MICROBIOLOGY and PARASITOLOGY Medical Board Exam Review for August 2007

Nenacia Ranali Nirena R. Palma, MD

BACTERIOLOGY

Basic Bacterial Structure

Appendages
flagella and pili

cell envelope
capsule, cell wall and plasma membrane

cytoplasmic region
genome (DNA), ribosomes and inclusions

Appendages
Flagella
filamentous protein structures for motility

Pili ~ Fimbriae
short, hair-like structures usually involved in adherence (attachment) resist attack by phagocytic white blood cells F or sex pilus, mediates the transfer of DNA

Cell Wall
Gives rigid support protects from osmotic lysis Peptidoglycan
polymer of disaccharides cross-linked by short chains of amino acids (peptides) Murein (N-acetylmuramic acid)

Cell Wall
Gram positive
Thicker Teichoic acid an antigenic determinant No endotoxin, except Listeria monocytogenes

Gram negative
periplasmic space (contains enzymes, eg beta-lactamases) Outer membrane w/ lipopolysaccharide Endotoxin = Lipid A High lipid content

Plasma/Cytoplasmic Membrane
site of oxidative phosphorylation and photophosphorylation permeability barrier consist of saturated or monounsaturated fatty acids (rarely polyunsaturated fatty acids) and do not normally contain sterols

Capsule/Glycocalyx
Composed of polysaccharide, except Bacillus anthracis (D-glutamate) Mediates adherence to surfaces Protects against phagocytosis

Cytoplasmic Constituents
Chromosome typically one large circular molecule of DNA Plasmids extra-chromosomal; genes for antibiotic resistance, enzymes and toxins Ribosomes for protein synthesis

Exotoxin
Source Secreted from cell Gram (+) and gram (-) (bacteria Yes

Endotoxin
Cell wall of gram (-) (bacteria & Listeria No Bacterial chromosome Low No toxoids formed, no vaccines available Stable at 100 C for 1 hour Poorly antigenic Meningococcemia, sepsis by gram (-) rods (-

Location of genes Plasmid or bacteriophage toxicity vaccines Heat stability antigenicity Typical diseases high toxoids Destroyed at 60 C Induces antitoxins Tetanus, botulism, diphtheria

Gram Stain
Crystal Violet (the Primary Stain) Iodine Solution (the Mordant) Decolorizer (ethanol) Safranin (the Counterstain) Water

Gram Positive Cocci

Staphylococcus
Clusters

Streptococcus
Chains

Micrococcus
tetrad

Gram Positive Bacilli

Bacillus and Clostridium
Produces spores

Listeria and Corynebacterium

Gram negative Cocci

Neisseria
diplococci

Acinetobacter
Coccobacilli Often gram variable

Gram negative Bacilli

Enterobacteriaciae
Thin rods

Hemophilus
Coccobacilli

Vibrio and Campylobacter

curved

Gram (+) Cocci Catalase (+) Staphylococcus Catalase (-) Streptococcus

Coagulase (+) S. aureus

Coagulase (-) Novobiocin sensitive S. epidermidis

-hemolysis (green) S. Pneumo Optochin sensitive, bile soluble, (+) capsule

-hemolysis (clear) Group A S. pyogenes Bacitracin sensitive

No hemolysis

Enterococcus E. fecalis

Novobiocin resistant S. saprophyticus

Peptostreptococcus

Viridans strep. S. mutans

Group B S. Agalactiae Bacitracin resistant

Gram negative

Cocci Neisseria

Coccoid H. influenza Bordetella pertussis

Bacilli

Maltose fermenter
N. meningitidis

Maltose Nonfermenter
N. gonorrhea

Pasteurella Brucella

Lactose fermenter Fast

Klebsiella E. Coli Enterobacter

Lactose nonfermenter Oxidase (+)

Pseudomonas

Oxidase (-) Slow

Citrobacter Serratia Shigella Salmonella Proteus

Genetic Exchange in Bacteria

Conjugation
cell-to-cell contact as DNA crosses a sex pilus from donor to recipient

Transduction
a virus transfers the genes between mating bacteria

Transformation
DNA is acquired directly from the environment, having been released from another cell

Oxygen Requirement
Obligate Aerobes Facultative anaerobes
Aerobic but can grow in the absence of oxygen

Microaerophilic (aerotolerant anaerobes)

Can tolerate low amounts of oxygen

Obligate anaerobes

Obligate aerobes Gram (+)

Nocardia Bacillus cereus

Facultative anaerobes
Staph. B. anthracis Corynebac. Listeria Actinomyces all other gram negatives

MicroMicroaerophilic
Streptococcus

Obligate anaerobes
Clostridium

Gram (-) (-

Neisseria Pseudomonas Bordetella Legionella Brucella Mycobacterium Nocardia

Bacteroides Spirochetes Treponema Borrelia Leptospira Campylobacter

Acid fast

No cell wall

Mycoplasma

Koch s Postulate
The bacteria must be present in every case of the disease. The bacteria must be isolated from the host with the disease and grown in pure culture. The specific disease must be reproduced when a pure culture of the bacteria is inoculated into a healthy susceptible host. The bacteria must be recoverable from the experimentally infected host.

Staphylococcus aureus
nonmotile, nonsporeforming facultative anaerobe fermentation of glucose produces mainly lactic acid ferments mannitol (distinguishes from S. epidermidis) catalase positive coagulase positive golden yellow colony on agar

Staphylococcus aureus
Protein A protect from opsonization and phagocytosis Coagulase clumping factor Hemolysins Leukocidins Hyaluronidase spreading factor Staphylokinase Exfoliatin scalded skin Enterotoxins TSST-1 superantigen; binds to MHC class II

Staphylococcus aureus
Pneumonia cavitations, empyema and effusions Endocarditis acute Food poisoning due to a preformed toxin, onset 1-8 hours TSS tampon use

Staphylococcus aureus
Treatment
Methicillin Nafcillin Dicloxacillin For MRSA give Vancomycin

No vaccine

 Staphylococcus epidermidis Normal flora of skin Foley catheters and IV lines Blood culture contaminant Infection of prosthetic devices Staphylococcus saprophyticus Urinary tract infections in sexually active women

Streptococcus pyogenes (GABHS)

nonmotile, nonsporeforming capsule composed of hyaluronic acid exhibit beta (clear) hemolysis on blood agar

Streptococcus pyogenes (GABHS)

M protein protection from phagocytosis but susceptible to antibodies Streptolysin O - oxygen-labile leukocidin, antigenic Streptolysin S oxygen stable Pyrogenic/erythrogenic toxin - superantigen Streptokinase - fibrin lysis

Streptococcus pyogenes (GABHS)

Scarlet fever strawberry tongue Pharyngitis Rheumatic fever sequela of pharyngitis Glomerulonephritis sequela of pharyngitis and skin infections Tx: penicillin, erythromycin

 S. agalactiae (Group B)
Beta hemolytic Neonatal meningitis, pneumonia and sepsis (B for baby)

Group D Streptococci
Enterococci (E. faecalis, E. faecium) Non-enterococci (S. bovis, S. equinus) Urinary and biliary tract infections, SBE S. bovis associated with colon cancer

Viridans streptococci
S. salivarius, S. sanguis, S. mitis, S. intermedius, S. mutans alpha hemolytic (green) Optochin resistant Dental caries (S. mutans) Subacute bacterial endorcarditis (S. sanguis)

Streptococcus Pneumoniae
lancet-shaped diplococci Alpha-hemolytic, optochin sensitive Capsule (Quellung reaction)

Streptococcus Pneumoniae
Adults: pneumonia and meningitis Children: otits media Pneumonia lobar with consolidation Increasing resistance to penicillins, erythromycin, cotrimoxazole, chloramphenicol Pneumococcal vaccine advised for elderly and asplenic patients

Clostridium perfringens
Alpha toxin lecithinase Spores resistant to cooking Gas gangrene/myonecrosis Food poisoning - abdominal cramps and diarrhea 8-16 hours after eating contaminated meat or poultry

Clostridium difficile
Antibiotic associated diarrhea (pseudomembranous colitis) Toxin A - causes fluid accumulation in the bowel Toxin B - an extremely lethal (cytopathic) toxin Tx: Metronidazole or vancomycin

Clostridium tetani
Found in soil terminal spores within a swollen sporangium drumstick appearance

Tetanus toxin/tetanospasmin blocks release of inhibitory glycine neurotransmitter from Renshaw cells in spinal cord

Clostridium tetani
severe painful spasms and rigidity of the voluntary muscles "lockjaw" - spasms of the masseter muscle rigidity and violent spasms of the trunk and limb muscles Spasms of the pharyngeal muscles - difficulty in swallowing Death - interference with the mechanics of respiration

Clostridium tetani
Vaccines
Immune globulin preformed Ig Toxoid formaldehyde treated toxin

Penicillin, ventilatory support, muscle relaxant

Clostridium botulinum
Flaccid paralysis Floppy babies Botulinum toxin
Neurotoxin Toxin ingested in food absorbed in duodenum and jejunum bloodstream peripheral neuromuscular synapses Blocks release of acetylcholine

Canned foods; ingestion of honey (infants)

Bacillus cereus
Motile, non-encapsulated "short-incubation" or emetic form
nausea and vomiting and abdominal cramps incubation period of 1 to 6 hours resembles Staphylococcus aureus food poisoning caused by a preformed heat-stable enterotoxin Associated with fried rice and eating in Chinese restaurants

Bacillus cereus
"long-incubation" or diarrheal form
abdominal cramps and diarrhea with an incubation period of 8 to 16 hours Diarrhea may be a small volume or profuse and watery resembles more food poisoning caused by Clostridium perfringens heat-labile enterotoxin - activates intestinal adenylate cyclase and causes intestinal fluid secretion meat or vegetable-containing foods after cooking

Bacillus anthracis
large cells with square ends and centrallylocated ellipsoid spores Non-motile Spores on animal products (skin, hide) Poly-D-glutamate capsule

Bacillus anthracis
Factor I - edema factor (EF); inherent adenylate cyclase Factor II - protective antigen (PA), induces protective antitoxic antibodies; binding (B) domain Factor III - lethal factor (LF) PA+LF combine to produce lethal activity EF+PA produce edema EF+LF is inactive PA+LF+EF produces edema and necrosis and is lethal

Bacillus anthracis
Cutaneous anthrax
via injured skin or mucous membranes Vesicular papules covered by black eschar

Inhalation anthrax (woolsorters' disease)

inhalation of spore-containing dust where animal hair or hides are being handled begins abruptly with high fever and chest pain progresses rapidly to a systemic hemorrhagic pathology and is often fatal

Bacillus anthracis
Gastrointestinal anthrax
Rare Very high mortality rate

Tx: Penicillin, tetracyclines and fluoroquinolones effective if administered before the onset of lymphatic spread or septicemia, estimated to be about 24 hours Vaccine: protective antigen (three subcutaneous injections given two weeks apart followed by three additional subcutaneous injections given at 6, 12, and 18 months)

Listeria monocytogenes
Peritrichous flagella are produced at room temperature but not at 37 C may be coccoid, so they can be mistaken for streptococci; longer cells may resemble corynebacteria Tumbling motility

Listeria monocytogenes
listeriolysin O LPS ability to multiply at low temperatures associated with ingestion of milk, meat or vegetable products that have been held at refrigeration temperatures for a long period of time Neonatal meningitis and sepsis, abortion, premature delivery Tx: ampicillin, no vaccine

Corynebacterium diphtheriae
Loeffler s bacillus aerobic, nonmotile irregular shaped, club-shaped or V-shaped arrangements (resembles Chinese letters) Metachromatic granules

Corynebacterium diphtheriae
Culture: potassium tellurite agar, Loeffler s coagulated blood serum Beta prophage encodes exotoxin (inhibits protein synthesis via ADP ribosylation of elongation factor 2 (EF2) Pharyngitis with grayish pseudomembrane Hematogenous spread to affect heart and neural cells (myocarditis and laryngeal nerve palsy)

Corynebacterium diphtheriae
Tx: penicillin or erythromycin Vaccine: trivalent toxoid (diphtheria, pertussis, tetanus)

Neisseria gonorrhea
Kidney bean shaped Gram (-) intracellular diplococci Fimbriae No capsule IgA protease, LPS Culture: Thayer-Martin chocolate agar
V Vancomycin C Colistin (polymixin) N - Nystatin

Neisseria gonorrhea
Males: urethritis (discharge); painful urination Females: dyspareunia due to cervicitis; PID, sterility, ectopic pregnancy, tubo-ovarian abscess, perihepatitis (Fitz-Hugh-Curtis syndrome) Neonates: ophthalmia neonatorum Most common cause of septic arthritis in sexually active

Neisseria gonorrhea
Treatment:
Ceftriaxone; Ciprofloxacin or spectinomycin if allergic to cephalosporins Plus Doxycycline or azithromycin for Chlamydia Erythromycin eyedrops prophylaxis for ophthalmia neonatorum

No immunity

Neisseria meningitidis
Meningococcus Encapsulated, maltose fermenter Strict human parasite (in nasopharynx) Respiratory transmission

IgA protease Serotypes A, B and C associated with meningitis (usually type B)

Neisseria meningitidis

Meningitis fever, HA, stiff neck, photophobia Meningococcemia fever, arthralgias, myalgias, petechial rash Waterhouse-Friedrichsen fulminant; fever, purpura, DIC, adrenal insufficiency (bilateral adrenal hemorrhage), shock, death

Neisseria meningitidis
Treatment:
Penicillin or ceftriaxone Rifampicin for prophylaxis of close contacts

Vaccine
Against capsular antigens

Enterobacteriaciae
E. coli, Salmonella, Shigella, Klebsiella, Enterobacter, Serratia, Proteus Ferments glucose Oxidase negative Antigens:
O somatic (polysaccharide of endotoxin) H flagellar K capsular

Lactose fermenters: Klebsiella, E. coli, Enterobactor and Citrobacter

E. coli
2nd most common cause of neonatal meningitis UTI, diarrhea, gram (-) sepsis LT (heat labile toxin) cAMP; similar to cholera toxin ST (heat stable) cGMP

E. coli
Enterotoxigenic (ETEC)
Do not invade diarrhea in infants and travelers diarrhea without fever

Enterohemorrhagic (EHEC)
Serotype O157:H7 moderately invasive pediatric diarrhea, copious bloody discharge (hemorrhagic colitis) hemolytic uremic syndrome (HUS) inadequately cooked hamburger meat

E. coli
Enteroinvasive (EIEC)
invasive (penetrate and multiply within epithelial cells) does not produce shiga toxin dysentery-like diarrhea (mucous, blood), severe inflammation, fever similar to Shigella

Enteropathogenic (EPEC)
non fimbrial adhesin (intimin) moderately invasive usually infantile diarrhea; some inflammation, no fever;

E. coli
Index organism for fecal contamination of water (coliforms) Treatment
Cephalosporins Aminoglycosides Trimethoprim-Sulfamethoxazole Fluoroquinolones

Salmonella
Non-lactose fermenter, motile, produces H2S

Vi antigen Contamination of food and water with animal feces, except S. typhi (carried only by humans) 105 organisms infective dose

Salmonella
Never part of normal flora, always pathogenic Typhoid fever fever, rose spots, RLQ pain Carrier state in gallbladder Sepsis S.cholerasuis, osteomyelitis (in asplenic patients and those with sickle cell disease) Gastoroenteritis S. enteritidis; watery diarrhea, may contain mucus and trace blood

Salmonella
Can survive intracellularly in monocytes Treatment:
Ciprofloxacin or ceftriaxone for typhoid fever Fluid and electrolyte replacement in S. enteritidis as antibiotics may prolong the course of bacterial shedding

Shigella
101 organisms infective dose Non-motile, no H2S production No animal reservoir, transmitted via food, fingers, feces and flies Never part of normal flora Shiga toxin verotoxin; inactivates 60s ribosomal unit

Shigella
S.boydii S.dysenteriae type I - deadly epidemics; HUS S.flexneri - "group B ; Reiter's syndrome (urethritis, conjunctivitis, arthritis) S.sonnei - "Group D" Shigella, accounts for over two-thirds of the shigellosis

Shigella
Bloody diarrhea, fever, and stomach cramps starting a day or two after exposure Usually resolves in 5 to 7 days Treament
ampicillin, trimethoprim/sulfamethoxazole, nalidixic acid, ciprofloxacin Avoid loperamide or diphenoxylate which prolong excretion of the organism

Klebsiella pneumoniae
Usually nosocomial, UTI in px with foley catheters, pneumonia in debilitated px 2nd most common cause of sepsis in hospitals (next to E. coli) Cavitary pneumonia with red currant jelly sputum Serratia bright red pigment

Proteus mirabilis
Very motile, swarming colony on blood agar Urea-splitting Cross-reacts with rickettsia Common cause of UTI and nosocomial infections

Vibrio cholera
Comma-shaped, single flagella

Toxin via ADP ribosylation that permananently activates adenylyl cyclase rapidly fatal illnesses - healthy person may become hypotensive within an hour of the onset of symptoms and may die within 2-3 hours if no treatment is provided; first liquid stool to shock in 412 hours, with death following in 18 hours to several days

Vibrio cholera
rice-water stools Treatment:
Immediate fluid and electrolyte replacement Tetracyclines may shorten the duration of diarrhea and reduce fluid loss

V. parahemolyticus
Uncooked seafood Leading cause of diarrhea in Japan

Campylobacter jejuni
Comma or S-shaped Zoonotic (reservoir in wild animals and poultry) Fecal-oral transmission or by drinking unpasteurized milk Bloody diarrhea

Helicobacter pylori
Most common cause of duodenal ulcers and chronic gastritis Urease (+) protects from stomach acid Risk for gastric CA Treatment:
Combination bismuth, metronidazole, ampicillin and/or tetracycline Combination metronidazole, omeprazole and clarithromycin

Pseudomonas aeruginosa
Aerobic single, polar flagellum Ubiquitous in soil and water Colony types
rough colony smooth fried-egg appearance which is large,, with flat edges and an elevated appearance mucoid - respiratory and urinary tract secretions, attributed to the production of alginate slime

Pseudomonas aeruginosa
Pigments (pyoverdin and pyocyanin)

Opportunistic pathogen Wound and burn infections, pneumonia, sepsis, external otitis (swimmer s ear), UTI, drug or diabetic osteomyelitis, hot tub folliculitis

Pseudomonas aeruginosa
Endotoxin (fever, shock) Exotoxin A (inactivates EF2) Treatment
Aminiglycoside plus extended-spectrum penicillin (piperacillin, ticarcillin)

Bacteroides fragilis
Anaerobic No lipopolysaccharide Encapsulated Predominant flora of colon Exits colon via break in mucosa in chronic disease, PID or trauma Peritoneal abscesses Tx: metronidazole, clindamycin, chloramphenicol, drain surgically

Hemophilus influenza
Coccobacillus Polysaccharide capsule Culture:
Chocolate agar with Factor X (hemin) and Factor V (NAD) present in blood

Hemophilus influenza
Type B
Leading cause of meningitis in children (6 mos to 1 yr) Bacteremia epiglottitis (obstructive laryngitis)

Non-typable
osteomyelitis, and joint infections otitis media and sinusitis in children pneumonia in infants, children and adults.

Hemophilus influenza
Treatment
Meningitis: ampicillin for strains of the bacterium that do not make -lactamase, and a thirdgeneration cephalosporin or chloramphenicol for strains that do Sinusitis, otitis media and respiratory infections: Amoxicillin with clavulanic acid Penicillin-resistant meningitis: Chloramphenicol Sinusitis or respiratory infection caused by nontypable H. influenzae: Tetracyclines and sulfa drugs

Hemophilus influenza
Vaccine
Hib conjugate vaccines - children 15 - 59 months old should receive a single dose of conjugate vaccine; Children 60 months of age or older and adults normally do not need to be immunized

Rifampicin prophylaxis in close contacts

Legionella pneumophila
Identified using silver stain (poor gram stain properties) Aerosol transmission from water source habitat No person-to-person transmission Culture: charcoal yeast extract with iron and cysteine Atypical pneumonia with high fever and unproductive cough Tx: erythromycin

Bordetella pertussis
Gram-negative aerobic coccobacillus that appears singly or in pairs

Pertussis toxin increase in cAMP Filamentous hemagglutinin attachment to ciliated epithelial cells; does not invade Tracheal cytotoxin damages ciliated cells Culture: Bordet-Gengou agar

Bordetella pertussis
Catarrhal stage
Lasts 1-2 weeks, most contagious

Paroxysmal stage
2-10 weeks Lymphocytosis; bursts of non-productive cough (whoop) Antibiotics ineffective at this stage

Convalescent stage Tx: erythromycin, if given before the paroxysmal stage

Zoonotic Bacteria
Yersinia pestis
Bipolar staining flea bite; rodents and prairie dogs Bubonic plague swollen regional lymph nodes black death Tx: Streptomycin, gentamycin, doxycycline

Brucella
Unpasteurized dairy products Undulant fever melitensis (goat/sheep), abortus (cattle), suis (pigs)

Zoonotic Bacteria
Francisella tularensis
Tick bite; rabbits and squirrels Tularemia ulceroglandular lesions (hole in skin, black base, swollen LN, draining pus) Tx: gentamycin or streptomycin

Pasteurella multocida
Animal bite; cats and dogs Rapid onset cellulitis at bite site Tx: penicillin

Spirochetes
Borrelia burgdorferi
Bite of Ixodes tick that live on deer and mice

Lyme disease

Stage I erythema chronicum migrans (

eye red rash with central clearing

bull s

Lyme Disease
Stage 2 disseminated stage
Neurologic and cardiac manifestations

Stage 3 persistent infection

Autoimmune migratory polyarthritis

Treatment: Tetracycline

Borrelia recurrentis
Transmitted via body louse (Pediculus humanus) Relapsing fever antigenic variation
Fever every 8 days Chills, drenching sweat, headaches, muscle aches

Culture: during febrile periods only Treatment: doxycycline or erythromycin

Treponema pallidum
Primary syphilis painless chancre Secondary syphilis disseminated disease, maculopapular rash on palms and soles, condyloma lata Tertiary syphilis gummas, aortitis, neurosyphilis, Argyll Robertson pupil (accommodates but unreactive to light) Congenital syphilis saber shin, saddle nose, deafness

Treponema pallidum
Non-specific tests: VDRL, RPR Specific tests: FTA-ABS, MHA-TP Jarisch Herxheimer reaction acute worsening of symptoms after initiation of antibiotics Tx: Penicillin G, Erythromycin, Doxycycline T. pertenue
Yaws (skin infection, not an STD but VDRL positive)

Leptospira
Tight coil with hooks on one or both ends ( ice tongs appearance) Direct contact with infected urine or animal tissue (intact mucous membrane, abraded skin) Leptospiremic phase
Spiking temperature, headache, myalgias, red conjunctiva, photophobia

Immune phase
IgM antibodies; meningismus (neck pain) urine

Leptospira
Culture:
blood and CSF during the 1st week Urine during 2nd week to months later

Weil s disease (icteric leptospirosis)

Renal failure, hepatitis, mental status changes and hemorrhage in many organs

Tx: Penicillin G, Doxycycline

Mycobacterium tuberculosis
Infects only humans Acid fast (Ziehl-Nielsen stain) Obligate aerobe Facultative intracellular parasite Slow generation time Culture: Lowenstein-Jensen medium (eggbased)

Mycobacterium tuberculosis
Virulence factors
Mycolic acid Cord factor inhibits neutrophil migration and damages mitochondria; present only in virulent strains Sulfatides inhibit phagosome from fusing with lysosome Wax D activates protective cellular immune system

Mycobacterium tuberculosis
Primary infection
Middle and lower lung zones Ghon focus calcified tubercle in middle or lower lung zone Ghon or Ranke complex focus plus perihilar lymph node calcified granulomas

Secondary or Reactivation
Pulmonary apical areas of lungs Lymph node (scrofula), kidney, spine (Pott s disease), joints, CNS Miliary

Mycobacterium leprae
Hansen s bacillus Favors cool areas not grown in vitro (only in footpads of mice, armadillos and monkeys) Transferred through respiratory secretions; less likely, skin lesions Lepromatous most severe form; defective T8 (T suppressor cells); leonine facies, saddlenose deformity Tuberculoid greater auricular, ulnar, posterior tibial and peroneal nerves usually affected

Mycobacterium leprae
Tuberculoid Number of single skin lesions Hair growth absent on skin lesion Sensation in Completely lesions of the lost extremities none Acid fast bacilli in scrapings Lepromin skin test Strongly positive Borderline several Slightly decreased Moderately lost several Lepromatous Many Not affected Not affected*

Innumerable

No reaction

No reaction

Mycobacterium leprae
Treatment
Long-term oral dapsone (toxicity: hemolysis and methemoglobinemia) Alternative: rifampin and combination of clofazimine and dapsone

Chlamydia
Obligate intracellular parasite Elementary bodies
Extracellular form Infectious form, non-replicating, nonmetabolically active

Reticulate bodies
Intracellular form Replicating, metabolically active, non-infectious

Chlamydia trachomatis
Types A, B, C trachoma Types D-K urethritis/PID, ectopic pregnancy, neonatal pneumonia, inclusion conjunctivitis (ophthalmia neonatorum inclusion bodies stain with iodine or giemsa) Types L1 L2 L3 lymphogranuloma venereum (positive Frei test) Tx: Doxycycline (for adults only), erythromycin (infants and pregnant), azithromycin

Mycoplasma pneumonia
No cell wall Eaton s Agent Cholesterol in cell membrane Cold agglutinins agglutination of RBC s at 4 C, due to cross-reactivity Dome-shaped colonies with fried egg appearance Walking pneumonia (fever, with dry nonproductive hacking cough) Tx: Erythromycin, Tetracycline

MYCOLOGY

Fungi
Eukaryotic with rigid cell wall chemoheterotrophs (require organic compounds for both carbon and energy sources) Obtain nutrients by absorption obtain nutrients as saprophytes (live off of decaying matter) or as parasites (live off of living matter) Yeast - unicellular fungi which usually appear as oval cells Molds - multinucleated, filamentous fungi composed of hyphae

Superficial Mycoses
Malassezia furfur
Tinea/pityriasis versicolor hypo/hyperpigmented patches spaghetti and meatballs Tx: selenium sulfide shampoos; imidazoles

Exophiala werneckii
Tinea nigra Black lesions on palms and soles Tx: topical salicylic acid

Cutaneous Mycoses
Dermatophytes
Microsporum (Wood s light), Trichophyton, Epidermophyton floccosum

Branched hyphae Affects skin, hair and nails

Tinea corporis, cruris, capitis, pedis, unguium, barbae

Pruritic lesions with central clearing resembling a ring Tx: topical imidazoles; oral griseofulvin for hair and nail involvement

Subcutaneous Mycoses
Sporothrix schenckii
Rose gardener s disease Dimorphic fungus that grows on vegetation Cigar-shaped budding yeast Local pustule or ulcer with ascending lymphangitis Tx: Amphotericin B or potassium iodide

Phialophora and Cladosporium

Chromoblastomycosis cauliflower warts Copper-colored sclerotic bodies

Systemic Mycoses
Dimorphic
Mycelial forms with spores at 25 C on Saboraud s agar, yeast at 37 C on blood agar or tissue, except Coccidioides (spherule in tissue)

Transmitted by spore inhalation Tx: Amphotericin B, itraconazole

Coccidioides immitis
San Joaquin valley or desert ( desert bumps, valley fever ) Mild lung infection Dissemination: bone granulomas or meningitis Erythema nodosum in 10%

Histoplasma capsulatum
Bird/bat droppings Tiny yeasts within macrophages Mild pneumonia, disseminated in immunocompromised Mississippi and Ohio river valleys

Blastomyces dermatitidis
Big, broad-based budding Almost always symptomatic From the soil or rotten wood Rarest systemic mycoses

Paracoccidioides brasiliensis
Captain s wheel appearance

Opportunistic Mycoses
Candida albicans
oval yeast with pseudohyphae Oral thrush in immunocompromised Vulvovaginitis Chronic mucocutaneous candidiasis TX: clotrimazole for skin infections; imidazole supppositories for vaginitis; nystatin for oral thrush; Amphotericin B for sytemic

Cryptococcus neoformans
Heavily encapsulated yeast India ink stain Soil, pigeon droppings Culture: Saboraud s agar Meningitis Tx: Amphotericin B x 6 months, Flucytosine

Aspergillus fumigatus
Allergic bronchopulmonary aspergillosis type I hypersensitivity reaction Invasive necrotizing pneumonia in AIDS, with aspergilloma (fungus ball) not dimorphic Mold with hyphae that branch at 45 deg. Angle (V-shaped) A. flavus produces aflatoxin in cereals and nuts (carcinogenic to the liver)

Mucor and Rhizopus

Mold only with irregular non-septate hyphae Rhinocerebral mucormycosis assoc. with diabetes Proliferate in walls of blood vessels causing infarction of distal tissue

Pneumocystis carinii
Diffuse interstitial pneumonia Yeast Usually seen in AIDS patients Methenamine silver stain Tx: co-trimoxazole, pentamidine, dapsone

Fungi-like bacteria
Actinomyces israelii
Has sulfur granules Causes eroding abscesses

Nocardia asteroides
Acid fast Lung abscess and cavitations

VIROLOGY

DNA viruses
HHAPPPy (Hepadna, Herpes, Adeno, Pox, Parvo, Papova) Double-stranded except Parvo Linear except Papova (circular, supercoiled) and Hepadna (circular, incomplete) Icosahedral except Pox (complex) Replicate in the nucleus except Pox Naked: PAP (Parvo, Adeno, Papova) Enveloped: HPH (Hepadna, Pox, Herpes)

Parvoviridae
Smallest DNA virus B19
Fifth disease (erythema infectiosum) Slapped-cheek appearance Transient aplastic anemia crisis Hydrops fetalis Transmitted via respiratory droplets

Papovaviridae
Human Papilloma virus
Common warts (types 1 2 4 7) Genital warts (6 11 16 18) Cervical cancer (16 18) Through direct contact

BK Polyomavirus nephritis/urethritis JC Polyomavirus progressive multifocal leukoencephalopathy; inhalation of infectious aerosols

Adenoviridae
Respiratory diseases (3 7 14 21) Epidemic keratoconjunctivitis pink eye (8 11 19 37) Acute hemorrhagic cystitis (11 21) Gastroenteritis (40 41) Hepatitis (1 2 3 5) Transmitted via respiratory droplets, fecal matter, hands, fomites

Herpesviridae
HSV 1 oral lesions; keratoconjunctivitis HSV 2 genital lesions
Tzanck smear multinucleated giant cells with Cowdry type A inclusion bodies

Varicella zoster (Human herpesvirus 3)

dewdrop on a rose petal Respiratory droplets or direct contact with ruptured vesicles Shingles single dermatome

Herpesviridae
Epstein Barr virus (HHV 4)
Infectious mononucleosis (kissing disease) fever, sore throat, enlarged lymph nodes and spleen Burkitt s lymphoma (+) heterophile antibody Downey cells atypical lymphocytes

Cytomegalovirus (HHV 5)
In milk, saliva, urine and tears Congenital defects; immunocompromised, transplant recipients Owl s eye inclusion body

Herpesviridae
HHV 6 (Human B-lymphotrophic virus)
Exanthem subitum, roseola infantum, fourth disease high fever for 3 to 5 days followed by rash as the fever subsides Saliva

HHV 8
Sexually transmitted esp. in homosexual men Kaposi s sarcoma

Poxviridae
Largest virus No animal reservoirs Variola smallpox; Guarneri s inclusion bodies Vaccinia cowpox; milkmaid s blisters Molluscum contagiosum small white bumps with a central dimple, genital region

Hepadnaviridae
Hepatitis B virus
Acute or chronic hepatitis Has reverse transcriptase

HBs Ag
Acute HBV Chronic HBV, high infectivity Chronic HBV, low infectivity Recovery Immunized + +

AntiAnti- HBe Ag AntiAntiAntiAntiHBsAg HBeAg HBcAg

+ + IgM IgG

IgG

+ +

+ -

IgG -

RNA viruses
Single stranded except Reoviridae Replicate in the cytoplasm except orthomyxoviruses and retroviruses Enveloped except Calicivirus, Picornavirus, Reovirus Helical capsid symmetry except Reo, Picorna, Toga, Flavi, Calici which have icosahedral symmetry Toga, Corona, Retro, Picorna, Calici, Reo, Orthomyxo, Parmyxo, Rhabdo, Bunya, Arena, Filo

Picornaviridae
Smallest RNA virus Poliovirus affects anterior horn cells of spinal cord Coxsackie A herpangina; hand foot and mouth disease Coxsackie B aseptic meningitis; pleurodynia, myocarditis Echovirus aseptic meningitis Rhinovirus common cold Hepatitis A virus acute viral hepatitis

Caliciviridae
Cup-shaped Norwalk virus epidemic viral gastroenteritis (summer diarrhea) Hepatitis E virus endemic hepatitis

Reoviridae
Rotavirus leading cause of fatal diarrhea in children Colorado tick fever - encephalitis

Togaviridae
Rubella
German measles 3 day measles Congenital rubella syndrome cataracts, deafness, heart defects, microcephaly

Alphavirus
Eastern and Western equine encephalitis

Chikungunya myositis and arthritis Onyong-nyong fever, rash, arthralgia

Flaviviridae
Dengue break bone fever Yellow fever Hepatitis C virus St. Louis encephalitis West Nile virus

Arenavirus
Lymphocytic choriomeningitis virus
Hamsters, animals in rodent breeding facilities

Lassa fever virus West Africa

Coronaviridae
2nd most common cause of common cold SARS

Retroviridae
Reverse transcriptase HTLV adult T-cell leukemia HIV

ELISA screening, highly sensitive, RULE OUT Western blot confirmatory, highly specific, RULE IN

Orthomyxoviridae
Influenza virus
Hemagglutinin (HA) Neuraminidase (NA) Antigenic drift minor changes; epidemics Antigenic shift major reassortment; pandemics Amantadine and Rimantadine (Influenza A) Zanamivir, Oseltamivir (Ifluenza A and B)

Paramyxoviridae
Parainfluenza virus laryngotracheobronchitis (croup) Respiratory syncytial virus most common cause of pneumonia in infants less than 6 months of age Mumps parotitis Measles rubeola
SSPE

Rhabdoviridae
Zoonotic all warm-blooded animals; saliva of infected animal Bullet-shaped Negri bodies collection of virions in the cytoplasm Hydrophobia most characteristic symptom of the neurologic phase

PARASITOLOGY

Protozoa
Entamoeba hystolytica
Bloody diarrhea, liver abscess; most are asymptomatic Trophozoite: single nucleus with ingested RBC Cyst: 4 small nuclei Transmission: cyst in water

Giardia lamblia
old man s face, pear-shaped trophozoite Bloating, flatulence, foul-smelling diarrhea Cyst in water

Protozoa
Cryptosporidium
Severe diarrhea in AIDS Fecal-oral transmission of oocyst

Trichomonas vaginalis
Foul-smelling green vaginal discharge Sexually transmitted Trophozoite: undulating membrane, jerky movement

Protozoa
Toxoplasma gondii
Brain abscess in HIV Birth defects Transmitted via cysts in meat or cat feces Tx: sulfadiazine + pyrimethamine

Naegleria
Rapidly fatal meningoencephalitis Swimming in freshwater lakes (enter via cribriform plate)

Plasmodia
Vector: Anopheles mosquito P. falciparum most severe; cerebral malaria, almost constant fever P. malariae Quartan malaria (every 72 hours) P. vivax and ovale Tertian malaria (every 48 hours)

Malaria
Treatment
Chloroquine Mefloquine falciparum resistant to chloroquine Primaquine prevent relapse of vivax and ovale Prophylaxis: mefloquine/chloroquine

Protozoa
Trypanosoma cruzi
Chaga s disease dilated cardiomyopathy, megacolon, megaesophagus Reduviid bug kissing bug Tx: Nifurtimox

T. gambiense/rhodesiense
African sleeping sickness Tse-tse fly Tx: suramin for blood-borne disease; melarsoprol for CNS penetration

Protozoa
Leishmania donovani
Kala-azar visceral leishmaniasis Fever, anorexia, weight loss, bone marrow involvement, splenomegaly Sandfly Tx: sodium stibogluconate

L. tropica (cutaneous, Old World) L. mexicana (cutaneous, Americas) L. braziliensis (mucocutaneous, Central/South America)

Cestodes
Taenia solium (pork tapeworm)
Undercooked pork Cysticercosis mass lesions in brain caused by larva Tx: Niclosamide, Praziquantel

Taenia saginata (beef)

No cysticercosis

Diphyllobothrium latum (fish)

Megaloblastic anemia (B12 deficiency)

Cestodes
Echinococcus granulosus (dog)
Unilocular hydatid cyst disease in liver Anaphylaxis Humans are dead end hosts

Hymenolepsis nana (dwarf)

No intermediate host Eggs directly infectious to humans

Trematodes
Schistosoma
Snails are intermediate hosts Cercaria infective stage; skin penetration (swimmer s itch) Fever, chills, diarrhea, lymphadenopathy S. hematobium (bladder), mansoni (large intestine), japonicum (small intestine)

Clonorchis sinensis
Oriental liver fluke Eating undercooked fish

Trematodes
Paragonimus westermani
Lung fluke Chronic cough with bloody sputum Eating undercooked crab

Intestinal Nematodes
Enterobius vermicularis
Pinworm Perianal itching Scotch tape swab

Trichuris trichiura
Whipworm Soil-transmitted

Ascaris lumbricoides
Giant roundworm Larval migration to lung

Intestinal Nematodes
Ancylostoma/Necator
Hookworm Microcytic anemia, Skin penetration by larva

Strongyloides stercoralis
Pneumonitis, eosinophilia Larvae in stool used for diagnosis Tx: Ivermectin

Trichinella spiralis
Eating raw pork with encysted larva Larva develop in striated muscle Inflammation of muscle, periorbital edema

Tissue Nematodes
Wuchereria bancrofti
Filariasis blockage of lymphatics (elephantiasis) Female Anopheles mosquito Diethylcarbamazine against microfilariae

Onchocerca volvulus
River blindness Female blackflies Tx Ivermectin

Loa loa
Deerfly; swelling in skin TX DEC

Tissue Nematodes
Dracunculus medinensis
Guinea fire worm disease Worm protrudes from skin Ingestion of tiny crustaceans (copepods) in drinking water

Toxocara canis
Visceral larva migrans Blindness due to retinal involvement Dog: definitive host Humans: dead end hosts

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