Viral Skin Infections Practice Questions

Q: A 24-year-old woman presents with painful genital ulcers and lymphadenopathy. Tzanck smear shows multinucleated giant cells. What is the most appropriate initial treatment?

Valacyclovir 1g BD for 7-10 days. ***Valacyclovir 1g BD for 7-10 days*** - This is the **preferred initial treatment** for first-episode genital herpes due to its **superior bioavailability** (55% vs 15-20% for acyclovir) and convenient twice-daily dosing. - The **multinucleated giant cells** on Tzanck smear confirm **HSV infection**, and valacyclovir provides excellent therapeutic efficacy with improved **patient adherence**. *Acyclovir 400mg TID for 7-10 days* - This is a **valid CDC-recommended regimen** for first-episode genital herpes, not just for suppressive therapy or recurrent episodes. - However, it requires **three-times-daily dosing** which may reduce patient compliance compared to valacyclovir's twice-daily schedule. *Famciclovir 250mg TID for 7-10 days* - This is the **correct CDC-recommended dose** for first-episode genital herpes treatment (250mg TID for 7-10 days). - While effective as a **prodrug of penciclovir**, valacyclovir is generally preferred due to its more convenient dosing schedule and established efficacy profile. *Acyclovir 200mg 5 times daily for 7-10 days* - This is another **valid CDC-recommended regimen** for initial genital herpes episodes with proven clinical efficacy. - The **five-times-daily dosing** is less convenient and may lead to **poor adherence** compared to valacyclovir's twice-daily regimen.

Q: Pleomorphic rash is a feature of:

Chickenpox. ***Chickenpox*** - A **pleomorphic rash** in chickenpox means that lesions in different stages of development (macules, papules, vesicles, scabs) are present simultaneously in the same body area. - This characteristic presentation is a key diagnostic feature, differentiating it from smallpox where lesions typically appear in synchronized stages. *Smallpox* - The rash in smallpox tends to be **monomorphic**, meaning all lesions in a given area are at the same stage of development. - Smallpox lesions are typically *deep-seated*, firm, and progress slowly over several days. *Erythema subitum* - Also known as **roseola infantum**, this condition typically presents with a high fever followed by a **maculopapular rash** that appears as the fever breaks. - The rash is not pleomorphic and usually consists of small, discrete, rose-pink spots. *Erythema infectiosum* - Also known as **fifth disease**, it is characterized by a "slapped cheek" rash on the face, followed by a **lacelike or reticular rash** on the trunk and extremities. - The rash is not pleomorphic; its appearance is distinct and usually fades and reappears over several weeks.

Q: A child presents with grouped vesicles on the lips. What is the bedside investigation that you would like to do?

Tzanck smear. ***Tzanck smear*** - A **Tzanck smear** is a rapid bedside test that can identify **multinucleated giant cells**, which are seen in herpes simplex virus infections. - The presence of **grouped vesicles on the lips** is highly suggestive of **herpes labialis** (HSV-1), which is primarily a **clinical diagnosis**. - Among the options provided, Tzanck smear is the only relevant bedside investigation, though it has **limited sensitivity and specificity** and **cannot distinguish between HSV and VZV**. - In modern practice, **PCR or direct immunofluorescence** are preferred when laboratory confirmation is needed, but Tzanck smear remains a low-cost option in resource-limited settings. *Wood's lamp* - A Wood's lamp uses **ultraviolet light** to detect certain fungal or bacterial infections by revealing characteristic fluorescence. - It is useful for conditions like **tinea capitis** (green fluorescence) and **erythrasma** (coral-red fluorescence), but has no role in diagnosing viral vesicular lesions. *Slit skin smear* - A **slit skin smear** is used to detect **acid-fast bacilli** in the diagnosis of **leprosy**. - It is not indicated for vesicular lesions and is irrelevant to herpes simplex infection. *KOH* - A **KOH (potassium hydroxide) mount** is used to diagnose **fungal infections** by dissolving keratinocytes and revealing fungal hyphae or spores. - It has no utility in diagnosing viral infections such as herpes simplex.

Q: Which of the following is true about secondary herpes simplex?

All of the options. **All of the options** - **Secondary herpes simplex**, also known as recurrent herpes, often presents with visible symptoms like **painful ulcers**, typically on the **lips, hard palate, and gingiva** [1]. - **Acyclovir** is a primary antiviral treatment used to manage and reduce the severity and duration of secondary herpes simplex outbreaks. *Treatment – Acyclovir* - While acyclovir is indeed a standard treatment for herpes simplex, this option alone does not encompass all accurate statements regarding secondary herpes. - Acyclovir works by inhibiting viral DNA synthesis, helping to alleviate symptoms and prevent further viral replication. *Symptoms- Painful ulcers* - **Painful ulcers** are a characteristic symptom of secondary herpes simplex, particularly during outbreaks [2]. - These lesions are crucial for clinical diagnosis and patient discomfort. *Location – Lips, Hard palate and gingival* - The **lips (herpes labialis)**, **hard palate**, and **gingiva (herpetic gingivostomatitis)** are common sites for recurrent herpes simplex virus (HSV) infections due to viral latency in associated neural ganglia [1]. - Localization is a key diagnostic feature distinguishing it from other oral lesions.

Q: Pseudo koebner's sign is seen in

Warts. ***Warts*** - The **pseudo-Koebner phenomenon** refers to the appearance of new lesions at sites of trauma due to **viral inoculation** rather than an isomorphic response of a pre-existing dermatosis. - **Warts** (verruca vulgaris) caused by **human papillomavirus (HPV)** classically demonstrate pseudo-Koebner phenomenon, where the virus is inoculated into traumatized or abraded skin, leading to new wart formation along the trauma line. - Similarly, **molluscum contagiosum** can also show pseudo-Koebner phenomenon through viral seeding at trauma sites. *Psoriasis* - Psoriasis exhibits the **true Koebner phenomenon** (isomorphic response), not pseudo-Koebner. - In true Koebner, pre-existing psoriatic disease manifests as new psoriatic lesions at sites of trauma due to immune-mediated mechanisms. - This is fundamentally different from viral inoculation seen in pseudo-Koebner. *Lichen planus* - Lichen planus also demonstrates **true Koebner phenomenon**, where new lichen planus lesions appear at trauma sites. - This represents an isomorphic immune response, not viral spread, and therefore is not pseudo-Koebner phenomenon. *Inverse psoriasis* - Inverse psoriasis affects **intertriginous areas** (skin folds) and does not typically manifest Koebner or pseudo-Koebner phenomena. - The smooth, erythematous patches in flexural areas are less prone to the superficial trauma needed to elicit these responses.

Q: What is the diagnosis of an umbilicated, pearly white, asymptomatic skin lesion?

Molluscum contagiosum. ***Molluscum contagiosum*** - This **viral skin infection** typically presents with **multiple, small (2-5 mm), firm, pearly, dome-shaped papules** that have a **central umbilication**. - The lesions are usually **asymptomatic**, as described, though they can occasionally be itchy or inflamed. - Caused by a **poxvirus** and is highly contagious through direct contact. *EBV* - **Epstein-Barr Virus (EBV)** is primarily associated with **infectious mononucleosis**, which presents with fever, sore throat, and lymphadenopathy, not umbilicated skin lesions. - EBV can cause oral hairy leukoplakia in immunocompromised individuals, which is a white lesion, but it is **not pearly, umbilicated, or dome-shaped**. *HSV* - **Herpes Simplex Virus (HSV)** causes lesions that are typically **grouped vesicles on an erythematous base** that evolve into erosions or ulcers. - HSV lesions are often **painful or itchy** and **do not appear as pearly, umbilicated papules**. *None of the options* - This is incorrect because **Molluscum contagiosum** perfectly matches the clinical description of umbilicated, pearly white, asymptomatic skin lesions. - The classic **central umbilication** is the pathognomonic feature that distinguishes molluscum from other viral skin infections.

Q: Which of the following types of wart is treated by local application of podophyllin?

Genital wart. ***Genital wart*** - **Podophyllin** is an antimitotic agent that is commonly used for the topical treatment of **genital warts (condyloma acuminata)**. - Its mechanism involves arresting cell division in metaphase, leading to **necrosis of the wart tissue**. *All of the options* - While podophyllin is effective for some warts, it is not universally recommended for all types due to potential side effects and varying efficacy. - Other wart types, such as **plantar warts** and **verruca vulgaris**, often require different treatment modalities like salicylic acid, cryotherapy, or surgical excision. *Plantar wart* - **Plantar warts** are typically located on the soles of the feet and are often treated with **salicylic acid**, cryotherapy, or laser therapy, as they can be resistant to topical podophyllin. - The thick stratum corneum on the soles of the feet can limit the penetration of podophyllin, making it less effective for these warts. *Verruca wart* - The term "**verruca wart**" is general and usually refers to **verruca vulgaris** (common warts), which are often found on hands and fingers. - Treatment for common warts typically includes **cryotherapy**, salicylic acid preparations, or duct tape occlusion, rather than podophyllin, which can cause significant irritation on non-genital skin.

Q: A 10-year-old child had fever for 5 days, along with which he developed multiple fluid filled lesions on the lips as shown below. What is the probable underlying etiology for the skin lesions?

Herpes simplex virus. **Herpes simplex virus** - The image shows **multiple small, fluid-filled vesicles** on the lips, consistent with **herpes labialis**, commonly caused by **Herpes Simplex Virus type 1 (HSV-1)**. - The presentation with **fever for 5 days** preceding or accompanying the lesions is typical, as fever can **trigger HSV reactivation** or be part of primary herpetic gingivostomatitis in children. *HIV* - HIV infection can lead to various oral manifestations, but **direct fever blisters (herpes labialis)** are not a primary feature of HIV itself; rather, recurrent HSV infections may be more severe or frequent in immunocompromised individuals. - The lesions in the image are classic for HSV and do not directly suggest the underlying etiology is HIV without other clinical findings. *Syphilis* - Oral lesions of syphilis, such as chancre (primary stage) or mucous patches (secondary stage), are typically **painless ulcers** or **whitish plaques**, not clusters of fluid-filled vesicles. - Syphilis is also less common in a 10-year-old child presenting solely with these oral lesions and fever. *Cytomegalovirus* - CMV can cause oral lesions, particularly in immunocompromised patients, but these are often **ulcerative** and not typically presenting as the vesicular "cold sore" appearance seen in the image. - CMV also causes a wider range of systemic symptoms and is less likely to present purely with fever and these specific lip lesions in an otherwise healthy child.

Q: Herpetic Whitlow is seen in

Fingers. ***Fingers*** - **Herpetic whitlow** is a painful infection caused by the **herpes simplex virus (HSV)**, predominantly affecting the fingers or toes. - It often presents with **vesicular lesions** and **erythema** on the digits, commonly occurring in healthcare workers or children with oral herpes. *Bone* - HSV infection of the bone is **extremely rare** and would typically manifest as osteomyelitis, not herpetic whitlow. - Herpetic whitlow primarily involves the **skin and subcutaneous tissues**, not skeletal structures. *Tongue* - HSV can cause **oral herpes (cold sores)** on the tongue, gums, or other perioral areas, but this is distinct from herpetic whitlow. - **Herpetic whitlow** specifically refers to digital HSV infection. *Lymph nodes* - While regional **lymphadenopathy** can be a secondary symptom of herpetic whitlow due to immune response, the primary infection site is not the lymph nodes. - Lymph nodes are part of the immune system and **filter lymph**, not typically sites for primary viral skin lesions.

Q: What diagnosis is suggested by the finding on the sole of this patient's foot?

Plantar wart. ***Plantar wart (Verruca plantaris)*** - The image shows a **hyperkeratotic lesion with central black dots** on the sole of the foot, which is pathognomonic for a **plantar wart** - Plantar warts are caused by **human papillomavirus (HPV)** infection, most commonly types 1, 2, and 4 - The characteristic **black dots represent thrombosed capillaries**, not necrosis - Key diagnostic features include **interruption of skin lines** across the lesion and **tenderness on lateral compression** (pinch test) - They occur on **pressure-bearing areas** of the foot and can be solitary or multiple (mosaic warts) *Chemical burn* - Chemical burns present with **erythema, blistering, or ulceration** with more diffuse or irregular borders - History of **chemical exposure** would be present, and the lesion lacks the characteristic black dots seen in plantar warts - The pattern and location don't fit typical chemical injury *Pemphigus* - Pemphigus is an **autoimmune blistering disease** presenting with **flaccid bullae** that rupture easily - It primarily affects **mucous membranes and flexural areas**, rarely presenting as a solitary hyperkeratotic lesion on the sole - The clinical presentation is completely different from the hyperkeratotic lesion with black dots shown *Radiation dermatitis* - Radiation dermatitis occurs after **therapeutic or accidental radiation exposure** - Presents with **erythema, desquamation, hyperpigmentation, or fibrosis** in the radiation field - Would not present as a discrete hyperkeratotic lesion with black dots, and the sole of the foot is an unusual site for radiation therapy

Question 1

A 24-year-old woman presents with painful genital ulcers and lymphadenopathy. Tzanck smear shows multinucleated giant cells. What is the most appropriate initial treatment?

Accepted Answer

Valacyclovir 1g BD for 7-10 days

Answer

Acyclovir 400mg TID for 7-10 days

Answer

Acyclovir 200mg 5 times daily for 7-10 days

Answer

Famciclovir 250mg TID for 7-10 days

Question 2

Pleomorphic rash is a feature of:

Accepted Answer

Chickenpox

Answer

Smallpox

Answer

Erythema subitum

Answer

Erythema infectiosum

Question 3

A child presents with grouped vesicles on the lips. What is the bedside investigation that you would like to do?

Accepted Answer

Tzanck smear

Answer

Wood's lamp

Answer

Slit skin smear

Answer

KOH

Question 4

Which of the following is true about secondary herpes simplex?

Accepted Answer

All of the options

Answer

Treatment – Acyclovir

Answer

Symptoms- Painful ulcers

Answer

Location – Lips, Hard palate and gingival

Question 5

Pseudo koebner's sign is seen in

Accepted Answer

Warts

Answer

Inverse psoriasis

Answer

Psoriasis

Answer

Lichen planus

Question 6

What is the diagnosis of an umbilicated, pearly white, asymptomatic skin lesion?

Accepted Answer

Molluscum contagiosum

Answer

EBV

Answer

HSV

Answer

None of the options

Question 7

Which of the following types of wart is treated by local application of podophyllin?

Accepted Answer

Genital wart

Answer

All of the options

Answer

Plantar wart

Answer

Verruca wart

Question 8

A 10-year-old child had fever for 5 days, along with which he developed multiple fluid filled lesions on the lips as shown below. What is the probable underlying etiology for the skin lesions?

Accepted Answer

Herpes simplex virus

Answer

HIV

Answer

Syphilis

Answer

Cytomegalovirus

Question 9

Herpetic Whitlow is seen in

Accepted Answer

Fingers

Answer

Bone

Answer

Tongue

Answer

Lymph nodes

Question 10

What diagnosis is suggested by the finding on the sole of this patient's foot?

Accepted Answer

Plantar wart

Answer

Chemical burn

Answer

Pemphigus

Answer

Radiation dermatitis

Viral Skin Infections — MCQs

Viral Skin Infections — MCQs

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