1.

The latest and most effective therapy for AIDS patients includes azidothymidine (AZT), dideo yinosine (DDI), and sa!uinavir or similar a"ents. #se of these three dru"s $ould inhi%it $hich of the follo$in" viral processes& A. '(ase, D(ase ). "p1*+ formation ,. p*- anti%ody e pression D. All mem%rane synthesis .. 'everse transcriptase, protease The ans$er is/ . The advent of triple therapy or a therapeutic 0coc1tail0 has had a mar1ed effect on AIDS patients. The com%ination of dru"s $or1 to"ether as reverse transcriptive inhi%itors and a protease inhi%itor. 2atients improve rapidly, their ,D- lymphocyte counts increase, and their 3I4 viral load is drastically reduced, often to 56+ copies per ml. 7n the other hand, an untreated 3I48positive patient $ith a lo$ ,D- and a hi"h viral load (a) is at increased ris1 of opportunistic infection and (%) has a much "reater chance of developin" AIDS than if the viral load $as 56+,+++. The patient is infectious and his 3I4 anti%ody screenin" test $ill %e positive. The hi"h viral load, ho$ever, is not a predictor of response to therapy. 9any patients $ith hi"h viral loads do very $ell on triple therapy, althou"h resistance to one or more of the a"ents may su%se!uently occur. A lo$ ,Dcount does not predict pro"ression to AIDS %ut does indicate increased chance of opportunistic infection such as those listed. :aposi;s sarcoma, $hich has %een lin1ed to herpesvirus type <, pneumocystis, and myco%acterial disease are three of the most prevalent opportunistic infections. =hile 3I48positive patients contract pneumococcal pneumonia, they are pro%a%ly at no more ris1 than the "eneral population, as protection a"ainst pneumococcal disease is lin1ed to the presence of anticapsular anti%ody. *. A tu%e of mon1ey 1idney cells is inoculated $ith nasopharyn"eal secretions. Durin" the ne t > days, no cytopathic effects (,2.s) are o%served. 7n the ei"hth day, the tissue culture is infected accidentally $ith a picornavirus? nevertheless, the culture does not develop ,2.s. =hich of the follo$in" is the most li1ely e planation of this phenomenon& A. ). ,. D. .. The nasopharyn"eal secretions contained hema""lutinins The nasopharyn"eal secretions contained ru%ella virus 2icornavirus does not produce ,2.s 2icornavirus does not replicate in mon1ey 1idney cells 9on1ey 1idney cells are resistant to ,2.s

The ans$er is/ ) 'u%ella virus does not produce cytopathic effects (,2.s) in tissue8culture cells. 9oreover, ru%ella8infected cells challen"ed $ith a picornavirus are resistant to su%se!uent infection and thus $ould not e hi%it ,2.s. 9on1ey 1idney cells infected only $ith picornavirus $ould sho$ ,2.s. @. =hich of the follo$in" is the most sensitive test for the dia"nosis of herpes simple (3S4) menin"itis in a ne$%orn infant& A. 3S4 I"A anti%ody ). 3S4 polymerase chain reaction (2,') ,. 3S4 culture D. Tzanc1 smear .. ,ere%rospinal fluid (,SB) protein analysis

The ans$er is/ ) 3S4 menin"itis or encephalitis is difficult to dia"nose %y la%oratory tests as there is a lo$ titer of virus present in the ,SB. (eonatal 3S4 infects the child durin" the %irth process. =hile culture, Tzanc1 smear, and even anti%ody tests may %e useful in adults, particularly those $ith 3S48rich lesions, they are not useful for ,SB testin". 7nly 2,' is sensitive enou"h to detect 3S4 D(A in the ,SB. 7nce dia"nosed rapidly, 3S4 encephalitis or menin"itis can %e treated $ith acyclovir. -. 7ne of the most common se ually transmitted diseases that may lead to cervical carcinoma is caused %y $hich of the follo$in" viruses& A. ,ytome"alovirus ). 2apillomavirus ,. .pstein8)arr virus D. 3erpes simple virus .. Adenovirus The ans$er is/ ) 3uman papillomavirus (324) is the cause of "enital $arts. It is one of the most pervasive of all the se ually transmitted diseases. There is no specific cure or vaccine. There are multiple serotypes of papillomavirus and some serotypes are lin1ed to cervical cancer. (e$ techni!ues for molecular dia"nosis of 324 sho$ promise for rapid and sensitive detection and perhaps more a""ressive treatment. 6. 9enin"itis is characterized %y the acute onset of fever and stiff nec1. Aseptic menin"itis may %e caused %y a variety of micro%ial a"ents. Durin" the initial *- h of the course of aseptic menin"itis, an affected person;s cere%rospinal fluid is characterized %y $hich of the follo$in"& A. Decreased protein content ). .levated "lucose concentration ,. Cymphocytosis D. 2olymorphonuclear leu1ocytosis .. .osinophilia The ans$er is/ D Aseptic menin"itis is characterized %y a pleocytosis of mononuclear cells in the cere%rospinal fluid? polymorphonuclear cells predominate durin" the first *- h, %ut a shift to lymphocytes occurs thereafter. The cere%rospinal fluid of affected persons is free of cultura%le %acteria and contains normal "lucose and sli"htly elevated protein levels. 2eripheral $hite %lood cell counts usually are normal. Althou"h viruses are the most common cause of aseptic menin"itis, spirochetes, chlamydiae, and other microor"anisms also can produce the disease. D. :uru is a fatal disease of certain (e$ Auinea natives and is characterized %y tremors and ata ia? ,reutzfeldt8Ea1o% disease (,ED) is characterized %y %oth ata ia and dementia. These diseases are thou"ht to %e caused %y $hich of the follo$in"& A. Slo$ viruses ). ,ell $allFdeficient %acteria ,. .nvironmental to ins D. 2rions .. Bla"ellates The ans$er is/ D

:uru and ,reutzfeldt8Ea1o% disease (,ED) are similar %ut not identical diseases $ith very different epidemiolo"y. :uru is prevalent amon" certain tri%es in (e$ Auinea $ho practiced ritual canni%alism %y eatin" the %rains of the departed. ,ED is found $orld$ide and has %een transmitted %y corneal transplants and in pituitary hormone preparations. There is some association %et$een ,ED and 9ad ,o$ Disease in .n"land. 2rions are unconventional selfreplicatin" proteins, sometimes called amyloid. It is no$ thou"ht that ,ED, :uru, and animal diseases such as scrapie, visna, and %ovine spon"iform encephalopathy (9ad ,o$ Disease) are caused %y prions. >. An infant, seen in the .', presents $ith a fever and persistent cou"h. 2hysical e amination and a chest 8ray su""est pneumonia. =hich of the follo$in" is most li1ely the cause of this infection& A. 'otavirus ). Adenovirus ,. ,o sac1ievirus D. 'espiratory syncytial virus .. 'hinovirus The ans$er is/ D 'espiratory syncytial virus ('S4) is the most important cause of pneumonia and %ronchiolitis in infants. The infection is localized to the respiratory tract. The virus can %e detected rapidly %y immunofluorescence on smears of respiratory epithelium. In older children, the infection resem%les the common cold. Aerosolized ri%avirin is recommended for severely ill hospitalized infants. <. =hich one of the follo$in" viruses may %e human tumor virus& A. .pstein8)arr virus (.)4) ). 3I4 ,. 2apillomavirus D. 4aricella8zoster virus (4Z4) .. 3erpes simple virus, type * (3S4) The ans$er is/ , 7nly t$o human viruses have %een confirmed as human tumor viruses. They include human T8 cell lymphomaGleu1emia virus (3TC4) and papillomavirus. 7thers, such as .)4, 3S4, and hepatitis ) and ,, have %een implicated as tumor viruses. The virus that causes chic1en po (4Z4) is not 1no$ to %e onco"enic. H. There is considera%le overlap of si"ns and symptoms seen in con"enital and perinatal infections. In a neonate $ith 0classic0 symptoms of con"enital cytome"alovirus (,94) infection, $hich one of the follo$in" tests $ould %e most useful in esta%lishin" a dia"nosis& A. ,94 I"A titer on neonate;s serum at %irth ). ,94 I"A titer on mother;s serum at %irth of infant ,. ,94 I"9 titer on neonate;s serum at %irth and at 1 month of a"e D. Total I"9 on neonate;s serum at %irth .. ,ulture of mother;s urine The ans$er is/ , (See fi"ure %elo$.) 2resently, cytome"alovirus (,94) is the most common cause of con"enital and perinatal viral infections. ,ulture of the virus is a sensitive dia"nostic techni!ue? in the case

of a neonate $ith classic symptoms, serum samples from the mother and neonate are o%tained at %irth. The I"9 anti%ody titer in the infant;s serum should %e hi"her than the mother;s titer, %ut they may %e similar. Bor this reason, another sample from the infant at 1 month of a"e is tested simultaneously $ith the initial sample. The results should indicate a rise in I"9 titer. 9easurement of total I"9 in the infant;s sera at %irth is nonspecific and may sho$ false8ne"ative and false8 positive reactions. ,ytome"alovirus8infected human em%ryonic fi%ro%lasts stained $ith fluorescein8la%eled monoclonal anti%ody to early nuclear anti"en (I1+++). 1+. Interferon, a protein that inhi%its viral replication, is produced %y cells in tissue culture $hen the cells are stimulated $ith $hich of the follo$in"& A. )otulinum to in ). Synthetic polypeptides ,. 4iruses D. ,hlamydiae .. Aram8positive %acteria The ans$er is/ , Interferon is a protein that alters cell meta%olism to inhi%it viral replication. It induces the formation of a second protein that interferes $ith the translation of viral messen"er '(A. 2roduction of interferon has %een demonstrated $hen cells in tissue culture are challen"ed $ith viruses, ric1ettsiae, endoto in, or synthetic dou%le8stranded polynucleotides. Interferon confers species8 specific, not virus8specific, protection for cells. 11. =hich one of the follo$in" viruses $ould %e most li1ely to esta%lish a latent infection& A. Adenovirus ). 9easles virus ,. Influenza virus D. 2arvovirus .. ,o sac1ievirus "roup ) The ans$er is/ A =hile the herpesviruses (3S4, ,94, 4Z4) are all $ell 1no$n for latency, adenovirus can also form a latent infection in the lymphoid tissue. In 6+ to <+J of sur"ically removed tonsils or adenoids, adenovirus can %e cultured. The virus has also %een cultured from mesenteric lymph nodes, and, in rare cases, viral D(A has %een detected in peripheral lymphocytes. 'ecurrent illness usually does not arise from these latent infections? ho$ever, activation can occur in the immunosuppressed. 1*. ,hic1en po is a common disease of childhood. It is caused %y $hich of the follo$in" viruses& A. ). ,. D. .. ,ytome"alovirus 'otavirus 4aricella8zoster virus Adenovirus 2apillomavirus

The ans$er is/ , 4aricella8zoster virus is a herpesvirus. ,hic1en po is a hi"hly conta"ious disease of childhood

that occurs in the late $inter and early sprin". It is characterized %y a "eneralized vesicular eruption $ith relatively insi"nificant systemic manifestations. Adenovirus has %een associated $ith adult respiratory disease amon" ne$ly enlisted military troops. ,ro$ded conditions and strenuous e ercise may account for the severe infections seen in this other$ise healthy "roup. 2apillomavirus is one of t$o mem%ers of the family 2apovaviridae, $hich includes viruses that produce human $arts. These viruses are host8specific and produce %eni"n epithelial tumors that vary in location and clinical appearance. The $arts usually occur in children and youn" adults and are limited to the s1in and mucous mem%ranes. 'otavirus is $orld$ide in distri%ution and has %een implicated as the maKor etiolo"ic a"ent of infantile "astroenteritis. Infection $ith this virus varies in its clinical presentation from asymptomatic infection to a relatively mild diarrhea to a severe and sometimes fatal dehydration. The e act mode of transmission of this infectious a"ent is not 1no$n. )ecause of severe side effects, the rotavirus vaccine has %een recalled and is temporarily unavaila%le. Infectious mononucleosis caused %y cytome"alovirus (,94) is clinically difficult to distin"uish from that caused %y .pstein8)arr virus. Cymphocytosis is usually present $ith an a%undance of atypical lymphocytes. ,948induced mononucleosis should %e considered in any case of mononucleosis that is heterophil8ne"ative and in patients $ith fever of un1no$n ori"in. 1@. 3uman $arts are not only cosmetically unsi"htly %ut may lead to cancer of the cervi . They are caused %y $hich one of the follo$in" viruses& A. ,ytome"alovirus ). 'otavirus ,. 4aricella8zoster virus D. Adenovirus .. 2apillomavirus The ans$er is/ . 1-. A child has mononucleosis8li1e symptoms yet the test for mononucleosis and the .)4 titers are ne"ative. =hich of the follo$in" is one cause of heterophile8ne"ative mononucleosis& A. ,ytome"alovirus ). 3erpes simple virus ,. 4aricella8zoster virus D. Adenovirus .. ,o sac1ievirus The ans$er is/ A 4aricella8zoster virus is a herpesvirus. ,hic1en po is a hi"hly conta"ious disease of childhood that occurs in the late $inter and early sprin". It is characterized %y a "eneralized vesicular eruption $ith relatively insi"nificant systemic manifestations. Adenovirus has %een associated $ith adult respiratory disease amon" ne$ly enlisted military troops. ,ro$ded conditions and strenuous e ercise may account for the severe infections seen in this other$ise healthy "roup.

2apillomavirus is one of t$o mem%ers of the family 2apovaviridae, $hich includes viruses that produce human $arts. These viruses are host8specific and produce %eni"n epithelial tumors that vary in location and clinical appearance. The $arts usually occur in children and youn" adults and are limited to the s1in and mucous mem%ranes. 'otavirus is $orld$ide in distri%ution and has %een implicated as the maKor etiolo"ic a"ent of infantile "astroenteritis. Infection $ith this virus varies in its clinical presentation from asymptomatic infection to a relatively mild diarrhea to a severe and sometimes fatal dehydration. The e act mode of transmission of this infectious a"ent is not 1no$n. )ecause of severe side effects, the rotavirus vaccine has %een recalled and is temporarily unavaila%le. Infectious mononucleosis caused %y cytome"alovirus (,94) is clinically difficult to distin"uish from that caused %y .pstein8)arr virus. Cymphocytosis is usually present $ith an a%undance of atypical lymphocytes. ,948induced mononucleosis should %e considered in any case of mononucleosis that is heterophil8ne"ative and in patients $ith fever of un1no$n ori"in. 16. 9alaise and fati"ue $ith increased 0atypical0 lymphocytes and a reactive heterophil anti%ody test is most commonly caused %y $hich of the follo$in"& A. ). ,. D. .. To oplasma )orrelia %ur"dorferi .pstein8)arr virus 2arvovirus 'u%ella virus

The ans$er is/ , .pstein8)arr virus (.)4) is a herpesvirus that causes a num%er of syndromes? the most common is infectious mononucleosis. It is a u%i!uitous enveloped D(A virus. 7nly one serotype of .)4 has %een reco"nized, althou"h molecular methods have reor"anized a num%er of "enotypes of .)4. Infectious mononucleosis is an acute disease most commonly seen in youn"er people. It is characterized %y a proliferation of lymphocytes, lymph node enlar"ement, pharyn"itis, fati"ue, and fever. Infection in youn" children is usually either asymptomatic or characteristic of an acute upper respiratory infection. Dia"nosis is usually made %y a positive heterophil test. 3eterophil anti%odies are those that occur in one species (human) and react $ith anti"ens of a different species. The heterophil test may %e insensitive (@+ to D+J) in children. Definitive dia"nosis is made %y detection of anti%odies to .)4 components. .)4 causes a variety of other syndromes includin" )ur1itt;s lymphoma, the most common childhood cancer in Africa, and nasopharyn"eal carcinoma, commonly seen in ,hina. Similar mononucleosis8li1e diseases are caused %y cytome"alovirus (,94) and To oplasma "ondii, a parasite. ,94 causes fe$er than 1+J of infectious mononucleosis8li1e diseases. ,94 0mono0 is primarily characterized %y fati"ue. ,on"enital infection $ith ,94 almost al$ays causes serious se!uelae, such as retardation and hearin" loss. T. "ondii also causes a variety of clinical pro%lems, amon" them encephalitis in AIDS patients and food poisonin" from the in"estion of ra$ meat. Althou"h ,94 and T. "ondii are relatively rare causes of infectious mononucleosis, they must %e ruled out, particularly $hen .)4 tests are nonreactive.

1D. =hich of the follo$in" viruses causes pro"ressive multifocal leu1oencephalopathy (29C), a disease causin" demyelination in the central nervous system& A. 3uman papillomavirus ). =est (ile virus ,. Tic18%orne encephalitis virus D. 2olyomavirus .. SS2. The ans$er is/ D 3uman papillomaviruses (324) are the causative a"ents of cutaneous $arts as $ell as proliferative s!uamous lesions of mucosal surfaces. Althou"h most infections %y human papillomavirus are %eni"n, some under"o mali"nant transformation into in situ and invasive s!uamous cell carcinoma. )oth 324 and polyomavirus have icosahedral capsids and D(A "enomes. E, virus, a polyomavirus, $as first isolated from the diseased %rain of a patient $ith 3od"1in;s lymphoma $ho $as dyin" of pro"ressive multifocal leu1oencephalopathy (29C). This demyelinatin" disease occurs usually in immunosuppressed persons and is the result of oli"odendrocyte infection %y E, virus. E, virus has also %een isolated from the urine of patients sufferin" from demyelinatin" disease. ,ryotherapy and laser treatment are the most popular therapies for $arts, althou"h sur"ery may %e indicated in some cases. At the present time, there is no effective antiviral therapy for treatment of infection $ith polyomavirus or 324. =est (ile virus is an ar%ovirus. =hile prevalent in .urope, Africa, and the 9iddle .ast, it $as not seen in the #nited States until the summer of 1HHH. It is transmitted %y mos!itoes and %irds, especially cro$s? these animals are a reservoir. =(4 causes a rather mild encephalitis in humans, the e ception %ein" older patients or those $ho may %e immunocompromised. 1>. =hich of the follo$in" is the leadin" cause of %ronchiolitis and community8ac!uired pneumonia in infants& A. 9easles virus ). Influenza virus ,. 'espiratory syncytial virus D. 2arainfluenza virus .. Adenovirus The ans$er is/ , 7rthomy oviruses and paramy oviruses are '(A viruses that contain a sin"le8stranded '(A "enome. The influenza viruses %elon" to the orthomy oviruses. They cause acute respiratory tract infections that usually occur in epidemics. Isolated strains of influenza virus are named after the virus type (influenza A, ), or ,) as $ell as the host and location of initial isolation, the year of isolation, and the anti"enic desi"nation of the hema""lutinin and neuraminidase. )oth the hema""lutinin and neuraminidase are "lycoproteins under separate "enetic control, and %ecause of this they can and do vary independently. The chan"es in these anti"ens are responsi%le for the anti"enic drift characteristic of these viruses. The paramy oviruses include several important human patho"ens (mumps virus, measles virus, respiratory syncytial virus, and parainfluenza virus). )oth paramy oviruses and orthomy oviruses possess an '(A8dependent '(A polymerase that is a structural component of the virion and produces the initial '(A. 'espiratory syncytial viruses ('S4) are not related to the paramy oviruses. They are 16+8nm sin"le8stranded '(A viruses. There are * anti"en "roups, A and ), $hich play no role in dia"nosis and treatment. =hile the overall mortality is +.6J, at8ris1 "roups may %e *6 to @6J mortality if untreated. Some parainfluenza virus infections (type @) may %e indistin"uisha%le from 'S4, %ut most parainfluenza infections produce a laryn"otracheo%ronchitis 1no$n as croup. 1<.

A patient $ith a peptic ulcer $as admitted to the hospital and a "astric %iopsy $as performed. The tissue $as cultured on chocolate a"ar incu%ated in a microaerophilic environment at @>L, for 6 to > days. At 6 days of incu%ation, colonies appeared on the plate and $ere curved, Aram8 ne"ative rods, o idase8positive. =hich of the follo$in" is the most li1ely identity of this or"anism& A. ,ampylo%acter KeKuni ). 4i%rio parahaemolyticus ,. 3aemophilus influenzae D. 3elico%acter pylori .. ,ampylo%acter fetus The ans$er is/ D 3elico%acter pylori $as first reco"nized as a possi%le cause of "astritis and peptic ulcer %y 9arshall and =arren in 1H<-. This or"anism is readily isolated from "astric %iopsies %ut not from stomach contents. It is similar to ,ampylo%acter species and "ro$s on chocolate a"ar at @>L, in the same microaerophilic environment suita%le for ,. KeKuni (,ampy82a1 or anaero%ic Kar MAas 2a1N $ithout the catalyst). 3. pylori, ho$ever, "ro$s more slo$ly than ,. KeKuni, re!uirin" 6 to > days incu%ation. ,. KeKuni "ro$s optimally at -*L,, not @>L,, as does 3. pylori. 1H. At a church supper in (ova Scotia, the follo$in" meal $as served/ %a1ed %eans, ham, colesla$, eclairs, and coffee. 7f the @+ people $ho attended, - senior citizens %ecame ill in @ days? 1 eventually died. T$o $ee1s after attendin" the church supper, a 1H8year8old "irl "ave %irth to a %a%y $ho rapidly %ecame ill $ith menin"itis and died in 6 days. .pidemiolo"ic investi"ation revealed the follo$in" percenta"es of people $ho consumed the various food items/ %a1ed %eans, @+J? ham, <+J? colesla$, D+J? eclairs, 1++J? and coffee, H+J. 9icro%iolo"ic analysis revealed no "ro$th in the %a1ed %eans, ham, or coffee? many Aram8positive %eta8hemolytic, short, rod8shaped %acteria in the colesla$? and rare Aram8positive cocci in the eclairs. =hich of the follo$in" is the most li1ely cause of this out%rea1& A. Staphylococcus aureus ). Cisteria ,. ,lostridium perfrin"ens D. ,lostridium %otulinum .. (onmicro%iolo"ic The ans$er is/ . There have %een a num%er of out%rea1s of food poisonin" caused %y Cisteria monocyto"enes. Cisteria is a common inha%itant of farm animals and can %e readily isolated from sila"e, hay, and %arnyard soil. 3umans at the e tremes of a"e are most suscepti%le to Cisteria infection %ut only recently has food %een implicated as a vehicle. In the out%rea1 in (ova Scotia, it is li1ely that the ca%%a"e used for the colesla$ $as fertilized $ith animal droppin"s and not properly $ashed prior to consumption. 9aKor Cisteria out%rea1s associated $ith cheese have %een seen in the #nited States and most li1ely have ori"inated from contaminated mil1. .pidemiolo"ic investi"ation often $ill provide data on attac1 rates in such out%rea1s. The eventual solution of the pro%lem al$ays lies in a com%ination of epidemiolo"ic, micro%iolo"ic, and clinical information. Bor e ample, in the (ova Scotia case, it should not %e assumed that the eclairs $ere the culprit %ased on the fact that everyone ate them. *+. Aroup ) streptococcus sepsis in an infant is preventa%le. =hich one of the follo$in" procedures is most li1ely to reduce the incidence of "roup ) streptococcal disease& A. Intrapartum anti%iotic treatment ). #se of a polysaccharide vaccine ,. Screenin" of pre"nant females in the last trimester D. Identification of possi%le hi"h8ris1 %irths

..

Screenin" of pre"nant females at the first office visit, usually durin" the first trimester

The ans$er is/ A The incidence of "roup ) streptococcal disease (A)S) is 1F@ cases per 1+++ %irths. (eonates ac!uire the disease durin" %irth from mothers $ho har%or the or"anism. 'is1 factors include prematurity, premature rupture of mem%ranes, and "roup ) streptococcal carria"e. The AramOs stain of cere%rospinal fluid is a rapid test for A)S disease. Althou"h sensitive, the AramOs stain re!uires e perience to differentiate these streptococci from other Aram8positive cocci. Cate tests for A)S anti"en are also availa%le, %ut sensitivity in ,SB is not si"nificantly hi"her than the AramOs stain. A)S can %e reduced %y intrapartum administration of penicillin. . perimentally, A)S polysaccharide vaccines have also %een used. Screenin" pre"nant females early in pre"nancy pro%a%ly offers little advanta"e %ecause of the possi%le ac!uisition of A)S late in the pre"nancy. There has %een speculation concernin" the patho"enesis of A)S. These include failure to activate complement path$ays and immo%ilization of polymorphonuclear leu1ocytes (29(s) due to the inactivation of complement ,6A, a potent chemoattractant. =hile A)S is relatively more resistant to penicillin than "roup A streptococci, the "reat maKority of A)S isolates are still penicillin8suscepti%le. An amino"lycoside such as "entamicin may %e added to A)S treatment re"imens due to the relative reduced suscepti%ility of some strains. *1. There has %een much speculation on the patho"enesis of "roup ) streptococcal disease in the neonate. =hich of the follo$in" is the most li1ely patho"enic mechanisms& A. ,omplement ,6a, a potent chemoattractant, activates 29(s ). The streptococci are resistant to penicillin ,. The alternative complement path$ay is activated D. In the a%sence of specific anti%ody, opsonization, pha"ocyte reco"nition, and 1illin" do not proceed normally The ans$er is/ D The incidence of "roup ) streptococcal disease (A)S) is 1F@ cases per 1+++ %irths. (eonates ac!uire the disease durin" %irth from mothers $ho har%or the or"anism. 'is1 factors include prematurity, premature rupture of mem%ranes, and "roup ) streptococcal carria"e. The AramOs stain of cere%rospinal fluid is a rapid test for A)S disease. Althou"h sensitive, the AramOs stain re!uires e perience to differentiate these streptococci from other Aram8positive cocci. Cate tests for A)S anti"en are also availa%le, %ut sensitivity in ,SB is not si"nificantly hi"her than the AramOs stain. A)S can %e reduced %y intrapartum administration of penicillin. . perimentally, A)S polysaccharide vaccines have also %een used. Screenin" pre"nant females early in pre"nancy pro%a%ly offers little advanta"e %ecause of the possi%le ac!uisition of A)S late in the pre"nancy. There has %een speculation concernin" the patho"enesis of A)S. These include failure to activate complement path$ays and immo%ilization of polymorphonuclear leu1ocytes (29(s) due to the inactivation of complement ,6A, a potent chemoattractant. =hile A)S is relatively more resistant to penicillin than "roup A streptococci, the "reat maKority of A)S isolates are still penicillin8suscepti%le. An amino"lycoside such as "entamicin may %e added to A)S treatment re"imens due to the relative reduced suscepti%ility of some strains. **. A man $ho has a penile chancre appears in a hospitalOs emer"ency service. The 4D'C test is ne"ative. =hich of the follo$in" is the most appropriate course of action& A. Send the patient home untreated ). 'epeat the 4D'C test in 1+ days ,. 2erform dar18field microscopy for treponemes D. S$a% the chancre and culture on Thayer89artin a"ar .. 2erform a Aram stain on the chancre fluid

The ans$er is/ , In men, the appearance of a hard chancre on the penis characteristically indicates syphilis. .ven thou"h the chancre does not appear until the infection is * or more $ee1s old, the 4D'C test for syphilis still can %e ne"ative despite the presence of a chancre (the 4D'C test may not %ecome positive for * or @ $ee1s after initial infection). 3o$ever, a lesion suspected of %ein" a primary syphilitic ulcer should %e e amined %y dar18field microscopy, $hich can reveal motile treponemes. *@. In people $ho have sic1le cell anemia, osteomyelitis usually is associated $ith $hich of the follo$in" or"anisms& A. 9icrococcus ). .scherichia ,. 2seudomonas D. Salmonella .. Streptococcus The ans$er is/ D 9any types of infection, nota%ly respiratory tract infections and osteomyelitis, are common in people $ho have sic1le cell anemia. Bor un1no$n reasons, Salmonella is implicated fre!uently in these infections. 7steomyelitis in other persons is caused most often %y Staphylococcus. *-. A hyperemic edema of the laryn and epi"lottis that rapidly leads to respiratory o%struction in youn" children is most li1ely to %e caused %y $hich of the follo$in"& A. :. pneumoniae ). 9. pneumoniae ,. (eisseria menin"itidis D. 3. influenzae .. 3. hemolyticus The ans$er is/ D 3aemophilus influenzae is a Aram8ne"ative %acillus. In youn" children, it can cause pneumonitis, sinusitis, otitis, and menin"itis. 7ccasionally, it produces a fulminative laryn"otracheitis $ith such severe s$ellin" of the epi"lottis that tracheostomy %ecomes necessary. ,linical infections $ith this or"anism after the a"e of @ years are less fre!uent. *6. A >+8year8old female patient $as readmitted to a local hospital $ith fever and chills follo$in" cardiac sur"ery at a maKor teachin" institution. )lood cultures $ere ta1en and a Aram8positive coccus "re$ from the %lood cultures $ithin *- hours. Initial tests indicated that this isolate $as resistant to penicillin. =hich of the follo$in" is the treatment of choice for the isolate& A. Aentamicin ). Aentamicin and ampicillin ,. ,iproflo acin D. 'ifampin .. (o availa%le treatment The ans$er is/ .

.nterococci causes a $ide variety of infections ran"in" from less serious, for e ample, urinary tract infections, to very serious, such as septicemia. A Aram8positive coccus resistant to penicillin must %e assumed to %e enterococcus until other more definitive %iochemical testin" places the isolate in one of the more esoteric "roups of Aram8positive cocci. 7nce isolated, there are a variety of tests to speciate enterococci. 3o$ever, penicillin8resistant, non88lactamase8producin", vancomycin8resistant, Aram8positive cocci are most li1ely .nterococcus faecium. There are a variety of mechanisms for vancomycin resistance in .. faecium and they have %een termed 4an A, ), or ,. These isolates have %ecome one of the most feared nosocomial patho"ens in the hospital environment. #nfortunately, no approved anti%iotics can successfully treat vancomycin8 resistant enterococci (4'.), only some e perimental anti%iotics such as Synercid. *D. A *8year8old infant is %rou"ht to the emer"ency room $ith hemolytic uremic syndrome and throm%ocytopenia. =hich one of the follo$in" %acteria $ould most li1ely %e isolated from a stool specimen& A. Shi"ella ). Salmonella ,. Aeromonas D. .. coli +16>G3> .. .ntero%acter The ans$er is/ D Bood poisonin" $ith .. coli +16>G3> causes hemorrha"ic colitis? it is often seen after eatin" %eef ham%ur"ers. The same or"anism also causes a hemorrha"ic uremic syndrome. The to in, called Shi"a8li1e to in, can %e demonstrated in 4ero cells, %ut the cytoto icity must %e neutralized $ith specific antiserum. =ith the e ception of sor%itol fermentation, there is nothin" %iochemically distinctive a%out these or"anisms. *>. =hich of the follo$in" is the most effective noninvasive test for the dia"nosis of 3elico%acter8 associated "astric ulcers& A. Detection of 3. pylori anti"en in stool ). Aro$th of 3. pylori from a stomach %iopsy ,. Aro$th of 3. pylori in the stool D. I"9 anti%odies to 3. pylori .. ,ulture of stomach contents for 3. pylori The ans$er is/ A 3. pylori anti"en tests usin" an .CISA format and a monoclonal anti%ody to 3. pylori are as sensitive as culture of the control portion of the stomach. #rea %reath tests are also $idely used. 3. pylori has an active enzyme (urease) $hich %rea1s do$n radioactive urea. The patient releases radioactive ,7* if 3. pylori are present. 3. pylori anti%ody tests, I"A and I"A, indicate the presence of 3. pylori and usually decline after effective treatment. ,ulture of stomach contents is insensitive and not appropriate as a dia"nostic procedure for 3. pylori. Direct tests such as anti"en or culture of "astric mucosa are preferred %ecause they are the most sensitive indication of a cure. *<. A patient $ith symptoms of urinary tract infection had a culture ta1en, $hich "re$ 6 I 1+@ .. coli. The la%oratory reported it as 0insi"nificant.0 =hich of the follo$in" is the most clinically appropriate action& A. Do no further clinical $or1up ). Su""est to the la%oratory that lo$ colony counts may reflect infection ,. Determine if fluorescent microscopy is availa%le for the dia"nosis of actinomycosis

D. ..

,onsider vancomycin as an alternative dru" Su""est a repeat anti%iotic suscepti%ility test

The ans$er is/ ) This !uestion demonstrates a commonly occurrin" clinical infectious disease and micro%iolo"ic pro%lem. .nterococci may %e resistant to ampicillin and "entamicin. 4ancomycin $ould %e the dru" of choice. 3o$ever, la%oratory results do not al$ays correlate $ell $ith clinical response. The (ational ,ommittee on ,linical Ca%oratory Standards recommends testin" enterococci only for ampicillin and vancomycin. Some symptomatic patients may have 1+ leu1ocytes per mC of urine %ut relatively fe$ %acteria. The patient is li1ely infected and the or"anisms, particularly if in pure culture, should %e further processed. *H. =hich of the follo$in" is the anti%iotic of choice for Cyme disease& A. 2enicillin ). Ampicillin ,. .rythromycin D. 4ancomycin .. ,eftria one The ans$er is/ . There are fe$ %acteria for $hich antimicro%ial suscepti%ility is hi"hly predicta%le. 3o$ever, some a"ents are the dru" of choice %ecause of their relative effectiveness. Amon" the three anti%iotics that have %een sho$n to treat le"ionellosis effectively (erythromycin, rifampin, and minocycline), erythromycin is clearly superior, even thou"h in vitro studies sho$ the or"anism to %e suscepti%le to other anti%iotics. 2enicillin remains the dru" of choice for S. pneumoniae and the "roup A streptococci, althou"h a fe$ isolates of penicillin8resistant pneumococci have %een o%served. 'esistance amon" the pneumococci is either chromosomally mediated, in $hich case the minimal inhi%itory concentrations (9I,s) are relatively lo$, or plasmid8mediated, $hich results in hi"hly resistant %acteria. The same is "enerally true for 3. influenzae. #ntil the mid81H>+s, virtually all isolates of 3. influenzae $ere suscepti%le to ampicillin. There has %een a rapidly increasin" incidence of ampicillin8resistant isolates, almost @6 to -+J in some areas of the #nited States. 'esistance is ordinarily mediated %y 8lactamase, althou"h ampicillin8resistant, 8lactamase8ne"ative isolates have %een seen. (o resistance to penicillin has %een seen in "roup A streptococci. ,. difficile causes to in8mediated pseudomem%ranous enterocolitis as $ell as anti%iotic8 associated diarrhea. 2seudomem%ranous enterocolitis is normally seen durin" or after administration of anti%iotics. 7ne of the fe$ a"ents effective a"ainst ,. difficile is vancomycin. Alternatively, %acitracin can %e used. Cyme disease, caused %y ). %ur"dorferi, has %een treated $ith penicillin, erythromycin, and tetracycline. Treatment failures have %een o%served. ,eftria one has %ecome the dru" of choice, particularly in the advanced sta"es of Cyme disease. @+. (. "onorrhoeae is a fastidious patho"en and found in sites often contaminated $ith normal flora. =hich of the follo$in" is the %est medium for isolation& A. Sheep %lood a"ar

). ,. D. ..

CPfflerOs medium Thayer89artin a"ar Thiosulfate citrate %ile salts sucrose medium CP$enstein8Eensen medium

The ans$er is/ , The medium of choice for the isolation of patho"enic neisseriae is Thayer89artin (T9) a"ar. T9 a"ar is %oth a selective and an enriched medium? it contains hemo"lo%in, the supplement Isovitale , and the anti%iotics vancomycin, colistin, nystatin, and trimethoprim. 4. cholerae as $ell as other vi%rios, includin" 4. parahaemolyticus and 4. al"inolyticus, are isolated %est on thiosulfate citrate %ile salts sucrose medium, althou"h media such as mannitol salt a"ar also support the "ro$th of vi%rios. 9a imal "ro$th occurs at a p3 of <.6 to H.6 and at @>L, incu%ation. CP$enstein8Eensen slants or plates, $hich are composed of a nutrient %ase and e"" yol1, are used routinely for the initial isolation of myco%acteria. Small inocula of 9. tu%erculosis can also %e "ro$n in oleic acid al%umin media? lar"e inocula can %e cultured on simple synthetic media. CPfflerOs medium, $hich is very rich, supports the "ro$th of ,. diphtheriae %ut suppresses the "ro$th of most other nasopharyn"eal microflora. ,. diphtheriae colonies on this medium appear small, "ray, and "ranular and have uneven ed"es. S. aureus "ro$s very $ell on sheep %lood a"ar, $hich is made up of a nutrient %ase and 6 to <J sheep %lood? selective and differential media, such as mannitol salt a"ar, also are availa%le for S. aureus. @1. ,. diphtheriae may %e difficult to isolate from the nasopharyn $ithout the use of special media. =hich of the follo$in" is the medium of choice& A. Sheep %lood a"ar ). CPfflerOs medium ,. Thayer89artin a"ar D. Thiosulfate citrate %ile salts sucrose medium .. CP$enstein8Eensen medium The ans$er is/ ) The medium of choice for the isolation of patho"enic neisseriae is Thayer89artin (T9) a"ar. T9 a"ar is %oth a selective and an enriched medium? it contains hemo"lo%in, the supplement Isovitale , and the anti%iotics vancomycin, colistin, nystatin, and trimethoprim. 4. cholerae as $ell as other vi%rios, includin" 4. parahaemolyticus and 4. al"inolyticus, are isolated %est on thiosulfate citrate %ile salts sucrose medium, althou"h media such as mannitol salt a"ar also support the "ro$th of vi%rios. 9a imal "ro$th occurs at a p3 of <.6 to H.6 and at @>L, incu%ation. CP$enstein8Eensen slants or plates, $hich are composed of a nutrient %ase and e"" yol1, are used routinely for the initial isolation of myco%acteria. Small inocula of 9. tu%erculosis can also %e "ro$n in oleic acid al%umin media? lar"e inocula can %e cultured on simple synthetic media.

CPfflerOs medium, $hich is very rich, supports the "ro$th of ,. diphtheriae %ut suppresses the "ro$th of most other nasopharyn"eal microflora. ,. diphtheriae colonies on this medium appear small, "ray, and "ranular and have uneven ed"es. S. aureus "ro$s very $ell on sheep %lood a"ar, $hich is made up of a nutrient %ase and 6 to <J sheep %lood? selective and differential media, such as mannitol salt a"ar, also are availa%le for S. aureus. @*. =hich of the follo$in" %acterial transport methods is ener"y8independent& A. Bacilitated diffusion ). Simple diffusion ,. 2roton "radient ener"ized active transport D. Aroup translocation .. AT28dependent active transport The ans$er is/ ) Almost no important nutrients enter the %acterial cell throu"h simple diffusion, an e ception %ein" car%on dio ide and o y"en. Some diffusion, ho$ever, is facilitated %y specific protein carriers. 9ost transport, e cept simple diffusion, is ener"y8dependent, particularly in Aram8ne"ative %acteria. Aroup translocation occurs in the a%sence of o y"en. Bor e ample, a simple car%ohydrate such as "lucose is phosphorylated enzymatically and is then transported into the cell. @@. Iron is essential in %acterial meta%olism. =hen %acteria invade the human host they must capture iron in order to survive. =hich of the macromolecules listed %elo$ is important in %acterial iron meta%olism& A. ). ,. D. .. Transferrin Cactoferrin Berric o ide Cipopolysaccharide (C2S) Siderophores

The ans$er is/ . Siderophores such as aero%actin and entero%actin are chelators that trap iron Be@Q. This Be8 chelator comple is actually transported inside the cell. Transferrin and lactoferrin are iron8%indin" proteins found in %lood and mil1. Berric or iron o ide is rust and lipopolysaccharide (C2S) is a micro%ial cell8$all constituent. @-. An ali!uot of .scherichia coli is treated $ith ethylenediaminetetraacetic acid (.DTA). The first $ash is analyzed and found to contain al1aline phosphatase, D(ase, and penicillinase. =hich of the follo$in" anatomic areas of the cell is most li1ely to have %een affected %y the .DTA& A. 2eriplasmic space ). 9esosomal space ,. ,hromosome D. 2lasma mem%rane .. Slime layer The ans$er is/ A

The periplasm is the space %et$een the outer mem%rane and plasma mem%rane of %acteria. The periplasmic space in .scherichia coli has %een sho$n to contain a num%er of proteins, su"ars, amino acids, and inor"anic ions. .thylenediaminetetraacetic acid (.DTA) is a chelatin" a"ent that disrupts the cell $alls of Aram8ne"ative %acteria. @6. The formation of adenosine triphosphate (AT2) is essential for the maintenance of life. In mammalian systems, the num%er of moles of AT2 formed per "ram atom of o y"en consumed (the 2G7 ratio) is @? in %acteria, ho$ever, the 2G7 ratio may %e only 1 or *. =hich of the follo$in" is the primary reason for the lo$er 2G7 ratio in %acteria& A. A%sence of nicotinamide adenine dinucleotide ((AD) ). Coss of o idative phosphorylation couplin" sites ,. Cess dependence on AT2 as an ener"y source D. A%sence of a nonphosphorylative %ypass reaction .. A less8efficient mesosome The ans$er is/ ) Adenosine triphosphate (AT2) is %elieved to %e "enerated at three reaction points in the electron transport chain/ the reductions of flavoprotein, cytochrome %, and cytochrome c. This phenomenon, demonstrated in e periments $ith mammalian mitochondria, can %e e pressed in terms of the relationship %et$een the moles of AT2 "enerated for each atom of o y"en consumedRthe 2G7 ratio. In mammalian cells, the 2G7 ratio is @? that is, there are three se"ments in the electron transfer chain in $hich there is a relatively lar"e free ener"y drop. In %acteria, ho$ever, there appears to %e only one or t$o of these se"ments. Coss of these phosphorylation sites as $ell as reactions that %ypass these sites of AT2 synthesis account for the lo$er 2G7 ratio in %acteria. Some %acteria, such as 9yco%acterium phlei, have 2G7 ratios of @. @D. 'eversion of (eisseria "onorrhoeae from a fim%riated (fim 1) to a nonfi%riated (fim *) state $ould result in $hich one of the follo$in" phenomena& A. Ina%ility of (. "onorrhoeae to colonize the mucosal epithelium ). 'eversion to a Aram8positive stain ,. Death of the or"anism D. Coss of serolo"ic specificity .. A ne"ative capsule strain The ans$er is/ A )acteria may shift rapidly %et$een the fim%riated (fim Q) and the nonfim%riated (fim 8) states. Bim%riae function as adhesions to specific surfaces and conse!uently play a maKor role in patho"enesis. Cac1 of fim%riae prevents colonization of the mucosal surface %y the %acterium. @>. ,ertain enzymes catalyze the cross8lin1in" of peptido"lycan, a uni!ue constituent of %acterial cell $alls. =hich of the follo$in" may %e a factor in anti%iotic resistance, the tar"et of $hich is cell8 $all synthesis& A. )actoprenol ). 'everse transcriptase ,. '(A polymerase D. D(A "yrase .. 2enicillin8%indin" proteins (2)2s) The ans$er is/ .

2enicillin8%indin" proteins (2)2s) com%ine $ith penicillin and inhi%it the final cross8lin1in" of peptido"lycan in the cell $all. All of the other choices are involved in polymerization processes. . amples of polymerization include the cell mem%rane (%actoprenol) and synthesis of D(A and '(A. @<. .arly attempts at the polymerase chain reaction (2,') used .. coli D(A polymerase. This $as replaced $ith D(A polymerase from Thermus a!uaticus (0Ta!0 polymerase). =hich of the follo$in" is the primary advanta"e in usin" this enzyme& A. It is cheaper than .. coli polymerase ). Specificity is increased %ecause nonspecific hy%ridization of primers does not occur ,. #se of Ta! polymerase results in fe$er 2,' cycles D. #se of Ta! polymerase ena%les lo$er temperatures to %e used .. #pon repeated cyclin", Ta! polymerase %ecomes denatured, $hich causes less interference $ith the hy%ridization process The ans$er is/ ) D(A polymerase isolated from the hot sprin"s thermophilic %acterium named Thermus a!uaticus is essential for the polymerase chain reaction (2,') process %ecause of its sta%ility at hi"h temperatures (H6L,). =hile the .. coli enzyme can %e used, the enzyme itself %ecomes denatured, fe$er cycles are possi%le, and nonspecific reactions occur %ecause of hy%ridization of primers to nontar"et D(A. The use of Ta! polymerase allo$s D(A copyin" at >*L, rather than @>L,, $hich further reduces nonspecific hy%ridization. @H. D(A from a host sample can %e amplified %y a process 1no$n as the polymerase chain reaction (2,'). =hich of the follo$in" is re!uired for 2,'& A. :no$led"e of the "enetic se!uence to %e amplified ). An sin"le nucleotide primer ,. An ultracentrifu"e D. A universal pro%e to detect the amplified product .. A heat8sensitive D(A polymerase enzyme The ans$er is/ A 2,' is a $idely used tool for amplification of small pieces of nucleic acid present in minute !uantities. 7nce the se!uence to %e amplified is 1no$n, a specific primer is added. The temperature is alternately raised and lo$ered up to -6 to 6+ times in the presence of a heat8 resistant D(A polymerase from T. a!uaticus. The amplified "ene product is then detected %y one of a num%er of techni!ues. -+. =hich of the follo$in" is a !uinolone anti%iotic $ith %road Aram8ne"ative and Aram8positive activity& A. 2iperacillin ). ,efoperazone ,. ,eftria one D. ,iproflo acin .. Imipenem The ans$er is/ D 9any ne$ anti%iotics have %ecome availa%le durin" the past fe$ years. Althou"h e pensive, these anti%iotics "enerally have a %roader spectrum of effectiveness than the ones they are

intended to replace. 'esistance to these ne$ly introduced a"ents may %e a pro%lem that $ill minimize their effects on the treatment of infectious disease. =hile most are la%eled %road spectrum, each appears to %e characteristically more effective a"ainst some or"anisms than others. ,eftria one is a ne$8"eneration cephalosporin. It is administered once a day either intravenously or intramuscularly. =hile ceftria one is used a"ainst a $ide variety of Aram8ne"ative rods, it has found special use in the treatment of Cyme disease. It is no$ claimed to %e the most effective anti%iotic for %orreliosis. -1. =hich one of the follo$in" anti%iotics inhi%its dihydrofolate reductase& A. 2enicillin ). Amdinocillin ,. Amphotericin D. ,hloramphenicol .. Trimethoprim The ans$er is/ . The anti%iotics in these !uestions have si"nificantly different modes of action. 'ecent evidence su""ests that $hile penicillin inhi%its the final cross8lin1in" of the cell $all, it also %inds to penicillin8%indin" proteins and inhi%its certain 1ey enzymes involved in cell8$all synthesis. The mechanism is comple . Amdinocillin, althou"h classified as a penicillin, selectively %inds to penicillin8%indin" protein8* (2)28*). )indin" to 2)28* results in a%errant cell8$all elon"ation and spherical forms, seen $hen .. coli, for e ample, is e posed to mecillinam. )ecause amphotericin %inds to sterols (such as cholesterol) in the cell mem%rane, its ran"e of activity is predicta%le? that is, it is effective a"ainst microor"anisms that contain sterol in the cell mem%rane (such as molds, yeasts, and certain ame%ae). These polyene anti%iotics cause reorientation of sterols in the mem%rane, and mem%rane structure is altered to the e tent that permea%ility is affected. If sterol synthesis is %loc1ed in fun"i, then amphotericin is not effective. This occurs $hen fun"i are e posed to miconazole, another antifun"al anti%iotic. ,hloramphenicol is a %acteriostatic anti%iotic. Its action does not 1ill the cell %ut only inhi%its it. If chloramphenicol is removed from the culture, then protein synthesis is reinitiated. )acterial ri%osomes are spherical particles $ith a molecular $ei"ht of @ @ 1+D. 2rotein synthesis ta1es place on the ri%osome %y a comple process involvin" various ri%osomal su%units, t'(A, and n'(A. ,hloramphenicol, in contrast to the amino"lycosides and tetracycline, attaches to the 6+S ri%osome su%unit. The enzyme peptidyl transferase, found in the 6+S su%unit, is inhi%ited. 'emoval of the inhi%itionRin this case, chloramphenicolRresults in full activity of the enzyme. Trimethoprim (T92), a diaminopyrimidine, is a folic acid anta"onist. Althou"h T92 is commonly used in com%ination $ith sulfa dru"s, its mode of action is distinct. T92 is structurally similar to the pteridine portion of dihydrofolate and prevents the conversion of folic acid to tetrahydrofolic acid %y inhi%ition of dihydrofolate reductase. Bortunately, this enzyme in humans is relatively insensitive to T92. -*. =hich one of the follo$in" anti%iotics %inds to penicillin8%indin" protein8* (2)28*)& A. 2enicillin ). Amdinocillin

,. D. ..

Amphotericin ,hloramphenicol Trimethoprim

The ans$er is/ ) The anti%iotics in these !uestions have si"nificantly different modes of action. 'ecent evidence su""ests that $hile penicillin inhi%its the final cross8lin1in" of the cell $all, it also %inds to penicillin8%indin" proteins and inhi%its certain 1ey enzymes involved in cell8$all synthesis. The mechanism is comple . Amdinocillin, althou"h classified as a penicillin, selectively %inds to penicillin8%indin" protein8* (2)28*). )indin" to 2)28* results in a%errant cell8$all elon"ation and spherical forms, seen $hen .. coli, for e ample, is e posed to mecillinam. )ecause amphotericin %inds to sterols (such as cholesterol) in the cell mem%rane, its ran"e of activity is predicta%le? that is, it is effective a"ainst microor"anisms that contain sterol in the cell mem%rane (such as molds, yeasts, and certain ame%ae). These polyene anti%iotics cause reorientation of sterols in the mem%rane, and mem%rane structure is altered to the e tent that permea%ility is affected. If sterol synthesis is %loc1ed in fun"i, then amphotericin is not effective. This occurs $hen fun"i are e posed to miconazole, another antifun"al anti%iotic. ,hloramphenicol is a %acteriostatic anti%iotic. Its action does not 1ill the cell %ut only inhi%its it. If chloramphenicol is removed from the culture, then protein synthesis is reinitiated. )acterial ri%osomes are spherical particles $ith a molecular $ei"ht of @ @ 1+D. 2rotein synthesis ta1es place on the ri%osome %y a comple process involvin" various ri%osomal su%units, t'(A, and n'(A. ,hloramphenicol, in contrast to the amino"lycosides and tetracycline, attaches to the 6+S ri%osome su%unit. The enzyme peptidyl transferase, found in the 6+S su%unit, is inhi%ited. 'emoval of the inhi%itionRin this case, chloramphenicolRresults in full activity of the enzyme. Trimethoprim (T92), a diaminopyrimidine, is a folic acid anta"onist. Althou"h T92 is commonly used in com%ination $ith sulfa dru"s, its mode of action is distinct. T92 is structurally similar to the pteridine portion of dihydrofolate and prevents the conversion of folic acid to tetrahydrofolic acid %y inhi%ition of dihydrofolate reductase. Bortunately, this enzyme in humans is relatively insensitive to T92. -@. =hich one of the follo$in" anti%iotics inhi%its the final peptide %ond %et$een d8alanine and "lycine& A. 2enicillin ). Amdinocillin ,. Amphotericin D. ,hloramphenicol .. Trimethoprim The ans$er is/ A --. A man $ith chills, fever, and headache is thou"ht to have 0atypical0 pneumonia. 3istory reveals that he raises chic1ens and that appro imately * $ee1s a"o he lost a lar"e num%er of them to an undia"nosed disease. =hich of the follo$in" is the most li1ely dia"nosis of this manOs condition& A. Anthra ). S fever ,. 'elapsin" fever D. Ceptospirosis

..

7rnithosis (psittacosis)

The ans$er is/ . 7rnithosis (psittacosis) is caused %y ,hlamydia psittaci. 3umans usually contract the disease from infected %irds 1ept as pets or from infected poultry, includin" poultry in dressin" plants. Althou"h ornithosis may %e asymptomatic in humans, severe pneumonia can develop. Bortunately, the disease is cured easily $ith tetracycline. -6. =hich of the follo$in" mycoplasmas has %een implicated as a cause of non"onococcal urethritis ((A#)& A. 9ycoplasma hominis ). 9. pneumoniae ,. 9. fermentans D. 9. mycoides .. #reaplasma urealyticum The ans$er is/ . #reaplasma urealyticum has %een associated $ith non"onococcal urethritis ((A#) as $ell as infertility. 9ycoplasma pneumoniae is the etiolo"ic a"ent of primary atypical pneumonia. 9. hominis, althou"h isolated from up to @+J of patients $ith (A#, has yet to %e implicated as a cause of that disease. 9. fermentans has on rare occasions %een isolated from the oropharyn and "enital tract. 9. mycoides causes %ovine pleuropneumonia. -D. =hich one of the follo$in" or"anisms normally inha%its the healthy human oral cavity& A. 9. hominis ). 9. orale ,. 9. pneumoniae D. 9. fermentans .. #. urealyticum The ans$er is/ ) 9em%ers of the mycoplasma "roup that are patho"enic for humans include 9. pneumoniae and #. urealyticum. 9. pneumoniae is %est 1no$n as the causative a"ent of primary atypical pneumonia (2A2), $hich may %e confused clinically $ith influenza or le"ionellosis. It also is associated $ith arthritis, pericarditis, aseptic menin"itis, and the Auillain8)arrT syndrome. 9. pneumoniae can %e cultivated on special media and identified %y its a%ility to lyse erythrocytes of sheep or "uinea pi"s. #. urealyticum (once called tiny, or T, strain) has %een implicated in cases of non"onococcal urethritis. As the name implies, this or"anism is a%le to split urea, a fact of dia"nostic si"nificance. #. urealyticum is part of the normal flora of the "enitourinary tract, particularly in $omen. The only other species of 9ycoplasma associated $ith human disease is 9. hominis. A normal inha%itant of the "enital tract of $omen, this or"anism has %een demonstrated to produce an acute respiratory illness that is associated $ith sore throat and tonsillar e udate, %ut not $ith fever. 9. orale and 9. salivarium are %oth inha%itants of the normal human oral cavity. These species are commensals and do not play a role in disease.

9. fermentans is an animal isolate. ->. =hich one of the follo$in" or"anisms normally inha%its the female "enital tract %ut may cause acute respiratory illness& A. 9. hominis ). 9. orale ,. 9. pneumoniae D. 9. fermentans .. #. urealyticum The ans$er is/ A -<. =hich of the follo$in" is the causative a"ent of lympho"ranuloma venereum& A. ). ('ochalimaea) henselae ). .. chaffeensis ,. ,. trachomatis D. '. ric1ettsii .. ,. %urnetii The ans$er is/ , 'ic1ettsiae are small %acteria that are o%li"ate, intracellular parasites. 9ost %ut not all ric1ettsiae are transmitted to humans %y arthropods. ,o iella is transmitted throu"h the respiratory tract rather than throu"h the s1in, and ). henselae, from animal scratches. ,o iella may cause chronic endocarditis that is not very responsive to either antimicro%ial therapy or valve replacement. ). henselae is a fastidious Aram8ne"ative rod that causes %acillary an"iomatosis, a disease that forms dermal or su%cutaneous nodules. The role of ). henselae in cat8scratch disease has recently %een reco"nized. 9olecular ta onomic studies have indicated that the causative or"anism is more closely related to )artonella than 'ochalimaea, hence the name chan"e. .hrlichia is an o%li"ate, intracellular parasite that resem%les ric1ettsia. .. chaffeensis has %een lin1ed to human ehrlichiosis, althou"h this infection is primarily seen in animals. The maKority of patients $ith this disease report e posure to tic1s. It is thou"ht that I. scapularis carries .hrlichia, althou"h the Cone Star tic1, A. americanum, may also transmit the disease. ,hlamydiae are Aram8ne"ative %acteria that are o%li"ate, intracellular parasites. They are divided into three species/ ,. trachomatis, ,. pneumoniae, and ,. psittaci. ,hlamydiae have a uni!ue developmental cycle. The infectious particle is the elementary %ody. 7nce inside the cell, the elementary %ody under"oes reor"anization to form a reticulate %ody. After several replications, the reticulate %odies differentiate into elementary %odies, are released from the host cell, and %ecome availa%le to infect other cells. Three of the 16 serovars of ,. trachomatis (C1, C*, C@) are 1no$n to cause lympho"ranuloma venereum (CA4), a se ually transmitted disease. ,. trachomatis is a leadin" cause of se ually transmitted disease in the #nited States. It is insidious %ecause so many early infections are asymptomatic, particularly in $omen. 'oc1y 9ountain spotted fever is a spotted fever caused %y '. ric1ettsii and is characterized %y acute onset of fever, severe headache, and myal"ias. The rash occurs * to D days later first in the hands and feet and then moves to the trun1. Dia"nosis must %e made on clinical presentations, and therapy instituted immediately. Ca%oratory dia"nosis is made on a risin" anti%ody titer

(delayed). #ntreated disease can %e fatal. -H. =hich one of the follo$in" is transmitted %y the %ite of a hard I odes tic1& A. ). ('ochalimaea) henselae ). .. chaffeensis ,. ,. trachomatis D. '. ric1ettsii .. ,. %urnetii The ans$er is/ ) 'ic1ettsiae are small %acteria that are o%li"ate, intracellular parasites. 9ost %ut not all ric1ettsiae are transmitted to humans %y arthropods. ,o iella is transmitted throu"h the respiratory tract rather than throu"h the s1in, and ). henselae, from animal scratches. ,o iella may cause chronic endocarditis that is not very responsive to either antimicro%ial therapy or valve replacement. ). henselae is a fastidious Aram8ne"ative rod that causes %acillary an"iomatosis, a disease that forms dermal or su%cutaneous nodules. The role of ). henselae in cat8scratch disease has recently %een reco"nized. 9olecular ta onomic studies have indicated that the causative or"anism is more closely related to )artonella than 'ochalimaea, hence the name chan"e. .hrlichia is an o%li"ate, intracellular parasite that resem%les ric1ettsia. .. chaffeensis has %een lin1ed to human ehrlichiosis, althou"h this infection is primarily seen in animals. The maKority of patients $ith this disease report e posure to tic1s. It is thou"ht that I. scapularis carries .hrlichia, althou"h the Cone Star tic1, A. americanum, may also transmit the disease. ,hlamydiae are Aram8ne"ative %acteria that are o%li"ate, intracellular parasites. They are divided into three species/ ,. trachomatis, ,. pneumoniae, and ,. psittaci. ,hlamydiae have a uni!ue developmental cycle. The infectious particle is the elementary %ody. 7nce inside the cell, the elementary %ody under"oes reor"anization to form a reticulate %ody. After several replications, the reticulate %odies differentiate into elementary %odies, are released from the host cell, and %ecome availa%le to infect other cells. Three of the 16 serovars of ,. trachomatis (C1, C*, C@) are 1no$n to cause lympho"ranuloma venereum (CA4), a se ually transmitted disease. ,. trachomatis is a leadin" cause of se ually transmitted disease in the #nited States. It is insidious %ecause so many early infections are asymptomatic, particularly in $omen. 'oc1y 9ountain spotted fever is a spotted fever caused %y '. ric1ettsii and is characterized %y acute onset of fever, severe headache, and myal"ias. The rash occurs * to D days later first in the hands and feet and then moves to the trun1. Dia"nosis must %e made on clinical presentations, and therapy instituted immediately. Ca%oratory dia"nosis is made on a risin" anti%ody titer (delayed). #ntreated disease can %e fatal. 6+. =hich of the follo$in" is the causative a"ent of 'oc1y 9ountain spotted fever& A. ). ('ochalimaea) henselae ). .. chaffeensis ,. ,. trachomatis D. '. ric1ettsii .. ,. %urnetii The ans$er is/ D 'ic1ettsiae are small %acteria that are o%li"ate, intracellular parasites. 9ost %ut not all ric1ettsiae

are transmitted to humans %y arthropods. ,o iella is transmitted throu"h the respiratory tract rather than throu"h the s1in, and ). henselae, from animal scratches. ,o iella may cause chronic endocarditis that is not very responsive to either antimicro%ial therapy or valve replacement. ). henselae is a fastidious Aram8ne"ative rod that causes %acillary an"iomatosis, a disease that forms dermal or su%cutaneous nodules. The role of ). henselae in cat8scratch disease has recently %een reco"nized. 9olecular ta onomic studies have indicated that the causative or"anism is more closely related to )artonella than 'ochalimaea, hence the name chan"e. .hrlichia is an o%li"ate, intracellular parasite that resem%les ric1ettsia. .. chaffeensis has %een lin1ed to human ehrlichiosis, althou"h this infection is primarily seen in animals. The maKority of patients $ith this disease report e posure to tic1s. It is thou"ht that I. scapularis carries .hrlichia, althou"h the Cone Star tic1, A. americanum, may also transmit the disease. ,hlamydiae are Aram8ne"ative %acteria that are o%li"ate, intracellular parasites. They are divided into three species/ ,. trachomatis, ,. pneumoniae, and ,. psittaci. ,hlamydiae have a uni!ue developmental cycle. The infectious particle is the elementary %ody. 7nce inside the cell, the elementary %ody under"oes reor"anization to form a reticulate %ody. After several replications, the reticulate %odies differentiate into elementary %odies, are released from the host cell, and %ecome availa%le to infect other cells. Three of the 16 serovars of ,. trachomatis (C1, C*, C@) are 1no$n to cause lympho"ranuloma venereum (CA4), a se ually transmitted disease. ,. trachomatis is a leadin" cause of se ually transmitted disease in the #nited States. It is insidious %ecause so many early infections are asymptomatic, particularly in $omen. 'oc1y 9ountain spotted fever is a spotted fever caused %y '. ric1ettsii and is characterized %y acute onset of fever, severe headache, and myal"ias. The rash occurs * to D days later first in the hands and feet and then moves to the trun1. Dia"nosis must %e made on clinical presentations, and therapy instituted immediately. Ca%oratory dia"nosis is made on a risin" anti%ody titer (delayed). #ntreated disease can %e fatal 61. Infected tissues demonstratin" %uddin" fun"al cells are seen in $hich of the follo$in"& A. ,occidioidomycosis, chromomycosis, asper"illosis ). Tinea versicolor, tinea ni"ra, candidiasis ,. )lastomycosis, paracoccidioides, dermatophytosis D. ,andidiasis, cryptococcosis, and sporotrichosis .. Asper"illosis, mucormycosis, and mycetoma The ans$er is/ D ,ryptococcus neoformans causes cryptococcosis, especially cryptococcal menin"itis. The or"anisms can %e seen in cere%rospinal fluid (,SB) in india in1 preparations as an oval %uddin" yeast surrounded %y a $ide, unstained polysaccharide capsule. ,andida al%icans, the most important species of ,andida, causes thrush and va"initis, as $ell as other diseases. It may appear in tissue as a %uddin" yeast or as elon"ated pseudohyphae (nonseptate). Sporothri schenc1ii is a dimorphic fun"us $hich appears as round or ci"ar8shaped %uddin" yeasts in tissue. It causes a local pustule or ulcer that may %ecome chronic. 6*. A D8year8old "irl presents to the clinic $ith scaly patches on the scalp. 2rimary smears and culture of the s1in and hair $ere ne"ative. A fe$ $ee1s later, she returned and $as found to have inflammatory lesions. The hair fluoresced under =oodOs li"ht and primary smears of s1in and hair contained septate hyphae. 7n spea1in" $ith the parents, it $as discovered that there $ere several pets in the household. =hich of the follo$in" is the most li1ely a"ent&

A. ). ,. D. ..

9icrosporum audouinii 9icrosporum canis Trichophyton tonsurans Trichophyton ru%rum .pidermophyton floccosum

The ans$er is/ ) 3airs infected $ith 9icrosporum canis and 9. audouini %oth fluoresce $ith a yello$8"reen color under =oodOs li"ht, $hile Trichophyton ru%rum, T. tonsurans, and .pidermophyton floccosum do not. )ut 9. audouini is an anthropophilic a"ent of tinea capitis, $hereas 9. canis is zoophilic. 9. canis is primarily seen in children and is associated $ith infected cats or do"s. 6@. A patient $ith AIDS has a persistent cou"h and has sho$n pro"ressive %ehavioral chan"es in the past fe$ $ee1s after eatin" an undercoo1ed ham%ur"er. A cere%rospinal fluid (,SB) sample is collected and an encapsulated, yeast8li1e or"anism is o%served. )ased only on these o%servations, $hat is the most li1ely or"anism& A. To oplasma ). ,ryptosporidium ,. ,andida D. ,ryptococcus .. 2neumocystis The ans$er is/ D 2atients $ith paralysis of their cellular immune system, such as in AIDS, are suscepti%le to a $ide variety of diseases, includin" infection $ith ,ryptococcus. A %rain a%scess caused %y ,. neoformans is not unusual in patients $ith AIDS. Initial la%oratory suspicion is usually aroused %y the presence of encapsulated yeast in the ,SB. There also could %e other microor"anisms as $ell as noninfectious artifacts that superficially resem%le yeast. =hile ,. neoformans can %e readily cultured, a rapid dia"nosis can %e made %y detectin" cryptococcal capsular polysaccharide in ,SB or %lood. ,are must %e ta1en to strictly control the test %ecause rheumatoid factor may cross8react. 7nce the yeast is isolated, then specific stains as $ell as panels of assimilatory car%ohydrates are availa%le to definitively identify this or"anism as ,. neoformans. The patient may also %e infected $ith 2neumocystis carinii, %ut not in the central nervous system. 2. carinii has recently %een reclassified as a fun"us. 6-. A section of tissue from the foot of a person assumed to have eumycotic mycetoma sho$s a $hite, lo%ulated "ranule composed of fun"al hyphae. In the #nited States, the most common etiolo"ic a"ent of this condition is a species of $hich of the follo$in"& A. Acremonium ). (ocardia ,. Actinomyces D. 2seudallescheria (2etriellidium) .. 9adurella The ans$er is/ D .umycotic mycetoma is a slo$ly pro"ressin" disease of the su%cutaneous tissues that is caused %y a variety of fun"i. The term 9adura foot has %een used to descri%e the foot lesion. Althou"h several fun"i have %een isolated in the #nited States from persons $ho have mycetoma, 2seudallescheria %oydii appears to %e one of the most common. 7ther foot infections that may resem%le 9adura foot are actinomycotic (%acterial) in nature. These are caused %y (ocardia %rasiliensis and Actinomadura.

66. The formation of "ranulomas is seen in maKor systemic fun"al infections. =hich of the follo$in" "roups of fun"i is most li1ely to cause "ranulomas& A. Asper"illus, ,occidioides, ,ryptococcus ). 9ucor, ,andida, 9alassezia ,. ,ladosporium, Asper"illus, 9icrosporum D. ,occidioides, )lastomyces, 3istoplasma .. .pidermophyton, )lastomyces, Trichophyton The ans$er is/ D Aranuloma formation occurs in response to infection $ith many fun"i. This cell8mediated immune response is seen in coccidioidomycosis, histoplasmosis, and %lastomycosis, as $ell as in several others. 6D. The mechanism of mucosal invasion %y ,. al%icans is at least partially understood. =hich one of the follo$in" modifications in the structure or function of this yeast $ould %e most li1ely to affect its invasive a%ility& A. ). ,. D. .. Coss of a%ility to produce ethanol from "lucose Coss of a%ility to produce "erm tu%es or hyphae 'educed a%ility to "ro$ at @>L, Coss of a%ility to produce a polysaccharide capsule 'eplacement of mannans in the cell $all $ith "lucan

The ans$er is/ ) ,. al%icans is part of the normal flora of the "astrointestinal tract, mouth, and "enital surfaces. (ot$ithstandin", ,. al%icans causes severe disease particularly in those patients $ith compromised immunity. It is "enerally thou"ht that $hen ,. al%icans is una%le to adhere to mucosa it is nonpatho"enic and that production of "erm tu%es or hyphae plays a maKor role in colonization and infection of the mucosal epithelial cells %y allo$in" direct penetration of these cells $ith specific hydrolytic enzymes. =hile other mutations such as temperature intolerance, meta%olic alterations, and structural su%stitutions may affect the a%ility of ,andida to survive, these chan"es $ould not affect adherence. 6>. Tinea capitis is caused %y $hich of the follo$in"& A. .. floccosum ). 9. furfur ,. 9. canis D. .. $ernec1ii .. T. %ei"elii The ans$er is/ , Dermatomycoses are cutaneous mycoses caused %y three "enera of fun"i/ 9icrosporum, Trichophyton, and .pidermophyton. These infections are called tinea or rin"$orm, a misnomer that has persisted from the days $hen they $ere thou"ht to %e caused %y $orms or lice. Tinea capitis (rin"$orm of the scalp) is due to an infection $ith 9. canis or T. tonsurans. It usually occurs durin" childhood and heals spontaneously at pu%erty. ,ircular areas on the scalp $ith %ro1en or no hair are characteristic of this disorder.

Tinea corporis (rin"$orm of the %ody) is caused %y 9. canis and T. menta"rophytes. This disorder affects smooth s1in and produces circular pruritic areas of redness and scalin". )oth tinea cruris (rin"$orm of the "roin, 0Koc1 itch0) and tinea pedis (rin"$orm of the feet, athleteOs foot) are caused %y T. ru%rum, T. menta"rophytes, or .. floccosum. These common conditions are pruritic and can cause scalin". Tinea versicolor (pityriasis versicolor) is not a dermatomycotic condition %ut, rather, a superficial mycosis no$ thou"ht to %e caused %y 9alassezia furfur. The disorder is characterized %y chronic %ut asymptomatic scalin" on the trun1, arms, or other parts of the %ody. 6<. =hich one of the follo$in" fun"i causes su%cutaneous zy"omycosis& It is most often seen in Africa and Asia? the infections are most often seen on the trun1 or lim%s and %e"in as painless, small nodules? and the hyphae are D to *6 mm in len"th $ith irre"ular %ranchin". A. A. fumi"atus ). ,. al%icans ,. ,onidio%olus coronata D. 'hizopus arrhizus .. )asidio%olus ranarum The ans$er is/ . ,andidiasis, cryptococcosis, zy"omycosis, and asper"illosis are amon" the most common opportunistic fun"al infections. These fun"i are commonly o%served in the environment and are innocuous to people $ith intact host defenses. 3o$ever, $hen host defenses are compromised %y immunosuppression (AIDS), cytoto ic dru"s, dia%etes, or devices that %reach the normal host defenses, these usually harmless fun"i %ecome potent patho"enic microor"anisms. Cun"s are the most common site for infection %y Asper"illus. These infections ran"e from aller"ic %ronchopulmonary disease ($ith increased serum I".), to fun"us %alls 1no$n as asper"illomas, to life8threatenin" invasive infections of the lun" parenchyma. Typically, the fun"us $ill spread to other or"ans. 2atients $ith lymphoma, for instance, are hi"hly suscepti%le to invasive asper"illosis. Death rates of *6J are not uncommon. ,. al%icans is a mem%er of the normal human microflora. This yeast causes such relatively mild infections as 0Koc1 itch0 and diaper rash. Suppression of cellular immunity often results in more serious yeast infections. 7ral candidiasis is one of the earliest and most fre!uent of the opportunistic infections in patients $ith AIDS. Dia"nosis of invasive candidiasis is difficult, especially $hen patients are symptomatic and ,andida is not recovered from %lood specimens. ,andidal anti%ody tests, anti"en detection, and meta%olite detection have not %een successful in differentiatin" %et$een invasive disease and colonization. Zy"omycosis (sometimes called mucormycosis) is caused %y a variety of fun"i called Zy"omycetes. These fun"i include ,onidio%olus, 'hizopus, and )asidio%olus, $hich can %e differentiated mycolo"ically, %ut all are characterized %y lar"e (D to *6 mm), irre"ularly %ranched, usually nonseptate hyphae. The differentiation of these fun"i clinically is a function of the location of the lesion/ lim%s and trun1, nose, or %rain. )asidio%olus lesions are most commonly seen on the arms and le"s. ,onidio%olus is usually found in the nasal mucosa and nasal sinuses. 'hizopus infection may start in the nasal tissue %ut spreads rapidly to the eyes and %rain 6H. A recently reco"nized or"anism secretes potent to ins, has %een responsi%le for si"nificant fish 1ills, and has also caused disease in humans. This or"anism has %een identified as $hich of the follo$in"& A. Cisteria monocyto"enes ). Aiardia lam%lia

,. D. ..

4i%rio parahaemolyticus 2fiesteria piscicida Aeromonas salmonicida

The ans$er is/ D 2fiesteria is a to in8producin" dinofla"ellate $ith a comple life cycle. 2fiesteria can live either as a plant or a dinofla"ellate. It has %een responsi%le for massive fish 1ills due to al"al 0%looms.0 Such %looms are commonly called tides. 'ed tides, and the li1e, are also responsi%le for many cases of human food poisonin". D+. Trypanosoma cruzi initially penetrates throu"h the mucous mem%ranes on the s1in and then multiplies in a lesion 1no$n as a cha"oma. In the chronic sta"e of the disease, the main lesions are often o%served in $hich part of the %ody& A. Spleen and pancreas ). 3eart and di"estive tract ,. Civer and spleen D. Di"estive tract and respiratory tract .. 3eart and liver The ans$er is/ ) American trypanosomiasis (,ha"asO disease) is produced %y Trypanosoma cruzi, $hich is transmitted to humans %y the %ite of an infected reduviid %u". After multiplication, the tissues most li1ely to %e affected in the chronic sta"e of the disease are the cardiac muscle fi%ers and the di"estive tract. A diffuse interstitial fi%rosis of the myocardium results and may lead to heart failure and death. The inflammatory lesions in the di"estive tract that are seen in the esopha"us and colon produce considera%le dilatation. ,ha"asO disease has not %een an important disease in the #nited States? most cases have %een imported, althou"h there are a fe$ reports of endo"enous disease in the southern #nited States. D1. 7ne of the most clinically si"nificant infections in patients $ith AIDS is 2neumocystis carinii pneumonia (2,2). 2,2 is a treata%le disease? therefore, rapid dia"nosis is essential. =hich of the follo$in" is the method of choice for detection of 2. carinii in respiratory specimens& A. 9ethenamine8silver stain ). Toluidine %lue stain ,. Direct fluorescent anti%ody (DBA) microscopy D. Indirect fluorescent anti%ody (IBA) microscopy .. ,ulture in rat lun" cells The ans$er is/ , )oth methenamine8silver and toluidine %lue stain pneumocysts nonspecifically. These preparations are difficult to read %ecause %ac1"round material may nonspecifically stain %lac1 or %lue. 2neumocystis carinii cannot %e routinely cultured from human specimens. )oth IBA and DBA tests are BDA8approved and availa%le for detection of 2. carinii. The advanta"e of DBA is that it is !uic1er (-6 to D+ min versus @ h) and there is less nonspecific fluorescence o%served in the preparation. 'ecent evidence su""ests that 2neumocystis is a fun"us. D*. 9alaria is a si"nificant $orld$ide pu%lic health pro%lem. The life cycle of 2lasmodium can %e seen in the fi"ure %elo$. =hich one of the follo$in" control methods for malaria is currently effective& A. A vaccine

). ,. D. ..

,hemoprophyla is Anti%iotics =hite clothin" Tic1 repellents

The ans$er is/ ) 2rophyla is for malaria should %e considered $henever travelin" in a malaria8endemic area. Dru"s consist of meflo!uine or chloro!uine and Bansidar. 7ther control measures such as drainin" s$amps, protective clothin" and nettin", and insect repellents are also effective. There is no currently availa%le vaccine for malaria. D@. =hich of the follo$in" or"anisms penetrates s1in, is endemic in Africa and Catin America, and has a lar"e lateral spine on its e""s& A. 2ara"onimus ). ,lonorchis ,. S. mansoni D. Schistosoma Kaponicum .. Schistosoma haemato%ium The ans$er is/ , The life cycle of the medically important trematodes (or flu1es) involves a se ual cycle in humans and an ase ual cycle in snails. The schistosomes can penetrate the s1in $hereas ,lonorchis and 2ara"onimus are in"ested, usually in fish or seafood. These flu1es can %e easily differentiated morpholo"ically %y the appearance of the e"". Schistosome e""s have an identifia%le spine, and %oth ,lonorchis and 2ara"onimus e""s are operculated? that is, they have $hat appears to %e a cover that opens. Serolo"ical tests are not useful. 9any patients $ith schistosomiasis are asymptomatic, %ut disease may %ecome chronic, resultin" in malaise, diarrhea, and hepatosplenome"aly (an enlar"ed liver and spleen). ,lonorchis infection usually causes upper a%dominal pain %ut can also cause %iliary tract fi%rosis. 2ara"onimiasis is characterized %y a cou"h, often $ith %loody sputum, and pneumonia. 2razi!uantel is the treatment of choice for these flu1es. D-. A %utcher, $ho is fond of eatin" ra$ ham%ur"er, develops chorioretinitis? a Sa%in8Beldman dye test is positive. This patient is most li1ely infected $ith $hich of the follo$in"& A. Trichinosis ). Schistosomiasis ,. To oplasmosis D. 4isceral larva mi"rans .. Aiardiasis The ans$er is/ , All the diseases listed in the !uestion have si"nificant epidemiolo"ic and clinical features. To oplasmosis, for e ample, is "enerally a mild, self8limitin" disease? ho$ever, severe fetal disease is possi%le if pre"nant $omen in"est To oplasma oocysts. ,onsumption of uncoo1ed meat may result in either an acute to oplasmosis or a chronic to oplasmosis that is associated $ith serious eye disease. 9ost adults have anti%ody titers to To oplasma and thus $ould have a positive Sa%in8Beldman dye test. Trichinosis most often is caused %y in"estion of contaminated por1 products. 3o$ever, eatin" undercoo1ed %ear, $alrus, raccoon, or possum meat also may cause this disease. Symptoms of trichinosis include muscle soreness and s$ollen eyes.

Althou"h "iardiasis has %een classically associated $ith travel in 'ussia, especially St. 2eters%ur" (Cenin"rad), many cases of "iardiasis caused %y contaminated $ater have %een reported in the #nited States as $ell. Dia"nosis is made %y detectin" cysts in the stool. In some cases, dia"nosis may %e very difficult %ecause of the relatively small num%er of cysts present. Alternatively, an enzyme immunoassay may %e used to detect Aiardia anti"en in fecal samples. Schistosomiasis is a $orld$ide pu%lic health pro%lem. ,ontrol of this disease entails the elimination of the intermediate host snail and removal of streamside ve"etation. A%dominal pain is a symptom of schistosomiasis. 4isceral larva mi"rans is an occupational disease of people $ho are in close contact $ith do"s and cats. The disease is caused %y the nematodes To ocara canis (do"s) and T. cati (cats) and has %een reco"nized in youn" children $ho have close contact $ith pets or $ho eat dirt. Symptoms include s1in rash, eosinophilia, and hepatosplenome"aly. D6. A parasite resem%lin" malaria that infects %oth animals and humans and is carried %y the same tic1 that transmits ). %ur"dorferi (the %acterium that causes Cyme disease) $ould most li1ely %e o%served in $hich of the follo$in"& A. 4a"inal secretions ). Duodenal contents ,. )lood D. )iopsied muscle .. Sputum The ans$er is/ , Trichomonas va"inalis, an odd8loo1in" protozoan, moves $ith a Ker1y, almost dartin" motion. Trichomoniasis, a %othersome va"inal infection, can %e dia"nosed %y o%servin" this or"anism in a $et mount of va"inal secretions. It may %e $ashed out in the urine as $ell. T. va"inalis can %e "ro$n in special media and there are no$ several products availa%le for direct detection of the or"anism. Trichinella spiralis causes trichinosis, a parasitic disease that is usually mild and results in muscle pain and a mild fe%rile illness. 3o$ever, fulminant fatal cases have %een descri%ed. 3umans, $ho are accidental hosts, %ecome infected %y in"estin" cysts that are in the muscle of animals. 9ost infections still come from por1, althou"h re"ulations on pi" feedin" have mar1edly reduced the incidence. Ca%oratory dia"nosis is %y serolo"y or demonstration of the larvae in the muscle tissue. 2ara"onimus $estermani is a lun" flu1e. This trematode infects lun" tissue and is seen not only in sputum %ut also in feces %ecause infected patients s$allo$ respiratory secretions. 2ara"onimiasis is contracted %y in"estin" the metacercariae that are encysted in cra%s or crayfish. Aiardia infection may %e difficult to dia"nose %y stool e amination as patients may shed the cysts intermittently. =hen symptoms persist and the stool e amination is ne"ative, then duodenal contents may %e sampled directly $ith the enterotest. The patient s$allo$s a "elatin capsule that contains a coiled strin". The other end is attached to the patientOs face. The "elatin capsule dissolves, and Aiardia or"anisms, if present, adhere to the strin" $ithin a -8h period. The strin" is retrieved and e amined microscopically. Alternatively, an enzymatic immunoassay can detect Aiardia anti"en directly in a sin"le specimen of feces. )a%esia is a sporozoan parasite transmitted %y the %ite of I. scapularis, the same tic1 that carries ). %ur"dorferi. 'eproduction of this parasite occurs in erythrocytes and may resem%le

2lasmodium species $hen %lood smears are e amined. )a%esia is endemic in the northeastern #nited States, particularly in the islands of 9assachusetts. Ca%oratory dia"nosis is made %y e aminin" %lood smears for this parasite or %y detection of specific anti%ody. )a%esiosis clinically resem%les malaria. DD. It is determined an infant suffers from )rutonOs a"amma"lo%ulinemia. =hich of the follo$in" patho"ens $ill present the most serious threat to this child& A. 9easles virus ). 9yco%acterium tu%erculosis ,. ,hlamydia trachomatis D. 4aricella8zoster virus (4Z4) The ans$er is/ , )rutonOs a"amma"lo%ulinemia is a con"enital defect that %ecomes apparent at appro imately D months of a"e $hen maternal I"A is diminished. The child is una%le to produce immuno"lo%ulins and develops a series of %acterial infections characterized %y recurrences and pro"ression to more serious infections such as septicemia. ,ell8mediated immunity is not affected and the child is a%le to respond normally to diseases that re!uire this immune response for resolution. D>. A youn" "irl has had repeated infections $ith ,andida al%icans and respiratory viruses since the time she $as @ months old. As part of the clinical evaluation of her immune status, her responses to routine immunization procedures should %e tested. In this evaluation, the use of $hich of the follo$in" vaccines is contraindicated& A. ). ,. D. .. Diphtheria to oid )ordetella pertussis vaccine Tetanus to oid ),A Inactivated polio

The ans$er is/ D 'ecurrent severe infection is an indication for clinical evaluation of immune status. Cive vaccines, includin" ),A attenuated from 9yco%acterium tu%erculosis, should not %e used in the evaluation of a patientOs immune competence %ecause patients $ith severe immunodeficiencies may develop an over$helmin" infection from the vaccine. Bor the same reason, oral (Sa%in) polio vaccine is not advisa%le for use in such persons. D<. The "raph %elo$ sho$s the se!uential alteration in the type and amount of anti%ody produced after an immunization. (Inoculation of anti"en occurs at t$o different times, as indicated %y the arro$s.) ,urve A and curve ) each represent a distinct type of anti%ody. The class of immuno"lo%ulin represented %y curve ) has $hich of the follo$in" characteristics& A. ). ,. D. .. An estimated molecular $ei"ht of 16+,+++ A composition of four peptide chains connected %y disulfide lin1s An appearance in neonates at appro imately the third month of life The human A)7 isoa""lutinin A symmetric dipeptide

The ans$er is/ D The "raph presented in the !uestion e hi%its hema""lutinatin" anti%ody responses to primary

and secondary immunization $ith any standard anti"en. ,urve ) represents the early response to primary immunization, $hich is chiefly an I"9 response. 'echallen"e elicits an accelerated response that mainly involves I"A and occurs * to 6 days after reimmunization. I"9 has a molecular $ei"ht of H++,+++ and is a pentamer that the fetus can produce !uite early in "estation. DH. =hich of the follo$in" tests com%ines features of "el diffusion and immunoelectrophoresis and is applica%le only to ne"atively char"ed anti"ens& A. Cate a""lutination (CA) ). .nzyme8lin1ed immunosor%ent assay (.CISA) ,. .nzyme multiplied immunoassay test (.9IT) D. ,ounterimmunoelectrophoresis (,I.) .. ,oa""lutination (,7A) The ans$er is/ D 7f the many methods availa%le for anti"en and anti%ody detection, CA, .CISA, .9IT, ,I., and ,7A are the most $idely used. Cate a""lutination (CA) employs late polystyrene particles sensitized %y either anti%ody or anti"en. CA is more sensitive than ,I. and ,7A %ut sli"htly less sensitive than either 'IA or .IA. CA has %een used to detect 3aemophilus influenzae, (eisseria menin"itidis, and Streptococcus pneumoniae anti"ens in cere%rospinal fluid. CA has also %een used for detection of cryptococcal anti"en. 9ost recently, CA has %een $idely used for rapid detection of "roup A streptococcal anti"en directly from the pharyn . The test is rapid (6 minutes), sensitive (appro imately H+J), and specific (HHJ). ,oa""lutination (,7A), also an a""lutination test, is sli"htly less sensitive than CA %ut less suscepti%le to chan"es in environment (e."., temperature). 9ost strains of coa"ulase8positive staphylococci have protein A in their cell $all. 2rotein A %inds the Bc fra"ment of micro%ial anti"ens in %ody fluids. ,7A has also %een used to rapidly type or "roup %acterial isolates. .nzyme immunoassays (.IAs) can %e either homo"eneous (.9IT) or hetero"eneous (.CISA). .9IT has %een used primarily for assays of lo$8molecular8$ei"ht dru"s. Its primary use in micro%iolo"y has %een for assays of amino"lycoside anti%iotics. .IAs vary as to the solid support used. A variety of supports can %e used, such as polystyrene microdilution plates, paddles, plastic %eads, and tu%es. The num%er of layers in the anti%ody8anti"en sand$ich varies? usually as additional layers are added, detection sensitivity is increased. The t$o most common enzymes are horseradish pero idase (3'2) and al1aline phosphatase (A2). 8"alactosidase has also %een employed. 7rthophenylene diamine is the most common su%strate for 3'2 and p8nitrophenyl phosphate for A2. )ecause .IAs are usually read in the visi%le color ran"e, the tests can %e read !ualitatively %y eye or !uantitatively %y machine. ,ounterimmunoelectrophoresis (,I.) $as ori"inally used for 0Australia anti"en0 (3)sA") %ut $as soon replaced %y 'IA. Bor a decade, ,I. $as used to detect anti"ens in %ody fluids, ,I. is not an easy techni!ue. Its success depends on the control of many varia%les, includin" solid support, volta"e, current, %uffer, affinity and avidity of anti%odies, char"e on the anti"en, and time of electrophoresin" >+. =hich of the follo$in" tests is homo"eneous immunoassay and is preferred for detection of lo$8 molecular8$ei"ht su%stances& A. Cate a""lutination (CA) ). .nzyme8lin1ed immunosor%ent assay (.CISA) ,. .nzyme multiplied immunoassay test (.9IT) D. ,ounterimmunoelectrophoresis (,I.) .. ,oa""lutination (,7A)

The ans$er is/ , 7f the many methods availa%le for anti"en and anti%ody detection, CA, .CISA, .9IT, ,I., and ,7A are the most $idely used. Cate a""lutination (CA) employs late polystyrene particles sensitized %y either anti%ody or anti"en. CA is more sensitive than ,I. and ,7A %ut sli"htly less sensitive than either 'IA or .IA. CA has %een used to detect 3aemophilus influenzae, (eisseria menin"itidis, and Streptococcus pneumoniae anti"ens in cere%rospinal fluid. CA has also %een used for detection of cryptococcal anti"en. 9ost recently, CA has %een $idely used for rapid detection of "roup A streptococcal anti"en directly from the pharyn . The test is rapid (6 minutes), sensitive (appro imately H+J), and specific (HHJ). ,oa""lutination (,7A), also an a""lutination test, is sli"htly less sensitive than CA %ut less suscepti%le to chan"es in environment (e."., temperature). 9ost strains of coa"ulase8positive staphylococci have protein A in their cell $all. 2rotein A %inds the Bc fra"ment of micro%ial anti"ens in %ody fluids. ,7A has also %een used to rapidly type or "roup %acterial isolates. .nzyme immunoassays (.IAs) can %e either homo"eneous (.9IT) or hetero"eneous (.CISA). .9IT has %een used primarily for assays of lo$8molecular8$ei"ht dru"s. Its primary use in micro%iolo"y has %een for assays of amino"lycoside anti%iotics. .IAs vary as to the solid support used. A variety of supports can %e used, such as polystyrene microdilution plates, paddles, plastic %eads, and tu%es. The num%er of layers in the anti%ody8anti"en sand$ich varies? usually as additional layers are added, detection sensitivity is increased. The t$o most common enzymes are horseradish pero idase (3'2) and al1aline phosphatase (A2). 8"alactosidase has also %een employed. 7rthophenylene diamine is the most common su%strate for 3'2 and p8nitrophenyl phosphate for A2. )ecause .IAs are usually read in the visi%le color ran"e, the tests can %e read !ualitatively %y eye or !uantitatively %y machine. ,ounterimmunoelectrophoresis (,I.) $as ori"inally used for 0Australia anti"en0 (3)sA") %ut $as soon replaced %y 'IA. Bor a decade, ,I. $as used to detect anti"ens in %ody fluids, ,I. is not an easy techni!ue. Its success depends on the control of many varia%les, includin" solid support, volta"e, current, %uffer, affinity and avidity of anti%odies, char"e on the anti"en, and time of electrophoresin". >1. 'eactive cold a""lutinins su""ests $hich one of the follo$in" diseases& A. ,hronic infectious mononucleosis ). 2rimary syphilis ,. Scarlet fever D. 2rimary atypical pneumonia .. Immunity to ru%ella (Aerman measles) The ans$er is/ D Scarlet fever is usually a clinical dia"nosis su%se!uent to streptococcal pharyn"itis. Acute "roup A streptococcal infections result in elevated anti%ody titers to streptolysin (AS7), D(ase ), (ADase, and hyaluronidase, all solu%le products of streptococcal "ro$th. 'u%ella immune status tests are usually done %y hema""lutination inhi%ition (3I), enzyme immunoassay (.IA), or late a""lutination. 'eactive 3I titers are 1/1+ or "reater. I"9 tests for ru%ella are often necessary in con"enital infection in order to separate maternal from fetal anti%odies. 9ycoplasma pneumoniae causes primary atypical pneumonia. Althou"h physicians rely on the presence of cold a""lutinins (,A) for dia"nosis, ,A may %e ne"ative in up to 6+J of cases. =ith symptoms of pneumonia, a positive ,A is relia%le. A complement8fi ation (,B) test for 9. pneumoniae is indicated $hen ,A is ne"ative. Isolation of 9. pneumoniae is time8consumin" (1

to @ $ee1s) and not practical in most circumstances. Infectious mononucleosis (I9) may %e suspected clinically %ut it is confirmed serolo"ically. The heterophil anti%ody test, ho$ever, may %e ne"ative in up to 16J of adults and @6 to -+J of children. )ecause I9 is caused %y .pstein8)arr virus (.)4), a specific test for viral capsid anti"en (4,A) of .)4 is indicated $hen heterophil tests are ne"ative. Acute I9 is characterized %y a 4,A8I"9 titer, and no 4,A8I"A anti%ody or .)(A. ,hronic .)4 disease causes elevated 4,A8I"A titers as $ell as hi"h .A anti%ody titers. In the rapid plasma rea"in ('2') tests, the patientOs serum is mi ed on a card $ith '2' anti"en and sensitized charcoal particles. If anti%ody is present, the particles clump. The '2' is more sensitive than the 4D'C test, %ut as $ith the 4D'C test, false positives may occur in 16 to *+J of the positive '2' results. All positives must %e confirmed $ith a specific treponemal test for syphilis such as the fluorescent treponemal anti%ody8a%sorption test (BTA8A)S). >*. .pstein8)arr virus (.)4) 4,A8I"A 1/<+ and .)4 anti%ody to early anti"en (.A) 1/@*+ su""est $hich one of the follo$in" diseases& A. ,hronic infectious mononucleosis ). 2rimary syphilis ,. Scarlet fever D. 2rimary atypical pneumonia .. Immunity to ru%ella (Aerman measles) The ans$er is/ A Scarlet fever is usually a clinical dia"nosis su%se!uent to streptococcal pharyn"itis. Acute "roup A streptococcal infections result in elevated anti%ody titers to streptolysin (AS7), D(ase ), (ADase, and hyaluronidase, all solu%le products of streptococcal "ro$th. 'u%ella immune status tests are usually done %y hema""lutination inhi%ition (3I), enzyme immunoassay (.IA), or late a""lutination. 'eactive 3I titers are 1/1+ or "reater. I"9 tests for ru%ella are often necessary in con"enital infection in order to separate maternal from fetal anti%odies. 9ycoplasma pneumoniae causes primary atypical pneumonia. Althou"h physicians rely on the presence of cold a""lutinins (,A) for dia"nosis, ,A may %e ne"ative in up to 6+J of cases. =ith symptoms of pneumonia, a positive ,A is relia%le. A complement8fi ation (,B) test for 9. pneumoniae is indicated $hen ,A is ne"ative. Isolation of 9. pneumoniae is time8consumin" (1 to @ $ee1s) and not practical in most circumstances. Infectious mononucleosis (I9) may %e suspected clinically %ut it is confirmed serolo"ically. The heterophil anti%ody test, ho$ever, may %e ne"ative in up to 16J of adults and @6 to -+J of children. )ecause I9 is caused %y .pstein8)arr virus (.)4), a specific test for viral capsid anti"en (4,A) of .)4 is indicated $hen heterophil tests are ne"ative. Acute I9 is characterized %y a 4,A8I"9 titer, and no 4,A8I"A anti%ody or .)(A. ,hronic .)4 disease causes elevated 4,A8I"A titers as $ell as hi"h .A anti%ody titers. In the rapid plasma rea"in ('2') tests, the patientOs serum is mi ed on a card $ith '2' anti"en and sensitized charcoal particles. If anti%ody is present, the particles clump. The '2' is more sensitive than the 4D'C test, %ut as $ith the 4D'C test, false positives may occur in 16 to *+J of the positive '2' results. All positives must %e confirmed $ith a specific treponemal test for syphilis such as the fluorescent treponemal anti%ody8a%sorption test (BTA8A)S). >@. A reactive rapid plasma rea"in ('2') test su""ests $hich one of the follo$in" diseases

A. ). ,. D. ..

,hronic infectious mononucleosis 2rimary syphilis Scarlet fever 2rimary atypical pneumonia Immunity to ru%ella (Aerman measles)

The ans$er is/ ) Scarlet fever is usually a clinical dia"nosis su%se!uent to streptococcal pharyn"itis. Acute "roup A streptococcal infections result in elevated anti%ody titers to streptolysin (AS7), D(ase ), (ADase, and hyaluronidase, all solu%le products of streptococcal "ro$th. 'u%ella immune status tests are usually done %y hema""lutination inhi%ition (3I), enzyme immunoassay (.IA), or late a""lutination. 'eactive 3I titers are 1/1+ or "reater. I"9 tests for ru%ella are often necessary in con"enital infection in order to separate maternal from fetal anti%odies. 9ycoplasma pneumoniae causes primary atypical pneumonia. Althou"h physicians rely on the presence of cold a""lutinins (,A) for dia"nosis, ,A may %e ne"ative in up to 6+J of cases. =ith symptoms of pneumonia, a positive ,A is relia%le. A complement8fi ation (,B) test for 9. pneumoniae is indicated $hen ,A is ne"ative. Isolation of 9. pneumoniae is time8consumin" (1 to @ $ee1s) and not practical in most circumstances. Infectious mononucleosis (I9) may %e suspected clinically %ut it is confirmed serolo"ically. The heterophil anti%ody test, ho$ever, may %e ne"ative in up to 16J of adults and @6 to -+J of children. )ecause I9 is caused %y .pstein8)arr virus (.)4), a specific test for viral capsid anti"en (4,A) of .)4 is indicated $hen heterophil tests are ne"ative. Acute I9 is characterized %y a 4,A8I"9 titer, and no 4,A8I"A anti%ody or .)(A. ,hronic .)4 disease causes elevated 4,A8I"A titers as $ell as hi"h .A anti%ody titers. In the rapid plasma rea"in ('2') tests, the patientOs serum is mi ed on a card $ith '2' anti"en and sensitized charcoal particles. If anti%ody is present, the particles clump. The '2' is more sensitive than the 4D'C test, %ut as $ith the 4D'C test, false positives may occur in 16 to *+J of the positive '2' results. All positives must %e confirmed $ith a specific treponemal test for syphilis such as the fluorescent treponemal anti%ody8a%sorption test (BTA8A)S). >-. Suestion 1 of A @+8year8old male patient $as seen %y the emer"ency service and reported a *8$ee1 history of a penile ulcer. 3e noted that this ulcer did not hurt. =hich one of the follo$in" conclusionsGactions is most valid& A. Dra$ %lood for a herpes anti%ody test ). 2erform a dar18field e amination of the lesion ,. 2rescri%e acyclovir for primary "enital herpes D. .ven if treated, the lesion $ill remain for months .. Bailure to treat the patient $ill have no unto$ard effect, as this is a self8limitin" infection The ans$er is/ ) This patient appears to have primary syphilis as evidenced %y a penile chancre that $as not tender. 7ne of the differences %et$een syphilis and herpes simple virus (3S4) is that an 3S4 lesion is e cruciatin"ly painful. Treponemal or"anisms may %e seen microscopically in the lesion if the lesion is scraped. If not treated, the chancre $ill disappear and the patient $ill %e asymptomatic until heGshe e hi%its the si"nsGsymptoms of secondary syphilis, $hich include a disseminated rash and systemic involvement such as menin"itis, hepatitis, or nephritis. There are

t$o 1inds of tests for the detection of syphilis anti%odies/ nonspecific tests such as the '2' and 4D'C, and specific tests such as the BTA, T23A (Treponema pallidum hema""lutination test), and the 93T2 (microhema""lutination8T. pallidum). The difference is that the nonspecific tests use a cross8reactive anti"en 1no$n as cardiolipin, $hile the specific tests use a T. pallidum anti"en. Althou"h the nonspecific tests are sensitive, they lac1 specificity and often cross8react in patients $ho have dia%etes, hepatitis, infectious mononucleosis, or $ho are pre"nant. Some patients, especially those $ith autoimmune diseases, $ill have %oth nonspecific ('2') and specific tests (BTA) positive. 'esolution of such a situation can %e done %y molecular methods for T. pallidum such as 2,', or %y the immo%ilization test usin" live spirochetes and the patientOs serum. In the T2I test, the spirochetes $ill die in the presence of specific anti%ody. >6. Suestion * of The la%oratory reports that the 4enereal Disease 'esearch Ca%oratory (4D'C) test performed on the a%ove patient is reactive at a dilution of 1/- (- dils). The patient also reports to you that he has recently %een dia"nosed $ith hepatitis A. =hich one of the follo$in" actions $ould %e most appropriate& A. ). ,. D. .. 'eport this patient to the health department, as he has syphilis 7rder a confirmatory test such as the fluorescent treponemal anti%ody test (BTA) 'epeat the 4D'C test 7rder a rapid rea"in test ('2') 2erform a spinal tap to rule out central nervous system syphilis

The ans$er is/ ) >D. Suestion @ of In the a%ove patient, $hich one of the follo$in" test com%inations for syphilis is most appropriate& A. BTA8A%s (I"A)GBTA8A%s (I"9) ). '2'GBTA8A%s ,. '2'Gculture of the lesion D. 4D'CG'2' .. Treponema pallidum hema""lutination (T23A)Gmicrohema""lutination8Treponema pallidum (93T2) tests The ans$er is/ )U >>. Suestion - of Assume that the patient a%solutely denied any contact, se ual or other$ise, $ith a person $ho had syphilis. Assume also that %oth the '2' and the BTA A%s $ere positive on this patient. =hich one of the follo$in" tests could %e used to sho$ that this patient pro%a%ly does not have syphilis& A. 4D'C ). Suantitative '2' ,. Treponema pallidum immo%ilization (T2I) test D. Brei test .. 93T2 test The ans$er is/ , This patient appears to have primary syphilis as evidenced %y a penile chancre that $as not tender. 7ne of the differences %et$een syphilis and herpes simple virus (3S4) is that an 3S4

lesion is e cruciatin"ly painful. Treponemal or"anisms may %e seen microscopically in the lesion if the lesion is scraped. If not treated, the chancre $ill disappear and the patient $ill %e asymptomatic until heGshe e hi%its the si"nsGsymptoms of secondary syphilis, $hich include a disseminated rash and systemic involvement such as menin"itis, hepatitis, or nephritis. There are t$o 1inds of tests for the detection of syphilis anti%odies/ nonspecific tests such as the '2' and 4D'C, and specific tests such as the BTA, T23A (Treponema pallidum hema""lutination test), and the 93T2 (microhema""lutination8T. pallidum). The difference is that the nonspecific tests use a cross8reactive anti"en 1no$n as cardiolipin, $hile the specific tests use a T. pallidum anti"en. Althou"h the nonspecific tests are sensitive, they lac1 specificity and often cross8react in patients $ho have dia%etes, hepatitis, infectious mononucleosis, or $ho are pre"nant. Some patients, especially those $ith autoimmune diseases, $ill have %oth nonspecific ('2') and specific tests (BTA) positive. 'esolution of such a situation can %e done %y molecular methods for T. pallidum such as 2,', or %y the immo%ilization test usin" live spirochetes and the patientOs serum. In the T2I test, the spirochetes $ill die in the presence of specific anti%ody. ><. Suestion 1 of * A >+8year8old female patient $as readmitted to a local hospital $ith fever and chills follo$in" cardiac sur"ery at a maKor teachin" institution. )lood cultures $ere ta1en and a Aram8positive coccus "re$ from the %lood cultures $ithin *- hours. Initial tests indicated that this isolate $as resistant to penicillin. =hich of the follo$in" is the most li1ely identification& A. Streptococcus pneumoniae ). (eisseria ,. Aroup A streptococcus D. .nterococcus .. Aroup ) streptococcus The ans$er is/ D .nterococci causes a $ide variety of infections ran"in" from less serious, for e ample, urinary tract infections, to very serious, such as septicemia. A Aram8positive coccus resistant to penicillin must %e assumed to %e enterococcus until other more definitive %iochemical testin" places the isolate in one of the more esoteric "roups of Aram8positive cocci. 7nce isolated, there are a variety of tests to speciate enterococci. 3o$ever, penicillin8resistant, non88lactamase8producin", vancomycin8resistant, Aram8positive cocci are most li1ely .nterococcus faecium. There are a variety of mechanisms for vancomycin resistance in .. faecium and they have %een termed 4an A, ), or ,. These isolates have %ecome one of the most feared nosocomial patho"ens in the hospital environment. #nfortunately, no approved anti%iotics can successfully treat vancomycin8 resistant enterococci (4'.), only some e perimental anti%iotics such as Synercid. >H.

Question 2 of 2 Further testing revealed that the isolate possessed the group D antigen, was not lactamase-positive, but was resistant to vancomycin. Which of the following is the most likely identification of this isolate A. Enterococcus faecalis B. Enterococcus durans C. Enterococcus cassiflavus D. S. pneumoniae

E. Enterococcus faecium The answer is: E !nterococci causes a wide variety of infections ranging from less serious, for e"ample, urinary tract infections, to very serious, such as septicemia. # $ram-positive coccus resistant to penicillin must be assumed to be enterococcus until other more definitive biochemical testing places the isolate in one of the more esoteric groups of $ram-positive cocci. %nce isolated, there are a variety of tests to speciate enterococci. &owever, penicillin-resistant, non- -lactamase-producing, vancomycin-resistant, $ram-positive cocci are most likely Enterococcus faecium. 'here are a variety of mechanisms for vancomycin resistance in E. faecium and they have been termed (an #, ), or *. 'hese isolates have become one of the most feared nosocomial pathogens in the hospital environment. +nfortunately, no approved antibiotics can successfully treat vancomycinresistant enterococci ,(-!., only some e"perimental antibiotics such as /ynercid. 01 Question 2 of 3 # 20-year-old menstruating woman appeared in the emergency room with the following signs and symptoms4 fever, 2156F ,516*.7 W)*, 28,1119 :7 blood pressure, ;198< mm&g7 a scarlatiniform rash on her trunk, palms, and soles7 e"treme fatigue7 vomiting7 and diarrhea. Which of the following is the most likely diagnosis A. /calded skin syndrome B. 'o"ic shock syndrome C. $uillain-)arr= syndrome D. *hicken po" E. /taphylococcal food poisoning The answer is: B 'o"ic shock syndrome ,'//. is a febrile illness seen predominantly, but not e"clusively, in menstruating women. *linical criteria for '// include fever greater than 2126F ,30.;6*., rash, hypotension, and abnormalities of the mucous membranes and the gastrointestinal, hepatic, muscular, cardiovascular, or central nervous system. +sually three or more systems are involved. 'reatment is supportive, including the aggressive use of antistaphylococcal antibiotics. *ertain types of tampons may play a role in '// by trapping %2 and depleting magnesium. >ost people have protective antibodies to the to"ic shock syndrome to"in ,'//'-2..

'o"ic shock syndrome is caused by a to"in-producing strain of Staphylococcus aureus ,'//'-2.. While there have been reports that S. epidermidis produces '//, they have largely been discounted. (aginal coloni?ation with S. aureus is a necessary ad@unct to the disease. S. aureus is isolated from the vaginal secretions, con@unctiva, nose, throat, cervi", and feces in 5< to ;0A of cases. 'he organism has infreBuently been isolated from the blood. !pidemiologic investigations suggest strongly that to"ic shock syndrome is related to use of tampons, in particular, use of the highly absorbent ones that can be left in for e"tended periods of time. #n increased growth of intravaginal S. aureus and enhanced production of '//'-2 have been associated with the prolonged intravaginal use of these hyperabsorbent tampons and with the capacity of the materials used in them to bind magnesium. 'he most severe cases of '// have been seen in association with $ramnegative infection. '//'-2 may enhance endoto"in activity. -ecently, group # streptococci have been reported to cause '//.
<1.

Question 2 of 3 *ulture of the menstrual fluid in the case cited would most likely reveal a predominance of which of the following A. S. aureus B. S. epidermidis C. C. perfringens D. C. difficile E. Gardnerella vaginalis 'he answer is4 # 82. Question 3 of 3 Which of the following is the most characteristic finding not yet revealed in the case @ust presented A. 'ravel to (ermont B. -ecent e"posure to rubella C. # retained tampon D. &eavy menstrual flow E. # meal of chicken in a fast-food restaurant

* 03. Question 2 of 3 #n 20-year-old male patient appeared at the emergency room with a 3-day history of fever, dry cough, difficulty breathing, and muscle aches and pains. &is chest "-ray showed a diffuse left upper lobe infiltrate. Mycoplasma pneumoniae pneumonia ,walking pneumonia. may be rapidly identified by which of the following procedures A. Detection of specific antigen in urine B. *old agglutinin test C. !lectron microscopy of sputum *ulture of respiratory secretions in &e:a cells after centrifugation of the D. inoculated tubes E. *ulture of respiratory secretions on monkey kidney cells 'he answer is4 ) C#typical pneumoniaC is an old classification used for respiratory disease that is not lobar and is not Ctypical.C 'hat is, it does not include pneumonia caused by pneumococcus, Klebsiella, Haemophilus, or -hemolytic streptococci that results in a typical lobular infiltrate. Dn recent years, the atypical pneumonias have become much more freBuent than pneumococcal pneumonia. 'hey are characteri?ed by a slower onset with headache, @oint pain, fever, and signs of an acute upper respiratory infection. 'here are usually no signs of acute respiratory distress, but patients report malaise and fatigue. 'he most common cause of atypical pneumonia is Mycoplasma pneumoniae. # Buick test for M. pneumoniae infection is cold agglutinins. 'he test may lack both sensitivity and specificity, but it is rapid and readily available compared with culture of M. pneumoniae or specific antibody formation.

05. Question 2 of 3 #n 20-year-old male patient appeared at the emergency room with a 3-day history of fever, dry cough, difficulty breathing, and muscle aches and pains. &is chest "-ray showed a diffuse left upper lobe infiltrate. Dnfluen?a can be treated7 therefore, specific detection of the virus becomes much more important. Which of the following would be best for detection of influen?a

A. Detection of specific antigen in urine B. *old agglutinin test C. !lectron microscopy of sputum D. Detection of antigen in respiratory secretions E. *ulture of respiratory secretions on monkey kidney cells The answer is: E 'he gold standard for identification of influen?a virus is isolation of the agent on primary ,directly from the animal and put into cell culture. monkey kidney cells. 'he cells support the growth of the virus and may or may not show cytopathic effects ,*E!. brought about by the growth of the virus in the cells. /pecific identification is made by doing an immunofluoresence test ,monoclonal antibody specific for influen?a virus and labeled with FD'*, observed with a fluoresence microscope.. 'he laboratory can also use the immunofluoresence test directly on respiratory secretions if there are cells present in the secretions. 'he cells would contain viral antigens within the cells since that is where the virus is growing, and would be detectable by the F# ,fluoresence antibody. test. # is definitely incorrect. *old agglutinins ,). are used for >ycoplasma detection. * would never be used because of costs and lack of individuals who can interpert !> micrographs. #lthough D could arguably be correct, the single best answer is !.
<6.

Question 3 of 3 #n 20-year-old male patient appeared at the emergency room with a 3-day history of fever, dry cough, difficulty breathing, and muscle aches and pains. &is chest "-ray showed a diffuse left upper lobe infiltrate. Which of the following is the most sensitive method for diagnosis of :egionnairesF disease A. Detection of specific antigen in urine B. *old agglutinin test C. !lectron microscopy of sputum D. Detection of antigen in respiratory secretions E. *ulture of respiratory secretions on a charcoal-based nutrient agar The answer is: E

Dn certain age groups ,men over << years old., :egionnairesF disease must be ruled out. *ulture onto charcol-yeast e"tract agar or similar enriched medium is the most sensitive method for diagnosis of legionellosis and permits identification of infections caused by species and serotypes other than L pneumophila serotype 2. DiterleFFs silver staining of tissue, pleural fluid, or other infected material is also a relable method for detecting legionella species. Direct flourescent antibody stains and seroligic testing are less sensitive because these will detect only infection cased by L pneumophila serotype 2. Dn addition, making a seroligic diagnosis reBuires that the host respond with sufficient specific antibody production. +rinary antigen tests, which are targeted for detection of L pneumophila serotype 2, are also less sensitive than culture.
<D.

Chlamydia pneumoniae has recently been implicated in respiratory disease primarily in children. Which of the following would best isolate this fastidious bacterium
A. ). ,. D. .. Detection of specific anti"en in urine ,old a""lutinin test .lectron microscopy of sputum ,ulture of respiratory secretions in 3eCa cells after centrifu"ation of the inoculated tu%es ,ulture of respiratory secretions on mon1ey 1idney cells

The ans$er is/ D ,hlamydia pneumoniae may cause respiratory infection, particularly in, %ut not limited to, children. Dia"nosis is %est made %y "ro$in" these ener"y8defective %acteria in tissue culture such as 3eCa cells. Serolo"y is usually not helpful. <>. )ordetella %ronchitis, sometimes called $hoopin" cou"h, can %est %e detected %y $hich of the follo$in" procedures& A. Bluorescent anti%ody detection of the or"anism in sputum ). ,old a""lutinin test ,. Direct microscopy of sputum %y Aram stain D. ,ulture of respiratory secretions in 3eCa cells after centrifu"ation of the inoculated tu%es .. ,ulture of respiratory secretions on 'e"an8Co$e a"ar The ans$er is/ . Durin" the $inter months, )ordetella infection may %e !uite prevalent, particularly in those patients $hose immunizations are not current. Adult )ordetella infection may not present $ith typical $hoopin" cou"h symptoms and must %e differentiated from other forms of acute %ronchitis %y culture on specific media or direct fluorescent microscopy. <<. Suestion 1 of @ Vou have %een as1ed to desi"n a nucleic acid amplification test for a rarely isolated %acterium. There are several !uestions that you must as1 in order to develop a test that could %e used to dia"nose disease. Assume, initially, that the polymerase chain reaction (2,') $ill amplify any D(A, human or micro%ial. =hich of the follo$in" is the %est $ay to prevent contamination of the 2,' process& A. =ear "loves

). ,. D. ..

=ash %enches $ith %leach #se universal precautions Incorporate self8sterilizin" a"ents into the 2,' mi ture Do all of the $or1 under a hood

The ans$er is/ D The polymerase chain reaction (2,') has revolutionized the detection of infectious microor"anisms, particularly those that are difficult to "ro$. =hile physicians durin" their normal practice $ill usually not %e re!uired to desi"n a 2,' test, they should 1no$ some of the desi"n elements of 2,' so that they mi"ht %etter understand the results from these $idely used tests. 7ne of the maKor pro%lems of 2,' in the past $as contamination from e traneous nucleic acid. There are several $ays to prevent contamination and the resultin" falsely positive results. They include the use of separate la%oratories, hoods, "loves, and surface disinfectants. The most effective method, ho$ever, is the use of internal sterilizin" a"ents such as uracil ("lycosyls (#(A). These a"ents cross8lin1 e traneous D(A so that the product cannot %e amplified. 2rimers no$ can %e purchased from a catalo"ue and their se!uence o%tained online. 2rimers are easily synthesized, must %e complementary to se!uences on the %acterial chromosome, and $hen coupled to such se!uences must promote replication. The specificity of 2,' is a function of choosin" a primer pair that is uni!ue to the or"anism that you $ish to detect. The 2,' process is %est e plained %y the 0needle in the haystac10 analo"y. 7ne needle in a haystac1 is difficult to find. 3o$ever, if one needle %ecomes a million needles, then detection is easy. The same is true for nucleic acids. The amplicons (amplified nucleic acids) can %e detected %y a num%er of methods %ecause they are so plentiful. These methods include specific stainin" $ith ethidium %romide of a "el containin" these amplicons and Southern %lottin" of the amplicons 0ta"s0 them so that they can %e seen on photo"raphic film. Amplicons are also %ound to solid phases and detected $ith la%eled enzymes or an instrument that reads a fluorescent ta". 9icroscopy is not used. <H. Suestion * of @ Vou have %een as1ed to desi"n a nucleic acid amplification test for a rarely isolated %acterium. There are several !uestions that you must as1 in order to develop a test that could %e used to dia"nose disease. Vou must choose primers for this 2,'. 2rimers are small pieces of nucleic acid that reco"nize a pair of uni!ue sites on the %acterial chromosome. Bor an optimum test to %e developed, $hich of the follo$in" characteristics is the least desira%le& A. ). ,. D. .. A%ility to %e constructed %y a synthesizer #ni!ueness to the or"anism that you $ish to detect ,omplementary to se!uences on the %acterial chromosome A%ility to serve as a template for replication That the se!uences are $idely reco"nized %y many %acterial species

The ans$er is/ . H+. Suestion @ of @ Vou have %een as1ed to desi"n a nucleic acid amplification test for a rarely isolated %acterium. There are several !uestions that you must as1 in order to develop a test that could %e used to dia"nose disease. Vou have chosen the primers for the 2,' that you have desi"ned. Vou have also developed a reaction mi ture that contains, amon" other su%stances, a polymerase enzyme. After the primer

pairs have %een amplified, they must %e detected. =hich of the follo$in" detection methods is most sensitive (that is, $ill detect the hi"hest num%er of amplicons)& A. ). ,. D. .. Southern %lot .thidium stainin" of the amplified products (amplicons) 9icroscopy ,apture of the amplicons on a solid phase follo$ed %y an enzyme immunoassay Ca%elin" of the amplicons $ith fluorescent dyes

The ans$er is/ A The polymerase chain reaction (2,') has revolutionized the detection of infectious microor"anisms, particularly those that are difficult to "ro$. =hile physicians durin" their normal practice $ill usually not %e re!uired to desi"n a 2,' test, they should 1no$ some of the desi"n elements of 2,' so that they mi"ht %etter understand the results from these $idely used tests. 7ne of the maKor pro%lems of 2,' in the past $as contamination from e traneous nucleic acid. There are several $ays to prevent contamination and the resultin" falsely positive results. They include the use of separate la%oratories, hoods, "loves, and surface disinfectants. The most effective method, ho$ever, is the use of internal sterilizin" a"ents such as uracil ("lycosyls (#(A). These a"ents cross8lin1 e traneous D(A so that the product cannot %e amplified. 2rimers no$ can %e purchased from a catalo"ue and their se!uence o%tained online. 2rimers are easily synthesized, must %e complementary to se!uences on the %acterial chromosome, and $hen coupled to such se!uences must promote replication. The specificity of 2,' is a function of choosin" a primer pair that is uni!ue to the or"anism that you $ish to detect. The 2,' process is %est e plained %y the 0needle in the haystac10 analo"y. 7ne needle in a haystac1 is difficult to find. 3o$ever, if one needle %ecomes a million needles, then detection is easy. The same is true for nucleic acids. The amplicons (amplified nucleic acids) can %e detected %y a num%er of methods %ecause they are so plentiful. These methods include specific stainin" $ith ethidium %romide of a "el containin" these amplicons and Southern %lottin" of the amplicons 0ta"s0 them so that they can %e seen on photo"raphic film. Amplicons are also %ound to solid phases and detected $ith la%eled enzymes or an instrument that reads a fluorescent ta". 9icroscopy is not used. H1. Suestion 1 of 6 The follo$in" dia"ram illustrates the amplification of D(A %y the polymerase chain reaction (2,'). There are at least four points in the 2,' process (AFD) that are critical to the reaction. The Southern %lot detection system for amplified 2,' products fails to function. =hich one of the follo$in" $ould %e affected& A. ). ,. D. A ) , D

The ans$er is/ D The process of 2,' is complicated and its steps are interrelated. A num%er of steps in the process can mar1edly affect the results of clinical testin". Bor e ample, the detection of amplified products is essential in order to determine $hether tar"et nucleic acid $as present in the specimen. 2roduct can %e detected %y stainin" of the "el that separates the products, Southern %lot (a radioactive procedure), or an .CISA8li1e capture method. A failure of this production step

prevents detection of product. 7ne of the essential parts of the 2,' process is the thermal cyclin" of the reaction. If the reaction is not heated, primer D(A $ill not hy%ridize $ith the tar"et se!uences. (or $ill the strands reanneal if the mi ture is not cooled. Bailure of the thermocycler could cause such a pro%lem. Balse8positive results are usually due to contamination of the reaction %y forei"n D(A. In such a case, the forei"n D(A se!uences are amplified even if the tar"et se!uences are not present. There are a num%er of reasons $hy 2,' $ould %e falsely ne"ative, %ut a prime reason is failure to choose the ri"ht primer sets. Su%optimum detection of amplified products is another. .thidium %romide stainin" of the 2,' "el is less sensitive than detection of the products %y Southern %lot. H*.

Question 2 of < 'he following diagram illustrates the amplification of DG# by the polymerase chain reaction ,E*-.. 'here are at least four points in the E*- process ,#HD. that are critical to the reaction.

DG# does not hybridi?e with the primers. Which one of the following would be affected 9icro A. # B. ) C. * D. D

The answer is: C 93. 'he laboratory observes a series of false-positive results. Which one of the following processes would you suspect to be faulty A. # B. ) C. * D. D

;5 5 of < 'he DG# strands fail to reanneal. Which one of the following processes would you suspect to be faulty A. # B. ) C. * D. D

answer is: C 95. Question < of < 'he following diagram illustrates the amplification of DG# by the polymerase chain reaction ,E*-.. 'here are at least four points in the E*- process ,#HD. that are critical to the reaction.

'he laboratory observes a series of false-negative results. Which one of the following processes would you suspect to be faulty

A. #

B. )

C. *

D. D

The answer is: B 'he process of E*- is complicated and its steps are interrelated. # number of steps in the process can markedly affect the results of clinical testing. For e"ample, the detection of amplified products is essential in order to determine whether target nucleic acid was present in the specimen. Eroduct can be detected by staining of the gel that separates the products, /outhern blot ,a radioactive procedure., or an !:D/#-like capture method. # failure of this production step prevents detection of product. %ne of the essential parts of the E*- process is the thermal cycling of the reaction. Df the reaction is not heated, primer DG# will not hybridi?e with the target seBuences. Gor will the strands reanneal if the mi"ture is not cooled. Failure of the thermocycler could cause such a problem. False-positive results are usually due to contamination of the reaction by foreign DG#. Dn such a case, the foreign DG# seBuences are amplified even if the target seBuences are not present. 'here are a number of reasons why E*- would be falsely negative, but a prime reason is failure to choose the right primer sets. /uboptimum detection of amplified products is another. !thidium bromide staining of the E*- gel is less sensitive than detection of the products by /outhern blot.
HD.

Question 2 of < 'he following serum electrophoretic profiles ,#H!. are associated with a variety of diseases. For each diagnosis given, choose the serum electrophoretic profile with which it is most likely to be associated.

-#ntitrypsin deficiency is associated with which one of the following patterns A. # B. ) C. * D. D E. !

The answer is: B !lectrophoresis of human serum proteins identifies five distinct types4 albumin, 2proteins, 2-proteins, -proteins, and globulins. # normal electrophoretic profile appears below.

>any human diseases can be diagnosed, at least in part, on the basis of abnormal electrophoresis profiles. For e"ample, absence of the second peak , 2. is compatible with a diagnosis of 2-antitrypsin deficiency in symptomatic persons. # sharp and high peak indicates the presence of a monoclonal gammopathy, such as multiple myeloma7 on the other hand, a peak that is diffusely elevated points to polyclonal hypergammaglobulinemia. *omplete absence of the peak is associated with /wiss-type agammaglobulinemia.

H>.

Question 2 of < 'he following serum electrophoretic profiles ,#H!. are associated with a variety of diseases. For each diagnosis given, choose the serum electrophoretic profile with which it is most likely to be associated.

>ultiple myeloma is associated with which one of the following patterns A. # B. ) C. * D. D E. !

The answer is: C !lectrophoresis of human serum proteins identifies five distinct types4 albumin, 2proteins, 2-proteins, -proteins, and globulins. # normal electrophoretic profile appears below.

>any human diseases can be diagnosed, at least in part, on the basis of abnormal electrophoresis profiles. For e"ample, absence of the second peak , 2. is compatible with a diagnosis of 2-antitrypsin deficiency in symptomatic persons. # sharp and high peak

indicates the presence of a monoclonal gammopathy, such as multiple myeloma7 on the other hand, a peak that is diffusely elevated points to polyclonal hypergammaglobulinemia. *omplete absence of the peak is associated with /wiss-type agammaglobulinemia.
H<.

Question 3 of < 'he following serum electrophoretic profiles ,#H!. are associated with a variety of diseases. For each diagnosis given, choose the serum electrophoretic profile with which it is most likely to be associated.

/wiss-type agammaglobulinemia is associated with which one of the following patterns A. # B. ) C. * D. D E. !

The answer is: D !lectrophoresis of human serum proteins identifies five distinct types4 albumin, 2proteins, 2-proteins, -proteins, and globulins. # normal electrophoretic profile appears below.

>any human diseases can be diagnosed, at least in part, on the basis of abnormal electrophoresis profiles. For e"ample, absence of the second peak , 2. is compatible with a diagnosis of 2-antitrypsin deficiency in symptomatic persons. # sharp and high peak indicates the presence of a monoclonal gammopathy, such as multiple myeloma7 on the other hand, a peak that is diffusely elevated points to polyclonal hypergammaglobulinemia. *omplete absence of the peak is associated with /wiss-type agammaglobulinemia
HH.

Question 5 of < 'he following serum electrophoretic profiles ,#H!. are associated with a variety of diseases. For each diagnosis given, choose the serum electrophoretic profile with which it is most likely to be associated.

Eolyclonal hypergammaglobulinemia is associated with which one of the following patterns A. # B. ) C. * D. D E. !

The answer is: E

99 !lectrophoresis of human serum proteins identifies five distinct types4 albumin, 2proteins, 2-proteins, -proteins, and globulins. # normal electrophoretic profile appears below.

I >any human diseases can be diagnosed, at least in part, on the basis of abnormal electrophoresis profiles. For e"ample, absence of the second peak , 2. is compatible with a diagnosis of 2-antitrypsin deficiency in symptomatic persons. # sharp and high peak indicates the presence of a monoclonal gammopathy, such as multiple myeloma7 on the other hand, a peak that is diffusely elevated points to polyclonal hypergammaglobulinemia. *omplete absence of the peak is associated with /wiss-type agammaglobulinemia.
1++.

Question < of < 'he following serum electrophoretic profiles ,#H!. are associated with a variety of diseases. For each diagnosis given, choose the serum electrophoretic profile with which it is most likely to be associated.

Which one of the following patterns would be seen in a normal person A. # B. ) C. * D. D E. !

The answer is: A !lectrophoresis of human serum proteins identifies five distinct types4 albumin, 2proteins, 2-proteins, -proteins, and globulins. # normal electrophoretic profile appears below.

>any human diseases can be diagnosed, at least in part, on the basis of abnormal electrophoresis profiles. For e"ample, absence of the second peak , 2. is compatible with a diagnosis of 2-antitrypsin deficiency in symptomatic persons. # sharp and high peak indicates the presence of a monoclonal gammopathy, such as multiple myeloma7 on the other hand, a peak that is diffusely elevated points to polyclonal hypergammaglobulinemia. *omplete absence of the peak is associated with /wiss-type agammaglobulinemia.