Genital Herpes — MCQs
Which type of HSV is most commonly associated with recurrent genital herpes?
What is the characteristic microscopic finding in a Tzanck smear from a herpes lesion?
Which of the following statements about nucleic acid amplification tests (NAATs) for STIs is FALSE?
A 25-year-old woman is diagnosed with first-episode genital herpes. Which clinical feature best predicts the likelihood of frequent recurrences?
A 19-year-old woman presents with painful genital ulcers and vesicles for 4 days, accompanied by fever, malaise, and tender inguinal lymphadenopathy. What is the most appropriate initial management?
Which of the following is the MOST CRITICAL indication for Acyclovir use during pregnancy?
A pregnant female presents with active herpetic lesions on the vulva. What is the most appropriate management?
A neonate who is febrile, presents with features of encephalitis. On examination, the baby is found to have vesicular skin lesions. Most probable causative organism is:
Which of the following genital ulcer diseases is LEAST likely to cause inguinal lymphadenopathy?
Treatment of partner is required in all infection except:
Genital Herpes Indian Medical PG Practice Questions and MCQs
Question 1: Which type of HSV is most commonly associated with recurrent genital herpes?
- A. HSV-2 (Correct Answer)
- B. HSV-1
- C. VZV (Varicella-Zoster Virus)
- D. CMV (Cytomegalovirus)
Explanation: ***HSV-2*** - **HSV-2** is the primary cause of **genital herpes** and is significantly more likely to cause recurrent outbreaks than HSV-1 in the genital region. - The virus establishes **latency in sacral ganglia**, leading to frequent reactivation and subsequent genital lesions. *HSV-1* - While **HSV-1** can cause **genital herpes** (often through oral-genital contact), it is more commonly associated with **oral herpes (cold sores)**. - Genital infections caused by HSV-1 tend to recur less frequently and are generally less severe than those caused by HSV-2. *VZV (Varicella-Zoster Virus)* - **VZV** causes **chickenpox** (initial infection) and **shingles** (reactivation), not genital herpes. - It establishes latency in **dorsal root ganglia** and reactivation presents as a dermatomal rash (shingles). *CMV (Cytomegalovirus)* - **CMV** is a common virus that usually causes **asymptomatic infection** in healthy individuals, but can cause severe disease in immunocompromised patients or neonates. - It is not associated with genital lesions or recurrent genital herpes.
Question 2: What is the characteristic microscopic finding in a Tzanck smear from a herpes lesion?
- A. Multinucleated giant cells (Correct Answer)
- B. Intracellular inclusion bodies
- C. Budding yeast cells
- D. Clue cells
Explanation: ***Multinucleated giant cells*** - The presence of **multinucleated giant cells** (also called Tzanck cells or multinucleated keratinocytes) is the **most characteristic** cytological finding in a Tzanck smear from herpes simplex virus (HSV) or varicella-zoster virus (VZV) lesions. - These giant cells with **2-15 nuclei** form due to **viral-induced cell fusion (syncytia formation)** and are readily identified on routine staining. - This is the hallmark finding that makes Tzanck smear a useful rapid diagnostic test. *Intracellular inclusion bodies* - While **intranuclear inclusion bodies** (Cowdry type A inclusions) are indeed present in herpes infections, they are **less prominent** and require careful examination [1]. - These inclusions are **strictly intranuclear** (within the nucleus), appearing as eosinophilic inclusions surrounded by a clear halo [1]. - Although diagnostic when present, multinucleated giant cells are more readily identified and thus considered the characteristic finding on Tzanck smear. *Budding yeast cells* - **Budding yeast cells** are characteristic of fungal infections, most commonly *Candida* species. - They are typically seen in conditions like candidiasis, not viral infections such as herpes. *Clue cells* - **Clue cells** are epithelial cells covered with bacteria, specifically *Gardnerella vaginalis*, and are a hallmark of **bacterial vaginosis**. - They are not associated with viral vesicular lesions or herpes infections. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Infectious Diseases, pp. 366-367.
Question 3: Which of the following statements about nucleic acid amplification tests (NAATs) for STIs is FALSE?
- A. They can be used for test of cure after 3 weeks
- B. They can detect dead organisms after treatment
- C. They can be used for pharyngeal gonorrhea screening
- D. They are less sensitive than culture for rectal chlamydia (Correct Answer)
Explanation: ***They are less sensitive than culture for rectal chlamydia*** - This statement is **FALSE**. NAATs are generally **more sensitive** than culture methods for detecting *Chlamydia trachomatis* in all anatomical sites, including the rectum. - The high sensitivity of NAATs allows for the detection of very low bacterial loads, making them the preferred diagnostic method for many STIs. *They can be used for test of cure after 3 weeks* - This statement is generally **true**. While a "test of cure" (TOC) is not routinely recommended for uncomplicated *Chlamydia* or *Gonorrhea* infections due to high treatment efficacy, it can be considered in specific circumstances (e.g., persistent symptoms, pregnancy, or use of alternative regimens). - If a TOC is performed, it should ideally be done **no sooner than 3 weeks post-treatment** to minimize potential false positives from detecting residual nucleic acids from dead organisms. *They can detect dead organisms after treatment* - This statement is **true**. NAATs detect the **nucleic acids (DNA or RNA)** of the target organism. - These nucleic acids can persist in the body for a period even after the organism has been killed by treatment, leading to a positive NAAT result despite successful eradication of the infection. *They can be used for pharyngeal gonorrhea screening* - This statement is **true**. NAATs are the **recommended method** for detecting *Neisseria gonorrhoeae* in extragenital sites, including the pharynx. - Pharyngeal gonorrhea is often **asymptomatic**, making screening of at-risk individuals important for public health.
Question 4: A 25-year-old woman is diagnosed with first-episode genital herpes. Which clinical feature best predicts the likelihood of frequent recurrences?
- A. Severe primary episode
- B. HSV-2 versus HSV-1 etiology (Correct Answer)
- C. Presence of prodromal symptoms
- D. Duration of lesions >10 days
Explanation: ***HSV-2 versus HSV-1 etiology*** - **HSV-2 infections** are associated with significantly **higher recurrence rates** (typically 4-5 recurrences per year) compared to genital HSV-1 infections (approximately one recurrence every two years) [1]. - The **anatomical site** (genital vs. oral) and the **viral serotype** are key determinants of recurrence frequency [1]. *Severe primary episode* - While a severe primary episode may indicate a higher viral load or a less robust immune response, it does **not reliably predict the frequency of future recurrences**. - Its severity is more indicative of the **initial symptomatic presentation** rather than the long-term recurrence pattern [1]. *Presence of prodromal symptoms* - **Prodromal symptoms** (e.g., tingling, itching) precede a recurrence but **do not predict the likelihood or frequency** of subsequent recurrences. - They are an important patient cue for an impending outbreak, but not a prognostic factor for recurrence rate. *Duration of lesions >10 days* - The **duration of primary lesions** is characteristic of the initial infection's severity and the time taken for healing, but it does **not predict the frequency of future recurrences**. - Longer lesion duration may reflect a more widespread or intense initial viral shedding, rather than persistent viral activity over time.
Question 5: A 19-year-old woman presents with painful genital ulcers and vesicles for 4 days, accompanied by fever, malaise, and tender inguinal lymphadenopathy. What is the most appropriate initial management?
- A. Azithromycin 1g orally as single dose
- B. Benzathine penicillin G 2.4 million units IM
- C. Acyclovir 400mg orally TID for 7-10 days (Correct Answer)
- D. Doxycycline 100mg orally BID for 14 days
Explanation: Acyclovir 400mg orally TID for 7-10 days - The patient's presentation with painful genital ulcers and vesicles, fever, malaise, and tender inguinal lymphadenopathy is highly suggestive of primary herpes simplex virus (HSV) infection [1]. - Acyclovir is an antiviral medication that effectively reduces the duration and severity of symptoms in primary HSV outbreaks [1]. Azithromycin 1g orally as single dose - Azithromycin is primarily used to treat bacterial infections, particularly chlamydia and gonorrhea, which typically present with urethritis or cervicitis, not painful vesicles. - It is ineffective against viral infections such as HSV. Benzathine penicillin G 2.4 million units IM - Benzathine penicillin G is the treatment of choice for syphilis, which causes a painless chancre in its primary stage, not painful vesicles. - This antibiotic has no efficacy against HSV. Doxycycline 100mg orally BID for 14 days - Doxycycline is an antibiotic used for various bacterial infections, including chlamydia, lymphogranuloma venereum, and granuloma inguinale [1]. - These conditions typically present with different clinical features (e.g., painless ulcers, buboes) and not the vesicular rash seen in HSV.
Question 6: Which of the following is the MOST CRITICAL indication for Acyclovir use during pregnancy?
- A. Treatment of disseminated herpes (Correct Answer)
- B. Treatment of chickenpox in the first trimester
- C. Prophylaxis for recurrent herpes during pregnancy
- D. Prevention of cytomegalovirus infection in pregnancy
Explanation: ***Treatment of disseminated herpes*** - **Disseminated herpes** in pregnancy is a severe, life-threatening condition for both the mother and the fetus, making acyclovir use critically indicated. - This systemic infection can lead to **visceral organ involvement**, **encephalitis**, and significantly increased maternal and fetal morbidity and mortality. - Immediate treatment with intravenous acyclovir is essential to prevent **multi-organ failure** and death. *Treatment of chickenpox in the first trimester* - While chickenpox in the first trimester can be serious, leading to **congenital varicella syndrome**, acyclovir's role here is primarily to mitigate maternal illness, not as critical as disseminated herpes. - The risk of congenital varicella syndrome for the fetus is relatively low (around 0.4%) after maternal infection in the first trimester. *Prophylaxis for recurrent herpes during pregnancy* - **Prophylactic acyclovir** in the third trimester is commonly used to prevent recurrent genital herpes and reduce the risk of **neonatal herpes**, but it is not as acutely critical as treating disseminated disease. - This intervention aims to prevent transmission during delivery rather than managing an immediate, life-threatening maternal or fetal condition. *Prevention of cytomegalovirus infection in pregnancy* - Acyclovir has **minimal activity against CMV** and is not indicated for CMV prevention or treatment. - **Ganciclovir** or **valganciclovir** are the antivirals used for CMV, not acyclovir.
Question 7: A pregnant female presents with active herpetic lesions on the vulva. What is the most appropriate management?
- A. Wait & watch
- B. Acyclovir & elective cesarean section (C-section) (Correct Answer)
- C. Acyclovir & allow spontaneous progression of labor
- D. Induction of labor
Explanation: ***Acyclovir & elective cesarean section (C-section)*** - Active **genital herpetic lesions** at the time of delivery pose a significant risk of transmitting **herpes simplex virus (HSV)** to the neonate. - **Acyclovir** can help suppress viral replication, but a **cesarean section** is necessary to prevent direct contact with the lesions during birth, which could lead to severe neonatal HSV infection. *Wait & watch* - This approach is inappropriate due to the high risk of **vertical transmission** of HSV to the neonate if lesions are active during vaginal delivery, potentially causing life-threatening complications. - **Neonatal HSV** can result in significant morbidity and mortality, including neurological damage and disseminated disease. *Acyclovir & allow spontaneous progression of labor* - While **acyclovir** can reduce viral load, it does not completely eliminate the risk of transmission from active lesions during a vaginal birth. - The primary concern is protecting the neonate from direct contact with the **active lesions** in the birth canal. *Induction of labor* - **Induction of labor** does not mitigate the risk of **vertical transmission** from active lesions during a vaginal delivery. - The focus should be on preventing contact with the lesions, not on expediting vaginal birth once active lesions are present.
Question 8: A neonate who is febrile, presents with features of encephalitis. On examination, the baby is found to have vesicular skin lesions. Most probable causative organism is:
- A. Meningococci
- B. Streptococci
- C. HSV I
- D. HSV II (Correct Answer)
Explanation: ***HSV II*** - **Herpes simplex virus type 2 (HSV-2)** is the most common cause of **neonatal herpes**, presenting with neurological manifestations like encephalitis and characteristic vesicular skin lesions. - Transmission usually occurs during **vaginal delivery** from a mother with genital herpes, leading to widespread infection in the neonate. *Meningococci* - While *Neisseria meningitidis* can cause **meningitis** and **septicemia** in neonates, it does not typically produce vesicular skin lesions. - Its infections are more commonly associated with a **petechial or purpuric rash**, not vesicles. *Streptococci* - **Group B Streptococcus (GBS)** is a leading cause of **neonatal sepsis and meningitis**, but it does not cause vesicular skin lesions. - GBS typically presents with non-specific signs of sepsis or meningitis in neonates. *HSV I* - Although **herpes simplex virus type 1 (HSV-1)** can cause neonatal herpes, **HSV-2 remains the predominant cause** of vertically transmitted neonatal infection with encephalitis and disseminated disease. - HSV-1 is more commonly associated with **oral herpes (cold sores)** in older children and adults, though its incidence in neonatal infection is increasing.
Question 9: Which of the following genital ulcer diseases is LEAST likely to cause inguinal lymphadenopathy?
- A. Lymphogranuloma venereum
- B. Chancroid
- C. Granuloma inguinale (Correct Answer)
- D. Genital herpes
Explanation: ***Granuloma inguinale*** - While ulcers are present, **granuloma inguinale** typically causes a **painless, progressive ulcerative lesion** and is notable for a lack of significant **lymphadenopathy** [1]. - Systemic manifestations are rare, and regional lymph node involvement, if present, is usually due to **secondary bacterial infection**. *Lymphogranuloma venereum* - Characterized by **painful inguinal lymphadenopathy** (buboes) developing weeks after a transient, often unnoticed, primary ulcer [1]. - The **buboes** can become fluctuant, rupture, and drain, a hallmark feature of the disease. *Chancroid* - Causes **painful genital ulcers** and frequently leads to **tender, unilateral inguinal lymphadenopathy** [1]. - The affected lymph nodes (buboes) can also become suppurative and may rupture. *Genital herpes* - Often presents with painful vesicular lesions that progress to ulcers, accompanied by **tender bilateral inguinal lymphadenopathy** [1], [2]. - The lymphadenopathy is typically more generalized and less likely to suppurate compared to chancroid or LGV.
Question 10: Treatment of partner is required in all infection except:
- A. Trichomonas
- B. Herpes
- C. Gardnerella (Correct Answer)
- D. Candida
Explanation: ***Gardnerella*** - **Gardnerella vaginalis** is a common inhabitant of the vaginal flora and its overgrowth causes **bacterial vaginosis**, which is not typically considered a sexually transmitted infection (STI) in the same way others are. - While it can be transmitted sexually, treating the male partner has not been shown to prevent recurrence in the female; therefore, routine **partner treatment is generally not recommended**. *Trichomonas* - **Trichomoniasis** is a sexually transmitted infection caused by the parasite **Trichomonas vaginalis**. [1] - **Partner treatment is essential** to prevent reinfection and interrupt the cycle of transmission, as asymptomatic infection is common. [1] *Herpes* - **Genital herpes** is caused by the **Herpes Simplex Virus (HSV)** and is highly transmissible sexually. [2] - While treatment often focuses on managing symptoms in the infected individual, open communication and potential treatment or counseling for partners are crucial to prevent transmission and manage outbreaks. *Candida* - **Candidiasis** (yeast infection) is typically caused by an overgrowth of **Candida albicans**, a fungus naturally present in the body. - While it is not strictly an STI, sexual activity can sometimes trigger or exacerbate symptoms, and in recurrent cases, treating a male partner might be considered, but **it's not routinely required** as it is for true STIs like trichomonas or chlamydia. [2]
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