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INFECTIOUS DISEASE PATHOLOGY

Lecture 4

Prepared and presented by
Marc Imhotep Cray, M.D.

Scanning electron micrograph of Staphylococcus aureus bound to the surface of a human neutrophil. “Granulocytic Phagocytes,” by Frank R. DeLeo and William M. Nauseef.
Learning Objectives
By the end of this presentation learnings will be able to:
1. Difference between bronchopneumonia and lobar pneumonia.
2. List and discuss the defense mechanisms that protect the lung against
bacterial infection.
3. Describe the agents most commonly cause bacterial pneumonia.
4. List and describe the four classical stages of lobar pneumonia.
5. Discuss the most important complications of bacterial pneumonia.
6. Describe the clinical features of bacterial pneumonia.
7. Identify primary atypical pneumonias, and describe the most common
causes.
8. Discuss the most frequent conditions that predispose to the formation of
pulmonary abscess.
9. Read gross and microscopic pathology plates and radiographic findings of
the most common bacterial and atypical pneumonias.
Marc Imhotep Cray, M.D. 2
Pneumonia: Overview
 Pneumonia is a respiratory disease characterized by inflammation of lung
parenchyma (excluding bronchi) caused by viruses, bacteria, fungi, or
irritants
 General clinical signs and symptoms of pneumonia include:
 Fever, chills, muscle stiffness, pleuritic chest pain, cough, blood-tinged or rusty sputum,
shortness of breath, rapid heart rate, and difficulty breathing
 Diagnosis is made by several laboratory methods and (or) diagnostic
procedures, including:
 Chest x-ray; Gram stain and culture (bacterial); bronchoalveolar lavage (Pneumocystis
carinii pneumonia [PCP]); serodiagnosis (Mycoplasma)
 Classic laboratory findings associated with bacterial pneumonia are a
neutrophilic leukocytosis with an increase in band neutrophils (left shift)

Marc Imhotep Cray, M.D. 3
Pneumonia: Overview (2)
The four most common bacteria causing sinus and respiratory
infections are:
1. Streptococcus pneumoniae
2. Haemophilus influenzae
3. Staphylococcus aureus
4. Mycoplasma pneumoniae

Three common morphologic patterns of pneumonia are:
1. Lobar pneumonia
2. Bronchopneumonia and
3. Interstitial pneumonia
Marc Imhotep Cray, M.D. 4
Bronchopneumonia vs Lobar Pneumonia
 Bacterial pneumonia is characterized by exudative consolidation of pulmonary
tissue caused by bacterial invasion of lung parenchyma

According to gross anatomic distribution, it can be classified into the following
categories:
 Lobular pneumonia (bronchopneumonia) is a patchy consolidation (wo
tactile fremitus on PE) of lung (areas of acute suppurative inflammation)
o Infection is usually an extension of a preexisting bronchitis or bronchiolitis
o It tends to occur more frequently in infancy and old age
o Consolidation is more often multilobar and frequently bilateral and basal
 Lobar pneumonia is an acute bacterial infection involving a large portion of
one lobe or an entire lobe (increase tactile fremitus on PE )
o It is infrequent today (in the West) because of effectiveness with which antibiotics
abort these infections and prevent development of full-blown lobar consolidation

Marc Imhotep Cray, M.D. 5
Defense mechanisms against lung
bacterial infection
Several defense mechanisms work to protect lung against bacterial
infection, including:
 Nasal clearance (sneezing, blowing, and swallowing)
 Tracheobronchial clearance (mucociliary action)
 Alveolar clearance (alveolar macrophages)

Whenever these defense mechanisms are impaired or whenever
resistance of host is lowered (chronic disease, immunologic deficiency,
treatment with immunosuppressive agents, leukopenia, and unusually
virulent infections) end result may be pneumonia

Marc Imhotep Cray, M.D. 6
Pulmonary defense mechanisms
 Abrupt changes in direction of
airflow in nasal passages can trap
potential pathogens
 Epiglottis and cough reflex prevent
introduction of particulate matter in
lower airway
 Ciliated respiratory epithelium
propels overlying mucous layer
(right) upward toward mouth
 In alveoli, cell-mediated immunity,
humoral factors, and inflammatory
response defend against lower
respiratory tract infections Bloch KC. Ch. 4 Infectious Diseases. In Hammer GD and McPhee Eds. JS. Pathophysiology of
Disease - An Introduction to Clinical Medicine, 7th Ed., 2014
Bacterial pneumonias: most common
causative agents
 Bronchopneumonia is caused by
 staphylococci,
 streptococci,
 pneumococci,
 Haemophilus influenzae,
 Pseudomonas aeruginosa, and
 coliform bacteria
 Lobar pneumonia is most frequently (90%–95%) caused by
pneumococci (Streptococcus pneumoniae)
 encapsulated gram-positive coccus known for causing rust-
colored sputum
Marc Imhotep Cray, M.D. 8
Common causes of pneumonia (2)
Neonates Children Adults Adults Elderly
(< 4 Wks.) (4 Wks.–18 Yrs.) (18–40 Yrs.) (40–65 Yrs.)
Group B Viruses (RSV) Mycoplasma S. pneumoniae S. pneumoniae
streptococci Mycoplasma C. pneumoniae H. influenzae Influenza virus
E. coli C. trachomatis S. pneumoniae Anaerobes Anaerobes
(infants–3 yr.) Viruses H. influenzae
C. pneumoniae Mycoplasma Gram-negative
(school-aged rods
children)
S. pneumoniae
Redrawn and modified from: Le T and Bhushan V. First Aid for the USMLE Step 1 2015

Note: Most common pneumonias in childhood are Viral pneumonias
Most commonly implicated viruses are Influenza, parainfluenza,
respiratory syncytial virus, rhinovirus, and adenovirus
Marc Imhotep Cray, M.D. 9
Common causes of pneumonia (3)
Special groups
Alcoholic/IV drug user S. pneumoniae, Klebsiella, S. aureus
Aspiration Anaerobes (e.g., Peptostreptococcus, Fusobacterium,
Prevotella, Bacteroides)
Atypical Mycoplasma, Legionella, Chlamydia
Cystic fibrosis Pseudomonas, S. aureus, S. pneumoniae

Immunocompromised S. aureus, enteric gram-negative rods, fungi, viruses, P.
jirovecii (with HIV)
Nosocomial (hospital S. aureus, Pseudomonas, other enteric gram-negative rods
acquired)

Postviral S. aureus, H. influenzae, S. pneumoniae
Redrawn from: Le T and Bhushan V. First Aid for the USMLE Step 1 2015

Marc Imhotep Cray, M.D. 10
Features of Selected Pneumonias

Modified from Davis JL and King EE. Respiratory Pathology (Ch. 7) In: Deja Review Pathology , 2010 11
Four classical stages of lobar pneumonia
Congestion heavy, boggy, and red lung Histologic characteristics are vascular
engorgement, intraalveolar fluid with few neutrophils, and often presence of numerous
bacteria
Red hepatization consolidation of airspaces of lungs on cross section lungs appear
brown-red, firm, and airless, and they resemble liver
 Histologically, alveolar capillaries are congested, and alveolar spaces are filled with
erythrocytes, neutrophils, and fibrin
Gray hepatization persistent consolidation exudate inside alveoli compresses
capillaries and reduces pulmonary blood flow on cross-section lung parenchyma appears
airless, consolidated and pale, and grayish-yellow
 Histologically, alveoli are filled with a fibrinopurulent exudate, and capillaries in alveolar
walls appear compressed and contain less blood than in previous stage
Resolution is final stage, characterized by granular, semifluid debris that is resorbed,
ingested by macrophages, or coughed up

Marc Imhotep Cray, M.D. 12
Clinical features of bacterial pneumonia
Major symptoms of pneumonia include malaise, fever, and cough
productive of sputum

 If fibrinosuppurative pleuritis develops, it manifests with pleuritic pain
and pleural friction rub

 Typical radiologic appearance of
 lobar pneumonia is that of a radiopaque infiltrate involving entire lobe
 bronchopneumonia shows focal opacities

 Identification of causative microorganism and subsequent determination
antibiotic sensitivity (C&S) are key to appropriate therapy

 Clinical findings are dramatically modified by administration of antibiotics
Marc Imhotep Cray, M.D. 13
Complications of bacterial pneumonia
Most important complications of bacterial pneumonia include:
 Pleuritis: It is so common that some authorities consider it a feature of
pneumonia (pleurisy) and not a separate complication

 Abscess: It results from lytic action of neutrophils and is most often found
in pneumonia caused by Staphylococcus aureus

 Empyema: Intrapleural fibrinosuppurative reaction

 Chronic pneumonia: Caused by organization of exudate and persistence of
infection

 Bacteremia with hematogenous dissemination: May cause metastatic
abscesses, endocarditis, meningitis, or suppurative arthritis
Marc Imhotep Cray, M.D. 14
Pulmonary Abscess
 Pulmonary abscess is a local suppurative process within lung characterized by
necrosis of lung tissue

 Causative organisms (e.g., aerobic and anaerobic streptococci, S. aureus, and
gram-negatives)  introduced by following mechanisms:
 Aspiration of infective material is most common cause, particularly in
conditions in which cough reflexes are depressed (e.g., acute alcoholism,
coma, anesthesia, sinusitis, gingivodental sepsis, debilitation)
 Antecedent to primary bacterial infection of lungs
 Septic embolism
 Neoplasia (postobstructive pneumonia)
 Direct traumatic penetration of lungs, spread of infections from a
neighboring organ, and hematogenous seeding of lung by pyogenic
organisms
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Pneumonia Case
A 65-year-old woman is taken to the emergency room by her daughter. She
has had “cold”-like symptoms for the past couple of days. This morning, her
temperature spiked to 102°F and she experiences shaking chills, pain in her
chest, and a productive cough with bloody sputum. Gram stain
evaluation of the sputum revealed the presence of gram-positive lancet-
shaped diplococci. A sputum specimen was sent to the laboratory for culture
and sensitivity testing and a course of penicillin begun. Preliminary laboratory
results reported alpha-hemolytic colonies on blood agar.

Marc Imhotep Cray, M.D.
Streptococcus pneumoniae (Pneumococcus)
Features:
1. Gram-positive, alpha-hemolytic, lancet-shaped diplococcus
2. Oropharyngeal mucosal colonist/opportunist
Diseases:
1. Otitis, sinusitis, pinkeye; pneumonia or meningitis in nonvaccinated young,
old or alcoholics
2. Pathogenesis:
a. Colonizes with help of protein adhesins and an IgA protease; reduces
numbers of competing NF by production of large amounts of hydrogen
peroxide
b. Thick polysaccharide capsule reduces effectiveness of complement and
antibodies, decreasing phagocytic uptake more than 80 different capsular
polysaccharide types
c. Hemolyzes cells through pneumolysin and partially reduces hemoglobin to
green pigment (alpha-hemolysis)
Marc Imhotep Cray, M.D.
Pneumococcal pneumonia cont.
Transmission: direct contact, respiratory droplets, and aspiration
of organisms colonizing the oropharynx
 Viral respiratory infections and chronic pulmonary diseases
increase susceptibility to infection
 Meningitis can occur following ear and sinus infections,
pneumonia, bacteremia, and head trauma
Clin. Findings: usually lobar or a diffuse bronchopneumonia, and
is characterized by an abrupt onset of fever, shaking chills, and a
productive cough Sputum often contains blood (rust colored
sputum)
 Bacteremia is common S pneumoniae is a common cause of
meningitis, otitis media, and sinusitis
Marc Imhotep Cray, M.D.
Streptococcus pneumoniae cont.
3. Lab ID Streptococcus pneumoniae
a. Alpha-hemolytic and lysed by bile and inhibited by optochin
b. Capsules are typed by quellung reaction (apparent capsular swelling when
mixed with the specific matching antibody)
4. Tx: Penicillin is drug of choice (DOC): penicillin resistance due to decreased
binding to penicillin-binding proteins mandates testing
 Chloramphenicol, vancomycin, and erythromycin effective in penicillin-
resistant strains
5. Prevention
a. A 7-valent polysaccharide-protein conjugate vaccine (T-cell dependent) for
infants
b. A 23-valent polysaccharide vaccine for patients 65 years or older, asplenics,
diabetics, human immunodeficiency virus (HIV) positive, COPD, and so forth

Marc Imhotep Cray, M.D.
Typical Pneumonia Case
A 60-year-old man with a history of alcohol abuse is seen in the
emergency room with a necrotizing pneumonia. Gram stain of a
sputum sample reveals gram-negative encapsulated rods. A
sample is sent to the laboratory for identification and sensitivity
testing.

Marc Imhotep Cray, M.D.
Klebsiella pneumoniae
 Phy. Char: Gram-negative rod, large mucoid capsule
 Etio. and Epi: found in soil, water, and large intestine colonization of
oropharynx is uncommon but can occur in individuals with compromised host
defenses (alcoholics, the elderly, chronic respiratory illness=COPD)
 Aspiration of organisms from oropharynx leads to pneumonia (alcoholics w
LOC)
 Clin. Findings: Opportunistic necrotizing pneumonia (and urinary tract
infections)
 Bronchopneumonias are characterized by acute inflammatory infiltrates
from bronchioles into adjacent alveoli
 Dark red “currant jelly” sputum (blood/mucus)
 Pathogenesis: virulence factors include cell wall endotoxin, a thick mucoid
capsule, and a variety of proteases
 Tx: resistant to many antibiotics, so sensitivity testing is required
Marc Imhotep Cray, M.D.
Atypical pneumonia
 Primary atypical pneumonia is an acute febrile respiratory disease
characterized by patchy inflammatory changes in lungs largely confined to
alveolar septa and pulmonary interstitium
 Term atypical emphasizes lack of alveolar exudates a more accurate designation is
interstitial pneumonitis

 Features of atypical pneumonia: Acts like a common cold patients may
never be febrile caused often by Mycoplasma and viruses
 Other etiologic agents are viruses, Chlamydia spp., and Coxiella burnetii (Q-fever) In
many cases, cause cannot be identified

 Chest x-ray often appears worse than patient appears (walking pneumonia)
High-Yield Note: Q-fever is most common rickettsial pneumonia,
caused by Coxiella burnetii
Who typically gets Q-fever? People working with infected cattle or
sheep, people who consume unpasteurized milk from infected animals
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Atypical pneumonias: interstitial pneumonitis
General features:
(a) Have a dry nonproductive cough early, often later becoming
more productive
(b) Causative agents do not show up on Gram stain of lavage
fluids or induced sputum
(c) Causative agents do not grow on blood or chocolate agar
(d) Are caused by mycoplasmas or chlamydiae
(e) Resemble viral pneumonias

Marc Imhotep Cray, M.D.
Atypical pneumonia case
A 15-year-old boy is taken to the family’s primary care doctor
because of a “cold” that has lasted several weeks. On
examination, the boy has a fever and headache that has lasted
several days. He has recently developed a dry, unproductive
cough. Microscopic examination of a Gram-stained sputum
reveals neutrophils but no bacteria. Chest X-ray reveals patchy
infiltrates. The patient is started on a course of tetracycline.

Marc Imhotep Cray, M.D.
Mycoplasma
 Mycoplasma pneumoniae
 Mycoplasma genitalium
Key Concepts:
 Mycoplasma do not contain a cell wall  therefore not
susceptible to action of cell wall antibiotics such as penicillins,
cephalosporins, vancomycin, bacitracin, and cycloserine
 Cell membrane is unique  contain sterols
 Mycoplasma are smallest free-living bacteria

Marc Imhotep Cray, M.D.
Mycoplasma pneumoniae (Mp)
Etiology and Epidemiology: Transmission is by infectious aerosols
 Mp is more common in patients < 30 years old
 Frequent outbreaks in military recruits and prisons
Clinical Finings: causes both upper and lower respir. infections
 URIs include pharyngitis, otitis media, and tracheobronchitis
 Lower respiratory disease is known as primary atypical pneumonia or
“walking pneumonia”
 X-ray looks worse than patient
 Pathogenesis M pneumoniae has one primary virulence factor
called the P1 adhesin protein binds to ciliated epithelial cells
causing ciliostasis, cell destruction, and reduced ciliated
clearance
 Fusion of mycoplasma and host membrane deposits mycoplasma
antigens, which then play a role in autoimmune-like reactions
Marc Imhotep Cray, M.D.
Mp X-ray looks worse than patient
X-ray of 25-year old female with cough due
to Mycoplasma Pneumonia

http://www.intechopen.com/books/respiratory-disease-
http://www.medicalgrapevineasia.com/mg/2012/11/20/the-mycoplasma-story/ and-infection-a-new-insight/pneumonia-in-children
Marc Imhotep Cray, M.D.
Mycoplasma pneumoniae (2)
 Laboratory: Diagnosis largely made by clinical recognition of
syndrome (laboratory tests of secondary value)
Cold agglutinins--Titers 1:32 or greater are considered positive
 Culture (when done) is on cholesterol-containing
mycoplasma medium, taking 2 to 3 weeks and producing
tiny ‘‘fried egg’’ appearing colonies

 Treatment includes antibiotics: tetracycline or macrolides
(erythromycin) or fluoroquinolones
 Remember: Because no cell wall, cell wall active antibiotics
(penicillins, cephalosporins, vancomycin) not effective

Marc Imhotep Cray, M.D.
Atypical pneumonia case 2
A 54-year-old man is seen by his primary care doctor with a fever,
headache, and a persistent dry unproductive cough. Chest X-ray
reveals patchy infiltrates. Potential candidate causative agents
include Mycoplasma pneumoniae, Legionella pneumophila, and
Chlamydophila pneumoniae.
A sputum sample is sent to the laboratory for culture identification
and serologic analysis. In the meantime, a 14-day course of
erythromycin is prescribed because of its effectiveness for all three
agents.

Marc Imhotep Cray, M.D.
Atypical pneumonia, Chlamydiae
 Key Concepts
 Chlamydiae are obligate intracellular Chlamydia
parasites
 cell wall is similar to gram-negative organisms,
but does not contain a typical bacterial Chlamydia Chlamydophila
peptidoglycan
 Two forms of Chlamydia are present during its
life cycle
1. infectious form is called elementary body Chlamydia Chlamydophila
trachomatis pneumoniae
2. metabolically active intracellular form Chlamydophila
called reticulate body psittaci

Marc Imhotep Cray, M.D.
Chlamydophila pneumoniae
Phy. Char: Previously a member of Chlamydia genus, Obligate
intracellular parasite, Gram-negative-like cell wall lacking typical
peptidoglycan
Etio. and Epi: Transmission by respiratory droplets
Clin. Findings: causes several respiratory illnesses including
pharyngitis, bronchitis, and pneumonia
 Infection is characterized by a persistent cough that can last weeks
Pneumonia is atypical and similar to that caused by Mycoplasma
pneumoniae and Legionella pneumophila
Lab Dx: Serologic assays assist in diagnosis, Cell culture
Tx: sensitive to tetracyclines and macrolides (erythromycin and
azithromycin)
Marc Imhotep Cray, M.D.
Pneumocystis carinii pneumonia
(Pneumocystis jiroveci pneumonia)
 The most common opportunistic infection in patients with human
immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS)
and others with impaired immunity
 Lung damage is seen in patients with pneumocystis infection is a diffuse,
interstitial pneumonitis
 Best way to diagnose pneumocystis carinii pneumonia is bronchoalveolar
lavage, bronchial washing, or sputum
 If unsuccessful, endobronchial biopsy open lung Bx
 Human immunodeficiency virus (HIV), is a retrovirus that has a propensity
for helper T-cell lymphocytes
 Depletion of these helper T cells (also known as CD4 cells) leads to infections such as
Pneumocystis jiroveci pneumonia, tuberculosis, esophageal candidiasis, cryptococcus
and histoplasmosis etc.
Marc Imhotep Cray, M.D. 32
Gross and microscopic pathology
plates and radiographic findings of
bacterial and atypical pneumonias
and abscess follow.

Marc Imhotep Cray, M.D. 33
Bacterial pneumonia, gross and radiograph

Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015

Marc Imhotep Cray, M.D. 34
Bacterial pneumonia, gross and radiograph

Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015

Marc Imhotep Cray, M.D. 35
Bacterial pneumonia, microscopic

Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015

Marc Imhotep Cray, M.D. 36
Bacterial pneumonia, microscopic

Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015

Marc Imhotep Cray, M.D. 37
Bacterial pneumonia, microscopic

Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015

Marc Imhotep Cray, M.D. 38
Lung abscesses, gross

Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015

Marc Imhotep Cray, M.D. 39
Lung abscess, radiograph and CT image

Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015

Marc Imhotep Cray, M.D. 40
Aspiration, CT image

Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015 41
Marc Imhotep Cray, M.D.
CASE
A 32-year-old man is brought into the emergency department
because of extensive bruising of the chest in a minor motor vehicle
accident. He is known to be HIV-positive. He complains of
progressive fatigue over the last 3 months and has not visited a
doctor for over a year. A complete blood count (CBC) shows
pancytopenia, and a bone marrow biopsy shows narrow-based
budding yeast.
 What is the most likely diagnosis?
 What are the usual mechanisms of HIV-induced disease?

Marc Imhotep Cray, M.D. 42
HISTOPLASMOSIS AND HIV INFECTION
Summary: A 32-year-old HIV-seropositive man develops fatigue and
bruising with minor trauma. A CBC shows pancytopenia, and a bone
marrow biopsy shows narrow-based budding yeast consistent with
Histoplasma capsulatum.
 Most likely diagnosis: Disseminated histoplasmosis of the bone
marrow.

 Mechanism: HIV is a retrovirus that has a propensity for helper T-cell
lymphocytes. Depletion of these helper T cells (also known as CD4
cells) leads to infections such as Pneumocystis jiroveci pneumonia,
tuberculosis, esophageal candidiasis, and histoplasmosis etc.
Marc Imhotep Cray, M.D. 43
CLINICAL CORRELATION
 This 32-year-old man has an HIV infection.
 Involvement of hemopoietic system is common, causing lymphadenopathy, anemia,
leukopenia, and thrombocytopenia
 These effects can be due to virus itself, consequences of antiviral therapy, or opportunistic
infections
 Histologic studies and culture of the lymph nodes or bone marrow are often diagnostic
 Bone marrow aspirates may reveal malignancy or a fungal infection such as histoplasmosis
Histoplasmosis is an opportunistic infection that is seen most frequently in the Mississippi
and Ohio valleys, where Histoplasma capsulatum is endemic
 Most common manifestation in HIV patients is reactivation after initial primary pulmonary
disease has been contained
 Disseminated disease after reactivation can lead to fever, weight loss, hepatosplenomegaly,
and lymphadenopathy
 Central nervous system involvement with a cerebral mass may be seen
 Bone marrow involvement is common, with pancytopenia noted in approximately one-third
of patients
 Treatment is with either Itraconazole or amphotericin B
Marc Imhotep Cray, M.D. 44
Question 1
A patient in the hospital develops pleuritic chest pain, shortness of breath,
fever, chills, productive cough, and colored sputum after 3 days of being in the
hospital for major surgery.
Physical examination shows tenderness to palpation without any areas of
increased tactile fremitus. Blood and sputum cultures confirm gram-negative
rods that ferment lactose, have a large mucoid capsule, and form viscous
colonies.
The patient subsequently dies from her infection. Which of the following is
most likely to be found at autopsy?
(A) Acute inflammatory infiltrates from bronchioles into adjacent alveoli
(B) Congestion, red hepatization, gray hepatization, and resolution
(C) Diffuse, patchy inflammation localized to the alveolar wall interstitium
(D) Intra-alveolar hyaline membranes without alveolar space exudates
(E) Predominantly intra-alveolar exudate resulting in consolidation
Marc Imhotep Cray, M.D.
Answer
The correct answer is A. The characteristics of the microorganism indicate
infection with Klebsiella species, while the physical exam points to a
bronochopneumonia rather than a lobar pneumonia. K. pneumoniae is a gram
negative rod that ferments lactose and has a mucoid capsule.
Bronchopneumonias are characterized by acute inflammatory infiltrates from
bronchioles into adjacent alveoli. Pneumonia resulting from infection by this
bacterium is often caused by aspiration, so that it is often seen in people with a
loss of consciousness (i.e. alcoholics). It is also more common in patients with
diabetes.

Marc Imhotep Cray, M.D.
Question 2
A 28-year-old man comes to the physician because of worsening muscle
weakness that began in his legs and feet 3 days ago, and has now spread to his
arms and hands. Other than having a flu-like illness 2 weeks ago, the patient
has been in good health. Cerebrospinal fluid analysis shows an increased
protein concentration, a normal cell count, and a normal glucose level. An
infection with which of the following organisms is the most likely cause of the
nervous system syndrome described in this patient?
(A) Candida albicans
(B) Legionella pneumophila
(C) Mycoplasma pneumoniae
(D) Pseudomonas aeruginosa
(E) Streptococcus pneumoniae

Marc Imhotep Cray, M.D.
Answer
The correct answer is C. The syndrome described is Guillain-Barré syndrome, a
common cause of acute peripheral neuropathy that results in progressive
weakness over a period of days. Although one-third of patients report no history
of an antecedent infection, the other two-thirds have recently experienced an
acute gastrointestinal or influenza-like illness prior to developing the neuropathy.
The most common epidemiologic associations involve infections with
Campylobacter jejuni, Haemophilus influenzae, CMV, EBV, Mycoplasma
pneumoniae, and VZV. Laboratory abnormalities associated with Guillain-Barré
syndrome include elevated gamma-globulin, decreased nerve conduction velocity
indicative of demyelination, and albuminocytologic dissociation (CSF shows
increased protein concentration with normal cell count in the setting of normal
glucose). Although the organisms listed frequently precede the syndrome, there
has never been any consistent demonstration of any single infectious agent in the
peripheral nerves of these patients, and the cause of the disease is thought to be
mediated by hypersensitive T lymphocytes.
Marc Imhotep Cray, M.D.
THE END

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Sources and further study:
 Chen EM and Kasturi SS. Deja review, Microbiology and Immunology 2nd Ed. New York: McGraw-Hill,
2010
 Kishiyama JL. Ch. 3 Disorders of the Immune System, Pgs. 31-59 and Bloch KC. Ch. 4 Infectious Diseases,
Pgs. 61-87 In: Hammer GD and McPhee Eds. JS. Pathophysiology of Disease : An Introduction to Clinical
Medicine, 7th Ed. New York: McGraw-Hill Education, 2014
 Johnson AG et al. Bacterial Diseases. In: Microbiology and immunology. 4th Ed. Baltimore: Lippincott
Williams & Wilkins, 2010
 Le T and Bhushan V. First Aid for the USMLE Step 1 2015, New York: McGraw-Hill, 2015

eLearning (IVMS Cloud)
 Infectious Disease
 Microbial biology & Immune System
 Rural Medicine Global Health (Focus on Ethiopia)

Textbooks:
 Ryan KJ and Ray CG Eds. Sherris Medical Microbiology, 5th Ed. New York: McGraw-Hill, 2010
 Carroll KC etal. Jawetz, Melnick, & Adelberg’s Medical Microbiology 27th Ed. New York: McGraw-Hill, 2016

Marc Imhotep Cray, M.D. 50