Professional Documents
Culture Documents
Immunology
M icr biology
Mary Ruebush, PhD.
Assistant Director of Curriculum
~~
BECKER
PROFESS I ONAL EDUCAT I ON
v 1.1
Contributing Editors
Louise Hawley, PhD.
Professor and Chair, Department of Microbiology and Immunology
Ross University, Roseau, Dominica
The United States Medical Licensing Examination (USMLE) is a joint program of the Federation
of State Medical Boards (FSMB) and National Board of Medical Examiners (NBME). United States
Medical Licensing Examination, USMLE, National Board of Medical Examiners, and NBME are registered
trademarks of the National Board of Medical Examiners. The National Board of Medical Examiners does
not sponsor, endorse, or support Becker Professional Education in any manner.
2 3 4 5 6 7 8 9
18
17
16
15
14
13
Immunology
Chapter 1
Overview of Immunity . . .... . ... .. ... . .... . .... . ... . .... . ... . 1-1
Chapter 2
The Birth of the Immune Response . .. .. ... . .... . ... .. ... . .... . . 2-1
2
3
4
Review Questions: Chapters 1-2 ..... . ... .. ... . . . . . . . . . .. ... . .... 2-16
Chapter 3
Chapter 4
Chemotaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-1
3
4
5
Chapter 5
3
4
5
6
Phagocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4- 5
Review Questions: Chapters 3-5 . ........ .. ... . .... . ... . .... . ... 5-10
iii
Immunology
Chapter 6
Humoral Immunity . . . .... . .... . ... . .... . .... . ... .. ... . .... . . 6-1
3
4
Affinity Maturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6- 7
Chapter 7 Cell-Mediated Immunity .... . ... . .... . .... . ... .. ... . .... . ... .. . 7-1
1
Chapter 8 Immunologic Memory .. . ... . .... . .... . ... .. ... . .... . ... .. ... . . 8-1
1
Overview of Immunologic Memory ... . . . . . . . . . . . . . . . . ...... ....... 8- 1
2
Comparison of Primary and Subsequent I mmune Responses ... ...... ..... 8-3
Chapter 10 Immunodeficiency Diseases . ... .. ... . .... . ... .. ... . .... . ... . . 10-1
1
iv
Immunology
Chapter 11 Hypersensitivity and Autoimmunity .... . ... . .... . .... . ... .. ... . 11-1
Chapter 12 Transplantation Immunology . .... . ... .. ... . .... . ... .. ... . ... . 12-1
Radioimmunoassay (RIA)
and Enzyme-linked Immunoassay (EIA) . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 -4
Review Questions: Chapters 11-13 .. .. ... . .... . ... . .... . .... . ... . 13-7
Clinical Cases .. .. ... . .... . ... .. ... . .... . ... .. ... . .... . .... . ... . .... . . C-1
Appendix 1 Cytokines . .... . ... . .... . .... . ... .. ... . .... . ... .. ... . .... . . . A-1
Appendix 2 CD Markers .. . .... . ... .. ... . .... . ... .. ... . .... . .... . ... . .. . A-3
Appendix 3 Cell Adhesion Molecules . ... .. ... . .... . ... .. ... . .... . ... .. ... . A-4
Appendix 4 The Immune Response in Infection .... . .... . .... . ... . .... . ... . . A-5
Immunology
Figures
vi
Immunology
Figures
vii
Immunology
Figures
viii
Immunology
Figures
ix
Immunology
Tables
--
Immunology
Tables
Appendix 1 Cytokines
Table A-1.1 Cytokines . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . . . . ..... ... A-1
Table A-1.2 Cytokines Available in Recombinant Form . . . . . . . . . . . . . . . . . . . . . . A-2
Appendix 2 CD Markers
Table A-2.1 CD Markers . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . . . . ..... .. A-3
xi
Microbiology
Chapter 1 Microbial Pathophysiology . . . .... . .... . ... . .... . .... . ... .. ... . .. 1-1
1
Chapter 2 Bacterial Genetics and Drug Resistance . .... . ... . .... . .... . .... . .. 2-1
1
Review Questions: Chapters 1-2 .... . ... . .... .. .... . ... . .... . .... .. 2-27
Chapter 3 Bacteriology . . .... . ... . .... . .... . .... . ... . .... . .... . ... . .... . 3-1
Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-5
Gram-Positive Cocci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3- 10
Spirochetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3- 52
10
11
Chapter 4 Virology . .... . ... .. . . . . . . . . . ... .. ... . . . . . . . . . . . ... . .... . ... . 4-1
xii
Microbiology
Biology of Fungi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5- 1
3
4
2
3
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-31
Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-44
Bone and Joint ... . . . . . . . . . . . . . . . . ...... . . . . . . . . . . . . . . . . .... A-48
Eye .. ...... . . . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . . . ...... . A-51
Ear, Nose, Throat, and Respiratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A- 55
Central Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-66
Cardiac ... . . . . . . . . . . . . . . . . ...... . . . . . . . . . . . . . . . . ..... .... A-74
Gastrointestinal ... . . . . . . . . . . . . . . . . ...... . . . . . . . . . . . . . . . . ... A-77
Urinary/Renal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-88
Reproductive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-92
xiii
Microbiology
Figures
xiv
Microbiology
Figures
Chapter 3 Bacteriology
Figure 3-1.1A .. Gram-Positive Cell Envelope .. ..... . . . . . . . . . . . . . . . . . .. 3-1
Figure 3-1.18 .. Gram-Negative Cell Envelope ...... . . . . . . . . . . . . . . . . ... 3-2
Figure 3-1.1C .. Location of Antibacterial Action . . . . . . . . . . . . . . . . . . . . . . . . 3-2
Figure 3-1.2 ... Endospore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-4
Figure 3-2.1 ... Four Phases of Bacterial Growth .... . . . . . . . . . . . . . . . . ... 3-5
Figure 3-3.1A .. Gram-Positive and Gram-Negative Bacilli . . . . . . . . . . . . . . . . . 3-7
Figure 3-3.18 .. Acid-Fast Bacilli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3- 8
Figure 3-4.0 ... Bacterial Taxonomy .... ..... . . . . . . . . . . . . . . . . ...... . 3-9
Figure 3-5.0 ... Laboratory Algorithm: Gram-Positive Cocci . . . . . . . . . . . . . . . 3-10
Figure 3-5.1 ... Gram-Positive Cocci in Clusters: Staphylococcus . . . . . . . . . . . 3- 10
Figure 3-5.2A .. Gram-Positive Cocci in Chains ... . . . . . . . . . . . . . . . . ..... 3-12
Figure 3-5.28 .. Patterns of Hemolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-12
Figure 3-5.2C .. Laboratory Algorithm: Streptococcus . . . . . . . . . . . . . . . . . . . 3- 13
Figure 3-5.20 .. CAMP Test: Positive for GBS {left) and Negative for GBS (right) .. 3-16
Figure 3-5.2E .. Lancet-Shaped Diplococcus: Pneumococcus . . . . . . . . . . . . . . 3-17
Figure 3-5.2F .. Alpha Hemolysis (Middle Streak) . . . . . . . . . . . . . . . . . . . . . . 3- 17
Figure 3-5.2G .. Mucoid Colonies: Encapsulated .. . . . . . . . . . . . . . . . . ..... 3-17
Figure 3-5.2H .. Colon Cancer Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-18
Figure 3 - 6.0 ... Laboratory Algorithm: Gram -Positive Rods . . . . . . . . . . . . . . . 3- 19
Figure 3-6.1A .. Bacillus anthracis .... ..... ..... . . . . . . . . . . . . . . . . ... 3-20
Figure 3-6.18 .. Anthrax Eschar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-20
Figure 3-6.1C .. Mediastinal Widening in Pulmonary Anthrax . . . . . . . . . . . . . . 3-20
Figure 3-6.10 .. Clostridium . ........ ..... . . . . . . . . . . . . . . . . ...... . 3-21
Figure 3-6.1E .. Risus Sardonicus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-21
Figure 3 - 6.1F .. Opisthotonus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-21
Figure 3-6.1G .. Nagler Reaction . . . . . . . . . ..... . . . . . . . . . . . . . . . . .... 3-23
Figure 3-6.1H .. Endoscopy of Colon with Pseudomembranous Colitis ........ 3-23
Figure 3-6.2A .. Diphtheria Pseudomembrane . . . . . . . . . . . . . . . . . . . . . . . . . 3-24
Figure 3-6.28 .. Tellurite Agar. . . . . . . . . ..... . . . . . . . . . . . . . . . . ...... 3-24
Figure 3-6.2C .. Listeria monocytogenes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-25
Figure 3-6.3A .. Actinomycotic Mycetoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-26
Figure 3-6.38 .. Partially Acid-Fast: Nocardia ..... . . . . . . . . . . . . . . . . . ... 3-26
Figure 3-6.3C .. Nocardia! Mycetomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-26
XV
Microbiology
Figures
xvi
Microbiology
Figures
xvii
Microbiology
Figures
xviii
Microbiology
Figures
Chapter 5 Mycology
Figure 5-1.1 ... Anatomy of Yeast Cell. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1
Figure 5-1.4 ... Yeast . . . . . . . . . . . . . . . . ...... . . . . . . . . . . . . . . . . .... 5-2
Figure 5-1.6 ... Action of Antifungal Agents ... ...... . . . . . . . . . . . . . . . . .. 5-4
Figure 5 - 2.1A .. KOH Preparation of Malassezia Skin Scraping . . . . . . . . . . . . . . 5- 5
Figure 5-2.18 .. Pityriasis Versicolor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-5
Figure 5-2.2A .. Tinea Capitis . . . . . . . . . ..... . . . . . . . . . . . . . . . . ...... . 5-6
Figure 5-2.28 .. Tinea Corporis . . . . . . . . . ..... . . . . . . . . . . . . . . . . ...... 5-6
Figure 5-2.2C .. Tinea Cruris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5- 6
Figure 5-2.20 .. Tinea Unguium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6
Figure 5-2.3A .. I nfectious Form of Sporothrix schenckii . . . . . . . . . . . . . . . . .. 5-7
Figure 5-2.38 .. Rose Gardener's Disease .... ..... . . . . . . . . . . . . . . . . . .. 5-7
Figure 5 - 3.0 ... Geographic Distribution of Systemic Mycoses in the U.S . . . . . . . 5- 8
Figure 5-3.1A .. Dissemination of Blastomyces to the Skin . . . . . . . . . . . . . . . . . 5-8
Figure 5-3.18 .. Blastomyces Budding Yeast ... ...... . . . . . . . . . . . . . . . . .. 5-8
Figure 5-3.2A .. Environmental Form of Histoplasma capsulatum . . . . . . . . . . . . 5-9
Figure 5-3.28 .. Tissue Form of Histoplasma capsulatum . . . . . . . . . . . . . . . . . . 5-9
Figure 5-3.3A .. Coccidioides Spherule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-9
Figure 5-3.38 .. Arthroconidia of Coccidioides . .. . . . . . . . . . . . . . . . . ...... 5-10
Figure 5-3.4 ... Paracoccidioides Tissue Form ...... . . . . . . . . . . . . . . . . .. 5-10
Figure 5-4.1A .. India Ink Preparation of Cryptococcus neoformans . . . . . . . . . . 5- 11
Figure 5-4.18 .. Cryptococcus neoformans Encapsulated Yeasts in Tissue ..... 5-11
Figure 5-4.2 ... Aspergillus Conidiophores and Conidia . . . . . . . . . . . . . . . . .. 5-11
Figure 5-4.3A .. Candida albicans: Thrush .. ..... . . . . . . . . . . . . . . . . . ... 5-12
Figure 5-4.38 .. Germ Tube Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5- 12
Figure 5-4.4A .. Zygomycosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-13
Figure 5-4.48 .. Ribbon-Like Hyphae of Zygomycophyta . . . . . . . . . . . . . . . .. 5-13
Figure 5-4.5 ... Pneumocystis Honeycomb Exudate .. . . . . . . . . . . . . . . . . .. 5-13
Chapter 6 Parasitology
Figure 6-2.2A .. Plasmodium Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-4
Figure 6-2.28 .. Patterns of Malarial Fevers .... . . . . . . . . . . . . . . . . ..... .. 6-5
xix
Microbiology
Tables
XX
--
Microbiology
Tables
xxi
Chapter 1- 1
Immunology
Serum proteins
Complement
Antibod ies
Cells
Specificity
No
Yes
Memory
No
Yes
Limited
High
Characteristics
Chapter 1- 2
Immunology
,..
, ,
'
Innate
Immunity
Specificity for
shared microbial
structures
INJURY
Anatomi c barriers
skin, mucosa, cilia
Chemical barriers
acid, lysozyme,
comp lement
iJt
Ce llular barriers
phagocytes
Limited diversity
No memory
Neutrophils
Macrophages
. :I:
Activate
(promote
chemotaxis
and
phagocytosis)
Cytor
Enhance
phagocytosis
(opsonization)
Cytokines
activate
Cytokines
ac:
ivate
?
t
Acquired
Immunity
,,.,
Memory
...
._~--B lymphocytes
Specificity for
precise antigens
High diversity
Th
lymphocytes
Humoral
Immunity
-....('~",..,.
-\)~ Antibodies
Defense against
extracellular
pathogens
Cytotoxic
lymphocytes
Cell-Mediated
Immunity
Defense
against
intracellular
pathogens
Chapter 1- 3
Hematopoiesis
lymphocytes recognize
foreign substances.
Bone Marrow
segment rearrangement
produces the diversity of
Pluripotent
stem cell
GMCSy
EPO
lo/1
Erythroblast
Hvdo~
~y~ho~
stem oell
stem cell
cell receptors.
ll-7
JIL-3
Megakaryocyte
fPO
~~..
Erythrocytes
Plotelets
BlododL
h
an ymp
1;
,.,
~g'!~tt;;!.
I
IgM -
U
Granulocyte/
\
l
!~\
0 'e
ea
h'l ,:
sop '
:
,'
B progenitor
Basophil
TPO
progenitor
IL7
progenitor
Tissue
'
;~-
-...,
fOsinophil
Thymocyte
~ lf' lgD
f"
8 lymphocyte
Monocyte
.... )
....
_ J\...i
Dendritic cell
)
CytotOXIC
Hefper T
lymphocyte
(Th)
Ploama T lymphocyte
coli
(Tc)
m (for myeloid)
Chapter 2-1
......
Immunology
--~--
Name
Identification
location
Function
IN THE CIRCULATION
Neutrophil (polymorphonuclear
leukocyte or PMN)
Multilobed nucleus
and small pink
cytoplasmic granules
Blood, 1,800-7,800/fll
Phagocytosis, microbicidal
to extracellular organisms,
abscess formation
Eosinophil
Bilobed nucleus,
large pink
cytoplasmic granules
Blood, 0-450/ltl
(increase in allergic
and anthelmin th ic
responses)
Basophil
Bilobed nucleus,
large purple
cytoplasmic
granules, Fcc
receptor
Blood , 0- 200fltl
Monocyte
larg e, indented,
non-lobed nucleus,
CD4+, CD16+, and
CD14 +
Blood, 0-900/,..L
Phagocytic, leave
blood to become t issue
macrophages
IN THE TISSUES
Macrophage
(H istiocyte,
Langerhans cell,
Kupffer cell,
osteoclast,
mesangial cell,
microglia)
Ruffled membrane,
cytoplasm filled
with vesicles and
vacuoles, CD4+,
CD16+, and CD14+
Tissues
Phagocytosis, secretion
of cytokines, an tigen
presentation
Dendritic cell
Long cytoplasmic
arms
Phagocytosis, antigen
capture, presentation and
transport
Mast cell
Tissues
Chapter 2- 2
Immunology
J
Clinical
-'Yy-- Application - - - - - - - - - - - - - - -
a Important Concept
.~
Clinical
Application - - - - - - - - - - - - - - -
-'YV'1
Name
Identification
Location
Function
IN THE CIRCULATION
B cell
T heIper (Th)
cell
CD3+,CD4+
Cytotoxic T (Tc)
cell
CD3+, CDS+
Natural killer
(NK) cell
CD16+, CD 56+
IN THE TISSUES
Plasma cell
Chapter 2- 3
Immunology
Development of Antigen
Recognition Molecules
An antigen (from "antibody generator") is a foreign substance that
can bind to a lymphocyte antigen receptor. It is distinct from an
immunogen (from immunity generator), which is a foreign substance
with enough size and molecular complexity to generate an immune
response.
B and T lymphocytes possess antigen recognition molecules on
their surfaces that allow them to respond specifically to the small
molecular details of a foreign substance. These antigen recognition
molecules are members of the immunoglobulin superfamily of genes,
encoding soluble or cell surface proteins that are involved in cell
recognition, binding, and adhesion abilities.
The antigen receptor of the mature, naive B lymphocyte (BCR)
consists of the molecules IgM and IgD, which are membranebound and possess an intracytoplasmic tail required for signal
transduction. BCRs are capable of binding unprocessed antigens
of virtually any chemical composition.
The antigen receptor of the mature, naive T lymphocyte consists
of a related structure referred to as the T cell receptor (TCR).
TCRs are able to recognize only peptides found on the surface of
specialized antigen- presenting cells (APCs).
B lymphocyte
T lymphocyte
B Cell Receptor
(Antibody) Structure
T Cell Receptor
Structure
Antigen
binding site
I
~chain
Heavy chain
constant domains
~~ - Cytoplasmic tail
Cytoplasmic t ail -
Chapter 2- 4
Immuno logy
Two
Two
Two
Two
Two
Connection to
Microbiology
Epstei nBa rr virus (the
agent of heterophi lepositive
mononucleosis) uses CD21
as its receptor to infect B
lymphocytes. The resulting
polyclona I activation of
B lymphocytes causes
the lymphadenopathy,
splenomegaly, and production
of heterophilic antibodies
characteristic of the disease.
The isotypes of the light chains are referred to as kappa (K) or lambda
(A.), and each monomer of BCR will have two identical chains produced
by that cell and all of its descendants for life. The heavy chains are
held together with a "hinge region" of chemical bonds that allow some
flexibility of movement between the two antigen-binding arms.
Heavy chain
-- ~
.....
~---
Clinical
~\(._Application
Because a II lymphocytes
have a signal
transduction complex, the
measurement of numbers
of cells wearing CD 19 and
CD21 is used clinically
to count the number of
B cells in a patient. The
number of CD3+ cells
is taken to represent
the total number ofT
lymphocytes.
Antigen
.. ~ -------- binding site
'. N
Hinge region ..
Clinical
~\(.__ Application
Determines
idiotype
Determines
isotype
Chapter 2- 5
Immunology
.~
, Clinical
Application - - - - - - - - - - - - - - -
41('-
BCR
Iga
TCR
CD19
Chapter 2-6
Immunology
One
One
One {C/~ or y( 6 )
Two
One
Flexibility
Yes (h inge)
No
Secretion
Yes
No
Signal transduction
CD3
Important Concept
Cells expressing Tdt and RAG
gene activity are extremely
primitive lymphoid cells and
should never be found outside
of the primary lymphoid
organs. Finding them in
the circu lation is a marker
toward the diagnosis of acute
lymphoblastic leukemia (ALL).
Chapter 2-7
Immunology
Germline DNA
a;
Cr
Ce
Ca
3'
S'
Ge ~arrangement
l VHl OJ JH4
Rearranged DNA
C~
a;
Cy
Ce
Ca
3'
5'
O-J Joining
Pre-mRNA
5'
3'
V-DJ Joining
VDJ
C~
~ AAAAAA
mRNA
VDJ-C Joining
=- c
Germline DNA
Gene rearrangement
5'
3'
V-J Joining
Pre-mRNA
3'
5'
mRNA
AAAAAA
VJ-C Joining
Chapter 2- 8
Immunology
VDJ recombination
...
~
.
Immunoglobulin
heavy chains
VDJ
C11
Co
Cy3
Cyl
Cal
Cy2
Cy4
Ce
Ca2
3'
lgt4
Chapter 2- 9
Immunology
Connection to
Pathology
4.1 B Lymphocytes
I n the bone marrow,
B lymphocytes that
produce self-reactive
BCRs are induced to
undergo apoptosis when
they bind too strongly to
stromal cells there. This
creates central tolerance
by destroying any cell
that might become
autoreact ive if it were
allowed t o enter the
general circulation. Only
cells that have /ow affinity
(binding strength) t o self
molecules in the bone
marrow are allowed to
progress to the mature,
naive B cell stage.
Bone
Marrow
lymphoid
stem cell
Ig
heavy
chain
gene
rearrangement
Tdt
Pro B cell
RAG
expression
Cytoplasmic
ll
Pre B cell
Ig
light
chain
gene
rearrangement
I
I
I
,;
4.2 T Lymphocytes
I
I
Immature
B cell
Blood
and
Lym ph
CD19
CD20
CD21
CD40
Mature B lymphocyte
MHC 2
Cytoplasmic
~~~~
Plasma
cell
IgE
B cells
Chapter 2 - 10
Immunology
The cells entering the thymus are said to be triple-negative cellsthey do not express CD3, CD4, or CDS markers.
Epithelial cells in the cortex mediate positive selection of
thymocytes with TCRs capable of recognizing self antigens
referred to as HLA (human leukocyte antigen) molecules.
Cells that have undergone positive selection successfully become
triple-positive cells : they are CD3+, CD4+, and CD8+. These cells
are exposed to dendritic cells in the corticomedullary junction to
undergo negative selection.
In negative selection, any cells with excessive affinity for self HLA
molecules are forced to undergo apoptosis.
Only a very small proportion of thymocytes entering this organ
ever emerge into the lymphatics or circulation as mature, naive T
cells that are now CD3+ and either CD4 + or CD8+ , and capable
of expressing either helper (Th, CD4+) or cytotoxic (Tc, COB+)
activities in the rest of the body.
T cell precursors
Capsule -
cells)
Cortex
Cortex
.............
Medulla
cytotoxic
T lymphocyte
(Tc)
Helper T
lymphocyte
Mature T cells
(Th)
(single-posit ive)
C03+ an<l CD4+ or CDS+
Chapter 2- 11
Immunology
CD3
CD4
TCR
TCR
CTL (Tc)
T h elper (Th )
MH C Class 1
MH C Class 2
Peptide binding
Chapter 2- 12
Immunology
Gene products
HLA A, B, and C
Distribution
Rec ognition by
Tc (CDS+)
Th (CD4+)
So urce of peptides
bound
Intracellular
Ingested or endocytosed
Function
Killing of infected or
abnormal cells
Presentation of foreign
peptides to generate
"help"
Next, cells with too much affinity for these m olecules are induced
to undergo apopt osis (negative select ion) .
As a result, the only cells allowed to leave the thymus and patrol
the body for invasion or injury are those capable of cooperating
to produce an immune response (CD4+ Th cells) or those capable
of recogn izing and killing a cell that is altered by intracellular
infection or malignant t ransformation (CDS+ Tc cells).
Chapter 2 - 13
Immunology
Thymic
Stromal
Cells
Thymocytes
Self peptide
Low affinity
for self-MHC
class 1
C04
Class 1 MHC
)~
CDS
Low affinity
for self-MHC
class 2
Selected
Cells
Cytotoxic
T lymphocyte
(Tc)
-1?. ---
~T
CD4
Class 2 MHC
HelperT
lymphocyte
Positive
selection,
cell divides,
mat ures,
and
migrates
to blood
and lymph
Positive
selection,
cell divides,
mat ures,
and
m igrates
to blood
and lymph
(Th)
No
selection,
cell never
leaves
thymus
No binding
to self- MHC
Eventual
cell deat h
Negative
selection,
cell induced
t o under9o
apoptOSIS
High affinity
for self-MHC
cll!SS 1
Apoptosis
Negative
selection,
cell Induced
t o under9o
apoptOSIS
High affinity
for self-MHC
class 2
Apoptosis
Chapter 2- 14
Immunology
Bone
Marrow
: T cell progenitor
Anatomy
: (tri ple-negative)
I
...
TCRII+
Pre-T cell
(doub~negative) :
RAG+
~~--CD3~
1
1
TCRajl+
CD4
Thymocyte
~ (double- positive)
:,.
~r"
TCRocP+
CD3+
CDS+
TCR
Connection to
Cortex
(positive
selection)
Thymus
Medulla
(negative
selection)
TCRoc~+
Selected cells
(single-positive)
....
CD3+
CD4+
I
I
I
I
Cytotoxic
T lymphocyte
(Tc)
Blood
and
Lymph
Halper T
lymphocyte
(Th)
Chapter 2- 15
Review Questions
Immunology
Chapters 1-2
2. A 3-year-old boy is discovered to have a genetic mutation that resu lts in deficient production
of IL-1 1. A bone marrow smear would most likely show a deficiency in which of the following
cell types?
A.
B.
C.
D.
E.
T lymphocytes
B lymphocytes
Erythrocytes
Megakaryocytes
Polymorphonuclear cells
3. A patient has a complete blood count performed, and a peripheral blood smear is examined.
The blood smear contains a cell that is approximately 10 microns in diameter with a dense
basophilic nucleus that almost fil ls the cell. Which of the following is an important function of
this cell?
A.
B.
C.
D.
E.
Abscess formation
Antibody secretion
Destruction of virus-infected cells
Phagocytosis
Release of vasoactive amines
Chapter 2- 16
Immunology
Chapters 1-2
Review Questions
A. 162
B. 320
c. 5000
D. 50,000
E. 100,000
6. Cells passing through the thymic cortex are exposed to normal self antigens during their
development. Which of the following is true of the most important molecule in the production
of single-positive CD4+ helper cells?
A.
B.
C.
D.
E.
<9 DeVry/Becker
Chapter 2- 17
Review Answers
Immunology
Chapters 1-2
Chapter 2- 18
Cha pter 3 - 1
Immunology
2.1.1 Architecture
Lymph enters each lymph node through afferent lymphatics that
punctuate the organ's fibrous capsule. The fluid then percolates
through a subcapsular sinus into the outer cortex, then to the inner
medulla, and final ly into the medullary sinus, which exits the lymph
node through a hilum. Fluid from efferent lymphatic vessels is
ult imately collect ed int o the thoracic duct, which empties into the
vena cava.
B + T cells
+ Antibodies
fY
Efferent lymphatic
(memory cells and
antibody exit)
Macrophage
Chapter 3- 2
Immunology
2.2 Spleen
The spleen is the largest lymphoid organ in the adult. It plays the
dual role of removing aged or injured red blood cells in the red pulp
and producing antibodies in the white pulp.
2.2.1 Architecture
The spleen is supplied by the single splenic artery entering the
capsule at the hilum . The arterioles branching from this become
surrounded with lymphoid sheaths, which make up the white pulp.
The arterioles terminate in sinusoids, which comprise the red pulp.
Any antigen entering the blood is filtered out and responded to within
the spleen.
Connection to
Arteriole
Microbiology
and Physiology
Marginal zone
I
Red pulp
Marginal sinus
Follicle (B cell zone)
Germinal center
Central arteriole
Peri arteriolar
-";:;+- - lymphoid sheath
(T cell zone)
Splenic artery
and vein
Venule
Chapter 3- 3
Chemotaxis
A variety of small chemicals produced in the area of injury serve as
chemoattractants for phagocytic cells to enter the area.
Source
Leukotriene B4
Jnterleukin -8
CSa
Fibrinopeptides
Chapter 4- 1
Immunology
Diapedesis
The process by which leukocytes leave the vasculat ure to enter an
area of acut e inflammation, diapedesis, involves fo ur steps: rolling,
activation, t ight adhesion, and extravasation/transmigrat ion.
3.1 Rolling
The first leukocyte responders travel to the area of inflammation at
the same speed as the blood moving through the body. However,
as they near the area of inflammation, they are slowed by the
dilation of vascular channels. Low-affinity binding bet ween leukocyte
membranes (addressins) and the surface of the injured endothelium
(E-selectins) causes t he leukocytes to attach and detach repeatedly
and ro ll along the endothelial surface.
3.2 Activation
Resident cells (mast cells and macrophages), invading microbes,
and newly arriving inflammatory cells stimulate the release
of chemoattractants within the area of inflammation. These
small chemicals bind to the phagocyte membrane and trigger a
conformational change in the affinity of integrin molecules on
their surfaces.
Chapter 4- 2
Immunology
Lymphocyte
Neutrophil
Transendothelial
migration
LFA-1
~ f
_ __;;;-=~
-~ :
ICN<-;p
Monocyte
ll-s;f~...,-
Arachidonic acid
cascade
Division/
differentiation
Chemokines
IL-1
IL-6
TN F-a.
Chemotaxis
#'
..
INJURY
.,
Histarri'ines
:;~
'
,.
I.. "'=r
V
f-met peptides -.,...(
/~ ,.., ..\.
t'
Endo t h e li a l
d a m age
r..
Blood
kotc;ene
Prostatandins
Pyr ex i a
Plasmin
>
lr '..(
Mast cell
Macrophages
and
dendritic
cells
CSa
Comple"!1ent
~ct1vat1on
Activated
m acrophage
Fibrin/
Fibrinopeptides
Bradykinin-----==========--- - - - - --
Ti ssue
J
Clinical
-'Y~ Application - - - - - - - - - - - - - - - - - - - - - - - i
Leukocyte adhesion deficiency type I (LAD 1) results from failure to prod uce CD18, which is the common (32
subunit of the (32 integrins (LFAl family). (32 integrins are involved in leukocyte diapedesis, but also serve
as receptors for C3b to promote opsonization and phagocytosis. Binding of (32 integrins to thei r ICAM ligands
induces intracellular signaling that is important for a host of other cellular functions including cytokine
production, cytotoxicity, apoptosis, and proliferation. Microbial infections can be hand led temporarily with
antibiotics in these patients, but the long-term solution is bone marrow transplantation.
Chapter 4 - 3
Immunology
Recognizing Nonself
The ability of phagocyt es t o discriminate between friend and foe is
essential to t he working of a healt hy immune response.
TLR 1:
TLR 2:
Triacyl
Lipoproteins,
lipoproteins, peptidoglycan
mycobacteria
TLR 3:
TLR4:
TLR 5:
TLR 6:
TLR 7:
TLR 9:
dsRNA
LPS
Flagellin
Diacyl
lipoproteins,
ssRNA
CpG DNA
Mycoplasma
A Figure 4-4.2 Toll-Like Receptors
Chapter 4- 4
Immunology
Phagocytosis
A common trait shared by the immune cells that first enter the area
of inflammation is that they are phagocytic: They ingest and digest
particulate debris from the injury and any invading m icrobes.
Pseudopodia
Endocytosis
of bacterium bacterium
bactcnum
bactPrium
Phagolysosome
5.2 Opsonization
Opsonization is possible in the area of inflammation if either
immunoglobulin G (IgG) or complement component 3b (C3b) are
available. This process involves the coating of non-self particles with
IgG, C3b, or both in such a way that the non- bound end can then
fit into a complementary receptor on the surface of a phagocyte.
This process has been shown to enhance the speed of phagocytic
engulfment by up to 4,000-fold .
OeVry/Becker Educational Development Corp. All rights reserved.
Chapter 4- 5
Immunology
.. .
Oxygen independent
killing
..
Chapter 4- 6
Immunology
MPO produces
HOCI from H,02
and Cl-
Enterobacteriaceae
Aspergillus
Listeria
Candida
Pseudomonas
Cytotoxic HOCI
kills the ingested
bacterium
cIngested
Ingested
coccus
coccus
Chapter 4-7
Chapter 5- 1
Immunology
Class 1
Endogenous
Pathway
Class l
MHC
........0-..
~
Golgi complex
Dendritic cells
Macrophages
B lymphocytes
Class 2
Exogenous
Pathway
Cell distribution
Invariant chain
(32 Microglobulin
Peptide source
Recog nition by
Function
I No
I Yes
I Endogenously synthesized
I Tc (CDS+ T lym phocytes)
I Killing of abnorma l cells
IYes
I No
I Exogenously processed
I Th (CD4 + T lymphocytes)
I Elicitation of T cell h elp
Chapter 5- 2
Immunology
Epithelium
~--- Dendritic cell
associated antigen
Afferent
lymphatic
Th cell ~_
~V
~~
a-
)...(.
()
Effector T
lymphocytes
~rf! A
.(.
Y...j
~
Secreted
antibodies
-r
Antigen transported
via lymphatics into
regio nal lymph node
or via blood to spleen
Effector
B lymphocyte
(plasma cells)
-~/-~. ./--~
Antibodies
"" -a ~
Effecto~~
T cells
Memory
lymphocyte
Spleen
Chapter 5- 3
Immuno logy
Differentiation of Macrophage
Populations
Depending on the environment in which monocytes are exposed
to foreign particles, they differentiate down one of two pathways
that make them a pivotal force in the evolution of the protective
immune response.
Alternatively
activated
macrophage (M2)
Arginase,
proline, -+
polyaminases,
TG F-13
IL-10,
~Inhibits
Microbial
TLR-Iigands
IFN-y
,.
Promotesl
Wound repair,
fibrosis
TGF-~
...
Anti-inflammatory
effects
onocyt
V)
~
:0
IL-13, IL-4
:E
"'
lPromotes
Inhibitsj
Classically
activated
macrophage (Ml}
...
Il-l,
l l - 12,
ll-23,
chemokines
ROS, NO,
lysosomal -+
enzymes
1
Pathologic
inflammation
Microbicidal actions:
phagocytosis and
killing of many
bacteria and fungi
Chapter S- 4
I m munology
J
,
Clinical
--,\(....._Application
.....
,
.....
.
-
.
..
.... .. ..
LFA-3
activates
Cha pter S- 5
Immunology
.A
Clinical
Application _ __ _ _ _ __ _ __ _ _ __
Connection to
M icrobiology
Su perantigens
Soluble products of bacteria or viruses that cause
polyclonal stimulation ofT cells and macrophages are
known as superantigens. They do this by cross-linking
the outsides of the TCRs and MHC class 2 molecules
on Th cells and macrophages that otherwise have no
affinity for each other. Because these cells are being
held together in the absence of an antigen-specific
signal from the MHC/peptide complex, the remainder
of the stimulatory cascade proceeds in a non-specific
fashion. Co-stimulatory molecules lock on to one
another, signal transduction is activated, and cytokine
secretion begins, but in such a volume that the
normally helpful cytokines (IL-l, IL-6, TNF-a, IFN-y,
and IL-2) can become life-threatening. Toxic shock
syndrome toxin-1 (TSST-1) of Staphylococcus aureus
and Exotoxins A through C (pyrogenic exotoxins) of
Streptococcus pyogenes act as superantigens.
Common superantigens:
TSST, Toxin A of
Streptococcus pyogenes
CD
t ocomplementarity
N
MHC 2
TCR Q}.~
'*'~
Superantigen
Chapter 5-6
Immunology
Chapter 5- 7
Immunology
Treg
APC
!L-10
inhibits
Th1
Th1
IFN-y,
ll-2, TNF-~
Help for
- - - - - - cell-mediated
imm unity
l' .
I
'll-4,
!FN-v
'
L-1 Q I inhibits
:inhibit ' Th2
~ Th1 '
I
Microbiology
Microbes that live outside
of host cells: These are most
effectively destroyed by the
product ion of antibodies,
activation of complement, and
enhancement of phagocytosis:
the Th2, humoral immune
response. This category includes
most bacteria, fungi, and
parasites.
Th O
~
TGF fl, ll- 1,
l l-6, ll-23
Connection to
.
I
....
Th 17
l l-17
-t inflammation
I L-4, IL S,
ll-6, ll-10,
l l- 13,
TGF-jl
-----+
Co ntrol of
humoral immunity
Th2
CD3+ , CD4+
CD3+ , CD4+
CD3+ , CD4+
FoxP3
CD3+ , CD4+,
RORgammat
Induced by
IFN-y, IL-12
ll-4
TGF-13, glucocorticoids
TGF-13 I L-6
Il-l, l 'l -23 '
Cytokines
produced
IFN-y, ll-2,
Lymphotoxin
(LT or TNF I3)
l l 17, IL 23,
chemokines
Result in
Macrophage
activation,
sti mulation of
l gG production
Stimulation of
Inhibition of
IgE production, Th 1, antiactivation of
inflammatory
mast cells and
eosinophils
Recru itment
of neutrophils,
monocytes
Defense
against
Intracellular
microbes
Helminths
Extracellular
bacteria, fungi
Role in
disease
Chronic
autoimmune
hyper
sensitivities
Allergies
Chron ic
autoimmune
hyper
sensitivities
Chapter 5-8
Immunology
J
--'Yr
1
Clinical
Application _ _ _ _ _ _ _ _ _ _ _ _ _ __
Connection to
Pathology
Regulates immune
response
Treg
Defense against
intracellular microbes
Thl
..
/:,...W ILlO
/__,;,"".
.
................
APC
IL-10 inhibits
Th1
TGFjj '
ThO
Intracellula r
pathogens
ll-12, IFN "f
Cytokines
Thymocyte
TGF-~,
~
ll-1,
IL-6, IL- 23
Thl7
__..
Granuloma
IFN-y, _ , . formation
ll-2, TNF-13
"----J
help for CMI
.~ .
:inhibit ., Th2
~ Thl
..
IL-4, ll-5, IL-6,
: ILlO, IL13,
;
TGF-Il
help for IgG,
lgA, lgE_ .
t Inflammation
...._...
~-17, IL-23
;.
Extracellula r
pathogens
IL-4
'\ :. ;
, ..
Th2
Defense against
extracellular microbes
and parasites
___
Abscess
......_
formation
Chapter 5- 9
Review Questions
Immunology
Chapters 3-5
2. A 2-year-old child who has suffered recurrent bacterial infections and delayed wound healing
is evaluated for immunologic deficiency. Numbers of CD19+ and CD3+ cells in the peripheral
blood are within normal limits but neutrophil counts are elevated to almost twice normal
values. I ntracellular digestion is normal. What is the most likely defect in this child?
A.
B.
C.
D.
E.
Addressin
CD18
Chemokine receptors
E-selectin
L-select in
Catalase
Lactoferrin
Myeloperoxidase
NADPH oxidase
Superoxide dismutase
Activation
Adherence
Chemotaxis
Demargination
Rolling
Transmigration
5 . Radiolabeled autologous neutrophils are injected int ravenously into a patient wit h an occult
bacterial infect ion, and this treatment is followed by whole-body scint igraphy. Which of
the fol lowing molecules will be found in the highest concentration in areas with elevated
radioactive signal?
A.
B.
C.
D.
E.
I nterleukin- 1
C3b
CSa
Hageman factor
Prostaglandin
Chapter S- 10
Immunology
Chapters 3-5
'
Review Questions
6. A 60-year-old woman is admitted to the hospital with sudden onset of fever, left-sided chest
pain, and labored breathing. On auscultation there is evidence of pleural effusion. Which of
the following is most likely to characterize the histologic appearance of the lung?
A.
B.
C.
D.
E.
Macrophage
Natural killer cell
Thl lymphocyte
Th2 lymphocyte
Thl7 lymphocyte
Treg lymphocyte
9. One of the drugs used to treat multiple sclerosis is glatiramer acetate. Its mechanism of
action is thought to involve a switch in T cell response from a proinflammatory to an antiinflammatory response. If this is true, which of the following cytokines would be found in the
serum of a patient who has been taking this drug for several months?
A.
B.
C.
D.
E.
IFN-y
IL- l
IL- 10
IL- 12
TNF-a
10. Transgenic mice are generated that are incapable of expressing MHC invariant chain. Which
of the following components of host defense is most likely to be altered in these mice?
A.
B.
C.
D.
E.
I mmunoglobulin M synthesis
Cytotoxic T lymphocytes
Interleukin-2 (IL-2) secretion
Natural killer cells
Antibody-dependent cell-mediated cytotoxicity (ADCC)
Chapter 5 - 11
Review Answers
Immunology
Chapters 3-5
Chapter 5-12
In the absence ofT cell help, B lymphocytes are "stuck" making IgM
and IgD, and if their BCRs become cross-linked by their cognate
antigen, IgM- and !gO-producing plasma cells can be produced.
However, there is no "memory" or amplification or refinement of the
response in the absence ofT cell help. Antigens that evoke this sort
of response directly from B cells without T cell help are referred to as
T cell independent antigens.
These molecules share a common trait: They are devoid of protein.
Because protein is a necessary constituent of any living cell or
infectious agent, there are no naturally occurring agents of infectious
disease that cause B cell stimulation in a T cell independent fashion,
but there are single molecular constituents that can be used as
examples of this phenomenon. Since BCRs are capable of binding
specifically to any type of molecule (protein, polysaccharide, lipid,
and nucleic acid) they can produce antibodies against virtually
anything with sufficient size and molecular complexity.
...
...
...
...
...
...
Chapter 6- 1
.~
Immunology
, Clinical
Application - - - - - - - - - - - - - - -
41('-
Chapter 6-2
Immunology
co4
TCR~~
=~ ~
I l -4, ll-5, ll- 6
""....
e~
4f'
_."f Cytokine
receptors
.......
.:
":'I
I
I
Plasma
cells
Proliferation and
class switching
Chapter 6- 3
Immunology
Class Switching
The cytokines secreted by activated Th2 cells cause B lymphocyte
cloning, isotype switching, and differentiation into plasma cells:
B lymphocyte cloning produces the number of antigen-specific
effector cells necessary for the destruction of the invader.
Isotype switching changes the function of the antibody molecule
by changing the expression of the constant domains of the
molecule.
Differentiation into plasma cells provides a short-lived factory for
antibody synthesis so that the maximum amount of the protective
protein can be pumped out into the circulation.
'\,)
c~'
''J
The Fe portion
is destroyed
Chapter 6-4
Immunology
2 Fab fragments
Papain cleaves
the hinge region
1 Fe fragment
.~
Clinical
Application - - - - - - - - - - - - - - -
--'YV''-
Chapter 6- 5
Immunology
4.2.1 Structure
The IgM found in the plasma exists as a pentamer, with five identical
monomer units held together by a single joining chain, and its
functions are ideally suited for its role as a first responder. It has the
largest number of combining sites of any antibody produced.
lsotypes
IgG, IgE,IgD
~
~
~~
lgM
monomer
Joining
/
(J) chain/
lgM
IgA
4.2.2 Function
The structure of IgM allows it to work like an immunological
sponge, capturing antigen and trapping it in a secondary lymphoid
organ for subsequent immune stimulation.
The IgM pentamer has a valence of 10, meaning that it has 10
identical idiotypes to bind to its antigen.
IgM is the strongest activator of complement produced, and this
serves to enhance inflammation and attract more immune cells
into the area.
IgM cannot act as an opsonin, since this would require a free
Fe tail to fit the CD16 receptor on a phagocyte, and the internal
structure of this pentamer is much too sterically hindered.
Chapter 6- 6
Immunology
Affinity Maturation
As the B lymphocyte interacts with a Th2 cell, the Th2 cell delivers a
signal that causes the B cell to change the isotype of antibody that
it is producing. By definition, then, the new antibodies produced
will have a lower valence, because IgM has the highest number of
combining sites of any isotype.
To make up for this loss of valence, all subsequent antibodies have
refinements of the goodness-of-fit of their idiotypes that increase the
affinity of their antibodies.
Affinity
Affinity of IgM
be low
may
Avidity of IgM
is the highest
of all lsotypes
IgM
lgG
Random DNA
mutations create
clones with slightly
different affinities
No
specificity "")...
--+
-.. . l-
--+
l-
.,. .. .
)...
.10'.
.v . . . .).
,.. -+. ~ --~
Lymphoid
stem cell
.. ,
Natural selection
favors clones with
best fit affinities
and increases their
overall number (
~
~
Ag
l-;
J..,.,_
&':> {
~~~pecifit.y ill
.[
~ t-~
Primary
...,.
.,..
)...respon se
)...
.... ,
'+
Affinity maturation
J...J...
<
.[
<
~ '<"l"'
Plasma
Stenl
cells
cells-
An tibody
release
Chapter 6- 7
Immunology
lsotype Switching
Isotype switching changes the function of the antibody molecule
by changing the expression of the molecule's constant domains.
Because the isotype of the molecule dictates its ultimate effector
function, this is the body's way of developing the specific killing
mechanism most appropriate for a given invader.
Chapter 6-8
Immunology
Constant y heavy
chain domain
Variable"{ heavy
chain domain
Antigen
binding site
N/
Hinge region
Va riable light
chain domain
Constant light
chain domain
K or A, class
Complement
- - - - binding region
~Cell receptor
binding region
Chapter 6 - 9
Immunology
Lumen
_,,
~
Plasma
) ) cell
J IgA,v,..dimer
)~
~ ~.t!"
~~~;
\
'
J chain
Mucosa-........._ ~~
~ Epithelia
Serum level
(mg/dl)
45-250
trace
Naive B cell
receptor
Memory B
cell receptor
(one only)
Classical
complement
activation
620-1 420
80-350
trace
or +
or+
Opsonization
ADCC
Crosses placenta
Mast cell
degranulation
Ch apter 6-10
Immunology
J , Clinical
Complement
-lv~ Application
C4l
.
....
: .. c2
C.4 a / c l
""'
csa
opsonin
(Membrane
attack
complex)
C4b2a3b
make
CS convertase
lectin
Pathway
Collagenlike
domain
Man nosebind ing
lectin
C6-8 ~
CS convertase
Alternative
Pathway
MAC
C3b w
..
Cell membrane
accumulates C3b
C3bBb
make
C3 convertase,
attract more
C3
C3bBb3b
make
CS convertase
stabilized by
properdin
(Factor P)
MAC
Chapter 6 - 11
Immunology
Alternative
Pathway
..
csa
C4a
--- .
\
C a,.,....
3
classical
Pathway
Anaphylatoxins
attract leukocytes
Destruction of
microbe
! ':"' ~
C3b opsonlzes
CS- 9k::::;: :
convertase
Lectin
Pathway
CS- 9 form
membrane
attack connplex"'_ _ _,;:~
(MAC)
lectin activates and
splits C2 and C4 t o
form C3 convertase
Lysis of m icrobe
Ch apter 6-12
Immunology
Thl
T helper
c ell
activation
--t>l
ThO
B lymphocyte
activation
Cell-mediated
effector
mechanisms
Cyt okines
~~
..
....ll...nn..
li"..........
Th2
B lymphocyte
. . .n~
Antibody-secreting
plasma cells
Antibody-secreting
plasma cells
IgM, JgG
.(.,.
IgA,lgG
K
, ?
IgM
CytotOXICity
against worms
and parasites
Neutralization
of pathogens
Antibodydependent
cytotoxicity
receptor
Phagocytosis
of opsonized
microbes
Opsonization
and
phagocytosis
Chapter 6-13
~ ~
CD4
APC
1
::.. Il - 12
C04
...........
~~~~~
...\
(ThO)
'
I.L-4, Jl -5
macrophaoe
f) ~ (\
[L-4
Ml
TCR
The
Nirva na
Diagram
Antigen
presenting a:lls
can be 8 cells.
M0, dendritic cells
'
.......................
IL-6, Jl-10
....
ll 13, TGFil /
:
,'
t-:
HelperT \
'".,
'",.
Helpe:rT
'\ .
.
,.
.. proliferat1on
:
:
'"
....
......
can be monocyte,
PMN, M0,
NKcells
8 lymphocyte
.(
,_
or
production
'"
'"
(Thl)
Jl-10 inhibits
"' .. .,
'".. ,.
I
I
I
I
I
...
....
I
I
I
I
.,.....
........
.. . . . . . . . : . ..........
~, . . . . . . . . . . . I
.,
'
:
,' tFN-"(
'
JL-2
TNF-p
.L
...
Maaophage
cytotoxic
T lymphocyte
(Tc)
''
IIIKcell
COO
/R.b
TCR
L aass
1
MHC
,.,-
ADCC
(Antibody-dependent
cell--mediated cytotoxicity)
IFN-'Y
....
\
: Cytokines .Aiir'l~'\
:
:
: IL- Z
: TNF-p
: Cytolones
:
:
:
...........
: IFN-:y
,. IFN-y
IL-2
TNF-jl
Cytokines
lymphocyte
IL- l , lL-6,
11-B,TIIIF-a,
OTH
/11tative
~ i~tracellular
oroanisms
Virus-
infected
NK
target cells
cells
Humoral
Immunity
Cell-Mediated lmrnunlty
<IIIII
Imm un ol ogy
Connection to
2.1 Macrophages
Macrophages are the only cell of CMI that kills its enemy
intracellularly fo llowing phagocytosis. Although phagocytosis is an
innate ability of macrophages, when these cells are bathed in the
cytokines of Th1 cells, and in particular, int erferon-y, they become
more aggressive and effective killers. Macrophages are t he preferred
effector cell, then, when t he microbe is a facultative intracellular
organism, or one that survives inside phagocytes after being ingested.
Microbiology
The medically important
facultative intracellular
pathogens are a fairly short list
Francisella tularensis
Listeria monocytogenes
Mycobacterium spp.
Brucella spp.
Salmonella enterica
subsp. typhi
Legionella pneumophila
Yersinia pestis
The cytotoxic T cell {Tc) is tasked with killing altered host cells
expressing abnormal peptides in the groove of their MHC class
1 molecules. This effector cell of the CMI is therefore the major
protective effector against viruses and other obligate intracellular
microbes. Tc can also kill tumor cells as long as they express MHC
cla ss 1 molecules, but often tumor de-differentiat ion cau ses a loss of
these m olecules, and such t um or cells become refractory to Tc killing.
Tc kill their targets extracellularl y, by delivering toxic granule contents
through channels produced in the target cell membrane. This is a fourstep process that can be repeated again and again by a single Tc:
..
It('
..
Virusinfected cell
Conjugate
Formation
Cytoplasm ic
Rearrange ment
Apopt osis
Degranulation
Perforln
Granzymes
Nocardia spp.
Histoplasma capsulatum
Leishmania spp.
Connection to
Pathology
The classic demonstration
of chronic activation of this
effector system of CM 1 is the
development of granulomas.
Granulomas are spherical
accumulations of Thl
lymphocytes and activated
macrophages (epithelioid cells).
Macrophages that are frustrated
by their inability to efficiently
kill an ingested microbe
become highly secretory, calling
for more Thl cell help. By
contrast, neutrophils explode
when frustrated in the act of
phagocytosis. Accumulations
of dead and dying, frustrated
neutrophils produce abscesses.
Dissociation
and
Target Cell
Destruction
Chapter 7- 2
Immunology
Microbiology
Obligate intracellular microbes
are incapable of living outside of
hOst cells. They include:
All viruses
Chlamyd iaceae
Mycobacterium leprae
Rickettsiae
Sporozoan parasites
(Plasmodium, Toxoplasma,
Isospora, Cryptosporidium,
Babesia)
Leishmania spp.
NK cell
KIR+
(activating......._._.
receptor)
Connection to
KIR(inhibitory
receptor)
NK
target cell
Virus-infected cell with
normal levels of class 1 MHC
expression
Chapter 7- 3
Immunology
-------
.......
Connection to
Microbiology
Other tha n tumor cells, which
tend to be genetically unstable
and delete portions of their
genome, therefore stopping
expression of MHC class 1
molecules, many viruses have
evolved evasive techniques to
avoid Tc killing.
Herpes viruses
Hepatitis B (during
hepatocellular carcinoma)
Papillomaviruses
Human immunodeficiency
virus (HIV)
Connection to
Microbiology
An example of a disease in
which ADCC represents a
crucial immune response
is cytomegalovirus (CMV)
infection. CMV is a herpes virus
and therefore down-regulates
expression of MHC class 1 on the
cell surface. This makes CMV
infected cells refractory to Tc
killing, so the mobilization of NK
cells is expected. The problem
Lytle enzymes
and TNF
CD14+
Nonspecific
No
Intracellular
digestion,
TNF-a, NO,
Oxygen
radicals
Tc
CD3+,CD8+
Specific with
TCR
Yes, class 1
Perforin,
granzymes, LT,
IFN-y
NK cell
CD16+, CD 56+
Lectins
ADCC
CD16+
By antibody
No
Perforin,
granzymes,
cytokines
Chapter 7-4
Chapter 8- 1
Immunology
Jy,__Clinical
Application
-'"~
Memory
T LYMPHOCYTES
Recirculation
Secondary
lymphoid organs
ILow
Cell cycle
INo
Effector functions I None
IL-2 receptor
Areas of
inflammat ion
Areas of
inflammation
IHigh
IYes
ICytokines
and
cytotoxicity
ILow
I+/INone
IIncreasing
IlgG, lgA, or lgE
ILarge
IAntibody secretion
IHigh
IlgG, lgA, or lgE
ISmall
INone
B LYMPHOCYTES
ILow
lsotype
IlgM and lgD
Appearance
ISmall
Effector functions I Primary immune
response
Affinity
The respiratory
adenovirus vaccine
administered to military
recruits in boot camp
is the only example of
a live, non-attenuated
viral vaccine on the
market. It is delivered
within an enteric
capsule that releases
the living virus within
the intestinal mucosa,
where it produces an
asymptomatic intestinal
infection. The memory
cells generated in this
way, however, recirculate
to protect all of the
mucosal surfaces of the
body, and the military
recruit is protected from
the natural route of entry
of adenoviruses across
the respiratory mucosa.
Dissemination of Memory
During the memory phase, cells activated in secondary lymphoid
organs at the time of the initial exposure migrate out to generalize
the protection over the entire body. Memory cells tend to recircu late
in a tissue-specific fashion, returning preferentially to the type
of tissue in which they first encountered antigen. This process is
mediated by differential expression of adhesion molecules on the
surfaces of memory cells that appear to attract them specifically to
particular types of tissues.
Chapter 8-2
Immunology
Secondary
anti-x
r esponse
),~
O'-
O Qf
't-'(
Antigen x
9o
Gl
VI
)'
Q.
Gl
.rl ~.<.
~ --1'
-,
ts
9o~
..J'y
C) 'i
Primary
anti-y
response
Memory
cells
Naive cells
...
.J.,.
.(~ 1-
E
E
'r ~1:'
Antigen y
VI
Gl
~
:I
,\-A
.( .l)..
><. . .
~ .JV
'r-{
Antigen x
Prima ry
anti-x
response
~-r
Activated
cells
.--....
Activated
cells
-.(
"
0 >-Jl.-J-.
1.. 0
10
12
Weeks
Anti-y cells
Anti-x cells
Chapter 8- 3
Immunology
Review Questions
Chapters 6-8
1. A "knockout" mouse strain has been developed with a complete defect in a single gene
product. The B and T lymphocyte counts in this strain are within normal parameters. Serum
antibody measurements reveal high titers of IgM without significant presence of IgG, IgA, or
IgE. Which of the following deficiencies best explains this mouse's condition?
A.
B.
C.
D.
E.
B27
CD4
CD40L
IL-4
TNF-o.
2. A biotech company has developed a new line of compounds prepared by proteolytic digestion
of purified anti-nickel IgG antibodies. Compound A is prepared with papain. Compound B is
prepared with pepsin. Which one of the two compounds is most useful as a positive control
reagent for a nickel agglutination assay?
A.
B.
C.
D.
E.
F.
Compound
Compound
Compound
Compound
Compound
Compound
A,
B,
B,
B,
A,
B,
because
because
because
because
because
because
3. Marriage licenses in all SO states of the United States require proof of rubella antibody titer.
Which of the following descriptions fits the antibody isotype detected in this assay that would
confer protection to any fetus?
A.
B.
C.
D.
E.
4. A child who has suffered repeated bacterial septicemias is found to have a genetic deficiency
of complement component 6. When plasma from this patient is incubated with bacteria,
which of the fol lowing outcomes is most likely?
Production of Anaphylatoxins
A. Decreased
B. Decreased
C. Normal
D. Normal
Bacterial Lysis
Decreased
Normal
Decreased
Normal
5. A patient with hepatitis C hepatocellular carcinoma joins a trial protocol intended to stimulate
production of CDS+ cells specific for his transformed cells. His MHC class 1 haplotype is
determined to be Al/A7, B2/B3, and C2/C3. Which of the following molecules implanted
into the membrane of cultured tissue fibroblasts enriched for expression of costimulatory
molecules would serve to stimulate the most effective cytotoxic killing?
A.
B.
C.
D.
E.
Chapter 8 - 4
Immunology
Chapters 6-8
Review Questions
6. Genetic testing of a family reveals that both parents are carriers of a mutation that
produces a stop codon in the IFN-y receptor. To which of the fol lowing pathogens would their
homozygous child have most increased susceptibility?
A. Bacillus anthracis
B. Chlamydia trachomatis
C. Herpes simplex v irus
D. Listeria monocytogenes
E. Streptococcus pyogenes
Dendritic cells
Macrophages
Neutrophils
Plasma cells
Tc lymphocytes
Absence
Absence
Absence
Absence
Absence
of complement
of Fas
of interferon-y
of perforin
of tumor necrosis factor
9. A group of experimental rats are inoculated with tetanus toxoid (TT) three times, seven days
apart, over a three-week period . The last injection of TT is m ixed with anthrax toxoid (AT).
Two days after the last injection, the rats are bled and their sera analyzed for the presence of
antibodies to TT and AT. Which of the following antibodies would be present in elevated titers?
A.
B.
C.
D.
E.
F.
IgG
IgG
IgG
IgG
IgM
IgM
against TT
against TT and IgM against AT
against TT and AT
and IgM against TT
against AT
against TT and IgG against AT
10. In comparisons of the efficacy of the live attenuated intranasal influenza vaccine ( FiuMist) and
the injectable killed virus vaccine, it has been shown that the intranasal vaccine provides much
greater protection. Which of the following statements most likely explains this finding?
A.
B.
C.
D.
E.
<9 DeVry/Becker
Chapter 8 - 5
Review Answers
Chapters 6-8
Immunology
Chapter 8- 6
I
I
I Protect the fet us and neonate Transplacental IgG; breast
I milk and colostrum with IgA
Post-exposure prophylaxis
Chapter 9 - 1
Immunology
Active Immunization
Vaccination of children and adults has dramatically reduced morbidity
and mortality due to infectious disease over the past 100 years. In the
United States, vaccinations are recommended according to a schedule
established by the Centers for Disease Control and Prevention.
c.;.u-.
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For further guidance on the usc of the vaccines mentioned, sec: http://wwv..-.cdc.govivacci'lcs/ pubs/acip list.htm
Organism
DTaP
Toxoid
Toxoid
Toxoid + filamentous
hemagg lutinin
Corynebacterium diphtheriae
Clostridium tetani
Bordetel/a pertussis
Hib
Haemophilus influenzae
type b
PCV (pediatric)
PPV (adult)
MCV4
13 capsular serotypes
+ protein
1
I 23 capsular serotypes
4 capsular serotypes
(Y,
W-135, C, A) + protein
1
I Streptococcus pneumoniae
I Streptococcus pneumoniae
I Neisseria meningi tidis
Chapter 9-2
Immunology
Hapten-specific
B cell receptor
Capsular polysaccharide
Linear peptide
"carrier epitope"
ca.- - - Hapten
(epitope of
capsular polysaccharide)
.. -
Endocytosis and
processing of
carrier protein
-~
Cytokines
I
I
Peptide binds
to class 2 MHC
--
' -~ 2 ...
-~:;:;;:::::
.......~
ll,ITcR
---
~
~
.~
Peptide activates
Th cells and
causes cytokine
production
A Figure 9-2.1 The Hapten-Carrier Effect in Conjugate Vaccines
Chapter 9-3
Immunology
Jy,__Clinical
Application
-'"~
Vaccines
contraind icated during
pregnancy-MMR (the
rubella component).
Vaccines
contraind icated in
patients with egg
allergy-influenza,
yellow fever.
Recombinant DNA
Yes
No
No
Safe in
No
immunocompromised
Yes
Yes
Immunogenicity
High
(CMI and Ab)
Middle (Ab to
specific molecule)
Potential for
contamination
No
No
Special storage
Yes
No
No
Examples
Measles, mumps,
rubella, rotavirus,
varicella zoster,
adenovirus, Sabin
polio
Hepatitis B, human
papilloma virus
Potential for
reversion
2.3 Adjuvants
Adjuvants are materials added to vaccines to increase immunogenicity
nonspecifically. Aluminum salts or aluminum gels are the only vaccine
adjuvants currently licensed for use in the United States. Adjuvants
do not alter the nature of the immune response to vaccination; they
simply increase the speed and amplitude of the response, perhaps by
increasing nonspecific inflammation or by increasing the persistence
of the immunogen at the injection site. Adjuvants are currently
used in the vaccines for hepatitis A and B, DTaP, Hib, HPV, and adult
pneumococcus. They are not used in live attenuated viral vaccines.
Chapter 9-4
Immunology
1,20
-Birth
1,00
800
60%
...... 600
...J
E
80%
..
.....
..
0
0
.....
c:n
E
c:n
400
J
Clinical
-v y._ Application
i
Administration of live
viral vaccines in the
first six months of life
is unproductive due
to the presence of
maternal antibodies.
Immunologic deficiency
diseases usually do not
present until maternal
antibodies are gone.
Elevated lgG can not
be used to diagnose
in utero infections; the
only fetal antibody that
can be proven to come
from the child is lgM.
200
150
100
75%
50
20%
0
0
10
12
Months
Chapter 9-5
Immunology
__
..._
......;;;;;;...._
Passive Immunotherapy
J
Clinical
_, y._ Application
1
Chapter 9- 6
Primary Immunodeficiencies
Primary immunodeficiencies are flaw s in the functioning of the
immune system that result from genetic defects in the expression
of one or more of the working parts. Many of these are discussed
in t he Clinical Cases presented in this book. Here, the focus is on
differential diagnosis and comparative pathogenesis.
Molecular Basis
Deficiency of NADPH
oxidase, fa ilure to
generate oxygen rad icals
for intracellular killing
Leukocyte adhesion
deficiency
Chronic extracellular
microbial infections, failure
to form abscesses and
pus, omphal itis
Chediak-Higashi
syndrome
Chemotactic and
Granule structural defect
(giant granules) in NK cells degranulation defects,
and phagocytes
absent NK activity, partial
oculocutaneous albinism
G6PD
(glucose- 6-phosphate
dehydrogenase)
deficiency
Loss of essential
enzyme of the hexose
monophosphate shunt
Myeloperoxidase
deficiency
lob syndrome
Chapter 10- 1
Immunology
Therapy
Bruton X - linked
agammaglobulinemia
Deficiency of CD40L on
Th cells
Decreased expression of
Antibiotics, no
immunoglobulins
(most common)
Repeated infections of
mucosal surfaces, increased
atopic allergy
Mutation in t ransmembrane
activator and cyclophilin
ligand interactor (TACI) that
med iates isotype switching
Antibiotics
Common variable
Immunodeficiency
Component Missing
Therapy
C3
As above
CS - C9
Repeated neisserial
bacteremias
As above
All pathways
Cl-IN H (hereditary
I angioedema)
I Infusion of Cl
esterase
inhibi tor, androgen therapy
Chapter 10- 2
I mmunology
D/ George syndrome
(velo-ca rd io-facia I
syndrome)
Failure of formation of
3rd and 4th pharyngeal
pouches, 22qll.2 deletion
Thymic aplasia,
abnorma l facies,
hypoparathyroidism,
cardiac malformations,
decreased T cell numbers,
absence ofT cell
responses
Disease
Wiskott- Aidrich
syndrome
X-linked defect in
WASp ca uses defective
cytoskeletal signali ng
Eczema, thrombocytopenia
and variable
immunodeficiency
(usually IgM)
Atax ia telangiectasia
Spinocerebellar
degeneration,
telangiectasias, diminished
IgG, IgA, and IgE
synthesis
IL2R SCID
As above
Lymphocytopenia
Chapter 10- 3
Immunology
Severe combined
im munodeficiency
ADA deficiency
Pluripotent
stem cell '
Chroni c
granulomatous
disease and
Ched iak- Higash i
syndrome
B progen itor
I
I
1
DiGeorge
syndrome
I
I
T progenitor
SCID
IL-2R
I
I
Basophil
progenitor
X- linked
agammaglo bulininemia
', Thymus
'
I
I
candidiasis
MHC 1
deficiency
Basophil ,'
,
,
,
Chronic
mucocutaneous
Eosinophil
I
I
--
?.
Q -__.. . .
##
Mast cell
Dendritic cell
Macrophage ,....-
!gA
deficiency
Helper T
I m mature
lymphocyte
B cell
.
(Th)
I Hyper lgM
Cytot OXIC
"'T ,,( _1
.A
,~,;.gc;:o,
.L
T
Mature B lymphocytes
<0 DeVry/ Becker Educational Develop ment Corp . All r ig hts reserved .
Chapter 10 - 4
I mmunolo g y
J , Clinical
~y'- Application
Acquired (or secondary) immunodeficiencies are not caused
by inherit ed defects within the immune system, but rat her by
immunosuppressive agents or diseases. While many forms of cancer
and some chronic infections can cause immunosuppression, HIV is
the one virus most closely associated with this condition .
..,
<9 DeVry/Becker
Chapter 10- 5
Immunology
HIV-infected
cell dies
Cellular
debris
processed
Antigen
presenting cells
can be B cells,
M0, dendritic cells
Class2
MHC
.>i.-
.r.,,.
~~
TCR
t..!Jil
- ./} /'..,. {\)IIIII"
M2
macrophage
APC
~~
~4
co4'
.......
I L-4
TCR ~
c;;r
..
IL-4 IL-5 I
IL-6' ' Il-13
TGF-P ,'
..
t-
' .......
Helper T
lymphocyte
(~ 1)
!L-10 inhibits
production
....................
,
..:
.....
-~,
Can be
monocyte,
PMN, M0, or
NK cells
I FN-y
.
I L-2
/
TNF-p
Cytoklnes
IFN -y
IL-2
: TNF-P
: Cytokines
I
I
+
NK cell
'f t-
=<',;
AOCC
Antibodies ......_(
Humoral
......
.... .............
...
.........
.
.
....
. .
Plasma cell
Immunity
~~
Helper T ,
',
lymphocyte ', IFN -')'
'
(Th2)
' inliibits
',
'., proliferation
"..
,...~,
B lymphocyte
r'-
M1
macrophage
.
APC
Helper T
lymphocyte
(ThO)
Kills
infected
CD4+
cells
"'."
....... IL-1 2
.......... ..
-..
.,
~
.~.:
' IFN-y
',,
: IL- 2
: TNF- p
'
: Cytokines
'. I FN-y
~
:
I
I
.,
Cytotoxic
T lymphocyte
(Tc}
May be
useful effector,
but weak response
without Th1
cytokines
I
I
!.
..
Macrophage
Kills Infected
macrophages
Cell-Mediated Immunity
Chapter 10- 6
Immunology
Chapters 9-10
Review Questions
1. A patient being studied for an unusual immunologic disorder is found to lack class 1 MHC
molecules, and homogenized lymphocyte precipitates are found to lack TAP1 molecules.
Which of the fo llowing vaccines would most likely be ineffective in this patient?
A.
B.
C.
D.
2.
A child is taken to the pediatrician because of his mother's suspicion of food allergies. Skin
testing is positive for hypersensitivity to egg albumin. Which of the fol lowing vaccinations
would be contraindicated in this child?
A. Haemophilus influenzae
B.
C.
D.
E.
3.
Prior t o 1990, pediatric vaccines against Haemophilus influenzae type B cont ained capsular
material from the organism plus an adjuvant. What immune response is expected from this
inoculation?
A.
B.
C.
D.
E.
4.
Hepatitis B
Influenza
Measles, mumps, rubella
Rotavirus
Th lymphocyte activation
Cytotoxic T lymphocyte stimulation
IgM production
Immunologic memory induct ion
Isotype switching
If patients receiving the Salk polio vaccine are compared with those receiving t he Sabin
vaccine, which of the fol lowing stat ements is most likely to be t rue?
A.
B.
C.
D.
E.
Only
Only
Only
Only
Only
<9 DeVry/Becker
recipients
recipients
recipients
recipients
recipients
of
of
of
of
of
the
the
the
the
the
Chapter 10 - 7
Review Questions
5.
Chapters 9-10
6.
Immunology
Hepatitis B
Influenza
MMR (measles, mumps, rubel la)
Pneumococcal (23-valent)
Td (tetanus-diphtheria)
A female neonate with low birth weight is evaluated because of dysmorphic facia l features
and generalized cyanosis. Shortly after delivery, she developed seizures resulting from
severe hypocalcemia. What additional findings are most likely in this individual?
A.
B.
C.
D.
E.
Decreased alpha-fetoprotein
Decreased IgA levels
Diminished numbers of CD3 + cells
Elevated IgM levels
Prominent telangiectasias around the eyes
7. A 6-month-old boy is seen by his pediatrician for epistaxis. The patient has a history of
multiple bacterial and viral respiratory tract infections and eczema. Serum IgM is decreased,
IgG is normal, and IgA and IgE are increased. The mean diameter of platelets is decreased.
Which of the following is the most likely defect?
A.
B.
C.
D.
E.
Chapter 10- 8
Immunology
Chapters 9-10
8.
Review Questions
A man who is seropositive for HIV has a CD4+ T lymphocyte count of 495. Which of the
following is likely to be most decreased in this patient?
A.
B.
C.
D.
E.
10. A 3-year-old boy is seen by a pediatric specialist after developing cellulitis for the
third t ime in four months. The doct or notes that the boy has pale hair, blue eyes, and
patchy hypopigmentation of the skin. Attempts at funduscopic examination revea l
moderate photophobia . Oral ulcers also are noted . Blood testing reveals neutropenia and
hypergammaglobulinemia . Blood smear will most likely reveal which of the fol lowing?
A.
B.
C.
D.
E.
Lymphocytosis
Elevat ed reticulocytes
Mononuclear cells with "owl's eye" nuclei
Granulocytes wit h giant granules
Irregularly shaped lymphocyt es
<9 DeVry/Becker
Chapter 10 - 9
Review Answers
Immunology
Chapters 9-10
Chapter 10- 10
Overview of Hypersensitivity
and Autoimmunity
Hypersensitivity diseases occur when there is too much immune
response, and the resulting immune products damage host tissues.
Hypersensitivities include responses to foreign antigens as well
as failures of self-tolerance, which are referred to as autoimmune
diseases. Excesses of the immune response are classified into four
general types based on the molecular basis of pathogenesis.
T Table 11-1.0 Types of Hypersensitivity
USMLE Key Concepts
Type
For Step 1, you must be able to:
I (immediate)
II (antibody-mediated)
lgE
Circulating immune
complexes
Opsonization and
phagocytosis,
complement-med iated
lysis and inflammation
IV (delayed-type)
Tc-killing, cytokine-driven
inflammation
Chapter 11- 1
Immunology
Type I Hypersensitivity
Type I hypersensitivity is the only form of hypersensitivity mediated
by immunoglobulin E, mast cells, and basophils. It represents the
body's natural response against helminth parasites that are too large
to be killed by other immune responses.
2.1 Mechanism
When the body mounts a type I hypersensitivity against harmless
environmental substances such as dust or animal dander or
pollen, the result is atopic allergy. It is also known as immediate
hypersensitivity, since the manifestations of tissue damage happen
immediately on re -exposure to an allergen after sensitization .
............
I L-4, IL- 13
'~.nn..
~ ..........
Th2
.1.. lgE
~
~gE
B lymphocyte
Mast cell
Plasma cells
IgE attaches to Fe
receptors on mast cells
~anulation
Immediate reaction
vasodilation
~- vascular leakage
smooth muscle spasm
1
Late-phase r eaction
Leukocyte infiltration
Epithelial damage
Bronchospasm
Chapter 11-2
Immunology
2.2 Mediators
After their membrane-bound IgE molecules become cross-linked by
repeated exposures to allergens, the degranulation of mast cells and
basophils results in the release of a variety of pharmacologically active
mediators. Release of these granular contents causes immediate
smooth muscle contraction and increased vascular permeability. Four
to six hours later, the late-phase reaction adds additional smooth
muscle contraction, inflammation, and vascular permeability due to
the production of mediators from the arachidonic acid cascade.
Result
Histamine
Heparin
Anticoagulant
Chemotactic
late-Phase Mediators
Prostaglandin 02, E2, F2a
Leukotriene 84
Systemic anaphylaxis
Asthma
Inhaled materials
constriction, edema,
mucus, inflammation
Food allergies
Hives and
gastrointestinal edema
Chapter 11- 3
Immunology
.. . . . .
. .......
Z
.
.. .
Enzymes
Upid mediators Cytokines
(e.g., trypase)
(e.g., PAF,
(e.g.,TNF)
PGD2 , LTC4 )
/
Upid mediators
(e.g., PAF,
Biogenic amines
(e.g., histamines)
PGO,, LTC,)
\
.
.-:: .
::.~
1 \
Tissue
damage
~- ~
Intestinal
Inflammation hypermotility
/
Enzymes
(e.g., eosinophil
peroxidase)
Eosinophil
*"
'
. ~
,~ 4
.z ~- ':.:.C.;"-~..-
Bronchoconstriction
Vascular
leakage
Tissue remodeling
Killing of parasites
and host cells
Chapter 11- 4
Immunology
Rho-
3.1 Mechanism
Type II hypersensitivities cause tissue damage by three main
mechanisms:
Opsonizat ion or complement activation.
Recruitment of inflammatory cells like PMNs and macrophages.
Antibodies may bind to normal cellular recept ors and cause
interference with normal cellular function without cell lysis.
Maternal
imm une
response
!'
~ ~
Fet.ll
erythrocytes
Rh or other RBC
membra ne proteins
Rheumatic feve r
Streptococcus
pyogenes: cell -
Opson ization,
complementmediated lysis
Hemolysis, anem ia
During delivery, or
from placent.>l bleeding,
mother is sensitized to
Inflammation,
opsonization
Myocardit is,
arthritis
Type I V collagen
in basement
mem branes
Complement and
opsonization
Linear deposits o f
antibody in kidney
and lung, nephritis
Transfusion
r eaction
IgM
isohemagglutinins
made in response
to norma l flora
cross-react w ith
alloa ntigens,
activate
complement, and
cause opsonization
Hemolysis
Autoimmune
thrombocytopenic
pu rpur a
Platelet membrane
proteins
Bleeding dyscrasia
RhO antigen.
wa ll antigen
cross-reacts with
myoca rdium
Goodpasture
s yndrome
1'-'\
Maternal
/ anti-Rho
IgG
/'- t"'
w
In a subsequent
pregnancy, mother's IgG
anti-RhO+ antibodies
cross placenta to react
with fetus' RhO+ red
blood cells.
A Figure 11 -3.2A
Hemolytic Disease of
the Newborn
Chapter 11- 5
Immunology
Antigen
Pathogenesis
Symptoms
and Signs
Thyroid-stimulating
hormone receptor
An ti body-med iated
stimulation of
secretion of T3, T4
Hyperthyroidism
followed by
hypothyroidism;
biopsy negative for
cell injury
Myasthenia
gravis
Acetylcholine
receptor
An ti body blocks
acetylcholine
binding, downregu lates receptors
Muscle weakness,
paralysis
Type II
(non-insulindependent)
diabetes
I nsulin receptor
Antibody inhibits
binding of insulin
Hyperglycemia
.Figure 11-3.28
Graves Disease
a-mModlcaiSiod<-
Grav es Di sease
Hashimot o Thyroidit is
Helper
T cell
Thyroid-stimulating
hormone (TSH)
B cell
~Activates
~
. . . , Cytotoxic
Tc
,.._.........--..,.. "
................./
TSH receptors
}-
"--...................~.........--..,..,.._.......,.
Thyroid hormones
T3 and T4
Initial Hyperthyroidism
Excess of T3 and T4
until cell gives up
Hypothyroidis m
Deficiency of
T3 and T4
.Figure 11-3.2D Pathogenesis of Graves Disease (Type II) vs_ Hashimoto Thyroiditis (Type IV)
N orm al
Motor axon
- -r
Vesicles
containing
acetylcholi ne
Ax on terminal
Antibodies attach to
Chapter 11- 6
Immunology
4.1 Mechanism
These hypersensitivities may be autoimmune or directed against
foreign antigens. The key difference between Type II and Type III
hypersensitivities is that the damage Type III causes is system-wide,
injuring small diameter blood vessels when they become plugged with
complexes of antigen and antibody. Once the immune complexes lodge
in the vasculature, they activate complement in that location that may
be quite distant from their point of origin. These hypersensitivities
tend to be causes of vasculitis with fibrinoid necrosis.
IS~ Inc.
Antigen
Manifestations
Arthus reaction
Poststreptococcal glomerulonephritis
Serum sickness
I Several p roteins
I
IArth rit is, vasculitis, nephritis
Polyarteritis nodosa
I Hepatiti s B virus Ag
Scleroderma
I CREST
I Drug-ind uced lupus
I Sj ogren syndrome
I Mixed con nective t issue disease
I Polymyosit is/dermatomyositis
Chapter 11-7
Immunology
Type IV Hypersensitivity
Also known as delayed type hypersensitivity, Type IV hypersensitivity is
a cell -mediated immune response that takes 48 to 72 hours to develop.
5.1 Mechanism
In Type IV hypersensitivities, a sensitized Thl or Th17 cell is the root
of the problem. At the effector cell level, damage may be caused
by CDS+ Tc cells, macrophages activated by IFN-y, or neutrophils
activated by IL-17 and IL-23.
Rheumatoid Arthritis
Disease
Rheumatoid arthritis*
Hashimoto
thyroiditis*
I Thyroid antigen
Multiple sclerosis
Pernicious anemia
Ty pe 1 diabetes
(insulin-dependent)*
Guillain- Barre
syndrome*
Crohn disea se
I
Celiac disease
I
I Polydipsia, polyuria, polyphag ia
*Type I V hypersensitivity pathologies in which autoantibod ies are used for diagnosis
Food- B12
Small intestine
Normal
Pernicious anemia
Transport
No
transport
Blood
IF B12
Ileum
.A. Figure 11 -5.2( Pernicious Anemia
Chapter 11- 8
Immunology
Pathogenesis of Autoimmunity
The basis of autoimmune disease is a failure of self-tolerance . There
are genetic, environmental, hormonal, and infectious triggers.
6.1 Mechanism
Tissue injury may serve as an inciting feature, exposing antigens that
would normally be hidden. Molecular mimicry between host cells and
invading microbes is often implicated in the early stages of disease.
Because the immune response remains activated until the antigen
is destroyed, when the antigen is "self," the damage is chronic and
progressive.
B27
Primary hemochromatosis
A3
Graves disease
B8
Goodpasture syndrome, MS
DR2
DR2/DR3
DR4
Type 1 diabetes
DR3/DR4
Celiac disease
DQ2/DQ8
Chapter 11- 9
Jy,__Clinical
Application
Therapy of Hypersensitivities
and Autoimmune Diseases
-'"~
Trastuzumab
Eculizumab
Dacliximab, basiliximab
Muromonab
Rituximab
Palivizumab
~Table
Monoclonal antibodies
(MAbs) are produced by
fusion of myeloma cells
(immortal in culture)
and antigenspecific
lymphocytes. Although
this is a laborious
laboratory procedure,
screening of these
random fusions for cells
that produce useful
antibod ies has produced
monospecific antibodies
from immortal cultured
cells that have the
advantage of producing
very specific results in
the patient.
I (immediate)
lgE
No
Basophils and
mast cells
II (cytotoxic)
IgM, IgG
Yes
PMN,ADCC
cells
II (non-cytotoxic)
IgG
No
None
lgM, lgG
Yes
PMN,
macrophages
IV (delayed-type)
None
No
Th 1 cells, Tc,
macrophages
Chapter 11- 10
Immunology
Regulates immune
response
Treg ; ; , ;
APC
Macrophage activation,
Type IV hypersensitivities
i~-10
Thl
~ .
...............
. ~
TGF-p
ThO
IL-10 inhibits
Thl
IL-12, IFN-y
Cytokines
Thymocyte
\
TGF-p, IL-l,
IL-6, IL-23
"
f"
"
--~
IFN-y,
,., .
IL-2, TNF-p
help for CMI
I
II
IL-4, IFN-y
: IL-10 11 inhibits
:inhibit . Th2
~ Thl
.
IL-4 IL-5 IL-6
I
' IL-13,
'
'
IL-10,
TGF-p
help for IgG,
IgA, IgE
..
IL- 17,
Recruitment of
neutrophi/s and monocytes,
Type IV
hypersensitivities
-...
.
....... ~. .
~ IL-22,
Th2
Chapter 11- 11
Chapter 12- 1
Immunology
>
.."'"':c
.t:
1:1.
Graft/
cells
.!::
~.~
Cll
"1:1
...c
.....
.,-- ....
~ .~
#; ;
CD4+ helper
T cells
Renal blood
vessel
/ Damage
CDS
Chapter 12- 2
Immunology
Alloantlgen
(e.g., brood
group ant igen)
Blood vessel
Circulating alloantlgen
specific antibody
(preformed)
Complement
activation,
endothelial
damage,
inflammation
and thrombosis
Parenchymal
cell damage,
interstitial
inflammation
Endothelialitis
Endothelial
cell
Chapter 12- 3
Immunology
)\T
h
..
''~:.:.?.
~
Causes unclear:
Chronic DTH
reaction In
vessel wall,
Int imal smooth
muscle cell
proliferation,
vessel occlusion
Cytokines
Chapter 12- 4
Immunology
J
Clinical
-'Yvr-- Application - - - - - - - - - - - - - - 1
Chapter 12- 5
Immunology
, - - - - - Blood Types - - - - - .
(
Serum from
0 pl!tient
contains
anti-A and anti-B antibodies
Serum from
AB pl!tient
contains
no antibodies to A or B
AB
rr
Serum from
A patient
contains
l!nti-B l!ntibodies
Serum from
B pl!tient
contains
anti-A antibodies
I'
A
I
[I
= Agglutination
N = No Agglutination
Chapter 12- 6
Immunology
Recipien t Cell
HLA-A allele 1
Antibody to
HLA-A allele 2
ooeooeooo
QQeQQeQQQ
QQQQQQQ
Dye
( t rypan blue
or eosin Y)
Chapter 12- 7
Immunology
Recipient cells
lacking class 2
MHC of donor
"'
"- /
Irradiation
~ O ~ AIIeleB
oo
a a-
-r---+1111
1
[H)3-Thymidine
Incorporation of
radioactivity into
nuclear DNA
.Q.
a'o'Q8 oo
Q ~~.0
-
a 0
Allele A
donor cells
........ .
oo
Chapter 12-8
.. :;:~. .
Y~ l
.,.~--~
~f
<;d
~~
Antlbody-excess
zone
Excess
Ti me After I nfection
Chapter 13- 1
Immunology
RBCs agglutinated by
the addition of rabbit
anti-immunoglobulin serum
~~
\ ( ~ tJ
tk ~
fl
..
~+ .,
~ ~f~
RhO+
RBCs from
donor
Donor RBCs
coated with
anti-RhO+
antibodies
Chapter 13-2
Immunology
Immunofluorescent Assays
Immunofluorescent assays use microscopy to visualize the location
and distribution of fluorescent dyes tagged to antibodies in blood
and tissue samples.
,_
..
,_ -~>
..,....._(
Immunology
----------------
-{ -r
Antibody
Antigen
coated on
microtiter
plate
Enzyme-linked
antihuman
y-glo""""
J~~~~~
Positive
Aeeee
see
ceeeee
oeee
Eeeeeeeeee
F
eeeeee
Ge
Heee
1
10
1
\
Negative
e
e
e
e
e
e
e
11
12
Chapter 13-4
Immunology
Western Blot
Connection to
Biochemistry
In the Western blot for HIV confirmation, the viral antigens are
separated by electrophoresis in gel, and the bands are blotted onto
nitrocellulose filter paper. The fi lter paper is then bathed in serum
from the patient with the positive EIA results, and fina lly a visualizing
method is used. In some cases, an enzyme-linked ant ihuman
globulin is added, and the substrate color change is noted. In other
cases, a radioactive antihuman globulin is added, and the resu lts are
read on radiographic fi lm.
Jy,_Clinical
Application
1
-1
Larger
Smaller
l,,,
~,,,,~
Protein bands
Antihuman
y-globulin
~
~ ~\
{7
Antibody
11111111111111~
... Y\
I
3 . Serum from a patient
is introduced and antibodies
bind to any antigens that
are recognised.
Enzymeor radioactive
labeled
marker
Chapter 13- 5
Immunology
Fluorochrome
~ (fluorescent dye)
Antibody
Anti-CD4
dye~-
Sheath
flu id
Hydrodynamic
focusing
c+-f--- Cells pass In
single file
Laser light makes
fluoresce
Fluorescence
is detecteddyed cells
are counted
.....
i..,. .......
11/.
0 ---------~---------
u
'
:;:;
'
:l
.. :s:~
OO:l,\!.
'
'~!1'- '- :
.. .
..
.......-. .
Anti-COS --+
db
Negatively
charged plate
deflects positively
charged droplets
System works
the same using
either charge
Dyed cells
are separated
0
0
Chapter 13- 6
Immunology
Chapters 11-13
Review Questions
1. A 42-year-old scout leader reports to his doctor with an itchy rash on his right calf. He
reports being on a campout three days ago with his scout troop. Physical examination
revea ls a red, vesicular rash on the outer aspect of the right lower leg. Which of the
following is the cause of this rash?
A. B lymphocytes
B. Neutrophils
C. Plasma cells
D. Th1 lymphocyt es
E. Th2 lymphocyt es
2. A 60-year-old male presents to his physician complaining of pain in his wrist, hand, and
knee joints associated with swelling, tenderness, and heat. Laboratory studies reveal a
normocytic, normochromic anemia with an elevated erythrocyte sedimentation rate. Seru m
is positive for IgM antibodies against autologous IgG . A sample of synovial fluid from the
affected joints is most likely to reveal which of the following?
B.
c.
Norma l
D.
Nonma l
Norma l
E.
3. A 6-year-old boy is brought to the pediatrician because of abrupt onset of malaise, fever,
and nausea. On examination, the child has mild hypertension and periorbital edema, and
urinalysis is positive for protein. He recovered uneventfully from a sore throat two weeks
ago. Which of the following is most likely to be found in a kidney biopsy at this time?
A.
B.
C.
D.
E.
4. A 45-year-old female with type 1 diabetes since childhood requires a kidney allograft.
Her peripheral blood lymphocytes are mixed with the irradiated lymphocytes of f ive
potential donors. Tritiated thymidine is added to the cultures and the counts per minute of
radioactivity after 24 hours are measured . The results are shown in the fol lowing table :
A.
B.
c.
Donor 2
Recipient
8,0 66
Donor 3
Recipient
419
D.
Donor 4
Recipient
5,376
E.
Donor 5
Recipient
19,333
6,517
D. Donor 4
E. Donor 5
Chapter 13- 7
Immunology
--
Review Questions
Chapters 11-13
5. A 49-year-old man comes to the physician complaining of rash and diarrhea of three days'
duration. He underwent bone marrow transplantation for acute myelogenous leukemia 40
days ago. Physical examination shows an erythematous maculopapular rash and jaundice.
Serum studies show a total bilirubin concentration of 2.2 mg/dL and AST activity of 30 U/L.
Which of the following is the most likely cause of this patient's condition?
A.
B.
C.
D.
E.
6. A 69-year-old man is admitted to the hospital for a painless, lower GI bleed. His hemoglobin
drops from 12 to 9 in four hours. His type and screen shows antibodies to Band Rh. What
type of blood should he receive?
A. A+
B. AC. B+
D. B-
E. 0+
7. The peripheral blood leukocytes of a healthy donor were stained with fluorescent-labeled
monoclonal antibodies to CD3, CD4, CDS, and CD20. They were then processed through a
fluorescence-activated cell sorter. In which quadrant of which graph would the sensitized
cells responsible for the tuberculin test response be found?
.
.,.,,_
....
.
'
--- - T----------3 , , I4
' ;.,.
!; '
A.
B.
C.
D.
E.
F.
G.
H.
I.
Graph
Graph
Graph
Graph
Graph
Graph
Graph
Graph
Graph
J. Graph
K. Graph
L. Graph
I
I
'
A quadrant
A quadrant
A quadrant
A quadrant
B quadrant
B quadrant
B quadrant
B quadrant
C quadrant
C quadrant
C quadrant
C quadrant
CDS
.\.
.,.
.
....
.
'
---- T-----------
3 , , I4
':
.
!;.
CD4
"'
0
u
'i
~
..
' ----------
---- T3 , I4
~)
;;.;.
.:.:..-,
.....
CD20
1
2
3
4
1
2
3
4
1
2
3
4
Chapter 13- 8
Immunology
Chapters 11-13
Review Questions
8. A multiparous 33-year-old Rh - negative woman seeks the advice of her physician regarding
the risks of having another child. She has received standard anti-Rh therapy with each of her
pregnancies. Which of the fo llowing tests is best to establish her current antibody status?
A.
B.
C.
D.
E.
Coombs test
Direct fluorescent antibody test
Enzyme-linked immunoassay
Indirect fluorescent antibody test
Western blot
10. A 21-year-old female goes to her college clinic. She admits concerns about unsafe sexual
practices and requests standard screening for HIV. When this test is returned with positive
results, the physician requests a second blood sample for a confirmatory test. Which of the
following tests will the laboratory perform?
A.
B.
C.
D.
E.
Enzyme-linked immunoassay
Flow cytometry
Radioallergosorbent test
Radial immunodiffusion
Western blot
<9 DeVry/Becker
Chapter 13- 9
Review Answers
Immunology
Chapters 11-13
Chapter 13- 10
Immunology
Cl inical Cases
Physical Findings
Erythroderma with pachydermia and desquamation
Alopecia
Hepatosplenomegaly
Laboratory Results
Leukocytosis
Eosinophilia
Elevated IgE levels
Immunology
Clinical Cases
Discussion
Omenn syndrome is a genetic disorder with autosomal recessive
inheritance. It manifests as a severe combined immunodeficiency
(SCID) because the mutations involve the RAG1 and RAG2 genes,
which are essential for VDJ recombination in lymphocytes. Because
lymphocytes without antigen receptors are nonfunctional, the
condition is associated with virtual absence of B cells. T cell counts
are elevated but they are autoreactive, perhaps because of the
failure of thymic education in the absence of a functional TCR. T cell
activity is the source of the red rash, desquamation, and generalized
autoimmune destruction of highly mitotic cells. This makes the
syndrome resemble graft versus host disease in that T cells in
individuals with Omenn syndrome recognize and attack self cells.
If not treated with bone marrow transplantation, the syndrome will
generally prove fatal within the first two to six months of life.
Clinical Cases C- 2
Immunology
Clinical Cases
History
A 4-year-old child is referred to a specialist because of recurrent
necrotic lesions on the legs and arms. His previous history reveals
that he had delayed umbilical cord separation and has had a WBC
count greater than 2 x 104/JJL on multiple occasions in the absence of
evidence of infection.
Physical Findings
Fever
Gingivostomatitis
Serosanguineous fluid oozes from necrotic lesions
Laboratory Results
Flow cytometry shows an absence of CD 18 on myeloid cells.
Discussion
Leukocyte adhesion deficiency type I (LAD 1) results from failure to
produce CD18, which is the common ~2 subunit of the ~2 integrins
(LFA-1 family). ~2 integrins are involved in leukocyte diapedesis,
but also serve as receptors for C3b to promote opsonization and
phagocytosis. Binding of ~2 integrins to their ICAM ligands induces
intracellular signaling that is important for a host of other cellular
functions including cytokine production, cytotoxicity, apoptosis, and
proliferation. Microbial infections can be handled temporarily with
antibiotics in these patients, but the long-term solution is bone
marrow transplantation.
Clinical Cases C- 3
Clinical Cases
Immunology
History
A 4-year-old boy is brought to the pediatrician because of severe
recurrent subcutaneous abscesses. His mother denies any history of
eczema or typical childhood illnesses such as chickenpox. The child
has had all of his immunizations.
Physical Findings
With the exception of abscesses, no abnormalities are found.
Laboratory Results
Immunology
Discussion
Chronic granulomatous disease (CGD) is a primary immunodeficiency
disease which results from an inability to produce any one of several
subunits of the enzyme NADPH oxidase. Because of this, the patient
is genetically unable to produce the oxygen radica ls that are a
key component of the phagocyte's ability for intracellular killing
of microbes. In many cases, however, the hydrogen peroxide that
is produced as a metabolic by-product of aerobic respiration by
microbes can be used against them, as the substrate for the second
oxygen- dependent killing mechanism involving myeloperoxidase.
The problem with recurrent infections in these patients occurs then,
when they are infected with catalase-positive organisms that destroy
t heir own metabolic product (hydrogen peroxide) . In such cases, both
of the oxygen-dependent killing mechanisms are inactive and, left
alone, the remaining content s of t he lysosomes are never enough to
accomplish microbial killing .
MPO produces
HOCI from H, O.,
and c1- - -
Cytotoxic HOCI
ki lls the ingested
Cl-
! Ingested\
Ingested
' coc.cus I
COCW5
bacterium
Catalase destroys
H,o,, inhibiting the
production of HOCI,
and the ingested
bacterium lives
Clinical Cases C- 5
Immunology
Clinical Cases
Incubate phagocytes
in the presence of
nitroblue tetrazolium
dye
Normal
Formazan positive
(purple- blue)
Abnormal
Formazan negative
(yellow)
Clinical Cases C- 6
Immunology
Cl inical Cases
History
A 12-month-old male infant is referred to a specialist for fai lure to
thrive. He has developed numerous upper and lower respiratory tract
infections and protracted diarrhea.
Physical Findings
Height and weight are at the 30th percentile for age.
Laboratory Results
Neutropenia
Thrombocytopenia
Anemia
Mitogen proliferation is normal
Low serum concentrations of IgG and IgA and elevated levels
of I gM
Flow cytometry for CD40L on T cells is negative
Discussion
Hyper-lgM syndrome is a family of disorders affecting the ability of
B lymphocytes to isotype switch. The most common form, X-linked
hyper-lgM syndrome, results from failure of expression of CD40L on
Th cells. As a resu lt, these patients suffer deficiencies of IgG, IgA,
and IgE, and extreme elevation of levels of IgM (sometimes reaching
2,000 mg/dL when normal is 45-250 mg/dL). Large numbers of
IgM-producing plasma cells will be found in the bloodstream as
well as autoantibodies to erythrocytes, neutrophils, and platelets.
Patients will suffer recurrent gastrointestinal and pulmonary
infections because IgA is the most important protector of the
mucosal surfaces, and Pneumocystis pneumonia is common. B cell
responses to T cell independent antigens will be normal.
Clinical Consequences
Without bone marrow transplantation, this disease is often fata l by
age 25. Recombinant granulocyte-colony stimulating factor (G-CSF)
to combat chronic neutropenia, antimicrobial therapy for infections,
immunosuppressants for autoimmune disorders, and intravenous
immunoglobulin are all used as req uired.
Clinical Cases C- 7
Immunology
Clinical Cases
History
A 42-year-old male sees a urologist, complaining that he has
occasional cola-colored urine some mornings. He says the incidents
have been increasing in frequency over the past several years, as has
his sensation of chronic fatigue.
Physical Findings
Skin pallor
Fever 39 C
Gingival bleeding
Skin ecchymoses
Laboratory Results
Urinalysis: Hemoglobinuria and hemosiderinuria
Blood: Hemoglobinemia and haptoglobinemia, increased lactate
dehydrogenase, reticulocyte count, and bilirubin
Direct antiglobulin test was negative
Acidified serum lysis test was positive
Flow cytometry for CDSS was negative
Discussion
This disease results from an acquired defect in myeloid stem cells.
When platelets, leukocytes, and erythrocytes lose the ability to
express glycosylphosphatidylinositol (GPI) on their membranes,
they lose the ability to express decay accelerating factor (DAF; C3
convertase inhibitor; CD 55) and membrane inhibitor of reactive
lysis (MIRL; CS convertase inhibitor; CD59). These two membrane
molecules are essential protection to prevent the accidental binding
of complement components and avoid membrane lysis. Because
these normal blood cells have no protection from complementmediated lysis, at night, when shallow breathing can cause a
respiratory acidosis, complement activation will occur and produce
the paroxysmal micturit ion of hemoglobin.
Clinical Consequences
These patients typically die within 10 years of diagnosis due to
thrombosis. The paroxysmal release of platelet contents into the
blood due to complement lysis causes hepatic, portal, and cerebral
thromboses. I n the absence of bone marrow transplantation, iron
deficiency anemia will persist, and 10% of patients will develop acute
myelogenous leukemia.
Clinical Cases C- 8
Immunology
Clinical Cases
History
A 4-year-old boy is referred to a specialist for evaluation of
persistent nonmalignant lymphadenopathy and splenomegaly of 9
months' duration . More recently, the child has developed idiopathic
thrombocytopenic purpura.
Physical Findings
Lymphadenopathy of cervical, axillary, and femoral lymph
node chains
Petechiae
Pallor
Icterus
Laboratory Results
Elevated dou ble-negative (TCR+, CD3+, CD4-, CDS-) T lymphocytes
and relative lymphocytosis
Discussion
Mutations of the FAS gene have been identified as the cause of 74%
of all cases of autoimmune lymphoproliferative syndrome, although
other causes include genetic defects in the Fasl gene, the caspase
10 gene, and the caspase 8 gene. These disorders result in the
fai lure of normal apoptosis that should fol low lymphocyte activation.
This causes inappropriate persistence and accumulation of
autoreactive lymphocytes that are double-negative, and increased
ris k of lymphoma. Some studies suggest that these are oligoclonal
Tc cells t hat have subsequent ly lost CDS expression.
Clinical Consequences
Most patients will have a normal life span, but life-threatening
cytopenias may be chronic and refractory. Splenectomy is oft en
necessary, with the associated risk of asplenic sepsis.
Clinical Cases C- 9
Clinical Cases
Immunology
History
A 10-year-old boy is referred to a specialist because of chronic
sinusitis and postnasal drip. Since the age of 6 months, he has been
plagued with otitis media, bronchitis, and bacterial pneumonia.
Physical Findings
Laboratory Results
Fluorescence-activated cell sorter (FACS) analysis of peripheral blood
demonstrates an absence of MHC class 1 expression.
Discussion
MHC class 1 deficiency can lead to a diverse disease spectrum,
but in some patients defects in TAP1 or TAP2 genes have involved
the generation of a premature STOP codon. In the absence of an
ability to generate a.~ CDS+ T cells, there is an expansion of NK
and y8 T cells which may be involved in the pathogenesis of the
granulomatous skin lesions. These cells also may account for the
absence of severe viral infections.
Clinical Consequences
Patients often die of chronic lung damage and bronchiectasis due to
the recurrent bacterial infections. For this reason, therapy is centered
on early diagnosis and aggressive treatment of respiratory infections.
Immunology
Cl inical Cases
History
A 6-month-old female is referred to an immune specialist following a
diagnosis of Pneumocystis pneumonia. She was treated successfully
with pentamidine, but a severe combined immunodeficiency was
suspected and immunological studies were undertaken.
Physical Findings
No abnormalities found.
laboratory Results
Complete blood count: 20,000 WBC/IJL; 82% neutrophils, 10%
lymphocytes, 6% monocytes, 2% eosinophils
Immunoglobulin analysis: IgG 96 mg/dl, IgA 6 mg/dL, IgM 30
mg/dL
Absent in vitro response to tetanus toxoid despite normal
vaccination history
T cells responsive to allogeneic B cells in culture
Lymphocytes treated with fluorescent-labeled antibodies to HLADQ and HLA-DR did not fl uoresce
Discussion
MHC class 2 deficiency is inherited as an autosomal recessive trait.
Health problems begin in infancy. These patients are deficient in
CD4 Th cells and have moderate to severe hypogammaglobinemia.
In contrast to bare lymphocyte syndrome type 1 (MHC class 1
deficiency), these patients have normal numbers of CDS+ Tc cells.
The deficiency results from defects in the transcription factors
required to regulate MHC class 2 molecule expression.
Clinical Consequences
Therapy for patients with bare lymphocyte syndrome involves bone
marrow transplantation. Because the patient's cells have no MHC
class 2 molecules, there will be no graft versus host disease, and
engraftment is normally curative.
Clinical Cases C- 11
Immunology
Secreted By
Monocytes, macrophages,
B cells, dendriti c cells,
endothelial cells, others
Interleukin
(IL)-1
IL- 2
IL-3
I T cells
I T cells
IL- 5
Monocytes, macrophages,
Th2 cells, bone marrow
stromal cells
IL- 6
IL- 8
Th 2 cells
IL-4
IL-7
Th cells
B cells
NK cells
Enhances activity
Endothelial cells
Macrophages and
neutrophils
Chemotactically attracts
Hepatocytes
Hypothalamus
In duces fever
Antigen-primed Th and
Tc, NK cel ls, B cells
Hematopoietic cells
(myeloid)
T cells
Th 2 differentiation, proliferation
Activated B cells
Activated B cells
Eosinophil s
Proliferating B cells
Hepatocytes
Macrophages, endothelial
cells
I Macrophages
IL- 11
I Bone manrow
IL- 17
IL-35
I Treg
IL- 13
Interferon-a
(type I)
I
I Promotes megakaryocyte differentiation
ThO, Th l , activated Tc
NK cells
Stimulates proliferation
I B cells
Fibroblasts, endothelial
cells, macrophages
I
IThl, Th2, Th17
Leukocytes
Neutrophi Is
IL- 10
IL- 12
Activity
Uninfected cells
I
I Inhibits Thl, Th2, Th17; stimulates Treg
Inhibits v iral replication and increases
MHC 1 and 2 expression
(continued)
AppendiX A-1
Immunology
(continued)
Secreted By
Target Cell/Tissue
Activity
lnterferon -IJ
(type I )
Fibroblasts
Uninfected cells
lnterferon -y
(type II)
Macrophages
Proliferating B cells
Th2 cells
Inhibits proliferation
Transforming
growth factor-J3
Tumor necrosi s
factor-a
Tumor necrosis
factor-IJ
( lymphotoxin)
I Platelets, macrophages,
lymphocytes, mast cells
Macrophages and NK cells
Th1 and Tc
I Proliferating B cells
Tumor cells
Inflammatory cells
Tumor cells
Macrophages and
neutrophils
Granulocyte
col ony-stimulating
factor ( G-CSF)
Bone marrow
granul ocyte precursors
Bone marrow
granul ocyte and
macrophage
precursors
Filgrastim (G-CSF)
Interferon-a
lnterferon-IJ
lnterferon-y
Oprel vekin ( IL- 11)
'c'
AppendiX A- 2
Immunology
Key
ADCC:
MHC:
APC:
antigen-presenting cell
NK:
natural killer
CALLA:
Tc:
cytotoxic T cell
CD:
cluster of differentiation
TCR:
T cell receptor
LFA:
Th:
T helper
LPS:
lipopolysaccharide
Known Functions
C02 (LFA- 2)
CD3
CD4
CDS
COlO (CALLA)
CD14
(LPS receptor)
CD18
Leukocytes
CD19
6 cells
CD20
Matu re B cells
CD25
CD28
T cells
CD34
CD40
CD45 (leukocyte
common antigen)
Hematopoietic cells
CD54 (ICAM- 1)
CDSS
(decay-accelerating
factor, OAF)
Ubiquitous
CD 56
CDSB (LFA-3)
I NK cells
I Ubiquitous
CD59 (membrane
inhibitor of reactive
lysis; MIRL)
Ubiquitous
coso (87)
CD152 (CTLA- 4)
I
I Acti vated T cells
I Not known
I Binds C02; adhesion
Binds C9; inhibits complement m embrane attack
complex
AppendiX A-3
Immunology
Selectins
addressins
Integrins
Immunoglobulin
superfamily
cellu lar adhesion
molecules {!CAMs)
'c'
Function
Bind carbohydrates;
initial binding
leukocyte-endothelia
Bind to L-selectin
and initiate leukocyte
endothelial interaction
Bind to cell-adhesion
molecu les and
extracellular matrix;
strong adhesion
Name
Tissue Distribution
Ligand
L-selectin
Leukocytes
Addressins
P-selectin
Endothelium and
platelets
Addressins
E-selectin
Activated endothelium
Addressins
CD34
Endothelial venules
L-selectin
Gly-Cam-1
High endothelial
venules
L-selectin
MAdCAM-1
Mucosal lymphoid
t issue venules
L-selectin
LFA-1
Monocytes, T cells,
macrophages,
neutrophils, dendrit ic
cells
!CAMs
CR3
Neutrophils,
monocytes,
macrophages
ICAM - 1, iC3b,
fibrinogen
CR4
Dendritic cells,
macrophages,
neutrophils
iC3b
CD2
T cells
LFA-3
ICAM -1
Activated vessels,
lymphocytes,
dendritic cells
LFA-1 , CR3
ICAM -2
Resting vessels,
dendritic cells
LFA- 1
ICAM -3
Lymphocytes
LFA-1
LFA-3
Lymphocytes,
antigen -presenting
cells
CD2
VCAM-1
Activated endothelium
VLA-4
AppendiX A-4
Immunology
.:
.:
..
:
Protective Mechanism
Extracellular
bacte ria
All
Ab or C enhance phagocytosis
or block toxin binding
Gram-positive,
extracellular
bacte ria
Streptococcus
pyogenes
Catalase- positive
bacteria
All
Serious in CGD
patients
Staphylococcus
aureus
Exotoxins act as
superantigens
Encapsulated
bacteria
Hyaluronic
acid capsule is
non immunogenic
Protein A binds Fe
o f lgG and inhibits
opson ization
Exotoxins act as
superantigens,
non suppurative
sequelae:
types II and III
hypersensitivit ies
IgA protease
producers
Streptococcus
pneumoniae,
Haemophilus
influenzae,
Neisseria
meningitidis,
and Neisseria
gonorrhoeae
Destroy lgA
Abscess formation
Coagulasepositive bacteria
Staphylococcus
aureus and
Yersinia pestis
Inhibit phagocytosis
Abscess formation
Gram-negative
extracellular
bacteria
All
Ab or C enhance phagocytosis
or block toxin binding
Neisseria
gonorrhoeae
MAC lyses
Antigenic variation
of pill and outer
mem brane proteins
Neisseria
meningitidis
MAC lyses
Type B sialic
acid capsule is
non immunogenic
Pseudomonas
Intracellular
bacteria
Borrelia burgdorferi
Immune complexes
cause rash, arthritis,
neurologic symptoms
Treponema
pall/dum
Indigestible, chronic
organism promotes
granuloma formation
(gummas)
All
Mycobacterium
tuberculosis
Sulfatides inhibit
phagolysosome
formation
Granuloma formation
is CMImediated
Mycobacterium
leprae
Th 2 stimulation
results in
lepromatous form
Nerve damage in
tuberculoid form is
DTHmediated
(continued)
AppendiX A-5
Immunology
Intracellular
bacteria
(continued)
Viruses
Pathogen
(continu ed)
...
Listeria
monocytogenes
DTH and Tc
Chlamydia
trachoma tis
DTH and Tc
Naked capsid
(all)
Rhinovirus
See above
Antigen ic drift
Adenovirus
See above
Decreases MHC 1
expression
Syncytia l v iruses
(herpesviridae,
pa ramyxoviridae,
HIV)
CMI is essential
Enveloped (all )
Hepatit is C
Hepat it is B
All herpesviridae
Nuclear membrane
envelope is
non immu nogenic
Herpes simplex 1
and 2
Cytomegalovirus
Genera lized
immunosu ppression;
-!. MHC 1 and 2
expression; produces
chemokine receptor and
MHC 1 homolog ues
Epstein-Ba rr
virus
Genera lized
immunosu ppression;
produces molecule
homologous to IL-10
(shuts down Th1}
Paramyxoviruses
Generalized
immunosuppression
Hemolysin disrupts
phagosome membrane,
allows escape into
cytoplasm
Scarring of fallopian
tubes is DTH-mediated
-13
Immune complexes
cause vasculitis
(continued)
'c'
AppendiX A-6
Immunology
Viruses
( continued)
Prion
Fungi
Extracellular
protozoa
Intracellular
protozoa
Helminth
parasites
.:
(continued)
..
Protective Mechanism
Human
immunodeficiency
v ir us
Ru beola
Influenza
I No immune response
I None
Most
Phagocytosis by PM Ns and
macrophages; Abs not
protective
Cryptococcus
neoformans
As above
Histoplasma
capsufatum
All
Trypanosoma
orucei
rhodesiense and
gambiense
Antigenic variation
o f variable surface
glycoprotein
Entamoeba
histofytica
All
Plasmodium spp.
Trypanosoma
cruzi
Amastigotes killed by
CMI; trypomastigotes
(extracellular) killed by
Ab and C
Leishmania spp.
All
ADCC-mediated by
eosinophils and macrophages
I None
Ca lcifying lesions due
to indigestibility of
cell-wall carbohydrates
Inhibits Th l; stimulates
Th 2, capsule protects
against phagocytosis
Granulomas and
calcifications
Maturational stages
change antigens;
antigenic variation
Immunosuppression
secondary to lymphatic
obstruction
Schistosoma spp.
ADCC-mediated by
eosinophils and macrophages
AppendiX A- 7
Cell Type
Acellular
No DNA
or RNA;
infectious
protein
Acellular
Prokaryotic
cells
Use host
organelles;
obligate
intracellular
parasites
DNA or RNA
Replicates in
Deposits
extracellularly host cells
Eukaryotic cells
Mono and
poly-cistronic
mRNA
Monocistronic mRNA
Exons,
no introns
~USMLEe
Key Concepts
Replicatio n
Alteration of
configuration
of normal
cellular
proteins
Make and
assemble
viral
components
Cellular
Membrane
None
Some are
enveloped,
but without
membrane
function
No sterols
except
Mycoplasma,
which has
cholesterol
Ergosterol is Sterols
major sterol; such as
synthesis
cholesterol
targeted by
nystatin and
imidazoles
Cell Wall
None
No cell wall
Peptidoglycan;
synthesis
targ eted by
penicillin and
cephalosporins
Complex
No cell wall
carbohydrate
cell wall
(chitin,
glucan,
mannan)
Chapter 1- 1
Microbiology
Normal Flora
'Y Table 1- 2.0 Normal Flora
location
Important Organisms
Skin
Staphylococcus epidermidis
Staphylococcus aureus,
Corynebacterium (d iphtheroids),
various streptococci, anaerobes,
yeasts
Nose
Staphylococcus aureus
S. epidermidis, Corynebacterium
(d iphtheroids), various streptococci
Oropharynx
Gingival Crevices
Colon
Clostridium, Bifidobacterium,
Eubacterium, Fusobacterium,
Lactobacillus, various anaerobic
gram -negative rods, Streptococcus
faecalis, and other streptococci
Vagina
.~ , Clinical
-'V 1('- Application - - - - - - - - - - - - - - Carrier
A person infect ed with a pathogen but withou t overt
disease.
Bacteremia
Presence of bacteria in the bloodstream without
clinical signs.
Septicemia
Bacteria multiplying in bloodstream with clinical
symptoms.
Chapter 1- 2
Microbiology
3.1 Adherence
The first step for microbes to initiate infection of host tissues is
adherence. Many varieties of microbial adherence mechanisms exist.
Viruses
Parasites
Gram negatives
Pili (fimbriae)
Escherichia coli
Type 1 pili
Man nose
P and S pili
Galactose
Unknown
Bordetella pertussis
Integrin?
Gram positives
Lipoteichoic acid
Fibronectin
Streptococcus pyogenes
M protein
Fibrinogen
Staphylococcus epidermidis
and Streptococcus mutans
Biofilm
Chlamydia
N-acetylglucosamine
Mycoplasma
Protein P1
Sialic acid
Hemagglutinin
Sialic acid
Human immunodeficiency
virus (HIV)
Gp120
Epstein-Barr virus
Envelope glycoproteins
CD21 (B lymphocytes)
Rabies virus
Envelope glycoproteins
Acetylcholi ne receptor
Rh inovirus
Capsid proteins
ICAM-1
Plasmodium falciparum
PfEMPl (Plasmodium
falciparum erythrocyte
membrane protein)
Erythrocyte binding antigen
ICAM-1
Glycophorins
P. vivax
Duffy-binding protein
Duffy antigen
Chapter 1-3
Microbiology
3.2.2 Capsules
Also known as slime layers, or glycocalyces (singular glycocalyx),
capsules are gelatinous, non-adherent secretions of many
extracellular microbes that protect them from phagocytosis. These
slippery surface coatings act by making it difficult for phagocytic
cells to engulf the invading organism.
3.2.3 Anti-opsonins
Opsonization is the coating of a particle with IgG and/or complement
component C3b to enhance the speed of phagocytosis. Microbes
that can inactivate this process are at a selective advantage to be
protected from rapid phagocytosis.
Streptococcus pneumoniae
Klebsiella pneumoniae
Haemophilus influenzae type B
Pseudomonas aeruginosa
Neisseria meningitidis
Salmonella spp.
Cryptococcus neoformans
3.2.4 Pili
The pili of Neisseria gonorrhoeae are anti -phagocytic, although this is
not true of all pili.
Chapter 1-4
Microbiology
Haemophilus influenzae
Streptococcus pneumoniae
Neisseria gonorrhoeae
Neisseria meningitidis
Chapter 1- 5
Microbiology
3.5.3 Hypersensitivities
~Table
1-3.5 Hypersensitivities
Manifestation
Type 1
Allergy
Type 2
Rheumatic fever
Type 3
Type 4
3.6 Toxins
Toxins are poisonous substances produced by living cells. They can be
part of the microbial anatomy or be released by microbial secretion.
Chapter 1- 6
Microbiology
J~Application
Clinical
--------------1
--'Y
p...... ..
Factor XII
.... =. .. .
C3
Monocyte
e C3a
Complement
'-----~~~/.
Cytokines and
cytokinelike
mediators
Endothelium
Secondary
anti-inflammatory
mediators
Systemic
effects
Microvascular
thrombosis (DJC)
Fever, diminished
myocardial contractility,
metabolic abnormalities
Immunosuppression
MULTJORGAN FAILURE
Chapter 1-7
Microbiology
cAMP Inducers
Organism
Toxin
Mechanism of Action
Role in Disease
C. diphtheriae
Diphtheria toxin
ADP-ribosylates eEF-2
1o targets: heart,
nerves, epithelium
Inhibits eukaryotic
protein synthesis
P. aeruginosa
Exotoxin A
ADP-ribosylates eEF-2
1o target: liver
Inhibits eukaryotic
protein synthesis
S. dysenteriae
Shiga toxin
Inhibits eukaryotic
protein synthesis
EHEC E. coli
Verotoxin
Inhibits eukaryotic
protein synthesis
ETEC E. coli
Adenylate cyclase
ADP ribosylates GTP
bp
V. cholerae
Cholera toxin
Adenylate cyclase
ADP ribosylates GTP
bp
Profuse, watery
diarrhea
B. anthracis
Anthrax toxin
EF-edema factor
LF-Iethal factor
PA-protective antigen
.J.
B. pertussis
Pertussis toxin
ADP ribosylates Gi
Edema, histamine
sensitization,
lymphocytosis,
islet activation
t cAMP
Cytolysins
Neurotox ins
Superantigens
Phagocytosis,
causes edema and
kills cells
C. perfringens
toxin
Lecithinase
Damages cell
mem branes,
myonecrosis
S. aureus
toxin
Intercalates, forming
pores
Cell membrane
becomes leaky
C. tetani
Tetanus toxin
Blocks release of
inhibitory transmitters
glycine and GABA
Inhibits
neurotransmission in
inhibitory synapses,
rigid paralysis
C. botulinum
Blocks release of
acetylcholine
Inhibits cholinergic
synapses, naccid
paralysis
S. aureus
(gram -positive)
TSST- 1
S. pyogenes
(gram-positive)
Exotoxin A, C
Similar to TSST- 1
As with TSST-1
Chapter 1-8
RNA Reprcation
(t)MA-d.-ndont
OMA polym. .se)
(~d.-rodent
~ polymerase}
Jl(""'\
AHA Aeplialiw
DNA .,.
"""""' t
Transcription
"',..'"
Translation
..
and disinfection.
(DHA-depen6tftt
' - . . IUCA polpnorllse)
Reverse Transcription
Ol'flftllml)
MocllkloiiOrl of
(IUCA-dopen6ent
DNA pofVrneruo)
Pott-trll IC'WWollll
moclllclltloll
(MoboJ S' ellds
of 'Wirll i'niUIA
Pof1dlfttlaaotl
Imino .ads
Culllllg 1 ..... p IPtlcM
1111102 Of-
or:r-...
Chapter 2-1
Microbiology
Connection to
Biochemistry
Polymerases are enzymes that synthesize nucleic acid strands. They are named using the
following convention:
DNA
-depeoldent
DN
(product}
R
(product)
s- ~~~~~(~----~~----~- -~
I I
3- ..,;,;.....;.;,;,w.;;,.;.;..;-...-~....~...._ _ _ _ _ -s
-~
3-
~:,..,....,...,....,.._ _~------...,;;,;,j-
-s
Chapter 2- 2
Microbiology
2.1
Chromosome
2.2 Plasmids
Chapter 2- 3
Microbiology
3.1
Homologous Recombination
'
Chapter 2-4
Microbiology
sites up
-----l
Chapter 2- 5
Microbiology
Gene Transfer
E. coli pap ami'
4.1
Overview
~I
lin. 1
~ r..
.sm.. uatbe
or
2. ~alloll
or
a. Tnnsdudton
(any one of tflese tlfte ptp<IIIOI!OIIRS
NO!t-CUI'Ipet~ tOUOfl
~non-.ocapsul ed)
adadam
2 Comp~ut C*ll
now atJia lo lllnd
tr.. DNA
~ DNA
a.cta.t.l
Nowsmoodl
~ana ps~~lated)
a<tat1um
Cl""'-...
fv \6{
Hom~s
realtl'ltJinabon
D~=~
cbroMo-.ma
DNA uptab
,.eM otCA
binds to cell
Cartain
gro~
CDncllioiiS
no )
....,
Chapter 2-6
Microbiology
4.2.2 Conjugation
Conjugation is gene transfer from one cell to another using direct
cell-to-cell contact. It is analogous to sexual exchange in eukaryotes
in that it requires a male (donor) cell and a female (recipient) cell.
The "gender" of a bacterium is determined by its possession of a
fertility factor.
Fertility Factors These may exist as plasmids or may become
integrat ed into chromosomal DNA by a variety of mechanisms.
In eit her case, they may possess the fol lowing regions :
tra operon : A region including many genes, all of which are
necessary for the process of conjugation. If a cell has a tra operon,
it becomes a donor in the exchange process. A cell without a tra
operon is phenotypically a recipient.
The genes encode:
Sex pili
Enzymes to direct conjugal DNA transfer
Products to stabilize mating pairs
oriT (origin of transfer}: The place where a break is made in
one strand of the DNA so that it can begin to be unraveled into
the recipient cell.
oriV (origin of vegetative replication}: The place where a
replication fork is formed when the plasmid replicates its DNA.
Plasmids replicate autonomously and are not under chromosomal
control.
Inte gration site: A region of genetic homology with the
chromosome (a common restriction endonuclease site) that may
allow the plasmid to
become integrated into
oeamblnllllon "-'s
the chromosome by site1D ~ . . Hlrall
specific recombination .
Not all fertility factors
7
8
have integration sites,
but those capable of
chromosomal integration
must have them .
5
10
----
U.Mt.,._
Fertility
11
fiiCtor
...,._
........
orIV
Qrl9lild
12
14
\ rn
origin ol
~er
!~~Gins
oiiiiSilllhl
- ibl'- nglan llo ...
'ri
~
Chapter 2- 7
Microbiology
Bacterial Mating Types Three mating types for bacterial cells exist:
1. F" cells: These cells entirely lack the fertility factor DNA and
always serve as recipients in any conjugal cross.
tra
0
F' (recipient)
F (donO!")
tra
Hfr {donor)
High-~uency
recombination
Chapter 2- 8
Microbiology
f> cell
P"ceil
Pilus
lhlnster of p&asmld
F- ceil now
has pilus
f+ cell
(undlanoed)
Chapter 2-9
Microbiology
The Hfr and F- Cross A second conjugal cross involves the Hfr
cell as the donor and the F- cell as the recipient. In this case,
chromosomal genes are transferred from donor to recipient.
The Hfr Chromosome: To understand the mechanism of this
cross, it is necessary to review the process by which the Hfr
chromosome arose. When fertility factor plasmids have integration
site regions in common with a site on the bacterial chromosome,
site-specific recombination can cause the two circles of DNA to
become stably incorporated. Once this occurs, the two sides of
the integration site-the original sticky ends-become the f lanking
sequences dividing DNA of plasmid origin from that of DNA of
chromosomal origin. The sequence of DNA transfer in the cross,
however, now follows the normal rule: oriT begins the process,
followed in sequence first by plasmid origin genes and then
chromosomal ones.
,....y,_
Slte-speclllc
recomlllnabon
Hft ch,.,mosome
e..ct.rial dvomosome
tra
6 '
11M 100
Therearevenlly
...,.rallllooosud
bdrilll'l"'es
'-= 1,500
bK500
bloc 1,000
Chapter 2-10
Microbiology
Chapter 2- 11
Microbiology
0
..
H& cell
(und>arqed)
4.2.3 Transduction
Transduction is defined as the transfer of DNA from one bacterium to
another using a phage as a vector. There are two forms of transduction,
both of which may occur as an error of the phage life cycle.
Generalized Transduction
The Lytic Phage Life Cycle Bacterial viruses may exhibit two
types of life cycles: lytic (virulent) or lysogenic (temperate) . The lytic
phage life cycle runs a rapid course:
Attachment to the bacterial cell and injection of phage DNA
Destruction of bacterial DNA and use of cellular machinery to
produce phage proteins
Replication of phage genome and assembly of phage particles
Release of phage particles by cell lysis
The Accident of Generalized Transduction Sometimes, as an
accident of this life cycle, a piece of bacterial DNA rather than a viral
genomic copy gets loaded into a developing phage head . This creates
a generalized transducing phage: a virus particle that is incapable of
repeating its life cycle, but is still capable of delivering and injecting its
DNA into a new bacterial cell. The injection of this linear piece of DNA
picked up accidentally from the first infected cell must now undergo
homologous recombination if it is to be saved inside that cell.
Chapter 2-12
Microbiology
._llc.atlotl, tramcrlpdon
anil trallSiatlon ol ~Jh.ag bNA
to corwert al to pU!Je fadOfl'
;c
~ty
of,_ pha9es
(morphOIJMesls)
Chapter 2-13
Microbiology
Specialized Transduction
The Temperate Phage Life Cycle A bacterial viru s that undergoes
a period of stable associat ion wit h the bacterial genome is said t o be
a temperate or lysogenic phage.
Integration : The first step of the temperate phage life cycle
again involves attachment to the bacterial cell and injection of
DNA. Next, however:
The inj ected DNA circularizes and integrat es into t he
chromo some at a specific integration site by site-specific
recombination.
I f a repressor protein encoded in the phage genome is
produced rap idly enough, the phage remains stably integrated
into the chromosome, and the viral DNA is under the replicative
control of the bacterial chromosome : Binary fission of one
lysogenized cell produces identical lysogenized progeny.
1 DNA is
InJeCt~
2 Lambda rep~
Inhibits active phage
produet.IOn
Important Concept
Chapter 2- 14
Microbiology
lt
Chapter 2- 15
Microbiology
Chapter 2- 16
Microbiology
Competency
Required
Comments
Transformation
Free DNA
Any
Yes, homologous
Yes
Sensitive to
extracellular
nucleases
f+ X f "
Conjugation
Ce II -to-cell
transfer of
plasmid DNA
Fertility factor
No, plasmids
are circles and
intrinsically stable
No
Gender change in
recipient
Hfr X F"
Conjugation
Ce II-to-cell
transfer of
chromosomal
DNA
Chromosomal,
nearest to oriT
Yes, homologous
No
No gender change
in recipient
Generalized
Transduction
Accident of
packaging in the
lytic virus Iife
cycle
Any
Yes, homologous
No
Requires previous
lytic phage
infection
Specialized
Transduction
Error of excision
in a lysogenic
virus life cycle
Chromosomal,
near to
integration site
of phage
Yes, homologous
No
Requires previous
lysogenic phage
infection
Chapter 2 -17
Microbiology
Drug Resistance
The mechanisms of horizontal genetic exchange discussed above are
crucial in the evolution of drug-resistant strains of bacteria that are
now capable of surviving many of our first-line antibiotic therapies.
Bacteria will always be able to evolve resistance mechanisms more
rapidly than humans can develop new drugs, so global understanding
of these emerging resistances is critical. In the case of vancomycinresistant Staphylococcus aureus (VRSA) and carbapenem-resistant
Klebsiella pneumoniae (CRKP), therapeutic options are extremely
limited, and concern that these resistances may spread globally
throughout microorganisms is significant. Microbial drug resistances
may be broadly categorized into three forms: intrinsic, chromosomemediated, and plasmid-mediated.
5.1
Chapter 2-18
Microbiology
Penicillin,
cephalosporins
enzyme
( beta-lactllmase)
Tetracyclines,
sulfonamides
erayrne
(el'llux alldblotlc out or cetl)
Aminoglycosides,
chloramphenicol
enzyme
(rnocltles antibiotic)
P lasmid
Mac:rolides,
lincosarnides
erayrne
(rnelhylates rlbo5Mie)
Vancomyc in
ligase
(produces oel wall ~
ltlat terminate In C>-Aia-0-t..ae.
wllldl wll not bind to di"UQ)
Tetracydine
enzyme
(mutates rlbo~mal binding slta)
Chapter 2- 19
Microbiology
I I
-........
l
I I 5
2
Resi.ur-
C>
lltte 8
dJ
~
C...-.tte A
~t..lstanoe
0..0111
orp' - ld
Cautt e
ezrsette A
Ch apter 2- 20
Microbiology
CGATACGC
ds DNA Jndinort
Transp
Nse
Jndinort
~~
gene
~....
CGCATAGC
GCTATGCG
lr
---
GTCGCAGAG
CAGCGTCTC
GCGTATCG
CGATACGC GTCGCAGAG
gene
n!pYtS.
CAGCGTCTC
CGCATAGC
GTCGCAGAG
Direa
repeat
CAGCGTCTC
repeats
GCTATOCG
GCGTATCG
Jndi....n Transp
repeit?'
gene
CGCATAGC
CGATACGC GTCGCAGAG
e In,a;......,. Direct
reii&u'* repeat*
GCTATGCG CAGCGTCTC
Chapter 2- 21
Microbiology
Key:
ern ClllorampflenkiOI
Sl'l'l ~onrycln
Su SulfonamiM
~ Am~n
ICI'n
Nm
Tn
IS
llTI'
Kanamycin
,._,ydn
ll'a~SOC'I
IJ!sertlofl Sequenoe
Donor
Re~t
6)
Donor
Tnlnsconjugant
<a
Chapter 2-22
Microbiology
Streptococcus pneumoniae
Conjugation
Most r esistances
Staphylococcus aureus
Vancomycin resistance
Conjugation using
non-conjugative plasmids
via mobilization
Neisseria gonorrhoeae
Most resistances
Transduction
Staphylococcus aureus
Chapter 2-23
Microbiology
Ten..,late to
read <:Wg A
Template to
read drug 8
No growth Of'
growth inhibited
Bacteria) Gral..-th
( patient's isolate not inhilited)
Chapter 2- 24
Microbiology
............
-IDirlllllR~
- I M M IC.
'
N BC
~
~~
,)l :.J
_.,'-S-
Chapter 2- 25
Micro biology
Jy--Clinical
Application
t
-1
Enveloped viruses
surrounded with a
membrane captured
from host cells are
easily inactivated with
membrane-damaging
agents.
Chapter 2- 26
Microbiology
Chapters 1-2
Review Questions
1. A 28-year-old Peace Corps volunteer in Haiti suddenly develops fever, abdominal cramping,
and voluminous, watery diarrhea. On physical exam she is tachycardic and has dry mucous
membranes, decreased skin turgor, sunken eyes, and flat veins. Which of the following
describes the mechanism of action of the toxin of the most likely causal bacterium?
A.
B.
C.
D.
E.
2 . A one-year-old boy is brought to the emergency department because of a runny nose, lowgrade fever, and a cough that is becoming increasingly more violent. He now appears cyanotic
and his coughs are followed with inspiratory stridor. His parents confess that he is not up
to date on his vaccinations because they do not have access to medical care. Which of the
following best describes the mechanism of action of the toxin produced by the most likely
causal agent?
A.
B.
C.
D.
E.
3. A 60-year-old male has been in the hospital recovering from coronary artery bypass surgery.
The day after his Foley catheter is removed, he begins to complain of dysuria, frequency, and
urgency. Urine analysis reveals elevated leukocytes and numerous gram-negative rods. Which
of the following is the most important pathogenic mechanism of the most likely causal agent?
A.
B.
C.
D.
E.
Biofilm
Capsule
Endotoxin
Exotoxin
Pili
4. An 80-year-old female is being treated for a fractured hip when she develops a fever
and elevated WBC count. Blood and urine cultures are sent and she is started on empiric
antibiotics. A chest x-ray is also obtained, which is clear. She quickly becomes tachycardic,
hypotensive, anuric, tachypneic, and confused. Blood and urine cultures return positive for E.
coli. Which of the following is most directly involved in the patient's hypotension?
A.
B.
C.
D.
E.
Bacterial lipopolysaccharide
Interleukin-1
Mast cell degranulation
Nitric oxide
Tumor necrosis factor
Chapter 2 - 27
Review Questions
Microbiology
Chapters 1-2
5. A 20-year-old college student was seen at the student health clinic with complaints of vaginal
irritation and discharge. Speculum examination of the introitus revealed patchy erythema and
thick white discharge. Gram-stained smear of the discharge showed gram-negative bacilli
and gram-negative diplococci. She said she had unprotected sexual activity. What is the
significance of the Gram-stain smear in this case?
A.
B.
C.
D.
E.
It
It
It
It
It
F+ x F- conjugation
Hfr x F- conjugation
Generalized transduction
Specialized transduction
Transformation
7. Which of the fol lowing mechanisms is the most likely means by which normal f lora
diphtheroids can acquire the ability to cause pseudomembranous pharyngitis?
A.
B.
C.
D.
E.
8. A nursing home resident requires hip replacement surgery after a fall. While receiving a
course of post-operat ive antibiotics, she develops diarrhea . Which of the following treatments
for bedpans should be implemented to destroy the most likely causal agent of her diarrhea?
A.
B.
C.
D.
E.
Alcohol
Chlorox
Formaldehyde
St eam under pressure
Ultraviolet light
Chapter 2- 28
Microbiology
Chapters 1-2
Review Questions
Transfer Vector
Free DNA
F+ donor
Process
Transformation
Conjugation
c.
Chromosome
Hfr donor
Conjugation
D.
E.
Chromosome
Phage
Transduct ion
Plasmid
F. Plasmid
Free DNA
F+ donor
Transformation
Conjugation
G. Plasmid
Hfr donor
Phage
Conjugation
Transduct ion
H. Plasmid
10.
If cell 1 and cell 2 from the figure below were mixed in culture, what would be the most
likely outcome?
Cetll
A.
B.
C.
D.
E.
Cell 2
Chapter 2 - 29
Review Answers
Microbiology
Chapters 1-2
Chapter 2-30
Cytoplasmic
membrane
::r~-11- (penicillin-binding
proteins-PBPs)
from symptomatic,
diagnostic, and
epidemiologic clues.
Chapter 3-1
Chapter 3 Bacteriology
Microbiology
outer
membrane -
protein
---T"-
Cell wall
synthesizing enzymes
( penici !lin-binding -r--'\!.i+1~
proteins- PBPs)
layer
Ribosomes
Inhibition
of nudeic acid
replicaton and
transcription
Bacitracin
Vancomycin
Quinolones
Rifampin
DNA
mRNA
Chapter 3- 2
Microbiology
Chapter 3 Bacteriology
Outer membrane
Cell wall
Peri plasmic
space
Cytoplasmic
(inner, plasma)
membrane
Composition
Polysaccharide gel except
Bacillus anthracis = poly
D-glutamate
Lipopolysaccharide =
endotoxin
Outer-membrane proteins
Porin proteins
Passive t ransport
Thick in
gram +,
thin in gram -
Peptidoglycan, mesh of
N-acetylglucosamine and
N-acetylmuram ic acid
Gram+ on ly
Teichoic acids
Mycolic acids
Gram- on ly
Phospholipid bilayer
Penicillin-binding proteins
(PBPs) = transpeptidases
and carboxypeptidases
Many gram+
and gram -
Only gram-
Both gram +
and gram -
Chapter 3- 3
Microbiology
Chapter 3 Bacteriology
J
Clinical
-v y._ Application
1.2.1 Organisms
Bacillus
Clostridium
1.2.2 Function
One spore
Spore
waii ------++-+-
Normal peptidoglycan
Cortex ------~--
Chapter 3- 4
Chapter 3 Bacteriology
Microbiology
Physiology
2.1
f _
Stationary phase
log phase
(exponential phase)
Death phase
.!!!.
"ii
u
Rapid growth;
bactericidal antibiotics
best here
..
!
~
lag
::J
ell
L - - --
.3
Time
I
I Haemophilus
Chapter 3-5
Chapter 3 Bacteriology
Microbiology
+ 2w
superoxide dismutase
H0
2 2
+ catalase
Important Examples
Obligate aerobes
Require oxygen
Have no fermentation pathways
Generally produce su peroxide
dismutase
Mycobacterium
Pseudomonas
Bacillus
Nocardia
Corynebacterium
Mic roaerophiles
Campylobacter
Helicobacter
Facultative anaerobes
Obligate anaerobes
Actinomyces
Bacteroides
Clostridium
Killed by oxygen
Lack superoxide dismutase
Generally lack cata lase
Are fermenters
Cannot use oxygen as term inal
electron acceptor
Chapter 3- 6
Chapter 3 Bacteriology
Microbiology
Laboratory Techniques
3.1
Medium
Corynebacterium
Enteric bacteria
I
Intestinal pathogens
Legionella
Mycobacterium
Neisseria from normally sterile sites,
Haemophifus
Neisseria from sites w ith normal flora
I
I Charcoal-yeast extract agar (CYE agar): contains cysteine and iron
LowensteinJensen medium: conta ins egg yolk and antibiotics to
suppress non-mycobacterial growth
I
I Chocolate agar
Vibrio choferae
I
I Thiosulfate citrate bile salts sucrose (TCBS) : extremely alkaline
Anaerobes
I Thiogfyco/ate
3.1.2 Stains
Gram Stain This stain is the foundation of microbiological
diagnosis. Some summary statements:
All cocci are gram-positive except Neisseria, Moraxella, and
Veillonella.
All spore formers are gram-positive.
Any modification of the technique for use with tissues will cause
human cells to stain pink.
-'''I
~~
..~
;1"
.l!
-.l{;L#~~J
"'. _. _. -. ,I
-......:-.1\ I ,;
:s-a,~ 1~~
- ~L ~-J~ ~
A Figure 3-3.1 A
Gram-Positive and
Gram-Negative Bacilli
Chapter 3 -7
Chapter 3 Bacteriology
Microbiology
Blue/purple
Blue/purple
Wash (acetone/alcohol)
Blue/purple
Colorless
Counterstain, safranin,
pa le pink
Blue/purple
Pink
Acid-Fast Bacilli
Procedure
Non Acid-Fast
Bright red
Red
Colorless
Methylene blue
Red
Blue
Chapter 3-8
Chapter 3 Bacteriology
Microbiology
______
..:..,._
Non-Gram Staining
Gram .;::
Gram
Rods
Cocci
Anatomically
Gram
Mycoplasma
Mycobacterium*
Staphylococcus*
Streptococcus*
Aerobic
Bacillus
Listeria
Corynebacterium*
Nocardia
Mycobacterium*
Anaerobic
Clostridium
Actinomyces
Propionibacterium
Lactobacillus
Rods
Cocci
Neisseria*
Moraxelfa
Veiffonella
Aerobic
PseudotnOfliiS
Legionelfa
Bruce/fa
Bordetelfa*
Francisella
Spirochetes*
Rickettsiae
Ollamydiaceae
Facultative
Anaerobes
Enterobacteriaceae*
Spirilar
Spirochetes*
Pasteurella
Hi!HmJOPhifus*
CW"Yed,
Hiaoaerophilic
campylobacter
Helicobacter
Vibrio
Intrac:ellular
Rickettsiae*
Chlamydiaceae
Anaerobic
Straight
Bteroides
Fusobacterium
Cha pter 3- 9
Microbiology
Chapter 3 Bacteriology
Gram-Positive Cocci
catalase
Staphyfococrus
streptococaJs
Coagulase
_c
S. aureus
- - Novob"""io-c""
in- - - .
Resistant
S. saprophyticus
Sensitive
s. epidermidis
5.1
Staphylococcus
Coagulase positive
Golden colonies on blood agar
{3-hemolytic
Ferments mannitol on mannitol salt agar
A Figure 3-5.1
Gram-Positive Cocci in
Clusters: Staphylococcus
Chapter 3 - 10
Microbiology
Pathogenic Features
Coagulase: Converts fibrinogen to fibrin
Alpha Toxin: Pore-forming, cytolytic t oxin
Protein A: Inhibits IgG opsonization by binding Fe component
Enterotoxins: Fast acting, heat stable
Toxic Shock Syndrome Toxin-1 (TSST-1): Acts as superantigen
Exfoliatins: Proteases specific for cadherin desmoglein 1, promote
epidermal blistering of scalded skin syndrome and bullous impetigo
Pathogenesis
Enterotoxins A-E, preformed in
food, heat stab le
Infective endocarditis
Pneumonia
Osteomyelitis
(No. 1 cause overall)
Surgical infections
Mastitis
Subcutaneous tenderness,
swelling, heat, redness
Coagulase, cytolysins
Impetigo
Coagulase, exfoliatins
Coagulase, exfoliatins
TSST-1 (superantigen)
Treatment
Gastroenteritis : Self-limiting
Nafcillin/oxacillin
Methicillin-resistant Staphylococcus aureus (MRSA): Vancomycin
Vancomycin-resistant (VRSA) or vancomycin-intermediate (VISA):
Quinupristin/dalfopristin
Chapter 3- 11
Chapter 3 Bacteriology
Microbiology
5.2 Streptococcus
5.2.1 Genus Characteri stics
Gram-positive cocci
Chains or pairs
Catalase negative
Chapter 3- 12
Chapter 3 Bacteriology
Microbiology
Hemolysis
Optochin sensitive
Bile soluble
Optochin resistant
Bile insoluble
S. pneumoniae
Alpha-hemolytic
Non-typeable
Viridans Strep.
Alpha-hemolytic
Non-typeable
L.ancefield
Group 0,
bile esculin
L
'----+
Lancefield Group
+
..
6.5% Naa
S. p yogenes
Bacitracin
sensitive
Group 0,
Enterococcus
S . bovis
spp.
S. agalactiae
Bacitracin
resistant
Hippurate +
CAMP+
and others
~-hemolytic
Bacitracin sensitive
Pyrrolidonyl arylamidase {PYR) positive
Reservoir Throat and skin
Transmission
Chapter 3-13
Microbiology
Chapter 3 Bacteriology
Attachment
M protein
F protein
Exotoxins A-C
Streptolysin 0
Streptolysin S
CSa peptidase
Chemokine protease
Streptokinase
Streptodornase
Hyaluronidase
Surface features
Soluble secretions
Spreading factors
Chapter 3-14
Chapter 3 Bacteriology
Microbiology
Clinical Syndromes
Scarlet fever
Impetigo/pyoderma
Honey-crusted lesions of
skin
Necrotizing fasciitis
Erysipelas
Chapter 3-15
Chapter 3 Bacteriology
Microbiology
Follows
Symptoms/Diagnosis
Pathogenesis
Rheumatic fever
Acute
glomerulonephritis
Pharyngeal or cutaneous
infection with M12 and
others
Treatment:
~ lactams or macrolides
A Figure 3-5.2 D CAMP Test : Positive for GBS (left) and Negative
for GBS (right)
Chapter 3-16
Chapter 3 Bacteriology
Microbiology
a -hemolytic
Optochin sensitive
Lysed by bile
A Figure 3-5.2E
Lancet-Shaped Diplococcus:
Pneumococcus
Respiratory droplets
Predisposing Factors
Damage to lung's natural cleansing mechanisms
Ant ecedent influenza (damage t o mucociliary escalator)
COPD
Congestive heart fai lure
Alcoholism (loss of gag reflex)
Asplenia : Predisposes to any encapsulated organism spreading
via the blood
A Figure 3-5.2F
Alpha Hemolysis
(Middle Streak)
Pathogenic Features
Capsule
IgA protease
Teichoic acids
Pneumolysin 0: Released with bacterial death; damages
respiratory epithelium, inhibits respiratory burst, and inhibits
complement fixation
A Figure 3-5.2G
Mucoid Colonies:
Encapsulated
Macrolides
Ceftriaxone or cefotaxime
Prophylax is
Pediatric Vaccine: PCV, pneumococcal conjugate vaccine; 13 of the
most common capsular serotypes conjugated to diphtheria toxoid
Adult Vaccine: PPV, pneumococcal polysaccharide vaccine; 23 of
the most common capsular serotypes; recommended for all adults
>65, t hose who are immunocompromised, and asplenics
OeVry/Becker Educat ional Development Corp. All rights reserved.
Chapter 3- 17
Chapter 3 Bacteriology
Microbiology
Endogenous
Streptococcus bovis)
Species Characteristics
Variable hemolysis, usually gamma
PYR test positive
Hydrolyze esculin in 40% bile and 6.5% NaCI
Reservoir Colon, urogenital tract
Transmission
Endogenous
Predisposing Factors
.A Figure 3-5.2H Colon Cancer Lesion
Injuries (medical procedures, colon cancer lesions) t o
gast roint estinal or genitourinary tract allow entry into blood
Preexisting damage to valves
Pathogenic Features Bile and salt tolerance promote survival in
bowel and gall bladder
Clinical Syndromes
Urinary and biliary t ract infections
Subacute endocarditis
Treatment
All strains have some drug resistance
Vancomycin-resistant strains have D-alanyi-D-Iactate terminal
residue in cell wall pentapept ide which will not bind t he drug
Prophylaxis Penicillin and gent amicin before GI or GU surgery in
patient s with preexisting damage to heart valves
Chapter 3- 18
Chapter 3 Bacteriology
Microbiology
Gram-Positive Rods
Spore Fonning
Non-Spore Forming
Aerobic
Anaerobic
Bacillus
aostridium
...
Aerobic
Listeria
Anaerobic
Actinomyces
Corynebacterium
Nocardia
Clostridium
Yes
Yes
Yes,
except C.
No
No
Yes
No
No
No
No
perfringens
Corynebacterium
No
No
No
Yes
No
No
No
No
Listeria
No
No
Yes,
No
No
Yes
Yes
No
No
Yes
No
No
No
tumbling
Actinomyces
No
Yes
motility
No
Nocardia
No
No
No
No
Yes
No
Yes
Partially
Mycobacterium
No
No
No
No
No
Yes
Yes
Yes
6.1
Spore Formers
6.1.1 Bacillus
Genus Characteristics
Gram- positive bacilli
Aerobic
Spore forming
Bacillus anthracis
Species Characteristics
Large, boxcar shaped
OeVry/Becker Educat ional Development Corp. All rights reserved.
Chapter 3-19
Chapter 3 Bacteriology
Microbiology
.A Figure 3-6.1A
Bacillus anthracis
Capsule: Anti-phagocytic
Clinical Syndromes
Cutaneous Anthrax: Skin ulcer, "malignant pustule" or "black
eschar"
Pulmonary Anthrax: Rapidly fatal pneumonia, fever, malaise,
nonproductive cough, mediastinal widening, hemorrhagic
mediastinal lymphadenitis
Gastrointestinal Anthrax: Very rare, vomiting, diarrhea,
event ual bact eremia
.A Figure 3-6.1 B
Anthrax Eschar
Diagnosis
Gram stain and cult ure of blood, sputum, lesion
PCR
Serology
Treatment
Ciprofloxacin
Doxycycline
Prevention
Bacillus cereus
Clinical Syndromes Rapid onset (from 1 to 6 hours) food
poisoning associated with buffet-style restaurants and rice dishes
.A Figure 3-6.1C
Mediastinal Widening
in Pulmonary Anthrax
Virulence Factors
Emetic Toxin: Preformed, fast-act ing (from 1 to 6 hours)
Diarrheal Toxin: Produced in vivo, increases cAMP, slow acting
(18 hours)
Diagnosis Clinical
Treatment Supportive
Chapter 3- 20
Microbiology
Chapter 3 Bacteriology
6.1.2 Clostridium
Genus Characteristics
Gram-positive bacilli
Spore forming (terminal spores)
Anaerobic
Clostridium tetani
Reservoir/Transmission
Pathogenic Features
Toxin: Tetanospasmin
Carried intra-axonally to CNS, where it blocks inhibitory
neurotransmitters (glycine and GABA); excitatory neurons are
unopposed leading to spastic (rigid) paralysis
.A Figure 3-6.1 D
Clostridium
Clinical Syndromes
Trismus: Lock j aw
Risus Sardonicus: Sardonic grin
Opisthotonus: Unopposed contraction of back muscles
.A Figure 3-6.1 E
Risus Sardonicus
Type of wound
Completed primary
series
Booster at 10-year
intervals
Status unknown or
uncompleted primary
series
Vaccinate
Chapter 3-21
Chapter 3 Bacteriology
Microbiology
Treatment
Hyperimmune human globulin (TIG) to neut ralize t oxin plus
met ronidazole or penicillin
Spasmol ytic drugs; debride; delay closure
Prophylaxis
Toxoid vaccine , component o f DTaP, repeated at 10-year intervals
after primary series
Pathogenic Features
Botulinum toxin: Blocks acetylcholine release, flaccid paralysis
Heat labile at 60C, absorbed by gut, carried by blood to
peripheral nerve synapse
Clinical Syndromes
Ingestion
of spores,
tax i-infection
Constipation,
lim pness,
dysphag ia, weak
feeding and
crying, respiratory
arrest, flaccid
paralysis
Find toxin in
serum or stool
Su pportive
Adult
(food-borne)
Ingestion o f
tox in, in poorly
canned alkaline
vegetables,
smoked fish
Descend ing
weakness,
d izziness, d ryness
of the mouth,
b lurred v isio n,
nausea and
vomit ing, inability
to swallow,
d ifficu lty in
speech
Find toxin in
leftover food o r
patie nt serum
Resp iratory
su pport, trivalent
antitoxin
Wound
Traumatic
im plantation of
spores
No GI sym ptoms
but otherw ise as
in ad ult form
Find toxin in
serum
Delay closure,
amoxicillin,
antitoxin,
respiratory
support
Debridement
Chapter 3 - 22
Chapter 3 Bacteriology
Reservoir/Transmission
food borne
Microbiology
Pathogenic Features
Spores germinate in tissues in anaerobic conditions
Alpha toxin (phospholipase C) is a lecithinase ; disrupts cell
membranes, destroys RBCs, WBCs, platelets, endot helial cells,
causes massive tissue destruction and hepatic toxicity
Twelve other toxins
Enterotoxin acts like E. coli LT to cause watery diarrhea
Clinical Syndromes
Gas Gangrene ( Myonecrosis) :
Rapid, high mortality
Acute and extreme pain
Tissue fil ls with gas and edema
Fever, tachycardia, diaphoresis
Food Poisoning: Noninflammatory diarrhea due to enterotoxin
produced in gut, from reheated meat dishes
Diagnosis/ Treatment
Gas Gangrene:
Clinical diagnosis
Treatment: Debridement, delayed closure, clindamycin and
penicillin, hyperbaric oxygen
Clostridium difficile
Species Characteristics
Normal flora of the colon, overgrows when antibiotics kill
competing flora
Toxins A and B
Pathogenic Features
Toxin A: Enterotoxin increases fluid loss, attracts granulocytes
Toxin B: Cytotoxin
Clinical Syndromes No. 1 nosocomial, antibiotic-associated
diarrhea, pseudomembranous colitis
Treatm e nt
Discontinue antibiotics if possible
Severe disease : Metronidazole
Prophylax is
Caution with broad-spectrum antibiotics
Isolation in nursing-home settings
Autoclave bedpans
Chapter 3- 23
Chapter 3 Bacteriology
Microbiology
Chapter 3- 24
Chapter 3 Bacteriology
Microbiology
Adult/ Foodbor ne
Asymptomatic/diarrhea
Pregnant women : Septicemia with fever and chills can cause
transplacental transmission
N eonatal
Granulomatosis infantisept icum: Transplacental transmission;
granulomatous septicemia with high mortality
Meningitis and septicemia (three to fo ur weeks after birth) :
Acquired during parturition
Chapter 3- 25
Microbiology
Chapter 3 Bacteriology
A. Figure 3-6.3A
Actinomycotic
Mycetoma
A. Figure 3-6.38
Partially Acid-Fast:
Nocardia
Sulfonamides or trimethoprim-sulfamethoxazole
A. Figure 3-6.3C
Nocardia! Mycetomas
Chapter 3-26
Chapter 3 Bacteriology
Microbiology
lipids
(waxes, mycosides, cord factor)
<~-AJraD1nogalactan
mycolate
Peptidoglycan (bilayer)
' O,top,laslmlc membrane
6 .4.2 M. tuberculosis
Species Characteristics
Auramine-rhodamine staining
Aerobic, slow-growing (on Lowenstein-Jensen agar)
Produces niacin
Heat-sensitive catalase: Negative at 68C; positive at body
temperature
Reservoir/ Transmission
Pathogenic Features
Facultative Intracellular (granuloma former)
Cord Factor (trehalose dimycolate)
Causes "cord-like" growth in vitro
Inhibits leukocyte diapedesis
Disrupts mitochondrial respiration and oxidative
phosphorylation
Strongest correlation to virulence overall
Sulfat ides
Sulfolipids which hydrolyze to produce H 2S04
Inhibit fusion of lysosome with phagosome, allows intracellular
survival
Mycobactin: Siderophore, chelates iron
Tuberculin
Clinical Syndromes Tuberculosis
Primary Pulmonary Disease
Organisms replicate in alveolar macrophages until CMI begins
(Ghon focus)
Macrophages transport bacilli to the mediastinal nodes
(Ghon complex)
Many individuals heal without disease, but organisms that are
walled off remain viable unless treated
Reactivational Disease
Organisms begin to replicate again under conditions of
diminished CMI
Granulomas in the apices due to high P0 2
Disseminated Disease ( Miliary TB}: Granulomas may spread to
any oxygen-rich location
OeVry/Becker Educat ional Development Corp. All rights reserved.
Chapter 3 Bacteriology
Microbiology
P rimilry
Laten t
"Reilctiv iltional"
Tube rculosis
T uberculosis
Tuberculosis
Progre ssion
after 2 y ears,
5%
Ski n-test
Spontaneous
healing in
6 m onths
Progression
within 2 y ears,
5%
Pr ogression with
concurrent HIV infection,
10% e a ch year
.A Figure 3-6.4F
Positive Tuberculin Test
.A Figure 3-6.4G
Primary TB: The Ghon
Complex
Chapter 3- 28
Chapter 3 Bacteriology
Microbiology
6.4.3 M. /eprae
Species Characteristics
Obligate int racellular (cannot be cultured)
Reservoir / Transmission
contact
Clinical Syndromes
TTable 3-6.4A M. leprae Clinical Syndromes
Tuberculoid
lepromatous
Weak CMI
Th2 response, IL-4
Lepromin s kin
test ( type IV
hypersensitivity)
Positive
Negative
Numbe r of o rganis m s
in tiss ue
Low
High
"
;:
c
Damage from
Immune response
(CM I kill ing infected
cells)
Granuloma formation:
Nerve enlargement/
damage
f0
ID
Lar ge number
of intracellu lar
organisms
Nerve damage
f rom overgrowth o f
bacteria in cells
Loss o f sensation:
Loss o f sensation:
Numerous lesions
becom ing nodular - loss
of eyebrows, destruction
of nasal septum,
paresth esia
Diagnostic Features
Acid -fast bacilli in punch biopsy or nasal scrapings
Lepromin skin t est is positive only in the tuberculoid form
Treatment
Dapsone and rifamp in
Clofazimine added for lepromatous cases
Chapter 3- 29
Chapter 3 Bacteriology
Microbiology
M. avium
intracellulare
Nonchromogen
M. kansasii
Photochromogen
M. marinum
M. scrofulaceum
Aerosol, ingestion
Pulmonary,
gastrointestin al,
dissem inated
AIDS, cancer,
chronic lung
disease
Macrolide plus
ethambutol,
standard AIDS
prophylaxis <SO
CD4 cells
Photochromogen
Fish tanks
Fish tank
granuloma
Tropical fish
enthusiasts
Isoniazid,
rifampin, or
ethambutol
Scotochromogen
Water sources
Solitary cervical
lymphadenopathy
Children
Surgery
Chapter 3-30
Chapter 3 Bacteriology
Microbiology
Cocci
Gram stain
Neisseria sp.
l
staphylococcus sp.
streptrx:occus sp.
Maltose
fennentation
N. gonorrhoeae
Moraxella
Veillonella
N. meningitidis
7.1
Neisseria
Oxidase positive
7.1.2.Species Differentiation
T Table 3- 7.1 Gram-Negative Cocci: Species Differentiation
C
.
Spec1es
apsu1e
accme
Source of
Exposure
Maltose
Ut1.11zat1on
. .
Glucose
.
ut1.11zat1on
f1-Lactamase
d
Pro uctlon
N. m eni ngi t id is
Yes
Yes
Respiratory
Yes
Yes
None
N. gonorrhoeae
No
No
Gen ital
No
Yes
Some
7.1.3 N. meningitidis
Species Characteristic
Large cap sule
Oxidizes maltose and glucose
Reservoir / Transmission
Human nasopharynx/respiratory droplets
Chapter 3 - 31
Microbiology
Chapter 3 Bacteriology
Pathogenic Fe atures
Lipooligosaccharide (LOS) : Same role as LPS but lacks
repeating a -antigen subunits and has highly branched basal
oligosaccharide; blebs of membrane shed at all times
IgA Protease: Destroys local mucosal immunity
Pili and Outer-Membrane Proteins: Mediate attachment
Capsule: Polysaccharide, protect s against phagocytosis,
fi ve serogroups
Four serogroups are immunogenic and included in the
vaccine (Y, W-135, C, and A)
Serogroup B capsule = sialic acid (nonim munogenic): Causes 50% of infect ions in the U.S.
Clinical Syndromes
Meningococcemia and Meningitis: Abru pt onset of fever,
petechial rash, prostration
Waterhouse-Friderichsen Syndrome: Hemorrhagic
adrenalitis, ecchymoses, DIC, shock, coma, death
Deficiency of membrane attack complex components (CSCS) predisposes to repeated bacteremias
Diagnostic Features
Gram stain of CSF: Gram-negat ive diplococci
Culture on chocolate agar in 5% C0 2 , oxidase-posit ive
colonies
PCR
Latex particle agglutination t o det ect capsular serotype
Treatment
Neonates and infants: Cefotaxime, ampicillin
Older infants to adults: Cefotaxime or ceftriaxone, with or
without vancomycin
Prophylaxis
Vaccine: Capsule of strains Y, W-135, C, A
Rifampin to contacts (reaches high concentration in saliva)
7.1.4 N. gonorrhoeae
Species Characteristics
No capsule
Oxidizes only glucose
Reservoir/Transmission
parturition
Pathogenic Features
Pili
Attachment t o m ucosa
I nhibit phagocytosis
Antigenic variation (more than 1 million variants)
Chapter 3- 32
Chapter 3 Bacteriology
Microbiology
Outer-Membrane Proteins
Por Protein: May prevent phagosome-lysosome fusion inside
neutrophils
Opa Proteins: Adherence
lgA Protease: Destroys local m ucosal immunity
Lipooligosaccharide: Endotoxic effects, causes ciliary loss and
mucosal cell death in fal lopian tubes
Invades mucosa, causes inflammation
Clinical Syndromes
Gonorrhea
Male: Urethritis, proctitis
Female: Endocervicitis, pelvic
inflammatory disease, proctit is
Septic Arthritis: More common in
females, in knees, ankles, wrists
Ophthalmia Neonatorum : Rapidly
leads to blindness
0:
~~----_.~~~- 0
Figure 3-7.1D
Gonococcal Urethritis
Figure 3-7.1 E
Gonococcal Cervicitis
Diagnostic Features
Gram-negative diplococci inside PMNs in t he urethral exudat e of
males is diagnostic
In females : Culture on Thayer-Martin or genetic probe is
necessary to dist inguish from normal flora
Test for all other possible sexually transmitted infections
Treat ment
Ceftriaxone
Plasmid-encoded 13-lactamase provides high-level resistance
to penicillin
Prophylax is
Safe sex
Neonatal : Erythromycin ointment in eyes
Figure 3-7.1F
Gonococcal Ophthalmia
Neonatorum
Treatment
Amoxicillin plus clavulanat e, trimethoprim -sulfamethoxazole, or
second- or third -generat ion cephalosporin
Most strains produce 13-lactamase
Chapter 3- 33
Chapter 3 Bacteriology
Microbiology
Ox id.se-Negative
Aerobic
Bordete/la
Brucella
Francisella
t...gk>nella
Pseudomonas
Facultative
Facult ative
Anaerobic o r
Microaerophilic
Vibrk>
Anaer obic
Enterobacteriaceae
CNnpylobader*
Helicobacter*
Pasteurella
Haemophilus
*microaeropnilic
Anaerobic
Bacteroitks
Non-,J actose
Lactose
Fer 111e:11ters
Ferntenters
Escherichia
Klebsiella
Motile H1S
Non- motile,
Producers
Proteus
Salmonella
non-H2S Producers
Shigella
Yersinia
8.1
Oxidase Positive
8.1 .1 Aerobic
Bordetella pertussis
Species Characteristics
Encapsulated
Aerobic
Gram-negative rod
Reservoir/ Transmission
Humans/respiratory droplets
Adults vaccinated in childhood may transmit
Pathogenic Fe atures
Mucosal Surface Pathogen : Attachment by
Filamentous hemagglutinin
Pertussis toxin
Toxins (chromosome-encoded)
Pertussis Tox in: (A/B toxin in outer membrane;
ADP-ribosylates Gi keeping cyclase activity turned on and
affecting multiple intracellular signaling pathways)
- Promotes lymphocyt osis
- Sensitizes to histamine
- Enhances insulin secretion
- Promotes edema
Chapter 3- 34
Chapter 3 Bacteriology
Microbiology
Whooping Cough
Catarrhal
Paroxysmal
Co nva lesce nt
7 - 10 days
1 - 2 weeks
2 - 4 w eeks
1 month o r longer
Rhinorrhea,
malaise,
Repetitive cough
with whoops (air
through narrowed
glottis) vomiting,
leukocytosis (up
to 40,000/mm')
Diminished paroxysmal
cough, development
of secondary
complications
(pneumonia, seizures,
subconjunctival or
cerebral hemorrhage,
encephalopathy)
Durat io n
Sympto m s None
sneezing,
anorexia,
fever
Bacterial
Culture
A Figure 3-8.1B
Whooping Cough
Macrolides (erythromycin)
Brucella spp.
Genus Characteristics
Gram-negative, aerobic rods
Zoonotic
Facultative intracellular
Chapter 3- 35
Chapter 3 Bacteriology
Microbiology
Reservoir/Transmission
Domestic livestock/unpasteurized dairy, direct contact, t ravel t o
Mexico; California and Texas have highest number of cases
B. melitensis (goat s)
B. abortus (cattle)
B. suis (pigs)
Pathogenic Features
Endotoxin
Granulomatous inflammation
Facultative intracellular, causes septicemia
Clinical Syndrome Brucellosis
Chronic illness with fever, night sweats, and weight loss
Potential cycling of nocturnal fevers (undulant fever)
Diagnostic Clues
Slow-growing in cult ure, serology
Treatment Doxycycline with an aminoglycoside
Prophylaxis Vaccinat e livest ock, pasteuri ze dairy foods; no human
vaccine available
Francisella tularensis
Species Characteristics
Small, gram-negative coccobacillus
Requires cysteine and iron
Reservoir /Transmission
Rabbits, deer, rodents/implantation, aerosol, ingestion
Tick (Dermacentor) or deerfly (Chrysops)
Pathogenic Features
Facultative intracellular
Escapes phagosome to live in cytoplasm
Clinical Syndromes Tularemia
Begins with fever, chills, malaise
Ulceroglandular: Papule at inoculation site necroses and ulcerates
Oculoglandular: Painful purulent conjunctivitis
Typhoidal: Abdominal course m imicking typhoid fever
Pneumonic: Resembles plague pneumonia
Diagnostic Clues
A hunter in Arkansas, Missouri, or Oklahoma
Serology, direct fluorescent antibody on biopsy material
Culture is hazardous
.A Figure 3-8.1 C
Ulceroglandular
Tularemia
Chapter 3- 36
Chapter 3 Bacteriology
Microbiology
Legionella pneumophila
Species Characteristics
Weakly gram-negative rods
Require cysteine and iron
Facultative intracellular
Re se rvoir / Transmission
Aerosols inhaled from water sources
No human-to-human transmission
Pathogenic Features
Facultative intracellular
Inhibits phagosome-lysosome fusion
Pore-forming toxin kills macrophages and facilitates spread
Alveoli f ill with exudate of f ibrin, PMNs, macrophages, and RBCs
Clinical Syndromes
Legionnaires' Disease
Atypical pneumonia
Confusion, delirium
Diarrhea
Pontiac Feve r
Self-limiting
Fever, myalgia, dry cough
Diagnostic Clues
Patient is an elderly smoker with high alcohol intake or is
immunosuppressed
Dieterle silver stain or direct fluorescent antibody of biopsy
Cult ure on buffered charcoal-yeast agar
Urine antigen test
Treatment
Fluoroquinolone, azithromycin, or erythromycin
Add rifampin for immunocompromised patients
Prophylaxis
Avoidance of contaminated water aerosols
Legionella are resistant to chlorine and heat
Silver and copper ionization systems to treat water sources
Chapter 3- 37
Chapter 3 Bacteriology
Microbiology
Pseudomonas aeruginosa
Species Characteristics
Gram-negative, oxidase-positive bacillus
Obligat e aerobe (nonfermenter)
Blue-green (pyocyanin) and fluorescent (fluorescein)
pigments
Fruity (grape-like) odor
Alginate capsule (slime layer)
Reservoir/Transmission
Water/aerosols
A Figure 3-8.1 D
Encapsulated Gram-Negative
Rods: Pseudomonas
Pathogenic Features
Endotoxin
Exotoxin A: ADP-ribosylat es eEF- 2, action like diphtheria toxin but
primary t arget is the liver
Capsule impedes phagocytosis
Elastase: Hemorrhagic dest ruct ion of blood vessel walls
Clinical Syndromes
Normal individuals
GI colonization: Transient diarrhea
Hot t ub fol liculitis
Eye ulcers : Trauma, prolonged contact lens wear
Opportunistic infections
Cystic fibrosis patients: Pneumonia (No. 1 cause of death)
Burn pat ients: Cellulitis and sept icemia, blue-green pus
Wounds exposed to water: Nail through tennis shoe
Neut ropenic patients : Pneumonia and septicemia
Chronic granulomatous disease patients : Pneumonia and
septicemia
Catheterized patients : Urinary tract infections
Diagnostic Clues
Clinical: Patient population, blue-green pus, fruity odor
Ecthyma gangrenosum: Classic lesion of pseudomonal
septicemias; black necrotic center w ith raised
hemorrhagic ring
Gram stain, culture of nonfermenting colonies on EMB or
MacConkey's agar
Treatment
Susceptibility testing: P. aeruginosa is the most consistently
drug resistant of all of the pathogenic bacteria
Ant i- pseudomonal penicillin plus aminoglycoside
A Figure 3-8.1 E
Ecthyma Gangrenosum
Prophylaxis
Disinfection of any wat er-containing equipment
Avoid having flowers or ice water baths in units with at-risk patients
Ch apter 3- 38
Chapter 3 Bacteriology
Microbiology
8.1.2 Microaerophilic
Campylobacter jejuni
Species Characteristics
Gram-negative, curved rods
Microaerophilic
Grows at 4 2C
Oxidase positive
Polar flagel la ("seagull's wing s")
Reservoir/ Transmission
Pou ltry/fecal-oral
Pathogenic Features
Invades mucosa producing inflammatory diarrhea
Low infectious dose (resistant to gastric acidity)
Rarely produces septicemia
Clinical Syndromes
Gastroenteritis: No. 1 bacterial cause in the U.S. (more than
Salmonella and Shigella combined)
Blood and pus in stool, fever
Generally self-limit ing in three to five days
Guilla in-Barre syndrome (GBS): Responsible for 30% of cases
in the U.S. (serotype 0:19 oligosaccharides cross-react with
glycosphingolipids on neural tissue)
React ive arthritis
Diagnostic Features Culture on Campylobacter or Skirrow agar at
42C in 5% 0 2 and 10% C0 2
Treatment
Supportive: Fluid and elect rolytes
Severe: Macrolides and f luoroquinolones
Helicobacter pylori
Species Characteristics
Gram-negative, spirillar rods with flagella
Oxidase positive
Microaerophilic, best growth at 37C
Urease positive
Reservoir / Transmission
Humans/fecal-oral, oral-oral
Pathogenic Features
Urease neut ralizes gast ric acidity to allow survival
Motility aids invasion
Mucinase dissolves mucous covering of stomach lining
Vacuolating cytotoxin kills cells and assists inflammation
Chapter 3- 39
Chapter 3 Bacteriology
Microbiology
Clinical Syndrome s
Gastritis and ulcers
Type I carcinogen: Gastric adenocarcinoma, MALT-oma, B cell
lymphomas
Fundus
I
_ _ __
_L- Body
Pylorus
Incisura
Type I
gastric ulcer
Antrum
Vibrio cholerae
Species Characteristics
Dist inguished by 0 (envelope antigens); 01 and 0139 cause
cholera
Produce cholera toxin
Reservoir/ Transmission
Human/fecal-oral, no carriers
Shellfish may be contaminated
.A Figure 3-8.1 H
Gram-Negative,
Comma-Shaped Rods:
Vibrio
Chapter 3-40
Chapter 3 Bacteriology
Microbiology
Pathogenic Features
Sensitive to acidity, high infectious dose (10 7 organisms)
Att achment via toxin coregulated pili, mucinase, motility
Cholera Tox in : Choleragen
ADP ribosylat es Gs alpha, act ivates adenylate cycl ase,
increases cAM P, and causes loss of Cl and water
Function similar to E. coli LT
Encoded in prophage (lysogeny)
Clinical Syndrome Cholera
"Rice water" stools
Hypovolemic shock
Electrolyte imbalances
Diagnostic Features Culture of oxidase positive gram-negative
curved rods on TCBS (thiosulfate citrate bile salts sucrose) agar
Treatment
Fluids and electrolyt es
Doxycycline or ciprofloxacin may shorten course of the disease
Prophylaxis
Proper sanitation, chlorination of water, cooking of shellfish
Vaccines available for t ravelers (whole-cell, lipopolysaccharide,
and toxin B subunit) but only live-attenuated vaccine strains
produce local secretory IgA response
Marine, undercooked
seafood
V. vu/nificus
Brackish water,
oysters
Gastroenteritis
following ingestion
Profuse, watery
diarrhea
Cellulit is if introduced
through abrasions
Rapidly spreading,
ulcerative abscess
Tetracycline,
third-generation
cephalosporin
Haemophilus spp.
Genus Characteristics
Gram-negative, coccobacilli
Requires factors X (hemin) and V (NAD) for growth
Haemophi/us influenzae
Species Characteristics
Polyribitol phosphate capsule
Type b capsule causes 90% of invasive disease
A Figure 3-8.11
Gram-Negative
Pleomorphic Rods:
Haemophilus
Chapter 3 - 4 1
Chapter 3 Bacteriology
Reservoir/Transmission
Microbiology
Humans/respiratory droplets
Pathogenic Features
Capsule prevents phagocyt osis
IgA protease
Clinical Syndromes
Meningitis : 3-month- t o 3-year-old, unvaccinated children
Ot itis media : Not typeable strains
Bronchitis: Smokers with COPD
Pneumonia: Smokers
Epiglottitis: Unvaccinated children, major causal agent
A Figure 3-8.1J
Thumb Sign
Diagnostic Features
Culture of blood or CSF on chocolate agar: Provides factors X and V
Culture with Staphylococcus aureus on blood agar: Satellite
phenomenon
PCR
Latex particle agglutination for capsular antigen detection
Treatment
Cefotaxime or ceftriaxone
Rifampin to reduce nasal carriage
Prophylaxis
Hib vaccine, 95% effective, four doses
Conjugated capsular polysaccharide-protein (T cell dependent)
vaccine
Haemophi/us ducreyi
Reservoir/Transmission
Pathogenic Features
Attachment: Pili and out er- membrane prot ein
Toxin: Cytolethal distending toxin (kills T cells)
Clinical Syndrome Chancroid
Soft, painful genit al ulcer
Common in Africa, Asia, India, and Latin America
Diagnostic Features
Genus features for culture
Clinical
DNA probe
Treatment Azithromycin, ceftriaxone, ciprofloxacin, erythromycin
Prophylaxis Safe sex
A Figure 3-8.1K
Chancroid
Chapter 3-42
Chapter 3 Bacteriology
Microbiology
Pasteurella
Genus Characteristics
Gram-negat ive coccobacillus
Oxidase positive
Reservoir/ Transmission
Pathogenic Features
Endotoxin
Capsule
Clinical Syndromes Cellulitis, wound infections
Diagnostic Features
J
Clinical
-'YrApplication - - - - - - - - - - - - - - 1
Chapter 3- 43
Chapter 3 Bacteriology
Microbiology
Oxidase--Positive
Aerobic
Bordetella
BI""UCella
Frandsella
Legionella
PseudonJonas
Oxidase Negative
Faculbtive
Facultative
Anaerobic or
Anaerobic
Microaerophilic
Enterobacteriaceae
Anaerobic
Bact~roides
Vibrio
-campy#~
Helicobader*
Pasteurella
Haenrophilus
microaerophilic
Lactose
Fermenten
Escherich~
Klebsiella
Non-l actose
Fennenten
Motile H~
Producer s
No..-.notile,
,_., . H~ Producers
Shigella
Prot~s
Salmonella
Yers;nia
Chapter 3- 44
Chapter 3 Bacteriology
Microbiology
Escherichia coli
Genus Characteristics
fermenting rod
..,
...
' '
...
..
....
Reservoir /Transmission
Human colonic normal flora
Endogenous
Mother to child during delivery
Fecal-oral contamination of food
Enterohemorrhagic strains: Cattle feces
II
.A Figure 3-8.2C
Escherichia coli
Gram Stain
Pathogenic Features
Fluoroquinolones
or sulfonamides
Ceftriaxone
Fluoroquinolones,
third-generation
cephalospori ns
Watery diarrhea
Infants and children in
developing world
Stacked-brick
biofilm on
mammalian cells
Antibiotics
contraindicated:
May increase risk
of HUS
Septicemia
EHEC
( enterohemorrhagic E. coli;
0157:H7 most common)
EIEC
I nvades colon
Inflammatory diarrhea
(blood, pus, fever)
Children under 5 in the
developing world
Trim ethoprim
sulfamethoxazole
or
fluoroquinolones
Infants
Developing world
f:Hactams,
macrolides
Traveler's diarrhea
Noninflammatory
Immunoassay for
enterotoxin
Rehydration,
trimethoprimsulfamethoxazole
only in severe
cases
( enteroinvasive E. coli)
EPEC
(enteropathogenic E. coli)
ETEC
(enterotoxigenic E. coli)
Chapter 3-45
Microbiology
Chapter 3 Bacteriology
Klebsiella pneumoniae
Species Characteristics
Ent erobact eriaceae, lactose ferment er
Encapsulat ed, nonmotile
Reservoir/ Transmission
tract/ endogenous
Pathogenic Features
Large capsule interferes with complement activation and impedes
phagocytosis
Pili mediate attachment
Endotoxin
Clinical Syndromes
Pneumonia:
Typical pneumonia wit h many abscesses
Thick, gelatinous sputum (currant jelly)
Patient wit h chronic lung disease or alcoholism
High fatality and drug resistance
Urinary Tract Infections: Fecal contamination of catheters
(nosocomial)
Septicemia : Immunocompromised pat ients from invasion of IV
lines or bowel defects
Diagnostic Features
Culture of sputum or urine
Lactose fermenting, gram-negative, oxidase negative bacillus
A Figure 3-8.20
Mucoid Growth of
Klebsiella pneumoniae
Treatment
Fluoroquinolones, third-generation cephalosporin with or without
aminoglycoside
Among the most drug resistant of the enterobacteriaceae
Prophylaxis Limit use of catheters
Non-lactose Fermenters
Motile, H 2 S Producers
Proteus mirabilis, P. vulgaris
Genus Characteristics
Ent erobacteriaceae, non-lact ose ferment ing
Peritrichous f lagella : Swarming motility
Urease posit ive
Reservoir/ Transmission Human colon and environment/
endogenous or from water, soil
Pathogenic Features
Motility aids movement against flow of urine
Urease raises urinary pH and causes struvite or staghorn stones
Endotoxin important in sept icemias
@ OeVry/Becker Educational Development Corp. AU rights reserved.
A Figure 3-8.2E
Staghorn Renal Calculus
Chapter 3-46
Microbiology
Chapter 3 Bacteriology
Clinical Syndromes
Urinary tract infections
Kidney stones
Septicemia
Diagnostic Features
Culture of blood or urine
Lactose non-fermenting enterobacteriaceae
Urease positive (ammoniac odor to urine and raised pH)
Treat ment Fluoroquinolones, third-generation cephalosporin,
trimethoprim-sulfamethoxazole
Chapter 3- 47
Microbiology
Chapter 3 Bacteriology
Diagnostic Features
Traveler to endemic area
Extended fever and abdominal pain
Rose spots on abdomen
Culture of blood or feces, non-lactose fermenting, H2S producing
gram -negat ive bacilli
Serologic determination of 0, H, and Vi antigens (Widal test)
Treatment Ceftriaxone, cefixime, ciprofloxacin
Prophylaxis
Provision for clean water supplies
Treatment of carriers
Old vaccines: Whole killed bacteria, live-attenuated and Vi antigen
New vaccine: Vi antigen conjugated to a bacterial protein
Nontyphoidal Salmonellae
Serovar Characteristics As with S. enterica serovar Typhi, except
capsules are not important
Reservoir/ Transmission
Pathogenic Features
High infectious dose required ( 10 5)
Pili attach to D-mannose receptors
Organisms invade to lamina propria, induce inflammation, kill
macrophages, induce prostaglandin synthesis
Prostaglandins increase cAMP, cause fluid loss
Clinical Syndromes
Gastroenteritis: 6- to 48-hour incubation, nausea, vomiting, fever,
only occasionally bloody
Septicemia: Uncommon unless patient is elderly or very young
Osteomyelitis: No. 1 cau se in sickle cell pat ients
Diagnostic Features
Stool cult ure on Hektoen agar, H2S product ion
Serotype by serologic analysis of 0 , H ant igens (Widal test)
Treatment
Fluid and electrolyte rep lacement
Antimicrobics increase potential for carrier state
Prophylax is Proper preparation of food; hand washing
Chapter 3-48
Chapter 3 Bacteriology
Microbiology
Yersinia spp.
Genus Characteristics
Enterobacteriaceae
Non -lactose fermenter, nonmotile, non- H2 S producer
Bipolar st aining
Zoonot ic
Chapter 3- 49
Chapter 3 Bacteriology
Microbiology
Pathogenic Features
Multiplies in the cold
Invades M cells
Invasins
Major effector proteins: Yaps
Clinical Syndromes
Acute mesenteric lymphadenitis (pseudoappendicitis) in children
Enterocolitis
Polyarthritis associated with diarrhea
Diagnostic Features
Treatme nt
Usually self-limiting
Immunocompromised patients: Fluoroquinolones or thirdgeneration cephalosporins
Prophylax is
Pasteurizat ion of dairy product s
Proper cooking of pork
Yersinia pestis
Reservoir/ Transmission
Zoonotic, rodents/flea bite
Pneumonic form: Human to human
U.S. desert southwest
Pathogenic Fe ature s
Coagulase clogs mouthparts of f lea and increases t ransmission
Facultative intracellular
Endotoxin and Yops
Envelope antigen (Fl) antiphagocytic
Clinical Syndromes
Bubonic plague
Flea bit e or contact wit h
infected animal
Rapid increase in fever
Regional buboes
(hemorrhagic lymph nodes)
Conjunctivitis
Septicemia and death
Pneumonic plague
Spread to lung from bubonic
fo rm or inhalation from
infected human
Much more ra pid
progression to death by
sept icemia
A. Figure 3-8.2F
Disseminated Intravascular
Coagulation From Plague
A Figure 3-8.2G
Bubonic Plague Buboes
Chapter 3- 50
Chapter 3 Bacteriology
Microbiology
Diagnostic Features
Specimens and cult ures are hazardous
Serodiagnosis or direct immunofluorescence
Treatment
Aminoglycosides
72-hour quarantine after drug initiation
Prophylaxis
Killed vaccine (military)
Animal control
8.2.2 Anaerobic
Bacteroides tragi/is
Genus Characteristics
Gram-negative bacillus
Obligate anaerobe (aerotolerant, produce superoxide dismutase)
Endotoxin is missing part of lipid A
Reservoir/ Transmission
Human colon/endogenous
Chapter 3- 51
Microbiology
Chapter 3 Bacteriology
Intracellular
9.1
Order Characteristics
Spiral morphology
Motile via endoflagellum (axial fi lament)
Gram-negative morphology
Difficult to culture
Pathogenic Features
Endotoxin
Primary lesion: Endarteritis with swelling and proliferation of
endothelial cells
Granulomatous cuffs of lymphocytes, monocytes, and plasma cells
surround vessels
Jarisch-Herxheimer reaction: Endotoxin shock response, which
starts in first 24 hours of drug treatment (fever, fall in blood
pressure, leukopenia, rigors)
Chapter 3- 52
Chapter 3 Bacteriology
Microbiology
Clinical Syndromes
Table 3-9.2 Syphilis: Clinical Syndromes
Therapy
Primary
10 days to 3 months
after exposure
Painless, indurated
chancre on genitalia,
hea ls spontaneously
in 3 to 6 weeks
Biopsy or scraping
observed with darkfield microscopy;
serology usually
negative
Benzathine penicill in
Secondary
1 to 3 months later
Generalized bronzing
maculopapular rash,
involves palms and
soles, alopecia,
condylomata lata
Serology: Nonspecific
test confi rmed by
specific test
Benzathine penicill in
None
Nonspecific and
specific serologic tests
are positive
Benzathine penicill in
Penicillin G
Rhinitis, rash of
secondary stage
disease, bone
deformations
Penicillin G
Latent
Tertiary
5 to 20 years after
initial infection (one
third of patients)
Congenital syphilis
Diagnostic Tests
Non-treponema! {nonspecific} serologic tests
Detect antibodies (reagin) against mammalian cardiolipin
VDRL: Venereal disease research laboratory
RPR: Rapid plasma reagin
Inexpensive and readily available, but titers decline with time
Treponema! {specific} serologic tests
FTA-ABS: Fluorescent t reponema! antibody-absorption
MHA-TP: Microhemagglutination using treponema! antigens on
erythrocytes
More expensive, less readily available
Prophylaxis
Safe sex
Contact tracing
Benzathine penicillin to contacts
Chapter 3-53
Chapter 3 Bacteriology
Microbiology
Ticks (Ixodes),
Pathogenic Features
A Figure 3-9.3A
Lacks cl assic endotoxin
Borrelia burgdorferi
Outer surface proteins (Osps) inhibit
complement f ixation
I nflam mation st imulated by cell wall pept idoglycan
Arthritis has aspect s of autoim munity
A. Figure 3-9.38
Ixodes dam mini
(3 instars)
Clinical Syndromes
T Table 3-9.3 Lyme Disease (Borreliosis): Clinical Syndromes
Stage
Onset
Pathogenesis
Signs
Early localized
With in a month
Target-shaped (bull's-eye)
rash (erythema migra ns),
fever, fatigue, myalgia,
headache, joint pains, mild
neck stiffness
Dissemination
Days, weeks,
months
Organ ism
disseminates
Chronic persistent
Weeks to years
Diagnostic Features
Enzyme immunoassay fol lowed by Western blot
Early infections often seronegative; many false positives
Clinical, exposure
Treatment Doxycycline and amoxicillin
Prophylaxis Avoid tick bite
Ch apter 3 -54
Chapter 3 Bacteriology
Microbiology
Clinical Syndromes
Leptospirosis : Flu-like prodrome with fever, nausea, vomiting,
headache, abdominal pain, myalgia
Weil disease: Vasculitis, jaundice, renal damage, hemorrhagic rash
Diagnostic Features
Occupational or recreational exposure to water
Highest incidence is in Hawaii
Serology: Agglutination
Treatment
Prevention
Chapter 3- 55
Chapter 3 Bacteriology
Microbiology
Unusual Bacteria
'YTable 3- 10.0 Unusual Bacteria
Mycoplasmataceae
Free-living
I Limited
I None
Peptidoglycan lacks
muram ic acid
Cell wall
Yes
I Normal
No cell wall, sterols in cell
membrane
Ohrs
The EB reorganizes
to fonn a retirulate
body (RB)
Reticulate body
(RB}
12 hrs
Development of a
larg; cytoplasmic
30 hrs
tndUSIOn
20 hrs
The RB then
undergoes several
binary fissions
Chapter 3- 56
Chapter 3 Bacteriology
Microbiology
Pathogenic Features
Organism has t ropism for epithelial cells of endocervix and upper
genital t ract of women and urethra, rectum, and conjunct iva of
both genders
IL- 8 is released by infected cells and causes early tissue infiltrates
with PMNs, replaced later wit h lymphocytes, macrophages,
plasma cells
Obligate int racellular
Granulomatous inflammation results in fibrosis and scarring
Clinical Syndromes
Trachoma
Serotypes A, B, Ba, and C
No. 1 cause of infectious prevent able blindness worldwide
Granulomatous inflammation leads to entropion and scarring
Sexually t ran sm itted infection serotypes D-K (No. 1 bacterial STI
in the U.S.)
Nongonococcal urethritis, cervicitis, PID, infertility
Inclusion conjunctivitis in neonates
Atypical pneumonia in neonates
Lymphogranuloma venereum
Serotypes L1,2,3
Common in Africa, Asia, and South America
Transient genital lesion fo llowed by multilocular suppurative
involvement of the inguinal lym ph nodes
Diagnostic Features
Scraping of affected area: Female cervix, male urethra,
ocular conjunctiva
Intracytoplasmic inclusions in epithelia
Tissue culture
10.1.2
Chlamydophila ps ittaci
Reservoir/Transmission
inhalation of excreta
Pathogenic Features
Reticulate Bodies
Clinical Findings
Poultry worker or parrot fancier
Atypical pneumonia
Diagnostic Features
Intracytoplasmic inclusions (no glycogen) in epithelial cells
Tissue culture
Serology, complement fixation
Chapter 3- 57
Chapter 3 Bacteriology
Microbiology
Humans/respiratory droplets
Pathogenic Fe atures
Infects smooth muscle, endothelial cells
May have association with development of atherosclerosis
Clinical Syndrome Atypical pneum onia and bronchitis
Diagnostic Features As for genus
Treatment Tetracycline, eryt hromycin
l 0.2 Rickettsiae
TTable 3- 10.2A Rickettsiae Species
Disease
Rocky Mountain s potted
fever
R. rickettsii
Tick
Ricketts ialpox
R. akari
Mite
Scrub typhus
Orient/a tsutsugamushi
Mites, chiggers
Epidemic typhus
R. prowazekii
Louse
Murine typhus
R. typhi
Flea
Wild rodents
Ehrlic hiosis
Anaplasma phagocytophilum,
Ehrlich/a chafeensis
Tick
10 .2.1
Rickettsia rickettsii
Reservoir/Transmission
Pathogenic Features
Obligat e intracellular in endothelial cells of capillaries
Vasculitis and rash
Endotoxin may precipitate shock
Clinical Syndrome Rocky Mountain spotted fever (prevalent in
Oklahoma, Tennessee, North Carolina, and South Carolina)
Maculopapular to petechial rash starts on ankles and wrists and
spreads to midline
Palms and soles involved
Centripetal movement
Ankle and wrist swelling
Fever, headache, malaise, myalgia, vomit ing, confu sion
Gastrointestinal symptoms, periorbital swelling, conjunctivit is, st iff
neck, arthralgia
Chapter 3- 58
Chapter 3 Bacteriology
Microbiology
Diagnostic Features
Clinical, tick bite
Indirect fluorescent antibody test
Weii-Felix test (heterophile ant ibody detected with
Proteus organisms)
Treatment
Doxycycline
Begin therapy without laboratory confirmation
Prevention
10.2.2
Ehrlichia
Ticks and
deer
Anaplasma
Ticks, deer,
phagocytophilum mice
Amblyomma Infects
t icks
monocytes
and
macrophages
Human monocytic
ehrlich iosis similar
to RMSF without
rash; leukopenia, low
platelets, morulae
Indirect FA
PCR, blood
film with
morulae
Doxycycline
Ixodes ticks
Human granulocytic
anaplasmosis similar
to RMSF without
rash; leukopenia, low
platelets, morulae
Indirect FA
PCR, blood
film with
moru lae
Doxycycline
Infects
neutrophils
Chapter 3- 59
Chapter 3 Bacteriology
Microbiology
Mycoplasmataceae
11.1 Family Characteristics
Sterols in membrane
Smallest extracellular bacterium
Require cholesterol for culture
Humans/respiratory droplets
Pathogenic Features
Attachment t o cilia and m icrovilli of bronchial epithelium
via Pl protein
Interference with ciliary action leads t o desquamat ion
I nfiltrat ion wit h lymphocytes, plasma cells, and macrophages
Clinical Syndrome
Atypical pneumonia ("walking pneumonia" ) : Most prevalent form
of atypical pneumonia in young adults
Pharyngitis
Diagnostic Features
Mulberry-shaped colonies on media containing sterols
10 days for growth
Cold agglutinins ( isohemagglutinins which function at 4C) present
in 65% of patient s
EIA and immunofluorescent serological test s
Treatment Erythromycin, tetracycline
Pathogenic Features
Urease allows organism t o live in acidic pH
Sexual act ivit y may promote movement up urinary tract
Struvit e stones/staghorn renal calculi
Clinical Syndrome
Uret hrit is
Prost atitis
Renal calculi
Diagnostic Features
Non-Gram staining
Urease posit ive
Treatment Tetracycline
Chapter 3- 60
1.1.1 Ca p s id s
Viruses are divided into two groups:
...
...
...
...
Helical
...
'
Nucleoca
No naked
helical viruses
Chapter 4- 1
Microbiology
Chapter 4 Virology
1.1.2 Genomes
Animal viruses may possess genomes made of single- or doublestranded DNA, or single- or double-stranded RNA. RNA viruses are
classified int o two groups:
Positive-Sense RNA Viruses: These cont ain an RNA strand t hat
is analogous to eukaryotic mRNA.
Negat ive- Sense RNA Viruses: These viruses have the strand
complementary to mRNA-a strand that does not naturally occur
in eukaryotic cells.
Proline
Poly
CCC
Poly
GGG
Jy,__Clinical
Application
-'"~
Chapter 4- 2
Chapter 4 Virology
Microbiology
DNA Vi ruses
Poxviru s
Para myxovirus
co0
~0
Rhabdovin.ls
00
0
~~
@
Herpesvirus
~q,
"~;<.Wrrr,fJ
I
I
_J
gIfv. C:'
-.) s~~
~
~
Orthomyxovirus
<t',(mk\~-.v
Hepadnavlr us
N ak ed DNA Viruses
Coronavirus
0 e
Flaviviru s
Tog avlru s
Adenovir us
\
''
'\
IIi
\ ,.,,
Polyorna. Papilloma
.,~~~
~~~
~'
Calicivirus
Hepevlr us
Reovirus
Parvovln.JS
'~~"'
Picornavirus
Chapter 4- 3
Microbiology
Chapter 4 Virology
3. Uncoating
4. Macrbmolecular
synthesis
~
- --H-- IWU\ IWU\
5. Postranslational
modification
0
.....,_
JVVVV
JVVVV
[]
\6.
8 . Release - -
1.2.2 Attachment
Viruses attach to host cells by interaction with specific host cell
recept ors. This interaction defines the virus' tropism or host range
(its choice of target cell). For enveloped viruses, it is viral proteins
embedded in the envelope that att ach to host cell receptors. In t he
case of naked capsid viruses, virus-encoded capsid proteins serve
this purpose.
A few specific virus/receptor interactions may be tested. These
include:
Chapter 4- 4
Chapter 4 Virology
Microbiology
Naked
virus
proteins
Enveloped virus
glycoproteins
Receptor
on cell
1.2.3 Penetration
Enveloped viruses enter cells in one of two ways:
Direct Fusion: Viral envelope fuses with the cellular membrane/
discharging the nucleocapsid directly into the cell.
Viropexis: Virus penetrates via receptor-med iated endocytosis
and production of an endosomal vesicle.
Naked capsid viruses only can enter the cell by viropexis.
. - --
Llt.a.LW.oJ
. -
1J I 1. u.u...
Chapter 4-5
Chapter 4 Virology
Microbiology
-'Y.~v---
Clinical
Application - - - - - - - - - - - - - - Viruses that enter cells via direct fusion leave viral
glycoproteins on the surface of the cell. This result s in
the tendency for infected cells to fuse with neighboring
cells, and causes formation of syncytia (mult i-nucleated
giant cells), which can be both diagnostic and important
in the protection of the virus from humoral immune
responses. The classic syncytial viruses are the
paramyxoviridae, the herpesviridae, and HIV.
1.2.4 Uncoating
Nucleocapsids of viruses that enter cells via direct fusion are
discharged directly into the cytoplasm. Viruses that are enclosed in
an endosomal vesicle are released by fusing viral membrane with
endosomal membrane. Some viruses use fusion with lysosomes to
release the nucleocapsid.
1----
s s(- )DNA
l cCA IGGAI AGC I --+
ss( + ) transcribed
by viral reverse
transcrip tase
transcribe~
ss( - )
by host into mRNA
ss( +)
IGGU I CCU I UCG I - - - - - - - - - - - - . IGGU I CCU I UCG I -i~;~nps~ap~~~e-. l glycine l proline I se1ine I
ss( +} used directly
as mRNA
ssRNA
mRNA
ss( +) used directly
as mRNA
dsRNA
Chapter 4- 6
Chapter 4 Virology
Microbiology
dsDNA
Semi-conservative
replication
dsDNA
Hepadnavirus
dsDNA
ss(+ )RNA
dsDNA
Most
+RNA
-RNA
+RNA
Retrovirus
+RNA
dsDNA
+RNA
All
-RNA
+RNA
-RNA
DNA
+ RNA
- RNA
1.2.7 Assembly
The individual component parts- enzymes, nucleic acid strands, and
proteins- are assembled into the next generat ion of virions.
1.2.8 Release
Most naked capsid viruses leave a host cell by causing cellular lysis.
Most enveloped viruses will bud off the surface of the cell, capturing
surrounding membrane as they leave.
Virus specific
7\
..&. Figure 4-1.2E Viral Release
Chapter 4 - 7
Chapter 4 Virology
Microbiology
/II\
/It\
/ \ = Virus titer
.A
= symptomatic period
Measles
SSPE
Latent infection
(Varicella - Zoster)
Some v iral
proteins made to
maintain latency
Chickenpox
Chronic infection
(hepatitis B)
Noninfectious
Shingles
Vira l shedding
L()
Fatigue
Chapter 4 - 8
Chapter 4 Virology
Microbiology
In Utero
At Birth
Infants
Children
Adolescents
and
Young Adults
Adults
Senior
Citizens
Cytomegalovirus
Rubella---+
Rubella - - - - - - - - - - +
HSV 2 - - - - - - - - +
HSV2----------+
HIV----------+
H I V - - - - - - - - - - - - - - -+
819 virus - - +
819 - - +
Hepatitis 8-+
Hepatitis 8 - - - - - - - - - - - - - -
HSV1-----------------------------+
Respiratory
syncytial-------------------------------------~
(bronchiolitis)
Parainfluenza
(croup) -------------------------------------- +
(colds)
Rotavirus
(infant
diarrhea)
Influenza --------------~----------+
Measles---------------+
M u m p s - - - - - - - - - - - - - --+
Hepatitis A - - - - - - - - - - - - - - +
Epidemic gastroenteriti s - - - - - - - - - - - - - - - +
(Norwalk virus)
Varicella
(chickenpox)
Zoster
St. Louis
encephalitis
WNV
(West Nile
virus)
Chapter 4- 9
Microbiology
Chapter 4 Virology
Not virus-specific
Produced by virus-infected cells
Inhibit viral protein synthesis in nearby cells by
Activation of an RNA endonuclease
Activation of a protein kinase that then inactivates eiF2
~
'
Interferon
produced
and
released
'-....Antiviral
protein
halts virus
production
Jy,__Clinical
Application
-'"~
Infected Cell
Interferon-Treated Cell
I FN-y: Chronic
granulomatous disease .
1.4.1 Mutation
Most DNA viruses use the DNA synthetic machinery of their
host cell and benefit from the proofreading and error-correcting
mechanisms that are built into those systems. The larger DNA
viruses (adenovirus, herpesvirus, poxvirus) encode their own
DNA polymerases, which are more error prone than those of their
eukaryotic counterparts.
RNA virus replication is fraught with even more mutation, because
viral RNA polymerases possess no proofreading capacity. This
provides this group of viruses with impressive genetic plasticity
to evolve successful strains in the face of changing environmental
pressures. The origination of genetic variants due to mutational
change is referred to as antigenic drift.
@ OeVry/Becker Educational Development Corp. AU rights reserved.
Chapter 4-10
Chapter 4 Virology
Microbiology
Animal
Human
New progeny
In same cell
+
In same cell
Progeny
Chapter 4- 11
Chapter 4 Virology
Microbiology
+
In same cell
Progeny
1.4.5 Complementation
When two related, defective viruses infect one cell, progeny viruses
can be produced as long as their defects are in different genes,
because they can "complement" one another by sharing gene
products. However, if both defective viruses lack the same essential
gene product, no viral progeny are formed and the result is abortive
infection .
In same cell
Progeny
=:Ill~
No C gene product,
thus no virus made
In same cell
A Figure 4-1.40 Complementation
Chapter 4- 12
Microbiology
Ch apter 4 Virology
B cell lymphomas
Hepatocellular carcinoma
T cell leukem ia
Hepatocellular carcinoma
DNA
Hepatitis B virus
HTLV-1
RNA
Hepatitis C virus
Chapter 4- 13
Chapter 4 Virology
Extracellula~
Microbiology
Growth Signal
EBNA---+
activates
p53
CDK4
Cyclin D
HTLV-1
inactivates
-activates---+
~ activates
p21
--:--- E6
inactivates
E7 of HPV
- - - inactivates
""'
l -------.
CDK2
Gl/S
Checkpoint
G1
CDK
= CycUn-Dependent Kinase
.A. Figure 4-1.5 Viral Oncogenesis and Cell Cycle Regulation
Chapter 4-14
Chapter 4 Virology
Microbiology
Maraviroc
(entry)
absorption~::::===========:::::
Amantadine
Raltegravir
(integration)
DNA polymerase inhibitors
(ciclovir or cyclovir drugs)
Viral
release
Neuraminidase
inhibitors
(zanamivir,
oseltamivir)
Nucleic acid
Reverse transcriptase inhibitors
synthesis ---1+-1 ("ine" drugs)
RNA polymerase inhibitor
( ribavirin)
Antisense inhibitor of
Protein
mRNA synthesis
Viral ---synthesis
(fomivirsen)
assembly
and processing
Host Cell
Protease
inhibitors
(Inavir drugs)
Chapter 4-15
Chapter 4 Virology
Microbiology
Hepatotropic Viruses
2.1 Distinguishing Characteristics
The symptoms of viral hepatitis are similar regardless of the viral
etiology: Fatigue, loss of appetite, nausea, pain and fullness in
the right epigastric region, clay-colored stools, darkening of urine,
and jaundice. It is important to distinguish between these agents
serologically to evaluate prognosis and predict sequelae of infection.
Family and
M
h
orp o 1ogy
T
. .
ransmss1on
cl .
1n1ca1
Picornavirus
ss(+ )RNA,
naked,
icosahed ral
Fecal-oral
Hepadnavirus
Partially
dsDNA, circular,
enveloped,
icosahed ral,
carries DNA
polymerase
(reverse
transcri ptase)
enzyme
Sexual,
parenteral
Flavivirus
ss(+ )RNA,
enveloped,
icosahed ral
Sexual,
parenteral
Anicteric or asymptomatic
acute infection, 85%
Hepatitis D
Defective,
circular ssRNA
vir us with HBsAg
envelope
Sexual,
parenteral
Hepatitis E
Hepevirus
ss( + )RNA,
naked,
icosahedral
Fecal-oral
Hepatitis B
Hepatitis C
T
reatment
Pooled
immunoglobulins
Supportive care,
killed vaccine
chronic hepatitis
10% chronicity adults,
9 0% infants
Primary hepatocellular
carcinoma, cirrhosis
Liver injury due to cellmed iated immunity
Anti-HAV
lgM =Active
disease
HBsAg plus
Su pportive for
acute infection,
lgM antichronic cases
HBcAg
may respond
to a-IFN and
lamivudine
Prevention :
Recombinant DNA
vaccine contains
HBsAg; blood and organ -donor
screening
a-IFN, ribavirin
Prevention :
Vaccine unlikely
because of
genomic
mutability
EIA and
Western blot
for anti-HCV
antibod ies,
often negative
for up to 4
months
IFN-alpha and
lamivudine
Prevention:
Hepatit is B
vaccine
HbsAg plus
anti -HDV
Supportive
Serology
chronicity
No. 1 infectious cause of
chronic liver disease and
liver transplantation
Cirrhosis, primary
hepatocellular carcinoma
D'
1agnos1s
Chapter 4-16
Chapter 4 Virology
Microbiology
Genomic DNA
(double-stranded with
partial single strand)
Envelope lipid
(from host cell)
Nucleocapsid
(viral ca~>sid )--i-t--1
Hepatitis
B surface
antigen
( HBsAg)
Viral DNA
polymerase
(reverse transcriptase)
Hepatitis B e antigen
(HBeAg)
Chapter 4-17
Microbiology
Chapter 4 Virology
Jaundice
HBs
window
Anti-HBs
Anti-HBc
~Anti-HBe
Virus
shedding
12
Fatigue
Anti-HBc
Anti -HBe
1 2 3 4 5 6
Month s
1 2 3 4 5 6 7 8 9
Years
Chapter 4-18
Chapter 4 Virology
Microbiology
HBcAg
HBcAb
HBeAg
+
+I-
HBeAb
HBsAg
HBsAb
-I+
+
+
Chapter 4-19
Microbiology
Chapter 4 Virology
DNA Viruses
3.1 Summary of Characteristics
DNA viruses:
Are double-stranded, except parvovirus.
Replicate in the nucleus (create intranuclear inclusion bodies),
except poxvirus.
Are icosahedral, except poxvirus.
Parvovirus
ssDNA
No
Naked
Nucleus
B19 (fifth
disease)
Papillomavirus
dsDNA circular
No
Naked
Nucleus
HPV
Polyomavirus
dsDNA ci rcular
No
Naked
Nucleus
JC, BK
Adenovirus
dsDNA linear
No
Naked
Nucleus
Adenovirus
Hepadnavirus
Partial dsDNA
circular
Yes 1
Envel ope
Nucleus, RNA
intermediate
Hepatitis B
Herpesvirus
dsDNA linear
Envelope
(nuclear)
Nucleus: Virus
assembles in the
nucleus
Cytopl asm
Variola (virus),
Vaccinia
(vaccine),
Molluscum
contagiosum
Poxvirus
dsDNA linear
Yes 3
Envelope
1. Hepadnavirus carries a DNA polymerase that has RNA-dependent DNA polymerase, DNA-dependent DNA
polymerase, and RNase H activit ies (reverse transcriptase).
2 . The herpesvirus genome encodes two ear ly proteins: A DNA polymerase and a thym idi ne kinase involved in DNA
replication. Both of these are important targets of antiviral chemotherapy, but they are not carried with the virus
into the cell.
3 . Poxvirus carries a DNA-dependent RNA polymerase with it into the cell since it intends to replicate DNA in the
cytoplasm. I n addition, the genome encodes both DNA and RNA polym erases.
Chapter 4-20
Chapter 4 Virology
Microbiology
Cytoplasm
V1rrons mature
(Onl y herpes
viruses assemble
iM ide nuCleus)
5
L<'lte translaton;
capsid proteins
a re syn:heszed
4
Late transcnpto'i
DNA is repllcatea
translator~;
Diagnosis
Serology, PCR
Chapter 4- 21
Microbiology
Chapter 4 Virology
3.4.2 Papillomaviridae
Human Papillomavirus
Characteristics
dsDNA, circular
Naked, icosahedral
Transmission
Pathogenesis
I nfects basal layer of skin and mucous membranes
Hyperkeratosis leads to warts
Viral oncoproteins E6 and E7 cause cell cycle dysregulation and
neoplastic transformation
E6 binds and promotes degradation of p53 (tumor suppressor)
E7 binds and ant agonizes p105RB (retinoblastoma)
Causes koilocytosis, benign condylomas, or carcinoma
Clinical Syndromes
Plantar warts: Serotype 1
Comm on warts: Serotypes 2 and 4
Anogenital warts (condy loma acuminata), laryngeal papillomas:
Serotypes 6 and 11 (benign)
Cervical intraepit helial neoplasia, penile cancer: Serotypes 16, 18,
31 , 35 (preneoplastic)
Diagnosis
Cutaneous warts: Clinical grounds
Anogenital: Koilocytot ic cells on Pap smear
(perinuclear vacuolizat ion and nuclear enlargement)
DNA probes and PCR
Treatment
Cytotoxic: Podophyllin, podophyllotoxin,
5-fluorouracil, and trichloroacetic acid
Laser or liquid nitrogen
Cervical lesions: Electrocaut ery
Carcinoma: Radiat ion therapy or surgery
Prevention
Safe sex (not a perfect solut ion, virus may be
transmitted by skin flakes)
Vaccine: Made by recombinant DNA, L1 capsid
proteins from serotypes 6, 11, 16, and 18
CWl1/l'f.WIIf/age ftxoslodc
Chapter 4-22
Chapter 4 Virology
Microbiology
3.4.3 Polyomaviridae
BK Virus
Transmission
JC Virus
Transmission
Pathoge ne sis
Targets oligodendroglia! cells in the brain (also spread widely in
lymphocytes)
Giant astrocytes with intranuclear inclusions
Foci of demyelination
Clinical Syndrome
Progressive multifocal leukoencephalopathy in AIDS
Hemiparesis, hemianopsia, cognitive deterioration
Diagnosis PCR of brain or CSF
Chapter 4- 23
Microbiology
Chapter 4 Virology
3.4.4 Adenoviru s
Characterist ics dsDNA, naked, icosahedral
Transmission
Pathogenesis
Epithelial cell necrosis and mononuclear infilt ration
Penton fibers act as hemagglutinins and are cytotoxic
E3 protein inhibits MHC class 1 expression
E1A prot ein makes cells susceptible to TNF and other cytokines
Clinical Syndromes
Upper resp iratory disease in children-most common serotypes
3 and 7
Acute respiratory disease-most commonly serotypes 3, 7, 14
Keratoconj unctivitis- serotypes 3, 19
Acute hemorrhagic cystit is- serotype 11
Conjunct ivitis- serotype 19
Infant ile watery diarrhea or intussusception- serotypes 40 and 41
Diagnosis Serology
Treatment Supportive
Prophylax is Live, non-attenuated vaccine delivered by enteric
capsule, in military use only
Chapter 4-24
Chapter 4 Virology
Microbiology
Pathogenesis
HSV- 1 and -2 infect and replicate in mucoepithelial cells and
produce lytic, productive infection
HSV-1 is most common above the waist
HSV- 2 is most common below the waist
Latency is established in sensory ganglia
HSV-1 in trigeminal, superior cervical, and vagal nerve ganglia
HSV- 2 is most common in sacral (52- 53) ganglia
Stress causes recurrence
Syncytia formation protects from immunoglobulins
Clinical Syndromes
Gingivostomatitis: Painful, recurring blister-like skin vesicles
Eczema Herpeticum : Children with eczema or at opic dermatitis
Keratoconjunctivitis: Dendritic ulcers may lead to blindness
Meningoencephalitis: Focal temporal lesions; 70% mortality if
untreated
Genital Lesions: Painful vesicular lesions, potential for
transmission during parturition
Neonat al Herpes: Disseminated; encephalitis, skin lesions, high
mortality
Chapter 4- 25
Chapter 4 Virology
Microbiology
Diagnosis
Oral or genital lesions: Clinical, Tzank smear to fi nd syncytia at
t he base of vesicular lesions, Cowdry type A inclusions
Virus culture
a~ w
.t!
I
oi
~
!
~
>i
I:S
Varicella-Zoster Virus
Transmission
Pathogenesis
Infection of upper respiratory tract leads to
rep lication in regional lymph nodes
Primary viremia causes spread into the
reticu loendothelial system
Secondary viremia associated with T
lymphocytes causes infection of skin
Latency in dorsal root ganglia
Reactivation due to stress
Clinical Syndromes
Varicella (chickenpox)
Fever, malaise, and headache
Asynchronous rash starts on the face and
trunk and spreads to the entire body (red
base with fl uid-filled vesicle on top)
Pruritic
<$) DeVry/Becker Educational Developm ent Corp. All rights reserved.
NalrtMIII'nage<,'~
Chapter 4 - 26
Microbiology
Chapter 4 Virology
Zoster/Shingles
Reactivation of latent infection from dorsal root
ganglia
Fifth or sixth decades of life
Rash with burning and paresthesia along a single
dermatome
Ii
Epstein-Barr Virus
Transmission
seropositive)
Pathogenesis
Virus infects B lymphocytes and nasopharyngeal epithelial cells
Chapter 4- 27
Microbiology
Chapter 4 Virology
Symptoms
Treatment
Supportive care
Acyclovir for hairy oral leukoplakia
""'"'111::::~- EA
Cytomegalovirus
Transmission
Sexual, parenteral
Transplacental
Organ transplant, blood products
~ VCA-IgM
0123456
Months
Years
Pathogenesis
Infects vascular endothelial cells, lymphocytes, and monocytes
Latency in monocytes
Immunologic damage is hypothesized to be responsible for
severity of disease
Clinical Syndromes
The No. 1 in utero infection in the United States
1% of infants excrete CMV in urine or nasopharynx
90% appear normal or asymptomatic, but may progress to
develop sensory nerve hearing loss or psychomotor mental
retardation
Microcephaly, sensorineural deafness, thrombocytopenic purpura
(blueberry muffin baby), periventricular brain calcification, and
hepatosplenomegaly
Immunocompetent adults: Heterophile-negative mononucleosis;
80% of adults are seropositive
Immunosuppressed individuals: Retinitis (especially in AIDS),
interstitial pneumonia, colitis (especially in transplant patients),
esophagitis, and encephalitis
Chapter 4-28
Chapter 4 Virology
Microbiology
Diagnosis
Cytopat hology: Owl's eye inclusion bodies in
biopsy and urine
Cult ure of blood, urine, PCR
IgM specific fo r CMV
Treatment Ganciclovir, foscarnet, cidofovir
Prophylax is Blood- and organ-donor screening
HHV-6
Pathogenesis
T cell lymphotropic virus
Infects children 6 months to 3 years of age
Clinical Syndromes
Roseola infantum, exanthem subitum, sixth disease
Abrupt onset of high fever
Erythematous maculopapular rash, begins on the
face and trunk after fever breaks
React ivational disease in transplant recipients pneumonia, meningoencephalitis, bone marrow
suppression
Diagnosis Serology or PCR
Chapter 4- 29
Chapter 4 Virology
Microbiology
Direct contact
gang lia
Gingivostomatitis
Keratoconjunctivit is
Encephalitis (No. 1
cause of viral
encephalitis in the
U.S.)- focal temporal
lesions, RBC in CSF,
high opening pressure
Herpes simplex
virus-2 (HSV-2)
Varicella-Zoster
virus
Epstein -Barr
virus (EBV)
Direct
contact;
sexual
transmission
Sacral gangl ia
Tzanck test:
Acyclovir
Reveals
Valacyclovir
multi nucleated
Famciclovir
giant cells and
Condom use
intranuclear
inclusion bodies
Viral culture
Polymerase chain
reaction
Tzanck test
Acyclovir
Valacyclovir
Viral culture
Polymerase chain Famciclovir
reaction
Dorsal root
asynchronous vesicular gang lia
rash
Respiratory
d roplets,
contact with
ruptured
vesicles
Varicella (chickenpox)-
Intimate
contact, saliva
Tzanck test
Vesicles a re
Acyclovir
Valacyclovir
described as
Famciclovir
dew d rops on
Live, attenuated
the top of a rose
ch ickenpox
petal: A red base
vaccine
with fluid -filled
Sh ingles vaccine
vesicle on top,
asynchronous
Zoster immune
rash
globulin
B lymphocytes
Nasopharyng eal
carcinoma
Hodgkin lym phoma
Condom use
Elevated
heterophile
antibod ies
"Atypical
lymphocytes"
Serology: IgM
against viral
capsid antigens
(VCA)
Supportive
Serology
Gancyclovir
Foscarnet
Cidofovir
Owl's eye
intranuclear
inclusion bodies
PCR
Human
Herpesvirus 6
(HHV-6)
Close personal
contact;
infants to 3
years o ld
HHV- 7
None
HHV-8 (KSHV)
Sexual and
nonsexual
transmission
IFN-o.
Cofactor in formation of
Kaposi sarcoma, turns on
VEGF
Ganciclovir,
foscarnet (virus
has no thymidine
kinase, but a
d ifferent kinase
product of UL97)
Chapter 4-30
Chapter 4 Virology
Microbiology
Smallpox Virus
Transmission
Respiratory droplets
Pathogenesis
Virus ent ers through small breaks in skin, localized infection
Hyperplasia, ballooning degeneration, and acanthosis of epidermis
Painless, wart-like umbilicated lesions with central caseation/
indentation
Clinic al Syndrome
Children in general, young athletes or AIDS patients
Small, pink, benign wart-like tumors or umbilicated flesh -colored
papules
Diagnosis
Clinical
Molluscum bodies ( large, eosinophilic cytoplasmic inclusions found
in superficial epithelial cells)
Treatment
Curettage
Self-limiting in immunocompetent hosts
Ritonavir, cidofovir in immunocompromised patients
OeVry/Becker Educational Development Corp. All rights reserved.
Chapter 4- 3 1
Chapter 4 Virology
Microbiology
ss( + )RNA
Linear
Nonsegmented
No
Naked
Icosahedral
Cytoplasm
Coxsackie
Echovirus
Enterovirus
Hepatitis A
Poliovirus
Rh inovirus
Calicivirus
ss(+ )RNA
Linear
Nonsegmented
No
Naked
Icosahedral
Cytoplasm
Nero-like virus
Norwalk agent
Hepevirus
ss( + )RNA
linear
Nonsegmented
No
Naked
Icosahedral
Cytoplasm
Hepatitis E v irus
Flavivirus
ss( + )RNA
Linear
Nonsegmented
No
Enveloped
Icosahed ral
Cytoplasm
Dengue
Hepatitis C
St . Lou is
encephalitis
West Nile virus
Yellow fever
v irus
Togavirus
Enveloped
lcosahed ral
Cytoplasm
Ru bella
ss( + )RNA
linear
Nonsegmented
No
Coronavirus
ss(+)RNA
Linear
Nonsegmented
No
Enveloped
Helical
Cytoplasm
Coronavirus
SARS-CoV
Retrovirus
Diploid
ss( + )RNA
linear
Nonsegmented
RNA-dep. DNA
polymerase
Enveloped
lcosahed ral
or truncated
conica l
Nucleus
HIV
HTLV Sarcoma
EEE
VEE
WEE
Chapter 4-32
Chapter 4 Virology
Microbiology
~~
ss( + )RNA (
rr
--~- - +
SS(+)RNA
~--~
,.J,
.j
Translation
3'AAA
ss(-)RNA
SS(+)RNA
~ v ~ u ~
RNA-dependent
RNA polymerase
~ ~ ~
l and,
y
Released by lysis
or budding
Enterovirus Genus
Fecal-oral transmission
Stable in acid
Replicate best at 37oc
Leading cause of aseptic meningitis
Infection begins in oropharyngeal mucosal cells and lymphoid tissue
Virus moves into intestinal mucosa and gut lymphoid tissue
Viremia causes dissemination throughout the body
Diagnosis by serology or virus culture
Treat ment supportive and symptomatic
Chapter 4- 33
Chapter 4 Virology
Microbiology
Echoviruses
Aseptic meningitis
Poliomyelitis-like muscle weakness
Exanthems
Conjunctivitis
Poliovirus
Rhinovirus Ge nus
Characteristics
Acid -labile
Grows best at 33oc
More than 100 serotypes
Most common cause of common cold
Virus receptor is ICAM-1
Peak incidence summer and fa ll
Chapter 4-34
Chapter 4 Virology
Microbiology
(discussed previously)
4.4.2 Calicivirus
Characteristics
ss(+)RNA
Naked, icosahedral
Norwalk Virus
Chapter 4- 35
Chapter 4 Virology
Microbiology
Tropical geography
Aedes mosquito
Acute onset of high fever, headache, myalgias
Hemorrhagic fever
Break-bone fever
Tropical geography
Aedes mosquito
Hemorrhage and degenerat ion of liver, kidney, and heart
Live, attenuated vaccine for travelers to endemic area
Chapter 4 - 36
Chapter 4 Virology
Microbiology
Rubella Virus
Transmission Respiratory
droplets, transplacent al
Pathogenesis
Virus infects upper
respiratory tract,
replicates locally
A Figure 4-4.5A & B Rubella Rash: Day 1 (/eft) and Day 3 (right)
Serology, PCR
Chapter 4- 37
Chapter 4 Virology
Microbiology
4.5.3 Coronaviru s
Characteristics
ss(+ )RNA
Enveloped, helical
Coronavirus
Second most common cause of the common cold
Winter-spring peak incidence
Chapter 4-38
Chapter 4 Virology
Microbiology
4.5.4 Retroviruses
Characteristics
ss( +)RNA, diploid
Enveloped, modified icosahedral
Virion-carried RNA-dependent DNA polymerase
Oncovirus Group
Human T Cell Leukemia Virus 1 and 2
Transmission
Sexual, parenteral
Geography: Japan, Caribbean, and Central Africa
Pathogenesis
The virus binds to CD4 T lymphocytes
Viral Tax protein increases production of IL-2 and IL-2 receptors
4. 5. 5 Lentivi ruses
Human
Immunodeficiency
Virus (HIV)
p 1700 Matrix
Characteristics
ss( +)RNA, diploid
Enveloped, icosahedral
Truncated conical capsid
Carries RNA-dependent
DNA polymerase, integrase
and protease enzymes
Binds to CD4 and
uses CXCR4 and CCRS
chemokine coreceptors
p249"9 Capsid
Reverse
transcriptaseool
Upid bilayer
( host-derived)
Chapter 4-39
Microbiology
Chapter 4 Virology
VPR REV
REV
I I
II
GAG
VIF TATVPU
LTR
POL
TAT
ENV
NEF
LTR
gp120
gp41
p24
Capsid antigen
p7p9
Nucleocapsid proteins
pl7
Matrix protein
lntegrase
Protease
Env (envelope)
Pol (polymerase)
Reverse t ranscriptase
tat
I
Lon g term inal repeats in
DNA (U3, US)
ITat
rev
Rev
nef
Nef
vpu
Vpu
vpr
Vpr
vif
IVif
Chapter 4-40
Chapter 4 Virology
Microbiology
Membrane
fusion
.-- s.
7
ooooooooc
~
55(+}~~~
--
,,
\.
l~
Assembly
Chapter 4-41
Chapter 4 Virology
Microbiology
HIV-infected
cell dies
Cellular
debris
processed
Antigen
presenting cells
can be B cells,
M0, dendritic cells
Kills
infected
CD4+
cells
......... .
.........
IL-4
Helper T
lymphocyte
(ThO)
........... . .
~
r,
..
Helper T ,
',
lymphocyte ', IFN-y
(Th2)
' inHibits
',
"',... proliferation
"'...
Helper T
lymphocyte
!L-10 inhibits
(Thl)
production
:
.....................:.
.........
J
.
...
...
..
-.....
B lymphocyte
......
~ ~
#..
:
.-
Can be
monocyte,
PMN, M0, or
NK cells
*IFN v
'
,
-
'
ll-2
TNF-~
Cytokines
Plasma cell
: !FN-y
ll-2
: TNF-li
: Cytokines
NK cell
'IFN -y
: IL-2
....
..
"'
, TNF-n
:
1:'
, Cytokmes
:
Cytotoxic
T lymphocyte
(Tc)
~ IFN-y
't
Macrophage
-r ~ t-
<'"
Antibodies
ADCC
.,.,,....(
Humoral
Immunity
May be
useful effector;
but weak response
without Thl
cytokines
Kills infected
macroppages
Cell-Mediated Immunity
A Figure 4-4.5H The Global Effects of HIV Infection on the Immune Response
Chapter 4-42
Chapter 4 Virology
Microbiology
Acute Infection
Infection in macrophages is established. These cells resist the
cytopathic effect s of the virus, but serve as a reservoir of infection,
and contribut e t o t he spread of the virus throughout the body.
A st rong immune response against the virus produces antibodies,
and cytotox ic T cells seem to control the virus for a t ime.
This stage of disease may be asymptomatic or present with
mononucleosis-like symptoms and lasts from two t o six weeks.
The normal value of CD4 T cells in the blood at this time is
SOO to 1200/iJL.
Clinical Latency
Ant ibodies against vira l proteins contribut e t o t he decline of
v iremia, but t he virus cont inues to replicat e rapidly in infected cells.
Latency is controlled by specific viral proteins: tat and rev genes
upregulat e viru s production.
The length of lat ency varies between patients, but generally lasts
until the CD4 cell count falls below 600 CD4 cells/iJL.
Early Symptomatic
Ongoing mutation during infection allows escape from the immune
response and leads to antiviral drug resist ance.
There is a shift in viral preference from CCRS to CXCR4 co-recept ors
(found primarily on Th cells).
CD4+ T cells are lost through viral lysis, fragility of fused Th cell
syncyt ia, CDS+ T cell killing, complement mediated lysis, and
apoptosis.
The CD4 T cell count fa lls below 400/iJL, IgG antibodies against
p24 antigen can no longer be produced, and the viremia returns.
Constitutional symptoms such as fever, diarrhea, fatigue, and
weight loss begin .
Mild opportunistic diseases such as bacillary angiomatosis, oral
and vaginal candidiasis, listeriosis, etc., increase in incidence.
Acquired Immunodeficiency Syndrome (AIDS)
As CD4 + T cells fall below 200 per IJL, virus tit er rises rapidly
and the remaining immune response (including CDS+ T cells)
col lapses.
Patients are now susceptible to severe opportunistic infections
such as Pneumocystis pneumonia; candidiasis of the esophagus,
bronchi, trachea, or lungs; histoplasmosis; atypical mycobacterial
infection;
cryptosporidiosis;
and cerebral
toxoplasmosis.
.
k'lU~7Ll f
0:
}
Figure 4-4.51 Kaposi Sarcoma,
Skin Lesions
OeVry/ Becker Educat ional Development Corp. All rights reserved.
~~~r::J
Chapter 4-43
Microbiology
Chapter 4 Virology
> 1,000
(Excludes conditions
in Band C);
Acute (primary) or
asymptomatic HIV
infection;
Persistent
genera lized
lymphadenopathy
Symptomatic but
not conditions in C;
Condition attributed
to HIV infection
or indicative of
a defect in cell mediated immunity
AIDS-defining
conditions
> 500
Al
Bl
Cl
2 0 0 - 4 99
A2
B2
C2
< 200
A3
B3
C3
Chapter 4-44
Microbiology
Chapter 4 Virology
Abacavir (ABC)
Delavirdine
Amprenivir
Didanosine (ddl )
Nevi rapine
lndinavir
Efavirenz
Atazaniv ir
Emtricitabine (FTC)
Nelfinavir
Stavudine ( d4T)
Ritonavir
zalcitabine (ddC)
Saquinavir
Enfuvirtide
(T-20) Fuzeon
Maraviroc
(CCRS
antagonist)
Raltegravir
Tenofovir (nucleotide
prophylactic)
< 2 00
< 100
Pneumocystis jirovecii
Trimethoprim sulfamethoxazole
Histoplasma capsulatum
(in the endemic area)
Itraconazole
Toxoplasma gondii
Trimethoprim sulfamethoxazole
Cytomegalovir us
Ganciclovir, valganciclovir
Cryptococcus neoformans
Fluconazole
Cryptosporidium parvum
< 50
Chapter 4-45
Microbiology
Chapter 4 Virology
Fusion with
lysosome
~ ss(-}RNA
ss(- }RNA
ss( - }RNA
""
Replication
-~t'"""Late
Proteins
~s(+}RNA
t- y
;,7.;~~
Early Proteins
Chapter 4-46
Chapter 4 Virology
Microbiology
Para myxovirus
ss( - )RNA
Linear
Nonsegmented
Yes
ss( - )RNA
Linear
Nonsegmented
Yes
Bullet-shaped,
helical
Cytoplasm
Helical
Cytoplasm
Rabies
Vesicular stomatit is
v irus
Mumps
Measles
Respiratory syncytial
v irus
Parainfluenza v irus
Filov irus
ss(- )RNA
Linear
Nonsegmented
Yes
Helical
Cytoplasm
Marbu rg
Ebola
Arenaviru s
ss( - )RNA
2 segments:
end-to-end circle,
ambisense
Yes
Helical, ribosomes
in virion
Cytoplasm
Lymphocytic
ss(- )RNA
Linear to circular
3-segmented
Yes
ss( - )RNA
Linear
a-segmented
Yes
Bunyavirus
Orthomyxo virus
Helical
Cytopl asm
California encephalitis
LaCrosse encephalitis
Hantavirus
Helical
Cytoplasm
and nucleus
Influenza
Rabies Virus
Transmission Bite or contact with reservoir animal
Raccoon: East of the Mississippi River
Skunk: West of the Mississippi River
Pathogenesis
Virus binds to nicotinic acetylcholine receptors of nerve or muscle
cells at the bite site
Virus moves by retrograde axoplasmic transport to the dorsal root
ganglia and spinal cord
Spread to the brain causes encephalitis, coma, and death
Clinical Syndrome
Prodromal stage with pain or it ching at t he site of the wound
Fever, headache
Neurologic sympt oms: Salivation, hydrophobia, seizures,
hallucinations, paralysis, coma, and death
Chapter 4- 47
Microbiology
Chapter 4 Virology
Diagnosis
Clinical
Direct fl uorescent antibody test of corneal epithelial cells
PCR
Brain biopsy: Negri bodies (eosinophilic intracytoplasmic
inclusions)
Treatment
5.4.2 Paramyxovirus
Characteristics
Negative-sense, ssRNA
Helical, enveloped, nonsegmented
All are syncytial viruses (possess a fusion protein)
Measles Virus
Characterist ics
Single serotype
Hemagglutinin and fusion protein, but no neuraminidase
A Figure 4 -5.48
Electron Micrograph
of Measles Virus
Transmission Aerosol
Pathogenesis
The virus replicates in the respiratory tract following inhalation
It moves into the lymphatic tissues and t he blood, causing viremia
It infects T and B lymphocytes, monocytes, and neutrophils without
cytolysis, but with impairment of their immunologic function
A Figure 4 -5.4C
Koplik Spots
Clinical Syndromes
Measles
Cough, coryza and conjunctivitis,
fever, malaise, photophobia
Koplik spots (small red-based
lesions with blue-white centers
in mouth)
Nonpruritic, maculopapular rash
begins on the face and spreads to
the trunk and extremities
Giant cell pneumonia
(Warthin-Finkeldey cells)
Chapter 4 - 48
Chapter 4 Virology
Microbiology
Mumps Virus
Characteristics
Single hemagglutinin-neuraminidase glycoprotein, fusion protein
Single serotype
Tra nsmission
Respiratory droplets
Pathogenesis
Virus rep licates in the respiratory tract, lymphoid tissue, and
bloodstream
It then spreads to the salivary glands, kidney, and CNS
Tissue response is cell necrosis and inflammation with
mononuclear cell infiltration
Clinical Syndromes
Fever, anorexia, malaise, myalgia, and inflamed, tender parotid
glands (parotitis)
Secondary complications can include pancreatitis, orchitis in adult
males, meningoencephalitis, and polyarthritis
CDql'aiJ1da~
A Figure 4-5.4E
Mumps-Associated
Parotitis
Diagnosis
Clinical, amylase may be elevated
Virus isolation from saliva, CSF, urine
Serology: EIA
Treatment Supportive care
Prevention
Chapter 4- 49
Microbiology
Chapter 4 Virology
Parainfluenza Virus
Characteristics
Single hemagglutinin-neuraminidase glycoprotein
Fusion protein
Transmission
Respiratory droplets
Pathogenesis
Similar to influenza viruses
Subglottic airway obstruction leads to inspiratory stridor, dyspnea,
hoarseness, and a "seal bark" cough
Clinical Syndrome
Croup (laryngotracheobronchitis), bronchiolitis, and pneumonia
Children 6 months to 3 years
Diagnosis PCR or serology
Treatment Supportive
Respiratory droplets
Pathogenesis
Infection is confined to the respiratory epithelium; viremia occurs
rarely
Th2 responses may cause more severe disease
Necrosis of epithelial cells, interstitial mononuclear infiltrates,
m ultinucleated giant cells
Clinical Syndrome s
Bronchiolitis and pneumonia in infants 6 weeks to 6 months of age
Cough, tachypnea, respiratory distress, hypoxemia, and cyanosis
Adults: Common cold
Diagnosis
I mmunofluorescence, PCR
Syncytia formation in cell culture
Treatment Supportive care
Prophylaxis Palivizumab (monoclonal against fusion protein) is
given prophylactically to high-risk groups
Chapter 4 - 50
Chapter 4 Virology
Microbiology
5.4.3 Filovirus
Characteristics
ss(- )RNA, nonsegmented
Enveloped, helical
Filamentous
Transmission Reservoir in African simians and Old World rodents;
direct contact, blood, secretions
Clinical Syndromes
Marburg fever and Ebola fever
Fatal hemorrhagic fevers
Replicate in vascular endothelium and cause necrosis
Diagnosis
EIA, PCR
Chapter 4- 51
Microbiology
Chapter 4 Virology
Lassa fever
Fever, hemorrhagic
shock, neurologic
disturbances,
bradycardia,
hepatitis, myocarditis,
deafness
Supportive, ribavirin
Lymphocytic
choriomeningitis
virus
Fever, headache,
myalgia, meningitis,
meningoencephalitis
History of rodent
contact, serology
Supportive, ribavirin
5.5.2 Bunyavirus
Characteristics
ss(- )RNA, three segments
Enveloped, helical
T Table 4-5.58 Bunyaviruses
Virus
Diagnosis
Treatment
Hantavirus (Sin
Nombre virus)
Inhalation from
nesting rodent
excretions, spring
months
Four-corners states
(Utah, New Mexico,
Colorado, Arizona),
acute pulmonary
edema, effusion,
35% mortality
Serology, PCR
Respiratory support,
ribaviri n experimental
California and La
Crosse encephalitis
viruses
Chipmunks, Aedes
mosquito
Encephalit is with
seizures, 5- 18
year olds, Midwest
(Wisconsin, Ohio,
Minnesota, Indiana,
and West Virginia)
Serology
Supportive
Chapter 4-52
Chapter 4 Virology
Microbiology
5.5.3 Orthomyxoviru s
Characteristics
ss(- )RNA, eight segments.
Enveloped, helical.
Requires cell nucleus to cannibalize capped 5' termini of cellular
RNA for use as primers for viral mRNA transcription.
Genetic drift (influenza A and B): Mutat ional changes in
hemagglutin and/or neuraminidase molecules lead t o epidemics.
Genetic shift ( influenza A): When animal and human influenza
v iruses co-infect a cell, accident al reassortment of the segments
of t he genomes can lead t o the sudden appearance of progeny
v iruses that are drastically different from their parent al strains.
This can cause pandemics of disease because of t he lack of "herd
immunity" to this new variant. The 2009 HlNl ("swine flu") virus
was a quadruple reassortment virus: North American swine,
avian, and human plus Asian/European swine.
H-hemagglu tinin
N-neuraminid ase
Polymerase
compl ex
Lipid bilayer
membrane
M protein
Helica l nucleocapsid
(RNA plus NP nucleocapsid protein)
A. Figure 4-5.58
Electron Micrograph
of Influenza Virus
Chapter 4 - 53
Chapter 4 Virology
Microbiology
Influenza Virus
Transmission Aerosol
I nfluenza A reservoir: Humans, pigs, birds
I nfluenza B reservoir: Humans only
Pathogenesis
Hemagglutinin molecule mediates attachment to sialic acid
containing glycoproteins or glycolipids on resp iratory cell surfaces
Virus multiplies in ciliated respiratory epithelial cells causing death
and desquamation of both mucus-producing and ciliated cells
Loss of the mucociliary escalator makes the patient prone to
bacterial superinfection
Neuraminidase splits off t he t erminal neuraminic (sialic) acids
preventing possible multiple infections of one cell, and also plays
an important role in viral release
Clinical Syndromes
I nfluenza
Abrupt onset of fever, headache, myalgias
Dry, non-productive cough
Complications
Reye syndrome
-Rash
-Vomiting
-Liver damage associated with aspirin use
Guillain-Barre syndrome
- Flaccid, ascending paralysis
- Antibodies against myelin proteins
-Causes demyelination and polyneuropathy
Diagnosis
Clinical, season
Serology
Treatme nt
Supportive
Amantadine/rimantidine: Prevent t he uncoat ing of influenza A;
current isolates are resistant
Zanamivir and oseltamivir: Neuraminidase inhibitors which can be
used for influenza A and B
Prophylaxis
Killed, inj ectable vaccine produced yearly; epidemiologic "best
guess" of two most likely A strains and one B strain; prepared
in eggs
Live, attenuated vaccine of similar composition but for intranasal
administration available for use in individuals 2 to 49 years of age
Chapter 4-54
Chapter 4 Virology
Microbiology
Linear, dsRNA,
10 - 11 segments
Yes
Naked
Icosahedral,
double shelled
Reovirus
Rotavirus
Colorado tick
fever virus
Treatment
Prophylaxis
Transmission
Syndrome
Diagnosis
Reovirus
Fecal-oral,
respiratory
Common cold,
gastroenteritis
Serology
Supportive
Hygiene
Rotavirus
Fecal-oral
Infantile watery
diarrhea
EIA
Supportive
Live, attenuated
oral vaccine
Colorado tick
fever virus
Tick-borne
{Dermacentor)
Headache,
myalgia, fever,
encephalitis
Serology
Supportive
Tick avoidance
Chapter 4- 55
Microbiology
Chapter 4 Virology
Prions-Small Proteinaceous
Infectious Particles
7.1 Characteristics
Protein encoded by a normal cellular gene (PrPc) is converted into
a disease-causing form (PrPsc) by change in conformation.
Particles are not inactivated by formalin, ionizing radiation,
boiling, or most disinfectants.
No nucleic acids or other virion structures.
Do not elicit an inflammatory response.
Cause invariably fatal subacute spongiform encephalopathies
(amyloidopathies of the brain).
Kuru
Creutzfeldt-lakob
disease
4-7 months
14 months
Gerstmann-StrausslerScheinker syndrome
Familia l, sporadic
5 years
Familial
13-2 5 months
Chapter 4- 56
Chapter 4 Virology
Microbiology
-
Chapters 3-4
'
Review Questions
Carboxypeptidases
Cell wall glycoproteins
Lipopolysaccharide
Lipoteichoic acid
Polysaccharide
2. A new laboratory technician forgets the iodine fixation step in a Gram stain of Staphylococcus.
The organisms on the slide will:
A. Appear blue
B. Appear colorless
C. Appear pink
D, Dissolve
E, Wash off
3. If a culture is inoculated to a density of 3 x 102 cell/mL at time 0 and has both a generation
and lag time of 10 minutes, how many cells/mL will there be in 40 minutes?
A, L2 X 103
B, 2A X 103
C. 4,2 X 103
D, 6 X 103
E, 3 X 106
A
A
A
A
A
5. A 3-year-old is brought to the ER for fever and difficulty breathing. When the physician walks
in the room she notices that the child is drooling, sitting upright, and leaning forward , Lung
exam shows stridor and retractions, X-ray revea ls a thickened epiglottis. The vaccine that
would have prevented this child's infection contains which of the fo llowing?
A.
B.
C.
D.
E.
Capsular polysaccharide
Killed virus
Live virus
Polyribitol phosphate plus toxoid
Toxoid
<9 DeVry/Becker
Chapter 4- 57
Chapter 4 Virology
Microbiology
r
Review Questions
Chapters 3-4
7 . A 16-year-old immigrant from Africa developed massive unilateral enlargement of his lower
face in the region of the mandible. Biopsy of the lesion demonstrated sheets of medium-sized
blast cells admixed with larger macrophages. Which of the following is the correct pairing of
causal agent and mechanism of oncogenesis for this malignant lesion?
A.
B.
c.
D.
E.
Causal Agent
Epstein- Barr virus
Epstein- Barr virus
HHV-8
HTLV-1
Human papilloma virus
Mechanism of Oncogenesis
NFKB and Bcl2 activation
t(8; 14)
VEGF activation
p16/INK4a inactivation
PS3 and Rb inactivation
8. A child with sickle cell anemia is seen in a hematology clinic. Her mother states that the child
has been feeling very tired lately. The girl is very pale and a complete blood count shows
severe anemia. A bone marrow aspirate is devoid of erythroid precursors. How does the most
likely causal agent produce its mRNA?
A.
B.
C.
D.
E.
Chapter 4- 58
Chapter 4 Virology
Microbiology
Chapters 3-4
Review Questions
9. A 4-month-old female was brought into the emergency room in severe respiratory distress,
wheezing and with fever. Her symptoms began with cough and runny nose. Her physical
exam showed a temperature of 39 degrees centigrade, a pulse of 200, and tachypnea with
respiratory rate of 35 per minute. She had significant intercostal retractions and nasal flaring.
A chest x-ray revealed interstitial infiltrates and hyperexpansion . The antiviral biological,
which can be administered prophylactically to daycare contacts, acts by which of the following
mechanisms?
A.
B.
C.
D.
E.
10.
A 25-year-old male is suffering from fatigue and jaundice. His laboratory workup is
positive for HBsAg, positive for IgG antibody to HBcAg, positive for HBeAb, and negative for
HBsAb. Which of the fol lowing is the most likely definition of his status?
A.
B.
C.
D.
E.
Acute hepatitis B
Chronic hepatitis B
Convalescent from hepatitis B
Successfully vaccinated against hepatit is B
Window period of hepatitis B
<9 DeVry/Becker
Chapter 4- 59
Microbiology
Chapter 4 Virology
Review Answers
Chapters 3-4
Chapter 4-60
Biology of Fungi
1. 1 Structure
Fungi are eukaryotic, with all the typical cellular organelles. They
differ from all other eukaryotes in that they:
Possess a rigid cell wall containing mannan , g/ucan , and chitin.
Have ergosterol as their major membrane sterol.
Chromosome
Filxillr
Chapter 5-1
Microbiology
Chapter 5 Mycology
1.3 Reproduction
Fungal reproduction may be asexual or sexual.
Asexual reproductive elements: Conidia.
Conidia that form exogenously: Macroconidia and microconidia.
Conidia that form within the hypha: Arthroconidia (conform to
shape of hypha wit h "joints" to break loose).
Sexual reproductive elements: Ascospores, basidiospores, and
zygospores.
Spores: Specialized sexual or asexual reproductive forms with
enhanced survival in the environment.
1.4 Morphology
1.4.1 Yeasts
Yeasts are single-celled fungi that grow by ext ension, constriction,
and separation of new cells from the parent. The buds formed in this
way are called blastoconidia.
1.4.2 Molds
The growth of fungi through the development of apical t ube-like
extensions generates hyphae. An intertwined mass of hyphae is
called a mycelium, and organisms that grow in this fashion are
typically called molds. Most fungal hyphae develop with septae,
cross-walls perpendicular to the cell walls dividing the cell into
subunits. Non-septate hyphae grow as a single, continuous cell with
irregularly wide filaments and without regu lar cross-walls.
Chapter 5-2
Chapter 5 Mycology
Microbiology
1.4.3 Pseudohyphae
Some fungi produce pseudohyphae that form as buds that become
elongated and fai l to detach from the parental yeast cell.
1.5 Diagnosis
1.5.1 Direct Examination
JY'-Clinical
Application
1
-1
Because fi lamentous
fungi grow apically, it
is important to sample
fungal skin lesions
for diagnosis from the
leadi ng edge in the active
growing margin.
1.5.2 Culture
Fungi are slow growing, but Sabouraud agar is most commonly used .
Yeasts are further differentiated by biochemical tests, and molds are
identified by the morphology of their conidia.
1.5.3 Serology
Not sufficiently specific or sensit ive for use.
Chapter 5 Mycology
Microbiology
Blocked by
tefbinafl ne
Pyrimidine
precursors...........-BJocked.by
~
flucytosme
Pyrimid ines
Chapter 5- 4
Chapter 5 Mycology
Microbiology
Keratinized Tissues
Versicolor
Chapter 5- 5
Chapter 5 Mycology
Microbiology
Diagnosis
Clinical: Pruritic, circular lesions on the skin, some fluoresce with
Wood's lamp
Skin scraping treated with KOH: Septate hyphae
Treatme nt
Topical tolnaftate or azoles
Nail bed and hair shaft infections: Systemic griseofulvin,
itraconazole, terbinafine
Chapter 5- 6
Chapter 5 Mycology
Microbiology
Itraconazole or amphotericin B
Chapter 5- 7
Chapter 5 Mycology
Microbiology
Systemic Mycoses
The syst emic mycoses, sometimes referred to as the classical fungal
pat hogens, are all- except Paracoccidioides, which occurs in Sout h
and Central America - problems
in AIDS pat ients in the U.S.
Histo plasmosis:
They are all believed t o be
Mssissippi and Ohio river valleys
transmitted via inhalat ion.
They may cause similar
clinical presentations: acute
pulmonary, chronic pulmonary,
or disseminated infections.
They are distinguished by
microscopic examination of
sputum or lesions, and may
also be distinguished by their
geographic incidence.
Coccidioidomycosis:
Southwestern United States
Figure 5-3.0 Geographic
Distribution of Systemic Mycoses
in the U.S.
IJJJ..
3.1
and California
Blastomycosis:
states east of Mississippt River
Blastomyces dermatitidis
Characteristics Dimorphic
Tissue form is a large yeast wit h broad-based buds and a
thick cell wall
Environmental form: Septate hyphae with round to
oval conidia
Geographic incidence coincides with histoplasmosis, but
also includes Atlantic seaboard states (North Carolina and
South Carolina) and goes north through Minnesota into
Canada
Clinical Syndrome Blastomycosis
Acute or chronic pulmonary (product ive cough, chest pain,
fever)
Skin lesions on exposed skin, necrosis and fibrosis
Chapter 5- 8
Chapter 5 Mycology
Microbiology
Itraconazole, amphotericin B
Prophylaxis in AIDS begun with itraconazole at 100 CD4
cells/f.tl in endemic area
Chapter 5- 9
Chapter 5 Mycology
Microbiology
Dimorphic fungus
Tissue phase is a yeast with multiple
blastoconidia produced on the same yeast cell
creating the appearance of a "captain's wheel"
Geographic incidence : Tropical and subtropical
areas of Central and South America
Clinical Syndromes Paracoccidioidomycosis,
South American blastomycosis: Chronic
mucocutaneous or cutaneous ulcers
Diagnosis Tissue biopsy, KOH and calcofluor,
multiple-budding blastoconidia
Treatment Sulfonamides, amphotericin B,
and azoles
Ch apter 5-10
Chapter 5 Mycology
Microbiology
unistic Mycoses
4.1
Cryptococcus neoformans
Characteristics
Monomorphic, encapsulated yeast
Antiphagocytic polysaccharide capsule
Urease positive
Transmitted via inhalation from soil enriched with bird droppings,
especially pigeons, t urkeys, and chickens
Clinical Syndromes
Meningitis: I nsidious onset, headache, irritability, behavioral
changes, seizures, fever
Pneumonia:
Asymptomatic or mild,
atypical
Diagnosis
50% of patients may have
organisms demonstrable
in sediment of CSF mixed
with India ink
Latex particle agglutination
to det ect capsular
polysaccharide in CSF
.A Figure 5-4.1A
Treat ment Amphotericin B
India Ink Preparation of
plus flucytosine, fol lowed by
Cryptococcus neoformans
an extended course of fluconazole
.A Figure 5-4.1B
Cryptococcus neoformans
Encapsulated Yeasts in Tissue
.A Figure 5-4.2
Aspergillus Conidiophores
and Conidia
Chapter 5- 11
Chapter 5 Mycology
Microbiology
Diagnosis
Lung aspiration, biopsy or lavage
Uniformly branching septate hyphae
Treatment
Voriconazole, itracona zole, caspofungin, amphotericin B
Surgical resection of fungus balls
Clinical Syndromes
Candida! Growth
Treatment
Nystatin, azoles
AIDS
Esophagitis, gastritis
Fluconazole, amphotericin B.
caspofungin
Septicemia
Fluconazole, amphotericin B,
caspofungin
IV drug users
Endocarditis
Fluconazole, amphotericin B,
caspofungin
Diabetic women
Vaginitis
Nystatin, azoles
Chronic mucocutaneous
candidiasis
Fluconazole
I
---- ~
Chapter 5- 12
Chapter 5 Mycology
Microbiology
Zygomycosis
Ribbon-Like Hyphae of
Zygomycophyta
Pneumocystis Honeycomb
Exudate
Chapter 5- 13
Biology of Parasites
Parasit es are t he m ost diverse group of organism s that cause human
disease. They range from single-celled protozoa, classified by t heir
m odes of motility, to mult icellular metazoa, classified by t heir
com plex anatomical feat ures.
Category
Am ebae
Ciliates
Flagellates
Sporozoa/
apicomplexa
Acanthamoeba
Entamoeba
Naegleria
Motility by cilia
Life cycle involves trophozoite
and cyst
Balantidium
Motility by flagella
Gastrointestinal and urogenital
forms alternate between
trophozoite and cyst
Hemoflagellates have nonflagellated (amastigote} and
flagellated ( trypomastigote} forms
Giardia
Leishmania
Trichomonas
Trypanosoma
Babesia
Cryptosporidium
Isospora
Plasmodium
Toxoplasma
Chapter 6 - 1
Chapter 6 Parasitology
1.2
Microbiology
Metazoan Parasites
Class
Characteristics
Genera
Ne mathelminthes
Nematoda
Round in cross-section
Complete digestive tract
Separa te sexes
Simpl e life cycles alternate between
egg , la rva, and adult
Platyhelminthes
Cestoda
Flattened in cross-section
No digestive tract
Hermaph roditic
Complex life cycles have egg, larvae,
and adults in separate hosts
Diphyllobothrium
Echinococcus
Taenia
Trematoda
Flattened in cross-section
Incomplete digestive tract (no anus)
Hermaphroditic (except schistosomes}
Complex life cycles have egg , larvae,
and adults in sepa rate hosts
Ancylostoma
Ascaris
Brugia
Dracunculus
Enterobius
Loa
Necator
Onchocerca
Strongyloides
Toxocara
Trichinella
Trichuris
Wuchereria
Clonorchis
Fasciola
Fasciolopsis
Paragonimus
Schistosoma
1.3 Hosts
The organism that harbors the adult or sexual stages of the parasite
is known as the definitive host. The organism that harbors larval or
asexual stages of the life cycle is referred to as the intermediate host.
Paromomycin
Chloroquine
Primaquine
IAminog lycoside
IInhibits the degradation of hemoglobin
ICryptosporidiosis
IMalaria, acute attack
Chapter 6- 2
Chapter 6 Parasitology
Microbiology
Protozoa
2.1 Mucosal (Gastrointestinal or Urogenital)
Protozoa
TTable 6- 2.1 Mucosal Protozoa
Pathogenesis
Treatment
Travel to Mexico or
t ropics, blood and
pus in stool, fever,
may produce liver
abscesses
Metronidazole with
diloxanide
Trophozoites attach
to small intestinal
mucosa, block ent ry
of small bile ducts
Trophozoites or
cysts in fresh feces,
t rophozoites w ith
falling leaf motility
Metronidazole
Obligate intracellular
Explosive diarrhea in
immunocompetent,
lasts 5-10 days;
AIDS: indolent and
persisten t
Self-limiting in
norma l patients;
paromomycin in
immunocompromised
patients
Similar to
Cryptosporidium
Self-limiting except in
AIDS
Trophozoite
Giardia Iamblia
(g iardiasis)
....\ i.~~~.i:
.
'f. .
. ..
\"
/~
Trophozoites
Cryptosporidium
parvum
( cryptosporid iosis)
~--.
I Obligate intracellular
Isospora belli
(isosporiasis)
.,
Sexual
Vaginitis after
menses; thin, yellow,
frothy discharge;
males generally
asymptomatic
Flagellate in vaginal
(or urethral) smear,
corkscrew motility
Metronidazole,
contact tracing
Chapter 6- 3
Chapter 6 Parasitology
Microbiology
Cycle in
Mosquito
Exoerythrocytic
Sporozoites migrate
into the bloodstream
Stomach
lumen
Sporozoites invade
the parenchymal
OD
\ ' v/Vax+
P. ovale
Fertilization
~'?/>
==::::~
0 ~ ' f>
\ 0.. Q,
'
Asexua I cycle
determines the
t ime between
febrile episodes
.. ... .,!"
',
Some merozoites
differentiate into
sexua Ifarms
:<..e"'\<:",},...oe
~ a.. ,
1
'0'1
' '
' '
' '
'
Blood
~es ~
':-1{'00<,0:.
e'~-ov
Latent stage
Division to form ~~~ followed by
primary tissue ~- reactivation
schizont
Mosquito
Maturation division
(:,1>:" '1.'(-..e
..
0 ..
Liver
hypnozoites
(sleeping forms)
' '
'
' '
'
Erythrocytic
schizont
~Trophozoite
- :.~.
' '
' '
Cycle in
Humans
Erythrocytic
Chapter 6-4
Chapter 6 Parasitology
Microbiology
Pathoge ne sis
There is no pathology or symptomatology associated with the
exoerythrocyt ic phase of t he life cycle.
Once erythrocytes begin to be lysed in a cyclical fashion, spikes of
fever will occur with each crop of RBCs lysed.
The fever drops as the parasites enter new red blood cells and the
cycle repeats.
Lysis of RBCs and dumping of malarial pigment (hemozoin) into
the blood cause reticuloendothelial congestion, hemolytic anemia,
and even kidney fai lure.
P. falciparum causes infected RBCs to adhere to the endothelia
of visceral capillaries, impairing microcirculation, causing tissue
hypoxia, lactic acidosis, and hypoglycemia (cerebral malaria).
Clinic al Syndrome
Chills, fever, splenomegaly, and anemia
Malarial paroxysm : Synchronized lysis of RBCs causes rigors, fever
of 40- 41. 7C, and diaphoresis, repeated in 48- or 72-hour cycles
P. vi vax and P. ovate-Benign Tertian ( 48-Hour Fever Spikes)
98.6
36
48
Hours
98.6 .
12
24
36
Hours
48
60
72
Chapter 6- 5
Chapter 6 Parasitology
Microbiology
Diagnosis
Plasmodium vivax
(85% of all cases worldwide)
P. ovale
Chloroquine resistance is a
problem, no radical cu re necessary,
recrudescence possible due to global
drug resista nee
P. falciparum
(95% of all ma larial deaths)
'
P. malariae
1.-4. Malylb.Jellush
Prophylax is
Mefloquine or doxycycline
Natural immunity
HbS heterozygote is protected from P. falciparum
Duffy blood group-negative: Cannot be infected with P. vivax
Thalassemic and ot her abnormal hemoglobins: Indigestible to
all malaria parasit es
Chapter 6- 6
Microbiology
Hemojlogellotes
Trypanosoma
brucei
rhodesiense or
T. b. gambiense
(African sleeping
sickness)
Saliva from
tsetse bite
T. cruzi
(Chagas disease,
Am erican
trypanosomiasis
Patient from
Africa w ith fever,
lymphadenopathy,
rash, headache, and
im paired mentation
Trypomastigotes
in blood or CSF
Blood stage:
suram in
CNS:
melarsoprol
Feces of
reduviid
(kissing) bug
Parasite invades
Patient from South
when feces o f bug
America with dilated
are ru bbed into
cardiomyopathy,
wound or eyes after achalasia
feeding (Romaiia
sign); parasitemia
causes amastigote
infection in ca rdiac
and smooth muscle,
megaesophagus,
megacolon, cardiac
failure
Trypomastigotes
in blood
Nifurtimox or
benznidazole
Leishmania
donovan!
(v iscera l
leishmaniasis,
kala azar)
Sandfly bite
Amastigotes are
intracellu lar in
macrophages
throughout the
reticuloendothelial
system
Patient from
Africa, Middle
East, or Asia w ith
hepatosplenomega ly
Bone marrow,
liver, spleen
biopsy w ith
amastigotes
packed into
macrophages
Stibog luconate
sodium
L. tropica,
L. major, and
L. mexicana
(cutaneous
leishmaniasis)
Sandfly bite
Amastigotes are
intracellu lar in
macrophages of
the skin
Leishmanin skin
test positive,
amastigotes in
biopsy materia Is
Stibog luconate
sodium
..
'
"'
,I
Loca lized
inflammation
at site of bite
(Winterbottom
sign) followed
by parasitem ia;
organisms loca lize
in blood vessels
of heart and CNS;
antigenic variation
and polyclona l B
cell activation cause
vasculit is
-.
,.;.
.....
..
..,.......
,.
. t $\'\
l .....
I
~;&;
"; '
-~
,IJI1
L. braziliensis
(m ucocutaneous
leishmaniasis)
Sandfly bite
Amastigotes are
intracellu lar in
mucocutaneous
macrophages
Patient from
South America
wit h disfig uri ng
m ucocutaneous
lesions
Leishmanin skin
test positive,
amastigotes in
biopsy materia Is
Stibog luconate
sodium
Chapter 6- 7
Microbiology
Chapter 6 Parasitology
Nlsc:ell11neous 11plcomplex11
Toxoplasma gondii
(toxoplasmosis)
Obligate
intracellular
organism replicates
th roughout the
body, causing
death of involved
host cells; spread
v ia the blood is
possible in the
tachyzoite stage,
as is transplacental
tra nsm ission;
slow-growing
cystic stages
( bradyzoites)
persist for life
and may cause
reactivationa l
disease
Adult: flu-like;
congenital; abortion,
neonatal blindness,
hydrocephalus, and
neuropathies; AIDS:
No. 1 cause of ringenhancing lesions
in CNS and No. 1
diagnosis at autopsy
Serology
Ixodes tick
bite
Intraerythrocytic
trophozoites cause
RBC lysis and
anemia
Geographic rang e
same as Lyme
disease, summer
months, patient has
been outside, fever,
anem ia
Blood film
Clinda mycin and
reveals delicate quinine
intraerythrocytic
ring forms,
splenectomy
pred isposes,
tetrads may be
mentioned
Sulfadiazine,
pyrimethamine
~-living 11meblle
Naegleria spp.
(prima ry amebic
meningoencephalitisPAM)
Acanthamoeba spp.
(granulomatous
amebic encephalit isGAE)
Through
breaks in skin
or m ucous
membranes,
from soil or
contaminated
contact lens
solution
Keratitis or
hematogenous
spread to cause
diffuse necrotizing
granulomatous
encephalitis,
insidious onset but
progresses to death
Amphotericin
B plus rifampin
(rarely
successful)
No history of
swimm ing; older
individual or
immunocompromised
patient
Keratitis:
m iconazole
GAE:
ketoconazole,
sulfamethazine
(rarely
successful)
Star -shaped
cysts on biopsy
Chapter 6-8
Chapter 6 Parasitology
Microbiology
Helminth Parasites
3.1 Nematodes
TTable 6- 3.1 Nematodes
Diagnosis
Heavy infections:
ad ults may block
intestine, mig rate
extra-intestinally.
Lung migration:
verminous
pneumonia,
eosinoph ilia
Mebendazole
Trichuris trichiura
(wh ipworm )
Mebendazole
Enterobius
vermicu/aris
(pinworm)
Scotch-tape test;
eggs are flattened
on one side and
contain infectious
larvae
Visceral larva
migrans
(most commonly
Toxocara canis; dog
roundworm)
Serology
Eosinophilia
Chapter 6 -9
Chapter 6 Parasitology
Microbiology
Larvae penetrate
skin, migrate through
lung, coughed up and
swallowed, mature in
small intestine, suck
blood
Strongyloides
stercora/is
(threadworm)
Trichinella spiralis
~~
:;#.
Cutaneous Larva
Migrans (Commonly
Ancylostoma
braziliense; cat
hookworm)
Mebendazole
Larvae penetrate
Vom iting, diarrhea,
skin, migrate through anemia, and weight
lung, coughed up, and loss, occasiona l fatal
swallowed, mature in
cases caused by
massive autoinfection,
small intestine, and
produce live larvae
high rates in mental
institutions
Th iabendazole
Ingestion of larvae in
meat (No. 1 source
in U.S. is wild game);
adults produced
in small intestine
immediately produce
live larvae, which are
carried via the blood
to all striated muscles,
where they encyst
Classical tetrad:
fever, myalgia,
splinter hemorrhages,
eosinophil ia,
periorbital edema
Serologic tests,
muscle biopsy,
increased levels of
muscle enzymes
circulating in blood,
eosinophilia
Mebendazole,
corticosteroids
Creeping eruption,
plumber's itch, raised,
pruritic, serpiginous
skin rash on areas of
skin exposed to soil
Clinical
Th ia bendazole,
topical corticosteroids
Chapter 6-10
Microbiology
Chapter 6 Parasitology
Clinica l Findings
Diagnosis
Onchocerca volvulus
(river blindness)
Blackfly (Simulium)
t ransmits larvae, which
mature to adulthood
in subcutaneous
nodules; adults
produce microfilariae,
which cause chronic
inflammat ion in tissues
Allergic reaction to
Central and South
microfilariae migrating America, West
through the dermis
Africa; skin biopsy
leads to pruritic
reveals microfilariae
rash with darkened
pigmentation;
microfilariae in eyes
can lead to blindness
Loa loa
(African eye worm)
Deerfly (Chrysops)
injects larvae, ad ults
wander in subcutaneous
t issues, cause allergic
inflammation
Wuchereria bancrofti
and Brugia malayi
(lymphatic filaria)
Anopheles, Culex or
Mansonia mosquitoes
transm it larvae, adu lts
form in lymphatics,
cause obstruction,
granuloma formation,
fibrosis
Low-grade fever,
lymphaden it is,
eosinophilia,
lead ing to eventual
elephantiasis
Blood examination
for microfilariae,
patient from Asia
and South Pacific
( Brugia) or Africa,
Latin America,
South Pacific Islands
(Wuchereria)
Diethylcarbamazine
Dracunculus
medinensis
(Guinea worm)
Allerg ic symptoms
occur during
the release of
larvae: nausea,
vomiting, hives, and
breathlessness
Adult worm
erupts from skin,
eosinophil ia,
increased lgE
Careful excision
Chapter 6-11
Chapter 6 Parasitology
Microbiology
Asymptomatic or
vague abdominal pain
Praziquantel
Taenia so/ium
(pork tapeworm)
Asymptomatic or
vague abdominal pain
Praziquantel
Cysticercosis, fecal-oral or
autoinfection with eggs
Neurocysticercosis:
ocu lar and neurologic
problems, adult-onset
epilepsy
Patient from
endemic area
(South America,
Africa, Asia},
imaging, larvae
may calcify
Praziquantel,
su rgery
Diphyllothrium
Ia tum
( fish tapeworm)
Praziquantel
Echinococcus
granulosus
Fecal-oral contamination o f
ova from canines ( definitive
host)
Man becomes
accidental
intermediate host,
hydatid cysts produce
symptoms depend ing
on location
Su rgery,
albendazole
E. multilocularis
Fecal-oral contamination o f
ova from wild canines ( foxes,
definitive host)
Man becomes
accidental
intermediate host,
mu ltilocular cysts
produce symptoms
depend ing on location
Imaging, serology
Su rg ery,
albendazole
Chapter 6 - 12
Chapter 6 Parasitology
Microbiology
S. mansoni,
S. japonicum
(blood flukes}
Skin penetration by
cercariae
Praziquantel
Schistosoma
haematobium
(bladder flukes}
Skin penetration by
cercariae
Praziquantel
Paragonimus
westermani
(oriental lung fluke}
Ingestion of larvae in
raw crabs or crayfish
Similar to tuberculosis
Praziquantel
Fasciola hepatica
(sheep liver fluke}
Ingestion of
metacercariae on
water plants
Subclinical to fever
and malaise
Praziquantel
Fasciolopsis buski
(g iant intestinal fluke}
Metacercariae on
water chestnut
Epigastric pain,
nausea, diarrhea,
edema, ascites
Praziquantel
Clonorchis sinensis
(Chinese liver fluke}
Inflammation and
deformation of bile
duct, hepatiti s,
anemia, and
edema, risk of
cholangiocarci noma
Praziquantel
Chapter 6-1 3
Chapter 6 Parasitology
Review Questions
Microbiology
Chapters 5-6
1. A 16-year-old male presents to his physician with several weeks of slowly worsening pruritus
of both of his feet, with erythematous, dry scaling lesions that are most obvious in the
interdigital web spaces. Which of the following is most likely to be found on a potassium
hydroxide (KOH) mount of a scraping of the affected skin?
A.
B.
C.
D.
E.
2. Physical exam on an otherwise healthy man presents with several subcutaneous nodules on
his hand . Examination of the exudate from one of the erythematous fluctuant lesions reveals
cigar-shaped yeasts. What is the mechanism of action of the drug of choice for this infection?
A.
B.
C.
D.
E.
3. A 54-year-old poultry farmer in rural Missouri presents to his physician with chronic cough,
fever, and malaise. Chest radiograph reveals small calcifying pulmonary lesions and hilar
lymphadenopathy. Which of the following is most likely to be found on biopsy of the lung?
A.
B.
C.
D.
E.
Chapter 6 - 14
Microbiology
-
Chapters 5-6
'
Review Questions
4. A male is admitted to hospital because of fever, chills, night sweats, and weight loss over
the past few weeks. He has a tender, ra ised erythematous papule on the bridge of the nose.
An x-ray shows consolidation of the right middle lobe of the lung, but a PPD skin test is
negative. A bronchoscopy is performed and a silver-stained specimen shows large, round
budding yeasts with broad bases connecting the mother cell to the daughter cell. Which of the
fol lowing is t he correct pairing of causal agent and infectious form in t his case?
A,
B.
C.
D.
E.
Causal Ag ent
Blastomyces dermatitidis
Candida albicans
Coccidioides immitis
Cryptococcus neoformans
Histoplasma capsulatum
Infectious Form
Septate hyphae with oval conidia
Yeasts and pseudohyphae
Arthroconidia and hyphae
Encapsulated yeast s
Tuberculate macroconidia and microconidia
5. A 27-year-old male presents with fever, night sweats, cough, and weight loss. He has had
mult iple sex partners. His chest x-ray shows bilateral pulmonary infiltrates with interstit ial and
alveolar markings. His CD4 count is 125. Which of the following is the mechanism of action of
the drug of choice for his pneumonia?
A.
B.
C.
D.
E.
It
It
It
It
It
6. A 20-year-old man complains of cramping abdominal pain and diarrhea that is worse after
meals for the past 3 weeks. He has lost 10 pounds in the same time period. His symptoms
began 2 weeks after returning from a camping t rip in upstate New York. His vital signs and
physical exam show no abnormalit ies. Which of the fol lowing diagnostic tests would be most
likely to identify the causal agent ?
A.
B.
C.
D.
E.
<9 DeVry/Becker
Chapter 6 - 15
Chapter 6 Parasitology
Review Questions
Microbiology
Chapters 5-6
7 . A 31-year-old news correspondent on his return from Indonesia complains of tiredness, sore
muscles, and spiking fevers. He subsequently develops a disabling illness complicated by
severe anemia, pulmonary edema, renal fai lure, and shock. Which of the following is the
correct pairing of means of infection and causal agent in this case?
A.
B.
C.
D.
E.
Ca usa l Age nt
Clonorchis sinensis
Yellow fever virus
Dengue virus
Plasmodium falciparum
Babesia microti
8. A middle-aged AIDS patient is brought into the emergency room after experiencing a
seizure witnessed by several friends. The observers relate that the patient suddenly lost
consciousness and his limbs began jerking. The man's tongue has been severely bitten, and
loss of bowel and bladder control is evident on admission . On physical exam, the patient is
lethargic, unable to answer simple questions, and has left-sided hemiparesis. An MRI of the
head reveals multiple-ring enhancing lesions. Which of the following would most likely be
found on a biopsy of one of these lesions?
A.
B.
C.
D.
E.
Chapter 6 - 16
Chapter 6 Parasitology
Microbiology
Chapters 5-6
Review Questions
9. A 31-year-old Hispanic woman is brought to the emergency room after suffering a seizure at
home. The patient has been a resident of the United States for five years, but occasionally
travels to her previous home in the Dominican Republic. CT scan of the head reveals multiple
punctate calcifications, and two enhancing cystic lesions with surrounding edema . Which of
the fol lowing is the most direct source of her cerebral lesions?
A.
B.
C.
D.
E.
Autoinfection
Exposure to swine feces
Exposure to cat feces
Ingestion of poorly cooked pork
Unsafe sexual practices
10.
A child is brought to the pediatrician because of perianal itching. Physical examination
reveals scaly skin in the perianal region. A scotch-tape test reveals oval eggs that are
flattened on one side. What is the mechanism of action of the drug of choice in this case?
A. It blocks enzymes involved in arachidonic acid metabolism
B. It causes degeneration of microtubules and blocks glucose uptake
C. It increases the opening of glutamate-gated chloride channels
D. It is an agonist at nicotinic acetylcholine receptors
E. It is an organophosphorus cholinesterase antagonist
<9 DeVry/Becker
Chapter 6 - 17
Chapter 6 Parasitology
Review Answers
Microbiology
Chapters 5-6
Chapter 6- 18
Microbiology
Taxonomic Charts
Abbreviations Used
means progressing on to
means about or approximately
immunocompromised
IC
Infl'd inflamed
Infl'n
inflammation
increasing
infxn
infection
IUD
IV
intrauterine device
intravenous
LOS
lipooligosaccharide
mo
month(s)
'
decreasing
abd
abdominal
AIDS
acquired immunodeficiency
syndrome (CD4+ count <200)
attntd
NF
normal flora
CA
attenuated
cancer
obi. IC
CF
cystic fibrosis
occ
obligate intracellular
occasional
CGD
ox phos
oxidative phosphorylation
CMI
PMNs
CNS
cell-mediated immunity
central nervous system
polymorphonuclear leukocytes
patient
cvs
cardiovascular system
resistant
CYS
cysteine
RBCs
DOC
recrnt
Drha
drug of choice
diarrhea
RPR
recurrent
rapid plasma reagin
dx
diagnosis
RSV
EV
encephalitis virus
Rx
treatment
Fac
sensitive
Fac IC
facultative
facultative intracellular
subQ
FQ
fluoroquinolones
URT
subcutaneous
upper respiratory tract
UTI
VORL
pt
GU
genitourinary
WNV
HIV+
xrxn
cross-reaction
If there are multiple causal agents, at the end of the description there may be a # with the abbreviation "CA." This
means you should be able to list that number. If it specifically says "species," you should give species.
AppendiX A-1
C O CCI
I-
GRAM STRAIN
-----l
Neisseria sp
Staphrlococcus sp
Streptococcus sp
CATALASE
------Sf>
1
Staphrlococcus sp
<f.
I
COAGULASE
S . aureus
s.
'IF-
MALTOS~
fermentation
N . meningitidis
~ NOVOBIOCIN
le
N . gonorrhoeae
Streptoco ccus sp
S . saprophyticus
epidermidis
I
ALPHA-HEMOLYTIC
BETA-HEMOLYTIC
OPTL.,N
BACIT~CIN
r
4
4
Group A
s . pyogenes
Variable hemolysis
(Usually none)
Group 0
Growth in
6.5% NaCI
Group 8
E. faeca/is
S. agalactiae
S . bovis
3:
a
IT
(j"
0
00
<
COCCI
Gram ()
Gram 8
. - - - - -- Staphylococcus sp- - - - - ,
r----
coagulase 0
Coagulase 8
coagulase 0
S. aureus
S. epiderm/dis
S. saprophvticus
NF in nose, skin
Protein A
Abscesses
Food poisoning ( 26 n)
j!hemolytic
Hea~le
enll!rotoxins
Arub! endocarditis in
IV drug users
o CAMP Arub! ost@Omyelitis
hemolysin
DOC: MSSA: Nafcillin
Salt-tolu.~nt
MRSA: Vancomycin
Milooitol salt agar VRSA! Quinupristin
Yellow/ gold pigment
Toxic Shock synd
Non-hemolytic
Bicfllm
NF in skin,
Oxidizes
maltose
N. meningitidis
Non nemolytic
1-.tysacchande
U11 in sexualty
active adolescents
Novobiocin
Subacull!
endocarditis
in IV drug users
Neisseria sp
capsule
Kidnerbunsh~ped
diplococci
cath@ll!r. prosthetic
device infections
Novobiocin sensitive
ElkeMIJiJ
Vei1Jooelfa
Kinge/la
Does not
Catalase ( +)
oxicize maltose
Oxid.... ( +)
N. gonorrlweae
JQA prom"'
No apsul@
Overproduces LOS
JH.actamase
Pili
Oxidizes glucose
jHadamase (rare)
Chocolam agar
Pili
Candle jM; co,
Colonizes URT
Watemo~Friderichsen synd.
Tetravalent vaccine (Y, \Y-135, C. A)
DOC: Cefctaxime, ceftriaxone
resistant
Also
Horaxellit
Thaya-Martin med"rum
DOC: Ceftriaxone
PlUS Tetracydine
for Or/amydja
No vaccine
Gram ()
I
streptococcus sp
l
Alpha Hemolytic
s. pneumoniae
lanc~ped
# 1 Otitis media
capsule
in kids
DOC: Macrolides,
ceftriaxone.,
Quellung ( +)
lgA prollease
Optochin sensitive
a.moxicillin
Beta Hemolytic
Variable Hemolytic
Yiridans group
Group A
S. sanguis
S. mutans
S. pyogenes
NF oropharynx
Dextran biofllm ,
dental caries
Subacute
endocarditis
Lysed by bile
~20% Pen resist.
NF in URT
Vaccine for elderly
# 1 for pneumonia {23 serotypes)
(po~dental
work or poor
> 60 yr
Vaccine pediatric
#1 for adult
( 13 serotypes
dental hygiene)
meningitis
conjugated to protein) DOC: Penicilin
+ aminoglycosides
capsule.-
nyaluronic acid
M pnotein
Streptolysin 0
Streptolysin S
Streptolci.n ase
Hya l...,nidase
Erythrogenic
toxin (SPE A)
Rheumatic fever
~Strep
Group B
S. aga/actiae
CAMP Test(+)
(incomplete
nemolysin)
Hydrolyzes
nippurate
Colonizes
vagina in 1S.20%
Screen preg,
treat witt. ampicillin
I meningitis
# 1 for neonatal
acute GN
meningitis (ling)
Cellulitis
DOC: Ampicillin +
aminoglycoside
Impetigo
DOC: Penicillin G/V
Group D
Group D
E. faecalis
S. bovis
Enll!rococcus
Hydrolyzes bile
esculin with
black complex
Salt-tolerant
NF in colon, gut
UTI
Bilary tract
infections
Subacute
Non..,nterococcal
endocarditis Hydrolyzes bile
post surgical esculin with
or assoc. of
black complex
colon cancer
Opportunistic
infxns
DOC: Sensitivity
testing
3:
;:;
0c:r
c;
0
<
IC
GRAM ( +) RODS
.---------~
Aerobic
Hotile
Non- Hotile
8 . anthracis
Heat-stable
Poly-0-glutamatl!
capsule
ln R-E cells
Heat-labi'l e toxin:
Hotile
C. tetani
Terminal spores
Exotoxin:
Telllnospasmin,
inhibits GABA,
g lycine
Toxin:
Dia nflea
Fried rice
Food poisoning
(2-18 h)
Symptomatic Rx
. - - - - - - - Anaerobic - - - - - - - - . ,
8 . cereus
exotoxin: Vomiting
increase cAMP
Protective Ag,
lethal Factor.
edema Factor
(a n adenylate cydase)
Pain.l ess skin u lcer 'JS'IIo
Blade eschar
Striking local edema
Wools.>rter's disease
Pneumonia
DOC: aprofloxacin
.,.. doxycycline
Tetanus
Spastic paralysis
DOC: Hyperimmune
g lobultn, penicillin
+ Spasmolytic
Toxoid vaccine
Clu!Hhaped
chinese Olaraaers
Exotoxin (ADP-R of eEF-2)
heart.. nl!;rves,
epnhelium
Volutin granuJes on
Crosses placenta
Meningitis
'"1-Renal n.nsplant
Neonatal
C.na>r
C. difficile
Nosocomial
Neurotoxin
heat-labile
blocks ACh release
Flaccid paralysis
Cannedfoods,
vacul.l'npacked fish
Trivalent antitoxin
Antibiotic
sen.m, no drugs
colitis
Yellow plaques
Colon
TOl<ins A + B
DOC: Change
or stop antibiotic
C. perfringrens
Subterminal spore
Alpha lecithinase =
Phospholipase C
Enterotoxin
Stormy fermentation
Ooubl..-zone hemolysis
Egg yolk aga.r
Normal in colon
Food pois.>ning
Gas gang rene
Myonecrosi:s
Hig h mortality
DOC: PeniciiUn G
z Clindamycin PLUS
debridement
Anaerobic
C. d iphtheriae
13-hemolytic
Cold enrichment
Sepsis
C. botulinum
Non- Hotlle
Hotlle
Tumbling motility
"Jets" from cell to cell
Fac IC
Non-Motile
f'NoN-SPORE- FORHING t -- - - - - - .
Aerobic
L. monocytogenes
Loeffler's medium
Tellurite: blade colo nies
ElK test
Gray pseudomembrane
Myocardili5
Reant laryngl nerve palsy
DOC: Antitoxin + Erythromycin
Toxoid vaccine
H . asteroides
Filaments to rods
Urease(+)
Partially acid-fast
Cavitary bromchopulmanary
Multiple brair> abscesses
MycetO<"na (granules)
DOC: Sulfonamicles
A . israelii
Branching rods
Non-motile
Sulhr' granules
in exudab!S from
sinustrKt
NF in mouth
and female GU
Invasive growth
Cervicof~cial (lumpy jaw)
IUD-associated infections
3:
r;
CT
a
IQ
<
Treponema sp
T. pa//idum-Syphilis
cannot be cultured
!"-PAINLESS dlancre,
SPIROCHETES
Gram negative
anatomy, poorly
staining
Spin~I-Shaped
Axial Filaments
(motile)
Jarisc::h-Henchetrner
infectious
Rxn
2"-RASH, condylomata
lata, infectious
3" -Gummas, CVS, CNS
Borrelia sp
Congenital: Stillbirths, malformed Microaerophillic
VORL & RPR-Screening tests
Giemsa stain
Reagin ab-xrxn with cardiolipin
B. burgdorferi
FTA-ABS (spe<;ific l.e:it)
Lyme disease
Dark-field mia'OSCOpy
(I. sapu/aris), I. padficus
DOC: Benzathine penicillin
Reservoirs: Mice, deer
Leptospira sp
Dark-field miaoscopy
Contaminated water,
animal urine
Fever, jaundice, uremia
Non-icteric Leptospirosis:
Meningitis-No PMN in CSF,
uveitis, rash
Icteric Leptospirosis:
CT, WI, CA
Erythema M igl'llns
Target lesions
B. recvrrentis
Relapsing fever
Vector. Body louse
Antigenic variation
DOC: Penicillin or azithromycin
3:
;:;
a
IT
"'<
GRAM { - ) RODS
Facultative Anaerobes
8.
pertussis
Adhesion via
hemagglutinin and
pertussis lloxin
Endotoxin
Bordet-Gengou or
ReganLowe agar
Whooping cough
DOC: Etythromycin
1/accine-toxoid +
filamentous
Brucella
sp
Fac: IC
Endotoxin
Requires CYS, C02
Unpast..urized m ilk
Undulant fever
B. aborlus cattle: Mild
B. suis pigs:
Suppurative. chronic
B. melitensis goats:
Seven!, acute
DOC: Rifampin and
doxycycline
hemagglutinin
Bartonella henselae
cat saatch fever
Bacillary angiomatosis
in .AIDS
F. tularensis
Fac IC
Requires CYS
Dennacentor tick bite
Transavarian trans.
Aerosol
Rabbits, rodents
Tularemia- AR, MO, TX
Granulomatous
DOC: Streptomycin
r
L pneumophi/a
Fac IC
Requires CYS & Fe
Bulfered Charcoal
Yeast agar
Oieterie siJver stain
Water--loving,
air cond1tioning
Not contagious
Atypical pneumonia
Mental confusion
Dian-hea
DOC: Erythromycin
P. aeruginosa
Slime-layer (capsule)
Grape-like odor
Exotoxin A:
ADP-R of eEF 2 in 6ver
Pigme~
ots
pyocyanin, pyoverdin
Transient colonization,
in 10% .X nonnal pop
Osteomyelitis In drug
abuseB
Pneumonia in
cystic fibrosis
Nosocomial infections_,
bum pat;erots,
neutropenic patients
Ecthyma gangrenosum
Obligate
ANAEROBES
DOC: Penicillin+
Aminoglycoside
Bacteroides spp.
Modified LPS, capsule
Predominant colonic Rora
Normal in oropharynx, vagina
Pn!disposing factors:
Su-ge!y, trauma
Prevotella melaninogenica:
Human oropharynx
Hlsobacterium {combined w/
Trepor>en>a microdentium):
Vincent's angina,
trench mouth
DOC: Metronidazole
3:
r;
CT
a
IQ
<
I
Pasteurella
multocida
Requires CYS
Animal bites (cats & dogs)
Cellulitis, lymphadenitis
DOC: Amoxicillin/Clavulanate
(prophylaxis)
Haemophilus
influenzae
Polyribitol capsule
Quellung ( +)
IgA protease
Requires X (Hemin), V (NAO)
Normal in nasopharynx and
conjunctiva
Pathogenic in kids: Type B
Meningitis in 1-2 yr
Otitis media, pneumonia
Acute epiglottitis
DOC: Cefotaxime/Ceftriaxone
Prev: HIB vaccine, rifampin
H. ducreyi: Soft, painful
genital chancroid
campyloba cter sp
Helicobacter sp
Vibrio
sp
Polar flagella, comma-shaped
Enterotoxin (Choleragen)
ADP-R, increases cAMP
Catalase ( +)
Alkaline culture (TCBS)
Classic cholera 0 1
Biotypes: 8 Tor, Cholerae
Ric:e-water stools
Severe dehydration
Rx: Auid & electrolytes
tetracycline for contacts
V. parahaemolyticus:
Catalase (- ), salt-tolerant,
H. pylori:
raw seafood
V. vulnificus:
Brackish-water oysters,
cellulitis, septicem ia
DOC: Tetracycline
Microaerophillic
Polar flagella
Comma or 5-shaped
Catalase ( +)
Skirrow's agar C02
Invasive
37"C, urease ( +)
gastritis, ulcers
caranoma
DOC: Omeprazole + amoxicillin +
clarithromycin
C. jejuni: 42"C,
No. 1 bacterial diarrhea U.S.A.
"Gull Wings"
DOC: Erythromycin, fluoroquinolones
3:
;:;
0c:r
c;
0
<
IC
1
ENTEROBACTERIACEAE
Ferment Gluex>se
Oxidase (-), Catalase (+)
Reduce Nitrates to Nitrites
_..,__ Lactose-Fenne,,u,,v
P-pili, X-Adhesins
Nosocomial
in~ions
Capsule
Quellung (+)
Typical pneumonia in
alcoholism,
Neonatal meningitis
(Kl capsule)
aspiration.,
ElEC-Traveler's diarmea currant jelly supbJm
Toxins: LT, ST
UTI:
EIEC- lnvasive
Nosocomial,
EHEC-VTEC 0157:H7,
catheterization
hemorrh;ogk colitis,
DOC: Cephalosporin
hemolytic uremic S,
+1- aminoglycoside
does not ferment sorbitol
EPEC
Plasmid-ended EAF
EAEC
Rmbriae/biofilm
DAEC
Infants
Bacteria in m icrovilli
DOC: Ampicill'in or
sulfonamides,
cephalosporins
I
...nuoo__ ..
LactOSe-fennenting
Motile and
H~-Producing
Proteus sp_
Salmonella
enterica subsp_
Swarming motility
Indole ( + ), Urease ( +) Antigens: Vi, 0, H
EMB/MacConkey
UTI, septicemia
Staghom Cil!a.rli
DOC: Ruoroq uinolones
~isposing
Non-Motile and
Non-H 2S-Producing
Shigella sp.
No H Antigens
Invasive
Shigatoxin
N!cks ~s
faaors;
g a strectomy
Widal test (0, H, Vi)
Osteomyelitis in siclde
cell disease
S. enb!rica subsp. typhi:
No animal res.,
no H,S produced,
invasive (RE) cells,
rose spots
DOC: Fluoroquinolones
or cephalosporins
Ne...-otoxi n
Cytotoxin
Ent:erolxlxin
Enterocolitis
Bloody diarrhea
DOC: Fluid a nd
electrolytes, FQ,
azithromycin
Y. pestis
Coagulase ( +)
V&.W antigens
Bipolar staining
warson's stain
Wild rodents
Aea bite
Southwest
u.s.
(Syivatic)
Bubonic plague
fever, buboes,
conjunctivitis
Pneumonic plague
Rx: Aminoglycosides
quarantine (72 n)
Y. entenxolmca:
Cold growth,
heat-stable toxins,
pseudoa ppendicitis
3:
r;
CT
a
IQ
<
DNA Viroses
DOUBLE-STRANDED
SINGLE- STRANDED
NA.K ED
ENVELOPED
ICOSAHEDRAL
ICOSAHEDRAL
COMPLEX
_j
CIRCULAR
CIRCULAR
LINEAR
PAPILLOHAVIRUS ADENOVIRUS
PapiUoma Virus
LINEAR
I
I
NAKED
I COSAHEDRAL
HEPADNAVIRUS
HERPESVIRUS
POXVIRUS
PARVOVIRUS
Hepatitis B Virus
Variola
819
Adenolliruses
Epstein-Barr Virus
Polyoma Viruses
Cytomegalovirus
Herpes virus 6, 7, 8
Vacdnia
Mollu50Jm
c:onr.agiosum
RNA Viroses
SINGLE-STRANDED
DOUBLE-STRANDED
POSITIVE SENSE
NAKED
ENVELOPED
rICOSAHEDRAL
NEGATIVE SENSE
AHBISENSE
AND N~GATIVE
ENVELOPED
ENVELOPED
NAKED
ICOSAHEDRAL
HELICAL
HELICAL
HELICAL
ICOSAHEDRAL
CAUCIVIRUS
FLA VIVIRUS
CORONA VIRUS
PARAHYXOVIRUS
ARENA VIRUS
REOVIRUS
Norwalk Agent
Noro-lik"
Coronavirus
(Segmented)
SARS-CoV
Reovirus
Rotavirus
HEPEVIRUS
Dengue Virus
St. Louis EV
Mumps Virus
Measles Virus
Hepatitis E
WNV
Parc~influenza
Lymphocytic
Choriomeningitis VIrUs
Hepatitis C
RHABDOVIRUS
BUNYAVIRUS
TOGA VIRUS
Rab;es Virus
Vesicubr Stomatitis
(Segmento>d)
Califomiil EV
La Crosse EV
Hantavirus
PICORNA
Polio Virus
Enteroviruses
Echovirus
Coxsad<ie A&. B
Rhinoviruses
Hepatitis A Virus
Rubella Virus
Western Equine EV
Eastern Equine EV
Venezuelan EV
RETROVIRUS
H!V
HTLV
RSV
Virus
FILOVIRUS
M arbWlJ
Ebola
ORTHOHYXOVIRUS
(Segmented)
Influenza A &. B
Colorildo tide
fever virus
3:
;:;
0c:r
c;
0
<
IC
COCCI
___c
e
CATALASE
_ I___
GRAM STRAIN
MALTOSE
fermentation
~ COAG~LASE ~
@J
NOVOBIOCIN
l @
I
ALPHA- HEMOLYTIC
Partial (green) Hemolysis
@J
I
OPTOCHIN
l @
BETA- HEMOLYTIC
Complete (clear} Hemolysis
@J
I
BACITRACIN
l @
VARIABLE HEMOLYSIS
Usually none (Gamma)
0rJ
I
Growth in
6 . 5 % NaCI
--.8
l
3:
a
IT
i)'
0
00
<
COCCI
Staphylococcus sp
S. aureus
S. epidermidis
Neisseria sp
N. meningitidis
S. saprophyticus
N. gonorrhoeae
Streptococcus sp
Alpha Hemolytic
r
S. pneumoniae
Beta Hemolytic
'I
1
Viridans group
S. sanguis
S. mutans
I
Group A
S.pyogenes
Variable Hemolytics
1
Group B
S . agalactiae
I
Group D
S. faecalis
I
Group D
S. bovis
3:
;:;
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c;
0
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IC
GRAM ( +) RODS
.---------------~ SPORE-F~N~
. - - - - - - Anaerobic - - - - - - - ,
Aerobic
Motile
Non- Motile
Non-Motile
Motile
NG~:--------,
. - - - - - - NON-SPORE-FORMI
_..
Anaerobic
. - - - - - - - Aerobic
Motile
3:
a
IT
i)'
0
00
<
Microbiology
AppendiX A-] 3
Microbiology
.....
....
I
AppendiX A-14
Microbiology
AppendiX A-] 5
Microbiology
lor
, .iJ
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1 i]
j
.f
L]j
llh:z:..
c
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L_
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I
T
AppendiX A-16
Microbiology
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Ill
Ill
e'l
01
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AppendiX A-] 7
DNA Viruses
DOUBLE-STRANDED
SINGlE-STRANDED
NAKED
ENVElOPED
NAKED
ICOSAHEDRAl
ICOSAHEDRAl
I
CIRCUlAR
LINEAR
CIRCUlAR
I
COMPlEX
LINEAR
ICOSAHEDRAl
_j
RNA VIruses
SINGLE-STRANDED
DOUBLE-STRANDED
POSmVE SENSE
NEGATIVE SENSE
AMBISENSE
AND NEGATIVE
ENVElOPED
NAKED
I
ICOSAHEDRAl
ICOSAHEDRAl
ENVElOPED
ENVElOPED
NAKED
HELICAl
HELICAl
ICOSAHEDRAL
I
HELICAl
3:
r;
CT
a
IQ
<
Microbiology
..
Function
Attachment
Anti-phagocytosis
Biofilm
Lipoteichoic acids
Pili
Capsules
Primary:
Streptococcus pneumoniae
Klebsiella pneumoniae
Haemophilus influenzae
Pseudomonas aeruginosa
Neisseria meningitidis
Salmonella (Vi)
Cryptococcus neoformans
Pseudomonas aeruginosa
Staphylococcus aureus
S. epidermidis
Viridans Streptococci
M protein
Group A streptococci
Staphylococcus aureus
Pili
Neisseria gonorrhoeae
Microbe
Coagu lase
Staphylococcus aureus
Yersinia pestis
I Collagenase
Clostridium perfringens
Promotes clotting
I Heparinase
I Hyaluronidase
lgA proteases
Hydrolysis of fibrin
I Kinases
I Lecithinase
I Prevotella melaninogenica
Bacteroides
I Prevotella melaninogenica
I Group A streptococci
Haemophilus
Neisseria
Streptococcus pneumoniae
Staphylococcus
I Streptococcus
I Clostridium perfringens
AppendiX A-19
Mirobiology
Microbe
Catalase
H,O, -
H,O
+ 'h o,
Most important:
Staphylococcus
Nocardia
Enterobacteriaceae
Aspergillus
Listeria
Candida
Pseudomonas
(Mnemonic: Staph 'N Enterobacteriaceae Are
Listed Catalase Posit ive)
Most anaerobes are catalase negative
Oxidase
Neisseria
Most gram negatives, except the
Enterobacteriaceae
Urease
Proteus
Ureaplasma
Nocardia
Cryptococcus
Helicobacter
(Mnemonic: PUNCH)
...
Mechanism
Flagella
I Spirochetes
I Entamoeba histolytica
Axial filaments
Pseudopodia
Bacil/us
Clostridium
I All fungi
Yellow-orange
Blue-green, fluorescent
Red
Yellow
'c'
Microbiology
Microaerophiles
Borrelia
Campylobacter
Helicobacter
Obligate anaerobes
Bacillus
Corynebacterium
Mycobacterium
Nocardia
Pseudomonas
Actinomyces
Bacteroides
Clostridium
Fusobacterium
Prevotella
2 Transmission
T Table A-2.2A Transmission Types and Associated Microbes
Type
0 0
Chlamydia trachomatis
Corynebacterium diphtheriae
Mycobacterium tuberculosis and M. leprae
Neisseria meningitidis and N. gonorrhoeae
Rickettsia prowazekii
Salmonella enterica subspecies typhi
Shigella species
Streptococcus pneumoniae
Streptococcus pyogenes
Bordetella pertussis
Chickenpox
Corynebacterium diphtheriae
Haemophilus influenzae
Influenza and all respiratory v iruses
Measles, mumps, rubella
Mycoplasma pneumoniae
Neisseria meningitidis
Pneumocystis jirovecii
Pneumonic plag ue
Blastomyces
Chlamydophi/a psittaci
Coccidioides
Histoplasma
Legionella
Nontuberculous mycobacteria, e.g.,
M. avium-intracellulare (MAC)
Pseudomonas
rc
AppendiX A-21
Mirobiology
.. -
All cestodes
All nematodes except fi laria and Trichinella
Bacillus cereus
Campylobacter
Clostridium
Enteroviruses, includ ing poliovirus
Giardia
Hepatit is A and E viruses (the vowels are transm itted by
the bowels)
Norwalk and Noro like viruses
Rotavirus
Salmonella
Shigella
Staphylococcus
Toxoplasma-cat feces
Vibrio
Yersinia enterocolitica
Yersinia pseudotuberculosis
Ascaris lumbricoides
Echinococcus granulosusjmultifocularis
Enterobius vermicularis
Taenia sofium
Toxocara canis
Trichuris trichiura
Toxoplasma gondii
Rubella
Cytomegalovirus
Herpes simplex 2
H uman immunodeficiency virus
Syphilis
(Mnemonic: ToRCHHeS)
Others that may also cross the placenta:
B19 virus
Coxsackie B
Listeria monocytogenes
Polio
* All other parasitic infections are transmitted in larval stage.
'c'
Appendix A-22
Microbiology
Bacillus anthracis
Anim al hides
Bartonella henselae
Cat scratch es
Borrelia burgdorferi
Deer, m ice
Brucella species
Livestock
Capnocytophaga canimorsus
Dog bites
Chlamydophila psittaci
Parrots, birds
Deer, m ice
Francisella tularensis
Rabbits, deer
Leptospira interrogans
Lister ia monocytogenes
Mycobacterium marinum
Fish tanks
Pasteurella multocida
Cat bites
Rabies virus
Streptobacillus moniliformis
Rat bites
Vibrio parahaemolyticus
Fish
Vibrio vulnificus
Oysters
Y. enterocolitica
Swine
Yersinia pestis
Small rodents
Y. pseudotuberculosis
Domestic animals
AppendiX A-23
Mirobiology
Sandfly
Blackfly
Deerfly
Tsetse
Fleas
True bugs ( Reduviidae)
Disease
Dengue (Aedes)
Filariasis
Malaria (Anopheles)
Viral encephalitides (EEE, SLE, VEE, WEE, WNV)
Yellow Fever
I Leishmaniasis
I Onchocercosis
Loaloasis
I Tularemia
I African trypanosomiasis
Endemic typhus
I Plague
I Chagas Disease
Lice
Endemic typhus
Relapsing fever
Trench fever
Tick (Ixodes)
Babesiosis
Ehrl ichiosis
Lyme Disease
Tick (Ornithodoros )
Mite (Leptotrombium)
3 Mechanisms of Pathogenesis
Plasmid
Bacteriophage (lysogeny)
'c'
Appendix A-24
Microbiology
Microb e
Antigenic variation
Borrelia recurrentis
Enterobacteriaceae
Neisseria gonorrhoeae
Trypanosoma brucei
I HIV and any other agent that uses nucleic acids to replicate
Antigenic drift
Antigenic shift
Diphtheria toxin
Verotoxin
Shiga toxin
LT of E. coli
Cholera toxin
Pertussis toxin
Botulinum toxin
Tetanus toxin
Toxic shock toxin-1
Erythrogenic toxins of
Streptococcus pyogenes
I Diphtheria
IYes, eEF- 2
I EHEC
I Shigellosis
I Traveler's diarrhea
INo
INo
IYes, Gs
IYes, Gs
IYes, Gi
I Cholera
I Whooping cough
I Botu lism
I Tetanus
I Toxic shock
I Streptococcal toxic shock
INo
INo
INo
INo
Stable Up To
E. coli ST
Staphylococcus aureus enterotoxin
Yersinia enterocolitica toxin
Endotoxin
AppendiX A-25
Mirobiology
Bacteria
Chlamyd iaceae
Mycobacterium leprae
Rickettsiae
Viruses
All
Protozoa
Babesia
Leishmania
Plasmodium
Toxoplasma
Trypanosoma (in amastigote form)
Facultative
Produce granulomas
Yersinia pestis
Francisella
M ycobacterium tuberculosis and
atypical mycobacteria
Brucella
Bartonella henselae
Salmonella enterica subsp. Typhi
Listeria
Nocardia
Legionella
Bacteria
Histoplasma capsulatum
Fungi
I Schistosoma spp.
Parasites
.. .
Lung
Cerebral
'c'
...
Type
Bacteria
Mycobacterium tuberculosis
Fungi
Blastomyces
Coccidioides
Histoplasma
Bacteria
Mycobacterium tuberculosis
Treponema pallidum
Viruses
Cytomegalovirus
Fungi
Cryptococcus
Appendix A-26
Microbiology
4 Diagnostic Attributes
TTable A-2.4A Staining Characteristics
Microbe
Acid Fast (Kinyoun or Ziehi- Neelsen)
Bipolar staining
Calcofluor white
Darkfield microscopy
Giemsa stain
India ink
Kidney bean-shaped diplococci
Lancet-shaped diplococci
Metachromatic staining (aniline dyes)
Silver stain (Dieterle)
Silver stain (Gomori Methenamine)
Haemophilus influenzae
Francisella tularensis
Pasteurella multocida
Yersinia pestis
I Fungi
I Spirochetes (Treponem a)
Babesia
Leishmania
Plasmodium
Trypanosoma
Histoplasma capsulatum (inside macrophages)
I Campylobacter
I Cr yptococcus neoform ans
I Neisseria
I Streptococcus pneumoniae
I Corynebacterium
I Legionella
I Pneumocystis, fungi
Intranuclear inclusions
I inclusions)
I Rabies
I Most DNA v iruses (except pox)
I Cytomegalovirus
Syncytia formation
AppendiX A-27
Mirobiology
I Mycoplasma
Cholesterol
Cysteine
Francisella
Brucella
Pasteurella
Legionella
I
2
incubator)
Campylobacter
Helicobacter (m icroaeroph iles)
Listeria
Yersinia enterocolitica
(Mycobacterium leprae prefers cooler body temperatures
but cannot be cultured)
Thioglycollate broth
Enterococci
Staphylococcus aureus
Vibrio
I Campylobacter
Blastomyces
Coccidioides
Histoplasma
Mycobacterium
Mycoplasma
I Obligate anaerobes
Elek test
Lepromin test
Monospot ( heterophile antibody test)
Tzank smear
Tuberculin test (Mantoux or PPD)
VORL ( Venereal Disease Research Lab)
Weii-Felix test
Widal test
'c'
I Corynebacterium diphtheriae
I Mycobacterium leprae (tuberculoid form)
I Epstein-Barr virus
I Herpes simplex virus
I Mycobacterium tuberculosis
I Treponema pa/lidum
I Rickettsiae
I Salmonellae
Appendix A-28
Microbiology
I Neisseria meningitidis
Known exposures
.
1
Neonatal eyes
Yersinia pestis
Hepatiti s A and B
Chlamydia trachomatis
Neisseria gonorrhoeae
Treponema pallidum
I Mycobacterium tuberculosis
Chlamydia trachomatis
Neisseria gonorrhoeae
Treponema pallidum
Trichomonas vagina/is
I Haemophilus influenzae
AppendiX A-29
Mirobiology
~Table
Bacterial
Viral
'c'
Type
Toxoid
Subun it
Live, attenuated
Inactivated
RecoMbinant DNA
Hel'atitis B ( HBsAg)
Human papilloma virus (capsid proteins from
serotypes 6, 11, 16 and 18)
Measles
Mumps
Rotavirus
Rubella
Sabin polio
Smallpox
Varicella zoster
Yellow fever
Hepatitis A
Influenza
Rabies
Salk polio
Appendix A-30
Microbiology
Dermatology
Infections: Cutaneous/Mucocutaneous
Vesicles
Keratinized layers
(rlngwonn)
Impetigo
Trichophyton spp.
(skin, hair, nails)
Epidermophyton spp.
(skin, nails)
Microsporum spp.
(skin, hair)
Herpes simplex
Staphylococcus
aureus
Streptococcus
pyogenes
Lips ( HSV 1) or
genitalia (HSV 2)
Various
Various
Often preceded by
neurologic pain
Weeping, oozi ng
(honey-crusted)
Streptokinase
A and B, DNAse,
hyaluronidase
Wood's lamp,
fluorescence; skin
scraping + KOH;
arthroconidia + hyphae
Catalase ( + ),
coag ulase ( +),
gram ( + ) cocci in
clusters
Catalase (-),
gram ( +) cocci,
bacitracin sensitive
Acyclov ir,
valacyclovir,
famciclovir
Penicillin, macrolide
AppendiX A-3 1
Microbiology
Dermatology
l!oslnophlllc
dennlltltls
Warlll
Human Papilloma
v irus
(dsDNA, naked
icosahedral)
Molluscum
contagiosum (pox
family, dsDINA,
enveloped complex)
2 stage syphilis
Treponema pallidum
(condylomata lata)
Anogenital, axillary
Plantar surfaces:
HPV 1
Common warts:
HPV serotypes 2, 4
Anogenital warts:
HPV 6 and 11
(most common)
HPV 16 and 18
(premalignant)
Umbilicated warts;
wrestling teams; may
be anogenital
Snake-like tracks on
bare skin exposed
to dog/cat feces
(plumber's itch,
cutaneous larva
migrans)
Infects epidermal
cells to form neshy
lesion
Lymphocytic
+ plasma cell
infiltration
Ski n penetration
by larvae 7 death
in skin
7 hypersensitivity
(type 1)
Intranuclear inclusion
bod ies
Intracytoplasmic
inclusions
VDRL + FTA-Abs
Cryotherapy for
common warts;
imiquimod,
interferon-a,
cidofovir for
anogenital warts
Cryotherapy
Penicillin,
doxycycline,
erythromycin
Topical an ti inflammatory,
th iabendazole
rc
AppendiX A-32
Microbiology
Dermatology
Infections: Cutaneous/Mucocutaneous
~lnophlllc
dennatltla
Bird schistosomes
(Swimmer's itch)
Staphylococcus
aureus
Propionibacterium
acnes
Pseudomonas
aeruginosa
Outside of bathing
suit coverage
Boils, carbuncles,
furuncles
Acne vulgaris
Adolescent
Skin penetration
by cercariae 7
death in skin 7
hypersensitivity
(type 1)
Coagulase makes
fibrin clot
Neutrophils +
bacteria 7 pus
Inflammation
of follicles and
sebaceous glands;
fatty acids and
peptides produced
from sebum cause
inflammation
Ca psule inhibits
phagocytosis
Catalase ( + ),
coagulase ( + ), gram
(+)cocci in grape-like
clusters
Clinical clues:
gram(+) rod
Oxidase ( + ),
gram (-) rod,
blue-green pigment,
grape odor
Topical antiinflammatory
Nafcillin for
methicillin-sensiti ve
S. aureus (MSSA);
vancomycin for
methicillin-resistant
5. aureus (MRSA)
Tetracycline,
macrolide
Antipseudomonal
beta-lactam +
aminog lycoside
AppendiX A-33
Microbiology
Dermatology
Infections: Cutaneous/Mucocutaneous
Cutaneous
Mucocutaneous
Infections: Subcutaneous
Clean
Dirty
L. tropica
L. braziliensis
Staphylococcus
aureus
Enterobacteriaceae,
anaerobes
Face
Wound site
Wound site
Military stationed in
Immigrant from
Suppurating lesion,
South America
no odor to pus
anaerobes involved
Contamination from
fecal nora
Gram ( +) cocci,
catalase ( + },
coag ulase ( + )
Antimonials, pentamidine
3rd -generation
cephalosporin
rc
AppendiX A-34
Microbiology
Dermatology
Infections: Subcutaneous
SUppurative
Trauma with damage
to blood supply
Ulcerating absclsss
Clostridium perfringens
and others
Pse.udomonas aeruginosa
Vibrio vulnificus
Wound site
Feet
Hands
Cytolytic compounds,
anti phagocytic
polysaccharides
Debridement, clindamycin,
chloramphenicol, tetracycline
Tetracycline, aminoglycosides
AppendiX A-35
Microbiology
Dermatology
Infections: Subcutaneous
Suppurati(mywtoma)
Swollen abscle&a with pain, sinua tract formation, yellow granule& in exudate
Non -myotic, Actinomyces
israeli!; "lumpy jaw";
actinomycosis
Eumycotic, Sporothrix
schenckii (rose gardener's
disease)
Hands, limbs
Hands, arms
Solitary or lymphocutaneous
lesions; rose gardeners or
florists; sphagnum moss
Unknown, invasive
Unknown
Unknown
Penicillin, debridement,
doxycycline, clindamycin
Sulfonamide, sulfa
ant ibiotics; carbapenem for
resistant cases
Potassium iodide,
ketoconazole
rc
AppendiX A-36
Microbiology
Dermatology
Infections: Subcutaneous
Suppurtlve
nlml bite wounds
Pasteurella multocida
Eikenella corrodens
Capnocytophaga
canimorsus
Streptobacillus
moniliformis and
Spirillum minus
Dog bite
Rat bite
Bite wound
Bite of various
animals
Capsu le
Sialidase allows
adherence to host
cells
Endotoxin
Gram(-)
pleomorphic rod
Amoxicillin/
clavulanate
3rd -generation
cephalosporins,
fluoroquinolones
Amoxicillin/
clavulanate
Pen icillin G or V
AppendiX A-37
Microbiology
Dermatology
Infections: Subcutaneous
SUppurative
Malignllnt pustule
(anthrax e~~ehar)
Acute mastitis
Granulomatous
Malignant pustule
(ecthyma
(fishtank
granuloma)
Staphylococcus
aureus, Streptococcus
Bacillus anthracis
Pseudomonas
aeruginosa
Mycobacterium
marinum
Breast, unilateral
Various
Various
Hands
Pustule -7 dark-red,
flu id-filled, tumorlike lesion -7 necrosis
-7 black eschar
surrounded! by red
margin; postal worker
or wool importer
Pseudomonal
septicemia
Tropical fish
enthusiasts;
granu lomatous
lesion
Poly-D-gl utamate
capsule, exotoxin
causes edema, cell
death
Th ree-component
toxin
Endotoxin
Blood cu lture,
gram(-),
oxidase ( + ),
produces bl ue-green
pigments, fruity odor
Biopsy, slow
growing, acid-fast
bacilli
Penicillin, surgical
drainage
Ciprofloxacin, penicillin
Susceptibility testing
necessary
Clarithromycin
initi ally, then
ant i mycobacterial
therapy
rc
AppendiX A-38
Microbiology
Dermatology
Infections: Subcutaneous
Leprosy
Mycobacterium leprae
(tubercu loid form)
Mycobacterium leprae
(lepromatous form)
Various
Bartonella henselae
Exposure to cats
leonine facies
Cell-mediated immunity
kills intracellular organisms,
damages nerves
Dapsone, clofazimine,
rifampin
Rifampin , ciprofloxacin,
gentamicin, TMP
sulfamethoxazole
AppendiX A-39
Microbiology
Dermatology
Rashes
Erythematous
Lyme disease
Erysipelas
Ervthematous
+Macular
Toxic shock
syndrome
Scarlet fever
Borrelia burgdorferi
(No. 1 vector-borne
disease in U.S.)
Streptococcus
pyogenes
Staphylococcus
aureus
Streptococcus
pyogenes
Originates at site of
tick bite
Concentric rings
(bull's-eye, target)
Raised facial
butterfly wi1ng
Diffuse, sunburnlike
Trun k and neck-)
extremities with
desq uamat ion on
pa lms and soles
Fever, headache,
myalg ia, Bells palsy
TSST-1
( su perantigen)
Exotoxins A-C
(superant igens)
Serology; EIA +
Western blot
Catalase ( -') ,
gram (+ ) cocci,
bacitracin-sensitive
Gram ( +),
catalase ( + ),
coag ulase ( + ) cocci
Gra m(+),
catalase (- ) cocci
Doxycycline,
ceftriaxone
Penicillin, macrolide
Nafcillin, oxacillin;
vancomycin in
penicill in allergy
Penicillin , clindamycin
PhoiDs, top to bollllm, IGit to r1ght: SCience SOurce; SCience SOurce; 81opllato ~SOurce; Dr. P. Marazzi/Sclence SOurce
ra DeVry/ Becker
Append iX A-40
Microbiology
Dermatology
Rashes
Papular
Maculopapular
Secondary syphilis
Treponema pal!idum
Treponema pa!lidum
Generalized bronzing
rash involving t he palms
and soles
Anogenital, axillary
Fever, lymphadenopathy,
malaise, sore throat,
splenomegaly, headache,
arthralgias, IV drug
abusing females
Cough , coryza,
conj unctivit is, fever, Koplik
spots, bronchopneumonia,
ear infections,
unvaccirnated child
Endotoxin
Endotoxin
Serology: VORL
(nonspecific),
FTAABS (specific)
VORL + FTAABS
Supporti ve
top to boClDm, left to right: Sdence 111.1/CDCJI/louols Unllmlllod, Inc.; SaJit Comomz~ Source; Lowell Georgiii/Scll!na! Soura!
AppendiX A-4 1
Microbiology
Dermatology
Rashes
Vesicular
Vesicular+
Pruritic
Vesicular+
Painful
Shi n gl es
Staphylococcus aureus
Varicella-Zoster
v irus (Herpesviridae,
dsDNA)
Varicella-Zoster virus
(Herpesviridae, dsDNA)
Generalized with
involvement of
mucous membranes
Asynchronous rash,
unvaccinated child
Fever, pharyngitis,
malaise, rh init is,
exanthem
Exfoliatins
Exotox ins
Virus replicates in
mucosa and is latent in
dorsal root ganglia
Gram ( + ), catalase ( + ),
coagulase ( + ) cocci
Supportive, avoid
aspirin due to Reye
synd rome
Acyclovir, famciclovir,
valacyclovir
P, tup tD - . ,, left tD right: SCXJtt Co rnu~era Sourc:e; Medloaiii/VIIUals Unllm-, Inc.; liiMI c:.v.mnVSdenco Sourc:e; Dr. P. Mlrvd/
Sc-Sourte
AppendiX A-42
Microbiology
Dermatology
Rashes
Petechial/Purpuric
Meningococcemia
Rocky Mountain
spo tted fever
Epidemic typhus
Neisseria meningitidis
Rickettsia rickettsii
Rickettsia prowazekii
Generalized
Trunk--? extremities;
spares palms, soles,
and face
Endotoxin (overproduces
outer membrane
fragments)
Endotoxin
Gram(-) diplococcus on
chocolate agar; LPA for
capsular antigens
Serology, Weii-Felix
Serology, Weii-Felix
Ceftriaxone
Doxycycline,
chloramphenicol
Doxycycline,
chloramphenicol
AppendiX A-43
Microbiology
Hematology
Hematologic Changes Associated With Infectious Disease
Neutrophilia
(1' PMNs)
!oslnophllla
( 1' eoslnophlls)
Mononucl-is
( 1' lymphocytes
monocyte&)
Many extracellular
bacterial infect ions
Allergy
Helminths during
migrations
Immediate onset
of symptoms after
e xposure
Exposure to source
of helm inth parasite
Depends on agent
N formyl methionyl
peptides are
chemotactic for
PMNs
ECF A released by
mast cells attracts
eosinoph ils
Parasites release
allergens
In tracellular organisms
elicit Thl cells and CMI
Cu lt ure, Gram
stain
Depends on agent
Depends on agent
Depends on agent
rc
AppendiX A-44
Microbiology
Hematology
Mononudeosls
Lymphocytollis
Infectious mononucleosis:
Epstein -Barr virus
Infectious mononucleosis:
CMV
Bordetefla pertussis
Monospot ( +)
Complete blood count
Gram(-) rod,
culture BordetGengou agar
or serology
Supportive
Erythromycin, antitoxin
rc:
AppendiX A-45
Microbiology
Hematology
Normocytic to Microcytic
Megaloblastic
Ch ronic infections
Ancylostoma, Necator,
Trichuris
Diphyllobothrium tatum
Depends on agent
Depends on agent
Mebendazole
Praziquantel
Append iX A-46
Microbiology
Hematology
(cD4+ cells)
Hemolytic
rc:
Plasmodium spp.
HIV
Lymphadenopathy
Opportun istic infections
Rings/trophozoites in blood
film
AppendiX A-4 7
Microbiology
Osteomyelitis
(Fever, bone pain, erythema, swelling)
No. 1 overall in
adults, children, and
Infants without major
trauma or special
conditions
Sickle cell
anemia
Immigrants
from Indian
subcontinent;
spine, hlp,
knee, hands
Trauma
Staphylococcus aureus
Salmonella spp.
Pseudomonas aeruginosa
Mycobacterium
tuberculosis
Hematogenous spread
7 lytic bone lesions,
lytic toxins
HbS patients
are functionally
asplenic and
cannot ki ll
bloodborne
pathogens
Tuberculous
granuloma erodes
into bone
Gram( - ),
oxidase ( - ),
non lactose
fermenting
Gram (- ), oxidase ( + ),
blue-green pigments,
grape odor
Auramine screen
for acid -fast
bacilli
Nafcillin, 3rd-generation
cephalosporin,
IV vancomycin
3rd-generation
cephalosporin,
fluoroq ui nolones,
chloramphenicol
Antipseudomonalj3-lactam
+ aminoglycoside,
or carbapenem +
antipseudomonal
fluoroqu inilone +
aminog lycoside
Multiple drug
therapy
AppendiX A-48
Microbiology
Infectious Arthritis
(Pain, low-grade fever, reduced joint mobility, swelling)
High neutrophil count In joint ftuld
Chronic: onset,
~=========;;========:::;;==========:I monoertlc:uler,
weightbeering
No.1 overall (except
15-40 yean;, monoProsthetic joint
joints
in the 15-40 age
or polyarticular
Staphylococcus aureus
Neisseria gonorrhoeae
Coagu lase-negative
staphylococci
M. tuberculosis
or fungal
Pil i mediate
adherence and inhibit
phagocytosis
Biofilm allows
ad herence to Tenon
Granulomas
erode into bone
Gram ( - ) diplococcus;
ferments glucose but
not maltose
Acid-fast
bacillus or
auram ine stain,
fungus stain
Nafcillin,
3rd generation
cephalosporin, IV
vancomycin
Ceftriaxone
Nafcillin,
3rd generation
cephalosporin
Multiple drug
therapy
AppendiX A-49
Microbiology
Immune complex
Reiter syndrome
(ureltls, arthritis, conjunctivitis)
(type Ill
hypenenllltlvlty)
rc
Rubella and
hepatiti s B,
Parvovirus,
Lyme disease
Salmonella, Shigella,
Campylobacter,
Yersinia enterocolitica
( 1- 3 weeks following
GI infection}
Immune complex
mediated (type III
hypersensitivity}
Detect immune
complexes
Clinical
I mmunosuppressive
therapy
Symptomatic
Chlamydia trachomatis
( 1- 3 weeks following
STI}
AppendiX A-50
Microbiology
Eye
Eye Infections
Eyelid
Stye
Conjunctiva
Swelling
Conjunctiv it is
Neonate
All
Staphylococcus
aureus
Propionibacterium
acnes
Trypanosoma cruzi
Trichinella spiralis
Chlamydia
trachomatis,
serovars D K
Unilateral
inflammation at bi te
site; t ravel t o Central
or South Am erica
Bilateral eyelid
swell ing, > 10%
eosinophilia, fever,
muscle pain; earlier
GI Sx
Abscess formation
Inflammation due to
parasite invasion
Int racellular
granulomatous
Clin ical
Blood film
Muscle biopsy
Int racytoplasmic
inclusion bodies in
scrapings
Supportive
Benznidazole,
nifurtimox
Supportive
Erythromycin
rc:
AppendiX A-51
Microbiology
Eye
Eye Infections
Conjunctiva
Conjunctivitis
Neonate
Adult (bacterial)
Nisseria gonorrhoeae
Staphylococcus
aureus
Chlamydia
trachomatis,
serovars A-C;
Trachoma
Staphylococcus
aureus
Group A Strep
Streptococcus
pneumoniae,
all gram(+)
Haemophilus
influenzae
H. aegyptius
"Sticky eye"
Entropion,
intracytoplasmic
inclusions
Intracellular
granulomatous
Neutrophilic
infi ltration
Neutrophilic infiltrate
Gram(+),
catalase ( + ),
coagulase ( +) cocci
I ntracytoplasmic
inclusion bodies in
scrapings
Clinical
Erythromycin
Tetracycline ointment
Erythromycin
Tetracycli ne ointment
rc
Append iX A-52
Microbiology
Eye
Eye Infections
Conjunctiva
Cornea
Conjunctivitis
Keratitis
Adult (viral)
Neonate
Adenovirus (more
common than
Treponema palfidum
Toxoplasma gondii
Acanthamoeba spp.
Mother is IV drug
user
Contaminated
contact len s solution
Viral
cytopathogenesis
Unknown
Intracellular
organism proliferates
in immunoprivileged
sites
Clinical
Cli nical
Eye lubricant
Penicillin
Pyrimethamine,
sulfadiazine
Adult
* Disti nguish from allergic: Allergic conjunctivit is subsides with elimination of allergen.
rc:
AppendiX A-53
Microbiology
Eye
Eye Infections
Chorioretinitis
Neonate or AIDS
rc
Toxoplasma gondii
Cytomegalovirus-No. 1
in utero infection in u.s.
Intracellular organism
proliferates in
immunoprivileged sites
Clinical; focal
necrotizing
chorioretinitis
Pyrimethamine,
sulfadiazine
Ganciclovir; damage
irreversible
AppendiX A-54
Microbiology
Otitis externa
Pseudomonas
aeruginosa
Staphylococcus
aureus (f rom normal
flora)
Candida albicans
(from normal flora)
Pseudomonas
aeruginosa (from
water sources)
Purulent lesion
Ear pain
Creamy exudate
Capsule
Capsule protects
against phagocytosis
Gram ( - ) rod,
oxidase ( + ), bluegreen pigments,
fruity odor
Gram ( +) yeast,
germ tube test
Gram (- ) rod,
oxidase ( + ), bluegreen pigments
13-lactamase-resistant
penicillin
Nystatin, m iconazole
AppendiX A-55
Microbiology
Otitis extema
Streptococcus
pneumoniae
(No. 1 overall)
Swimmerurease(+), gram(-)
bacil lus
Capsule protects
against phagocytosis
Capsule, IgA
protease
Capsule, IgA
protease, endotoxin
13-lactamase
producer
Treat empirically
Gram ( + ) coccus,
catalase ( - )
Treat empirically
Gram(-) rod,
chocolate agar
Treat empirically
Gram(-)
diplococcus
Penicillin
Amoxicill in
Ceftriaxone
H. influenzae
(nontypeable}
Moraxefla catarrhalis
rc
AppendiX A-56
Microbiology
Sinullitis
Streptococcus
pneumoniae
(No. 1 overall)
Haemophilus
influenzae
Moraxella catarrhalis
Zygomycota (Mucor,
Rhizopus, Absidia)
Ketoacidotic diabetic,
leukemic patient,
black nasal discharge
Capsu le,
IgA protease
Capsule,
IgA protease,
endotoxin
13-lactamase
producer
Gram ( + ) coccus,
catalase (-)
Gram ( - ) rod,
chocolate agar
Gram (- ) coccus,
butyrate esterase
producer
Pen icillin
Amoxicill in
Ceftriaxone
Amphotericin B
rc:
AppendiX A-57
Microbiology
sore throat
(bacterial; abscesslng
exudative}
Candida albicans
Fusobacterium +
Treponemes
Streptococcus pyogenes
Acute necrotizing
ulcerative
gingivostomatitis,
painfu l mouth
(Vincent a,ngina)
Innamed tonsils/pharynx,
abscesses; cervical
lymphadenopathy, fever,
sandpaper rash
Overgrowth of
Overgrowth of normal
Exotoxins A-C
normal nora,
immunocompromised ,
overuse of ant ibiotics
nora
(superantigens)
Spirochete +
fusobacterium
Nystatin, miconazole
Debridement
Pen icillin
rc
AppendiX A-58
Microbiology
Bac:teriali ab.clulling
exudative
Corynebacterium
diphtheriae
Coxsackie A
Epstein-Barr vir us
Rhinoviruses
(summer- fall)
Coronaviruses
(winter -spring)*
Severe fatigue,
lymphadenopathy,
fever, + 1- rash
Rhinitis, sneezing,
cou ghin g;
seasonal peaks
Diphtheria toxin
inactivates eEF-2 in
heart, nerves, epit helium;
pseudomem brane ~
airway obstruction when
dislodged
Unknown
Infects 6
lymphocytes by
attachment to
CD21, causes 1' Tc
Virus attaches
to ICAM -1 on
respiratory
epithelium
Serology
Clinical
Supportive
Heterophile ( +)
(Monospot test);
mononucleosis;
70% lymphocytosis
(Downey type II
cells =Tc)
Supportive
rc:
AppendiX A-59
Microbiology
Epiglottitis
Laryngotradleltls,
laryngotracheobrondlltls
Bronchitis, brondliolitis
Haemophilus
influenzae
Parainfluenza virus
Respiratory syncytial
v irus
Mycoplasma
pneumoniae
Inflamed
epiglottis;
patient often 2-3
year s old and
unvaccinated
Wheezy; infant or
child :SS years old
Release of o 2
Capsule
Viral cytolysis;
Fusion protein
( polyribitol
creates syncytia
phosphate) inhibits
phagocytosis;
IgA protease
formed
Gram ( - ) rod,
chocolate agar
(requ ires hemin
and NAD)
Direct
immunofluorescence
for v iral Ags
Slow growth on
Eaton medium,
cold agg lutinins
Ceftriaxone
Ribavirin
Ribavirin,
palivizuma b to high
risk contacts
Symptomatic
radicals causes
necrosis of
epithelium
rc
AppendiX A-60
Microbiology
Bronchiti,
bronchioliti
Bordetefla pertussis
Streptococcus
pneumoniae
Staphylococcus
aureus
Anaerobes,
m ixed infection
(Bacteroides,
Fusobacterium,
Peptococcus }
Whooping cough:
Unvaccinated,
inspiratory stridor,
cough > 2 weeks
afebrile
Adults, aspiration
or ventilator;
nosocomial; salmoncolored sputum
Capsu le
anti phagocytic,
l gA protease
Abscessing,
necrotizing
Serology
Gram(+}
diplococcus,
catalase ( - ) ,
a -hemolytic,
lysed by bile,
inhibited by optochin
Gram(+},
catalase ( + },
coagulase ( + } coccus
Culture of sputum
Erythromycin +
antitoxin
3rd-generation
cephalosporin,
azit hromyci n
MSSA: amoxicillin +
clavulanate
MRSA: va ncomycin
Empiric antibiotic
therapy (amoxicill in/
clavu lanate,
gentam icin }
AppendiX A-61
Microbiology
Pseudomonas
aeruginosa
Klebsiella
pneumoniae
Mycobacterium
tuberculosis
Histoplasma
capsulatum
Neutropenic
patients, burn
patients, CGD, CF
Alcoholic with
aspiration, facultative
anaerobic, gram (-)
bacterium with large
capsule, currant jelly
sputum
Over 55 years,
HIV ( + ), or
imm igrant from
developing country
Fever, night sweats,
weight loss,
hemoptysis
Dusty environment
with bird or bat
fecal contamination
(M issouri chicken
farmers, Oh io River
drainage), AIDs
Opportunist,
endotoxin
Capsu le protects
against phagocytosis
Facultative
intracellular parasite - >
cell -med iated immunity
and DTH
Facu ltative
int racellular
- > granuloma
formation
Gram ( - ) rod,
oxidase ( + ), bluegreen pigments
Gram (- ) rod,
lactose fermenting,
oxidase(-)
Auramine-rhodam ine
stain of sputum, acid fast bacilli
Intracellular yeast
cells in sputum
Sensitivity testing
required
Susceptibility testing
necessary
Mu It id rug therapy
Amphotericin B
rc
AppendiX A-62
Microbiology
Blastomyces
dermatitidis
Coccidioides immitis
Mycoplasma
pneumoniae (most
common in school
age children)
Legionella
pneumophila
Rotting,
contaminated wood,
same endemic focus
as Histoplasma +
East Coast states
(N.C. and S.C.),
AIDS
Desert sand of
Southwest U.S.,
AIDS
Pneumonia teens/
young ad ults; bad
hacking, dry cough;
"walking pneumonia"
Air-conditioning
exposure; common
showers; especially
>50 years; heavy
smoker, drinker
Adhesin causes
adhesion to mucus;
oxygen rad icals
cause necrosis of
epi thelium
Intracellular in
macrophages,
granulomatous
inflammation
Endospores in
spheru les in t issues
Serology, cold
agglutinins
Direct fluorescent
antibody
Ketoconazole
Amphotericin B
Tetracycline,
erythromycin
Erythromycin
AppendiX A-63
Microbiology
Bacterial origin
VIral origin
Fungal origin
Chlamydophila
psittaci
Influenza vi rus
Measles
Pneumocystis
jirovecii (carinii)
Primary influenza
pneumonia
Poorly nourished,
unvaccinated baby/
child; giant cell
pneumonia w it h
hemorrhagic rash,
Koplik spots
AIDS patients or
premature infants
wit h staccato coug h;
"ground glass" x-ray;
honeycomb exudate
wit h silver-sta ining
cysts
Cytolysis in
respiratory tract;
cytokines contribute;
secondary infections
common
Cytolysis in lymph
nodes, ski n,
mucosa
Syncytia -> giant
cell pneumonia
Attaches to type I
pneumocytes, causes
excess replication of
type II pneu mocytes
Direct fluorescent
antibody,
intracytoplasmic
inclusions
Virus culture,
serology
hemagg lutinin titer
Serology
Tetracycli ne,
erythromycin
Amantad ine,
rimantadine
Supportive
Trimethoprim
sulfamethoxazole,
pentamidine
rc
AppendiX A-6 4
Microbiology
SARS coronavirus
Serology, v ir us isolation
Ribavirin, experimental
Ribavirin
AppendiX A-65
Microbiology
Yes
~ No
/~
(< 5 is normal)
PMNs
Lymphocytes
Bacterial
/~
Glucose l
Glucose normal
Fungal/TO
VIral
Puftllant
(bacterial)
Normal val-
.beptic: (viral)
Gf11nulomlltvu
(mywbacterial/
fungal)
70- 180
Markedly elevated
Slightly elevated
Moderately elevated
Up to 90,000
neutrophils
Normal
Decreased ( <45)
15- 45
Increased (>50)
Increased (>50)
Increased (>50)
Append iX A-66
Microbiology
Meningiitis
(Headache, fever, nuchal rigidity, obtundation, coma, neutrophilic exudate.
May develop hydrocephalus herniation, cranial nerve damage.)
Neonate
Bacterial
Streptococcus agalactiae
(No. 1 cause)
Escherichia coli
(No. 2 cause)
Listeria monocytogenes
(No. 3 cause)
Bulgirng fontanelles
Bulging fontanelles
CSF-gram ( +) cocci
CSF-gram (+)rods
Ampicillin, penicillin G
Cefotaxime
AppendiX A-6 7
Microbiology
Meningitis
(Headache, fever, nuchal rigidi ty, obtundation, coma, neu t ro philic exudate.
May develop hydrocephalus, herniation, cra nial nerve dam age.)
3 months -+ 2 years
3 months -+ young
adult
Adult
Bacterial;
unvaccinated
Haemophilus
in fluenzae type b
Streptococcus
pneumon iae
Streptococcus
pneumoniae
Immigrant family,
religious obj ections
to vaccination, gram
( - ) bacill i, chocolate
agar
Very young
or very old,
immunocomprom ised
Adolescent, dorm
or barracks living,
extremely acute
onset, petechial rash
Very young
or very old,
i m m unocom promised
Capsule, endotoxin,
I g A protease
I gA prot ease,
capsule, PMN
infiltra tion
Ig A protease capsule,
PMN infiltration
Quellu ng or
latex particle
agg lutination (LPA)
Chocolate agar requires factors
X+V
Quellung, LPA to
serotype capsule,
gram(+),
catalase (-),
a-hemolytic,
optochin sensitive,
bile soluble
LPA, culture
chocolate agar,
gram (-) diplococcus
Quellung, LPA to
serotype capsule,
gram (+) ,
catalase (- ),
a-hemolytic,
optochin sensitive,
bile soluble
Ceftriaxone
Cefotaxime ,
vancomycin
Penicillin G,
chloram phenicol,
cefotaxime,
ceftriaxone
Cefotaxime,
vancomycin
Bacterial
AppendiX A-68
Microbiology
Meningitis
(Headache, fever, nuchal rigidity, obtundation, coma, neutrophilic exudate.
May develop hydrocephalus, herniation, cranial nerve damage.)
Any
Adult
Fungal; immune
compromised
Viral; aseptic
Listeria
monocytogenes
Mycobacterium
tuberculosis or MAl
Cryptococcus
neoformans
(No. 1 cause)
Enterovirus most
common
Ingestion of
unpasteurized dairy,
renal transplant,
leukemic patient
Leptomeningeal
inflammation,
lymphomonocytic
infiltrates,
depressed
consciousness,
low mortality
Facultative
intracellular
Dissemination from
lung
Unknown
fecal/oral spread
gut -> blood -> brain
CSF-motile,
gram ( +) bacilli
Lym phocytes
predominate in CSF,
.j. glucose
Lymphocytes
predom inate in CSF,
.j. glucose,
urease ( + }, yeast,
India ink ( +)
Ampicill in with
or w ithout
aminoglycoside
2 monthsisoniazid, rifampin,
pyrazinam ide +
10 months- isoniazid
+ rifampin
Amphotericin B +
flucytosine
Supportive
AppendiX A-6 9
Microbiology
Meningoencephalitis
Often children
Any
Any+ AlDS
<100 CD4+ cells/mm
Parasitic
Naegleria fow/eri
Acanthamoeba castellani
Toxoplasma gondii
lmmunocompromised
Enters through skin
Intracellular
parasite persists in
immunoprivileged sites
Flagellated trophozoites
in CSF
Serology, PCR
Amphotericin B
(rarely successfu l)
Amphotericin B
(rarely successful)
Pyrimetham ine +
sulfad iazine
AppendiX A- 70
Microbiology
Encephalitis
(Fever, headache, changes in mental status, coma)
All
Viral
Herpes simplex I
Arboviruses:
St. Louis, California,
Eastern, Western,
West Nile, and
Venezuelan
encephalitis viruses
Rabies
HIV
Hemorrhagic necrosis
of temporal lobe,
RBC in CSF
Summer months,
mosquito-borne
Negri bodies in
hippocampal +
Purkinje neurons
of cerebellum,
hallucination,
excessive salivation
PCR
PCR
Serology, RT-PCR
PCR or serology
Acyclovir
Supportive
None
Antiretroviral therapy
AppendiX A-71
Microbiology
Miscellaneous
Any
Any
Child
Mass lesion
Reye syndrome
Epilepsy
Bell Palsy
Streptococcus or
Bacteroides
Influenza, varicella
Taenia so/ium
Borrelia burgdorferi
t Intracranial
pressure, headache,
Aspirin use +
vomiting, lethargy,
Recent immigrant,
Summer months,
travel to Mexico,
northeastern
nausea, vomiting,
seizures; follows
sinus, ear, dental
infection
irritability
exposure to swine;
epilepsy of adu lt
onset
geography, tick
exposure, targetshaped rash
Contiguous spread t o
brain
Unknown
Larvae encyst
in brain
( neurocysticercosis),
calcifying lesions
Invades endothelial
cells
Ring-enhancing
lesion on CT
Clinical
Debridement,
ant ibiotics
Supportive
Praziquantel,
albendazole
Doxycycline
u.s.
AppendiX A- 7 2
Microbiology
Miscellaneous
Any
Progressive multifocal
leukoencephalopathy
(immunocom promised/AIDS)
JC v irus
Clin ical
Plasmapheresis, IVIGs
Invariably fatal
AppendiX A-73
Microbiology
Cardiac
Endocarditis
Janeway lesions (erythematous, nont ender lesions on palms and soles),
Osier nodes (eryt hematous, tender lesions on fingers and toes, splint er hem orrhages,
Roth spots ( ret inal hemorrhages)
Ac:ulla
endocarditis
(rapid onset,
high fever, chills,
dlest pain}
Streptococcus
vir/dans (55%)
Staphylococcus
epiderm/dis
Enterococcus
Previously normal
valves, tricuspid
in IV drug users
Rapid onset
IV drug abuser
Highly v irulent
organism, PMN
infiltration,
abscesses,
vegetations
Norma l flora,
oropharynx
Blood culture:
Staph: gram ( + ) ,
catalase ( +),
coagulase ( + )
cocci
Strep: gram ( + ),
catalase (-) cocci
Gram(+),
catalase (- ) coccus,
a - hemolytic, lysed
by bile, optochin
sensitive
Gram(+),
catalase ( + ),
coagulase (- ) coccus
Gram ( + ),
catalase (- ),
PYR (+ )coccus,
escu lin agar
Ceftriaxone,
vancomycin
Penicillin , ceftriaxone
Staphlyococcus
aureus (SO%)
Streptococci (35%)
rc
AppendiX A-74
Microbiology
Cardiac
Endocarditis
Rheumatic Fever
Acute, type II
hypanenllitivity
HACEK group:
Haemophilus aphrophilus,
Aggregatibacter
actinomycetemcomitans,
Cardiobacterium hominis,
Eikenella corrodens,
Kingella kingae
Candida albicans
Leu kocytosis
Previous rheumatic fever
Prolonged PR interval
Normal flora of mouth
Organ isms with low
v irulence introduced
into blood and grow on
damaged valves
Gram ( + ) yeast
Ceftriaxone
Amphotericin B
Penicillin
AppendiX A-75
Microbiology
Cardiac
Myocarditis
Rheumatic Heart Disease
Chronic: result of
inflammatory insult
Neutrophilic:
(bac:terial)
Mononudear
(viral)
GAS
(ongoing au toimm une
response)
Meningococcus or
diphtheria ( toxin
mediated)
Adenovirus
Enteroviruses
(coxsackie B)
Also polio, rubella,
influenza
Trypanosoma cruzi
(See discussion
of Neisseria
meningitidis
meningitis or
diphtheria respiratory
syndrome)
Potentially
recurrent; may
necessitate cardiac
transplant
Immigrant from/
travel to South
America; preceded
by unilateral eyelid
swell ing ( Romana
sign)
Dilated
cardiomyopathy
rc
Parasitic
(protuzoal)
Clinical
Serology
Interferon u or
Trypomastigot es on
blood film
13
Benznidazole,
nifurtimox
AppendiX A-76
Microbiology
Gastrointestinal
Inflammatory Diarrheas
(Invasive organisms that cause fever, blood, and pus in stool;
all patient age groups.)
Allsoc:lated with
antibiotic use
(cllndamydn)
Campylobacter
jejuni (No. 1
bacterial diarrhea in
U.S.)
Salmonella spp.
(non -typhoidal
Salmonellae)
Yersinia
enterocolitica
Clostridium difficile
3- 5 days
8- 48 hours
2- 7 days
N/A
Invades epithelium
Penetrates to
lamina propria of
ileocecal reg ion
-> PMN response
and prostaglandin
synthesis, wl'l ich
stimulates cAMP
Cold -climate
pseudoappendicitis;
heat-stable
enterotoxin;
arthrit is may occur
Pseudomembranous
colitis, normal flora
organism overgrows
when competitors killed
Oxidase ( + },
gram(-}, curved
rod, seagull
wings shape;
grows at 42C;
microaeroph ile
Gram(-},
motile rod;
nonencapsulated,
oxidase ( - )
Gram(-},
motile rod;
nonencapsulated,
oxidase ( - },
urease ( + ); bipolar
staining; best
growth at 25C
Treatment for
severe cases only;
erythromycin for
invasive disease
Switch antibiotic;
metron idazole
AppendiX A-77
Microbiology
Gastrointestinal
Enteroinvasive
E. coli
Shigella spp.
Entamoeba histofytica
(typically ingested
during foreign t ravel,
often Mexico)
2-3 days
1-7 days
2-4 weeks
Trophozoites invade
colon; flask-like
lesions, extraintestinal
abscesses (liver)
Gram (- ) rod;
nonlactose
fermenting; nonmoti le
Motile trophozoit es or
quadrinucleate cysts
Metronidazole
rc
AppendiX A-78
Microbiology
Gastrointestinal
Noninflammatory Diarrheas
(Intoxication; pre-formed toxin is ingested; no fever, blood, or pus;
all patient age groups.)
Staphylococcus aureus
Fried rice
Bacillus cereus
(emetic form)
<6 hou rs
Meat, vegetables
Bacillus cereus
(diarrheal form)
18 hours
Heat-stable enterotoxin
is produced in food
(contam ination by
food hand ler w ith skin
lesions); food sits at
room temperature
Heat-stable tox in
causes vomiting
Symptoms, ti me of
onset, food source
Symptoms, t ime of
onset, food source
Recovery w ithout
treatment
Recovery w ithout
treatment
Recovery without
treatment
rc:
AppendiX A-79
Microbiology
Gastrointestinal
Children, immunocompromised
Day care,
fecal-oral, animals,
homOMXuals
Nosocomial
Rotaviruses
Enteropathogenic
E. coli ( EPEC) (often
ingested during
travel to/from
developing cou ntries)
Cryptosporidium
parvum
Adenovirus, types
40/41
1- 3 days
2-6 days
2-4 weeks
7 - 8 days
Microvilli of small
intestine blunted;
dehydration
Adherence to
enterocytes th rough
pili --+damage to
adjoining microvilli
Parasites intracellular
in brush border
Diagnosis by
exclusion;
dsRNA naked,
double-shelled ,
icosahedral
(Reovirus family)
Gram ( - ) rod;
motile; lactose
fermenter;
serotyping compares
0 , H, K antigens
Acid-fast oocytes in
stool
Diagnosed by
exclusion: naked,
dsDNA, icosahedral
Supportive
Sensitivity testing
required
Nitazoxanide,
pu romycin,
azithromycin in
immunocomprom ised
No specific therapy
rc
AppendiX A-80
Microbiology
Gastrointestinal
Noninflammatory Diarrheas
(Noninvasive organisms; no fever, no !blood, no pus; all patient age groups.)
Beef, poultry,
gravies, Mexican
food
Food, fecal-oral
(hamburger)
Water, food,
fecal-oral
Clostridium
perfringens
Vibrio
parahaemolyticus
Enterohemorr hag ic
E. coli (EHEC)
Vibrio cholerae
8-24 hours
5-92 hours
3-5 days
9-72 hours
Enterotoxin
Self-limited
gastroenteritis
m im icking cholera
Verotoxin, wh ich
inhibits 60S
r ibosomal subunit,
causes bloody
diarrhea; no fever
Toxin stimulates
adenylat e cyclase;
rice water stools
Anaerobic,
gram (+)rods,
spore form ing
Oral rehydration
therapy; tetracycline
shortens sym ptoms
Not indicated
AppendiX A-81
Microbiology
Gastrointestinal
Noninflammatory Diarrheas
(Noninvasive organisms; no fever, no blood, no pus; all pat ient age groups.)
Enterotoxigenic E. coli
(ETEC)
Norwalk virus
(or Norovirus and
Norwalk-lilke vir us)
12- 72 hours
18- 48 hours
5- 25 days
Blunt ing of
microvilli; "cru ise
ship" diarrhea
Cysts ingested;
trophozoites; multipl y
and attach to small
intestinal villi by
sucking disc, cause
fat malabsorption - >
steatorrhea
Diagnosis by
exclusion: ss(+)RNA,
naked, icosahedral
(Calicivirus family)
Flagellated binucleate
trophozoites;
"falling-leaf' motility;
quadrinucleate cysts
Sensitivity testing
required
Supportive
Metron idazole
Append iX A-82
Microbiology
Gastrointestinal
Hepatic
Hepatitis
(Increased liver function tests, malaise, anorexia, nausea, right upper quadrant pain, j aundice.)
Food borne
Sexual/ parental'lll
u.s.
Africa/ Asia
Hepatitis A virus:
Infectious hepatitis,
picornavirus; naked,
ss{+)RNA
Hepatit is C virus:
"Post-transfusion"
hepatitis flavivir us;
enveloped
ss(+)RNA
Raw oysters,
no chronicity
Pregnant women,
20% fatality,
no chronicity
Prison -system,
high chronicity,
carci noma
Virus is cytopath ic
CMI is cytopathic;
carcinogenesis from
DNA integration
Chronic cell
damage-->
cirrhosis and
carcinogenesis
Serology
Serology
HBsAg+
HBcAb+
Serology
Supportive
Interferon
Interferon
ribavirin
a,
rc:
AppendiX A-83
Microbiology
Gastrointestinal
Hepatic
Cirrhosis
(Chronic scarring + fibrosis ~ t portal
pressure ~ varices ~ rupture ~
hematemesis)
Hepatitis
Travel history:
Tropics, Africa , Asia; 10% o f popu lation of
Puerto Rico is infected
Coinfectionhepatitis B and
delta agent
acqu ired at same
time; no gr eater
risk of chronicity
Superinfection - delta
agent acquired in
chronic hepatit is B ~
fulm inant disease
(massive hepatic
necrosis + dysfunction
mortality 25%- 9 0%)
Praziquantel
fibrosis from
rc
AppendiX A-84
Microbiology
Gastrointestinal
Hepatic
Abscess (Mass Lesion)
Seeding from
INic:blremia
Fecal-oral
Entamoeba histolytica
Ascaris lumbricoides
Ascending cholangitis
Adults
Migrate to
extraintestinal sites
in heavy infections
Blood culture
Cysts o r trophs in
feces or none
Scint igraphy
Serology
Depends on agent
cultured
Metronidazole +
dilanoxanide fu roate
Surgery
rc:
AppendiX A-85
Microbiology
Gastrointestinal
Hepatic
Pancreatic
Fecaloral
Cholangiocarcinoma
Pancreatitis
Respiratory
droplets
Ascaris
lumbricoides
(large
roundworm)
Fasciola hepaUca
(sheep liver fl uke)
Clonorchis sinensis
(Chinese liver fluke)
Mumps virus
(Paramyxovirus)
Abdominal pain,
distention,
jaund ice, weight
loss
Outside of U.S. ;
rural, exposu re to
sheep
With parotitis,
fever
Unvaccinated
Orchitis in older
males
Virus attacks
glandu lar tissue
Large, oval
rough-shelled
eggs in stool
Serology PCR
Surgery
Triclabendazole
Supportive
rc
AppendiX A-86
Microbiology
Gastrointestinal
Intestinal blockage
fecal-oral
Peritonitis
Ascaris lumbricoides
Diphylfobothriium
Iatum
Ingestion of
raw fish; Great
Lakes region;
megaloblastic
anemia
Tapeworm grows to
3 m, compebes for
v itam in Bl2
Cu lture blood
Surgery
Praziquantel
Metronidazole
AppendiX A-87
Microbiology
Urinary /Renal
Urethritis
Urea.e ( + ), no wll
wall; not Gramlltaining; diagnORCI
by exdullion,
urinarypHt
Gram(-)
diplococx:i in
PMNs, growth on
Thayer-Martin
agar, DNA probes
Tluue culture;
glycogen-containing
lnduslon bodies In
Neisseria
gonorrhoeae
Chlamydia
trachomatis
Ureaplasma
urealyticum
Trichomonas
vagina/is
Obligate intracellular
in epithelial cells;
CMI and DTH cause
scarring
Urease raises pH of
urine -> struvite stones
Unknown, PM N
filtrate
Ceftriaxone
Tetracyclines, macrolides
c:ytopla~~m
Flagellated
protozoan;
corkscrew
motility
Metronidazole
AppendiX A-88
Microbiology
Urinary/Renal
Cystitis
( Uri nary frequency, urgency, dysuria , suprapubic pain,
no WBC cast s in urine.)
Culture of urine
itiOS CFU/mL of
gram (-) rods in
urine
Culture of urine,
gram(+) ClOcci
"honeymoon
cystitis"
Culture of urtne.
lactose nonfermenting gram (-)
badlll with IIWIIrmlng
motility t urinary pH
E. coli
(No. 1 cause), other
gram (- ) enterics
Staphylococcus
saprophyticus
Proteus spp.
Pili, adhesins,
motility, many are
Sexual intercourse
introduces normal
flora organisms into
urethra
Fluoroquinolones,
TM P-SMX
Fluoroquinolones
~-hemolytic
Fluoroquinolones,
sulfonam ide
AppendiX A-89
Microbiology
Urinary /Renal
Pyelonephritis
(Previous + flank pain, fever + WBC casts)
Gl'llm (-)
ladoM fennenting
bacillus
Escherichia coli
Proteus mirabilis
Klebsiella spp.
Pil i mediate
adherence; motility
Large capsule
swarming non
bacillus
AppendiX A-90
Microbiology
Urinary /Renal
to RPSJI.
Streptococcus pyogenes
(post-infectious sequela)
Symptomatic
n~hts
1cscrvcd.
AppendiX A-91
Microbiology
Reproductive
+ inflammation)
Chancroid
Adherent yellowish
discharge, pH >5,
fishy amine odor
in KOH, clue cells,
gram ( - ) cells
dom inate
"Strawberry cervix,"
foamy, pur ulent
discha rge; many
PMNs and motile
trophozoites
m icroscopically
(corkscrew motility)
Gardnerella
vagina/is
(bacterial vag inosis)
Candida spp.
Trichomonas
vagina/is
Haemophilus
ducreyi
Overgrowth of
Immunocompromised
Unknown
anaerobic bacteria
patient
Antibiotic u se leads to
fungal overgrowth
Pear -shaped
trophozoites w ith
corkscrew motility
Metron idazole
Nystatin, m iconazole
Metronidazole
Cefotaxime,
ceftriaxone
rc
Append iX A-92
Microbiology
Reproductive
Lymphogranuloma
venereum
Primary syphilis
Secondary syphilis
Tertiary syphilis
Painless chatncre
forms on glans penis
(or vulva/cervix}
and heals with in 1- 3
months
Local or generalized
rash lasting 1- 3
months, can involve
the palms and soles
Chlamydia
trachomatis
serotypes ll- 3
Treponema pallidum
Obligate intracellular
3-week inculbation
duri ng which
spirochetes spread
throughout the body
Develops 1- 2
months after
pri mary stage
Cell culture,
glycogen-containing
inclusions
Biopsy/scraping
viewed with darkfield microscopy
shows spiri liar
organisms
Serology- VORL
( +} (nonspecific};
FTA-ABS (specific}
Serology- FTA-ABS,
nonspecific tests may
be negative
Tetracyclines,
erythromycin
AppendiX A-93
Microbiology
Reproductive
Condyloma acumlnatum
(genital warts)
Genital herpes
Herpes simplex
(usually type 2)
reactivates
Podophyllin, imiquimod
rc
AppendiX A-94
Microbiology
Reproductive
Cervicitis
Cervicitis
Cervicitis
Cervie~~l e~~rcinoma
Neisseria
gonorrhoeae
Herpes simplex
virus
Chlamydia
trachomatis
Invades mucosa,
Obligate
pa inful
intraepithelial neoplasia
I gA protease
Gram(- ) diplococci,
Thayer-Martin agar
dsDNA, nuclear
envelope,
icosahed ral; Tzanck
smear, intranuclear
inclusions
May be asymptomatic,
or may have postcoital
bleed ing, dyspareun ia,
discha rge
Early detection possible
with Papanicolaou ( Pap)
smear-koi locytic cells
Ceftriaxone
Tetracycl ines,
macrolides
Acyaclovir,
val acyclovir,
famciclovir
Cryotherapy
rc:
AppendiX A-95
Microbiology
Reproductive
Endometrttls
Pelvic Inflammatory d l -
Bacteroides, Chlamydia
trachomatis, Gardnerella,
group B streptococcus,
Ureaplasma,
Peptostreptococcus
Neisseria gonorrhoeae
Chlamydia trachomatis
(No. 1 bacterial STI)
Intracellula r in mucosal
epithelia; causes type IV
hypersensitivity damage
Culture
Gram ( - )diplococci
in PMNs or culture on
Thayer-Martin
Tissue culture,
intracytoplasmic
inclusions in mucosal cells
Depends on agent
Ceftriaxone + doxycycline
(doxycycline given for
presumed coinfection
with Chlamydia)
Doxycycline, macrolides
Append iX A-96
Microbiology
Reproductive
CMV
Congenital
rubella
syndrome
(CRS)
COngenital
syphilis
ToxopiMmosls
Hydrops fetalls
Thrombocytic
purpu ra,
hepato
splenomegaly,
microcephaly
Patent ductus
arteriosus,
pulmonary
stenosis,
sensorineural
hearing loss,
cataracts
Maculopapular
rash, rhinorr hea,
dactylitis,
osteochondritis
periostitis
Hydrocephalus
diffuse
intracran ial
calcification
chorioretinitis
Di ffuse edema
(hydrops fetal is)
CMV (No. 1 in
utero infection)
Rubella
Treponema
palfidum
Toxoplasma
gondii
Parvovirus Bl9
PCR
Antivirals,
supportive
Supportive
Virus destroys
bone marrow
erythrocyte
precur sors
Serology VDRL,
FTA ABS
Serology
Virus cu lture
Penicillin G,
azithromycin,
3rdgeneration
cephalosporin
Atovaquone,
clindamycin
Intravenous
immunog lobulin
t herapy
AppendiX A-97
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