DIP Ep 626: The Clutch Herpes Podcast (Step 1-3), Part A

And it's also incredibly high yield to know for level one, level two, and level three. So we're gonna run through the high yield things you need to know, make a bunch of very nice integrations, and try to prepare you really well for your exam. And one thing I would like to say is that

Uh friends at the MBMEs, they really love. So if you see me say the word MBME, I also mean MBOME, the National Board of Osteopathic Medical Examiners, right? Um, so the thing is the MBMEs, they love people to know the classifications of viruses.

So I'll say that that's something that's imperative to know. Like for example, uh in one of the classes I held recently, uh I was explaining how knowing that parvovirus B19 is a single-stranded DNA virus is a pretty high-yield thing to know for your exam. Because as you know, many DNA viruses tend to be double-stranded, right? So, like for example, uh herpes is a double-stranded virus, right? Herpes HSV is a double-stranded virus. It's a double-stranded linear enveloped virus. All right.

So let's jump right into it, right? So what if they give you a question about a dentist that has herpetic weight loss? Right, what is the most likely herpes virus that they have? I really hope you're saying divine. This is probably going to be HSV1. Again, can it be HSV2? Absolutely, but it's probably going to be HSV1. Right. So how do people get HSV1? Well, typically people are gonna get HSV1, you know, from saliva. That's why you can see the association with dentists.

and dental hygienists on your exams, right? You can get it from respiratory secretions, you can get it from saliva, right? And it can cause many different findings, right? Like for example, on your exams, it can cause uh cold sores on the mouth. Right. So if you see a person that has cold sores on the mouth, right, on the lips, for example, like the outer lips, it's probably going to be HSV1, right? But it can also cause other presentations, right? It can cause gingival stomatitis.

Right. So it can cause issues in your oral cavity. Right. It can also, and remember, what's the drug that can cause gingival hyperplasia? I hope you're seeing old divine. That sounds a lot like cyclosporine toxicity. Remember, cyclosporine is an immunosuppressant, right? It can cause eye inflammation, right? It can cause keratoconjunctivitis, right? Especially when you have these dendritic ulcers. If they use the term dendritic ulcers on your exam.

think about HSV1 right but remember HSV1 is not just limited to the face it can also cause problems in the you know in the person's genitals right so it can be a cause of uh herpes labialis but Typically that's gonna be more than a purview of HSV2, but HSV1 can absolutely on your exams cause herpes labialis, right? And again, if you're a person that contacts people's mouths a lot. Right. So let's say for example you're an examiner that tests people's mouth.

or you're a dentist or you're a dental hygienist or your dental assistant, those can be people that get HSV1 or infection on the exam. So that's going to be herpetic weight low. Remember, whenever you have a herpes infection, you're going to manage your day cyclovair. If you have herpetic weight low, the management

Strategy of choice is going to be oral acyclov. Oral acyclove. Okay. And also remember, HSV1 is typically the one that causes temporal lobencephalitis. Why? Because the thing is it likes to stay dormant in the trigeminal ganglia. So because he can stay dormant in the trigeminal ganglion, it has a direct access. to the actual brain. Remember, there's a difference between encephalitis and meningitis.

Encephalitis is when you infect the brain itself. Meningitis is when you infect the meninges, right? So HSV1 of the HSVs tends to be strongly associated with encephalitis, right? Although it can also cause meningitis. But typically on your exams is going to be associated with encephalitis.

Okay. And also, what if they give you a question about a person that has this breakout of skin lesions, you know, targetoid lesions on the skin? It looks like dark red in the middle, dark red on the outside, and pale in the middle, right? So it's like dark red in on the inside. Pale in the middle layer, dark red on the outside. You have a bullseye lesion, a target eye lesion, an iris. I R I S an iris looking lesion, then I want you to think about erythema multiformi.

HSV1 is the most commonly identified cause of erythema multiformi, typically on the USMLE exam. Okay. And again, remember HSV1 likes to stay latent in the trigeminal ganglion. Okay. So again, it can absolutely positively cause encephalitis. And many times this encephalitis is going to be associated with like aphasia, it's going to be associated with seizures.

Why is it associated with seizures? Because HSV likes to go after a person's temporal lobes, right? And remember, most seizures in the brain begin in the temporal lobe. Now another high yield factoids to know about HSV encephalitis.

is the fact that most times it's gonna be a hemorrhagic encephalitis. You're gonna see a lot of red blood cells in the C S F when you do a lumbar puncture. That's why sometimes for these people, right, we may be confused that, hey, does this person have um a subarachnoid hemorrhage because remember you can also see a lot of red blood cells. On a lumbar puncture if a person has sobrachnoid hemorrhage. Okay. So please make sure you know these key facts about HSV1.

Right. And remember, HSP1 is going to be treated with IV acyclovir. Although if you have uh herpes that is resistant to a cyclovir, it is very high yield to know that those people should get phoscarn. Right, because remember aclovair has to be activated by a thymidine kinase, by a thymidine kinase. That thymidine kinase, right, activates the acyclovaire for it to go ahead and inhibit DNA polymerase. But the thing is force carnage.

Uh but but think about it, right? That already introduces a middleman. Whenever you introduce a middleman, that's gonna increase your risk of there's just more points of failure, right? It's like ooh, you're relying on thymiding kinese for you to be able to work as a cyclovist. But if for some bizarre reason you're able to bypass that middleman of thymidine kinase, because that's a common mode of resistance.

a mutation in thymiding kines, then that can be very, very, very amazing. That can be very very very amazing, right? In that case, if you can bypass that kinase step, remember kineses are things that phosphorylate, right? Kineses are things that phosphorylate. Right, so if you can bypass that phosphorylation, then that would be amazing. So that's where phoscarnate comes in. Phoscarnate is a pyrophosphate analog.

Phoscarnet is a pyrophosphate. Look at the name. Pyrophosphate. So it's already been phosphorylated. It doesn't really need that thymidink kinase step that acyclovare requires. It does not really need that thymidine kinase step that a cyclovaire requires. So you can bypass that step, right? So if you have uh resistance, right, in the in regards to thymiding kinase in a person that has HSV, just go ahead and give that person phoscarnate. Okay, go ahead and give that person phoscarnate. All right.

And remember I said again, HSV one is strongly associated with erythema multiforming. those target lesions. Remember, most times those things are just going to involve the skin, right? At least we call that erythema multiformi minor, right? But sometimes you can have erythema multiformi that involves the skin and mucosal surfaces.

We call that erythema multiformi major, right? Obviously, EM major is going to be more significant than EM minor. Now, the high-you thing you want to know for your exams with erythema multiformi is that again, HSV1 is most commonly associated with it. But remember, there are other things that can cause it, right? Things like mycoplasma, especially in children and in young adults, can absolutely positively cause erythema multiformi, right? And remember, certain drugs. Like insects.

like allopurinol can also be associated with erythema multiformi. Although remember, typically erythema multiformi is caused more commonly than by infections. Than by drugs. I'm gonna say that again. Erythema multiformi tends to be caused more commonly than in by infections than by drugs. Right? Contrast that with SJSTN, Stevens Johnson syndrome, and toxic epidermal necrolysis.

which has a much more strong association with drugs, right? And remember, erythema multiformi is going to be Nikolsky negative. It's going to be Nikolsky negative. When you rub your palm over those skin lesions, you're not going to get denudement of the skin. But a person that has Stevens Johnson syndrome or a person that has toxic epidomal necrolysis.

Those things are going to be Nikolsky positive. Nikolski positive. When you rub your hands over those lesions, you're going to remove the skin with it. Remember the other things that are Nikosky positive. Like um Pemphigos vulgaris, right? Remember, Bullos Pemphigoid is going to be more Nikolski negative. Again, since we're talking about HS, I want to talk about the high yield points that surround it, right? Because again, that's something that uh is pretty high yield to know for your exam.

Right. And then the last thing I want to say here is remember the patholphism behind Erithima multiformi. Number one, it involves cell-mediated immunity, right? So you have this antigen, right, like HSV1, for example, and then T cells. Because remember, HSV1 is a virus. And what arm of the immune system helps us handle virus?

it's gonna be t cells right so you can have t cells going after that hsv one As you go after that HSV1, you're going to, you know, that cell mediated immunity with C D8 positive T cell. That can cause a lot of damage to the skin, right? That can cause a lot of damage to the skin, right? Another thing that can also happen is that you can form antigen antibody complexes, right? So the antigen in this case, HSV1.

Antibodies against it can go and settle within your dermal system, within your skin, and that can trigger inflammation and cause disease. Okay. And remember, remember, HSV1 can also cause herpes zoster ophthalmica. HSV1 can also cause herpes zoster ophthalmicus, right? Especially if he stays dormant in the first branch of the trigeminal nerve, right? Because remember, your trigeminal nerve.

Cranial nerve 5 has three branches, right? Your trigeminal nerve, cranial nerve five has three branches. Your trigeminal nerve cranial nerve five has three branches. Branch number one is the ophthalmic nerve. Right? Branch number two is the maxillary nerve. Branch number three is the mandibular nerve. So ophthalmic, maxillary, and mandibular. And that makes sense if you look at the face, right? Ophthalmic, your iron region. Maxillary, below your eye region. Mandibular.

Well below your ear, well below your eyes, right? So the thing is happy zosterophthalmica. Think about it. Herpes zosterophthalmicus. Herpes zosterophthalmicus. What branch of the trigeminal nerve, right? What branch of the trigeminal nerve? What branch of the trigeminal nerve, right? What branch of the trigeminal nerve is going to harbor HSV1 for you to have herpes oster ophthalmicus? What do you think?

Ophthalmicus. It has to be the ophthalmic nerve, right? It has to be the first branch of the trigeminal nerve. Okay? It has to be the first branch of the trigeminal nerve. Again, that's the ophthalmic nerve. That's very high you to know for your exam. That's very high you have to know for your exams. Okay. Now, one other thing I want to say about the trigeminal nerve. Again, this is just kind of

Hitting my brain, right? Again, we're trying to make integrations here. I know this is a HSV podcast, but there's all these other little things our friends at the MBMEs love to test. Now, remember, you can also have trigeminal neuralgia. You can have trigeminal neuralgia, right? Where you have like this fleeting pain that just comes on very suddenly, right? And you'll it really, really hurts. And we're gonna manage that with carbamezepine.

That's something that can happen, right? When you have inflammation or you have pressure around branches of your trigeminal nerve, right? That's why most times people that have trigeminal neuralgia tend to have uh pain on their face. Right. So if wind blows across their face, it really hurts a lot. And one thing that I think is very, very high to know for your exams is an alternate name that our friends at the MBMEs can use for trigeminal neuralgia. Right? What is an alternate?

Well, sorry, not for trigeminal neuralgia, for cluster headaches. Cluster headaches. Because cluster headaches also tend to occur around the eye. You know, again. Sorry, I know things may seem a little disorganized, but I'm really trying hard to make integrations as they come to my mind that are necessary for your exams, right? So We've talked about HS V1, right? We've talked about herpes zostrophalmicus.

Because of latency is the in the first branch of the trigeminal nerve, right? That's the ophthalmic nerve. We've talked about trigeminal neuralgia, right? Fleeting pain. Wind blows on your face or a cloth is moved across your face. You have this fleeting pain that is like very, very intense. Very very intense. That's going to be uh trigeminal neuralgea. We managed that with carbamezepine, which as we know can cause SIDH, right? And uh uh and uh agranulocytosis, it can cause a neutropinic fever.

But a third thing that is very high yield to know with the trigeminal nerve on your exams is actually that people that have trigeminal nerve problems, right, can actually have cluster headaches. In fact, the thing is. Cluster headaches are linked to pathologies of the trigeminal nerve. Cluster headaches are linked to pathologies of the trigeminal nerve.

In fact, sometimes our friends at the MBMEs, that's the alternate name I was referring to. Our friends at the MBMEs sometimes can test cluster headaches and they can give it an alternate name. The alternate name is trigeminal autonomic cephalalgia. Trigeminal, right? So it's cranial five related. Autonomic

So your genomic nervous system is kind of linked to it. Cephalalgia. Cephalo means your head, right? And algae means oh this thing hurts, right? If you're taking an analgesic, you're taking an analgesic because you're trying to prevent pain, right? So cephalalgia and algae means it hurts. Right? So that's a cluster headache. Remember a cluster headache is going to be a unilateral headache.

And then you're gonna have eye findings on the same side. You're gonna have a unilateral headache and you're gonna have eye findings on the same side. Eye findings on the same side. Eye findings on the same side. Many of those eye findings are autonomic symptoms. You can have tearing, you can have redness. Many of those things are autonomic symptoms. That's why. Trige uh

Cluster headaches are called trigeminal autonomic cephalalgias. And remember, we're gonna manage that with verapamil. Virapamil is gonna reduce how many cluster headaches you have. But acutely, for the acute phase of a cluster headache, you're going to manage it with. Oxygen, right? You give it within about 15 minutes of the onset of the headache, you can abort the headache very, very quickly. Okay, so I think uh, because again, I

Ton of commitments these days, right? So uh what I'm gonna try to do is let me summarize what we've talked about today, right? So there's gonna be a herpes podcast part B. Again, please, with my podcast, I know this is a common complaint online that divine, you know, you

You you go off on these different tangents. See, the thing is going off on these tangents is beneficial for the USMLEs, right? That is one differentiator between these podcasts and other resources. Right? Many other resources they teach things in linear fashion. For me, I teach things in integrity fashion. The thing is, for your exams, it's more beneficial to learn things in integrity fashion because you can see links between different concepts.

That's more realistic prep for the exam that is being placed before you. That's just the truth. I'm just trying to be completely honest with you, right? So I know it may be uncomfortable, but it's actually better for your brain with regards to exam prep. Okay. Integrative learning is actually better for your brain, right? Again, is the road less traveled? People do not like it.

It's not very fun and exciting, but it's actually the better way to prepare for your exams. Because the questions you're gonna see on your exams are not gonna be linear questions. They're gonna be what? Integrative questions. So it's better to deal with the discomfort right now so that when you get to your real test. that discomfort

Is gone. You're like, oh, I already think in an integrative fashion, not in a linear fashion. So again, remember, the fact that something is easy on your brain does not necessarily mean it's the best thing for you long term. Just a extra thought I want to throw out there, right? So again, key factor about HSV1. We've discussed today. Respiratory secretions, right? You can get it from your saliva. We talked about the dental assistant association, dental hygienist, dentist.

Right? Keratoconjunctivitis, herpes asterophthalmicus. I'm just calling out the keywords. Herpes ostraophtalmicus. Trigeminal nerve latency, right? Herpes ostroophthalmicus, we said is especially with the ophthalmic nerve, right? That's where it tends to lay dormant, right? We said that hey, you can get herpes oralis, right? The side of your lips, but HSV1 can also cause herpes labialis. Right. Uh it can cause cold sores on your genital area, right? We talked about herpetic weight loid dentist.

We talked about temporal lobo encephalitis, and we said that that's gonna happen because HSV1 is stays dormant in the trigeminal ganglion, so it has a direct connection to the brain, it has a stronger association with HSV encephalitis than HSV2. HSV2. typically does not stay dormant in the trigeminal ganglia. We talked about erythema multiformia, we talked about the minor kind that just involves the skin, and the major kind that involves the skin and mucosal surfaces.

Right, we talked about esophagitis. Right, HSV can absolutely cause esophagitis, especially in immunocompromised people, although candida is gonna be the more likely cause. Right. And then we talked about how people can get uh hemorrhagic encephalitis, right? And then we talked about the trigeminal nerve associations. We talked about Um trigeminal neuralgia. We talked about

Clostra headaches, right? Which is a trigeminal autonomic cephalalgia. And then we also talked, uh, I didn't talk about this, but I guess I'm gonna mention it. Right. Uh remember another trigeminal issue is uh port wine stain, right? In fact, sometimes we call this encephalotrigeminal angiomatosis.

Encephalotrigeminal langiomatosis. Uh that's Sturgeva Weber syndrome, right? That's one of those neurocutaneous disorders. Okay, so I think I'm gonna go ahead and stop here. Again, there has to be a part B of this podcast. A bunch of stuff I discussed here, didn't plan to discuss them, but They pretty high yield to know for your exam. So we're gonna pick up from here, God willing, in the next episode, episode six hundred and twenty-seven. Uh again if you're interested in any of my classes.

Uh starting in the month of December, right? December 1st to December 5th. I have a 25-hour step one class. It's a basic science review. It's intended for step one and level one. But if you're a person that is studying for step two or level two, step three or level three, and you have a poor basic science foundation because basic sciences.

are becoming very, very important on those exams. This is a class you're gonna benefit from. And also within the month of December, I also have my test taking class for step one to three, my biostats class for step one to three, my social sciences quality improvement and ethics class for step one to three.

And then I have a last minute review for step two and step three. And I have a 20 hour class for step two and step three. And then I also offer one-on-one tutoring and I help with mock interviews and personal statements and all those things. So if you're interested in any of these things, uh they're gonna All happen over Zoom. Shoot me an email and I can give you some more information. I can give you some more information.

Right. Uh so thank you for listening to me today. Have a wonderful, wonderful rest of your day. I will see you, God willing, in episode 627. Have a wonderful day. God bless you. And bye for now. And don't forget, if you're looking for some good life lessons, check out divine interventionlife lessons.com. It's another website that I have. There's actually an Apple podcast associated with that, the Divine Intervention Life Lessons Podcast.

Every week I post one to two podcasts where from a biblical perspective I address a life lesson. Many of you know I'm a Christ follower, right? So I make these podcasts based on Bible verses. And many people listen to them and find them to be helpful. All right. So I will see you in the next episode. Have a wonderful day. God bless you and bye for now. Thank you.