1) An 18 year old male presented to the clinic complaining of a sore throat and

difficulty swallowing. He had an 8 day history of throat pain, fever, malaise, and
myalgia. He had enlarged tonsils as well as an enlarged spleen and enlarged
cervical lymph nodes. He had elevated WBCs, but no pathology visible on neck or
chest radiographs. Serological and throat culture tests were ordered. The patient
was treated with IV hydration, clindamycin, and steroids. On day 2, one of the tests
ordered came back positive. Clindamycin therapy was stopped and oral prednisone
was given. The patient improved, with tonsil swelling disappearing after day 5.

a. What are 3 possible infections in this patient? Explain why you included
these.
Answer: Following are enlisted the three possible infections that the patient might
have been suffering from:
1. Mononucleosis:
It is often called the kissing disease. It is caused by the Epstein-Barr virus (EBV).
Its primary symptoms include,
 Fever
 Swollen lymph nodes in your neck and armpits
 Swollen tonsils
 Headache.
As the patient has enlarged cervical lymph nodes, it signs that he might be
suffered by mononucleosis.

2. Tonsillitis:

Tonsillitis is inflammation of the tonsils, two oval-shaped pads of tissue at the

back of the throat (one tonsil on each side). Signs and symptoms of tonsillitis
include
 swollen tonsils,
 sore throat,
 difficulty swallowing
 Tender lymph nodes on the sides of the neck.
As the patient has tender and swollen nodes, it is evident that the patient might be
suffering from tonsillitis.

3. Glandular fever:
It is an infectious disease common among youngsters and teenagers. Its signs and
symptoms might be:
 Sore throat
 fever,
 swollen glands, and
 Fatigue.
As the age of the patient is 18, it strongly symptomize that he might have been
suffering from glandular fever. Moreover, fever and fatigue also categorize the
vulnerability of this infection.
 b. What is the most likely cause of the infection? How do you know and which
test would have been the one to come back positive (serology or throat
culture)?
Answer: The infection that is most likely to occur in the patient is glandular
infection. This infection is caused by the Epstein-Barr virus (EBV), because of the
age and onset of the disease. Moreover, the test that comes back positive would be
the serological test. Throat culture mostly detects the bacterial infections while the
patient is suffering from a viral infection.

c. Briefly describe the epidemiology of the infection.

Answer: About 90 to 95 percent of adults are eventually EBV-seropositive. By

age four, EBV sero-prevalence is close to 100 percent in developing countries and
ranges from 25 to 50 percent in lower socioeconomic groups in the United States.
Many attribute this finding to intense personal contact and poor personal hygiene
among children, which provide opportunities for early acquisition and subsequent
spread of EBV.

d. Why was this patient prescribed steroids?

Answer: Corticosteroids
e. What complications can this infection cause in immunocompromised hosts?
How does this occur?

The disease might raise its extent to a level where the immune system of the host
might get affected that might result in serious consequences and even may
become fatal. Complications such as myocarditis, aneurysm might result if the
virus penetrates in the vital organs such as heart and brain.

2) A 2-year-old female presented to the ER with a 4 day history of fever, diffuse rash,
and swollen right hand. She was irritable but alert. She had lesions all over her
body, with some of these being clearly older and crusted. She had cellulitis of the
right hand with redness, swelling and tenderness. There were no lesions in the
mouth. The lungs were normal. There was no enlargement of the spleen or liver.
She had elevated WBCs. X-ray of the hand showed only soft-tissue swelling. The
patient was treated with intravenous antibiotics. Improvement in her right hand was
noted within 2 days. The patient had a systemic viral infection with a complication
of bacterial superinfection in the hand.

a. What was the underlying viral infection? What other causes of a skin rash
should be considered?

Answer: The possible disease that the child might be suffering from is Kawasaki
disease. As it is common in the children and the age factor suggests the presence
of this disease moreover, swelling of hand might also sign the presence of this
disease.
 b. How is diagnosis of this infection made? Describe the epidemiology of this
infection.

Answer: Diagnosis: There is no specific test for the detection of this disease but
the pediatricians may carry out other tests to check whether the presence of this
disease has affected other parts of the body or not such as ECG, Chest X-Rays,
blood and serological testing.

c. Why was the patient prone to the bacterial infection? What is the most likely
causative agent of the cellulitis?

Answer: Whenever a disease attacks the immune system of the body, the person is
subjected to other diseases as well such as a bacterial infection. The 2 year old
female was also in the same situation that is her body became subjected to several
different diseases. Moreover, cellulitis is caused by, Streptococcus bacteria that
might have entered the body through a break or rash caused by the viral disease.

d. What illness may occur years later as a result of viral reactivation? How do
the clinical manifestations of this reactivation differ from the primary
infection?

Answer: If not treated properly the virus my reactivate in the body and cause
severe medical conditions that might be serious than the prior primary infection
because the virus will now become more powerful and resistant to the host’s
immune system.

e. What infection control issues are related to this patient’s illness? How could
this infection have been prevented?

Answer: The infection might be controlled by keeping certain precautionary

measures in consideration. For example this viral disease is more common in
Asian countries; their residents should protect their child from this disease by
keeping the conditions hygienic and viral free for the baby.

3) A 21-year-old male presented to the ER with a 6 day history of fever, chills, and
muscle pain. Two days prior to this, he had noted painful lesions on the penis. On
the day of admission, he developed a stiff neck, headache, and light sensitivity. He
had previously been in good health. He admitted to sexual activity but had no
history of sexually transmitted infections. On examination, his vital signs were
normal except for his elevated temperature. His throat was clear and there were no
swollen lymph nodes. A pelvic examination revealed extensive lesions on the penis
and scrotum with swelling. Specimens were taken to culture for Neisseria
gonorrhoaea, viruses, and Chlamydia trachomatis. General tests were
unremarkable. No bacterial cultures were positive. The CSF showed some
leukocyte infiltration. A rapid diagnostic test was done on the genital lesion and
 gave positive results. Performing the same test on the CSF also gave positive
results. The patient’s condition improved after IV therapy. He was discharged on
oral medication.

a. What is the differential diagnosis of genital lesions? What rapid test can be
used so specific therapy can be started?

Answer: The differential diagnosis for genital ulcers or lesions includes genital
herpes, genital cancroid, drug eruptions, traumatic ulcers and Behçet disease. A
quick Viral Culture test might be performed to distinguish between certain genital
lesion conditions; this test involves scrapping of the lesson area and examining it
in lab.

b. Which uncommon complication of his underlying illness did he develop?

Answer: Iridocyclitis (light sensitivity) is the complication that he developed in

genital herpes as this condition is rare to occur and occurs only in serious
conditions.

c. If the patient had been a pregnant woman at the time of infection, what would
be the risk to the fetus? How could this complication be prevented?

Answer: If a woman with genital herpes has virus present in the birth canal during
delivery, herpes simplex virus (HSV) can be spread to an infant, causing neonatal
herpes, a serious and sometimes fatal condition.

d. Briefly describe the course of infection with this virus.

Answer: Infections are transmitted through contact with HSV in herpes lesions,
mucosal surfaces, genital secretions, or oral secretions. HSV-1 and HSV-2 can be
shed from normal-appearing oral or genital mucosa or skin and the virus begin to
move in the whole body.

e. There are two different serotypes of the virus that can cause these genital
lesions. What similarities do they share? What are the differences between
these agents?

Answer: Human HSV exists as two distinct serotypes: herpes simplex virus type -
1 (HSV-1 / HHV1) and type -2 (HSV-2 / HHV2). Both HSV-1 and HSV-2 are
neurotrophic viruses that invade the central nervous system (CNS), where they
replicate and have the capacity to establish a latent infection (Nicoll, MP et al).

4) A 53-year-old woman developed oropharyngeal cancer 7 years after her husband

was diagnosed with the same cancer. She had pain in her right ear and was treated
for otitis media. Within 2 months, the pain had radiated to her jaw. Her dentist
diagnosed temporomandibular joint syndrome (TMJ), and she was also referred for
possible root canal. A few months later, an MRI showed an opacity in the right
maxillary sinus, and the woman was treated for a sinus infection. A second MRI
next month showed no signs of infection, but her pain continued, and within three
weeks she had difficulty opening her mouth. A neurologist treated her with pain
medication and muscle relaxants. The woman's symptoms persisted for another year
when she noted an inability to articulate clearly and noted her tongue was deviated
to the left. An MRI of her cranium and neck revealed a large mass of the left
oropharynx. Results of a biopsy indicated squamous cell carcinoma. The woman
began aggressive chemotherapy and radiation treatment. Further investigation
revealed that her husband's oral cancer was caused by the same virus. This
information was never reported to them at the time of his diagnosis or treatment.

a. What is the causative agent of this woman’s cancer? What features of this
virus make it oncogenic?

Answer: Human papilloma virus is the most possible causative agent of

oropharyngeal cancer in the woman. Sexual activity, including oral sex, with
someone who has HPV is the most common way someone gets HPV.
HPV is believed to cause cancer both by integrating into DNA and in non-
integrated epitomes. Some of the "early genes" carried by the HPV virus, such as
genes E6 and E7, act as oncogenes that promote tumor growth and malignant
transformation.

b. What other types of infection do serotypes of this organism cause? Is this

particular virus capable of causing infection at other body sites? If so, which?

Answer: The serotypes are capable to affect other parts of the body too such as,
Genitals and cervical region.

c. What is the nature of the immune response to the virus?

Answer: Immune components become active on the detection of a foreign viral

antigen and react with cell mediated and humeral response to produce sufficient
amount of antibodies against it to remove the foreign antigen as soon as possible
moreover, the immune system might activate the complement proteins as well.

d. After treatment of the cancer, are either of the patients at risk for recurrent
infection? Why or why not?

Answer: After the treatment, the patient might be vulnerable to another attack if
the viral antigens are not removed properly from the body. They may reactivate
and cause the same infection and subsequent cancers.

e. How can transmission and disease be prevented with this infection?

 Answer: To maintain the sexual hygiene with the sex partner i.e., avoiding oral
sex might save you from the onset of the infection and subsequent cancer.

5) A healthy 18-year-old woman arrived at Navy basic training in Great Lakes, Illinois.
Her medical history was negative for underlying illnesses. She took no medications
and was not a user of alcohol or tobacco. Upon arrival, she received several standard
vaccinations, including meningococcal vaccine. Three weeks later, she presented to
the medical clinic with upper respiratory symptoms. Her clinical evaluations did not
suggest severe illness, and a bacterial throat culture was negative. She was
prescribed a 5-day course of antibiotics for suspected bronchitis. The next day, she
was found unconscious in the barracks. She was transported to a local hospital
where she began to seize and went into respiratory failure that required a ventilator.
A chest radiograph revealed a right upper lobe infiltrate, and CT of the head was
positive for a sinus infection. Examination of CSF revealed elevated protein levels,
but no identifiable pathogens. Blood cultures were negative. She was treated with
broad-spectrum antibacterial and antivirals agents. Se did not regain consciousness
and died within a week from complications of encephalitis. Autopsy findings
included changes in the CNS consistent with viral encephalitis. Both lungs showed
pneumonia. Cultures, special stains, and electron microscopy of autopsy specimens
did not identify specific pathogens.

a. This is a rare manifestation of a rather common viral illness in the military.

What is the likely virus causing this patient’s illness and what strain(s) are
most common in this population? How do you know?

Answer: The possible virus causing this disease would have been the
rhinovirus. I have seen a documentary on the disease military workers do
catch due to their duties, environment and surroundings.

b. What patients are most at risk for infections with viruses from this group?
What are the most common manifestations of infection?

b. The common clinical manifestations of this disease include Pneumonia, chest

pain, upper airways infraction that might in severe condition leads to death.

c. Answer: People at their young age mostly teenagers are at verge of getting
this disease and infection more likely.

d. What type of immune response is best for clearance of infections caused by

these viruses?
 Answer: Humoral response is the best for the clearance of infections
caused by the viruses. As this response by the immune system produces
large amount of antibodies that are targeted towards the foreign antigens.

e. How are these viruses transmitted? What features of the virus or its
infection make prevention of these infections difficult?

Answer: There are two modes of transmission: via aerosols of respiratory

droplets and from fomites (contaminated surfaces)

f. How could this infection have been prevented in this particular patient?
Why is prevention in this type of patient critical?

Answer: The best way to prevent rhinovirus infection is to: Also, when
possible, avoid close contact with people who have colds or other upper
respiratory infections. Scrub hands with soap and water for at least 20
seconds, and help young children do the same.

6) Viral infections are often more difficult to treat than bacterial infections. A)
Describe in detail why this is true. B) Using examples from recent (2018-2019)
primary literature only, detail three antiviral therapies including type of infection
treated, target of the therapy, and discovery of the compound.

Answer: Viral infections are mostly difficult to treat in comparison to that of the
bacterial culture because viruses have strength of being resistant to the immune
components of the host’s body in comparison to that of the bacterial attack because
bacteria are easily handled and evacuated by the immune components easily. Following
are enlisted some antiviral therapies to combat a viral infection:
1. NRTIs
2. NNRTIs
3. Protease Inhibitors.

7) Clinicians used to rely heavily on tissue culture for diagnosis of viral infections.
This is no longer the case. Give specific examples of why clinicians would no
longer want to culture viral infections. Since tissue culture is no longer the primary
diagnostic tool, what do clinicians use to diagnose viral infections? What are the
pros and cons of these newer techniques when compared to each other and to tissue
culture?

Answer: The viral infections are no longer detected or diagnosed by using tissues
cultured because it has been found that tissue sculpturing might contribute to more
problems than that of solution, moreover, it don’t provide the accuracy that is required as
there is a vast variety of viruses and distinguishing them with tissues culture is not
possible. There are several modern techniques that have been developed to overcome
these issues and get the level of accuracy some of them are enlisted below:

 Immunoassay: Is a technique in which formation of antigen–antibody through

recognition and binding takes place and detection occurs.
 NAAT: Is a techniques in which amplification and detection of sequences from
the viral genome (DNA or RNA) occurs.
 NGS: Is a technique in which polymerization of DNA template by incorporation
of labeled dNTPs, and terminate the extension occurs.

8) Viruses variously depend on their host cell for parts of the viral replication and
maturation process. Many viruses do however encode for some enzymes that
facilitate certain steps or virus-specific processes for viral replication and
maturation. Which cellular processes and enzymes do all viruses lack and must
therefore ALWAYS be supplied by the host cell? Give examples of specialized
enzymes or proteins that some viruses may bring with them. How is any of this
information clinically relevant?

“Viral replication involves six steps: attachment, penetration, uncoating, replication,

assembly, and release.” Viral replication is the arrangement of organic viruses during the
contamination procedure in the objective host cells. Viruses should initially get into the
cell before viral replication can happen. Through the age of rich duplicates of its genome
and bundling these duplicates, the virus keeps contaminating new hosts. Replication
between viruses is significantly differed and relies upon the kind of qualities associated
with them. The symptoms of viral maladies result from the insusceptible reaction to the
virus, which endeavors to control and take out the virus from the body and cell harm
brought about by the virus. Numerous creature viruses, for example, HIV (Human
Immunodeficiency Virus), leave the contaminated cells of the resistant framework by a
procedure known as maturing, where virions leave the phone exclusively. During the
offering procedure, the phone doesn't experience lysis and isn't promptly murdered.
Notwithstanding, the harm to the cells that the virus taints may make it outlandish for the
cells to work ordinarily, even though the cells stay alive for quite a while. viruses are
committed intracellular pathogens they can't recreate without the hardware and digestion
of a host cell. Even though the replicative life cycle of viruses contrasts significantly
among species and class of virus, six fundamental stages are basic for viral replication.
Describe 3 viral immune evasion strategies and compare/contrast them with
bacterial immune evasion strategies.
Following are enlisted the three immune evasion strategies:

 evasion by noncytocidal infection (Arena and Hanta viruses),

 evasion by cell to cell spread (Canine distemper virus and cytomegalovirus),
 evasion by infection of no permissive, resting or undifferentiated cells
These evasion strategies are far more significant than those of the bacterial immune
evasion strategies as they provide more defense and resistance to the immune
components of the body.
Immune avoidance is a technique utilized by pathogenic creatures and tumors to sidestep
a host's insusceptible reaction to expand their likelihood of being transmitted to a new
host or to keep developing, separately. Avoidance of the resistant framework by viruses
is a well-considered field. It stays a test to see how these viral strategies influence
pathogenesis and the viral lifecycle. Simultaneously, the investigation of viral proteins
engaged with resistant avoidance has helped us to more readily comprehend a few cell
forms at the atomic level. Here we audit ongoing information on various viral strategies
for insusceptible avoidance and feature what these viral intercessions may show us cell
science.
10. A 14 year old female presented to the ER with a 2 day history of fever and
vomiting. The morning of admission, she had diarrhea, increased fever, and
continued vomiting. She was seen by an outside physician who noted she was
hypotensive with a heart rate of 120 beats/min. She had an erythematous rash.
Blood, throat, and vaginal specimens were sent for culture. She was given IV fluids
and antibiotics and admitted to the ICU. She had abnormal liver and kidney
function. She began her menstrual period 4 days prior to admission and uses
tampons.
 Periodic fever disorders allude to illnesses that reason occasional (verbose) fever
that doesn't have an irresistible (virus, microbes) cause. As a rule, youngsters with
these disorders are well between scenes.
 Huge numbers of these disorders are inherited (passed down from guardians) and
result from a change (deformity or slip-up) in quality this is the code that decides
the structure of our proteins). Assaults of fever and aggravation may keep going
for a considerable length of time to weeks isolated by interims of good wellbeing
for quite a long time to months.
 The fever design span and periodicity and clinical highlights are factors among
disorders and patients. Related symptoms more often than not unexpectedly
resolve when the patient ends up afebrile.
 Nonetheless, in extreme instances of acquired malady, irritation can be ceaseless
with steady symptoms and the improvement of long haul entanglements. FMF is a
hereditary illness.
 The mindful quality is known as the MEFV quality, named after the
Mediterranean Sea, and it influences a protein called pyrin, which assumes a job
in the regular control of irritation.
 At the point when this quality has an imperfection, the guideline of aggravation is
impossible appropriately and patients experience scenes of fever and different
symptoms. Contamination, injury, menses (periods) or mental pressure may
trigger scenes.

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