68. Which of the following is the object designated by the arrow in the photomicrograph below?

A. B. . !. ".

An encapsulated yeast A thick-walled spore A spherule A hyphal strand A macroconidium

The answer is: B #hick-walled spores are characteristic of many fungal infections$ including blastomycosis$ coccidioidomycosis$ and histoplasmosis. %bser&ation of these structures in sputum or in tissue should alert the microbiologist to a diagnosis of systemic fungal infection. #he presence of encapsulated yeast in clinical specimens may suggest the presence of Cryptococcus. 69. A clinical diagnosis of meningitis is confirmed with a late' agglutination test on () for the capsular polysaccharide of the organism. Which of the following is the most likely causati&e agent? A. andida albicans B. ryptococcus . *aracoccidioides brasiliensis !. +istoplasma capsulatum ". Aspergillus fumigatus The answer is: B C. neoformans occurs widely in nature$ particularly in soil contaminated with bird droppings. +uman infection occurs when inhalation of the organism occurs. ,ung infection is often asymptomatic but can result in pneumonia. -eningitis occurs through

dissemination$ particularly in immunosuppressed patients. .ndia ink preparations of () re&eal a budding yeast with a wide$ unstained capsule in infected persons. /0. .nfection with Sporothrix schenckii 1formerly Sporotrichum schenckii2 is an occupational ha3ard for gardeners. Which of the following is the portal of entry for this organism? A. ,ymphatic system B. 4espiratory tract . (kin !. -outh ". -ucous membranes The answer is: C utaneous sporotrichosis$ caused by S. schenckii, begins at the site of inoculation$ usually on an e'tremity or the face. #he organism often is found on thorns of rose bushes. 5lceration is common and new lesions appear along paths of lymphatic channels. "'tracutaneous sporotrichosis is seen primarily in bones and joints. #here is no e&idence to suggest that any portal of entry besides skin is important. /6. C. albicans is recogni3ed in microscopic e'amination of infected tissues by the presence of which of the following? A. (pherules containing endospores B. -etachromatic granules . 7easts and pseudohyphae !. Asci containing 898 ascospores ". Abundance of septate rhi3oids The answer is: C C. albicans is the most important species of Candida and causes thrush$ &aginitis$ skin and nail infections$ and other infections. .t is part of the normal flora of skin$ mouth$ :. tract$ and &agina. .t appears in tissues as an o&al budding yeast or elongated pseudohyphae. .t grows well on laboratory media and is identified by germ-tube formation. A &accine is not a&ailable and serologic and skin tests ha&e little &alue. /8. 7ou ha&e been designated as coordinator of construction of a bone marrow transplant unit 1B-#52. #here will be e'tensi&e remo&al of walls and floors in order to install the laminar flow rooms re;uired for a B-#5. )rom the standpoint of fre;uency and lethality$ which one of the following fungi should be your biggest concern? A. B. . Aspergillus andida Wangiella

!. ".

ryptococcus Blastomyces

The answer is: A While all fungi such as Candida and Cryptococcus are potentially serious in a bone marrow transplant unit 1B-#52$ the most fre;uent cause of fungal infection and death is Aspergillus. Aspergilli are ubi;uitous in the en&ironment. #here are instances of multiple infections in new units that ha&e not been monitored prior to opening or in units adjacent to construction projects. (trict precautions should be taken to e'clude dust and debris from the B-#5 area during construction$ but in any e&ent the en&ironment should be monitored for airborne microorganisms$ especially Aspergillus, prior to opening the unit. /<. .nhalation of fungal spores can cause primary lung infections. %f the following organisms$ which one is most likely to be associated with this mode of transmission? A. . immitis B. (. schenckii . . albicans !. #. tonsurans ". andida tropicalis The answer is: A C. albicans and Candida tropicalis are opportunistic fungi$ and as part of the normal flora are not transmitted by inhalation. C. immitis is a dimorphic fungus and inhalation of the spores transmits the infection. Sprothrix is also a dimorphic fungus but its portal of entry is cutaneous. Trychophyton is a dermatophyte and one of the causes of athlete=s foot />. *atients who ha&e disseminated coccidioidomycosis may usually demonstrate which one of the following? . B. . !. ". A negati&e coccidioidin skin test and a rising complement-fi'ing 1 )2 titer A negati&e coccidioidin skin test and a stable ) titer A positi&e skin test and a mildly ele&ated ) titer Absence of ) antibodies ,ack of immunity to reinfection

The answer is: A .n patients with coccidioidomycosis$ a positi&e skin test to coccidioidin appears 8 to 86 days after the appearance of disease symptoms and may persist for 80 years without ree'posure to the fungus. A decrease in intensity of the skin response often occurs in clinically healthy people who mo&e away from endemic areas. A negati&e skin test fre;uently is associated with disseminated disease. omplement-fi'ing 1 )2 immunoglobulin : 1.g:2 antibodies$ which may not appear at all in mild disease$ rise to a

high titer in disseminated disease$ a poor prognostic sign. )or this reason$ a persistent or rising ) titer combined with clinical symptoms indicates present or imminent dissemination. 4arely is the ) titer negati&e. -ost persons infected with C. immitis are immune to reinfection. /?. (porulation from flask-shaped$ pigmented projections is commonly obser&ed in which one of the following fungi? A. ". floccosum B. . immitis . *. &errucosa !. -. canis ". B. dermatitidis The answer is: C -icroscopic e'amination of fungal isolates is essential to the identification of the organism. -acroscopically$ the colonies of Epidermophyton ha&e a yellowish appearance. #his fungus in&ades skin and nails but ne&er hair. %n microscopic e'amination$ cla&ate or paddle-shaped macroconidia are e&ident with rounded ends and smooth walls. -icroconidia are absent. C. immitis is a dimorphic fungus endemic in some regions of the southwestern 5nited (tates and in ,atin America. .n tissue$ the organism e'ists as a spherule filled with endospores. When grown on solid media$ the organism produces barrel-shaped arthroconidia$ which stain with lactophenol cotton blue. hialophora !errucosa is one of the causes of chromoblastomycosis$ a chronic locali3ed infection of the skin and subcutaneous tissue. -icroscopically$ short or somewhat elongated$ flask-shaped$ pigmented phialides are seen. #he collarettes are &ase-shaped and darkly pigmented. ". canis is a dermatophyte that infects skin and hair but rarely nails. When hair is infected with this organism$ it will fluoresce. -icroscopic e'amination of this organism demonstrates rough-walled macroconidia of 8 to 6? cells. #lastomyces dermatitidis causes a chronic granulomatous disease. #he yeast cells are globose or o&oid in shape. #he single blastoconidium is attached by a broad base to the parent cell. #he following figure illustrates the broad-based budding cells.

#lastomyces dermatitidis in its yeast form. @ote broad base of attachment of blastoconidium to parent cell.

/6. la&ate macroconidia are characteristic of which one of the following fungi? A. ". floccosum B. . immitis . *. &errucosa !. -. canis ". B. dermatitidis The answer is: A 77. #inea corporis is caused by which of the following? A. ". floccosum B. -alasse3ia furfur . -. canis !. "'ophiala werneckii ". #richosporon beigelii The answer is: C

!ermatomycoses are cutaneous mycoses caused by three genera of fungiA "icrosporum, Trichophyton, and Epidermophyton. #hese infections are called tinea or ring$orm, a misnomer that has persisted from the days when they were thought to be caused by worms or lice. #inea capitis 1ringworm of the scalp2 is due to an infection with ". canis or T. tonsurans. .t usually occurs during childhood and heals spontaneously at puberty. ircular areas on the scalp with broken or no hair are characteristic of this disorder. #inea corporis 1ringworm of the body2 is caused by ". canis and T. mentagrophytes. #his disorder affects smooth skin and produces circular pruritic areas of redness and scaling. Both tinea cruris 1ringworm of the groin$ Bjock itchB2 and tinea pedis 1ringworm of the feet$ athlete=s foot2 are caused by T. rubrum, T. mentagrophytes, or E. floccosum. #hese common conditions are pruritic and can cause scaling. #inea &ersicolor 1pityriasis &ersicolor2 is not a dermatomycotic condition but$ rather$ a superficial mycosis now thought to be caused by "alasse%ia furfur. #he disorder is characteri3ed by chronic but asymptomatic scaling on the trunk$ arms$ or other parts of the body. /8. #inea cruris is caused by which of the following? A. ". floccosum B. -. furfur . -. canis !. ". werneckii ". #. beigelii The answer is: A !ermatomycoses are cutaneous mycoses caused by three genera of fungiA "icrosporum, Trichophyton, and Epidermophyton. #hese infections are called tinea or ring$orm, a misnomer that has persisted from the days when they were thought to be caused by worms or lice. #inea capitis 1ringworm of the scalp2 is due to an infection with ". canis or T. tonsurans. .t usually occurs during childhood and heals spontaneously at puberty. ircular areas on the scalp with broken or no hair are characteristic of this disorder. #inea corporis 1ringworm of the body2 is caused by ". canis and T. mentagrophytes. #his disorder affects smooth skin and produces circular pruritic areas of redness and scaling.

Both tinea cruris 1ringworm of the groin$ Bjock itchB2 and tinea pedis 1ringworm of the feet$ athlete=s foot2 are caused by T. rubrum, T. mentagrophytes, or E. floccosum. #hese common conditions are pruritic and can cause scaling. #inea &ersicolor 1pityriasis &ersicolor2 is not a dermatomycotic condition but$ rather$ a superficial mycosis now thought to be caused by "alasse%ia furfur. #he disorder is characteri3ed by chronic but asymptomatic scaling on the trunk$ arms$ or other parts of the body. /C. #inea pedis is caused by which of the following? A. ". floccosum B. -. furfur . -. canis !. ". werneckii ". #. beigelii The answer is: A 80. #inea &ersicolor is caused by which of the following? A. ". floccosum B. -. furfur . -. canis !. ". werneckii ". #. beigelii The answer is: B !ermatomycoses are cutaneous mycoses caused by three genera of fungiA "icrosporum, Trichophyton, and Epidermophyton. #hese infections are called tinea or ring$orm, a misnomer that has persisted from the days when they were thought to be caused by worms or lice. #inea capitis 1ringworm of the scalp2 is due to an infection with ". canis or T. tonsurans. .t usually occurs during childhood and heals spontaneously at puberty. ircular areas on the scalp with broken or no hair are characteristic of this disorder. #inea corporis 1ringworm of the body2 is caused by ". canis and T. mentagrophytes. #his disorder affects smooth skin and produces circular pruritic areas of redness and scaling. Both tinea cruris 1ringworm of the groin$ Bjock itchB2 and tinea pedis 1ringworm of the feet$ athlete=s foot2 are caused by T. rubrum, T. mentagrophytes, or E. floccosum. #hese common conditions are pruritic and can cause scaling.

#inea &ersicolor 1pityriasis &ersicolor2 is not a dermatomycotic condition but$ rather$ a superficial mycosis now thought to be caused by "alasse%ia furfur. #he disorder is characteri3ed by chronic but asymptomatic scaling on the trunk$ arms$ or other parts of the body. 86. Which one of the following fungi causes rhinocerebral 3ygomycosis and is usually associated with acute diabetes? A. A. fumigatus B. . albicans . . coronata !. 4. arrhi3us ". B. ranarum The answer is: D andidiasis$ cryptococcosis$ 3ygomycosis$ and aspergillosis are among the most common opportunistic fungal infections. #hese fungi are commonly obser&ed in the en&ironment and are innocuous to people with intact host defenses. +owe&er$ when host defenses are compromised by immunosuppression 1A.!(2$ cytoto'ic drugs$ diabetes$ or de&ices that breach the normal host defenses$ these usually harmless fungi become potent pathogenic microorganisms. ,ungs are the most common site for infection by Aspergillus. #hese infections range from allergic bronchopulmonary disease 1with increased serum .g"2$ to fungus balls known as aspergillomas, to life-threatening in&asi&e infections of the lung parenchyma. #ypically$ the fungus will spread to other organs. *atients with lymphoma$ for instance$ are highly susceptible to in&asi&e aspergillosis. !eath rates of 8?D are not uncommon. C. albicans is a member of the normal human microflora. #his yeast causes such relati&ely mild infections as Bjock itchB and diaper rash. (uppression of cellular immunity often results in more serious yeast infections. %ral candidiasis is one of the earliest and most fre;uent of the opportunistic infections in patients with A.!(. !iagnosis of in&asi&e candidiasis is difficult$ especially when patients are symptomatic and Candida is not reco&ered from blood specimens. andidal antibody tests$ antigen detection$ and metabolite detection ha&e not been successful in differentiating between in&asi&e disease and coloni3ation. Eygomycosis 1sometimes called mucormycosis2 is caused by a &ariety of fungi called Eygomycetes. #hese fungi include Conidiobolus, &hi%opus, and #asidiobolus, which can be differentiated mycologically$ but all are characteri3ed by large 16 to 8? mm2$ irregularly branched$ usually nonseptate hyphae. #he differentiation of these fungi clinically is a function of the location of the lesionA limbs and trunk$ nose$ or brain. #asidiobolus lesions are most commonly seen on the arms and legs. Conidiobolus is

usually found in the nasal mucosa and nasal sinuses. &hi%opus infection may start in the nasal tissue but spreads rapidly to the eyes and brain. 88. A person who had recently consumed half a bo' of raspberries came down with se&ere watery diarrhea. (urprisingly$ the patient felt tired for a few days and had a low-grade fe&er. Which of the following is the most likely cause of infection? A. ryptosporidium B. "scherichia coli 06?/A+/ . .sospora !. Fibrio ". yclospora The answer is: E yclosporiasis is a newly recogni3ed food- and water-borne infectious disease associated with eating contaminated berries imported from some entral American countries. Cyclospora are moderately acid-fast but twice the si3e of Cryptosporidium. *atients usually ha&e fre;uent diarrhea for up to < weeks and usually suffer only malaise and fatigue. #he disease is self-limiting$ but relapses can occur 8<. A man coughed up a long 1> to 6 cm2 white worm and his chief complaint was abdominal tenderness. +e reports that he goes to sushi bars at least once a week. #he following parasites ha&e been obser&ed in people who eat raw fishA Anisakis, seudoterrano!a, Eustrongylides, and Angiostrongylus. Which of the following would best differentiate the specific parasitic agent? A. .dentification of specific species of fish in&ol&ed B. (tudy of distincti&e morphology of the parasite . (pecific antibody tests !. Antigen detection in tissues ". haracteristic signs and symptoms The answer is: B #he consumption of raw fish products in Asian restaurants$ especially the growing popularity of sushi and sashimi$ has led to a &ariety of infections$ most of which are characteri3ed by symptoms consistent with intestinal blockage or meningitis. #he parasites are tissue nematodes and parasites of marine mammals. )ish$ s;uid$ and other edible marine life are often secondary hosts. #he most reliable way to differentiate the specific helminth is by e'amination of the whole worm or by histologic e'amination of the parasites in tissue sections. 8>. .n the 5nited (tates$ certain enteric proto3oan and helminthic infections were pre&iously considered to be e'otic illnesses related to foreign tra&el or to contaminated food or

water. +owe&er$ se'ual transmission of these diseases has produced a BhyperendemicB infection rate among male homose'uals. Which of the following is the most common infection seen in this group? A. :iardiasis B. Ascariasis . Amebiasis !. "nterobiasis ". #richuriasis The answer is: A #he infection rate with 'iardia lamblia in male homose'uals has been reported to be from 86 to >0D. #hese high pre&alence rates are probably related to three factorsA the endemic rate$ the se'ual beha&ior that facilitates transmission 1the usual barriers to spread ha&e been interrupted2$ and the fre;uency of e'posure to an infected person. 8?. Analysis of a patient=s stool re&eals small structures resembling rice grainsG microscopic e'amination shows these to be proglottids. Which of the following is the most likely organism in this patient=s stool? A. "nterobius &ermicularis B. Ascaris lumbricoides . @ecator americanus !. #. saginata ". #richuris trichiura The answer is: D Enterobius 1pinworm2$ Ascaris 1roundworm2$ (ecator 1hookworm2$ and Trichuris 1whipworm2 are roundworms$ or nematodes. T. saginata 1tapeworm2$ a segmented flatworm$ affects the small intestine of humans. #apeworm segments$ called proglottids$ appear in the stool of infected persons. 86. An A.!( patient complains of headaches and disorientation. A clinical diagnosis of Toxoplasma encephalitis is made and Toxoplasma cysts were obser&ed in a brain section 1see figure below2. Which one of the following antibody results would be most likely in this patient?

A. B. . !. ".

.g- nonreacti&e$ .g: nonreacti&e .g- nonreacti&e$ .g: reacti&e 1low titer2 .g- reacti&e 1low titer2$ .g: reacti&e 1high titer2 .g- reacti&e 1high titer2$ .g: reacti&e 1high titer2 .g- reacti&e 1high titer2$ .g: nonreacti&e

The answer is: B %ne of the leading causes of death among A.!( patients is central ner&ous system to'oplasmosis. .t is thought that Toxoplasma infection is a result of reacti&ation of old or pree'isting to'oplasmosis. %ccasionally$ the infection may be ac;uired by needle sharing. Because the disease is a reacti&ation of old or pree'isting to'oplasmosis$ routine ;uantitati&e tests for .g- antibody are usually negati&e and .g: titers are low 1 6A8?6$ .)A2. -ore sophisticated methods$ such as .g- capture or .g: a&idity$ may re&eal an acute response. 8/. A woman$ recently returned from Africa$ complains of ha&ing paro'ysmal attacks of chills$ fe&er$ and sweatingG these attacks last a day or two at a time and recur e&ery <6 to >8 h. "'amination of a stained blood specimen re&eals ringlike and crescent-like forms within red blood cells. Which of the following is the infecting organism? A. *lasmodium falciparum B. *lasmodium &i&a' . #rypanosoma gambiense !. Wuchereria bancrofti ". (chistosoma mansoni The answer is: A #he febrile paro'ysms of lasmodium malariae malaria occur at /8-h inter&alsG those of . falciparum and . !i!ax malaria occur e&ery >8 h. #he paro'ysms usually last 8 to 68 h with . !i!ax malaria but can last 66 to <6 h with . falciparum disease. .n . !i!ax, . o!ale, and . malariae infections$ all stages of de&elopment of the organisms can be seen

in the peripheral bloodG in malignant tertian 1 . falciparum2 infections$ only early ring stages and gametocytes are usually found. 88. A woman who recently tra&eled through entral Africa now complains of se&ere chills and fe&er$ abdominal tenderness$ and darkening urine. +er febrile periods last for 88 h and recur regularly. Which of the blood smears drawn below would most likely be associated with the symptoms described?

A. B. . !. ".

A B ! "

#he answer isA B #he case history presented in the ;uestion is characteristic of infection with *. falciparum$ the causati&e agent of malignant tertian malaria. #he long duration of the febrile stage rules out other forms of malaria. #he presence of ringlike young tropho3oites and crescent-like mature gametocytesHas represented in the illustration belowHas well as the absence of schi3onts is diagnostic of *. falciparum malaria. 8C.

A medical technologist &isited (candina&ia and consumed raw fish daily for 8 weeks. (i' months after her return home$ she had a routine physical and was found to be anemic. +er &itamin B68 le&els were below normal. Which of the following is the most likely cause of her &itamin B68 deficiency anemia? A. B. . !. ". "'cessi&e consumption of ice-cold &odka .nfection with par&o&irus B 6C .nfection with the fish tapeworm !. latum .nfection with 7ersinia ysticercosis

#he answer isA onsumption of raw fish causes endemic diphyllobothriasis in (candina&ia and the Baltic countries. While most people do not become ill$ a small percentage 18D2 de&elop &itamin B68 deficiency anemia. #he adult fish tapeworm has an affinity for &itamin B68 and may induce a serious megaloblastic anemia. *ar&o&irus B 6C causes acute hemolytic anemia primarily in immunosuppressed patients. 7ersinia infection is common in (candina&ia but is not fish-borne and does not cause anemia. #he lar&al stage of #. solium is called cysticercus. +umans usually ac;uire cysticercosis by ingestion of food and water contaminated by infected human feces. C0. A renal transplant patient was admitted for graft rejection and pneumonia. A routine e&aluation of his stool showed rhabditiform lar&ae. (ubse;uent follow-up re&ealed similar worms in his sputum. +e had no eosinophils in his peripheral circulation. Which of the following is the most likely organism? A. @ecator B. +ymenolepsis . Ascaris !. ,oa loa ". (trongyloides #he answer isA " (trongyloidiasis may be obser&ed in three phasesA cutaneous$ pulmonary$ and intestinal. #he pulmonary presentation of (trongyloides in patients with A.!( is the most common. %ften$ all body fluids will contain lar&ae. *rognosis is poor. @ecator must be distinguished from (trongyloides by microscopy. :ross appearances are similar. C6. Which of the following organisms may be ingested with raw fish$ affects the li&er$ and has an operculated egg? A. *aragonimus B. lonorchis . (. mansoni

!. ".

(. japonicum (. haematobium

#he answer isA B #he life cycle of the medically important trematodes 1or flukes2 in&ol&es a se'ual cycle in humans and an ase'ual cycle in snails. #he schistosomes can penetrate the skin whereas lonorchis and *aragonimus are ingested$ usually in fish or seafood. #hese flukes can be easily differentiated morphologically by the appearance of the egg. (chistosome eggs ha&e an identifiable spine$ and both lonorchis and *aragonimus eggs are operculatedG that is$ they ha&e what appears to be a co&er that opens. (erological tests are not useful. -any patients with schistosomiasis are asymptomatic$ but disease may become chronic$ resulting in malaise$ diarrhea$ and hepatosplenomegaly 1an enlarged li&er and spleen2. lonorchis infection usually causes upper abdominal pain but can also cause biliary tract fibrosis. *aragonimiasis is characteri3ed by a cough$ often with bloody sputum$ and pneumonia. *ra3i;uantel is the treatment of choice for these flukes. C8. Which of the following organisms penetrates skin$ is endemic in Asia$ and has a small lateral spine on its eggs? A. *aragonimus B. lonorchis . (. mansoni !. (. japonicum ". (. haematobium The answer is: D #he life cycle of the medically important trematodes 1or flukes2 in&ol&es a se'ual cycle in humans and an ase'ual cycle in snails. #he schistosomes can penetrate the skin whereas Clonorchis and aragonimus are ingested$ usually in fish or seafood. #hese flukes can be easily differentiated morphologically by the appearance of the egg. (chistosome eggs ha&e an identifiable spine$ and both Clonorchis and aragonimus eggs are operculatedG that is$ they ha&e what appears to be a co&er that opens. (erological tests are not useful. -any patients with schistosomiasis are asymptomatic$ but disease may become chronic$ resulting in malaise$ diarrhea$ and hepatosplenomegaly 1an enlarged li&er and spleen2. Clonorchis infection usually causes upper abdominal pain but can also cause biliary tract fibrosis. *aragonimiasis is characteri3ed by a cough$ often with bloody sputum$ and pneumonia. *ra3i;uantel is the treatment of choice for these flukes. C<. '. lamblia is best diagnosed by which of the following? A. (igmoidoscopy and aspiration of mucosal lesions B. Baermann techni;ue . !ilution followed by egg count !. "n3yme immunoassay 1".A2

".

"'amination of a cellophane tape swab

The answer is: D .t is not uncommon that repeated stool specimens do not re&eal the suspected parasite. Also$ microscopic analysis of stool may not re&eal parasite load when such data are necessary. )or these reasons$ other techni;ues are a&ailable to identify parasites as well as to ;uantitate them. !uring sigmoidoscopy$ a curette or suction de&ice may be used to scrape or aspirate material from the mucosal surface. otton swabs should not be used. A direct mount of this material should immediately be e'amined for E. histolytica tropho3oites$ and then a permanent stain made for subse;uent e'amination. #he Baermann techni;ue may be helpful in reco&ering Strongyloides lar&ae. "ssentially$ fecal material is placed on damp gau3e on the top of a glass funnel that is three-;uarters filled with water. #he lar&ae migrate through the damp gau3e and into the water. #he water may then be centrifuged to concentrate the Strongyloides. Worm burdens may be estimated by a number of microscopic methods. While not often done$ such procedures may pro&ide data on the e'tent of infection or the efficacy of treatment of hookworms$ Ascaris, or Trichuris. #hirty thousand Trichuris eggs per gram$ 8000 to ?000 hookworm eggs per gram$ and 6 Ascaris egg are clinically significant and suggest a hea&y worm burden. #he diagnosis of giardiasis is usually made by detecting tropho3oites and cysts of '. lamblia in consecuti&e fecal specimens. Alternati&ely$ a gelatin capsule on a string 1enterotest2 can be swallowed$ passed to the duodenum$ and then retrie&ed after > h. #he string is then e'amined for 'iardia. A recent inno&ation is the introduction of an en3yme immunoassay 1".A2 for '. lamblia. #he ".A is more sensiti&e than microscopy$ can be performed on a single stool specimen$ and does not depend on the presence of entire tropho3oites and cysts. A cellophane tape swab is used to trap pinworms crawling out of the anus during the night. #he tape is then e'amined microscopically for Enterobius. C>. E. histolytica infection is best diagnosed by which of the following? A. B. . !. ". (igmoidoscopy and aspiration of mucosal lesions Baermann techni;ue !ilution followed by egg count "n3yme immunoassay 1".A2 "'amination of a cellophane tape swab

The answer is: A

.t is not uncommon that repeated stool specimens do not re&eal the suspected parasite. Also$ microscopic analysis of stool may not re&eal parasite load when such data are necessary. )or these reasons$ other techni;ues are a&ailable to identify parasites as well as to ;uantitate them. !uring sigmoidoscopy$ a curette or suction de&ice may be used to scrape or aspirate material from the mucosal surface. otton swabs should not be used. A direct mount of this material should immediately be e'amined for E. histolytica tropho3oites$ and then a permanent stain made for subse;uent e'amination. #he Baermann techni;ue may be helpful in reco&ering Strongyloides lar&ae. "ssentially$ fecal material is placed on damp gau3e on the top of a glass funnel that is three-;uarters filled with water. #he lar&ae migrate through the damp gau3e and into the water. #he water may then be centrifuged to concentrate the Strongyloides. Worm burdens may be estimated by a number of microscopic methods. While not often done$ such procedures may pro&ide data on the e'tent of infection or the efficacy of treatment of hookworms$ Ascaris, or Trichuris. #hirty thousand Trichuris eggs per gram$ 8000 to ?000 hookworm eggs per gram$ and 6 Ascaris egg are clinically significant and suggest a hea&y worm burden. #he diagnosis of giardiasis is usually made by detecting tropho3oites and cysts of '. lamblia in consecuti&e fecal specimens. Alternati&ely$ a gelatin capsule on a string 1enterotest2 can be swallowed$ passed to the duodenum$ and then retrie&ed after > h. #he string is then e'amined for 'iardia. A recent inno&ation is the introduction of an en3yme immunoassay 1".A2 for '. lamblia. #he ".A is more sensiti&e than microscopy$ can be performed on a single stool specimen$ and does not depend on the presence of entire tropho3oites and cysts. A cellophane tape swab is used to trap pinworms crawling out of the anus during the night. #he tape is then e'amined microscopically for Enterobius.

C?. Which of the following is the best method for the detection of Strongyloides lar&ae? A. (igmoidoscopy and aspiration of mucosal lesions B. Baermann techni;ue . !ilution followed by egg count !. "n3yme immunoassay 1".A2 ". "'amination of a cellophane tape swab The answer is: B 96. A fur trapper complains of sore muscles$ has swollen eyes$ and reports eating bear meat on a regular basis. +e is at risk for infection with which of the following?

A. B. . !. ".

#richinosis (chistosomiasis #o'oplasmosis Fisceral lar&a migrans :iardiasis

The answer is: A All the diseases listed in the ;uestion ha&e significant epidemiologic and clinical features. #o'oplasmosis$ for e'ample$ is generally a mild$ self-limiting diseaseG howe&er$ se&ere fetal disease is possible if pregnant women ingest Toxoplasma oocysts. onsumption of uncooked meat may result in either an acute to'oplasmosis or a chronic to'oplasmosis that is associated with serious eye disease. -ost adults ha&e antibody titers to Toxoplasma and thus would ha&e a positi&e (abin-)eldman dye test. #richinosis most often is caused by ingestion of contaminated pork products. +owe&er$ eating undercooked bear$ walrus$ raccoon$ or possum meat also may cause this disease. (ymptoms of trichinosis include muscle soreness and swollen eyes. Although giardiasis has been classically associated with tra&el in 4ussia$ especially (t. *etersburg 1,eningrad2$ many cases of giardiasis caused by contaminated water ha&e been reported in the 5nited (tates as well. !iagnosis is made by detecting cysts in the stool. .n some cases$ diagnosis may be &ery difficult because of the relati&ely small number of cysts present. Alternati&ely$ an en3yme immunoassay may be used to detect 'iardia antigen in fecal samples. (chistosomiasis is a worldwide public health problem. ontrol of this disease entails the elimination of the intermediate host snail and remo&al of streamside &egetation. Abdominal pain is a symptom of schistosomiasis. Fisceral lar&a migrans is an occupational disease of people who are in close contact with dogs and cats. #he disease is caused by the nematodes Toxocara canis 1dogs2 and T. cati 1cats2 and has been recogni3ed in young children who ha&e close contact with pets or who eat dirt. (ymptoms include skin rash$ eosinophilia$ and hepatosplenomegaly.

C/. A retired Air )orce colonel has had abdominal pain for 8 yearsG he makes yearly freshwater fishing trips to *uerto 4ico and often wades with bare feet into streams. Which of the following should be in your differential diagnosis? A. #richinosis B. (chistosomiasis . #o'oplasmosis !. Fisceral lar&a migrans ". :iardiasis

The answer is: B All the diseases listed in the ;uestion ha&e significant epidemiologic and clinical features. #o'oplasmosis$ for e'ample$ is generally a mild$ self-limiting diseaseG howe&er$ se&ere fetal disease is possible if pregnant women ingest Toxoplasma oocysts. onsumption of uncooked meat may result in either an acute to'oplasmosis or a chronic to'oplasmosis that is associated with serious eye disease. -ost adults ha&e antibody titers to Toxoplasma and thus would ha&e a positi&e (abin-)eldman dye test. #richinosis most often is caused by ingestion of contaminated pork products. +owe&er$ eating undercooked bear$ walrus$ raccoon$ or possum meat also may cause this disease. (ymptoms of trichinosis include muscle soreness and swollen eyes. Although giardiasis has been classically associated with tra&el in 4ussia$ especially (t. *etersburg 1,eningrad2$ many cases of giardiasis caused by contaminated water ha&e been reported in the 5nited (tates as well. !iagnosis is made by detecting cysts in the stool. .n some cases$ diagnosis may be &ery difficult because of the relati&ely small number of cysts present. Alternati&ely$ an en3yme immunoassay may be used to detect 'iardia antigen in fecal samples. (chistosomiasis is a worldwide public health problem. ontrol of this disease entails the elimination of the intermediate host snail and remo&al of streamside &egetation. Abdominal pain is a symptom of schistosomiasis. Fisceral lar&a migrans is an occupational disease of people who are in close contact with dogs and cats. #he disease is caused by the nematodes Toxocara canis 1dogs2 and T. cati 1cats2 and has been recogni3ed in young children who ha&e close contact with pets or who eat dirt. (ymptoms include skin rash$ eosinophilia$ and hepatosplenomegaly. C8. A teenager who works in a dog kennel after school has had a skin rash$ eosinophilia$ and an enlarged li&er and spleen for 8 years. Which of the following is the most likely cause of this infection? A. #richinosis B. (chistosomiasis . #o'oplasmosis !. Fisceral lar&a migrans ". :iardiasis The answer is: D All the diseases listed in the ;uestion ha&e significant epidemiologic and clinical features. #o'oplasmosis$ for e'ample$ is generally a mild$ self-limiting diseaseG howe&er$ se&ere fetal disease is possible if pregnant women ingest Toxoplasma oocysts. onsumption of

uncooked meat may result in either an acute to'oplasmosis or a chronic to'oplasmosis that is associated with serious eye disease. -ost adults ha&e antibody titers to Toxoplasma and thus would ha&e a positi&e (abin-)eldman dye test. #richinosis most often is caused by ingestion of contaminated pork products. +owe&er$ eating undercooked bear$ walrus$ raccoon$ or possum meat also may cause this disease. (ymptoms of trichinosis include muscle soreness and swollen eyes. Although giardiasis has been classically associated with tra&el in 4ussia$ especially (t. *etersburg 1,eningrad2$ many cases of giardiasis caused by contaminated water ha&e been reported in the 5nited (tates as well. !iagnosis is made by detecting cysts in the stool. .n some cases$ diagnosis may be &ery difficult because of the relati&ely small number of cysts present. Alternati&ely$ an en3yme immunoassay may be used to detect 'iardia antigen in fecal samples. (chistosomiasis is a worldwide public health problem. ontrol of this disease entails the elimination of the intermediate host snail and remo&al of streamside &egetation. Abdominal pain is a symptom of schistosomiasis. Fisceral lar&a migrans is an occupational disease of people who are in close contact with dogs and cats. #he disease is caused by the nematodes Toxocara canis 1dogs2 and T. cati 1cats2 and has been recogni3ed in young children who ha&e close contact with pets or who eat dirt. (ymptoms include skin rash$ eosinophilia$ and hepatosplenomegaly. CC. %ne of the most remarkable aspects of the human immune system is its di&ersity$ that is$ the ability to recogni3e a wide range of antigens and to mount a specific antibody response. #his is called clonal selection. At the cellular le&el$ which of the following are primarily responsible for such specificity? A. ytoto'ic # cells B. +yper&ariable regions in domains of B cells . #he major histocompatibility comple' !. (pecific # cell receptors ". -emory cells The answer is: B #he great heterogeneity in the B cell response is characteri3ed by a wide &ariety of antigenic stimuli. #he end result of this remarkable process is a set of &ery specific surface receptors on B lymphocytes. +owe&er$ it is the hyper&ariable regions in the &ariable domain of these B cells that pro&ide the amino acid residues that confer specificity by synthesis of surface immunoglobulin receptors. # cells$ on the other hand$ do not secrete immunoglobulins.

600. A latent$ measles-like &iral infection and$ presumably$ a defect in cellular immunity is associated with which of the following diseases? A. *rogressi&e multifocal leukoencephalopathy 1*-,2 B. -ultiple sclerosis 1-(2 . reut3feldt-Iakob disease !. (ubacute sclerosing panencephalitis 1((*"2 ". "pstein-Barr &irus 1"BF2 infection The answer is: D -easles-like &irus has been isolated from the brain cells of patients with subacute sclerosing panencephalitis 1((*"2. #he role of the host immune response in the causation of ((*" has been supported by se&eral findings including the followingA 162 progression of disease despite high le&els of humoral antibodyG 182 presence of a factor that blocks lymphocyte-mediated immunity to ((*"-measles &irus in ((*" cerebrospinal fluid 1 ()2G 1<2 lysis of brain cells from ((*" patients by ((*" serum or () in the presence of complement 1a similar mechanism could cause in &i&o tissue injury2. +igher-than-normal le&els of serum antibodies 1Ab2 to measles &irus and local synthesis of measles Ab in ()$ as e&idenced by the oligoclonal .g:$ imply a connection between the &irus and multiple sclerosis 1-(2. +owe&er$ the other studies ha&e implicated the other &iruses. (e&eral studies of cell-mediated hypersensiti&ity to measles and other &iruses in -( ha&e been done$ but the results ha&e been conflicting. !efinite conclusions regarding defects in cellular immunity in this disease cannot be reached until further research is completed.

606#he amounts of protein precipitated in a series of tubes containing a constant amount of antibody and &arying amounts of antigen are presented below. .n which tube is antigen-antibody e;ui&alence obtained? Tube A B ! " A. B. . !. ". Antigen Precipitated ( g! 0.08 0.08 0.<8 6.0 8.0 A B ! " Pr"tein ( g! 6.6 8.6 <.6 <./ 8.C

The answer is: D .n tube d in the ;uestion presented$ the ma'imum protein precipitate is obser&ed. According to the rules go&erning precipitin reactions$ ma'imum precipitation occurs at appro'imately antigen-antibody e;ui&alence. .n tubes a through c$ antibody e'cess occursG in tube e$ antigen e'cess occurs. 608. A widely used method for detecting either antigen or antibody in body fluids is known as ",.(A 1en3yme-linked immunosorbent assay2. #he figure below demonstrates an ",.(A for detection of antigen. %ne of the problems with ",.(A is nonspecific reacti&ity due to nonspecific antibody present in the reaction. %f the four steps depicted$ A$ B$ $ and !$ which one may be the major cause of nonspecificity?

!ouble antibody sandwich method of ".A for assay of antigen. A$ antibody is adsorbed to surface. B$ test solution containing antigen is added. $ en3yme-labeled specific antibody is added. !$ en3yme substrate is added. A. B. . !. B A !

The answer is: B ",.(A 1en3yme-linked immunosorbent assay2 methods can be used to detect either antigens or antibodies. .f antibody is to be detected$ then antigen is initially bound to the plate 1see A in the diagram presented with the ;uestion2. .f antigen is to be detected$ then

specific antibody is bound to the solid phase. #he bound antigen and antibody then BcapturesB the analyte to be detected. %ne of the major causes for high background in ",.(A tests is the failure to wash off unbound antigen or antibody 1see B in the diagram presented with the ;uestion2. 60<. A 6C-year-old college student de&elops a rash. (he works part-time in a pediatric A.!( clinic. +er blood is drawn and tested for specific antibody to the chicken po' &irus 1&aricella-3oster2. Which of the following antibody classes would you e'pect to find if she is immune to chicken po'? A. .gA B. .g! . .g" !. .g: ". .gThe answer is: D #he initial response to a new infection is with an .g- class antibody. .g- de&elops ;uickly and usually disappears within a few months. #he secondary response is .g: and reflects the patient=s immune status or$ in the case of chicken po'$ a &accination gi&en. 60>. #here are at least 60 properties of cytokines. Which of the following is one of these characteristics? A. -itogenesis B. B-cell lipids . ,ipopolysaccharide 1,*(2 acti&ation !. #-cell differentiation ". +ormonal antibody synthesis The answer is: A #here are at least 60 functions of the known cytokines$ including mitogenesis$ lymphocyte acti&ation$ pyrogenesis$ lymphocyte proliferation$ and #-cell differentiation. @ot all cytokines 1such as interleukins2 are responsible for all of these functions. ytokines do not acti&ate ,*($ but ,*( may acti&ate macrophages. 60?. #he major role of # cells in the immune response includes which one of the following? A. 4ecognition of epitopes presented with major histocompatibility comple' molecules on all surfaces B. omplement fi'ation . *hagocytosis !. *roduction of antibodies

The answer is: A # cells do not synthesi3e antibodyG that is the task of B cells. 4ecognition of certain epitopes$ lymphokine production$ and eradication of Bforeign cellsB are all functions of # cells. %ne of the best-recogni3ed # cells is the !> cell. #he importance of !> cells to the immune response is demonstrated by the effects of a specific inhibition of !> functions$ that is$ human immunodeficiency &irus 1+.F2. 606. 4elati&e to the primary immunological response$ secondary and later booster responses to a gi&en hapten-protein comple' can be associated with which one of the following? A. ,ower titers of antibody B. .ncreased antibody affinity for the hapten . !ecreased antibody a&idity for the original hapten-protein comple' !. -aintenance of the same subclass$ or idiotype$ of antibody produced ". Antibodies that are less efficient in pre&enting specific disease The answer is: B With repeated immuni3ation$ higher titers of all antibodies are obser&ed$ and$ as priming is repeated$ the immune response recruits B cells of progressi&ely greater affinity. #he affinity of antibody for a hapten-protein comple' rises$ cross-reacti&ity also rises$ and the response becomes wider in specificity. As the number of antigenic sites detected per reacting particle increases$ the a&idity increases. .n addition to shifts in the class of immunoglobulin synthesi3ed in response to an antigen 1.g- to .g:2$ shifts also may occur in the idiotype of antibody. 60/. Which immunoglobulin mediates immediate hypersensiti&ity and is in&ol&ed in immune response to parasitic infections? A. .g: B. .g. .g" !. .gA ". .g! The answer is: C .g: antibody pro&ides an Bimmune history.B #hat is$ .g: antibody persists in most people and indicates the antigens to which they ha&e been e'posed. .g: is not formed early in infection but is a secondary response arising weeks to months after antigenic challenge. .g: also has a built-in memory. "&en people with &ery low le&els of specific .g: will respond to an antigen challenge with an .g: response. .g- antibody$ in contrast$ arises early in infection and then disappears within a couple of months. .g- is intra&ascular and does not cross the placental barrier. )or this reason$

infants with specific .g: responses to disease must be tested for .g- to determine whether their immune systems ha&e produced antibody or whether the test was positi&e because of passi&ely transferred .g:. .gA antibody is in&ol&ed in local immunity at the le&el of the mucous membrane. .gA antibody also arises early in disease. .gA antibody is shortli&ed and will disappear similarly to .g-. .g" antibody is characteristically seen in parasitic infections$ particularly worm 1helminth2 infections because of the attraction of eosinophils to the site of the infestation. ertain allergies are due to e'cessi&e production of .g". .g! antibody consists of two light chains and two hea&y chains. .ts role is not known but can be found on the surface of lymphocytes where it may act as a surface receptor. .g: is susceptible to proteolytic en3ymes$ which may e'plain why it is present in such low le&els in serum. 608. Which immunoglobulin is the primary antibody in sali&a$ tears$ and intestinal and genital secretions? A. .g: B. .g. .g" !. .gA ". .g! #he answer isA ! .g: antibody pro&ides an Bimmune history.B #hat is$ .g: antibody persists in most people and indicates the antigens to which they ha&e been e'posed. .g: is not formed early in infection but is a secondary response arising weeks to months after antigenic challenge. .g: also has a built-in memory. "&en people with &ery low le&els of specific .g: will respond to an antigen challenge with an .g: response. .g- antibody$ in contrast$ arises early in infection and then disappears within a couple of months. .g- is intra&ascular and does not cross the placental barrier. )or this reason$ infants with specific .g: responses to disease must be tested for .g- to determine whether their immune systems ha&e produced antibody or whether the test was positi&e because of passi&ely transferred .g:. .gA antibody is in&ol&ed in local immunity at the le&el of the mucous membrane. .gA antibody also arises early in disease. .gA antibody is shortli&ed and will disappear similarly to .g-.

.g" antibody is characteristically seen in parasitic infections$ particularly worm 1helminth2 infections because of the attraction of eosinophils to the site of the infestation. ertain allergies are due to e'cessi&e production of .g". .g! antibody consists of two light chains and two hea&y chains. .ts role is not known but can be found on the surface of lymphocytes where it may act as a surface receptor. .g: is susceptible to proteolytic en3ymes$ which may e'plain why it is present in such low le&els in serum. 60C. "le&ated .g: and .g- antibody titers to par&o&irus suggest which of the following diagnosis? . )ifth disease B. (usceptibility to chicken po' . *ossible subacute sclerosing panencephalitis 1((*"2 !. *ossible hepatitis B infection ". Acute ,yme disease The answer is: A #orrelia burgdorferi, the causati&e agent of ,yme disease$ elicits an acute antibody response. .g- appears within days to a few weeks following tick bite$ and .g: appears a few weeks later. .g: persists$ .g- does not. ross-reactions occur with other treponemes. )ifth disease is a &iral e'anthem commonly seen in children 8 to 68 years old. hildren are ill for a few days but reco&er without incident. 5nfortunately$ if a pregnant female ac;uires the disease in the first trimester of pregnancy$ the fetus is at risk. #he causati&e agent is thought to be a par&o&irus 1par&o&irus B 6C2. Adults with no titer to &aricella 1FEF2 are at risk for ac;uisition of chicken po'. .f they are health care workers$ there is additional risk in transmitting FEF to immunodeficient children. Antibodies to FEF are readily detected by both en3yme immunoassay 1".A2 and fluorescent-antibody 1)A2 techni;ues. !elta agent is a recently disco&ered antigen associated with +BsAg. .ts presence usually correlates with +BsAg chronic carriers who ha&e chronic acti&e hepatitis. ".A and radioimmunoassay 14.A2 tests are a&ailable to detect antibodies to delta agent. ((*" is thought to be caused by a measles-related &irus present in the central ner&ous system. -ost ((*" patients show ele&ated measles &irus antibodies in serum and (). .n patients with multiple sclerosis 1-(2$ lower () antibody titers ha&e been obser&ed$ suggesting a possible etiologic role for measles &irus in -(.

660. A negati&e &aricella antibody titer in a young woman signifies which of the following? A. B. . !. ". )ifth disease (usceptibility to chicken po' *ossible subacute sclerosing panencephalitis 1((*"2 *ossible hepatitis B infection Acute ,yme disease

The answer is: B #orrelia burgdorferi, the causati&e agent of ,yme disease$ elicits an acute antibody response. .g- appears within days to a few weeks following tick bite$ and .g: appears a few weeks later. .g: persists$ .g- does not. ross-reactions occur with other treponemes. )ifth disease is a &iral e'anthem commonly seen in children 8 to 68 years old. hildren are ill for a few days but reco&er without incident. 5nfortunately$ if a pregnant female ac;uires the disease in the first trimester of pregnancy$ the fetus is at risk. #he causati&e agent is thought to be a par&o&irus 1par&o&irus B 6C2. Adults with no titer to &aricella 1FEF2 are at risk for ac;uisition of chicken po'. .f they are health care workers$ there is additional risk in transmitting FEF to immunodeficient children. Antibodies to FEF are readily detected by both en3yme immunoassay 1".A2 and fluorescent-antibody 1)A2 techni;ues. !elta agent is a recently disco&ered antigen associated with +BsAg. .ts presence usually correlates with +BsAg chronic carriers who ha&e chronic acti&e hepatitis. ".A and radioimmunoassay 14.A2 tests are a&ailable to detect antibodies to delta agent. ((*" is thought to be caused by a measles-related &irus present in the central ner&ous system. -ost ((*" patients show ele&ated measles &irus antibodies in serum and (). .n patients with multiple sclerosis 1-(2$ lower () antibody titers ha&e been obser&ed$ suggesting a possible etiologic role for measles &irus in -(.

666. A patient with neurological problems has an ele&ated cerebrospinal fluid 1 ()2 antibody titer to measles &irus. 7ou would most likely suspect which of the following? A. B. . !. )ifth disease (usceptibility to chicken po' *ossible subacute sclerosing panencephalitis 1((*"2 *ossible hepatitis B infection

".

Acute ,yme diseas

The answer is: C ##$. )inding .g: antibodies to core antigen$ antibodies to e antigen$ and antibodies to surface antigen reflects which of the following? A. Acute infection 1incubation period2 B. Acute infection 1acute phase2 . *ost infection 1acute phase2 !. .mmuni3ation ". +BF carrier state The answer is: C #he following table presents the patterns of hepatitis B &irus serologic markers obser&ed in &arious stages of infection with +BF. #he diagnosis of +BF infection is usually based on three testsA hepatitis B surface antigen$ antibodies to surface antigen$ and antibodies to core antigen. #ests are a&ailable$ howe&er$ for e antigen and antibodies to e antigen. A &ariety of testing methods are a&ailable and include en3yme immunoassay$ radioimmunoassay$ hemagglutination$ late' agglutination$ and immune adherence. #he delta agent has recently been described. #he delta agent e'acerbates infection with +BF$ apparently in a synergistic manner. ommercial tests are now a&ailable for the delta agent. %er"&"gic 'ar(ers Anti+ )g' Anti+ T"ta& *BeAg *Bc Anti+*Bc Anti+*Be

)nterpretati"n Acute infection .ncubation period Acute phase "arly con&alescent phase on&alescent phase ,ate con&alescent phase ,ong past infection

*BsAg

*Bs

JK J J 9 9 9

JK J 9 9 9 9

9 J J J 9L 9

9 J J J J JM

9 9 J J J J or 9

9 9 9 9 J JM

hronic infection hronic acti&e hepatitis hronic persistent hepatitis hronic +BF carrier state

JN

J or 9

Jor 9

JN

J or 9

9N

JO JO

J or 9 J or 9

J or 9 Jor 9

J J

J or 9 Jor 9

9 9 J

+BsAg immuni3ation 9 9 9 9 9 K +BsAg and +BeAg are occasionally undetectable in acute +BF infection. L .g- anti-+Bc may persist for o&er a year after acute infection when &ery sensiti&e assays are employed. M #otal anti-+Bc and anti-+Bs may be detected together or separately long after acute infection. N +BsA:-negati&e chronic acti&e hepatitis may occur where total anti-+Bc and anti-+Bs may be detected together$ separately$ or not at all. O +BsAg-negati&e chronic persistent hepatitis and chronic +BF carriers ha&e been obser&ed 66<. )inding +BsAg positi&e$ +BeAg positi&e$ and .g- core antibody positi&e reflects which of the following? A. B. . !. ". Acute infection 1incubation period2 Acute infection 1acute phase2 *ost infection 1acute phase2 .mmuni3ation +BF carrier state

The answer is: B ##,. )inding +BsAg positi&e$ no antibodies to +BsAg$ and other tests &ariable reflects which of the following? A. Acute infection 1incubation period2 B. Acute infection 1acute phase2 . *ost infection 1acute phase2 !. .mmuni3ation ". +BF carrier state The answer is: E ##-.

Which of the following tests depends on the presence of protein A on certain strains of Staphylococcus aureus) A. ,ate' agglutination 1,A2 B. "n3yme-linked immunosorbent assay 1",.(A2 . "n3yme multiplied immunoassay test 1"-.#2 !. ounterimmunoelectrophoresis 1 ."2 ". oagglutination 1 %A The answer is: E %f the many methods a&ailable for antigen and antibody detection$ ,A$ ",.(A$ "-.#$ ."$ and %A are the most widely used. ,ate' agglutination 1,A2 employs late' polystyrene particles sensiti3ed by either antibody or antigen. ,A is more sensiti&e than ." and %A but slightly less sensiti&e than either 4.A or ".A. ,A has been used to detect *aemophilus influen%ae, (eisseria meningitidis, and Streptococcus pneumoniae antigens in cerebrospinal fluid. ,A has also been used for detection of cryptococcal antigen. -ost recently$ ,A has been widely used for rapid detection of group A streptococcal antigen directly from the pharyn'. #he test is rapid 1? minutes2$ sensiti&e 1appro'imately C0D2$ and specific 1CCD2. oagglutination 1 %A2$ also an agglutination test$ is slightly less sensiti&e than ,A but less susceptible to changes in en&ironment 1e.g.$ temperature2. -ost strains of coagulasepositi&e staphylococci ha&e protein A in their cell wall. *rotein A binds the )c fragment of microbial antigens in body fluids. %A has also been used to rapidly type or group bacterial isolates. "n3yme immunoassays 1".As2 can be either homogeneous 1"-.#2 or heterogeneous 1",.(A2. "-.# has been used primarily for assays of low-molecular-weight drugs. .ts primary use in microbiology has been for assays of aminoglycoside antibiotics. ".As &ary as to the solid support used. A &ariety of supports can be used$ such as polystyrene microdilution plates$ paddles$ plastic beads$ and tubes. #he number of layers in the antibody-antigen sandwich &ariesG usually as additional layers are added$ detection sensiti&ity is increased. #he two most common en3ymes are horseradish pero'idase 1+4*2 and alkaline phosphatase 1A*2. -galactosidase has also been employed. %rthophenylene diamine is the most common substrate for +4* and p-nitrophenyl phosphate for A*. Because ".As are usually read in the &isible color range$ the tests can be read ;ualitati&ely by eye or ;uantitati&ely by machine.

ounterimmunoelectrophoresis 1 ."2 was originally used for BAustralia antigenB 1+BsAg2 but was soon replaced by 4.A. )or a decade$ ." was used to detect antigens in body fluids$ ." is not an easy techni;ue. .ts success depends on the control of many &ariables$ including solid support$ &oltage$ current$ buffer$ affinity and a&idity of antibodies$ charge on the antigen$ and time of electrophoresing.

666. Antistreptolysin titer of >00 international units 1.52 indicates which one of the following diseases? A. B. . !. ". hronic infectious mononucleosis *rimary syphilis (carlet fe&er *rimary atypical pneumonia .mmunity to rubella 1:erman measles2

The answer is: C (carlet fe&er is usually a clinical diagnosis subse;uent to streptococcal pharyngitis. Acute group A streptococcal infections result in ele&ated antibody titers to streptolysin 1A(%2$ !@ase B$ @A!ase$ and hyaluronidase$ all soluble products of streptococcal growth. 4ubella immune status tests are usually done by hemagglutination inhibition 1+.2$ en3yme immunoassay 1".A2$ or late' agglutination. 4eacti&e +. titers are 6A60 or greater. .g- tests for rubella are often necessary in congenital infection in order to separate maternal from fetal antibodies. "ycoplasma pneumoniae causes primary atypical pneumonia. Although physicians rely on the presence of cold agglutinins 1 A2 for diagnosis$ A may be negati&e in up to ?0D of cases. With symptoms of pneumonia$ a positi&e A is reliable. A complement-fi'ation 1 )2 test for ". pneumoniae is indicated when A is negati&e. .solation of ". pneumoniae is time-consuming 16 to < weeks2 and not practical in most circumstances. .nfectious mononucleosis 1.-2 may be suspected clinically but it is confirmed serologically. #he heterophil antibody test$ howe&er$ may be negati&e in up to 6?D of adults and <? to >0D of children. Because .- is caused by "pstein-Barr &irus 1"BF2$ a specific test for &iral capsid antigen 1F A2 of "BF is indicated when heterophil tests are negati&e. Acute .- is characteri3ed by a F A-.g- titer$ and no F A-.g: antibody or "B@A. hronic "BF disease causes ele&ated F A-.g: titers as well as high "A antibody titers. .n the rapid plasma reagin 14*42 tests$ the patient=s serum is mi'ed on a card with 4*4 antigen and sensiti3ed charcoal particles. .f antibody is present$ the particles clump. #he 4*4 is more sensiti&e than the F!4, test$ but as with the F!4, test$ false positi&es may occur in 6? to 80D of the positi&e 4*4 results. All positi&es must be confirmed with a specific treponemal test for syphilis such as the fluorescent treponemal antibodyabsorption test 1)#A-AB(2. 66/. +emagglutination inhibition titer 1P6A802 suggests which one of the following diseases? A. hronic infectious mononucleosis

B. . !. ".

*rimary syphilis (carlet fe&er *rimary atypical pneumonia .mmunity to rubella 1:erman measles2

The answer is: E (carlet fe&er is usually a clinical diagnosis subse;uent to streptococcal pharyngitis. Acute group A streptococcal infections result in ele&ated antibody titers to streptolysin 1A(%2$ !@ase B$ @A!ase$ and hyaluronidase$ all soluble products of streptococcal growth. 4ubella immune status tests are usually done by hemagglutination inhibition 1+.2$ en3yme immunoassay 1".A2$ or late' agglutination. 4eacti&e +. titers are 6A60 or greater. .g- tests for rubella are often necessary in congenital infection in order to separate maternal from fetal antibodies. "ycoplasma pneumoniae causes primary atypical pneumonia. Although physicians rely on the presence of cold agglutinins 1 A2 for diagnosis$ A may be negati&e in up to ?0D of cases. With symptoms of pneumonia$ a positi&e A is reliable. A complement-fi'ation 1 )2 test for ". pneumoniae is indicated when A is negati&e. .solation of ". pneumoniae is time-consuming 16 to < weeks2 and not practical in most circumstances. .nfectious mononucleosis 1.-2 may be suspected clinically but it is confirmed serologically. #he heterophil antibody test$ howe&er$ may be negati&e in up to 6?D of adults and <? to >0D of children. Because .- is caused by "pstein-Barr &irus 1"BF2$ a specific test for &iral capsid antigen 1F A2 of "BF is indicated when heterophil tests are negati&e. Acute .- is characteri3ed by a F A-.g- titer$ and no F A-.g: antibody or "B@A. hronic "BF disease causes ele&ated F A-.g: titers as well as high "A antibody titers. .n the rapid plasma reagin 14*42 tests$ the patient=s serum is mi'ed on a card with 4*4 antigen and sensiti3ed charcoal particles. .f antibody is present$ the particles clump. #he 4*4 is more sensiti&e than the F!4, test$ but as with the F!4, test$ false positi&es may occur in 6? to 80D of the positi&e 4*4 results. All positi&es must be confirmed with a specific treponemal test for syphilis such as the fluorescent treponemal antibodyabsorption test 1)#A-AB(2.