only. [1]- While it offers protection against the HPV types most commonly associated with **cervical cancer**, it does not protect against **genital warts** (caused by HPV 6 and 11).
Question 2: Which of the following statements about HPV vaccination is true?
- A. It is given to women aged 20-40 years.
- B. The primary dose consists of 2 doses.
- C. It has an efficacy greater than 70% for cervical cancer. (Correct Answer)
- D. There are two types available in the market.
Explanation: ***It has an efficacy greater than 70% for cervical cancer.*** - HPV vaccines are highly effective in preventing **HPV infections**, which are the primary cause of cervical cancer. Studies show they have an efficacy of **over 70%** (and often much higher for certain strains) in preventing cervical precancers and cancers. - The vaccine works by inducing an immune response to the **HPV L1 capsid protein**, which prevents the virus from infecting cells. *It is given to women aged 20-40 years.* - The primary target group for HPV vaccination is **adolescents**, typically aged 9-14 years, before potential exposure to the virus. - While catch-up vaccination may be recommended for young adults up to age 26, routine vaccination in women aged 20-40 years is **less common and less effective** due to likely prior exposure. *The primary dose consists of 2 doses.* - For individuals initiating vaccination before their 15th birthday, the primary dose schedule consists of **2 doses**. - For individuals 15 years and older, a **3-dose schedule** is typically recommended. *There are two types available in the market.* - Currently, there are **three types** of HPV vaccines available globally: bivalent (targeting HPV 16, 18), quadrivalent (targeting HPV 6, 11, 16, 18), and **nonavalent (targeting HPV 6, 11, 16, 18, 31, 33, 45, 52, 58)**. - The specific types available in a particular market may vary, but globally, there are more than two.
Question 3: Which statement is TRUE regarding the relationship between HPV vaccination and cervical cancer screening?
- A. Vaccinated women require less frequent screening than unvaccinated women
- B. Screening recommendations are currently the same regardless of vaccination status (Correct Answer)
- C. HPV vaccination eliminates the need for cervical cancer screening
- D. Screening should begin at a younger age in vaccinated women
Explanation: ***Screening recommendations are currently the same regardless of vaccination status*** * Current guidelines recommend the same cervical cancer screening schedule for all eligible individuals, **regardless of their HPV vaccination status**. * This is because the HPV vaccine does not protect against all oncogenic HPV types, and individuals may have been exposed to HPV prior to vaccination. *Vaccinated women require less frequent screening than unvaccinated women* * This statement is incorrect because there is **no evidence to support less frequent screening** for vaccinated women. * The persistence of **high-risk HPV types not covered by the vaccine** and the possibility of prior exposure necessitate consistent screening. *HPV vaccination eliminates the need for cervical cancer screening* * This is incorrect; HPV vaccination significantly reduces the risk of cervical cancer but **does not eliminate it completely**. * Vaccines protect against the most common high-risk HPV types but **not all of them**, making continued screening essential. *Screening should begin at a younger age in vaccinated women* * This is incorrect; current guidelines recommend the **same starting age for cervical cancer screening** (typically 21 or 25, depending on the guideline) for both vaccinated and unvaccinated women. * There is **no clinical rationale to initiate screening earlier** in vaccinated individuals.
Question 4: Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
- A. Statements 1 & 2 are correct, 2 is not explaining 1 (Correct Answer)
- B. Statements 1 and 2 are correct and 2 is the correct explanation for 1
- C. Statements 1 and 2 are incorrect
- D. Statement 1 is incorrect
Explanation: ***Correct: Statements 1 & 2 are correct, 2 is not explaining 1*** **Analysis of Statement 1:** - A 59-year-old patient with **flaccid bullae** and **suprabasal acantholytic split** on histopathology is the classic presentation of **Pemphigus vulgaris** - The flaccid (easily ruptured) nature of bullae distinguishes it from tense bullae seen in bullous pemphigoid - The suprabasal location of the split (just above the basal layer) with acantholysis (loss of cell-to-cell adhesion) is pathognomonic - **Statement 1 is CORRECT** ✓ **Analysis of Statement 2:** - The **"row of tombstones" or "tombstone appearance"** is indeed a diagnostic histopathological feature of Pemphigus vulgaris - This appearance results from basal keratinocytes remaining attached to the basement membrane while suprabasal cells separate due to acantholysis - The intact basal cells standing upright resemble a row of tombstones - **Statement 2 is CORRECT** ✓ **Does Statement 2 explain Statement 1?** - Statement 2 describes a **histopathological appearance** (tombstone pattern) that is a **consequence** of the suprabasal split - However, it does NOT explain the **underlying cause** of the flaccid bullae or the suprabasal split - The true explanation involves **IgG autoantibodies against desmoglein 3 (and desmoglein 1)**, which attack intercellular adhesion structures (desmosomes), causing **acantholysis** - Therefore, **Statement 2 does NOT explain Statement 1** ✗ *Incorrect: Statement 2 is the correct explanation for Statement 1* - While both statements describe features of Pemphigus vulgaris, the tombstone appearance is a descriptive finding, not an explanatory mechanism *Incorrect: Statements 1 and 2 are incorrect* - Both statements are medically accurate descriptions of Pemphigus vulgaris features *Incorrect: Statement 1 is incorrect* - Statement 1 correctly describes the cardinal clinical and histopathological features of Pemphigus vulgaris
Question 5: Which of the following HPV types is MOST strongly associated with cervical cancer?
- A. HPV 18
- B. HPV 6
- C. HPV 16 (Correct Answer)
- D. HPV 11
Explanation: ***HPV 16*** - **HPV 16** is the most prevalent **high-risk HPV type**, accounting for approximately 50-60% of all cervical cancer cases globally. - It's highly effective at integrating its DNA into host cells and producing **oncoproteins E6 and E7**, which promote cell proliferation and inhibit tumor suppressor genes [1]. *HPV 18* - While **HPV 18** is also a **high-risk type** and the second most common cause of cervical cancer (around 10-15%), it is less frequently associated than HPV 16 [1]. - HPV 18 is more commonly linked to **adenocarcinomas** of the cervix, whereas HPV 16 is more often associated with **squamous cell carcinomas**. *HPV 6* - **HPV 6** is considered a **low-risk HPV type**, primarily associated with benign conditions such as **genital warts (condyloma acuminata)** [1]. - It rarely causes cervical cancer and is not considered an oncogenic type. *HPV 11* - Similar to HPV 6, **HPV 11** is also a **low-risk HPV type** and is a common cause of **genital warts**. - It is not associated with an increased risk of cervical cancer. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 334-335.
Question 6: A 35-year-old professional businesswoman notices the appearance of several hyperkeratotic, well-demarcated growths on the palmar surface of her index finger and on her toe. They do not change in size and cause her only minimal discomfort. A biopsy of one of the lesions, viewed at 40x magnification, is shown. Which of the following viruses is the most likely etiologic agent?
- A. Adenovirus
- B. HPV (Correct Answer)
- C. Molluscum contagiosum virus
- D. Echovirus
Explanation: ***HPV*** - The clinical description of **hyperkeratotic**, **well-demarcated growths** on the palmar surface and toe is highly characteristic of **warts** (verrucae), which are caused by **Human Papillomavirus (HPV)**. - The biopsy likely shows **koilocytes** (HPV-infected keratinocytes with perinuclear vacuolization), which are pathognomonic for HPV infection in the skin. *Adenovirus* - Adenovirus typically causes **respiratory tract infections**, **conjunctivitis**, or **gastroenteritis**, and less commonly skin lesions. - Skin manifestations from adenovirus are usually non-specific rashes, not hyperkeratotic growths like those described. *Molluscum contagiosum virus* - **Molluscum contagiosum** is caused by the **Molluscum contagiosum virus (MCV)** and presents as **umbilicated papules**, differing morphologically from the described hyperkeratotic warts. - Histologically, molluscum contagiosum lesions are characterized by **Molluscum bodies** (large eosinophilic cytoplasmic inclusions), which are different from koilocytes. *Echovirus* - Echoviruses are enteroviruses primarily associated with a wide range of syndromes including **aseptic meningitis**, **exanthems (rashes)**, and **respiratory illnesses**. - They do not typically cause localized, hyperkeratotic skin growths like warts.
Question 7: Koebner's phenomenon is seen in all except
- A. Psoriasis
- B. Warts
- C. Tinea corporis (Correct Answer)
- D. Molluscum contagiosum
Explanation: ***Tinea corporis*** - **Koebner's phenomenon**, also known as the isomorphic response, is the appearance of skin lesions characteristic of a **pre-existing dermatosis** at sites of **trauma** to previously uninvolved skin. - **Tinea corporis**, a **superficial fungal infection**, does NOT exhibit true Koebner's phenomenon. - Its spread occurs through **direct fungal contact or autoinoculation**, not through an isomorphic response to non-specific trauma. *Psoriasis* - **Psoriasis** is the **classic example** of Koebner's phenomenon. - New psoriatic plaques can appear at sites of **skin trauma** such as scratches, surgical scars, burns, or tattoos within **10-20 days** of injury. - This occurs in approximately **25-50%** of psoriasis patients. *Warts* - **Warts** (verruca vulgaris), caused by **human papillomavirus (HPV)**, can show what is sometimes called **pseudo-Koebner's phenomenon**. - Trauma facilitates **viral inoculation** and seeding of HPV into the skin, leading to new wart formation along scratch lines. - However, this is technically **viral spread through trauma**, not a true isomorphic response of a pre-existing dermatosis. *Molluscum contagiosum* - **Molluscum contagiosum** can similarly demonstrate **pseudo-Koebner's phenomenon**. - Scratching spreads the **molluscum contagiosum virus** to adjacent areas, creating linear arrays of lesions. - Like warts, this represents **direct viral inoculation** rather than true isomorphic response, but is often grouped with Koebner's phenomenon in clinical practice.
Question 8: Genital warts are caused by which virus?
- A. Herpes simplex
- B. Cytomegalovirus
- C. Varicella zoster
- D. Human Papillomavirus (Correct Answer)
Explanation: ***Human Papillomavirus*** - **HPV types 6 and 11** are the most common causes of **genital warts (condyloma acuminata)**. - HPV is a **DNA virus** that infects epithelial cells and can cause benign proliferative lesions. *Herpes simplex* - **Herpes simplex virus (HSV)** causes **genital herpes**, characterized by painful vesicles and ulcers, not warts. - HSV is a **DNA virus** that primarily infects mucocutaneous sites and establishes latency in sensory ganglia. *Cytomegalovirus* - **Cytomegalovirus (CMV)** is a **beta-herpesvirus** that causes a wide range of clinical syndromes, especially in immunocompromised individuals, but does not cause genital warts. - CMV infection can manifest as mononucleosis-like syndrome, retinitis, colitis, or pneumonitis. *Varicella zoster* - **Varicella zoster virus (VZV)** causes **chickenpox** (varicella) and **shingles** (herpes zoster), characterized by vesicular rashes, not genital warts. - VZV is an **alpha-herpesvirus** that remains latent in dorsal root ganglia after primary infection.
Question 9: A cervical Pap smear report stating that "koilocytic atypia is present" indicates the presence of:
- A. Cytologic changes caused by herpes simplex virus (HSV)
- B. Cytologic changes caused by human papillomavirus (HPV) (Correct Answer)
- C. High-grade cervical intraepithelial neoplasia (CIN)
- D. Cytologic changes caused by chlamydial infection
Explanation: ***Cytologic changes caused by human papillomavirus (HPV)*** - **Koilocytic atypia** is a characteristic cytopathic effect seen in cervical epithelial cells infected with **human papillomavirus (HPV)** [2]. - Koilocytes are squamous epithelial cells with **perinuclear halos** and nuclear changes such as enlargement, hyperchromasia, and irregular contours [2]. *High-grade cervical intraepithelial neoplasia (CIN)* - While HPV infection can lead to high-grade CIN, **koilocytic atypia** itself is typically associated with **low-grade squamous intraepithelial lesion (LSIL)**, which is often a precursor to CIN [1]. - High-grade CIN (CIN 2/3) involves more severe architectural disorganization and loss of cell maturation not solely defined by koilocytic atypia. *Cytologic changes caused by herpes simplex virus (HSV)* - HSV infection in a Pap smear would show characteristic changes like **multinucleated giant cells**, **nuclear molding**, and **intranuclear inclusions**, not koilocytic atypia [3]. - These findings are distinct from the perinuclear halo and nuclear irregularities seen in HPV infection. *Cytologic changes caused by chlamydial infection* - Chlamydial infections are bacterial and primarily cause signs of **inflammation**, such as an increased number of neutrophils and plasma cells, and reactive changes in epithelial cells. - **Chlamydia** does not induce koilocytic changes; these are specific to viral infections, particularly HPV. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1006-1008. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 466-467. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Infectious Diseases, pp. 365-366.
Question 10: A 60-year-old patient presents with unilateral vesicular lesions in a dermatomal distribution on the torso. The lesions are painful and appeared over the past 2-3 days, progressing from erythematous patches to fluid-filled vesicles. The patient reports prodromal burning and tingling sensation in the affected area. Which of the following is the most likely diagnosis?
- A. Herpes zoster infection (Correct Answer)
- B. Irritant contact dermatitis
- C. Allergic contact dermatitis
- D. Herpes Simplex Infection
Explanation: ***Herpes zoster infection*** - The patient's presentation of **unilateral vesicular lesions** in a **dermatomal distribution**, accompanied by severe pain and a **prodromal burning and tingling sensation**, is classic for herpes zoster (shingles). - Herpes zoster results from the **reactivation of latent varicella-zoster virus (VZV)** in a sensory ganglion, leading to painful rash along the affected nerve path. *Irritant contact dermatitis* - This condition involves inflammation due to direct contact with an irritating substance, often presenting with **eczematous lesions**, redness, itching, and sometimes vesicles. - However, it typically lacks the characteristic **dermatomal distribution** and severe neuropathic pain seen in herpes zoster. *Allergic contact dermatitis* - Allergic contact dermatitis is an immune-mediated reaction to an allergen, causing intensely pruritic, erythematous, and often **vesicular or bullous eruptions** that tend to spread beyond the initial contact area over time. - While it can cause vesicles, it does not follow a **dermatomal pattern** and is usually very itchy, rather than primarily painful and burning, with a distinct prodrome. *Herpes Simplex Infection* - Herpes simplex virus (HSV) infections also cause **vesicular lesions** but typically present as clusters of vesicles on an **erythematous base** in a localized area, often around the mouth (cold sores) or genitals. - Unlike herpes zoster, HSV lesions are usually **recurrent** in the same small area and typically do not exhibit a widespread, **unilateral dermatomal pattern** or the associated severe, persistent neuropathic pain.
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