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.  

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

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

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

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

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

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

 DCM   .  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.  DIRECT-­‐VIRAL  DAMAGE  (NOT  type-­‐II   HS.

 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).  like  rheumatic  heart  disease).e.  DIRECT-­‐VIRAL  DAMAGE  (NOT  type-­‐II   HS.  ssRNA  virus)   .  DCM   —  echovirus  à  meningitis.  they’ll  tell  you  kid’s  got   meningitis  from  RNA  virus  and  then  ask  you  for  the   structure  (i.  non-­‐enveloped.

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

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

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

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).   —  For  HepE.   .  Asia  >  USA  (particularly   Tibet).  and  of  course  it’s  enteric.

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

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

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

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

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)   .

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   .

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)   .

 Yellow/Dengue   fevers.RNA  viruses   —  The  icosahedral  enveloped  viruses  are  SS(+)-­‐non-­‐ segmented  and  SS(+)  diploid.  Japanese  encephalitis   .  West  Nile.    (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.

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

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

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

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

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

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

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

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.

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

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

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

   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.RNA  viruses   —  But  here’s  where  your  points  are.  here’s  your  reward:   —  For  the  sake  of  the  USMLE.

  .  and  its   reservoir  is  birds.   —  Seemingly  ridiculous.    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  know  it.  here’s  your  reward:   —  For  the  sake  of  the  USMLE.  but  West  Nile   virus  is  transmitted  by  the  CULEX  mosquito.RNA  viruses   —  But  here’s  where  your  points  are.    West  Nile  virus  is   transmitted  by  the  Culex  mosquito.

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.      

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

  .  SS(-­‐)  segmented  and  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   .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   —  The  SS(-­‐)  segmented  ones  are  orthomyxoviridae  and   bunyaviridae.RNA  viruses   —  The  helical  RNA  viruses  are  divided  into  SS(+)  non-­‐ segmented.  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   —  The  SS(-­‐)  segmented  ones  are  orthomyxoviridae  and   bunyaviridae.   —  Orthomyxoviridae  are  the  influenza  A.  B  +  C  viruses   .

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

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

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

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

  —  In  contrast.   —  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).RNA  viruses   —  For  influenza.  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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)   .

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

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

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

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

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

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

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

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

RNA  viruses   —  All  RNA  viruses  replicate  in  the  cytoplasm  EXCEPT   FOR  THE  LENTIVIRIDAE  (retroviruses)  AND   INFLUENZA.  WHICH  REQUIRE  THE  NUCLEUS.  but  I’ve   seen  it  in  a  question).   —  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.

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

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

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

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

”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?  .  they’ll  take   pretty  much  any  and  every  concept  and  indirectly   relate  to  it.    Just   take  it  as  a  lesson  that  on  the  real  deal.   ..

 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!).   .  on  the  RBC  surface.DNA  viruses   —  I’ve  also  seen  in  a  question  that  PB19  binds  to  P-­‐ antigen.

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

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

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

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

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

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

 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.    For  HC.  they’ll  throw  rotavirus  in  there  for  kicks   just  bc  that’s  so  common  in  infants.DNA  viruses   —  The  icosahedral  non-­‐enveloped  DS-­‐linear  DNA  virus   is  adenovirus.   .    Conjunctivitis  will   be  straightforward.

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

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

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

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

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

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

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

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

DNA  viruses   —  HHV4  =  EBV  à  mononucleosis  (“atypical   lymphocytes”  on  blood  smear  à  they’re  CD8+  T-­‐ CELLS  NOT  B-­‐CELLS.    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.  particularly  when   enlarged).   .

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

    Antivirals  discussed  later  in  this  lecture.    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.  remember  “linear  ulcers.   —  Remains  latent  in  mononuclear  cells  (in  contrast  to   EBV.”    Retinitis  is   most  common  CMV  manifestation  (CD4+  <200).  causes   blueberry  muffin  rash  +  hepatomegaly  in  neonate  if   TORCHeS.

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

  .  and   Castleman’s  disease  (non-­‐cancerous  lymph  node   growths).  body-­‐fluid  lymphoma.    Kaposi’s  can  occur  in  the  GIT  à  blood  in   stool.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.    That’s  all  you  need  to  know  about  it.    Bacillary  angiomatosis  (caused  by  bartonella   henselae)  can  cause  Kaposi-­‐like  lesions.   —  HHV8  causes  Kaposi’s  sarcoma  in  HIV  pts   (abnormal  endothelial/vascular  proliferations   histologically).

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

  .  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.  rubella  and  influenza.An3virals   —  Amantadine  à  blocks  viral  uncoating.    You’ve  also  gotta  know  that  antivirals   reduce  the  length  of  Sx  by  1-­‐1.   RImantidine  has  fewer  CNS  side-­‐effects  bc  it  doesn’t   cross  the  BBB.5  days.

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

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

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

 so   remember  the  neutropenia).     —  Ultra  high-­‐yield:  CMV  has  increased  susceptibility  to  this   drug  bc  of  DIFFERENT  DNA  POLYMERASE  STRUCTURE.    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.    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.  that  CMV  must   have  been  the  organism  treated.   —  NEUTROPENIA  (and  leuko-­‐/thrombocytopenia)  is  the  big   one.  and  that  the  pt  may  have   had  retinitis/colitis).   —  Side-­‐effects  for  this  drug  are  EXCEEDINGLY  HIGH-­‐Y.     Mechanism  of  phosphorylation  similar  to  w/  acyclovir.An3virals   —  Ganciclovir  is  for  CMV  (HHV5).   .

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