Slide 1 - Viruses That Destroy Anterior Horn Cells

● Two viruses to remember for anterior horn destruction:

○ Polio virus (commonly tested)
○ West Nile virus (less commonly tested)

● Polio virus is a positive-stranded RNA virus, part of the picornavirus family.

○ "Pico" means small, and "rna" signifies it’s an RNA virus.

● Picornaviruses are also called enteroviruses.

○ Important note: Enteroviruses don’t cause gastroenteritis.
○ They can cause aseptic meningitis (non-bacterial meningitis).

● Poliovirus transmission: fecal-oral route.

● Infection target: anterior (ventral) horn of the spinal cord.

○ Location of alpha motor neurons which connect to the neuromuscular
junction.
○ Alpha motor neurons receive input from corticospinal tract fibers.
● Both polio and West Nile viruses cause flaccid paralysis.
● No sensory deficits in these infections.
● Classic patient: someone not immunized, often an immigrant.
● Prevention:
 ○ Live vaccine: Sabin vaccine (no longer used in the US).
○ Killed vaccine: Salk vaccine (used in the US).
○ Reason: Sabin vaccine has a higher risk of causing polio reactivation.

Slide 2 - Coxsackie Toxidromes

● Coxsackie viruses:
○ Coxsackie A and Coxsackie B are the focus.
○ They are part of the picornavirus family.

● Coxsackie A:
○ Causes hand, foot, and mouth disease.
○ Causes herpangina: lesions on the buccal mucosa with a whitish center and
erythema around it, often seen in children.
○ Prevention: primarily through good hand washing.
○ Pro tip: Always wash your hands in the hospital, especially after seeing
patients.

● Coxsackie B:
○ Causes viral myocarditis (most common cause).
○ Classic patient: a young person without heart failure risk factors who presents
with acute onset shortness of breath and hypotension.
○ Often has a history of an upper respiratory infection 2 weeks prior.
○ Leads to reduced ejection fraction.

● Differential diagnosis for rashes on palms and soles:

○ Mnemonic: “Drive Kawasaki CARSS with your hands and feet” refers to
Coxsackie A for the "CA" association.
 ● R: stands for Rickettsia rickettsii.
○ Causes Rocky Mountain Spotted Fever.
● S: stands for Secondary syphilis.
● S: Stands for Staph Aureus (Toxic Shock Syndrome)
● Kawasaki’s disease: only time on NBME you should give aspirin to a child.
○ Be cautious of Reye’s syndrome with aspirin use.

Slide 3 - Causes of the Common Cold

● The common cold is classically caused by viruses.

● Major viruses to know:
○ Coronaviruses.
○ Rhinoviruses (most common cause).
● No permanent immunity against rhinoviruses due to many serotypes.
○ Possibly hundreds of serotypes.
○ You can catch rhinoviruses repeatedly over the years.
● Rhinovirus: a positive-stranded RNA virus.

Coronavirus: a negative-stranded RNA virus.

● SARS virus:
○ Part of the coronavirus family.
○ Examples include avian flu, bird flu.
○ Spread by respiratory droplets.
○ Clues on exams: severe cold symptoms with associations to China or certain
parts of Canada.
○ Think about coronavirus or SARS virus in such scenarios.
● Possible exam setup: bioterrorism scenario.
○ Virus weaponized or received in the mail.

Slide 4 - Hepatitis A Case (Travel to South America)

Recent travel to South America, AST/ALT in the thousands. Consumed lots of food, now
presents with scleral icterus.

● Important to note: not trying to discourage eating on foreign trips, just exercise
common sense.
○ Applies both abroad and in the U.S.
● Likely thinking about a hepatitis viral infection, more specifically Hepatitis A.
○ Hepatitis B and C are less likely because no mention of sexual contact or
blood transfusions.
○ Hepatitis E also unlikely because no mention of a pregnant woman.
 ● Hepatitis A:
○ Spread via fecal-oral route.
○ Remember: Hepatitis A and E are both acquired through fecal-oral
transmission.

● Hepatitis alphabet mnemonic: A through E (ABCDE).

○ Fecal-oral transmission links A and E.
○ Think of mouth and anus as GI tract orifices.
● No chronic stage for Hepatitis A.
● Classic exam clues:
○ Trip to a foreign country, exposure to contaminated food or water.
○ AST/ALT levels can be extremely elevated (in the thousands).
○ Preventable by vaccine.
● Daycare association: for pediatric shelf exams, Hepatitis A can be acquired from
daycares due to poor sanitation.

Slide 5 - Overview of Flaviviruses

● Focus on dengue virus and yellow fever virus.

● Dengue fever:
○ Nicknamed break-bone fever due to severe pain.
○ Presents with:
■ Super high fever.
■ Extreme muscle and joint pain.
● Flavivirus family:
○ Primarily arboviruses (arthropod-borne infections).
○ Exception: Hepatitis C.
■ Hepatitis C is a flavivirus but doesn’t follow the usual transmission
pattern.
● Dengue (Break-bone Fever)
● Dengue fever: Nicknamed break-bone fever due to extreme muscle and
joint pain.
○ Remember the association with high fever and severe pain.

Yellow Fever

● Yellow fever: Important but low-yield, though it can appear on exams.

○ Called yellow fever because it causes jaundice.
○ Key finding: Black vomit (important clue).
○ Risk factor: Exposure to Aedes mosquito.
○ Black vomit + jaundice + mosquito exposure = Yellow fever.

● Zika virus:
 ○ Also transmitted by Aedes mosquito.
○ Exam context: More likely seen as sexually transmitted or vertical
transmission (mom to baby).
○ Key finding: Microcephaly in newborns, especially after travel to South
America.

Yellow Fever and the Liver

● Yellow fever affects the liver.

○ Causes jaundice, so it’s tied to liver damage.

● Liver zones:
○ Zone 1: Around portal triads (portal vein, hepatic artery, bile duct).
■ Classic zone for viral hepatitis.
○ Zone 2: Intermediate zone.
■ Specifically affected by yellow fever.
■ Classic finding: Councilman bodies (dead hepatocytes, pink on
histology).
○ Zone 3: Also called central lobular zone or pericentral zone.
■ Most susceptible to ischemic change due to distance from blood
flow.
■ Contains lots of cytochrome P450 enzymes.
■ Affected by metabolic toxins and alcoholic hepatitis.
■ Alcohol breaks down through cytochrome P450 pathways.
Slide 6 - Rubella vs. Rubeola (Showdown)

● Rubella:
○ A togavirus.
○ Known as German measles.
○ Acquired through the respiratory tract.
○ Rash starts on the forehead and spreads downward.
○ Less toxic presentation compared to rubeola.

● Rubeola:
○ Known as measles.
○ Rash starts below or behind the ears or on the neck and then spreads
downward.
○ More toxic presentation compared to rubella.
○ Associated with posterior auricular lymphadenopathy.

Congenital Rubella Syndrome

● Classic triad:
○ Cataracts.
○ Deafness.
○ Patent ductus arteriosus (PDA): Characterized by a machine-like murmur.
○ Microcephaly.

Yellow Fever Vaccine

● Yellow fever is vaccine-preventable.

Summary

● Dengue: Break-bone fever, high fever + severe pain.

● Yellow fever: Jaundice, black vomit, liver zone 2 damage, Aedes mosquito.
● Zika: Microcephaly, South American travel, Aedes mosquito, vertical/sexual
transmission.
● Rubella: German measles, rash starts on forehead, congenital syndrome (cataracts,
deafness, PDA, microcephaly).
● Rubeola: Measles, rash starts below/behind ears, more toxic, posterior auricular
lymphadenopathy.

Rubella is Vaccine Preventable

● Rubella can be prevented by the MMR (Measles, Mumps, Rubella) vaccine.

● MMR is a live attenuated vaccine.
● Avoid administering MMR to pregnant women, children <1 year old, or severely
immunocompromised individuals.
 ● Example: Avoid giving MMR to HIV patients with a CD4 count of 50.

Rubella (German Measles) vs Rubeola (Measles)

● Rubella (German Measles):

○ Rash starts on the forehead and moves down.
○ Less toxic presentation than rubeola.
● Rubeola (Measles):
○ Rash starts behind the ears or at the neck and moves down.
○ More toxic presentation.
○ Associated with posterior auricular lymphadenopathy.
○ 3 C’s + K: Cough, Coryza (runny nose), Conjunctivitis, and Koplik spots.

Koplik Spots

● Koplik spots are erythematous whitish spots on the buccal mucosa.

● A classic finding in measles (rubeola).

Subacute Sclerosing Panencephalitis (SSPE)

● Occurs in individuals with a history of measles infection.

● Presents 10-15 years later with progressive neurological deficits.
● SSPE is almost always fatal.

Vaccine Prevention for Measles and Rubella

● Both measles and rubella are preventable by vaccination (MMR).

Congenital Rubella Syndrome

● Key findings: Cataracts, Deafness, Patent Ductus Arteriosus (PDA), and

Microcephaly.
 ● PDA presents with a "machine-like murmur" on auscultation.

Cataracts in Children and Galactosemia

● Consider galactosemia in children with liver symptoms and cataracts.

● Galactosemia is caused by a deficiency in galactose-1-phosphate uridyl
transferase.

Slide 7 - Croup (Parainfluenza Virus)

● Presents with a barky seal-like cough and steeple sign on chest X-ray.
● Croup is a subglottic infection and often associated with stridor (upper airway
obstruction).
● Caused by parainfluenza virus.
Slide 8 - Ebola Virus

Peace Corps worker in Liberia, contact with monkeys, and bleeding from multiple orifices.

● A filovirus that is enveloped and has a helical shape.

● Causes widespread bleeding due to destruction of endothelial cells.
● Transmission through contact with infected blood or exposure to monkeys.
● Prevention: Barrier protection and strict patient isolation.
● Reportable illness: Can break patient confidentiality under duty to warn others.

Slide 9 - Influenza Virus

● Orthomyxovirus causing the flu.

● Influenza A: Infects humans and animals.
● Influenza B: Infects humans only.
● Two important proteins:
○ Hemagglutinin (HA): Binds to sialic acid, enabling viral entry into cells.
○ Neuraminidase (NA): Helps the virus release from infected cells.
● Influenza virus uses the acidic environment of lysosomes to uncoat itself.

Acidic pH is created by a proton pump called the M2 proton pump.

Inhibiting the M2 proton pump inhibits the encoding of the virus.

Drugs like amantadine and rimantadine work by inhibiting the M2 proton pump.

Amantadine and rimantadine are no longer used.

After the virus has completed replication in a human, it uses neuraminidase.

Neuraminidase cleaves hemagglutinin from sialic acid, allowing the virus to spread to
other cells.
Neuraminidase is inhibited by drugs like zanamivir.

Zanamivir covers both influenza A and B.

These drugs must be given within the first 48 hours of infection to be effective.

Amantadine and rimantadine are not used anymore due to 100% resistance.

Amantadine was discovered to have some pro-dopaminergic properties.

Therefore, amantadine is currently used in the treatment of Parkinson’s disease.

Influenza is transmitted through exposure to respiratory droplets.

A notable aspect of the flu virus is that it has a segmented genome.
The segmented genome causes various problems.
These problems involve antigenic drift and antigenic shift.
Antigenic drift is a milder process compared to antigenic shift.

RNA polymerase in the influenza virus is error-prone and lacks good proofreading
capabilities.
This leads to mutations in hemagglutinin and neuraminidase, creating a modified
virus.
Such mutations can lead to an epidemic.

In contrast, antigenic shift occurs when two influenza viruses infect the same cell.
This results in the recombination of different segments of their segmented genomes.
A new virus is created that the population has never encountered before.
Antigenic shift can lead to a pandemic.

It's crucial to differentiate between antigenic drift and shift and their causes.

Clinical presentations of influenza often include myalgias, headache, cough, and runny
nose.
Symptoms usually appear around December and January.

A person recovering from the flu who suddenly has high fevers and cavitary lesions on a
chest.
X-ray may have a secondary bacterial infection from Staphylococcus aureus.

If a child had the flu and then presents with hypoglycemia and neurologic problems, consider
Reye's syndrome.
Reye's syndrome occurs due to aspirin use.

The flu can also lead to Guillain-Barré syndrome, not just Campylobacter jejuni infections.
During the flu season (November to December), sensitivity and specificity of flu
detection tests remain fixed.

Positive predictive value (PPV) increases during this time.

Increased prevalence in the fall enhances the likelihood of a true positive result.

Most people receive the injectable flu vaccine.

The live attenuated vaccine is available as an intranasal option.

Children under one year, severely immunocompromised individuals, and pregnant

women should avoid the live vaccine.

A patient with severe leg myalgias and respiratory difficulty due to pulmonary edema after
exposure to rodent droppings is likely infected with hantavirus.

Hantavirus is a bunyavirus associated with myalgias and pulmonary edema.

Slide 10 - Watery diarrhea in an infant

Often caused by rotavirus.

Rotavirus is a double-stranded RNA virus.

It classically causes watery diarrhea in infants.

Rotavirus is vaccine-preventable.
Avoid rotavirus vaccination in children with a history of intussusception.

Intussusception can lead to currant jelly stools.

In an alcoholic patient with currant jelly sputum, think of Klebsiella pneumoniae.

Klebsiella pneumoniae is a urease-positive bacterium.