eMedicine Specialties > Infectious Diseases > Viral Infections

Human Papillomavirus: Differential Diagnoses & Workup

Author: Peter A Gearhart, MD, Assistant Professor of Obstetrics and Gynecology, University of Pennsylvania School of Medicine
Coauthor(s): Thomas C Randall, MD, Assistant Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Pennsylvania School of Medicine; Roland Michael Buckley, Jr, MD, Clinical Professor of Medicine, University of Pennsylvania School of Medicine; Consultant, Department of Medicine, Division of Infectious Diseases, Pennsylvania Hospital
Contributor Information and Disclosures

Updated: Oct 22, 2009

Differential Diagnoses

Benign Cervical Lesions
Malignant Vulvar Lesions
Benign Vulvar Lesions
Molluscum Contagiosum
Carbon Dioxide Laser Surgery of the Lower Genital Tract
Penile Cancer
Cervical Cancer
Recurrent Respiratory Papillomatosis
Conization of Cervix
Surgical Treatment of Vaginal Cancer
Gynecologic Cryosurgery
Surgical Treatment of Vulvar Cancer
Hemorrhoids
Urethral Warts
Hidradenitis Suppurativa
Vestibular Papillomatosis

Other Problems to Be Considered

Actinic keratoses
Carbon dioxide laser surgery for intraepithelial cervical neoplasms
Cervical polyp
Condyloma lata
Dermatitis papillaris
Nevi
Oropharyngeal SCC
Pityriasis versicolor
Sinonasal Papillomas, Treatment
Warts (Nongenital)
Pap Test
Recurrent Respiratory Papillomatosis
Squamous Cell Carcinoma
Warts, Plantar
Bowenoid Papulosis
Warts
Epidermodysplasia Verruciformis
Squamous Cell Carcinoma, Eyelid
Warts (Genital)
Giant Condylomata Acuminata of Buschke and Löwenstein
Acanthosis Nigricans
Acrochordon
Corns and Calluses
Keloid and Hypertrophic Scar
Keratoacanthoma
Lichen Planus
Psoriasis (Plaque)
Seborrheic Keratosis
Malignant Tumors of the Mobile Tongue

Workup

Laboratory Studies

  • Cytologic testing
    • Cervical cytologic testing using the Pap test is the standard screening procedure for cervical neoplasia. It should be performed annually in all women beginning 3 years after they become sexually active or when they have reached age 21 years if they have remained abstinent. Once a woman has had findings within the reference range on 3 or more consecutive annual Pap smears, the Pap smear may be performed less frequently if the patient is at low risk for developing cervical dysplasia.
    • Pap smears should contain samples of cells from the ectocervix, transformation zone, and endocervical canal. Perform the test when the patient is not menstruating so that the cytologic specimen is not occluded with blood. Furthermore, if the patient has a cervicovaginal infection with a mucopurulent vaginal discharge, consider performing the test after the bacterial infection has resolved. If the test must be performed, the discharge should be gently cleared with a saline-moistened cotton swab.
    • This test may be modified as required to sample tissues of the vagina, vulva, or perianal region that are suspicious for intraepithelial neoplasia. Although not an established routine, consider performing annual anal Pap smears on men who have high risk and who participate in receptive anal intercourse. See Cervical Cancer for guidelines on how often to perform the Pap smear when abnormalities result.
    • Liquid-based Pap smears improve the diagnostic sensitivity of cervical cytology screening. They have the additional benefit of enabling easy testing for human papillomavirus (HPV). Thin Prep and SurePath are the 2 methods currently approved by the US Food and Drug Administration (FDA).
  • HPV DNA typing
    • The 2 common methods for HPV DNA testing include the Hybrid Capture II (HC II) and the polymerase chain reaction (PCR) enzyme immunosorbent assay. Both of these methods have similarly high sensitivities and are suitable tools for detection of HPV and posttreatment follow-up of cervical intraepithelial neoplasia (CIN).
    • HPV DNA testing is the preferred approach in the treatment of women whose Pap test results show atypical squamous cells of undetermined significance (ASC-US) whenever liquid-based cytology is used or co-collection is available. HPV DNA testing is also useful in the management of CIN in certain situations. Detailed consensus guidelines for management of abnormal Pap test results and management of CIN are available at American Society for Colposcopic and Cervical Pathology.

Procedures

  • Tissue biopsy
    • Tissue biopsy can be used to confirm HPV infection if the diagnosis is uncertain, particularly if warts are abnormally pigmented, ulcerated, or indurated.
    • Obtain a biopsy of a warty lesion if the patient is immunocompromised, if the lesions worsen during treatment, or if they do not respond to standard therapy. In addition, biopsy is recommended to clarify the diagnosis in older patients who are at risk for genital carcinoma.

Histologic Findings

Virus multiplication is confined to the host cell nucleus. Consequently, infected cells exhibit a high degree of nuclear atypia. Koilocytosis describes a combination of perinuclear clearing with a pyknotic or shrunken nucleus and is a characteristic feature of productive papillomavirus infection. Other cytologic markers of HPV infection include acanthosis, dyskeratosis, and multinucleation.

More on Human Papillomavirus

Overview: Human Papillomavirus
Differential Diagnoses & Workup: Human Papillomavirus
Treatment & Medication: Human Papillomavirus
Follow-up: Human Papillomavirus
Multimedia: Human Papillomavirus
References
Further Reading
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Keywords

human papillomavirus, HPV, wart virus, cervical cancer, human papilloma virus, epithelial tumors, anogenital warts, mucosal warts, nongenital cutaneous warts, epidermodysplasia verruciformis, EV, sexually transmitted disease, STD, squamous intraepithelial lesions, SIL

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Contributor Information and Disclosures

Author

Peter A Gearhart, MD, Assistant Professor of Obstetrics and Gynecology, University of Pennsylvania School of Medicine
Peter A Gearhart, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists
Disclosure: Schering Plough Honoraria Speaking and teaching

Coauthor(s)

Thomas C Randall, MD, Assistant Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Pennsylvania School of Medicine
Thomas C Randall, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, and American College of Obstetricians and Gynecologists
Disclosure: Nothing to disclose.

Roland Michael Buckley, Jr, MD, Clinical Professor of Medicine, University of Pennsylvania School of Medicine; Consultant, Department of Medicine, Division of Infectious Diseases, Pennsylvania Hospital
Disclosure: Nothing to disclose.

Medical Editor

Mary Nettleman, MD, MS, Chair, Department of Medicine, Michigan State University
Mary Nettleman, MD, MS is a member of the following medical societies: American College of Physicians, Association of Professors of Medicine, Central Society for Clinical Research, Infectious Diseases Society of America, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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