this presentation involves full simple easy description of HPV (human papilloma virus) as regard microbiology methods of transmission clinical presentation investigations needed for diagnosis mechanism by which HPV causes oncogenesis HPV screening for cervical cancer prevalence HPV warts lab detection Koilocytosis and koilocytes management (local medications and surgical destruction of warts) HPV vaccine HPV vaccine types (Gardasil, Gardasil 9,cervarix) age of administration indications for vaccination age of vaccination administration

1. Human papilloma
virus (HPV)
By
Dr. Ahmed Mohamed Amin Nasef
Assistant lecturer in Obstetrics & Gynecology
department
Benha University

2. HPV
Human species specific
Papilloma epithelium specific
More than 120 types have been identified
About 40 HPV types known to infect genital tracts of men and women
High risk types (HPV 16 & 18)

3. Microbiology
dsDNA virus
Member of papova family
This family has the following criteria:
Replication & assembly occur in nucleus
Virions are released by cell destruction
Infection are characterized by oncogenesis or
host cell transformation
This family is resistant to heat or formalin
Symptoms can occur after years of infection

4. Transformation
• Direct skin to skin contact
• Direct sexual intercourse
• Sexually active women
• Homosexuals
• Orogenital sex`
• Autoinoculation
• Fomites

5. Mechanism of oncogenesis by HPV
• Viral DNA integrate itself into host cell genome
• Expression of E6 & E7 viral genes
• Oncoproteins production
• Inactivation of p53 & other tumor suppressor genes
• Rapid cell proliferation and

6. • HPV is the most common sexually
transmitted disease
• 80% of women will be infected with
HPV at some point in their lifetime
• 3% - 5% of women HPV infection persist
and develop noninvasive lesion
• > 1% develop invasive cancer
• HPV also causative agent of other
malignancies (cancer oropharynx, anus,
penis, vulva & vagina)

7. Clinical
presentation
• Asymptomatic
• Genital warts (raised, flat, inverted, condyloma
acuminate)
Most cases resolve on its own
• Recurrence is common in (OCPs users, DM,
immunosuppression, pregnancy)

8. HPV warts

9. Lab detection
• Smear & stain with H&E the infected cells named Koilocytes and have the following criteria:
Nuclear enlargement
Irregular nuclear membrane contour
Darker than normal nucleus (hyperchromasia)
Clear area around the nucleus (perinuclear halo)
• direct probe assay methods for detection of DNA virus genotype
• NAAT (nucleic acid amplification test) by PCR
• HPV mRNA assay
There is no culture available
Serology for HPV is non sensitive

10. Koilocytes

11. HPV screening for cervical neoplasm
• WHO recommends HPV testing as the preferred one in areas where pap test isn’t
available
• Done every 5 years if combined with pap smear
• Done for all females (21-65 years old)

12. HPV
screening
for cervical
neoplasm

13. Management of
lesions
Local medications
Surgical destruction

14. Local medications
Proteolytic agents
• Trichloroacetic acid 70%
• It is a skin peel
Antimitotic agents
• Podophyllin delivered from
podophyllotoxin
• Not to be used during pregnancy
had teratogenic and CNS
damage effect
• No longer 1st line by CDC

15. Local medications
Topical immune modulating agent
• Imiquimod
• Immune response modifier group of
drugs
• Work by helping activate immune
system
• Induce macrophages to secrete
several cytokines to stimulate cell
mediated immune response against
HPV
chemotherapeutics
• 5-flurouracil
• FDA approved
• Prevent viral replication

16. Precautions
before local
treatment
application
Use Vaseline before
application to protect normal
skin around the lesion from
irritation
Wash medications off in 1 to
4 hours to reduce side effects

17. Surgical
destruction
This includes many methods as follows:
Electrosurgical excision
Cryotherapy
Laser ablation
Intralesional injection of interferon

18. There is no superiority for one treatment
over the others
treatment option is selected based on
circumstances and patient preferences
recurrences are common following
treatment

19. HPV vaccine

20. HPV vaccine
type
Recombinant vaccine

21. HPV vaccine
types
• Bivalent (cervarix)
For types 16 & 18
• Quadrivalent (Gardasil)
For types 16, 18, 6, 11
• 9 valent (Gardasil 9)
For types 16,18,6,11,31,33,45,52,58

22. HPV vaccine types

23. HPV
vaccine
effect
It prevents cervical
dysplasia with effectiveness
approaches 93 to 98%
It doesn’t work on existing
infection or preinvasive or
invasive disease

24. Administration
IM in upper arm
Given initial dose then
after 1 month then
after 6 months

25. Age of
vaccination
Most effective if given prior to sexual activity start
and exposure to HPV so target age is 11 or 12 years
old

26. Indications
Adolescents at age 11 or 12 years
People who get infected with one or more
HPV types can still get protection from
other HPV types covered by the vaccine
Not given in cases of allergy