DIP Ep 627: The Clutch Herpes Podcast (Step 1-3), Part B

Right. So we talked about HSV one at length in that podcast. Uh remember HSV two. Uh that's the one that uh you know, herpes simplex virus two, that's the one you get through, you know, sexual contact. Uh perinatally, right? So vertical transmission from mom to the baby. Um that's usually gonna be HSV2, right? So neonido herpes, herpes genitalis. Uh that's gonna be HSV2 a lot of the time on your exam.

Right. And I'm going to make some parallels with HSV1. Right. So remember HSV1, we said that most times it's going to be latent in the trigeminal ganglion. Right. But for HSV2, it's different. It's going to be latent in the sacral ganglion. In the sacral ganglion, right? And one thing that's kinda weird though, that I think is very high you to know for your exam. is that unlike HSV1 that typically tends to cause more of an encephalitis.

HSV two tends to cause more of a meningitis. Okay. HSV one tends to cause more of an encephalitis, it infects the brain tissue itself, the brain parenchyma. But HSV2 tends to cause more of a meningitis picture, right? That's very, very important to keep at the back of your mind for exams, right?

But really many of the things I said about HSV1 typically apply to HSV2. Alright, so let's keep going. How about HHV three? Human herpes virus number three. Well that's gonna be varicella, right? Zoster virus, right? And remember varicella. um is is is pretty high yield to know, right? That it can cause chicken pox, it can cause shingles, right? It can cause pneumonia, right? Especially in people that are immunocompromised, right? People that are immunocompromised

And one thing you want to be very careful about with varicella is hey, be careful of touching the the fluid from uh from the person's vesicles. If not you can get in trouble. You can get in trouble, right? You can get in trouble either by t touching the fluid from the vesicle. Or being in contact with your respiratory secretions. Because again, remember what I said, varicella can absolutely positively cause.

um cause uh pneumonia, right? Especially on the USMLE exams, right? Now, where does it stay latent? Again we said H H V one is gonna be in the trigeminal ganglion, H H V two is gonna be in the sacral ganglion, H H V three is usually going to be in the dorsal root ganglion or in the trigenal ganglion, right? Either in the dorsal root ganglion or in the trigenal ganglion.

Actually, one parallel you can see with H with HHV1 here is that it can be in the ophthalmic nerve branch of the trigeminal nerve. It can be in that ganglion, right? So that's why you can see herpes a zosterophthalmic. Right. Right. And one thing that's pretty high yield to know for your exams is remember the Varicella vaccine is a live attenuated vaccine. So you cannot give it to people that are under age one.

or people that are pregnant or people that have a CD4 count under 200, right? And the thing is whenever a person has a shingles infection, you know, many times on the USMLEs these days, one thing they really love to emphasize is prognosis. Right. In fact, in many of my classes and in many of my podcasts, you see me emphasize prognosis. Like my twenty hour class, I emphasize a ton of prognosis.

In my fifty hour class that holds once a year emphasizes ton of prognoses, right? The prognosis, especially like the most common complication, most likely complication after a person has shingles is PHN, post herpetic neuralgia. And on the US ML exams, how would you manage post trapidic neuralogy? Well I would hope you're saying, oh divine, we can use things like pregabalene or gabapentin or we can use um a tricyclic antidepressant, right? Um or we can use an SNR like duloxetine.

Now, one thing our friends at the MBMEs love to do these days is to give you many of those answers. all in the same question. You're like, hey, which one am I gonna pick? Right. So if they give you something like uh emitreptaline or notreptaline as an answer, but they also give you pregaboline or gabapentin as answer. For a person that is like sixty-seven years old, which answer should you pick if they have post herpetic neuralgia?

I would hope you're saying that, oh, divine, of course, I'm gonna pick uh gabapentin or pregabaline, right? The reason we do that is remember the TCA is the tricyclic antidepressant. They have anti-HAM effects. They have anti-H1 effects, so they can cause sedation. They have anti-alpha one effects, so they can cause orthostatic hypotension that can increase your risk of fall.

And then they also have anti muscarinic effects that can increase your risk of delirium and anticholinergic problems like uh urinary retention and things like that. Right. So say for example if a person has a history of BPA. is maybe not the smartest idea in the world to put them on a tricyclic antidepressant. In that case you want to consider pregabalin or gabapentin. Or you can try an S N R like duloxetine. Remember duloxetine

And I believe uh this uh drug are known as Mel Melnaciprin, M I L N A C I P R A N, Melnacipran, Doloxetine, their SNRIs, their serotonin, norepinephrine reoptic inhibitors. They work pretty well for uh

Neuropathic pain. Alright, so next let's go to HHV4. Right, so this is EBV, right? Epstein Bar virus, right? Remember the classic. thin on your exams. It's gonna be some young person that kisses another person And then they start having like really sore throat, tonoscervical lymphatonopathy, right? They may have hepatosplenomegaly, right? That's gonna be mono, right? It's gonna be infectious mononucleosis.

Right. So again, how do you get this problem? Respiratory secretions, right? Saliva. That's why it's called Kissin disease. Kissin disease. Right. So again, typically again, you're gonna see sore throat, so like pharyngitis, you're gonna have a lot of lymphatonopathy, especially posterior cervical lymphatonopathy. But again, please, that is not specific for mono.

Please, that is not specific for mono. That's very high yield to know for your exams. In fact, sometimes our friends at the MBMEs, they will intentionally give a person mono, and they will give that person anterior cervical lymphadenopathy. So just be careful about that. Okay. Now these people remember if a person has mono

What should they avoid for four weeks? Contact sports, right? So basketball, things where again your belly can be bumped into, right? Because those people can rupture the spleen. If you rupture the spleen, remember you're gonna start struggling with a lot of encapsulated organisms like strep pneumo, uh H flu, and Iceroming. Now, what are some other things to know about HHV4, about the Epstein Barr virus?

Well you do need to know the malignancies that it's associated with, right? So like for example, it's associated with Burkit's lymphoma. Don't forget that 814 translocation, you know, jaw mass in kids, especially Africans, and then abdominal mass in Europeans and adults.

Um don't forget nasopharyngeal carcinoma. So a cancer of the nose or the pharynx in a person that is from China, right? Especially people from southern China or just people that have Asian ancestry. You want to think about a nasopharyngeal carcinoma. Uh don't forget oral hairy locoplachia, right? Remember that's the lateral tongue lesion that does not

scrape with a tongue depressor that's also caused by the Epstein Bar virus, right? And then don't forget post-transplant limpoproliferative disease. Right. So you're gonna see this in a person that is severely immunocompromised or the immunosuppression was just bumped. And then you notice that they just have these uh uh lymph nodes just popping up all over their bodies, right? That's gonna be PTLD, post transplant lymphoproliferate.

disease. That's very, very, very classic for EBV infection, right? So why is it that EBV tends to cause a lot of B cell problems? Well G it's because it infects B cells, right? It infects B cells through the C D twenty-one uh receptor, right? So it infects B cells through C D twenty one, right? Infects B cells through C D twenty one. And remember, again, the way we're going to diagnose mono is to use the heterophile antibody test.

Right, the monospot test. But sometimes to mess with your head, instead of calling it the mono spot test, they will call it the heterophile antibody test. Okay. Uh the heterophile antibody test. You're you're pretty much detecting um sheep, uh, red blood cell um uh antigens, right? So uh You pretty b th th those antibodies, right? So the heterophile antibody tests, right? They're just basically antibodies against sheep or horse.

uh red blood cells, right? Now one other thing you may find with mono on your exams is that remember mono is a viral infection, right? EBV, Epstein Bar virus, right? So what arm of the immune system is gonna be dealing with that for us? It's gonna be the cell mediated immunity. It's gonna be T cell.

Right. So you can actually see these T cells on a blood smear, right? They're called uh downy cells or atypical T cells, downy cells. There's literally nothing atypical about them. It's just somebody decided to call them atypical T lymphocytes or downy cells. Literally it's T cells, cell mediated immunity that helps us deal with this problem, right? And remember when a person has got mono, right, you give them amoxicillin, they can have a rack.

They can have a rush. They can have a rush, right? Because again, remember the acute phase of mono can look like a person has like a pharyngeal infection, like strep. Uh groupase trep, you know, like trepyogenes, right? And you're like, hey, let's give you amoxicillin, but then they can have this full body rash. Well, it's pretty high yield to know for purposes of your exam. that that full body rash is not a hypersensitivity reaction. Okay?

That full body rash is not a hypersensitivity reaction. That's number one. Number two, uh those people can still take amoxicilline in the future, right? That's a very classic, weird question you may see on your exam. those people can absolutely, positively still take amoxicillin in the future. All right.

So I think that's all I'm gonna say about uh EBV, right? So now let's go to CMV, right? Cytomegalovirus. Right. Remember CMV, they love, love, love to test these things in uh newborns, right? So if you see a newborn with CMV, uh the key thing to know they may have sensory neural hearing loss. Right, they may have microcephaly, right? And they may have periventricular calcifications, periventricular calcifications, right? Calcifications around the ventricle.

Right, remember another cause of periventricular lesions on your exams are it's gonna be multiple sclerosis, or it's just something you want to it's not gonna be calcifications. But they're gonna have periventricular lesions, right? You're gonna see that in in MS.

Right. So remember CMV, right? Uh again, what what are the classic quiz people people get this stuff, right? So like you can get it congenitally from mom, right? That's how you can get congenital CMV, right? You can get it from blood transfusions, right? Sexual contact. Um, transplants, right? C M V is one of these things we're kinda scared about with transplant.

Right. Um, and it can also cause a mono-like syndrome, right? But many times it's gonna be monospot negative, right? So it's gonna be a monospot negative. Mononucleosis-like syndrome. Unlike EBV, HHV4, that is a monospot positive or heterophile antibody positive, mononucleosis-like syndrome, right?

So remember, what are the things that C M V can cause, right? It can cause uh pneumonia, right? Again, especially in people that are immunocompromised. It can cause esophagitis in HIV patients, right? Uh many times you're gonna see those uh Lesions in the esophagus, right? It can absolutely cause those issues, right? Um, it can cause vision problems, right? In fact, if you see vision problems in a HIV patient on your exam,

Uh that's a C M V infection right there, right? Uh it can cause uh you know, like C M V retinitis. Again, remember C M V likes, likes, likes to go after people that are um that I immunocompromised like HIV patients, right? And remember One if there is one thing I wanna know about C M V You better make sure that you can identify the Alzheimer nucleus, right? The Alzheimer nuclei. They can call it the Alzheimer nucleus on your exams. Or they can call it an intranuclear inclusion or your exams.

Right. Um it kind of looks like a Samoma body in a sense. If you look at a Samoma body and you look at the outside nucleus, they kind of look pretty pretty similar, right? So and remember how do we treat CMB on the USMLEs? We're gonna treat it with Gancyclovair, right? We're gonna treat it with Gancyclovair. We're gonna treat it with what with gan cyclovair.

Now remember Gancy Clovir inhibits DNA synthesis, but to do that it needs to be activated by an enzyme known as the UL ninety seven, University of Louva. Uh that's my alma mater, uh you know, for college. So U L ninety seven Chinese needs to activate it. Um M so you you can already begin to learn from that that hey, what's gonna be the mode of resistance to this stuff? Well if you have a mutation in the UL ninety seven kinase, then

You're not going to be able to treat that CMV, right? So you have to go for the second line treatment in this case, phosphornate. Phoscarnate, remember, is a pyrophosphate analog. It's a pyrophosphate analog. Okay. It's a pyrophosphate analog. All right. And again remember um CMV stays latent. Right. We've talked about how uh H H V one

stays latent in the trigeminal ganglion, H H V two, sacro ganglion, H H V three, dorsal ganglion or trigeminal ganglion, right? Um E B V can stay latent in B cells, right? Now don't forget that C M B H H V five can stay latent in um

in our mononuclear cells, right? So like macrophages for for examples, right? So okay, so let's go ahead and go to H H V six. This one, the the remaining H H Vs, there's not much with with them that we need to know for exams, right? But remember

HHV6, that's a roseola, right? That's rosiola. Sometimes they call it exact them subitum on the exams, right? You're gonna get it from saliva, right? So from like kissing your baby, right? And typically the way it's gonna present on your exams, it's gonna present in a child, little child, right? Child is gonna have high fevers for a couple of days. And then after the child has high fevers, the fever is gonna stop, and then they're gonna have this rash.

that uh kind of starts on the trunk and then spreads to the extremities, right? So a child crazy high fever. Sometimes these fevers can be 104, 105 style fevers, and then it stops. And then after that, they have a rash that's on the trunk. fans out to the extremities. When you see that, think of Rosiola. Okay? Think of Rosiola. Think of Rosiola.

Um this is usually going to be cost on the USML exams by HHV6. Okay. Sometimes you may see HHV7, right? Human herpes virus seven being the cause of roseola. Okay, so Rosiola, by the way, they can make it a febrile seizure question on your exams, right? So remember uh little kids when they have fever, uh I can kind of cook their brains. They can have seizures from that.

Right. So if you see febrile seizures again, it can be from a virus typically on your exams, it can be from a bacterial infection. But it can also be from from uh H V six, right? Rosola. And one thing I think that's pretty helpful to know about febrile seizures is again knowing how to differentiate a typical febral seizure from an atypical febrile seizure. Right, so a typical febrile seizure is going to be last for less than 15 minutes.

And it's gonna be generalized tonic chronic, right? And for those people, just give them acetaminophane, give those kids acetaminophane, reassure the parents that's all you gotta do. But if that seizure lasts from more than fifteen minutes. Or it is focal or both. That's really worrisome. That child probably needs some further evaluation. You you probably shouldn't give them acid amino fin and send them on their merry way.

Uh those kids probably need to be brought into the hospital and get some kind of a more detailed neurological evaluation.

Alright, so we've done H H V one, two, three, four, five, six and seven, right? So let's do eight, right? So eight sometimes is called uh KSHV, right? Carposis, sarcoma, herpes virus or whatever.

Right, you're gonna get this from sex, right? And it's gonna be in again in people that are immunocompromised, immunocompromised people, right? And many times uh this can cause a carposis uh sarcoma, right? Carposis sarcoma again, we tend to find it in the immunocompromise, especially people that have HIV or AI. Right, or people that are transplant patients. Again, remember, one of the things that our friends at the MBMEs love to do these days is to give

Um, these uh HIV-related infections to non-HIV people, right? So again, remember, HIV is not the only cause of immunocompromise, right? Diabetes can cause immunocompromise. uh because of the hyperinsulinemia, right? Um what else can cause immunocompromise if you're on chronic steroids, if you're on TNF inhibitors, right? If you're a transplant patient, if you have one of these immunodeficiency diseases like skid, severe combined immunodeficiency, for example, that can cause problems, right?

And remember Carposis sarcoma, right? It's a vascular tumor, right? It's literally a tumor of endothelial cells. It's literally a tumor of endothelial cells, right? So the classic thing you're gonna see on your exams, and you should be able to spot this, is you're gonna see these violet-colored, these dark uh lesions like plaques nodules on the skin, right? Those are just uh and sometimes the instead of

saying what it is, they may ask you to talk about the mechanism right behind those physical exam findings. Well the mechanism is going to be from proliferation of vascular structures, right? Proliferation of vascular structures. And remember that Excuse me, H H V eight can also mess up your GI tract, they can mess up your lungs. They can have long lesions, right? They can have GI tract lesions, right? So those are things you certainly want to keep at the back of your mind with HHV. And remember

HHV, do not forget, how do you detect it on your exams? You're gonna detect it on your exams with PCR, right? PCR is how you detect HHV, you know. Um or if a person has like herpes, encephalitis or meningitis, you can do again PCR of a CSF sample, right? And remember, uh whenever a person has HSV meningitis, right? Or encephalitis, remember encephalitis tends to be caused by HSV one.

meningitis sensor because by HSV two, uh those people typically will have um a lot of red cells in their CSF, right? Typically, I did not say always, but typically uh HSV can absolutely positively cause a um

a hemorrhagic meningitis or encephalitis on your exams, right? So please I would encourage you not to be picking the Zang smear. I would only pick that if there's nothing else available, right? But you know, you see these multinucleidic giant cells uh that we see in like H H V one, two or three. But nah, that's not gonna be what is gonna be right on your exams. Again, so only pick that if you don't see PCR of like some sample as the answer on your on your test, right? So uh

I'm gonna go ahead and stop here, right? But again, please make sure you know these things. Make sure you know these things. Don't forget that again, EBV infects B cells through CD twenty one. right. Uh C M V right, H V five, right? Kind of goes uh you know through integrants. Integrants are gonna be his route of entry, right? Especially like heparan sulfate. It's gonna be his ranch of ro route of entry into a into a cell, into a mononuclear cell. Right. And again one thing I think that is

Probably kind of helpful to uh know for your exams is that heparan sulfate is also part of the basement membrane of uh your glomerula, right? So remember your glomerula. barrier, right? So you have the fr on the inside, you have the uh globella um You have the endothelium of your glomerular capillaries, right? That's fenestrated, and then after that you have your glomerular basement membrane that contains heparan sulfate, which is negatively charged.

Right, that's a charge barrier. And then after that you have your puddle side food processes, right? So you want to kind of keep that at the back of your mind for your exams. All right, so I think I'm gonna go ahead and stop here. Um again, thank you for listening to me. If you like the way I teach, like the way I make integrations, you're gonna love my classes. I have a bunch of classes starting next week Monday for step one all the way to step three.

So the step one to three classes. I have a test taking class on Monday, uh over Zoom. It's two and a half hours long. On Tuesday I have a four hour biostatistics class also for step one to step three. Uh and then on Wednesday I have a social science quality improvement ethics and uh you know healthcare systems and a hospital medicine class. Also for step one to step three. It's a five hour class. And then after that I have a last minute review on Thursday, that's the eighteenth of December.

Um I th that's more for step two, step three. Um that's gonna be on Thursday, three hour clock. Very helpful class for many people. And then on Friday, Saturday, Sunday, and then the following Monday and Tuesday have a 20-hour step two, step three class. Again, many people have taken these classes and done extremely well on their exam.

Um and again it's over Zoom and it's not some other person teaching it. It's me that will literally teach it. And uh again, many people have taken these classes found them to be extremely helpful. And then I have a step one, twenty-five hour class that's gonna be taking place in the first week of February of next year. And then a fifty hour step two step three class that's gonna be taking place in the first two weeks.

of June next year. That's for step two, step three. Very helpful class, very amazing class. Again, many people have taken the class. absolutely just crushed their exam. So thank you for listening to me today. If you also desire one on one tutoring or help with your ERAS applications like mock interviews, personal statements and things like that, uh those are services I offer. And then don't forget that I have these podcasts on Apple Podcasts, Google Podcasts and Spotify.

And I also have another website called Divine Intervention Life Lessons dot com. Divine intervention lifelessons.com. Many of you know I'm a Christian, I'm a Christ follower. So every week I post like one or two podcasts where from a biblical perspective.

uh address a life lesson. Many people listen to those find those to be pretty helpful. I have almost like 400 podcasts on there as well. And there's actually an Apple podcast associated with that called the Divine Intervention Life Lessons Podcast.

Right. And then uh don't forget I have a YouTube channel, you know, Divine Intervention, USMLE podcast and videos. Uh that's where I post the videos that I make. So thank you for listening to me today. I will see you, God willing, in the next podcast. Have a wonderful day. God bless you. Bye for now. Thank you.