Sexually Transmitted Infections: Human Papillomavirus

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Chapter 52 Sexually Transmitted Infections: Human Papillomavirus

INTRODUCTION

Description: Infection by one or more subtypes (of the more than 100 known) of human papillomaviruses (HPV) causes epithelial proliferations at cutaneous and mucosal surfaces. Some serotypes are associated with warty growths on the hands, feet, and other locations (including genital warts). Some high-risk serotypes are found in more than 99% of cervical cancers.

Prevalence: Thought to be the most common sexually transmitted disease in the world. About 20 million people are currently infected with HPV. At least 50% of sexually active people acquire genital HPV infection at some point in their lives. One study estimated that 64% to 82% of adolescent girls were infected with at least one strain of HPV. By age 50, at least 80% of women will have acquired genital HPV infection. About 6.2 million Americans acquire a new genital HPV infection yearly.

Predominant Age: Reproductive and beyond.

Genetics: No genetic pattern to infection. The genetic characterization of the virus has led to the identification of those serotypes that are oncogenic.

ETIOLOGY AND PATHOGENESIS

Causes: Exposure to the DNA human papillomavirus. More than 40 serotypes are know to be sexually transmissible. Vertical transmission from mother to child during childbirth can occur and rarely results in laryngeal polyps (approximately 2/100,000 births). Papillomaviruses initiate infection in the basal layer of the epithelium, and viral genome amplification occurs in differentiating cells. After infection, differentiating epithelial cells that are normally nondividing remain in an active cell cycle. This can result in a thickened, sometimes exophytic, epithelial lesion. The virus is released as cells exfoliate from the epithelium. Research indicates that HPVs produce proteins (designated E5, E6, E7) that interfere with tumor suppressor p53 proteins that arrest the cell cycle when there is DNA damage.

Risk Factors: Direct contact with an infected individual; therefore, having multiple sexual partners or contact with a person with multiple sexual partners increases the risk. Viral persistence is more likely in those with reduced immunity and tobacco smokers. Other epidemiologic factors associated with risk of cervical cancer include long-term use of oral contraceptives, coinfections such as chlamydia, parity, and nutritional factors.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Most are asymptomatic and are cleared spontaneously (70% by 1 year and more than 90% within 2 years; median infection: 8 months)

• Persistent infections may be associated with warty growths at the site of infection (condyloma accuminata) and cellular changes associated with dysplasia or cancer (including cancers of the anus, vulva, vagina, cervix, and some cancers of the oropharynx).

The incubation period required before symptoms appear is highly variable and varies from several weeks to years.

DIAGNOSTIC APPROACH

Differential Diagnosis

• Secondary syphilis (Condyloma lata), other viral) infections.

Associated Conditions: Other sexually transmitted diseases.

Workup and Evaluation

Laboratory: No evaluation indicated (see special tests).

Imaging: No imaging indicated.

Special Tests: HPV serotyping for those with abnormal cervical cytology (Pap tests), colposcopy for those with persistently abnormal cytology or for surveillance of those with high-risk serotypes.

Diagnostic Procedures: Serotyping of HPV obtained from cervical cells can be performed but is not indicated on a routine or screening basis. Generally, this testing is reserved for those with abnormal cervical cytology (ASCUS [atypical squamous cells of undetermined significance] or above Pap tests). These tests will identify 13 high-risk serotypes. (Because most younger patients will clear even high-risk serotypes with no sequela, recommendations for serotyping and aggressive follow-up of abnormal Pap test results are changing to more conservative management schemes.)

Pathologic Findings

Cellular atypia (koilocytotic changes) may be found in infected cells. Recent research suggests the degree of atypia may be a function of the serotype involved.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: There is no specific therapy available or indicated for HPV infection—most (>90%) infections are cleared by the body with little or no symptoms or sequela.

Specific Measures: Only those directed at the specific symptoms generated by persistent infection; condyloma or cervical epithelial change.

Diet: No specific dietary changes indicated.

Activity: No restriction.

Patient education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Booklet AP073 (Human Papillomavirus [HPV] Infection), AP163 (Cancer of the Cervix), AP161 (Abnormal Pap Test Results), AP149 (Cancer of the Vulva and Vagina)

Drug(s) of Choice

Contraindications: The HPV vaccine is currently contraindicated in those with known allergies to any of its components and those who are currently pregnant.

Precautions: None.

Interactions: Quadrivalent HPV vaccine can be administered at the same visit as other age-appropriate vaccines, such as the tetanus, diphtheria, and pertussis (Tdap) and quadrivalent meningococcal conjugate (MCV4) vaccines.

HPV Serotypes and Common Clinical Conditions

Disease	HPV Strain
Anogenital warts	6 and 11(90% of cases), 42, 43, 44, 55, and others
Cervical cancer, vulvar squamous cancer	16 and 18 (70% of cases), 31, 33, 35, 39, 45, 51
Common warts	2, 7
Epidermodysplasia verruciformis	More than 15 strains
Flat cutaneous warts	3, 10
Focal epithelial hyperplasia	12, 32
Oral papillomas	6, 7, 11, 16, 32
Oropharyngeal squamous cell carcinoma	16 and others
Plantar warts	1, 2, 4
Respiratory papillomatosis	6 and 11

FOLLOW-UP

Patient Monitoring: Normal health maintenance. Frequent cervical monitoring (cytology and/or colposcopy) for those found to have persistent high-risk serotypes.

Prevention/Avoidance: Abstinence. Condom use is thought to reduce the risk of transmission. (A study among newly sexually active college women demonstrated a 70% reduction in HPV infection when their partners used condoms consistently and correctly.) A vaccine that provides immunity against high-risk types 16 and 18 (thought to account for 70% of cervical cancers) and low-risk types 6 and 11 (associated with condyloma accuminata). The vaccine is made up of a noninfectious virus-like particle formed from a single protein (L1) from the virus. Other vaccines against other high-risk serotypes will be introduced soon. The currently available vaccine is given as a series of three injections over 6 months (0, 2, and 6 months) and may be associated with local pain, swelling, itching and redness, fever, nausea, or dizziness. The vaccine is currently indicated for women ages 9 to 26.

Possible complications: Both high- and low-risk types of HPV can cause the growth of abnormal cells, but generally only the high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, and possibly a few others) are associated with cervical cancer. These high-risk types may cause flat condyloma that are often difficult to see compared with the more exuberant warts caused by low-risk types such as types 6 and 11. HPV 16 is the most common high-risk type, found in almost half of all cervical cancers (HPV 18 accounts for 10% to 12% of cervical cancers). HPV 16 is also one of the most common types found in women without cancer. High-risk types can be detected in 99% of cervical cancers. It is important to note that most infections by both high- and low-risk types are cleared spontaneously and do not cause clinical problems.

Expected outcome: Most infections clear spontaneously. For those with persistent infections, warty growths, dysplastic cellular changes, and epithelial cancers may emerge over time.

MISCELLANEOUS

Pregnancy Considerations: No direct effect on pregnancy. Vertical transmission to the infant during delivery may occur. Although vaccination during pregnancy is contraindicated, lactating women may receive the vaccine.

Other Notes: All warts are caused by papillomaviruses, but each type of HPV grows only in specific areas of the body. Those types associated with common warts found on the hands and feet are not transmitted sexually.

Patients with low-grade squamous intraepithelial lesions (LSIL) or high-grade squamous intraepithelial lesions (HSIL) on Pap test results almost always have high-risk HPV on serotyping; thus, typing for these patients does not add anything to their management and is usually not indicated for these individuals. Between 5% and 30% of individuals infected with HPV are infected with multiple serotypes.

ICD-9-CM Codes: 079.4 (Human papillomavirus), 795.05 (cervical high-risk human papillomavirus [HPV] DNA test positive), 078.1 (viral warts), 078.11 (condyloma accuminata).

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