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

Alright, welcome to episode 627 of the Divine Intervention Podcast. In today's podcast we're going to be continuing the series on Herpes. This probably will be the concluding part of this series. Again, if you remember from the first one, episode 626, we talked about a lot of things and made lots of very, very good integration. So I'd encourage you if you missed that, go back and listen to episode 626, right? So talk about HSV1 at length in that podcast. Remember HSV2, that's the one that, you know, Herpes simplex virus 2, that's the one you get through, you know, sexual contact perennatally, right? So vertical transmission from mom to the baby, that's usually going to be HSV2, right? So you need herpes, herpes genitalis, that's going to be HSV2, a lot of the time on your exams, 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 sickle ganglion, in the sickle ganglion, right? And one thing that's kind of weird though that I think is very high yield to know for your exams is that unlike HSV1, that typically tends to cause more than Encephalitis, HSV2 tends to cause more for meningitis, okay? HSV1 tends to cause more for Encephalitis, it infects the brain tissue itself, the brain parankoma, but HSV2 tends to cause more for meningitis, picture, right?

That's very, very important to keep on the back of your mind for, for exams, right? But really many of the things I said about HSV1 typically apply to HSV2, all right? So let's keep going, how about HHV3, human herpes virus number three? Well, that's going to be Varycella, right? Zoster virus, right? And remember Varycella is, it's pretty high yield to know, right? That it can cause chickenpox, it can cause shingle, so that 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 Varycella is, hey, be careful of touching the fluid 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 touching the fluid from the vesicles or being in contact with the respiratory secretions. Because again, remember what I said, Varycella can absolutely positively cause, cause pneumonia, right? Especially on the USMEL exams, right? Now where does it stay latent? Again, we said HHV1 is going to be in the trigeminal ganglion, HHV2 is going to be in the sacroganglion, HHV3 is usually going to be in the dorsal root ganglion or in the trigeminal ganglion, right? In the in the dorsal root ganglion or in the trigeminal ganglion. Actually, one parallel you can see 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 are zoster ophthalmicus, right? Herpes zoster ophthalmicus, right? And one thing that's pretty high yield to know for you exams is remember the Varycella vaccine is a live attenuated vaccine. So you cannot give it to people that are on the 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 USML is these days, one thing you really love to emphasize is prognosis, right? In fact, in many of my classes, and in many of my podcasts, you see me in the size prognosis, like my 20 hour class, I emphasize a ton of prognoses in my 50 hour class that holds once a year, I emphasize a ton of prognoses, right? The prognoses, especially like the most common complication, most likely complication after a person has shingles, is Ph.N. post-traupatic neurology. And on the USML exams, how would you manage post-traupatic neurology? Well, I hope you're saying, oh, divine, we can use things like pregabaline or gabapentin or we can use a tricyclic antidepressant, right? Or we can use an SNR like deloxetine. Now, one thing our friends at the MBM is 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 going to pick? Right? So if they give you something like an image-tripty lean or not tripty lean as an answer, but they also give you pregabaline or gabapentin as answers.

For a person that is like 67 years old, which answer should you pick if they have post-traupatic neurology? I would hope you're saying that, oh, divine, of course, I'm going to pick gabapentin or pregabaline, right? The reason we do that is remember, the TCA is the tricyclic antidepressants. They have anti-hamm effects. They have anti-H1 effects so they can cause sedation. They have anti-alpha-1 effects so they can cause orthostatic hypotension that can increase your risk of falls. And then they also have anti-mostcronic effects. That can increase your risk of delirium and anti-colonergic problems like urinary retention and things like that, right? So say, for example, if a person has a history of BPH is maybe not the smartest idea in the world to put them on a tricyclic antidepressant. In that case, you want to consider pregabaline or gabapentin, or you can try an SNR like deloxetine. Remember, deloxetine, and I believe this drug was known as melnasipran, M-I-L-N-A-C-I-P-R-A-N, melnasipran, deloxetine, they are SN Rs, they are serotonin, norepinephryoryoptic inhibitors. They work pretty well for neuropathic pain. All right, so next let's go to HHV4, right? So this is EBV, right? Epstein-bar virus. All right, remember, the classic phenoluexams is going to be some young person that kisses another person, and then they start having like really sore throat, ton of cervical lymphatic neuropathy, right? They may have hepato splino megaly, right? That's going to be mono, right?

It's going to be infectious mono-incliosis, right? So again, how do you get this problem? Respiratory secretions, right? Saliva, right? That's why it's called chisin disease, chisin disease, right? So again, typically again, you're going to see sore throat, so like pharyngeitis, you're going to have a lot of lymphatic neuropathy, especially posture cervical lymphatic neuropathy. But again, please, that is not specific for mono. Please, that is not specific for mono. That's very high you to know for your exams. In fact, sometimes our friends at the NBM is, they will intentionally give a person mono, and they will give that person anterior cervical lymphatic neuropathy. 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're rushing to the spleen, remember, you're going to start struggling with a lot of encapsulated organisms like strep pneumo, H Flu and iseremia angitis. Now, what are some other things to know about HHV4, about the Epstein Barvires? Well, you do need to know the malignancies that it's associated with, right? So like, for example, it's associated with Burketsl and Phuoma. Don't forget that 814 translocation, you know, jama, senkids, especially African, and then abdominal mass in Europeans and adults. Don't forget Nizofar and Jokarsinoma.

Also a cancer of the nose or the farings 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 Nizofar and Jokarsinoma. Don't forget oral hairy luchoplikia, right? Remember, that's the lateral tongue lesion that does not scrape with a tongue depressor. That's also caused by the Epstein Barvires, right? And then don't forget post transplant lymphoperuliferative disease, right? So you're going to see this in a person that is severely immunocompromised or the immunosuppression was just bumped. And then you notice that they just have these lymph nodes just popping up all over their bodies, right? That's going to be PTLD, post transplant lymphoperuliferative disease. That's very, very, very classic for ABV infection, right? So why is it that ABV tends to cause a little of B cell problems? Well, g is because it infects B cells, right? It infects B cells through the CD21 receptor, right? So it infects B cells through CD21, right? It infects B cells through CD21. And remember, again, the way we're going to diagnose mono is to use the heterofile antibody test, right? The mono spot test, but sometimes to mess with your head, instead of calling it the mono spot test, they'll call it the heterofile antibody test, okay? The heterofile antibody test. You're pretty much detecting sheep, red blood cell antigens, right? So, those antibodies, right? So the heterofile antibody test, right?

You're just basically antibodies against sheep or horse 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, abstin, bar virus, right? So what arm of the immune system is going to be dealing with that for us? It's going to be the cell-mediated immunity. It's going to be T cells, right? So you can actually see these T cells on a blood smear, right? They're called Downy cells, right? Typical 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, but literally it's T cells, cell-mediated immunity that helps us deal with this problem, right? And remember, when a person's got mono, right, you give them a moxicillin, they can have a rash, they can have a rash, they can have a rash, right? Because again, remember, the acute phase of mono can look like a person has like a foreign gel infection, like strep, groupase strep, you know, like strep biogenes, right? And you're like, hey, let's give you a moxicillin, but then they can have this full body rash. Well, it's pretty high yield to no for purposes of your exams, 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, those people can still take a moxicillin in the future, right? That's a very classic weird question you may see on your exams.

Those people can absolutely, positively still take a moxicillin in the future. All right. So I think that's all I'm going to say about an EBV, right? So now let's go to CMV, right? Cytomegalovirus, right? Remember CMV, they love, love, love to test these things in a newborns, right? So if you see a newborn with CMV, the key thing to note, they may have sensory neuroheren loss, right? They may have microcephaly, right? And they may have periventricular calcifications, periventricular calcifications, right? Calcifications are on the ventricles, right? Remember, I know the cause of periventricular lesions on your exams. It's going to be multiple sclerosis, right? It's just something that is not going to be calcifications, but they're going to have periventricular lesions, right? You're going to see that in MS, right? So remember CMV, right? Again, what one of the classic quiz people get the 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, transplants, right? CMV is one of these things where it kind of scared about transplants, right? And it can also cause a mono-like syndrome, right? But many times it's going to be a mono-spot negative, right? So it's going to be a mono-spot negative. Mononuclosis-like syndrome, unlike EBV, HHV4, that is a mono-spot positive or heterophyll antibody positive. Mononuclosis-like syndrome, right?

So remember, what are the things that CMV can cause, right? It can cause pneumonia, right? Again, especially in people that are immunocompromised, it can cause the suffigities in HIV patients, right? Many times you're going to see those lesions in the air, suffergas, right? It can absolutely cause those issues, right? It can cause vision problems, right? In fact, if you see vision problems in a HIV patient on your exams, that's a CMV infection right there, right? It can cause a, you know, like CMV right now. It is, again, remember, CMV likes likes likes to go after people that are, that are immunocompromised, like HIV patients, right? And remember, one, if there's one thing I want to know about CMV, you better make sure that you can identify the Alzheimer's nucleus, right? The Alzheimer's nuclei, they can call it the Alzheimer's nucleus on your exams, or they can call it an intra-nucleus-inclusion on your exams, right? It kind of looks like a Samoma body in a sense. If you look at a Samoma body, if you look at the Alzheimer's nucleus, they kind of look pretty, pretty similar, right? So, remember, how do we treat CMV on the USML? So we're going to try to go to a GAN cyclover, right? We're going to try to go GAN cyclover. We're going to try to what with GAN cyclover? Now remember, GAN cyclover inhibits DNA synthesis, but to do that, it needs to be activated by an enzyme known as the UL97, University of Louisville. That's my alma mater, you know, for college.

So UL97 kind needs to activate it. So you can already begin to learn from that that what's going to be the mode of resistance to this stuff. Well, if you have a mutation in the UL97, then you're not going to be able to treat that CMV, right? So you have to go for the second line trip, and in this case, first corner, the first corner you remember is a pyrophosphate analog, it's a pyrophosphate analog, okay? It's a pyrophosphate analog. All right, and again, remember, CMV stays latent, right? We've talked about how HHV1 stays latent in the trigeminal ganglion, HHV2, CCHO ganglion, HHV3, Dorsal Rouganglion, or trigeminal ganglion, right? EBV can still latent in B cells, right? Now, don't forget that CMV, HHV5 can still latent in mononuclear cells, right? So like, macrophages for example, right? So, okay, so let's go ahead and go to HHV6. This one, there are many HH Vs that is not much with them that we need to know for exams, right? But remember, HHV6, that's our Rosyola, right? That's Rosyola. Sometimes they call it exam-them subitump on the exams, right? You're going to get it from saliva, right? So from like kissing your baby, right? And typically the way it's going to present on you exams, it's going to present in a child, little child, right? A child is going to have high fever for a couple of days. And then, after the child has high fever, the fever is going to stop.

And then they're going to have this rash that kind of starts on the trunk and then spreads through the extremities, right? So a child, crazy high fever. Sometimes these fever can be 104, 105-style fever, and then it stops. And then after that, they have a rash. That's on the trunk, funds out to the extremities. When you see that, think of Rosyola, okay? Think of Rosyola, think of Rosyola. This is usually going to be caused on the USMEL exams by HHV6, okay? Sometimes you may see HHV7, right? Human Herpes virus 7 being the cause of Rosyola, okay? So Rosyola, by the way, they can make it a February seizure question on your exams, right? So remember, little kids when they have fever, they can kind of cook their brains, they can have seizures from that, right? So if you see February 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 HHV6, right? Rosyola. And one thing I think that's pretty helpful to know about February seizures is, again, knowing how to differentiate a typical February seizure from an eight typical February seizure, right? So a typical February seizure is going to be last for less than 15 minutes and it's going to be generalized tonic, chronic, right? And for those people, just give them a sedominophane, give those kids a sedominophane, we are sure the parents, that's all you got to do. But if that seizure lasts for more than 15 minutes or it is focal or both, that's really worrisome.

That child probably needs some full evaluation. You probably shouldn't give them a sedominophane and send them on their merry way. Those kids probably need to be brought into the hospital and get some kind of more detailed and neurological evaluation. All right, so we've done HHV1, 2, 3, 4, 5, 6, and 7, right? So let's do eight, right? So sometimes it's called KSHV, right? Carpocystorchoma, Herpes virus or whatever, right? You're going to get this from sex, right? And it's going to be, again, in people that are immunocompromised, immunocompromised people, right? And many times this can cause a carpocyzer sarcoma, right? Carpocystorchoma, again, we tend to find it in the immunocompromised. It's very difficult to have HIV or AIDS, right? Or people that are transplant patients. Again, remember, one of the things that our friends at the NBM is love to do these days is to give these HIV related infections to non-HIV people, right? So again, remember, HIV is not the only cause of immunocompromised, right? Diabetes can cause immunocompromised because of the hyperinsulinemia, right? What else can cause immunocompromised 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 SCAT, severe combined immunodeficiency, for example, that can cause problems, right? And remember, Carpocystorchoma, 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 I'm going to show you, exams, I should be able to spot this, is you're going to see these violet colored, these dark lesions, like plaques nodules on the skin, right? Those are just, and sometimes the, it's sort of sane what it is. They may ask you to talk about the mechanism, right, behind those, and physical exam findings. Well, the mechanism is going to be from proliferation of vascular structures, right? And remember that, excuse me, HHV8 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 in the back of your mind with HHV. And remember, HHV, do not forget, how do you detect it on your exams? You're going to detect it on your exams with PCR, right? PCR is how you detect HHV, you know? If a person has like herpes and severalitis or meningitis, you can do it again, PCR of a CSF sample, right? And remember, whenever a person has HHV meningitis, right? Or in severalitis. Remember, it's a variety of stem, so it's because of HHV1, meningitis stem, so it's because of HHV2, those people typically will have a lot of red cells in their CSF, right? Typically, you don't say always, but typically HHV can absolutely positively cause a hemorrhagic meningitis when severalitis on your exams, right? So please, I would encourage you not to be picking the zinc smear.

I would only pick that if there's nothing else available, right? But you know, you see these multi-nucleided giant cells that we see in like HHV1, 2, or 3. But that's not going to be what is going to 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 test, right? So I'm going to 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 CD21, right? CMV, right? HHV5, right? It kind of goes, you know, through integrins. Integrins are going to be is a lot of entry, right? Especially like Heparone sulfate. It's going to be is Rancho, a lot of entry into a cell, into a mononuclear cell, right? And again, one thing I think that is probably kind of helpful to know for you exams is that Heparone sulfate is also part of the bismond membrane of your glomeruli, right? So remember your glomeruli barrier, right? So you have the on the inside, you have the glomeruli, you have the endothelium of your glomeruli capillaries, right? That's finished. And then after that, you have your glomeruli bismond membrane that contains Heparone sulfate, which is negatively charged, right? That's a charged barrier. And then after that, you have your put aside food processes, right? So you want to kind of keep that at the back of your mind for your exams, right? So I think I'm going to go ahead and stop here.

Again, thank you for listening to me. If you like the way I teach, like the way I make integrations, you're going to love my classes. I have a bunch of classes starting next week Monday for step one on the week of step three. So the step one to three classes, I have a test taking class on Monday, over Zoom is two and a half hours long on Tuesday. I have a four by statistics class also for step one to step three. And then on Wednesday, I have a social science quality improvement, ethics and, you know, healthcare systems and a hospital medicine class also for step one to step three. It's a five hour class. And after that, I have a last minute review on Thursday, that's the 18th of December. That's more for step two, step three. That's going to be on Thursday, it's a three hour class. Very helpful class for many people. And then on Friday, Saturday, Sunday, and then the following Monday and Tuesday, I have a 20 hour step two, step three class. Again, many people have taken these classes and done extremely well on their exams. And again, it's over Zoom and it's not some other person teaching. It's me that will literally teach it. Again, many people have taken these classes from them to be extremely helpful. And then I have a step one, 25 hour class that's going to be taking place in the first week of February of next year. And then a 50 hour step two, step three class that's going to 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 exams. So thank you for listening to me today. If you also desire one or one tutoring or help with your era's applications like mocking reviews, personal statements, and things like that, 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.com. Divine intervention life lessons.com, many of you know I'm a Christian, I'm a Christful or so every week I post like one or two podcasts where from a biblical perspective, address a life lesson. Many people listening 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 don't forget I have a You Tube channel, you know, Divine Intervention, USMV podcasts and videos. That's where I post the videos that I make. So thank you for listening to me today. And we'll see you God willing in the next podcast. Have a wonderful day. God bless you. Bye for now.

Herpes Simplex Virus type 2 (HSV2).

HSV2.

Pregnancy and CD4 count < 200 cells/mm³.

Gabapentin or Pregabalin (or SNR Is like duloxetine), due to TCA's anticholinergic effects.

It is typically Mono-spot negative, unlike EBV infection which is positive.

Epstein-Barr Virus (EBV).

Sensorineuropathy loss, microcephaly, and periventricular calcifications.

HHV6; High fever lasting several days that suddenly resolves, followed by a rash starting on the trunk and spreading to the extremities.

Endothelium $\rightarrow$ Glomerular Basement Membrane (GBM) $\rightarrow$ Podocytes; The GBM contains negatively charged Heparan sulfate.

TC As have anti-H1, anti-alpha-1, and anticholinergic effects, increasing the risk of sedation, orthostatic hypotension, and urinary retention.

Burkitt's lymphoma, Nasopharyngeal carcinoma (NPC), and Oral hairy leukoplakia.

Ganciclovir; It requires activation by the UL97 enzyme.

Red blood cells (RB Cs) in the CSF, making it less likely to be diagnosed solely on a zinc stain.

It requires full neurological evaluation and should not be treated with sedominophane alone.

HHV6; High fever lasting several days that suddenly resolves, followed by a rash starting on the trunk and spreading to the extremities.

Endothelium $\rightarrow$ Glomerular Basement Membrane (GBM) $\rightarrow$ Podocytes; The GBM contains negatively charged Heparan sulfate.

TC As have anti-H1, anti-alpha-1, and anticholinergic effects, increasing the risk of sedation, orthostatic hypotension, and urinary retention.

Burkitt's lymphoma, Nasopharyngeal carcinoma (NPC), and Oral hairy leukoplakia.

Ganciclovir; It requires activation by the UL97 enzyme.

Red blood cells (RB Cs) in the CSF, making it less likely to be diagnosed solely on a zinc stain.

It requires full neurological evaluation and should not be treated with sedominophane alone.