Viral Skin Infections Practice Questions

Q: Multiple nodular lesions occurring most commonly on the lower lip, resembling oral papillomas and microscopically containing virus-like particles are most likely to be what condition?

Heck disease. ### Explanation **Heck Disease (Focal Epithelial Hyperplasia)** Heck disease is a rare, benign condition caused by **Human Papillomavirus (HPV) types 13 and 32**. It typically presents as multiple, soft, smooth, flattened or rounded papules/nodules on the oral mucosa, most frequently involving the **lower lip**, buccal mucosa, and tongue. * **Pathogenesis:** It is characterized by acanthosis and thickening of the epithelium. Microscopically, it shows "mitosoid cells" (cells with degenerating nuclei resembling mitotic figures) and virus-like particles under electron microscopy. * **Clinical Context:** It is most common in children and young adults, often showing a familial clustering or association with low socioeconomic status. **Analysis of Incorrect Options:** * **Fordyce Spots:** These are ectopic sebaceous glands. They appear as small (1-2 mm), yellowish-white granules on the vermilion border of the lips or buccal mucosa. They are not viral and do not form large nodular lesions. * **Lingual Varices:** These are dilated, tortuous veins (varicosities) typically found on the ventral surface of the tongue in elderly patients. They appear bluish-purple and are vascular, not epithelial/viral. * **Linea Alba:** This is a common white, horizontal line on the buccal mucosa at the level of the occlusal plane, caused by friction or pressure from teeth (hyperkeratosis). It is not nodular or viral. **High-Yield Pearls for NEET-PG:** * **Causative Agents:** HPV 13 and 32 (High-yield association). * **Mitosoid Cells:** The pathognomonic histological feature of Heck disease. * **Management:** Usually self-limiting; treatment (cryotherapy or CO2 laser) is only for cosmetic or functional concerns. * **Differential Diagnosis:** Must be distinguished from Condyloma acuminatum (HPV 6, 11), which usually has a more "cauliflower" appearance and a different transmission pattern.

Q: A 26-year-old male kidney transplant recipient presents with multiple brown keratotic papules on the forehead and scalp. What is the common cause of these lesions?

HPV subtype 3, 10. ### Explanation The clinical presentation describes **Verruca Plana (Flat Warts)**. These are characterized by small (1–5 mm), flat-topped, smooth or slightly keratotic, flesh-colored to brown papules. They commonly occur on the face, forehead, and dorsum of hands. In immunocompromised individuals, such as kidney transplant recipients, these lesions can be more numerous and persistent due to impaired cell-mediated immunity. **Why Option C is correct:** * **HPV subtypes 3 and 10** are the specific genotypes responsible for Verruca Plana. The description of "brown keratotic papules" on the forehead is the classic clinical vignette for this condition. **Why other options are incorrect:** * **Option A (HPV 6, 11):** These cause **Condyloma Acuminata** (Anogenital warts) and Laryngeal Papillomatosis. They are low-risk mucosal types. * **Option B (HPV 2, 4):** These are the most common causes of **Verruca Vulgaris** (Common warts), which are typically rough, exophytic, "cauliflower-like" lesions found on fingers and periungual areas. * **Option D (HPV 16, 18):** These are high-risk oncogenic types associated with **Bowenoid papulosis**, cervical cancer, and squamous cell carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Koebner Phenomenon:** Flat warts often show linear distribution due to autoinoculation (e.g., from shaving or scratching). * **Butcher’s Warts:** Caused by HPV-7. * **Deep Palmoplantar Warts (Myrmecia):** Caused by HPV-1. * **Epidermodysplasia Verruciformis (EV):** A rare genetic condition associated with HPV-5 and HPV-8, which carries a high risk of progression to Squamous Cell Carcinoma (SCC). * **Treatment:** First-line includes topical salicylic acid, cryotherapy, or topical retinoids (especially for flat warts).

Q: Podophyllin is used to treat which type of wart?

Genital wart. **Explanation:** **Podophyllin** (Podophyllum resin) is a potent cytotoxic agent derived from the Mayapple plant. It works by binding to tubulin, inhibiting mitotic spindle formation, which leads to cell cycle arrest and necrosis of the treated tissue. **Why Genital Warts (Condyloma Acuminata) is correct:** Podophyllin is specifically indicated for the treatment of **anogenital warts** caused by Human Papillomavirus (HPV) types 6 and 11. Because it is highly caustic and can be systemically absorbed, it is primarily used on mucosal or thin-skinned areas where penetration is effective. It must be applied by a healthcare professional and washed off after 4–6 hours to prevent severe local irritation or systemic toxicity. **Why other options are incorrect:** * **Plantar Warts (Verruca Plantaris):** These occur on the thick, keratinized skin of the soles. Podophyllin lacks the penetrative power to bypass this thick stratum corneum. Salicylic acid or cryotherapy are preferred. * **Verruca Plana (Flat Warts):** These are usually multiple and located on the face or dorsum of hands. Podophyllin is too corrosive for facial use and carries a high risk of scarring and post-inflammatory hyperpigmentation. **Clinical Pearls for NEET-PG:** * **Contraindication:** Podophyllin is strictly **contraindicated in pregnancy** due to its teratogenic potential and risk of fetal death. * **Podophyllotoxin:** This is the active purified fraction of podophyllin. Unlike the resin, it is stable and can be self-applied by the patient. * **Systemic Toxicity:** Over-application or failure to wash it off can lead to "Podophyllin Toxicity," characterized by bone marrow suppression, neurotoxicity (coma/seizures), and multi-organ failure.

Q: What is the diagnosis in this patient with axillary lymphadenopathy?

Herpetic whitlow. ***Herpetic whitlow*** - A **viral infection** caused by **herpes simplex virus (HSV)** that presents with **grouped vesicles** on the finger, commonly causing **regional lymphadenopathy** in the axilla. - The **vesicular appearance** and associated **axillary lymph node enlargement** are characteristic of HSV infection, distinguishing it from bacterial causes. *Bacterial felon* - A **deep bacterial infection** of the **fingertip pulp space** that presents as a **painful, swollen fingertip** without vesicles. - Does **not typically cause axillary lymphadenopathy** and lacks the characteristic vesicular lesions seen in viral infections. *Erysipelas* - A **superficial bacterial infection** of the skin caused by **Streptococcus pyogenes** with **raised, erythematous borders**. - Primarily affects **facial areas** and lower extremities, not typically the fingers, and would not present with vesicular lesions. *Paronychia* - A **bacterial or fungal infection** of the **nail fold** presenting as **erythema and swelling** around the nail margin. - Does **not cause vesicular lesions** or significant **axillary lymphadenopathy** as it remains a localized superficial infection.

Q: Hairy leukoplakia is associated with all of the following EXCEPT?

Filiform to flat patch on lateral tongue. **Explanation:** Oral Hairy Leukoplakia (OHL) is a benign, white mucosal lesion primarily caused by the **Epstein-Barr Virus (EBV)**. It is a hallmark opportunistic infection, most commonly seen in patients with **AIDS** or severe immunosuppression. **Why Option A is the Correct Answer (The "Except"):** The description "Filiform to flat patch" is clinically inaccurate for OHL. OHL characteristically presents as **corrugated, vertically oriented white ridges** (resembling "hair" or a "shaggy" surface) that **cannot be scraped off**. While it classically occurs on the **lateral borders of the tongue**, the morphology is typically thick and corrugated rather than a simple flat patch or filiform projection. **Analysis of Other Options:** * **Option B (Bilateral appearance):** OHL is frequently bilateral and symmetrical along the lateral margins of the tongue, which helps distinguish it from other unilateral lesions like squamous cell carcinoma. * **Option C (Epstein Barr virus):** EBV is the definitive causative agent. The virus replicates within the epithelial cells of the tongue, leading to the characteristic hyperkeratosis. * **Option D (AIDS):** OHL is one of the most common oral manifestations of HIV/AIDS. Its presence is often considered a clinical marker of disease progression and a low CD4 count (usually <200 cells/mm³). **High-Yield Clinical Pearls for NEET-PG:** * **Differential Diagnosis:** Unlike Oral Candidiasis, OHL **cannot be scraped off** with a tongue depressor. * **Histopathology:** Look for **"Balloon cells"** (koilocytosis-like changes) in the upper stratum spinosum and nuclear inclusions. * **Treatment:** Usually not required unless for cosmetic reasons; it often resolves with Highly Active Antiretroviral Therapy (HAART) or systemic antivirals like Acyclovir. * **Malignant Potential:** Unlike idiopathic leukoplakia, OHL has **zero** premalignant potential.

Q: What is the most common genital lesion observed in patients with HIV?

Herpes. **Explanation:** The correct answer is **Herpes (HSV-2)**. In patients living with HIV, **Herpes Simplex Virus (HSV)** is the most common cause of genital ulcer disease (GUD) worldwide [1]. There is a synergistic relationship between the two viruses: HIV-induced immunosuppression leads to more frequent, severe, and persistent herpetic outbreaks, while the open ulcers caused by HSV provide a portal of entry that increases the risk of HIV transmission and acquisition. **Analysis of Options:** * **B. Herpes (Correct):** Studies consistently show that HSV-2 is the most prevalent co-infection and the leading cause of genital lesions in HIV-positive individuals [1]. In advanced HIV, these lesions may become "chronic" (lasting >1 month), which is an AIDS-defining illness. * **A. Chlamydia:** While common as a cause of urethritis or cervicitis, it typically presents as a discharge rather than a visible external "genital lesion" (except for the rare Lymphogranuloma Venereum strain). * **C. Syphilis:** *Treponema pallidum* causes genital ulcers (chancre), and while its incidence is rising among HIV-positive populations, it remains less common than HSV [1]. * **D. Candida:** Candidiasis is a very common opportunistic fungal infection in HIV (especially oral thrush), and while it can cause balanitis or vulvovaginitis, it is not the most common cause of a primary genital lesion compared to HSV. **High-Yield Clinical Pearls for NEET-PG:** * **AIDS-Defining Condition:** A chronic herpetic ulcer (mucocutaneous) persisting for more than **1 month** is an AIDS-defining illness. * **Atypical Presentation:** In HIV patients, HSV may present as large, deep, "punched-out" necrotic ulcers or even hypertrophic/verrucous lesions that mimic malignancy. * **Treatment:** Acyclovir is the drug of choice, but higher doses or longer durations are often required. Be aware of **Acyclovir-resistant HSV** in non-responsive cases (treated with Foscarnet).

Q: What is the drug of choice for treating genital warts?

Podophyllin. **Explanation:** Genital warts (Condyloma acuminata) are caused by the **Human Papillomavirus (HPV)**, most commonly types 6 and 11. Unlike systemic viral infections, these are localized epidermal proliferations. **Podophyllin** (and its purified form, Podophyllotoxin) is a potent cytotoxic agent that acts as a mitotic inhibitor. It binds to tubulin, preventing mitotic spindle formation, which leads to cell death and the physical destruction of the wart tissue. It remains a standard provider-applied chemical treatment for external genital warts. **Analysis of Options:** * **Acyclovir (A):** This is an antiviral used specifically for DNA viruses of the **Herpes family** (HSV, VZV). It inhibits viral DNA polymerase but has no efficacy against HPV. * **Minocycline (C):** This is a tetracycline antibiotic used primarily for acne, rosacea, and certain bacterial infections. It has no antiviral properties. * **Interferon alpha (D):** While it has antiviral and immunomodulatory properties and can be used for refractory cases (intralesional), it is not the first-line drug of choice due to high cost, side effects, and lower clearance rates compared to topical destructive therapies. **Clinical Pearls for NEET-PG:** * **Imiquimod:** A high-yield alternative; it is an **immune response modifier** (TLR-7 agonist) used for patient-applied treatment. * **Trichloroacetic Acid (TCA):** The preferred chemical treatment for pregnant women with genital warts (Podophyllin is contraindicated in pregnancy). * **Histology:** Look for **Koilocytes** (cells with perinuclear halo and wrinkled "raisinoid" nuclei) on a Tzanck smear or biopsy. * **HPV 16 & 18:** These are high-risk types associated with cervical and anal carcinoma, whereas 6 and 11 are low-risk (benign warts).

Q: A 5-year-old child presents with raised, firm, flesh-colored nodules. Histopathological examination reveals characteristic findings. What is the most likely diagnosis?

Molluscum contagiosum. **Explanation:** **Molluscum Contagiosum (Correct Answer):** Molluscum contagiosum is a common viral infection caused by a **Poxvirus**. It typically presents in children as firm, flesh-colored, dome-shaped papules with a characteristic **central umbilication**. The histopathological hallmark is the presence of **Henderson-Paterson bodies** (large, eosinophilic intracytoplasmic inclusion bodies) within the keratinocytes, which displace the nucleus to the periphery. **Why other options are incorrect:** * **Myrmecia (A):** This refers to deep, painful palmoplantar warts caused by **HPV-1**. Histology shows large eosinophilic keratohyalin granules, but they lack the classic umbilication and specific inclusion bodies of Molluscum. * **Herpes Zoster (C) & Herpes Simplex (D):** Both are caused by the Herpesviridae family. Clinically, they present as **vesicles on an erythematous base** (not flesh-colored nodules). Histopathology reveals **multinucleated giant cells** (Tzanck smear positive) and Cowdry Type A intranuclear inclusions, rather than cytoplasmic inclusions. **NEET-PG High-Yield Pearls:** * **Etiology:** DNA Poxvirus (Molluscum Contagiosum Virus). * **Transmission:** Skin-to-skin contact; in adults, it is often considered an **STI** if found in the anogenital region. * **Histology:** Look for the "molluscum body" or **Henderson-Paterson body**. * **Clinical Sign:** Central umbilication (cheesy material can be expressed). * **Association:** Extensive or giant lesions in adults should prompt an **HIV screening**.

Q: The characteristic rash of chickenpox exhibits which of the following distribution patterns?

Centripetal distribution. **Explanation:** Chickenpox (Varicella), caused by the **Varicella-Zoster Virus (VZV)**, is characterized by a classic rash that follows a **centripetal distribution**. This means the lesions are most concentrated on the trunk (chest, back, and abdomen) and face, with relative sparing of the distal extremities (palms and soles). **Analysis of Options:** * **Centripetal distribution (Correct):** The rash typically begins on the trunk and spreads outward, but the density remains highest centrally. This is a hallmark diagnostic feature. * **Deep seated (Incorrect):** Varicella vesicles are superficial and thin-walled, often described as "dewdrops on a rose petal." Deep-seated, firm lesions are characteristic of Smallpox (Variola). * **Monomorphic (Incorrect):** Chickenpox is **pleomorphic**. This means lesions at various stages of development (macules, papules, vesicles, and crusts) are present simultaneously in the same anatomical area. Smallpox, conversely, is monomorphic. * **Umbilicated (Incorrect):** While some varicella vesicles may show slight central depression as they crust, "umbilication" is the classic descriptor for **Molluscum Contagiosum** or Smallpox. **NEET-PG High-Yield Pearls:** * **Incubation Period:** 10–21 days. * **Infectivity:** From 1–2 days before the rash appears until all lesions have crusted over. * **Tzanck Smear:** Shows **Multinucleated Giant Cells** (also seen in Herpes Simplex). * **Complications:** Secondary bacterial infection (most common in children) and Varicella pneumonia (most common/severe in adults). * **Smallpox vs. Chickenpox:** Smallpox is centrifugal (peripheral), monomorphic, and deep-seated; Chickenpox is centripetal (central), pleomorphic, and superficial.

Question 1

Multiple nodular lesions occurring most commonly on the lower lip, resembling oral papillomas and microscopically containing virus-like particles are most likely to be what condition?

Accepted Answer

Heck disease

Answer

Fordyce spots

Answer

Lingual varices

Answer

Linea alba

Question 2

A 26-year-old male kidney transplant recipient presents with multiple brown keratotic papules on the forehead and scalp. What is the common cause of these lesions?

Accepted Answer

HPV subtype 3, 10

Answer

HPV subtype 6, 11

Answer

HPV subtype 2, 4

Answer

HPV subtype 16, 18

Question 3

Podophyllin is used to treat which type of wart?

Accepted Answer

Genital wart

Answer

Plantar wart

Answer

Verruca plana

Answer

All of the above

Question 4

What is the diagnosis in this patient with axillary lymphadenopathy?

Accepted Answer

Herpetic whitlow

Answer

Bacterial felon

Answer

Erysipelas

Answer

Paronychia

Question 5

Hairy leukoplakia is associated with all of the following EXCEPT?

Accepted Answer

Filiform to flat patch on lateral tongue

Answer

Bilateral appearance

Answer

Epstein Barr virus

Answer

AIDS

Question 6

What is the most common genital lesion observed in patients with HIV?

Accepted Answer

Herpes

Answer

Chlamydia

Answer

Syphilis

Answer

Candida

Question 7

A 35-year-old man has noted a small bump on his upper trunk for the past 6 weeks. On physical examination, there is a solitary, 0.4-cm, flesh-colored nodule on the upper trunk. The dome-shaped lesion is umbilicated, and a curd-like material can be expressed from the center. This material is smeared on a slide, and the Giemsa stain shows many pink, homogeneous, cytoplasmic inclusions. The lesion regresses over the next 2 months. Which of the following infectious agents most likely produced this lesion?

Accepted Answer

Molluscum contagiosum

Answer

Histoplasma capsulatum

Answer

Human papillomavirus

Answer

Staphylococcus aureus

Question 8

What is the drug of choice for treating genital warts?

Accepted Answer

Podophyllin

Answer

Acyclovir

Answer

Minocycline

Answer

Interferon alpha

Question 9

A 5-year-old child presents with raised, firm, flesh-colored nodules. Histopathological examination reveals characteristic findings. What is the most likely diagnosis?

Accepted Answer

Molluscum contagiosum

Answer

Myrmecia

Answer

Herpes zoster

Answer

Herpes simplex

Question 10

The characteristic rash of chickenpox exhibits which of the following distribution patterns?

Accepted Answer

Centripetal distribution

Answer

Deep seated

Answer

Monomorphic

Answer

Umbilicated

Viral Skin Infections — MCQs

Viral Skin Infections — MCQs

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