Three days after her menses started, this 21-year-old woman began having sudden onset of nausea, vomiting, diarrhea, and a flu-like malaise. She does not use tampons, but has had sexual relations in the last several days and uses a cervical cap for contraception. On evaluation, you find her blood pressure to be 75/35 mm Hg, pulse of 130 bpm, and an oral temperature of 39.3°C (102.7°F). She has a diffuse macular rash over her entire body.
Of the following, which is correct?
Correct Answer D:
This is the classic picture for toxic shock syndrome. Although it is more commonly associated with tampon usage, it can occur after use of a contraceptive sponge, diaphragm, or cervical cap. It can also occur post-operatively in a patient with gauze packing. Cultures are usually negative, though Staphylococcus aureus is the most common pathogen. An exotoxin is the causative agent for the systemic effects. Correction of circulatory compromise is the most important initial therapy in treating this condition. If a source exists for the bacteria, it must be removed as well (i.e., tampon, etc).
A. In most cases of toxic shock syndrome, the causative agent will not be found in the blood stream.
B. This is not the typical presentation of disseminated gonococcemia.
C. The causative agent for the systemic effects is an exotoxin produced by the bacteria.
E. Correction of circulatory compromise and removal of the bacterial source are the most important initial therapies.
A 19-year-old woman with regular menses and a 28-day cycle now presents with 8 weeks of amenorrhea. If her last menstrual period was April 17, using Naegele’s rule, you would anticipate that her estimated date of confinement (EDC) is:
Correct Answer B:
Naegele’s rule is used to estimate when 40 completed weeks of pregnancy have occurred. Add 7 days and subtract 3 months from the LMP will result in the EDC. This rule requires the woman to have regular cycles of normal length.
A. For this date to be her EDC, her LMP would have been April 10.
C. For this date to be her EDC, her LMP would have been October 17.
D. For this date to be her EDC, her LMP would have been May 10.
E. For this date to be her EDC, her LMP would have been April 3.
Which of the following pairs of HPV types is most commonly associated with the clinical picture seen here?
Correct Answer A:
Over 60 types of HPV have been identified. Types 6/11 are associated with genital condylomata and the minor CIN groups. When HPV 6/11 are found with CIN, the regression rate is high. Types 16/18 have a high association with cervical carcinoma and advanced cervical dysplasia.
B. These are the HPV serotypes that are commonly associated with cervical neoplasia, with 16 having the greatest association with invasive squamous cell carcinoma.
C. These have also been associated with cervical neoplasia.
D. Not associated.
E. Not associated with genital lesions.
Women should be tested for human papillomavirus (HPV) DNA:
Human papillomavirus (HPV) DNA testing is useful for determining whether colposcopy is needed in patients whose Papanicolaou (Pap) test shows atypical squamous cells of undetermined significance (ASCUS). Women with a negative result for high-risk HPV can be safely followed without colposcopy.
→ Some recent studies suggest that screening HPV DNA testing for women in their thirties may be useful, most likely as a replacement for Pap smears (choice A); however, this is in the preliminary stages of study. Younger women would not benefit from screening for HPV DNA because it would identify the very large number of young women who have a transient infection.
→ The addition of HPV DNA testing to Pap smears (choice B) at currently recommended intervals would not change management.
→ The presence or absence of HPV DNA does not alter the indications for HPV vaccine (choice C), because patients with or without HPV are candidates for vaccination. The vaccine protects against HPV strains that the patient may not have contracted.
→ Genital warts (choice E) are caused by HPV, usually a low-risk strain, so testing for HPV in patients with this problem does not provide useful information.
On routine yearly exam of an otherwise healthy 45-year-old woman, you note a 1-cm erosive ulceration on the lower portion of the ectocervix.
Which of the following is the most appropriate next step?
It is important to remember that a Pap smear is only a screening test for cervical cancer. If a Pap smear is done of a visible cancer, it will only show cancer about 50% of the time. With a visible lesion, you must biopsy the lesion to diagnose; if it is invasive cancer then you would proceed with the appropriate staging workup. If the biopsy came back as microinvasive, a cone biopsy would be the next step.
B. Although this could be a herpetic lesion, any visible lesion of the cervix must be biopsied to rule out malignancy.
C. A Pap smear is only a screen. In the face of a visible cancerous lesion, the Pap smear will not be conclusive for cancer in a significant percentage of cases. If a lesion is seen, a biopsy must be done.
D. Although this could be a primary syphilitic chancre, the most likely diagnosis is a cervical neoplasia.
E. This would be done if the biopsy came back inconclusive for invasion (i.e., microinvasive). If the punch biopsy came back conclusive for a frankly invasive carcinoma, it would be at least a stage IB, requiring radical hysterectomy or radiation therapy.
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