Viral Skin Infections Practice Questions

Q: Ballooning is characteristic of which of the following conditions?

Herpes zoster. **Explanation:** **Ballooning degeneration** is a characteristic histopathological feature of viral infections caused by the Herpes family of viruses, including **Herpes zoster**, Herpes simplex, and Varicella. It refers to the marked swelling and rounding of keratinocytes due to intracellular edema. These "ballooned" cells often lose their intercellular attachments (acantholysis), leading to the formation of intraepidermal vesicles. Additionally, these cells may undergo nuclear division without cytoplasmic division, resulting in **multinucleated giant cells** (Tzanck cells). **Analysis of Incorrect Options:** * **B. Pemphigus:** While Pemphigus involves **acantholysis** (loss of cell-to-cell adhesion), the mechanism is immunological (IgG antibodies against desmogleins) rather than viral-induced ballooning. It typically shows a "row of tombstone" appearance on the basal layer. * **C. Pemphigoid:** Bullous pemphigoid is characterized by **subepidermal blisters** due to the destruction of the basement membrane zone (hemidesmosomes). It does not involve ballooning or acantholysis. * **D. Insect bite:** These typically present with dermal edema, eosinophilic infiltrates, and sometimes "spongiosis" (intercellular edema), but not the specific ballooning degeneration seen in viral infections. **NEET-PG High-Yield Pearls:** * **Tzanck Smear:** A rapid bedside test for Herpes zoster/simplex. Look for multinucleated giant cells and ballooning cells. * **Inclusion Bodies:** In Herpes, look for **Lipschütz bodies** (eosinophilic intranuclear inclusions). * **Ballooning vs. Spongiosis:** Ballooning is *intracellular* edema (viral), whereas spongiosis is *intercellular* edema (eczema/dermatitis). * **Other conditions with ballooning:** Hand-foot-mouth disease (Coxsackievirus) and Orf.

Q: An eight-year-old boy presents with multiple umbilicated pearly white papules on the trunk and face following a viral infection. What is the diagnosis?

Molluscum Contagiosum. **Explanation:** The clinical presentation of **multiple umbilicated pearly white papules** is the classic hallmark of **Molluscum Contagiosum**. This is a common viral skin infection caused by the **Molluscum Contagiosum Virus (MCV)**, a member of the **Poxvirus** family. The characteristic "umbilication" (a central depression) is due to the degeneration of keratinocytes, which forms a curd-like core containing viral particles known as **Henderson-Patterson bodies**. **Why other options are incorrect:** * **Chicken Pox (Varicella):** Presents with a pleomorphic rash (macules, papules, and vesicles in different stages) and is typically associated with fever and intense pruritus. The vesicles are often described as "dewdrops on a rose petal." * **Herpes Zoster:** Characterized by painful, grouped vesicles on an erythematous base, strictly following a **dermatomal distribution**. It is a reactivation of the latent Varicella-Zoster virus. * **Dermatophytosis:** This is a fungal infection (e.g., Ringworm) that typically presents as annular (ring-shaped) erythematous plaques with central clearing and peripheral scaling, not umbilicated papules. **High-Yield Clinical Pearls for NEET-PG:** * **Histopathology:** Look for **Henderson-Patterson bodies** (large, intracytoplasmic eosinophilic inclusion bodies). * **Transmission:** In children, it spreads via direct skin-to-skin contact or fomites (towels). In adults, if found in the anogenital region, it is considered a **Sexually Transmitted Infection (STI)**. * **HIV Association:** Extensive, giant, or recalcitrant lesions in an adult should prompt an investigation for underlying **HIV/immunosuppression**. * **Treatment:** Usually self-limiting; however, cryotherapy, curettage, or topical cantharidin are common interventions.

Q: Herpes zoster most commonly involves which nerve division?

Ophthalmic division of Trigeminal. **Explanation:** Herpes Zoster (Shingles) results from the reactivation of the latent Varicella-Zoster Virus (VZV) within the sensory ganglia. While the virus most frequently affects the **thoracic dermatomes** (50–60% of cases) [1], the **Trigeminal nerve (Cranial Nerve V)** is the most common cranial nerve involved. Among the three branches of the Trigeminal nerve, the **Ophthalmic division (V1)** is most frequently affected, a condition known as *Herpes Zoster Ophthalmicus*. This occurs because the virus remains latent in the trigeminal ganglion and, upon reactivation, travels preferentially along the V1 fibers to the forehead and cornea. **Analysis of Options:** * **Option B (Correct):** The Ophthalmic division (V1) is the most common site for cranial zoster. Involvement of the nasociliary branch (indicated by vesicles on the tip of the nose—**Hutchinson’s sign**) is a strong predictor of ocular complications like keratitis. * **Options C & D (Incorrect):** The Maxillary (V2) and Mandibular (V3) divisions are significantly less common sites for reactivation compared to V1. * **Option A (Incorrect):** While the Facial nerve (CN VII) can be involved (leading to **Ramsay Hunt Syndrome** or Herpes Zoster Oticus), it is less frequent than Trigeminal involvement. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common site overall:** Thoracic dermatomes (T3 to L2) [1]. 2. **Hutchinson’s Sign:** Vesicles on the side or tip of the nose; indicates high risk of corneal involvement. 3. **Ramsay Hunt Syndrome:** Triad of ipsilateral facial paralysis, ear pain, and vesicles in the auditory canal (CN VII involvement). 4. **Post-herpetic Neuralgia (PHN):** The most common complication of Herpes Zoster, defined as pain persisting >90 days after the rash heals [1]. 5. **Treatment:** Oral Acyclovir, Valacyclovir, or Famciclovir (ideally started within 72 hours) [1].

Q: Postherpetic neuralgia most commonly involves which division of the trigeminal nerve?

Ophthalmic division. **Explanation:** **Postherpetic Neuralgia (PHN)** is the most common chronic complication of Herpes Zoster (shingles), characterized by persistent neuropathic pain lasting more than 90 days after the onset of the rash. **Why the Ophthalmic Division is Correct:** Herpes Zoster occurs due to the reactivation of the Varicella-Zoster Virus (VZV) latent in the sensory ganglia. While the thoracic dermatomes are the most frequently involved site overall, the **Trigeminal nerve (Cranial Nerve V)** is the most common cranial nerve affected. Within the trigeminal nerve, the **Ophthalmic division (V1)** is involved significantly more often than the other branches. This clinical presentation is known as *Herpes Zoster Ophthalmicus (HZO)*. The high density of sensory fibers and the specific neurotropism of the virus for the ophthalmic branch make it the primary site for both acute infection and subsequent PHN in the head and neck region. **Why Other Options are Incorrect:** * **Maxillary (V2) and Mandibular (V3) divisions:** While these branches can be involved, they are statistically much less common than V1. V2 involvement typically presents with lesions on the upper lip or cheek, and V3 involves the lower jaw or tongue, but neither carries the same high risk of PHN as the ophthalmic branch. **High-Yield Clinical Pearls for NEET-PG:** * **Hutchinson’s Sign:** Vesicles on the side or tip of the nose indicate involvement of the nasociliary branch of V1, predicting a high risk of ocular complications (e.g., keratitis). * **Risk Factors for PHN:** Advanced age (>60 years), severe prodromal pain, and greater rash severity. * **Treatment:** First-line agents for PHN include Gabapentin, Pregabalin, and Tricyclic Antidepressants (Amitriptyline). * **Prevention:** The recombinant Zoster vaccine (Shingrix) is highly effective in preventing both HZ and PHN.

Q: Which of the following is NOT a treatment for complications of Herpes Zoster?

Acyclovir. ### Explanation The key to answering this question lies in distinguishing between the **acute treatment** of a viral infection and the **management of its chronic complications**. **1. Why Acyclovir is the correct answer:** Acyclovir is an antiviral agent used to treat the **acute phase** of Herpes Zoster (Shingles) [1]. It works by inhibiting viral DNA polymerase, thereby reducing viral shedding and accelerating the healing of acute skin lesions [3]. However, it is **not** a treatment for the complications of Herpes Zoster, most notably **Post-Herpetic Neuralgia (PHN)**. Once the virus has caused nerve damage leading to chronic pain, antivirals have no therapeutic role [1]. **2. Analysis of Incorrect Options (Treatments for Complications):** * **Amitriptyline (Option B):** A Tricyclic Antidepressant (TCA) considered a first-line agent for PHN. It modulates pain pathways by inhibiting the reuptake of norepinephrine and serotonin. * **Gabapentin (Option C):** An anticonvulsant that binds to the ̡2-̤ subunit of voltage-gated calcium channels. It is a mainstay for neuropathic pain management in PHN. * **Prednisone (Option D):** Corticosteroids are used to treat specific complications like **Ramsay Hunt Syndrome** (to reduce facial nerve edema) or **Zoster Ophthalmicus**. They may also be used in the acute phase to reduce pain and inflammation, though they do not prevent PHN. **Clinical Pearls for NEET-PG:** * **Post-Herpetic Neuralgia (PHN):** Defined as pain persisting for >90 days after the onset of the rash [2]. * **Treatment of Choice for PHN:** Gabapentin, Pregabalin, or TCAs (Amitriptyline). * **Acyclovir Timing:** Most effective when started within **72 hours** of rash onset. * **Hutchinson’s Sign:** Vesicles on the tip of the nose indicating involvement of the nasociliary nerve; a precursor to Zoster Ophthalmicus.

Q: Which of the following statements is FALSE regarding Herpes virus infections?

Steroids are useful in treating acute dendritic ulcers. ### Explanation **Why Option C is the Correct (False) Statement:** In Herpes Simplex Virus (HSV) keratitis, **topical steroids are strictly contraindicated** during the stage of **acute dendritic ulcers**. Steroids promote viral replication and inhibit epithelial healing, which can lead to the enlargement of the ulcer into a "geographic ulcer" and potentially result in corneal perforation. Steroids are only considered in later stages of disciform keratitis (immune-mediated) under strict antiviral cover. **Analysis of Other Options:** * **Option A:** Primary HSV-1 infection most commonly manifests as **acute herpetic gingivostomatitis**, especially in children. It presents with high fever, lymphadenopathy, and painful vesicles on the oral mucosa and gums. * **Option B:** **Herpes Gladiatorum** is a cutaneous HSV-1 infection seen in athletes involved in contact sports like wrestling. It occurs due to skin-to-skin contact, typically presenting on the face, neck, and arms. * **Option D:** **Topical Acyclovir** is highly specific because it is a prodrug that requires phosphorylation by the viral enzyme **thymidine kinase** to become active. This ensures the drug primarily affects virus-infected cells while sparing healthy host cells. **Clinical Pearls for NEET-PG:** * **Tzanck Smear:** The classic bedside diagnostic test showing **multinucleated giant cells** and **acantholytic cells** (also seen in Varicella and Herpes Zoster). * **Cowdry Type A bodies:** Eosinophilic intranuclear inclusion bodies are a hallmark histological finding. * **Eczema Herpeticum (Kaposi Varicelliform Eruption):** A medical emergency where HSV infects pre-existing skin conditions like atopic dermatitis. * **Drug of Choice:** Oral or IV **Acyclovir** is the mainstay of treatment. For acyclovir-resistant cases (often in HIV patients), **Foscarnet** is used.

Q: A child presents with an exophytic growth on the lower lip characterized by finger-like projections and hyperkeratosis. Similar growth is observed on the dorsal surface of the left thumb, which is shorter than the right thumb. What is the most likely diagnosis?

Papilloma. ### Explanation **Correct Answer: C. Papilloma (Verruca Vulgaris)** The clinical presentation describes a classic case of **Verruca Vulgaris (Common Wart)**. The "finger-like projections" and "hyperkeratosis" are hallmark features of a viral papilloma caused by **Human Papillomavirus (HPV)**. The key diagnostic clue in this question is the presence of a similar lesion on the **thumb**. This demonstrates the phenomenon of **autoinoculation**, where the virus is transferred from one site (the thumb) to another (the lip) through direct contact, often due to thumb-sucking or nail-biting in children. The mention of the thumb being "shorter" suggests a chronic habit or local growth interference, further supporting the diagnosis of a common wart. **Analysis of Incorrect Options:** * **A. Squamous cell carcinoma (SCC):** While SCC can be exophytic, it typically presents in older adults with risk factors like UV exposure or tobacco use. It is highly unlikely in a child and does not explain the synchronous thumb lesion. * **B. Acantholysis:** This is a histological term referring to the loss of intercellular connections (e.g., in Pemphigus). It is a microscopic finding, not a clinical diagnosis for an exophytic growth. * **C. Verrucous carcinoma:** This is a low-grade variant of SCC (Ackerman’s tumor). While it appears "wart-like," it is usually a large, locally invasive malodorous mass found in the oral cavity of elderly tobacco chewers. **High-Yield Clinical Pearls for NEET-PG:** * **HPV Types:** Verruca vulgaris is most commonly associated with **HPV types 2 and 4**. * **Histology:** Look for **koilocytes** (keratinocytes with pyknotic nuclei and perinuclear halos) and "tiered" parakeratosis. * **Koebner Phenomenon:** Warts can show a pseudo-Koebner phenomenon (linear spread due to trauma/scratching). * **Treatment:** First-line treatments include topical salicylic acid or cryotherapy with liquid nitrogen.

Q: Which viral association is found in pityriasis rosea?

HHV 7. ### Explanation **Pityriasis Rosea (PR)** is an acute, self-limiting papulosquamous disorder. The correct answer is **HHV-7** (and to a lesser extent HHV-6) because these viruses are implicated in the pathogenesis through systemic reactivation rather than a primary infection. #### Why HHV-7 is Correct: Current medical literature and PCR studies consistently show the presence of **Human Herpesvirus 7 (HHV-7)** and **HHV-6** DNA in the plasma and skin lesions of PR patients. The condition often follows a prodromal viral illness, and the seasonal clustering of cases further supports this viral etiology. #### Why Other Options are Incorrect: * **B. CMV (HHV-5):** Cytomegalovirus typically causes infectious mononucleosis-like syndromes or retinitis/colitis in immunocompromised patients; it has no established link to PR. * **C. Varicella Zoster (HHV-3):** Causes Chickenpox and Herpes Zoster (Shingles), characterized by dermatomal vesicular eruptions, unlike the scaly plaques of PR. * **D. EBV (HHV-4):** Epstein-Barr Virus is associated with Infectious Mononucleosis, Oral Hairy Leukoplakia, and certain lymphomas, but not PR. #### High-Yield Clinical Pearls for NEET-PG: * **Herald Patch:** The initial lesion; a large, erythematous, scaly plaque (2–10 cm) usually on the trunk. * **Christmas Tree Pattern:** Secondary eruption follows skin cleavage lines (Langer’s lines). * **Collarette of Scale:** Fine peripheral scaling with the free edge pointing inwards. * **Hanging Curtain Sign:** When the skin is stretched across the long axis of the lesion, the scales fold like a curtain. * **Management:** Usually reassurance (self-limiting in 6–8 weeks). Acyclovir may be used in severe cases to reduce duration.

Q: A 28-year-old woman presents with a "growth" in her genital area, first noticed 3 weeks ago and seemingly grown since then. She has hypothyroidism managed with thyroid hormone replacement. Examination reveals two non-tender, 6 mm, well-circumscribed, flesh-colored, papillated, oval lesions on the labia majora, with no ulceration, erythema, purulence, or inguinal lymphadenopathy. What is the most likely diagnosis?

Condyloma. **Explanation:** The clinical presentation is classic for **Condyloma acuminatum** (Anogenital warts), caused by Human Papillomavirus (HPV), typically types 6 and 11. The key diagnostic features here are the **flesh-colored, papillated (verrucous), and non-tender** nature of the lesions. Unlike inflammatory or malignant growths, these are well-circumscribed and lack secondary changes like ulceration or lymphadenopathy. **Analysis of Options:** * **Condyloma (Correct):** These are benign epithelial proliferations. The "papillated" or cauliflower-like surface is a hallmark of HPV infection. They are typically asymptomatic but can enlarge during pregnancy or immunosuppression. * **Chancre (Incorrect):** This is the primary lesion of Syphilis. It is typically a **painless, indurated ulcer** with a clean base, not a papillated growth. * **Herpes (Incorrect):** Genital Herpes (HSV-2) presents as **painful, grouped vesicles** on an erythematous base that quickly rupture to form shallow erosions. The absence of pain and ulceration in this patient rules it out. * **Squamous Cell Carcinoma (Incorrect):** While SCC can appear verrucous, it usually presents in older patients, grows slowly over months/years, and often shows signs of induration, friability, or ulceration. **NEET-PG High-Yield Pearls:** * **Histopathology:** Look for **Koilocytes** (keratinocytes with perinuclear halo and wrinkled "raisinoid" nuclei). * **Treatment of Choice:** Podophyllotoxin, Imiquimod (topical), or Cryotherapy/Electrocautery. * **Condyloma Lata vs. Acuminata:** Do not confuse these. *Condyloma lata* are flat, moist, highly infectious lesions of **Secondary Syphilis**, whereas *Condyloma acuminata* are the warty lesions of **HPV**.

Question 1

Ballooning is characteristic of which of the following conditions?

Accepted Answer

Herpes zoster

Answer

Pemphigus

Answer

Pemphigoid

Answer

Insect bite

Question 2

An eight-year-old boy presents with multiple umbilicated pearly white papules on the trunk and face following a viral infection. What is the diagnosis?

Accepted Answer

Molluscum Contagiosum

Answer

Chicken Pox

Answer

Herpes Zoster

Answer

Dermatophytosis

Question 3

Herpes zoster most commonly involves which nerve division?

Accepted Answer

Ophthalmic division of Trigeminal

Answer

Facial nerve

Answer

Mandibular division of Trigeminal

Answer

Maxillary division of Trigeminal nerve

Question 4

Herpes zoster infection can lead to which of the following complications?

Accepted Answer

Occipital neuralgia

Answer

Frontal lobe infarction

Answer

Parietal lobe infarction

Answer

Temporal lobe infarction

Question 5

Postherpetic neuralgia most commonly involves which division of the trigeminal nerve?

Accepted Answer

Ophthalmic division

Answer

Maxillary division

Answer

Mandibular division

Answer

None of the above

Question 6

Which of the following is NOT a treatment for complications of Herpes Zoster?

Accepted Answer

Acyclovir

Answer

Amitriptyline

Answer

Gabapentin

Answer

Prednisone

Question 7

Which of the following statements is FALSE regarding Herpes virus infections?

Accepted Answer

Steroids are useful in treating acute dendritic ulcers

Answer

The most common lesion seen is gingivostomatitis

Answer

Herpetic gladiatorum is seen in wrestlers

Answer

Topical Acyclovir is highly specific for herpes simplex

Question 8

A child presents with an exophytic growth on the lower lip characterized by finger-like projections and hyperkeratosis. Similar growth is observed on the dorsal surface of the left thumb, which is shorter than the right thumb. What is the most likely diagnosis?

Accepted Answer

Papilloma

Answer

Squamous cell carcinoma

Answer

Acantholysis

Answer

Verrucous carcinoma

Question 9

Which viral association is found in pityriasis rosea?

Accepted Answer

HHV 7

Answer

CMV

Answer

Varicella Zoster

Answer

EBV

Question 10

A 28-year-old woman presents with a "growth" in her genital area, first noticed 3 weeks ago and seemingly grown since then. She has hypothyroidism managed with thyroid hormone replacement. Examination reveals two non-tender, 6 mm, well-circumscribed, flesh-colored, papillated, oval lesions on the labia majora, with no ulceration, erythema, purulence, or inguinal lymphadenopathy. What is the most likely diagnosis?

Accepted Answer

Condyloma

Answer

Chancre

Answer

Herpes

Answer

Squamous cell carcinoma

Viral Skin Infections — MCQs

Viral Skin Infections — MCQs

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