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Phloston  

—  All  info  in  this  presentation  is  high-­‐yield.    I  had  two  

questions  on  my  real  deal  that  involved  viral  
structural  identification.  

RNA  viruses  

RNA  viruses  
—  Icosahedral  or  helical  nucleocapsids  

RNA  viruses  
—  Icosahedral  or  helical  nucleocapsids  
—  Icosahedral  are  either  enveloped  or  non-­‐enveloped.    

Helicals  are  always  enveloped.  

RNA  viruses  
—  Icosahedral  or  helical  nucleocapsids  
—  Icosahedral  are  either  enveloped  or  non-­‐enveloped.    

Helicals  are  always  enveloped.  
—  For  icosahedral,  non-­‐enveloped  viruses,  you’ve  got  
SS(+)  non-­‐segmented  and  DS-­‐segmented.  

  .  non-­‐enveloped  viruses.   —  SS(+)  non-­‐segmented.     Helicals  are  always  enveloped.  non-­‐enveloped  icosahedral   viruses  are  split  into  picornaviridae  and  caliciviridae.  you’ve  got   SS(+)  non-­‐segmented  and  DS-­‐segmented.   —  For  icosahedral.RNA  viruses   —  Icosahedral  or  helical  nucleocapsids   —  Icosahedral  are  either  enveloped  or  non-­‐enveloped.

 non-­‐enveloped  viruses.   —  Picornaviridae  are  split  into  rhinovirus  (on  its  own)   and  the  enteroviruses.  you’ve  got   SS(+)  non-­‐segmented  and  DS-­‐segmented.     Helicals  are  always  enveloped.RNA  viruses   —  Icosahedral  or  helical  nucleocapsids   —  Icosahedral  are  either  enveloped  or  non-­‐enveloped.   —  For  icosahedral.   .  non-­‐enveloped  icosahedral   viruses  are  split  into  picornaviridae  and  caliciviridae.   —  SS(+)  non-­‐segmented.

RNA  viruses   —  The  enteroviruses  comprise  polio.  HepA.  coxsackie   and  echovirus.   .

 know  anterior  horns.    Contraction  of  the  virus  is   THROUGH  INGESTION  (exceedingly  high-­‐yield).RNA  viruses   —  The  enteroviruses  comprise  polio.    Salk  (killed)  is  the  IM/ IV  vaccine.   —  For  polio.  HepA.  superior  gluteal  nerve   palsy  (trendelenburg  gait).     Sabin  (oral)  is  the  live-­‐vaccine.  coxsackie   and  echovirus.   .

RNA  viruses   —  The  enteroviruses  comprise  polio.  superior  gluteal  nerve   palsy  (trendelenburg  gait).   —  HepA  à  Asymptomatic  (high-­‐yield).  HepA.  coxsackie   and  echovirus.  know  anterior  horns.   —  For  polio.     Sabin  (oral)  is  the  live-­‐vaccine.  shortest   incubation  of  the  Heps  (2-­‐6  wks).  killed  vaccine   .    Salk  (killed)  is  the  IM/ IV  vaccine.    Contraction  of  the  virus  is   THROUGH  INGESTION  (exceedingly  high-­‐yield).

 hand-­‐foot-­‐mouth  disease   .RNA  viruses   —  coxsackieA  à  herpangina  (if  instead  herpes  they’ll   imply  Cowdry  bodies  via  mention  of  intranuclear   inclusions).

 DIRECT-­‐VIRAL  DAMAGE  (NOT  type-­‐II   HS.  DCM   .  hand-­‐foot-­‐mouth  disease   —  coxsackie-­‐B  àmost  common  cause  of  viral   myocarditis.  like  rheumatic  heart  disease).RNA  viruses   —  coxsackieA  à  herpangina  (if  instead  herpes  they’ll   imply  Cowdry  bodies  via  mention  of  intranuclear   inclusions).

 hand-­‐foot-­‐mouth  disease   —  coxsackie-­‐B  àmost  common  cause  of  viral   myocarditis.RNA  viruses   —  coxsackieA  à  herpangina  (if  instead  herpes  they’ll   imply  Cowdry  bodies  via  mention  of  intranuclear   inclusions).  DIRECT-­‐VIRAL  DAMAGE  (NOT  type-­‐II   HS.  like  rheumatic  heart  disease).e.  ssRNA  virus)   .  non-­‐enveloped.  they’ll  tell  you  kid’s  got   meningitis  from  RNA  virus  and  then  ask  you  for  the   structure  (i.  DCM   —  echovirus  à  meningitis.

RNA  viruses   —  Rhinovirus  à  most  common  cause  of  the  common   cold  (high-­‐%  question).    Sometimes  they’ll  ask   you  for  the  picornavirus  that’s  respiratory-­‐contracted.   .  contraction  occurs  via   ICAM-­‐1  (CD54)  à  know  that.

  .  but  remember  both   (just  do  it.   —  For  caliciviridae.  contraction  occurs  via   ICAM-­‐1  (CD54)  à  know  that.    Sometimes  they’ll  ask   you  for  the  picornavirus  that’s  respiratory-­‐contracted.  so  if  the  latter  shows   up.  know  calicivirus  (Norwalk  virus)  and   HepE.    The  catch  is  that  HepE  has  recently  been   reclassified  under  hepeviridae.  I’ve  seen  both  in  practice  questions).RNA  viruses   —  Rhinovirus  à  most  common  cause  of  the  common   cold  (high-­‐%  question).  it’s  correct  over  caliciviridae.

RNA  viruses   —  USMLE  likes  Norwalk  virus  for  cruise  ships  (anything   where  a  lot  of  people  in  close  contact  come  down  with   a  gastroenteritis).   .

 you’ve  just  gotta  remember  pregnant   women  (highest  yield).  Asia  >  USA  (particularly   Tibet).  and  of  course  it’s  enteric.RNA  viruses   —  USMLE  likes  Norwalk  virus  for  cruise  ships  (anything   where  a  lot  of  people  in  close  contact  come  down  with   a  gastroenteritis).   —  For  HepE.   .

 icosahedral.   .    For  DS-­‐segmented.  non-­‐enveloped  RNA   viruses  are  either  SS(+)-­‐non-­‐segmented  or  DS-­‐ segmented.  all  you  need  to   remember  is  the  reoviridae.RNA  viruses   —  As  we  said  before.

   For  DS-­‐segmented.  all  you  need  to   remember  is  the  reoviridae.RNA  viruses   —  As  we  said  before.  non-­‐enveloped  RNA   viruses  are  either  SS(+)-­‐non-­‐segmented  or  DS-­‐ segmented.   —  Reoviridae  à  rotavirus  and  reovirus  (coltivirus)   .  icosahedral.

  .RNA  viruses   —  Rotavirus  is  most  common  cause  of  viral  enteritis  in   young  children  (exceedingly  high-­‐yield).    They’ll  ask  you  for  the  virus  that   can  undergo  genetic  modulation  similar  to  influenza.  USMLE   wants  you  to  know  it  is  HIGHLY  SEGMENTED  [10]   (like  influenza  virus  [8])  and  therefore  can  undergo   REASSORTMENT.

  .    But  I  would  be   aware  of  the  viral  structure  regardless.RNA  viruses   —  Coltivirus  (reovirus)  causes  Colorado  Tick  fever.    I’ve   never  encountered  a  question  on  this.

RNA  viruses   —  The  icosahedral  enveloped  viruses  are  SS(+)-­‐non-­‐ segmented  and  SS(+)  diploid.    (deltavirus  used  to  be   in  this  category  but  has  recently  been  moved  to   helical)   .

   (deltavirus  used  to  be   in  this  category  but  has  recently  been  moved  to   helical)   —  SS(+)-­‐non-­‐segmented  are  togaviridae  and  flaviviridae   .RNA  viruses   —  The  icosahedral  enveloped  viruses  are  SS(+)-­‐non-­‐ segmented  and  SS(+)  diploid.

RNA  viruses   —  The  icosahedral  enveloped  viruses  are  SS(+)-­‐non-­‐ segmented  and  SS(+)  diploid.    (deltavirus  used  to  be   in  this  category  but  has  recently  been  moved  to   helical)   —  SS(+)-­‐non-­‐segmented  are  togaviridae  and  flaviviridae   —  Togaviridae  are  alpha  virus  (equine  encephalitides)   and  rubivirus  (rubella)   .

 West  Nile.  Yellow/Dengue   fevers.RNA  viruses   —  The  icosahedral  enveloped  viruses  are  SS(+)-­‐non-­‐ segmented  and  SS(+)  diploid.    (deltavirus  used  to  be   in  this  category  but  has  recently  been  moved  to   helical)   —  SS(+)-­‐non-­‐segmented  are  togaviridae  and  flaviviridae   —  Togaviridae  are  alpha  virus  (equine  encephalitides)   and  rubivirus  (rubella)   —  Flaviviridae  are  HepC.  Japanese  encephalitis   .

 Western  and  Venezuelan  equine   encephalitis.  there’s  EEE.  WEE  and   VEE  for  Eastern.  respectively.   .RNA  viruses   —  For  the  equine  encephalitides.

 know  the  structure.  respectively.  there’s  EEE.   —  All  you  need  to  know  for  these  are  that  they  cause   CNS  effects  and  are  associated  with  horses.  WEE  and   VEE  for  Eastern.   .RNA  viruses   —  For  the  equine  encephalitides.  Western  and  Venezuelan  equine   encephalitis.    Any   mention  of  horses  à  alphavirus.

  —  All  you  need  to  know  for  these  are  that  they  cause   CNS  effects  and  are  associated  with  horses.    Any   mention  of  horses  à  alphavirus.    It  also  causes  a  THREE-­‐DAY  rash.  know  the  structure.   —  For  rubella.  respectively.  Western  and  Venezuelan  equine   encephalitis.RNA  viruses   —  For  the  equine  encephalitides.    That  will  be   the  give-­‐away.  know  that  it  causes  post-­‐auricular  or   sub-­‐occipital  lymph  node  tenderness.   .  WEE  and   VEE  for  Eastern.  there’s  EEE.

RNA  viruses   —  For  HepC.  be  aware  that  it  has  the  longest   incubation  period  (in  contrast  to  HepA.   .  which  has   the  shortest).

  and  it  was  strictly  because  it  had  a  ground-­‐glass   appearance.RNA  viruses   —  For  HepC.    HepC  will  be  nodular  or  clumpy.  despite  HepC  being  more  common  in   IV  drug-­‐users.  not   ground-­‐glass.  HepB.  HepC  will  cause  a  nodular  or  clumpy   appearance.  not  HepC.  and  then  they  showed  the   liver  histology.  which  has   the  shortest).  in  contrast.  and  the  answer  was  HepB.   —  Histologically.  be  aware  that  it  has  the  longest   incubation  period  (in  contrast  to  HepA.   .    I’ve  seen  a  question  that   mentioned  an  IV  drug-­‐user.  will  cause  a  ground-­‐ glass  appearance.

 not  B.   .  it’s  HepB  Tx.    Regulater  interferon-­‐alpha  is  Tx  for  HepB.  if   it’s  regular.  it’s  HepC.   not  C.  if  it’s  pegylated.    If  they  list  pegylated  interferon-­‐alpha  and   regular  interferon-­‐alpha  as  answer  choices  to  the   same  question.RNA  viruses   —  You  treat  HepC  with  pegylated  interferon-­‐alpha  and   ribavirin.

   Regulater  interferon-­‐alpha  is  Tx  for  HepB.  HepB  is  transmissible  by  sex.    Obviously  if  there’s   menstruation.    If  they  list  pegylated  interferon-­‐alpha  and   regular  interferon-­‐alpha  as  answer  choices  to  the   same  question.  it’s  HepB  Tx.  if  it’s  pegylated.  there’s  a  risk.  it  is   NOT  TRANSMISSIBLE  BY  SEX.   —  HepC  is  transmitted  via  blood.  not  B.RNA  viruses   —  You  treat  HepC  with  pegylated  interferon-­‐alpha  and   ribavirin.   .  it’s  HepC.    That  means.   not  C.  but  HepC  is   not.  if   it’s  regular.  but  for  the  purpose  of  the   USMLE.

RNA  viruses  
—  Like  HepB,  HepC  is  transmitted  parenterally,  can  

cause  chronic  disease  and  hepatocellular  carcinoma.    
The  latter  will  be  implied  in  a  question  via  mention  of  
alpha-­‐fetoprotein  (the  tumor  marker  for  HCC;  it’s  also  
the  tumor-­‐marker  for  yolk-­‐sac  [endodermal  sinus]  
and  mixed  germ  cell  tumors).  

RNA  viruses  
—  If  they  tell  you  a  patient  has  HepC  (or  HepB  or  

EtOHism),  and  then  they  show  you  a  liver  with  lots  
of  neoplastic  lesions  à  colonic  metastases,  NOT  
primary  HCC.    So  HY.    USMLE  wants  you  to  realize  
that  a  primary  HCC  is  typically  a  solitary  lesion.  

RNA  viruses  
—  If  they  tell  you  a  patient  has  HepC  (or  HepB  or  

EtOHism),  and  then  they  show  you  a  liver  with  lots  
of  neoplastic  lesions  à  colonic  metastases,  NOT  
primary  HCC.    So  HY.    USMLE  wants  you  to  realize  
that  a  primary  HCC  is  typically  a  solitary  lesion.  
—  Sometimes  instead  of  listing  “colonic  
adenocarcinoma”  or  “HCC”  as  answer  choices,  they’ll  
just  ask  for  the  tumor  marker.    In  the  above  case,  it  
would  be  CEA,  not  alpha-­‐FP.    Alpha-­‐FP  is  HCC;  colon  
cancer  is  CEA.  

 just  remember  that  the  pt  is   yellow  (jaundice)  and  that  he  or  she  has  mid-­‐zone   necrosis  of  the  liver  (zone-­‐2).   .RNA  viruses   —  For  west  nile  virus.

 and  severe   retro-­‐ocular  headache.   —  For  dengue  fever.  remember  that  the  pt  will  have   thrombocytopenia.  just  remember  that  the  pt  is   yellow  (jaundice)  and  that  he  or  she  has  mid-­‐zone   necrosis  of  the  liver  (zone-­‐2).   .RNA  viruses   —  For  west  nile  virus.  severe  back  pain.

  .  and  severe   retro-­‐ocular  headache.   —  I’ve  never  seen  Sx  of  Japanese  encephalitis  asked  in  a   question  before.RNA  viruses   —  For  west  nile  virus.  just  remember  that  the  pt  is   yellow  (jaundice)  and  that  he  or  she  has  mid-­‐zone   necrosis  of  the  liver  (zone-­‐2).   —  For  dengue  fever.  remember  that  the  pt  will  have   thrombocytopenia.  severe  back  pain.

 here’s  your  reward:   .    So  if  you’ve  made  it   this  far  in  the  presentation.RNA  viruses   —  But  here’s  where  your  points  are.

  .RNA  viruses   —  But  here’s  where  your  points  are.  but  West  Nile   virus  is  transmitted  by  the  CULEX  mosquito.    So  if  you’ve  made  it   this  far  in  the  presentation.  they  want  you  to  know   that  Japanese  encephalitis  and  Dengue  fever  are   transmitted  by  the  Aedes  mosquito.  here’s  your  reward:   —  For  the  sake  of  the  USMLE.

  .    So  if  you’ve  made  it   this  far  in  the  presentation.  they  want  you  to  know   that  Japanese  encephalitis  and  Dengue  fever  are   transmitted  by  the  Aedes  mosquito.  but  West  Nile   virus  is  transmitted  by  the  CULEX  mosquito.   —  Seemingly  ridiculous.  but  know  it.  here’s  your  reward:   —  For  the  sake  of  the  USMLE.RNA  viruses   —  But  here’s  where  your  points  are.    West  Nile  virus  is   transmitted  by  the  Culex  mosquito.  and  its   reservoir  is  birds.

RNA  viruses  
—  The  SS(+)-­‐diploid  icosahedral,  enveloped  RNA  viruses  

are  HIV1/2  and  HTLV1/2  (discuss)  

RNA  viruses  
—  The  SS(+)-­‐diploid  icosahedral,  enveloped  RNA  viruses  

are  HIV1/2  and  HTLV1/2  (discuss)  
—  HTLV  à  mycosis  fungoides  /  Sezary  syndrome  

RNA  viruses  
—  The  SS(+)-­‐diploid  icosahedral,  enveloped  RNA  viruses  

are  HIV1/2  and  HTLV1/2  (discuss)  
—  HTLV  à  mycosis  fungoides  /  Sezary  syndrome  
—  HTLV  also  causes  TROPICAL  SPASTIC  
PARAPARESIS.    I’ve  seen  this  rock  up  in  a  question.    
Abs  against  infected  T-­‐cells  attack  neural  cells  and  
cause  muscle  weakness/stiffness  in  the  legs.      

  .       —  In  Sezary’s.  you’ve  got  Pautrier  microabscesses  (T-­‐ cell  collections).  enveloped  RNA  viruses   are  HIV1/2  and  HTLV1/2  (discuss)   —  HTLV  à  mycosis  fungoides  /  Sezary  syndrome   —  HTLV  also  causes  TROPICAL  SPASTIC   PARAPARESIS.    Don’t  confuse  with  the  Munro   microabscesses  of  psoriasis  (neutrophils  in  the  skin).RNA  viruses   —  The  SS(+)-­‐diploid  icosahedral.     Abs  against  infected  T-­‐cells  attack  neural  cells  and   cause  muscle  weakness/stiffness  in  the  legs.    I’ve  seen  this  rock  up  in  a  question.

 SS(-­‐)  segmented  and  SS(-­‐)  non-­‐ segmented.   .RNA  viruses   —  The  helical  RNA  viruses  are  divided  into  SS(+)  non-­‐ segmented.

 SS(-­‐)  segmented  and  SS(-­‐)  non-­‐ segmented.   —  The  SS(+)  non-­‐segmented  one  is  coronaviridae  à   coronavirus  à  causes  SARS   .RNA  viruses   —  The  helical  RNA  viruses  are  divided  into  SS(+)  non-­‐ segmented.

  .RNA  viruses   —  The  helical  RNA  viruses  are  divided  into  SS(+)  non-­‐ segmented.   —  The  SS(+)  non-­‐segmented  one  is  coronaviridae  à   coronavirus  à  causes  SARS   —  The  SS(-­‐)  segmented  ones  are  orthomyxoviridae  and   bunyaviridae.  SS(-­‐)  segmented  and  SS(-­‐)  non-­‐ segmented.

  —  Orthomyxoviridae  are  the  influenza  A.  SS(-­‐)  segmented  and  SS(-­‐)  non-­‐ segmented.   —  The  SS(+)  non-­‐segmented  one  is  coronaviridae  à   coronavirus  à  causes  SARS   —  The  SS(-­‐)  segmented  ones  are  orthomyxoviridae  and   bunyaviridae.  B  +  C  viruses   .RNA  viruses   —  The  helical  RNA  viruses  are  divided  into  SS(+)  non-­‐ segmented.

  .RNA  viruses   —  Bunyaviridae  à  bunyavirus  +  hantavirus  (mice  +   haemorrhagic  pulmonary  syndrome).

    I  even  have  a  friend  on  SDN  who  had  hantavirus  show   up  on  his/her  real  deal.    There  are   quite  a  few  “low-­‐yield”  viruses.   .  wants  you  to  know   that  hantavirus  is  transmitted  by  mice.    Hantavirus  is  transmitted  by  mice.   —  The  USMLE.  but  consider  this  detail   one  of  the  highest-­‐yield  of  the  low-­‐yield.RNA  viruses   —  Bunyaviridae  à  bunyavirus  +  hantavirus  (mice  +   haemorrhagic  pulmonary  syndrome).  for  whatever  reason.    I’ve  seen  it   in  a  few  questions.

 you  need  to  remember  that  it’s   HIGHLY  SEGMENTED.RNA  viruses   —  For  influenza.  and  that  reassortment  of  the   segments  with  animal  viruses  leads  to  antigenic  Shift.   .

  —  In  contrast.  and  that  reassortment  of  the   segments  with  animal  viruses  leads  to  antigenic  Shift.   .  point  mutations  in  haemagglutinin  and   neuraminidase  lead  to  antigenic  Drift.  you  need  to  remember  that  it’s   HIGHLY  SEGMENTED.RNA  viruses   —  For  influenza.

  .RNA  viruses   —  For  influenza.  and  that  reassortment  of  the   segments  with  animal  viruses  leads  to  antigenic  Shift.   —  In  contrast.  you  need  to  remember  that  it’s   HIGHLY  SEGMENTED.   —  You’ll  know  it’s  a  shift  vs  drift  bc  shift  causes   PANdemic  (worldwide  or  continental-­‐magnitude   disease).  whereas  drift  causes  EPIdemic  (towns  or   states).  point  mutations  in  haemagglutinin  and   neuraminidase  lead  to  antigenic  Drift.

RNA  viruses   —  If  they  ask  about  the  target  of  an  influenza  vaccine.  in  contrast.     Remember  that.  but  haemagglutinin  mediates   viral  attachment.   prevent  viral  spread  (“cells  packed  with  virions”).    I  talk  about  this  more  specifically  at   the  end  of  this  lecture.     Neuraminidase  inhibitors  (-­‐mivirs).   .    Vaccines  target  this  molecule.   the  answer  is  ALWAYS  HAEMAGGLUTININ.

RNA  viruses   —  If  they  ask  about  the  target  of  an  influenza  vaccine.  is  highly  segmented.     Neuraminidase  inhibitors  (-­‐mivirs).  in  contrast.    I  talk  about  this  more  specifically  at   the  end  of  this  lecture.   .     Remember  that.   the  answer  is  ALWAYS  HAEMAGGLUTININ.  want  you  to  remember  that   rotavirus.  once  again.  like  influenza  virus.  but  haemagglutinin  mediates   viral  attachment.   —  They  also.   prevent  viral  spread  (“cells  packed  with  virions”).    Vaccines  target  this  molecule.

 enveloped  SS(-­‐)  non-­‐segmented  ones  are   paramyxoviridae.   .  rhabdoviridae.  filoviridae  and   arenaviridae.RNA  viruses   —  The  helical.

 enveloped  SS(-­‐)  non-­‐segmented  ones  are   paramyxoviridae.  rhabdoviridae.RNA  viruses   —  The  helical.  rubulavirus  and   morbillivirus   .  pneumovirus  (RSV).   —  Paramyxoviridae  à  parainfluenza  virus   (paramyxovirus).  filoviridae  and   arenaviridae.

  .  know  that  for  DDx).  epiglottitis  causes  a  thumb-­‐ print  sign  on  x-­‐ray.RNA  viruses   —  For  parainfluenza  virus.    This  causes  a  steeple-­‐sign  on   lateral  x-­‐ray  (in  contrast.  which  has  a  seal-­‐ like  barking  cough.  remember  that  it  causes   laryngotracheobronchitis  (croup).

RNA  viruses   —  For  parainfluenza  virus.    It’s  the  most  common  cause  of  bronchiolitis   in  infants.   .  it’s  aka  respiratory  syncytial  virus   (RSV).  Tx  w/  ribavirin.  remember  that  it  causes   laryngotracheobronchitis  (croup).  which  has  a  seal-­‐ like  barking  cough.    This  causes  a  steeple-­‐sign  on   lateral  x-­‐ray  (in  contrast.  epiglottitis  causes  a  thumb-­‐ print  sign  on  x-­‐ray.    If  there’s  any  “pneumonia”-­‐type   presentation  in  an  infant  à  RSV.   —  For  pneumovirus.  know  that  for  DDx).

 roSeola  infantum  =  HHV-­‐6.   Don’t  confuse  with:   Rubivirus  =  rubella  =  German  measles  =  three-­‐day   measles.   à  This  slide  is  very  important.  which  is  measles.   .    Don’t  confuse   with  ruBeola.RNA  viruses   —  For  clarification  purposes:   Rubulavirus  =  mumps   Morbillivirus  =  measles  =  ruBeola   à Those  two  are  paramyxoviridae.  this  is  Togaviridae   In  addition.

 just  remember  MOP:  meningitis.RNA  viruses   —  For  mumps.   orchitis.   .  parotitis.

  orchitis.  parotitis.   —  For  measles.   .  just  remember  MOP:  meningitis.RNA  viruses   —  For  mumps.  just  remember  that  the  rash  starts  at  the   head  and  moves  to  the  toes.

 just  remember  that  the  rash  starts  at  the   head  and  moves  to  the  toes.   —  You  also  need  to  be  extremely  aware  of  subacute   sclerosing  pan-­‐encephalitis  (SSPE)  as  a  disease   associated  with  measles.   —  For  measles.RNA  viruses   —  For  mumps.   .  parotitis.   orchitis.  just  remember  MOP:  meningitis.

 and  there  will  concomitantly  be  no   evidence  of  anti-­‐M-­‐protein  Abs  in  the  CNS.  only  to  re-­‐present   later  as  SSPE.  you’ve  gotta  know  that  sometimes  children   can  get  measles.  but  that  the   virus  can  remain  latent  in  the  CNS.  the  infection  resolves.    This  occurs  in  M-­‐protein-­‐negative   measles  strains.   .RNA  viruses   —  For  SSPE.

 got   myalgias  and  then  rapidly  deteriorated  and  died.    Holy  cow.   .    It’s   measles.RNA  viruses   —  They’ll  tell  you  a  10-­‐yr-­‐old  girl  was  perfectly  normal.  but  it’s  ludicrously  HY   and  is  very  commonly  asked.     I’d  say  this  is  a  240+  question.     They’ll  ask  for  which  organism  is  responsible.   but  then  started  doing  poorly  in  school.    You’ve  gotta  know  this  is  SSPE.

  but  then  started  doing  poorly  in  school.     They’ll  ask  for  which  organism  is  responsible.  got   myalgias  and  then  rapidly  deteriorated  and  died.    HY!!   .RNA  viruses   —  They’ll  tell  you  a  10-­‐yr-­‐old  girl  was  perfectly  normal.     I’d  say  this  is  a  240+  question.   —  Or  they  might  tell  you  a  17-­‐yr-­‐old  immigrant  had   similar  Sx  à  you’d  need  to  infer  that  her  immigrant   status  means  she  likely  wasn’t  immunized  with  MMR   when  younger.    It’s   measles.  but  it’s  ludicrously  HY   and  is  very  commonly  asked.    You’ve  gotta  know  this  is  SSPE.  and  she  got  SSPE  subsequently.    Holy  cow.

 which  allows  them  to  spread  cell-­‐to-­‐cell  via   syncytia  formation.   .RNA  viruses   —  Another  thing:  all  paramyxoviridae  produce  F-­‐ protein.

RNA  viruses   —  Another  thing:  all  paramyxoviridae  produce  F-­‐ protein.   —  Palivizumab  targets  F-­‐protein.  which  allows  them  to  spread  cell-­‐to-­‐cell  via   syncytia  formation.   .

 you  know  it’s  any  one  of  the  four   paramyxoviridae.RNA  viruses   —  Another  thing:  all  paramyxoviridae  produce  F-­‐ protein.    This  means  very  strong  CD8+   immunity  is  needed  to  kill  it.    If  they  ask  you  for   which  virus  requires  really  good  intracellular   immunity.  which  allows  them  to  spread  cell-­‐to-­‐cell  via   syncytia  formation.   —  Palivizumab  targets  F-­‐protein.   —  You’ve  gotta  realize  that  syncytia  formation  means   the  virus  has  very  little  exposure  to  the  humoral   environment.   .

RNA  viruses   —  Filoviridae  à  filovirus  à  subdivided  into  Marburg  +   ebola  viruses   .

RNA  viruses   —  Filoviridae  à  filovirus  à  subdivided  into  Marburg  +   ebola  viruses   —  Arenaviridae  à  lymphocytic  choriomeningitis  virus   aka  lassavirus   .

RNA  viruses   —  Filoviridae  à  filovirus  à  subdivided  into  Marburg  +   ebola  viruses   —  Arenaviridae  à  lymphocytic  choriomeningitis  virus   aka  lassavirus   —  Rhabdoviridae  à  lyssavirus  (rabies)   .

   I’ve  seen  this  in  a   couple  questions.RNA  viruses   —  For  lyssavirus  (rabies).  it’s  actually  very  HY  to  know   that  it  looks  bullet-­‐shaped  on  EM.   .

 it’s  actually  very  HY  to  know   that  it  looks  bullet-­‐shaped  on  EM.   .    I’ve  seen  this  in  a   couple  questions.RNA  viruses   —  For  lyssavirus  (rabies).   —  It  also  has  a  very  long  incubation  period  (up  to  several   months).

 bats.   —  It  also  has  a  very  long  incubation  period  (up  to  several   months).   .  it’s  actually  very  HY  to  know   that  it  looks  bullet-­‐shaped  on  EM.RNA  viruses   —  For  lyssavirus  (rabies).  wild  dogs  and  raccoons  are  reservoirs.   —  Skunks.    I’ve  seen  this  in  a   couple  questions.

  —  It  ascends  MOTOR  neurons  to  the  CNS.   —  Skunks.RNA  viruses   —  For  lyssavirus  (rabies).  it’s  actually  very  HY  to  know   that  it  looks  bullet-­‐shaped  on  EM.  wild  dogs  and  raccoons  are  reservoirs.    I’ve  seen  this  in  a   couple  questions.   —  It  also  has  a  very  long  incubation  period  (up  to  several   months).   .  bats.

 it’s  actually  very  HY  to  know   that  it  looks  bullet-­‐shaped  on  EM.  first  step  is  IV  immunoglobulin.  bats.RNA  viruses   —  For  lyssavirus  (rabies).   —  It  also  has  a  very  long  incubation  period  (up  to  several   months).    Ok?    IV   immunoglobulin  first  (passive  immunity).  THEN   give  the  killed  vaccine  (active  immunity).   THEN  killed  virus  vaccine.   .   —  If  bit  by  animal.  wild  dogs  and  raccoons  are  reservoirs.   —  Skunks.    I’ve  seen  this  in  a   couple  questions.   —  It  ascends  MOTOR  neurons  to  the  CNS.

  transmitted  by  female  mosquito.RNA  viruses   —  The  only  organism  that  has  a  longer  incubation  period   than  rabies  is  elephantitis  (~9  months.   .  which  is  Wuchereria  bancrofti.   lymphadenopathy).

RNA  viruses   —  For  ebola/marburg.    Realize  that  the  rarer  the  condition.    I  may  have   only  seen  one  question  on  ebola.  the   more  obvious  they’ll  make  the  vignette.  just  know  that  primates  can   transmit  the  virus  and  it’s  rapidly  fatal.   .  and  it  was  pretty   obvious.

 and  it  was  pretty   obvious.   —  I’ve  never  seen  a  question  on  lymphocytic   choriomeningitis  virus  (arenavirus)  beyond  just   knowing  its  structure  and  that  it’s  rodent-­‐ transmitted.    Realize  that  the  rarer  the  condition.  the   more  obvious  they’ll  make  the  vignette.RNA  viruses   —  For  ebola/marburg.    I  may  have   only  seen  one  question  on  ebola.   .  just  know  that  primates  can   transmit  the  virus  and  it’s  rapidly  fatal.

 WHICH  REQUIRE  THE  NUCLEUS.   .RNA  viruses   —  All  RNA  viruses  replicate  in  the  cytoplasm  EXCEPT   FOR  THE  LENTIVIRIDAE  (retroviruses)  AND   INFLUENZA.

 but  I’ve   seen  it  in  a  question).RNA  viruses   —  All  RNA  viruses  replicate  in  the  cytoplasm  EXCEPT   FOR  THE  LENTIVIRIDAE  (retroviruses)  AND   INFLUENZA.  WHICH  REQUIRE  THE  NUCLEUS.   .   —  SS(+)  non-­‐segmented  RNA  viruses  are  notable  for   synthesizing  their  proteins  as  a  SINGLE   TRANSLATIONAL  TRANSCRIPT  THAT  IS   SUBSEQUENTLY  CLEAVED  (retarded  detail.

DNA  viruses  (hooray)   .

  .DNA  viruses   —  Icosahedral  or  complex  nucleocapsids.

  —  The  only  virus  with  a  complex  nucleocapsid  is   Poxvirus.DNA  viruses   —  Icosahedral  or  complex  nucleocapsids.   .    It’s  DS-­‐linear  and  is  the  only  DNA  virus   that  DOESN’T  NEED  THE  NUCLEUS  TO  REPLICATE.

 there  are  non-­‐enveloped   and  enveloped  types.   .DNA  viruses   —  For  the  icosahedral  ones.

  —  The  non-­‐enveloped  are  SS-­‐linear.DNA  viruses   —  For  the  icosahedral  ones.   .  there  are  non-­‐enveloped   and  enveloped  types.  DS-­‐circular  and  DS-­‐ linear.

 PB19  crosses  placenta  (add  to  TORCHeS)   .    à  slapped  cheek   appearance.    Aplastic  anaemia  in  children  and   ARTHRITIS  IN  ADULTS  (oh  em  gee  high-­‐yield   wowwies).DNA  viruses   —  The  SS-­‐linear  icosahedral  non-­‐enveloped  DNA  virus  is   erythrovirus  (aka  parvovirus  B19).  once  rash  forms  VIRUS  HAS  BEEN   CLEARED  AND  PARENTS  CAN  BE  TOLD  CHILD   DOESN’T  NEED  Tx.

”giant  red  cell  precursors  seen  on   BM  biopsy”  à  indicative  of  pure  red-­‐cell  aplasia.  rather  than  just  telling  you  straight-­‐up.   .DNA  viruses   —  How  would  the  USMLE  throw  the  PB19  aplastic   anaemia  at  you?  .    Just   take  it  as  a  lesson  that  on  the  real  deal.  they’ll  take   pretty  much  any  and  every  concept  and  indirectly   relate  to  it..

DNA  viruses   —  I’ve  also  seen  in  a  question  that  PB19  binds  to  P-­‐ antigen.  on  the  RBC  surface.   .  aka  globoside.    Don’t   confuse  that  P  with  that  in  Palivizumab  for  F-­‐protein   (syncytia  formation  in  paramyxoviridae  à  they’ll  ask   you  which  virus  needs  super-­‐high  CD8  for  immunity   à  bc  syncytium  means  virus  doesn’t  see  humoral   environment!).

DNA  viruses   —  The  DS-­‐circular  non-­‐enveloped  icosahedral  DNA   viruses  are  the  papovaviridae.   .

   PML  shows  up  in   immunocompromised  so  the  latter  is  juicy.   .  but  the   former  is  right.    BK  affects  the  kidneys  (BK  =  kidney)   à  all  you  need  to  know  about  BK.DNA  viruses   —  The  DS-­‐circular  non-­‐enveloped  icosahedral  DNA   viruses  are  the  papovaviridae.  à  When   PML  (JC)  appears.   —  These  are  HPV  and  JC/BK  polyomaviruses.  NOT  because  of  recent  infection  in   immunocompromised.  the  USMLE  wants  you  to  know  that   it’s  always  because  of  REACTIVATION  OF  LATENT   VIRUS  (holy  cow).

 just  know  that  is  causes  koilocytes  (large.   .DNA  viruses   —  For  HPV.    Be  familiar  with  cervical  cancer   histology.   irregular  cells  with  peri-­‐nuclear  halos  on  Pap-­‐smear)   and  cervical  cancer.  that’s  really  HY.

DNA  viruses   —  For  HPV.  that’s  really  HY.  just  know  that  is  causes  koilocytes  (large.   HPV-­‐16/18/31/33/45  cause  cervical  cancer.   irregular  cells  with  peri-­‐nuclear  halos  on  Pap-­‐smear)   and  cervical  cancer.   —  HPV-­‐6/11  cause  condyloma  acuminata  (warts).   .    Be  familiar  with  cervical  cancer   histology.

DNA  viruses   —  The  other  thing  is  that  the  papovaviridae  are   SUPERCOILED  circular.  whereas  HepB  (to  be   discussed  soon)  is  PARTIAL  circular.   .

 whereas  HepB  (to  be   discussed  soon)  is  PARTIAL  circular.DNA  viruses   —  The  other  thing  is  that  the  papovaviridae  are   SUPERCOILED  circular.  when  PML  shows  up  in  a   question.  they’ll  mention  it  as  MANY  NON-­‐ CONTRASTING  LESIONS  on  MRI.    I’ve  seen  that  in  a   few  questions.   —  As  far  as  I  can  remember.   .

   Conjunctivitis  will   be  straightforward.    For  HC.  they’ll  throw  rotavirus  in  there  for  kicks   just  bc  that’s  so  common  in  infants.  but  it’s   adenovirus.   .    à  just  remember  CONJUNCTIVITIS   and  HAEMORRHAGIC  CYSTITIS.  they’ll  mention  a  bunch   of  kids  at  daycare  with  reddish  urine  and  then  ask  you   for  the  virus.DNA  viruses   —  The  icosahedral  non-­‐enveloped  DS-­‐linear  DNA  virus   is  adenovirus.

  .DNA  viruses   —  The  enveloped  icosahedral  DNA  viruses  are  the   herpesviridae  and  hepadnaviridae  (HepB).

 they  like  “intranuclear  inclusions”  for   Cowdry  bodies.DNA  viruses   —  For  herpes.    “Punched  out”  ulcers  is  herpes.     “Linear  ulcers”  is  CMV.   .

DNA  viruses   —  For  herpes.   —  HepB  is  enveloped.  icosahedral  and  circular.    “Punched  out”  ulcers  is  herpes.  not   linear.   .     “Linear  ulcers”  is  CMV.  they  like  “intranuclear  inclusions”  for   Cowdry  bodies.

  .  icosahedral  and  circular.   —  HepB’s  DNA-­‐dependent  DNA-­‐polymerase  is  mega-­‐ high-­‐yield  to  remember.  the  DNA-­‐d-­‐DNA-­‐pol  is  >>>  important  than   its  reverse  transcriptase.    “Punched  out”  ulcers  is  herpes.     “Linear  ulcers”  is  CMV.  not   linear.    If  they  ask  you  about  HepB’s   enzyme.  they  like  “intranuclear  inclusions”  for   Cowdry  bodies.   —  HepB  is  enveloped.  but  remember  both.DNA  viruses   —  For  herpes.

 but  remember  both.   —  HepB  is  enveloped.    “Punched  out”  ulcers  is  herpes.  they  like  “intranuclear  inclusions”  for   Cowdry  bodies.     “Linear  ulcers”  is  CMV.  not   linear.  icosahedral  and  circular.   —  HepD  (deltavirus)  requires  HepB  to  form  envelope.   .   prevention  for  HepD  is  HepB  vaccination.  the  DNA-­‐d-­‐DNA-­‐pol  is  >>>  important  than   its  reverse  transcriptase.   —  HepB’s  DNA-­‐dependent  DNA-­‐polymerase  is  mega-­‐ high-­‐yield  to  remember.    If  they  ask  you  about  HepB’s   enzyme.DNA  viruses   —  For  herpes.

 are  VERY  SIMILAR   histologically  to  cells  w/  herpes-­‐induced  Cowdry  A   bodies.  they  cause  Cowdry  A   bodies.    I  also   just  want  to  point  out  that  WARTHIN-­‐FINKELDEY   cells.   .    These  are  intra-­‐NUCLEAR  inclusions.  caused  by  MEASLES.DNA  viruses   —  Remember  that  for  Herpes.    So  be  aware  of  the  patient’s  overall   presentation/Hx  to  make  the  correct  diagnosis.

 they  can  be  seen  swapped.DNA  viruses   —  HHV1/2  =  HSV1/2.  HSV1  =  herpes  labialis  (oral).   .  those  are  the   associations.   whereas  HSV2  =  genital.   but  for  the  purpose  of  the  USMLE.

DNA  viruses   —  HHV1/2  =  HSV1/2.  Antivirals  discussed  later   in  this  lecture.  can  present  years  later  as  shingles   (herpes  zoster.   —  HHV-­‐3  =  chickenpox  (“crops  of  vesicles  on  the  trunk”)   =  varicella  zoster.   but  for  the  purpose  of  the  USMLE.  not  a  different  virus.  those  are  the   associations.  HSV1  =  herpes  labialis  (oral).  if  shingles  à   pain  (herpetic  neuralgia)  and  vesicles  in  a   dermatomal  distribution.  but  herpes  zoster   is  literally  the  other  name  for  shingles).   whereas  HSV2  =  genital.  they  can  be  seen  swapped.   .

  .DNA  viruses   —  HHV4  =  EBV  à  mononucleosis  (“atypical   lymphocytes”  on  blood  smear  à  they’re  CD8+  T-­‐ CELLS  NOT  B-­‐CELLS.  particularly  when   enlarged).    Can  cause  Burkitt’s  lymphoma.  DESPITE  the  virus  normally   infecting  B-­‐cells)  à  splenomegaly  (pt  with  mono   should  avoid  contact  sports  bc  spleen  is  most  easily   ruptured  abdominal  organ.

  .    CMV  colitis  occurs  in  HIV  pts  w/  <50   CD4+  count.     Antivirals  discussed  later  in  this  lecture.”    Retinitis  is   most  common  CMV  manifestation  (CD4+  <200).  causes   blueberry  muffin  rash  +  hepatomegaly  in  neonate  if   TORCHeS.  remember  “linear  ulcers.DNA  viruses   —  HHV5  =  CMV  à  commonly  spread  via  renal   transplantation  or  blood  transfusions.

 remember  “linear  ulcers.”    Retinitis  is   most  common  CMV  manifestation  (CD4+  <200).    CMV  colitis  occurs  in  HIV  pts  w/  <50   CD4+  count.  which  remains  latent  in  B-­‐cells)   .DNA  viruses   —  HHV5  =  CMV  à  commonly  spread  via  renal   transplantation  or  blood  transfusions.   —  Remains  latent  in  mononuclear  cells  (in  contrast  to   EBV.     Antivirals  discussed  later  in  this  lecture.  causes   blueberry  muffin  rash  +  hepatomegaly  in  neonate  if   TORCHeS.

   That’s  all  you  need  to  know  about  it.DNA  viruses   —  HHV6  =  roseola  infantum  =  spiking  fever  followed  by   rash.   .

 and   Castleman’s  disease  (non-­‐cancerous  lymph  node   growths).DNA  viruses   —  HHV6  =  roseola  infantum  =  spiking  fever  followed  by   rash.  except  there   will  be  neutrophils  on  biopsy  instead  of  the  vascular   proliferations  à  don’t  ****  that  up.  body-­‐fluid  lymphoma.    Kaposi’s  can  occur  in  the  GIT  à  blood  in   stool.   —  HHV8  causes  Kaposi’s  sarcoma  in  HIV  pts   (abnormal  endothelial/vascular  proliferations   histologically).    That’s  all  you  need  to  know  about  it.    Bacillary  angiomatosis  (caused  by  bartonella   henselae)  can  cause  Kaposi-­‐like  lesions.   .

  .DNA  viruses   —  You’ve  gotta  know  that  all  viruses  derive  their   envelopes  from  the  cell  membrane.  but  herpesviridae   GET  IT  FROM  THE  NUCLEAR  MEMBRANE.

 but  herpesviridae   GET  IT  FROM  THE  NUCLEAR  MEMBRANE.   —  You’ve  also  gotta  know  that  dsDNA  and  SS(+)RNA   viruses  are  infective  VIA  PURIFIED  NUCLEIC  ACID   ALONE  à  they’ll  ask  you  this  to  see  if  you   understand  the  molecular  biology   .DNA  viruses   —  You’ve  gotta  know  that  all  viruses  derive  their   envelopes  from  the  cell  membrane.

   You’ve  also  gotta  know  that  antivirals   reduce  the  length  of  Sx  by  1-­‐1.  can  cause  ATAXIA.  can  be  used   for  Parkinson’s  disease.  mutated  M2   protein  =  resistance.   .    à  I’ve  seen  this   in  a  question  where  “reduce  Sx  duration  by  half”  was   also  an  answer  choice.   RImantidine  has  fewer  CNS  side-­‐effects  bc  it  doesn’t   cross  the  BBB.An3virals   —  Amantadine  à  blocks  viral  uncoating.  rubella  and  influenza.5  days.

 they’ll  tell  you  that  a  med   was  given  and  now  the  cells  are  “filled  with  virions.   .An3virals   —  For  oseltamivir  /  zanamivir.  where  sialic  acid  is  cleaved  by  the   latter  for  release.     You’ve  gotta  know  haemagglutinin  and   neurominidase.  and  the  – mivirs  are  right.    If  they  ask  about  the  target  of  the   best  vaccine.”     à  prevent  viral  release.  the  answer  is  ALWAYS   HAEMAGGLUTININ  (exceedingly  high-­‐yield).  they’ll  also  ask  you  for  which   drug  prevents  the  spread  of  virus  the  best.    They’re  SIALIC  ACID  ANALOGUES.

   That’s  in  FA  too  btw.     Ribavirin  inhibits  IMP  dehydrogenase.   .  but   the  extent  that  is  important  is  that  there  is  decreased   IMP  to  GMP  conversion.     I’ve  also  seen  in  a  question  that  ribavirin  CAUSES   HAEMOLYTIC  ANAEMIA.An3virals   —  Ribavirin  is  used  for  HepC  and  RSV.    UWorld  went   into  extensive  detail  about  ribavirin  mechanisms.  à  high-­‐yield.

   USMLE  wants   you  to  know  that  the  drug  causes  CHAIN   TERMINATION.    Cellular  kinases  then  bring  the   G*MP  to  the  G*TP  form.   .    I’ve  seen  altered  kinase  and  lack  of  kinase  as   answers  to  the  same  question.  the  latter  is  the  real   deal  and  also  in  FA.  guanosine  analogue.    FAMcyclovir  is  for  shingles  (HY).    Acylcovir  (not  oral)  decreases   LENGTH  of  outbreak.An3virals   —  Acyclovir  à  HHV1-­‐4.    Just  know   that  HHV1-­‐4  phosphorylate  the  drug  to  the   monophosphate.  daily  oral  VALacyclovir   decreases  RECURRENCE  of  outbreaks.    HHV1-­‐4  resistance  is  due  to   LACK  (NOT  ALTERED)  OF  VIRAL  THYMIDINE   KINASE.

 so   remember  the  neutropenia).   .  and  that  the  pt  may  have   had  retinitis/colitis).     —  Ultra  high-­‐yield:  CMV  has  increased  susceptibility  to  this   drug  bc  of  DIFFERENT  DNA  POLYMERASE  STRUCTURE.    They’ll  give  you  a  vignette  of  someone  with  a  drop  in   grans  who’s  taking  an  anti-­‐viral  (won’t  be  obvious  at  all.    They  could  even  be  tricky   and  ask  for  what  was  being  treated  (so  you’d  have  to  know   the  drop  in  grans  was  bc  of  ganciclovir.An3virals   —  Ganciclovir  is  for  CMV  (HHV5).   —  Side-­‐effects  for  this  drug  are  EXCEEDINGLY  HIGH-­‐Y.   —  NEUTROPENIA  (and  leuko-­‐/thrombocytopenia)  is  the  big   one.     Mechanism  of  phosphorylation  similar  to  w/  acyclovir.  that  CMV  must   have  been  the  organism  treated.

An3virals   —  Foscarnet  à  just  know  this  is  for  ganciclovir-­‐ refractory  CMV.  but  I’ve  actually  never  seen  it  rock   up  in  a  question.  -­‐ KALAEMIA.    Like  ganciclovir.   —  Cidofovir  is  in  FA.    Just  know  that  it  also  is  nephrotoxic   and  doesn’t  need  the  initial  phosphorylation.  so  it  doesn’t  require   the  initial  phosphorylation  that  ganciclovir  does.   .     They’ll  ask  you  this.   —  It’s  a  pyrophosphate  analogue.  its  side-­‐effects  are   ultra-­‐HY:   —  NEPHROTOXICITY  and  HYPOCALCAEMIA.    Crazy  HY.  -­‐MAGNAESEMIA.  so  it’s   used  for  acyclovir-­‐refractory  illness.