DIP Episode 626 - The Clutch Herpes Podcast (Step 1-3), Part A

Alright, welcome. My name is Divine. This is episode 626 of the Divine intervention podcast. In today's podcast, we're going to be addressing herpes and the USML Es. So we're going to call this the High-Eld Herpes Podcast for the USMLE exams. This stuff is incredibly high-ealt to know for step 1, step 2 and step 3. And it's also incredibly high-ealt to know for level 1, level 2 and level 3. So we're going to run through the high-ealt things you need to know, make a bunch of very nice integrations and try to prepare you really well for your exams. And one thing I would like to say is that friends at the MBM Es, they really love. So if you see me say the word MBME, also being MBOME, the national board of osteoporetic medical examiners. Right? So the thing is the MBM Es, they love people to know the classifications of viruses. So I'll say that that's something that's imperative to know. For example, in one of the classes I held recently, I was explaining how knowing that Parvulvirus B19 is a single-stranded DNA virus, is a pretty high-ealt thing to know for your exams. Because as you know, many DNA viruses tend to be double-stranded. Right? So like for example, herpes is a double-stranded virus. Herpes, HSV is a double-stranded virus. It's a double-stranded linear-enveloped virus. All right, so let's jump right into it. So what if they give you a question about a dentist that has herpetic with low? Right? What is the most likely herpes virus that they have?

I'll really hope you're saying divine. This is probably going to be HSV1. Again, can it be HSV2? Absolutely. What is probably going to be HSV1? So how do people get HSV1? Well, typically people are going to get HSV1. You know, from saliva, that's why you can see the association with dentists and dental hygienists on your exams. Right? You can get it from respiratory secretions. You can get it from saliva. Right? And it can cause many different findings. Right? Like for example, on your exams, it can cause a cold source on the mouth. Right? So if you see a person that has cold source on the mouth, right? On the lips, for example, like the outer lips, it's probably going to be HSV1. Right? But it can also cause other presentations. Right? It can cause gingivostomatitis. Right? So it can cause issues in your oral cavity. Right? It can also, and remember, what's the drug that can cause gingivostomatitis? I hope you're seeing old divine. That sounds a lot like cyclosporrine toxicity. Remember, cyclosporrine is an immunosuppressant. Right? It can cause ion inflammation. Right? It can cause caradoconjunctivitis. Right? Especially when you have these dendritic ulcers. If they use the term dendritic ulcers on your exams, think about HSV1. Right? But remember, HSV1 is not just limited to the face. It can also cause problems in the, you know, in the person's genitals. Right? So it can be a cause of herpes labialis. But typically, that's going to be more than the purview of HSV2.

But HSV1 can absolutely on your exams cause herpes labialis. Right? And again, if you're a person that contacts people's mouths a lot. Right? So let's say, for example, you're an examiner that tests people's mouths, or you're a dentist, or you're a dental hygienist, or you're a dental assistant. Those can be people that get HSV1 infection on the exams. Right? That's going to be herpetic with them. Remember, whenever you have herpes infection, you're going to manage your e-cyclopedia. If you have a predicate weight low, the management strategy of choice is going to be oral e-cyclopedia, oral e-cyclopedia. And also remember, HSV1 is typically the one that causes temporal lobe and cephalitis. Why? Because the thing is it likes to stay dormant in the trigeminal ganglion. So because you can stay dormant in the trigeminal ganglion, it has a direct access to the actual brain. Remember, there is a difference between encephalitis and meningitis. Encephalitis is when you infect the brain itself. meningitis is when you infect the meninges. Right? So HSV1 of the HS Vs tends to be strongly associated with encephalitis. Although it can also cause meningitis, but typically on your exams, it's going to be associated with encephalitis. And also, what if they give you a question about a person that has this breakout of skin lesions? You know, targeted lesions on the skin. It looks like dark red in the middle, dark red on the outside, and pale in the middle. Right?

So it's like dark red on the inside, pale in the middle layer, dark red on the outside. You have a bullseye lesion, or targeted lesion, an iris, iris, an iris-looking lesion. Then I want you to think about erythema-multipormy. HSV1 is the most commonly identified cause of erythema-multipormy, typically on the USMLE exams. And again, remember, HSV1 likes to stay latent in the trigeminal ganglion. So again, it can absolutely positively cause encephalitis. And many times this encephalitis is going to be associated with like ephagia, it's going to be associated with seizures. Why is it associated with seizures? Because HSV likes to go after a person's temporal lobes. And remember, most seizures in the brain begin in the temporal lobes. Now, another high olfactory to know about HSV encephalitis is the fact that most times it's going to be hemorrhagic encephalitis. You're going to see a lot of red blood cells in the CSF when you do a lumbar puncture. That's why sometimes for these people, right, we may be confused that, hey, does this person have a sub-arachnoid hemorrhage? Because remember, you can also see a lot of red blood cells on a lumbar puncture if a person has sub-arachnoid hemorrhage. So please, make sure you know these key facts about HSV1. And remember, HSV1 is going to be treated with IV acyclovere. Although if you have herpes that is resistant to acyclovere, it is very high you to know that those people should get forced carnit.

Because remember, acyclovere has to be activated by a thymidine kinase. That thymidine kinase activates the acyclovere for it to go ahead and inhibit DNA polymerase. But the thing is, forced carnit, but think about it, right, that already introduces a middle man. Whenever you introduce a middle man, that's going to increase your risk of, there's just more points of failure, right? It's like, oh, you're relying on thymidine kinase for you to be able to work as acyclovere. But if for some bizarre reason, you're able to bypass that middle man of thymidine kinase. Because that's a common mode of resistance, a mutation in thymidine kinase. Then that can be very, very, very amazing. That can be very, very, very amazing, right? In that case, if you can bypass that kinase step, remember kinases and things that force for relief, right? Kinases are things that force for relief, right? So if you can bypass that force for relief, then that'll be amazing. So that's where forced carnit comes in. Foss carnit is a pyrophosphate analog. Foss carnit is a pyrophosphate. Look at the name pyrophosphate. So it's already been forced for relief. It doesn't really need that thymidine kinase step. That acyclovere requires. It does not really need that thymidine kinase step. That acyclovere requires. So you can bypass that step, right? Resistance, right? In regards to thymidine kinase, in a person that has HSV, just go ahead and give that person forced carnit.

Okay, go ahead and give that person forced carnit. And remember, I said again, HSV1 is strongly associated with erythema multi-formy. Those target-oilisions. Remember, most times those things are just going to involve the skin, right? At least we call that erythema multi-formy minor, right? But sometimes you can have erythema multi-formy that involves the skin and nucleosophysis. We call that erythema multi-formy major, right? Obviously, EM major is going to be more significant than EM minor. Now, the high-yield thing you want to know for you exempts you the erythema multi-formy is that again, HSV1 is most commonly associated with it. But remember, there are other things that can cause it, right? Things like microplasma, especially in children and young adults, can absolutely, positively cause erythema multi-formy, right? And remember, certain drugs, like sulfonamides, like NSAI Ds, like alopurinol, can also be associated with erythema multi-formy. Although, remember, typically, erythema multi-formy is caused more commonly than by infections than by drugs. I'm going to say that again. Erythema multi-formy tends to be caused more commonly than by infections than by drugs, right? That by infections than by drugs. Contrast that with SJSTN, Stevens-Johnson syndrome and toxic epidermal necrolases, which has a much more strong association with drugs, right? And remember, erythema multi-formy is going to be nicosky-negative, is going to be nicosky-negative.

When you rob your palm over those skin lesions, we are not going to get denudement of the skin. But a person that has Stevens-Johnson syndrome or a person that has toxic epidermal necrolases, those things are going to be nicosky-positive, nicosky-positive. When you rob your hands over those lesions, you're going to remove the skin with it. Remember the other things that are nicosky-positive, like pemphygos vulgaris. Remember, vulospemphygoid is going to be more nicosky-negative. Again, since we're talking about HSC, I want to talk about the high-yield points that surround it, because again, that's something that is pretty high-yield to know for your exams. And then the last thing I want to say here is remember the pathophys behind erythema multi-formy. Number one, it involves cell mediated immunity, right? So you have this antigen, right? Like HSCV1, for example. And then T cells, because remember HSCV1 is a virus. And what arm of the immune system helps us handle viruses? It's going to be T cells, right? So you can have T cells going after that HSCV1. As you go after that HSCV1, you're going to, you know, that's cell mediated immunity with CD-positive T cells. That can cause a lot of damage to the skin, right? That can cause a lot of damage to the skin, right? Another thing that can also happen is that you can form antigen antibody complexes, right?

So the antigen in this case, HSCV1, antibodies against it can go and settle within your dermal system, within your skin, and that can trigger inflammation and cause disease, okay? And remember, remember HSCV1 can also cause herpes' zoster ophthalmicus. HSCV1 can also cause herpes' zoster ophthalmicus, right? Especially if he stays dormant in the first branch of the trigeminal nerve, right? Because remember, your trigeminal nerve, cranial nerve 5, has three branches, right? Your trigeminal nerve, cranial nerve 5, has three branches. Your trigeminal nerve, cranial nerve 5, has three branches. Branch number one is the ophthalmic nerve, right? Branch number two is the maxillary nerve. Branch number three is the mandibular nerve, so ophthalmic, maxillary, and mandibular. And that makes sense if you look at the face, right? Ophthalmic, your eye region, maxillary, below your eye region, mandibular, well below your eye. Right? So the thing is, happy zoster ophthalmicus. Think about it. Herpes' zoster ophthalmicus. Herpes' zoster ophthalmicus. What branch of the trigeminal nerve, right? What branch of the trigeminal nerve? What branch of the trigeminal nerve, right? What branch of the trigeminal nerve is going to harbor HSCV1 for you to have herpes' zoster ophthalmicus. What do you think? Ophthalmicus. It has to be the ophthalmic nerve, right? It has to be the first branch of the trigeminal nerve, okay? It has to be the first branch of the trigeminal nerve.

Again, that's the ophthalmic nerve. That's very high yield to know for your exams. That's very high yield to know for your exams, okay? Now, one other thing I want to say about the trigeminal nerve. Again, this is just going to hit in my brain, right? Again, we're trying to make integrations here. I know this is a HSCV podcast, but there's all these other little things our friends at the NB Ns love to test. Now, remember, you can also have trigeminal neurology, right? You can have trigeminal neurology, right? Where you have like this fleeting pain that just comes on very suddenly, right? And it really, really hurts. We're going to manage that with carbamazepine. That's something that can happen, right? When you have inflammation or you have pressure around branches of your trigeminal nerve, right? That's why most times people that have trigeminal neurology, they tend to have pain on their face, right? So if wind blows across their face, it really hurts a lot. And one thing that I think is very, very high yield to know for your exams is an alternate name that our friends at the NB Ns can use for trigeminal neurology, right? What is an alternate, well, sorry, not for trigeminal neurology for cluster headaches, cluster headaches, because cluster headaches also tend to occur around the eye. You know, again, sorry, I know things may seem a little disorganized, but I'm really trying hard to make integrations as they come to my mind that are necessary for your exams, right?

So we talked about Hisha's V1, right? We talked about herpesosterophthalmicus because of latency in the first branch of the trigeminal nerve, right? That's the ophthalmic nerve. We've talked about trigeminal neurologia, right? Fleeting pain, wind blows on your face or cloth is moving across your face. You have this fleeting pain that is like very, very intense, very, very intense. That's going to be trigeminal neurology. We manage that with carbamazepine, which as we know can cause SIDH, right? And Igrenolosytosis and Cosolinsropinic fever. But a third thing that is very high yield to know the trigeminal nerve on your exams is actually that people that have trigeminal nerve problems can actually have cluster headaches. In fact, the thing is cluster headaches are linked to pathologies of the trigeminal nerves. Closter headaches are linked to pathologies of the trigeminal nerves. In fact, sometimes our friends at the NBM Es, that's the alternate name I was referring to, our friends at the NBM Es sometimes can test cluster headaches and it can give you an alternate name. The alternate name is trigeminal autonomic cephalalgia. Trageminal, right? So it's craniofiber related, autonomic. So the autonomic nervous system is kind of linked to it. Cephalalgia, cephalumins your head, right? And algea means all this thing hurts, right? If you're taking an analgesic, you're taking an analgesic because you're trying to prevent pain, right? So cephalalgia, an algea means it hurts, right?

So that's a cluster headache. Remember, a cluster headache is going to be a unilateral headache and then you're going to have eye findings on the same side. You're going to have a unilateral headache and you're going to have eye findings on the same side. Eye findings on the same side. Eye findings on the same side. Many of those eye findings are autonomic symptoms. You can have tearing, you can have redness. Many of those things are autonomic symptoms. That's why cluster headaches are called trigeminal autonomic cephalalogens. And remember, we're going to manage that with verapamil. Verapamil is going to reduce how many cluster headaches you have. But acutely, for the acutely phase of a cluster headache, you're going to manage it with oxygen, right? You give it within about 15 minutes of the onset of the headache. You can abort the headache very, very quickly, okay? So, I think because again, that's part of why I have a ton of commitments these days, right? So, what I'm going to try to do is let me summarize what we've talked about today, right? So, there's going to be a herpesportcast part B. Again, please, with my podcast, I know this is a common complaint online that divine, you know, you go from these different tangents. See, the thing is going off on these tangents is beneficial for the USMEL Es, right? That is one differentiator between these podcasts and other resources, right? Many other resources, they teach things in linear fashion.

For me, I teach things in integrated fashion. The thing is for you exams, it's more beneficial to learn things in integrated fashion, because you can see links between different concepts. That's more realistic prep for the exam that has been placed before you. That's just the truth. I'm just trying to be completely honest with you, right? So, I know it may be uncomfortable, but it's actually better for your brain with regards to exam prep, okay? Integrative learning is actually better for your brain, right? Again, it's the road less traveled, people do not like it. It's not very fun and exciting, but it's actually the better way to prepare for your exams. Because the questions you're going to see on your exams are not going to be linear questions. They're going to be what? Integrative questions. So, it's better to deal with the discomfort right now so that when you get to your real test, that discomfort is gone. You're like, oh, I already think in an integrated fashion, not in a linear fashion. So, again, remember, the fact that something is easier in your brain does not necessarily mean it's the best thing for you long term. Just an extra thought I want to throw out there, right? So, again, key factor about HSV1 we've discussed today. Respiratory secretions, right? You can get it from your saliva. We talked about the dental assistant association, dental hygienist, dentist, right? Kerado conjunctivitis, Herpesosterophthalmicus, I'm just calling out the keywords.

Herpesosterophthalmicus, trigeminal nerve, latency, right? Herpesosterophthalmicus, we said it's especially with the ophthalmic nerve, right? That's where it tends to lead dormant, right? We said that, hey, you can get Herpes oralis, right? The side of your lips, but HSV1 can also cause Herpesly Bialis, right? I can cause cold source on your genital area, right? We talked about herpetic with low-identists. We talked about temporal lobe and cephalitis, and we said that that's going to happen because HSV1 is stays dormant in the trigeminal ganglion. So, it has a direct connection to the brain. It has a stronger association with HSV in cephalitis than HSV2. HSV2 typically does not stay dormant in the trigeminal ganglion. We talked about herethema-mortiforming. We talked about the minor kind that just involves the skin, and the major kind that involves the skin and mucusosophysis, right? We talked about hersofagitis, right? HSV can absolutely cause hersofagitis, especially in immunocompromised people, although, although, it's going to be the more likely cause, right? And then, we talked about how people can get hemorrhagic and cephalitis, right? And then, we talked about the trigeminal nerve associations. We talked about trigeminal neuralgia. We talked about cluster headaches, right? Which is a trigeminal autonomic cephalalgia. And then, we also talked, I didn't talk about this, but I guess I'm going to mention it, right?

Remember, another trigeminal issue is a port-wine stain, right? In fact, some things we call this encephalute trigeminal angiomatosis. Encephalute trigeminal angiomatosis. That's a sturgvibers syndrome, right? That's one of those neurocutaneous disorders. Okay, so I think I'm going to go ahead and stop here again. There has to be a part B of this podcast. A bunch of stuff I discussed here didn't plan to discuss them, but they're pretty high up to know for your exams. So we're going to pick up from here God willing in the next episode of episode 627. Again, if you're interested in any of my classes, starting in the month of December, right? December 1st to December 5th. I have a 25-hour step one class. It's a basic science review. It's intended for step 1 and level 1. But if you're a person that is studying for step 2 or level 2, step 3 or level 3, and you have a poor basic science foundation because basic sciences are becoming very, very important on those exams. This is a class you're going to benefit from. And also within the month of December, I also have my test-taking class for step 1 to 3, my bio-stats class for step 1 to 3, my social sciences, quality improvement, and ethics class for step 1 to 3. And then I have a last minute review for step 2 and step 3. And I have a 20-hour class for step 2 and step 3. And then I also offer one on one tutoring and I help with mock interviews and personal statements and all those things.

So if you're interested in any of these things, they're going to all happen over Zoom. Shoot me an email and I can give you some more information and give you some more information. So thank you for listening to me today. Have a wonderful, wonderful rest of your day. I will see you God willing in episode 627. Have a wonderful day. God bless you and bye for now. And don't forget, if you're looking for some good life lessons, check out divineinterventionlifelessens.com. It's another website that I have. There's actually an Apple podcast associated with that. The Divine Intervention Life Lessons podcast. Every week I post one to two podcasts where from a biblical perspective, I address a life lesson. Many of you don't have a Christ follower, so I make these podcast based on Bible verses. And many people listen to them and find them to be helpful. All right, so I will see you in the next episode. Have a wonderful day. God bless you and bye for now. Thank you.

HSV-1 (Herpes Simplex Virus Type 1).

The ophthalmic nerve (CN V1), which is the first branch.

Foscarnet.

EM is Nikolsky-negative; SJS/TEN are Nikolsky-positive.

Trigeminal Autonomic Cephalalgia.

HSV Encephalitis.

1. Dental/Oral mucosal infections (saliva source). 2. Herpes Zoster Ophthalmicus (latency in CN V1). 3. Temporal lobe encephalitis.

Foscarnet is a pyrophosphate analog that bypasses the need for Thymidine Kinase activation, which is the common resistance pathway for acyclovir.

Carbamazepine.

Ophthalmic (V1), Maxillary (V2), and Mandibular (V3).

Cell-mediated immunity.

1. Dental/Oral mucosal infections (saliva source). 2. Herpes Zoster Ophthalmicus (latency in CN V1). 3. Temporal lobe encephalitis.

Foscarnet is a pyrophosphate analog that bypasses the need for Thymidine Kinase activation, which is the common resistance pathway for acyclovir.

Carbamazepine.

Ophthalmic (V1), Maxillary (V2), and Mandibular (V3).

Cell-mediated immunity.